Santa Monica Rehabilitation Center

Based on observation, interview and record review, the facility failed to ensure 35 out of 132 Soft-and-Bite-Sized (SB6) texture modified meal lunch trays were prepared according to the International Dysphagia Diet Standardization Initiative (IDDSI: standardized framework [0-7 levels] that uses consistent terminology, colors, and testing methods to define texture-modified foods and thickened liquids for people with swallowing difficulties [dysphagia]. Level 6-designed for individuals with mild dysphagia or chewing difficulties. Requiring foods to be soft, tender, and moist, with pieces no larger than 15 millimeters (mm-unit of measurement) x 15 mm [about the standard with of a fork]) according to the IDDSI guidelines, dated January 2019, and facility's document titled Diet Descriptions This deficiency had the potential to result in decreased intake related to inconsistent and large size meats, meal dissatisfaction and increased choking and aspiration (inhalation of food or liquids into the lungs) food risk for 35 residents requiring Soft-and-Bite-Sized texture meals. Findings:…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and sanitary food storage and distribution practices, by failing to:Ensure kitchen staff practiced sanitary glove use during meal preparation.Prevent the contamination of food contact surfaces from cloths and rags.Ensure the kitchen's can opener blade was kept clean.Ensure the floors under kitchen equipment were not heavily soiled with debris.These deficient practices had the potential to result in harmful bacterial growth that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or toxins) in 132 of 133 residents who received food from the facility kitchen.Findings:1. During an observation of the facility's kitchen on 05/18/26 at 12:10 PM, [NAME] 1 was observed assembling meals during lunch service with gloved hands and proceeded to open a steam oven and reach into a pan to pick up a vegetarian patty with his gloved hand, plated the vegetable patty, and continued to assemble lunch meals. During continued observation, a second vegetarian meal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 out of one sampled resident (Resident 63) was wearing an identification (ID) armband (a resident identification system used to help facility personnel provide medical and nursing care) according to the facility's policy and procedures titled, Resident Identification System, dated 1/9/2026. This failure had the potential to result in physical and psychosocial harm to the resident. Findings: During a review of Resident 63's admission record, dated 6/4/2025, the admission record indicated Resident 63 was admitted to the facility on [DATE] with diagnoses not limited to dementia (a progressive state of decline in mental abilities), psychotic disturbance (a mental state where a person loses touch with reality), hypertension (high blood pressure), and anxiety (a feeling of fear of what might happen next). During a review of Resident 122's history and physical (H&P- a doctor's thorough medical report), dated 6/6/2025, the H&P 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 observation, interview, and record review the facility failed to maintain dignity (providing care that respects a resident's self-esteem, identity, and personal choices) and respect for one of one sampled resident (Resident 80) as per the facility's policy and procedure (P&P) tiled Dignity revised on1/29/2026, when Certified Nursing Assistant (CNA) 2 stood over Resident 80 when feeding the resident. This failure had the potential to violate Resident 80's right to personal dignity, and respect, and could negatively affect Resident 80's psychosocial well-being and have impact on Resident 80's self-esteem (sense of personal worth and value).Findings: During a review of Resident 80's admission Record, the admission Record indicated the facility admitted Resident 80 on 11/27/2024 and readmitted Resident 80 on 10/27/2026 with diagnoses including gastro enteritis reflux disease (GERD - chronic acid reflux caused by the muscle between the stomach and food pipe doesn't close properly, letting harsh stomach acid splash upward), traumatic brain injury (TBI - a disruption in normal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure call light was within reach for two of two sampled residents (Resident 110 and Resident 122). This failure practice resulted in Resident 122 feeling frustrated and the potential to not meet the needs of the resident and had the potential for Resident 110 to not communicate needs to the staff, lead to poor outcomes and hospitalization. Findings: 1. A review of Resident 110's admission record indicated the facility admitted Resident 110 on 01/21/2025 with diagnoses that included atrial fibrillation (irregular heartbeat), anxiety disorder (excessive, persistent, and disproportionate fear or worry), hypertension (abnormally high blood pressure), dysphagia (difficulty or discomfort in swallowing) and schizophrenia (brain disorder that affects a person's ability to interpret reality characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions,). A review of Resident 110's Minimum Data…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 report changes of condition (COC, major decline or improvement in a resident's status that will not resolve itself without intervention) to the physician for two of six sampled residents (Residents 17 and 126) by failing to:Report Resident 17's multiple, consecutive Restorative Nursing Aide (nursing aide program that helps residents maintain any progress made after therapy intervention to maintain their function) refusals in April 2026 to the physician in accordance with the facility's Policy and Procedure (P/P) titled, Change in a Resident's Condition or Status.Report Resident 126's multiple refusals to wear a helmet when walking with a merry walker (adapted mobility aid that combines a walking frame which encircles the individual and built in seat designed for individuals with balance issues, weakness, and cognitive [mental action or process of acquiring knowledge and understanding] impairments) in accordance with physician's orders,…

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

Based on observation, interview, and record review, the facility failed to protect residents' right to privacy when computer screens were left open and unattended displaying the residents' personal and medical information on the computer screens for three of the three residents (Residents 46, 81, and 105) according to the facility's policy and procedures (P&P - policy explains the rules and presents them in a logical framework while procedures outline the step-by-step implementation of various tasks) titled Resident Rights with a revision date of 1/29/2026, and the facility's P&P titled Confidentiality of Information and Personal Privacy with a revision date of 1/29/2026 This deficient practice had the potential to result in unauthorized person to view personal and medical information for Residents 46, 81, and 105. Findings: During a concurrent observation and interview on 5/19/2026 at 10:01 AM, laptop computer was observed sitting on top of a medication cart (a mobile workstation used by nurses to securely store, organize, and administer daily medications to residents) with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one out of one sample resident (Resident 126) was free from unnecessary physical restraint (a device or method used to limit a patient's movement to prevent self-harm or harm to others), by failing to ensure:1. Resident 126's left side of the bed was not pushed against a wall, and a bedside table and a Merri walker (ambulation device designed for individuals with balance, mobility, or cognitive impairments) was not placed on Resident 126's bedside table right lateral side to prevent Resident 129 from getting out of bed and ambulating (walking).2. Obtain a physician's order for the Merri walker for Resident 126. This deficient practice violated the right to be free from physical restraints and had the potential to cause significant negative implications including delirium, pressure injuries, and psychological trauma leading to compromised patient dignity, autonomy and resulting in severe physical deconditioning, reduced dignity and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure the assessment entries on the Minimum Data Set (MDS- an assessment and care screening tool) related to Pre -admission Screening and Resident Review (PASRR -a safety check done before someone enters a Medicaid-certified nursing home to ensure the facility can meet their specific needs, or if they would be better served in the community) was accurately documented [NAME] to the facility's policy and procedure (P&P) titled Certifying Accuracy of the Resident Assessments, dated 1/21/2026 for two of two sampled residents (Resident 5 and Resident 127). This deficient practice had the potential to negatively affect the plan of care and delivery/provision of necessary care and services for Resident 5 and Resident 127. Findings: 1. A review of Resident 5's admission Record indicated the facility admitted Resident 5 on 9/20/2018, and readmitted resident 5 on 1/10/2026 with diagnoses including schizophrenia (a mental illness that is characterized by…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 submit the required complete information contained in the Minimum Data Set (MDS- standardized data collection tool used to assess cognitive and functional status, and care needs) for one of 27 sampled residents (Resident 4) within 14 days after discharge/expiration date ([DATE]) to the Centers for Medicare & Medicaid Services (CMS: a federal agency within the United States Department of Health and Human Services) System. This deficient practice had the potential for Resident 4's death to go unreported.Findings: During a review of Resident 4's admission record, the admission record indicated the facility re-admitted the resident on [DATE] with diagnoses that included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (mild or partial weakness or loss of strength on one side of the body) after cerebral infarction (also known as a stroke in which blood flow stops to part of the brain). During a review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to accurately assess and code the Minimum Data Set (MDS, a resident assessment tool) assessments for three of 11 sampled residents (Residents 47, 2, and 105) according to the facility's policy and procedures (P&P) titled, Resident Assessments, revised 1/29/202, by failing to:1. Ensure the section relating to insulin (a hormone that lowers the level of glucose (a type of sugar) in the blood) use for Resident 47 was accurately coded.2. Ensure Section GG 0115A (assessment item that tracks Functional Limitation in Range of Motion (ROM- is how far a person can move a joint or muscle in different directions)) was coded accurately to indicate functional limitations (limited ability to move a joint [where two bones meet] that interferes with daily functioning, including activities of daily living, or places the resident at risk of injury) in range of motion (ROM, full movement potential of a joint) of Resident 2's left arm. 3. Ensure Section GG…

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

Based on interview and record review, the facility failed to ensure that a pre-admission screening Resident Review (PASRR -a detailed assessment that determines if someone with a mental illness [like serious mental illness, intellectual disability, or related conditions] needs specialized services and the most appropriate place to receive them) level II for residents identified with mental disorder were evaluated to receive care and services in the most integrated setting appropriate to their needs for one of two sampled residents (Resident 11), in accordance with the facility's policy and procedures (P&P) titled PASRR Completion Policy with review date of 4/15/2026. This deficient practice had the potential to negatively affect the appropriate care and services rendered and required for Resident 11.Findings: A review of Resident 11's admission Record indicated the facility admitted Resident 11 on 1/10/2025 and readmitted Resident 11 on 2/17/2026 with diagnoses including dementia (a progressive state of decline in mental abilities), bipolar (sometimes called manic-depressive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 treatment and services to improve two of six sampled resident's (Resident 17 and 126) abilities to carry out activities of daily living (ADL, basic activities such as mobility, eating, dressing, toileting, and communicating) by failing to:Ensure staff assisted Resident 17 out of bed daily to maintain and improve mobility (ability to move). 2. Ensure Resident 126 who had communication difficulties and a language barrier was provided access to a communication aid (tool designed to assist persons with speech and language difficulties in expressing their needs and understanding to others) and/or alternative communication strategies to facilitate communication with residents and staff. These deficient practices had the potential for Resident 17 to experience a functional decline in mobility and ADLs and prevent Resident 126 from communicating her needs, resulting in frustration, isolation, and delay in care. Findings: 1. During 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, for two of two sampled residents (Resident 11 and Resident 105), the facility failed to:1. Transfer Resident 11 to General Acute Care Hospital (GACH -full service community hospital) on 2/13/2026. Resident 11 experienced a change of condition (COC - a significant deviation in a person's health, functional status that requires timely recognition, response to prevent complication or death) on 2/13/2026, according to physician's order dated 2/13/2026, and the facility's policy and procedures (P&P) titled Change in a Residents Condition or Status with review date of 1/29/2026. 2. Notify the physician and document why the facility did not transfer Resident 11 to GACH until 2/14/2026.These deficient practices resulted in one day delay of the appropriate care and services placing Resident 11 at increased risk for further decline/complication in the resident health and death.3. Ensure an Occupational Therapist (OT, profession that provides services to increase and/or maintain 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 ensure that low air loss mattress (LAL -a medical-grade mattress that prevents and treats pressure ulcers [bedsores] by constantly blowing air through tiny holes in the fabric, keeping the patient's skin cool and dry) guidelines were adhered to for appropriate pressure redistribution support in accordance with the facility's policy and procedures (P&P) titled Support Surface Guidelines dated 1/29/2026, for one of one sampled residents (Resident 80). This deficient practice had the potential to significantly compromise Resident 80's safety, leading to serious skin breakdown, infection, increased discomfort and hospitalization.Findings: A review of Resident 80's admission Record indicated the facility admitted Resident 80 on 11/27/2024 and readmitted Resident 80 on 10/27/2026 with diagnoses including gastro enteritis reflux disease (GERD - ongoing acid reflux caused by the muscle between the stomach and food pipe doesn't close properly, letting harsh stomach acid splash upward), traumatic brain injury (TBI - a disruption in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide treatments and services to maintain or improve mobility (ability to move) and Range of Motion (ROM, full movement potential of a joint) for two of six sampled residents (Residents 50 and 105) with ROM and mobility concerns. 1. For Resident 105, the facility failed to: a. Objectively (evaluating or viewing something based solely on observable facts, measurements, and evidence) measure both of Resident 105's knees, shoulders, elbows, wrists, and hands during the Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) and Occupational Therapy (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday activities) evaluations, dated 2/18/2026. b. Assess both of Resident 105's legs during the Joint Mobility Assessment (JMA, a brief assessment of a resident's ROM in both arms and both legs), dated 1/22/2026. 2. For Resident 50, the…

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

Based on observation, interview, and record review, for one of six sampled residents (Resident 126) identified as a high fall risk, was supervised and wore a helmet when walking in the hallway in accordance with physician's orders dated 5/2/2026. These deficient practices placed Resident 126 at risk for repeated falls and injury, pain, and a decline in overall physical functioning. Findings: During a review of Resident 126's admission Record, the admission Record indicated the facility originally admitted Resident 126 on 2/7/2025 and re-admitted Resident 126 on 1/6/2026 with diagnoses including dementia (decline in mental ability severe enough to interfere with daily life), muscle weakness, and Alzheimer's disease (a type of disease that affects memory, thinking, and behavior). During a review of Resident 126's Fall Risk Assessment, dated 1/4/2026, the Fall Risk Assessment indicated that Resident 126 had a history of three of more falls in the last three months. The same fall risk assessment indicated Resident 126 scored 18, indicating Resident 126 was a high fall risk. During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one out of one sampled Residents (Residents 147) received lidocaine external patch (a topical, medicated adhesive patch that delivers the local anesthetic lidocaine directly through the skin to the nerves) 5 percent (%-unit of measurement) according to physician's orders and the facility's policy and procedures (P&P) titled Administering Medications dated 1/29/2026. These deficient practices resulted in the Lidocaine External Patch 5% patches left on Resident 147 right elbow and outer left ankle in excess of 12 hours (hrs) with the potential for undesired complications not limited to Lidocaine External Patch 5% dose buildup, skin irritation, dizziness, confusion, or serious health complications, hospitalization, and death. Findings: A review of Resident 147's admission record indicated Resident147 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included, Parkinson's (a progressive,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff provide specialized rehabilitative services (Rehab, services that require specialized training and experience of a licensed therapist or therapy assistant), Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function), and Occupational Therapy (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) evaluations for one of six sampled residents (Residents 17) in accordance with physician's orders, dated 4/4/2026. These deficient practices prevented Residents 17 from receiving skilled Rehab services to maintain, improve, and achieve his highest practicable level of function.Findings: During a review of Resident 17's admission Record, the admission Record indicated the facility originally admitted Resident 17 on 5/23/2025 and re-admitted Resident 17 on 6/20/2025 with diagnoses including muscle wasting and atrophy (thinning or loss of muscle tissue), osteoarthritis (loss…

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

Based on interview and record review, the facility failed to ensure all Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) and Occupational Therapy (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) therapy records prior to 2/2026 were systematically organized and readily accessible for three of six sampled residents (Residents 17, 50, and 105). This deficient practice had the potential to delay and negatively affect the delivery of necessary care and services.Findings: During a review of Resident 17's admission Record, the admission Record indicated the facility initially admitted Resident 17 on 5/23/2025 and re-admitted Resident 17 on 6/20/2025 with diagnoses including muscle wasting and atrophy (thinning or loss of muscle tissue), osteoarthritis (loss of protective cartilage that cushions the ends of your bones), and lack of coordination (ability to use different parts of the body together smoothly and efficiently). During a review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to follow their policy and procedures (P&P) titled, Care Plans [a written step by step outlining a specific health or personal care needs and actions with goals to be med], Comprehensive Person-Centered, with a review date of 1/29/2026 for one of the three sampled residents (Resident 1). By failing to develop and implement a care plan for Resident 1 who was admitted with a history of falls and identified as a moderate risk for falls on 1/2/2026. As a result of this deficient practice Resident 1 had a fall on 3/17/2026 as well as an injury of unknown origin on 4/28/26.Findings:During a review of Resident 1's admission record, the admission record indicated that Resident 1 was admitted to the facility on [DATE] with diagnoses including toxic encephalopathy (a general term for brain dysfunction, disease, or damage caused by exposure to poisonous substances with symptoms from mild confusion and memory loss to severe delirium), dementia (a progressive state…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 clean and sanitary ventilation intake screens for two of seven sampled residents (Resident 5 and 6). This failure resulted in extensive dust buildup on the ventilation intake screens and had the potential to expose residents to allergens (a substance that can cause an allergic reaction).During a concurrent observation and interview on 3/24/26 at 10:35 AM with Resident 5 in Resident 5's room, the intake screen for the ventilation system above the foot of her bed was observed covered with a thick layer of dust. The resident verified this and stated it has been like that for quite a while and she would not want the dust to fall on her and then inhale it. During a concurrent observation and interview on 3/24/26 at 11:19 AM with Resident 6 in the resident's room the intake screen for the ventilation system above the foot of his bed was observed covered with a layer of dust. The resident verified this and stated he has been at the…

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

Based on observation, interview and record review, the facility failed to ensure resident's refrigerator/ freezer storage P&P was followed by failing to ensure:The resident nutrition room cabinets were free from undated and unlabeled open box of cornflakes and bag of potato chips and all food in the resident's refrigerators were labeled and dated properly as well as the food being stored in a manner that would provide air circulation.During an observation with concurrent interview on 3/20/26 at 1:07 pm with Infection Preventionist Nurse (IPN) in the 2nd floor nutrition room, a cabinet was observed with undated and unlabeled open box of corn flakes and bag of potato chips. The IPN removed the items from the cabinets and stated they should not be stored there and should be labeled with the resident name and date of expiration everything should have a date name and date it was opened.During further observation in the same resident nutrition room there was a variety of bags inside the resident's refrigerator that were not appropriately labeled and dated the IPN verified and stated the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, facility failed to ensure the staff assisting English-only speaking residents were not speaking in a language the residents did not understand when providing care for two of seven sampled residents (Resident 3 and 5). This failure resulted in Resident 3 and 5's primary language not being respected and used in front of the residents and had the potential to affect the resident's communication and understanding with the staff. During a review of Resident 3's admission Record (AR), dated 3/24/26, indicated the resident was admitted to the facility on [DATE], with diagnoses including hypertension (HTN - high blood pressure), anemia (a condition where the body does not have enough healthy red blood cells) hemiplegia (weakness of one side of the body) and hemiparesis (paralysis of one side of the body) following cerebral infarction (stroke). The same admission record further indicated the resident's primary language as English. During a review of Resident 3's Minimum Data Set…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility failed to follow the resident's care plan of wandering risk for one of seven sampled residents (Resident 7). This failure resulted in Resident 7 having an elopement incident on 3/10/26 at 3:20 am. During a review of Resident 7's AR dated 3/25/26 indicated, the resident was admitted to the facility on [DATE], with diagnoses encephalopathy (a broad term for any diffuse disease, damage, or malfunction of the brain that alters its structure or function), Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), epilepsy (a chronic neurological disorder characterized by recurrent, unprovoked seizures caused by sudden, abnormal electrical activity in the brain), schizophrenia (a mental illness that is characterized by disturbances in thought), and anemia. During a review of Resident 7's History and Physical (H&P) dated 6/12/25, indicated the resident did not have the capacity to understand and make decisions. During a review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to handle linen according to the facility's policy and procedures titled, Departmental (Environmental Services) Laundry and Linen reviewed 6/2/2025. This deficient practice places all residents in the facility at risk for infection. Findings: On 3/6/2026 The California Department of Public Health (CDPH) received an anonymous complaint alleging the facility does not have enough linen and blankets. A review of a facility in service titled, Proper handling of Linen, dated 12/5/2025 indicated store clean linen in a designated clean area or cart, keep linen covered when transporting it to a patient room, only bring the amount of linen needed for each resident.A review of the sign in sheet for the in service titled, Proper handling of Linen, dated 12/5/2025 did not include the name of Certified Nursing Assistant (CNA) 1.A review of Resident 2's admission Record indicated the facility admitted this [AGE] year old female on 2/17/2026 with Diagnosis…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ensure facility staff implemented the facility's policy and procedures (P&P) titled, Assisting the Resident with in-room meals reviewed 6/2/2025, for three of three residents (Residents 1, 3, and 4) by failing to:Assist Residents 1, 3, and 4 with feedingDocument meal intake percentages according t, Residents 1, 3 and 4.Ensure Certified Nursing Assistant (CNA) 1 reported/notified to a licensed nurse (Licensed Vocational Nurse [LVN] and or Registered Nurse [RN] when Resident 1 had decreased meal intake.These deficient practices had the potential to cause inadequate nutrition, choking and or weight loss for Residents 1, 3, and 4. Findings: On 2/24/2026 The California Department of Public Health (CDPH) received an anonymous complaint alleging the facility Licensed staff does not walk around and ensure the CNA's are working. On 2/27/2026 CDPH received a complaint alleging the facility staff was observed ignoring residents and the care 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.

Based on interview and record review, the facility failed to ensure one of four residents (Resident 1) was free from any significant medication error by failing to notify a physician when a resident refused to take two antipsychotic medications (medications to treat mental illness) three consecutive times according to the facility's policy and procedures (P&P - policy explains the rules and presents them in a logical framework while procedures outline the step-by-step implementation of various tasks) titled Preparation and General Guidelines with a revision date of 12/2019. This deficient practice had the potential for Resident 1 to experience worsening of bipolar disorder (mood swings that range from the lows of depression to elevated periods of emotional highs) symptoms such as extreme, episodic mood swings, deep depression and symptoms of schizophrenia such as hallucinations (often hearing voices), delusions (false, fixed beliefs) and disorganized thinking or behavior to return, reduce medication efficacy (effectiveness) and increased side effects such as anxiety, headache,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 reliable transportation arrangement for a resident to receive medically required dialysis treatment (process of removing waste products and excess fluid from the body using a machine when the kidneys are not able to do so) for one of five sampled residents Resident 5. This failure resulted in Resident 5 missing three medically necessary dialysis treatments on [DATE], [DATE] and [DATE] and placed the resident at risks for potentially serious unwanted outcomes. A review of Resident 5's admission Record indicated Resident 5 was admitted to the facility on [DATE], and readmitted on [DATE] with a diagnoses including pulmonary hypertension (high blood pressure in the arteries of the lungs, causing the blood vessels there to become narrow, stiff, or blocked), type 2 diabetes mellitus (a disease that result in too much sugar in the blood) end stage renal disease (ESRD-- The stage of renal impairment that appears irreversible and permanent, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure the resident and resident's responsible party received changes in coverage made to services and share of cost (SOC) were provided periodically for one of four sampled residents, Resident 2. This deficient practice resulted in Resident 2's responsible party/POA not being able to exercise their rights to file for appeal and take timely action for bills past due since September 2025. Findings: During a review of Resident 2's admission Records, the Records indicated Resident 2 was admitted to the facility on [DATE] and readmitted [DATE] with a diagnoses including aphasia (difficulty speaking) following cerebral infraction (loss of blood flow to a part of the brain causing brain cells to die), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (mild or partial weakness or loss of strength on one side of the body). During a review of Resident 2'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility staff failed to perform hand hygiene while caring for one of seven sampled residents (Resident 7). This deficient practice had the potential to spread infection to residents. Findings: During a facility tour on 1/6/2026 at 12:53 PM the following was observed:Certified Nursing Assistant (CAN) 3 was observed assisting a resident on 3rd floor in a room occupied by two residents. CNA 3 used a bed remote to assist Resident 7, left the bed remote on the floor, picked up the bed remote and did not clean the remote before placing it on the resident's bed. CNA 3 proceeded to feed Resident 7 without performing hand hygiene. CNA 4 walked into Resident 7's room from the hallway, approached to feed Resident 7 without performing hand hygiene. During a review of Resident 7's admission Records, the Records indicated Resident 7 was admitted to the facility on [DATE] with a diagnoses including, anoxic brain damage (serious types of brain injuries resulting in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to develop a discharge care plan for three of three sampled residents, (Residents 1, 2 and 3). This deficient practice has the potential to result in Residents 1, 2, and 3's needs not been met.A review of Resident 1's admission record indicated the facility admitted this [AGE] year old female on 2/19/2025 with diagnoses including left humerus fracture (broken arm), generalized muscle weakness, encephalopathy (broad term to describe any disease, damage or change that alters brain function), cystitis (bladder infection), bilateral osteoarthritis of knee (a progressive disorder of the joints, caused by a gradual loss of cartilage), Anxiety (feeling of fear or unease), hypertension (high blood pressure), major depressive disorder (persistent sadness) and repeated falls.A review of Resident 1's History and Physical (H&P-a physician assessment) dated 2/20/2025 indicated Resident 1's cognition (mental ability to make decisions for daily living) was intact. 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 report an allegation of verbal abuse (any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to patients or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability), for one out of two sampled residents (Resident 1) to the Department of Public Health and Ombudsman (an official appointed to investigate individuals' complaints against maladministration) in accordance with the facility's policy and procedures (P&P) titled, Abuse Investigation and Reporting, reviewed 1/21/2025, within 2 hours after the facility became aware of the abuse allegation on 11/27/2025. This deficient practice had the potential to delay of an onsite inspection by the California Department of Public Health (CDPH) and the Ombudsman to ensure Resident 1's circumstance were investigated. This deficient practice also had the potential to place Resident 1 at further risk for abuse.A review of Resident 1's admission Record indicated the facility…

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

Based on interview and record review, the facility failed to provide social services to four out of six sampled residents (Resident 1, Resident 3, Resident 4, and Resident 5) by failing to have the Social Services Director (SSD) assess the residents' psycho-social well-being after the residents' were involved in physical and/or abuse allegations. On 11/27/2025, Resident 1 alleged Resident 2 hit him on the leg the previous day and Resident 1 called law enforcement to investigate. On 11/29/2025, the Activity Assistant (AA) witnessed an episode of verbal abuse when Resident 4 called Resident 3 an invective while passing Resident 4 and Resident 4 addressed Resident 3 as a curse word in return. On 12/5/2025, Resident 5 alleged Resident 6 hit Resident 5 on the wrist. This deficient practice had the potential for the residents' psychosocial needs to go unaddressed. a. A review of Resident 1's admission Record indicated the facility originally admitted the resident on 5/23/2025 and readmitted the resident on 6/20/2025 with diagnoses that included heart failure (condition in which the heart…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 reasonable accommodation of needs for two of three sampled residents (Resident 4 and Resident 5), by failing to ensure Resident 4 and Resident 5's call light (a device with a button or touchpad a resident uses to set off an alarm that flashes/rings to alert the facility staff the resident needs assistance) was answered in a timely manner, as per the facility's Policy and Procedures (P&P) titled Answering the Call Light revised on 11/26/2025. This deficient practice had the potential for Resident 4 and Resident 5 not to receive emergency care or have a delay in care and services that could result in a fall or accident.Findings: A review of Resident 4's admission records indicated Resident 4 was admitted to the facility on [DATE] with diagnoses including systemic lupus erythematous (immune system mistakenly attacks your own healthy tissues and organs, causing widespread inflammation, pain, fatigue), pain due to internal orthopedic…

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

Based on interviews and record review the facility failed to supervise and monitor the whereabouts of one of four residents (Resident 1). On 9/05/2025 the facility admitted Resident 1 from a general acute care hospital (GACH) with diagnoses including hearing voices to kill himself and verbalized to Registered Nurse (RN) 1 and Licensed Vocational Nurse (LVN) 1 that he wanted to leave the facility. This deficient practice resulted in Resident 1 eloping (the unauthorized departure of a patient from a healthcare facility without notifying staff or receiving proper discharge) from the facility on 9/06/2025 after 8:30 AM without notifying any facility staff. Resident 1's whereabouts remain unknown. Findings: A record review of Resident 1's GACH Physician Psychiatric Evaluation Note dated 8/30/2025, indicated, Resident 1 had a history of bipolar disorder with psychotic features (a collection of symptoms, like hallucinations [sensory experiences without real stimuli] and delusions (false beliefs), that signify a loss of contact with reality). The Physician Psychiatric Evaluation Note also…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 maintenance failed to report nonfunctioning thermostats to facility administration for three of three sampled residents (Residents 1,2 and 3). This deficient practice caused the facility maintenance to turn off the air conditioning unit at night as they were unable to regulate the temperatures in the building leaving residents to complain about the heat.On 8/20/2025 and 9/2/2025 The California Department of Public Health (CDPH) received anonymous complaints alleging the facility's air conditioning was not functioning properly; and the facility was turning off the air conditioning which caused the temperature to be warmer at night. A review of Resident 1's admission Record indicated the facility originally admitted this [AGE] year old female on 1/22/2020 and most recently on 7/28/2025 with diagnoses including peripheral neuropathy(permanent nerve damage causing numbness, tingling and weakness), migraines (severe headaches), obesity (severely…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 keep the nursing station phone ringer on a volume that could be heard and answered for four of four nursing stations. This failure had the potential to limit/miss communication with doctors, family members, and staff. During an observation and a concurrent interview on 8/23/25 at 1:30 pm by nursing station three (3) a call from the main facility phone line was made and transferred to nursing station 3, the phone was noted to not be ringing at the station. An overhead page was heard to answer the phone at nursing station 3 and Licensed Vocational Nurse (LVN) 1, answered the phone. LVN 1 states and verifies the phone volume was down all the way and was unable to hear the phone ring. LVN 1 further stated they do not usually have the volume down that low and it is important to have it set at an audible level so that they can answer the calls of the doctors, family and patients. During an observation and a concurrent interview on 8/23/25 at 1:48 pm by nursing station one (1) a call from the main facility phone line…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 intravenous (IV, access to the bloodstream via a vein) access care as per facility's policy and procedures (P&P) for one of three sampled residents (Resident 1), by failing to ensure IV therapy fluids were infused over 20 hours, as ordered. This failure resulted in a delay in IV fluid infusion and had the potential to affect Resident 1's electrolytes (minerals in your blood and other body fluids that carry an electric charge, regulating your body's function).During a review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including hypertension (HTN- high blood pressure), diabetes mellitus type two (DMII-a disorder characterized by difficulty in blood sugar control and poor wound healing), muscle weakness, abnormalities of gait and mobility, heart failure (HR- a disorder characterized by difficulty in blood sugar control and poor wound healing), and asthma (chronic 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 explain and obtain a signature for the admission agreement upon an admission per its policy and procedures (P&P) for one of three sampled residents (Resident 1).This deficient practice had the potential to result in a knowledge deficit as to which covered services were provided by the facility verses Resident 1's insurance.Findings:A review of Resident 1's admission record indicated the facility admitted this [AGE] year old female on 6/13/2025 with diagnoses including ventricular fibrillation (heart arrythmia), morbid obesity (overweight), diabetes type 2 (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), asthma (long term lung disease causing inflammation), acute pulmonary edema (fluid in the lungs), congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), obstructive sleep apnea (sleep disorder), vascular dementia (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 protect the resident's right to be free from physical abuse for one of four residents (Resident 1) by Resident 2. Resident 1 had a behavior of wandering behavior into other residents' rooms. The facility failed to:- Develop a comprehensive care plan (a plan of care that summarizes a resident's health conditions, specific care needs, and current treatments) to address Resident 1's wandering, per the facility's policy and procedure (P&P) titled, Wandering and Elopements. - Accurately assess Resident 1's risk for wandering upon admission- Adequately monitor Resident 1's location to ensure the resident's safety and prevent the resident from wandering into other resident rooms. - Provide a safe environment for Resident 1 As a result, On 7/6/2025, Resident 1 wandered into Resident 2's room and ate Resident 2's sandwich.On 7/20/2025, Resident 1 again wandered into Resident 2's room and drank Resident 2's sports drink causing Resident 2 to become angry and throw a bottle at Resident 1's head. Findings: During 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 implement their policy regarding reporting of a resident-to-resident altercation and to submit a conclusion report of investigation within five days or in accordance with state or federal law for two of three sampled residents (Resident 1 and 2).This resulted in a delay in an onsite inspection by the Department of Public Health to ensure the residents' allegation of abuse was investigated, which can also lead to a delay in prevention of further abuse.Findings:1a. During a review of Resident 1's admission Record, it indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including type II Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), During a review of the Minimum Data Set (MDS - resident assessment tool) dated 5/29/2025, indicated Resident 1's cognitive (mental action…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to provide necessary respiratory care services for one of three sampled residents (Resident 4), by failing to follow physician's order for bilevel positive airway pressure machine (BiPAP - a device that helps people breathe easier, especially when they have breathing difficulties like sleep apnea [a sleep disorder where breathing repeatedly stops and starts during sleep]) per facility's protocol.This deficient practice had the potential to cause complications associated with respiratory treatment.Findings:During a review of the admission Record indicated Resident 4 was admitted to the facility on [DATE] with diagnosis including obstructive sleep apnea (OSA - is characterized by episodes of a complete (apnea) or partial collapse (hypopnea) of the upper airway with an associated decrease in oxygen saturation or arousal from sleep. This disturbance results in fragmented, nonrestorative sleep), type II Diabetes Mellitus (DM-a disorder characterized by…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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. Answer call light in timely manner for one of three sampled residents, Resident 1, 2. Provide a director of staff development (DSD-a professional who oversees and manages the training and development activities for employees within an organization) to train staff, and 3. Ensure the certified nursing assistants (CNA) from the registry (an agency the provides CNA's to health care facilities on a temporary, as needed basis to fill their staffing needs) were competent to provide care for one of three sampled residents, Resident 2. These deficient practices placed the residents' safety at risk Findings: A review of Resident 1's admission record indicated the facility admitted this [AGE] year old female on 12/5/2024 with diagnoses including metabolic encephalopathy, chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), Type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review for 6 of 7 Residents sampled, Residents 1,2,3,4,5 and 6. The facility failed to provide a physical therapist (PT-healthcare professional who helps people improve or restore mobility and reduce pain) to perform initial evaluations (a comprehensive assessment conducted by a licensed PT to understand a patient's physical condition and movement limitations). This deficient practice placed these residents at risk of a decline in mobility. Findings: A review of Resident 1's admission Record indicated the facility admitted this [AGE] year old female on 5/22/2025 with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (total weakness of the arm, leg, and trunk on the same side of the body) following cerebral infarction (CI-stroke, loss of blood flow to a part of the brain), type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), chronic kidney…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 open the dining room for dinner to all residents every day. This deficient practice is a violation of resident's rights. Cross Reference F725 Findings: On 6/2/2025 The California Department of Public Health (CDPH) received a complaint alleging the facility only allowed residents to eat in the dining room for lunch. During an unannounced visit on 6/16/2025 the activity director (AD) was interviewed at 11:55 a.m. and stated, I have been working here for 2 months; since I have been here, I have seen staff bring residents to the dining room for lunch only . The AD stated for breakfast and dinner residents usually eat in their rooms . The AD stated, I don't know why but it's been that way since I have been working here . Lastly, The AD stated, all residents are welcome to eat here, I am here from 9:00 a.m. until 5:30 p.m. Monday through Friday . During an interview on 6/16/2025 at 12:26 p.m. with the restorative nursing assistant (RNA) 1stated, The dining…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 enough staff to have the dinning room open for all meals. This deficient practice placed all residents at risk of . Findings: On 6/2/2025 The California Department of Public Health (CDPH) received a complaint alleging the facility only allowed residents to eat in the dining room for lunch. During an unannounced visit on 6/16/2025 the activity director (AD) was interviewed at 11:55 a.m. and stated, I have been working here for 2 months; since I have been here, I have seen staff bring residents to the dining room for lunch only . The AD stated for breakfast and dinner residents usually eat in their rooms . The AD stated, I don't know why but it's been that way since I have been working here . Lastly, The AD stated, all residents are welcome to eat here, I am here from 9:00 a.m. until 5:30 p.m. Monday through Friday . During a concurrent interview and record review on 6/16/2025 at 10:29 a.m. with the registered nurse (RN). The facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement their policy regarding reporting of an employee to resident altercation and to submit a conclusion report of investigation within five days or in accordance with state or federal law for one of four sampled residents (Resident 2). This resulted in a delay in an onsite inspection by the Department of Public Health to ensure the residents' allegation of abuse was investigated which can also lead to a delay in prevention of further abuse for Resident 2. Findings: 1a. During a review of the Resident 2 ' s admission Record, it indicated Resident 2 was originally admitted to the facility 2/27/2025 and readmitted on [DATE] with diagnosis including nontraumatic intraverbal hemorrhage (a type of stroke where bleeding occurs within the brain tissue itself), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing). During 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 employ a full-time Physical Therapist to provide a specialized rehabilitative service to 144 residents bed-capacity in the facility that may need a physical therapy evaluation and treatment. This deficient practice may result in delayed treatment and services and placed the residents at higher risk for further decline. Findings: During an interview with Occupational Therapist 1 (OT 1) on 12:39 p.m., OT 1 stated, there are currently no PT staff working in the facility as their previous PT resigned about two weeks ago. OT 1 stated, there are about nine residents who have a current physical therapy order from their physician. During an interview with Director of Nursing (DON) on 4/24/2025 at 2:19 p.m., DON stated, there are no active PT working in the facility at this time. DON stated, a rehabilitative service such as physical therapy is important as it will improve residents' physical mobility. DON further stated, if these residents were not given the physical therapy as ordered, this may delay their physical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to employ a qualified social worker on a full-time basis that met the qualifications specified in the regulation. This deficient practice had a potential for 144 bed capacity of residents residing in the facility not being assisted and receiving medically related necessary care to attain highest practicable well-being. Findings: During a review of the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnosis including bilateral (both) primary osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) of knee, unspecified asthma (respiratory condition marked by spasms in the bronchi of the lungs, causing difficulty in breathing) and spinal stenosis (narrowing of the spaces within the spine, which can put pressure on the nerves that travel through the spine). During a review of the Minimum Data Set (MDS – resident assessment tool) dated 3/27/2025, indicated Resident 2 ' s cognitive (mental…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure resident's call light (a device used to notify the nurse that the resident needs assistance) were answered promptly for one of six sampled residents (Resident 6). This deficient practice had the potential to result in the residents not being able to summon staff for assistance for care and services as needed, which could lead to accidents such as falls with injuries. Findings: During a review of the admission Record indicated Resident 6 was admitted to the facility on [DATE] with diagnosis including type II Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), fibromyalgia (a condition that causes pain all over the body, sleep problems, fatigue, and often emotional and mental distress) and chronic kidney disease (CKD-a longstanding disease of the kidneys leading to renal failure). During a review of the Minimum Data Set (MDS – resident assessment tool) dated 2/28/2025 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 use two people to transfer a resident (Resident 1) from bed to wheelchair, using a Mechanical lift (Hoyer lift - sling lift, an assistive device that allows residents to be transferred between a bed and a chair, by the use of electrical or hydraulic power) instead only using one person for one of six sampled residents. This placed Resident 1 at risk for falls or accidents during use of the mechanical lift and can lead to injuries including possible fractures. Findings: During a review of the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and age-related osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D). During 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 report an allegation of verbal abuse (any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to patients or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability), for one of two sampled residents (Resident 1) to the Department of Public Health and Ombudsman (an official appointed to investigate individuals' complaints against maladministration) within two hours after the allegation occurred on 4/5/2025 in accordance with the facility's policy and procedures (P&P) titled, Abuse Investigation and Reporting. This failure had the potential to delay of an onsite inspection by the California Department of Public Health (CDPH) and the Ombudsman to ensure Resident 1's circumstance were investigated. This deficient practice also had the potential to place Resident 1 at further risk for abuse. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident 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 for one of three sampled Residents, Resident 1. The facility failed to develop interventions to stop resident 2 from allegedly verbally abusing Resident 1. This deficient practice places Resident 1 at risk for continued verbal abuse from Resident 2. Findings: A review of Resident 1 ' s admission record indicated the facility admitted this [AGE] year-old female on 12/19/2022 with diagnoses including bilateral osteoarthritis of knee (a progressive disorder of the joints, caused by a gradual loss of cartilage), anemia (a condition where the body does not have enough healthy red blood cells), myalgia (generalized muscle pain), hyperlipidemia (high fat in the blood), anxiety (intense, excessive worrying over everyday situations), essential hypertension (HTN-high blood pressure), chronical peripheral venous insufficiency (improper functioning veins in legs), chronic sinusitis (long term infection of sinuses), cardiac murmur(sound of blood flowing through a diseased…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 history of liver transplant for one of five sampled residents (Resident 2). This failure resulted in no plan of care for Resident 2's history of liver transplant and had the potential to affect continuity and delivery of care to meet the resident's needs. Findings: During a review of Resident 2's admission Record, the record indicated the resident was admitted to the facility on [DATE] with diagnoses including: paranoid schizophrenia (a severe mental health condition that can involve delusions and paranoia), anemia (a condition where the body does not have enough healthy red blood cells), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), kidney transplant (a surgical procedure where a healthy kidney from a donor is placed into a person whose kidneys have failed,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 to: 1. Ensure communication of high risk for elopement (the act of leaving a facility unsupervised and without prior authorization) was made for one of two sampled residents (Resident 1). 2. Ensure one of two sampled residents (Resident 1) was wearing an identification (ID) wristband. These deficient practices had the potential to affect the resident's safety and wellbeing during medication administration, delivery of services and monitoring of wandering and elopement. Cross reference with F689 Findings: During a review of Resident 1's admission Record, the record indicated the resident was admitted to the facility on [DATE] with diagnoses including: parkinsonism (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), dysphagia (difficult…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 follow physician's orders regarding skin tear (traumatic wounds caused by friction when the upper layer of the skin becomes torn from the underlying layers) treatment for one of two sampled residents (Resident 1). This deficient practice had a potential for retearing and delayed healing of the skin tear on the resident's right wrist/ hand. Findings: During a review of Resident 1's admission Record, the record indicated the resident was admitted to the facility on [DATE] with diagnoses including: parkinsonism (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), dysphagia (difficult swallowing) and neurocognitive disorder with Lewy bodies (a progressive brain disorder characterized by the presence of Lewy bodies, abnormal protein deposits in brain cells, leading to decline in thinking,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 communication of high risk for elopement (the act of leaving a facility unsupervised and without prior authorization) was made for one of two sampled residents (Resident 1). 2. Ensure one of two sampled residents (Resident 1) was wearing an identification (ID) wristband. This failure had the potential to place the resident at risks for elopements and other accidents affecting resident's safety during delivery of services and monitoring of wandering and elopement. Cross reference with F658 Findings: During a review of Resident 1's admission Record, the record indicated the resident was admitted to the facility on [DATE] with diagnoses including: parkinsonism (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), dysphagia (difficult swallowing) and neurocognitive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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: 1. Notify the physician (MD) when one of three sampled residents (Resident 2) had change of condition (COC/CIC) 2. Documented that Resident 2 had complained of a sore throat, swallowing issues, and body itching. These deficient practices had the potential to result in possible delayed provision of necessary care and services to Resident 2. Findings: A review of Resident 2's admission Record indicated the facility admitted Resident 2 on 3/4/2025 with diagnoses including congestive heart failure (CHF-a chronic condition in which the heart does not pump blood as well as it should), diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]) and dementia (loss of cognitive functioning-thinking, remembering, and reasoning). A review of Resident 2 ' s Minimum Data Set (MDS-a resident assessment tool), dated 3/11/2025, indicated Resident 2's cognitive (mental action or process of acquiring knowledge and…

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

Based on interview and record review, the facility failed to ensure document grievances per facility policy for one of three sampled resident (Resident 2). This deficient practice violated Resident 2 and Resident 2 ' s family member (R2FM) right to have grievance addressed and had a potential to delay any necessary care and services for Resident 2. Findings: A review of Resident 2's admission Record indicated the facility admitted Resident 2 on 3/4/2025 with diagnoses including congestive heart failure (CHF-a chronic condition in which the heart does not pump blood as well as it should), diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]) and dementia (loss of cognitive functioning-thinking, remembering, and reasoning). A review of Resident 2 ' s Minimum Data Set (MDS-a resident assessment tool), dated 3/11/2025, indicated Resident 2's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making was severely impaired and requiring moderate assistance from staff for activities of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to protect two of three sampled residents (Residents 2 and 3) from misappropriation (the unauthorized, improper, or unlawful use of funds or other property for purposes other than that for which intended) of property and personal belongings by failing to: 1. Inventory and document belongings upon admission and discharge for Resident 2. 2. Release Resident 3's belongings to Resident 3 or the Resident 3 ' s representatives when Resident 3 was transferred to general acute care hospital (GACH). These deficient practices: 1. Resulted in Resident 3 not receiving all belongings. 2. Had the potential to loose Residents 2 and 3 belongings. Findings: 1. A review of Resident 2's admission Record indicated the facility admitted Resident 2 on 3/4/2025 with diagnoses including congestive heart failure (CHF-a chronic condition in which the heart does not pump blood as well as it should), diabetes mellitus (DM-a chronic condition that affects the way the body processes…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 baseline care plan was developed and implemented within 48 hours of admission for one of six sampled residents (Resident 2). This deficient practice had the potential to negatively affect the provision of care and services for Resident 2. Findings: A review of Resident 2's admission Record indicated the facility admitted Resident 2 on 3/4/2025 with diagnoses including congestive heart failure (CHF-a chronic condition in which the heart does not pump blood as well as it should), diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]) and dementia (loss of cognitive functioning-thinking, remembering, and reasoning). A review of Resident 2 ' s Minimum Data Set (MDS-a resident assessment tool), dated 3/11/2025, indicated Resident 2's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making was severely impaired and requiring moderate assistance from staff for activities of daily livings (ADLs-bed mobility, dressing,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 reasonable accommodation of resident needs and preferences for four of six sampled residents (Resident 4, 5, 6 and 7) by failing to: 1. Ensure television (TV) was working at all times for Resident 4, 5 and 6. 2. Ensure hot water was available throughout the day during showers for Resident 4, 5, 6 and 7. These deficient practices had the potential to negatively impact the psychosocial well-being of the residents and had the potential to delay necessary care for Residents 4, 5, 6 and 7. Findings: a. A review of Resident 4's admission Record indicated that Resident 4 was originally admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnosis including fracture (broken bone) of right femur (a break, crack or crush injury of the thigh bone) and low back pain. A review of Resident 4's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool) dated 8/22/2024, MDS indicated Resident 4 has an intact…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 protection of resident ' s rights to privacy for one of five sampled residents (Resident 5) by failing to ensure Resident 5 received unopened mail. This deficient practice violated Resident 5 ' s right to privacy. Findings: A review of Resident 5's admission Record indicated that Resident 5 was admitted to the facility originally on 10/28/2014 and was re-admitted on [DATE] with diagnosis including spinal stenosis (narrowing of the spaces within the spine, which can put pressure on the nerves that travel through the spine), obesity (a disorder involving excessive body fat that increases the risk of health problems) and chronic obstructive pulmonary disease (COPD-group of lung diseases that block airflow and make it difficult to breathe). A review of Resident 5's Minimum Data Set (MDS - a resident ssessment tool) dated 11/4/2024, MDS indicated Resident 5 has an intact cognition (mental action or process of acquiring knowledge and understanding)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure sufficient nursing staff was available to provide nursing and related services to meet the resident ' s needs safely and in a manner that promotes each resident ' s rights, physical, mental, and psychosocial well-being for one of six sampled residents (Residents 4) by failing to ensure call light was answered promptly for Resident 4. This deficient practice has the potential to affect the quality of life and had the potential to delay necessary care for Resident 4. Findings: A review of Resident 4's admission Record indicated that Resident 4 was originally admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnosis including fracture (broken bone) of right femur (a break, crack or crush injury of the thigh bone) and low back pain. A review of Resident 4's Minimum Data Set (MDS - a resident assessment tool) dated 8/22/2024, MDS indicated Resident 4 has an intact cognition (mental action or process of acquiring knowledge and…

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

Based on observation, interview, and record review the facility failed to ensure a licensed administrator was appointed by the Governing Board. This failure had the potential to affect resident care and management of the facility. Findings: During a review of posted licensing information on the facility consumer bulletin board in the lobby area of the facility, on 2/27/25 at 4:32 pm, no administrator license was noted posted on the consumer board. During an interview with Acting Administrator (AA) on 2/27/25 at 4:34 pm, AA states his license was not up on the consumer board because he was not appointed by the governing board because he would be over the 200-bed limit to supervise. During a review of facility ' s policy and procedure titled Administrative Management (Governing Board) reviewed 11/21/24 indicated, 2. The administrator is appointed by and accountable to the governing board. During a review of facility ' s policy and procedure (P&P) titled Administrator reviewed 11/21/24, the P&P indicated, A licensed administrator is responsible for the day-to-day functions of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of six residents ' (Resident 1) family member representative (FMR) 1, received copies of Resident 1 ' s medical records within two days of the request. As a result, FMR1 requested the facility for copies of the medical records four times causing FMR1 to become frustrated. As of 2/25/2025, FMR1 had not received requested medical records for Resident 1. Findings: During a record review, Resident 1 ' s admission Record (a document containing demographic and diagnostic information) indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including: metabolic encephalopathy (a general term that describes a brain disease, damage or malfunction; brain function is disturbed), muscle weakness (when muscles are weak causing difficulty performing normal activities that require strength), unspecified dementia (a condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff did not placed their personal monster energy drink in the refrigerator in the kitchen. 2. Staff performed hand hygiene after leaving the patient's room that was on isolation and after disposing of dirty linen from a resident's room. 3. Ensure standard infection control practices were followed for four (2) out of 23 sampled residents (Residents 21 and 227) by: a. Failing to ensure oxygen nasal cannula tubing (a device used to deliver supplemental oxygen placed directly on a resident's nostrils) were off the floor for Resident 21. b. Failing to ensure nebulizer (nebulizer is a drug delivery device used to administer medication in the form of a mist inhaled into the lungs) was securely wrapped in a clear plastic cover and not touching the bedside table for Resident 227. These deficient practices had the potential to result in pathogen (germ) exposure for Residents 21 and Resident 227 and placed both residents at risk for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the resident's clinical records were complete and updated concerning advance directives (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) for four out of four sampled residents (Residents 72, 27, 65 and 114) by failing to maintain an accurate and current copy of the resident's advance directives in the resident's clinical record. This failure had the potential to cause conflict with a resident's wishes regarding health care. Findings: During record review, Resident 72's admission record, indicated Resident 72 was admitted to the facility (skilled nursing facility [SNF]) on 8/10/21, with diagnoses that included, hypertension (high or raised blood pressure), anxiety disorder (restlessness, worried, tense or afraid of what may happen in the future), and muscle weakness (a lack of physical or muscle strength, throughout 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 reinforce the residents right to a safe and homelike environment for two of seven sampled residents (Resident 18 and Resident 118). 1. For Resident 18 the facility failed to replace a scortched black mark on the wood floor near the foot of Resident 18's bed 2. For Resident 18 the facility failed to inventory the resident's personal belongings. 3. For Resident 118, the facility failed to repair damaged wall and paint the wall behind the resident's bed. This failure resulted in the loss of Resident 18's personal checks, and Resident 118 feeling ashamed of living with damaged and unpainted walls. in the facility. Findings: a. During record review, Resident 18' s admission Record indicated the facility initially admitted Resident 18 on 8/15/2023 and re-admitted the resident on 11/28/24 with diagnoses that included, chronic kidney disease (kidneys are damaged and cannot filter blood as well as they should), diabetes mellitus (DM-a disorder…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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: 1. Nursing staff and the certified nurse assistant (CNA) are competently wearing N95 masks (is the most common of the seven types of particulate filtering facepiece respirators. This product filters at least 95% of airborne particles) during an ongoing influenza outbreak in the facility. 2. The director of staff development (DSD), a licensed vocation nurse (LVN) had the skill set to train registered nursing staff concerning resident care and assessment for abuse reporting during in-service training. These deficient practices had the potential to result in: 1. Vulnerable residents to contract influenza causing a larger spread of influenza (Flu- viruses known to cause flu pandemics that infects people and has the ability to spread efficiently among people, and against which people have little or no immunity) outbreak. 2. Unsatisfactory training for the registered nursing staff. Findings: 1. During an observation of LVN 6 on 2/05/2025 at 2:04 PM, LVN 6 was observed sitting at the nurse's station 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 Based on observation, interview, and record review the facility failed to ensure that one of 23 sampled residents (Resident 20) was free of unnecessary medication by failing to clarify the physicians order for Amoxicillin (a drug used to treat infections caused by bacteria and other microorganisms), to be administered orally (by mouth) for 120 days. This deficient practice resulted in Resident 20 receiving an excessive dose of antibiotics, for an excessive duration without adequate indication for prolonged use, rationale or monitoring and had the potential to result in adverse consequences such as antibiotic resistance, kidney, and liver failure. Findings: A review of Resident 20's admission record indicated Resident 20 was admitted to the facility on [DATE] with diagnoses that included heat failure (a condition where the heart cannot pump enough blood to meet the body's needs), depression (persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities), irritative hyperplasia of…

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

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen for 114 of 114 residents who received food from the kitchen. By failing to ensure: 1. The Italian and ranch dressings were not unlabeled and undated, 2. The bacon slices was not uncovered and undated. 3. The leftover chicken and ground beef stored in the refrigerator had record of following the cool down method. 4. The 16 pre-packed sandwiches were not undated. 5. The meat slicer was uncleaned. These failures had the potential to result in harmful bacteria growth and cross contamination (a transfer of harmful bacteria from one place to another or one object to another) that could lead to foodborne illness (illness caused by food contaminated with bacteria, viruses and other toxins). Findings: During the initial tour of the facility on 2/03/2025 at 7:23 am, of the kitchen with Dietary Supervisor(DS), it was observed there was 16 prepackaged sandwiches without labels and no expiration dates on them, large container of Italian…

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

Based on observation, interview, and record review, the facility failed to provide a safe homelike environment by not equipping corridors with firmly secured handrails on each side. This deficient practice had the potential to result in a fall causing injury to a resident using the unsafe railing. Findings: During an observation on 2/4/2025 at 1:44 pm the hallway railing on the third floor was broken at the metal area that is attached to the wall making the railing unstable for resident use. The rail was not attached securely to the wall and had the possibility of braking away from the wall if pressure is applied to the unsecured railing. During an interview on 2/4/2025 at 1:46 pm, the Maintenance Supervisor (MS) stated he was not aware of the railing being lose from the wall in this area of the third floor in the hallway. The MS stated no one informed him and he did not see it during his initial assessment. The MS stated he will get it fixed immediately. The MS confirmed and stated that it was the facility's responsibility to provide a safe and homelike environment for the…

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

Based on observation, interview, and record review, the facility failed to ensure staff wear identification (ID - a card that identifies a person/staff) badges while on the nursing floor providing nursing care to the residents. This deficient practice had the potential for: 1. Residents to decline nursing care from staff who they cannot identify causing residents to miss the nursing care they need. 2. Residents to fear for their safety when staff did not have proper identification causing residents to feel unsafe while residing in the facility. Findings: During an observation on 2/03/2025 at 10:29 AM, Certified Nursing Asisstant (CNA) 3 was observed walking down the hallway near Nurse's Station 1 and not wearing an ID badge. CNA3 stated, I forgot (ID Badge). CNA3 stated it was necessary while working on the floor caring for facility residents so my patients know who is taking care of them. So they know I am here for them. CNA3 stated not wearing an ID badge will cause the residents to be afraid cuz they don't know who I am, why I am here. During an observation on 2/05/2025 at 2:59…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 facility's Use of Restraints, policy and procedures for one of 23 sampled residents (Resident 12) by failing to: 1. Execute an informed consent for restraints prior to administration 2. Conduct a pre-restraining assessment 3. Initiate a flow sheet documenting restraint site, observation, range of motion, and repositioning and every two-hour release of the physical restraint These deficient practices have the potential to place the residents at risk for unnecessary prolonged use of restraints, a decline in physical functioning and skin injuries. Findings: During record review, Resident 12's admission Record indicated the facility admitted the resident on 7/20/11, with diagnoses dementia (a progressive state of decline in mental abilities), atrial fibrillation (an irregular heartbeat that can lead to blood clots and increases the risk of stroke and other heart complications) and chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing). During record review,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the Facility failed to ensure a care plan was initiated for one out of 23 sampled residents (Resident 20) for amoxicillin (antibiotic - medication to treat infection/s) ordered for 120 days to treat oral lesions (abnormal cell growths or sores in the mouth that can be painful). This deficient practice had the potential to negatively affect the delivery of care and services and had the potential to result in complications from unnecessary medications such as resistance to antibiotics and a super bag infection (a microorganism/bacteria that has become resistant to antibiotics or antifungal medications). Findings During record review, Resident 20's admission record indicated Resident 20 was admitted on [DATE] with diagnoses that included heat failure (a condition where the heart cannot pump enough blood to meet the body's needs), depression (persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities), irritative hyperplasia of the…

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

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 5), who had limited range of motion (ROM - the extent of movement of a joint) in the right hand received Restorative Nursing Aide (RNA - assistant that help residents to maintain their function and joint mobility) services as ordered by the physician. This deficient practice put Resident 5 at risk for further decline and contracture formation. Findings: During record review, Resident 5's admission record indicated the facility originally admitted the resident on 10/10/12 and readmitted the resident on 6/8/24 with diagnoses including Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), multiple sclerosis (disabling disease of the brain and spinal cord that causes the nerves to deteriorate or become permanently damaged) and scoliosis (a condition in which the spine curves abnormally to the side, usually in an S or C shape). During record review, Resident 5's Minimum Data Set (MDS - a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one out 23 sampled residents (Resident 277) was evaluated and demonstrated the ability to self-administer medication prior leaving medication at the Residents bedside. This deficient practice had the potential to result in an allergic reaction, poor patient outcomes and even death from accidental ingestion of unknown medication/substance. Findings: During record review, Resident 277 admission Record indicated Resident 277 was originally admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses that included toxic encephalopathy (brain dysfunction caused by exposure to toxic substances), diabetes mellitus (metabolic disease characterized by abnormally high blood sugar (glucose) levels in the blood), dysphagia (swallowing difficulty), pneumonitis (lung inflammation) and depression (mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure 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 observation, interview, and record review, the facility failed to ensure that a resident with an indwelling urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) received catheter care as ordered by the physician for one of two sampled residents (Resident 55). This deficient practice had the potential to result in urinary tract infections (UTI- is an infection of the urinary tract, which includes the kidneys, bladder, ureters, and urethra) for Resident 1. Findings: A review of the admission Record indicated the facility originally admitted Resident 55 on 4/28/2017 and was re-admitted on [DATE] with diagnoses including acute kidney failure (a condition in which the kidneys suddenly can't filter waste from the blood), prostate cancer and a history of urinary tract infections (UTI- an infection in the bladder/urinary tract). A review of the Quarterly Minimum Data Set (MDS - a resident assessment tool) dated 10/21/2024, indicated Resident 55'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 provide necessary respiratory care services for two of three sampled residents (Resident 21 and Resident 39). 1. Resident 39 the facility failed to administer two liters of oxygen continuously according to physician's order and failed to date the resident's nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen). 2. The facility failed to ensure Resident 21 received the correct therapeutic dose (of oxygen (a colorless, odorless gas that is essential for life and the proper functioning of the body) as ordered by the physician. This deficient practice placed Resident 21 at risk of oxygen poisoning (lung damage that happens from breathing in too much extra (supplemental) oxygen.) and had the potential to cause complications associated with oxygen therapy and negatively impact the Residents 21 and 39's health and well-being. Findings: 1. A review of the admission Record 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 ensure a safe and functioning environment in the resident care area as evidenced by the following: 1. Two occupied resident beds in room [ROOM NUMBER] A and B were observed the mechanical part to lift vertically up and down, to lift the head of bed up and down were not functioning. 2. A maintenance Work Sheet for December 2024 and January 2025 indicated multiple bed remotes and call lights repair requests. 3. Facility staff observed routinely disabling emergency exit alarms located at the corner of Station 1 and 2 on 2nd Floor and Station 3 and 4 on 3rdfloor of resident care areas while utilizing emergency exits. These failures have the potential to put residents at risk for fall and injury, unauthorized person accessing resident care areas, and fire safety risks for residents and staff. Findings: During an initial tour of the facility on 1/11/2025 at 9:05 AM, surveyor observed facility staff accessing emergency exit door at the corner of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Treatment Administration Record (TAR) was accurate and complete for two of two sampled residents (Residents 1 and 2). This failure resulted in an inaccurate and incomplete medical record and had the potential to affect the pressure ulcer/injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) healing. Findings: 1. A review of Resident 1 ' s admission Record dated 12/4/24 indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including dementia (a progressive state of decline in mental abilities), pneumonia (infection in the lungs), cerebral infarction (stroke), atrial fibrillation (Afib—a heart condition that causes an irregular heartbeat), and contractures (shortening of the muscles causing flexing and stiffness of a joint). A review of Resident 1 ' s Minimum Data Set (MDS, a resident assessment tool), dated 10/7/24, indicated Resident 1 had severe memory problems…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 have soap available in soap dispenser in kitchen and the [NAME] failed to perform hand hygiene in between glove change while preparing lunch. These deficient practices placed all residents at the facility at risk of infection due to poor hand hygiene. Findings: On 11/25/2024 the California Department of Public Health (CDPH) received a complaint alleging the facility does not provide soap in dispensers for employees to wash hands and employees do not wash hands while preparing food. During a concurrent observation and interview on 11/26/2024 at 9:15 a.m. the employee handwashing sink was blocked by a large, tall dish rack, the paper towel was hanging from the dispenser above the sink. The Dietary Supervisor (DS) moved the cart from in front of the sink. The survey turned on water, pumped soap dispenser and nothing came out. The DS then opened the dispenser and pulled out the empty bag of soap and replaced it with a new bag. The DS stated, oh we just used the sink this morning . During an observation 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 report an allegation of physical abuse for one of three sampled Residents (Resident 1). This deficient practice left Resident 1 and others at risk for potential abuse. Findings: A review of Resident 1's admission Record indicated the facility admitted this [AGE] year-old male on 10/16/2024 with diagnoses including bilateral primary Osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage of the knee), Hypercalcemia (high calcium in the blood), presence of right artificial knee joint, presence of right artificial hip joint, Hypothyroidism condition in which the thyroid gland does not produce enough thyroid hormone), and Hyperlipidemia high fat in the blood). A review of Resident 1's Minimum Data Set (MDS-a resident assessment tool) dated 10/21/2024, indicated Resident 1's cognition (mental ability to make decisions for daily living) was intact. Resident 1 was independent with toileting, personal hygiene, and transfers…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 keep two of three sampled resident's room free of roaches, (Residents 1 and 3). This deficient practice placed all residents at risk of roach infestation. Findings: A review of Resident 1's admission Record indicated the facility admitted this [AGE] year-old male on 10/16/2024 with diagnoses including bilateral primary Osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage of the knee), Hypercalcemia (high calcium in the blood), presence of right artificial knee joint, presence of right artificial hip joint, Hypothyroidism condition in which the thyroid gland does not produce enough thyroid hormone), and Hyperlipidemia (high fat in the blood). A review of Resident 1's Minimum Data Set (MDS-a resident assessment tool) dated 10/21/2024, indicated Resident 1's cognition (mental ability to make decisions for daily living) was intact. Resident 1 was independent with toileting, personal hygiene, and transfers (moving…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 request for documents was fulfilled in a timely manner for one of three sampled residents (Resident 1) when the facility did not provide the requested documents to Resident 1's representative (RR) within the timeframes specified in the facility's policy and procedures (P&P) titled Release of Information. This deficient practice violated the right of the RR to have access to Resident 1's medical records and the potential to cause undue concern and anxiety on behalf of the resident. Findings: A review of Resident 1's admission Record indicated the facility originally admitted this [AGE] year old female on 4/23/2024 and most recently on 5/30/2024 with diagnoses including aphasia (a disorder that makes it difficult to speak) hemiplegia and hemiparesis (total paralysis of the arm, leg, and trunk on the same side of the body) on the left side after Cerebral Vascula Accident (CVA-stroke, loss of blood flow to a part of the brain), atherosclerotic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident representative (RR) of an accident for one three sampled residents (Resident 1). This deficient practice violated the right of the RR to be informed of the Residents' condition. Findings: A review of Resident 1's admission Record indicated the facility originally admitted this [AGE] year old female on 4/23/2024 and most recently on 5/30/2024 with diagnoses including aphasia (a disorder that makes it difficult to speak) hemiplegia and hemiparesis (total paralysis of the arm, leg, and trunk on the same side of the body) on the left side after Cerebral Vascula Accident (CVA-stroke, loss of blood flow to a part of the brain), atherosclerotic heart disease (hard plaque in vessels surrounding the heart), morbid obesity (overweight), essential hypertension (HTN-high blood pressure), and osteomyelitis (inflammation of bone or bone marrow, usually due to infection). A review of Resident 1's Minimum Data Set (MDS-a federally mandated 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 administer Losartan Potassium (medication used to treat high blood pressure) 25 milligrams (MG) for hypertension (High blood pressure) for one of three sampled residents, Resident 2 as per Physician order dated 9/22/2024. As a result, Resident 2 did not receive Losartan Potassium from 9/22/2024 to 9/25/2024. Placing Resident 2 at risk for elevated blood pressure which could cause a stroke (an emergent condition in which ruptured blood vessels in the brain can bleed due to high blood pressure). Findings: A review of Resident 2 ' s admission record indicated the facility admitted this [AGE] year-old female on 9/22/2024 with diagnoses including Cellulitis, Diabetes Mellitus, Anxiety, Anemia, Dementia, Essential Hypertension, chronic embolism, and thrombosis of DVT. A review of Resident 2 ' s History and physical (H&P- the attending physician ' s physical exam and recommendations) dated 9/23/2024 indicated the resident was alert and oriented…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review for one of four sampled residents (Resident 4), the facility failed to: 1) Ensure Certified Nursing Assistant 5 (CNA 5) immediately reported Resident 4 ' s injuries of unknown origin to the forehead and the left cheek to Licensed Vocational Nurse 6 (LVN 6) when CNA 5 noticed Resident 4 ' s injuries on 8/02/2024. 2) Ensure LVN 1, LVN 2 and LVN 5 immediately notified a physician, Medical Doctor 1 (MD 1), the Director of Nursing 1 (DON 1) and or the Administrator that Resident 4 had injuries of unknown origin to the forehead and the left cheek on 8/02/2024 at 7:05 AM, 8/04/2024 between 4:30 PM and 5 PM, and on 8/04/2-24 at 11 PM. These deficient practices resulted in three days and four hours delay of necessary medical services for Resident 4. Cross Reference F609 Findings: A review of Resident 4 ' s admission Record, indicated Resident 4 was admitted to the facility on [DATE] and was re-admitted on [DATE], with the diagnoses including dehydration (a dangerous loss…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review for one of four sampled residents (Resident 4), the facility failed to ensure: 1) Certified Nursing Assistant 5 (CNA 5) immediately reported Resident 4's injuries of unknown origin to the forehead and the left cheek to Licensed Vocational Nurse 6 (LVN 6) when CNA 5 noticed Resident 4's injuries on 8/02/2024. 2) Licensed Vocational Nurses 1, 2, and 5 (LVN 1, LVN 2 and LVN 5) immediately notified a physician, Medical Doctor 1 (MD 1), the Director of Nursing (DON) and or the Administrator (Admin 1) that Resident 4 had injuries of unknown origin to the forehead and the left cheek on 8/02/2024 at 7:05 AM. These deficient practices resulted in three days and four hours delay of reporting to the officials in accordance with the State law. Cross Reference F600 Findings: A review of Resident 4's admission Record, indicated Resident 4 was admitted to the facility on [DATE] and was re-admitted on [DATE], with the diagnoses including dehydration (a dangerous loss of body…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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. Place call light within reach for one of four sampled residents, (Resident 1). b. To answer call light timely for one of four residents, (Resident 3). c. Ensure call system is functioning for one for four sampled residents, (Resident 4) These deficient practices placed Residents 1, 3, and 4 risk for accidents. Findings: On 6/18/2024 the California Department of Public Health (CDPH) received a complaint alleging Resident 1's call light was not working and was not within Resident 1's reach. A review of Resident 1's Face Sheet indicated the facility originally admitted this [AGE] year-old female on 4/23/2024 and more recently on 5/30/2024. Resident 1 had diagnoses including Gastrointestinal Hemorrhage (bleeding in the stomach and or intestines), Atherosclerotic heart disease of native coronary artery (a condition that causes plaque to form along the walls of the blood vessels in the heart causing them to harden) without angina pectoris…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 reasonable access to a telephone for one of four sampled residents, Resident 1. This deficient practice is a violation of Resident 1's right to access to a telephone. Findings: A review of Resident 1's Face Sheet indicated the facility originally admitted this [AGE] year-old female on 4/23/2024 and more recently on 5/30/2024. Resident 1 had diagnoses including Gastrointestinal Hemorrhage (bleeding in the stomach and or intestines), Atherosclerotic heart disease of native coronary artery (a condition that causes plaque to form along the walls of the blood vessels in the heart causing them to harden) without angina pectoris (chest pain), Aphasia (a language disorder that affects how one communicates caused by damage to the area of the brain that controls speech) following cerebral infarction (occurs as a result of disrupted blood flow to the brain due to the problems with the blood vessels that supply it), hemiplegia and hemiparesis…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 three sampled Certified Nursing Assistants (CNAs) and two sampled Licensed Vocational Nurses (LVNs) had the specific competencies and skill sets necessary to care for one of four sampled residents (Resident 1). This deficient practice resulted in the dislocation of Resident 1's left tibia proximal to the femur. Findings: A review of Resident 1's admission Record indicated the facility initially admitted Resident 1 on 9/27/2018 and readmitted Resident 1 on 7/16/2019 with diagnoses senile degeneration of brain (a decrease in the ability to think, concentrate, or remember) bilateral (two sided) primary osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down over time) of knee, and osteoporosis without current pathological fracture (bones become fragile and more likely to break). A review of Resident 1's History and Physical (H&P -most formal and completed assessment of the patient and the problem) dated 1/27/2023,…

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 apply non-rebreathing oxygen mask (NRM- a mask with a small bag (reservoir bag) attached that fills with oxygen when connected to a tank and delivers high flow oxygen, usually in an emergent situation) with the correct amount of oxygen for two of three sampled residents, (Residents 1 and 3). This deficient practice had the potential to have caused Residents 1 and 3 to be deprived of oxygen in an emergent situation and lead to a complaint being filed with the California Department of Public Health (CDPH). Findings: A review of resident 1 ' s Face Sheet indicated the facility admitted this [AGE] year-old female on 3/31/2024 with diagnoses including Pressure ulcer of the sacrum stage 4 (full thickness tissue loss with exposed bone, tendon or muscle on the lower back), Essential Hypertension (high blood pressure), Dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to display appropriate transmission-based precaution sign and follow appropriate transmission-based precautions, for one of three sampled residents, (Resident 2) These deficient practices had the potential to place residents, staff and visitors at potential risk of spread of infection. Findings: A review of Resident 2 ' s Face Sheet indicated the facility originally admitted this [AGE] year old female on 2/9/2024, more recently on 3/5/2024 with diagnoses including Pressure ulcer of the sacrum stage 4 (full thickness tissue loss with exposed bone, tendon or muscle on the lower back), Essential Hypertension (high blood pressure), 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), functional quadriplegia (paralysis of all four limbs), Urinary [NAME] Infection (UTI- infection in any part…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 dressing change to stage 4 pressure ulcer of the sacrum (full thickness tissue loss with exposed bone, tendon, or muscle on the lower back) as per physician order for one of three sampled residents, Resident 2. This deficient practice placed Resident 2 at risk of decline in wound healing and possible infection. Findings: A review of Resident 2 ' s Face Sheet indicated the facility originally admitted this [AGE] year old female on 2/9/2024, more recently on 3/5/2024 with diagnoses including Pressure ulcer of the sacrum stage 4 (full thickness tissue loss with exposed bone, tendon or muscle on the lower back), Essential Hypertension (high blood pressure), 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), functional quadriplegia (paralysis of all four limbs), Urinary [NAME]…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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) had home health services arranged for the resident when discharged to a board and care (small private facility, usually with 20 or fewer residents where residents receive personal care and meals while staff is available around the clock). This failure resulted in Resident 1 not receiving ordered home health services during the days Resident 1 was at the board and care. Findings: A review of Resident 1 ' s Face Sheet (a document with a summary of patient information), undated, indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses including: cardiomyopathy (disease of the heart muscle), chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breath), diabetes mellitus type two (a condition were your body has trouble controlling the level of sugar in the blood), hypertension (high blood pressure), and adult failure to thrive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to meet professional standards of care and practice for one of three sampled residents (Resident 1) by failing to: 1. Ensure an orthopedic (specialty in medicine concerned with the correction or prevention of deformities [alteration in the natural form of a part, organ, or the entire body], disorders or injuries of the skeleton) appointment for Resident 1 ' s right ankle dislocation was ordered and scheduled within seven days per General Acute Hospital (GACH ' s) discharge summary when Resident 1 was admitted to the facility on [DATE]. 2. Ensure a physician order and proper documentation when Resident 1 ' s right leg medical device was removed on 12/21/2023. 3. Ensure physician treatment orders were signed via treatment administration record (TAR). These deficient practices resulted in 24 days orthopedic appointment follow delay for follow up for Resident 1 and had the potential to negatively impact the delivery of required/necessary care services 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 interview, and record review, the facility failed to maintain accurate medical record in accordance with accepted professional standards and practices for one of six sampled residents (Resident 1) by failing to: 1. Obtain a physician order to remove Resident 1 ' s right leg short leg splint (SLS). 2. Document that Resident 1 ' s right leg short leg splint (SLS) facility removed on 12/21/2023. 2. Sign Resident 1 ' s treatment administration record (TAR) after completing physician treatment orders 3. Ensure Resident 1 and or responsible person consented to treatment. These deficient practices had the potential to negatively impact the delivery of service provided to Resident 1. Cross Reference F658 Findings: 1. A review of Resident 1 ' s face sheet, indicated that Resident 1 was admitted to the facility on [DATE], with diagnoses including dislocation of right ankle joint, syncope (fainting or passing out) and osteoporosis (a condition in which bones become weak and brittle). 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 interview and record review, the facility failed to ensure prompt attempt was made to resolve grievances for one of five sampled resident (Resident 1). This deficient practice violated Resident 1 ' s responsible party (R1 RP ' s) right to have grievances addressed. Findings: A review of Resident 1 ' s face sheet, indicated that Resident 1 was admitted to the facility on [DATE], with diagnoses including dislocation of right ankle joint, syncope (fainting or passing out) and osteoporosis (a condition in which bones become weak and brittle). A review of Resident 1's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool), dated 12/21/2023, indicated Resident 1 has intact cognition (mental action or process of acquiring knowledge and understanding) for daily decision-making and requiring moderate assistance from staff for activities of daily living (ADL- bed mobility, surface transfer, eating, walk in room, dressing, toileting, and personal hygiene). Resident 1 also…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 meets the care/services based on resident ' s individual assessed needs for one of six sampled residents (Resident 1) by failing to ensure Resident 1 ' s right short leg splint (SLS-provide support and stabilize injuries in legs, ankle and foot) care plan was developed and implemented per facility policy. This deficient practice resulted in Resident 1 ' s unstageable pressure-induced tissue damage (full thickness pressure injuries in which the base is covered by slough/eschar [dead tissues]) of the right foot related to a medical device (SLS). Findings: A review of Resident 1 ' s face sheet, indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including dislocation of right ankle joint, syncope (fainting or passing out) and osteoporosis (a condition in which bones become weak and brittle). A review of Resident 1's Minimum Data Set (MDS - a comprehensive standardized 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 During an interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), received the treatment and care in accordance with professional standards of practice, related to pain prevention and management by failing to ensure that Resident 1 ' s right soft leg splint (SLS-provide support and stabilize injuries in legs, ankle and foot) pain was addressed and treated for any underlying causes of the right leg pain. This deficient practice resulted in Resident 1 ' s right foot medical device related, unstageable pressure-induced tissue damage (full thickness pressure injuries in which the base is covered by slough/eschar [dead tissues]). Resident 1 was also started an antibiotic (medication to treat bacteria) therapy for the right foot wound cellulitis (bacterial skin infection). Cross Reference (F656, F686) Findings: A review of Resident 1 ' s Face Sheet, indicated that Resident 1 was admitted to the facility on [DATE], with diagnoses including dislocation of right ankle…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 prompt notify the physician about diet modification changes for one of three sampled residents (Resident 1) per facility ' s policy titled Interdisciplinary Referral. This deficient practice had the potential for Resident 1 to aspirate (choked) on the provided mechanical soft diet (A mechanical soft diet consists of any foods that can be blended, mashed, pureed, or chopped using a kitchen tool such as a knife, a grinder, a blender, or a food processor) instead of the recommended puree diet (foods you don't need to chew, such as mashed potatoes and pudding. Food can also be can also blended or strained to make them smoother. Liquids such as broth, milk, juice, or water may be added to foods to make them easier to swallow). Findings: A review of the admission record (Facesheet) indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included, Cachexia (weakness and wasting of…

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

Based on observations, interviews, and record review the facility failed to ensure kitchen staff were trained and evaluated for competency skills as followed: a. Two (2) of 2 staff (Diet Aide (DA) 1 and DA2) and were not able to verbalize proper dishwashing procedures. b. One (1) of 1 staff (Cook 1) was not following the manufacturer's guidelines when checking the Quaternary Ammonium Compounds (QAC's a type of chemical that is used to kill bacteria, viruses, and mold) sanitizer concentration (levels should be maintained from 200-400 parts per million [ppm] for various food-contact surfaces) as per facility policy indicating to submerge the test strip for 10 seconds. These failures had a potential to result in cross-contamination (a transfer of bacteria from one object to another), ineffective dish washing, and unsanitized food preparation areas that could lead to food borne illness (an illness caused by contaminated food and beverages) in 93 of 93 medically compromised residents who received food and ice from the kitchen. Placing all 93 facility residents at risk for serious…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and sanitary food storage and food preparation practices in the facility's kitchen, by failing to: 1. Safely store, label, and discard expired food: a. Refrigerated food not labeled correctly and expired food was found in the walk-in refrigerator, resident's refrigerator in the second (2nd) floor Station 1 and resident's refrigerator in third (3rd) floor Station four (4). b. Uncovered four cups of ice in the resident's refrigerator in 3rd floor Station 4. 2. Ensure kitchen environment, equipment, servicing supplies, and utilities were in good repair, functioning, and kept clean. a. The facility's kitchen refrigerator had reach-in shelves and undercounter refrigerator shelves were cracked and rusted. b. There was no hot water in the kitchen. c. The food weighing scale (a device to measure weight of ingredients and foods) used in tray line (an area for tray and food assembly) had dust and dirt debris. d. The tray line roof top in the kitchen had black and amber dirt residue and build up. e. 39 of 63…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the kitchen ice machine, the second (2nd) floor ice machine and the third (3rd) floor ice machine in a safe operating condition when staff made their own ice for resident's use and stored the ice in uncovered cups in the resident's freezer. This deficient practice had the potential to result in contamination of ice that could lead to foodborne illness in 93 of 93 medically compromised residents who received food from the kitchen. Findings: During an observation of the ice machine in the kitchen on 1/23/2024 at 2:23 PM, and a concurrent interview with staff, the ice machine was off and empty. Kitchen staff stated the ice machine was broken since yesterday (1/22/24). During an interview with [NAME] 1 on 1/23/2024 at 2:38 PM, [NAME] 1 stated the ice machine was broken since Friday and the technician had tried to fix it. [NAME] 1 stated the facility bought ice and ice was stored in the walk-in freezer. During an observation of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to sit down at eye level while feeding during lunch for two of two sampled residents, (Residents 37 and 57). This deficient practice had the potential to cause aspiration (sucking food into an airway causing choking) by missing resident cues (signs that resident still has food in mouth or choking) due to not being eye level for Residents 37 and 57. Findings: A. A review of Resident 37's Face Sheet indicated Resident 37 was initially admitted to the facility on [DATE] and was readmitted at 9/20/2023 with diagnoses including chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should), essential hypertension (high blood pressure - HTN) and hyperlipidemia (elevated level of fats in the blood). A review of Resident 37's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 12/22/2023, indicated Resident 37's cognition (the mental ability to make decisions of 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 observation, interview and record review the facility failed to order low air loss (LAL - A mattress designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown) mattress for one of one sampled resident (Resident 16) with a re-opened stage 4 sacral coccyx (A large flat bone in the lower part of the spine) pressure ulcer (Localized skin and soft tissue injuries that form as a result of prolonged pressure and shear, usually exerted over bony prominences). This deficient practice may have caused sacral coccyx stage 4 pressure ulcer to worsen for Resident 16. Findings: A review of Resident 16's face sheet indicated the facility originally admitted this [AGE] year-old female on 1/18/2020 and most recently on 4/26/2023 with diagnoses including metabolic encephalopathy (chemical imbalance in the brain causing confusion), urinary tract infection (infection in any part of the urinary system), diabetes mellitus, pressure ulcer of the sacral region unstageable healed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain a medication error rate of less than 5 % (percent) during medication pass for 2 of 13 sampled residents (Resident 51 and Resident 249). This deficient practice had the potential to lead to a worsening in medical conditions, hospitalization and/or death. Findings: A. A review of Resident 51's face sheet indicated the facility originally admitted this [AGE] year-old male on 4/2/2019 and most recently on 1/3/2024 with diagnoses including acute kidney failure (a condition in which the kidneys suddenly can't filter waste from the blood), acute embolism and thrombosis of unspecified deep vein of unspecified lower extremity (a blood clot forms in one of the deep veins of the legs), peripheral vascular disease (the reduced circulation of blood to a body part other than the brain or heart), Schizoaffective disorder (a mental health disorder with symptoms of hallucinations, delusions, and mood disorder), Hyperlipidemia (high levels of fat…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 professional standards of practice for safe medication storage, medication ordering, and medication receiving by failing to: a. to check the expiration date of the emergency kit (e-kit - secured container or secured electronic system containing drugs which are used for either immediate administration to residents or in an emergency or as a starter dose). b. To sign for delivery receipt of oral pills in the e-kit. These deficient practices could have caused the medications contained inside of the e-kit to lose their potency (strength) and not be effective and inaccurate records of emergency pills on hand, resulting in missed doses, or lack of emergency medications. Finding: a. During an observation of the medication storage room on the 2nd floor on 1/25/2024 at 7:34 a.m., an e-kit containing 2 vials of Narcan (medication used to reverse opioid overdose), 4 vials of Ondansetron (medication used to stop nausea and vomiting), 2 vials of promethazine (medication used to treat allergies), 1 vial of Solumedrol…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 prepare food by methods that conserved flavor and appearance. This deficient practice placed 74 of 74 facility residents on regular (diet with no restrictions) and soft mechanical (chopped foods) texture diets and 19 of 19 facility residents on puree diet (blended to a smoothie like consistency) at risk of not consuming adequate calories, and carbohydrates causing unplanned weight loss, a consequence of poor food intake, getting food from the kitchen. Findings: A review of the facility's winter menu spreadsheets dated 2023, indicated regular texture diet received parsley rice ½ cup (c) and puree diet (diet with smooth pudding like consistency) received puree bread 1 each. During an observation of tray line (an area for food assembly) lunch service of the puree bread on 1/23/2024 at 12:26 PM, the puree bread was dried out on the steam table. During a test tray conducted with the Dietary Supervisor (DS) on 1/23/2024 at 12:35 PM for regular diet, rice with parsley was undercooked. DS stated the rice needed a bit…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the call light was answered in a timely manner for three (3) of eight (8) sampled residents (Resident 62, 44, and 84). This deficient practice had the potential to result in delay in meeting the residents' needs for assistance which could lead to accidents such as falls. Findings: 1. A review of Resident 62's admission record indicated Resident 62 was re-admitted to the facility on [DATE], with diagnoses including but not limited to fracture of right femur (a break in the thigh bone), contusion of right thigh (is the result of a severe impact to the thigh which consequently compresses against the hard surface of the femur). A review of Resident 62's History and Physical dated 8/28/23, indicated Resident 62 had decision making capacity. A review of Resident 62's Minimum Data Set (MDS- a comprehensive assessment and screening tool) dated 11/29/2023, indicated Resident 62's cognitive (relating to thinking, remembering, and reasoning)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 about advance directives (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) for three of six sampled residents (Residents 249, 69, and 32) by failing to maintain a current copy of the resident's advance directives in the resident's clinical record. This failure resulted in or had the potential to cause conflict with a resident's wishes regarding health care for Residents 249, 69, and 32. Findings: A review of Resident 249's admission record, indicated Resident 249 was admitted to the facility (skilled nursing facility - SNF) on 1/13/2024 with diagnoses that included Cellulitis, (A common skin infection) of the left upper limb, muscle weakness (a lack of physical or muscle strength, throughout the body), and osteoporosis (A condition that causes pain and stiffness, especially in 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 observations, interviews, and record reviews, the facility failed to protect the privacy of personal and medical information of two of the 20 residents (Residents 91 and 300) by having residents' personal and medical information exposed prior to logging out of the computer. This deficiency violated the rights of residents to personal privacy and confidentiality of personal and medical information for Residents 91 and 300. Findings: A review of Resident 91's face sheet (background information; a document containing demographic and diagnostic information) indicated Resident 91 was admitted to the facility on [DATE]. Resident 91 had diagnoses of protein-calorie malnutrition (not enough protein [animal and plant foods] and calories [energy from food] consumed into the body), hyperlipidemia (high cholesterol [fat] in the body), visual disturbances (changes in eyesight that interferes with the ability to see clearly and comfortably), hypertension (HTN- high blood pressure), and osteoarthritis (when 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 complete quarterly fall risk assessment for one of two sampled residents (Resident 16). This deficient practice caused noncompliance with assessment requirements for Resident 16. Findings: A review of Resident 16's face sheet indicated the facility originally admitted Resident 16 on 1/18/2020 and most recently on 4/26/2023 with diagnoses including metabolic encephalopathy (chemical imbalance in the brain causing confusion), urinary tract infection (UTI - infection in any part of the urinary system), diabetes mellitus, pressure ulcer of the sacral region unstageable healed (skin breakdown as a result of prolonged pressure on a bony part of the body), hypertension (HTN - high blood pressure), dementia (a progressive loss of intellectual functioning), seizures, hyperlipidemia (high fat in the blood), bipolar disorder (mental illness characterized by high moods and low moods), anemia (low red blood cells), and gastro esophageal reflux disease (GERD -stomach acid irritated food pipe). A review of Resident 16's Minimum Data Set…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to pre-admission screening and resident review Preadmission Screening and Resident Review (PASARR - Patient screening prior to admission, to determine if the person has, or is suspected of having, a mental illness, intellectual) program under Medicaid in subpart C of this part to the maximum extent practicable to avoid duplicative testing and effort for two of eight sampled residents (Residents 2 and 23) This deficient practice placed the residents at risk of not receiving necessary care and services they need for Residents 2 and 23. Findings: During a review of Resident 2's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses not limited to major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), schizoaffective disorder (a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 update activity of daily living (ADL) care plan for one of one sampled resident, Resident (57). This deficient practice may have caused staff to be unknowledgeable about Resident 57's level of assistance for feeding subsequently causing Resident 57 to waste food with the potential of losing weight. Findings: A review of Resident 57's face sheet indicated the facility originally admitted Resident 57 on 8/29/2017 and more recently on 5/3/2023 with diagnoses including Alzheimer's disease (a progressive disease beginning with mild memory loss and possible leading to loss of ability to carry on conversation and respond to the environment), Hypothyroidism (abnormally low activity of the thyroid), Hyperlipidemia and Hypertension. A review of Resident 57's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 12/15/2023, indicated Resident 57's cognition (Mental ability to make decisions of daily living) was not intact. Resident 57 required supervision or touch assistance (Helper provides verbal cues and…

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

Based on observation, interview, and record review, the facility failed to maintain safe and functional toilets for two (2) of eight (8) resident bathrooms and wheelchair armrests for Residents 2 and 66. This deficient practice had the potential to place residents and staff at risk for accidents with injury. Cross reference F921 Findings: During an observation in the hallway on 01/24/2024 at 10:30 a.m., bilateral armrests of wheelchairs were observed loose and secured with torn and worn-out tape for Resident 66 and 2. During an interview on 01/24/2024 10:38 a.m., Resident 2 stated that he had asked the facility's maintenance for months to fix the broken armrests to his wheelchair so that he would not get hurt while wheeling himself around. During an interview on 01/24/2024 10:50 a.m., Resident 66 stated he got tired of wheeling himself around in the facility with a broken wheelchair armrest. Resident 66 stated he had told the facility's former social worker and the previous maintenance supervisor about the issue with his wheelchair armrest. Resident 66 stated the facility did not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that the facility's Interim Director of Nursing (IDON) had appropriate competency and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of all 96 residents in the facility. This deficeint practice had the potential to place all 96 residents at risk of an adverse outcome to a resident's care or services. Cross Reference: F644, F730, and F919. Findings: During an interview on 01/26/24 10:20 a.m., the IDON stated he has been employed with the facility for 3 weeks as IDON. The IDON stated he has never had any training or obtained any certificates of completion as a Director Of Nursing (DON). The IDON further stated he do not know what a PASSR [Preadmission Screening and Resident Review (is guided by federal regulations that require all individuals being considered for admission to a Medicaid-certified nursing facility be screened…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 maintain documentation of state certification for three out of three sampled certified nurse aids (CNA: CNA 5, CNA 6, and CNA 7). This deficient practice had the potential to lead to inadequate care and a delay resident's care. Findings: During an interview on 01/26/24 10:06 a.m., CNA1 had been employed with a staffing registry (staffing agency for healthcare workers) for two years and had been assigned at the facility for 5 months. CNA1 stated she (CNA1) was not asked by the facility for verification of state certification. During an interview on 01/25/24 11:56 a.m., the Director of Staff Development (DSD) had been the DSD for the facility for 3 years. The DSD did not have a complete employee file (required documentation for each employee of the facility which includes, background check, license, annual performance evaluations, and competencies) for CNA1. The DSD stated CNA 1 was from a staffing registry. The DSD did not have documentation of state certification for any of the registry staff. The DSD did not have 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 three out of three sampled certified nurse aids (CNA: CNA 5, CNA 6, and CNA 7) had annual performance evaluations and competency verifications needed to provide care and services to all 96 facility residents. This deficient practice had the potential to lead to inadequate care and a delay resident's care. Findings: During an interview on 01/26/24 10:06 a.m., CNA1 had been employed with a staffing registry (staffign agency for healthcare workers) for two years and had been assigned at the facility for 5 months. CNA1 stated she (CNA1) not had an annual performance evaluation or in-services from the Registry or the facility since being hired by the registry two years prior. CNA1 did not know what an in-service was. During an interview on 01/25/24 11:56 a.m., the Director of Staff Development (DSD) had been the DSD for the facility for 3 years. The DSD did not have a complete employee file (required documentation for each employee of the facility which includes, background check, license, annual performance evaluations,…

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

Based on interview and record review, the facility failed to ensure that the person functioning as the social worker in the facility met the qualifications required to be employed as a full-time social worker at the facility, which had 144 licensed beds. This deficient practice had the potential for the resident's social service needs not being identified and provided. Findings: During an interview on 1/25/24 at 9:45p.m., Social worker (SW) stated that she was transferred back to this facility to work as the social worker, until a permanent replacement was hired. The SW stated that she had been on duty at the facility as acting social worker for a week and half, working 40 hours a week. The SW stated that she had attended a Social Service Designee Course and the completion of the course was her qualification for doing this job. The SW also stated that she did not have a bachelor's or a master's degree in any discipline. During an interview on 1/25/24 at 11:23 a.m., the administrator (ADM) stated the facility has 144 licensed beds. The ADM stated that he was in the process of hiring…

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

Based on observation, interview, and record review, the facility failed to maintain safe and functional toilets for two (2) of eight (8) resident bathrooms and wheelchair armrests for Residents 2 and 66. This deficient practice had the potential to place residents and staff at risk for accidents with injury. Cross reference F689 Findings: During an observation in the hallway on 01/24/2024 at 10:30 a.m., bilateral armrests of wheelchairs were observed loose and secured with torn and worn-out tape for Resident 66 and 2. During an interview on 01/24/2024 10:38 a.m., Resident 2 stated that he had asked the facility's maintenance for months to fix the broken armrests to his wheelchair so that he would not get hurt while wheeling himself around. During an interview on 01/24/2024 10:50 a.m., Resident 66 stated he got tired of wheeling himself around in the facility with a broken wheelchair armrest. Resident 66 stated he had told the facility's former social worker and the previous maintenance supervisor about the issue with his wheelchair armrest. Resident 66 stated the facility did not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide nutritional care and services to two of three sampled residents (Resident 1 and 2) by failing to: 1. Ensure implementation and modification of interventions consistent with Resident 1 and 2's needs and goals per registered dietitian (RD) recommendations when weekly weights were ordered for monitoring on 12/21/2023. 2. Ensure recording of weights for Residents 1 and 2 were properly documented. This deficient practice placed Resident 1 and at risk for possible weight loss. Findings: 1a. A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including breast cancer (a disease in which abnormal cells divide uncontrollably and destroy body tissue), generalized weakness and congestive heart failure (CHF-a chronic condition in which the heart does not pump blood as well as it should). A review of Resident 1's Minimum Data Set (MDS - a comprehensive standardized assessment and…

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

Based on observation, interview and record review, the facility failed to maintain an infection control measure and prevention program by failing to: 1. Ensure staff N95 (filtering facepiece respirator) fit testing (test used for proper respirator fit) log record was updated. 2. Ensure one of five sampled staff (Licensed Vocational Nurse 1-LVN 1) was wearing proper fit tested N95 mask when entering a COVID-19 (Coronavirus- a deadly respiratory disease transmitted from person to person) isolation room. These deficient practices had the potential to result in the spread of disease and infection to residents and staff. Findings: 1. During a concurrent interview and record review with the Infection Preventionist Nurse (IPN) on 1/10/2024 at 2:57 p.m., IPN stated and verified missing N95 fit testing log record on the previous 2022-2023 year. IPN stated that the facility was unable to find the last N95 fit testing that was completed for the past two years. IPN stated that staff should know what they were N95 fit tested from the last time. IPN also stated importance of wearing proper N95…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 access and document medication administration using a secured device to protect Resident privacy by allowing licensed nurses to use their personal laptops for documentation of medication administration. These deficient practices placed all 104 facility residents at risk for having their confidential information accessed and shared with unauthorized people and/or entities. Findings: During an interview with Licensed Vocational Nurse (LVN 6) on 12/30/23 at 7:15 p.m., LVN stated that she (LVN 6) did not have a laptop for medication cart 2 which was not new for the facility. LVN 6 stated that the facility had been encouraging staff to bring in their personal laptops whenever staff complained about insufficient laptops. LVN 6 stated that many LVNs brought in and used their personal laptops for medication administration documentation. During a concurrent observation and interview with LVN 11 on 12/30/23 at 7:39 p.m., LVN 11 was observed with a laptop that was not labelled with the facility name. LVN 11 confirmed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interviews, and records review, the facility failed to ensure six of eight staff, Registered Nurse 4 (RN 4), Licensed Vocational Nurses 2, 4, 11, and 14 (LVNs 2, 4, 11, and 14) and Certified Nurse Aides 9 and 10 (CNAs 9 and 10), were competent (a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully) and had the skills set to perform Cardiopulmonary Resuscitation (CPR - a lifesaving emergency procedure performed when a person breathing and/or heart stops) correctly during a medical emergency. This failure had the potential for facility staff to perform ineffective CPR which could result in death for a resident found unresponsive, not breathing and pulseless (no heartbeat). Findings: A review of LVN 14 employee file, indicated, on [DATE] , LVN 14 was certified (officially recognized as possessing qualifications) in CPR. A review of RN 4's employee file, indicated 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 interviews, and record reviews the facility failed to implement abuse policy and procedure when the facility did not report to the State Agency or law enforcement of the alleged abuse between three residents (Resident 1, 2, and 3). This deficient practice resulted in Resident 1 and Resident 2 exposed to continuous verbal and mental abuse from Resident 3 causing mental anguish and emotional distress. Cross Reference: F600, F610. F689, F645, F740 Findings a. A review of Resident 1's admission record indicated the resident was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes (a disease characterized by high levels of sugar in the blood), hyperlipidemia (a condition in which there are high levels of fat particles in the blood), hypertension (high blood pressure) cerebral infarction (a disrupted blood flow and oxygen to the brain due to problems with the blood vessels that supply it), and hemiplegia (paralysis that affects only ones 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 investigated allegations of ongoing resident-to-resident abuse for three of three residents (Resident 1, 2, and 3). This deficient practice resulting in Resident 1 and Resident 2 continuously being abuse. Cross Reference: F600, F609, F689, F645, F740 Findings a. A review of Resident 1's admission record indicated the resident was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes (a disease characterized by high levels of sugar in the blood), hyperlipidemia (a condition in which there are high levels of fat particles in the blood), hypertension (high blood pressure) cerebral infarction (a disrupted blood flow and oxygen to the brain due to problems with the blood vessels that supply it), and hemiplegia (paralysis that affects only ones side of the body) and hemiparesis (weakness or inability to move one side of the body) affecting the left non-dominant side. A review of Resident 1's history and physical (H&P)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 conduct Preadmission Screening and Resident Review Level 1 (PASRR1- a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care), reevaluate it and notify the appropriate state mental health authority after a significant change in the resident's mental condition for one of one sampled resident (Resident 3). This deficient practice resulted in Resident 3 not receiving specialized mental health services to manage the resident's behaviors including harassing and threatening other residents and staff. Cross References: F689, F600, F609, F610, F740 Findings: A review of Resident 3's admission record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses that included schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 care, assistance, and supervision needed to ensure an environment free of risks and hazards for one out of one sampled resident (Resident 1), by failing to provide supervision and assistance with ambulation, and respond to the resident's calls for assistance in a timely manner. These deficient practices resulted in Resident 1 falling on 11/30/2023 resulting in a lumbar (lower back) fracture. Cross Reference: F600, F609, F610, F919 Findings: A review of Review of Resident 1's face sheet indicated the facility admitted the resident on 4/11/2023 with diagnoses that included Type 2 diabetes (an impairment in the way the body regulates and uses glucose [sugar] as a fuel), stroke, and hemiplegia and hemiparesis of the left side (loss of strength and use in the arm, leg, and sometimes the face on one side of the body). The face sheet indicated the facility readmitted the resident on 12/07/2023 with a new diagnosis of lumbar fracture. A review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of one sampled resident (Resident 3) was provided necessary behavioral health care and services for the treatment of Resident 3's displays of verbal and physical aggression towards others by ensuring: 1. Ensure Resident 3 was properly assessed after displaying a significant change in mental condition. 2. Review and revise Resident 3's Behavioral health care plan after the resident displayed behavioral changes (verbal and physical). 3. Ensure facility residents and staff (general) did not experience Resident's 3's aggressive behavior, verbal and physical threats when using a shared bathroom. This deficient practice denied Resident 3 of the care and services needed to achieve the highest practicable physical, mental, and psychological wellbeing and placed. Cross Reference: F600, F609, F610, F645, F689 Findings: a. A review of Resident 3's admission record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, for one of three sampled residents (Resident 14), the facility failed to ensure Resident 14 received scheduled medications in accordance with physician's orders. As a result, Resident 14 did not receive scheduled medications on 2/16/2924 which placed Resident 14 at increased risk for repeat medication error, hospitalization, and/or death. Findings: A review of Resident 14's face sheet indicated the facility admitted the resident on 1/31/2024 with diagnoses that included chronic obstructive pulmonary disease (COPD- an ongoing lung disease that causes obstruction of airflow from the lungs making it difficult to breathe), atrial fibrillation (A-Fib an irregular and often very rapid heartbeat) and transient ischemic attack (TIA- a mini stroke when there is a temporary disruption in the blood supply to part of the brain). A review of Resident 14's Minimum Data Set (MDS- standardized assessment and care screening tool) dated 12/12/2023, indicated the resident had moderately cognitive (the mental ability to make decisions of 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 observation, interviews, and record reviews the facility failed to ensure one of four medication carts (Med Cart 2) remained locked, secured, and not left unattended per facility's policy and procedures. This deficient practice had the potential for unauthorized person to access medications in Med Cart 2, diversion of medication, and consumption of the medications by unintended person with the potential to result in undesired outcome including death. Findings: During an observation on the second floor and concurrent interview on 2/16/24 at 4:20 p.m., two surveyors observed Med Cart 2 unattended, and drawers left open exposing several medications in bubble packs. Licensed vocational nurse 15 (LVN 15) was observed in a room with another resident. LVN 15 confirmed and stated that Med Cart 2 was left open and unattended. LVN 15 stated Med Carts must always be locked to prevent other residents or families from accessing the medications in the cart. During a concurrent observation and interview with director of nursing (DON) on 2/16/24 at 4:25 p.m., DON confirmed and stated Med…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop and implement a comprehensive care plan that met the care/services based on the resident's individual assessed needs for two of six sampled residents (Resident 4 and Resident 5) by failing to: 1. Develop a comprehensive care plan for Resident 4 who was on oxygen therapy. 2. Develop a comprehensive care plan for Resident 5's an indwelling urinary catheter (foley catheter - a hollow tube left implanted in a body canal or organ, especially the bladder, to promote drainage) These deficient practices had the potential to result negative impact on residents' health and safety, as well as the quality of care and services received. Findings: A. A review of the Face Sheet indicated Resident 4 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including acute and chronic respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide), hemiplegia and hemiparesis (loss…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a resident received appropriate treatment and services to prevent urinary tract infections (UTI-an infection in any part of your urinary system your kidneys, ureters, bladder and urethra) for one of one sampled resident (Resident 5) by: 1. Failing to assess Resident 5 who had an indwelling urinary catheter (foley catheter - a hollow tube left implanted in a body canal or organ, especially the bladder, to promote drainage) and document sediments (visible particles in the urine that can be made up of a variety of substances, including sloughing of tissue (debris). The most common cause of sediment in the urine is a UTI. 2. Failing to notify the physician of sediments in Resident 5's urine. As a result, Resident 5 was placed at risk for a delay in necessary care and services to treat a possible UTI. Findings: A review of the Face Sheet indicated Resident 5 was admitted to the facility on [DATE], with diagnoses including type II…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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. Provide necessary respiratory care services for one out of one sampled resident (Resident 4) by failing to ensure the nasal cannula (NC -a connector attached to oxygen) tubing and humidifier (a device used to make supplemental oxygen moist) was changed per policy. 2. Ensure a physician's order are in place for oxygen therapy. These deficient practices had the potential for the residents to develop respiratory infection. Findings: A review of the Face Sheet indicated Resident 4 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including acute and chronic respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide), 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 atrial fibrillation…

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

Based on observation, interview and record review, the facility failed to maintain an infection control measure and prevention by failing to 1. Ensure one of one sampled facility staff, Housekeeping 1 (HS 1) wear the required personal protective equipment of an N95 respirator (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) while cleaning resident's room. 2. Ensure one of two sampled facility staffs, Licensed Vocational Nurse 2 (LVN 2) wear the required eye protection/goggles as a PPE while providing care to residents. These deficient practices had the potential to result in the spread of disease and infection to residents and staff. Findings: A. During an observation tour of the facility on 12/12/2023 at 11:08 A.M., observed HS 1 cleaning residents' room and wearing a surgical mask (a type of face mask). During an interview with HS 1 on 12/12/2023 at 11:13 a.m., HS 1 stated, she forgot to wear an N95 respirator. HS 1 stated, she is aware that the facility was currently on a COVID-19 (an infectious…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 seven sampled residents (Residents 2 and 10) by failing to ensure facility staff introduced self-prior to entering the residents ' rooms. This deficient practice had the potential to cause psychosocial harm to the resident and can violate resident ' s right to be treated with dignity and respect. Findings: 1. A review of Resident 2 ' s admission Record indicated Resident 2 was originally admitted to the facility on [DATE], and was re-admitted on [DATE], with diagnoses including chronic obstructive pulmonary disease (COPD-group of lung diseases that block airflow and make it difficult to breathe), congestive heart failure (CHF-a chronic condition in which the heart does not pump blood as well as it should) and atrial fibrillation (AF-an irregular rapid heart rate that commonly causes poor blood flow). A review of Resident 2's Minimum Data Set (MDS…

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

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 practice for two of two sampled residents (Residents 6 and 8) by failing to ensure physician order for wound care treatment was checked via treatment administration record (TAR) before providing wound care treatment to Residents 6 and 8. This deficient practice had the potential to negatively impact the delivery of service given to Residents 6 and 8. Findings: 1. A review of Resident 6 ' s admission Record indicated Resident 6 was admitted to the facility on [DATE], with diagnoses including cellulitis (bacterial skin infection) of right toe, dorsalgia (type of back pain) and depression (a mood disorder that causes persistent feeling of sadness and loss of interest). A review of Resident 6's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool), dated 9/30/2023, indicated Resident 6 was moderately impaired in cognition (mental action or process of acquiring knowledge and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure resident environment remains as free of accident hazards as possible and to provide adequate supervision to prevent accidents for one of one sampled resident (Resident 6) by failing to ensure Resident 6 ' s diclofenac 1 percent (%) cream (medication that reduces pain and inflammation), visine eye drops (medication that treats eye symptoms such as redness, itching and allergies) and Benadryl extra strength (ES) cream (medication that treat itchy skin, rash and pain) were left unattended in Resident 6 ' s bedside table tray. This deficient practice had the potential to compromise Resident 6 ' s safety when being administered inappropriately. Findings: A review of Resident 6 ' s admission Record indicated Resident 6 was admitted to the facility on [DATE], with diagnoses including cellulitis (bacterial skin infection) of right toe, dorsalgia (type of back pain) and depression (a mood disorder that causes persistent feeling of sadness…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 proper storage of medications to one of one sampled resident (Resident 6). Resident 6 had diclofenac 1 percent (%) cream (medication that reduces pain and inflammation), visine eye drops (medication that treats eye symptoms such as redness, itching and allergies) and Benadryl extra strength (ES) cream (medication that treat itchy skin, rash and pain) in Resident 6 ' s bedside table tray. This deficient practice had the potential to compromise Resident 6 ' s safety when being administered inappropriately. Findings: A review of Resident 6 ' s admission Record indicated Resident 6 was admitted to the facility on [DATE], with diagnoses including cellulitis (bacterial skin infection) of right toe, dorsalgia (type of back pain) and depression (a mood disorder that causes persistent feeling of sadness and loss of interest). A review of Resident 6's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain accurate medical record in accordance with accepted professional standards and practices for two of two sampled residents (Resident 6 and 8) by failing to ensure accurate documentation of wound care treatment in Resident 6 and 8 ' s treatment administration records (TARs) when Treatment Nurse (TN) documented wound care treatment first before providing care to Residents 6 and 8. This deficient practice had the potential to negatively impact the delivery of service given to Residents 6 and 8. Findings: 1. A review of Resident 6 ' s admission Record indicated Resident 6 was admitted to the facility on [DATE], with diagnoses including cellulitis (bacterial skin infection) of right toe, dorsalgia (type of back pain) and depression (a mood disorder that causes persistent feeling of sadness and loss of interest). A review of Resident 6's Minimum Data Set (MDS - a comprehensive standardized assessment and care-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 observation, interview and record review, the facility failed to maintain an infection control measure and prevention to one of one sampled resident (Resident 6) by failing to ensure handwashing was completed and changing the gloves after removing an old wound dressing to Resident 6. This deficient practice had the potential to result in the spread of an infection and inability to promote wound healing. Findings: A review of Resident 6 ' s admission Record indicated Resident 6 was admitted to the facility on [DATE], with diagnoses including cellulitis (bacterial skin infection) of right toe, dorsalgia (type of back pain) and depression (a mood disorder that causes persistent feeling of sadness and loss of interest). A review of Resident 6's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool), dated 9/30/2023, indicated Resident 6 was moderately impaired in cognition (mental action or process of acquiring knowledge and understanding) for daily decision-making and…

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

Based on interview and record review, the facility failed to implement their Personnel Records policy by failing maintain the personnel file which included a background check for Janitor (JT) 1. This deficient practice had the potential to place the residents at the facility at risk for elder abuse. Findings: During an unannounced visit interview for a complaint on 10/10/23 at 5:35 p.m., at the facility, JT 1 stated that three days ago (10/6/23) he had been in an argument with Certified Nursing Assistant (CNA) 1, over a box of gloves that had been left in the hallway railing in front of a resident ' s room. He stated that since he worked in central supplies (department responsible for receiving, storing, and distributing medical supplies and equipment), he removed the box of gloves from the railing and told CNA 1 not to place them there anymore. He further stated to her This is America so we cannot just place items anyhow. During an interview with CNA 1 on 10/11/23 at 9:58 a.m., CNA 1 state that three days prior on 10/6/23 during the evening shift (3-11 p.m.) had discovered that 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 and interview, the facility failed to provide a functioning call light (the primary method of patient-nurse communication in a hospital setting, often used as a measure of nurse responsiveness) for three of five sampled residents (Residents 1, 2, and 3). This deficient practice had the potential to result in staff delay in meeting resident's needs for hydration, toileting, and activities of daily living as well as a delay in provision of assistance which may lead to falls and accidents. Findings: A review of Resident 1's admission record indicated Resident 1 was initially admitted to the facility on [DATE], with diagnoses which included, blindness, acquired absence of right great toe (amputation of the right big toe), and Depression (a common and serious medical illness that negatively affects how you feel, the way you think and how you act). A review of Resident 1's Minimum Data Set (MDS- a standardized assessment and care screening tool) dated 8/29/23 indicated the resident was cognitively…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 four sample residents (Resident 1) a care plan developed for enterocutaneous fistulae care upon admission and revised as indicated in the facilities policy and procedures. This failure had the potential to negatively affect the delivery of care and services for Resident 1. Findings: 1. During a review of Resident 1's Face Sheet (first page of resident medical record with summary of the resident's information including diagnosis), dated 10/6/23, the face sheet indicated, Resident 1 was readmitted to the facility on [DATE] with diagnoses including fistula of intestine (a connection between the intestine and another organ or surface, i.e., enterocutaneous fistula connection between the intestine and skin), bilateral (both sides) nephrostomy tubes (a surgically placed tube inside the kidney to drain urine when the ureter [tubelike structure connecting the kidney to the bladder] is compromised in some way i.e., kidney stones, tumors, trauma or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of four sample residents (Resident 1): 1. had and initial care plan developed for nephrostomy tubes and revised which each incident of dislodgement. 2. had Interdisciplinary team meetings completed in a timely manner after nephrostomy tube dislodgement. 3. had staff in-service trainings initiated and completed for all nursing staff for nephrostomy tube care. 4. had an accurate assessment documented in the medical record detailing site of nephrostomy tube dislodgement for two of five instances. This failure resulted in five instances where Resident 1 ' s nephrostomy tubes were dislodged and required hospitalization to replace the dislodged tubes. Findings: 1. During a review of Resident 1's Face Sheet (first page of resident medical record with summary of the resident ' s information including diagnosis), dated 9/27/23, the face sheet indicated, Resident 1 was readmitted to the facility on [DATE] with diagnoses including bilateral (both…

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

Based on interviews and record review the facility failed to have a system in place to ensure facility staff providing care to residents were licensed, certified, or registered as per state laws and facility policy. An unknown person worked in the facility using Certified Nursing Assistant 1 (CNA 1) ' s identification and provided care to residents from June 2023 to August 2023 with no valid certification that was verified by the facility. This deficient practice placed all residents assigned to CNA 1 at risk for serious injury or harm from receiving unqualified incompetent care. Findings: A review of facility ' s entity-reported incident (an official notification to Licensing and Certification from a self-reporting facility or health care provider that alleges noncompliance of federal and/or state laws and regulations) dated 9/21/2023 indicated, a registry employee, Certified Nursing Assistant 1 (CNA 1) came to the facility and said someone was coming to the facility as her (CNA 1). A review of facility ' s staffing schedule dated 8/11/2023, 8/12/2023, 8/13/2023, 8/14/2023 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.