Blue Oak Post-Acute

Based on observation, interview, and record review, the facility failed to ensure residents' rights to confidentiality for a census of 142 residents, when residents' meal tickets containing personal and medical information were found in a kitchen trash can.This failure decreased the facility's potential to protect the residents' personal details and health information.Findings:During a concurrent observation and interview on 9/22/25 at 9:29 a.m. with the Dietary Services Supervisor (DSS) in the kitchen, a dietary aide was scraping food off breakfast plates into a large trash can. Numerous resident meal tickets were found in the trash can along with discarded food. Trash bags were then tossed into an unsecured dumpster behind the building. DSS stated the kitchen team had always discarded the meal tickets in the trash along with uneaten food, and this had been their practice for over a year. DSS also stated she was not aware that resident meal tickets' confidential information needed to be protected, nor was she familiar with the method of shredding meal tickets. DSS further stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement their medication storage policy and procedure (P&P) for a census of 142 residents, when multiple medications were not labeled and stored in a safe manner.This failure decreased the facility's potential to prevent unsafe medication administration to residents.Findings:During a concurrent observation and interview on [DATE] at 10 a.m. with Licensed Nurse 1 (LN 1), medication cart 2A was observed. The following findings were identified and confirmed by LN 1:1. Budesonide inhaler (an inhaled respiratory medication) was found open with no open date;2. Fluticasone/salmeterol Diskus (an inhaled respiratory medication) and a decongestant nasal spray were found with resident information on outer packaging only, not on the actual product;3. Beclomethasone inhaler (an inhaled respiratory medication) was found with an expiration date of 8/25 and only a room number written on it; and 4. An unidentified peach oval shaped tablet was found…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 recipe for a pureed diet (consists of foods that have been blended or mashed to a smooth, pudding-like consistency) for nine residents of a census of 142, when [NAME] 1 (C 1) did not add the correct amount of bread slices and broth cups while preparing pureed lunch for residents.This failure decreased the facility's potential to serve the right food consistency to residents with specific nutritional needs and dysphagia (difficulty swallowing).Findings:A review of the facility's menu, dated 9/24/25, indicated the lunch menu consisted of smothered pork chop, whipped potatoes, mixed vegetables, bread or roll with margarine, and lemon chiffon dessert.A review of the facility's recipe titled, Pureed Bread or Roll and Margarine (Pureed Diet Level 4 [PU4- a specialized dietary modification designed for individuals with severe dysphagia]), dated 2025, indicated the amount of white bread slices to add for 15 servings was seven and a half slices.A review of the facility's recipe titled, Pureed Smothered Pork…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 accommodate five residents' (Resident 119, Resident 14, Resident 43, Resident 44, and Resident 129) food allergies, intolerances, and preferences for a census of 142, when:1.Resident 119 had lactose allergy and was served mashed potatoes with sour cream; and2.Resident 14, Resident 43, Resident 44, and Resident 129's food preferences were not served as indicated on their meal tray tickets.These failures increased the residents' potential to sustain an allergic reaction and unmet nutritional needs.Findings:1. A review of an admission record indicated Resident 119 was admitted to the facility in July 2022 with a diagnosis of lactose allergy.A review of Resident 119's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 8/4/25, indicated Resident 119 was cognitively intact.During an observation on 9/24/25 at 10:30 a.m., Prep [NAME] 1 (PC1) was preparing mashed potatoes per the facility's recipe which included sour cream.A review of the facility's recipe for mashed potatoes, dated 2025,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 properly prepare and store food for a census of 142 residents, when:1. Food items were found undated, unlabeled, unsealed and expired;2. Food bins were stored on a corroded metal shelf;3. One cutting board had brown stains, another contained a sticky substance, one frying pan had an oily substance and brown residue on the inside, a steam warmer tray had brown residue on the outside;4. Two insect control machines were placed on walls above a food preparation area and a toaster;5. The inside of a ceiling ventilation fan had a thick, black substance; and6. The second step of the cool down log for cooked food items was incomplete from June to September 2025.These failures increased the facility's potential to serve contaminated food and cause foodborne illnesses among vulnerable residents.Findings:1. During a concurrent observation and interview on 9/22/25 at 9:04 a.m. with the Dietary Services Supervisor (DSS), the following items were found:- In the reach-in refrigerator: a container of fresh minced garlic 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.

Based on observation, interview, and record review, the facility failed to ensure proper infection control measures were implemented for a census of 142 residents, when:1. Two washing machines in the behavioral unit were found closed while not in use with moisture inside and the washing machine in station B had black spots around the door seal;2. Licensed Nurse 2 (LN 2) did not perform proper hand hygiene prior to medication preparation; and3. Enhanced Barrier Precautions (EBP- an infection control intervention designed to reduce the spread of multidrug-resistant organisms [MDRO]) were not followed for Resident 5, Resident 135, and Resident 4.These failures had the potential to spread infection among residents, staff, and visitors.Findings: 1.During a concurrent observation and interview on 9/25/25 at 9:05 a.m. with Director of Environmental Services (DES) in station A's laundry room in the behavioral unit, the washing machine was found not in use with the door closed and with visible moisture inside the washer. DES confirmed the washer was closed with moisture inside and stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure call systems (an electronic communication network that allows residents to alert staff when they need assistance) were provided for 46 residents out of a census of 142, when the residents' rooms and bathrooms in the behavioral unit (a specialized area that provides focused care for residents who have mental health disorders, substance use disorders, or complex behaviors) were found without a functioning call system. This failure decreased the facility's potential to maintain residents' safety.Findings:A review of Resident 102's admission Record, indicated Resident 102 was admitted to the facility in February 2025 with a diagnosis of schizophrenia (a mental illness that is characterized by disturbances in thought).A review of Resident 102's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 8/13/25, indicated Resident 102's Brief Interview for Mental Status (BIMS- an assessment tool used by facilities to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two of 31 sampled residents (Resident 28 and Resident 140) were free from abuse, when both residents were subjected to offensive language and profanity during an argument as witnessed by staff.This failure decreased the facility's potential to maintain Resident 28's and Resident 140's highest practicable physical, mental, and psychosocial well-being.Findings:A review of an admission record indicated Resident 28 was admitted to the facility in December 2024 with a diagnosis of recurrent depressive disorder.A review of Resident 28's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 8/16/25, indicated Resident 28 had a Brief Interview for Mental Status (BIMS, an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 15 out of 15 with intact cognition.A review of an admission record indicated Resident 140 was admitted to the facility 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 accurately assess the nutritional status for one of 31 sampled residents (Resident 127), when a Minimum Data Set (MDS; an assessment tool) quarterly review indicated Resident 127 had no weight loss.This failure decreased the facility's potential to identify Resident 127's severe weight loss.Findings:A review of an admission record indicated Resident 127 was admitted to the facility in December 2016 with a diagnosis of type two diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing).During an observation on 9/22/25 at 9:59 a.m. in Resident 127's room, Resident 127 was observed lying in bed on his side facing away from an untouched meal tray.A review of Resident 127's medical record (MR), indicated Resident 127's weight was 193.8 pounds (a unit of measure) on 1/1/25 with a severe weight loss of 16.82 percent (%; a unit of measure) in six months. MR further indicated Resident 127's weight…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 professional standards of care were followed for enteral feeding and medication administration for one of 31 sampled residents (Resident 132), when:1. Resident 132's physician's order for enteral (involving or passing through the intestine, either naturally via the mouth and esophagus, or through an artificial opening) feeding was incomplete, without start and stop times, and lacked medication administration and flushing instructions; and2. Licensed Nurse 3 (LN 3) did not follow the facility's policy during medication administration through a gastrostomy tube (G-tube; a surgical opening fitted with a device to allow feedings to be administered directly into the stomach, common for people with swallowing problems).This failure increased Resident 132's risk for inconsistent enteral feeding times, increased residual, and potential tube clogging.Findings:A review of Resident 132's admission Record, indicated Resident 132 was admitted to the facility in October 2012 with diagnoses including enterocolitis…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 an enteral feeding (a method of providing nutrition directly into the stomach through a surgically placed tube) was administered as per physician's order for one of 31 sampled residents (Resident 33), when Resident 33's feeding pump was observed off during scheduled feeding times.This failure increased Resident 33's potential for malnutrition (an imbalance between the nutrients your body needs to function and the nutrients it gets) and dehydration (occurs when the body uses or loses more fluid than it takes in).Findings:A review of Resident 33's admission record indicated he was admitted to the facility on [DATE] with diagnoses including dysphagia (difficulty swallowing) and a gastrostomy tube (g-tube, a device to allow feedings to be administered directly to the stomach, common for people with swallowing problems). During an observation on 9/23/25 at 9:24 a.m. with Resident 33 in his room, Resident 33's tube feeding pump 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 observation, interview, and record review, the facility failed to provide respiratory care services according to professional standards of quality for one of 31 sampled residents (Resident 28), when Resident 28's administered oxygen was not consistent with the physician's order.This failure decreased the facility's potential to follow the physician's order when providing respiratory services.Findings:A review of an admission record indicated Resident 28 was admitted to the facility in December 2024 with a diagnosis of chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing).A review of Resident 28's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 8/16/25, indicated Resident 28 had a Brief Interview for Mental Status (BIMS, an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 15 out of 15 with intact cognition.During a concurrent observation and interview on 9/22/25 at 10:33 a.m. with Resident 28, Resident 28 was observed in bed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 accurate documentation, disposition, and storage of controlled medications for one of 31 sampled residents (Resident 135), when:1. Resident 135's controlled drug was found in a sealed plastic bag stored inside a general medication drawer in the medication cart; and 2. Resident 135's Controlled Drug Record (CDR-a paper log of controlled drug removal for administration to residents) did not match the actual medication count.These failures had the potential to contribute to unsafe controlled medication handling and/or risk of controlled drug diversion.Findings:1.A review of Resident 135's admission record indicated she was admitted to the facility on 8/25 with diagnoses including closed fracture (break in the bone) and an anxiety disorder.A review of Resident 135's Order Listing Report, dated 9/25/25, indicated an order for clonazepam (a controlled medication for anxiety) 0.5 milligrams (mg- a unit of measurement), give two tablets one time a day and one tablet at bedtime.During a concurrent observation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 properly dispose garbage for a census of 142 residents, when a kitchen garbage dumpster was found to have two warped lids. This failure had the potential to produce unsanitary conditions for residents due to easy access for rodents and other pests.Findings:During a concurrent observation and interview on 9/22/25 at 9:17 a.m. with the Maintenance Director (MD) at the kitchen dumpsters, one garbage dumpster's lids were separated at the midline, leaving a one inch (a unit of measure) gap between the lids. Three flies were hovering at the gap. MD stated it was a pest problem because insects and rodents could access the dumpster. A review of the facility's document titled, Garbage and Trash, dated 2023, indicated, Adequate, clean, vermin-proof areas must be provided for storage of garbage . and that the lids are closed.

Based on interview and record review, the facility failed to maintain record of Coronavirus disease 2019 (COVID-19) vaccination status for one of two sampled staff (Certified Nursing Assistant 2; CNA 2), when CNA 2 was not provided an education regarding COVID-19 vaccination and the refusal of the vaccine was not documented.This failure decreased the facility's potential to assess staffs' vaccination status against infectious disease.Findings:During a concurrent interview and record review on 9/25/25 at 11:02 a.m. with Director of Staff Development (DSD), CNA 2's employee record was reviewed. DSD confirmed CNA 2 did not have COVID-19 vaccination record on file. DSD stated COVID-19 vaccine was offered to CNA 2 and CNA 2 declined. DSD further stated education regarding COVID-19 vaccination was not provided and CNA 2's refusal of vaccine was not documented. A review of the facility's policy titled, Employee Infection and Vaccination Status, revised January 2024, indicated, Employees are provided with educational materials to make informed decisions for . vaccinations. If declined, a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to prevent abuse for one resident (Resident 1) of two sampled residents when Resident 2 threw water at Resident 1.This failure resulted in Resident 1 having had water thrown at him.Findings:A review of an admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included respiratory failure, hemiplegia (paralysis of one side of the body) and hemiparesis (partial weakness of one side of the body) after a stroke, and major depressive disorder.A review of Resident 1's Minimum Data Set (an assessment tool) dated 6/18/25 indicated a Brief Interview for Mental Status (BIMS, an assessment of cognitive function (the mental processes the brain uses to perceive, learn, remember, reason)) score of 12 which meant Resident 1's cognition was moderately intact.A review of an admission record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses which included stroke, anxiety disorder (a mental health condition…

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

Based on interviews and record reviews, the facility failed to honor the right to self-determination (making own decisions) nor ensured one out of three sampled residents (Resident 1) was treated with respect and dignity, when Licensed Nurse (LN) B touched Resident 1 without consent.This failure resulted in Resident 1 feeling she was not treated with respect and dignity and that her rights were violated.Findings:A review of Resident 1s face sheet (front page of the chart that contains a summary of basic information about the resident) indicated she was admitted to the facility in April of 2025 and was self-responsible (taking ownership of one's actions and decisions).During an interview on 7/22/25 at 3:00 p.m., Resident 1 stated there was an incident when LN B had dragged her from the floor in the hallway back to her bed. Resident 1 stated at the time of incident, she was in a lot of pain and had laid down on a blanket in the hallway, as she believed it would help relieve her pain. Resident 1 stated LN B had grabbed her on the side by her armpits and dropped her onto her bed.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 ensure an abuse allegation was reported timely, not later than two hours, for one out of three sampled residents (Resident 1), when an allegation of abuse was made on 7/7/25 but wasn't reported to the local police department until 7/8/25.This failure could result in continued harm and further abuse.Findings:A review of the report of suspected dependent adult/elder abuse, dated 7/7/25, indicated Resident 1 reported an allegation of physical abuse against Licensed Nurse (LN) B.A review of the Interdisciplinary team (IDT, a group of health care professionals with various areas of expertise who work together toward the goals of the residents) note, dated 7/14/25, indicated Resident 1 reported the physical abuse allegation on 7/7/25 at 3:10 p.m.During an interview on 7/22/25 at 2:35 p.m., the Director of Nursing (DON) stated abuse allegations should be reported to California Department of Public Health (CDPH, state licensing), the Ombudsman (an advocate…

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

Based on observation, interviews and record review, the facility failed to ensure medications were secured and inaccessible to unauthorized staff and residents when one medication cart was left unlocked and unattended.This failure had the potential to put all 95 facility residents at risk for unauthorized access to and ingestion of unsecured medications.Findings:During an observation on 7/22/25 at 2:26 p.m., one medication cart was not locked while unattended. There was no nurse in sight. During a concurrent observation and interview on 7/22/25 at 2:29 p.m., a nurse came and locked the medication cart. Licensed Nurse (LN) A verified she left station 1B medication cart unlocked to go with the Director of Nursing (DON) inside the medication room. LN A stated medication cart should be kept locked at all times when unattended to ensure there was no unauthorized access to the medications inside the cart. LN A stated keeping the medication cart locked when unattended was for resident and staff safety. During an interview on 7/22/25 at 2:50 p.m., the DON stated she knew about one 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 interview and record review, the facility failed to ensure the preservation of dignity for one of two sampled residents (Resident 1), when Resident 1 was left on a soiled bedpan (a medical device used to collect urine or feces for individuals who are unable to leave their bed to use a regular toilet) for hours without any response to his multiple call light (typically a light or bell used in healthcare setting to notify staff that a resident requires assistance) activation attempts to get assistance from facility staff. These failures resulted in Resident 1 being made to endure an undignified experience being left for hours, on a soiled bedpan, feeling helpless and embarrassed with an increased potential for skin breakdown. Findings: A review of Resident 1 ' s face sheet (front page of the chart that contains a summary of basic information about the resident) indicated Resident 1 was admitted to the facility in April 2025, for surgery aftercare following a right lower leg fracture, with a history of falling, and difficulty walking. During an interview on 5/8/25 at 3:34 p.m.…

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

Based on interview and record review, the facility failed to complete and provide a timely investigation report for one of two resident abuse allegation incidents (Resident 1) to the Department. This failure subjected Resident 1 to the potential reoccurrence of abuse, and lack of information had the potential to hamper the Department's ability to intervene, should protective actions be required to ensure the safety of the 60 other vulnerable residents in the facility. Findings: A review of the Intake Information, dated 3/27/25, indicated an allegation of Resident 1 not being treated with dignity and respect by a facility staff member. During an interview on 4/16/25 at 12:05 p.m., Administrator A stated he investigated the allegation Resident 1 made against Housekeeper B but did not send a five-day follow-up Investigation Report to the Department. Administrator A stated he referred to an AFL (All Facilities Letter, or a State letter of communication to providers) and a Mandated Reporter (healthcare professionals have a legal duty to report suspected cases of abuse or neglect) Chart,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 resident (Resident 1) received proper treatment to maintain hearing abilities, when the facility did not arrange for suitable transportation to a scheduled hearing appointment. This failure resulted in a delay of treatment for a period of five months and a decreased quality of life for Resident 1. Findings: During an interview on 3/28/24 at 4:58 PM, Family Member 1 (FM 1) stated Resident 1 (R1) needed a hearing assessment. The regular driver was not at the facility. FM 1 stated the Social Services Assistant (SSA) informed her the facility contracted with a transport company. FM 1 further stated that R1 missed an appointment for a hearing assessment because her wheelchair did not fit in the transport van. FM 1 stated the next available appointment was not until August. During an interview on 3/29/24 at 11:05 AM, R1 stated she had been anxious to get hearing aids. R1 further stated her quality of life had been affected because she had a hard…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents were treated with dignity and respect, when: 1. Unlicensed Staff D was observed assisting Resident 137 with meals, in the standing position; 2. Unlicensed Staff E and Unlicensed Staff F were observed chatting in the facility's hallway adjacent to the dining room, speaking a language other than English during lunch time, and; 3. Licensed Nurse G was observed texting in her personal cellphone during regular work hours. These findings had the potential to result in loss of dignity, and feelings of neglect and frustration for the residents of the facility. Findings: 1. Record review indicated Resident 137 was admitted to the facility on [DATE], with medical diagnoses including Malignant Neoplasm of Temporal Lobe (Brain cancer) and Pulmonary Hypertension (A type of high blood pressure that affects the arteries in the lungs and the right side of the heart), according to the facility Face Sheet (Facility demographic). 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 ensure 13 of 13 sampled residents (Resident 44, Resident 61, Resident 81, Resident 63, Resident 34, Resident 93, Resident 23, Resident 112, Resident 10, Resident 85, Resident 98, Resident 80 and Resident 120), who attended the Resident Council meeting on 11/15/23 at 10 a.m., knew where to find the information to file a complaint with the State Department. This failure had the potential to result in lack of ability to advocate for their care at the facility, and poor quality of care. Findings: During the Resident Council meeting on 11/15/23 at 10 a.m., all 13 residents who attended the meeting (Resident 44, Resident 61, Resident 81, Resident 63, Resident 34, Resident 93, Resident 23, Resident 112, Resident 10, Resident 85, Resident 98, Resident 80 and Resident 120), were asked if they knew how to file a complaint with the State Department. All 13 residents stated not knowing how to do this. The 13 residents were asked if they had been notified where to find the information to file a complaint with the State. They all stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure the sliding doors and the sliding screens on five of six resident rooms (Rooms 115, 214, 218, 317, 321) were intact and in good working conditions. This failure created a safety hazard for the residents at the facility and exposed them to insects and pests. Findings: During an observation and interview on 11/17/23, at 8:45 a.m., with the Director of Maintenance (DM), the sliding screen on room [ROOM NUMBER] that led to the outside was not operational (off its rails). During an observation and interview on 11/17/23, at 8:58 a.m., with the DM, the sliding door on room [ROOM NUMBER] that led to the outside did not close completely and did not lock. During an observation and interview on 11/17/23, at 9:02 a.m., with the DM, the screen in the sliding door on room [ROOM NUMBER] that led to the outside did not close completely leaving gaps of 1-2 inch. During an observation and interview on 11/17/23, at 9:08 a.m., with the DM, the screen in the sliding…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 safety of 14 residents (Resident 210, Resident 140, Resident 202, Resident 92, Resident 7, Resident 203, Resident 118, Resident 442, Resident 4, Resident 60, Resident 37, Resident 301, Resident 302, Resident 303), when nine Facility-Reported Incidents of resident abuse, were not reported to authorities within two hours after the allegation was reported. This failure to report allegations of abuse within the Federally-mandated requirement of two hours, had the potential to contribute to ongoing resident abuse, physical harm and the potential for mental and emotional harm. Findings: During an interview with Licensed Staff on 11/16/23, at 10:35 AM, Licensed Staff U stated any report of abuse was to be reported immediately to authorities, but no later than 24 hours, per facility Policy and Procedure. During an interview and concurrent document review with Licensed Staff T, on 11/16/23, at 10:40 AM, he stated abuse reporting was supposed to occur…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure two of 10 sampled residents (Resident 137 and Resident 22) had resident-centered comprehensive care plans when: 1. Resident 137, who was in palliative care (A type of medical care aimed at optimizing quality of life and mitigating suffering among people with serious, complex, and often terminal illnesses), did not have a resident-centered comprehensive care plan for pain/discomfort that was resident-specific and included nonpharmacological interventions (Interventions to help relieve pain not consisting of medications), and; 2. Resident 22, who had a left lower leg surgical wound, did not have a comprehensive care plan for care of the wound. These findings had the potential to result in insufficient information and lack of guidance to attain and maintain the residents' highest practicable physical, mental, and psychosocial well-being, poor quality of care, and suffering. Findings: 1. Record review indicated Resident 137 was admitted…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure 1 of 7 sampled residents (Resident 137), received assistance with Activities of Daily Living (ADLs-Activities related to personal care such as dressing, bathing and toileting) such as incontinence care (Cleaning the skin and changing the soiled undergarments and clothing of people with bowel or bladder incontinence [inability to control urination and defecation])., bed repositioning and bathing, as needed. This failure had the potential to result in feelings of neglect, frustration, shame, and skin breakdown for Resident 137. Findings: Record review indicated Resident 137 was admitted to the facility on [DATE], with medical diagnoses including Malignant Neoplasm of Temporal Lobe (Brain cancer) and Pulmonary Hypertension (A type of high blood pressure that affects the arteries in the lungs and the right side of the heart), according to the facility Face Sheet (Facility demographic). Record review of Resident 137's MDS (Minimum Data Set-An…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 1 of 7 sampled residents (Resident 49) was kept comfortable when she experienced pain of 10/10 (Pain scale where 10 is the worst pain experienced in a person's lifetime, and 0 is no pain) for a prolonged period of time, and the assigned nurse (Licensed Staff R) did not transfer her to the hospital despite multiple verbal requests by Resident 49, until more than two hours after the pain started. In addition, Licensed Staff R did not document administering any medications to treat Resident 49's pain. This caused Resident 49 a lot of suffering, and had the potential to result serious harm, including death to Resident 49. Findings: Record review indicated Resident 49 was admitted to the facility on [DATE] with medical diagnoses including Multiple Sclerosis (A potentially disabling disease of the brain and spinal cord that causes many different symptoms, including vision loss, pain, fatigue, and impaired coordination) and Muscle 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 interview and record review, the facility failed to ensure there was enough staff available to meet the needs of residents, when call lights were not answered promptly. During a Resident Council Meeting, three of 13 sampled residents (Resident 81, Resident 85 & Resident 93) complained the call lights were taking more than ten minutes to be answered. One resident indicated the call light took up to an hour to be answered. In addition, family members of Resident 137 also stated the call light took a long time to be answered. These findings had the potential to result in inability for residents to obtain assistance when needed, decreased resident satisfaction and safety, and poor perception of health care quality. Findings: During an interview on 11/15/23 at 10:12 a.m., during a Resident Council Meeting, Resident 81 and Resident 85 stated call lights took a long time to be answered. They stated, at nighttime, sometimes it took 10 to 15 minutes for staff to respond. Resident 93, who was also present, stated…

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

Based on observations, interviews and record reviews, the facility failed to ensure food was prepared and stored in accordance with professional standards of food service safety, when the roast beef was not cooled down (a processing technique used to reduce the temperature of the food from one processing temperature to another or to a required storage temperature) properly. This failure could put residents at risk for foodborne illness due to growth of bacteria and microorganisms. Findings: Potentially Hazardous Foods (PHFs) are those capable of supporting bacterial growth associated with foodborne illness. Cooked meat is considered a PHF and requires time/temperature control for food safety. Cooked meats must be cooled from 135 F to 70 F within two hours and to 41 F within an additional four hours, not to exceed a total timeframe of six hours. A review of the facility's menu for Tuesday indicated the facility was serving roast beef for dinner. During an observation on 11/14/23 at 11:30 a.m., there were four pieces, each weighing approximately five pounds, of cooked roast beef, on…

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

Based on interview and record review, the facility failed to have a Social Services Director with the qualifications required by the Federal regulations, since April of 2023. This finding had the potential to result in inability to provide medically-related Social Services to the residents of the facility and poor quality of care. Findings: During an interview on 11/15/23 at 2:38 p.m., the Administrator stated the facility currently did not have a Social Services Director, but a new employee, currently working as a Social Services Assistant, would be appointed the Social Services Director position as soon as she obtained her Bachelor's Degree, which was expected to happen in the summer of 2024. The Administrator stated the last Social Services Director left her position in April of 2023. During a second interview with the Administrator on 11/17/23 at 3:06 p.m., he stated the Social Services Assistant who would be appointed the Social Services Director, would be getting her Bachelor's Degree in Social Work in about a month. Record review of the facility job description for Social…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure the televisions (TVs) of five of five residents (Resident 78, 81, 34, 23 & 85) worked properly. In addition, the call bells of two of two residents (Resident 33 & 78) did not work properly either. These failures prevented the residents from watching the TV channels they liked and placed other residents at risk of not being able to watch the channels of their preference. These failures also placed Resident 33 and Resident 78 at risk of not being able to get the help or assistance they needed, due to the malfunctioning call bells, which could have resulted in harm and neglect. Findings: During an interview on 11/17/23, at 8:45 a.m., Resident 78 stated he liked to watch TV but stated Channel 5 did not work and Channel 12 (CNN) had no sound. During a concurrent observation, the Director of Maintenance (DM) tested Resident 78's TV and confirmed what Resident 78 reported. During an interview on 11/17/23, at 8:52 a.m., Resident 81 stated she liked to…

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

Based on interview and record review, the facility failed to ensure the safety of six residents (Resident #7, Resident #203, Resident #202, Resident #92, Resident #201, Resident #140), when they did not have an effective abuse prevention program which provided staff with updated reporting information. This failure to have the correct information available to staff for orientation, yearly in-service and availability in the nursing stations, resulted in delayed reporting of abuse. Findings: (Refer F609) During an interview with Licensed Staff on 11/16/23, at 10:35 AM, Licensed Staff U stated any report of abuse was to be reported immediately to authorities, but no later than 24 hours, per facility Policy and Procedure. During an interview and concurrent document review with Licensed Staff T, on 11/16/23, at 10:40 AM, Licensed Staff T stated abuse reporting was supposed to occur immediately but needed to be reported in 24 hours. During a review of a binder titled, Abuse, no date, a document titled, Mandated Reporter, indicated multiple abuse situation timelines: Immediately, 2 hours,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 ensure the physician was notified for a significant weight loss (5% in 1 month, 10% in 3 months and 7.5 % in 6 months) for one out of two sampled residents (Resident 38). This failure had the potential to further aggravate and compromise his medical status. Findings: A review of Resident 38's face sheet (demographics) indicated he was initially admitted to the facility on [DATE]. His diagnoses included Essential Hypertension (occurs when you have abnormally high blood pressure that is not the result of a medical condition), Type 2 Diabetes Mellitus (a disease that occurs when your blood glucose, also called blood sugar, is too high), and Congenital stenosis and stricture of esophagus (an intrinsic narrowing of the esophagus, the organ that food travels through to reach the stomach for further digestion, present at birth) His Minimum Data Sheet Assessment (MDS, a federally-mandated process for clinical assessment of all residents in Medicare 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 interviews and record reviews, the facility failed to ensure a resident was free from abuse for one out of two sampled residents (Resident 118), when another resident (Resident 442) hit him on his face three times with open palm and one time with a closed fist. This failure led Resident 118 feeling in pain and afraid. This failure could also result in injury. Findings: A review of Resident 118's face sheet (demographics) indicated he was initially admitted to the facility on [DATE]. His diagnoses included Essential Hypertension (occurs when you have abnormally high blood pressure that is not the result of a medical condition), Type 2 Diabetes Mellitus (a disease that occurs when your blood glucose, also called blood sugar, is too high), Hemiplegia (one-sided muscle paralysis- the inability to move part of your body or weakness) and Hemiparesis (weakness or the inability to move on one side of the body, making it hard to perform everyday activities like eating or dressing). His Minimum Data Sheet…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to timely complete a nutritional assessment by a Registered Dietician for one of three residents (Resident 131) at risk for malnutrition. Resident 131 was admitted with a Body Mass Index (BMI - a nutritional status indicator) score of 15.1 (BMI scores less than 16.5 indicate severely underweight). The Registered Dietician assessment was completed ten days after admission. This failure placed Resident 131 at risk of suffering complications from being underweight. Findings: A review of Resident 131's facesheet indicated she was admitted to the facility on [DATE], with an admitting diagnosis of cerebral infarction (stroke). A review of Resident 131's, Weight Summary, record indicated Resident 131 was 5 feet and 2.5 inches tall and weighed 83.8 pounds on 6/14/23, the first recorded weight after admission. Resident 131's Body Mass Index (BMI - a scientific indicator of body fat/nutrition calculated with a formula that uses weight divided by height) on 6/14/23,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 ensure residents who require dialysis, receive such services consistent with professional standards of practice, for one out of two sampled residents (Resident 8), when staff were not regularly assessing the hemodialysis (HD, a treatment used to filter wastes and water from your blood) access site on his left arm. This failure could result in staff not being able to detect infection, bleeding or a failed HD access site. Findings: A review of Resident 8's face sheet (demographics) indicated he was initially admitted to the facility on [DATE]. His diagnoses included Essential Hypertension (occurs when you have abnormally high blood pressure that is not the result of a medical condition), Type 2 Diabetes Mellitus (a disease that occurs when your blood glucose, also called blood sugar, is too high), and Stage 4 Chronic Kidney Disease (CKD, the kidneys are moderately or severely damaged and are not working as well as they should to filter waste from your…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 record reviews, the facility failed to ensure: 1. the menu was followed for a pureed (a paste or thick liquid suspension usually made from cooked food ground finely) diet, when the cook did not follow the menu instruction while preparing a pureed meatball, for two out of two sampled residents (Residents 58 and 137); and, 2. the development of a plant-based menu. These failures had the potential to alter the taste of the food when not following the menu and residents not meeting the recommended daily intake (RDI, the average daily dietary intake level that is sufficient to meet the nutrient requirements of nearly all (97-98 per cent) healthy individuals in a particular life stage and gender group) for certain nutrients like protein or vitamins, which could further compromise their medical status. Findings: A review of Resident 58's face sheet (demographics) indicated she was initially admitted to the facility on [DATE]. Her diagnoses included Essential Hypertension (occurs…

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

Based on observations, interviews and record reviews, the facility failed to ensure food was prepared and stored in accordance with professional standards of food service safety, when the roast beef was not cooled down (a processing technique that is used to reduce the temperature of the food from one processing temperature to another or to a required storage temperature) properly. This failure could put residents at risk for foodborne illness due to growth of bacteria and microorganisms. Findings: A review of the facility's menu for Tuesday indicated it would be serving roast beef for dinner. During an observation on 11/14/23 at 11:30 a.m., there were large portions of cooked roast beef on two large trays, cooling down. The smaller portion roast beef had a temperature of 174 Fahrenheit (F, a scale for measuring temperature, in which water freezes at 32 degrees and boils at 212 degrees) and the large roast beef temperature was 170 F. During an observation on 11/14/23 at 12:48 p.m., the temperature for the roast beef was 136 F and 128 F. During a concurrent observation and interview…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure it offered COVID-19 immunizations and education to two of five residents (Residents 11 and 61) and failed to ensure it had a COVID-19 Policy and Procedure available for consultation and reference. These failures placed facility residents at risk for COVID-19. Findings: During an interview and record review on 11/17/23, at 10:09 a.m., the Infection Preventionist (IP) stated Resident 11 had been admitted to the facility on [DATE], and Resident 61 on 7/19/23. The IP stated both were still residents at the facility. The IP was asked for documentary evidence both residents were offered and provided COVID-19 vaccines and education. The IP reviewed the clinical record of both residents. The IP stated there were no records of Resident 11's COVID-19 immunizations. The IP stated there was a note in the record indicating Resident 11 refused a COVID-19 vaccine on 2/16/23. The IP stated there was no record that Resident 11 was provided education about…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 COVID-19 vaccination status of two of five staff members (Licensed Staff G and Unlicensed Staff Q). This failure placed residents at risk of COVID-19. Findings: A review of the facility's staffing sheet for 11/17/23, indicated Licensed Staff G and Unlicensed Staff Q were scheduled to work at the facility. During an interview and record review on 11/16/23, at 11:17 a.m., the Infection Preventionist (IP) stated Licensed Staff G was hired on 8/25/23, and Unlicensed Staff Q was hired on 9/20/23. The IP was asked for documentation of their vaccination status. The IP reviewed their personnel records and stated the facility had no records of their COVID-19 vaccinations. During an interview on 11/17/23, at 11:37 a.m., the IP stated she contacted Licensed Staff G and Unlicensed Staff Q and asked for their COVID-19 vaccination status. During an interview on 11/17/23, at 11:39 a.m., the IP was asked for the facility's policy and procedure on screening staff for COVID-19 and stated documentation of COVID-19…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the kitchen walls were in good repair, when cracks and holes in the walls were noted during rounds. This failure could result in rodents and pests accessing the kitchen area through these cracks and holes which could put residents at risk for harmful diseases. Findings: During an observation on 11/14/23 at 9:56 a.m., there was a crack in the wall in the area by the manual dishwasher sink. There were also multiple holes in the wall underneath the sink/drying area near the dishwashing machine and a crack in the wall beside the area where staff would hand wash cutlery and glasses. During a concurrent observation and interview on 11/14/23 at 10:27 a.m., the Maintenance Supervisor stated they usually did environmental rounds outside the facility but not inside the facility unless staff told them to fix something. The Maintenance Supervisor stated they did not have an environmental rounds form. The Maintenance Supervisor was shown the areas in the kitchen where there were holes and cracks. The Maintenance…

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

Based on observation and interview, the facility did not ensure eight residents (Residents, 109, 112, 113, 11, 76, 18, 59, and 128) were offered the opportunity to choose whether they wanted condiments or substitute foods during meal service. The failure to ask residents or their families about things important to their lives and how they enjoyed their food, had the potential for each resident, who did not like their food, to not eat and potentially experience weight loss, or depression. Findings: During an observation on 1/31/22 at at 12:20 p.m., lunch trays were delivered to seven resident rooms, by Unlicensed Staff F and Unlicensed Staff G. Unlicensed Staff F, who set-up the trays for the residents, did not ask any of the residents whether they wanted condiments, if the food was to their liking or if the residents wanted to have a substitutions. During an interview on 2/2/22, at 10:20 a.m., Resident 128 stated he missed home cooking. He stated he was never asked about salt or pepper or if he wanted something different to eat. He stated no one had asked him if he liked the food…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility did not ensure seven Residents' (Resident 129, Resident 112, Resident 71, Resident 3, Resident 1, Resident 1A, and Resident 1B), Minimum Data Set Documentation (The MDS is a health status screening and assessment tool used for all residents, to ensure that facilities have provided resident-specific information for payment and quality measure purposes, and to enable a facility to better monitor each resident's decline and progress over time. Computer-aided data analysis facilitates a more efficient, comprehensive and sophisticated review of health data) was completed and submitted, according to the regulations. The facility's failure to completely assess each resident's preferences, capabilities and goals of care, as part of a time-dependent and ongoing Comprehensive Assessment process, had the potential to result in resident harm from missed assessments of weight loss, missed identification of resident preferences and needs, and care plans that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not ensure resident care plans were reviewed, revised and updated, at least every three months, for 9 residents (Residents 71, 113, 128, 135, 40, 11, 9, 19, and 93). This failure to follow the Policy and Procedure (P&P) for Care Planning, had the potential for these residents to not receive the care and services necessary to meet their physical, psychosocial and functional needs. Findings: During a record review on 1/31/22, for Resident 128, a document titled, admission Record, indicated he was admitted [DATE], with diagnoses that included, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, (When blood supply is blocked to the brain, paralysis of one side of the body may occur), Myocardial Infarction, (Blood supply to the parts of the heart is blocked causing tissue to die), Major Depressive Disorder, (A mental disorder lasting at least two weeks, where someone experiences pervasive low mood, low self-esteem,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 did not ensure Certified Nursing Assistants (CNAs) were provided at least 12 hours a year of in-services annually. The failure to provide education in-service for CNAs had the potential to result in resident harm from cross-contamination and infection by staff who did not know how to properly don and doff Personal Protective Equipment (PPE) and when to engage in hand hygiene after contact with residents and their surroundings. Findings: During an observation in the Red Zone (Area in quarantine as having Covid Positive residents), on 1/31/22, at 12:20 p.m., staff were donning (putting on) and doffing (taking off) gowns and gloves while passing resident lunch trays to residents in their rooms. Unlicensed Staff F donned a gown and gloves before entering a resident room with a lunch tray. Unlicensed Staff F delivered the lunch tray to the resident in bed one, removed the tray warmer lid, pushed the tray table closer to the resident and then walked to the doorway and handed the tray warmer lid to Unlicensed Staff G.…

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

Based on observation, interviews, and record review, the facility failed to: 1A. Ensure 3 of 3 refrigerated insulin injections (Basaglar, Victoza and Admelog) were stored at the temperature required to maintain their overall safety and effectiveness. This failure had the potential to reduce the efficacy of the medication, from exposure to excessively low temperatures, thereby being potentially ineffective to residents receiving insulin. 1B. Ensure 1 of 3 medication refrigerators was monitored for an acceptable temperature for refrigerated medications. This failure had the potential to reduce the efficacy of the medication, from exposure to excessively low or excessively high temperatures, thereby being potentially ineffective to residents receiving these medications. 2. Ensure that 2 of 2 vials of refrigerated Tuberculin Purified Protein Derivative (PPD) (also known as Tubersol - used in a skin test to help diagnose tuberculosis (TB) infection) were stored according to manufacturer's recommendations. This failure had the potential to result in an inaccurate reading for every…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 document review, the facility's Quality Assurance and Performance Improvement committee (QAPI) failed to identify and develop a QAPI Plan (A QAPI plan is the written plan containing the process that will guide the facility's efforts in assuring care and services are maintained at acceptable levels of performance and continually improved. The plan describes how the facility will conduct its required QAPI and QAA committee functions. The facility is required to develop a QAPI plan), and implement Performance Improvement Plans to address: 1. Residents' food preferences for seasonings or substitutions. (Reference F561) 2. Required resident assessment and documentation completion and submission, according to policy and procedure. (Reference F640 3. Resident Care plan reviews and updates to reflect resident needs. (Reference F657) 4. Staffing vacancies to address orientation, competency and mandatory in-service hours for Unlicensed Staff. (Reference 730) 5. Medication refrigeration safety. (Reference F761) 6. Infection Prevention program designed to prevent 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 an Infection Prevention Program was followed to prevent transmission of communicable diseases and did not follow its Policy and Procedure (P&P) when: 1. Screening Visitors and Staff for Covid Symptoms, before entering the facility; 2. a) Donning and doffing (putting on and taking off) Personal Protective Equipment (PPE); b) Staff did not follow its P&P for hand hygiene; and, 3. Trash cans were not placed inside resident rooms, in the Red Zone. These failures to follow Infection Prevention P&P had the potential for resident harm and possible death from cross-contamination and infection. Findings: 1. During an observation on 1/31/22, at 9 a.m., Unlicensed Staff K was behind a desk and used a laser thermometer to determine body temperature of incoming visitors. She scanned a visitor's forehead with the thermometer equipment and stated the temperature to the visitor. The visitor made a notation in a binder at the desk. Unlicensed Staff K did not ask the visitor any questions or document anything 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.

Based on interview and record review, the facility failed to ensure one resident (Resident 441) was free from abuse when they did not follow its Policy and Procedure (P&P) for assessment, monitoring or documenting allegations of abuse by Resident 441. This failure had the potential for harm, when Resident 441 was not assessed for physical harm or monitored for safety or signs of psychosocial harm. Findings: Resident 441 was admitted to the facility 9/8/21, for diagnoses that included Stroke (Blood supply to brain was limited causing brain damage), Diabetes (High levels of sugar in the blood over a prolonged period of time), Dysphagia (Difficulty swallowing), and adjustment disorder with Mixed Anxiety and Depressed Mood (Stress related conditions resulting in depression). During an interview on 2/3/22, at 11:05 a.m., the Social Services Director (SSD) stated she remembered an incident Resident 441 reported to her about an Unlicensed Staff member speaking rudely to her. She stated she remembered Resident 441 came to her office and stated Unlicensed Staff had been verbally, Rough. 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 implement care plan interventions to monitor a resident with a known history of elopement attempts, for one of three residents (Resident 54). This failure resulted in Resident 54 leaving the building, unsupervised, in the early hours of the morning on 8/8/21, putting Resident 54 at risk for serious injury or death. Findings: Resident 54 was 78 year's-old with a BIMS score of 5 (BIMS stands for Brief Interview for Mental Status and is used to see how a person is cognitively functioning. A score of 0-7 shows severe cognitive impact), a history of Dementia (a term used for the impaired ability to remember, think or make decisions and interferes with doing everyday tasks), Muscle weakness (a decrease in strength of one or more muscles in the body), Delirium (serious disturbance in mental abilities resulting in confused thinking and reduced awareness of surroundings), Depression (serious medical illness which negatively affects how you feel,…

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