Rolling Hills Care Center

Based on interview and review of facility documents, the facility failed to ensure there was a full time qualified Dietary Manager (DM) met state requirements, California Health and Safety Code (CA HSC) 1265.4(b) when the Registered Dietitian (RD) was not employed full-time. This failure resulted in puree food not in the proper form, puree foods not being prepared by methods that conserve nutritive value and flavor, menus not being followed and food stored not being monitored for cool down procedures for the 31 residents admitted to the facility. (Cross Reference F803, 804, 805, 812). During a review of the California Health and Safety Code (CA HSC) 1265.4 (a), If the facility employs a RD less than full-time, they shall also employ a full-time dietetic services supervisor who meets the requirements of subdivision (b) to supervise dietetic service operations. 1265.4 (b) stated, the dietetic services supervisor shall have completed one of seven recognized pathways, two of which include the completion of an education program approved by the Dietary Managers Association and successful…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 review of facility documents, the facility failed to ensure puree foods were prepared by methods that conserve nutritive value and flavor when [NAME] 1 made puree roasted potatoes and cauliflower were prepared with water for two residents (Residents 4 and 26) that were on a physician's prescribed puree diet. This can result in residents receiving improper nutrients from the food which can result in a decrease in meeting the nutrient needs which can further compromise their medical status. During an observation in the kitchen and concurrent interview with [NAME] 1 on 5/19/26 at 10:21 a.m, [NAME] 1 scooped two #8 (1/2 cup) scoop portions into blender then added, #24 scoop (1-1/3 ounces) butter, and five ounces of hot water from hot water dispenser spicket then blended. The measuring cup contained 8 ounces of hot water then after hot water was poured into blender there were three ounces of hot water left. [NAME] 1 used plastic spoon to stir then poured into two bowls. The puree…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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, staff interviews and review of facility documents, the facility failed to ensure puree food was in the proper form for two sampled residents (Residents 4 and 26) on their lunch meal tray on 5/19/26. This failure has the potential to result in choking (when the airway is obstructed by food, drink, or foreign objects) for Residents 4 and 26 who were on the physician prescribed therapeutic diet. During an observation in the kitchen and concurrent interview with [NAME] 1 on 5/19/26 at 10:21 a.m, [NAME] 1 scooped two #8 (1/2 cup) scoop portions into blender then added, #24 scoop (1-1/3 ounces) butter, and five ounces of hot water from hot water dispenser spicket then blended. The measuring cup contained 8 ounces of hot water then after hot water was poured into blender there were three ounces of hot water left. [NAME] 1 used plastic spoon to stir then poured into two bowls. The puree potatoes had flecks of skin present, appeared very thin and watery. [NAME] 1 stated she is looking for creamy…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 accurate and confidential medical records in accordance with accepted professional standards and practices for one of five sampled residents (Resident 15) when Resident 15's electronic health record (EHR) contained annual History and Physicals (H&P - A comprehensive assessment of a person's medical history), that belonged to five different residents (Residents 6, 17, 24, 40, and 41).These failures resulted in the compromised accuracy of Resident 15's medical records and violated the confidentiality of Protected Health Information (PHI - any health-related information that identifies a specific person) for Residents 6, 17, 24, 40, and 41.Findings: During a concurrent interview and record review on 5/21/26 at 3:44 p.m. with Medical Records/Activities Director (MR/AD), Resident 15's EHR document titled Annual H&P Examination, dated 12/28/2025, was reviewed. Resident 15's Annual H&P Examination included H&P's that belonged to Residents 6, 17, 24, 40 and 41. MR/AD stated the records for Residents 6,17, 24, 40 and 41…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 sterile water bottles used for oxygen humidification were labeled with the open date for one of 32 residents (Resident 35) observed receiving oxygen therapy. This failure had the potential to result in the use of contaminated respiratory equipment and increased the risk of infection. Findings:During an interview on 5/19/26 at 9:36 a.m. in Resident 35's room, Resident 35 stated he had been admitted to the facility approximately six days prior. Resident 35 was observed wearing a nasal cannula connected to an oxygen concentrator and stated he had not used oxygen prior to admission, but used it at the facility as needed. The sterile water bottle attached to the oxygen concentrator for humidification was not labeled with the date opened. During a review of Resident 35's admission Record (a summary of important information regarding a patient which include patient identification, past medical history, insurance status, care providers,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Dietary [NAME] (DC) 1 was competent to carry out the functions of the food and nutrition services safely and effectively when DC 1 thawed frozen meat without running cold water. This failure had the potential to result in unsafe food being served, consumed, and could have cause food borne illness (contamination of food and occur at any stage of the food production, delivery and consumption chain) to 29 residents who were served food from the kitchen. Findings: During a concurrent observation and interview on 11/20/24 at 11:17 a.m. in the kitchen, with Dietary [NAME] (DC) 1, frozen meat was submerged in a bucket of water. DC 1 stated she pulled out the frozen meat to make dinner for 11/20/24. DC 1 stated she worked as a cook for nine months. DC 1 stated, I had a rapid training from my previous supervisor that was three days of training. DC 1 stated she was trained to defrost meat submerged in water. DC 1 stated she was not aware of having cold water running when frozen meat was submerged in water. DC 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.

Based on observation, interview and record review, the facility failed to store, prepare, and serve food in accordance with professional standards of practice for food service safety when: 1 One opened box of pancake batter mix was not labeled with an open on date. 2. Residents snacks were not labeled with prepared on date an in refrigerator for residents to eat. 3. A hornet and wasp pesticide (bug spray) bottle was found below kitchen sink cabinet. 4. Six bags of muffins in the freezer were not labeled with the received-on date. 5. Resident refrigerator contained unlabeled foods with no received on date, resident name and content. 6. Uncooked frozen meat were found inside the resident refrigerator. These failures had the potential to transmit food-borne illnesses (caused by eating or drinking something that is contaminated with germs such as bacteria, viruses, or parasites or chemicals such as toxins or metals that can make people sick) and cross-contamination( transfer of harmful bacteria, parasites, or viruses from one food to another, or from surfaces to food ) to 29 of 29…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 during the survey period of 11/19/24 to 11/25/24, the facility failed to provide the minimum of at least 80 square feet (sq. ft- unit of measurement) per resident in multiple resident bedrooms, and at least 100 sq. ft in single residents rooms for 11 of 20 rooms (Rooms 1, 5, 6, 8, 9, 10, 11, 12, 18, 19, and 20), when the amount of usable living space was not adequate for residents. This failure had the potential for residents in Rooms 1, 5, 6, 8, 9, 10, 11, 12, 18, 19, and 20 to not have reasonable privacy or adequate space. Findings: During an environment tour with the Maintenance Director on 11/25/24 03:05 PM, the inspection indicated the following rooms did not meet the minimum square footage as required by regulation. These rooms were as follows: Room Number Square Feet # of Residents 1 120 2 2 120 1 3 118 1 4 118 1 5 92 1 6 174 3 7 102 1 8 118 2 9 117 2 10 117 2 11 117 2 12 111 2 13 114 1 14 110 1 15 113 1 16 118 1 17 111 1 18 117 2 19 92 1 20 95 1 However, variations were…

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

Based on observation, interview and record review, the facility failed to keep the environment free from insects in accordance with the facility's policy and procedure (P&P) Pest Control Program when ants were observed in the kitchen floor and cabinet. This failure led to insects being observed in the kitchen facility and had the potential to cross contaminate food being prepared in the kitchen for 29 residents. Findings: During a concurrent observation and interview on 11/19/24 at 8:15 a.m. in the kitchen with the Certified Dietary Manager (CDM), multiple live and dead ants were on the ground and under the sink of a cabinet. The CDM stated ants should not be in the kitchen. The CDM confirmed multiple ants were in the kitchen floor and under the sink cabinet. During an interview on 11/21/24 on 4:38 p.m. with the CDM, the CDM stated, ants should not be in the kitchen. The CDM stated, ants could have cross contamination (the transfer of harmful bacteria, parasites, or viruses from one food to another, or from surfaces to food) food and items in the kitchen. The CDM stated residents…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 person-centered care plans (CP - a detailed approach to care customized to an individual resident's needs) for three of 16 residents (Residents 3, 9 and 23) when: 1. Resident 9's care plan was not developed to address the use and storage of Resident 9's Incentive Spirometer (IS - a hand-held device that helps people take slow deep breaths to improve lung functioning). This failure put Resident 9 at risk of infection and harm due to improper storage and use of the IS. 2. Resident 23's care plan was not developed to address the use and care of a nebulizer (a device that changes medication from a liquid to a mist so it can be inhaled into the lungs). This failure put Resident 23 at risk of infection and harm due to improper storage and use of Resident 23's nebulizer. 3. Resident 23's care plan was not developed and implemented to address Resident 23's non-compliance with the proper use and storage 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 meet professional standards of practice for three of 16 sampled residents (Resident 23 and Resident 3) when: 1. Resident 23's oxygen flow rate was set to 3L (liters-a unit of measurement) instead of the ordered 2L. This failure had the potential to result in shortness of breath and respiratory distress (difficulty breathing) for Resident 23. 2. The Attending Physician (AP) was not notified of Resident 3's refusal of lidocaine (medication is used on the skin for pain) patch. This failure resulted in Resident 3 not receiving ordered pain medication. 3. Resident 3's physician order (a set of instructions written by a doctor for clinicians to follow when caring for a resident) for pain medication was not followed. This failure resulted in Resident 3's physician not being notified of his continued moderate pain (pain measuring at a four to six on the pain scale- a tool used to measure pain intensity and help doctors manage pain). Findings: 1.…

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

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals (a substance such as vaccines or drugs derived from a living organism used for treatment) were stored and labeled in accordance with currently accepted professional standards and practice when: 1. One of one bottle of folic acid (a mineral) did not have a readable expiration date on the bottle, and one of 161 pill packets (a packet that contains a set number of medication pills of the same brand in individual pop-out wrapping) was expired. These failures had the potential for residents to receive expired medications resulting in medication ineffectiveness (not producing any significant or desired effect). 2. One of 3 bottles of artificial tears (medication used to moisturize the eyes) and one of 15 inhalers (medications used to treat respiratory disease with a mist or spray that the patient breathes in through the nose or mouth) were not labeled with the resident's name or expiration date. These failures placed residents at risk for receiving the wrong medication which could lead…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 be established and maintained an infection control program to provide safe, sanitary, and comfortable environment to help prevent infections for two of 12 sampled residents (Resident 30 and Resident 23) when: 1. Resident 30's continuous positive airway pressure (CPAP- is a machine that uses mild air pressure to keep breathing airways open while you sleep) mask was observed not stored in a bag and on the ground. 2. Resident 23's oxygen tubing (a tube that delivers oxygen to people who have low oxygen levels) was observed wrapped around Resident 23's bed rail, not stored in a bag, and Resident 23's nebulizer (a device that changes medication from a liquid to a mist so it can be inhaled into the lungs) was observed on the ground, not covered in a bag. These failures placed Resident 30 and Resident 23 at risk to develop respiratory and healthcare associate infections. Findings: 1. During a concurrent observation and interview on 11/19/24 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe, comfortable and homelike environment for two of 16 sampled Residents (Resident 9, Resident 23), when Resident 9 and Resident 23 were unable to access and use their personal belongings and medical equipment to the extent possible as needed. This failure resulted in Resident 9 and Resident 23 not having a safe homelike environment. Findings: During a concurrent observation and interview on 11/19/24 at 10:35 a.m. with Resident 9, in Resident 9's room, Resident 9 was observed dressed, laying in his bed with plastic grocery bags on his bed against the wall. A bed-side table with food and condiments was observed next to his bed and Resident 9's wheelchair was observed facing Resident 9 pushed up against his bed. Resident 9 stated he had been in the facility for one month due to an infection that went to his heart. Resident 9 stated there was not enough room to move around in his room. During a review of Resident 9's admission…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 eight sampled residents (Resident 31) had a post-discharge plan of care (narrative document for communicating clinical information about what happened to the resident in the facility) when Resident 31 left AMA (Against Medical Advice- term used in healthcare when a patient leaves the hospital before their doctor recommends discharge). This failure resulted Resident 31's not having a post-discharge plan of care (document that summarizes a patient's health conditions, treatments, and other information) and had the potential to not adjust to new living environment. Findings: During a review of Resident 31's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 11/25/25, the AR indicated Resident 31 was admitted to the facility on [DATE] with diagnoses of osteomyelitis…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 honor resident rights when: A hot shower request for three of nine sampled residents (Resident 1, 2 and 6), was not an option, and the alternative was a cold shower or no shower. This failure resulted in Resident 1, 2 and 6 individual preferences or choice being devalued (reduce or underestimate the worth of importance of) and not being treated with honor or respect. Findings: During an interview on 9/19/24 at 6:35 p.m., with Resident 1, Resident 1 stated the facility did not have hot water in the showers and she was not able to take a shower as scheduled. Resident 1 stated the facility has two showers but one had been broken for some, the facility only had one working shower and now that shower wasn ' t working. Resident 1 stated she cannot shower tonight (9/19/24) unless she wanted a cold shower. During an observation on 9/19/24 at 6:40 p.m., the [NAME] side shower was turned on. Water was turned on for 4 minutes and no hot or warm water…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 30 of 30 sampled residents when: 1. The cabinet storing clean pots and pans had dust and food crumbs, and a drawer that stored clean utensils had food crumbs. 2. The side wall of the stove was caked with black grime and grease, and the floor behind the stove had a build-up of black grime and crumbs. The upstairs dining room food serving area had a dirty wall with a yellow drip stain and wadded paper observed behind the steam table. Food particles and dirt were observed next to the steam table along the space between the wall and floor where there was no baseboard in place. 3. The floor under the dishwasher was not smooth and easily cleanable. 4. There was an opening in the wall of the kitchen that was open to the outside. This had the potential to allow insects and rodents to enter from the outside. 5. The ice machine and food prep sink did not have an air gap (a vertical space between the end…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 complete and accurate medical records in accordance with accepted professional standards and practices for three of eight sampled residents (Resident 12, Resident 13 and Resident 20) when: 1.Resident 12's Physician Orders for Life Sustaining Treatment (POLST-a written portable medical order form with instructions for emergency medical care that travels with a resident ) was not completely documented with Resident 12's information. 2. Resident 13 and Resident 20's POLST did not have the second page completed. These failures resulted in Resident 12, Resident 13, and Resident 20's medical information to not be readily accessible and portable in case of an emergency. Findings: During a review of Resident 12's Physician Orders for Life Sustaining Treatment (POLST), dated 10/3/19, the back side of the POLST form that provides resident information, supervising physician, and additional contact information was not completed. 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 implement a system to oversee grievances in accordance with their policy and procedure (P&P) for one of twelve sampled residents (Resident 15) when the facility's Social Services Director (SSD) failed to document, track, and investigate the grievance reported by Resident 15. This failure had the potential to result in Resident 15 not being able to exercise her rights and lack of appropriate action to resolve her grievances. Findings: During a review of Resident 15's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 1/11/24, the AR indicated, Resident 15 was admitted from an acute care hospital on [DATE] to the facility, with diagnoses which included Fracture of Left Femur (broken left thigh bone), Malignant Neoplasm of the Lung (a type of cancer that starts in the lungs, symptoms includes coughing up blood, shortness of breath, chest…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 review the facility failed to meet standards of quality for one of seven sampled residents (Resident 26) when Resident 26's morning medications (sertraline-antidepressant and lamotrigine-anticonvulsive) were in a medication cup on Resident 26's bedside table. This failure had the potential to result in Resident 26 not taking her medications and other residents in the facility at risk for taking the unprescribed medications. Findings: During a concurrent observation and interview on 1/9/24 at 9:17 a.m. with Resident 26, in Resident 26's room, Resident 26 lay in bed with a bedside table next to her. Resident 26's bedside table had a cup of juice, a bowl of cream of wheat and a medication cup with two medications in it. The medication cup had one blue pill and one green and white capsule. Resident 26 stated the medications in the medication cup were hers. Resident 26 stated the two medications in the cup were sertraline and lamotrigine. Resident 26 stated she was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure residents were free from unnecessary medications for one of four sampled Residents (Resident 25) when Resident 25 was administered oxycodone HCl (a narcotic used to treat severe pain that can result in physical dependence) for treatment of a healed wound. This failure placed Resident 25 at risk for receiving pain medication unnecessarily which could lead to medication dependence. During an interview on 1/9/24 at 11:42 a.m. with Resident 25, Resident 25 stated he was experiencing pain in both shoulders that was progressing down both arms. Resident 25 stated the pain increased when lifting both arms and pain medication was not effective. During a review of Resident 25's admission Record (a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), indicated Resident 25 was admitted to 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 observation, interviews and record review, the facility failed to store and secure medications in a locked compartment for five of five sampled medications when discontinued medications albuterol sulfate inhalation aerosol (medication for breathing), ipratropium and albuterol (nebulizer solution, used to open the airways in lung diseases where spasm may cause breathing problems), and two boxes of loperamide hydrochloride and simethicone tablets (antidiarrheal and anti-gas tablets) and guaifenesin (helps clear mucus) were stored in an unlocked drawer in the nurse's station. This failure had the potential for residents and staff to have access to the medications. Findings: During a concurrent observation and interview on 1/10/24 at 4:20 p.m. with Licensed Vocational Nurse (LVN) 1 in the nurses' station, five medication boxes were stored in an unlocked drawer. LVN 1 validated the medications observed were albuterol sulfate inhalation aerosol with a handwritten date of 12/3/23, ipratropium and albuterol with a handwritten date of 12/28/23, loperamide hydrochloride 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 maintain and provide one of one resident (Resident 12) beds in safe operating condition when Resident 12's head of the bed and foot of the bed would not raise up or lower. This failure resulted in Resident 12 being uncomfortable while in her bed. During a concurrent observation and interview on 1/9/24 at 9:17 a.m. with Resident 12, Resident 12's bed would not raise or lower at the head of the bed (HOB) or the foot of the bed (FOB). Resident 12 stated, the bed had not functioned for six months, and she had made staff aware of the issue. Resident 12 stated when she wanted to sit upright, the staff would position pillows behind her back in bed, causing discomfort. Resident 12 stated she would have to sit up in her wheelchair during her meals or sit up at the edge of the bed having to adjust frequently. Resident 12 stated she felt uncomfortable because she did not always want to lay flat on the bed. During a review of Resident 12's admission…

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