Sherman Oaks Health & Rehab

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the licensed nursing staff failed to ensure the residents and/or responsible party (RP) were informed in advance, of the risks and benefits of psychoactive medication (psychotropic medication, psychotherapeutic medication - a drug that changes brain function and results in alterations in perception, mood, consciousness or behavior) for four of five sampled residents (Residents 96, 89, 48, and 8) reviewed for informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) by failing to ensure: 1. Resident 96's sertraline (treat the symptoms of depression [persistent feelings of sadness and loss of interest that can interfere with daily living]) or other mental health problems) and alprazolam (drug used to treat anxiety disorders [a feeling of worry, nervousness, or fear, often about things that might happen, and it can involve physical symptoms like a racing heart or sweating] and…

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

Based on observation, interview, and record review, the facility failed to promote the resident rights to examine the results of the most recent survey (a survey to determine compliance with state and federal regulations) of the facility by failing to post the most recent survey results in places that are prominent and accessible (a place where individuals wishing to examine survey results do not have to ask to see them) to residents, family members, and legal representatives of residents. This deficient practice resulted in the residents' and their representative not having access to examine the most recent survey results. Findings: During an interview on 3/12/2025 at 10:03 a.m., inside the dining room, seven (7) of 7 resident council group attendees stated they do not know where to examine the most recent survey results. The attendees pointed at the black metal rack outside the Activity Director's (AD) office where they can locate the binder for the most recent survey results. During a concurrent observation, upon inspection of the black metal rack, there was no survey binder…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 respect and dignity including the right to be free from physical restraints (any manual method, physical or mechanical device, equipment, or material that is attached or adjacent to the resident's body, cannot be removed easily by the resident, and restricts the resident's freedom of movement or normal access to his/her body) for two of two sampled residents (Residents 49 and 267) reviewed for restraints by: 1. Failing to complete a restraint assessment, obtain a physician's order, obtain informed consent, and development and implement a care plan prior to application of the bed alarm while in bed for Resident 49. 2. Failing to ensure Resident 267 did not have pillows tucked under the fitted sheet on both sides as observed on 3/13/2025 at 10:11 a.m. These deficient practices had the potential to result in the restriction of residents' freedom of movement, a decline in physical functioning, psychosocial…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents received person-centered care by failing to implement the Care Plan (a document outlining a detailed approach to care customized to an individual resident's need) for two (2) of three (3) sampled residents (Resident 42 and 79) reviewed for unnecessary medications (any drug in excess) by failing to: 1a. Monitor the side effects (also known as adverse consequences - unwanted, uncomfortable, or dangerous effects that a drug may have) of clopidogrel (a medication used for paroxysmal atrial fibrillation [irregular and fast heartbeat] that thins the blood) and Eliquis (a medication used for atrial fibrillation that thins the blood) for Resident 42. As a result, Resident 42 did not have monitoring for sign and symptoms of bleeding for the use of clopidogrel and Eliquis between 3/1/2025 and 3/13/2025. 1b. Monitor the side effects of gabapentin (a medication used for epilepsy [seizure - bursts of uncontrolled electrical activity between brain…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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's licensed nursing staff failed to provide care in accordance with professional standards to three (3) of four sampled residents (Residents 107, 17, and 48) reviewed for insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin administration sites. This deficient practice had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin such as excessive bruising, lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin). Cross reference F760. Findings: 1. During a review of Resident 107's admission Record, the admission Record indicated the facility admitted the resident on 2/17/2025, with diagnoses…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 4. During a review of Resident 4's admission Record, the admission Record indicated the facility originally admitted the resident on 1/13/2017 and readmitted on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), hypertension (HTN-high blood pressure), and type II diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 4's Fall Risk Assessment, dated 2/27/2025, the Fall Risk Assessment indicated the resident as high risk for falls and care plan will be developed to reduce falls and injuries. During a review of Resident 4's physician order, dated 2/28/2025, the physician order indicated low bed with bilateral upper siderails up with bilateral floor mats to decrease potential injury due to unpredictable related to dementia. During a review of Resident 4's Care Plan (CP) Report focus on falling star program, dated 3/3/2025, the CP Report indicated interventions including floor mats. 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 3. During a review of Resident 96's admission Record, the admission Record indicated the facility admitted the resident on 3/6/2024, and readmitted the resident on 2/3/2025, with diagnoses including acute respiratory failure (the lungs are suddenly unable to get enough oxygen into the blood or are struggling to remove carbon dioxide), novel influenza A virus (a new type of flu virus that can infect humans), and pleural effusion (an abnormal buildup of fluid between the lungs and the chest wall, which can make it harder to breathe). During a review of Resident 96's H&P, dated 2/5/2025, the H&P indicated the resident was alert and oriented to person, place, time, and situation. During a review of Resident 96's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others and had an intact cognition (a person's mental abilities, like thinking, learning, remembering, and understanding, are functioning normally and effectively). The MDS indicated the resident was 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 ensure residents who received hemodialysis (HD, process of removing waste products and excess fluid from the body) received treatment consistent with professional standards of practice for one of one sampled resident (Resident 5) reviewed under the Dialysis care area by failing to ensure licensed nurses performed and documented assessments after Resident 5's hemodialysis sessions. This deficient practice placed the resident at risk for a delay in care and services and a delay in detecting complications resulting from HD. Findings: During a review of Resident 5's admission Record, the admission Record indicated the facility admitted the resident on 6/14/2023 and readmitted the resident on 7/25/2024 with diagnoses that included end stage renal disease (the kidneys cease functioning on a permanent basis), dependence on renal dialysis, and hypertension (high blood pressure [the force of the blood pushing on the blood vessel walls is too high]). During a review of Resident 5's Minimum Data Set (MDS - resident assessment tool)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to account for three (3) doses of Controlled Medication (also known as Controlled Drug and Controlled Substance [CM, CD, CS]- medications which have a potential for abuse and may also lead to physical or psychological dependence) for Residents 5, 97 and 272 in one (1) of four (4) inspected medication carts (Medication Cart Middle Station Morning.) As a result, control and accountability of CMs and availability of medications did not follow state and federal regulations and facility policy and procedures (P&P). These deficient practices increased the opportunity for CM diversion (the transfer of a controlled medication or other medication from a lawful to an unlawful channel of distribution or use) and the risk that Residents 5, 97 and 272 could have accidental exposure to harmful medications possibly leading to physical and psychosocial harm and hospitalization. Findings: During a concurrent observation and interview on 3/12/2025 at 11:45…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Consultant Pharmacist (CP) failed to report any irregularities in the monthly drug regimen review to the attending physician and director of nursing to two (2) of three (3) sampled residents (Resident 42 and 79) reviewed for unnecessary medication (Resident 42 and 79) use by failing to: 1. Ensure Resident 42 had monitoring for signs and symptoms of bleeding with the use of clopidogrel (a medication used for paroxysmal atrial fibrillation [irregular and fast heartbeat] that thins the blood) and Eliquis (a medication used for atrial fibrillation that thins the blood) 2. Ensure Resident 42 had monitoring for signs and symptoms of drug toxicity (accumulation of an excessive amount of any medication in the bloodstream) with the use of gabapentin (a medication used for epilepsy [seizure - bursts of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle movements, behaviors, sensations or states of awareness]) 3. Ensure Resident 79…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that resident's drug regimen was free from unnecessary drugs (any drug in excess) for three (3) of three (3) sampled residents (Resident 42, 79, and 40) for unnecessary medication review by failing to: 1. Monitor the side effects (also known as adverse consequences - unwanted, uncomfortable, or dangerous effects that a drug may have) of clopidogrel (a medication used for paroxysmal atrial fibrillation [irregular and fast heartbeat] that thins the blood) and Eliquis (a medication used for atrial fibrillation that thins the blood) for Resident 42. As a result, Resident 42 did not have monitoring for sign and symptoms of bleeding for the use of clopidogrel and Eliquis between 3/1/2025 and 3/13/2025. 2. Monitor the side effects of gabapentin (a medication used for epilepsy [seizure - bursts of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle movements, behaviors, sensations or states of awareness])…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 5. During a review of Resident 95's admission Record, the admission Record indicated the facility admitted the resident on 9/4/2024 with diagnoses including dementia (a progressive state of decline in mental abilities), generalized anxiety disorder (a mental health disorder that produces fear, worry, and a constant feeling of being overwhelmed), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 95's History and Physical (H&P), dated 9/8/2024, the H&P indicated, the resident does not have the capacity to understand and make decisions. During a review of Resident 95's Minimum Data Set (MDS-a resident assessment tool), dated 12/17/2024, the MDS indicated the resident sometimes had the ability to understand others and make self understood. The MDS indicated the resident was taking a high-risk anti-anxiety drug class medication. During a review of Resident 95's physician orders, dated 2/5/2025, the physician orders indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five (5) percent (%). Four (4) medication errors out of 32 total opportunities contributed to an overall medication error rate of 12.5% affecting two (2) of three (3) residents observed for medication administration (Resident 21 and 77.) The medication errors were as follows: 1. Resident 21: a. Received carvedilol (a medication used to for hypertension [HTN - a condition in which the blood vessels have persistently raised pressure]) at a different time than ordered by Resident 21's physician. b. Received a form of multivitamin (a medication used as a dietary supplement to provide essential vitamins, minerals, and other nutritional elements) that was different than the one ordered by Resident 21's physician c. Did not receive PEG (a medication used to prevent cerebrovascular accidents [CVA] - an interruption in the flow of blood to cells in the brain] by thinning the blood) as ordered by…

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

2. During a review of Resident 17's admission Record, the admission Record indicated the facility originally admitted the resident on 11/2/2021 and readmitted in the facility on 9/22/2024 with diagnoses including type two (2) diabetes mellitus (DM 2 - a disorder characterized by difficulty in blood sugar control and poor wound healing), long term use of insulin, and dementia (a progressive state of decline in mental abilities). During a review of Resident 17's History and Physical (H&P) dated 9/25/2024, the H&P indicated Resident 17 did not have the capacity to understand and make decisions. During a review of Resident 17's Minimum Data Set (MDS, a resident assessment tool) tool), dated 1/25/2025, the MDS indicated Resident 17 had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) and required substantial/maximal assistance to total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS further indicated Resident 17 received insulin. During…

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

Based on interview and record review, the facility failed to revise and provide a current staffing plan in the Facility's Assessment (evaluates the resident population and determines what resources are necessary to care for residents competently during both day-to-day operations [including nights and weekends] and emergencies) to meet resident's needs. This deficient practice placed the residents at risk for lack or delay of care and treatment services and resulted in Resident 21 and 77 receiving medications at later time than scheduled. Cross reference F759 Findings: During an interview on 3/11/2025 at 12:30 p.m., with Licensed Vocational Nurse (LVN) 3, LVN 3 stated she administered carvedilol at 9:27 a.m. instead of 7:15 a.m. that morning to Resident 21 because LVN 3 was busy with another resident. LVN 3 stated carvedilol needed to be administered with food to prevent stomach discomfort and increase the absorption of the medication. LVN 3 stated she failed to administer carvedilol as prescribed by Resident 21's physician and that a delay in medication administration was considered…

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

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by failing to ensure clean linens were protected from environmental contaminants when 17 of 17 clean linen cart covers were covered with a permeable (can be passed through, especially by liquids or gases)/loosely woven material to cover the linens. This deficient practice had the potential to spread infections and illnesses among residents and staff. Findings: During a concurrent observation and interview on 3/13/2025 at 9:01 a.m. with Certified Nursing Assistant (CNA) 7, CNA 7 stated each CNA has a clean linen cart and the blue cover is made of nesh and netted. CNA 7 stated the laundry staff disinfects the linen carts. During a concurrent interview and record review on 3/13/2025 at 1:36 p.m. with CNA 8, CNA 8 stated the clean linen cart covers have tiny holes. During a concurrent observation and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide care in a manner that promoted dignity and respect for one of one sampled resident (Resident 115) when facility staff failed to follow the Do Not Resuscitate (DNR- a written document signed by the patient or their legal representative and the patient's physician, and it is placed in the patient's medical records indicating the resident's wishes of withholding resuscitation efforts) physician order for Resident 115 reviewed under Death care area. This deficient practice violated the rights of the resident to be treated with dignity and respect. Cross-reference: F678 Findings: During a review of Resident 115's admission Record, the admission Record indicated the facility originally admitted the resident on 11/26/2024 and readmitted on [DATE] with diagnoses including metabolic encephalopathy (a condition where the brain does not work normally because of problems with the body's metabolism [how the body manages food, energy, or chemicals]), 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 provide reasonable accommodation of resident needs and preferences by failing to ensure the call light (CL, an alerting device for nurses or other nursing personnel to assist a patient when in need) was within reach for two of six sampled residents (Residents 46 and 107) reviewed under the Environment task. This deficient practice had the potential to result in the delay of care and services and possible injury to residents when they are unable to summon health care workers. Findings: a. During a review of Resident 46's admission Record, the admission Record indicated the facility admitted the resident on 3/25/2022 and readmitted the resident on 6/12/2023 with diagnoses that included dysphagia (difficulty swallowing) unspecified cerebrovascular disease (conditions that affects blood vessels and blood supply of the brain), sequelae (a condition which is the consequence of a previous disease or injury) of nontraumatic subarachnoid hemorrhage…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 offer the resident or their resident representative assistance with formulating an Advance Directive (AD - a legal document indicating resident preference on end-of-life treatment decisions) upon admission for two of two sampled residents (Residents 79 and 97) reviewed for advance directive. This deficient practice violated the residents and/or their representatives the right to be fully informed of the option to formulate an AD and had the potential to delay emergency treatment or the potential to force emergency, life-sustaining procedures against the residents' personal preferences. Findings: a. During a review of Resident 79's admission Record, the admission Record indicated the facility originally admitted the resident on 1/29/2024 and readmitted in the facility on 9/17/2024 with diagnoses including dementia (a progressive state of decline in mental abilities), and hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe, comfortable, and homelike environment for two (2) of six (6) sampled residents (Residents 79 and 70) reviewed under the environment task by failing to: 1. Ensure Resident 79's floor mat (a cushioned floor pad designed to help prevent injury should a person fall) was free from tears and patched with black tape. 2. Ensure windowsills and baseboards were in good repair and walls were free from red stenciled letters F-L-A-I for one of six sampled residents (Resident 70) reviewed under the Environment task. These deficient practices had the potential to negatively affect the resident's psychosocial wellbeing and make the residents feel uncomfortable in their living space. Findings: a. During a review of Resident 79's admission Record, the admission Record indicated the facility originally admitted the resident on 1/29/2024, and readmitted the resident into the facility on 9/17/2024 with diagnoses including dementia (a…

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

Based on interview and record review, the facility failed to complete and provide a notice of bed-hold policy and return form (reserving a resident's bed while the resident is absent from the facility) when the resident was transferred to general acute care hospital (GACH) 1 for one of three sampled residents (Resident 33) selected for closed record review. This deficient practice had a potential to result in the resident's responsible party being unaware of the bed hold policy and can lead to a transfer of the resident to another skilled nursing facility not of the resident's or responsible party's preference. Findings: During a review of Resident 33's admission Record, the admission Record indicated the facility admitted the resident on 3/29/2019, and readmitted the resident on 1/31/2025, with diagnoses including metabolic encephalopathy (a change in how your brain works due to an underlying condition), sepsis (a life-threatening blood infection), and pneumonitis (swelling and irritation, also called inflammation, of lung tissue). During a review of Resident 33's History 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.

Deficiency Text Not Available

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow the Do Not Resuscitate (DNR- a written document signed by the patient or their legal representative and the patient's physician, and it is placed in the patient's medical records indicating the resident's wishes of withholding resuscitation efforts) physician order for one of one sampled resident (Resident 115) when cardiopulmonary resuscitation (CPR-emergency procedure used to restart a person's heartbeat and breathing after one or both have stopped) was administered to Resident 115. This deficient practice violated the resident's preferred treatment wishes. Cross-reference: F550 Findings: During a review of Resident 115's admission Record, the admission Record indicated the facility originally admitted the resident on 11/26/2024 and readmitted on [DATE] with diagnoses including metabolic encephalopathy (a condition where the brain does not work normally because of problems with the body's metabolism [how the body manages food, energy, or…

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

Based on interview and record review, the facility failed to ensure residents who experienced a significant change of status is comprehensively assessed for one of one sampled resident (Resident 3) reviewed under change of condition by failing to perform a change of condition assessment on 8/25/2024, when the resident was discharged to General Acute Care Hospital (GACH) 2 for abnormal laboratory and elevated white blood cells (WBC, a part of the immune system that protects your body from infection) and blood urea nitrogen (BUN, measures the amount of a waste product called urea nitrogen in your blood, which is a byproduct of protein breakdown, and helps doctors assess kidney function). This deficient practice had the potential to negatively affect the provision of necessary care and services. Findings: During a review of Resident 3's admission Record, the admission Record indicated the facility admitted the resident on 3/24/2007, and readmitted the resident on 9/4/2024, with diagnoses including metabolic encephalopathy (a change in how your brain works due to an underlying…

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

Based on observation, interview, and record review, the facility failed to ensure residents with a urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) received appropriate care and services to prevent urinary tract infections (UTI, an infection in the bladder/urinary tract) for two of two sampled residents (Residents 272 and 371) reviewed for urinary catheter or UTI by failing to ensure Residents 272's and 371's urinary catheter tubing did not have a loop while hanging on the side the bed. This deficient practice had the potential for the resident's urine not to flow freely which may lead to development of UTI. Findings: a. During a review of Resident 272's admission Record, the admission Record indicated the facility admitted the resident on 3/3/2025 with diagnoses including obstructive and reflux uropathy (a condition where urine flow is blocked in the urinary tract causing the urine to back up and damage the kidneys), difficulty in walking, and generalized muscle weakness. During a review of Resident 272's Order Summary Report, the Order Summary…

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

Based on observation, interview, and record review, the facility failed to implement interventions consistent with the resident's assessed needs and goals to maintain acceptable parameters of nutritional for one of four sampled residents (Resident 42) by failing to provide Ensure (a nutritional supplement) to Resident 42 as ordered. This deficient practice had the potential to place Resident 42 at further risk of weight loss. Findings: During a review of Resident 42's admission Record, the admission Record indicated the facility originally admitted the resident on 6/30/2019 and readmitted the resident on 4/20/2024 with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), chronic pain syndrome (pain that lasts longer than three months), Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements) without dyskinesia (involuntary, erratic, writhing movements of the face, arms, legs or trunk). During a review of Resident 42's physician order, dated…

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

Based on observation, interview, and record review, the facility failed to ensure parenteral fluids (are liquids that are administered intravenously or by injection to bypass the digestive system) were administered consistent with professional standards of practice for two (2) of 2 sampled residents (Residents 269 and 15) reviewed during a random observation by: 1. Failing to change the loose and soiled dressing on Resident 269 right upper arm (RUA) peripherally inserted central line catheter (PICC line - a long, thin tube inserted through a vein in the arm and passed through to the larger veins near the heart used for long-term intravenous access) as observed on 3/11/2025 at 9:10 a.m. 2. Failing to place a sterile injection cap over the injection port of Resident 15's peripheral intravenous line (PIV - a soft, flexible tube placed inside a vein, usually in the hand or arm to give a person medicine or fluids). These deficient practices had the potential to place Residents 269 and 15 at risk for developing complications such as inflammation of the vein and infection. Findings: a.…

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

Based on observation, interview, and record review, the facility failed to assess the risk of entrapment (an event in which a resident is caught, trapped, or entangled in spaces in or about the bed rail, mattress, or hospital bed frame) from bed rails (a safety device that's installed along one or both sides of a bed to prevent falls) prior to its continued use to one of 2 sampled residents (Resident 88) reviewed for restraints (are any action or procedure that prevents a person's free body movement to a position of choice and/or normal access to the body by the use of any method, attached or adjacent to a person's body that the person cannot control or remove easily) use by failing to assess the resident for risk of entrapment from bed rails quarterly. The deficient practices predisposed residents to bed entrapment and unnecessary restraints. Findings: During a review of Resident 88's admission Record, the admission Record indicated the facility admitted the resident on 2/19/2023, with diagnoses including dementia (a progressive state of decline in mental abilities), age-related…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 were labeled in accordance with currently accepted professional principles to facilitate consideration of precautions and safe administration of medications by failing to ensure intravenous (administered within a vein) meropenem (medication used to treat a wide range of bacterial infections) was labeled with the resident's name for one of two sampled residents (Resident 109) reviewed under the Antibiotic care area. This deficient practice had the potential to result in medication administration to the wrong resident resulting in adverse effects (an undesired and harmful result of a treatment or intervention, such as a medication or surgery) of medication. Findings: During a review of Resident 109's admission Record (AR), the AR indicated the facility admitted the resident on 12/6/2024 and readmitted the resident on 3/10/2025, with diagnoses that included malignant neoplasm (cancer) of prostrate (small gland in the male reproductive system, located below the bladder), and urinary tract infection…

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

Based on interview and record review, the facility failed to follow-up with the endocrinologist when Resident 77's hemoglobin A1C (HbA1c-a test that indicates the average level of blood sugar control over the last couple of months, a high number is a sign of poor blood sugar control) test result was reported to the facility for one of five sampled residents (Resident 77) reviewed under Unnecessary Meds, Psychotropic (medications capable of affecting the mind, emotions, and behavior) Meds, and Med Regimen Review Care Area. This deficient practice placed Resident 77 at risk for uncontrolled Hb1A1c levels which could lead to hyperglycemia (high blood sugar), kidney damage, and make the resident susceptible to infections and poor wound healing. Findings: During a review of Resident 77's admission Record, the admission Record indicated the facility admitted the resident on 11/5/2022 with diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) with diabetic neuropathy (a complication of diabetes that damages 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 proper sanitation and food handling practices by failing to ensure a pitcher of cranberry juice stored in the refrigerator in the kitchen was labeled with the date it was poured on the container. These deficient practices had the potential to cause food-borne illnesses (also known as food poisoning, a sickness from eating or drinking contaminated food or beverages, often causing symptoms like nausea, vomiting, and diarrhea). Findings: During a kitchen observation tour and interview on 3/11/2025, at 10:35 a.m., with the Dietary Manager (DM), inside the facility's kitchen, observed a pitcher of cranberry juice stored in the kitchen refrigerator without the date it was poured on the pitcher. The DM stated the staff should have dated the pitcher of cranberry juice once poured to ensure the cranberry juice was fresh and not passed it best use by date to prevent food-borne illness to residents due to ingestion of potentially expired drinks. During an interview on 3/14/2025, at 11:37 a.m., with the Director…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medical records within accepted professional standards for one of eight sampled residents (Resident 17) reviewed for accidents by failing to complete the elopement risk assessment accurately. This deficient practice had the potential to result in inaccurate documentation in the medical record regarding Resident 17's elopement risk status. Findings: During a review of Resident 17's admission Record, the admission Record indicated the facility originally admitted the resident on 11/2/2021 and readmitted the resident on 9/22/2024 with diagnoses including cerebral infarction (also known as stroke, loss of blood flow to a part of the brain) and dementia (a progressive state of decline in mental abilities). During a review of Resident 17's History and Physical (H&P) dated 9/25/2024, the H&P indicated Resident 17 did not have the capacity to understand and make decisions. During a review of Resident 17's Minimum Data Set (MDS, a resident assessment tool) tool), dated 1/25/2025, the MDS indicated Resident 17 had…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 fairness and integrity of the binding arbitration process (method of resolving disputes outside of court) when one of three sampled residents (Resident 3) reviewed under the Arbitration Agreement (AA - legal document agreeing to arbitration) task, was offered and entered into an AA that failed to provide for the selection of a neutral arbitrator (impartial, or unbiased third-party decision maker) agreed upon by both parties and for the selection of a venue that was convenient to both parties. This deficient practice had the potential to cause psychosocial harm to residents during the binding arbitration process. Findings: During a review of Resident 3's admission Record (AR), the AR indicated the facility admitted the resident on 3/24/2007 and readmitted the resident on 9/4/2024, with diagnoses that included metabolic encephalopathy a (general term that describes brain disease, damage, or malfunction usually related to inflammation within the body), acute on chronic respiratory failure (a serious condition 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.

Based on interview and record review, the facility failed to ensure necessary care was provided consistently for a resident who was receiving hospice service (a program designed to provide a caring environment for meeting the physical and emotional needs of the terminally ill) for one of two sampled residents (Resident 95) reviewed under Hospice Care Area by, failing to: 1. Ensure the hospice doctor signed Resident 95's initial Certification of Terminal Illness (CTI-a document in which the physician certifies the patient is terminally ill with a prognosis of six (6) months or less). 2. Ensure Hospice Provider (HP) 1 provided Resident 95's hospice plan of care to the facility upon completion of the recertification of the resident's CTI. These deficient practices had the potential to negatively affect Resident 95's physical comfort, psychosocial well-being, and had the potential to result in a delay or a lack of necessary care and services. Findings: During a review of Resident 95's admission Record, the admission Record indicated the facility admitted the resident on 9/4/2024 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 the urinary catheters of two of five sampled residents (Resident 2 and Resident 5) were positioned properly to allow unobstructed flow of urine. This deficient practice had the potential to result in Resident 2 and Resident 5 ' s increased risk for infection, injury, and pain. Findings: a. A review of Resident 2 ' s admission Record indicated the facility admitted the resident on 1/4/2023 with diagnoses including cerebral palsy (abnormal brain development or damage to the developing brain that affects a person ' s ability to control their muscles), type 2 diabetes mellitus (a disease that occurs when the blood sugar is too high), and obstructive and reflux uropathy (a condition in which the flow of urine is blocked). A review of Resident 2 ' s History and Physical Examination, dated 2/14/2024, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 2 ' s Minimum Data Set (MDS – a standardized assessment and care-screening tool), dated 2/16/2024, indicated…

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

Based on observation, interview, and record review, the facility failed to follow infection control procedures for one of five sampled residents (Resident 5) when Licensed Vocational Nurse 1 (LVN 1) failed to wear a disposable isolation gown (protective apparel used to protect healthcare workers and patients from the transfer of microorganisms and body fluids) while repositioning Resident 5 ' s urinary catheter (a flexible tube inserted into the bladder [a hollow, stretchy organ that stores urine] to empty urine). Resident 5 was on Enhanced Standard Precaution (ESP – a resident-centered approach and activity-based approach for preventing multiple drug resistant organisms [MDRO] transmission in skilled nursing facilities [SNF]). This deficient practice had the potential to spread infection to other residents. Findings: A review of Resident 5 ' s admission Record indicated the facility admitted the resident on 10/19/2023 with diagnoses including chronic kidney disease (a condition in which the kidneys were damaged and cannot filter blood as well as they should), dementia (impaired…

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

Based on interview and record review the facility failed to provide prompt efforts to resolve request and grievances on outings voiced by the residents to the facility through the Resident Council Meetings (resident's representative group) for seven of seven resident council group interview attendees during review of resident council facility task. This deficient practice had the potential to result in the residents' grievances to remain unresolved and could lead to increased frustration affecting the residents' overall satisfaction and well-being in the facility. Findings: During a resident council interview on 3/19/2024 at 11:04 a.m., in the physical therapy room, seven of seven resident council group attendees stated the facility does not act promptly on the resident's grievances and recommendations for outings. The resident council group attendees stated this was brought up few months ago during their resident council meetings, and there has been no resolution yet. During an interview on 3/19/2024 at 4:17 p.m., with the Activity Director (AD), the AD stated the facility used 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 residents rights to forms of communication with privacy by failing to ensure mail was delivered on Saturdays for seven of seven residents interviewed during the resident council task. This deficient practice violated the residents' right to receive mail on Saturdays and had the potential to negatively affect the resident's psychosocial well-being. Findings: During a resident council interview on 3/19/2024 at 11:04 a.m., in the physical therapy room, seven of seven resident council group attendees stated the facility does not deliver their mails on Saturdays and they would wait until Monday to receive it. During an interview on 3/19/2024 at 4:25 p.m., with the Activities Director (AD), the AD stated after the activity staff sort out the mail, they would take it with them during their room visits and give to the residents. The AD stated they do not distribute mail on the weekends because the front lobby is closed, and the receptionist is off on Saturdays and Sundays. During an interview on 3/19/2024 at 4:30 p.m., 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 promote the resident rights to examine the results of the most recent survey (a survey to determine compliance with state and federal regulations) of the facility by failing to post the most recent survey results in a place that is prominent and accessible (a place where individuals wishing to examine survey results do not have to ask to see them) to residents, family members, and legal representatives of residents. This deficient practice resulted in the residents' and their representative not having access to examine the most recent survey results. Findings: During a resident council interview on 3/19/2024 at 11:04 a.m., in the physical therapy room, seven of seven resident council group attendees stated they do not know where to examine the most recent survey results. During a concurrent observation and interview on 3/19/2024 at 11:57 a.m., in the lobby with the Activity Director (AD), the AD stated the survey binder is placed on top of the counter and cordoned off because residents take it and at night,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review facility failed to maintain privacy of confidential information when a display of multiple appointments along with the resident's date of birth and type of appointment were posted on the wall of the resident's room for one of one random observation (Resident 46). This deficient practice had the potential result in unauthorized exposure of resident's confidential information. Findings: A review of Resident 46's admission Record indicated the facility originally admitted the resident on 1/4/2023 and readmitted on [DATE] with diagnoses including cerebral palsy (a group of conditions that affect movement and posture), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and psychosis (severe mental disorder in which thought, and emotions are so impaired that contact is lost with external reality). A review of Resident 46's History and Physical, dated 2/14/2024, indicated the resident does not have the…

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

Based on interview and record review, the facility staff failed to provide care in accordance with professional standards to two out of five sampled residents (Resident 48 and 91) investigated during review of unnecessary medications by failing to: 1. Ensure licensed nurses rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) administration sites of insulin (a hormone that lowers the level of sugar in the blood) to Resident 48 and Resident 91. The deficient practice had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin such as lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (a rare disease that occurs when a protein called amyloid builds up in organs). 2. Ensure licensed nurses clarified the order for prednisone for Resident 48 dated 3/6/2024 from the Nurse Practitioner (NP) before administering the medication to the resident. The deficient practice resulted in a medication error due to licensed nurse administered the wrong dosage…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide care consistent with professional standards of practice to prevent pressure ulcer/injury (breakdown of skin integrity due to pressure) for five (5) out of 5 sampled residents (Resident 51, 303, 38, 7, and 57) investigated during review of pressure ulcers care area by failing to set the low air loss mattress (LALM, designed to distribute the resident's weight over a broad surface area and help prevent skin breakdown) according to the resident's weight. This deficient practice had the potential for the development and worsening of pressure ulcers/injuries. Findings: a. A review of Resident 51's admission Record indicated the facility admitted the resident on 1/19/2024 with diagnoses including same level fall incident, left femur fracture (a break in the thigh bone), generalized muscle weakness, and difficulty in walking. A review of resident 51's History and Physical dated 1/21/2024, indicated the resident had the capacity 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 two out of five sampled residents (Resident 48 and Resident 91) were free from significant medication errors by failing to: 1. Ensure licensed nurses rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) administration sites of insulin (a hormone that lowers the level of sugar in the blood) to Resident 48 and Resident 91. The deficient practice had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin such as lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (a rare disease that occurs when a protein called amyloid builds up in organs). 2. Ensure licensed nurses clarified the order for prednisone for Resident 48 dated 3/6/2024 from the Nurse Practitioner (NP) before administration of medication to Resident 48. The deficient practice resulted in a medication error due to licensed nurse administered the wrong dosage of prednisone to Resident 48 for two days. Cross reference…

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

Based on observation, interview, and record review the facility failed to: 1. Store and label one inhalation treatment with an open date for Residents 2, in accordance with facility and manufacturer's requirements in one of three inspected medication carts (Medication Cart West.) 2. Store one insulin (a medication used to treat high blood sugar) Novolin R (fast-acting insulin) Flexpen (type of insulin injection device) for Resident 17 and one insulin Lispro (short-acting insulin) Kwikpen (type of insulin injection device) for Resident 46, in accordance with manufacturer's requirements in one of three inspected medication carts (Medication Cart Middle.) 3. Store one lorazepam (a medication used to treat anxiety and restlessness) oral concentrate (a solution with increased strength) bottle in the refrigerator for Resident 27 in accordance with the manufacturer's requirements in one of three inspected medication carts (Medication Cart West.) 4. Label one inhalation treatment with an open date for Residents 28, in accordance with facility requirements and manufacturer's requirements in…

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

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen by: 1. Failing to ensure 13 clear plastic containers of blueberries and one container of strawberries with white patches were discarded timely. 2. Failing to ensure three bottles of spices were labeled when they were opened. These deficient practices had the potential to result in harmful bacteria growth and cross-contamination (the physical movement of transfer of harmful bacteria from one person, object, or place to another) that could lead to foodborne illness (any illness of a toxic or infectious nature contracted through consumption of contaminated water or food) in 92 out of 95 medically compromised residents who receive food from the kitchen. Findings: During a concurrent observation and interview accompanied by the Dietary Supervisor (DS), observed during a kitchen tour are the following: - 13 clear plastic containers of blueberries and 1 container of strawberries with white gray patches. - 3 bottles of spices did not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain medical records that are complete and accurately documented for one of three (Resident 90) sampled residents investigated during medication regimen review by failing to maintain accurate documentation of Resident 90's Klonopin (a prescription drug used to treat anxiety [persistent and excessive worry that interferes with daily activities]) ordered on 3/1/2024 and 3/4/2024. This deficient practice had the potential to result in the resident's medical record containing inaccurate documentation. Findings: A review of Resident 90's admission Record indicated the facility originally admitted the resident on 1/3/2024 and readmitted the resident on 2/5/2024 with diagnoses including anxiety disorder and unspecified mood (affective) disorder (mental health condition marked by disruptions in emotions [severe lows or highs]). A review of Resident 90's History and Physical, dated 2/6/2024, indicated the resident has the capacity to understand and make…

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

Based on interview and record review, the facility failed to implement the facility's in-service training program by failing to monitor the mandatory in-service (training) attendance, including abuse-related and dementia (a collection of symptoms that affect the mind, where there has been some loss of contact with reality) training, of four of four Certified Nursing Assistants (CNA 1, CNA 2, CNA 3, and CNA 4) investigated under sufficient and competent staffing. This deficient practice had the potential to result in an increased risk of failing to recognize and properly handle instances of abuse or neglect towards residents. Findings: During a concurrent interview and record review on 3/22/2024 at 9 a.m., reviewed the following in-services and the Director of Staff Development (DSD) stated: - 1/12/2023 - Elder abuse prevention Policy and Procedure (P&P), CNA 1 did not attend. - 4/13/2023 - Elder abuse prevention P&P, CNA 1 and CNA 4 did not attend. - 11/4/2023 - Prevention of abuse and mistreatment, CNA 1, CNA 2, CNA 3, and CNA 4 did not attend. - 12/2/2023 - Dementia Abuse…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide care in a manner that maintained or enhanced a resident's dignity and respect in full recognition of their individuality by: 1. Failing to ensure Certified Nursing Assistant 2 was not standing over one of one sampled resident (Resident 38) while assisting the resident during a meal during review of dignity care area. 2. Failing to ensure CNA 4 was not standing over one of seven sampled residents (Resident 64) while assisting the resident during a meal during review of dining observation task. This deficient practice had the potential to affect Resident 38 and 64's self-esteem, self-worth, and the residents' sense of independence. Findings: 1. A review of Resident 38's admission Record indicated the facility admitted the resident on 6/28/2017, and readmitted the resident on 2/11/2024, with diagnoses including muscle wasting (loss of muscle tissue) and atrophy (a decrease in the size of a body part, cell, organ, or other tissue),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 call light (device used to alert nurses and other facility staff to assist a resident in need) within reach of the resident for one of three sampled residents investigated under the environment facility task (Resident 204) when Resident 204's call light was observed on the floor next to the resident's bed. This deficient practice had the potential to result in the resident not being able to call the facility staff for assistance and delay provision of care and services. Findings: A review of Resident 204 admission Record indicated the facility admitted Resident 204 on 3/8/2024 with diagnoses including, but not limited to, generalized muscle weakness, difficulty in walking, and dysphagia (difficulty swallowing). A review of Resident 204's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 3/13/2024, indicated Resident 204 was able to make herself understood and understand others and had moderately impaired cognition (the mental action or process of acquiring knowledge…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide an environment that is restraint-free as indicated in the facility's policy for one resident (Resident 60) out of one sampled resident investigated during review of physical restraints care area by: 1. Failing to ensure an order was obtained from the physician prior to use of bed pad alarm. 2. Failing to ensure the informed consent was obtained from Resident 60 or responsible party (RP) prior to use of bed pad alarm. 3. Failing to ensure a restraint assessment was completed prior to use of bed pad alarm. These deficient practices placed Resident 60 at risk for unnecessary prolonged use of restraints which can lead to a decline in functioning. Findings: A review of Resident 60's admission Record indicated the facility originally admitted the resident on 4/17/2019 and readmitted the resident on 3/13/2024 with diagnoses including metabolic encephalopathy (a condition in which brain function is disturbed either temporarily or…

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

Based on interview and record review the facility failed to complete and provide the resident or resident representative the bed hold notification form on 11/22/2023, when the resident was transferred to general acute care hospital 1 (GACH 1), for one out of three sampled residents (Resident 101) selected for closed record review. This deficient practice had a potential to result in the resident's responsible party being unaware of the bed hold policy and can lead to a transfer of the resident to another skilled nursing facility/acute care hospital not of the resident's or responsible party's preference. Findings: A review of Resident 101's admission Record indicated the facility admitted the resident on 10/16/2023, and readmitted the resident on 11/23/2023, with diagnoses including fracture of lower end of left femur (a beak of a bone in the thighbone that occur just above the knee joint), sepsis (the body's extreme response to an infection), mild protein-calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and…

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

Based on interview and record review the facility failed to develop a baseline care plan (initial written guide that organizes information about the resident's care) addressing the use of bed pad alarm for one (1) out of 1 sampled resident (Resident 60) reviewed for use of physical restraints. This deficient practice had the potential for Resident 60 not to receive the appropriate care and treatment specific to her needs. Cross Reference F604 Findings: A review of Resident 60's admission Record indicated the facility originally admitted the resident on 4/17/2019 and readmitted the resident on 3/13/2024 with diagnoses including metabolic encephalopathy (a condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body), dementia (a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities), generalized muscle weakness, and history of falling. A review of resident 60's History and Physical dated 3/15/2024, indicated the resident did not have the capacity 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 develop and implement a comprehensive person-centered care plan for: 1. One of two sampled residents investigated under the communication-sensory care area (Resident 9) when the facility failed to develop interventions in Resident 9's care plan to include the use of a communication board (an assistive visual aid with pictures and words translated into various languages used to facilitate communication between residents and staff). This deficient practice had the potential for the delay of Resident 9's care and communication with staff and visitors. 2. One of one sampled resident investigated under the respiratory care area (Resident 50) when a care plan for Resident 50's use of personal Bilevel positive airway pressure (BiPAP - a machine that delivers pressurized air into the lungs to facilitate breathing via a mask which is worn over the nose and mouth improving the level of oxygen in the blood) was not developed. The inconsistent…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 review and revise the resident's care plan to reflect the accurate status of the resident for one out of four sampled residents (Resident 38) investigated during review of pressure ulcers/injuries (damage to an area of the skin caused by constant pressure on the area for a long time) by failing to resolve the care plan for actual pressure injury when the resident's pressure injury was resolved on 2/26/2024. The deficient practice had the potential to result in the failure to address a resident's changing needs. Findings: A review of Resident 38's admission Record indicated the facility admitted the resident on 6/28/2017, and readmitted the resident on 2/11/2024, with diagnoses including mild protein calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function), pressure induced deep tissue damage of sacral region (occur when a bony prominence, such as the sacrum [tailbone], is subjected to prolonged pressure and can result in soft tissue injury), and…

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

Based on observation, interview, and record review, the facility failed to ensure residents were provided a communication device to allow communication between staff and residents for one of two sampled residents investigated under the communication-sensory care area (Resident 9), when Resident 9 was not provided a communication board (an assistive visual aid with pictures and words translated into various languages used to facilitate communication between residents and staff) to communicate with staff and visitors. This deficient practice had the potential to delay Resident 9's care and communication with staff and visitors. Findings: A review of Resident 9's admission Record indicated the facility originally admitted Resident 9 on 6/26/2019 and readmitted the resident on 9/5/2019 with diagnoses including, but not limited to, major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). The admission record further indicated Resident 9's primary language was Arabic.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents receive proper assistive devices to maintain vision and hearing abilities by failing to notify the resident's physician of a missed ophthalmology (the branch of medical science dealing with the anatomy, functions and diseases of the eye) appointment and by failing to follow the Ear, Nose, and Throat (ENT) doctor's recommendation for one of three sampled residents (Resident 29) investigated during review of communication and sensory care area. This deficient practice had the potential to result in worsening of the resident's condition and could negatively affect their daily activities and overall well-being. Findings: A review of Resident 29's admission Record indicated the facility originally admitted the resident on 5/2/2022 and readmitted the resident on 3/18/2024 with diagnoses including chronic obstructive pulmonary disease with acute exacerbation (COPD, a lung disease characterized by long term poor airflow), unspecified hearing loss, and history of falling. A review of Resident 29's…

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

Based on observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections (UTI, common infections that happen when bacteria infect the urinary tract) for one (Resident 98) out of one sampled resident during a random observation by: 1. Failing to ensure the urinary catheter (a tube that is inserted into the bladder, allowing urine to drain freely) tubing was not touching the floor. 2. Failing to ensure the urinary drainage bag (a bag designed to collect urine from the bladder via a catheter) was not placed on top of the bed. These deficient practices had the potential for Resident 98's urine not to flow freely which may lead to urinary tract infection. Findings: A review of Resident 98's admission Record indicated the facility admitted the resident on 2/14/2024 with diagnoses including obstructive and reflux uropathy (a condition in which the flow of urine is blocked causing the urine to back up and injure one or both kidneys), generalized 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.

Based on observation, interview, and record review, the facility failed to provide residents with necessary respiratory care and services that is in accordance with professional standards of practice to one (1) out of two sampled residents (Resident 50) investigated during review of respiratory care area by: 1. Failing to obtain an order from the physician regarding the use of personal Bilevel positive airway pressure (BiPAP - a machine that delivers pressurized air into the lungs to facilitate breathing via a mask which is worn over the nose and mouth improving the level of oxygen in the blood) from home prior to use. 2. Failing to obtain an order from the physician regarding monitoring of setting and maintenance for the use of BiPAP. 3. Failing to complete an assessment prior to use the BiPAP machine. These deficient practices could place the resident at risk for respiratory problems related to the use of the BiPAP machine without monitoring and without a physician's order. Cross Reference to F656 Findings: A review of Resident 50's admission Record indicated the facility…

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

Based on interview and record review the facility failed to provide pharmaceutical services accurately and safely to one out of one sampled resident (Resident 48) investigated during review of pharmacy services by failing to clarify an order of prednisone (a drug used to reduce inflammation and lower the body's immune system) prior to administration of the medication to Resident 48. The deficient practice had resulted to administering an incorrect dose of prednisone for two days, placing the resident at risk for medical complications. Cross refereance to F658 and F760. Findings: A review of Resident 48's admission Record indicated the facility admitted the resident on 1/9/2024, with diagnoses including acute respiratory failure with hypoxia (a condition where the body does not have enough oxygen in the tissues and have too much carbon dioxide in the blood), merkell cell carcinoma (a very rare disease in which malignant cells form in the skin), and malignant neoplasm (another term for a cancerous tumor) of prostate. A review of Resident 48's History and Physical (H&P), dated…

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

Based on interview and record review, the facility failed to act upon the recommendations of the consultant pharmacist and review a resident's medical record for one of one sampled residents investigated under the antibiotic (medication that inhibits the growth or destroys microorganisms) use care area (Resident 80) when the facility failed to obtain a stop date from the physician for Resident 80's erythromycin (a type of antibiotic) ophthalmic (relating to the eye and its diseases) ointment and review the medication during the February 2024 medication regimen review (a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication). These deficient practices had the potential for Resident 80 to develop antibiotic resistance (when germs like bacteria and fungi develop the ability to defeat the drugs designed to kill them) and decrease the efficacy (the ability to produce a desired or intended result) of antibiotics prescribed in the future. Cross-reference…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a resident was free from unnecessary drugs for one of one sampled resident (Resident 80) investigated under the antibiotic (medication that inhibits the growth or destroys microorganisms) use care area when Resident 80 was administered erythromycin (a type of antibiotic) ophthalmic (relating to the eye and its diseases) ointment without a stop date. This deficient practice had the potential for Resident 80 to develop antibiotic resistance (when germs like bacteria and fungi develop the ability to defeat the drugs designed to kill them) and decrease the efficacy (the ability to produce a desired or intended result) of antibiotics prescribed in the future. Cross-reference F756 and F881 Findings: A review of Resident 80's admission Record indicated the facility admitted the resident to the facility on 1/29/2024 with diagnoses including dry eye syndrome (a group of symptoms which consistent occur together) of unspecified lacrimal gland (gland that secretes tears). A review of Resident 80's Minimum Data Set (MDS - a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to incorporate resident's food preferences for one of three sampled residents (Resident 57) being investigated under food preferences by failing to serve prune juice on his breakfast tray on 3/19/2024. This deficient practice denied Resident 57 of his right for food preferences. Findings: A review of Resident 57's admission Record indicated the facility admitted the resident on 12/13/2022, and readmitted on [DATE], with diagnoses including moderate protein-calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function), dysphagia (swallowing difficulties), and type 2 diabetes mellitus (is a disease that occurs when the blood glucose, also blood sugar, is too high). A review of Resident 57's History and Physical (H&P), dated 1/26/2024, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 57's Minimum Data Set (MDS, a standardized…

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

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of seven sampled residents (Resident 12) investigated under the infection control care area when Housekeeper (HK) 1 was observed cleaning Resident 12's bathroom without wearing the appropriate personal protective equipment (PPE - protective clothing used to protect the wearer's body from infection), when Resident 12 was placed under enhanced standard precautions (ESP - a resident-centered and activity-based approach for preventing multi drug resistant organism transmission in skilled nursing facilities). This deficient practice had the potential for transmission of infection to staff and other residents. Findings: A review of Resident 12's admission Record indicated the facility originally admitted Resident 12 on 10/11/2023 and readmitted the resident on 2/24/2024 with diagnoses including…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow its Antibiotic Stewardship Program ([ASP]-a set of commitments and actions designed to improve the use of antibiotics [a medication used to treat bacterial infections]) for one of three sampled residents investigated under the medication administration care area (Resident 54) and for one of seven sampled residents investigated under the infection control care area (Resident 80) when the facility failed to follow its Antibiotic Stewardship policy and procedure (P&P) for Resident 54's Bactrim (an antibiotic used for urinary tract infection [UTI - an infection in the system of organs that makes urine]) order and Resident 80's erythromycin (a type of antibiotic) order. These deficient practices had the potential for inappropriate antibiotic therapy, of increasing the risk of adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) and leading to antibiotic resistance (the ability of bacteria or other microbes to resist…

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

Based on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 3) was free from unnecessary physical restraint (a strap or other thing that holds a person in place) by: 1. Failing to obtain a physician order for the use of four side rails. 2. Failing to obtain an informed consent (the process in which a health care provider educates a patient about the risks, benefits, and alternatives of a given procedure or intervention) on the use of four side rails. 3. Failing to monitor Resident 3 on the use of four side rails. 4. Failing to create a care plan to address the use of four side rails. These deficient practices resulted to unnecessary restraint and placed Resident 3 at risk of entrapment and injury. Findings: A review of Resident 3 ' s admission Record indicated the facility admitted the resident on 12/29/2021 with diagnoses that included displaced (the bone snaps into two or more) bimalleolar fracture (means that two of the three parts of the ankle are fractured) of right lower leg, asthma (a chronic disease of the airways…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 complete and accurate medical records in accordance with accepted professional standards for one of three sampled residents (Resident 1). On 9/24/2023 and 9/29/2023, nurses did not document indication of oxygen use as per physician ' s order. This deficient practice had the potential to result in confusion in the care and services rendered to Resident 1 and resulted in inaccurate information entered into Resident 1 ' s medical records. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 9/22/2023 with diagnoses that included encephalopathy (any disturbance of the brain's functioning that leads to problems like confusion and memory loss), Coronavirus Disease 2019 (COVID-19, highly contagious respiratory disease is thought to spread from person to person through droplets released when an infected person coughs, sneezes or talks), pneumonia (lung infection that causes your air sacs to fill up with fluid or pus [white-yellow, yellow, or yellow-brown, formed at the site…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 floor mat near the bed to prevent injuries from a potential fall as indicated in the care plan for one of three sampled residents (Resident 1) who has a history of multiple falls including the recent fall on 11/23/23 at the facility. This deficient practice had the potential to have an injury from fall from Resident 1's bed. Findings: A review of Resident 1's admission Record indicated the facility originally admitted Resident 1 on 11/6/23 and readmitted on [DATE] to the facility with diagnoses including unspecified intracapsular fracture (a broken bone located within the joint capsule) of left femur, subsequent encounter for closed fracture, multiple falls, and muscle weakness. A review of History and Physical (H & P - the most formal and complete assessment of the patient and the problem), dated 6/08/23, indicated his cognition (relating to conscious intellectual activity such as thinking, reasoning, or remembering) and memory…

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

Based on observation, interview, and record review, the facility failed to maintain infection prevention and control program for two out of three sampled residents (Resident 4 and Resident 5) by: 1. Failing to ensure Licensed Vocational Nurse 1 (LVN 1) wore fit-tested (a test protocol conducted to verify that a respirator is both comfortable and provides the wearer with the expected protection) N95 respirator (a respiratory protective device/mask designed to achieve a very close facial fit) while assisting Resident 4. 2. Failing to ensure Certified Nursing Assistant 5 (CNA 5) wore N95 respirator covering both her nose and mouth while assisting Resident 4. 3. Failing to ensure Family Member 1 (FM 1) was provided education when she was seated beside Resident 5 who was on isolation for Coronavirus Diseasse-2019 (COVID-19- highly contagious respiratory disease that is spread from person to person through droplets released when an infected person coughs, sneezes, or talks) with no face shield or goggles and her protective gown was untied with opening at the front. These deficient…

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

Based on interview and record review, the facility failed to hold (suspend the medication administration under specific conditions) the administration of nifedipine, metoprolol, and hydralazine (these medications are used to treat high blood pressure [BP - pressure circulating blood against the wall of the blood vessels]) as per physician ' s orders when the resident ' s systolic blood pressure (SBP - pressure in the arteries when the heart beats) was below 110 for one of three sampled residents (Resident 4). This deficient practice had the potential to result in further drop in Resident 4 ' s blood pressure. Findings: A review of Resident 4 ' s admission Record (face sheet) indicated the facility admitted the resident on 10/26/2023 with diagnoses that included metabolic encephalopathy (chemical imbalance in the blood that can lead to personality changes), muscle weakness, hypertension (uncontrolled elevated blood pressure) and pneumonitis (inflammation in the lung tissues without an infection). A review of Resident 4 ' s History and Physical (H&P), dated 10/28/2023, indicated the…

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

Based on interview and record review, the facility failed to update its written policies on abuse prohibition by not including reporting abuse to the State Survey Agency (SSA) within two hours from an abuse allegation being made. This deficient practice had the potential to place residents at risk for further abuse. Findings: A review of the facility ' s policy and procedure titled, Abuse Allegation Reporting, dated 9/30/2022, indicated that all allegations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property will be reported immediately to the Administrator (ADM) and abuse coordinator. The policy also indicated that an employee who identifies suspected abuse committed against an individual who was a resident must report the incident to local law enforcement entity by phone within 24 hours and provide a written report to the local Ombudsman (a residents' advocate group), the SSA and local law enforcement within 24 hours for non-serious bodily injury. A review of the facility ' s policy and procedure titled, Abuse…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to meet professional standards of quality care by documentation of unchanged orthostatic blood pressure (a form of low blood pressure that happens when you stand up from sitting or lying down) for both lying and sitting positions in the Medication Administration Record (MAR) for four of four sampled residents (Residents 3, 40, 50, and 17). This deficient practice had the potential for staff not to identify orthostatic hypotension in residents. Findings: a. A review of the admission record indicated Resident 3 was admitted to the facility, on 6/3/2019 and readmitted on [DATE], with diagnoses that included major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest) and essential hypertension (elevated blood pressure that is not due to a medical condition). A review of the Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 3/8/2022, indicated Resident 3 had the ability to make self…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that two of three sampled residents received proper treatment to maintain vision by failing to: 1. Ensure Resident 66 was referred to a glaucoma (disorder of the eye) specialist per the consulting doctor's treatment plan/recommendations. 2. Ensure Resident 43 was referred to an ophthalmologist (eye doctor) per the resident's optometrist (doctor for eyes) treatment plan/recommendations. These deficient practices had the potential to cause a decline in vision leading to accidents. Findings: a. A review of the admission record indicated Resident 66 was admitted to the facility, on 04/17/2019 and readmitted on [DATE], with diagnoses that included glaucoma (a group of eye conditions that damage the optic nerve and can lead to blindness), unspecified cataract (a cloudy area in the lens of the eye that leads to a decrease in vision), and unspecified macular degeneration (a disease that affects a person's central vision). A review 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 one of one sampled Resident (Resident 9) received an order to continue and increase House Protein Nourishment (HPN) as indicated in the plan of care. This deficient practice placed Resident 9 at risk for continued weight loss. Findings: A review of the admission record indicated Resident 9 was admitted to the facility, on 11/25/2021, with diagnoses that included Parkinson's disease (a progressive nervous system disorder that affects movement) and dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning). A review of the Minimum Data Set (MDS- a standardized assessment and screening tool), dated 03/17/2022, indicated Resident 9 could sometimes understand and sometimes understood others. The MDS indicated Resident 9's cognition was severely impacted. A review of physician's order, dated 02/21/2022, indicated Resident 9 was to receive a regular diet mechanical soft texture with thin consistency. A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents' pain were managed as indicated in the facility's Pain Management policy for three of three sampled residents (Resident 217, 77, and 47), by failing to: 1. Ensure Resident 217's pain medication, oxycodone (medication to manage moderate to severe pain) scheduled every four hours, was administered according to the physician order. This had the potential to result in unnecessary pain experienced during daily activities and can lead to a decline in the quality of the resident's life. 2. Document pre and post pain assessments for two of three sampled residents (Residents 47 and 77). This deficient practice had the potential to result in confusion on the delivery of care and services rendered and may lead to inaccurate assessment and inadequate management of residents' pain. Findings: a. A review of Resident 217's admission Record indicated resident was admitted on [DATE] with diagnoses including malignant neoplasm (cancer, 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: 1. Ensure the Controlled Drug Record (CDR- accountability record of medications that are considered to have a strong potential for abuse) coincided with the Medication Administration Record (MAR) for three of three sampled residents (Resident 47, 77, and 58). This deficient practice resulted in inaccurate reconciliation of the controlled medication and placed the facility at potential for inability to readily identify loss and drug diversion (illegal distribution of abuse of prescription drugs or their use for unintended purposes) of controlled medications. 2. Meet professional standards of quality for one of five sampled residents (Resident 40) by failing to administer blood pressure medications according to parameters (limit or boundary) set by the physician. This deficient practice had the potential to result in unintended complications related to the management of blood pressure such as hypotension (abnormally low blood pressure) for Resident 40…

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

Based on interview and record review, the facility failed to implement the facility's abuse prevention policy to ensure a background check was completed prior to hiring one of five sampled employees (Registered Nurse 1 [RN 1]). This deficient practice has the potential to result in elder abuse. Findings: During a concurrent interview and record review of RN 1's Employee File, on 03/25/2022 at 1:59 p.m., the Director of Staff Development (DSD) confirmed RN 1's date of hire was on 11/05/2021. The DSD stated RN 1's background check was completed on 11/23/2021 (approximately 17 days later). During a concurrent interview and record review, on 03/25/2022 at 2:20 p.m., of the 11-7 CNA Daily Assignments, dated 11/06/2022, DSD stated RN 1's background check had to be cleared first before working on the floor. DSD confirmed RN 1 first worked on the floor on 11/06/2021. During an interview, on 03/25/2022 at 2:57 p.m., the Administrator stated RN 1 should have a background check done before orientation to protect the residents and for their safety. A review of the facility's policy titled Abuse…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Preadmission Screening and Resident Review (PASARR-program to prevent individuals with mental illnesses from being inappropriately placed) Form was completed accurately, for one of one sampled resident (Resident 116). This deficient practice has the potential to result in delay in determining whether the nursing facility was appropriate and whether the resident needed specialized services. Findings: A review of the admission record indicated Resident 116 was admitted to the facility, on 03/18/2022, with diagnoses that included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and anxiety disorder. A review of Resident 116's History and Physical, dated 03/20/2022, indicated the resident had the capacity to understand and make decisions. A review of the Hospital's Discharge summary, dated [DATE], indicated Resident 116 had a diagnosis of depression and anxiety and unchanged medications…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 8) had a signage for oxygen in use while oxygen was in use. This deficient practice had the potential to place Resident 8 at increased risk for accidents including risk for fire hazard. Findings: A review of the admission record indicated Resident 8 was admitted to the facility, on 7/29/2019 and readmitted on [DATE], with diagnoses that included anemia (condition that occurs when there is a lack of healthy red blood cells to carry adequate oxygen to the body's tissues), and dementia (group of symptoms affecting memory, language, problem-solving, and other thinking abilities) without behavioral disturbance. A review of the Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 2/25/2022, indicated Resident 8 had to ability to usually make self understood and the ability to usually understand others. The MDS further indicated Resident 8 required one-person extensive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete a post-dialysis assessment (evaluation done after the process of removing waste products and excess fluid from the body) for one of two sampled residents (Resident 8) upon returning to the facility from a dialysis session. This deficient practice had the potential for unidentified complications after dialysis treatment such as redness, swelling, pain, and bleeding at the access site and changes in vital signs. Findings: A review of Resident 8's admission Record indicated the resident was admitted into the facility on 7/29/2019, and was most recently readmitted on [DATE], with diagnoses that included, but not limited to, end stage renal disease (condition in which a person's kidneys cease functioning on a permanent basis), dependence on renal dialysis, and essential hypertension (elevated blood pressure that is not due to a medical condition). A review of Resident 8's Minimum Data Set (MDS, a standardized assessment and care screening tool),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to discard a discontinued bubble pack (a package that contains multiple sealed compartments with medication) of Xanax (medication used to treat anxiety [intense, excessive, and persistent worry and fear about everyday situations]) for one of seven sampled residents (Resident 61) investigated during the facility task Medication Storage and Labeling. This deficient practice had the potential to place the facility at potential for inability to readily identify loss and drug diversion (illegal distribution of abuse of prescription drugs or their use for unintended purposes) of controlled medications. Findings: A review of Resident 61's admission Record indicated the resident was admitted to the facility on [DATE] with a readmission date of 12/29/2021 with diagnoses that included anxiety disorder, major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), and bipolar disorder (mental disorder 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 failed to implement infection control policy and procedures by failing to ensure visitors in the yellow zone (cohort of the facility consisting of mixed quarantine and symptomatic coronavirus disease 2019 [COVID-19 - a highly contagious respiratory illness capable of producing severe symptoms] residents) for two of two sampled residents (Residents 116 and 117) wore the appropriate personal protective equipments (PPE - equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses). These deficient practices had the potential to transmit infectious microorganisms and placed the residents, visitors, and staff at increased risk for infection. Findings: a. A review of Resident 116's admission Record indicated the resident was admitted on [DATE] with diagnoses including major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and anxiety disorder (state of excessive…

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