Greenfield Care Center Of South Gate

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure infection control measures were maintained and/or implemented for eight of 19 sampled residents (Residents 71, 70, 74, 1, 18, 52, 5, and 20) when: 1. Signage for enhanced barrier precautions (EBP, infection control measures used to reduce the spread of multidrug-resistant organisms [MDROs], requiring staff to wear a protective gown and gloves during high-contact activity) was not placed outside of Rooms A, B, and C.2. Certified Nursing Assistant (CNA) 2 and CNA 3 did not don the required personal protective equipment (PPE, clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) before entering Room D.3. CNA 1 did not don the required PPE before entering Resident 5's room.4. Failed to ensure Resident 20's suprapubic catheter (a tube inserted through the abdomen into the bladder that allows urine to drain from the bladder into a bag) drainage bag was not touching the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure care plans were developed and interventions implemented for three of 19 sampled residents (Residents 71, 37, and 67). This deficient practice placed Residents 71, 37, and 67 at risk for not receiving the necessary interventions for the services and/or treatments they were receiving.Findings: 1. During a review of Resident 71’s admission Record, the admission Record indicated the facility originally admitted Resident 71 on 12/23/2024, and most recently re-admitted Resident 71 on 6/16/2025. Resident 71’s admitting diagnoses included chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body) and obstructive sleep apnea (a sleep disorder characterized by repeated pauses in breathing during sleep due to a blockage in the upper airway). During a review of Resident 71’s Minimum Data Set (MDS, a resident assessment tool), dated 6/5/2025, the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to clarify hold parameters (specific instructions that accompany a medication order for safe and effective drug administration) for amlodipine (medication to lower blood pressure) and lisinopril (medication to lower blood pressure) for one of seven sampled residents (Resident 19).This deficient practice had the potential to result in Resident 19 experiencing bradycardia (heart rate less than 60 beats per minute [bpm], a normal heart rate is between 60 to 100 bpm) with symptoms of dizziness, fatigue, chest pain, and/or fainting.Findings:During a review of Resident 19's admission Record (Face Sheet), the Face Sheet indicated Resident 19 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and hypertension (elevated blood pressure). During a review of Resident 19's Minimum Data Set (MDS- a resident assessment tool), dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not accommodate the preference to use a urinal for one of 19 sampled residents (Resident 1). This deficient practice resulted in Resident 1 wearing and voiding into an incontinence brief despite being continent, removing his ability to void in a dignified manner. Cross-reference: F-tags F657, F690Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 5/15/2025. Resident 1's admitting diagnoses included pleural effusion (a collection of fluid around your lungs) and pneumonia (lung inflammation caused by infection). During a review of Resident 1's MDS, dated [DATE], the MDS indicated Resident 1 did not have cognitive impairments, and was dependent on staff for showering, and required substantial to maximal assistance from staff for mobility while in and out of bed. During a review of Resident 1's admission Nursing Assessment, dated 5/15/2025, the assessment indicated Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to obtain informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) from the Responsible Party (RP) 2 prior to administering Depakote (an anticonvulsant medication used to treat seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness] and other behavioral conditions) and placing the bed against the wall for one of five sampled residents (Resident 37).This deficient practice resulted in the facility obtaining informed consent from Resident 37, who did not have the capacity to understand and make decisions, and resulted in Resident 37 making uninformed decisions regarding her care and unable to understand the risks and benefits of her treatment.Findings:a. During a review of Resident 37's admission Record (Face Sheet), the Face Sheet indicated Resident 37…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 call light (a device that residents use to request assistance from staff) was within reach for one of six sampled residents (Resident 82). This deficient practice had the potential to result in delay or an inability for Resident 82 to obtain necessary care and services as needed. Findings:During concurrent observation and interview on 7/15/2025 at 11:14 a.m., in Resident 82's room, with Resident 82, observed Resident 82 lying in bed. Resident 82's call light was observed on the left side of the resident's bed. Resident 82's call light was not within reach. Resident 82 stated she needed assistance with personal care and was not able to reach the call light to call for assistance. During a review of Resident 82's admission Record, the admission Record indicated the facility admitted Resident 82 on 7/14/2025 with diagnoses including seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), and acute respiratory…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to timely notify one of three sampled residents' (Resident 81) physician of significant weight loss on 3/17/2025 and 6/3/2025.This deficient practice resulted in a delay in care and services and had the potential to result in further weight loss. Cross Reference F692.Findings:During a review of Resident 81's admission Record (Face Sheet), the Face Sheet indicated Resident 81 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included multiple myeloma (a type of blood cancer that affects white blood cells), cauda equina syndrome (a rare but serious condition where the nerve roots at the bottom of the spinal cord, called the cauda equina, are compressed), and chronic kidney disease (a type of blood cancer that affects).During a review of Resident 81's Minimum Data Set (MDS- a resident assessment tool), dated 6/27/2025, the MDS indicated Resident 81's cognition (process of thinking) was severely impaired. The MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide a written notice of financial liability (Skilled Nursing Facility Advance Beneficiary Notice- SNF ABN) to two out of three sampled residents (Resident 13 and Resident 23) when Medicare Part A coverage ended and the residents chose to continue receiving skilled nursing services. This failure had the potential to result in unexpected pay charges for Resident 13 and Resident 23.Findings: a. During a review of Resident 13's admission Record, the admission Record indicated Resident 13 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing), heart failure ( a condition in which the heart cannot pump enough blood to meet the body's needs), and urinary tract infection (UTI- an infection in the bladder/urinary tract). During a review of Resident 13's Minimum Data Set ([MDS], a resident assessment tool), dated 7/11/2025,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the Minimum Data Set (MDS, a resident assessment tool) assessments for two of 19 sampled residents (Residents 71 and 81) were accurate. This deficient practice resulted in the transmission of inaccurate data to the Centers for Medicare and Medicaid Services (CMS) regarding Resident 71 and 81's health status. This deficient practice also created the potential for Residents 81 and 71 to not receive the care and interventions needed to reach their highest practicable physical and psychosocial well-being.Findings: 1. During a review of Resident 71’s admission Record, the admission Record indicated the facility originally admitted Resident 71 on [DATE], and most recently re-admitted Resident 71 on [DATE]. Resident 71’s admitting diagnoses included chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body) and obstructive sleep apnea (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 revise the incontinence care plan for one out of 19 sampled residents (Resident 1). This deficient practice placed Resident 1 at risk of not receiving interventions to maintain his continence and dignity. Cross-reference: F-tags F690 and F550Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 5/15/2025. Resident 1's admitting diagnoses included pleural effusion (a collection of fluid around your lungs) and pneumonia (lung inflammation caused by infection). During a review of Resident 1's MDS, dated [DATE], the MDS indicated Resident 1 did not have cognitive impairments, and was dependent on staff for showering, and required substantial to maximal assistance from staff for mobility while in and out of bed. During a review of Resident 1's admission Nursing Assessment, dated 5/15/2025, the assessment indicated Resident 1 was incontinent bladder. The assessment was documented by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents' (Resident 67) low air loss mattress ([LALM], a mattress designed to distribute body weight over a broad surface area to help prevent skin breakdown) was accurately set to Resident 67's weight.This deficient practice had the potential to cause the avoidable development and/or worsening of pressure ulcers (PU, localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) and the complications associated with impaired skin integrity.Findings:During an observation on 7/15/2025 at 9:34 a.m., 7/15/2025 at 1:21 p.m., and 7/16/2025 at 9:46 a.m., in Resident 67's room, Resident 67 was observed lying on a Tuffcare brand LALM. The weight setting on the pump to inflate the LALM indicated the LALM was set for an individual who weighed 305 pounds (lbs, a unit of measurement).During a review of Resident 67's admission Record (Face Sheet), the Face Sheet indicated Resident 67…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 applied an incontinence brief and failed to allow use of a urinal for one of 19 sampled residents (Resident 1). This deficient practice placed Resident 1 at risk for being unable to void with dignity into a urinal and maintain his continence (the ability to control movements of the bowels and bladder).Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 5/15/2025. Resident 1's admitting diagnoses included pleural effusion (a collection of fluid around your lungs) and pneumonia (lung inflammation caused by infection). During a review of Resident 1's MDS, dated [DATE], the MDS indicated Resident 1 did not have cognitive impairments, and was dependent on staff for showering, and required substantial to maximal assistance from staff for mobility while in and out of bed. During a review of Resident 1's admission Nursing Assessment, dated 5/15/2025, the assessment indicated Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to reweigh one of three sampled residents (Resident 81) to confirm Resident 81's significant weight loss on 3/27/2025 and 6/3/2025. This deficient practice had the potential to result in improper management of Resident 81's weight.Cross Reference F580.Findings:During a review of Resident 81's admission Record (Face Sheet), the Face Sheet indicated Resident 81 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included multiple myeloma (a type of blood cancer that affects white blood cells), cauda equina syndrome (a rare but serious condition where the nerve roots at the bottom of the spinal cord, called the cauda equina, are compressed), and chronic kidney disease (a type of blood cancer that affects).During a review of Resident 81's Minimum Data Set (MDS- a resident assessment tool), dated 6/27/2025, the MDS indicated Resident 81's cognition (process of thinking) was severely impaired. The MDS indicated Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure oxygen therapy (a medical treatment that provides extra oxygen to breathe, typically prescribed for individuals with conditions causing low blood oxygen levels) was administered as ordered by the physician for two of 19 sampled residents (Residents 71 and 1). This deficient practice placed Resident 71 and Resident 1 at risk of sustaining complications of not receiving enough or receiving too much supplemental oxygen.Findings: 1. During a review of Resident 71's admission Record, the admission Record indicated the facility originally admitted Resident 71 on 12/23/2024, and most recently re-admitted Resident 71 on 6/16/2025. Resident 71's admitting diagnoses included chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body) and obstructive sleep apnea (a sleep disorder characterized by repeated pauses in breathing during sleep due to 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 follow the facility's policy and procedure (P&P) titled Usage of bedside rails revised 1/2024, which indicated consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for side rail use would be obtained from the resident and/or responsible party (RP-a person who has been legally authorized to act on behalf of a resident in matters to care within the facility), after presenting potential benefits and risks for one of six sampled residents (Resident 12).This deficient practice had the potential to result in inappropriate use of side rails for Resident 12 and could lead to injury. Findings: During a review of Resident 12's admission Record, the admission Record indicated the facility originally admitted Resident 12 on 6/6/2023 and readmitted on [DATE]. Resident 12's admitting diagnoses included chronic obstructive pulmonary disease (COPD-a chronic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Registered Nurse (RN) 3 documented on the Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) immediately after administering medications to one of seven sampled residents (Resident 19).This deficient practice had the potential to result in double administration of medication to Resident 19 which could lead to liver and kidney damage. Findings:During a review of Resident 19's admission Record (Face Sheet), the Face Sheet indicated Resident 19 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and hypertension (elevated blood pressure). During a review of Resident 19's Minimum Data Set (MDS- a resident assessment tool), dated 7/1/2025, the MDS indicated Resident 19's cognition (process of thinking) was intact. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to monitor for side effects for one of five sampled residents (Resident 67), who was on Cymbalta (medication used to treat depression [a mood disorder that causes a persistent feeling of sadness and loss of interest] and chronic pain). This deficient practice had the potential to result in undetected side effects, delay in physician notification of a change of condition, and a delay in providing necessary care and services to Resident 67.Findings:During a review of Resident 67's admission Record (Face Sheet), the Face Sheet indicated Resident 67 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included end stage renal disease (ESRD- irreversible kidney failure), type 2 diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing) with diabetic polyneuropathy (disease or dysfunction of one or more nerves, typically causing numbness or weakness in the hands 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 coordinate the initiation of RNA ([RNA] certified nursing aide program that helps residents to maintain their function and joint mobility) services with a resident's hospice (compassionate care for people who are near the end of life provided at the person's home or within a health care facility) provider after a resident exhibited documented limited range of motion [(ROM) full movement potential of a joint (where two bones meet)] for one out of five sampled residents. This failure resulted in unmet care needs and placed the resident at increased risk for functional decline. Findings: During a review of Resident 11's admission Record, the admission Record indicated Resident 11 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included cerebral infarction (an interruption in blood flow to the brain), fracture (broken bone) of unspecified part of neck of unspecified femur (leg bone), muscle weakness, 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 copies of medical records to one of four sampled residents (Resident 2) Responsible Party (RP 1) upon request.This deficient practice was a violation of RP 1's right to obtain a copy of Resident 2's medical records.Findings:During a review of Resident 2's admission Record, the admission record indicated Resident 2 was admitted to the facility on [DATE]. Resident 2's admitting diagnoses included muscle wasting and atrophy (thinning of muscle mass), lack of coordination, and generalized muscle weakness.During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 5/28/2025, the MDS indicated Resident 2 did not have cognitive (ability to think and reason) impairments. The MDS indicated Resident 2 required substantial to maximal assistance from staff with all mobility while in and out of bed.During a review of Resident 2's record titled Notice of Medicare Non-Coverage (NOMNC), undated, the record indicated it was signed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to timely report suspicions of abuse for one of four sampled residents (Resident 2).This deficient practice created a delay in the investigation of Resident 2's suspected abuse, and placed Resident 2 at risk for sustaining further abuse.Findings: During a review of Resident 2's admission Record, the admission record indicated Resident 2 was admitted to the facility on [DATE]. Resident 2's admitting diagnoses included muscle wasting and atrophy (thinning of muscle mass), lack of coordination, and generalized muscle weakness.During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 5/28/2025, the MDS indicated Resident 2 did not have cognitive (ability to think and reason) impairments. The MDS indicated Resident 2 required substantial to maximal assistance from staff with all mobility while in and out of bed.a. During a review of Resident 2's progress note dated 6/13/2025 at 3:13 PM, the progress note indicated on 6/13/2025,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure care plans were developed for two of four sampled residents (Resident 2 and Resident 3). This deficient practice placed Resident 2 and Resident 3 at risk of not receiving resident-centered care and interventions to assist them in reaching their highest practicable physical and psychosocial well-being.Findings: a. During a review of Resident 3's admission Record, the record indicated Resident 3 was originally admitted to the facility on [DATE] and was most recently re-admitted on [DATE]. Resident 3's admitting diagnoses included chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body) and hypotension (low blood pressure). During a review of Resident 3's Minimum Data Set (MDS, a resident assessment tool), dated 6/5/2025, the MDS indicated Resident 3 did not have cognitive impairments (a decline in one or more areas of mental function, such as…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Findings: 1. During a review of Resident 3's admission Record, the admission record indicated Resident 3 was originally admitted to the facility on [DATE] and was most recently re-admitted on [DATE]. Resident 3's admitting diagnoses included chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body) and hypotension (low blood pressure).During a review of Resident 3's Minimum Data Set (MDS, a resident assessment tool), dated 6/5/2025, the MDS indicated Resident 3 did not have cognitive impairments (a decline in one or more areas of mental function, such as memory, attention, or problem-solving). The MDS indicated Resident 3 was dependent on staff for toileting hygiene and rolling from left to right while in bed, requiring two-person assist. During a review of Resident 3's progress note, dated 6/20/2025, the progress note indicated that on 6/20/2025 at 8:30 AM, Registered Nurse (RN) 1 overheard Certified Nursing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Licensed Vocational Nurse (LVN) 1, Registered Nurse (RN) 1, and the Social Services Director (SSD) implemented the facility's policy and procedure titled Abuse and Neglect Prevention Management, revised 2/2018, related to abuse reporting, for one of four sampled residents (Resident 2).This deficient practice resulted in LVN 1 and RN 1 not reporting suspicions of Resident 2's abuse on 6/13/2025, and the SSD not reporting suspicions of Resident 2's abuse on 6/26/2025. Findings:During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE]. Resident 2's admitting diagnoses included muscle wasting and atrophy (thinning of muscle mass), lack of coordination, and generalized muscle weakness.During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 5/28/2025, the MDS indicated Resident 2 did not have cognitive impairments (a decline in mental abilities,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the physician of a resident's continued episodes of orthostatic hypotension (OH- a condition in which your blood pressure quickly drops when you stand up after sitting or lying down) and failed to ensure physician involvement in the discontinuation of Physical and Occupational Therapy (PT, OT) services for one of two sampled residents (Resident 1), This failure resulted in a delay in appropriate medical intervention, placed the resident at risk for adverse outcomes including falls, syncope (dizziness), and compromised perfusion (pressure needed for blood to flow to blood vessels), and resulted in the premature termination of Medicare coverage. Findings: 1. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] with diagnoses that included othrostatic hypotension (OH), history of falling, pleural effusion (a condition where an excessive amount of fluid…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 record review and interview, the facility failed to develop an individualized care plan for orthostatic hypotension (OH- a condition in which your blood pressure quickly drops when you stand up after sitting or lying down) for one of three sampled residents (Resident 1) when the facility failed to include clinically indicated instruction to administer Midodrine (an anti-hypotensive [low blood pressure] drug) prior to therapy sessions, despite the resident's history of symptomatic OH that affected participation in physical therapy. This failure placed Resident 1 at risk for falls, bodily injury, and early discontinuation of skilled therapy services. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] with diagnoses that included orthostatic hypotension (OH), history of falling, pleural effusion (a condition where an excessive amount of fluid accumulates in the pleural space, which is the area between the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident care plan was developed after brusing (a mark on skin, black and blue or red to purple form when blood pools under skin, caused by a blood vessel break) was noted for one resident out of three sampled residents (Residents 1). This deficient practice resulted in a delay in care and monitoring for Resident 1 and potentially negatively affected the delivery of care. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including dementia (the loss of cognitive functioning[ ability to think and reason] thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities) and legal blindness ( impaired vision). During a review of Resident 1 ' s History and Physical (H&P) dated 3/30/2025, the H&P indicated Resident 1 was alert and oriented to person ([AAO…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 following for one of three sampled residents (Resident 1): 1. Certified Nursing Assistant (CNA) 1 reported bruising (a mark on the skin, black and blue or red to purple form when blood pools under skin, caused by a blood vessel break) to Resident 1 ' s chest, left breast, flank, and left arm to the charge nurse or supervisor. 2. Treatment Nurse (TN) 1 documented the monitoring of Resident 1 ' s bruising. 3. TN 1 assessed Resident 1 ' s bruises. These deficient practices delayed Resident 1 ' s care and services. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1 ' s diagnoses included dementia (the loss of cognitive functioning [ability to think and reason], thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities) and legal blindness (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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain respect and dignity for one of three sampled residents (Resident 1) when Certified Nursing Assistant (CNA) 1 failed to ensure Resident 1 was cleaned timely as requested. This failure resulted in Resident 1 expressing feelings of anger towards CNA 1 and had the potential for Resident 1 to exhibit feelings of hopelessness and long-term psychological distress. Findings: During a record review of the facility ' s Five-Day Report, dated 4/7/2025, the Five-Day Report indicated Resident 1 alleged a night shift (11 p.m. to 7 a.m.) CNA had a bad attitude on 4/6/2025. The Five-Day Report indicated the CNA refused to change Resident 1 after she pressed the call light. The Five-Day Report indicated Resident 1 pressed the call light a second time because she needed to be changed, and the same CNA yanked her call light and told her not to press it anymore. During a review of Resident 1 ' s admission Record, the admission Record 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 interview and record review, the facility failed to follow their Policy and Procedure (P&P), titled, Abuse and Neglect Prevention Management, for one out of three sampled residents (Resident 2) by failing to: 1. Ensure Registered Nurse (RN) 1 reported within 24 hours to the Administrator (ADM), the Director of Nursing Services (DON) and the California Department of Health (CDPH) when Resident 2 ' s family member (FM 1) alleged Certified Nursing Assistant (CNA) 2 was physically rough handling Resident 2. 2. Suspend CNA 2 after an allegation of rough handling was made by Resident 2. This resulted in a delay of an investigation by CDPH and had the potential for further abuse by CNA 2 to other residents. Findings: During a review of Resident 2 ' s admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure with hypoxia (a chronic lung disease causing difficulty in breathing), hemiplegia (total paralysis of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of 10 sampled residents (Resident 3) who received dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) treatment received care in accordance with standards of practice, when the facility failed to: 1. Ensure nursing staff follow up on Resident 3 ' s potassium ([K] - a mineral the body needs, to help nerves and muscles work properly, especially your heart) lab order and notify the clinician of the abnormal results. 2. Ensure nursing staff ordered a potassium leverl instead of a Levetiracetam (Keppra – medications used to treat seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness] level as ordered by the clinician. These deficient practices had the potential to delay necessary care and treatment for hyperkalemia placing Resident 3 at serious risk for heart…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their Policy and Procedure (P&P), titled, Abuse and Neglect Prevention, when Certified Nursing Assistant (CNA) 2 did not report within two hours to the California Department of Public Health (CDPH), law enforcement, the ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities),the Administrator (ADM) and the Director of Nursing Services (DON) when Resident 1 informed CNA 2 that CNA 1 was rough with Resident 1 for one out of three sampled residents (Resident 1). This deficient practice resulted in a delay of an investigation by CDPH and had the potential for further abuse by CNA 1 to other residents within the facility while CNA 1 continued to work the remainder of CNA 1's scheduled shift. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 ' s diagnoses included muscle weakness, spinal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 their Policy and Procedure (P&P), titled, Abuse and Neglect Prevention, when the following occurred for one out of three sampled residents (Resident 1) by failing to: 1.Ensure a prompt investigation was initiated when Certified Nursing Assistant (CNA) 2 had knowledge Resident 1 alleged that CNA 1 was rough during care. 2. Ensure the facility implemented prompt measures to protect Resident 1 when CNA 2 had knowledge that Resident 1 alleged that CNA 1 was rough during care. These deficient practices resulted in the delay of a timely investigation and allowed for further potential abuse by CNA 1 to Resident 1 and other residents within the facility while CNA 1 continued to work the remainder of his scheduled shift. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE]. Resident 1 ' s diagnoses included muscle weakness, spinal stenosis (abnormal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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. Develop a person-centered care plan (document that helped nurses and other care team members organize aspects of resident care) and implement interventions (actions a nurse took to implement a care plan, intent to improve the resident's comfort and health) for one of four sampled residents (Resident 1), when the facility did not develop a care plan for Resident 1's non-compliance with the use of the call light (a button or device used in healthcare settings, typically located near a resident's bed, that allowed them to signal a nurse or caregiver when they needed assistance). This deficient practice had the potential to negatively affect Resident 1's physical, mental, and psychosocial well-being and had the potential to increase the resident ' s risk of falling. Findings: During a review of Resident 1's admission Record, the admission record indicated Resident 1 was originally admitted to facility on 8/1/2024 and readmitted on [DATE]. Resident 1 '…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) who required substantial/maximal assistance (staff does more than half the effort. Staff lifts or holds trunk or limbs and provides more than half the effort) with ADLs was provided water every two hours, according to physician order and care plan. This failure had the potential to cause dehydration and urinary tract infection ([UTI] an infection in the bladder/urinary tract) for Resident 1. Findings: During a review of the Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 1's diagnoses included diabetes mellitus ([DM] a disorder characterized by difficulty in blood sugar control and poor wound healing), hypothyroidism (a condition that occur when the thyroid gland does not produce enough thyroid hormone) and legally blindness. During a review of Resident 1's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow its policy to document the findings related to a change of condition (COC) every shift for two of three sampled residents (Resident 1 and Resident 2). This deficient practice had the potential to result in serious harm such as another episode of aggression towards others, and a delay of necessary treatments. Findings: 1. During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was originally admitted to facility on 12/21/2016 and re-admitted on [DATE]. Resident 1 ' s diagnoses included seizures (a sudden, uncontrolled electrical disturbance in the brain which could cause uncontrolled jerking, blank stares, and loss of consciousness), dementia (a progressive state of decline in mental abilities), anxiety disorder (a mental health condition that involved excessive and persistent feelings of fear, dread, and uneasiness), and insomnia (trouble falling asleep or staying asleep). During a review of Resident 1 ' s…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident was free from significant medication error by administering amiodarone (a medication that prevents and treats irregular heartbeat) and metoprolol tartrate (medicine to treat high blood pressure) outside the parameters (specific instructions that you could measure) as ordered by the physician for one of three sample residents (Resident 2). These deficient practices had the potential to cause complications of hypotension (low blood pressure, dizziness and fainting leading to falls) and low pulse (leading to loss of consciousness). Findings: During a review of Resident 2 ' s admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE]. Resident 2 ' s diagnoses included hypertension (high blood pressure), diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), congestive heart failure (CHF- a heart disorder which caused the heart to not pump 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 infection prevention and control was maintained when the following occurred: 1. Resident 8 was not tested for Covid-19 (an acute disease caused by a coronavirus, capable of progressing to severe symptoms, including death, especially in older people and those with underlying health conditions) after symptoms of phlegm and a runny nose were first reported on 7/7/2024. 2. Certified Nursing Assistant (CNA) 1 worked two shifts, on 7/9/2024 and 7/10/2024, while experiencing Covid-19 symptoms. These deficient practices created the risk for avoidable spread of infection to all facility residents and staff and placed vulnerable facility residents at risk of suffering severe illness and/or death. Findings: 1. During a review of Resident 8's admission Record, the admission record indicated the facility admitted Resident 8 on 9/27/2023, and most recently re-admitted the resident on 4/18/2024. Resident 8's admitting diagnoses included type 2 diabetes mellitus (uncontrolled blood sugar levels), chest pain, and nephrotic syndrome…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 answer the call light in a timely manner, ensure the resident's preference to shower by a certain time was honored, and ensure the call lights were not cancelled without asking the residents if they needed assistance for two residents out of two sampled residents (Resident 1 and Resident 2). These deficient practices had the potential to cause a negative impact on Resident 1's and Resident's ' 2s psychosocial well-being and caused a delay in care. Findings: 1. During an observation on 7/24/2024 at 10:15 a.m., in Resident 1's room, Resident 1's call light was not answered. During a review of Resident 1's admission Record, the admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including paraplegia (paralysis of the legs and lower body) and depression (a common and serious medical illness that negatively affects how a person feels, the way they think and how they act. Depression causes feelings of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a Registered Nurse (RN) signed the Minimum Data Set (MDS, a resident standardized assessment and care-screening tool) assessments for four of 26 sampled residents (Resident 53, 61, 56, and 3) and failed to ensure the MDS assessment was complete prior to certification (action or process of providing someone or something with an official document attesting to a status of level of achievement) of completion. This deficient practice had the potential to affect the provision of care and provided inaccurate information upon submission to the Federal database. Findings: a. A review of Resident 53's admission Record, indicated Resident 53 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 53's diagnoses included psychosis (severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality), major depressive disorders (depression, a mood disorder that causes a persistent…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to a develop care plans for 2 of 26 sampled residents (Resident 84 and 53) when: a. For Resident 84, the facility failed to develop a care plan for both 1/2 bedrails up to assist Resident 84 with repositioning and Resident 84's preference to have a female escort during outside clinic appointments. b. For Resident 53, the facility failed to develop a care plan for range of motion ([ROM] full movement potential of a joint [where two bones meet]) and mobility (ability to move) impairments, including the provision of Restorative Nursing Aide (RNA, certified nursing aide program that helps residents to maintain their function and joint mobility) services and activities of daily living (ADLs, tasks related to personal care including bathing, dressing, hygiene, eating, and mobility). This deficient practice had the potential to delay necessary monitoring and safety interventions related to both 1/2 side rails being in the up position while Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility staff failed to review, update and /or revised a care plan (a form that summarizes a person's health conditions and current treatments for their care) addressing fall, and the use of physical restraints for one of six sampled residents (Resident 32). These deficient practices had the potential to place Resident 32 at risk for recurrent falls, and to negatively affect the provision of care, and physical well-being of Resident 32. Findings: During an observation on 5/28/2024 at 11:32 a.m., in Resident 32's room, Resident 32 was observed in bed. Resident 32 was observed the bed against the wall on the right side of the room. A review of Resident 32's admission Record (Face Sheet), the Face Sheet indicated Resident 32 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including dementia (a loss of brain function such as memory, thinking, language, behavior), anxiety (a feeling of worry or fear), hypertension (high…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide treatment and services for two out of three residents (Resident 35 and Resident 53) by failing to: a. Document Resident 53's hypoglycemic (low blood sugar) episode. This deficient practice had the potential to cause miscommunication of Resident 35's negative health trends and medication adjustments of insulin. b. Ensure Resident 53 who had range of motion (ROM, full movement potential of a joint [where two bones meet]) and mobility (ability to move) concerns) were properly assessed for the provision and application of elbow splints (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion) to both arms, including the determination of Resident 53's splint wear time (length of time the splint was applied) of four to six hours in accordance with professional standards of practice for Occupational Therapy (OT, profession aimed to increase or maintain a person's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY During an observation, interview, and record review the facility failed to practice pressure related injury preventive practices for two out eight residents (Resident 3 and Resident 26) when the facility failed to: 1.Ensure a low air mattress (LAM) was set according to Resident 26's weight of 255 pounds and the LAM was set to 350 pounds. 2. Ensure the LAM was set according to Resident 3's weight of 161 pounds and LAM was set to 180 pounds. 3. Assess and prevent a pressure injury over Resident 3's ears. These deficient practices placed Resident 3 and Resident 26 at a higher risk of developing a pressure injury due to incorrect weight setting on the LAM and caused Resident 3 to develop a pressure injury on right ear due to prolonged use of medical device. Findings: 1. A review of Resident 3's admission Record, the admission record indicated Resident 3 was originally admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of kidney failure (occurs when kidneys suddenly become unable to filter…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 date and input the time of continuous tube feeding administration, the date and time the tube feeding formula per policy and standards of care for three of five sampled residents (Resident 25, Resident 53, and Resident 61). This deficient practice had the potential to cause weight loss or infection. Findings: a. A review of Resident 61's admission Record indicated Resident 61 was originally admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 61 diagnoses included cerebral palsy (a condition that develops before birth which affects movement and posture with exaggerated reflexes, floppy or rigid limbs, and involuntary motions), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) with a single episode of severe psychotic features (seeing or hearing stimuli that is not there, having false beliefs,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: 1. Ensure an informed consent was obtained for bed siderail use (a form of physical restraint) for five of five sample residents (Residents 13, 24, 27, 32 84). 2. Ensure Resident 27 had a physician's order for siderails prior to installing bed siderails. 3. Ensure Resident 13's responsible party (RP) was informed about the risk and benefits of bed siderail use. 4. Ensure Residents 84, 24, and 32 were evaluated for alternatives prior to installing bed rails. These deficient practices placed Residents 13, 24, 27, 32 and 84 at risk of inappropriate use of bedrails, placed the residents at risk for unnecessary restraints, and had the potential to violate the residents' rights and responsible party's right of being informed prior to restraint use. Findings: a. During an observation on 5/28/2024 at 11:32 a.m., in Resident 32's room, Resident 32 was observed lying in bed with bilateral bed siderails in upper position. A review of Resident 32's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure four of four Restorative Nursing Aides (RNA, certified nursing aide program that helps residents to maintain their function and joint mobility) received an evaluation of competence (possession of sufficient knowledge or skill) as evidenced by: a. Four of four sampled residents (Resident 53, 3, 56, and 61) with range of motion [ROM, full movement potential of a joint (where two bones meet)] and mobility (ability to move) concerns did not receive ROM exercises to each joint of both arms and both legs in accordance with physician orders and the facility's job description titled, Restorative Nursing Assistant. b. Four of four RNAs (RNA 1, RNA 2, RNA 3, and RNA 4) did not have an evaluation indicating each RNA was proficient (able to do something to a higher than average standard) to provide RNA services in accordance with the facility's policy titled, Competency of Nursing Staff. These deficient practices resulted in Resident 53, 3,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 standardized recipes for the lunch menu was followed on 5/28/2024 when the following occurred: 1. Ten residents receiving a puree diet (foods that do not require chewing and are easily swallowed, all foods should be smooth and pureed to the consistency of pudding) received lasagna in a texture or form that met their needs. The pureed lasagna was lumpy, not smooth and had large pieces of pasta present requiring chewing before swallowing. 21 residents receiving a mechanical soft diet (provides foods that are easily chewed) received toasted garlic bread with a hard crust per the spreadsheet (food portion and serving guide) and menu. 2. Ensure staff followed food production recipes for the dysphagia diet (foods that are moist, mechanically altered requiring little chewing and does not fall apart when swallowed) during lunch preparation and tray line observation. Two residents on a Dysphagia diet received chopped lasagna instead of the ground turkey patty with chopped pasta and green beans cut to ½…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 preparation practices when: 1. One staff working in the dish washing area did not wash their hands before removing the clean and sanitized dishes from the dish machine. 2. Expired food brought to residents from outside of the facility were stored in the resident food refrigerator. There was coffee from staff stored in the refrigerator. The refrigerator had no thermometer and monitoring system for the refrigerator temperatures. These deficient practices had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to food borne illness in 67 out of 74 residents who received food from the facility, including residents who had food stored in the resident refrigerator. Findings: 1. During an observation on 5/28/2024 at 8:45 AM, in the dishwashing area, DA 1 was observed rinsing soiled dishes and loading the dirty dishes in the dish machine while wearing gloves. DA 1 dipped his hands…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 clinical records were maintained in accordance with accepted professional standards and complete accurately the Advance Directives Acknowledgement ([ADA]- a form gives you the right to give instructions about your own health care) for three of six sampled residents (Residents 8, 63, and 53). These deficient practices resulted in inaccurate, and incomplete medical records, and had the potential to result in uncertainty in the care and services for residents and placed residents at risk of not receiving care based on their wishes due to inaccurate and incomplete documentation for Residents 8, 63, and 53. Findings: a. A review of Resident 8's admission Record (Face Sheet), the Face Sheet indicated Resident 8 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including diabetes (high blood sugar), major depressive disorder (a mental health condition that causes loss of interest in activities of daily…

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

Based on observation, interview, and record review, the facility Quality Assurance and Performance Improvement (QAPI - a systematic, interdisciplinary, comprehensive, and data-driven approach to maintaining and improving safety and quality in nursing homes while involving residents, families, and nursing home caregivers) committee failed to identify, develop, and implement action plans to ensure: 1. Range of motion (ROM- full movement potential of a joint where two bones meet) was monitored for all residents. (see F-Tag F688) 2. Informed consent for psychotropic medications (drug that affects how the brain works and causes changes in mood) including behavior monitoring and signature verification was done for all residents. (see F-Tag 758) 3. Informed consents were obtained for bed rails. (see F-Tag 700) 4. Physical therapy services were provided per physician's orders. (see F-Tag 825) 5. Restorative Nursing Aide (RNA- assists residents with exercises to improve or maintain mobility and independence) staff were competent to perform their duties as evidenced by: a. Residents with ROM…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 standard infection control practices were followed for seven of by failing to: 1. Ensure Resident 22 and Resident 24's oxygen nasal cannula tubing (a device used to deliver supplemental oxygen placed directly in a resident's nostrils) was dated, properly stored when not in use, and was off the floor, and ensure Resident 69's nebulizer (a drug delivery device used to administer medication in the form of a mist inhaled into the lungs) mask was dated, labeled, properly stored when not in use, and was not touching the floor. 2. Ensure the Social Services Director (DSD) and Registered Nurse (RN) 1 removed their gloves when moving between Resident 33 and Resident 274, and Resident 17 and Resident 13. 3. Ensure contact precautions were followed when Licensed Vocational Nurse (LVN) 3 put his hand in his pocket with contaminated gloves, and failed to perform hand hygiene after cleaning a contaminated blood pressure cuff used on Resident 61.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 assess the need for modifications to the call light system for one out of eight (8) residents, (Resident 27) by failing to: 1. Ensure the facility the call light for Resident 27 working properly and alarmed when activated by Resident 27. 2. Ensure the Certified Nursing Assistant (CNA 1) reported Resident 27's call light needed repair and was not working to the Maintenance Supervisor (MS). These deficient practices resulted in a delay in obtaining necessary care and services and placed Resident 27 at risk for an accident if called for help. Findings: A review of Resident 27's admission Record indicated Resident 27 was originally admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs) and heart failure (progressive heart disease that affects pumping action of the heart muscles that causes fatigue,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 obtain informed consent prior to the administration of psychotropics (medications that affect the mind, emotions, and behavior) for three out of five residents (Resident 31 and 32). This deficient practice placed Residents 31 and 32 at risk for avoidable harm from unwanted adverse effects (a harmful and undesired effect resulting from a medication or intervention) related to psychotropic medication use and removed the residents' rights to make decisions about the care and treatments they received in the facility. Findings: a. A review of Resident 31's admission Record indicated Resident 31 was originally admitted to the facility on [DATE] and was re-admitted on [DATE]. Resident 31's admitting diagnoses included schizoaffective disorder (a mental health condition that is a mix of schizophrenia symptoms such as hallucinations and delusions, and mood disorder symptoms such as depression and a milder form of mania), major depressive disorder…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to honor a resident's preference to have a female staff member escort the resident to clinic visits outside of the facility for one of one sampled resident (Resident 84's). This deficient practice caused Resident 84 to repeatedly be accompanied to appointments by a male staff member despite Resident 84's wishes to have a female escort. This failure also had the potential to cause unnecessary psychological harm to the resident. Findings: A review of Resident 84's admission Record, dated 5/30/2024, indicated Resident 84 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 84's diagnoses included left hip fracture (a partial or complete break of the thigh bone, where it meets the pelvic bone), syncope (fainting) and collapse, hypertension (high blood pressure), type 2 diabetes (too much sugar circulating in the blood) hyperlipidemia (an abnormally high concentration of fat particles in the blood), and osteoarthritis…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 notify the primary physician of the change in condition of decline in range of motion (ROM, full movement potential of a joint [where two bones meet]) in both ankles for one of four sampled residents (Resident 53), who had limited mobility (ability to move) concerns. This deficient practice resulted in Resident 53's development of contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to joint stiffness) to both ankles. Cross reference F688 and F726. Findings: A review of Resident 53's admission Record, indicated Resident 53 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 53's diagnoses included psychosis (severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality), major depressive disorders (depression, a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility staff failed to ensure one of six sampled residents (Resident 32) was free from an unnecessary physical restraint, as evidenced by: 1. Failing to ensure appropriate assessment for less restrictive measures prior to using a physical restraint for Residents 32. 2. Failing to obtain a physician order for the use of bed against the wall used as a physical restraint for Resident 32. 3. Failing to obtain a consent form for the use of a physical restraint, and of side rails for Resident 32. These deficient practices placed Resident 32 at risk for entrapment (when a person is trapped by the bed rail in a position they cannot move from) and had the potential to cause psychosocial harm from not being treated with dignity and respect. Findings: During an observation on 5/28/2024 at 11:32 a.m., in Resident 32's room, Resident 32 was observed lying in bed, eyes closed, visibly sleeping. Resident 32's bed was observed against the wall on the right site, big…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ([PASRR] resident screening prior to admission, to determine if the person has, or is suspected of having, a mental illness) Level I screen was completed accurately for one of one resident, (Resident 22). This deficient practice had the potential for Resident 22 to not receive the necessary and appropriate behavioral treatment and services and placed Resident 22 at risk for further complications of schizophrenia (mental illness that effects how person thinks, feels, and behaves) and major depressive disorder (a mental health condition that causes loss of interest in activities of daily living). Findings: A review of Resident 22's admission Record (Face Sheet), the Face Sheet indicated Resident 22 was originally admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses including schizophrenia, major depressive, Chronic Obstructive Pulmonary Disease ([COPD]- a lung disease causing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY During an observation, interview, and record review the facility failed to ensure the staff provided the necessary care and services to one out of eight sampled residents (Resident 27) that promoted residents well-being by failing to: 1. Ensure Certified Nursing Assistant (CNA 1) offered assistance to Resident 27, to clean up his bed that had a large amount of feces (stool). 2. Ensure CNA 1 gave Resident 27 had ice water when requested. 3. Ensure Resident 27 had a working call light to communicate his needs to staff. These deficient practices had the potential to have a negative impact on Resident 27's quality of life and caused Resident 27 needs not to be met like toileting, bathing receiving drinking water. Findings: A review of Resident 27's admission Record, the admission record indicated Resident 27 was originally admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide treatment and services to maintain or improve the ability to perform activities of daily living (ADLs, tasks related to personal care including bathing, dressing, hygiene, eating, and mobility) for one of four sampled residents (Resident 53) with limited range of motion [(ROM) full movement potential of a joint (where two bones meet)] and mobility by failing to transfer Resident 53 out of the bed daily. This deficient practice resulted in Resident 53, who had a history of depression, to experience limited social interaction and a decline in ROM, mobility, ADLs, affecting Resident 53's quality of life. Cross reference F656, F688, and F825. Findings: A review of Resident 53's admission Record, indicated Resident 53 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 53's diagnoses included psychosis (severe mental disorder in which thought and emotions are so impaired that contact is lost with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to monitor behaviors and provide non-pharmacological behavioral interventions for antipsychotic medication (a type of psychotropic psychiatric medication used to treat psychotic disorders) use for one out of five residents (Resident 61). This deficient practice had the potential to cause Resident 61 extrapyramidal side effects (a series of potentially irreversible psychiatric drug induced movement disorders) and potentially prevent Resident 61 from functioning at her highest practicable physical, mental, and psychosocial well being. Findings: A review of Resident 61's admission Record indicated Resident 61 was originally admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 61's admitting diagnose included cerebral palsy (a condition that develops before birth which affects movement and posture with exaggerated reflexes, floppy or rigid limbs, and involuntary motions) and major depressive disorder (a mental health disorder…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were free from medication error rates below 5% for one out of five residents (Resident 61). This deficient practice had the potential for residents to be at risk for medication errors. Findings: A review of Resident 61's admission Record indicated Resident 61 was originally admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 61's admitting diagnosis included cerebral palsy (a condition that develops before birth which affects movement and posture with exaggerated reflexes, floppy or rigid limbs, and involuntary motions) and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) with a single episode of severe psychotic features (seeing or hearing stimuli that is not there, having false beliefs, and confused or disturbed thoughts). A review of Resident 61's Minimum Data Set ([MDS] a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a therapeutic mechanical soft (texture-modified [moist and soft] foods for people who have difficulty chewing and swallowing) diet was served as prescribed by the physician for one of two sampled residents (Resident 42). This deficient practice had the potential to cause Resident 84 to choke on food that was too difficult to chew or swallow. Findings: A review of Resident 42's admission Record, dated 5/30/2024, indicated Resident 42 was initially admitted to the facility on [DATE]. Resident 42's diagnoses included altered mental status (AMS - disruption in how the brain works that causes a change in behavior), metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), hyponatremia (abnormally low level of sodium in the blood), and dehydration (a harmful reduction in the amount of water in the body). A review of Resident 42's Minimum Data Set (MDS - a standardized resident assessment care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement infection control measures by failing to: 1. Ensure a COVID-19 (Coronavirus, a highly contagious respiratory illness caused by a virus that can easily spread from person to person) outbreak was reported to the proper California Department of Public Health (CDPH) District Office. 2. Ensure staff was performing proper hand hygiene when going from one resident room to another resident room. This deficient practice had the potential to result in the spread of Coronavirus to residents and staff that could cause respiratory illness, hospitalization, and death. Findings: a. During an observation on 12/7/2023 at 10:00 a.m., the facility's highlighted floor map was noted to have 3 (three) COVID positive rooms and 2 (two) rooms that residents were exposed to close contacts upon entrance. During a concurrent interview and record review on 12/7/2023 at 12:04 p.m. with the Infection Prevention Nurse (IPN), the All Facilities Letter 23-08…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a comprehensive and resident-centered care plan to address the risk of exposure to COVID-19 (a highly contagious respiratory illness caused by a virus that can easily spread from person to person) for two of four sampled residents (Residents 1 and Resident 2). This deficient practice had the potential to negatively affect the delivery of nursing care and medical interventions to Residents 1 and 2. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE]. Resident 1's diagnoses included neuromyelitis optica (a rare condition where the immune system damages the spinal cord and the nerves of the eyes (optic nerves), major depressive disorder (a common and serious medical illness that negatively affects how you feel, the way you think and how you act.), exposure to COVID-19. During a review of Resident 1's History and Physical (H&P), dated 11/30/2023, the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the staff failed to ensure the admission agreement (contract) was reviewed, completed and signed by the resident or responsible party, for 1 of 3 residents (Resident 1), at the time of admission according to the facility's admission policy. This deficient practice resulted in Resident 1 not being informed of his rights, financial responsibilities, Medicare or Medicaid benefit, and had the potential that concerns about admissions were not addressed. Findings A review of Resident 1's admission record indicated Resident 1 was admitted to the facility on [DATE], with a diagnosis that included malignant neoplasm of kidney and renal pelvis (cancer in the kidney and the urinary tube), type 2 diabetes (DM-high blood sugar), and hypertension (HTN-high blood pressure). A review of Resident 1's history and physical (H&P) dated 7/19/2023, the H&P indicated Resident 1 had the capacity to understand and make medical decisions. A review of Resident 1'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 provide a copy of the personal belonging inventory list to 1 of 3 residents, Resident 1, on admission. This deficient practice had the potential that Resident 1 won't be able to monitor his belongings and were placed at risk to go missing, misplaced, or stolen. Findings A review of Resident 1's admission record indicated Resident 1 was admitted to the facility on [DATE], with diagnosis that included malignant neoplasm of kidney and renal pelvis (cancer in the kidney and the urinary tube), type 2 diabetes (DM-high blood sugar), and hypertension (HTN-high blood pressure). A review of Resident 1's history and physical (H&P) dated 7/19/2023, the H&P indicated Resident 1 had the capacity to understand and make medical decisions. A review of Resident 1's minimum data set ([MDS] a standardized care assessment and care screening tool), dated 7/31/2023, the MDS indicated Resident 1's cognitive skills (thought process) was intact and could understand and be…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 use of personal protective equipment (PPE, used to provide protection to the wearer from infectious agents) for a resident on COVID-19 isolation precautions for one of seven sampled residents (Resident 1). This deficient practice had a potential to place Resident 1, other residents, and staff at risk for COVID-19 infection. Findings: During a review of Resident 1's admission Record, the admission record indicated Resident 1's original admission date was on 6/8/2023 with diagnoses that included urinary tract infection (UTI [a common infection that happens when bacteria, often from the skin or rectum, enters the urethra, and infects the urinary tract]), primary and secondary malignant neoplasm of unspecified site (a new and abnormal growth of tissue [characteristic of cancer] that has spread to other parts of the body from the original site), chronic kidney disease, Stage 3 (mild to moderate damage to your kidneys, which do not work as well as they should to filter waste and extra fluid out of…

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

Based on observation, interview, and record review, the facility failed to ensure safe food preparation practices in the kitchen when: A. The Ice machine's internal compartments were dirty as evidenced by a black substance on the surfaces. B. Dietary Staff such as cook and assistant cook wearing jewelry (bracelet and dangling earrings) during food preparation. These failures had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness in 72 out of 79 medically compromised residents who received food and ice from the kitchen. Findings: A. During an initial tour with the Dietary Services Supervisor (DSS) on 3/14/2022 at 8:57 a.m., wiped the inside compartment of the ice machine using a paper towel and a black substance was noted. DSS stated that it is due for cleaning because it's been a month that was not cleaned it is expected that it is dirty, DSS stated that it could be risk for getting food borne illness due to black substance that was found underneath, DSS further…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ensure an accurate assessment was conducted for three of three sampled residents (Residents 124, 58 and 49). Residents 124, 58, and 49 did not have an accurate assessment for following: 1. Failure to address Resident 124's complaints of pain. 2. Failure to accurately assess and monitor Resident 58's skin integrity, who was at a very high risk for skin breakdown due to the application of an orthopedic brace (a medical devices designed to address musculoskeletal issues; they are used to properly align, correct the position, support, stabilize, and protect certain parts of the body as they heal from injury or trauma) to the right leg. 3. Failure to ensure Resident 49's bowel and bladder assessment was conducted timely. These deficient practices had the potential to result in a delay in necessary care and treatment for Residents 124, 58, and 49. Findings: a. During a review of Resident 124's admission Record, the admission Record 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two of eight sampled residents (Residents 123 and 58) fingernails and moustache/beard were clean and trimmed regularly. This deficient practice had the potential to negatively impact Resident 123 and 58's quality of life and self-esteem. Findings: a. During a review of Resident 123's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE]. Resident 123's diagnoses included sepsis (a potentially life-threatening condition that occurs when the body's response to an infection damages its own tissues), diabetes mellitus (high blood sugar), adult failure to thrive (a decline seen in older adults, typically those with multiple chronic medical conditions, resulting in a downward spiral of poor nutrition, weight loss, inactivity, depression and decreasing functional ability) and muscle weakness. During a review of Resident 123's Quarterly Minimum Data Set (MDS), a standardized assessment and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of eight sampled residents (Resident 58), who was readmitted to the facility with intact skin integrity and an order for an orthopedic brace (medical device designed to address musculoskeletal issues; used to properly align, correct the position, support, stabilize, and protect certain parts of the body as they heal from injury or trauma) to the right leg, received care consistent with professional standards of practice, to prevent medical-device related pressure ulcers (injuries result from use of medical devices, equipment, furniture, and everyday objects in direct contact with skin and because of increased external mechanical load leading to soft tissue damage) and received necessary treatment and services to promote healing, prevent infection and prevent new pressure ulcers from developing. This deficient practice resulted in Resident 58 developing a Stage I pressure ulcer (non-blanchable [discoloration of the skin 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 ensure two of 16 sampled residents (Residents 1 and 5), who had limited range of motion ([ROM] the extent of movement of a joint) and limited mobility, received appropriate treatment and services to increase ROM, prevent further decrease in ROM, and maintain or improve mobility. This deficient practice had the potential to place Residents 1 and 5 at increased risk for further decline and development of contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). Findings: a. During a review of Resident 5's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 5's diagnoses included hemiplegia (a severe or complete loss of strength or paralysis [inability to move] on one side of the body) and hemiparesis (a mild or partial weakness or loss of strength on one side of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the bed siderails were not loose for five of five sampled Residents (Residents 174, 6, 13, 1, and 49). This deficient practice placed Residents 174, 6, 13, 1, and 49 at risk for accidents and hazards such as having a body part caught between the rails, and/or falls. Findings: a. A review of Resident 174's admission Record indicated Resident 174 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 174's diagnoses included diabetes mellitus (increased blood sugar), complete traumatic amputation (removal of a body part) at knee level of the right lower leg and muscle weakness. A review of Resident 174's Minimum Data Set (MDS), a comprehensive standardized assessment and care-screening tool, dated 12/27/2021, indicated Resident 174's had clear speech, was able to make himself understood and was able to understand others. The MDS indicated Resident 174 required limited assistance with bed mobility,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 dietary staff were able to identify and produce the correct textures for pureed diets (food textures made of liquidized or crushed fruit or vegetables for people who cannot chew or have a problem swallowing). The dietary staff did not prepare the appropriate texture of meat according to the Dietary Services Supervisor (DSS). This deficient practice had the potential to result in choking or aspiration (when swallowed food goes down the airway, cutting off breathing) during lunch time for 12 out of 12 residents on a pureed diet. This deficient practice had the potential to result in choking or aspiration (when swallowed food goes down the airway, cutting off breathing) during lunch time for 12 out of 12 residents on a pureed diet. Findings: During an observation of tray line service for lunch on 3/15/2022 at 11:45 a.m., [NAME] 1(C1) checked the temperature of the pureed food that was on the steam table it was green beans, mashed potatoes, and Barbecue (BBQ) pork riblet. During an interview on 3/15/2022 at…

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

Based on observation, interview, and record review, the facility failed to ensure 12 of 12 residents receiving a pureed diet (food texture made of liquidized or crushed fruit or vegetables for those who do not need to chew or have problem swallowing) received a lump-free meal. This deficient practice had the potential to result in increased choking risk for the residents receiving a pureed diet. Findings: During an observation of tray line service for lunch on 3/15/2022 at 11:45 a.m., [NAME] 1 (C1) checked the temperature of the pureed food that was on the steam table. The foods observed were green beans, mashed potatoes, and barbecue (BBQ) pork riblet. During an interview on 3/15/2022 at 11:46 a.m. with the Dietary Services Supervisor (DSS), DSS stated that the BBQ pork riblet was pureed by C1 approximately 45 minutes before the tray line started and C1 would place it in the oven. When DSS was asked if the meat was pureed enough for him, DSS stated that it looked pureed to him. DSS was asked to feel the texture of all the pureed food. The mashed potatoes and green beans were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, and record review the facility failed to maintain Resident beds side rails (structural support attached to the frame of a bed, intended to prevent falls and assist in repositioning and getting out of bed). in a safe operating condition for 5 of 5 sampled Residents. (Resident 174, 6,13,1, and 49) These deficient practices placed the residents at risk for a potential accident or entrapment (when a resident becomes caught between the mattress, bed or headboard and the bed rail, or between the rails) related to lose and faulty screws on side rails. Findings: A. During a review of the admission record indicated Resident 174 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included diabetes mellitus (DM-increase blood sugar), complete traumatic amputation at knee level, right lower leg and muscle weakness. During a review of Resident 174's Minimum Data Set (MDS - a comprehensive standardized assessment and screening tool), dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to: a. ensure two out of 8 sampled Residents (Residents 29 and 3) were treated with respect to promote dignity by failing to serve Residents 29 and 3 meals at the same time as their roommates. b.respond to residents' needs and requests for assistance with toileting and activities of daily living (ADL) in a timely manner for three of 12 sampled residents (Resident 22, 123, and 124). These deficient practices has the potential to cause psychosocial harm or decline to the residents and violates residents' right to be treated with dignity. Findings: a. During a review of Resident 29's admission record, the record indicated Resident 29 was admitted on [DATE] with diagnoses including heart failure (a long-term condition in which the heart cannot pump blood well enough to meet the body's needs all the time), rheumatoid arthritis (a chronic inflammatory disorder affecting many joints, including those in the hands and feet.), dementia (loss of 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to dispose properly of the resident's medical records on the tube feeding bag (nutritional supplements) for one of five sampled residents (Resident 20). This failure has the potential outcome of residents' personal medical information being released to the public without the resident's knowledge or consent. Findings: During a review of Resident 20's admission Face Sheet, the Face Sheet indicated Resident 20 was admitted on [DATE]. Resident 20's diagnoses included atherosclerosis of native arteries of extremities (a disease of the arteries characterized by the deposition of plaques of fatty material on their inner walls) with gangrene (dead tissue caused by an infection or lack of blood flow) on the left leg, pneumonia (an infection of one or both of the lungs caused by bacteria, viruses, or fungi), type 2 diabetes (A group of diseases that result in too much sugar in the blood), hypertension (high blood pressure), depressive disorder (a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one out of one resident (Resident 16) was free from physical restraint when bed/chair alarm (pressure sensing devices that alarm when the resident gets up) order was not obtained from physician prior to applying. This deficient practice had the potential to inhibit Resident 16's freedom of movement or activity which had a potential for physical and psychosocial decline. Findings: A review of Resident 16's admission Record (Facesheet) dated 3/17/2022, indicated the resident was admitted to the facility on [DATE] with diagnoses not limited to atrial fibrillation (rapid, irregular beating of the heart), dementia (progressive brain disease causes symptoms such as memory loss), dysphagia (difficulty swallowing), hypertension ([HTN] condition present when blood flows through the blood vessels with a force greater than normal), schizophrenia (a chronic and severe mental disorder that affects how the person thinks, feels, and behaves), and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Minimum Data Set ([MDS] a comprehensive standardized assessment and care-screening tool) for a significant change in status was completed within the required time frame for one of eight sampled resident (Resident 58). This deficient practice had the potential to negatively affect the provision of necessary care and services. Findings: During a review of Resident 58's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 58's diagnoses included status post (S/P) fracture of right femur (broken thigh bone), protein-calorie malnutrition, dementia (a term used to describe a group of symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life), anemia (a condition in which you lack enough healthy red blood cells to carry adequate oxygen to your body's tissues) and muscle weakness. A review of Resident 58's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to effectively manage the pain for one of one sampled resident (Resident 13) experiencing pain. This deficient practice had the potential to negatively affect Resident 13's physical comfort and psychosocial well-being and had the potential to increase the pain level and result in an unmanageable pain level. Findings: A review of Resident 13's admission Record indicated Resident 13 was admitted to the facility on [DATE]. Resident 13's diagnoses included unilateral primary osteoarthritis (wearing down of the protective tissue at the ends of bones [cartilage] occurs gradually and worsens over time), bipolar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs), neuralgia and neuritis (pain caused by damaged or irritated nerves). A review of Resident 13's Minimum Data Set (MDS), dated [DATE], indicated Resident 13 was able to make herself understood and was able to understand others. The MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, staff failed to provide reasonable accommodation to meet the resident's needs by failing to ensure the resident's call lights was within reach for three of eight sampled residents (Residents 123 and 124). This deficient practice had the potential to negatively impact Resident 123, and 124's psychosocial well-being or result in delayed provision of services. Findings: a. During a review of Resident 123's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE]. Resident 123's diagnoses included sepsis (a potentially life-threatening condition that occurs when the body's response to an infection damages its own tissues), diabetes mellitus (refers to a group of diseases that affect how your body uses blood sugar), and adult failure to thrive (a decline seen in older adults - typically those with multiple chronic medical conditions - resulting in a downward spiral of poor nutrition, weight loss, inactivity, depression and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one controlled substance (medication with a high potential for abuse) was disposed of, after expiration and discontinuation of the physician's order for one out of one resident (Resident 9). This deficient practice increased the facility's risk for potential loss, diversion (transfer of a medication from a legal to an illegal use) or accidental exposure to controlled substances, and potential for harm to residents. Findings: A review of Resident 9's admission Record (Facesheet) dated [DATE], indicated the resident was admitted to the facility on [DATE] with diagnoses not limited to major depressive disorder ([MDD] a common but serious mood disorder, causing severe symptoms that affect how you feel, think, and handle daily activities, such as sleeping, eating, or working), dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure it was free of medication error rate of less than five (5) percent (%) for two of six randomly selected residents (Resident 48 and 35) observed during medication administration. This deficient practice of two medication errors out of 30 opportunities (observations during medication administration), resulted in a medication administration error rate of 6.67 %, that exceeded the five (5) percent threshold and the potential to increase the side effects of the medications. Findings: a. During a review of the admission Record, the record indicated Resident 48 was admitted to the facility on [DATE]. Resident 48's diagnoses include hemiplegia (a severe or complete loss of strength or paralysis on one side of the body) and hemiparesis (mild or partial weakness or loss of strength on one side of the body) following other nontraumatic Intracranial hemorrhage (acute bleeding inside the skull or brain) affecting the right dominant side, type 2…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure infection control practices were followed by Licensed Vocational (LVN 1) during care for one out of seven residents (Resident 124) who resided in a yellow zone room (area for newly admitted or readmitted residents, residents with incomplete or unknown COVID-19 [a highly contagious infection, caused by a corona virus that can easily spread from person to person] vaccination status). This deficient practice had the potential to place the residents, staff, and the community at risk for the spread of infection. Findings: A review of Resident 124's admission record (Facesheet) dated 3/17/22, indicated the resident was admitted to the facility on [DATE], with diagnoses not limited to urinary tract infection ([UTI] an infection of some part of the urinary tract), hyperlipidemia ([HLD] a condition that causes the levels of certain bad fats, or lipids, to be too high in the blood), dementia (memory loss), and hypertension ([HTN] a condition…

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