South Pasadena Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to:1. Ensure Resident 1's phenytoin sodium (a medication used to treat seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]) was available in stock to be administered on 7/25/2025 at its scheduled time of administration, in accordance with facility's policy and procedure (P&P) titled, Administering Medications, dated 7/2024. 2. Ensure Resident 2's ergocalciferol (also known as vitamin D2 - a vitamin used to treat low levels of vitamin D) was available in stock to be administered on 8/4/2025 at its scheduled time of administration, in accordance with the facility's P&P, titled Administering Medications, dated 7/2024.These deficient practices failed to ensure medications were available for two of three residents (Residents 1 and 2) that placed the residents at risk for vitamin D deficiency, seizures and hospitalization.Findings:1. During a review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to prevent significant medication error (a type of error which causes the resident discomfort or jeopardizes his or her health and safety) for Resident 1 by failing to ensure Resident 1's phenytoin sodium (a medication used to treat seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]) was available in stock to be administered on 7/25/2025 at its scheduled time of administration, in accordance with facility's policy and procedure (P&P) titled, Administering Medications, dated 7/2024. This deficient practice placed Resident 1 at risk for seizures, falls and other adverse consequences of not getting the medication.Findings:During a review of Resident 1's admission Record (a document containing demographic and diagnostic information), dated 8/4/2025, the admission record indicated, Resident 1 was originally admitted to the facility on [DATE] and readmitted on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident's call device (an alerting device for nurses or other nursing personnel to assist a patient when in need) was maintained within easy reach for two (2) of four (4) sampled residents (Resident 76, and Resident 120). This deficient practice had the potential to cause a delay in resident care for Resident 76 and Resident 120's resulting in unmet needs. 1. During a review of Resident 76's admission Record, the admission Record indicated Resident 76 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that included encephalopathy (a broad term for any brain disease that alters brain function or structure), other cerebral palsy (a group of neurological disorders that appear in early childhood and affect movement and muscle coordination), contracture of left and right hand ( the shortening and tightening of the tissues in the hand, causing fingers to bend or curl inwards, often impacting daily…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow its Policy and Procedure (P&P) on intravenous (into the through the vein) therapy for two (2) of three (3) sampled residents (Residents 54 and 58) by failing to ensure: 1. Resident 54's IV tubing (a flexible plastic tube that delivers fluids, medications, and other therapies into the body through a vein) was labeled. This deficient practice had the potential to put Resident 54 at risk of getting a bloodborne (carried by the blood) infection. 2. Resident 58's IV site was monitored every shift as indicated in the resident IV antibiotic (ATB, [medicines that fight bacterial infections]) care plan. This failure had the potential to put Resident 58 at risk for developing an infection and complications.Based on observation, interview and record review, the facility failed to follow its Policy and Procedure (P&P) on intravenous (into the body through the vein) therapy for two (2) of three (3) sampled residents (Residents 54 and 58) 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.

Based on observation, interview, and record review, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness (food poisoning), by failing to ensure the following:1. Six beef patties that were thawed in the walk-in refrigerator were used within 72 hours or discarded in accordance with the facility policy.2. Kitchen staff wore hairnets and beard restraints (worn by food handlers to avoid getting hair into the food) while preparing food and while dishwashing to prevent loose hair from falling into food or onto surfaces that can come into contact with food.3. Dietary aide used her mouth/teeth to cut the masking tape used to label beverages.4. Dishes and utensils were cleaned under sanitary conditions when dishwasher temperature gauge (a device to monitor temperature) glass cover was obscured making it impossible or difficult to see water temperature gauge readings clearly. These deficient practices had the potential to result in cross contamination (transfer of harmful bacteria [tiny, single-celled living things that are…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 dispose garbage (mostly decomposable food waste or yard waste) and refuse (dry material such as glass, paper, cloth or wood that does not readily decompose) by leaving two of four dumpsters (large trash container designed to be emptied into a truck) exposed to the environment and not cover or close completely. This deficient practice had the potential to attract vermin (animals that are believed to be harmful, carry disease such as rodents, parasitic worms , or insects), pests (any living thing that has a negative effect on humans), and wildlife (undomesticated animal species) that could potentially infiltrate the facility, affect the resident care areas and pose a disease threat to the residents and staff of the facility. Findings:During a concurrent observation and interview on 7/23/2025 at 8:22 AM with the Maintenance Supervisor (MS) at the garbage area, two of four dumpsters were observed with lids left exposed to the environment and not covered or completely closed. The MS confirmed the two dumpsters 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 interview and record review, the facility failed to ensure a coordination of care between the facility and hospice (care designed to give supportive care to people in the final phase if a terminal illness and focus on comfort and quality of life, rather than cure) staff for two of two sampled residents (Resident 14 and Resident 105) in accordance with the physician's order by failing to ensure:1. Resident 14 has a July 2025 Hospice nursing visitation calendar and hospice care in June 2025 was provided as indicated on the physician's order.2. Hospice visits for June 2025 and July 2025 were provided for Resident 105. This deficient practice had the potential for Resident 14 and Resident 105 not to receive the hospice care and services necessary to promote comfort and quality of life. Findings: 1. During a review of Resident 14’s admission Record, the admission Record indicated the facility admitted Resident 14 on 12/9/2024, with diagnoses including, but not limited to cerebral infarction (or stroke-an…

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

Based on observation, interview and record review, the facility failed to ensure standard infection prevention control practices (a set of practices that prevent or stop the spread of infections or diseases in the healthcare setting) was followed when medical waste (any waste generated by healthcare activities, ranging from used needles [the pointed hollow end of a syringe[medical device consisting or a hollow tube with a plunger]] and syringes to soiled dressings, body parts, blood, and medical devices) was not disposed safely and appropriately in accordance with the facility's policy and procedure (P&P). This deficient practice had the potential to result in the spread of and development of infection through possible cross contamination (passing of bacteria or other harmful substances indirectly from one resident to another through improper disposal of medical waste.Findings: During a concurrent observation and interview on 7/23/2025 at 10:30 AM with Licensed Vocational Nurse (LVN 4), inside Room B, LVN 4, performed wound care treatment. A sacral area wound (skin injury that…

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

Based on observation, interview, and record review, the facility failed to:1. Clean the dryer lint trap for one (1) of four (4) dryers located in the laundry room as indicated in the Facility's Policy and Procedures (P&P). This deficient practice had the potential to cause fire in the facility. 2. Ensure laundry washer temperature was accurately checked on 7/23/2025. This deficient practice had the potential of improper disinfection of residents' clothes. 3. Ensure restroom A and room A were free of urine on the toilet surfaces and floor. This deficient practice had the potential to affect resident's quality of life. 1. During a concurrent observation in the laundry room and interview with Laundry Staff 1 (LS 1) and Infection Prevention Nurse (IPN) on 7/23/2025 at 1:09 PM, 4 dryers were observed in the laundry room. Lint found in the lint traps in 1 dryer (dryer 1). LS 1 stated, Lint is removed from the lint traps every two (2) hours, and it is being logged. IPN verified that lint was found in the lint trap in dryer 1. IPN stated the log indicated a schedule of 6 AM, 8 AM, 10 AM, 12…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 promote dignity and respect for one of 30 sampled residents (Resident 115) when Certified Nurse Assistant 5 (CNA 5) was observed standing above Resident 115's eye level while assisting the resident during mealtime on 7/21/2025. This deficient practice had the potential to affect Resident 115's self-esteem and self-worth and violate the resident's right to be treated with dignity. During a review of Resident 115's admission Record, the admission Record indicated the resident was originally admitted to the facility on [DATE], with diagnosis of dementia (a progressive state of decline in mental abilities), Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements) and quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury). During a review of Resident 115'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 failed to ensure residents were provided with a homelike environment for one of one sample resident (Residents 139) for the environment care area by failing to provide bed linen that was damaged with multiple small holes. This deficient practice had the potential to negatively affect the residents' quality of life. During a review of Resident 139's admission Record indicated Resident 139 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease (a progressive lung disease that makes it difficult to breathe), type 2 diabetes mellitus with diabetic chronic kidney disease (a chronic condition that happens when you have persistently high blood sugar levels. Insulin resistance is the main cause, and it results in a condition where the kidneys are damaged and can't function properly), muscle weakness (a reduced ability of one or more muscles to generate force, making it harder to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure one (1) of five (5) sampled residents (Resident 1) was free from an unnecessary psychotropic drug (any medication capable of affecting the mind, emotions, and behavior) by failing to ensure Resident 1's Lorazepam (medication used to treat anxiety [persistent and excessive worry that interferes with daily activities) as needed (PRN) order had a documented rationale for extending the use beyond 14 days in accordance with the facility's policy. This deficient practice had the potential to place Resident 1 at risk for significant adverse consequences (serious negative outcomes resulting from an event, action, or situation) from the use of unnecessary psychotropic drug, which could result in impairment or decline in the residents' mental, physical condition, functional, and psychosocial statusDuring a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop a care plan (a document that outlines the facility's plan to provide personalized care to a resident based on the resident's needs) for three (3) of 30 residents (Residents 8, 79, and 126) as follows:Resident 79's 1,000 cubic centimeters (cc- a measurement of volume) fluid restriction (limiting the amount of liquids a person consumes each day) as ordered by the physician. Regarding Resident 126's Intravenous (IV) antibiotic (medicines that fight bacterial infections) administration.Regarding Resident 8's use of bolster low air loss mattress.These failures had the potential for Residents 79, 126 and 8 to receive care that is not personalized to meet the specific needs identified above, which could result in decreased quality of care and quality of life. 1. During a review of Resident 79’s admission Record, the admission Record indicated Resident 79 was originally admitted to the facility on [DATE] with diagnoses that included end…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the bolster (a raised, often inflatable, perimeter around the edges of the mattress that helps prevent patients from rolling out) low air loss mattress (LALM- a specialized medical mattress designed to prevent and treat pressure ulcer [pressure injury- wound that occurs as a result of prolonged pressure on a specific area of the body] by maintaining a cool, dry environment through constant airflow, which helps regulate temperature and moisture) was ordered for one (1) of five (5) sampled residents (Resident 8). This deficient practice had the potential for Resident 8's pressure ulcer to worsen and for the resident to develop new pressure injury.During a review of Resident 8's admission Record, the admission Record indicated the resident was originally admitted to the facility on [DATE], and readmitted on [DATE], with diagnosis of pressure ulcer of sacral region (are wounds that form as a direct result of pressure over a bony…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not ensure one of three sampled residents (Resident 87), received the correct amount of water flush via gastrostomy tube ( GTube- a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) after medication administration as indicated in the physician's order and care plan (a document that outlines the facility's plan to provide personalized care to a resident based on the resident's needs).This failure resulted in a decreased amount of water administration for Resident 87, with the potential risk for Resident 87 to experience inadequate hydration and/or clogging of the GTube, causing decreased nutrition and hydration.Findings:During a review of Resident 87's admission Record, the admission Record indicated Resident 87 was admitted to the facility on [DATE], with diagnoses that included gastrostomy status, moderate protein-calorie malnutrition (a nutritional…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the daily fluid restrictions (limiting the amount of liquids a person consumes each day) of 1000 cubic centimeters (cc- a measurement of volume) for one of five residents (Resident 79) on dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney[s] have failed) as ordered by the physician. This failure had the potential for Resident 79 to experience complications including fluid overload (having too much fluid in the body) which could negatively affect the resident's overall wellbeing.Findings:During a review of Resident 79's admission Record, the admission Record indicated Resident 79 was originally admitted to the facility on [DATE] with diagnoses that included End Stage Renal Disease (ESRD- irreversible kidney failure), dependence on renal dialysis, and heart failure (a chronic condition in which the heart does not provide adequate blood flow to meet the body's needs).…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 consistent and accurate account for controlled medications (medications that the use and possession of are controlled by the federal government) through staff documentation for all the controlled medication at shift change. This has the potential for the facility staff to not secure and safeguard controlled medications and not be able to account that the medications were administered to the residents safely and accurately.Findings:During a review of Resident 87's admission Record, the admission Record indicated Resident 87 was admitted to the facility on [DATE], with diagnoses that included gastrostomy status (GTube- a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), moderate protein-calorie malnutrition (a nutritional deficiency where the body doesn't receive enough protein and calories to meet its needs), and aphasia (a disorder that makes it…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 its medication error rate was less than five (5) percent (%). Three (3) medication errors (the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order/ manufacturer's specifications / accepted professional standards and principles) out of 25 opportunities (observed administered medications) for error, which yielded a facility medication rate of 12.5% for one (1) of four (4) sampled residents (Resident 87). Licensed Vocational Nurse 3 (LVN 3) failed to administer 10 to 15 cubic centimeters (cc-unit of volume) of water (fluid) via Resident 87's gastrostomy tube (GTube- a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) in between each medication in accordance with the physician's order.This failure resulted in Resident 87 not receiving the prescribed amount 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 did not ensure the glucose test strips (small, plastic strips used with a glucose meter to measure the amount of glucose [sugar] in a blood sample) were not expired prior to blood sugar testing for one of two sampled residents (Resident 6) observed during medication administration. This deficient practice had the potential to cause inaccurate test results in the testing of Resident 6's blood sugar, leading to inappropriate and ineffective treatment and management.Findings:During a review of Resident 6's admission Record, the admission Record indicated Resident 6 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), peripheral vascular disease (PVD - a slow progressive narrowing of the blood flow to the arms and legs) and gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain accurate and complete medical records in accordance with the facility's Policy and Procedures (P&P) for two (2) of 30 sampled residents (Resident 58 and Resident 87) when: Resident 58's intravenous (IV, within the vein) therapy medication record was not initialed on 7/14/2025, 7/15/2025, 7/16/2025, 7/17/2025, 7/18/2025, 7/19/2025, 7/20/2025, 7/21/2025, 7/22/2025 and included inaccurate information on 7/22/2025.Inaccurately documenting the administration of water flushes for one of four sampled residents (Resident 87), in the Medication Administration Record (MAR), when the water flushes were not given. These failures had the potential to result in a lack of or delay in the provision of care/interventions for Residents 87 and 58 and inaccurate communication between healthcare providers. 1. During a review of Resident 58’s admission Record, the admission Record indicated the resident was originally admitted to the facility on [DATE]…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, the facility failed to provide care in a manner that maintained the resident's dignity and treated the resident with respect for one of two sampled residents (Resident 1'sby failing to ensure Resident 1 was covered with a blanket/ towel when getting out of the shower. This deficient practice violated the resident's right for privacy and had the potential to affect the self-esteem, self-worth, sense of independence and psychosocial well-being (an individual's mental, emotional, and social health, encompassing aspects like happiness, life satisfaction, self-esteem, social functioning, and a sense of purpose, all of which are interconnected and influence overall functionality) of the resident. Findings: During a review of Resident 1's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with the following diagnoses of muscle weakness and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control 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 follow their Policy and Procedure (P&P) titled Abuse (misusing something, especially mistreating a person or harming them physically) Investigation and Reporting for one of two sampled residents (Resident 1) by: 1. Failing to report to the State Agency (SA where state law provides for jurisdiction in long-term care facilities), ombudsman (advocates for residents of nursing homes, board and care homes and assisted living facilities) and local enforcement within 2 hours after Resident 1 reported an allegation of physical abuse to Registered Nurse 1 (RN 1) on 4/22/2025 at 10 AM that Resident 2 jumped on top of Resident 1 and hit Resident 1's head. 2. Failing to separate Resident 1 and 2 immediately after the incident was reported on 4/22/2025 at 10 AM. These deficient practices had potential for ongoing abuse for Resident 1 and other residents. Findings: During a review of Resident 1'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 nursing staff failed to ensure one (1) of three (3) sampled resident (Resident 2) with a gastrostomy feeding tube (GT- a tube inserted into the stomach to provide nutrition when a person is unable to eat adequately through their mouth) received the GT feeding volume as ordered by the physician. This deficient practice had the potential to result in altered nutritional status, weight loss, not able to promote wound healing and potentially lead to more complications for Resident 2. Findings: During a review of Resident 2's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that including but not limit to protein calorie malnutrition (a condition that occurs when a person ' s body doesn ' t get the right amount of nutrients it needs to function properly), stage 3 pressure ulcer (a small open sore or wound generally found in the stomach or on the skin) on left…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 two sampled residents (Resident 1) was treated with respect and dignity by failing to ensure the television volume was in a comfortable level in Resident 1's room. This deficient practice resulted in a confrontation between Resident 1 and Resident 2 regarding the volume of the television in the room and violated Resident 1's right to be treated with dignity. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing), type 2 diabetes mellitus with diabetic chronic kidney disease (DM- a disorder characterized by difficulty in blood sugar control and chronic kidney damage due to high blood sugar levels), and acute respiratory failure with hypoxia (a medical condition where the lungs are unable…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 two (2) of four (4) sampled Residents (Residents 16 and 286) and/or Residents' representatives were informed and provided written information regarding the right to formulate an advance directive (written statement of a resident's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the resident be unable to communicate them to the doctor) in accordance with the facility policy and procedure. This deficient practice had the potential for Residents 16 and 286 or residents' representative to not know their rights and cause conflict in carrying out the Residents' wishes for medical treatment and health care decisions. Findings: 1. A review of Resident 16's admission Record indicated Resident 16 was admitted to the facility on [DATE] and readmitted on [DATE]. A review of Resident 16's History and Physical (H&P, the initial clinical evaluation and examination of the resident), 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 ensure grooming care assistance was provided for two (2) of three (3) sampled residents (Residents 43 and 75) as indicated in the facility policy. This deficient practice had the potential to lead to skin breakdown, poor hygiene, and diminished quality of life for Residents 43 and 75. Findings: 1. A review of Resident 43's admission Record indicated Resident 43 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses of metabolic encephalopathy (abnormalities of water, electrolytes, vitamins, and other chemicals that adversely affect the brain function), muscle weakness, and dementia (progressive brain disorder that slowly destroys memory and thinking skills). A review of Resident 43's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 7/3/24, it indicated the resident's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interventions to prevent accidents for three (3) of 3 sampled residents (Resident 58,103 and 28) who had history of seizures (burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements like stiffness, twitching or limpness) by failing to provide padded siderails (a barrier attached to the side of a bed) in accordance with the facility's seizure precaution policy. This deficient practice had the potential for Residents 58,103 and 28 to sustain injuries during a seizure disorder activity. Findings: 1. A review of Resident 58's admission Record indicated Resident 58 was initially admitted to the facility 3/24/24 and readmitted on [DATE], with diagnoses of epilepsy (a brain disorder that causes unprovoked, recurrent seizures), quadriplegia (paralysis of all four limbs), and dementia (progressive brain disorder that slowly destroys memory and thinking skills). 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 necessary care and services for two (2) of three (3) sampled residents (Resident 106 and 103) by failing to: 1. Monitor Resident 106's Foley catheter (brand name for urinary indwelling catheter - a flexible tube inserted into the bladder that remains there to provide continuous urinary drainage) in accordance with the physician's order. This failure had the potential to place Resident 106 at risk for developing a urinary tract infection (UTI, an infection in any part of the urinary system). 2. Resident 103 suprapubic stoma site (surgically made hole above the pubic area) dressing was not changed daily as ordered. This deficient practice had the potential for Resident 103 to develop an infection at the suprapubic stoma site which could affect the health and well-being of the resident. Findings: 1. A review of Resident 106's admission Record, indicated the resident was initially admitted to the facility on [DATE] with diagnoses of generalized…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 their policy and procedure regarding oxygen administration for two (2) of 2 residents (Residents 7 and 129) by failing to ensure: 1. Resident 7's oxygen was at the correct ordered setting in accordance with the physician's order. This deficient practice resulted in Resident 7 not receiving the correct ordered amount of oxygen which had the potential to result in complications associated with oxygen therapy. 2. Resident 129's oxygen nasal cannula (NC, a device that delivers extra oxygen through a tube and into your nose) was changed every seven (7) days. Facility also failed to maintain a clean oxygen concentrator (a medical device that gives extra oxygen). These deficient practices had the potential for Resident 129 to develop a respiratory infection and cause complications associated with oxygen therapy. Findings: 1. A review of Resident 7's admission Record, indicated the resident was initially admitted to the facility on [DATE]…

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

Based on observation, interview, and record review, the facility failed to follow proper food handling practices in accordance with the facility's policy and procedure by: 1. Facility failed to properly seal a container of chicken soup base and wheat flour. 2. Facility failed to ensure the refrigerator designated for resident's food items brought form outside was kept clean. These deficient practices had the potential to result in pathogen (germ) exposure to residents, which could place the residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever, which can lead to other serious medical complications and hospitalization. Findings: During concurrent observation in the kitchen and interview on 7/16/24 at 7:52 AM with the Dietary Supervisor (DSS), DSS stated the clear plastic container of chicken soup base and wheat flour was not sealed properly. During interview on 7/18/24 at 8 AM with the Dietary Staff (DS 1), DS 1 stated all containers are supposed to be closed or sealed properly…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide reasonable accommodations for resident needs and preferences for two (2) of 26 sampled residents (Residents 124 and 186) in accordance with the facility's policy when: 1. Resident 124's bathroom toilet seat was not at a comfortable and safe height for the resident. This deficient practice had the potential to result in a fall and injury to Resident 124. 2. Resident 186's call light was not within reach. This deficient practice had the potential for Residents 186 not to obtain necessary care and services to meet resident's needs. Findings: 1. A review of Resident 124's admission Record indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis that included Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). A review of Resident 1's History and Physical (H&P), dated 4/15/24,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a clean, comfortable, homelike environment for one of seven sampled residents (Resident 58). This deficient practice had the potential to result in the spread of diseases and infection. Findings: A review of Resident 58's admission Record indicated Resident 58 was initially admitted to the facility 3/24/24 and readmitted on [DATE], with diagnoses of sepsis (a serious condition resulting from the presence of harmful microorganisms in the blood), gastrostomy (a surgical procedure for inserting a tube through the abdomen wall and into the stomach used for feeding or drainage) status, and quadriplegia (paralysis of all four limbs). A review of Resident 58's Care Plan, initiated 3/29/24, indicated Resident 58 had bladder and bowel function incontinence (inability to control). The care plan interventions were to clean after each episode of incontinency, assure good skin care, and maintain privacy at all times. 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 develop/implement residents' care plan for two (2) of 26 sampled residents (Residents 28 and 103) as indicated in the policy and procedure by failing to: 1. Implement the use of padded side rail for Resident 28 who has a diagnosis of epilepsy (brain disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions, associated with abnormal electrical activity in the brain). This deficient practice had the potential to place the Resident 28 at risk for injuries. 2. Develop a care plan to address the treatment for Resident 103's suprapubic stoma site (surgically made hole above the pubic area). This deficient practice had the potential to increase Resident 103's risk for infection. Cross reference with F689 Findings: 1. A review of Resident 28's admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses of epilepsy, muscle weakness, and anxiety (a feeling…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 (1) of three (3) sampled resident (Resident 63) was provided a communication board (pre-printed picture board that has pictures, numbers, and user defined images that allows a resident to point or indicate on the board what he/she wants communicated) with the language the resident was able to understand in accordance with the facility policy. This failure had the potential to result in Residents 63 experiencing a delay in receiving appropriate care and treatment due to the staff not being able to properly communicate with the resident. Findings: A review of Resident 63's admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of aphasia (a language disorder caused by damage to in specific area of the brain that controls language expression and comprehension), including hemiplegia and hemiparesis (a condition caused by brain injury that results in a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement treatment for the prevention of pressure ulcer (painful wound caused as a result of pressure or friction) by failing to ensure that the low air loss mattress (LAL, mattress used for residents who are at risk for developing sores or already have pressure ulcer designed to circulate a constant flow of air for the management of pressure sores) was on the correct settings for two (2) of five (5) sampled residents (Residents 287 and 46), in accordance with the facility's policy and procedure. This deficient practice had the potential to place Resident 287 to have worsening stage 3 pressure ulcer (full-thickness skin loss in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole [rolled wound edges] are often present) and potential for Resident 46 to develop a pressure ulcer. Findings: 1. A review of Resident 287's admission Record indicated the resident was admitted to the facility on [DATE]. 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 ensure one (1) of three (3) sampled residents (Resident 106) received Restorative Nursing Assistant (RNA, nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible) services as indicated in the physician's order. This failure had the potential to put Resident 106 at risk for decline in physical function and developing contractures (a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff). Findings: A review of Resident 106's admission Record, indicated the resident was initially admitted to the facility on [DATE] with diagnoses of generalized (spread or extended throughout the body) weakness and neuromuscular dysfunction of the bladder (when the nerves and muscles do not work together well and as a result the bladder may not fill or empty correctly). A review of Resident 106's History and Physical Examination…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident received the two (2) liters (unit of volume used for measuring capacity of liquids) of water required to receive daily and to accurately record fluid intake for one (1) of two (2) sampled residents (Resident 112) as indicated in the physician's order and in accordance with the facility's policy. This deficient practice could potentially result to insufficient fluids received daily affecting Resident 112's overall health and well-being. Findings: A review of Resident 112's admission Record indicated the resident admitted to the facility on [DATE] with a diagnosis of hyperosmolality (condition wherein blood has high concentration of sodium (salt), glucose and other substance) and hypernatremia (a condition in which the blood has a high concentration of salt. A Review of Resident 112's History and Physical (H&P), dated 11/11/23, indicated Resident 112 had the capacity to understand and make decisions. A review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow the physicians order for one (1) of five (5) sampled residents (Resident 124) in accordance with the facility policy by failing to check Resident 124's heart rate prior to administering metoprolol (medication to treat high blood pressure (the force of blood pushing against the walls of your arteries), long term chest pain and heart failure (when the heart muscle does not pump blood as well as it should). This deficient practice had the potential for Resident 124 to experience adverse consequences (undesirable effect) or events such as bradycardia (slow heart rate). Findings: A review of Resident 124's admission Record indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis that included Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). A review of Resident 1's History and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that Restorative Nursing Assistant (RNA, nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible) services were documented timely and accurately for one (1) of 26 sampled residents (Resident 106). This failure resulted in the facility not documenting RNA services for Resident 106 timely and accurately as indicated in the facility policy. Findings: A review of Resident 106's admission Record, indicated the resident was initially admitted to the facility on [DATE] with diagnoses of generalized (spread or extended throughout the body) weakness and neuromuscular dysfunction of the bladder (when the nerves and muscles don't work together well and as a result the bladder may not fill or empty correctly). A review of Resident 106's History and Physical Examination (H&P), dated 5/31/24, indicated the resident has the capacity to understand and make decisions. A review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 186) had a hospice (a program that gives special care to residents who are near the end of life and have stopped treatment to cure or control their disease) comprehensive assessment for the plan of care to include the frequency of hospice staff visits. This deficient practice had the potential for Resident 186 not to receive the hospice care and services necessary to promote comfort and quality of life. Findings: A review of Resident 186's admission Record indicated Resident 186 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses of malignant neoplasm of colon (cancerous growths that affect the large intestine), cerebrovascular disease (a group of disorders that affect the blood vessels and blood supply to the brain), and hemiplegia (a condition caused by brain damage or spinal cord injury that leads to paralysis [loss of motor function in one or more muscles] on one…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 prevention control practices (a set of practices that prevent or stop the spread of infections and or diseases in the healthcare setting) were implemented for two (2) of 26 sampled residents (Residents 10 and 57) according to the facility's policy and procedure when: 1. Licensed Vocational Nurse 8 (LVN 8) failed to disinfect (clean with a chemical, in order to destroy bacteria) the shared blood pressure cuff after obtaining Resident 10's blood pressure (pressure of circulating blood against the walls of blood vessels) reading. This deficient practice had the potential to spread infection to other residents in the facility. 2. LVN1 did not wear personal protective equipment (PPE) during medication administration to Resident 57, who had a gastrostomy tube (GT, a tube inserted through the belly that brings nutrition directly to the stomach) and was on Enhanced Barrier Precautions (EBP, refer to an infection control…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that the resident call system (call light- allow resident to communicate when they need assistance) for two (2) of 26 sampled residents (Residents 35 and 119) was functional for Resident 35 and within reach for Resident 119 as indicated in the facility policy. This failure had the potential to put Residents 35 and 119 at risk for experiencing a delay in receiving assistance from facility staff which could lead to a fall or accident. Findings: 1. A review of Residents 35 admission Records indicated the facility admitted Resident 35 on 5/8/2024 with diagnosis including muscle weakness, difficulty in walking, unsteadiness on feet. A review of Resident 35's History and Physical Examination (H&P), dated 5/10/2024, indicated the resident has the capacity to understand or make decisions. A review of the Minimum Data Set (MDS, standardized care and screening tool) dated 5/17/2024, indicated Resident 35 cognition was intact (processes 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 provide a clean, safe, and sanitary environment when: 1. Food debris were observed under Resident 16's bed. 2. Used syringes were not properly disposed in the sharps container. 3. The rubber covering of two green silicon dumbbells were observed peeling off. These deficient practices had the potential to result in the spread of diseases and infection. Findings: 1. A review of Resident 16's admission Record indicated Resident 3 was admitted to the facility on [DATE] and readmitted on [DATE]. A review of Resident 16's History and Physical (H&P, the initial clinical evaluation and examination of the resident), dated 6/5/24, indicated Resident 16 had diagnoses of multiple sclerosis (MS, a disorder of the central nervous system marked by weakness, numbness, a loss of muscle coordination, and problems with vision, speech, and bladder control), pulmonary edema (when fluid collects in the air sacs of the lungs, making it difficult to breathe), and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide residents with a safe, clean, comfortable homelike environment for 13 of 15 sampled residents (Residents 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 14, and 15). a. Residents' 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 14 and 15 rooms had rodent (small gnawing mammals such as a mouse or rat) droppings. b. Resident 3's room had large clear plastic bag of clothes and hangers on the floor next to resident's bed. These deficient practices resulted in an unsafe and unclean environment with the potential for the spread of infection or accidents. Findings: A review of Resident 2's admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses of type 2 diabetes mellitus (a disorder in which the body does not produce enough or respond normally to insulin [a hormone released from the pancreas that controls the amount of glucose in the blood], causing blood sugar [glucose] levels to be abnormally high) with diabetic neuropathy…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an effective pest control protocol. This failure resulted in evidence of an active rodent infestation, including rodent (small gnawing mammals such as a mouse or rat) droppings and nesting materials, in Resident 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 14, and 15 ' s rooms, 13 out of 15 sampled residents. Findings: A review of Resident 2 ' s admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses of type 2 diabetes mellitus (a disorder in which the body does not produce enough or respond normally to insulin [a hormone released from the pancreas that controls the amount of glucose in the blood], causing blood sugar [glucose] levels to be abnormally high) with diabetic neuropathy (a type of nerve damage that can occur in people with diabetes), dementia (progressive brain disorder that slowly destroys memory and thinking skills), and functional quadriplegia (complete immobility due to severe disability…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide reasonable accommodation to meet the resident's needs by failing to ensure the resident had a working television and remote control for one of 15 sampled residents (Resident 1). This deficient practice had the potential to negatively impact the psychosocial well-being of Resident 1. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of multiple sclerosis (an autoimmune disease that affects the brain and spinal cord [central nervous system] with symptoms ranging from numbness and tingling to blindness and paralysis [loss of voluntary muscle function in one or more parts of the body as a result of damage to the nervous system]), pressure ulcer (painful wound caused as a result of pressure or friction) of right buttock, unsteadiness on feet, and contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a functioning call light for one of 15 sampled residents (Resident 1). This deficient practice had the potential to result in a delay in meeting Resident 1's needs for hydration, pain management, and activities of daily living (ADLs - activities related to personal care that include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating). Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnosis of multiple sclerosis (an autoimmune disease that affects the brain and spinal cord [central nervous system] with symptoms ranging from numbness and tingling to blindness and paralysis [loss of voluntary muscle function in one or more parts of the body as a result of damage to the nervous system]), pressure ulcer (painful wound caused as a result of pressure or friction) of right buttock, unsteadiness on feet, 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 one of three sampled residents (Resident 1) had the updated Physician Orders for Life-Sustaining Treatment (POLST, paradigm form designed to improve patient care by creating a portable medical order form that records resident treatment wishes so that emergency personnel know what treatments the resident wants in the event of a medical emergency, taking the resident's current medical condition into consideration) in the resident's medical record. This deficient practice had a potential in not honoring Resident 1's preferences/ wishes indicated on Resident 1's POLST. Findings: A review of Resident 1's admission Record indicated the resident was admitted to the facility on [DATE] and re- admitted on [DATE]. Resident 1's diagnoses included chronic obstructive pulmonary disease (COPD, a chronic inflammatory lung disease that causes obstructed airflow from the lungs), cerebral infarction (refers to damage to tissues in the brain due to a loss 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 implement and maintain infection control practices as followed: 1. A staff member did not clean and/or disinfect shared resident equipments, such as a front-wheeled walker (FWW, type of walking aid with a wide base for support) and a cloth gait belt (safety device worn around the waist used to help safely transfer a person from one surface to another) between use with two residents. 2. In the laundry room, the following were observed: a. There was a disposable yellow isolation gown [a type of personal protective equipment (PPE) used to prevent the spread of infection] hanging in the clean PPE donning (putting on) station for re-use. b. There was no sink for hand washing or alcohol-based hand sanitizer available in the soiled PPE doffing (taking off) station for staff to perform hand hygiene after handling soiled linens and doffing soiled PPE. c. The lint in the dryer machines were not cleaned every two hours according to the facility'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 implement safeguards to ensure labels containing resident information were discarded appropriately for two of two sampled residents (Resident 35 and 77). a. Resident 35's Glucerna formula (a total nutritional supplement) container with the resident's information was in the trash bin. b. Resident 77 threw away a sandwich with a label containing the resident's information, the Housekeeper 1 (HK 2) tied the trash bag and placed it in her cart. These deficient practices violated the residents' right to privacy of his/her medical information. Findings: a. A review of Resident 35's admission Record indicated the resident originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included type 2 diabetes (high blood sugar), dysphagia (difficulty swallowing), and dementia (a decline in mental ability). On 7/20/21 at 10:12 a.m., during an observation, there was a full trash bin at the entrance of Resident 35's room.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents were provided with a safe, clean, comfortable, and homelike environment for two of four sampled residents' (Residents 97 and 73). Residents 97 and 73's wheelchairs were observed with torn backs and worn arm rest cushions. This deficient practice had the potential to affect the residents' comfort. Findings: a. During an observation, on 7/20/21 at 11:02 a.m., Resident 73 was sitting in her room in her wheelchair. The back of Resident 73's wheelchair on the left side was torn and the left arm rest was torn with cushion padding exposed. During an interview, on 7/20/21 at 1:30 p.m., Janitor 1 (J1) stated that he and the maintenance staff would make repairs of resident wheelchairs as needed. J1 stated that the facility was constantly looking at residents' equipment, and if the facility staff reported something wrong with a wheelchair, the maintenance department would look at it. During an Interview on, 7/21/21 at 9:45 a.m.,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop an individualized, comprehensive care plan for one of seven sampled residents (Resident 100), who was on a restorative nursing aide program (RNA, nursing aide program that help residents to maintain their function and joint mobility). Resident 100 did not have a care plan for an RNA program for left upper extremities (LUE, shoulder, elbow, wrist, hand) and left lower extremities (LLE, hip, knee, ankle, foot) for passive range of motion (PROM, movement at a given joint with full assistance from another person) exercises and RNA program for right upper extremities (RUE) and right lower extremities (RLE) for active assistive range of motion (AAROM, movement at a given joint with a person's own effort and assistance from an external force or another person) exercises. This deficient practice had the potential to limit the resident and representative's involvement in care planning of the RNA program and review of the goals, objectives,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Licensed Vocational Nurse 6 (LVN 6) flushed with water in between administration of medications via a gastrostomy tube (G-tube, a tube inserted through the belly that brings nutrition directly to the stomach) during a medication administration to Resident 127. This deficient practice had the potential for the resident to have complications with the G-tube such as obstruction of the tubing and/or drug-to-drug interactions from mixing of drugs. Findings: During a medication pass observation, on 7/21/21 at 7:40 a.m., LVN 6 prepared the following medications for administration via G-tube for Resident 127: 1. Aspirin (a medication used to prevent blood clots) tablet chewable 81 milligram (mg, a unit of measurement) one tablet 2. Ferrous sulfate (FESO4, a nutritional supplement) 220 mg/5 milliliters (ml, a unit of measurement) 3. Metformin (a medication used to help control high blood sugar) 500 mg one tablet 4. Memantine (a medication…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Resident 36 with a communication board to assist the resident with his communication needs. This deficient practice prevented the resident from communicating with the staff and had a potential to delay receiving appropriate care/treatment services that the resident needed. Findings: A review of Resident 36's admission Record indicated the resident admitted to the facility on [DATE], with diagnoses that included aphasia (loss of ability to understand or express speech, cause by brain damage), dementia (loss of memory, language, problem solving and thinking ability), hemiplegia (paralysis of one side of the body), and hemiparesis (weakness or inability to move on one side of the body) affecting right dominant side. A review of Resident 36's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 5/5/21, indicated the resident had moderate impairment in cognitive skills (process of acquiring knowledge and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide the necessary treatment and services for one of two residents (Resident 36) to prevent pressure ulcers (PUs, skin breakdown caused from prolonged pressure to the skin) from worsening. The facility failed to turn Resident 36 every two hours and apply pressure relieving device as indicated in the resident's care plan. This deficiency had the potential for the resident to have worsening PUs and/or acquire new PUs. Findings: A review of Resident 36's admission Record indicated the resident re-admitted to the facility on [DATE], with diagnoses that included aphasia (loss of ability to understand or express speech, cause by brain damage), dementia (loss of memory, language, problem solving and thinking ability), hemiplegia (paralysis of one side of the body), and hemiparesis (weakness or inability to move on one side of the body) affecting right dominant side. A review of Resident 36's Minimum Data Set (MDS, a standardized assessment and 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 b. During an observation on 7/20/21 at 10:54 a.m., Resident 12 was noted sitting on the bed with bilateral upper side rails up. Left side rail was covered with sheep like wool padding while no pads were noted on the right side rail. Only one floor mat was observed on the left side of the resident's bed. A review of Resident 12's admission Record indicated the facility admitted Resident 12 on 10/16/2020 with diagnosis that included Fall and Fracture (complete or partial break in a bone) part of neck of right femur (bone of the thigh, articulating at the hip and the knee). A review of Resident 12's Minimum Data Set (MDS, a standardized assessment of care screening tool), dated 4/24/2021, indicated the resident had severe impairment in cognitive skills. The MDS indicated Resident 12 required assistance for activities of daily living (ADLs) from staff for bed mobility, toilet use, and on transfers. During an interview, on 7/21/21 at 7:42 a.m., a Restorative Nurse Aide 2 (RNA 2) stated that the side rail pads 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 observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 125) was provided with an assessment and education for the resident to disconnect and self-drain his urostomy (an opening in the belly that directs urine away from the bladder) pouch. This deficient practice had the potential for the resident to have urinary infections. Findings: A review of Resident 125's admission Record indicated the resident admitted to the facility on [DATE] with diagnoses that included disorder of urinary system (difficulty urinating) and acute (sudden) kidney failure. A review of Resident 125's physician order, dated 11/25/19, indicated an order for the resident to receive right lower quadrant urostomy treatment as needed for soiled or dislodgement. The order indicated to cleanse with normal saline (salt water), pat dry, apply Nystatin (antifungal medication) powder to the wound, and apply a urostomy pouch. A review of Resident 125's Minimum Data Set (MDS, standardized…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to monitor blood sugar levels and signs and symptoms of hypoglycemia (when blood sugar levels fall below normal levels) for one of one sampled resident (Resident 56), who received insulin (medication used to control elevated blood sugar levels) injections. This deficient practice had the potential for the resident to receive insulin when the resident's blood sugar levels were low, which could result in the resident's blood sugar levels to become critically low requiring emergency treatment. Findings: A review of Resident 56's Face Sheet (a record of admission) indicated the resident 56 admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus (DM, a disease in which blood sugar levels were high) and cellulitis (a common bacterial skin infection) of right lower limb (lower extremity refers to the part of the body from the hip to the toes). A review of Resident 56's Minimum Data Set (MDS, a standardized…

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

Based on observation, interview, and record review, the facility failed to label four (4) multi-dose vials (a vial of liquid medication that contained more than one dose for administration) of insulin (medication used to control blood sugar levels) with an open date when it was opened. This deficient practice had the potential to compromise the well-being of the residents by not being able to determine when to discard the medication after removing the seal. Findings: a. During an inspection of Medication Cart #3 with Licensed Vocational Nurse 1 (LVN 1), on 7/21/21 at 10:45 a.m., one vial of Novolin R (a short-acting type of insulin to control blood sugar levels) with an expiration date of 7/23, was opened and did not have a label to indicate when it was opened. LVN 1 stated that the medication should be labeled with a date immediately after opening the vial. During an inspection of Medication Cart #1 with LVN 2, on 7/21/21 at 1:05 p.m., a vial of Humalog Insulin Lispro (a fast-acting insulin) and a vial of Humulin R Regular Insulin (a short-acting insulin) were opened and did not…

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

Based on observation, interview, and record review, the facility failed to ensure food was stored in the freezer in accordance to professional standards for food safety. A bag of pork pot stickers was found in the freezer opened and undated. This deficient practice had the potential to cause foodborne illness (illness caused by food contaminated with bacteria, viruses, parasites, or toxins) of the residents. Findings: During an inspection of the kitchen and interview with the Director of Food and Nutrition (DFN), on 7/20/21 at 8:44 a.m., a bag of pork pot stickers was observed opened, with ice crystals, and undated in the freezer. The DFN stated that he did not know when the bag was opened. The DFN stated that opened foods should be dated when opened so that staff knew that it was safe to eat. A review of the facility's undated policy and procedure (P&P) titled, Food Storage: Cold Foods, indicated that all foods would be stored, wrapped, or in covered containers, labeled, and dated.

Based on interview and record review, the facility failed to ensure three of three staff knew how to notify the Quality Assurance Performance Improvement (QAPI) committee of any concerns. This deficient practice had the potential to result in identified problems within the facility would not be resolved. Findings: On 7/23/21 at 7:45 a.m., during an interview, Dietary Aide (DA) stated that if she could not resolve an issue in the kitchen that affected the facility's residents, she would notify the immediate supervisor. DA stated that the QAPI committee was a group of outsiders (not staff working in the facility) that came into the facility. DA stated that she was not sure what they did for the facility. On 7/23/21 at 7:53 a.m., during an interview, Restorative Nursing Aide 2 (RNA 2) stated that he did not know what a QAPI committee was or what it was for. RNA 2 stated he was not aware of any suggestion box in the facility to share any resident concerns. On 7/23/21 at 8 a.m., during an interview, Housekeeper 3 (HK 3) stated that she was not sure what the QAPI committee was and did not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a functioning call light (a button used by a resident to signal his or her need for assistance from staff) for three of 29 sampled resident beds (residents in Rooms 108B, 301A, 301B). This deficient practice had the potential to result in a delay for residents' needs being met and/or injury/harm from falls that may occur. Findings: During an initial tour of the facility on 7/20/21 at 9:36 a.m., the call light in room [ROOM NUMBER] B was checked and not be working. The signal light outside of room [ROOM NUMBER]'s door did not light up to alert staff. A Certified Nursing Assistant 2 (CNA) 2 stated that the call light was not working and notified the maintenance staff. During an interview on 7/23/21 at 9:55 a.m., Resident 97 (who was a resident in room [ROOM NUMBER]) stated that she used her call light to call for assistance when she felt like she was going to have a seizure (a sudden, uncontrolled electrical disturbance in the brain…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain a safe environment by not keeping the ceiling in some parts of the building free from moisture and water leaks. This deficient practice had the potential to expose the residents, staff, and visitors to accidents that could cause harm or injury. Findings: During an observation on 7/22/21 at 11:40 a.m., the ceiling in room [ROOM NUMBER] and the ceiling across the nursing Station B had water marks on the ceiling. During an interview on 7/22/21 at 11:45 a.m., Housekeeper 1 (HK 1) stated that she saw the ceiling damage in room [ROOM NUMBER] when she was performing housekeeping chores during the first week of July. HK 1 stated that she did not report what she saw to the Maintenance Supervisor (MS) because another staff (name unknown) told her that the ceiling damage was reported to the Maintenance Department already. During an interview on 7/22/21 at 12 p.m., the MS stated that he never saw the ceiling damage in room [ROOM NUMBER] or…

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