Clearwater Healthcare Center

Based on interview and record review, the facility failed to ensure appropriate transfer and discharge information was communicated to the receiving provider for Resident 1. This failure caused Resident 1 to be transferred to a facility that could not meet his needs and had the potential to negatively impact the safety and well- being of Resident 1.Findings: A review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility with diagnoses which included complete traumatic amputation (loss of body part due to accident or injury) at level between knee and ankle, right lower leg. During a telephone interview on 4/28/26 at 1:59 PM with Family Member (FM) 1, FM 1 stated Resident 1 was transferred to an Independent Living Facility (ILF) on 4/20/26. FM 1 further stated when Resident 1 arrived he was told by the ILF staff that they could not meet his needs since he was in a wheelchair. FM 1 stated the ILF was informed by the facility that Resident 1 was independent in his care needs and walked with a walker (mobility aid that provides support and stability while…

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

Based on interview, and record review, the facility failed to ensure one of two sampled residents (Resident 1) at risk of wandering/elopement received adequate supervision to prevent an elopement (when a resident leaves the facility without supervision) from occurring, when:1. Resident 1 did not have a care plan (a personalized, living document developed by healthcare professionals, patients, and families to manage health conditions, define care needs, and establish goals for daily living, treatment, and support) developed to address his known drug use; and,2. Resident 1 left the facility unsupervised with staff unaware of his location on 1/25/26.These failures had the potential to cause psychosocial harm and/or potential injury to Resident 1.Findings:1. A review of Resident 1's admission RECORD, dated 1/27/26, indicated Resident 1 was admitted to the facility in January of 2026 with a diagnosis of, but not limited to, sepsis (a life-threatening emergency caused by the body's extreme, dysfunctional immune response to infection, leading to tissue damage, organ failure, and potential…

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

Based on interview, and record review, the facility staff failed to maintain complete and accurate medical records in accordance with accepted professional standards for one of two sampled residents (Resident 1) when the substance use history section of Resident 1's admission nursing assessment was inaccurately documented.This deficient practice had the potential to result in confusion in the care and services for Resident 1 and placed Resident 1 at risk of not receiving appropriate care due to inaccurate and incomplete documentation.Findings:A review of Resident 1's admission RECORD, dated 1/27/26, indicated Resident 1 was admitted to the facility in January of 2026 with a diagnosis of, but not limited to, sepsis (a life-threatening emergency caused by the body's extreme, dysfunctional immune response to infection, leading to tissue damage, organ failure, and potential death), acute osteomyelitis of the right ankle and foot (a serious, rapid-onset infection and inflammation of the bone, often caused by the bacteria Staphylococcus aureus), and type 2 diabetes mellitus (a chronic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to safely discharge on e of one sampled resident (Resident 1) home with home health agency services (HHA, medical services provided at home) when Resident 1 was discharged home on [DATE], and the home health agency notified the facility they could not start home health services on 12/18/25.This failure had resulted in Resident 1's lack of home health services that caused a delay in the continuity of care following her discharge from the facility and had the potential risk for falls, injuries, and of readmission.Findings:Review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility in late 2025 with diagnoses that included displaced fracture of left femur (a broken left thighbone where the pieces have shifted out of alignment) and generalized muscle weakness. Review of Resident 1's doctor's orders indicated the following orders: a.Discharge to home with support on 12/17/25 following cessation [discontinued] of skilled services…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 appropriate and timely social services support for one of three sampled residents (Resident 1) when, the facility was made aware of Resident 1's wish to leave the facility approximately one month post admission due to not being able to use his motorized wheelchair in the facility, however, referrals were not sent to other facilities to find alternative placement until approximately three months later, nor was follow up conducted by facility staff following the referrals being sent to check on the status. This failure had the potential to negatively affect Resident 1's mental health and psychosocial well-being. Findings:A review of Resident 1's admission RECORD, indicated Resident 1 had a diagnosis of generalized muscle weakness, major depressive disorder (causing persistent sadness, loss of interest, and impacts how you feel, think, and act, interfering with daily life), acquired absence of right leg below knee (surgical removal of the lower…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 protect the rights of one of three sampled residents (Resident 2) to be free from physical abuse when, Resident 2, who was on continuous one-to-one (1:1 - a high-level intervention where a staff member provides continuous, direct observation of a single patient to prevent harm to themselves or others) observation, was punched in the chest by Resident 3, while Resident 2 wandered into Resident's 3's room unattended on 7/26/25.This failure had the potential to result in physical and psychosocial distress (state of emotional and psychological discomfort that can impact a person's well-being) to Resident 2.Findings:A review of Resident 2's admission RECORD, indicated Resident 2 was admitted to the facility with a diagnosis of, .UNSPECIFIED DEMENTIA [a condition characterized by a gradual decline in memory, language, reasoning, and problem-solving, that interferes with daily life] .WITH OTHER BEHAVIORAL DISTURBANCE .A review of Resident 2's Minimum Data Set, (MDS - a resident assessment tool) dated 6/18/25,…

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

Based on interview, and record review, the facility failed to ensure one out of three sampled residents (Resident 1) was assisted with transportation arrangements to attend a post-surgery appointment on 9/4/2025.This failure resulted in Resident 1 missing a scheduled physician's appointment and caused a delay in care and treatment.Findings:A review of Resident 1's admission RECORD, indicated Resident 1 had diagnoses which included amputation (removal of a limb or other body part by surgery), complications of amputation stump (the remaining part of a limb after it has been surgically removed), and orthopedic aftercare following surgical amputation (care given to the resident, usually by the surgeon who performed the surgery).During a telephone interview on 9/10/25, at 9:24 AM, with the Medical Receptionist (MR) at Resident 1's surgeon's office, the MR stated that Resident 1 did not show up for her appointment on September 4, and it was rescheduled for September 11.During an interview on 9/9/25, at 10:47 AM, with Resident 1 and utilizing Licensed Nurse (LN) 1 as an interpreter,…

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

Based on interview, and record review, the facility failed to ensure medications were administered according to physician orders for one of three residents (Resident 2) when Resident 2 missed a dosage of three medications on 8/20/25.This failure had the potential to negatively affect the health and well-being of Resident 2, and the efficacy of the medications being administered.Findings: A review of Resident 2's admission RECORD, indicated that Resident 2 was admitted to the facility in 2025 with diagnoses which included displaced intertrochanteric fracture of right femur (a break in the upper part of the hip in which the bones are out of place), and hypertension (a condition in which the force of the blood pushing against the blood vessel walls is consistently too high. This causes the heart to work harder to pump blood). A review of Resident 2's Physician Order Summary, indicated, .AmLODIPine Beselyte [medication to treat hypertension] Tablet 10MG [milligram, a unit of measure] Give 1 tablet by mouth one time a day for HTN [hypertension].Order Date.08/19/2025.Start…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 that accommodation of needs was met when call lights (system/device used by residents to call staff for assistance) were not answered in a timely manner for 2 of the 4 sampled residents (Resident 1, and Resident 3). This failure had the potential for residents' needs to be neglected and to negatively affect their psychosocial well-being for a census of 119. Findings: During a concurrent observation and interview on 7/2/25 at 10:51 AM, Resident 1 stated he waited too long for his incontinent brief (a type of absorbent undergarment) to get changed and the staff does not come on time when he uses the call light. Resident 1 stated even in the morning or evening time they still take longer to come when he presses the call light. At 10:58 AM Resident 1's call light was pressed because Resident 1 needed assistance to move from the bed and by 11:18 AM, there was still no response from staff. A review of Resident 1's Care Plan titled, ADL [Activities of Daily Living] Self Care Performance deficit r/t [related…

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

Based on interview and record review, the facility failed to ensure transportation was provided for two out of four sampled residents (Resident 1 and Resident 4), when Resident 1 missed a scheduled physician's appointment on 6/26/2025 at 11 AM and Resident 4 arrived late to a scheduled appointment on 6/20/25 and was not able to be seen. This failure resulted in Resident 1 and Resident 4 missing a scheduled physician's appointment. Findings:1. A review of Resident 1's admission RECORD (a document that contains the resident's demographic information) indicated Resident 1 had a diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (one side of the body becomes very weak or completely unable to move or paralyzed) and generalized muscle weakness. During an interview on 7/2/25 at 10:54 AM, Family Member (FM) 1 stated Resident 1 had an appointment with his primary care provider on June 26 at 11 AM, but the appointment was rescheduled because Resident 1 missed the appointment due to transportation issues. During an interview on 7/2/25 at 2 PM,…

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

Based on interview and record review, the facility failed to ensure Resident 1 who resided at the facility and was transferred to General Acute Care Hospital (GACH) was readmitted to the facility after Resident 1 was cleared by the GACH to return to the facility on 6/15/2025. This deficient practice resulted in Resident 1 remaining at the GACH after Resident 1 was deemed appropriate for discharge back to the facility but was denied readmission by the facility. Resident 1 did not return to the facility resulting in Resident 1's temporary loss of residence and had negative psychosocial outcome, as evidenced by vocalizations of emotional distress. Findings: A review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility with diagnoses which included generalized muscle weakness and paraplegia. Resident 1 was discharged from the facility on 6/14/2025. During an interview on 6/17/25 at 12:52 PM, License Nurse (LN) 1 stated Resident 1 went out of the facility without notifying a staff member and returned to the facility the same day on 6/14/25 at approximately…

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

Based on interview and record review, the facility failed to ensure Resident 1 who resided at the facility and was transferred to a General Acute Care Hospital (GACH) was provided a notice of transfer or discharge and a notice of a bed hold during transfer to a GACH when: 1. The facility did not provide a written notice of bed hold (holding or reserving a resident ' s bed while the resident is absent from the facility for therapeutic leave or hospitalization) to Resident 1 at the time of transfer to acute care hospital; 2. Resident 1 was not notified of the discharge in writing and in a manner he/she understood; and, 3. The facility did not notify or send Resident 1's Notice of Transfer or Discharge form to the Ombudsman's office (a government appointed person who actively supports the rights of residents). These failures resulted in Resident 1 not being fully informed of their right to request a bed hold and to return to the facility after hospitalization, Resident 1 not having the opportunity to have had an advocate to inform him of his right to appeal a facility-initiated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 discharge notice (also known as a 30-day notice) for one of three sampled residents (Resident 2) when, Resident 2, Resident 2's representative (FM; family member), and the Office of the Long-Term Ombudsman (OMB, a person who assists residents with resolving conflicts or concerns at the facility) did not receive written notification of Resident 2's impending discharge within 30 days or as soon as practicable when an impending discharge date had been determined by the facility. This failure violated Resident 2's right to be informed in writing of a pending discharge and how to appeal the decision of a facility-initiated discharge. This failure also resulted in Resident 2's representative and the State Long-Term Care Ombudsman from being uninformed of the discharge decision in writing and removed the opportunity for Resident 2's representative and/or the State Long-Term Care Ombudsman to advocate on Resident 2's behalf in a timely manner.…

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

Based on observation, interview, and record review, the facility failed to implement the repositioning (turning) intervention to prevent pressure ulcer/injury (PU - areas of damaged skin typically caused by staying in one position for too long), for 4 of 5 sampled residents (Resident 1, Resident 2, Resident 3, and Resident 4) who were assessed at risk for PU development. This failure had the potential for pressure ulcers to develop for Resident 1, Resident 2, Resident 3, and Resident 4. Findings: 1. Review of Resident 1 ' s clinical record titled, admission RECORD, indicated, Resident 1 was admitted with a diagnosis including, but not limited to, .HEMIPLEGIA AND HEMIPARESIS .AFFECTING RIGHT DOMINANT SIDE [weakness or total loss of movement on one side of the body] . During a concurrent observation and interview on 4/23/25 at 1:24 PM, in Resident 1 ' s room, Certified Nursing Assistant (CNA) 1, confirmed Resident 1 was dependent on staff for turning and repositioning in bed since Resident 1 was unable to move. CNA 1 further stated when the residents were turned and repositioned, they…

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

Based on observation, interview, and record review, the facility failed to implement individualized and effective interventions to protect one of four sampled residents, Resident 6, with known yelling behavior, from verbal threats of violence by her roommate (Resident 5), on 4/18/25. This failure resulted in Resident 6 screaming fearfully with a frightened look on her face, causing potential psychosocial distress. Findings: During an observation on 4/22/23 at 3:04 PM, in Resident 6's room, Resident 6 was heard calling out incoherently (words that are difficult to understand). Resident 6 stopped calling out when asked questions but did not answer any questions verbally or by gesture, including when asked her name. Resident 6 stared with a blank expression when asked questions and did not respond. Resident 6 was observed inside the room quiet and called out incoherent words when observed from outside the room. During an interview on 4/22/25 at 3:08 PM, Resident 7 stated that Resident 6 calls out a lot when she needs something. Resident 7 stated Resident 6 did not really talk. During…

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

Based on observation, interview, and record review, the facility failed to ensure it maintained effective pest control services for a census of 115 where 107 residents received facility prepared meals when a live baby cockroach was crawling on a clean colander on the shelf next to the stove in the kitchen. This failure had the potential to spread a variety of diseases and bacteria throughout the facility to its residents, staff, and visitors. Findings: During a concurrent observation and interview on 3/25/25, at 11 a.m., with the Food Services Director (FD) in the kitchen, the following findings were observed and confirmed by the FD: a. A pot on the stove that had a thick, brownish gummy substance on the bottom and sides was being used to prepare lunch for the facility residents. b. A flat pan with a brownish substance caked on the inner edges of the pan was on the shelf next to the stove with the clean pots and pans. c. A frying pan with dried brownish flaky substance on the inside was located on a shelf with the clean pots and pans next to the stove. d. The toaster oven next to…

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

Based on observation, interview, and record review the facility failed to provide safe food storage and preparation as well as maintain kitchen equipment and food contact surfaces in accordance with professional standards for food safety for the 107 residents who received facility prepared meals when: 1. Unlabeled open boxes of frozen chicken patties, frozen whole kernel corn, frozen green peas, and frozen green leaf spinach were stored in the walk-in freezer, 2. An expired container of spice was stored in the dry storage room in the kitchen, 3. A thick brownish gummy substance was on the bottom and sides of a large pot used for cooking resident food on the stove, 4. A flat pan with thick brownish gummy substance on the inside edges was on the shelf next to the stove with clean pots and pans, 5. A frying pan with a brownish flaky substance on the inside cooking edges was on the shelf next to the stove with the clean pots and pans, 6. The toaster oven next to the stove had a brownish substance on the shelves, and, 7. The stove top had a grayish discoloration on the grates of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to practice appropriate infection prevention and control measures for a census of 115, when: 1. Two unvaccinated (who did not receive an influenza(flu) vaccine) staff members, the assistant director of staff development (ADSD) and the receptionist (R1) did not wear a mask on 3/25/25 inside the facility; 2. Resident 307's door was left open while on airborne precaution; 3. A staff member was observed not providing hand hygiene (cleansing of hands with soap and water or an alcohol-based hand sanitizer) to residents before lunch during tray pass on 3/26/25, and the same staff member was observed not washing hands/using hand hygiene during lunch tray pass on 3/26/25. These failures in infection prevention and control measures had the potential to spread the infection to staff and other residents in the facility. Findings: 1. Review of facility's staff influenza vaccine record for 2024/2025 flu season indicated the ADSD and R1 declined flu…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 2 of 14 residents (Resident 15 and Resident 57) with urinary catheters (flexible tube used to empty the bladder) were treated with dignity and their privacy was protected, when Resident 15 and resident 57's urinary catheter bag (a drainage bag attached to a catheter (tube) that is inside the bladder to collect urine) was exposed and was not placed in a dignity bag (a bag used to the cover and hold the catheter drainage/collection bag so it is not visible). This failure had the potential to cause psychosocial harm to Resident 15 and Resident 57. Findings: 1. A review of Resident 57's admission RECORD, indicated Resident 57 was admitted to the facility with multiple diagnoses including paraplegia (paralysis that occurs in the lower half of the body) and neuromuscular dysfunction of bladder, unspecified (condition where the nerves and muscles controlling bladder function does not work properly, leading to difficulty emptying or controlling the bladder). During an observation on 3/24/25, at 11:05 AM,…

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

Based on interview, and record review, the facility failed to ensure one out of twenty-eight (28) sampled residents (Resident 102) received follow-up appointment care when, Resident 102 was not informed about his post-surgery appointment in advance. This failure resulted in Resident 102 missing his follow-up doctor's appointment which had the potential to result in readmission to the hospital when post follow-up care from a provider was not completed. Findings: Review of Resident 102's admission RECORD indicated, Resident 102 was admitted to the facility with diagnosis including surgical aftercare following surgery on the circulatory system (a system of organs that includes the heart, blood vessels, and blood which is circulated throughout the body). The record indicated Resident 102 was his own responsible party (can make decisions for himself). During an interview on 03/24/25 at 3:43 PM, Resident 102 stated that he missed his appointment on 3/21/25 with the cardiothoracic surgeon (a medical doctor specializing in surgical procedures of the heart, lungs, esophagus, and other organs…

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

Based on interview, record review and the facility policy review, the facility failed to ensure that Notice of Medicare Non-Coverage (NOMNC - a form required by the Centers for Medicare & Medicaid Services that providers must deliver to patients receiving certain Medicare services such as skilled nursing or rehabilitation services before those services are terminated, informing them of the end of coverage and their appeal rights) was received by the representative of one out of three sampled residents (Resident 26). As a result, Resident 26 and her representative did not have knowledge neither choice to appeal changes in cost of Skilled Nursing Services. Findings: Review of admission RECORD indicated Resident 26 was her own responsible party. Review of Resident 26's Notice of Medicare Non-Coverage form, indicated .Service Start/admission Date: 11/15/24 .Services Will End: 12/16/24 . The form did not have Resident 26's signature. During an interview with Case Manager (CM1) on 03/26/2025 at 9:57a.m., CM 1 stated Resident 26 opted for her representative to review and sign the NOMNC…

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

Based on interview, and record review, the facility failed to complete the Pre-admission Screening and Resident Review (PASRR - a required assessment for individuals with mental illness, intellectual or developmental disabilities, or related conditions, so that a determination of need, appropriate setting, and a set of recommendations for services to be included in the individual's plan of care is provided) Level II evaluation for one of twenty-eight sampled residents (Resident 90) when, Resident 90's PASRR Level II evaluation was not completed after having a positive result with the Level I screening. This failure had the potential for Resident 90 to not receive the necessary services to meet their mental and psychosocial (the link between social factors and individual thought and behavior) needs. Findings: A review of Resident 90's admission RECORD, indicated Resident 90 was admitted to the facility in late 2024 with diagnoses which included dementia (a progressive state of decline in mental abilities), psychosis (a severe mental condition in which thought, and emotions are so…

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

Based on interview and record review, the facility failed to provide necessary services to maintain personal hygiene for 2 of 28 sampled residents (Resident 357 and Resident 11) when, showers were not provided to Resident 357 and Resident 11 at least two times a week as scheduled. This failure had the potential for poor hygiene, infection, and emotional distress for Resident 357 and Resident 11. Findings: 1. A review of Resident 357's admission RECORD indicated Resident 357 was admitted to the facility with diagnoses including fracture of shaft of humerus left arm (broken bone of the left upper arm), fracture of lower end of left radius (broken bone on the left lower arm), fracture of shaft of left tibia (broken left lower leg), generalized muscle weakness, and abnormalities of gait and mobility. During an interview on 3/24/25, at 11:09 AM, Resident 357 stated she had not received a shower since she was admitted to the facility. A review of the facility's undated shower schedule indicated Resident 357 was scheduled to receive a shower on Monday and Thursday on the evening shift. As…

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

Based on observation, interview, and record review, the facility failed to ensure effective pain management was provided for one of twenty-eight sampled residents (Resident 463), when Resident 463 complained of pain and was not assessed or given pain medication for approximately 2 hours. This failure resulted in Resident 463 waiting for an extended period of time for pain medication and had the potential to experience emotional distress from inadequate pain relief. Findings: Review of Resident 463's admission RECORD, indicated Resident 463 was admitted to the facility with diagnosis of periprosthetic fracture around the internal prosthetic right knee joint (a break or crack in a bone, surrounding the knee replacement implant). Review of Resident 463's undated pain care plan titled Clinical Care Plan Detail, indicated, .risk for PAIN, has acute/chronic pain .decreased mobility .hx [history] of right periprosthetic knee fx [fracture] following assault s/p [state after intervention] ORIF [Open Reduction and Internal Fixation; a surgical procedure used to repair severely broken bones…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medications were administered according to the physician orders for one of twenty-eight sampled residents (Resident 43) when, Resident 43's medications were not administered in a timely manner and some medications were missed on 3/24/25. This failure had the potential to result in causing Resident 43 to experience preventable medication-related adverse events (undesirable medical occurrence experienced by a resident) of a serious nature related to high blood pressure (a condition in which the force of the blood pushing against the blood vessel walls is consistently too high), breathing difficulties, and pain. Findings: During an interview on 3/24/25, at 12:05 PM, Resident 43 stated she normally received her medication at 7:30 AM, but she still had not received her AM medications. Resident 43 stated she had used the call light to ask for her medications at least 10 times today. During an interview on 3/24/25, at 12:07 PM, Certified Nursing Assistant (CNA) 2 stated she answered Resident 43's call light…

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

Based on interview, observation, and record review, the facility failed to ensure safe medication storage practices in two out of five medication carts (a mobile cart stored medication and supplies for immediate use) when: 1. There was opened medication stored in the medication carts that were not labeled with an opened-on date (a date the medication was first opened); 2. An over-the-counter medication (OTC-medication that does not require a prescription) was stored in the medication cart that should have been refrigerated; 3. A Hazardous medication (medications that are known to cause harm if handled incorrectly) was not in the appropriate protective plastic bag (a specially engineered plastic bag/container designed to safely contain and transport hazardous medications, ensuring they are handled in accordance with regulations and best practice); and 4. A resident's rings were in a plastic bag labeled with a room number and placed in a drawer in the medication cart. These failures had the potential for residents in the facility to not get the full benefits of their prescribed…

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

Based on observation, interview, and record review the facility failed to follow the menu's prescribed portion sizes for mashed sweet potatoes (yams), and vegetables during lunch service on 3/26/25, and the roast beef entrée was served with blackened edges during lunch service on 3/26/25 for a total of 107 residents who received facility prepared meals. These failures had the potential to result in an unprescribed increase or decrease in meal intake based on resident diet ordered, and a potential for the residents' preferences not being met. Findings: During the lunch service tray line observation on 3/26/25 at 11:35 a.m., the [NAME] used a gray scoop to plate the yams and vegetables for all lunches served. The [NAME] removed a second tray of the roast beef entrée from the stove, then removed the foil cover from the tray. The roast beef in the second tray had black edges. The cook plated the roast beef with the black edges without removing the black edges from the roast beef during the lunch meal service and covered the roast beef with barbecue sauce. During an interview on 3/26/25…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 professional standards of care were met for 3 out 3 sampled residents, (Resident 1, Resident 2, and Resident 3) when: 1. Resident 1, Resident 2, and Resident 3 ' s scheduled medications were not administered in a timely manner, 2. Resident 1 did not receive timely interventions for constipation, and 3. The photo on Resident 1 ' s clinical documents, used for identification, was of another resident. These failures had the potential for: 1. Reduced therapeutic benefits of the medications prescribed to Resident 1, Resident 2, and Resident 3; 2. Discomfort from constipation for Resident 1; and, 3. Inaccurate identification of Resident 1, with a risk for incorrect treatment. Findings: 1a. A review of Resident 1 ' s admission RECORD, indicated, he was admitted to the facility in late 2024 with diagnoses which included Parkinsonism (a progressive disease of the nervous system marked by tremor, muscle rigidity and slow imprecise movement). During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure privacy and confidentiality were maintained for one of four sampled Residents ( Resident 4) when Resident 4's medication was sent home with Resident 1. This failure resulted in unauthorized access of Resident 4's health and personal information. Findings: A review of Resident 4's admission RECORD, indicated, she was admitted to the facility in mid-2024 with diagnoses which included essential hypertension ( high blood pressure with no identified medical cause). A review of Resident 4's Order Summary Report, indicated, .clonidine .Oral Tablet 0.1 MG .Give 3 tablet by mouth as needed for Systolic [first number of blood pressure reading, the pressure when your heart contracts and pumps blood ] BP > 170 TID [ blood pressure greater than 170 three times per day]. A review of the facility pharmacy's Electronic Shipping Manifest (list of medications delivered to the facility), dated 10/2/24, indicated, 135 tablets of clonidine were delivered to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a safe and effective transition of care after discharge from the facility for Resident 3, when Resident 3 was unable to care for herself, therapy did not prepare her to maneuver the steps in her home and was transferred home alone. This failure created undue stress for Resident 3 and her family and resulted in Resident 3 ' s readmission to a hospital. Findings: A review of Resident 3 ' s admission RECORD, indicated she was admitted to the facility on [DATE] and discharged on 9/27/24 with diagnoses which included chronic respiratory failure (condition that prevents proper oxygen exchange, may cause shortness of breath, and extreme tiredness), muscle weakness, abnormalities of gait (walking) and mobility and morbid obesity (being 80- 100 pounds over ideal body weight). A review of Resident 3 ' s clinical record, Physical Therapy [a health profession that uses activities and exercises to help restore or improve movement and physical function] PT…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 protect two of three sampled residents' (Resident 1 and Resident 3) right to be free from sexual abuse by another resident, when Resident 2, who had a history of inappropriate behaviors, touched Resident 1 ' s thigh and Resident 3 ' s abdomen and groin without consent. This failure had the potential to negatively affect Resident 1 and Resident 3's psychosocial well- being. Findings: a. A review of Resident 1 ' s BIMS [brief Interview for Mental Status] TEMPORARY WORKSHEET, dated 6/4/24, indicated a BIMS score of 15 which suggested his memory was intact. During an interview on 7/11/24, at 1:09 PM, Resident 1 pointed to his thigh and stated Resident 2 entered his room on 6/8/24 and touched him on his leg. Resident 1 further stated Resident 2 .kept doing it. By the fourth time I had enough. He would come in my room at night. I did not want to hit him because I would get in trouble . Resident 1 stated it scared him and he finally had to leave, .It took me…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 necessary care and services were provided for two of four sampled residents (Resident 1 and Resident 2), when 1a. Resident 1 did not get a shower on 2/20/24, due to a sling (part of a mechanical lift used to transfer residents between surfaces) not being available, 1b. Resident 1 received bed baths (sponge baths) instead of showers on 1/2/24, 1/19/24, 1/26/24, 1/30/24, 2/9/24, and 2/27/24, and there was no documentation which indicated Resident 1 had refused the 6 showers, and, 2a. Resident 2 received bed baths instead of showers on 1/31/24, 2/4/24, 2/21/24, and 3/2/24, and there was no documentation which indicated Resident 2 had refused the 4 showers, and, 2b. There was no record of a shower or bed bath being given to Resident 2 on 1/10/24, 1/13/24, 2/7/24, 2/10/24, and 2/28/24. These failures resulted in Resident 1 and Resident 2 not receiving showers, Resident 1 to feel unclean, and had the potential of poor hygiene and poor skin integrity…

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

Based on observation, interview, and record review, the facility failed to ensure a sufficient number of slings (part of a mechanical lift used to transfer a resident between surfaces) were available for 45 of 45 residents who used a mechanical lift for transfers, when the facility did not have enough slings for all 45 residents and did not have a system to evaluate the amount of slings needed for residents. As a result, Resident 1 did not receive a shower on 2/20/24 due to a lack of slings and placed other residents who required mechanical lift transfers at risk of not receiving quality care and needed services. Findings: During an interview on 3/4/24, at 12:35 p.m., Resident 1 stated he had only seven showers this year. Resident 1 stated he was disabled and was supposed to be getting showers twice a week on Tuesdays and Fridays. Resident 1 stated his roommate got more showers than him because his roommate could walk. Resident 1 stated he had right sided weakness and had his left leg amputated (removed surgically). Resident 1 stated staff would tell him that he could not get a…

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

Based on interview and record review, the facility failed to follow up on a grievance (cause for complaint) for one of four sampled residents (Resident 3) when Resident 3's grievance of two missing slings (part of a mechanical lift used to transfer residents between surfaces) was not followed up on appropriately or timely. This failure resulted in Resident 3's grievance to go unresolved. Findings: During an interview on 3/4/24 at 12:59 p.m., Resident 3 stated he purchased two of his own slings in 2022. Resident 3 stated the facility put his slings in the laundry, the facility started using the slings for other residents, and he never saw his slings again. Resident 3 stated he informed the facility when his slings went missing. Resident 3 stated the Administrator (ADM) told him last year that they would replace his slings and for him to send them his purchase receipt. Resident 3 stated he still has not gotten the replacement slings. Resident 3 showed the purchase history of the slings on his tablet to the Department which indicated Resident 3 purchased 2 slings on 6/1/2022, for a…

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

Based on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for one of five sampled residents (Resident 3) when: 1. Resident 3's care plan for an allegation of bending another resident's right pointer finger on 1/1/24 was not developed; and, 2. Resident 3's care plan for inappropriate behavior had no interventions in place. These failures decreased the potential for the facility to provide person-centered care and ensure safety for residents. Findings: 1. A review of Resident 3's clinical record indicated Resident 3 was originally admitted August of 2023 and had diagnoses that included nontraumatic intracerebral hemorrhage (a condition where a pool of blood is formed within the brain abnormalities in the brain, spinal cord, or other nerves) and dementia (a general term for the impaired ability to remember, think, or make decisions that interferes with everyday activities). A review of Resident 3's Minimum Data Set (MDS- an assessment tool used to guide care) Cognitive Patterns, dated 11/21/23, indicated Resident 3 was…

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

Based on interview, and record review, the facility failed to only employ licensed professional staff when one out of three sampled Licensed Nurses (LN) 4 was hired as a full time Licensed Vocational Nurse (LVN- nurse that is trained in basic nursing skills, such as taking vital signs, administering medications, and assisting with basic patient care) from 6/30/23 to 11/5/23 without an active California vocational nurse license. This failure had the potential to negatively impact the care and safety of the facility's residents. Findings: A review of a facility document titled, NEW HIRE CHECKLIST, dated 6/30/23, indicated, Employee's Name: [Name of LN 4], Date of Hire: 6/30/23, Department: NRSG [Nursing], Title: LVN . The document was signed by LN 4 on 6/30/23. A review of an undated facility document titled, New Employee/Employee Status Change Form, indicated LN 4 was hired as a full-time employee who would work 30 hours or more in the facility in a week. The document was signed by LN 4 on 6/30/23. A review of an undated facility document titled, BOARD OF VOCATIONAL NURSING AND…

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

Based on interview and record review, the facility failed to ensure a safe environment for one of six sampled residents (Resident 1) when Resident 1 reported a male resident (Resident 2), with a known history of wandering and aggressive behavior, came into her room on 10/26/23 and attempted to remove her bedding. This failure resulted in Resident 1 leaving the facility against medical advice due to a fear of being molested. Findings: a. Resident 1 was admitted to the facility in April of 2023 with diagnoses which included Urinary tract infection (infection of the kidneys and/or bladder) and muscle weakness. A review of Resident 1 ' s, Minimum Data Set, (MDS, a resident assessment and screening tool), dated September 21, 2023, indicated Resident 1 had a Brief Interview for Mental Status (BIMS) score of 9 out of 15 which suggested a moderate cognitive impairment. A review of Resident 1 ' s care plan, revised 9/21/23, indicated . [Resident 1] has an ADL [activities of daily living, activities related to personal care] Performance deficit r/t [related to] weakness, impaired mobility…

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

Based on observation, interview and record review, the facility failed to follow facility policy and standards of practice for medication administration for five of five residents, (Resident 1, Resident 2, Resident 3, Resident 4, and Resident 5) when four of four licensed nurses (LN), LN 2, LN 3, LN 4, and LN 5, failed to sign off medications at the time of administration. This failure had the potential to result in medication errors for all residents receiving medications in the facility. Findings: a. During a concurrent observation, interview, and record review with LN 2, on 10/10/23, at 11:49 AM, LN 2 was passing medications and the Electronic Health Record (EHR) displayed the residents' names in a box. The boxes were highlighted in red. LN 2 stated the boxes were red because she had not signed off her 9 AM medications before beginning the noon medication administration. LN 2 confirmed she had not signed off any of the medications for the 9 AM medication pass. LN 2 further explained it was important to sign off medications when given, so a nurse relieving her for breaks would…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 licensed nurses (LN) documented accurately when over an eight day period, over three shifts, licensed nurses documented, in three areas on the Medication Administration Record (MAR) and two areas on the Treatment Administration Record (TAR), urinary catheter (a tube inserted into the bladder to allow drainage of urine) care had been performed for Resident 1, who did not have a catheter at any time during the eight days. This failure resulted in inaccurate documentation in Resident 1's medical record for eight consecutive days, with LNs signing off assessments and care they did not perform, and had the potential for resident assessments not to be done. Findings: A review of Resident 1's admission Record (contains clinical and demographic data) indicated Resident 1 was admitted to the facility with diagnoses which included sepsis (serious blood infection) and muscle weakness. During an observation in Resident 1's room, on 10/10/23, at 9:20 AM, Resident 1 did not have a urinary catheter (tube inserted…

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

Based on observation, interview, and record review, the facility failed to maintain its infection control program when licensed nurse (LN) 1 did not consistently perform hand hygiene during wound care for two of ten residents (Resident 1 and Resident 2) receiving wound care in the facility. This failure had the potential to result in cross contamination (the physical movement or transfer of harmful bacteria, germs, from one person, object, or place to another) resulting in infection, affecting the health and wellbeing of residents receiving wound care services at the facility. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility with diagnoses which included sepsis (blood infection) and muscle weakness. During an observation of wound care for Resident 1 with LN 1, in Resident 1's room, on 10/10/23, at 9:20 AM, LN 1 removed a wound dressing from Resident 1's right ankle, performed hand hygiene, donned (put on) a new pair of gloves, cleansed the area with normal saline (a liquid used to clean wounds) and gauze, doffed (took off) gloves.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 prescribed treatment medications and treatment supplies were secured, when a treatment cart located at Nursing Station 2 was found to be unlocked in the center hall. This failure had the potential to result in access to prescription ointments and treatments, which could result in illness and/or injury from unauthorized use by residents or visitors. Findings: During a concurrent observation and interview with licensed nurse (LN) 4 on, 10/10/23, at 12:10 PM, a treatment cart at Nursing Station 2 was observed to be unlocked. LN 4 confirmed the treatment cart at Nursing Station 2 was unlocked. LN 4 stated the treatment cart at Nursing Station 2 should have been locked and it was not. LN 4 confirmed the treatment cart at Nursing Station 2 contained prescribed treatment medications for various residents in the facility, and treatment supplies. LN 4 explained it was important for the treatment cart to be locked so patients did not have access to it because there were prescribed treatments for specific…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the facility policy review, the facility failed to properly store, label, and prepare food in accordance with the professional standards for food service safety for 106 of 108 residents who received food from the facility kitchen, when: 1. One jug of pineapple juice in the refrigerator, two bags of hot dog buns with 6 buns in each bag, and one open bag of cereal in dry storage were available for use after the labeled use by date, 2. One bag of 12 burger buns, one open box of cereal, and 10 open 8 ounce boxes of spices were not labeled with an open and use by date, and 3. Chicken was not submerged in the water during thawing process. These failures placed residents at risk of food borne infections (illness caused by consuming contaminated foods or beverages). Findings: 1. During the initial kitchen tour with the Food and Nutrition Services Director (FNSD) on 7/12/21 at 8:40 a.m., one clear plastic jug with pineapple juice stored in the refrigerator was labeled prepared on 7/8/21 and use by 7/11/21. Two bags of hot dog buns with six buns in each…

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

Based on observation, interview, and record review, the facility failed to provide an accommodation of needs for one of 32 sampled residents (Resident 44) when Resident 44's request that the facility wash personal laundry with an alternative soap, due to a skin reaction, was not accommodated. This failure resulted in Resident 44 not receiving laundry services from the facility for personal clothing items. Findings: During a concurrent observation and interview, on 7/12/21, at 3:16 p.m., Resident 44 stated, she requested the facility wash her personal clothing with the laundry soap she had purchased, and was told the facility could only use their own soap. Resident 44 explained, she was going to have her boyfriend wash her clothes, but he was very busy. Resident 44 pointed to her stomach and stated the facility's laundry soap caused a rash. Resident 44 stated her back and stomach itched from the facility's laundry soap. There where multiple bumps on Resident 44's stomach, red in color, the size of a pencil tip, and scattered throughout the stomach area with the appearance as if they…

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

Based on observation, interview, and record review, the facility failed to provide services which meet professional standards of quality for one of three residents (Resident 78), when Resident 78's PICC line (a long, thin tube inserted into a large vein in the upper arm to administer medications) dressing was not changed weekly. This failure had the potential to cause infection. Findings: Review of Resident 78's admission record indicated Resident 78 was admitted to the facility in late June 2021 with the cellulitis (skin infection) of the left upper arm. During a concurrent observation, and interview on 7/12/21 at 12:01 p.m., Resident 78 had a PICC line at his right upper arm. The PICC line site had a transparent dressing that was loose, and was coming off at the edges. The PICC line dressing was dated 6/30/21. Resident 78 stated he came to the facility to receive antibiotics for his infection. Resident 78 stated his PICC line dressing needed to be changed and staff had not changed it. During an interview with Licensed Nurse (LN) 6 on 7/15/21 at 9:55 a.m., LN 6 stated PICC line…

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

Based on interview and record review, the facility failed to provide treatment and services for one of 34 sampled residents (Resident 61) to increase range of motion (ROM) and/or prevent further decline in ROM, when Resident 61 was not assisted to get out of bed and into the wheelchair to recieve restorative nurse aide (RNA) services (to provide restorative and rehabilitation care for residents to maintain or regain physical, mental and emotional well-being). This failure had the potential to decrease Resident 61's ROM. Findings: Review of Resident 61's admission record indicated, Resident 61 was admitted to the facility early 2021 with paraplegia (inability to move the legs and lower body, typically caused by spinal injury or disease). During an interview on 7/12/21, at 12:44 p.m., Resident 61 stated, in the past three weeks he received RNA services one time each week and was scheduled to receive RNA services three times a week. Resident 61 explained, he was supposed to get up in the wheelchair too, but staff had not assisted him to do so. During an interview on 7/15/21, at 9:43…

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

Based on observation, interview, and record review, the facility failed to ensure professional standards of practice and person-centered care were maintained for one of 32 sampled residents (Resident 201) when adequate pain management was not provided. This failure had the potential to negatively impact Resident 201's physical and emotional well-being and resulted in ineffective pain management. Findings: During a concurrent observation and interview in the hallway near nurse's station one on 7/13/21, at 9:18 a.m., Resident 201 was seated in his wheelchair rocking back and forth and stated he had severe pain to his lower back and no one listened to him. Two nurses were observed near Resident 201 in the hallway. During an interview with licensed nurse (LN) 2 on 7/13/21, at 9:30 a.m., LN 2 stated Resident 201 was taking Norco (a narcotic pain medication) 10 mg (a unit of measure) every eight hours around the clock. When asked if any non-medication interventions were in place to help alleviate his pain, LN 2 stated he was working with physical therapy. A review of Resident 201's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure; 1. A physician's order was followed for two of 32 sampled residents when a used nicotine patch was not removed prior to the application of a new patch for Resident 203 and oxygen was administered at a higher flow rate than prescribed for Resident 50. 2. A controlled medication (medications/drugs that are tightly controlled by the government because they may be abused or cause addiction) was not reconciled by licensed nurses after the initial receipt of acceptance for one of 108 residents (Resident 5). These failures had the potential to cause adverse health events for Resident 203 including an irregular heart beat, trouble sleeping, and increased blood pressure, lung damage caused by oxygen poisoning for Resident 50, and had the potential to result in drug diversion. Findings: 1. During an observation at Resident 203's bedside on 7/12/21, at 8:50 a.m., Resident 203 was seated at the edge of his bed without a shirt on and with two…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 safe storage of controlled substances (medications/drugs that are tightly controlled by the government because they may be abused or cause addiction) for a census of 108 when the key to open a locked refrigerator which contained a controlled substance, was accessible to unauthorized staff. These failures had the potential to result in drug diversion. Findings: During a concurrent observation and interview, on 7/14/21, at 1:09 p.m., in Medication Storage room [ROOM NUMBER], the Director of Nursing (DON) confirmed, refrigerator 2 contained an emergency drug kit which contained the medication lorazepam (used to treat anxiety), a controlled substance. The DON confirmed, the key to open refrigerator 2 was located on a hook inside Medication Storage room [ROOM NUMBER]. The DON stated, the key to the refrigerator 2 was to be kept by the supervisor on duty and should not have been located inside the medication storage room. Review of a…

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

Based on observation, interview and record review, the facility failed to maintain complete medical records for one of three residents (Resident 78), when Resident 78's clinical record had no physician order and documentation of PICC line ( a long, thin tube inserted into a large vein in upper arm to administer medications) dressing change. As a result, Resident 78's clinical record did not accurately reflect whether or when his PICC line dressing was changed. Resident 78's PICC line dressing change procedure was missed which placed him at risk of catheter related infection. Findings: Review of Resident 78's admission record indicated Resident 78 was admitted to the facility in late June 2021 with the cellulitis (skin infection) of left upper arm. During a concurrent observation and interview on 7/12/21 at 12:01 p.m., Resident 78 had a PICC line in his right upper arm. The PICC line site had a transparent dressing that was loose, and was coming off at the edges. The PICC line dressing was dated 6/30/21. Resident 78 stated he came to the facility to receive antibiotics for his…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to follow infection control practices when: 1. An isolation precaution (to create barriers between people and germs) sign was not located on or near the doorway of Resident 38's and Resident 86's room to indicate the personal protective equipment (PPE; protective clothing, goggles, facemask, or other garments used to prevent the spread of germs) staff should put on prior to entering their room; 2. Facility staff did not remove her isolation gown (barrier used to prevent the spread of infection) properly and prior to leaving room [ROOM NUMBER] that was designated as an isolation room. These failures had the potential to transmit and spread Carbapenem-resistant Acinetobacter baumannii (CRAB - a type of bacteria which can cause human infections of the blood, urinary tract, lungs, wounds, and other body sites. The bacteria are multidrug-resistant, making infections very difficult to treat) among patients and staff. Findings: 1. Durring a…

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

Based on observation, interview, and record review, the facility failed to maintain kitchen equipment in a clean and safe manner, when a convection oven (an oven that heats food by the circulation of hot air) had baked-on food and grease. This failure had the potential to cause a fire. Findings: During the initial kitchen tour with the Food and Nutrition Services Director (FNSD) and the Registered Dietitian (RD) on 7/12/21 at 8:40 a.m., a convection oven had baked-on dark brown food and grease on the racks, oven door and on the bottom of the oven. The FNSD stated, That's grease needs to be deep cleaned. She stated they clean the oven at least once a month. The FNSD stated the convection oven was last cleaned in June. She stated it should be cleaned for safety. The RD stated, It does need cleaning. During an interview with the RD on 7/15/21 1:31 p.m., the RD stated the oven should be cleaned weekly as per the facility policy, and if the oven was not clean there was a risk for fire. Review of the facility document titled, Nutrition Services Cleaning Schedule dated June 2021,…

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

Based on observation, interview and record review, the facility failed to ensure the medication error rate did not exceed 5% for three of 41 sampled residents (Residents 14, 94 and 352) when: 1. For Resident 14, a licensed nurse administered undiluted oral KCl 10% (potassium chloride, a bitter tasting medication indicated for low blood potassium), not in accordance with manufacturer specifications; and a multivitamin with minerals supplement, not plain multiple vitamin, in accordance with the Physician's Orders, with the potential for gastric upset. 2. For Resident 352, a licensed nurse administered 250 mg (milligrams, a unit of measure) of oral Vancomycin HCl (antibiotic medication indicated for infection) liquid, instead of 125 mg as ordered by the physician, with the potential for adverse medication effects. 3. For Resident 94, a licensed nurse did not gently shake the bottle of fluticasone propionate suspension (anti-inflammatory medication indicated for seasonal allergies) prior to administering the dose intranasally (into each nostril), in accordance with manufacturer…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, clinical record and facility document review, the facility did not implement their medication storage and labeling policies and procedures for a facility census of 106 when: 1. One of two medication refrigerators (Refrigerator #2) in the Station 1 medication room containing 74 doses of influenza vaccine and an emergency supply of Humulin R® (short acting insulin indicated for lowering blood sugar in diabetes) was observed to be below the manufacturer-recommended and facility policy storage threshold temperature of 36 degrees Fahrenheit when the thermometer indicated 22 degrees Fahrenheit; and the facility did not implement their policy of twice daily temperature monitoring in refrigerators storing vaccines. This failure had the potential for freezing the medications within and rendering them sub-potent or ineffective. 2. For Resident 24, licensed nursing staff did not document the date of first use of a Breo Ellipta® 100-25 oral inhaler (medication used for chronic lung disease);…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 facility policy review, the facility failed to discard food in the kitchen refrigerator by the use by date for a facility census of 106. This failure had the potential to cause food borne illness to the residents of the facility. Findings: During the initial tour of the kitchen on 4/2/19, at 8:25 a.m., two tubs of chocolate pudding were observed in a refrigerator labeled with a use by date of 4/1/19. At that time, the director of dietary services (DDS), took the tubs of pudding out of the refrigerator and stated, Food is supposed to be discarded by 12 a.m. the following day. PM shift usually gets rid of them. During an interview with the DDS on 4/4/19, at 1:37 p.m., the DDS stated she usually checks the refrigerator in the morning to make sure there is not any outdated food, but it had not been done yet on 4/2/19 when the pudding was found. In a policy dated 2018, titled, STORAGE OF FOOD AND SUPPLIES, indicated, .No food will be kept longer than the expiration date on the product .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews, and record review, the facility failed to implement its infection control program for 49 residents (residents whose meal trays were in dining carts 3, 4, and 5) out of a census of 106 when: 1. Certified Nurse Assistant (CNA) 3 did not perform hand hygiene after repositioning a resident in a wheelchair, before opening dining cart 3 with multiple residents' tray in it, and before handling the coffee pot used to serve residents in rooms 201 to 214; 2. CNA 4 did not perform hand hygiene after touching the privacy curtains in room [ROOM NUMBER], before opening dining cart 4 which had lunch trays for residents in rooms 1 to 11, and in rooms 215 to 222 in it, and before serving Resident 13's tray; 3. Licensed Nurse (LN) 1 did not perform hand hygiene after handling items in the immediate vicinity of a resident and before handling the coffee pot with dining cart 5, used to serve residents in rooms 115 through 133. This failure had the potential to spread infection to residents…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide information to one of 41 sampled residents (Resident 23) about the purpose of an advanced health care directive (AHCD-a form that allows an individual to name who would make health care decisions for them if they were unable to make that decision) and how to complete one. This failure placed Resident 23 at potential risk for not having a decision maker of choice in the event of a change in mental status, and that specific wishes would not be known and followed. Resident 23 was admitted to the facility with diagnoses including Parkinson's disease (a progressive nervous system disorder) and cerebral infarction (lack of blood flow to brain tissue). A review of Resident 23's Minimum Data Set (MDS-an assessment and care screening tool) dated 1/9/19, indicated a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognitive status. The MDS dated [DATE] further indicated that Resident 23 was able to express ideas and wants and…

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

Based on observation, interview, clinical record and facility document review, a licensed nurse did not document one of 41 sampled resident's (Resident 83's) fingerstick blood sugar in the electronic MAR (medication administration record) after the assessment was completed in accordance with facility policy. This failure placed Resident 83 at potential risk for administration of an inaccurate dosage of insulin. Findings: The Institute for Safe Medication Practices (ISMP), a nationally recognized standard of practice, included insulin among its list of drugs which had a heightened risk of causing significant patient harm when used in error. On 4/2/19 at approximately 11:25 a.m., licensed nurse (LN) 4 was observed to perform Resident 83's pre-lunch fingerstick blood sugar and handwrite the value, 153 mg/dL (milligrams per deciliter, a unit of measure) on a small piece of white paper on the medication cart adjacent to Resident 83's room number; the paper contained several other resident's fingerstick blood sugar values adjacent to room numbers. During an interview on 4/2/19 at 12:44…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 hygiene care for one of 41 sampled residents (Resident 50) when Resident 50 did not have his hands washed and teeth brushed regularly. This failure placed Resident 50 at potential risk of oral health problems and infection. Resident 50 was admitted to the facility with diagnoses including a stroke (blood supply to part of the brain is interrupted) with left sided weakness. A review of Resident 50's Minimum Data Set (MDS-an assessment and care screening tool) dated 2/4/19, indicated that Resident 50 required extensive assistance with activities of daily living (ADLs) in the area of personal hygiene. The MDS specified that personal hygiene included brushing teeth and washing hands. A review of the MDS dated [DATE] further revealed that Resident 50 did not reject care, including ADL assistance. A review of Resident 50's nursing care plan, last revised 3/19/19, indicated that staff must assist with Resident 50's ADL's due to a self…

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

Based on observation and interview, the facility failed to provide sufficient fluids to maintain proper hydration for one out of 3 (Resident 353) sampled residents, when water pitchers at the bedside were not filled. This failure had the potential for Resident 353 to become dehydrated. Findings: Resident 353 was admitted to the facility with diagnoses which included nondisplaced fracture of the medial malleolus of the left tibia (break of the inner bone of the ankle) and stress fracture to the right foot (small crack or severe bruise). Resident 354 was admitted to the facility with a diagnoses which included dislocation of right hip (thigh bone is knocked out of the hip joint socket). In an interview on 4/2/19, at 1:58 p.m., with Resident 353 she stated My water pitcher is empty and no water is offered; I had my son buy water for me. In a concurrent observation and interview on 4/2/19, at 2:00 p.m., with Certified Nurse Assistant (CNA) 1 she was observed picking up Resident 353's water pitcher and stating, It's empty. When CNA 1 was asked when she checks the resident's water pitcher…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, staff interview, and record review the facility failed to ensure the enteral tube feeding (nutrition administered through a tube inserted through the abdomen) bottle for 1 of 41 sampled residents (Resident 40) was labeled with the resident's name, date, time, and nurse's initials as specified in the physician's order. This failure had the potential for Resident 40 to receive the wrong formula and/or develop complications from being administered spoiled and/or contaminated tube feeding formula. Findings: Resident 40 was admitted to the facility with diagnoses which included dysphagia (difficulty swallowing) and required extensive assistance from staff for most activities of daily living. Resident 40 received enteral tube feeding (TF) by enteral pump (equipment used to administer tube feeding) and was dependent on staff to administer her tube feeding. In a review of Resident 40's current physician's orders, a physician's order originally dated 3/26/17, indicated, Enteral Nutrition via pump: Glucerna 1.2 (name of TF formula) at 50 milliliters (ml, units 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 implement pharmacy services policies and procedures for two of 41 sampled residents (Residents 36 and 351) when: 1. A licensed nurse did not follow manufacturer specifications to accurately measure a dose of diclofenac sodium 1% transdermal (an anti-inflammatory medication applied to the skin for joint pain) gel for Resident 351; as a result, the resident received an excessive dose of the medication. 2. Resident 36's expired supply of Advair 250-50 inhaler (medication used to open lung airways and decrease inflammation in chronic lung disease) was present in the medication cart and in use; as a result, the resident received expired medication that was potentially sub-therapeutic. Findings: During an inspection of the Station 1 medication cart 2 on [DATE] at 11:19 a.m.,Resident 351's supply of diclofenac sodium 1% gel was observed in the cart drawer; the manufacturer-supplied dosing administration guide was taped inside the manufacturer's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and facility document review, the CP (Consultant Pharmacist) did not identify a Medication Regimen Review (MRR) irregularities for one of 41 sampled residents (Resident 96) when Resident 96 was receiving quetiapine (antipsychotic medication indicated for psychosis-disordered thought processes) for an inadequate indication, with the potential for antipsychotic adverse effects such as sedation, falls and abnormal involuntary movements. Findings: Clinical record review indicated Resident 96 was an [AGE] year-old admitted to the facility from the acute care hospital in mid-March 2019. Resident 96's admission diagnoses included an abdominal surgical wound infection and abdominal and back pain. Review of Resident 96's clinical record acute hospital transfer documents indicated Resident 96 had no documented history of mental illness or psychosis. The documents further indicated quetiapine 25 mg at bedtime had been initiated for an unspecified indication while Resident 96 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and facility document review, one of 41 sampled residents (Resident 96) failed to be free of unnecessary psychotropic (drug prescribed to affect the mind, emotions or behavior) medications when Resident 96 was receiving quetiapine (antipsychotic, a type of psychotropic medication indicated for psychosis) for an inadequate indication, with the potential for antipsychotic adverse effects such as sedation, falls and abnormal involuntary movements. Findings: Clinical record review indicated Resident 96 was an [AGE] year-old admitted to the facility from the acute care hospital in mid-March 2019. Resident 96's admission diagnoses included abdominal wound infection (after gall bladder removal); abdominal and back pain. Review of Resident 96's clinical record acute hospital transfer documents indicated Resident 96 had no documented history of mental illness or psychosis. The documents further indicated quetiapine 25 mg (milligrams-unit of weight) at bedtime had been initiated for 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.