Imperial Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) for three of eleven sampled residents (Residents 116, 81 and 70) by: a. Failing to implement Resident 116 ' s care plan on the use of wheelchair pad alarm (a pad with sensors that will alarm when a resident stands up unassisted to help prevent falls by alerting staff) on 6/17/2025 and 6/18/2025 as per physician order. b. Failing to ensure a care plan was developed for Resident 116 ' s behavior of removing the bed pad alarm. c. Failing to ensure a care plan was developed for Resident 116 ' s use of Ativan (medication used to treat anxiety [common human emotion characterized by feelings of worry, nervousness, or unease, often about an event with an uncertain outcome] and related conditions) and Haldol (medication used to treat nervous, emotional, and mental…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 quality of care in accordance with professional standards of practice to meet the resident ' s physical, mental, psychosocial needs (encompass the emotional and social requirements that individuals have to feel safe, supported, and function effectively in their environment) for one of three sampled resident (Resident 116) by: 1. Failing to ensure nurses follow physician order to monitor Resident 116 for orthostatic hypotension (also known as postural hypotension, is a sudden drop in blood pressure that occurs when you stand up after sitting or lying down) every Tuesday. No blood pressure documentation on 6/3/2025 (Tuesday), 6/10/2025 (Tuesday), and 6/17/2025 (Tuesday) on a lying position. 2. Failing to ensure neurocheck (a series of quick assessments performed by nurses to evaluate a patient's neurological status [anything related to the nervous system, which includes the brain, spinal cord, and nerves]) was assessed after Resident 116 fall on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. During a record review of Resident 116 ' s admission Record, the admission Record indicated the facility admitted Resident 116 on 10/15/2024, with diagnoses that included unspecified (unconfirmed) cerebrovascular disease (a group of conditions that affect blood flow to the brain), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and vascular dementia (reduced blood flow to the brain, which damages brain tissue and impairs cognitive functions). During a review of Resident 116 ' s H&P Visit, dated 10/15/2024, the H&P indicated Resident 116 was alert and needed visual cues (non-verbal signals that provide information, guide actions, or enhance understanding through visual elements). During a review of Resident 116 ' s Care Plan, dated 10/17/2024, on at risk for recurrent fall/injury, the Care Plan indicated an intervention to use wheelchair with pad alarm to alert staff when resident gets up unassisted. During a review of Resident 116 ' s Order Summary…

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

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for one of five sampled residents (Resident 33) reviewed during the Medication Administration task, by failing to: 1. Ensure Licensed Vocational Nurse (LVN) 3 administered medication per facility policy and procedure (P&P) within one hour of the scheduled time. 2. Ensure LVN 3 documented the administration of medication per facility P&P at the time of administration in the resident ' s medication administration record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident). These deficient practices had the potential to result in adverse reactions (unwanted, uncomfortable, or dangerous effects that a drug may have) from the early administration of medication and miscommunication among caregivers. Cross Reference to F759 and F842. Findings: During a review of Resident 33 ' s admission…

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

Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five percent (% - one part in every hundred). Three medication errors out of 25 total opportunities contributed to an overall medication error rate of 12% affecting one of five sampled residents observed for medication administration (Resident 33). Resident 33 did not receive divalproex sodium (a medication to treat conditions related to mood regulation and the nervous system), apixaban (a medication to help prevent blood clots [clumps that occur when blood hardens from a liquid to a solid]), and olanzapine (a medication to treat mood disorders) on 6/18/2025 at the prescribed time. These failures had the potential for Resident 33 to experience the medications ' adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have) when not given at the prescribed time negatively impacting the resident ' s physical and mental health. Cross Reference F755 Findings: During a review of Resident 33 ' s admission Record (AR), the AR indicated…

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

Based on interview and record review, the facility failed to rotate (a method to ensure repeated injections are not administered in the same area) insulin (a hormone that lowers the level of sugar in the blood) injection sites each time insulin was administered for one of three sampled residents (Resident 96). This failure resulted in a significant medication error when multiple nurses repeatedly failed to rotate insulin injection sites during the administration of insulin to Resident 96 in 4/2025 and 5/2025. Findings: During a review of Resident 96 ' s admission Record, dated 6/20/2025, the admission Record indicated Resident 96 ' s diagnoses include cerebral vascular accident (when blood flow to the brain is blocked or there is sudden bleeding in the brain), diabetes mellitus (DM – a disease where the body is unable to properly control blood sugar levels), hypertension (high blood pressure), and major depressive disorder (a condition in which a person has persistent feelings of sadness, hopelessness, and a loss of interest in activities once enjoyed). During a review of Resident…

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

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen reviewed during the Kitchen task by failing to: 1. Ensure food items in Refrigerator 1, the Walk-in Refrigerator, and the Walk-in Freezer were labeled according to facility policy. 2. Ensure kitchen areas were cleaned and sanitized when the Walk-in Freezer floor had sticky, discolored ice buildup and the Dry Food Storage Area had spilled dry cereal. 3. Ensure five dented cans were not found with non-dented cans in the Dry Food Storage Area. These deficient practices had the potential to result in harmful bacterial growth and cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 122 of 124 medically compromised residents who received food and ice from the kitchen. Findings: a. During 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY d. During a record review of Resident 116 ' s admission Record, the admission Record indicated the facility admitted Resident 116 on 10/15/2024, with diagnoses that included unspecified (unconfirmed) cerebrovascular disease (a group of conditions that affect blood flow to the brain), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and vascular dementia (reduced blood flow to the brain, which damages brain tissue and impairs cognitive functions). During a review of Resident 116 ' s History and Physical Examination (H&P- a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings) Visit, dated 10/15/2024, the H&P indicated Resident 116 was alert and needed visual cues (non-verbal signals that provide information, guide actions, or enhance understanding through visual elements). During a review of Resident 116 ' s Advance Healthcare Directive Acknowledgment, dated 10/15/2024,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 d. During a concurrent observation and interview on 6/17/2025, at 8:27 a.m., with Laundry Staff 1 (LS 1), observed a liquid container with light green fluid and was placed inside the linen cart beside the folded clean linens. LS 1 stated the liquid container belongs to her (LS 1) and it contains water. During a concurrent observation, and interview on 6/17/2025, at 8:28 a.m., with the Account Manager (AC), inside the clean laundry room. The AC stated there should be no water or food inside the clean laundry room for infection control. The AC stated staff were informed not to put any food, water or belongings in the clean laundry room. The AC stated LS 1 failed to follow infection control policy. During an interview on 6/17/2025, at 8:36 a.m., with the IP, the IP stated staff are not allowed to keep food or water inside the laundry room. The IP stated the staff were provided a locker room for personal belongings. The IP stated the reason food or water was not allowed in the clean laundry room was to prevent 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 3. During a review of Resident 90 ' s admission Record, the admission Record indicated the facility admitted Resident 90 on 10/30/2024, with diagnoses that included metabolic encephalopathy (brain disorder resulting from chemical imbalances in the body, often caused by underlying medical conditions or organ dysfunction), sepsis (a life-threatening blood infection) due to MRSA and unspecified dementia (a progressive state of decline in mental abilities). During a review of Resident 90 ' s H&P, dated 6/9/2025, the H&P indicated Resident 90 did not have the capacity to understand and make decisions. During a review of Resident 90 ' s MDS, dated [DATE], the MDS indicated Resident 90 ' s cognitive skills for daily decisions were severely impaired. The MDS indicated Resident 90 needed maximum assistance from staff for toileting and showering. During a review of Resident 90 ' s Physician Order, dated 6/3/2025, the Physician Order indicated vancomycin hydrochloride intravenous (within the vein) solution, use 1 gram…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain the electrical patient care equipment was in safe operating condition for three of five sampled residents (Residents 102, 51, and 23) reviewed under environmental task by failing to ensure: 1. Resident 102 ' s pad/tab alarm (a device that helps caregivers monitor someone, usually in bed or a chair, who might need help getting up or moving) did not have a broken sensor cord. 2. Residents 51 and 23 ' s bed remote control did not have frayed/exposed wires. These deficient practices had the potential for Residents102, 51, and 23 to sustain accidents such as electrical shock and falls. Findings: 1. During a review of Resident 102 ' s admission Record, the admission Record indicated the facility admitted the resident on 1/10/2024, with diagnoses including Alzheimer ' s disease (a disease characterized by a progressive decline in mental abilities), age-related osteoporosis (the development of osteoporosis, a condition characterized by…

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

Based on observation, interview, and record review, the facility failed to keep the call light (an alerting device for nurses or other nursing personnel to assist a resident when in need) within reach of the resident for one of one sampled resident (Resident 5) reviewed under accommodation. This deficient practice had the potential for residents unable to summon health care worker for help as needed. Findings: During a review of Resident 5's admission Record, the admission Record indicated the facility originally admitted the resident on 3/23/2024 and readmitted the resident on 4/3/2025 with diagnoses including muscle weakness, abnormalities of gait (a manner of walking or moving on foot) and mobility, and history of falling. During a review of Resident 5's History and Physical (H&P), dated 4/4/2025, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 5's Minimum Data Set (MDS - a resident assessment tool), dated 4/8/2025, the MDS indicated the resident usually had the ability to make self-understood and understand others,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 three sampled residents (Residents 116) was free from chemical restraints (use of medication to manage a resident's behavior or restrict their freedom of movement, primarily to control agitation [a feeling of irritability, mental distress or severe restlessness] or aggression [any behavior, word, or action that is intended to harm another person, animal, or object]) by failing to ensure quarterly (every three months) behavior management interdisciplinary team (IDT - a coordinated group of experts from several different fields who work together) meeting for Resident 116 use of psychotropic (medications that affect the mind, emotions, and behavior) medication was done. This failure had the potential to result in unnecessary chemical restraint and placed Residents 116 at risk for decline, isolation (a state of reduced social interaction and lack of meaningful connections with others) and injury. Findings: During a record review of Resident 116's admission Record, the admission Record indicated the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report an allegation of resident to resident abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) immediately, but no later than two hours after the allegation was made to the State Survey Agency (CDPH, California Department of Public Health), the Ombudsman (a resident advocate), and local law enforcement (LLE) in accordance with federal and state law for one of seven sampled residents (Resident 37) reviewed under the Hospitalization care area. This deficient practice had the potential to result in unidentified abuse in the facility and failure to protect residents from harm from abuse. Findings: a. During a review of Resident 57's admission Record (AR), the AR indicated the facility originally admitted the resident on 7/8/2024 and most recently admitted the resident on 5/13/2025 with diagnoses including encephalopathy (a change in your brain function due to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide care in accordance with professional standards of practice as indicated in the resident ' s care plans by failing to check a resident ' s gastrostomy tube (g-tube-a surgical opening fitted with a device to allow feedings to be administered directly to the stomach for people with swallowing problems) placement before administering medications for one of seven sampled residents (Resident 61) reviewed under Medication Administration facility task. This deficient practice had the potential for Resident 61 to experience medication adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have). Findings: During a review of Resident 61 ' s admission Record, the admission Record indicated the facility originally admitted the resident on 2/13/2024 and readmitted on [DATE] with diagnoses including Alzheimer ' s disease (a disease characterized by a progressive decline in mental abilities), dementia (a progressive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident with pressure ulcer/injury (a skin and tissue injury caused by prolonged pressure on the skin, often over bony areas) received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one of one sampled resident (Resident 36) by failing to: 1. Ensure a thorough skin check of Resident 36 was done upon readmission to the facility on 5/22/2025. 2. Ensure a reassessment of Resident 36 ' s pressure injury was done within 24 hours after readmission. These deficient practices had the potential for a delay of necessary care and services and worsening of Resident 36 ' s pressure injury. Findings: During a review of Resident 36 ' s admission Record, the admission Record indicated the facility admitted the resident on 1/18/2024, and readmitted the resident on 5/22/2025, with diagnoses including pressure-induced deep tissue…

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

Based on observation, interview, and record review, the facility failed to ensure its residents with or without limited range of motion (ROM - movement of the joints) receive appropriate treatment and services to increase, prevent, or maintain the ROM mobility for one of three sampled residents (Resident 18) who had a physician's orders for Restorative Nursing Assistant (RNA) exercises and use of left knee splint (a device used to immobilize and support a body part, typically an arm or leg, that has been injured) five times a week. This failure resulted to Resident 18 not receiving RNA exercises and placed him (Resident 18) at risk for decline in physical function and at risk for contractures (a condition where muscles, tendons, or other tissues shorten and tighten, limiting the movement of a joint). Findings: During a review of Resident 18 ' s admission Record, the admission Record indicated the facility admitted Resident 18 on 8/11/2024, with diagnoses that included unspecified (unconfirmed) dementia (a progressive state of decline in mental abilities), generalized muscle weakness…

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

Based on observation, interview, and record review, the facility failed to offer a therapeutic diet when there was a nutritional problem, and the healthcare provider ordered a therapeutic diet for one of two sampled residents (Resident 70) reviewed under nutrition. The Interdisciplinary Team ' s (IDT, is a group of people from different fields or areas of expertise who work together towards a common goal) recommendation in Resident 70 ' s Weight Management Care Plan, dated 6/16/2025, was not followed by failing to obtain a physician ' s order for Glucerna (a brand of meal replacement shakes and bars) 1 can daily (qd). This deficient practice placed Resident 70 at risk for continued weight loss. Findings: During a review of Resident 70 ' s admission Record, the admission Record indicated the facility admitted the resident on 10/31/2023, and readmitted the resident on 6/13/2025, with diagnoses including dysphagia (difficulty swallowing), major depressive disorder (a serious mental health condition characterized by persistent sadness, loss of interest in activities, and a general…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 that one of three sampled residents (Resident 96) was free from unnecessary medication when Resident 96 was being treated with an anticoagulant (a medication that prevents blood clots from forming or existing clots from getting larger) without being adequately monitored for adverse effects (an undesired effect of a drug or other type of treatment). This failure had the potential to result in Resident 96 developing an adverse effect, such as bleeding, from the use of an anticoagulant without the facility being aware. Findings: During a review of Resident 96 ' s admission Record, dated 6/20/2025, the admission Record indicated Resident 96 ' s diagnoses include cerebral vascular accident (when blood flow to the brain is blocked or there is sudden bleeding in the brain), diabetes mellitus (DM – a disease where the body is unable to properly control blood sugar levels), hypertension (high blood pressure), and major depressive disorder (a condition in which a person has persistent feelings of sadness, hopelessness, and 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 implement its policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, by failing to report an allegation of physical abuse (deliberately aggressive or violent behavior with the intention to cause harm by one resident towards another) to the State Survey Agency (SSA) no later than two hours for one of four sampled residents (Resident 2) when on 5/31/2025 at 5 p.m. Resident 2's Family Member (FM) 1 reported to Skilled Nursing Facility (SNF- a healthcare setting that provides 24-hour medical care and rehabilitation services to individuals who need more care than they can receive at home, but not as much as they would in a hospital) 1 that Resident 2 was assaulted (an act of causing physical harm or unwanted physical contact to another person, or, in some legal definitions, the threat or attempt to do so). The allegation of abuse was reported to the SSA on 6/2/2025 at 4:04 p.m. This deficient practice had a potential to result in unidentified abuse and placed Resident 2…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice to meet the physical, mental, and psychosocial (relating to the interrelation of social factors and individual thoughts and behavior) needs for one of four sampled residents (Resident 1) by failing to measure Resident 1 ' s blood sugar when Resident 1 returned to the facility on 4/25/2025. This failure had the potential to delay Resident 1 ' s care and negatively affect Resident 1 ' s well-being. Findings: During a review of Resident 1 ' s History and Physical (H&P) from GACH 2, dated 3/9/2025, the H&P indicated Resident 1 was admitted to GACH 2 due to hypertensive urgency (a situation where blood pressure is significantly elevated, but there is no immediate evidence of organ damage), and had diagnoses of hypertension (high blood pressure), hyperlipidemia (a condition in which there are high levels of fat particles in the blood), diabetes mellitus (DM-a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a licensed Administrator (ADM) held a current and active license from the State to serve in the capacity of a nursing home administrator (NHA). This deficient practice resulted in the facility operating without a licensed ADM that had the potential to negatively affect the facility's functions. Findings: During an observation on 4/272025 at 9:05 a.m. in the hallway, ADM' s license was posted at the facility's lobby. The ADM ' s license indicated the license expired on [DATE]. During an interview on [DATE] at 3:07 p.m. with the ADM, the ADM stated the ADM ' S license had expired on [DATE] and the application for the renewal of the license had not been submitted yet. The ADM stated the application for the renewal of license should have been submitted 60 days prior to the expiration of the license. During a review of the current facility-provided policy and procedure titled, Administrator, last reviewed on 7/2024, the policy and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the medical records of two of four sampled residents (Resident 2 and 3) were maintained in accordance with accepted professional standards and practice, complete, and accurately documented by failing to: 1. Ensure Resident 2 ' s Informed Consent (IC, voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) was signed by a physician. 2. Ensure Resident 3 ' s Attending Physician (MD) reviewed and signed the resident's Order Summary every month. These deficient practices had the potential for inaccurate documentation and inaccurate medical interventions for Resident 2 and Resident 3. Findings: a. During a review of Resident 2 ' s admission Record on 4/26/2025, the admission Record indicated Resident 2 was admitted to facility on 10/22/2021 and readmitted on [DATE] with diagnoses including seizures (a sudden, uncontrolled electrical disturbance in the brain which can…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for one of three sampled residents (Resident 1) by not following the physician's orders. This deficient practice had the potential to result in Resident 1 not receiving medication order by the physician. Findings: During a record review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included acute respiratory failure (your lungs suddenly cannot get enough oxygen into your blood, causing severe breathing difficulties that require immediate medical attention), primary angle-open glaucoma (a common eye disease where the fluid inside the eye can't drain properly, causing pressure to build up and gradually damage the optic nerve, leading to vision loss, often without noticeable symptoms in the early stages) and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that one of three sampled resident (Resident 1) was allowed to keep medications at beside without a physician's order. Resident 2 kept a cold (a mild infection of your upper respiratory tract which includes your nose and throat) and flu (highly contagious [able to be passed on by contact between individuals] viral infection of the respiratory tract that can cause severe illness and life-threatening complications) medication at Resident 1's bedside drawer. This deficient practice had the potential to result in unsafe medication administration. Findings: During a record review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included acute respiratory failure (your lungs suddenly cannot get enough oxygen into your blood, causing severe breathing difficulties that require immediate medical attention), generalized muscle weakness and unspecified…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 report allegation of family-to-resident abuse within two hours to the State Survey Agency (SSA), the Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities), and local law enforcement (police) as per its policy on abuse for one of three sampled residents (Resident 1). This deficient practice had the potential to place Resident 1 at risk for further abuse. Findings: During a record review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included acute respiratory failure (your lungs suddenly cannot get enough oxygen into your blood, causing severe breathing difficulties that require immediate medical attention), generalized muscle weakness and unspecified (unconfirmed) vascular dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain). During a record…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 create a comprehensive care plan for one of three sampled residents (Resident 1) by failing to ensure care plan was created on Resident 1's refusal of facility food and Resident 1 receiving outside food delivery. This deficient practices had the potential for delayed provision of necessary care and services. Findings: During a record review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included acute respiratory failure (your lungs suddenly cannot get enough oxygen into your blood, causing severe breathing difficulties that require immediate medical attention), generalized muscle weakness and unspecified (unconfirmed) vascular dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain). During a record review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 11/4/2024, the MDS…

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

Based on interview and record review the facility failed to ensure Attending Physician (AP) sign the consent for Merry [NAME] (a walking device that combines a walker and a wheelchair designed to help people with balance or walking difficulties walk independently and safely) for one of three sampled residents (Resident 2). This deficient practice had the potential for delay of necessary services, poor continuity of care and follow-up on the resident's status. Findings: During a record review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 7/3/2018, with diagnoses that included unspecified (unconfirmed) abnormalities of gait (way a person walks) and mobility, generalized muscle weakness and dementia (a progressive state of decline in mental abilities). During a record review of Resident 2's History and Physical (H&P- a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings) dated 11/16/2024, the H&P indicated Resident 2 was unable to make decisions.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 one out of three sampled residents (Residents 1) with meals that accommodated their food preferences. This deficient practice had the potential to result in decreased meal intake and can lead to weight loss and malnutrition (lack of proper nutrition, caused by not having enough to eat or not eating enough of the right things). Findings: During a record review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included acute respiratory failure (your lungs suddenly cannot get enough oxygen into your blood, causing severe breathing difficulties that require immediate medical attention), generalized muscle weakness and unspecified (unconfirmed) vascular dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain). During a record review of Resident 1's Minimum Data Set (MDS- a resident assessment tool)…

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

Based on observation, interview, and record review, the facility failed to follow proper sanitation and food handling practices by failing to ensure that one of two sampled kitchen staff (Cook 1) was wearing a hair net (hair cover) while inside the kitchen. This deficient practice had the potential to compromise the integrity of food and placed the residents at risk for foodborne illnesses (illness caused by the ingestion of contaminated food or beverage). Findings: During a concurrent observation and interview on 2/3/2025, at 6:53 a.m., with [NAME] 1, inside the kitchen, observed [NAME] 1 walking in front of the stove with no hair net. [NAME] 1 stated he (Cook 1) got busy and forgot to put the hair net on. [NAME] 1 stated he should have placed the hair net as soon as he entered the kitchen. During an interview on 2/3/2025, at 10:14 a.m. with the Director of Nursing (DON), the DON stated staff in the kitchen need to wear a hair net for infection control. During a concurrent interview and record review on 2/3/2025, at 12:04 p.m., with the DON, facility's policy and procedure (PnP)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain accurate and complete medical record for one of three sampled residents (Resident 1).This deficient practices had the potential to cause confusion in care and the medical records containing inaccurate documentation. Findings: During a record review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included acute respiratory failure (your lungs suddenly cannot get enough oxygen into your blood, causing severe breathing difficulties that require immediate medical attention), primary angle-open glaucoma (a common eye disease where the fluid inside the eye can't drain properly, causing pressure to build up and leading to vision loss, often without noticeable symptoms in the early stages) and unspecified (unconfirmed) vascular dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain). During a record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program regarding influenza (a contagious respiratory illness caused by influenza viruses) for two of seven sampled residents (Resident 3 and Resident 5) by failing to: 1. Ensure Licensed Vocational Nurse 1's (LVN 1) personal protective equipment (PPE - equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) was worn properly before touching Resident 3. LVN 1's disposable gloves were worn under the disposable isolation gown. LVN 1's N95 mask (respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) top elastic strap was on the neck and created a break in the seal of the N95 mask. 2. Ensure LVN 1 performed hand hygiene (hand washing with soap and water and use of alcohol-based hand sanitizer) and change gloves after touching unclean surfaces while taking care of Resident 3. 3. Ensure…

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

Based on interview and record review, the facility failed to implement its policy and procedure (P&P) for one of three sampled residents (Resident 1) when on 12/4/2024 the facility failed to notify the local law enforcement officials (a law enforcement agency that is responsible for enforcing laws in a city, town, county, or region) when Resident 1 alleged being a victim of misappropriation of funds (an illegal use of another person's money or property for one's own gain or other unauthorized purpose). This deficient practice resulted to Resident 1's allegation not investigated by the local law enforcement. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 10/24/2024 with diagnoses including acute respiratory failure (a serious condition that makes it difficult to breathe on your own), muscle weakness (general), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for one of three sampled residents (Resident 1). On 10/11/2024 Certified Nurse Assistant hit Resident 1 on the face causing him to fall on the floor. This deficient practice resulted in Resident 1 being subjected to physical abuse by Certified Nurse Assistant (CNA 1) while under the care of the facility. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility originally admitted to the facility on [DATE] and with diagnoses that included schizophrenia (a disorder that affects the person's ability to think, feel, and behave clearly), cerebrovascular disease (a disorder that affects blood supply to the brain), dementia (memory loss), and anxiety (excessive and persistent worry and fear). During a review of Resident 1's Minimum Data Set (MDS- a standardized assessment and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to offer one of four sampled residents (Resident 91) or their resident representative assistance with formulating an Advance Directive (AD - a legal document telling the doctor one ' s wishes about their healthcare in the event they cannot make the decision for themselves) upon admission. Additionally, the facility failed to ensure resident's medical records were updated to show documented evidence that advance directives were discussed with three of five sampled residents (Residents 6, 118, and 114). This deficient practice violated the resident and/or their representative the right to fully be informed of the option to formulate an AD and had the potential to delay emergency treatment or the potential to force emergency, life-sustaining procedures against the resident's personal preferences. Findings: a. A review of Resident 91 ' s admission Record indicated the facility admitted the resident on [DATE] with diagnoses that included dementia (a general…

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

Based on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity including the right to be free from physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident ' s body that he or she cannot easily remove that restricts freedom of movement or normal access to one ' s body) for one of four sampled residents (Resident 4 by failing to: 1. Complete a Physical Restraint Assessment Form prior to the application of both upper side rails (adjustable rigid plastic bars attached to the bed that may be positioned in various locations on the bed; upper or lower, either or both sides) as a restraint. 2. Obtain an informed consent from the resident or resident representative prior to the application of both upper side rails as a restraint. 3. Obtain an order from the attending physician prior to the application of both upper side rails as a restraint. These deficient practices had the potential to result in the restriction of residents ' freedom of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan (CP, a written course of action that helps a patient achieve outcomes that improve their quality of life) for residents by failing to: 1. Develop and implement a person-centered care plan regarding Post Traumatic Stress Disorder (PTSD, a mental health condition caused by very stressful, frightening, or distressing events) for one of five residents (Resident 39) reviewed under the Behavioral-Emotional care area. 2. Develop and implement a comprehensive person-centered care plan for the use of insulin glargine-yfgn (a form of hormone insulin made in the laboratory used to control the amount of sugar in the blood of patients with diabetes) for one (1) out of five (5) sampled residents (Resident 74). 3. Develop and implement a comprehensive person-centered care plan for one of four sampled residents (Resident 4) reviewed under physical restraints (devices that limit a patient ' s movement) and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility ' s licensed nursing staff failed to provide care in accordance with professional standards for two of two sampled residents (Residents 20 and 74) investigated under insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin administration sites. This deficient practice had the potential to result in adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin such as lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin). Findings: 1. A review of Resident 20 ' s admission Record indicated the facility admitted theresident on 8/10/2021, and readmitted the resident on 4/2/2023, with diagnosesthat included type 2 diabetes mellitus (a disease that occurs when 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.

2. A review of Resident 93 ' s admission Record indicated the facility admitted the resident on 4/1/2024, with diagnoses that included lack of coordination, muscle weakness, and a Stage 4 pressure ulcer of the sacral region. A review of Resident 93 ' s Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 4/12/2024, indicated Resident 93 sometimes had the ability to make self-understood and understand others. The MDS indicated the resident had impaired upper and lower extremities and was dependent on mobility and activities of daily living (ADLs). The MDS indicated the resident was at risk for further developing pressure ulcer/injuries and had an unhealed Stage 4. The MDS did not indicate that Resident 93 was on a turning/repositioning program. A review of Resident 93 ' s History and Physical (H&P), dated 6/3/2024, indicated Resident 93 did not have the capacity to understand and make decisions. A review of Resident 93 ' s Order Summary Report, dated 7/2/2024, indicated an order Irrigate the Sacro coccyx Stage 4 Pressure Ulcer- with normal saline (a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide an environment free from accidents and hazards, ensure residents received adequate supervision, and implement interventions to prevent accidents for five (5) of 5 sampled residents (Resident 54, 58, 27, 77, and 60) investigated under the Accidents care area by failing to: 1. Ensure Resident 58 ' s left side floor mat was not overlapping with Resident 54 ' s right side floor mat during a random observation. This deficient practice placed Resident 54 and 58 at risk for fall incidents which may lead to injuries. 2. Ensure Resident 27 ' s sensor pad alarm (a device consisting of a pressure-sensing pad that sends a signal to a nearby receiver to sound when the resident rises and their weight shifts) was functioning properly when the resident tried to get out of bed unassisted during a random observation. This deficient practice placed Resident 27 at risk for exiting the bed without staff knowledge and sustaining injuries from falls. 3.…

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

Based on observation, interview, and record review the facility failed to ensure the safe and appropriate use of side rails (adjustable rigid plastic bars attached to the bed that may be positioned in various locations on the bed; upper or lower, either or both sides) to one of four sampled residents (Resident 4) investigated during review of physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident ' s body that he or she cannot easily remove that restricts freedom of movement or normal access to one ' s body) by failing to: 1. Complete a Physical Restraint Assessment Form prior to the application of both upper side rails as a restraint. 2. Obtain an informed consent from the resident or resident representative prior to the application of both upper side rails as a restraint. 3. Obtain an order from the attending physician prior to the application of both upper side rails as a restraint. These deficient practices had the potential to result in the restriction of residents ' freedom of movement, 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: 1.Ensure Licensed Vocational Nurse 2 (LVN 2) completed documentation indicating reconciliation (a system of recordkeeping that ensures an accurate inventory of medications that have been received, dispensed, administered, and wasted) for Resident 83 ' s clonazepam (a controlled substance [medications that are considered to have a strong potential for abuse and may also lead to physical or psychological dependence] to treat anxiety [feeling of worry, nervousness, or restlessness) on the Antibiotic or Controlled Drug Record form (a document used to track the administration of controlled substances) in one of two observed medication carts (Medication Cart 3) observed during the Medication Storage and Labeling task. 2.Ensure licensed nursing staff completed documentation indicating reconciliation of controlled medications at every change of shift on the Narcotic Count Sheet form in one of two medication carts (Medication Cart 3) observed during the Medication Storage and Labeling task. These deficient practices had the…

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

Based on interview and record review the facility failed to ensure residents were free of any significant medication errors (means the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber ' s order, manufacturer ' s specifications, and accepted professional standards) for one out of two sampled residents (Resident 20) investigated under insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) and one out of five sampled residents (Resident 74) reviewed under unnecessary medications by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin administration sites. The deficient practices had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin such as lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin). Findings: A review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure medication and biologicals were stored with currently accepted professional standards for one of two medication carts (Medication Cart 3) reviewed during the Medication Storage and Labeling task and for one of eight sample residents (Resident 48) reviewed during the Medication Administration task by failing to: 1.Ensure residents ' insulin pens were labeled with the open date in Medication Cart 3 for four randomly sampled residents (Residents 49, 101, 21, and 33). 2.Ensure the licensed nurse labeled the Artificial Tears (an eye drop medication administered in the eye to provide moisture) in Medication Cart 1 with the resident ' s name for one of eight sample residents (Resident 48). These failures increased the potential for residents in the facility to receive medications that were ineffective or contaminated due to the inadequate storage, and potentially experience medication adverse consequences resulting in the negative impact…

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

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen by failing to: 1. Ensure open bags of flour tortilla, frozen chocolate chip cookies, and a box of lentils were labelled with open date. 2. Indicate the received or delivery date on a bag of fresh cilantro and a bag of fresh parsley. 3. Ensure a bottle of chocolate syrup with an open date of 5/15/2024 had a cap on it and covered tightly with plastic wrap. 4. Ensure a can of applesauce with dent was placed in the shelf for dented cans. These deficient practices had the potential to result in harmful bacteria growth and cross contamination (a transfer of harmful bacteria from one place to another or one object to another) that could lead to foodborne illness (illness caused by food contaminated with bacteria, viruses, and other toxins) in 117 out of 121 medically compromised residents who receive food from the kitchen. Findings: During a brief tour of the kitchen on 7/9/2024 at 7:46 a.m., with the Dietary Supervisor (DS), 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 maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections by failing to: 1. Ensure Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDRO, microorganisms, mainly bacteria, that are resistant to one or more classes of antibiotics] that uses targeted gown and glove use during high contact resident care activities) were implemented for one of eight sampled residents (Resident 67) observed during the Medication Administration task. 2. Ensure a potentially contaminated box of tissues and an eye drop container were not placed in Medication Cart 1 for two of eight sampled residents (Residents 95 and 221) observed during the Medication Administration task. 3. The facility offered hand hygiene to the resident prior to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to meet the requirement for no more than four residents per room for two of 45 resident rooms (rooms [ROOM NUMBERS]). This deficient practice had the potential to result in inadequate space to provide sufficient nursing care and privacy for the residents. Findings: A review of the Client Accommodation Analysis form completed by the facility indicated rooms [ROOM NUMBERS] housed five beds per room. During the Resident Council Meeting on 7/10/2024, at 2:08 p.m., when the residents were asked about their room space, there were no concerns or issues brought up. During the recertification survey from 7/9/2024 to 7/12/2024, it was observed that the residents residing in the rooms with an application for variance had sufficient amount of space for residents to move freely inside the rooms. There was adequate room for the operation and use of wheelchairs, walkers, or canes. The room variance did not affect the care and services provided by nursing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that 2 of 45 resident rooms (rooms [ROOM NUMBERS]) met the square footage requirement of 80 square feet (sq. ft.) per resident in multiple resident rooms. The room size for these rooms had the potential to have inadequate space for resident care and mobility. Findings: During the Resident Council Meeting 7/10/2024, at 2:08 p.m., when the residents were asked about their room space, there were no concerns or issues brought up. During the recertification survey from 7/9/2024 to 7/12/2024, it was observed that the residents residing in the rooms with an application for variance had sufficient amount of space for residents to move freely inside the rooms. There was adequate room for the operation and use of wheelchairs, walkers, or canes. The room variance did not affect the care and services provided by nursing staff for the residents. On 7/10/2024, the Administrator submitted the application for the Room Variance Waiver for 16…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 facilitate the inclusion of the resident in all aspects of person-centered care planning for one of one sampled resident (Resident 30) reviewed under the Choices care area by failing to encourage and include the resident during the interdisciplinary team (IDT - professional disciplines that work together to provide the greatest benefit to the resident) meetings. This deficient practice had the potential to violate Resident 30's right to be an active participant in her care. Findings: During a review of Resident 30's admission Record, the record indicated the facility admitted the resident on 5/31/2024 with diagnoses that included unspecified dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) with unspecified severity; abnormalities of gait (manner of walking) and mobility; muscle weakness, and anxiety disorder (persistent and excessive worry that interferes with daily activities). During a review of Resident 30's Minimum Data Set (MDS - an assessment and care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the physician was notified of a change of condition/status for one of one sample residents (Resident 30) reviewed under the Choices care area by failing to notify the primary physician regarding the facility ' s assessment of a decline in the resident ' s capacity to understand and make decisions that significantly affected the resident ' s right to leave the facility against medical advice. This deficient practice had the potential to result in a delay of care and confusion in Resident 30 ' s plan for discharge, potentially resulting in psychosocial harm to the resident. Findings: A review of Resident 30 ' s admission Record indicated the facility admitted the resident on 5/31/2024 with diagnoses that included unspecified dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) unspecified severity; abnormalities of gait (manner of walking) and mobility; muscle weakness, and anxiety…

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

Based on interview and record review the facility failed to ensure a resident with limited range of motion receives appropriate treatment and services to increase range of motion (ROM, how far and in what direction the joint or muscle can move) and/or prevent further decrease in range of motion for one of two sampled residents (Resident 4) by failing to conduct a consistent restorative nursing weekly summary for the month of April 2024. This deficient practice had the potential to place the resident at increased risk of ROM decline. Findings: A review of Resident 4 ' s admission Record indicated the facility admitted the resident on 1/15/2015, and readmitted the resident on 3/6/2024, with diagnoses that included cerebrovascular disease (a group of conditions that affect blood flow and the blood vessels in the brain), obesity (having too much fat), and contracture (permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff) of the right hand. A review of Resident 4 ' s History and Physical (H&P), dated 3/12/2024,…

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

Based on observation, interview, and record review the facility failed to ensure a resident receiving enteral feeding (any method of feeding that uses the gastrointestinal tract to deliver nutrition and calories) received appropriate care and services to prevent complications of enteral feeding for one out of one sampled resident (Resident 93) being investigated under enteral nutrition by failing to label the irrigation syringe (a specialized medical instrument designed for the irrigation or cleansing of wounds, cavities, or body orifices) pouch with the name of the resident and the date it was last changed. The deficient practice had the potential for complications associated with enteral feeding such as peritonitis (a redness and swelling [inflammation] of the lining on the abdomen). Findings: A review of Resident 93 ' s admission Record indicated the facility admitted Resident 93 on 4/1/2024, with diagnoses that included gastrostomy (a surgical procedure used to insert a tube, often referred to as a g-tube, through the abdomen and into the stomach), enterocolitis (an inflammation…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the residents entire medication regimen was managed and monitored to promote the resident ' s highest practicable mental, physical, and psychosocial well-being for two of five sampled residents (Resident 74) selected for the unnecessary medications review by failing to ensure the monthly Psychotropic Monthly Summary Sheet was completed and readily available from 2/2024 to 6/2024. This deficient practice placed the resident at risk for not being accurately evaluated by the physician and experiencing side effects for the use of psychotropic medications (a type of medications that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) which may lead to unnecessary use of psychotropic medications. Findings: A review of Resident 74's admission Record indicated the facility admitted Resident 74 on 12/6/2023 and readmitted on [DATE] with diagnoses that included abnormalities of gait and mobility, bipolar…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the recommendation by the dentist for one (1) out of one sampled resident (Resident 9) during an interview by failing to schedule a full mouth x-ray (FMX - a safe and painless test that uses a small amount of radiation to make an image of bones, organs, and other parts of the body) for a new full upper denture (FUD). This deficient practice had the potential to result in the inability to effectively chew foods, weight loss, lack of energy and loss of muscle mass of the residents. Findings: A review of Resident 9 ' s admission Record indicated the facility admitted Resident 9 on 4/14/2017 and readmitted the resident on 12/8/2022 with diagnoses that included dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and osteoarthritis (a type of arthritis that only affects the joints, usually in the hands,…

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

Based on observation, interview, and record review, the facility failed to maintain mechanical, electrical, and patient care equipment in safe operating condition for one (1) of 1 sampled resident (Resident 91) investigated during a random observation when Resident 91 ' s bed controller (device used to change the height and angle of the bed) cable was observed with frayed and exposed wires. This deficient practice had the potential to place Resident 91 at risk for injury. Findings: A review of Resident 91 ' s admission Record indicated the facility admitted the resident on 5/8/2024 with diagnoses including dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), lack of coordination, and muscle weakness. A review of Resident 91 ' s History and Physical (H&P) dated 5/10/2024, did not indicate the resident had the capacity to understand and make decisions. A review of Resident 91 '…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 three of ten sampled facility staff (Registered Nurse 2 [RN 2], Licensed Vocational Nurse 2 [LVN 2], and Certified Nursing Assistant 2 [CNA 2]) were competent to provide nursing services to the residents by failing to ensure competency skill assessments were completed upon hire and annually. This deficient practice had the potential to negatively impact the residents ' safety and prevent the residents from attaining or maintaining their highest practicable physical, mental, and psychosocial well-being. Findings: A review of RN 2 ' s employee file indicated the hire date of 2/12/2007 and her most recent competency skills assessment was completed on 4/14/2021. There were no documented competency skills assessments done for the years 2022, 2023, and 2024. A review of LVN 2 ' s employee file indicated the hire date of 12/28/2017 and her most recent competency skills assessment was completed on 4/25/2023. There was no documented competency skills assessment done for the year 2024. A review of CNA 2 ' s employee file…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents received services with reasonable accommodation of the resident needs for one of three sampled residents (Residents 2). Resident 2, who was at risk for falls, did not have the call light (an alerting device for residents to call for assistance) within the resident ' s reach. This deficient practice had the potential for not meeting the residents needs for assistance. Findings: A review of Resident 2 ' s admission Record indicated the facility admitted the resident on 10/3/2023 with diagnoses including bipolar disorder (mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), post traumatic stress disorder (PTSD – an anxiety disorder that develops in reaction to physical injury or severe mental or emotional distress), and essential hypertension (an abnormally high blood pressure that was not a result of a medical condition). A review of Resident 2 ' s History and Physical, dated 11/14/2023, indicated the resident had fall precautions and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement its abuse policy by not conducting a thorough investigation for a resident-to-resident abuse for five of eight sampled residents (Residents 9, 10, 11, 12 ,and 15). This deficient practice had the potential to result in unidentified abuse and placed the residents at risk for further abuse. Findings: a. A review of Resident 9 ' s admission Record indicated the facility admitted the resident on 12/13/2023 with diagnoses that included major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy), dementia (a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and unspecified (unconfirmed) macular degeneration (an eye disease that can blur your central vision). A review of Resident 9 ' s History and Physical (H&P), dated 12/19/2023, indicated the resident did not have the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a comprehensive person-centered care plan for three of eight sample residents (Resident 8, 12, and 15) by: 1. Failing to develop and implement an individualized person-centered fall care plan with interventions that meet Resident 8 ' s needs. 2. Failing to develop a comprehensive person-centered care plan regarding the physical abuse allegation that Resident 15 did to Resident 12. These deficient practices had a potential to negatively affect the delivery of necessary care and services and increased the risk for further fall and abuse. Findings: a. A review of Resident 8 ' s admission Record indicated the facility admitted the resident on 8/14/2020 with diagnoses that included unspecified (unconfirmed) dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), atherosclerosis of aorta (a material called plaque [fat and calcium] has built up in 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 implement its abuse prevention policy by failing to report the resident-to-resident altercation to the State Survey Agency within 2 hours after the allegation occurred for two of three sample residents (Resident 12 and Resident 15). This deficient practice had the potential to place Resident 12 at risk for elder abuse. Findings: A review of Resident 12's admission Record indicated the facility admitted the resident on 11/2/2023 with diagnoses including schizoaffective disorder (a mental health problem where you experience psychosis [a collection of symptoms that happen when a person has trouble telling the difference between what's real and what's not] as well as mood symptoms), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (a mental health diagnoses that lead to excessive nervousness, fear, apprehension, and worry), and psychosis (a severe mental condition in which…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program regarding Coronavirus disease 2019 (COVID-19, a viral infection that is highly contagious and easily transmits from person to person, causing respiratory problems and may cause death) for four of six sampled residents (Residents 1, 2, 5, and 6), by failing to: a. Ensure Registered Nurse 1 (RN 1) perform hand hygiene (hand washing with soap and water or use of alcohol-based hand sanitizer) after exiting Resident 2's room and before touching the utility room door. RN 1 also failed to wear gloves when rendering care to Resident 2. Resident 2 was on enhanced standard precaution (ESP - an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities). b. Ensure Certified Nursing Assistant 1 (CNA 1) perform hand hygiene after removing her personal protective equipment (PPE - equipment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a comprehensive, person-centered care plan with measurable objectives and interventions for two of six sampled residents (Resident 5 and Resident 6) by failing to develop and implement individualized care plans and interventions addressing Coronavirus disease 2019 (COVID-19, a viral infection that is highly contagious and easily transmits from person to person, causing respiratory problems and may cause death) exposure. This deficient practice had placed Resident 5 and Resident 6 at risk for not receiving the necessary services and assistance that can result in exposure and contracting COVID-19. Findings: A review of Resident 5's admission Record indicated the facility admitted the resident on 11/14/2023 with diagnoses including bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), chronic obstructive pulmonary disease (COPD - a group of diseases that cause airflow…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 three Certified Nursing Assistants (CNA 9, CNA 10, and CNA 3) were not standing while assisting residents with feeding for three out of four sampled residents (Residents 46, 86, and 1) investigated for dignity. This deficient practice had the potential to affect the residents' sense of self-worth and self-esteem. Findings: a. A review of Resident 46's admission Record indicated the resident was originally admitted on [DATE] and was readmitted on [DATE] with diagnoses that included unspecified severe protein-calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function), anxiety disorder (state of extreme fear or worry), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily functioning). A review of Resident 46's Minimum Data Set (MDS - a standardized assessment and…

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

Based on observation, interview, and record review, the facility failed to ensure the call light was within reach for three out of three sampled residents (Resident 11, 350, and 351) investigated addressing accommodation of needs. This deficient practice placed the residents at risk for inability to summon health care workers as needed to receive assistance that may include urgent care. Findings: a. A review of Resident 350's admission Record indicated the facility admitted the resident on 05/06/2021 for diagnoses that included muscle weakness (lack of strength in the muscles), dysphagia (swallowing disorder), and need for assistance with personal care. A review of the History and Physical Examination, dated 05/05/2021, indicated Resident 350 did not have the capacity to understand and make decisions. A review of Resident 350's Minimum Data Set (MDS- a standardized assessment and care-screening tool), dated 05/08/2021 indicated the resident required extensive assistance for dressing, toilet use, personal hygiene, bed mobility, and transfers. During an observation, on 5/17/2021 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure professional standards were met for two of two sampled residents (Resident 30 and 58) investigated under the Medication Storage facility task by: 1. Failing to ensure Resident 30 was not administered expired doses of tramadol (used to treat moderately severe pain). 2. Failing to ensure Resident 58's Combivent (inhaler used to manage shortness of breath) was administered according to physician's orders. These deficient practices increased the risk that Resident 30 could have received a medication that had become ineffective or toxic due to improper storage or labeling; and placed Resident 58 at risk for health complications resulting from not receiving the medication as ordered. Findings: a. A review of Resident 30's admission Record indicated the resident was readmitted on [DATE] with diagnoses including dementia (decline in mental ability severe enough to interfere with daily functioning/life) with behavioral disturbance and wedge…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 observe proper storage and labeling of drugs and biologicals for one of two medication storage refrigerators (Yellow Zone Nursing Station - facility area where persons with unknown COVID-19 [a highly contagious viral infection that can trigger respiratory tract illness] status are placed) and for two of three medication carts (Medication Cart 1 and Medication Cart Station 2) by: 1. Failing to ensure Resident 30's tramadol (used to treat moderately severe pain) with expiration date of [DATE] was discarded immediately in Med Cart 1. Resident 30 received 22 expired doses from observation date of [DATE]. 2. Failing to ensure Florastor (dietary supplement) with expiration date of 01/2021 was discarded immediately in Medication Cart Station 2. 3. Failing to ensure the breathing treatments of Residents 62, 85, 60, 46, 29, and 38 were dated when the medications were opened in Medication Cart Station 2. 4. Failing to ensure that tuberculin…

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

Based on observation, interview, and record review, the facility failed to ensure proper food handling practices by: 1. Failing to ensure that a staff's Coca Cola bottle with a brown substance was not stored in the walk-in refrigerator intended for residents' foods. 2. Failing to ensure that the freezer in the kitchen was at or below zero degrees Fahrenheit (° F - a scale of temperature measurement). 3. Failing to ensure that cream puffs stored in the walk-in freezer were discarded on or before the best by date (indicates when a product will be of best flavor or quality). 4. Failing to ensure that Dietary Aide 3 (DA 3) wash hands in between tasks and before donning (putting on) new gloves. 5. Failing to ensure that a half-eaten banana was not left on a plastic storage bin in the dry storage room. These deficient practices had the potential to result in foodborne illness (an infection or irritation of the gastrointestinal tract [including the stomach and intestines] caused by food or beverages that contain harmful bacteria/germs, chemicals, or other organisms) for 97 residents who…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Ensure the inventory of resident's personal valuables and property was conducted on the day the resident was admitted to the facility for one (Resident 146) out of one sampled resident reviewed under the care area of personal property. This deficient practice had the potential for inaccurate inventory of the resident's personal valuables and property and the potential for possible inability to readily identify loss of property and/or theft. 2. Ensure the administrations of a resident's medications were accurately documented in the Medication Administration Record (MAR) for one (Resident 146) out of one sampled resident reviewed addressing accuracy of documentation. The medications were: a. Depakote sprinkles (medication for the treatment of mood disorder) b. Latanoprost emulsion (eye medication for glaucoma [group of eye conditions that can cause blindness]) c. Seroquel (an anti-psychotic [psychosis - condition that affect the mind described as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Implement infection control practices for Coronavirus disease (COVID-19, a highly contagious viral infection that can trigger respiratory tract illness) prevention by failing to monitor and document vital signs and signs and symptoms of COVID-19 for one (Resident 146) of two sampled residents investigated addressing transmission-based precautions (additional measures observed for patients who may be infected with certain infectious agents to prevent infection transmission). This deficient practice had the potential to result in increasing the risk of spreading COVID-19 to resident and staff members. 2. Ensure a resident's oxygen tubing (used to connect the oxygen source with the oxygenation device during administration of oxygen) was labeled with the date indicating when it was last changed for one of one sampled resident investigated addressing infections (Resident 49). This deficient practice had the potential to place the resident at increased…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify a resident's representative when a resident sustained scratches after Certified Nursing Assistant 1 shaved the resident's face, for one (Resident 146) out of one sampled resident investigated addressing the right to be informed/make treatment decisions. This deficient practice violated Resident 146's representative's right to be informed of change in the resident's health status and the right to make decisions about the resident's treatment. Findings: A review of Resident 146's admission Record (face sheet) indicated the resident was admitted to the facility on [DATE], with diagnoses including dementia (a group of thinking and social symptoms that interferes with daily functioning) with behavioral disturbance and cerebral infarction (damage to tissues in the brain due to loss of oxygen to the area). A review of Resident 146's Minimum Data Set (MDS-a standardized assessment and care screening tool) dated 05/11/2021, indicated the resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Social Services Designee (SSD) provided written information regarding Advance Directives (a legal document that explains how you want medical decisions about you to be made if you cannot make the decisions yourself) to two out of two sampled residents (Resident 8 and 23) investigated for Advance Directives. This deficient practice had the potential to violate the residents' and/or their representatives' right to be fully informed of the option to formulate an Advance Directive and had the potential to cause conflict due to lack of communication regarding residents' wishes about their medical treatment. Findings: a. A review of Resident 8's admission Record indicated the resident was admitted on [DATE] with diagnoses that included unspecified dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) without behavioral disturbance, major depressive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a comprehensive plan of care (written guide that organizes information about the resident's care) with measurable objectives and specific interventions for the use of Remeron (an antidepressant medication that can treat depression [a mood disorder that causes persistent feeling of sadness and loss of interest in activities causing significant impairment in life] for one (Resident 72) out of seven sampled residents reviewed for unnecessary medications. This deficient practice had the potential to result in inconsistent implementation of the care plan that may lead to a delay in or lack of delivery of care and services. Findings: A review of Resident 72's admission Record (face sheet) indicated the resident was admitted to the facility on [DATE], with diagnoses including major depressive disorder (a mood disorder that causes persistent feeling of sadness and loss of interest in activities causing significant impairment in life) and dementia (a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure an interdisciplinary team (IDT - involves team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) meeting was done and the care plan (contains all of the relevant information about a patient's diagnoses, the goals of treatment, the specific nursing orders [including what observations are needed and what actions must be performed], and a plan for evaluation) was updated with new interventions after a resident had a fall for one out of three sampled residents (Resident 62) investigated for accidents. This deficient practice had the potential to place the resident at risk for recurrent falls. Findings: A review of Resident 62's admission Record indicated the resident was originally admitted on [DATE] and was readmitted on [DATE] with diagnoses that included unspecified dementia (a general term for loss of memory, language, problem-solving and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to address the resident representative's interest in transferring a resident to another facility for one (Resident 146) of two sampled residents investigated under the care area of discharge. This deficient practice placed the resident at risk for not receiving the necessary care and services related to the resident's discharge goals and needs. Findings: A review of Resident 146's admission Record (face sheet), the resident was admitted to the facility on [DATE], with diagnoses including dementia (a group of thinking and social symptoms that interferes with daily functioning) with behavioral disturbance and cerebral infarction (damage to tissues in the brain due to loss of oxygen to the area). A review of Resident 146's Minimum Data Set (MDS-a standardized assessment and care screening tool) dated 05/11/2021, indicated the resident's cognition (mental action or process of acquiring knowledge and understanding) was severely impaired. The MDS indicated the…

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

Based on observation, interview, and record review, the facility failed to ensure that one of two sampled residents (Resident 18) investigated under the care area of activities was engaged in preferred activities as identified in the care plan. This deficient practice had the potential to affect the resident's sense of self-worth and psychosocial well-being through feelings of usefulness, self-respect, and self-satisfaction. Findings: A review of Resident 18's admission Record indicated the facility admitted the resident on 02/12/2014 with diagnoses that included Alzheimer's disease (a progressive disease that destroys memory and other mental functions), schizoaffective disorder (mental disorder characterized by abnormal thought processes and an unstable mood), and hypertension (elevated blood pressure). A review of Resident 18's Minimum Data Set (MDS- a standardized assessment and screening tool), dated 02/23/2021 indicated the resident had clear speech but rarely understood others and rarely was able to be understood by others. The MDS indicated Resident 18 required two-person…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 adaptive eating equipment (tools to assist individuals with their feeding independence) as ordered by the physician for one out of one sampled resident (Resident 52) investigated for assistive devices. This deficient practice had the potential to result in the resident not being able to feed herself. Findings: A review of Resident 52's admission Record indicated the resident was originally admitted on [DATE] and was readmitted on [DATE] with diagnoses that included unspecified abnormalities of gait and mobility, generalized muscle weakness (a lack of physical or muscle strength and the feeling that extra effort is required to move your arms, legs, or other muscles), and polyneuropathy (the simultaneous malfunction of many peripheral nerves throughout the body). A review of Resident 52's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 02/23/2021, indicated the resident was severely impaired in…

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