Menifee Lakes Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to initiate and maintain infection prevention precautions (measures intended to prevent transmission of infectious microorganisms) for a resident with repeated Urinary Tract Infections (UTIs) with the presence of the microorganism Pseudomonas aeruginosa (Pseudomonas - a Multi Drug Resistant Organism [MDRO]) in their urine for one out of three residents reviewed for infection control precautions (Resident 2). This failure had the potential to spread infection to other residents in the facility. Findings: On December 8 & 9, 2025, unannounced visits were made to the facility for infection prevention issues. On December 8, 2025, at 9:02 a.m., an observation and concurrent interview were conducted with Resident 2, who stated she was receiving antibiotics for a UTI and is feeling better. No signage indicating infection prevention precautions was observed outside Resident 2's room. On December 8, 2025, at 3:32 p.m., an interview was conducted with…

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

Based on observation, interview, and record review, the facility failed to ensure, for one of four residents reviewed (Resident 1), to monitor blood sugar level, assess meal intake percentage, or ensure proper communication among staff for a resident admitted with diabetes (abnormal blood sugar level). This failure had the potential to cause adverse health effects. Findings: On April 3, 2025, Resident 1's record was reviewed. Resident 1 was admitted to the facility with a diagnosis which included, type 2 diabetes mellitus with ketoacidosis (uncontrolled blood glucose levels in the body), chronic kidney disease, stage 3 (weakened kidney function), and acquired absence of left leg below knee. A further review of Resident 1's clinical admission form dated April 3, 2025, indicated, there was no documentation of Resident 1's baseline blood glucose level and oral intake upon admission. A review of Resident 1's physician order dated April 4, 2025, indicated, .Humulin R U-500 KwikPen subcutaneous Solution Pen-injector 500 unit/ml (insulin regular [human]) inject 110 unit subcutaneously 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 5. Resident 58's record was reviewed. Resident 58 was admitted to the facility on [DATE]. A review of Resident 58's MDS, dated January 18, 2025, indicated Resident 58 had BIMS score of 14 - cognitively intact. A review of Resident 58's POLST, dated March 22, 2024, indicated, .No Advance Directive .discussed with legally recognized decision maker (daughter) . A further review of Resident 58's medical records indicated the resident was not provided information or education about formulating an AD. On March 13, 2025, at 1:02 p.m. a concurrent interview and record review were conducted with Social Service Assistant (SSA) 1. SSA 1 stated, a social services assessment was conducted for all residents upon admission and that the assessment should include notations indicating whether an AD was discussed. SSA 1 stated, if a resident had an AD, a copy should be placed in the resident's medical record. SSA 1 stated, Resident 58 did not have an AD and there was no documentation in the resident's medical record indicating…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 provision of pharmacy services met the needs of the residents when Residents 54 and 182 were missing documentation for the administration of controlled substance (CS, those with high potential for abuse and addiction) medications. The CS medications were signed out of the Antibiotic or Controlled Drug Record Medication (count sheet, an inventory sheet that keeps record of the usage of controlled medications) but not documented on the Medication Administration Records (MAR) to indicate they were administered to the residents. Additionally, the CS medication was wasted (not administered to the resident and discarded) without two licensed nurses' documentation on the count sheet according to the facility's policy for Resident 54. These failures resulted in inaccurate accountability of CS medications, which had the potential for misuse or diversion. Findings: During an interview on March 11, 2025 at 10:05 a.m. with the Director of Nursing (DON), the DON stated the facility's process for CS medication administration and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of five residents (Resident 1) was free from unnecessary psychotropic (drugs that affects brain activities associated with mental processes and behavior) medications when administered a combination of psychotropic medications with sedating effects, sustained a fall, continued to receive additional sedating psychotropic medications without consideration of the potential additive sedative effects, and sustained a second fall. This failure resulted in unnecessary medications for Resident 1 which increased the potential for medication interactions, adverse reactions, and unidentified risks associated with the use of psychotropic medications that included but not limited to falls, sedation, cognitive (the mental processes involved in thinking, learning, understanding, and remembering) impairment, blurred vision, and respiratory depression. Finding: During a review of Resident 1's admission Record, dated March 13, 2025, the admission 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 provide a recommended diet for Resident 51 after a change in health status. This failure had the potential for Resident 51 to have uncontrolled blood sugar levels and complications from type 2 diabetes mellitus (abnormal high sugar). Findings: Resident 51's record was reviewed. Resident 51 was admitted to the facility on [DATE], with diagnoses which included type 2 diabetes mellitus and hospice services (specialized end-of-life care). A review of Resident 51's Interdisciplinary Care Conference, dated December 5, 2024, indicated .Resident discharged from Hospice services and will remain in long term care . A review of Resident 51's Minimum Data Set (an assessment tool), dated July 16, 2024, indicated, Resident 51 had a Brief Interview of Mental Status (BIMS - a tool to assess cognitive function of an individual) score of 15, cognitively intact. A review of Resident 51's Care Plan, initiated on July 16, 2024, indicated, .The resident has…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when: 1. For Residents 36 and 57, nursing staff failed to properly clean and disinfect shared blood pressure (BP-pressure of blood in blood vessels) cuffs, stethoscopes, and glucometers (blood glucose meter to measure and display the amount of sugar (glucose) in your blood) according to the disposable Sani-Cloth Prime disposable wipe manufacturer's specified contact time (the time the resident equipment was to be in contact with the disposable wipes to kill micro-organisms). 2. For Resident 18, the neurotherapy treatment nurse (healthcare provider who examines brain activity and function) did not wear personal protective equipment (PPE - equipment, such as gloves and gown, used to protect against infection or illness) when providing therapy to Resident 18 on enhanced barrier precaution (EBP-an infection control intervention to reduce transmission of multidrug-resistant organisms [MDRO-…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an assessment was conducted for one of two residents reviewed for respiratory issue (Resident 30) when resident developed shortness of breath. This failure had the potential to negatively impact Resident 30's physical, mental, psychosocial wellbeing. Findings: On March 10, 2025, at 3:17 p.m., during a concurrent observation and interview with Resident 30, Resident 30 stated, he could not breath adequately, while pointing to his nose. Resident 30's nasal bridge appeared to be deviated toward the left side and his speech had noticeable nasal twang. Resident 30 stated that he had been bothered by this issue for about a month and nothing had been done to address it. A review of Resident 30 's admission Record indicated Resident 30 was admitted [DATE], with the diagnoses which included chronic subdural hemorrhage (a collection of blood that accumulates between the brain and the dura mater [the outermost layer of the brain's protective…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 post- (after) hemodialysis (removal of toxins and fluids from the blood through the use of a machine) assessment was completed on January 10, 2025, and January 27, 2025, for one of two residents reviewed for hemodialysis (Resident 20). This failure had the potential for delayed detection and/or management of complications arising from hemodialysis treatments for Resident 20. Findings: A review of Resident 20's admission Record, indicated Resident 20 was admitted to the facility on [DATE], with diagnoses which included End Stage Renal Disease (ESRD-inability of the kidney to make urine and remove waste from the blood). A review of Resident 20's Dialysis Communication Form, indicated the licensed nurse did not assessed Resident 20's weight post dialysis on the following dates: - January 10, 2025; and - January 27, 2025. On March 12, 2025, at 11:35 a.m., a concurrent interview and record review of Resident 20's Communication Log were conducted with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure medically-related social service referrals were obtained for two of 21 sampled residents (Residents 26 and 30) when: 1. A referral for CT scan (computerized tomography - procedure that uses a combinations of X-rays and computer technology to create detailed cross-sectional images of the body) of the abdomen for gross hematuria (bloody urination) was not obtained for Resident 26. This failure had the potential to delay the identification of underlying causes of gross hematuria for Resident 26; and 2. A referral for ENT (Ear, Nose, and Throat) evaluation for shortness of breath secondary to deviated nasal septum (occurs when your nasal septum [the thin wall of cartilage and bone that separates the two nasal passages], is significantly displaced to one side, making one nasal air passage smaller than the other) was not obtained for Resident 30 . This failure had the potential to result in unresolved symptoms of shortness of breath for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 request a medication regimen review (MRR) following changes in condition (worsening of an existing problem or the emergence of new signs or symptoms, such as falls); and failed to ensure the consultant pharmacist (CP) identified potential medications contributing to falls and make recommendations to the facility for reduction or discontinuation of one of the medications during the monthly MRRs for one out of five sampled residents (Resident 1). This failure had the potential for medications not being optimized for best possible health outcome, and unnecessary or prolonged use of medications which could lead to medication adverse effects (such as falls) for the resident. Findings: During a review of Resident 1's admission Record, dated March 13, 2025, the admission Record indicated, Resident 1 was elderly, initially admitted to the facility on [DATE], and was admitted again on December 23, 2024. Resident 1's diagnoses included metabolic encephalopathy…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medication storage when one refrigerated injectable medication vial was identified stored unrefrigerated not according to manufacturer's specifications. This failure had a potential for residents to receive medications that were inadequately monitored with unsafe and reduced effectiveness, which could lead to unsafe and ineffective medications for the residents. Finding: An inspection of the 300 Hall Medication Cart on March 11, 2025 at 11:26 a.m. in the Nursing Station with Licensed Vocational Nurse (LVN) 6 identified one unrefrigerated, opened and used multi-dose vial (MDV) of Tuberculin PPD (test agent used in the diagnosis of tuberculosis) 5 TU (test unit) per 0.1 ml (milliliter; unit of measurement) in the top drawer of the medication cart. LVN 6 was unable to demonstrate how long the PPD vial was stored unrefrigerated inside the medication cart. LVN 6 said, It [The PPD vial] should be refrigerated. LVN 6 acknowledged the PPD vial should not have been stored inside the medication cart 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 an allegation of abuse was reported within two hours to the California Department of Public Health (CDPH), for one of four residents, (Resident 1). This failure had the potential to place Resident 1 at risk for further abuse or harm. Findings: A review of Resident 1's medical records indicated he was admitted to the facility on [DATE], with diagnoses which included atrial fibrillation (irregular heartbeat), diabetes mellitus (abnormal blood sugar levels), with diabetic neuropathy (a type of nerve damage that can occur in people with diabetes), and anxiety disorder (a chronic condition characterized by an excessive and persistent sense of apprehension). A review of Resident 1's History and Physical dated February 10, 2025, indicated he had the capacity to make decisions. A review of Resident 1's Progress Notes dated February 8, 2025, at 3:39 a.m., indicated .Resident (Resident 1) aggressive towards staff. When writer came to respond to call light…

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

Based on interview and record review, the facility failed to implement their Respiratory Protection Plan to ensure N-95 filtering facepiece respirator, (FFR - filtering facepiece respirator - a disposable half-mask that covers the user's airway [nose and mouth] and offers protection from particulate materials) fit testing (to confirm the fit of any respirator that forms a tight seal on the wearer's face before it is used in the workplace) was conducted annually for one of four staff members. This failure had the potential to contribute to the spread of COVID-19 among residents and staff, potentially causing serious harm to the health and well-being of vulnerable residents with compromised health conditions. Findings: On January 6, 2025, at 8:41 a.m., an unannounced visit to the facility was initiated for an infection control issue. On January 6, 2025, at 10:13 a.m., an interview was conducted with the Infection Preventionist (IP). The IP stated that staff are fit-tested for the N-95 FFR upon hire and annually thereafter. The IP stated that the facility has two N-95 FFR models…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 accommodate needs for two of three sampled residents reviewed (Residents A and B), when: 1. Resident A was not provided bedrails for repositioning as requested. This failure had the potential for Resident A to have unmet needs. 2. Resident B's call light was found not within her reach. This failure had the potential for Resident B not to be able to call for assistance from the staff. Findings: On September 4, 2024, at 8:55 a.m., an unannounced visit to the facility was conducted to investigate an allegation of quality care and treatment issue. 1. A review of Resident A ' s, admission Record, indicated Resident A was admitted to the facility on [DATE], with diagnoses which included Aftercare Following Joint Replacement Surgery. Resident A ' s History and Physical, dated August 14, 2024, indicated Resident A has the capacity to understand and make decision. A review of Resident A ' s Bedrail Assessment, dated August 10, 2024, indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of seven residents (Resident 2), had a comfortable homelike environment when the curtain blinds, covering the resident's sliding door, were missing four slats and were not documented as needing repair in the maintenance repair log. This failure had the potential for Resident 2 to not feel like she was at home and has the potential to affect the efficiency of the blinds to block the sun's rays to keep the room cooler. Findings: On July 16, 2024, at 11:12a.m., an unannounced visit to the facility was conducted to investigate quality care issues. On July 16, 2024, at 12:56 p.m., an observation and concurrent interview was conducted with Resident 2, inside the resident's room. The resident had a sliding glass door, covered with curtain blinds. The curtain blinds was observed with four slats missing. Resident 2 stated, they knew about the blinds. Resident 2 was unable to state who or when the missing slats in the blinds were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure access to personal and Medical Records (MR) was provided within two working days for one of two sample residents (Resident 3). This failure has the potential to result in a delay of care and treatment for Resident 3 affecting the resident's physical wellbeing. Findings: On June 20, 2024, at 8:50 a.m., an unannounced visit to the facility was conducted to investigate a resident's rights issue. A review of Resident 3's admission Record, indicated, Resident 3 was admitted to the facility on [DATE] at 7:17 p.m. A review of the facility document titled Admission, Discharges, Room/Bed Transfers, indicated, Resident 3 was discharged from the facility on July 27, 2024 at 8:05 p.m. A review of Resident 3's Medical Records/Release of Information, request, indicated the following: - Dated May 28, 2024, indicated, (name) requester .Please consider this as (name) resident request and through this office as legal representative, that all writings related to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure Resident 2 ' s surgical incision staples to his right below knee Amputation (R-BKA) were removed timley as ordered for one of three residents, (Resident 2). Resident 2 ' s wound staples were removed on January 22, 2024, two months after his R-BKA amputation on November 22, 2023. This failure has the potential to result in delayed tissue healing and placed the resident at risk for wound infection. Findings: On January 22, 2024, at 9:10 a.m., an unannounced visit was conducted to investigate a quality care issue. On January 22, 2024, at 10:20 a.m., Registered Nurse Supervisor (RNS) was interviewed regarding Resident 2 ' s whereabout. RNS stated Resident 2 left for his ortho appointment (a specialized area of patient care for the maintenance of the skeletal system to correct and straighten misalignments) to remove his surgical incision staples. On January 22, 2024, Resident 2 ' s record was reviewed. Resident 2 was admitted to the facility on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to treat residents with dignity when staff stated residents who were continent of urine, (the ability to hold back urine), and unable to get out of bed would be placed in a brief and instructed to use the call light when the brief needed to be changed. This failure had the potential to result in a resident feeling humiliated and embarrassed. On November 21, 2023, at 9:19 a.m., a telephone interview was conducted with a family member, (FM). The FM stated that Resident 1 had a hip fracture and was discharged to the facility for rehabilitation. The FM stated that Resident 1 was continent of urine and feces, but was placed in a brief, and instructed to use the call light when her brief was wet and needed to be changed. The FM stated that Resident 1 was so distraught and cried for the first couple of days. On November 21, 2023, at 11:39 a.m., an unannounced visit to the facility on a complaint investigation was initiated. Resident 1's medical records indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure bilateral floor mats for one of the three sampled residents (Resident C) was in placed in accordance with the physician order. This failure increased Resident C ' s risk for injury and falls. Findings: On October 24, 2023, at 9:30 a.m., an unannounced visit to the facility was initiated to investigate an allegation of abuse. On October 24, 2023, at 12:19 p.m., a concurrent observation and interview was conducted with Resident C and Resident C's family member. Resident C ' s family member stated the resident has macular degenerative disease (an eye disease that causes vision loss), can barely see, is forgetful, and had multiple falls. The resident's family member stated the resident had one recent fall and she broke her nose. Resident C ' s family member stated, she could not remember if the resident is on a bowel and bladder program, when the resident needs to go to the bathroom, she sometimes would call for help, then gets up on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the alarm was functioning and audible, allowing the resident to leave the facility without the staff's awareness for two of three sampled residents (Residents 1 and 2). This failure had the potential to compromise the resident's safety and increased the potential for accidents to occur. Findings: On September 14, 2023, at 12:35 p.m., an unannounced visit was conducted to the facility to investigate an accident issue. Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which included metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood and can lead to personality changes). During a review of Resident 1's Progress Notes (PN), dated September 10, 2023, the PN indicated, .CNA called nurse at 910pm (9:10 p.m.) to inform that resident was outside facility, on wheelchair near the mortuary. Facility called 911 and staff searched parking lot. Charge nurse drove…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, for two of four residents reviewed (Resident 1 and 4), to maintain accurate medical records in accordance with accepted professional standards and practice when the staff failed to accurately document weekly skin assessments of wounds. This failure could increase the potential for confusion to occur in the provision of care for Resident 1 and 4. Findings: On October 25, 2023, at 10:24 a.m., an unannounced visit was conducted at the facility for a complaint investigation. On October 25, 2023, Resident 1's medical record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which included acute congestive heart failure (sudden failure of the heart to pump properly), atrial fibrillation (irregular heartbeat), and generalized weakness. Resident 1 was discharged from the facility on September 18, 2023. Review of Resident 1's admission Skin Only Evaluation dated August 18, 2023, at 7:36 p.m., indicated, .Does Resident have current…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of four residents' (Resident 4) call light was within reach, when he had a history of fall. This failure had the potential for Resident 4 getting out of bed without assistance, which would increase his risk for fall. Findings: On October 10, 2023, at 11:20 a.m., an unannounced visit to the facility was conducted to investigate a quality of care issue. On October 10, 2023, at 1:03 p.m., an interview was conducted with the Certified Nursing Assistant (CNA 1). CNA 1 stated to prevent residents from falling she would ensure the call light was within reach, the bed was in the lowest position, and would check on the residents every two hours. On October 10, 2023, at 1:28 p.m., observed Resident 4 in bed. He had a hard cervical collar around his neck. Resident 4's call light was behind the head of the bed, out of his reach. There was a family member, (FM) sitting in a chair at the right side of Resident 4's bed. On October 10, 2023,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of four residents' (Resident 4) call light was within reach. This failure had the potential for Resident 4 to have unmet needs. Findings: On October 17, 2023, at 11:23 a.m., an unannounced visit to the facility was conducted to investigate a quality of care issue. On October 17, 2023, at 1:36 p.m., observed Resident 4 sitting in a wheelchair on the left side of her bed. Resident 4's call light was in the center of the bed, not within the reach of Resident 4. Resident 4 had removed the Velcro strap to her abductor pillow (a soft but firm foam pillow that is placed between the thighs and strapped onto the legs while in a resting position. This aids in keeping the body stable and prevents an abducting motion that could cause pain or further injury after hip surgery). On October 17, 2023, at 1:36 p.m., an interview was conducted with Resident 4. Resident 4 did not know where she was at, and she was asking for assistance to get back…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 address the need to watch the television with volume within the confines of the resident's room. This failure had the potential to affect resident ' s mental, physical, and psychosocial well-being. Findings: On February 7, 2023, at 12:22 p.m., Resident 1 was observed in her wheelchair inside the room, watching television without volume. On February 7, 2023, at 12:25 p.m., Resident 1 ' s family member (FM) was interviewed in the resident ' s room. The FM was asked regarding Resident 1 ' s watching television without volume. The FM stated Resident 1 was unable to watch television with volume due to the presence of her roommate. The FM stated the resident ' s roommate did not want the television ' s volume on. The FM stated he informed the staff about his concern, and no steps were taken to address it. The FM stated watching television would help in boosting the resident's mental well-being. Resident 1 ' s record was reviewed. Resident 1 was…

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

Based on observation, interview, and record review, the facility failed to implement infection control practices when: 1. The staff did not use a NIOSH (National Institute for Occupational Safety and Health) approved particulate (very tiny separate particles) respirator with an N-95 (a type of mask approved for healthcare use) filter; 2. Source control recommendation for staff to wear a barrier face covering was not followed; 3. An outbreak of Covid-19 (a disease caused by a virus that is very contagious and spreads quickly) was not reported to the local and/or state public health authorities. These failures resulted in multiple residents developing Covid-19, and the potential for transmission (moving from one place to another) of Covid-19 to other residents in the facility. Findings: 1. On August 10, 2023, at 9:40 a m., a concurrent observation and interview were conducted with the Infection Preventionist (IP). The IP was observed in an isolation room (room that keep residents separate from other resident while receiving medical care), with the door open, wearing a surgical mask,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 for five of sixteen residents reviewed for Advance Directive (AD-written statement of a person's wishes regarding medical treatment) (Residents 21, 38, 63, 120, and 168): 1. A copy of the Advance Directive was in the resident's record; and 2. The facility offered assistance to the resident or responsible party in formulating the AD. These failures had the potential for Residents 21, 38, 63, 120, and 168 's advance directives not to be readily retrievable and available for the staff and physician and not know the residents' wishes regarding medical treatment. Findings: 1a. A review of Resident 21's record, indicated, Resident 21, was admitted to the facility on [DATE], with diagnoses which included diabetes (high blood sugar). A review of Resident 21's Minimum Data Set (MDS- an assessment tool), dated May 3, 2023, indicated, .BIMS (Brief Interview for Mental Status) Summary Score .12 (moderately impaired cognition) . A review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to incorporate the Preadmission Screening and Resident Review (PASARR - screening for individuals with a mental disorder and individuals with intellectual disability) Level II determination into the resident's care planning such as as psychotherapy and counseling, for one of one resident reviewed for PASARR (Resident 25). This failure had the potential to result in Resident 25 not receiving the appropriate care and services the resident needs. Findings: Resident 25's record was reviewed. Resident 25 was admitted to the facility on [DATE], with diagnoses which included bipolar disorder (mental illness), alcohol abuse and anxiety (a feeling of worry and nervousness). During a review of Resident 25's PASARR INDIVIDUALIZED DETERMINATION REPORT, (PASARR) dated April 24, 2023, the PASARR, indicated, .This Determination Report is based on a review of the applicant's medical and social history which reveals a signicant (sic) medical condition with 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 observation, interview, and record review, the facility failed to provide the resident with a copy of the summary of the baseline care plan, for one of 16 residents reviewed for baseline care plan (Resident 168). This failure had the potential to result in the resident not being aware of the care and services she would receive while at the facility. Findings: A review of Resident 168's record, indicated, Resident 168 was admitted to the facility on [DATE], with diagnoses which included fracture of right femur (broken thigh bone). Further review of Resident 168's record indicated no documented evidence the licensed nurse provided a copy of the baseline care plan to Resident 168. On May 17, 2023, at 9:44 a.m., during an interview with Resident 168, Resident 168 stated she did not receive a copy of the summary of the baseline care plan. On May 17, 2023, at 11:59 a.m., during an interview with the Director of staff Development (DSD), the DSD stated staff do not provide a copy of the summary of care plan…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop the comprehensive care plans for two of 26 residents reviewed (Residents 66 and 35) when: 1. For Resident 66, there was no care plan for hyponatremia (chemical imbalance of sodium in the body) and; 2. For Resident 35, there was no care plan for her left arm and hand edema. These failures had the potential for the residents not to be able to maintain a normal state of heath and receive necessary care and treatment. Findings: 1. A review of Resident 66's record indicated she was admitted to the facility on [DATE], with diagnoses which included dementia (memory loss), and hyponatremia. During a review of Resident 66's history and physical, (H&P), dated February 3, 2023, the H&P indicated, she does not have the capacity to understand and make decisions. During a review of Resident 66's Minimum Data Set (MDS-an assessment tool), dated February 6, 2023, the MDS indicated: - . BIMS (Brief Interview for Mental Status) Summary Score . 4…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 services were provided to meet professional standards of practice for two (Residents 30 and 42) of 16 residents reviewed, when: 1. For Resident 30, one opened bottle and one unopened bottle of Systane (eyedrops to prevent dry eyes) were observed on the resident's nightstand; and 2. For Resident 42, one opened tube of Orajel cream (medication to treat toothache) was observed on the resident's nightstand. These failures had the potential for Residents 30 and 42 to receive medications without a physician's order. Findings: 1. On May 15, 2023, at 10:18 a.m., during a concurrent observation and interview with Resident 30, the resident was observed lying in bed. One opened bottle and one unopened bottle of Systane eyedrops were observed on Resident 30's nightstand. Resident 30 stated she administered the eyedrops to herself last week. Resident 30 stated she had the Systane eyedrops with her since she was admitted to the facility. On May…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, for three of 26 residents reviewed (Resident 38, 62, and 158), the facility failed: 1. For Resident 62, to document the pacemaker information in the resident's record; and 2. For Resident 38, to notify the physician when the resident complained of dizziness. These failures had the potential to place these vulnerable residents at high risks for complications due to the delay of provision of care and treatment. Findings: 1. On May 15, 2023, at 12:45 p.m., Resident 62 was observed lying in bed awake, alert and able to verbalize his needs. Resident stated he was on a blood thinner because of his heart condition but was stopped when he had the accident. On May 16, 2023, Resident 62's record was reviewed. Resident was admitted to the facility on [DATE], with diagnoses which included an implanted pacemaker (a device used to control irregular heart beats). On May 16, 2023, at 3 p.m., Resident 62 was observed awake lying in bed. Resident 62 was asked about his pacemaker.…

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

Based on interview and record review, the facility failed to provide Methadone (offers rapid onset of long acting pain relief) the pain medication of choice for one of one resident reviewed for pain (Resident 168). This specific pain medication was from the resident's pain management physician. This failure had the potential for the resident's pain not effectively managed. Findings: On May 16, 2023, at 12:07 p.m., during an interview, Resident 168 stated she did not receive her pain medication Methadone for the first two and a half days. She stated she had severe pain on the right upper leg. Resident 168 stated the licensed nurses were giving excuses such as the medication has not been delivered by the pharmacy. She stated she brought in her own pain medication (Methadone) from the hospital. A review of Resident 168's record, indicated Resident 168 was admitted to the facility with diagnoses which included fracture of the femur (broken thigh bone), chronic pain syndrome (pain that carried on for longer than 12 weeks despite medication), and anxiety (a feeling of worry and…

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

Based on interview and record review, the facility failed to ensure that non-pharmacological interventions were offered before administering psychotropic (medication that affects behavior and mood) medication Lurasidone (treatment for bipolar disorder [severe mood swings]), for one of five residents reviewed for unnecessary medications. This failure had the potential to delay reducing the dose of resident's medication and prolong the duration of the resident's use of psychotropic medication. Findings: A review of Resident 168's record, indicated Resident 168 was admitted to the facility with diagnoses which included bipolar disease and anxiety (a feeling of worry and nervousness). Resident 168's Care Plan, dated May 7, 2023, indicated, .(name of resident) uses psychotropic medications (Lurasidone - antipsychotic) r/t (related to) Bipolar Disorder .Interventions .Review behaviors/interventions and alternate therapies attempted and their effectiveness . Further review of Resident 168's record indicated Resident 168 was not provided non-pharmacologic interventions. On May 17, 2023, 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 interview and record review, the facility failed to ensure the physician was notified timely, for one of one resident reviewed (Resident 66), when the resident had a low sodium (electrolyte that help control the amount of fluid and the balance of acids and bases [pH balance] in your body) level. This failure resulted in Resident 66 not to receive appropriate treatment and evaluation to address the resident's low sodium level and placed the resident at risk for further health complications. Findings: A review of Resident 66's record, indicated she was admitted to the facility on [DATE], with diagnoses which included dementia (memory loss), and hyponatremia (chemical imbalance of sodium in the blood). During a review of Resident 66's HISTORY AND PHYSICAL (H&P), dated February 3, 2023, the H&P indicated, she does not have the capacity to understand and make decisions. A review of Resident 66's Minimum Data Set (MDS-an assessment tool), dated February 9, 2023, the MDS indicated: - .BIMS (Brief Interview for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 food storage was in accordance with professional standards for food service safety when: 1. One plastic bag containing 13 slices of bread was unlabeled and readily available for use; and 2. One cartoon of pasteurized liquid egg was found on the floor underneath the rack. This failure had the potential to result in cross contamination and expose medically vulnerable residents to foodborne illness. Findings: On May 15, 2023, at 9:50 a.m., an observation of the walk-in refrigerator was conducted with the Nutritional Services Director (NSD - [NAME]). The following were observed: 1. One plastic bag containing 13 slices of bread with a flexible tie was unlabelled. In a concurrent interview the NSD stated the bread should have been labeled with the date opened and date to be consumed. He stated all staff were responsible in labeling all food items. The facility's policy and procedure titled, Date Marking for Food Safety, dated December…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide necessary care and services in accordance with professional standards of practice when: 1. For Resident 29, there was no physician notification of the constant potassium supplement refusals. In addition, there was no plan of care formulated to address the resident's constant refusal of medications. 2. For Resident 24, there was no assessment conducted when Resident 24 had multiple episodes of hypotension (low blood pressure). In addition, the physician was not notified of Resident 24's multiple episodes of hypotension. These failures had the potential to cause a delay in treatment and care for Resident 29's low potassium levels and Resident 24's low blood pressure. Findings: 1. On September 19, 2019, Resident 29's record was reviewed. Resident 29 was admitted to the facility on [DATE], with diagnoses which included localized edema (swelling), atherosclerotic heart disease (narrowing of the arteries), and major depressive disorder (mood…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 sanitary conditions were maintained in the food and nutrition services when the kitchen ice machine was noted to have a soft gray and light brownish substance on the edge of the ice chute (inclined channel) located in the inner upper portion of the ice bin. In addition, the ice machine was not sanitized according to the manufacturer's instructions. This failure had the potential to result in cross contamination and food borne illness in a highly susceptible resident population of 68 residents on oral diets out of a universe of 73 facility census. Findings: On September 18, 2019, at 10:53 a.m., an observation of the facility ice machine was conducted with the Dietary Supervisor (DS). A clean white napkin was used to wipe the upper edge of the ice bin chute. A smear of soft grayish and light brownish substance was observed on the napkin. In a concurrent interview with the DS, she confirmed the white napkin had a smear of grayish and brownish substance. On September 19, 2019, at 8:45 a.m., the Maintenance…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a copy of the Advance Directive (AD - written statement of a person's wishes regarding medical treatment) was in the resident's record for one of nine residents reviewed for AD (Resident 44). This failure had the potential for Resident 44's advance directive to not be readily retrievable by the staff and by the physician and not knowing the wishes of the resident regarding medical treatment. Findings: Resident 44's record was reviewed. Resident 44 was admitted to the facility on [DATE]. The Physician Orders for Life-Sustaining Treatment (POLST - end-of-life planning tool) indicated Resident 44 had no advance directive. There was no documentation Resident 44 was offered or provided information regarding AD. On September 18, 2019, at 8:52 a.m., Social Service Director (SSD) was interviewed. The SSD stated she was responsible for residents' AD. The SSD stated Resident 44 had an advance directive and was provided by his sister on November 16, 2018.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an adequate lighting was provided in room [ROOM NUMBER]. This failure had the potential to affect residents' comfort and safety. Findings: On September 16, 2019, at 10:45 a.m., Resident 158 was interviewed and he stated the room (room [ROOM NUMBER]) was dark. Resident 158 stated he was filling up paperwork last night and he could not see. Resident 158 stated he complained about the room being dark. He stated a staff tried to fix the light but was not able to fix it. On September 17, 2019, at 8:49 a.m., a concurrent observation of room [ROOM NUMBER] and interview were conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated the overhead center light bulb for A bed was not working. CNA 1 stated two overhead light bulbs were not working for B bed (Resident 158's bed). CNA 1 stated the light bulbs should have been replaced. On September 18, 2019, at 9:34 a.m., the Director of Nursing (DON) was interviewed. The DON stated there…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 allegation of physical abuse involving Residents 19 and 27 was reported to the California Department of Public Health (CDPH) immediately, but not later than two hours after the allegation was made. This failure had the potential to delay the identification and implementation of appropriate action and placed the residents at risk for further abuse. Findings: On September 17, 2019, at 9:08 a.m., a telephone interview was conducted with Resident 19's Responsible Party (RP). The RP stated Resident 19 had an injury during an incident with her roommate (Resident 27) involving the curtain. On September 18, 2019, at 2:16 p.m., Resident 27 was interviewed. Resident 27 stated she was unable to remember the incident and refused to talk about it. Resident 19's record was reviewed. Resident 19 was admitted to the facility on [DATE], with diagnoses which included Alzheimer's disease (memory disorder). Resident 19's progress notes dated July 11, 2019,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, for two of 19 residents reviewed for baseline care plan (Residents 55 and 108), the following: 1) For Resident 108, the baseline care plan did not include instructions to address the resident's dietary and nutritional need. This failure placed Resident 108 at risk for not receiving an effective and person centered care to maintain optimal physical and mental well-being; and 2) For Resident 55, the facility failed to provide a written summary of the baseline care plan to the resident and/or the resident's responsible party. This failure had the potential to result in the resident not being aware of the care and services he would receive while at the facility. Findings: 1.) Resident 108's record was reviewed. Resident 108 was admitted to the facility on [DATE], with diagnoses that included hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness on one side of the body) following cerebral infarction (stroke) affecting left…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record reivew, the facility failed to provide the preferred activity for one of one resident reviewed for activity care issues (Resident 18). This failure had the potential to affect Resident 18's physical, mental, and psychosocial well-being. Findings: Resident 18 was observed in bed. There was no music playing inside the resident's room and the television was turned off, as observed on multiple occasions: a. On September 16, 2019, at 10:15 a.m.; b. On September 17, 2019, at 9:39 a.m.; c. On September 17, 2019, at 2:40 p.m.; and d. On September 18, 2019, at 10:13 a.m. Resident 18's record was reviewed. Resident 18 was re-admitted to the facility on [DATE], with diagnoses which included multiple sclerosis (disabling disease of the brain and the spinal cord). The Progress Notes titled, Activity Participation Note, dated July 9, 2019, indicated, .Resident is alert but is unable to verbally respond .functional mobility may impede his ability to join activities. Staff will…

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

Based on observation, interview, and record review, the facility failed to ensure medications were stored and labeled properly when unlabeled tablets were observed in a Loratadine (medication for allergy symptoms) box. This failure had the potential to result for the licensed staff to administer the wrong medications to the residents. Findings: On September 17, 2019, at 3:56 p.m., an inspection of Medication Cart 400 was conducted with Licensed Vocational Nurse (LVN) 4. Six unidentified round, white tablets were observed inside a Loratadine box. In a concurrent interview with LVN 4, LVN 4 stated she could not identify the six round pills. LVN 4 stated the unidentified pills should not be in the Loratadine box. LVN 4 stated those identified pills could be mistaken for Loratadine and could be administered to the residents. The policy and procedure titled, Storage of Medication, dated September 2018, was reviewed. The policy and procedure indicated, Medications and biologicals are stored properly .to maintain their integrity and to support safe effective drug administration .Outdated,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow infection control measures for one of two residents reviewed for infection (Resident 409) when one staff member was observed entering and exiting an isolation room without following the proper infection control precautions. This failure had the potential to result in spreading infection to a vulnerable resident population. Findings: On September 16, 2019, at 11:45 a.m., the Maintenance Director (MD) was observed entering Resident 409's room and handling the TV remote. Resident 409's room has an isolation cart by the resident's door. The MD did not perform hand hygiene when entering or exiting the room, and did not wear appropriate PPE (Personal Protective Equipment- gown, face mask, and gloves) while in the room of Resident 409. On September 16, 2019, at 11:47 a.m., during an interview with the MD, the MD stated he should have worn appropriate PPE while in Resident 409's room, and should have performed hand hygiene when entering…

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