Pacifica Hospital Of The Valley DP SNF

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide reasonable accommodation for resident needs and preferences for two of four sampled residents (Resident 24 and Resident 5) by failing to: Ensure Resident 5's call light (an alerting device that allows a resident to call for help) was within reach. 2. Ensure Resident 24 was provided with a push button call light despite Resident 24 having wrist contractures (a condition where the muscles, tendons, or skin around the wrist tighten, shorten, and scar, causing the joint to become stiff and locked in a bent position) that limited the ability to grasp and activate the call light. This deficient practice had the potential to prevent Resident 5 and Resident 24 from summoning assistance, placing the residents at risk for unmet needs and delayed care. Findings: 1.During a review of Resident 5's admission Record (the front page of the chart that contains a summary of basic information about the resident), the admission Record indicated the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow its policy titled, Advance Directives, by not providing assistance with creating an advance directive (a legal document indicating resident preference on end-of-life treatment decisions) for two of four sampled residents (Residents 2 and 27) reviewed under the Advance Directive care area. This deficient practice resulted in Residents 2 and 27 not receiving assistance with creating advance directives, increasing the risk that the residents' wishes regarding their medical care would not be known or honored if they became unable to make or communicate their own decisions Findings: During a review of Resident 2's Patient Registration Form, the Patient Registration Form indicated the facility admitted the resident on 6/11/2022. During a review of Resident 2's History and Physical (H&P), dated 7/11/2025, the H&P indicated Resident 2 had diagnoses including, but not limited to, a history of assault with a spinal cord injury (damage to the bundle of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide care in accordance with professional standards for one (1) of one (1) sampled residents (Resident 26) investigated for gastrostomy tube ([G-tube] - a tube inserted through the belly that delivers nutrition and medications directly to the stomach) care by failing to flush the tube with the prescribed volume of water. This deficient practice increased the risk that Residents 26 could experience adverse effects (unwanted, unintended result) from lower volume of water, possibly leading to clogging of the G-tube and requiring procedures for declogging (removing a blockage) or replacement of the tube. Findings: During an observation on 2/9/2026 at 9:20 a.m. in Medication Cart 4, licensed vocational nurse (LVN) 7 was observed flushing Resident 26's G-tube with 25 milliliter ([ml] - a unit of measure of volume) followed by administering amiodarone (a medication used for middle cerebral artery (mca) occlusion (a blood clot blocking 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 provide preventative care for one of one sampled resident (Resident 64) by not applying sequential compression device (SCD-inflatable sleeves wrapped around the legs that automatically inflate and deflate to mimic muscle movement, increasing blood flow and preventing deep vein thrombosis [DVT-a condition where a blood clot [clump of blood cells in blood stream] forms in a deep vein]) at all times to prevent DVT as ordered by the physician. This deficient practice had the potential to increase the risk of developing blood clots, causing pain, poor blood circulation and serious harm to Resident 64's health. Findings: During a review of Resident 64's Patient Registration Form, the Patient Registration Form indicated that Resident 64 was originally admitted to the facility on [DATE], then readmitted to the facility on [DATE]. During a review of the History and Physical (H&P) dated 4/2/2025, the H&P indicated Resident 55 was admitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide appropriate services, equipment and assistance to one of three residents (Resident 8) reviewed under the care area of Position/Mobility, to maintain or improve mobility by not applying ankle-foot orthosis ([AFO] - a brace made of plastic or metal to support the lower leg and foot) in accordance with the facility's splinting protocol (rules for temporary, rigid immobilization of a joint to prevent further damage, reduce pain, and protect soft tissue) and physician's order. This deficient practice had the potential to increase the risk for decreased Range of Motion ([ROM] - the full distance and direction a joint can move comfortably, measuring how far you can bend, straighten, or rotate it), discomfort and worsening of Resident 8's contractures (a permanent tightening or shortening of muscles, tendons, skin, or other tissues that causes joints to become stiff, deformed, and limited in movement). Findings: 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents who were incontinent (lacks voluntary control over urination) of bladder received appropriate treatment and services to prevent urinary tract infections (UTI- an infection in the bladder/urinary tract) for two of three sampled residents (Resident 1 and Resident 8) by failing to keep Resident 1 and Resident 8's urinary indwelling catheter (a tube inserted into the bladder to drain or collect urine) in a manner that prevents urine backflow. This deficient practice had the increased potential for Resident 1 and Resident 8 to develop catheter associated urinary tract infection (CAUTI - UTI developed in a resident with an indwelling catheter). Findings: a. During a review of Resident 1's admission Record (the front page of the chart that contains a summary of basic information about the resident), the admission Record indicated the facility admitted Resident 1 to the facility on [DATE]. During a review of the History and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain accurate clinical records in accordance with accepted professional standards and practices for one of four sampled residents (Resident 13) when Respiratory Therapist 2 (RT 2) documented on the Medication Administration Record (MAR - a daily documentation record used by licensed staff to document medications and treatments given to a resident) that Resident 13's bubble humidifier (a medical device that includes a plastic bottle partially filled with distilled water to add moisture to supplemental oxygen given to residents) was changed when the bubble humidifier had not changed. This deficient practice resulted in inaccurate documentation in Resident 13's medical record. Findings: During a review of Resident 13's admission Record (the front page of the chart that contains a summary of basic information about the resident), the admission Record indicated the facility admitted Resident 13 to the facility on [DATE]. During a review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement its protocol for Antibiotic Stewardship Program (a coordinated program that promotes the appropriate use of drugs used to treat infections, including antibiotics [medications that fight infections caused by bacteria]) for one of one sampled resident (Resident 8) by not completing an Antibiotic Time-Out (a scheduled check-up, treatment is paused to re-evaluate if the medication is still necessary, effective, or needs adjustment) between 48 to 96 hours of therapy initiation as indicated in facility's policies and procedures (P&P). This deficient practice had the potential to result in inappropriate or prolonged antibiotic use, increased risk of side effects (unwanted effects of medications), and antibiotic resistance (occurs when bacteria evolve to survive drugs designed to kill them, making infections difficult or impossible to treat). Findings: During a review of Resident 8's Patient Registration Form, the Patient Registration Form 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 ensure one of one sampled Certified Nursing Assistant (CNA) reviewed for sufficient and competent nurse staffing was provided the required annual in-service training for dementia (a condition characterized by decline in mental ability such as memory, reasoning and communication) management. The deficient practice had the potential to negatively affect the quality of care received by residents with dementia. Findings: During a concurrent interview and record review on 2/12/2026 at 1:50 p.m. with the Human Resources Supervisor (HRS), Restorative Nursing Assistant (RNA- a CNA who has received additional training in restorative care) 2's employee file was reviewed. The HRS stated there was no record of RNA 2 having received dementia training in the last 12 months. During an interview on 2/12/2026 at 3:03 p.m. with the Director of Staff Development (DSD), the DSD stated he is responsible for ensuring required trainings are completed. The DSD stated that dementia training was not provided to RNAs in the last 12 months and 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure Resident 1's conservator was included in the decision to cancel a long-awaited medical appointment.This failure had the potential to result in Resident 1 to have a delay in his medical care due to the unplanned rescheduling. During a review of Resident 1's History and Physical (H&P), dated 6/8/2022, the H&P indicated Resident 1 admitted to the facility on [DATE] for long term care and management related head trauma (bodily injury) resulting in cerebral (relating to the brain) swelling (abnormal enlargement of a part of the body, typically as a result of an accumulation of fluid) and right temporal (portion of brain) contusion (bruising).During a review of Resident 1's Surgical Consult, dated 6/17/2025, the consult indicated the reason for consultation was for a skin lesion (type of wound) on his back related to dermatitis (skin inflammation).During a review of Sub Acute Appointment June 2025 calendar, dated June 2025, the calendar 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 inform the family of Patient 1 ' s plan of care and change of condition. This deficient practice led to anxiety while the family had no input into Patient 1 ' s treatment for an extended period of time. Findings: During an observation on 2/20/205 in Patient 1 ' s room at 11:49 AM, Patient 1 was seen to have a tracheostomy (an incision on the front of the neck to open a direct airway to the trachea and lungs) and was able to speak in short sentences. A staff member had just returned Patient 1 to his room from the activity room and placed Patient 1 on the end of the bed. During an interview on 2/20/2025 at 11:49 AM, Patient 1 stated he did not have any problems with the medical care at this facility but could not recall the last time a medical physical came to visit him. Patient 1 said his mother visits him every day; the only plan his mother had mentioned to him was to recover and go back to work. Finally, Patient 1 stated his mother 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.

Based on interview and record review, the facility failed to electronically submit staffing information based on payroll data on a quarterly schedule to the Centers of Medicare and Medicaid Services [CMS, a federal government agency that manages the Medicare and Medicaid programs, which provide health coverage to millions of Americans]) for two of four fiscal quarters (3rd quarter [April 1 to June 30, 2024] and 4th quarter of 2024 [July1- September 30, 2024]. The deficient practice prevented the provision of complete and accurate direct care staffing information to the public. Findings: During a concurrent interview and record review on 1/30/2025 at 11:25 a.m., with the Director of Staff Development (DSD), reviewed the Payroll-Based Journal Staffing Data Report (PBJ-SDR) for 3rd and 4th quarter of 2024. The DSD stated that the person in-charge now of submitting the PBJ-SDR is on medical leave and he has no idea if she had submitted the data for these particular reporting period on or before the due date. The DSD also stated that the previous facility Administrator and the Director…

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

Based on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a plan of care that summarizes a resident's health conditions, specific care and services facility staff need to provide a resident to promote healing and prevent a worsening of a condition, and current treatments) to meet the resident`s needs for three of three sampled residents (Resident 46, Resident 55 and Resident 57) by failing to: 1. Develop and implement a comprehensive person-centered care plan addressing Resident 46`s Restorative Nursing Assistant program (RNA-nursing aide program that helps residents to maintain their function and joint mobility). This deficient practice had the potential to result in Resident 46`s inadequate care. 2. Develop and implement a comprehensive person-centered care plan addressing Resident 57 and 55`s antibiotic (drugs that kill bacteria) therapy. This deficient practice had the potential to result in failure to deliver the necessary care and services. Findings: 1. During a review of Resident 46's History and Physical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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. During a review of Resident 38's History and Physical (H&P) dated 6/25/2024, the H&P indicated that the facility admitted the resident on 5/23/2022, with diagnoses including hemorrhagic stroke (a life-threatening emergency that happens when a blood vessel in your brain breaks and bleeds), tracheostomy (an opening surgically created through the neck into the windpipe to allow air to fill the lungs), gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), and recurrent Urinary Tract Infection (UTI- an infection in the bladder/urinary tract). During a review of Resident 38's Minimum Data Set (MDS - a resident assessment tool) dated 11/26/2024, the MDS indicated that the resident was at persistent vegetative state (a chronic disorder in which an individual with severe brain damage appears to be awake but shows no evidence of awareness of their surroundings). The MDS indicated that Resident 38 was dependent to staff (helper does all of the effort) for oral hygiene, toileting hygiene,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement accident risk and hazard interventions for three of five sampled residents (Residents 30, Resident 34, and Resident 18) by failing to: 1. Ensure padding was applied to Resident 30 and 34`s bed side rails for seizure precaution (the safety measures taken before an individual experiences a seizure). 2. Repair or replace Resident 18`s broken wheelchair. These deficient practices had the potential to place Residents 30, 34 and 18 at risk for injuries. Findings: 1.a During a review of Resident 30's History and Physical (H&P) dated 7/1/2024, the H&P indicated that the facility admitted the resident on 7/15/2022, with diagnoses including tracheostomy (an opening surgically created through the neck into the windpipe to allow air to fill the lungs), gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), and seizure disorder (a sudden,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to: 1. Check the gastrostomy tube (G-tube, a tube inserted through the abdomen] to deliver nutrition and medications directly to the stomach]) residual volume (the amount of fluid in the stomach after a feeding) before administering a medication to one of five residents (Resident 7) observed during medication administration This deficient practice had the potential to place Resident 7 at increased risk for aspiration pneumonia (a type of lung infection that occurs when food, saliva, or other substances are inhaled into the lungs, which occurs when medication is accidentally delivered into the lungs instead of the stomach because an improperly placed tube could be in the esophagus or trachea, allowing medication to enter the airway). 2. Ensure the G-tube (G-tube - a flexible tube surgically inserted through the abdomen into the stomach for feeding, fluid, and medication administration) feeding bottle was labeled with the date and time the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the physician sign and date all orders in the physical or electronic record, during visits of three out of 23 sampled residents (Resident 4, Resident 13, and Resident 51). This deficient practice had the potential to cause a delay in a resident's plan of care. Findings: a. During a review of Resident 4's Patient Information Form (a page with information indicated for a resident such as facility admission date and pertinent diagnoses), the document indicated the resident was admitted to the facility on [DATE] with diagnoses that included respiratory failure (condition when the lungs cannot get enough oxygen into the blood). During a review of Resident 4' s Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 12/18/2024, the MDS indicated Resident 4 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement its policy and procedure titled, Patient Care Services-Assessment, for one of two sampled residents (Resident 46) by failing to conduct a social service assessment within 48 hours of the resident`s admission to the facility. This deficient practice placed the residents at risk of not receiving sufficient and appropriate social services to meet the resident's needs. Findings: During a review of Resident 46's History and Physical (H&P) dated 9/19/2024, the H&P indicated that the facility admitted the resident on 9/19/2024, with diagnoses including stroke (a loss of blood flow to part of the brain, which damages brain tissue), tracheostomy (an opening surgically created through the neck into the windpipe to allow air to fill the lungs), gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), and seizure disorder (a sudden, uncontrolled…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Controlled Drug Record (CDR- accountability record of medications that are considered to have a strong potential for abuse) coincided with the Medication Administration Records (MAR) affecting Resident 6 and Resident 42 in one of three inspected medication carts (subacute unit two medication cart 3). This deficient practice had the potential to result in medication error and/or drug diversion (illegal distribution or abuse of prescription drug). 2. Ensure that the refrigerator emergency kit (e-Kit, a collection of medications that can help people survive or respond to an emergency) in two of two medication storage rooms investigated (subacute unit two and subacute unit three medication rooms), were replaced within 72 hours after removing three residents' medications (Resident 4, Resident 27, Resident 14) This deficient practice had the potential to delay the necessary pharmaceutical services to the residents in the subacute unit two 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 safe provision of pharmaceutical services in accordance with professional standards by failing to: 1. Ensure an open (in-use) potassium chloride (supplement used for treatment of hypokalemia [lower than normal potassium level]) solution was labeled with an open date to readily identify the beyond use date for one of one sampled resident (Resident 44). 2. Discard an open and discontinued chlorhexidine 0.12% (antiseptic [slows or stops growth of microorganisms] used to treat skin infection), solution stored in the medication cart for one of one sampled resident (Resident 54). 3. Ensure a container of Vitamin A and Vitamin D (a medication used as a moisturizer to treat or prevent dry, rough, scaly, itchy skin and minor skin irritations, known simply as A & D Ointment) Skin Ointment was labeled upon opening for one of four medication carts (Medication Cart B) investigated for medication storage. 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 observation, interview, and record review, the facility failed to ensure proper food storage practices by failing to ensure food stored in the facility's freezers were labeled with the date they were placed in the freezer. This deficient practice had the potential to place 17 out of 58 residents who receive food from the facility's kitchen at risk for foodborne illnesses (refers to illness caused by the ingestion of contaminated food or beverages). Findings: During a concurrent observation and interview on 1/27/2025 at 8:10 a.m., in the facility's kitchen with Registered Dietician 1 (RD 1), observed an unlabeled plastic bag containing five individually sealed frozen pork chops in Freezer 1. RD 1 stated all food items in the freezer are required to be labeled with the date they were placed in the freezer. During a concurrent observation and interview on 1/27/2025 at 8:13 a.m., in the facility's kitchen with RD 1, observed an unlabeled bag of frozen fish sticks in Freezer 2. RD 1 stated all food items in the freezer are required to be labeled with the date they were placed 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 3. During a review of Resident 8's Inpatient Information Form, the Inpatient Information Form indicated that the facility admitted Resident 8 on 1/25/2013. During a review of Resident 8's H&P dated 3/15/2024, the H&P indicated the resident was admitted with diagnoses including chronic respiratory failure, gastroparesis (a condition that affects the stomach muscles and prevents proper stomach emptying), and hemiplegia and hemiparesis (weakness or paralysis of one side of the body). During a review of Resident 8's MDS dated [DATE], the MDS indicated that the resident had moderately impaired cognition (thought processes). The MDS further indicated that Resident 8 was totally dependent on staff or required maximal assistance with all activities of daily living (ADLs - activities related to personal care). During a review of Resident 8's Order Summary Report, the Order Summary Report indicated an order dated 4/21/2020 for enteral feed every four (4) hours of bolus (administration of a discrete amount of medication,…

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

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 patient when in need) within reach of the resident for one out of one sampled resident (Resident 11). This deficient practice had the potential to result in the resident not being able to call for facility staff assistance and delay in the provision of necessary care and services that can negatively affect resident's comfort and well-being Findings: During a review of Resident 11's Inpatient Registration Form, the Inpatient Registration Form indicated the facility admitted Resident 11 on 5/4/2015 and readmitted Resident 11 on 5/9/2017. During a review of Resident 11's History and Physical (H&P), dated 7/1/2024, the H&P indicated Resident 11 was admitted with diagnosis included Guillain-Barre (GBS- a rare autoimmune disease that occurs when the body's immune system attacks the peripheral nervous system), diabetes mellitus type 2 (a long-term medical condition in which the body does not use insulin [a hormone that lowers…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the facility`s policy and procedure titled Advanced Directives, for two of five sampled resident (Resident 46 and Resident 35) by failing to: 1. Ensure that Resident 46 was provided written information concerning the right to refuse or accept medical or surgical treatments and formulate an Advanced Directive (AD-a written instruction, recognized under State law, relating to the provision of health care when the individual is unable to make decisions for themself) upon admission. 2. Maintain a current copy of Resident 35`s advance directives in the resident's clinical record. These deficient practices had the potential for the facility to not honor the resident's medical decisions regarding end-of-life treatment and had the potential to cause conflict with Resident 35 and 46's wishes regarding health care. Findings: 1. During a review of Resident 46's History and Physical (H&P) dated 9/19/2024, the H&P indicated that the facility admitted the resident on 9/19/2024, with diagnoses including stroke (a loss of blood…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility failed to follow the facility's Policy and Procedure (P&P) titled Discharge Planning, for one of two sampled residents (Resident 60) investigated under closed record review by failing to: 1. Develop a care plan (a document outlining a detailed approach to care customized to an individual resident's need) addressing Resident 60`s discharge plan. 2. Initiate a discharge planning assessment prior to Resident 60`s discharge. These deficient practices placed Resident 60 at risk for not receiving the necessary care and services related to the resident's discharge goals and needs. Findings: During a review of Resident 60's Patient Information Form (face sheet), the patient information form indicated that the facility admitted the resident on 11/9/2023, with diagnoses including tracheostomy (an opening surgically created through the neck into the windpipe to allow air to fill the lungs), gastrostomy (a surgical opening fitted with a device to allow feedings to be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to follow the physician's order by failing to check a resident's orthostatic hypotension (a condition where blood pressure drops significantly upon standing or sitting up from a lying position) on 10/23/2024 and 11/27/2024 for one of one (Resident 33) sampled resident. This deficient practice had the potential for Resident 33 to experience dizziness, lightheadedness, or even fainting when standing up, which can lead to falls and injury. Findings: During a review of Resident 33's Patient Information, the Patient Information indicated that the facility admitted the resident on 8/17/2021. During a review of Resident 33`s History and Physical (H&P- the most formal and complete assessment of the patient and the problem) dated 1/20/2024, the H&P indicated that the resident had the following diagnoses, including: a. Dysphagia (difficulty swallowing) b. bipolar disorder (a mental health condition where you have extreme mood changes) c. Schizophrenia (a disorder…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents' pain was assessed before and after administration of pain medication for two of two sampled residents (Resident 6 and Resident 42). This deficient practice resulted in Resident 6 and Resident 42's pain not being assessed and placed the residents at risk for having unmanaged pain that may diminish the residents' quality of life. Cross reference F755 Findings: a. During a review of Resident 6's Patient Information Form (a page with information indicated for a resident such as facility admission date and pertinent diagnoses), the document indicated the resident was admitted to the facility on [DATE] with diagnoses that included respiratory failure (condition when the lungs cannot get enough oxygen into the blood). During a review of Resident 6' s Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 1/09/2025, the MDS indicated Resident 6 was severely impaired in cognition (the process of acquiring knowledge and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Medication Regimen Review (MRR - review of a resident's drug therapy to assure appropriateness of medication usage completed each month by the consultant pharmacist) was acted upon for two of five sampled residents (Resident 17 and 35) by: 1. Failing to act upon the facility consultant pharmacist's recommendation to assess the need for the medication, FeroSul (also known as ferrous sulfate, medication given for those with an iron [a mineral that the body needs for growth, development, and transporting oxygen] deficiency) for Resident 17. 2. Failing to act upon the facility consultant pharmacist's recommendation to order blood testing for the medication, levetiracetam solution (Keppra [brand name], medication that treats seizures) for Resident 35. These deficient practices placed the residents at an increased risk of experiencing adverse side effects (unwanted undesirable effects that are possibly related to a drug). Findings: a. During a…

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

Based on interview and record review, the facility failed to monitor a resident for side effects for the use of Cymbalta (medication used for depression [mood disorder that causes a persistent feeling of sadness and loss of interest]) for one of five sampled residents (Resident 11) investigated under the care area of unnecessary medications. This deficient practice had the potential to place the resident at increased risk of taking an unnecessary medication and experiencing adverse side effects (undesired harmful effect resulting from a medication or other intervention). Findings: During a review of Resident 11's Inpatient Registration Form, the Inpatient Registration Form indicated the facility admitted Resident 11 on 5/4/2015 and the facility readmitted Resident 11 on 5/9/2017. During a review of Resident 11's History and Physical (H&P- a formal assessment by a healthcare provider that involves a resident interview, physical exam, and documentation of findings) dated 7/1/2024, the H&P indicated Resident 11 was admitted with diagnosis included Guillain-Barre (GBS- a condition 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 Based on observation, interview, and record review, the facility failed to ensure three residents' call lights (a device used by patients in hospitals, nursing homes, and other healthcare facilities to request assistance from staff) were within reach while the residents were in bed for three of three sampled residents (Residents 54, 25, and 15) investigated for accommodation of needs. This deficient practice had the potential to cause a delay in resident care and for the residents' needs to remain unmet. Findings: a. A review of Resident 54's admission Record indicated the facility admitted the resident on 11/1/2023 with diagnoses including chronic respiratory failure with hypoxia (condition in which not enough oxygen passes from your lungs into your blood and reaching the body's tissues). A review of Resident 54's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 11/8/2023, indicated the resident had intact cognition (the mental process of acquiring knowledge and understanding…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 professional standards of practice by failing to label the gastrostomy tubes (G-tube -a plastic tube inserted into a resident's stomach to administer nutrition and medications for one who has swallowing problems) feeding bottle for three (3) of 15 residents sampled residents (Resident 9, Resident 39, Resident 41). This deficient practice had the potential to result in nosocomial infections (infections that develop while a person is receiving medical attention) for Resident 9, Resident 39, and Resident 41. Findings: a. A review of Resident 9's Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses that included pneumonia (lung infection). A review of Resident 9' s Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 1/17/2024 indicated Resident 9 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and 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: 1. Provide range of motion (ROM - exercises that improve the movement of a joint) exercises as prescribed by the physician for two of seven sampled residents (Residents 1 and 34) investigated for position and mobility. 2. Ensure one of seven sampled residents (Resident 42) received their prescribed Restorative Nursing Assistant (RNA, a program designed to ensure each resident maintains their physical and functional abilities) order for bilateral (both sides) hand rolls (used to prevent contractures [permanently shortened muscles that resist stretching] of the fingers) as ordered by the physician. These deficient practices had the potential to decrease the residents' range of motion and mobility which could affect their overall function. Findings: 1.a. A review of Resident 1's admission Record indicated the facility admitted the resident on 6/7/2022 with diagnoses including cardiovascular respiratory distress (a term related to breathing problems). 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: 1. Ensuring the Controlled Drug Record (CDR- accountability record of medications that are considered to have a strong potential for abuse) coincided with the Medication Administration Records (MAR, a record of all medications taken by a resident on a day-to-day basis) for four of six sampled residents (Resident 2, Resident 15, Resident 26, and Resident 209). This deficient practice had the potential to result in medication error and/or drug diversion (illegal distribution or abuse of prescription drug). 2. Ensure midodrine (medication to treat low blood pressure [the force of the blood pushing on the blood vessel walls is too low]) was administered in accordance with the physician's order to hold (do not give) for a systolic blood pressure (SBP, measures the pressure in your arteries [pathway that carries blood away from the heart]) greater than (>) 120 millimeters of mercury (mmHg, a unit of measure for blood pressure) for one of 11 sampled…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 two of five residents (Resident 19 and 22), who were reviewed for psychotropic medication (medications that affect mental processes, resulting in temporary changes in perception, mood, consciousness, and behavior) use, were free from unnecessary medications by failing to: 1. Ensure Resident 19's physician order for Ativan (medication used to treat anxiety [intense, excessive, and persistent worry and fear about everyday situations]) as needed had a duration and documented evidence that the physician indicated the clinical rationale why the medication is being used longer than 14 days. 2. Provide Resident 22 with non-pharmacological interventions (any type of healthcare intervention which is not primarily based on medication) prior to administering lorazepam (Ativan [brand name]) as needed. These deficient practices had the potential to result in adverse reaction (undesired harmful effect resulting from a medication or other intervention) or impairment in the residents' mental or physical condition. Findings: a. A…

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

Based on interview and record review, the facility failed to develop a person-centered comprehensive care plan (a written document that summarizes a patient's needs, goals, and care) for a resident's use of lorazepam (Ativan [brand name]- medication used to treat anxiety [(intense, excessive, and persistent worry and fear about everyday situations]) by failing to include non-pharmacological interventions (therapies that do not involve drugs or medicine) in the care plan for one of five sampled residents (Resident 22) investigated for unnecessary medications. This deficient practice had the potential to result in failure to deliver necessary care and services. Findings: A review of Resident 22's admission Record indicated the facility admitted the resident on 5/15/2017 with diagnoses including chronic respiratory failure (condition in which not enough oxygen passes from your lungs into your blood). A review of Resident 22's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 1/6/2024, indicated the resident had moderately impaired cognition (the 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.

Based on interview and record review, the facility failed to renew and revised the resident's comprehensive Care Plan (a care plan is a form where you can summarize a person's health conditions, specific care needs, and current treatments) for Range of Motion (the extent or limit to which a part of the body can be moved around a joint or a fixed point) for one of three sampled residents (Resident 44) investigated under Care Planning. This deficient practice resulted to the resident not being evaluated if the desired outcome or care plan goals have been met or if the plan of care needs to be updated with new interventions to prevent further decline in range of motion. Findings: A review of Resident 44's admission Record indicated the facility admitted the resident on 10/24/2023 with diagnoses that included respiratory failure (a serious condition that makes it difficult to breathe on your own) and seizure disorder (sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain). A review of Resident 44's Minimum Data Set…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the low air loss mattress (LAL - a medical-grade mattress designed to prevent and treat skin breakdown) for a resident at high risk for developing a pressure ulcer (a wound that develops when skin is damaged by constant pressure or fiction) was set correctly according to the resident's weight for one of five sampled residents (Resident 43) investigated for pressure ulcer/injury. This deficient practice placed the resident at risk of discomfort and development of new pressure ulcers. Findings: A review of Resident 43's admission Record indicated the facility admitted the resident on 4/14/2022 with diagnoses including respiratory failure (a serious condition that makes it difficult to breathe on your own). A review of Resident 43's History and Physical (H&P - a formal assessment of a patient and their problem), dated 4/15/2023, indicated the resident was unable to make decisions. A review of Resident 43's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 1/19/2024,…

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 follow proper food handling practices by failing to ensure two transparent plastic bins containing poultry meat (chicken) in one of two facility refrigerators (Refrigerator 1) were labeled and dated while being thawed. This deficient practice had the potential to place 14 of 59 residents living in the facility at risk for foodborne illnesses (refers to illness caused by the ingestion of contaminated food or beverages). Findings: During an observation of the facility's kitchen and concurrent interview on 2/6/2024 at 8:26 a.m., with Catering Manager 1 (CM 1), observed two transparent plastic container bins containing cut up chicken legs and thighs. Upon closer inspection, the container bins did not have a date as to when the chicken legs and thighs were placed in Refrigerator 1 for thawing. CM 1 stated that he thinks the poultry meat were thawed two days ago and the person in charge called in sick, which is why it was not labeled and dated. During an interview on 2/8/2024 at 3:04 p.m., with the Director of Food…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: 1. Ensure staff labeled a wash basin found on the sink countertop of a shared resident bathroom with a resident identifier for three of eight sampled residents (Residents 25, 54, and 15) investigated for infection control. 2. Ensure soiled linens, soiled blankets, and soiled towels were placed in the soiled linen hamper and not on top of the red biohazard waste container bin (used for the disposal of waste that may be contaminated with pathogens [any organism or agent that can produce disease] that present a danger to people and the environment) for one of four contact isolation (used when a patient has an infectious disease that may be spread by touching either the patient or other objects the patient has handled) rooms (Room A). These deficient practices had the potential to result in contamination of the resident's environment and risk of transmission of bacteria that can lead to infection. Findings: 1. A review of Resident 54'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.