Santa Anita Convalescent Hospital

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure standard infection prevention control practices (a set of practices that prevent or stop the spread of infections and or diseases in the healthcare setting) were followed for two of seven sampled residents (Residents 380 and 2) in accordance with the facility's policy and procedure when:1. Resident 380's Peripheral Inserted Central Catheter (PICC, a long, thin, flexible tube inserted through a vein in the upper arm and guided into a large vein near the heart) line dressing was not changed every seven (7) days) in accordance with the physician's order.2. Licensed Vocational Nurse 12 (LVN 12) did not wear gloves during an intramuscular (IM) injection medication administration of Resident 2's Ceftriaxone (medication used to treat bacterial infections) on 5/27/2026.These deficient practices have the potential to cause infection to Resident 2 and to Resident 380's PICC line site, which could result in other complications. 3. The lids of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not provide privacy for one of one sampled resident (Resident 217) reviewed for dignity when Resident 217 was exposed from the waist down during activities of daily living on 5/27/2026.The deficient practice had the potential to result in Resident 217 not being able to enhance the resident's sense of well-being and feeling of self-worth and self-esteem.Findings: During a review of Resident 217's admission Record (AR), the AR indicated Resident 217 was admitted on [DATE] with diagnosis that included Parkinson's disease (progressive neurological disease characterized by a fixed inexpressive face, tremor at rest, slowing of voluntary movements), type 2 Diabetes Mellitus (DM 2, a condition that results in too much sugar circulating in the blood), anxiety disorder (a group of mental disorders characterized by significant feelings of fear that affect with daily activities), and bipolar disorder (a mental illness that causes unusual shifts in 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete the Minimum Data Set (MDS, a standardized assessment and care screening tool) within 14 calendar days of admission for one of seven sampled residents (Resident 336) reviewed for Resident Assessment.This failure had the potential to delay the development of a resident centered care plan which may result in Resident 336 not receiving timely care and services needed for overall wellbeing.Findings:During a review of Resident 336's admission Record, the admission Record indicated Resident 336 was admitted on [DATE], with the following diagnoses but not limited to; malnutrition (imbalance between the nutrients the body needs to function and the nutrients it gets), type two diabetes (where the body either cannot make process sugars in the blood properly), and dementia (a decline in mental abilities severe enough to interfere with daily life).During a review of Resident 336's MDS, dated [DATE], the MDS did not indicate it was completed within 14 days…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 complete a Minimum Data Set (MDS-a resident assessment and care-screening tool) discharge tracking assessment (a type of assessment conducted when a resident leaves a nursing home, which includes clinical items for quality monitoring as well as discharge tracking and is transmitted to the Centers for Medicare and Medicaid Services [CMS, a United States government agency that administers healthcare programs]) for one (1) of seven (7) sampled residents (Resident 319) reviewed for Resident Assessment. This deficient practice had the potential to result in the facility's inaccurate quality monitoring data at transition points, such as when residents enter or leave the facility.Findings: During a review of Resident 319's admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE] with diagnoses including osteoarthritis of the knee (wear-and-tear joint disease) and hypertension (blood pressure that is higher than normal).…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to create a measurable activities care plan for one of 35 sampled residents (Resident 336).This failure has the potential for Resident 336's activity needs not to be met which could result in negatively affecting the resident's psychosocial wellbeing.Findings:During a review of Resident 336's admission Record, the admission Record indicated Resident 336 was admitted on [DATE], with the following diagnoses but not limited to; malnutrition (imbalance between the nutrients the body needs to function and the nutrients it gets), type two diabetes (where the body either cannot make or process sugars in the blood properly), and dementia (a decline in mental abilities severe enough to interfere with daily life).During a review of Resident 336's Minimum Data Set (MDS) dated [DATE], the MDS indicated Resident 336 was severely impaired with cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to review and revise all care plans by the target date for one of one sampled resident (Resident 336) reviewed for care planning.This failure had the potential to negatively impact the timeliness and appropriateness of Resident 336's interventions and care needs.Findings:During a review of Resident 336's admission Record, the admission Record indicated Resident 336 was admitted on [DATE], with the following diagnoses but not limited to; malnutrition (imbalance between the nutrients the body needs to function and the nutrients it gets), type two diabetes (where the body either cannot make or process sugars in the blood properly), and dementia (a decline in mental abilities severe enough to interfere with daily life).During a review of Resident 336's Minimum Data Set (MDS) dated [DATE], the MDS indicated Resident 336 was severely impaired with cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. 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 ensure proper maintenance and position of an indwelling urinary catheter (Foley catheter [FC]- a hollow tube inserted into the bladder to drain or collect urine) for one of two sampled residents (Resident 330) reviewed for catheter care area when staff did not maintain the FC tubing free of dependent loops (a U shaped sag in the drainage tubing that dips below the collection bag, allowing urine to pool and increasing the risk of infection). This deficient practice placed Resident 330 at risk for impaired urine drainage and increased the potential for urinary tract infection (UTI- an infection in the bladder/urinary tract).Findings:During a review of Resident 330's admission Record, the record indicated Resident 330 was admitted to the facility on [DATE] with diagnoses including quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury), kidney failure, and urine retention (a condition where…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 respiratory care services for two (2) of five (5) sampled residents (Residents 16 and 57) reviewed for respiratory care by failing to: 1. Administer continuous oxygen at 2 liters per minute (L/min, Measurement units) to Resident 16 in accordance with the physician's order.This deficient practice had the potential for Resident 16 to experience respiratory distress. 2. Ensure Resident 57 received aerolized inhaled medications (breathing treatment) as indicated on the physician's order.This deficient practice resulted in Resident 57 not receiving breathing treatment as ordered, which increased the risk of shortness of breath, wheezing, and respiratory distress. 1. During a review of Resident 16's admission Record (AR), the AR indicated the facility originally admitted Resident 16 on 9/3/2025 and readmitted on [DATE] with diagnoses that include chronic obstructive pulmonary disease (a progressive, incurable lung disease that blocks…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) care in accordance with professional standards of practice (established guidelines and expectations that ensure a professional performs their duties safely, ethically, and competently) for one of one residents (Resident 21) reviewed for dialysis care area by failing to ensure Resident 21 who is on fluid restrictions and receiving dialysis was not left an pitcher of water at Resident 1's bedside in accordance with Resident 21's physician orders. This deficient practice placed Resident 21 at risk for exceeding daily fluid allowance and potentially causing fluid overload (excess body fluid resulting in swelling, weight gain, or respiratory compromise due to impaired fluid balance), thereby compromising the safety and effectiveness of dialysis treatment.Findings:During a review of Resident 21's admission…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide medically related social service (services that assist residents in attaining or maintaining their mental [how a person thinks, feels, and behaves] and psychosocial health (the interaction between a person's psychological state [thoughts, feelings, and mental health] and their social environment [relationships, community, and cultural background]) in accordance with the facility's policy and procedure titled, Social Services Program for one of two sampled residents (Resident 361), who had loose upper teeth and had requested new dentures (removable oral appliances that replace missing teeth). The facility failed to follow up with the dental clinic and update the resident's responsible party (RP) 1 with his request for new dentures from 3/2/2026 to 5/26/2026 (approximately 3 months). The deficient practice placed Resident 361 to experience fear of swallowing loose upper teeth if they dislodged and RP 1 feel disappointed due to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure its medication error rate was less than five (5) percent (%). Two (2) medication errors (the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order/ manufacturer's specifications / accepted professional standards and principles) out of 25 opportunities (observed administered medications) for error, to yield an overall medication error rate of 8 % for one (1) of three (3) sampled residents (Resident 202) observed during medication administration (med pass). This deficient practice had the potential to result in adverse reactions (undesired effect of a drug or other type of treatment), ineffective treatment, worsening of Resident 202's condition, or potentially serious harm or injury.Findings:During a review of Resident 202's admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE] with diagnoses including paraplegia…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview and record review, the facility failed to serve lunch meal at the facility's scheduled delivery time in accordance with the facility's policy and procedure tilted, Meal Service Time, for one of 35 sampled resident (Resident 217). The deficient practice resulted in Resident 217 not receiving her lunch tray at regularly scheduled time, in which the resident verbalized dissatisfaction with late lunch and food did not taste good anymore. In addition, it placed the resident to be hungry and feel angry.During a review of Resident 217's admission Record (AR), the AR indicated Resident 217 was admitted on [DATE] with diagnosis that included Parkinson's disease (progressive neurological disease characterized by a fixed inexpressive face, tremor at rest, slowing of voluntary movements), type 2 diabetes mellitus (DM 2, a condition that results in too much sugar circulating in the blood), anxiety disorder (a group of mental disorders characterized by significant feelings of fear that affect…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 brought to residents by family/visitors was not shared for one of 35 sampled residents (Resident 149) in accordance with the facility's policy. This failure had the potential to result in inadvertently causing Resident 149 severe allergic reaction, diet conflict, infection, and or aspiration (unintentional entry of substance such as food, into the airway or lungs instead of the esophagus [flexible, muscular tube that moves swallowed food and drink to the stomach]).Findings: During a review of Resident 149's AR, the AR indicated the resident was admitted to the facility on [DATE], with diagnoses that included endocarditis (a serious and uncommon heart infection), peripheral vascular disease (PVD, a slow progressive narrowing of the blood flow to the arms and legs), and hypertension (HTN, high blood pressure). During a review of Resident 149's H&P dated 10/25/2025, the H&P indicated the resident did not have the capacity 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 maintain the complete and accurate medical records in accordance with the facility's policy and procedure (P&P) titled, Documentation-Nursing, for 2 of 35 sampled residents (Resident 380 and 273) as evidenced by:The nurse did not document in Resident 380's IV (intravenous, referring to delivering medicines or fluids through a needle or tube inserted into a vein) Administration Record after administering the residents meropenem (a medicine used to treat infections) IV which was scheduled at 10 PM on 5/24/2026.The nurse did not document in Resident 273's Controlled Drug (medications whose manufacture, possession, and distribution are strictly regulated by government authorities) Record after administering Endocet (a prescription medication used to relieve moderate to severe pain) on 5/27/2026 at 1:11 AM. These deficient practices had the potential to result in medication errors for Residents 380 and 273 and negatively impact on the delivery of services…

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

Based on interview and record review, the facility failed to ensure one of three sampled Residents (Resident 45) was informed and understood the concept of the proposed arbitration (solving disputes with a neutral third party instead of the court) and the Arbitration Agreement (a binding agreement by the parties to submit to arbitration all or certain disputes between them in respect of a defined legal relationship, whether contractual or not) Form before having the resident/ Resident Representative (RP) enter into a binding arbitration agreement. The deficient practice had the potential to result in Resident 45 unknowingly giving up their right to resolve any disputes with the facility through a court of law before a jury.During a review of Resident 45's admission Record (AR), the AR indicated the facility admitted Resident 45 on 3/20/2026 and readmitted him on 3/31/2026 with diagnoses that included heart failure (a condition in which the heart muscle cannot pump enough blood to meet the body's needs ) and diabetes mellitus (a diseases that affect how the body uses blood sugar and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow its policy and procedure to ensure an allegation of physical abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) was reported to state survey agency (CDPH, California Department of Public Health), local law enforcement (Police Department), and state ombudsman (advocates for residents of nursing homes) within two (2) hours for one (1) of five (5) sampled residents (Resident 1). This deficient practice had the potential to compromise the protection of Resident 1 from further abuse, which could affect the resident's physical, emotional and mental wellbeing.Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses including but not limited to metabolic encephalopathy (brain disease, damage, or malfunction that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain accurate medical records for one (1) of two (2) sampled Residents (Resident 1), when Resident 1's arbitration agreement (a legally binding contract where parties agree to resolve disputes through a private arbitrator rather than a public court trial) indicated an electronic signature from Resident 1 on 2/10/2026 and from Resident 1's responsible party (RP 1) on 3/7/2026, when neither signed the arbitration agreement.This failure resulted in an inaccurate arbitration agreement for Resident 1, which could potentially lead staff to follow an agreement that RP 1 did not approve/consent to.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 obtain an informed consent (is the act of agreeing to allow something to happen, or to do something, with a full understanding of all the relevant facts, including risks, and available alternatives) for the use of Zyprexa (antipsychotic medication primarily prescribed to treat schizophrenia [a mental illness that is characterized by disturbances in thought] and bipolar disorder ) for bipolar disorder for one (1) of two (2) sampled residents (Resident 1), as indicated in the facility policy.This deficient practice had the potential for Resident 1 or Resident 1's Responsible Party (RP) not to be able to exercise their right to choose the resident's treatment plan.Findings:During a review of Resident 1's admission Records, the admission Records indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), dementia…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one (1) of two (2) sampled residents (Resident 1) and/or Responsible Party 1 (RP 1) were given the right to choose an attending physician (the primary physician who is responsible for managing the resident's medical care) prior to or upon admission on [DATE], per facility policy.This failure resulted in Resident 1 being assigned to a different attending physician without RP 1's knowledge and consent.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), dementia (a progressive state of decline in mental abilities) and type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). The admission Record indicated RP 1 as Resident 1's Power of Attorney (POA- a legal document authorizing a person…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide safety measures and supervision by not assisting, and/or monitoring to prevent falls and injury for one (1) of two (2) sampled residents (Resident 1) when Resident 1 was assessed to be at high risk for falls and fell on [DATE], hitting his head on the floor.This deficient practice has the potential to cause injury and/ or future falls to Resident 1.Findings:During a review of Resident 1's admission Record, the admission Record indicated the resident was originally admitted on [DATE] and was readmitted on [DATE] including but not limited to diagnoses of cataract (a medical condition in which the lens of the eye becomes progressively opaque, resulting in blurred vision), muscle weakness and pain in the right arm.During a review of Resident 1's Care Plan with focus risk for falls, revised 10/30/2025, the Care Plan indicated the following but not limited to:To provide assistance with transferring and locomotion as needed.Educate/ remind resident to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to develop and implement a person-centered care plan for one (1) of two (2) sampled residents (Resident 1), to address Resident 1's need for supervision and assistant during the Activities of Daily Living (ADL's) as indicated on the facility's policy. This deficient practice had the potential of Resident 1 not receiving the necessary supervision and assistance during daily activities, which put Resident 1 at risk for falls and other accidents.Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] with diagnosis which including but not limited to lack of coordination, difficulty in walking, dementia (progressive brain disorder that slowly destroys memory and thinking skills), Parkinson's Disease (progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement). During a review of Resident 1's Minimum Data…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 concise, and accurate documentation on Minimum Data Set (MDS, a resident assessment tool) for one (1) of two (2) sampled residents (Resident 1) that was completed on 7/28/2025 and 10/23/2025 respectively. 1. Resident 1's admission MDS dated [DATE] did not indicate the resident's mobility device included wheelchair only and not walker. 2. Resident 1's Quarterly MDS dated [DATE] did not indicate the resident's history of fall that occurred on 10/7/2025. This deficient practice had the potential to result in inaccurate care plans, inaccurate representation of a resident's acuity, which affects residents' treatment progress and plan of care. Findings: During a review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included malignant neoplasm of liver not specified as primary or secondary ( a cancerous tumor in the liver where the origin is not specified ),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 supervise and ensure the safety of one (1) of 2 sampled residents (Resident 1) in accordance with the facility's Wandering and Elopement (leaving the facility without the staff's knowledge and/or supervision) Policy and Procedure (P&P).This failure resulted in Resident 1 eloping from the facility on 11/1/2025 around 4:15 PM which placed the resident at risk for exposure to extreme weather, medical complications, injury, serious harm, and/or death. Resident 1 was not found until approximately eight (8) hours later, on 11/2/2025, at 11:45 PM at the general acute care hospital (GACH).Findings:During a review of Resident 1's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of chronic (long term) chronic obstructive pulmonary disease (CODP; a group of lung diseases that block airflow and make it difficult to breathe) and chronic pulmonary…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the use of a bed pad alarm (a pad with sensors that will alarm when a resident stands up unassisted to help prevent falls by alerting staff) for one (1) of four (4) sampled residents (Resident 1) as indicated on the care plan (a document that outlines the facility's plan to provide personalized care to a resident based on the resident's needs) and facility fall policy.This failure had the potential for Resident 1 to have repeated falls which could cause injury and harm to the resident. Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses that included generalized muscle weakness, lack of coordination, and congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure two (2) of four (4) sampled residents (Resident 2 and 3), were treated with dignity and respect when: 1. Certified Nursing Assistant 3 (CNA 3) failed to speak respectfully to Resident 2 during incontinent (involuntary loss of urine or stool) care on 8/24/2025 during the night shift (11 PM through 7 AM). 2. CNA 3 failed to respect Resident 3's request not to receive incontinent care on 8/21/2025 during the night shift. These failures had the potential to negatively affect Residents 2 and 3's overall wellbeing. Findings: 1. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included adult failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity), dementia (a progressive state of decline in mental abilities) and weakness. 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 ensure one (1) of four (4) sampled residents (Resident 2), was assessed and monitored for 72 hours after an alleged incident episode of physical abuse (an intentional act causing injury or trauma to another person through bodily contact) as indicated in the facility's policy and procedure (P&P). This failure had the potential for Resident 2 not to be monitored for physical and/or psychosocial changes negatively affecting his overall well-being. Findings: During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included adult failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity), dementia (a progressive state of decline in mental abilities) and weakness. During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated…

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

Based on observation, interview, and record review, the facility failed to observe infection control measures as indicated in the facility's policy and procedure by failing to ensure:1. Licensed Vocational Nurse 1 (LVN 1) doff (remove an item or clothing) Personal Protective Equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) and perform hand hygiene (the process of cleaning one's hands to remove dirt, germs, and other microorganisms. It involves washing hands with soap and water or using alcohol-based hand rubs) prior to exiting Room B.2. Physician 1 don (putting on an item or clothing) on an N-95 (a disposable face mask that covers the user's nose and mouth which offers protection from small solid or liquid droplets found in the air) prior to entering Unit A (the COVID [Coronavirus Disease- a highly contagious respiratory disease caused by the SARS-CoV-2 virus. SARS-CoV-2 is thought to spread from person to person through droplets released when an infected person coughs, sneezes, or talks] unit).3.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that food was served at the proper serving temperature for one (1) of two (2) sampled residents (Resident 2) in accordance with the facility's policy and procedure titled Food Temperatures. This deficient practice had the potential to negatively affect Resident 2's meal intake. which could lead to health complications and weight loss. Serving food at improper temperatures can reduce palatability and discourage consumption, especially and inadequate nutritional intake may lead to health complications such as weight loss, malnutrition (a condition that occurs when the body does not receive enough nutrients or calories to function properly), and a decline in overall health statusFindings:During a review of Resident 2's admission Record, the admission Record indicated the resident was admitted on [DATE] and was readmitted on [DATE] with the following diagnoses of diabetes mellitus (DM-a disorder characterized by difficulty in 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.

Based on observation, interview, and record review, the facility failed to ensure one (1) of two (2) dumpsters (a movable waste container) were closed and not overflowing, in accordance with the facility's Policy and Procedure (P&P) titled, Garbage and Trashcan Use and Cleaning. This deficient practice had the potential to attract vermin (animals that are believed to be harmful, carry diseases such as rodents, parasitic worms, or insects), pests (any living thing that has a negative effect on humans), and wildlife (undomesticated animal species) and may cause disease and other health issues to residents, staff, and the community.During an observation on 8/12/2025 at 8:30 AM one dumpster located at the facility's back parking lot overflowing and its lid was not closed. It contained crushed eggshells in an open box and kitchen trash. The dumpster has strong odor of spoiled /rotten food and could visually see flies flying around the dumpster. The dumpster concurrent observation and interview on 8/12/2025 at 8:41AM at the facility's back parking lot with the staffing coordinator (SC),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain a safe, clean, comfortable sanitary and home-like environment for two (2) of 3 three sampled residents (Resident 1 and 2) by failing to:1. Ensure toilet was free from brownish to reddish color dry substants on the toilet seat.2. Ensure that the floor was free of clutters and food stains.3. Ensure that the dirty white towel with brownish colored substance was not placed on top of the covered linen barrel.4. Ensure that the old food tray from dinner was picked up.These deficient practices caused an unsanitary and unsafe environment potentially put residents in contamination and at risk for serious illness and/ or injury.During a record review of Resident 1's admission Record, the admission record indicated Resident 1 was admitted on [DATE] with diagnosis which included but not limit to anxiety (common mental health condition characterized by excessive and persistent worry, fear, and nervousness), history of falling, unspecified…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to accommodate the needs for one (1) of two (2) sampled residents (Resident 1) by ensuring the call light (initial communication between staff and residents) was within reach of Resident 1 when the resident needed to call for assistance for a brief change.This deficient practice has the potential to delay in the necessary care and services and/ or needs not being met for Resident 1.Findings:During a review of Resident 1's admission Record, the admission Record indicated the resident was originally admitted on [DATE] and was readmitted on [DATE] with the diagnoses of, but not limit to dementia (a progressive state of decline in mental abilities), displaced intertrochanteric fracture of right femur (a break between the bones located in the upper part of the thighbone), history of falling, and muscle wasting/atrophy (weakening, shrinking, and loss of muscle).During a review of Resident 1's Fall Risk Assessment, dated 7/5/2025, the assessment…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 return the resident's personal belongings for two (2) of 2 sampled residents (Resident 1 and Resident 2) upon discharge from the facility as indicated in facility's policy and procedures (P&P) This deficient practice resulted in the violation of Resident 1 and Resident 2's right to have their personal belongings.1.During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included dementia (a progressive state of decline in mental abilities), Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), and psychosis s (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 4/21/2025, the MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain accurate resident medical records for one (1) of two (2) sampled Residents (Resident 1) by failing to ensure Resident 1's inventory list (IL, a record of personal possessions brought into a healthcare facility upon admission) had the correct resident belongings and that the Il was signed and dated. This deficient practice had potential for all resident belongings not to be returned to Resident 1 upon discharge and potential for increased risk of loss or confusion.During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included dementia (a progressive state of decline in mental abilities), Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), and psychosis (a severe mental condition in which thought, and emotions are so affected that…

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

Based on interview and record review, the facility failed to ensure that 524 out of 552 direct care staff (all facility staff who directly provide program and/or nursing services to residents) and indirect care staff (provide essential support services that do not involve direct, hands-on patient care like housekeeping, dietary, laundry, maintenance, and clerical staff) were in services/ trained on April 2025 on the rights of the residents and facility responsibilities when caring for the residents based on the facility's policy. This deficient practice can affect the staff's knowledge about their Resident's Rights when providing care for their residents. Findings: During a record review of the undated In-Service Calendar, the in-service calendar indicated Resident Rights in- service was scheduled in April 2025. During a concurrent interview and record review on 6/25/2025 at 3PM with Director of the Staff Development 1 (DSD 1), The In-service Binder for 2025 was reviewed. The Resident Rights In- Service dated 4/4/2025 indicated, 23 staff from the night shift (11 PM to 7AM) staff and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide behavioral health training to the 452 out of 552 direct care staff (all facility staff who directly provide program and/or nursing services to residents) and indirect care staff (provide essential support services that do not involve direct, hands-on patient care like housekeeping, dietary, laundry, maintenance, and clerical staff) in the facility as required and determined by the facility assessment and facility policy. This deficient practice can affect the staff's knowledge when providing proper care for their 49 residents who have behavioral health issues and/ or concerns. Findings: During a record review of the facility's undated Annual In-Service Calendar, the in-service calendar indicated Behavioral Health Training in- service was scheduled in November 2024. During a record review of the Facility assessment dated [DATE], the Facility Assessment indicated that specialty unit: Unit A is the secure unit where the residents with dementia/…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and implement comprehensive care plan for one of two residents (Resident 2) to address Resident 2's sexual inappropriate behavior of touching his private area noted on 6/12/2025. . This failure placed other residents in the facility at risk of being sexually abused (unwanted sexual activity perpetrated by another adult, often involving the use of force, threats, manipulation, or taking advantage of someone's vulnerability or incapacitation) by Resident 2 and vice versa. Findings: During a review of Resident 2's admission Record indicated Resident 2 was initially admitted to the facility on [DATE] with diagnoses that included paranoid schizophrenia (a mental disorder characterized by psychosis, where individuals experience a disconnect from reality), and violent behavior (it is characterized by actions intended to cause physical harm or injury to others, or damage to property). A review of Resident 2's Minimum Data Set (MDS, 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 respect the resident's right to receive visitors of the resident's choice and the right to have a responsible party of the resident's choice for one of two sampled residents (Resident 1). This deficient practice resulted in Resident 1 being uncomfortable and feeling unsafe to be visited by Visitor 1, which had the potential to cause psychosocial (interplay between mental processes and the surrounding social environment, and how they affect a person's health, functioning, and development) and emotional distress. Findings: During a review of Resident 1's admission Records, the admission Records indicated the Resident 1 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including type 2 diabetes mellitus (a medication condition characterized by the body's inability to regulate blood sugar level), end stage renal disease (advanced stage kidney failure requiring dialysis), and dependence on renal dialysis (the process 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, interviews, and record review, the facility failed to provide safety and supervision for two out of three sampled residents (Resident 3 and 4) to prevent fall. 1. On 2/17/2025, Certified Nurse Assistant (CNA) 1 provided bed mobility, dressing, and personal hygiene (bedside care) to Resident 3 without the assistance of another facility staff. 2. On 4/28/2025, the facility failed to provide documented evidence 1:1 sitter (a caregiver or facility staff who provides continuous, one- on- one supervisions t a resident who requires constant monitoring due to safety concerns) was provided to Resident 4 in accordance with the physician's order dated 1/22/2025. This deficient practice resulted in Resident 3 falling from bed during bedside care on 2/17/2025, and Resident 4 was found on the floor unwitnessed, although she had a physician's order for continuous one-on-one supervision through a sitter and a bed alarm. Findings: 1.During a review of Resident 3's admission Record, indicated Resident 3 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure an accurate assessment to reflect the resident's weight loss on the Minimum Data Set (MDS, a resident assessment and tool) for one (1) of six (6) sampled residents (Resident 6) in accordance with the facility policy. This deficient practice had the potential for the facility not to develop and implement an individualized care plan (a document that outlines the facility's plan to provide personalized care to a resident that includes measurable objectives, interventions and timeframes to meet a resident's medical, nursing, and mental psychosocial needs) to prevent further weight loss and negatively affect Resident 6's overall well-being. Cross reference F692 Findings: During a review of Resident 6's admission Record, the admission Record indicated Resident 6 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE], with the diagnoses including but not limited to Parkingson's disease (progressive disease of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide nutritional care and services for one (1) of six (6) sampled residents (Resident 6) who had a significant weight loss in accordance with the facility's policy by failing to: a. Complete a Change of Condition (COC, tool used by health care professionals when communicating about critical changes in a resident's status) when Resident 6 had significant weight loss b. Follow the Registered Dietician recommendations when Resident 6 had a significant weight loss This deficient practice had the potential to place Resident 6 at risk for further weight loss and negatively affect the resident's overall wellbeing. Cross reference F641 Findings: During a review of Resident 6's admission Record, the admission Record indicated Resident 6 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE], with the diagnoses including but not limited to Parkingson's disease (progressive disease of the nervous system marked…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 administer a medication as indicated on the physician's order for one of six sampled residents (Resident 5) by failing to administer Diphenhydramine HCl Cream 2% (a medication used to treat allergic reactions) to Resident 5 from 6/1/2025 to 6/10/2025 (total of ten days). This deficient practice had the potential to result in worsening of Resident 5's skin rashes. Findings: During a record review of Resident 5's admission Record, the admission Record indicated Resident 5 was admitted to the facility on [DATE] with diagnoses including but not limited to pneumonia (lung inflammation caused by bacterial or viral infection), acute respiratory failure (an inability to maintain adequate oxygenation for tissues or adequate removal of carbon dioxide from tissues) with hypoxia (lack of oxygen in the tissues to sustain bodily function), and hemiplegia (a condition caused by brain damage or spinal cord injury that leads to paralysis [loss of motor…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 three of five sampled residents (Residents 124, 66, and 312) were free from chemical restraints (the use of medications such as psychotropic medications [drugs that affects brain activities associated with mental processes and behaviors, example is antipsychotics, antidepressants, anti-anxiety, hypnotics] not for therapeutic reasons, but to restrict a person's freedom of movement or control their behavior) when: 1. Resident 124 continued to receive Quetiapine (brand name: Seroquel; an antipsychotic medication that helps treat several kinds of mental health conditions) without target behavior monitoring, clinical documentation of Schizophrenia diagnosis, and without, documentation of nonpharmacological interventions (NPI, treatments or strategies that aim to improve health or manage conditions without using medications, focusing instead on physical, psychological, or behavioral approaches) attempted or provided for Resident 124's use 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 assist three of five sampled residents (Residents 40, 120, and 263) who were unable to carry out activities of daily living (ADL) to maintain good grooming, and personal and oral hygiene by failing to: 1. Provide oral care to Resident 40. This failure had the potential for Resident 40 to have dental carries, teeth and gum infections and mouth sores that could lead to hospitalization. 2. Provide Resident 120 with a communication board (a sheet of symbols, pictures or photos that residents will learn to point to, to communicate with those around them) for Resident 120 to effectively communicate his needs. This failure had the potential for Resident 120 to not be able to effectively communicate his needs and result in a decline in psychosocial being. 3. Keep Resident 263's fingernails clean. This failure had the potential for Resident 263 for skin injury, infection, and scarring. Findings: 1. During a review of Resident 40's admission…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure safe and accurate provision of medication for four of four sampled residents (Resident 15, 32, 238, and 299) observed by failing to: 1. and 2. Identify Residents 299 and Resident 32 prior to administering medications. 3. and 4. Ensure physician orders which include parameter to determine when to administer blood pressure medication matched the prescription labels for Resident 238 and Resident 15. These deficient practices increased the potential for inaccurate and unsafe medication administration to meet the needs of each resident (Resident 15, 32, 238, and 299). Findings: 1. During a concurrent interview and medication pass observation on 5/6/2025 between 8:32 AM to 8:58 AM, with Licensed Vocational Nurse (LVN) 4 on Unit 200 at Medication Cart 2. LVN 4 stated Resident 299 was alert and oriented times 4 (is alert and oriented to person, place, time and event). LVN 4 was prepared Resident 299's morning medications, entered 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 ensure it was free of medication error rate of five percent (5%) or greater, as evidenced by the identification of two medication errors out of 33 opportunities (observations during medication administration) for error, to yield a cumulative error rate of 6.06 % for two of four residents (Resident 32 and Resident 15) observed during the medication administration: 1. Facility failed to ensure the correct medication dose and form of docusate sodium was administered to Resident 32. 2. For Resident 15, facility licensed nurse did not check heart rate (HR, the number of times the heart beats per minute [bpm]) prior to administration of Amiodarone 200 mg as ordered. These deficient practices had the potential to result in harm to Resident 32 and Resident 15, by not administering medication as prescribed by the physician in order to meet resident's individual medication and therapeutic needs (the specific types of treatments or interventions…

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

Based on observation, interview, and record review, the facility failed to: 1. Ensure one of four (4) medication carts (med cart 1 - [Unit A medication cart ] a movable piece of equipment used in healthcare facilities to store, transport, and dispense medicines, medical supplies, and emergency equipment) was kept locked when unattended to prevent unauthorized access in accordance with the facility's P&P titled Medication Storage in the Facility. This deficient practice had the potential to result in unauthorized access of medications by residents, visitors and staff and predisposing them to possible medication overdose (taking a toxic or poisonous amount of a drug or medicine), unauthorized use of medications, adverse reactions (any unexpected or dangerous reaction to a drug), and drug-to-drug interactions (a reaction between two or more drugs or between a drug, and a food, beverage, or supplement). 2. Ensure medications and biologicals were properly stored and labeled for six of six current and discharged residents (Resident 174, 219, 231, 483, and 484): a. Remove a discharged…

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

Based on observation, interview, and record review, the facility failed to follow proper food handling practices in accordance with its policy and procedure by failing to ensure: 1. Two (2) can opener was clean and free of gunk (unpleasantly sticky or messy substance). 2. The apple bar from the cooling rack was properly covered. 3. Food trays were free of cracked and exposed metal that has rust (a reddish-brown substance that forms on the surface of iron and steel because of reacting with air and water). These deficient practices had the potential to result in pathogen (germ) exposure to residents, which could place the residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever, which can lead to other serious medical complications and hospitalization. Findings: 1. During a concurrent observation and interview in the kitchen on 5/5/2025 at 7:41 AM with the Dietary Director (DD), observed a can opener with gunk. DD stated the can opener was not clean and has sticky food residue. DD…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation interview and record review the facility failed to follow its own Policy and Procedures (P&P) titled, Food Brought in by Visitors by not labeling the food items brought by visitors to the facility with the resident's name and date they were brought to the facility. This failure had the potential to result in harmful bacterial growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) for residents with stored food in the resident's refrigerator. Findings: During a concurrent observation and interview on 5/6/2025 at 11:58 AM with the assistant director of nursing (ADON 1) at Unit B staff breakroom. ADON 1 stated one pint of [NAME] Daz ice cream, 14 pieces of ice [NAME], one [NAME] 's coffee with straw on, and four cans of Dr. Pepper were not labeled. During an interview on 5/7/2025 at 4:54 PM with the ADON1, ADON1 stated the resident 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.

Based on observation, interview, and record review, the facility failed to ensure six (6) of 6 dumpsters (a movable waste container designed to be brought and taken away) were closed and not overflowing, in accordance with the facility's Policy and Procedure (P&P) titled, Garbage and Trashcan Use and Cleaning. This deficient practice had the potential to attract vermin (animals that are believed to be harmful, carry diseases such as rodents, parasitic worms, or insects), pests (any living thing that has a negative effect on humans), and wildlife (undomesticated animal species) and may cause disease and other health issues to residents, staff, and the community. Findings: During an observation on 5/6/2025 at 5:52 AM 6 dumpsters located at the facility's back parking lot were overflowing lid not closed. During concurrent observation and interview on 5/7/2025 at 9:57 AM with the dietary director (DD), DD stated the 6 dumpsters at the facility's back parking were overflowing with clear plastic bag and black plastic bag containing facility trash and kitchen trash. The DD also stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to observe infection control measures for seven of nine sampled Residents (Residents 270, 145, 183, 324, 149, 4, and 275) as indicated on the facility's policy and procedure (P&P) when the facility failed to: 1.2.3.4. Ensure facility staff donned (to put on) full personal protective equipment (PPE; clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) before entering a contact (a type of transmission-based precaution [TBP; infection control measures used in healthcare settings to prevent the spread of pathogens] used for residents with diseases caused by microorganisms [bacteria and viruses] that are spread through direct and indirect contact) isolation room for Residents 270, 145, 183 and 324. 5. Ensure an enhanced barrier precaution (EBP; additional infection control measures used in healthcare settings to prevent the spread of multidrug resistant organisms [MDRO; bacteria that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to promote respect and dignity for two (2) of 2 sample residents (Resident 322, and 533) by failing to ensure: 1. Resident 233's privacy curtain (a cloth barrier used in health care settings to provide a private enclosure for residents) and/ or door was closed when staff provided incontinent care to the resident on 5/6/2025. 2. Resident 533's water pitcher was free of cracked, chipped parts and with sharp edges. These deficient practices had the potential for Resident 322 and 533 to experience loss of dignity, self-esteem and affect resident's psychosocial (pertaining to the influence of social factors on an individual's mind or behavior, and to the interrelation of behavioral and social factors) well-being. Findings: 1.During a review of Resident 322's admission Record, the admission Record indicated Resident 322 was initially admitted to the facility on [DATE] with diagnosis which included muscle weakness, dementia (a group of symptoms…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 two (2) of 41 sampled residents (Residents 8 and 369) had call lights (one of the major communication technologies that link nursing home staff to the needs of residents) placed within the residents' reach. This deficient practice had the potential for the delay in Residents 8 and 369 receiving care, which could affect the residents' overall wellbeing and could put them at risk for injury in an event of a fall if the residents attempted to get out of bed to reach for the call light to call for help. Findings: 1. During a review of Resident 8's admission Records, the admission Records indicated the Resident 8 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including history of falling, muscle spasm (involuntary contraction of a muscle, typically harmless and temporary, but can be painful), and dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure the side rail (vertical bars attached to the sides of a bed primarily designed to prevent falls and provide assistance with mobility) pads for one (1) of 41 sampled residents (Resident 139) were free of old food particles stains. This deficient practice caused an unsanitary environment and had a potential for Resident 139 to be placed at risk for infection. Findings: During a review of Resident 139's admission Record, the admission Record indicated Resident 139 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 139's diagnoses included hemiplegia (severe or complete loss of strength on one side of the body) and hemiparesis (loss of strength on one side of the body) following unspecified cerebrovascular disease (a group of conditions that affect blood flow and the blood vessels in the brain) affecting unspecified side, insomnia (persistent problems falling and staying asleep), and dependence on supplemental oxygen.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 protect the resident's right for one (1) of two (2) sampled residents (Resident 30) to be free from abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) by another resident (Resident 312) in accordance with the facility's policies and procedures (P&P) titled Abuse Prevention and Prohibition Program. This deficient practice resulted in Resident 30 hitting her head on a doorway after Resident 312 tipped over the wheelchair that Resident 30 was sitting on. Findings: 1. During a review of Resident 312's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included early onset Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities), major depressive disorder (a common mental health condition characterized by a persistent low mood, loss of interest…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 accurate assessment of the Minimum Data Set (MDS -resident assessment tool) for one of 41 sampled residents (Residents 275), by failing to reflect Resident 275's current oxygen therapy. This deficient practice had the potential for the facility to not develop and implement an individualized care plan (a document that outlines the facility's plan to provide personalized care to a resident that includes measurable objectives, interventions and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs), which could negatively affect Resident 275's care and overall well-being. Findings: During a review of Resident 275's admission Record, the admission Record indicated Resident 275 was admitted to the facility on [DATE] with diagnoses that included dementia (a progressive state of decline in mental abilities), epilepsy (a chronic disorder of the brain characterized by recurrent brief episodes of involuntary movement that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop or revise a comprehensive care plan (a guide that healthcare workers used to ensure residents received tailored care to his/her individual needs and goals) for one of five sampled residents (Resident 124), when a care plan was not developed or revised for the use of Seroquel (an antipsychotic medication that helps treat several kinds of mental health conditions) for Resident 124. This failure placed Resident 124 at risk for not receiving specific and individualized care related to the use of strong antipsychotic medications (Seroquel). Cross Reference F605 Findings: During a review of Resident 124's admission Record (AR, a document containing a resident's demographic and diagnostic information), the AR indicated Resident 124 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Bipolar Disorder, Major Depressive Disorder (low mood or loss of pleasure or interest in activities for long periods of time),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 set the low air loss mattress (LALM, pressure relieving mattress that operates using a blower based pump that is designed to circulate a constant flow of air through the mattress, commonly used to heal pressure ulcers [wound that occurs as a result of prolonged pressure on a specific area of the body]) at the correct setting for one (1) of four (4) sampled resident's (Resident 112) in accordance with the facility's policy and procedure (P&P) titled, Pressure Ulcer Prevention and physician's order. This deficient practice had the potential to result in Resident 112 developing pressure ulcers. Findings: During a review of Resident 112's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included muscle weakness, sepsis (a life-threatening blood infection) and chronic respiratory failure (condition in which not enough oxygen passes from the lungs into the blood). During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to lock the casters (wheels that are attached to the bottom of a furniture to make them easier to move) of the bed for one of seven sampled residents (Resident 190), who had a history of fall accidents. This deficient practice has the potential for Resident 190 to have a repeated fall and sustain serious injury. Findings: During a review of Resident 190's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included type 2 diabetes mellitus (a medication condition characterized by the body's inability to regulate blood sugar level), other abnormalities of gait and mobility, and muscle weakness. During a review of Resident 190's Minimum Data Set (MDS- a resident assessment tool), dated 3/13/2025, the MDS indicated Resident 190 was assessed having moderately impaired cognitive (mental action or process of acquiring knowledge and understanding) skills…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 proper care and treatment for gastrostomy tube (G-tube, a tube inserted through the abdomen that delivers nutrition directly to the stomach) was provided for two of five sampled residents (Resident 40 and 5) by failing to ensure: 1. Resident 40's head of bed (HOB) was elevated to an angle of 30 to 45 degrees while the resident was receiving G-tube feeding (a liquid food mixture provided through the G-tube). This deficient practice had the potential for Resident 40 to aspirate (when something swallowed enters the lungs) which could lead to pneumonia (infection that inflames air sacs in one or both lungs) and/or choke. 2. To maintain a clean [NAME] Valve (a stopcock-like device, which allows the health care worker to access enteral systems without breaking open the lines) for G-tube. This deficient practice had the potential to result in complications including infections and stomach discomfort. Findings: 1. During a review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure one of three sampled resident (Resident 74), who was receiving hemodialysis (process of removing waste products and excess fluid from the body) treatment was provided dialysis care and services by failing to assess the resident's right upper arm arteriovenous shunt (AV shunt, direct connection between an artery and a vein, bypassing the capillaries [tiny blood vessels that deliver nutrients and oxygen to cells throughout the body], which can be created surgically for various reasons including hemodialysis access) vascular (relating to vessels that carry blood or other liquids in a person's body) access in accordance with the facility policy. This deficient practice had the potential for Resident 74 to suffer from complications such as bleeding or infection and potential for unnoticed or missed excessive bleeding. Findings: During a review of Resident 74's admission Record, the admission Record indicated Resident 74 was originally admitted to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide necessary behavioral health care and services by failing to implement the care plan to provide a one to one sitter on 5/6/2025 for one of two sampled residents (Resident 270) who was diagnosed with depression (a constant feeling of sadness and loss of interest, which stops you doing your normal activities), and with suicidal ideation (when you think about, consider or feel preoccupied with the idea of death and suicide [death caused by self-directed injurious behavior with the intent to die as a result of the behavior]). This deficient practice had the potential to cause harm/injury to Resident 270. Findings: During a review of Resident 207's admission Record, the admission Record indicated Resident 207 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included depression, End Stage Renal Disease (ESRD- irreversible kidney failure), and gastrostomy (a surgical opening fitted with a device…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 one of one sampled resident (Resident 134), preferred meal choices were implemented as requested by Resident 134. This failure resulted in a violation of Resident 134's right to have preferred meal choices, with the potential for decreased food intake and inadequate nutrition. Findings: During a review of Resident 134's admission Record, the admission record indicated Resident 134 was admitted to the facility with diagnoses that included gastroesophageal reflux disease (GERD- occurs when stomach acid repeatedly flows back into the tube connecting your mouth and stomach), osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) and anemia (a condition where the body does not have enough healthy red blood cells) During a review of Resident 134's Minimum Data Set (MDS- a resident assessment tool), dated 3/18/2025, the MDS indicated Resident 134 with moderately impaired cognitive skills (ability to understand and make decisions) and usually understood when expressing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medical records for one (1) of 8 sample residents (Resident 263) by not documenting oxygen therapy (the odorless gas that is present in the air and necessary to maintain life) administration accurately. This deficient practice had the potential not to have accurate evaluation of the residents' progression or regression of the delivery of treatment and/ or care services. Findings: During a review of Resident 263's admission Record, the admission Record indicated Resident 263 was initially admitted to the facility on [DATE] with diagnosis which included sepsis (a serious condition in which the body responds improperly to an infection), dysphagia (swallowing difficulties) ,muscle weakness, chronic obstructive pulmonary disease (COPD, a common lung disease causing restricted airflow and breathing problems). During a review of Resident 263's Minimum Data Set (MDS, a resident assessment tool), dated 4/4/2025, the MDS 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, facility failed to ensure the arbitration (a process of resolving dispute outside of a court system which involves a neutral third party [arbitrator] who makes legally binding decisions, resolving disagreement between nursing home and the reisdent or the resident's family) agreement signed by one of three samples residents (Resident 583), included information that provided for the use of a neutral arbitrator and the selection of a venue that is convenient to both parties [facility and residents] in accordance with the facility's policy titled Arbitration Agreement, . This failure resulted in an incomplete understanding of the facility's arbitration agreement for Resident 538. Findings: During a review of Resident 583's Arbitration Agreement, signed on 5/8/2025, the agreement did not indicate information regarding the use of a neutral arbitrator and the selection of a venue convenient to both parties. During an interview on 5/8/2025 at 2:58 PM with the Resident Ambassador (RA), the RA stated she explained the arbitration agreement to Resident 583…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain a safe, clean, comfortable sanitary and home-like environment for two (2) of 5 sampled residents (Residents 90 and 533) by failing to: 1. Ensure the bedside control (used to adjust the bed height, head of bed and/or foot of the bed) wires for Residents 90 were not exposed (occurs when the insulation around electrical cords and cables is frayed or damaged, revealing the wires within). 2. Ensure the call light (a call bell or nurse call button) wires for Residents 533 were not exposed 3. Facility failed to ensure the trash cans were not overflowing in Room A. These deficient practices caused an unsanitary and had potential for residents to be placed at risk for serious illness and/ or injury. Findings: 1.During a review of Resident 90's admission Record, the admission Record indicated Resident 90 was initially admitted to the facility on [DATE] with diagnosis which included diabetes mellitus (condition that causes blood sugar to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide the appropriate care and services to for one (1) out of 1 sampled resident (Resident 1) who was admitted with Indwelling catheter (a tube that helps drain urine from the bladder [organ inside the body that stores urine] then your urine goes from your bladder and through a drainage tube [indwelling catheter tube] into a drainage collection bag) in accordance with the facility's policy and procedure title, Care of Catheter by failing to: 1. Monitor and document Resident 1 for signs and symptoms of urinary tract infection (UTI, an infection in the bladder/urinary tract): pain, burning, blood-tinged urine (presence of blood in the urine) in accordance with Resident 1's Care Plan for Indwelling Catheter and bilateral (both sides) nephrostomy tubes (small catheter placed through the skin of the lower back into the kidney to drain urine directly form the kidney into a bag outside the body). 2. Ensure Resident 1's laboratory test 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 provide laboratory services timely for one (1) out of 1 sampled resident (Resident 1) per physician's order dated on 4/3/2025. This deficient practice had the delay of providing the necessary care needed by Resident 1 and had resulted for Resident 1 to have critical laboratory results which needed for Resident 1 to be transferred to the General Acute Care Hospital (GACH) 2. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE]. Resident 1's diagnosis included bladder cancer (a type of cancer that develops in the bladder [the organ that stores urine], acute kidney failure (a sudden and temporary loss of kidney function, where the kidneys can no longer effectively filter waste and excess fluid from the blood) and anemia (a condition where the body does not have enough healthy red blood cells) During a review of Resident 1'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide grooming services for one (1) of two (2) sampled residents (Resident 2) who was dependent with activities of daily living (ADLs- are activities related to personal care that include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating), in accordance with the facility ' s policy. This deficient practice resulted in Resident 2 having oily matted hair(it has become a thick, untidy mass, often because it is wet or dirty), long and jagged (having rough, sharp points protruding) fingernails, potentially leading to skin injury, infection, and scarring. Findings: During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnosis including but not limit to diabetes II (body either doesn't produce enough insulin or can't effectively use the insulin it produces, leading to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to follow physician's orders to not change the wound vacuum assisted closure (VAC; a medical device that uses gentle suction to help wound heal faster by applying negative pressure [suction] around the wound effectively removing excess fluid and debris while promoting tissues growth) dressing for one (1) of two (2) sampled residents (Resident 1) when Treatment Nurse 2 (TXN 2) changed Resident 1's surgical wound VAC dressing on 2/15/2025. This failure had the potential to result in Resident 1's surgical wound not healing as intended by the orthopedic surgeon (MD; a medical doctor who specializes in diagnosing and treating injuries and diseases of the musculoskeletal system [the body's framework of bones and muscles and their interconnecting parts]). Findings: During a review of Resident 1's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted [DATE] with diagnoses of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement infection control practices (a set of practices that prevent or stop the spread of infections and or diseases in the healthcare setting) were followed in accordance with the facility's policy and procedure by failing to: 1. Ensure three (3) basins, located in residents shared restrooms were labeled. 2. Ensure Resident 1 ' s indwelling catheter drainage bag (a collection device that holds urine that drains from a catheter inserted into the bladder) was not touching the floor. This deficient practice had the potential to increase the risk for the spread of infection. Findings: 1. During a concurrent observation and interview on 2/25/25 at 11:23 AM in the shared male restroom, with Certified Nursing Assistant 1 (CNA 1), CNA1 stated that 2 unlabeled basins were observed on the floor in the male shower room. During a concurrent observation and interview on 2/25/25 at 11:26 AM in the shared female restroom with CNA 1, CNA 1 stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one (1) of three (3) residents (Resident 1), who had indwelling catheters (a tubing inserted through the urethra and into the bladder to drain urine), had a privacy bag to cover and maintain the resident dignity. This deficient practice had the potential for Resident 1 ' s dignity to not be maintained and negatively affecting Resident 1 ' s wellbeing (a person's physical, mental, emotional and social health factors.). Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and re-admitted to facility on 2/22/25, with diagnoses including, paraplegia (inability to move the lower parts of the body), GERD (gastroesophageal reflux disease - a digestive disorder, occurs when stomach acid flows back into the tube [esophagus] connecting the mouth and stomach), and hypertensive heart disease. During a review of Resident 1 ' s Minimum Data Set (MDS-…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 1) who had a diagnosis of diabetes mellitus [DM- a chronic disease where a person has high blood sugar level because the body does not produce insulin (a hormone made by the pancreas-an organ in the body)] received treatment and services, in accordance with professional standards of practice (guidelines and principles that define expected conduct, skills and responsibilities of professional in their roles) by failing to: 1. Ensure a licensed staff reviewed Resident 1's medical history of DM and complete the medication reconciliation (a formal process that involves healthcare providers and patients to ensure accurate medication information is communicated during care transition) of discharge orders from General Acute Care Hospital (GACH) 1 for Resident 1's insulin lispro (medication used to treat diabetes), insulin gargline (medication used to treat diabetes), and blood sugar monitoring upon…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 store and label medications for five (5) of 5 sampled residents (Residents 2, 3, 4, 5 and 6) in Medication Cart 2 by: 1. Failing to ensure a stored bottle of Vitamin D3 in the Central Supply room was not expired. 2. Failing to ensure Resident 2's open vial of insulin lispro (generic brand of a fast-acting insulin [a hormone that helps regulate blood sugar levels and metabolism]), Resident 3's open vial of Humulin R (brand name for insulin regular [a short acting insulin]) and Resident 4's opened bottle of Timolol (brand name for ophthalmic [referring to the eye] solution used to treat glaucoma [a group of eye conditions that damage the optic nerve which can lead to vision loss or blindness]) were labeled with an open date. 3. Failing to ensure Resident 5's unopened vial of Novolin R (brand name for regular human insulin) and Resident 6's unopened bottle of Latanoprost solution (brand name of a prescription eye drop medication used to treat…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide a copy of resident's medical records upon written request for one of 13 sampled residents (Resident 11) in accordance with the facility's policy and procedure titled, Resident Access to PHI (Protected Health Information; information in the medical record that can be used to identify an individual) or Financial Records,. This deficient practice resulted in violation of Resident 11's Responsible Party 1 (RP 1) right to obtain a copy of the resident medical records per facility policy. Findings: During a record review of Resident 11's admission Record, the admission Record indicated Resident 11 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses of chronic congestive heart failure (a long-term condition when the heart cannot pump well enough to give the body a normal supply), chronic pulmonary edema (an abnormal accumulation of fluid in the lungs, making it hard to breathe), and dependence on renal dialysis (a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide necessary treatment and services consistent with professional standards of practice for one (1) of two (2) sampled residents by failing to: a. Ensure Resident 1's physician orders for pressure ulcer (skin damage that occurs when constant pressure on a specific area of the body, often over a bony prominence, restricts blood flow and causes tissue breakdown leading to an open sore or wound if left untreated) treatments were transcribed when Resident 1 was admitted to the facility from Skilled Nursing Facility 1 (SNF 1- where reisdent was evacuated from) on 1/7/2025. b. Properly assess and document Resident 1's pressure ulcer/ skin condition and failed to provide treatment for the resident's pressure ulcer. These deficient practices had the potential to result in delayed healing of Resident 1's current pressure ulcer, pressure ulcer infection, and development of new pressure ulcer. Findings: During a review of Resident 1's admission Record, 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 follow the Policy and Procedure on pressure ulcer prevention and wound management by: 1. Failing to ensure the Low Air Loss mattress (LAL mattress, designed to prevent and treat pressure ulcer [localized damage to the skin and underlying soft tissue caused by prolonged pressure]) was set at the correct settings in accordance with the resident's weight. 2. Failing to do assess and monitor, inform Reisdent 2's primary physician and provide treatment for the resident's open wound noted in the Documented Survey Report (Certified Nurse Assistant's [CNA's] documentation) from 1/1/2025 to 1/7/2025. These deficient practices had the potential for Resident 2's pressure ulcer to worsen and for the resident to develop new pressure ulcer. Findings: A review of Resident 2's admission Record indicated the facility admitted Resident 2 on 8/31/2021 and was re admitted on [DATE]. Resident 2's diagnoses included anxiety (a feeling of fear, dread, 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 safe, clean, comfortable, sanitary, and home like environment for one of 51 sample rooms (room [ROOM NUMBER]) by failing to ensure trashcan is not overflowing, used and/ or dirty wash cloth were properly placed in the dirty bin and not on the floor or top of the white bin's (bin used to place residents' dirty clothes) lid. These deficient practices caused an unsanitary and had a potential for residents to be placed at risk for injury and/ or infection. Findings: During observation on 1/7/2025 at 9:35 AM, observed room [ROOM NUMBER]'s trashcan was overflowing with used gloves and gastrostomy tube (G-Tube- a tube inserted through the belly that brings nutrition directly to the stomach) feeding tube, used white washcloth was on top of the closed white bin. In addition, dirty white washcloth was on the floor. During observation and interview on 1/7/2025 at 10:20 AM with License Vocational Nurse (LVN1), LVN 1 stated room [ROOM NUMBER]…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 treatment and care in accordance with the professional standards of practice (define diagnostic, intervention, and evaluation competencies) to one (1) of two (2) sampled residents (Resident 1) who had a change in condition (a sudden, clinically important deviation form a resident's baseline in physical, cognitive, behavioral, or functional domains). 1. On 9/2/2024 to 9/9/2024, Resident 1 had periods of being verbally aggressive towards facility staff. There was no documented evidence that the facility staff monitored and have interventions in place to address the resident's behavior. 2. There was no documented evidence that the facility staff monitored and have treatments/ interventions in place to address the Resident 1's small pink/ reddish raised bumps with dry flaky skin on the resident's arm. This deficient practice has the potential to delay in the necessary care and services for Resident 1 and worsening of the resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement written policies and procedures to prevent misappropriation of resident's property (the intentional, illegal use of the property or funds of another person for one's own use or other unauthorized purpose) for one (1) of two (2) sampled residents (Resident 1). Resident 1's inventory form (a data tool for recording all the items, supplies and commodities in an organization at a specific time) dated 1/12/2024 and 2/18/2024 were not signed by the resident/ resident representative when admitted at the facility on 1/8/2024. This deficient practice place Resident 1's items at risk for unauthorized use/ loss. Findings: During a review of Resident 1's admission Record indicated resident was admitted on [DATE] with the following diagnoses of hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (one-sided muscle weakness) affecting the left non-dominant side and mononeuropathy (damage to a single nerve,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the follow call light was within reach for one of two sampled residents (Resident 1) as indicated on the facility policy. This deficient practice has the potential to delay in the provision of the necessary care and services Resident 1 needs which could result in injury and/harm to the resident. Findings: During a review of Resident 1's admission Record, the admission Record indicated resident was originally admitted on [DATE] and was readmitted on [DATE] with the following diagnoses of dementia (a progressive state of decline in mental abilities) abnormal posture and difficulty in walking. During a review of Resident 1's History and Physical (H&P), dated 4/28/2024, the H&P indicated resident cannot make own decisions but can make needs known. During a review of Resident 1's Minimum data set (MDS - a federally mandated resident assessment tool), dated 6/20/2024, the MDS indicated resident was moderately impaired with cognitive (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 ensure one of two sampled residents (Resident 1) was free of physical restraint (any manual method, physical or mechanical device, equipment, or material that is attached or adjacent to the resident's body; cannot be removed easily by the resident; and restricts the resident's freedom of movement or normal access to his/her body) when the facility failed to: a. Conduct an assessment for the use of bed alarm (alerting device intended to monitor a resident's movement. The device emits an audible signal when the resident moves in certain ways). b. Obtain a physician's order for the use bed alarm. This deficient practice had the potential to result in limiting Resident 1's mobility which may cause Resident 1 not to feel treated with respect and dignity. Findings: During a review of Resident 1's admission Record, the admission Record indicated resident was originally admitted on [DATE] and was readmitted on [DATE] with diagnoses including…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Care Planning policy for one of two sampled residents by not revising Resident 1's care plan after a fall on 8/11/2024 and 9/9/2024. This deficient practice had the potential for Resident 1 to have further falls. Findings: During a review of Resident 1's admission Record, the admission Record indicated resident was originally admitted on [DATE] and was readmitted on [DATE] with the following diagnoses of abnormal posture, difficulty in walking, dementia (a progressive state of decline in mental abilities), anxiety (intense, excessive, and persistent worry and fear about everyday situations), and depression (mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 1's History and Physical (H&P), dated 4/28/2024, the H&P indicated resident cannot make own decisions but can make needs known. During a review of Resident 1's Minimum data set (MDS - a federally mandated resident assessment tool),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to prevent the loss of personal property for one of two residents (Resident 1), when Resident 1 was transferred out of facility. This failure resulted in the misplacement and/or loss of Resident 1 ' s personal belongings/property. FINDINGS: During a review of Resident 1 ' s admission Record, the record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included major depressive order (MDD - a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), generalized muscle weakness (lack of muscle strength requiring extra effort to move), gout (a type of arthritis that causes joint inflammation, pain, swelling, and redness) and gastro-esophageal reflux disease (GERD - chronic digestive disease where the contents of the stomach refluxes and irritates the esophagus). 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 one of two sampled resident (Resident 2) was provided a communication board (pre-printed picture board that has pictures, numbers, and user defined images that allows a resident to point or indicate on the board what he/she wants communicated) with the language the resident was able to understand in accordance with the facility policy. This failure had the potential to result in Residents 2 experiencing a delay in receiving appropriate care and treatment due to the staff not being able to properly communicate with the resident and decreased quality of care and psychosocial well-being. Findings: During a review of Resident 2 ' s admission Record, the record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included gastro-esophageal reflux disease (GERD - chronic digestive disease where the contents of the stomach refluxes and irritates the esophagus), major depressive order (MDD - a mental health…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 policies and procedures for significant weight loss significant weight loss (a loss of five [5] percent or more in one [1] month, 7.5% in three [3] months, or ten [10] percent in [6] months for one of two sampled residents (Resident 1) by failing to: 1. Notify the physician after a Resident 1 had a decrease in weight. 2. Document a change of condition assessment for Resident 1 ' s weight loss. 3. Revise Resident 1 ' s care plans for episodes of significant weight loss as indicated in the facility ' s policy and procedure (P&P). 4. Obtain readmission and weekly weights as order by the physician and indicated in the facility ' s policy and procedure. These failures had the potential to result in the lack of appropriate, coordinated and/or revised care and treatments, potentially resulting in increased weight loss and worsening of Resident 1 ' s health condition. FINDINGS: During a review of Resident 1 ' s admission Record, the record 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 and interview, the facility failed to prevent sexual abuse (sexual behavior or a sexual act [with the intent to arouse or gratify sexual desire a person touches the anus, breast, or the genitals of another] forced upon a woman, man, or child without their consent) for one (1) of three (3) sampled residents (Resident 1). 1. On 9/14/2024, Resident 2 touched and squeezed Resident 1's left breast while in the activity room and was witnessed by Activity Aide (AA). 2. On 9/17/2024 and 9/18/2024, the facility failed to provide one- to- one monitoring (a type of care that involves a staff member providing constant observation and support to a patient. It's used to reduce the risk of harm to patients who may be at risk of falling, harming themselves or others, or exhibiting challenging behaviors) for Resident 2 to ensure resident will not repeat the sexual inappropriate behavior. This failure placed Resident 1 at risk for emotional or mental trauma. Findings: During a review of Resident 1's admission…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to assess, and implement facility's policies and procedure for a response to fall (to drop or descend under the force of gravity, as to a lower place through loss or lack of support) for one of three sampled residents (Resident 3) by failing to ensure that Resident 3 was assessed on [DATE] by a licensed nurse after Certified Nurse Assistant (CNA) 1 witnessed Resident 3 fall from the wheelchair. CNA 1 did not wait for licensed nurse to check Resident 3, and moved and placed Reisdent 3 back to the wheelchair. This deficient practice could have led to serious complications to Resident 1 due to the delay in care. Findings: A review of Resident 3's admission record indicated the facility originally admitted Resident 3 on [DATE] and was readmitted on [DATE] with diagnosis which include muscle weakness, dementia (a progressive state of decline in mental abilities), dysphagia (difficulty swallowing). A review of Resident 3's History and Physical (H&P) dated [DATE]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not follow infection control practices for three (3) of five (5) sampled residents (Residents 2, 3 and 4) by failing to: 1. Facility staff perform hand hygiene (the process of cleaning your hands to prevent the spread of infectious diseases. It can be through using a hand sanitizer [contains at least 60% alcohol (ethanol or isopropyl alcohol) when soap and water are not available] or hand washing with soap and water) and don (putting on Personal Protective Equipment [PPE; protective clothing, goggles, or other garments to prevent or minimize exposure to and spread of infection or illness]) PPE prior to entering Resident 3 and 4's isolation room (room that keeps patients separate from others to prevent the spread of germs or to protect patients who are more easily infected). 2. Ensure Visitor 1 (Resident 2's visitor) discard soiled (used) gloves, perform hand hygiene and did not touch the clean PPE cart with a soiled glove. These deficient…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 meet professional standards (practices, skills, ethics, and/or qualifications set forth by a professional body representing the respective profession or discipline) of quality for one (1) of three (3) sampled residents (Resident 1) by failing to have a blood sugar check for Resident 1's physician's order of glucagon (medication used to treat severe low blood sugar) from 8/6/2024 to 8/15/2024. This deficient practice has the potential to put Resident 1 at risk for hypoglycemia (a condition in which the body's blood sugar level goes below the standard range). Findings: During a review of Resident 1's admission Record indicated resident was admitted at the facility on 8/6/2024 with the following diagnosis of sepsis (a serious condition in which the body responds improperly to an infection) and diabetes (a chronic disease that occurs either when the pancreas does not produce enough insulin [helps your body turn food into energy and manages your blood sugar…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 revise one of two sampled residents (Resident 1) care plan after identifying Resident 1 ' s increased behaviors of rising out of bed independently. This deficient practice had the potential for Resident 1 to sustain further injuries due to falls. Findings: During a review of Resident 1 ' s admission Record, indicated resident was admitted on [DATE] with the following diagnoses of muscle weakness and dementia (a loss of cognitive functioning – thinking, remembering, and reasoning – to such an extent that it interferes with a person ' s daily life and activities). During a review of Resident 1 ' s Nursing admission Assessment, dated 6/25/2024, the Assessment indicated Resident 1 had an impaired gait (walk) and could not walk unassisted. The Assessment indicated Resident 1 was at moderate risk for falls. During a review of Resident 1 ' s Care Plan with focus of risk for falls and/or injuries, initiated on 6/25/2024, indicated interventions to provide…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 necessary respiratory care services for two (2) or three (3) sampled residents (Residents 2 and 3) in accordance with the facility policy by failing to ensure: 1. a. Resident 2's nebulizer (a drug delivery device used to deliver drugs in the form of inhalation into the lungs) face mask and tubing were changed weekly. b. Resident 2's nebulizer face mask and tubing bag was off the floor. 2. a. Resident 3's nasal cannula (NC, device used to deliver supplemental oxygen placed directly on a resident's nostril) tubing and humidifier (a device for supply moisture to the air to prevent dryness which could cause irritation) was changed weekly. b. Resident 3's nasal cannula was stored in a bag. c. Resident 3 had an order for oxygen administration by the physician. These deficient practices had the potential for the residents to develop a respiratory infection, cause complications, associated with oxygen therapy, and result in the spread 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 document records accurately and completely for two (2) of three (3) sampled residents (Residents 1 and 2) in accordance with the facility's policy and procedure by failing to: 1. Ensure Resident 1's two tablets of Sevelamer HCl (used to control phosphorus levels with chronic kidney disease who are on dialysis) was accurately documented on the Medication Administration Record (MAR, a medical record used by healthcare providers to document the administration of a medication or treatment) when found on her bedside table and documented as administered. 2. Ensure Resident 2's Ipratropium Bromide Inhalation Solution (administered by oral inhalation with the aid of a nebulizer to open the airways in lung diseases where spasm may cause breathing problems) was documented on the MAR when administered. These failures had the potential to result in medication errors which could lead to adverse reactions (any unexpected or dangerous reaction to a drug). Findings:…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 their employe handbook guidelines on Employee and Resident Relations for one (1) of two (2) sampled residents (Resident 1). As a result, Resident 1 felt uncomfortable when interacting with Activities Aid (AA) 1. Findings: During a review of Resident 1's admission Record, the admission Record indicated resident was originally admitted on [DATE] and was readmitted on [DATE] with the following diagnoses of asthma (a chronic lung disease affecting people of all ages) and muscle weakness. During a review of Resident 1's History and Physical (H&P), dated 7/28/224, the H&P indicated resident had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS, a standardized care screening and assessment tool), dated 6/14/2024, the MDS indicated resident was independent with cognitive skills for daily decision making. MDS also indicated Resident 1 required partial/moderate assistance (helper does less than half the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a comprehensive resident-centered care plan for one of three sampled residents (Resident 2) in accordance with the facility policy. This deficient practice had the potential to result in a delay of nursing care and medical interventions. Findings: During a review of Resident 2's admission Record, the record indicated Resident 2 was admitted to the facility on [DATE], with diagnoses of polyneuropathy (damage or disease affecting multiple nerves of the body, causing weakness, numbness, and burning pain), type 2 diabetes mellitus (a disease that occurs when there is a problem in the way the body regulates and uses sugar as fuel), and hypertensive (high blood pressure) chronic kidney disease (gradual loss of kidney damage where kidneys cannot filter the blood the way they should). During a review of Resident 2's Physician's Order Summary Report, dated 3/5/2024, the record indicated Ipratropium Bromide Inhalation Solution (administered…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, facility staff failed to address care needs for one of three sampled residents (Resident 1) who had colostomy (surgery to create an opening for the colon [large intestine] through the belly [abdomen]) who required assistance with colostomy care. This deficient practice had the potential for Resident 1 to experience discomfort or excoriation (a place where skin is scraped or worn away) of the skin at the colostomy site. Findings: During a review of Resident 1's admission Face Sheet, the admission Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses that included acute ischemia of large intestine (does not receive enough blood flow to the large intestine), kidney failure (kidney lose the ability to remove waste and balance fluid). During a review of Resident 1's History and Physical Examination (H&P) dated 8/2/24, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure pharmaceutical services procedures such as administering and disposing of drugs were followed in accordance with the facility's policy for one of three sampled residents (Resident 1) by failing to: a. Ensure Resident 1 was administered two tablets of Sevelamer HCl (used to control phosphorus levels with chronic kidney disease who are on dialysis) as ordered by the physician. b. Failing to dispose of Resident 1's Silvadene Cream (used to treat or prevent infections) in the appropriate container. These failures had the potential to result in medication errors and could lead to adverse reactions (any unexpected or dangerous reaction to a drug). Findings: During a review of Resident 1's admission Record, the record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses of heart failure (a lifelong condition in which the heart muscle can't pump enough blood to meet the body's needs for blood 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 one of three sampled residents (Resident 1) was provided a functioning call light. This deficient practice had the potential to result in staff delay in meeting Resident 1's care needs and services for activities of daily living (ADL: personal hygiene or grooming, dressing, toileting, transferring or ambulating, and eating). Findings: A review of Resident 1 ' s admission Record indicated the resident was admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses that included calculus of kidney (a small, hard deposit that forms in the kidneys.), dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), and difficulty in walking. A review of Resident 1 ' s History and Physical Examination (H&P) dated 8/1/24, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1 ' s the 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one (1) of two (2) sampled resident (Resident 4) was provided a communication board (pre-printed board that has pictures, numbers, and user defined images that allows a resident to point or indicate on the board what he/she wants communicated) for Resident 4 to understand and communicate care needs to facility staff. This failure had the potential to result in a delay of care services and needs for Resident 4. Findings: A review of Resident 4's admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnosis which included abnormalities with gait (walking pattern) and mobility (ability to move joints and use muscles easily and comfortably) and a history of fall. A review of Resident 4's Minimum Data Set (MDS, standardized assessment and care screening tool), dated 7/19/24, indicated Resident 4 has moderately impaired cognitive (mental action or 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 implement interventions to prevent injuries for one (1) of two (2) sampled residents (Resident 7) by not providing fall mats as indicated per physician ' s order. This deficient practice had the potential to result in injuries to Resident 7 in an event of another fall (to drop or descend under the force of gravity, as to a lower place through loss or lack of support). Findings: A review of Resident 7 ' s admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of epilepsy (a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements like stiffness, twitching or limpness) and fracture of the nasal bones. A review of Resident 7 ' s Minimum Data Set (MDS, standardized assessment and care screening tool), dated 7/9/24, indicated Resident 7 had severe cognitive (mental action or process of acquiring…

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

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services in accordance with the facility's policy by failing to ensure: 1. Two (2) of two Emergency Kits (E-Kits) were replaced within 72 hours per facility's policy. 2. Facility's Pharmacy was notified of medication usage obtained from 2 of 2 E-Kits. 3. Pharmacist checked two of two E-Kits monthly. This had a potential for the residents to result in an insufficient inventory of medications in stock in case of an emergency. Findings: A record review of Unit A's Refrigerator E-Kit indicated the E-Kit was filled on 12/12/2023 and 5/2/2024. A record review of Unit B's Refrigerator E-Kit indicated the E-Kit was filled on 6/10/2024. A record review of Unit A's Emergency Drug Kit Slip indicated Lorazepam (medication producing sedation [sleepiness or drowsiness] and relief of anxiety [emotion characterized by feelings of tension, worried thoughts and physical changes]) had been used on 6/27/2027. A record review of Unit B's Emergency Drug Kit Slip indicated Lorazepam had been used on 7/10/2024…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from verbal and physical abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) for one of two sampled Residents (Resident 1) when Resident 2 grabbed and squeezed Resident 1's thigh and aggressively used derogatory (lack of respect) language towards Resident 1 on 7/10/24. This failure resulted in Resident 1 having a bruise on the left eye, a scratch on the forehead, and another abuse attempt from Resident 2 trying to hit Resident 1 the following day on 7/11/2024. This failure also had the potential to affect Resident 1's psychosocial well-being. Findings: A review of Resident 1's admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses of major depressive disorder (a mental health disorder characterized by persistently depressed mood or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement its written abuse prevention policy for two (2) of 2 sampled residents (Residents 1 and 2) by failing to: 1. Report a resident to resident abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) to California Department of Public Health (CDPH) when Resident 2 grabbed and squeezed Resident 1's thigh and aggressively used derogatory (lack of respect) language towards Resident 1 on 7/10/24. 2. Protect Resident 1 from further abuse from Resident 2 by keeping both Residents 1 and 2 in the same room after the abuse incident on 7/10/24. This deficient practice had the potential to result in Resident 1 experiencing further abuse from Resident 2, which could lead to injury and harm. Findings: A review of Resident 1's admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses 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 3. A review of Residents 81's admission Record (Face sheet) indicated the facility admitted Resident 81 on 5/1/2024 with diagnoses that included unspecified dementia (the loss of cognitive functioning-thinking, remembering, and reasoning-to such an extent that it interfered with a person's daily life and activities) and unspecified psychosis. A review of Resident 81's Minimum Data Set (MDS-a standardized assessment and care screening tool), dated 5/8/2024 indicated the cognitive (the ability to think and process information) skills for daily decisions making was severely impaired. The MDS indicated Resident 81 had symptoms of feeling down, depressed (a common and serious medical illness that negatively affects how you feel, the way you think and how you act), hopelessness and little interest or pleasure in doing things. A review of Residents 81's psychiatric (the branch of medicine concerned with the study, diagnosis, and treatment of mental illness) evaluation, dated 5/15/2024, indicated Resident 81 was treated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that the call light (a device used by patients to call for assistance from hospital staff) for nine (9) of 36 sampled residents were: 1-4. Within reach (an arm's length) for Residents 132, 143, 223 and 303. 5-6. Within reach for Residents 164 and 160. 7-9. Within reach for Residents 3, 272, and 180. This deficient practice had the potential to result in delayed provision of services, delay in care and not receiving assistance with activities of daily living (ADLs). Findings: 1. A review of Resident 132's admission Record indicated resident was originally admitted on [DATE] and was readmitted on [DATE] with the following diagnoses of absence of left leg above knee and dislocation of the left hip. A review of Resident 132's History and Physical (H&P), dated 4/5/2024, indicated resident does not have the capacity to understand and make decisions. A review of Resident 132's Minimum Data Set (MDS, a standardized care screening 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 four of nine sampled residents (Resident 331, Resident 345, Resident 342, and Resident 151) medical records were updated to show documentation clarifying if a resident has an advance directive (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) or were provided an opportunity to complete the advance directive from. This deficient practice had the potential to result in confusion in the care and services for Resident 331, Resident 345, Resident 342, and Resident 151 and placed the residents at risk of receiving unwanted treatment and not receiving appropriate care based on the residents wishes. Findings: 1. A review of the admission record indicated Resident 331 was originally admitted on [DATE] with diagnoses that included but not limited to unspecified fracture of shaft of right fibula (a break in the bone that stabilizes 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 develop an individualized resident-centered care plan (a care plan that prioritizes the unique health needs and desired outcomes of the resident) with measurable objectives, timeframe, and interventions to meet the residents' needs for four of 36 sampled residents (Residents 306, 216, 300 and 36) by failing to: 1. Ensure Resident 306 did not have an individualized care plan for language barrier and interventions to address dementia (progressive brain disorder that slowly destroys memory and thinking skills). 2. Have a care plan for Resident 216 who had an indwelling foley catheter (a tube that drains urine from your bladder into a bag outside your body). 3. Resident 300 did not have a care plan created after an actual fall. This deficient practice resulted in a second fall which caused a right hip fracture (break in the bone) for Resident 300. 4. Preventing dry chapped lips and dry mouth for Resident 36, who was receiving gastrostomy tube…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 of three sampled residents (Residents 291, 651, and 65) were provided necessary treatment and services to prevent formation of and promote healing of pressure injury (pressure ulcers-injury to the skin and underlying tissue resulting from prolonged pressure on the skin) in accordance with the facility's policy and procedure and physician's order by failing to: 1. Resident 291's low air loss mattress (LAL mattress, an air mattress designed to prevent and treat pressure wound/ulcer [sores that happen on areas of the skin that are under pressure]) was not set accordingly. 2. Ensure facility staff provided incontinent (involuntary or accidental leakage of urine or stool) care after Resident 651 had a bowel movement. Resident 651 was left to sit in his soiled diaper for approximately 5 hours before incontinent care was provided by the Certified Nursing Assistant (CNA). 3. Ensure Resident 65 low air loss mattress (LALM-air filled…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 two of four sampled residents (Resident 197 and 310) who had an indwelling urinary catheter (Foley Catheter, tube inserted into the bladder to drain urine into a drainage bag) received appropriate care and services as indicated in the physician's orders, by failing to appropriately assess and document signs and symptoms (s/sx) of urinary tract infection (UTI- an infection in any part of the urinary system, the kidneys, bladder [organ that stores urine] or urethra [the tube through which urine leave the body]). These deficient practices resulted in delayed UTI identification, delayed treatment, and had the potential to lead to worsening infection. Findings: 1. A review of the Resident 197's admission Record indicated Resident 197 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE], with diagnoses of chronic kidney disease (gradual loss of kidney damage where kidneys cannot filter the blood 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 2. A review Resident 336 's admission Record (Face Sheet), indicated the facility admitted Resident 336 on 4/11/2024, and was readmitted on [DATE] with diagnoses including chronic respiratory failure (a condition in which the blood does not have enough oxygen or has too much carbon dioxide [a colorless, odorless, incombustible gas, present in the atmosphere and formed during respiration]), muscle weakness, and left hemiplegia (paralysis of the left side of the body). A review of Resident 336's Minimum Data Set (MDS- a standardized resident assessment and care screening tool), dated 4/8/2024, indicated Resident 336 cognitive (the ability to think and process information) skills for daily decisions making was severely impaired. The MDS indicated Resident 336 was totally dependent (totally dependent with staff for assistance of activities of daily living) with transfer, dressing, personal hygiene, toileting hygiene, and bathing. A review of Resident 336 's Order Summary Report, active order as of 5/24/2024,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 4. During a concurrent observation and interview on 5/23/2024 at 10:14 AM, Registered Nurse (RN) 1 threw into a regular trash can located inside Resident 36's room by the room entrance, the resident's intravenous (IV) medication bag (a piggyback or a small bag of solution attached to a primary infusion line to deliver medication over a specified period of time) and tubing (used for continuous infusion of fluids or medications. It was the one directly inserted end into the IV fluid bag or bottle. There were spikes at the top of IV tubing), after the resident completed the treatment. RN 1 stated the IV medication bag and tubing were disposed in the trash can in Resident 36's room. RN 1 stated she made a mistake. RN 1 stated used IV bag and tubing should be disposed in biohazard bin located in the biohazard room. RN 1 stated it was important to dispose appropriate the IV medication bag and tubing after completion of the treatment because of infection control. During an interview on 5/23/2024 at 3 PM with Infection…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 (3) of five (5) sampled residents (Residents 191, 302, and 306) were free from unnecessary use of psychotropic drug (any medication capable of affecting the mind, emotions, and behavior) in accordance with the facility policy and procedure by failing to ensure : 1.The indications of psychotherapeutic medications use for Resident 191 were consistent with the residents' psychiatric assessments and specific behaviors. There was no descriptive behavior documented for Resident 191. There were also no interdisciplinary team (IDT) meeting notes to evaluate the behavioral management of Residents 191. 2. The indications of psychotherapeutic medications use for Resident 302 were consistent with the residents' psychiatric assessments and specific behaviors. There was no descriptive behavior documented for Resident 302. There were also no IDT meeting notes to evaluate the behavioral management of Residents 302. 3. There was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 216) received the correct doses of lorazepam (or Ativan, a medication that treats anxiety) as per ordered for at least 4 doses. This deficient practice had a potential for adverse effect that may worsen Resident 216's conditions. Findings: A review of Resident 216's admission record indicated Resident 216 was originally admitted on [DATE] and recently readmitted on [DATE]. On 5/23/2024 at 11:56 AM during an observation and narcotic reconciliation with a registered nurse (RN 2) and the director of nursing (DON) at Nursing Unit 200, there was a bubble pack (unit-dose card that packages doses of medication within small, clear, or light-resistant plastic bubbles) of lorazepam in the narcotic compartment in the medication cart. The pharmacy label indicated it was for Resident 216 and the dosing instruction read lorazepam tablet 1 mg 1 tablet every 6 to 8 hours as needed. The pharmacy label also indicated the…

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

Based on observation, interview, and record review, the facility failed to: 1. Ensure 1 of 2 injectable emergency drugs supplies (E-kits) stored at the medication refrigerator at the nursing unit 300 had a label on the outside of the container. 2. Ensure 2 of 8 medication carts were kept clean. 3. Ensure an outdated inhalation device for Resident 59 would not be available for use. These deficient practices had the potentials of delayed care, contaminations, and/or medication error. Findings: 1. On 5/22/2024 at 2:45 PM during an observation at nursing unit 300, there was a refrigerator in a lockable cabinet located in the back right of the nursing station. Inside this medication refrigerator, there were two E-kits, each kit was secured with a red tag. However, 1 of the aforementioned 2 E-Kits did not have a label (or a content list) on the outside of the E-kit. On 5/22/2024 at 2:50 PM the unit manager (a licensed vocational nurse, LVN 2) inspected the E-kit and confirmed the E-kit did not have a label or content list. LVN 2 stated the E-kit without a label contained insulins. LVN 2…

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

Based on observation, interview, and record review, the facility failed to ensure the storage, preparation and distribution of food was done under sanitary conditions by failing to ensure food items inside the kitchen produce refrigerator and dry storage were labeled, and expired food items were discarded and not mixed with other non-expired foods. These deficient practices had the potential to result in pathogen (germ) exposure to residents and placed residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever and can lead hospitalization. Findings: During concurrent observation of the kitchen produce refrigerator and dry storage, and interview with the Dietary Director (DD) on 5/21/2024 at 7:53 AM, DD stated some of the food items inside the kitchen produce refrigerator and in the basement freezer were not labeled. DD further stated today's date was 5/21/2024 and some of the food had passed the use by date. DSS stated the following food observed in the dry storage and in the…

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

Based on observation, interview and record review, the facility failed to properly dispose food waste products into a covered trash bin located under the food preparation (prep) table in accordance with the facility policy. This failure had the potential to attract and spread vermin (animals that are believed to be harmful or that carry disease, e.g., rodents, parasitic worms, or insects) that could potentially infiltrate the facility, affect the resident care areas, and pose a disease threat to the residents of the facility. Findings: During an observation on 5/22/2024 at 10:24 AM, multiple trash bins were observed under the food prep station table and throughout the kitchen area. The trash bins were not covered, and trash bin lids were not observed anywhere on the floor. During an interview with the dietary staff supervisor (DSS) on 5/22/2024 at 10:34 AM, DSS confirmed the trash cans/bins were not covered. During an interview on 5/22/2024 at 11:31 AM with the Cook, the [NAME] confirmed the trash cans/bins were not covered and stated, It was more convenient to keep the trash can…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. During a concurrent interview and record review on 5/24/2024 at 11:44 AM with the Maintenance Director (MD), the report titled, IWC Innovation, dated 4/15/2024 was reviewed. The report indicated water sample in nurses station collected on 4/2/2024 was positive for Legionella. MD stated the affected sink was in Nursing Unit 500. Per MD, he turned off the water on the affected sink on 4/15/2024 upon notification of the positive Legionella result, and he replaced the faucet of the affected sink on 5/20/2024. MD stated even though he turned off the water, staff could turn the water back on. Per MD, he informed a female staff (not identified) on 4/15/2024 about not to use the sink, but he did not put a sign. During an interview on 5/24/2024 at 1:46 PM with Licensed Vocational Nurse (LVN) 5, LVN 5 stated they (the nurses) barely stopped using the sink in Nursing Unit 500 since yesterday. During an interview on 5/24/2024 at 2:42 PM with Certified Nursing Assistant (CNA) 9, CNA 9 stated she was still using the sink…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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. A review of Resident 8's admission Record indicated Resident 8 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included hydronephrosis with renal and ureteral calculous obstruction (a condition where one or both kidneys swell due to a blockage in the tubes that drain urine from the kidneys), retention of urine, and pleural effusion (a buildup of fluid between the tissues that line that lungs and the chest). A review of Resident 8's History and Physical Examination (H&P), dated 11/13/2023, indicated Resident 8 did not possess the general capacity to make their own decisions. A review of Resident 8's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 4/25/2024, indicated Resident 8 was assessed having severely impaired cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making and was dependent (helper does all of the effort) with eating, toileting hygiene, shower, upper and lower…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility staff failed to provide privacy and confidentiality (safeguarding the content of information including video, audio, or other computer stored information from unauthorized disclosure without the consent of the resident and/or the individual's surrogate or representative) of the resident's medical records by not closing the computer screen for one of 36 sampled residents (Resident 20). This deficient practice violated Resident 20's right for privacy and confidentiality. Findings: A review of Resident 20's admission Record indicated Resident 20 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included Parkinson's disease with dyskinesia (a brain disorder that causes unintended or uncontrollable movements), type 2 diabetes mellitus (a disease that occurs when the blood sugar is too high), and acute osteomyelitis (an infection of the bone that develops rapidly over a period of seven to 10 days) of left…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to exercise reasonable care for the protection of one of one sampled resident's (Resident 66) personal property from theft or loss, when Resident 66 reported to staff her personal belongings were missing. This deficient practice resulted in the violation of the resident's right of having a safe environment and had the potential to cause emotional distress to the resident. Findings: A review of Resident 66's admission Record indicated Resident 66 was admitted to the facility on [DATE], with diagnoses of rhabdomyolysis (the destruction or degeneration of muscle tissue accompanied by the release of breakdown products into the bloodstream), recurrent major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and anxiety disorder (persistent and excessive worry that interferes with daily activities). A review of Resident 66's History and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to complete a Preadmission Screening and Resident Review (PASRR, a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) timely for one of three sampled residents (Resident 216). This deficient practice had the potential to result in inappropriate placement and unidentified specialized services for Resident 216. Findings: A review of Resident 216 admission Record indicated resident was originally admitted on [DATE] and was readmitted on [DATE] with the following diagnoses of dementia (a condition characterized by memory loss and judgment) and schizophrenia (mental condition of a type involving a breakdown in the relation between thought, emotion, and behavior, leading to inappropriate actions and feelings). A review of Resident 216 History and Physical (H&P), dated 4/28/2024, indicated resident does not have the capacity to understand and make decisions. A review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure to update and revised care plan for two of 36 sampled residents (Resident 216 and Resident 277) by failing to ensure: 1. Resident 216 care plan was not revised to addressed fall and behavior of physical aggression. 2. To update and revise care plan for falls after Resident 277 had an unwitnessed fall on 5/8/2024. Resident 277 sustained a right eyebrow laceration (a deep cut or tear in skin), fracture (broken bone) of the right zygomatic arch (a bone surrounding the eyeball is broken), and a fracture of the right orbital floor (surrounding the eyeball), anterior (in front of) wall and posterior (toward the back) wall of the maxillary sinus (located to the side of the nasal [relating to the nose] cavity, and below the orbit). These failures had the potential to place the residents at risk for further falls and physical aggression. Findings: Cross reference with F689 1. A review of Resident 216 admission Record indicated resident was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of 36 sampled residents (Resident 306), with a hearing deficit and a language barrier was provided with a communication board/pencil and paper. This deficient practice had the potential for a delay in the necessary care and services for Resident 36. Findings: A review of Resident 306's admission Record indicated resident was originally admitted on [DATE] and was readmitted on [DATE] with diagnoses of dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and difficulty in walking. A review of Resident 306's History and Physical (H&P), dated 4/13/2024, indicated resident does not have the capacity to understand and make decisions. A review of Resident 306's Minimum Data Set (MDS; a standardized care screening and assessment tool), dated 4/17/2024, indicated resident was severely impaired in cognitive skills (the function brain uses to think, pay attention, process…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Cross Reference F686 Based on observation, interview, and record review, the facility failed to provide a shower and/ or bed bath according to the pre-determined schedule for one of two (2) sampled residents (Resident 1) who required assistance with activities of daily living (ADL). This deficient practice resulted in Resident 1 not receiving a shower and/ or bed bath from 3/29/24, for 12 days and had the potential to negatively impact Resident 1's quality of life and self-esteem. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included fracture of shaft of right fibula (a break in the smaller of the two bones between the knee and the ankle, acute bronchitis (an inflammation of the airways that carry air to the lungs), and obesity (a disorder that involves having too much body fat which increases the risk of health problems). A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a doctor's appointment was completed for one of 36 sampled residents (Resident 18) when facility staff failed to provide a documented evidence that Resident 18 was able to have an orthopedic (ortho- a branch of medication dealing with the correction of deformities or the bones or muscles) appointment, as ordered. This deficient practice resulted in delay in Resident 18's intervention and resulted in incomplete assessment and treatment of Resident 18's left leg. Findings: A review of Resident 18's admission Record indicated Resident 18 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included other abnormalities of gait and mobility (change to the walking pattern), age-related osteoporosis (a condition in which bones become weak and brittle) without current pathological fracture (a broken bone caused by a disease), contracture of left knee (shortening and hardening of muscles, tendons…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff failed to change the PICC line (peripherally inserted central catheter- a long and flexible catheter that is inserted through a vein in the upper arm) dressing every 5-7 days and as needed (PRN) per facility policy for one of 36 sampled residents (Resident 651). This deficient practice had the potential to result in Resident 651 to develop an infection on the PICC line insertion site. Findings: A review of Resident 651's admission Record indicated Resident 651 was admitted to the facility on [DATE] with diagnoses that included cellulitis (a deep infection of the skin caused by bacteria) of right lower limb, type 2 diabetes mellitus with other skin ulcer (a disease that occurs when the blood sugar is too high), and peripheral vascular disease (reduced blood flow to the limbs due to narrowing of the blood vessels). A review of Resident 651's Nursing admission Assessment, dated 5/16/2024, indicated Resident 651 was oriented to person, time,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 three sampled residents (Resident 221) who received dialysis (hemodialysis, is a process of filtering the blood of a person whose kidneys are not working normally) had a dialysis emergency kit (kit that contains emergency supplies that will be needed in case dialysis site got dislodged and/or is bleeding) at the bedside. This deficient practice had the potential for Resident 221 to receive a delay in intervention during accidental bleeding from the resident's dialysis site. Findings: A review of Resident 221's admission Record indicated Resident 221 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included metabolic encephalopathy (problem in the brain caused by a chemical imbalance in the blood), type 2 diabetes mellitus (a disease that occurs when the blood sugar is too high), and end stage renal disease (ESRD- a medical condition in which a resident's kidneys stop…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 complete a Medication Regimen Review (MRR, a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences associated with medication) for one (1) of five sampled residents (Resident 216). This deficient practice had the potential for Resident 216 to experience adverse drug reaction. Findings: A review of Resident 216 admission Record indicated resident was originally admitted on [DATE] and was readmitted on [DATE] with the following diagnoses of dementia (a condition characterized by memory loss and judgment) and schizophrenia (mental condition of a type involving a breakdown in the relation between thought, emotion, and behavior, leading to inappropriate actions and feelings). A review of Resident 216 History and Physical (H&P), dated 4/28/2024, indicated resident does not have the capacity to understand and make decisions. A review of Resident 216 Minimum Data Set (MDS,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow the tray card (a meal ticket with the resident's specific meal items and lists the resident's likes and dislikes and provides information about a resident for a specific meal) as written for one of four sampled residents (Resident 78). Resident 78's was served milk with the wrong milkfat (fatty portion of milk) percentage for lunch. This deficient practice had the potential to result in an elevated cholesterol (waxy substance found in the blood) level and placed Resident 78 at risk for complications from cardiovascular disease (a group of disorders of the heart and blood vessels) due to the excessive amount of milkfat in Resident 78's diet. Findings: A review of resident 78's admission Record indicated Resident 78 was admitted on [DATE] with diagnoses that included non-ST elevation myocardial infarction (partial blockage of one of the blood vessels that causes reduced flow of oxygen-rich blood to the heart muscle), type 2 diabetes…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 clinical records in accordance with accepted professional standards and practices for one of thirty- six sampled residents (Resident 18) by failing to accurately document Resident 18's wound intervention on the Interdisciplinary Team (IDT, a group of healthcare professionals who work together to help residents receive the care they need) Wound Meeting/Wound Report. This deficient practice had the potential to result in a lack of or a delay in communication between the facility staff and can interrupt provision of care/intervention to the resident. Findings: A review of Resident 18's admission Record indicated Resident 18 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included other abnormalities of gait and mobility (change to the walking pattern), age-related osteoporosis (a condition in which bones become weak and brittle) without current pathological fracture (a broken bone…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 prohibit and prevent retaliation (the act of hurting/ threatening and/ or harassing an individual due because they have reported an allegation of abuse or unlawful act) of Certified Nurse Assistant 1 (CNA 1) to one of two sampled residents (Resident 1) when CNA 1 went into the resident ' s room on 5/10/2024 and confronted Resident 1. This failure may result to psychosocial harm to Resident 1 such as experiencing fear (an unpleasant emotion or thought that you have when you are frightened or worried by something dangerous, painful, or bad that is happening) and/ or anxiety (a feeling of fear, dread, and uneasiness to get revenge). Findings: During a review of Resident 1 ' s admission record, it indicated Resident 1 was admitted on [DATE], with diagnoses of major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy), anxiety 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 observation, interview, and record review, the facility failed to provide a shower and/ or bed bath according to the pre-determined schedule for one of two (2) sampled residents (Resident 1) who required substantial/maximal (helper does more than half the effort, helper lifts or holds the trunk or limbs and provides more than half the effort) with activities of daily living (ADL, individual's self- care activities). This deficient practice resulted in Resident 1 not receiving a shower and/ or bed bath from 3/29/24 to 4/16/24 (18 days) and had the potential to negatively impact Resident 1's quality of life and self-esteem. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included fracture of shaft of right fibula (a break in the smaller of the two bones between the knee and the ankle, acute bronchitis (an inflammation of the airways that carry air to the lungs), and obesity (a disorder that involves having too much body…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 doctor was notified timely of a right femur [thigh bone] fracture (break in the bone) for one of three sampled residents (Resident 1). Resident 1 ' s medical doctor (MD) was made aware of the resident ' s abnormal Xray (an imaging study that takes pictures of bones and soft tissues) of the right leg result 18 hours from receipt of the Xray result, This failure had the delayed obtaining physician orders from the MD to treat and to provide necessary care for Resident 1 ' s femur fracture, which may lead to worsening of Resident 1 ' s femur fracture. Findings: A review of Resident 1 ' s admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included dementia (a condition characterized by progressive or persistent loss of intellectual functioning), muscle wasting (deterioration of muscle tissue) and atrophy (decrease in size), and epilepsy (a disorder in which nerve cell activity in the brain is…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Xray (an imaging study that takes pictures of bones and soft tissues) result for one of three sampled residents (Resident 1), was charted accurately in Resident 1 ' s medical chart. This failure had the potential to not only delay appropriate care and treatment for Resident 1 ' s fracture, but the potential to cause worsening of Resident 1 ' s femur (thigh bone) fracture (break in the bone). Findings: A review of Resident 1 ' s admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included dementia (a condition characterized by progressive or persistent loss of intellectual functioning), muscle wasting (deterioration of muscle tissue) and atrophy (decrease in size), and epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures). A review of Resident 1 ' s Minimum Data Set (MDS – a standardized resident assessment care screening tool) dated 1/9/2024, 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 provide supervision and a safe environment to prevent accidents for three of five sampled residents (Residents 1, 3, and 6) by: 1. Failed to prevent Resident 1 who has history of illegal substance (illegal drugs [drugs forbidden by law]) abuse from possessing crystal methamphetamine (a colorless and odorless drug that is powerful, highly addictive, and lets people stay awake and do continuous activity with less need for sleep) and offer party drugs (main types of party drugs are depressants, stimulants, and hallucinogens. Party drugs can make a user feel euphoric or 'high', but they can also be dangerous. The effect of a party drug depends on the individual, and the drug dose) to other residents while residing in the facility. 2. Prevent Resident 3 from possessing one bottle of alcoholic beverage while residing in the facility in accordance with the facility's policy. 3. Facility failed to ensure Resident 6' bed was locked on 4/18/2024 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 prevent physical abuse (willful infliction of injury which includes, but is not limited to, hitting, slapping, punching, biting, and kicking) for two (2) of 2 sampled residents (Resident 4 and 5) This failure resulted to Resident 4 striking Resident 5 on the chest and in return, Resident 5 pushed a chair towards Resident 4, which hit Resident 4's shin causing a skin tear (a traumatic wound that is caused by direct contact between the skin and another object) on 4/3/2024. Findings: A review of Resident 4's admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of anxiety (a disorder characterized by nervousness characterized by a state of excessive uneasiness and apprehension, typically with compulsive behavior or panic attacks), schizophrenia (a serious mental illness that affects how a resident thinks, feels, and behaves), and major depressive disorder (or also…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 oxygen therapy (treatment that provides supplemental, or extra oxygen) and necessary respiratory care services for one (1) of three (3) sampled residents (Resident 1) in accordance with the facility ' s policy and procedure. This deficient practice had the potential to place Resident 1 at risk for shortness of breath and/or hypoxia (low levels of oxygen in the body tissues) which could lead to irreversible damages of health and/or death. Findings: A review of Resident 1's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses which included but not limited to chronic congestive heart failure (also called heart failure) is a serious condition in which the heart doesn't pump blood as efficiently as it should, pleural effusion (also called water on the lung, happens when fluid builds up in the space between your lungs and chest cavity) and myocardial infarction (a heart attack which happens when…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Speech Therapy (ST, profession aimed in the prevention, assessment, and treatment of speech, language, communicative, and swallowing disorders) services to one of three sampled residents (Resident 1) who had swallowing and communication concerns. The facility failed to provide ST services when the facility discontinued Resident 1's ST services despite Resident 1 making progress in therapy and demonstrating skilled therapy (services that require specialized training and experience of a licensed therapist or therapy assistant) needs. This deficient practice prevented Resident 1 from receiving ST services to improve swallowing function, improve communication abilities, and maintain or achieve the highest practicable level of function. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 12/9/2023 and re-admitted Resident 1 on 12/18/2023 with diagnoses including…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to prevent sexual abuse (sexual behavior or a sexual act forced upon a woman, man, or child without their consent) for one (1) of four (4) sampled residents (Resident 2). This deficient practice resulted to Resident 1 went in Resident 2's room and squeezed Resident 2's breast. Findings: A review of Resident 1's admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses abnormal posture, bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), and abnormalities of gait and mobility. A review of Resident 1's History and Physical (H&P), dated 6/12/2023 indicated Resident 1 had no capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS- a standardized assessment and care planning tool) dated 12/11/2023, indicated Resident 1 had moderate cognitive impairment status (mental action or process of acquiring knowledge…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation interview and record review, the facility failed to ensure one (1) of four (4) sampled residents (Resident 1) had person centered care plan (taking a collaborative approach to assessing a person based on their needs, preferences, goals) to address resident's wandering a patient who goes beyond the view or control of staff without the intention of leaving the health care facility) behavior. This deficient practice resulted to Resident 1 went in Resident 2's room and squeezed Resident 2's breast. Findings: A review of Resident 1's admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses abnormal posture, bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), and abnormalities of gait and mobility. A review of Resident 1's History and Physical (H&P) dated 6/12/2023 indicated Resident 1 had no capacity to understand and make decisions. A review of Resident 1'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow a physician's order to monitor vital signs (clinical measurements specifically heart rate, temperature, respiration rate and blood pressure, that indicate the state of a patient's essential body functions) every four hours for Coronavirus (COVID; a viral disease that is highly contagious and spreads quickly) monitoring for one of two sampled residents (Resident 1). This failure resulted in not being able to monitor and provide treatment to the resident for possible decline or change of condition and can lead to resident's death. Findings: During a review of Resident 1's admission Record, admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of acute respiratory failure (when your lungs cannot release enough oxygen into your blood which prevents your organs from properly functioning and can also occur if your lungs cannot remove carbon dioxide from your blood) with hypoxia…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a comprehensive resident centered care plan (a formal process that correctly identifies existing needs and recognizes a resident's potential needs or risks to achieve healthcare outcomes) for one of three sampled residents (Resident 1) by not having fall mat (described as a cushioning pad designed with shock-absorbent properties to stay firm during normal transferring and walking activities but to soften under high impact to absorb the force of a patient falling)and call light (an alerting device for nurses or other nursing personnel to assist a patient when in need ) was out of the resident's reach. This deficient practice placed Resident 1 at risk for another incident of fall which can lead to serious injury and/ or fracture (complete or partial break of the bone, usually caused by a traumatic injury, such as a fall). Findings: A review of Resident 1's admission record indicated the facility admitted Resident 1 on 1/20/24 with diagnosis which include history of difficulty in walking, lack of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement, to attempt to reduce/remove underlying risk factors to prevent worsening of a pressure ulcer/injury (localized skin injury and underlying tissue) for four of four sampled residents (Resident 1, 2, 3 and 4) by failing to: 1. Put the correct setting on the Low Air Loss Mattress (LAL Mattress; an air mattress designed to prevent and treat pressure wounds) for Resident 1 and 2 2. Ensure the physician's order of utilizing a Low Air Loss Mattress was followed when Resident 3 was observed to be laying on top of a regular mattress on the floor 3. Reposition Resident 4 every two (2) hours in accordance with the resident's care plan. This deficient practice has the potential for the residents' pressure ulcer to worsen. Findings: 1. A review of Resident 1's admission Record, indicated Resident 1 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with the diagnosis of gout (a type of inflammatory arthritis that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure food was served at the residents' preferred temperature for three out of eight sampled residents (Resident 1, Resident 2, and Resident 3). This failure had the potential for resident's poor meal intake and possibly lead to weight loss. Findings: During a review of the admission record, it indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses included dysphagia (difficulty swallowing), diabetes mellitus (disease that affects body's ability to create insulin), and hyperlipidemia (high levels of cholesterol). During a review of Resident 1's History and Physical (H&P) dated 10/5/2022, it indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) ability was intact. During an interview on 1/3/2024 at 10:30 a.m., in Resident 1's room, Resident 1 stated the food was usually served cold. During a review of the admission record, it indicated Resident 2 was admitted 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 follow their policy and procedure on Abuse Prevention and Prohibition Program to investigate reports of injuries of unknown source timely for one (1) of two (2) sampled residents (Resident 1). This deficient practice had the potential to place Resident 1 for further injuries. Findings: A review of Resident 1 ' s admission Record indicated resident was admitted on [DATE] with diagnoses of muscle wasting and atrophy (body tissue waste away) to the left and right hand and Alzheimer ' s (a progressive disease that destroys memory and other important mental functions) disease. A review of Resident 1 ' s History and Physical (H&P), dated 9/20/2023, indicated Resident 1 does not have the capacity to understand and make decisions. A review of Resident 1 ' s Minimum Data Set (MDS, a standardized care screening and assessment tool), dated 12/7/23, indicated Resident 1 was severely impaired with cognitive (mental action or 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 report immediately, not later than two (2) hours of the allegation of injuries of unknown source to the State Survey Agency for (1) of 2 sampled residents (Resident 1), in accordance with the policy and procedure. This deficient practice had the potential to place Resident 1 at risk for further injuries. Findings: A review of Resident 1's admission Record indicated resident was admitted on [DATE] with diagnoses of muscle wasting and atrophy (body tissue waste away) to the left and right hand and Alzheimer's (a progressive disease that destroys memory and other important mental functions) disease. A review of Resident 1's History and Physical (H&P), dated 9/20/2023, indicated Resident 1 does not have the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS, a standardized care screening and assessment tool), dated 12/7/23, indicated Resident 1 was severely impaired with cognitive (mental action or process of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement the fall care plan for one (1) of two (2) sampled residents (Resident 1) in accordance with the facility policy. This deficient practice had the potential to result in repeated falls which could harm or cause injury to Resident 1. Findings: A review of Resident 1's admission Record indicated Resident 1 was originally admitted on [DATE] and was readmitted on [DATE] with the diagnosis of dementia (a group of thinking and social symptoms that interferes with daily functioning) and muscle weakness. A review of Resident 1's Minimum Data Set (MDS, standardized care screening and assessment tool), dated 11/24/2023, indicated Resident 1 was severely impaired with cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 1 required partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 safe and sanitary environment as indicated in the facility policy by: 1. Failing to ensure Certified Nursing Assistant (CNA 2) and Housekeeping (HKP) doffed (remove) personal protective equipment (PPE- gowns, N95 masks [respiratory protective device designed to achieve a very close facial fit and very efficient filtration or airborne particles], and face shield worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) before leaving Residents 1, 2, 3, and 4's (who were on droplet isolation [residents known or suspected to be infected with bacteria transmitted by respiratory droplets that are generated by residents who are coughing, sneezing, or talking]) shared room. 2. Failing to ensure CNA 2 correctly donned (put on) an N95 mask. This deficient practice had the potential to result in the spread of Influenza (a contagious respiratory illness that infect the nose, throat, and lungs) to residents…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure two (2) of three (3) sampled Residents (Resident 4 and Resident 5) received care with elimination/toileting in accordance with the facility's policy and procedure. This deficient practice resulted in Resident 4 and Resident 5's diapers left wet for an extended period which could potentially result in skin irritation and had the potential for residents' toileting capability to decline. Findings: 1. A review of Resident 4's admission Record indicated the resident was admitted to the facility on [DATE] with a diagnosis that included monoplegia (paralysis limited to a single limb) of lower limb following non traumatic subarachnoid hemorrhage (bleeding in the space surrounding the brain) and abnormalities in gait (a manner of walking or moving on foot) and mobility. A review of Resident 4's History and Physical (H&P), dated 4/23/23 and signed by the resident's attending physician, indicated Resident 4 has the capacity to understand and make…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medications were not left at the bedside for three (3) of six (6) sampled residents (Resident 1, 2, and 3) in accordance with the facility policy and procedure. This deficient practice had the potential for an inaccurate administration of medications for Resident 2 and Resident 3 as indicated on the physician's order and potential for other residents to access the unattended medications, which can cause possible harm to Resident 2, Resident 3, and and other residents if ingested. Findings: 1. During a review of Resident 1's admission Record, dated 11/15/2023, the admission Record indicated the resident was admitted on [DATE], with a diagnosis of cognitive (related to the mental process involved in knowing, learning, and understanding things) social or emotional deficit following cerebral infarction (impairment in an individual ' s mental processes following a disruption of blood flow to the brain due to problems with the 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 observation, interview, and record review, the facility failed to ensure one (1) of six (6) sampled residents (Resident 1) received medication according to the facility ' s policy and procedure (P&P). Resident 1 did not receive Famotidine (used to treat gastroesophageal reflux disease [GERD]) (Pepcid AC) 20 milligrams (mg, units of measurement) 1 tablet by mouth (PO) timely as indicated in the physician ' s order. This failure resulted in Resident 1 receiving her medication over an hour late, which had the potential to result in Resident 1 not receiving the full efficacy of the medication, which could affect resident ' s overall wellbeing. Findings: During a review of Resident 1 ' s admission Record, dated 11/15/2023 the admission Record indicated the resident was admitted on [DATE], with a diagnosis of cognitive (related to the mental process involved in knowing, learning, and understanding things) social or emotional deficit following cerebral infarction (impairment in an individual ' s 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 ensure one (1) of three (3) sampled residents (Resident 6) had a functioning call light in accordance with the facility's Policy and Procedure. This deficient practice had the potential for Resident 6 to not be able to call the facility staff for assistance, which could result to Resident 6's needs not being met. Findings: A review of Resident 6's admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Dementia (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems) and unspecified fracture of the right femur (broken right hip). A review of Resident 6's History and Physical (H&P), dated 3/26/23, indicated Resident 6 has the capacity to understand and make decisions. A review of Resident 6's Minimum Data Set (a standardized resident assessment care screening tool), dated 9/14/23, 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 interview and record review the facility failed to develop a resident- centered care plan (plan of care; a form where a residents health condition, specific care needs, and current treatment are summarized) for one of two sampled residents (Resident 1) to address resident's use of bed rails (mobility restraints and enablers in long term care facilities; can assist to facilitate movement) and the resident's behavior of pulling herself up and moving around in bed using the bed rails. This deficient practice had the potential to result in Resident 1 injuring self with the bed rail. Findings: A review of Resident 1's admission Record, indicated the resident was admitted on [DATE] with the following diagnosis of hemiplegia (loss of ability to move on one side of the body) and hemiparesis (muscle weakness) of the left side. A review of Resident 1's history and physical (H&P), dated 9/12/2023, indicated Resident 1 does not have the capacity to understand and make decision. A review of Resident 1's Minimum Data…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 prevent physical abuse (treating another person with violence, cruelty, hate, harm, or force) for one of three sampled residents (Resident 1) when Resident 2 struck Resident 1 on the head and punched the resident on the left eye after having a dispute with one another on 9/21/23. The facility also failed to prevent another possible abuse by Resident 2 when resident was observed going in and out of other resident ' s room on 10/6/23. These failures resulted to an actual abuse to Resident 1 leading to hospitalization and eight (8) inches with staples (used to close incisions or cuts) to the left side of head laceration with the potential for Resident 1 to feel powerless and unprotected by the facility. It also placed Resident 1 for further physical abuse and other residents in the facility by Resident 2. Findings: A review of Resident 1's admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Certified Nurse Assistant 1 (CNA1) did not tie a sheet around the neck of one of three sampled Residents (Resident 1) and obtain a consent to place Resident 1 in a geriatric chair (gerichair) . These failures resulted in Resident 1 having difficulty breathing and coughing which had the potential to result in strangulation, entrapment, and injury, and resulted in Resident 1 not being treated with respect and dignity. Findings: A review of Resident 1 ' s admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included seizures (sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain), dysphagia (difficulty swallowing), autistic disorder (developmental disability caused by differences in the brain), and schizoaffective disorder (a mental illness that can affect your thoughts, mood, and behavior). A review of Resident 1's Order…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 clinical records were complete, pertinent, and accurate for two (2) of six (6) sampled residents (Resident 4 and 7) in accordance with the facility's policy and procedure. This deficient practice placed Residents 4 and 7 at risk for not receiving appropriate care and interventions. It can also have the potential to result in incomplete assessment of the residents needs and could lead to a lack of or delay in delivery of necessary care or services to Resident 4 and 7. Findings: 1. During a review of the admission Record indicated Resident 4 was initially admitted on [DATE] and readmitted on [DATE] with diagnoses that included hypertrophic osteoarthropathy (a condition that affects the bones and joints), metabolic encephalopathy (brain dysfunction due to problems with metabolism), history of falling, and schizophrenia (a mental disorder that affects the way a person thinks, acts, expresses emotions, perceives reality, and relates to others).…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide supervision and interventions for one of five sampled resident (Resident 1) who is at risk for elopement (instance of running off secretly and when a resident who is not capable of protecting or caring for themselves leaves the facility without authorization). Resident 1 did not have care plan and interventions in place to address Resident 1's low risk for elopement from 8/7/23 to 9/3/23. The facility also failed to reassess Resident 1 for elopement risk though Resident 1 had verbalize wanting to leave the facility multiple times from 8/7/23 to 9/3/23. This failure resulted to Resident 1 was able to exit the facility and eloped on 09/03/23. This had the potential for Resident 1 to sustain an accidental injury, exposure to harsh environmental conditions including excessive heat and or cold, and medical complications including malnutrition (lack of proper nutrition), dehydration (body doesn't have enough water and other fluids 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 implement their policy and procedure to report an allegation of verbal abuse (harsh and insulting language or sounds directed at a person within hearing distance, regardless of age, ability to comprehend, or disability) to the State Agency, Ombudsman (an official appointed to investigate individuals' complaints against the facility), and local law enforcement within two hours for two of three sampled residents (Resident 17 and Resident 18). This failure occurred when a facility staff member witnessed both Residents 17 and 18 cursing (use of offensive or impolite language) at each other on 7/22/2023. This deficient practice had the potential to result in an unidentified abuse in the facility and resulted in another abuse allegation of Resident 18 running over Resident 17's left foot with the wheelchair (unknown date). Findings: A review of Resident 17's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses 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.