Torrance Care Center West, INC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure seven of seven sampled residents (Resident 25, Resident 29, Resident 41, Resident 58, Resident 59, Resident 96 and Resident 108) received their mail on Saturdays.This failure resulted in Resident 25, Resident 29, Resident 41, Resident 58, Resident 59, Resident 96 and Resident 108 rights violated to receive mail on Saturdays.Findings:1. During a review of Resident 25's admission Record (Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 25 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and homelessness.During a review of Resident 25'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 residents' advance directive forms (a legal document indicating resident preference on end-of-life treatment decisions) were executed by the resident or the resident's legally authorized representative ( is someone authorized to act on behalf of another person in legal matters), and medical records were updated to show documentation that advance directives were discussed and written information was provided to the residents and/or responsible parties for six of 10 residents (Resident 11, 12, 15, 22, 30, and 36).The facility failed to:1. Ensure facility's social worker did not sign residents' advance directive forms on behalf of the residents, even though documentation indicated each resident had a low Brief Interview for Mental Status ([BIMS]-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score and inability to provide informed consent (voluntary agreement to accept…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews and record review the facility failed to ensure staff were competent with facility policies and procedures by failing to:A. Ensure two of two licensed staff (Registered Nurse Supervisor 1 and Licensed Vocational Nurse 3) were able to verbalize the process for securing emergency medication kits (E-kits).B. Ensure annual performance evaluations (supervisor looks at how well staff are doing their job and gives feedback) were documented and completed for five of five facility staff as required by the facility policy and regulatory standards.This deficient practice had the potential to result in staff competency concerns going unrecognized, unmet training needs, and potential to result in delays during medical emergencies, unauthorized access, and loss of critical medications. Findings: A. During a concurrent observation and interview on 8/14/2025 at 10:07 a.m. with Registered Nurse Supervisor (RNS) 1 for intramuscular Emergency Kit (E-Kit) in Medication Storage 1 in building A, RNS 1 stated the E-Kit replacement process was to log the medications taken out on 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 ensure one of three sampled residents (Resident 168) with Post-Traumatic Stress Disorder (PTSD- a mental health condition that can develop after experiencing or witnessing a traumatic event) was referred to a psychologist (a trained mental health professional who helps people learn healthy ways to handle mental health challenges) per Resident 168 request and physician order. This deficient practice resulted in Resident 168 not receiving the proper assessment, necessary treatment, and resources for his diagnosis of PTSD. Findings: During a review of Resident 168's admission Record, the admission Record indicated Resident 168 was admitted to the facility on [DATE] with diagnoses including PTSD, major depressive disorder (a mood disorder that causes a persistent feeling and loss of interest), and anxiety (a common mental health condition characterized by excessive worry, fear, and unease). During a review of Resident 168's Minimum Data Set (MDS- a 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 Zyprexa (Olanzapine- medicine that treats mental disorders , including schizophrenia [a mental illness that is characterized by disturbances in thought] and bipolar disorder[sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs])10 milligrams (mgs.- unit of measurement) were not in the same plastic bag mixed with Zyprexa 5 mgs. and labeled for Zyprexa 5 mgs outside the plastic container for one of four sampled residents (Resident 148).This failure had the potential to place Resident 148 at risk for medication error.Findings:During a review of Resident 148's admission Records, the admission Records indicated Resident 148 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including unspecified psychosis(a severe mental condition in which thought, and emotions are so affected that contact is lost with reality),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 eight of eight residents (Resident 160, Resident 11, Resident 16, Resident 22, Resident 26, Resident 61, Resident 84, and Resident 92) opened medication bottles were labeled with the date opened.This failure had the potential to result in the use of medications beyond their recommended stability period, reducing their efficacy, and compromising resident safety through the administration of expired and contaminated medications. Findings:During a concurrent observation and interview on [DATE] at 10:54 a.m. with Licensed Vocational Nurse (LVN) 2, for morning (AM) medication cart located in building B, the following were inside the cart without opened dates:1. Valproic Acid (medication used to treat seizures, manic episodes associated with bipolar disorder, and to prevent migraine headaches) for Resident 11, 2. Constulose (used to treat chronic constipation) for Resident 61, 3. Constulose for Resident 84, 4. Megestrol (medication used…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an open date was placed on an open gallon of milk and an open bag of potato chips. 2.Ensure a bin of celery and multiple bags of hotdog buns were not expired.3.Ensure that chicken was defrosted safely, when the chicken was left in a tub of standing water while defrosting in the sink. 4.Ensure the sanitation bucket had sanitizer solution in it.These failures had the potential to expose residents to food-borne illnesses (any illness resulting from ingestion of food contaminated with bacteria, viruses, or parasites) and put residents at risk for cross contamination (unintentional transfer of harmful bacteria from one object to another).Findings:During a concurrent observation and interview on 8/11/2025 at 8:15 a.m. with the Dietary Aide 2 (DA2) in the kitchen, a gallon of milk and a bag of potato chips did not have an open date label. A bin of celery with an expiration date of 8/10/2025 and multiple bags of hotdog buns dated 7/1/2025, 7/9/2025 and 8/3/2025 were observed. Observed two tubs of chicken…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 arbitration (a form of dispute resolution where a neutral third party helps resolve a dispute between two or more parties) agreements were accurately completed for three of three sampled residents (Resident 29, 68, and 72). The facility failed to:1.Assess mental capacity (ability to make decisions) and provide information to Residents 29, 68, and 72 before signing the arbitration agreement. 2.Ensure the arbitration agreement forms are fully completed.This failure had the potential to result in Resident's 29, 68, and 72 not fully understanding his/her right to limit the opportunity to initiate judicial proceedings that challenge unfavorable decisions. Findings:During a review of Resident 29's admission Record, the admission Record indicated Resident 29 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including hypertension (HTN- high blood pressure) and chronic obstructive pulmonary disease (COPD- a…

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

Based on interview and record review, the facility's Quality Assessment and Assurance Committee (QAA- develop and implement appropriate plans of action to correct identified quality deficiencies) failed to ensure effective oversight of the facility and implementation of the facility's plan of correction (POC) of the deficient practices identified during the previous recertification survey. This failure resulted in the facility having repeat deficiencies in the areas of resident rights, advance directives, Medicare coverage notification, notice of transfer requirements, accuracy of assessments, implementing care plans, social services, pharmacy services, medication storage, and infection control and prevention. Findings:During a review of the facility's Statement of Deficiencies for the 2024 Recertification survey indicated the following repeat deficiencies: resident rights, advance directives, Medicare coverage notification, notice of transfer requirements, accuracy of assessments, implementing care plans, social services, pharmacy services, medication storage, and infection control…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 for two of five sampled residents ( Resident 77 and 98) The facility failed to:1.Ensure Licensed Vocational Nurse (LVN 2) disinfected the medication tray used on Resident 77 before using the tray on another resident during medication pass.2.Ensure soiled gown of Resident 98 was handled and disposed in a sanitary manner.3. Ensure one of one resident (Resident 141) was not allowed to obtain clean linen from the laundry cart.These failures had the potential for cross contamination (transfer of harmful substances, like bacteria from one source to another) and spread of infection to the residents and staff.Findings: 1.During a review of Resident 77’s admission Records, the admission Records indicated Resident 77 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including paranoid schizophrenia (mental health condition where a person experiences intense…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 at least 80 square feet ({sq. ft} unit of measurement) per resident in multiple resident bedrooms for 20 out of 78 resident rooms. This deficient practice has the potential to result in an inadequate provision of safe nursing care and privacy for the residents. Findings:During a facility tour on 8/11/2025 at 10:08 a.m., observed that rooms 17, 18, 19, 20, 21, 23, 24, 25, 27, 29, 30, 31, 32, 33, 34, 35, 37, 38, 39, and 40, residents were able to move in and out of their rooms, and there was space for the beds, side tables, and resident care equipment. During an interview on 8/14/2025 at 2:30 p.m., with the Administrator (ADM), the ADM confirmed they had rooms less than the required 80 sq. ft per resident.During a review of the facility's request for a waiver of room size letter dated 7/24/2025, submitted by the ADM for 20 resident rooms was reviewed. The waiver request letter indicated there was adequate space for residents to get in and out of wheelchairs and residents have sufficient freedom for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the call light (a vital communication tool, ensuring residents can easily alert nurses or other caregivers when they need help) was in reach and not observed on the floor for one of residents (Resident 90). This deficient practice had the potential to compromise Resident 90's ability to request staff assistance, placed the resident at risk for unmet needs, and deny Resident 90 the right to a dignified environment which could affect their health, safety, and quality of life.Findings:During a review of Resident 90's admission Record (a document containing demographic and diagnostic information) , the admission Record indicated Resident 90 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss 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 assess mental capacity(ability to understand information and make decisions) accurately on one of four sampled residents(Resident 22) when the resident was provided an informed consent(voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered)for a psychotropic medication(any drug that affects brain activities associated with mental processes and behavior).This failure had the potential to violate Resident 22's right to be informed.Findings:During a review of Resident 22's admission Record, the admission Record indicated Resident 22 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including unspecified dementia (a progressive state of decline in mental abilities),unspecified psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) and unspecified 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 observation, interview, and record review the facility failed to ensure reasonable accommodation of needs for one of one resident (Resident 90) when staff did not make the residents' pictogram communication board (involves using simple pictures or symbols to convey important information to residents, especially those with language barriers) accessible. This deficient practice had the potential to impede Resident 90's ability to express her needs, make choices, and participate in care decisions, thereby affecting her dignity and quality of life. Findings: During a review of Resident 90's admission Record (a document containing demographic and diagnostic information), the admission Record indicated Resident 90 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss 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 residents (Resident 182) was appropriately notified regarding the changes in their Medicare coverage through provision of Notice of Medicare Non-Coverage (NOMNC) ( a form that healthcare providers must give to Medicare beneficiaries to inform them that Medicare is expected to stop covering a specific service or item) form. This deficient practice had the potential to result in the responsible parties not being able to exercise their right to file an appeal.Findings:During a review of Resident 182's admission Record, the admission Record indicated Resident 182 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) and hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body). During a review of Resident 182'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 complete the required documentation for a transfer/discharge and assist resident with discharge planning for two of three sampled residents (Resident 51 and Resident 9) by failing to:1.Ensure a written copy of the bed hold notice was created and provided to Resident 51.2.Ensure the Notice of Proposed Transfer and Discharge was provided to the Ombudsman at the time of transfer to the General Acute Care Hospital (GACH) for Resident 51. This deficient practice resulted in the incomplete status of Resident 51's bed hold availability and had the potential to deny Resident 51's protection from being inappropriately discharged .3. Assist Resident 9 to look for placement back into the community.Findings: 1.During a review of Resident 51’s admission Record, the admission Record indicated Resident 51 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including diabetes mellitus (DM- a disorder characterized by difficulty in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure two of two sampled residents (Resident 36 and 182) had:1.Implemented intervention of padded siderails for Resident 36 who had a seizure disorder 2.Developed a care plan for Resident 182 who had a sacrococcyx (tailbone) wound.These failures had the potential to not having appropriate interventions and for injury to the residents. Findings: 1.During a review of Resident 36’s admission Record, the admission Record indicated Resident 36 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including paranoid schizophrenia (mental health condition), epilepsy (seizures- a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 36’s Minimum Data Set (MDS-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.

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 148) did not receive medication without physician's order.This failure resulted in a medication error and had the potential to place Resident 148 for an adverse reaction(an undesirable or harmful effect from a drug or treatment).Findings:During a review of Resident 148's admission Records, the admission Records indicated Resident 148 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD-- group of lung disease that block the airflow which can cause difficulty of breathing), epilepsy( sudden burst of electrical activity in the brain causing change in behavior, movements, feelings and levels of consciousness), hypothyroidism (condition where the thyroid does not produce enough thyroid hormones to meet the body's needs), and schizoaffective disorder (a mental illness that can affect thoughts, mood, 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 and interview, the facility failed to ensure two of three sampled residents (Resident 125 and Resident 3) who were dependent on activities of daily living (ADLS- activities such as bathing, dressing, and toileting a person performs daily) received the necessary care and services to maintain good grooming and personal hygiene by failing to:1.Ensure Resident 125 was provided with oral care. 2.Ensure Resident 3's long and dirty fingernails were trimmed. These failures had the potential to result in Resident 125 and Resident 3 feeling neglected and not thoroughly groomed which could lead to skin breakdown, infection and teeth/gum issues.Findings: 1.During a review of Resident 125’s admission Record, the admission Record indicated Resident 125 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including cerebral infarction (lack of adequate blood supply to the brain), dementia (a progressive state of decline in mental abilities), and aphasia (a disorder 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 one of one sampled residents ( Resident 152) 152 was provided with reading glasses when his eyeglasses broke.This failure had the potential to negatively affect Resident 152's quality of care and his safety at risk.Findings: During a review of Resident 152's admission Record, the admission Record indicated Resident 152 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including heart failure (heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen), chronic kidney disease (a long-term condition where the kidneys are damaged and cannot filter blood effectively) and anxiety (emotion characterized by feelings of tension, worried thoughts ).During a review of Resident 152's History & Physical (H&P) dated 8/01/2025, the H&P indicated Resident 152 was a poor historian with cognitive (ability to think, understand, learn, and remember) impairment. 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 oxygen tubing start date or change date was labeled for one of one resident (Resident 182) who required intermittent oxygen.This failure had the potential for respiratory infections. Findings: During a review of Resident 182's admission Record, the admission Record indicated the facility admitted the resident on 4/9/2025 and was readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing), diabetes mellitus type II (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing) and hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body).During a review of Resident 182's Minimum Data Set (MDS- resident screening tool) dated 4/26/2025 indicated the resident has severely impaired cognition (ability to think and understand) and required substantial/maximal assistance from staff for rolling left 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 facility staff provided care to residents with Post-Traumatic Stress Disorder (PTSD- a mental health condition that can develop after experiencing or witnessing a traumatic event) for two of two sampled residents (Resident 168 and 17). The facility failed to:1.Ensure Resident 168 and 17 were assessed, monitored, and provided interventions to help with Resident 168 and Resident 17 triggers. 2.Ensure facility staff who provided care to residents were aware of Resident 168 and Resident 17's diagnoses of PTSD and what triggers to monitor for. 3.Social Services Director (SSD) 1 failed to demonstrate competency on how to assess, document, and identify PTSD and triggers upon admission to the facility. These deficient practices resulted in a lack of interventions to address Resident 168 and Resident 17 PTSD triggers Findings: 1.During a review of Resident 168’s admission Record, the admission Record indicated Resident 168 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 observation, interview, and record review, the facility failed to provide medically related social services to meet residents' needs for two of four sampled residents (Resident 3 and Resident 97) needing dental services by failing to:1.Follow up Resident 3's dental recommendation for teeth extraction.2.Follow up Resident 97's dental recommendation for dentures.This failure had the potential to put Resident 3 and Resident 97 at risk for delayed treatment and care which could lead to weight loss. Findings:1.During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including cerebrovascular disease (damage to the brain from interruption of its blood supply), hemiplegia on right dominant side (paralysis of the right side of the body), schizoaffective disorder(a mental illness that can affect thoughts, mood, and behavior), absence of right leg above knee, and major depressive disorder(a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: 1.Ensure the facility's activities of daily living tasks (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) binder containing residents' information was left unattended and open at the bedside table near a resident room.2.Ensure telephone orders were transcribed accurately a physician's wound treatment order for one of one resident (Resident 182).These failures had the potential to have unauthorized access to medical records and inaccurate wound treatment. Findings: 1.During an observation on 8/11/2025, at 1:21 p.m., Certified Nursing Assistant (CNA 6) documented on a binder located at the bedside table in front of a resident’s room. Certified Nursing Assistant (CNA 6) left the binder open and unattended when CNA 6 helped another resident. During an interview on 8/11/2025, at 1:28 p.m. with CNA 6, CNA 6 stated she was documenting the ADL tasks of residents 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 ensure licensed vocational nurses (LVNs) were competent during medication administration when, two out of five sampled residents (Resident 1 and Resident 2) received blood pressure lowering medications that did not meet physician ' s parameters (specific instructions). This deficient practice had the potential for Resident 1 and Resident 2 to become hypotensive (low blood pressure, a sudden drop in blood pressure can cause symptoms like dizziness or fainting and can indicate that vital organs aren't getting enough blood flow.) Findings: a. During a review of Resident 2 ' s admission Record, the admission Record indicated Resident 2 was admitted to the facility 9/10/2019 with diagnoses of hypertension (HTN, high blood pressure) and dementia (a general term for a group of neurological conditions that cause a decline in mental abilities that affects daily life). During a review of Resident 2 ' s care plan initiated 9/18/2024, the care plan 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 ensure two out of five sampled residents (Resident 1 and Resident 2) was free from a significant medication error by failing to follow the physician ' s ordered parameters (specific instructions) when administering blood pressure lowering medications. This deficient practice had the potential for Resident 1 and Resident 2 to become hypotensive (low blood pressure, a sudden drop in blood pressure can cause symptoms like dizziness or fainting and can indicate that vital organs aren't getting enough blood flow.). Findings: a. During a review of Resident 2 ' s admission Record, the admission Record indicated Resident 2 was admitted to the facility 9/10/2019 with diagnoses of hypertension (HTN, high blood pressure) and dementia (a general term for a group of neurological conditions that cause a decline in mental abilities that affects daily life). During a review of Resident 2 ' s care plan initiated 9/18/2024, the care plan indicated Resident 2 was high…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident who was assessed as a high risk for falls and required assistance from staff during transfers, was provided with safe and appropriate transfer assistance to avoid a fall for one of three sampled residents (Resident 1). The facility failed to: 1. Ensure Certified Nurse Assistant (CNA) 1 utilized a gait belt ([transfer belt] a device placed on a resident who has mobility issues to aid in safe movement for the resident) upon transferring Resident 1. 2. Ensure Resident 1 ' s Care Plan included specific interventions indicating the requirement for two-person assistance when transferring Resident 1, in compliance with the facility ' s procedure Transfer from a Bed to a Wheelchair. These deficient practices resulted in Resident 1 falling to the ground on 8/30/2024 which had the potential to cause Resident 1 serious physical and psychosocial harm. Findings: During a review of Resident 1 ' s admission Record (Face Sheet), the Face Sheet…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY During an interview and record review the facility failed to ensure grievance was investigated and resolved promptly for one of one sampled resident (Resident 2). This deficient practice had the potential for Resident 1 concerns unresolved. Findings: During a review of Resident 2's admission Order, the admission Record indicated Resident 2 was admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses including anxiety disorder (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness), nicotine dependence (a chronic condition that occurs when someone compulsively craves nicotine[ a substance found in tobacco products]), and mood affective disorder (a mental condition that causes significant changes in a person emotions). During a review of Resident 2's Minimum Data Sheet (MDS- a standardized assessment and care screening tool) dated 08/06/2024 indicated Resident 2 had no cognitive impairment (ability to learn, understand, and make decisions) and requires…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 an individualized care plan with measurable objectives, timeframes, and interventions for one of three sampled residents This failure had the potential to place Resident 4 at increased risk for further falls and for injury from a fall. Findings During a review of the admission Record, the admission Record indicated Resident 4 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including epilepsy (seizures), extrapyramidal and movement disorder (involuntary movements that you cannot control), and schizoaffective disorder (a mental illness that can affect your thoughts, mood, and behavior). During a review of the Minimum Data Set (MDS- a comprehensive assessment and care screening tool) dated 6/20/2024, indicated Resident 4 requires supervision with bathing, picking up objects, and walking 150 feet. During a review of Resident 4 ' s Care Plan titled for At Risk for Falls. initiated on…

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

Based on interview and record review, the facility failed to employ a Social Worker on a full-time basis that met the qualifications specified in the regulation. This deficient practice had the potential for 175 out of 175 residents residing in the facility to not be assisted and receive medically related necessary care and behavioral health services to attain their highest practicable well-being. Findings: During an interview on 7/24/2024 at 10:48 a.m. with the Social Service Director (SSD), the SSD stated facility was licensed for 195 residents and need a full time Social Worker to be employed to meet the needs of all residents and if there were concerns and issues that need attention. The SSD stated she does not have a set schedule to work as a Director of the Social Service department since she work also as a Certified Nurse Assistant (CNA). The SSD stated she has 2 assistant that works in the Social Service Department, but they were not qualified to become a director. The SSD could not provide any evidence that she worked as a full time Director of the Social Service…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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's Quality Assessment and Assurance ([QAA] develop and implement appropriate plans of action to correct identified qualify deficiencies) and Quality Assurance Performance Improvement ([QAPI] takes a systematic, interdisciplinary, comprehensive, and data-driven approach to maintaining and improving safety and quality in nursing homes while involving residents and families, and all nursing home caregivers in practical and creative problem solving) committee failed to: 1.Employ a qualified social worker on a full-time basis that meet the qualifications specified in the regulation. This deficient practice had the potential for 175 out of 175 residents residing in the facility to not be assisted and receive medically related necessary care and behavioral health services to attain their highest practicable well-being. 2.Provide supervision for residents who was identified as unsafe smokers and evaluate the provisions of care and develop a policy and procedure for routinely checking cigarettes and lighter. This deficient practice had the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure one out of six Residents (Resident 12) was treated with dignity by having Resident 12 walk around the facility without proper shoes. This deficient practice of Resident 12 not wearing shoes had the potential for Resident 12 to experience loss of dignity and self-esteem. Findings: During a review of Resident 12's admission Record (Face Sheet), the Face Sheet indicated Resident 12 was initially admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 12's diagnoses included schizoaffective disorder (mental health disorder condition that is marked with a mix of hallucinations, delusions, and mood disorder), bipolar disorder (mental illness that causes unusual shifts in mood), and chronic kidney disease (long-term kidneys are damaged and can't filter blood the way they should). During a review of Resident 12's History and Physical (H&P), dated 4/3/2024, the H&P indicated Resident 12 had fluctuating 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 complete the Physician Orders for Life-Sustaining Treatment ([POLST] patients treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency) form was completed for one out six residents (Resident 125) This deficient practice of not having the POLST completed had the potential for Resident 125's wishes not to be carried out in the time of distress. Findings: During a review of Resident 125's admission Record (Face Sheet), the Face Sheet indicated Resident 125 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 125's diagnoses included major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), neuralgia (a sharp, shocking pain that follows the path of a nerve and due to irritation or damage to the nerve), and pancreatitis (the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three sampled resident (Resident 237) was appropriately notified regarding the changes in their Medicare coverage through provision of Notice of Medicare Non-Coverage (NOMNC) form. This deficient practice had the potential to result in the responsible parties not being able to exercise their right to file an appeal. Findings: During a review of Resident 237's Face Sheet (admission Record), indicated the facility originally admitted Resident 237 to the facility on 9/16/2022 and was readmitted on [DATE] with diagnoses including paranoid schizophrenia (a type of psychosis that affects a person's thoughts and behavior), unspecified glaucoma (group of eye conditions that can cause blindness), and dysphagia (difficulty of swallowing). During a review of Resident 237's Minimum Data Set ([MDS] resident assessment and care screening tool), dated 6/19/2024, indicated Resident 237's cognitive (the ability to think and process information) skills for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement behavioral modification and dementia care techniques prior to notifying the physician (MD) for one of three sampled residents (Resident 186). This failure had the potential to result in Resident 186's being inappropriately assessed and transferred to the GACH. Findings: During a review of Resident 186's admission Record (Face Sheet), the admission Record indicated Resident 186 was initially admitted to the facility on [DATE], and was readmitted to the facility on [DATE], with diagnoses including but not limited to Type 2 diabetes mellitus with hyperglycemia (high blood sugar), hypothyroidism (low thyroid hormones), and hypertensive heart disease without heart failure. During a review of Resident 186's MDS dated [DATE], the MDS indicated Resident 186's cognition was intact (resident has the capacity to understand and make decisions). During an interview with Certified Nursing Assistant (CNA) 3 on 7/26/24 at 10:42 a.m., CNA 3 stated 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 interview and record review, the facility failed to ensure the Notice of Proposed Transfer/Discharge form was completed and sent to the Office of the State Long-Term Ombudsman (public advocate for residents in long-term care facilities) for one of one sampled residents (Resident 186) who was transferred to the general acute care hospital (GACH). This failure had the potential to result in Resident 186 being denied additional protection from being inappropriately discharged and access to an advocate who could inform them of their options and rights. Findings: During a review of Resident 186's admission Record (Face Sheet), the admission Record indicated Resident 186 was initially admitted to the facility on [DATE], and was readmitted to the facility on [DATE], with diagnoses including but not limited to Type 2 diabetes mellitus with hyperglycemia (high blood sugar), hypothyroidism (low thyroid hormones), and hypertensive heart disease without heart failure. During a review of Resident 186's MDS 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 interview and record review, the facility failed to ensure one of three closed record sampled residents' (Resident 186) discharge status on the Minimum Data Set ([MDS], a resident care and screening assessment tool) was encoded correctly. This deficient practice resulted in incorrect data transmitted to Centers for Medicare and Medicaid Services (CMS) and had the potential to affect continuity of care. Findings: During a review of Resident 186's admission Record (Face Sheet), the admission Record indicated Resident 186 was initially admitted to the facility on [DATE], and was readmitted to the facility on [DATE], with diagnoses including but not limited to Type 2 diabetes mellitus with hyperglycemia (high blood sugar), hypothyroidism (low thyroid hormones), and hypertensive heart disease without heart failure. During a review of Resident 186's MDS dated [DATE], the MDS indicated Resident 186's cognition was intact (resident has the capacity to understand and make decisions). The MDS section A 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 ensure one out six sampled residents (Resident 126) had a complete dental assessment upon admission. This deficient practice of not completing the dental assessment had the potential of Resident 126 to not receive good and services. Findings: During a review of Resident 126's admission Record (Face Sheet), the Face Sheet indicated Resident 126 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 126's diagnoses included major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), schizoaffective disorder (mental health disorder condition that is marked with a mix of hallucinations, delusions, and mood disorder), oropharyngeal dysphagia (swallowing problems occurring in the mouth and the throat). During a review of Resident 126's History and Physical (H&P), dated 7/1/2024, the H&P indicated,…

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

Based on interview and record review, the facility failed to complete and transmit one of three residents (Resident 132) Preadmission Screening and Resident Review ([PASARR] an evaluation that determines whether an individual has mental illness and selects the appropriate services for the individual) Level II. This failure had the potential to result in Resident 132 not receiving specialized services for mental illness. Findings: During a concurrent interview and record review on 7/25/2024 at 3:40 p.m. with Registered Nurse (RN) 1, Resident 132's Preadmission Screening and Resident Review (PASARR) Level I Screening, dated 5/1/2024 was reviewed. Resident 132's PASARR Level I Screening indicated the need for a PASARR Level II Screening due to Resident 132's suspected mental illness. RN 1 stated that the PASARR Level II Screening was not completed. RN 1 stated that the PASARR Level II Screening was required for Resident 132 but was not performed. During an interview on 7/26/2024 at 12:40 p.m. with the Director of Nursing (DON), the DON stated if a PASARR Level II Screening 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 develop and implement an individualized care plan with measurable objectives, timeframes, and interventions for three out of 36 sampled residents (Resident 61, 6 and 139). a. For Resident 61 with bilateral bed rails (a rail attached to the side of the bed to prevent someone from falling out of the bed or to help in movement). b. For Resident 6 who was a smoker. c. For Resident 139 who refused dental services. These failures had the potential to negatively affect the delivery of necessary care and services for Resident 61,6 and 139. Findings: a.During a concurrent observation and interview on 7/24/2024 at 1:22 p.m., in Resident 61's room, observed Resident 61 had bilateral bed rails up. Resident 61 stated he liked to have the bed rails because he can use it to prop his arm or move a little in bed. During a review of Resident 61's admission Record (Face Sheet), the admission Record indicated Resident 61 was readmitted to the facility on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure one out of six Residents (Resident 12) had a revised care plan for not wearing shoes to prevent falls. This deficient practice of not revising a care plan for not wearing shoes with Resident 12 place the Resident 12 at risk falls. Findings: During a review of Resident 12's admission Record (Face Sheet), the Face Sheet indicated Resident 12 was initially admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 12's diagnoses included schizoaffective disorder (mental health disorder condition that is marked with a mix of hallucinations, delusions, and mood disorder), bipolar disorder (mental illness that causes unusual shifts in mood), and chronic kidney disease (long-term kidneys are damaged and can't filter blood the way they should). During a review of Resident 12's History and Physical (H&P), dated 4/3/2024, the H&P indicated Resident 12 has fluctuating capacity to understand and make decisions. 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 resident urinary output (amount of urine and fluid a person excrete) was monitored for one of two sampled residents (Resident 31) who had an indwelling foley catheter (a flexible plastic tube inserted into the bladder to provide continuous urinary drainage) as indicated in the plan of care and physician's order. This deficient practice had the potential to result in urinary retention (inability to urinate) and delayed identification of urinary tract infection ([UTI] an infection that can occur in any part of the urinary system, kidneys, bladder, ureter, or urethra). Findings: During a review of Resident 31's Face Sheet (admission Record), the Face Sheet indicated Resident 31 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including obstructive uropathy (a urinary tract disorder that occurs when urine flow is blocked), benign prostatic hyperplasia (a condition in which the prostate gland becomes very enlarged…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 appropriate use of bed rails (are adjustable metal or rigid plastic bars that attach to the bed) for one of 36 sampled residents (Resident 61), as indicated in the facility's policy and procedure by failing to: 1.Complete a siderail assessment per facility's policy and procedure. 2.Ensure Resident 61 had a physician order for the use of bed rails. 3.Ensure Resident 61 had a signed consent for the use of bilateral siderails. 4.Implement a care plan for the use of bedrails. These deficient practices had the potential to physical harm from possible entrapment (when a person is trapped by the bed rail in a position they cannot move from) from the use of bed rails for Resident 61. Findings: During a concurrent observation and interview on 7/24/2024 at 1:22 p.m., in Resident 61's room, Resident 61 had bilateral bed rails up. Resident 61 stated he liked to have the bed rails because he can use it to prop his arm or move a little in bed.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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, the facility failed to ensure a follow up appointment for a cataract (a medical condition in which the lens of the eye becomes cloudy) evaluation/referral was completed for one of 6 sampled residents (Resident 106). This deficient practice had the potential to result in the delay of necessary care and services for Resident 106. Findings: During a review of Resident 106's face sheet (admission record), the face sheet indicated Resident 106 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included congestive heart failure (a long-term condition in which your heart can't pump blood well enough to meet your body's needs), hepatic encephalopathy (the loss of brain function when a damaged liver doesn't remove toxins from the blood), schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), and type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it 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.

Based on observation, interview, and record review, the facility failed to ensure a Controlled Drug Record form (a log containing the date, time, quantity, and nurse's signature each time a dose is administered) was completed accurately. This deficient practice increased the risk of loss or diversion of controlled medications (a drug or other substances that is tightly controlled by the government because it may me abused or cause addiction and may cause significant risk to patient safety). Findings: During a concurrent observation and interview on 7/25/2024 at 7:45 a.m., with the Director of Nursing (DON) in her office, controlled medication area inspection was conducted. The DON produced four Controlled Drug Record forms that were given to her by licensed nursing staff for drug destruction. The four Controlled Drug Record forms did not indicate the signature of nurse receiving the medication, the date it was received, and the number of doses received. The DON stated she did not validate the accuracy of the number of medications she received against the quantity of the medications…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 remove one packet of expired norethindrone (medication for birth control) for Resident 168 from the medication cart. This deficient practice had the potential to result in the use of ineffective medication for Resident 168. Findings: During a concurrent observation and interview on 7/25/2024 at 2:17 p.m. with Licensed Vocational Nurse (LVN) 5, medication cart for the 7 a.m. to 3 p.m. and 3 p.m.-11p.m. shift was checked. LVN 5 stated the packet of Micronor (generic name, norethindrone, a medication to prevent pregnancy) for Resident 168 was expired with an expiration date of 05/2024. LVN 5 stated it was important to not give expired medications to the residents because the medication may not be as effective and will not have the intended effect. During a review of Resident 168's admission Record, the admission Record indicated Resident 168 was readmitted to the facility on [DATE] with diagnoses including sexual dysfunction (difficulty…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 dental services were obtained for one of 6 sample residents (Resident 169). This deficient practice had the potential to result in Resident 169's inability to chew foods and potentially result in weight loss, lack of energy and loss of muscle mass. Findings: During a review of Resident 169's face sheet (admission record), the face sheet indicated Resident 169 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), adult failure to thrive (a syndrome of weight loss, decreased appetite and poor nutrition, and inactivity) and moderate protein-calorie malnutrition (a state of nutrition in which a deficiency or imbalance of energy, protein, and other nutrients causes measurable adverse effects on tissue/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 observation, interview, and record review, the facility failed to maintain and observe infection control practices by failing to: a. Practice hand hygiene. b. Disinfect residents smoking aprons after each use. These deficient practices had the potential to result in cross contamination (physical movement or transfer of harmful bacteria from one person, object, or place to another) and place residents at risk for the spread of infection. Findings: a. During an observation on 7/23/2024 at 10:30 a.m. in Building B at nursing station B there was a sink for hand washing. Certified Nursing Assistant (CNA) 2 wiped up a wet substance from the floor next to nursing station B, threw away the paper towel, and failed to wash her hands. CNA 2 preceded to assigned area near Station A and sat in a chair near room [ROOM NUMBER] without washing her hands. During an interview on 7/23/2024 at 11:00 a.m. with CNA 2, CNA 2 stated, she failed to wash her hands after she picked up the wet substance off the floor. CNA 2 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 interview and record review, the facility failed to report one of four sampled resident ' s (Resident 1) allegation of sexual abuse to the California Department of Health (CDPH) and State Long Term Care Ombudsman (an agency that assist residents in long-term care facilities with issues related to day-to-day care, health, safety, and personal preferences) within the regulated time frame of two hours. This deficient practice resulted in CDPH's inability to investigation the allegation of sexual abuse timely and had the potential for other allegations of abuse to go unreported. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), major depressive disorder ([MDD] a mental health condition that causes a persistently low or depressed mood and a loss of interest in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to investigate an allegation of abuse and provide the five-day conclusion to their investigation to the California Department of Health (CDPH) after one of four sampled resident's (Resident 1) made an allegation of sexual abuse. This deficient practice resulted in the inability of the facility to determine if Resident 1's allegation of sexual abuse was true, had the potential for other allegations of abuse to not be investigated and failure to protect residents from abuse. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), major depressive disorder ([MDD] a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy), and schizoaffective…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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's Quality Assessment and Assurance (QAA) committee failed to identify quality deficiencies with allegations of abuse and care plans. This deficient practice resulted in the facility not developing and implementing appropriate plans of action to correct identified quality deficiencies, measuring its success, and tracking performance to ensure improvements are realized and sustained. Findings: A review of the facility's Quality Assurance and Performance Improvement (QAPI) plan indicated the facility did not incorporate allegations of abuse and care plans as needed improvement projects; included were infection control and reduction of hospital readmission rate. During a concurrent interview and record review, on November 22, 2021 at 2:33 p.m., with the Administrator (ADM), the ADM stated the facility's QAA committee meets quarterly in which they incorporate weekly meetings with the department heads to have a better idea of what is going on in the facility and to discuss issues and projects. The ADM stated the facility has several QAPI…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 nursing staff complied with infection prevention and control protocols to provide a safe, sanitary environment to help prevent the development and transmissions of communicable diseases and infections. This deficient practice had the potential to result in the transmission of communicable diseases and infections among residents and staff. Findings: During a concurrent observation and interview, on November 16, 2021, at 12:37 p.m., in front of Nursing Station A, Licensed Vocational Nurse (LVN) 1 was observed eating candy at the medication cart. LVN 1 stated she is not supposed to eat at the medication cart because it is not appropriate, but was unable to elaborate why this was inappropriate. LVN 1 stated she is supposed to eat in a designated area to prevent the spread of infection. During an interview, on November 19, 2021, at 11:43 a.m., with the Infection Prevention Nurse (IPN), the IPN stated it is not okay for staff to eat at the medication carts because of infection control. The IPN further 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 five out of five (5) sampled residents (Residents 86, 158, 149, 470, and 147) received treatment and care in accordance with professional standards of practice to meet the resident's physical, mental, and psychological needs as evidenced by: 1. For Resident 86, there was no care plan to reflect the resident's behaviors of being aggressive during feeding assistance, nor did resident receive the correct diet type as ordered by the physician; 2. For Resident 158, who reported abdominal pain, there was no assessment, monitoring, care planning, or notification of the physician or resident's family in a timely manner; 3. For Resident 149, there was no assessment or monitoring of a change of condition for which the resident was transferred to a local hospital for generalized weakness and lightheadedness; 4. For Resident 470, who has a history of type II diabetes (a chronic condition that affects how the body processes sugar), 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 licensed nursing staff completed pre and post hemodialysis (treatment to filter wastes, salts, and fluid from blood for those with kidney failure) assessments in accordance with standards of practice for two out of five (5) sampled residents (Residents 122 & 123). In addition, the facility failed to ensure licensed nursing staff accurately assessed the hemodialysis access site for Resident 123. This deficient practice had the potential to result in delayed detection of complications of the dialysis access site. Findings: A review of Resident 122's Face Sheet (a document that provides patient information at-a-glance), dated November 2, 2021, indicated the resident was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including transient cerebral ischemic attack (TIA - a brief episode of neurologic [relating to the nervous system] dysfunction), osteoarthritis (breakdown of cartilage in joints), hyperkalemia…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 observations, interviews, and record reviews, the facility failed to: 1. Ensure that the change of shift narcotics reconciliation record, for one (1) out of two (2) observed medication carts, out of four (4) total medication carts at the facility, was not missing one (1) licensed nurse's signature in the designated signature box over a one (1) month period. This deficient practice had the potential for loss of accountability, which affected the controls against drug loss, diversion, or theft. 2. Ensure that a change of shift narcotics reconciliation record, for one (1) out of two (2) observed medication carts, out of four (4) total medication carts at the facility, did not have one (1) pre-filled licensed nurse signature in a designated signature box for a future narcotics reconciliation verification to be conducted by two (2) licensed nurses. This deficient practice had the potential for loss of accountability, which affected the controls against drug loss, diversion, or theft. 3. Ensure that the physical count for one (1) narcotic medication matched the control drug…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to: 1. Ensure that one (1) bottle of an over-the-counter medication was not expired, located in one (1) out of three (3) observed medication storage rooms, out of five (5) total medication storage rooms at the facility. This deficient practice had the potential for harm to residents due to the potential loss of strength of the medication, and the potential for the residents to receive ineffective medication dosages due to expired medication. 2. Ensure that the refrigerator temperature was within the temperature range specified for refrigerated medications, in one (1) out of three (3) observed medication storage rooms, out of five (5) total medication storage rooms at the facility. This deficient practice had the potential for harm to residents due to the potential loss of strength of the medications, and the potential for the residents to receive ineffective medication dosages. 3. Ensure that the refrigerator temperature monitoring record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure two of eight sampled residents (Residents 29 and 128), Minimum Data Set (a documentation of the resident's clinical assessment [MDS]) was revised after a significant change in condition. This deficient practice had the potential to result in creating an inaccurate picture of the residents' health status. Findings: a. During a review of Resident 29's admission Record, the admission record indicated resident 29 was readmitted to the facility on [DATE] with diagnoses that included schizophrenia (a mental disorder that affects a person's ability to think, feel, and behave clearly), major depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (mental illness causing persistent fear and/or worry), and epilepsy (seizure disorder - sudden, uncontrolled electrical activity in the brain that causes temporary abnormalities in muscle tone or movements, behaviors, sensations, or states of awareness).…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 submit and transmit the Minimum Data Set (comprehensive screening tool [MDS]) Discharge Assessment to the Center for Medicare and Medicaid Services (CMS) for one of two Residents (Resident 2). This deficient practice had the potential to negatively impact the quality monitoring and discharge tracking for Resident 2 Finding: During a review of Resident 2's Minimum Data Set (MDS-comprehensive screening tool), dated May 11, 2021 indicated this was the last transmitted Quarterly assessment. During a review of Resident 2's Minimum Data Set (MDS-comprehensive screening tool), dated June 12, 2021 indicated this was the last transmitted Discharge assessment. During a review of The CMS Submission Report (MDS 3.0 NH Final Validation) ran for June and July 2021 indicated the last MDS transmission date was June 24, 2021. During an interview on November 19, 2021 at 1:25 p.m., with Minimum Data Set Coordinator (MDSC) 1, MDSC1 stated Resident known as Resident 2 is no…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 of eight residents (Residents 29 and 128) had an accurate Activity of Daily Living (daily self-care activities [ADL]) assessment. This failure placed resident 29 and 128 at risk for further decline in their functional mobility and prevented proper care planning. Findings: a. During a review of Resident 29's admission Record, the admission record indicated resident 29 was readmitted to the facility on [DATE] with diagnoses that included schizophrenia (a mental disorder that affects a person's ability to think, feel, and behave clearly), major depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (mental illness causing persistent fear and/or worry), and epilepsy (seizure disorder - sudden, uncontrolled electrical activity in the brain that causes temporary abnormalities in muscle tone or movements, behaviors, sensations, or states of awareness). During a review of Resident 29's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement a person-centered care plan addressing joint mobility for one of eight sampled residents (Residents 79). This failure had the potential to delay provision of necessary care and services. Findings: During a review of Resident 79's admission Record (AR), the AR indicated resident 79 was readmitted to the facility on [DATE] with diagnoses that included cerebrovascular disease (a group of conditions that affect blood flow and the blood vessels in the brain) and hemiplegia (muscle weakness or partial paralysis on one side of the body). During a review of Resident 79's History and Physical (H&P), dated August 16, 2021, the H&P indicated Resident 79 did not have the capacity to understand and make decisions. During a review of Resident 79's MDS Minimum Data Set (MDS-comprehensive screening tool), dated May 12, 2021, the MDS indicated Resident 79 required extensive assistance with ADL's. During a concurrent observation 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 accommodate and meet the needs of the resident's food preference for a kosher diet and meeting the individual resident's religious, cultural and ethnic preferences for 1 out of 8 Residents, (Resident 119). This deficient practice resulted in the resident's food preferences not being honored and had the potential for malnourishment and weight loss. Findings: During a review of the admission Record of Resident 129, dated October 12, 2021, indicated that Resident 129 was admitted on [DATE] for anemia (decreased red blood cells in the blood) and schizophrenia (a mental disorder that affects a person's ability to think, feel, and behave clearly). During a review of the discharge orders from GACH (General Acute Care Hospital) dated 7/15/21, it indicated, Resident 129 had orders to continue a Kosher diet on admission to the facility. During a review of the Nutritional Screening and Assessment at the facility dated 7/17/21, it indicated 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 observation and interview, the facility failed to maintain equipment in the kitchen when the following was observed during the initial kitchen tour in Building B: 1. Dishwasher temperature was observed at 110 degrees 2. Four concentrated juice boxes were observed undated. These failures have the potential to cause food borne illness and spread infection to all residents. 1. During a concurrent observation, interview and record review during the initial kitchen tour in building B on 11/16/21 at 8:50 a.m. with Assistant Dietary Supervisor (ADS), it was observed that during a cycle of running the dishwasher, the temperature only reached 110 degrees. The cycle was performed twice, and the temperature was still at 110 degrees. The ADS also said that the temperature should be above 120 degrees. The ADS stated he just need to keep running the machine to see if the temperature gets higher and notify maintenance to increase the temperature. The AD stated, I will run the machine again and on the second attempt, the temperature still reached only 119 degrees. The ADS observed 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.