Tulare Healthcare & Wellness Center, LP

Based on interview and records review, the facility failed to ensure one of five sampled staff (Certified Nursing Assistant [CNA] 2) had a completed initial competency evaluation completed upon hire. This failure had the potential to result in CNA 2 providing care that did not meet the resident's needs.Findings:During a concurrent interview and record review on 3/12/26 at 10:15 a.m. with Director Staff Development (DSD), CNA 2's personnel file (PF), undated, was reviewed. The PF indicated CNA 2 was hired on 4/23/25 and there was no initial competency evaluation document. DSD stated CNA 2's initial competency evaluation was not completed.During a review of the facility's Staff Competency Validation (SCV), dated 3/28/24, SCV indicated, Policy: Competency validation is completed to evaluate an individual's performance, evaluate group performance, meet standards set by regulatory agencies, address problematic issues, and enhance performance review.During a review of the facility's policy and procedures (P&P) titled, Performance Review, dated May 23, 2019, the P&P indicated, Procedure,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 records review, the facility failed to ensure one of five staff (Certified Nursing Assistant [CNA] 1) completed an annual performance review. This failure had the potential to result in CNA 1 providing care that did not meet the residents' needs. Findings:During a concurrent interview and record review on 3/12/26 at 10:15 a.m. with Director of Staff Development (DSD), CNA 1's personnel file (PF) undated, was reviewed. The PF indicated CNA 1's most recent performance evaluation was completed on 8/30/24. DSD stated CNA 1 did not have an annual performance in August 2025. DSD stated CNA 1 should have had an annual performance evaluation completed.During a review of the facility's policy and procedures (P&P) titled, Performance Review, dated 5/23/19, the P&P indicated, Procedure II. Formal Evaluations for Full-Time and Part-Time employees are to be conducted at a minimum of, annually.

Based on interview and record review, the facility failed to ensure the Monthly Medication Regimen Review (MRR evaluation of medications by a pharmacist to identify, prevent or resolve medication related problems) recommendations was acted upon for one of five sample residents (Resident 85). This failure had the potential to result in adverse health outcomes for Resident 85. Findings:During a review of Resident 85's Order Summary Report (OSR), dated 1/10/26, the OSR indicated Resident 85 was prescribed Lasix (a medication used to treat fluid retention) 20 milligram (mg) one time a day for seven days (1/10/26 to 1/17/26).During a concurrent interview and record review on 3/11/26 at 2 p.m. with Medical Records (MR), Resident 85's MRR, dated 1/17/26, was reviewed. The MRR indicated, consider continuing Lasix 20 mg po [by mouth] daily. MR stated Resident 85's MRR medication recommendation by the pharmacist was not implemented. MR stated Resident 85's Lasix was discontinued on 1/17/26 and was not continued.During an interview on 3/11/26 at 2:56 p.m. with Director of Nursing (DON), DON…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medications were properly labeled in two of four sampled medication carts (Med Cart 1 and Med Cart 2). This failure had the potential to result in residents receiving the wrong medication, the wrong dose, or another resident's medication. 2. Ensure medications were stored in a safe and secure manner when;a. One of four sampled medication carts (Med cart 2) was left unlocked;b. One of 24 sampled residents (Resident 44) medications were left unattended on Resident 44's bedside table. These failures had the potential to result in accidental ingestion by residents, drug diversion/theft, medication being misplaced and/or tampered with, and data breech of resident health information.Findings: 1. During a concurrent observation and interview on 3/10/26 at 10:20 a.m. with Licensed Vocational Nurse (LVN) 5 near the A and B wing nurses' station, Med Cart 1 contained one opened bottle of Geri Care (brand name) artificial tears eye drops (used to provide hydration and lubrication for dry, irritated eyes) 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, interview, and record review, the facility failed to implement infection prevention practices when:1. One of two clean laundry bins had dirt-like debris at the bottom.2. One of one unmarked laundry bin containing clean pillows was stored in the dirty laundry area.3. Two of five sampled staff members (Medical Doctor [MD] 1, Nurse Practitioner [NP] 1) did not apply appropriate Personal Protective equipment (PPE, gowns, gloves, face masks, face shields or other equipment designed to protect the wearer from injury or the spread of infection or illness) prior to providing care to a resident on enhanced barrier precautions (EBP, an infection control practice that utilizes the use of gown and gloves during high contact care activities to stop the spread of multi-drug resistant organisms [MDRO]). 4. One of two sampled Licensed Vocational Nurse (LVN 3) did not disinfect glucometers between resident use.These failures had the potential to result in the spread of disease causing organisms and infections of residents, staff, and visitors. Findings: 1. During a concurrent…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident's (Resident 9) feeding pump (used to deliver feeding and nutrition through a gastrostomy tube [G-tube inserted through the abdominal wall into the stomach) was secured to a pole to prevent pump from falling. This failure had the potential to cause injury to Residents, staff, and visitors and cause injury to Resident 9's G-tube if feeding pump falls. Findings: During an observation on 3/9/26 at 10:59 a.m. in Resident 9's room, a feeding pump was sitting on the overbed table next to Resident 9's bed. During a concurrent observation and interview on 3/11/26 at 1:57 p.m. with Licensed Vocational Nurse (LVN) 7, in Resident 9's room, a feeding pump was sitting on over bed table next to Resident 9's bed. LVN 7 stated she did not know why the feeding pump was on the overbed table and not attached to the pole. LVN 7 stated the pump could fall and should have been secured to the pole. During a review of the…

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

Based on observation, interview, and record review, the facility failed to ensure a safe, functional, sanitary, and comfortable environment when:1. Two of two laundry dryer filters were not free of thick lint buildup. This failure had the potential to increase the risk of a fire affecting residents' safety. 2. One of one shower room ceiling had cracked ceiling plaster. This failure had the potential to increase the risk mold and contaminants which can contribute to respiratory illness in residents.3. One of two housekeeping carts containing chemicals was missing the locking top. This failure had the potential to result in an increased risk of residents' exposure to accidental ingestion, poisoning, skin and or eye irritation, and burns from housekeeping chemicals. 4. Two of two resident restrooms had cracked flooring. This failure had the potential to increase the risk of lacerations (cuts) and severe bruising to residents. Findings: 1. During a concurrent observation and interview on 3/9/26 at 9:38 a.m. with the Maintenance Supervisor (MS), in the laundry room, there were two dryers…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 it's policy and procedure (P&P) was followed when apple crisp was substituted with apple cake and the Registered Dietician (RD) was not notified. This failure had the potential for the residents to be at risk of inadequate nutrition.Findings:During an observation on 12/23/25 at 12:36 p.m. in the hallway, Resident 1's lunch meal tray contained macaroni and cheese, zucchini and a large piece of cake.During a review of the facility's Winter Menu (WM) dated 12/23/25, the WN indicated Chicken Jambalaya, seasoned zucchini, parsley garnish, garlic bread, apple crisp and milk. was to be served for lunch.During a review of the Substitution List (SL) dated 12/22/25, the SL indicated, Menu Day/meal.lunch.date.12/22/25.item being substituted.apple crisp.replacement item.apple cake.reason for substitution.out of stock.RD initials.(blank)During an interview on 12/23/25 at 1:03 p.m. with Certified Dietary Manager (CDM) , CDM stated the apple crisp for lunch was substituted with apple cake due to not having all the…

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

Based on observation, interview, and record review, the facility failed to provide accommodation of needs for one of five sampled resident (Resident 1), when Resident 1 was left lying in bed while side rails (prevent falls and assist getting in and out of bed) were placed to Resident 1's bed using a drill (power tool). This failure resulted in Resident 1's bed shaking, causing severe pain to Resident 1's fractured (broken) left leg.Findings:During a review of Resident 1's admission Record (AR), dated 10/25, the AR indicated Resident 1 diagnoses including Left Tibia (shin bone) Fracture and chronic (persistent) pain syndrome. Resident 1's admission Minimum Data Set (MDS-a standardized, comprehensive assessment tool), dated 10/31/25, the MDS indicated, Resident 1 had a BIMS (Brief Interview for Mental Status-which evaluates cognition, the ability to remember and think clearly) score of 14 (score of 13-15 cognitively intact).During a concurrent observation and interview on 11/5/25 at 11:05 a.m. with Resident 1, Resident 1 was lying in bed. Resident 1's left leg was wrapped in a full…

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

Based on interview and record review, the facility failed to ensure transportation was provided for one of five sampled residents (Resident 1). This failure resulted in Resident 1 missing scheduled follow up appointment with orthopedic doctor (treats injuries and disease affecting bones, muscle, and etc.) and potential for increased risk of complications, prolonged recovery, and worsening pain.Findings:During a review of Resident 1's admission Record (AR), dated 10/25, the AR indicated Resident 1 had a diagnosis of Left Tibia (shin bone) Fracture. Resident 1's Order Summary Report (OSR), dated 10/24/25 indicated, Follow up with [doctor] x 2 weeks. schedule transportation.During a review of Resident 1's Progress Notes (PN), dated 10/28/25 at 10 a.m. indicated, Resident has an appointment 11/11/25 @ 10:16 w/ [doctor] (orthopedic).During a concurrent interview and record review on 11/24/25 at 11:01 a.m. with Social Service Designee (SSD), SSD reviewed Resident 1's clinical records and confirmed Resident 1 had a scheduled orthopedic appointment on 11/11/25 at 10:16 a.m. SSD 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.

Based on observation, interview, and record review, the facility failed to implement the care plan for one of three sampled resident's (Resident 1) when Resident 1's abrasion to the left shin treatment order ended and it was not re-evaluated. This resulted in Resident 1 not receiving treatment or monitoring of the abrasion and had the potential for the abrasion to worsen.Findings:During a review of Resident 1's Care Plan dated 8/10/25, the CP indicated, Altercation with roommate on 8/10/25.interventions. Abrasion to left shin. Cleanse with dermal wound spray, pat dry with 4x4 gauze, apply TAO (triple antibiotic ointment), leave open to air.Abrasion to left shin. Re-evaluate to extend or heal.During a review of the Order Summary Report (OSR) dated 8/1/25-8/31/25, the OSR indicated, Abrasion to left shin. Re-evaluate or heal.start date 8/18/25.During a review of the Treatment Administration Record (TAR) dated 8/2025, the TAR indicated, the last time the abrasion was monitored or treated was day shift on 8/18/25.During a review of Resident 1's Skin Issues (SI) dated 8/18/25 (completed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 care plan intervention for one of three sampled residents (Resident 1) with a known history of elopement (the act of leaving facility unsupervised and without prior authorization) attempts. This failure resulted in Resident 1 leaving the facility unsupervised and without a wander guard (wearable bracelet that detects resident with cognitive impairments approaches or attempts to exit), putting Resident 1 at risk for serious injury.Findings:During a review of Resident 1's admission Record (AR), undated, the AR indicated Resident 1 was admitted on [DATE] with diagnoses of dementia (a progressive state of decline in mental abilities). During a review of Resident 1's Change of Condition (COC) note dated 7/2/25, at 2:09 p.m. the COC indicated, Resident eloped from facility . resident was last seen at 1 p.m. in hallway. resident was found by CNA (Certified Nursing Assistant) by Burger King. Resident 1's Elopement Evaluation dated…

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

Based on interview and record review, the facility failed to follow its own policy and procedure when an allegation of abuse was not reported to the proper authorities for one of three sampled residents (Resident 1). This failure resulted in violation of Resident 1's rights. XXXXXXCan you change the failureXXX Findings: During an interview on 4/30/25 at 9 a.m. with Ombudsman (an advocate for residents of nursing homes), Ombudsman stated they did not receive an SOC 341 (a required form used to report suspected abuse of dependent adults and elders) from the facility regarding the allegation of abuse between Resident 1 and Certified Nursing Assistant (CNA). During a review of Resident 1's Progress Notes (PN), dated 4/24/25 at 3:44 p.m., the PN indicated, Resident (1) stated male CNA, transferred her out of bed to wheelchair, resident stated that male CNA hurt her during transfer. During an interview on 4/30/25 at 10:18 a.m. with Director of Nurses (DON), DON stated on 4/24/25 Resident 1 reported CNA being rough on purpose during wheelchair transfer. During a concurrent interview and…

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

Based on observation, interview, and record review, the facility failed to provide a working generator for 13 of 13 sampled residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, Resident 9, Resident 10, Resident 11, Resident 12, and Resident 13) requiring an oxygen concentrator (a device that provides oxygen) during a power outage. This failure resulted in the facility having no power for approximately 15 minutes and potential for Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, Resident 9, Resident 10, Resident 11, Resident 12, and Resident 13 without oxygen and potential for respiratory distress. Findings: During an interview on 12/27/24 at 10:50 a.m., with Administrator, Administrator stated a plan power outage with the electric company was initiated on 12/19/24 at 9:30 p.m. Administrator stated the generator immediately turned on at approximately 9:30 p.m. but continued shutting off after 12 p.m. Administrator stated the facility was without power for approximately 15 minutes from…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 when: 1. The facility policy and procedure (P&P) titled Laundry Services was not followed for one of one laundry room not clean and sanitary. 2. The facility P&P titled Housekeeping-General was not followed when a used toilet brush was left on top of the clean area of one of two housekeeping carts. 3. The facility P&P titled Personal Protective Equipment was not followed when two of 19 nursing staff (Licensed Vocational Nurse [LVN] 9 and Certified Nursing Assistant [CNA] 4) did not remove the N95 mask (respiratory protective device) before leaving an transmission based precaution (measures used to protect staff, patient and visitors from infection) room. 4. The posted Centers for Disease Control and prevention (CDC, national health organization) posted signage for required PPE (gown, gloves, face shield, and facemask) inside a transmission based precaution room was not followed by two of two staff…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 arrange regularly scheduled resident council meetings for three out of three sampled residents (Resident 53, Resident 51 and Resident 29). This failure resulted in the denial of Residents to meet regularly to discuss care and quality of life issues, and for the facility to be unaware of and unable to address residents' concerns. Findings: During a review of the facility's Resident Council Minutes (RCM) dated 7/29/24, the RCM indicated the last resident council meeting was held on 7/29/24. During an interview on 10/22/24 at 8:37 a.m. with Resident 53, Resident 53 stated, We have only met one time. During an interview on 10/22/24 at 8:51 a.m. with Resident 51, Resident 51 stated, I am not aware of resident council at all. During an interview on 10/22/24 at 9 a.m. with Resident 29, Resident 29 stated he is not aware of a resident council. Resident 29 stated, I do not know what that [resident council] is. During an interview on 10/24/24 at 8:52 a.m. with Administrator, Administrator stated, These [Resident Council…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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. Follow physician orders (PO) to wrap one of one sampled resident's (Resident 287) left leg daily. This failure resulted in Resident 287's leg to become red and swollen. 2. Complete weekly nursing assessments for two of three sampled residents (Resident 77 and Resident 36). This failure had the potential for residents' physical and emotional care needs to go unmet. 3. Follow its policy and procedure (P&P) titled, Medication-Self Administration, for three of 22 sampled residents (Resident 1, Resident 24, and Resident 43) when the facility did not complete the Assessment for Self Administration of Medications ([NAME]). This failure had the potential for medication to be inaccurately administered by the resident. Findings: 1. During a concurrent observation and interview on 10/23/24 at 10:27 a.m. with Resident 287, on the patio, Resident 287 was alert, oriented, and sitting in her wheelchair. Resident 287's left leg was unwrapped and was…

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

Based on interview and record review, the facility failed to follow their policy and procedure (P&P) titled Activity Program when: 1. Activity assessments were not completed for five of five sampled residents (Resident 337, Resident 46, Resident 438, Resident 42, and Resident 41). 2. Activity care plan was not completed for one of five sampled residents (Resident 438). These failures had the potential for the facility to not be aware of Resident 337, Resident 46, Resident 438, Resident 42, and Resident 41 activity preferences. Findings: 1. During a concurrent interview and record review on 10/23/24 at 3:55 p.m. with Minimum Data Set Coordinator (MDSC), Resident 337's medical record (MR), undated was reviewed. MDSC stated there was no activity assessment in Resident 337's MR. MDSC stated on 10/10/24, the facility admitted Resident 337. MDSC stated Resident 337's activity assessment should have been completed within seven days of admission. During a concurrent interview and record review on 10/23/24 at 3:59 p.m. with MDSC, Resident 46's MR, undated, was reviewed. MDSC stated there was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to complete Social Service Assessments (SSA) within seven days of admissin for three of seven sampled residents (Resident 388, Resident 438, and Resident 337). This failure had the potential for not meeting residents' psychosocial needs. Findings: During a concurrent interview and record review on 10/23/24 at 4:10 p.m. with Social Services Designee (SSD), Resident 337 medical record (MR), undated was reviewed. SSD stated there was no SSA started within seven days of Resident 337's admission to the facility. Resident 337 was admitted on [DATE] and social service assessment was started on 10/21/24. During a review of Resident 388's admission Record (AR), dated 10/8/24, the AR indicated Resident 388's admission date was 10/8/24. During a concurrent interview and record review on 10/24/24 at 10:44 a.m. with Social Services Designee (SSD), Resident 388 SSA dated 10/21/24 was reviewed. SSD stated the Social Services Department has seven days 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.

Based on observation and interview, the facility failed to ensure meals were served at a safe and palatable (appetizing) temperature for two of three sampled residents (Resident 41 and Resident 42). This failure had the potential for residents not meeting their nutritional needs. Findings: 1. During an interview on 10/21/24 at 11:20 a.m. with Resident 41, Resident 41 stated, The breakfast was cold this morning, extra cold. The food is bland. During a review of Resident 41's Minimum Data Set (MDS-assessment tool), dated 6/13/24, the MDS indicated Resident 41's Brief Interview for Mental Status (BIMS, cognition assessment tool, 15-point scale: 0-7 severe impairment, 8-12 moderate impairment, 13-15 cognitively intact) score was 13. During an interview on 10/21/24 at 3:07 p.m. with Resident 42, Resident 42 stated, Breakfast is always cold, the sausage and the eggs. The hot food is not hot. During a review of Resident 42's MDS dated 7/19/24, the MDS indicated Resident 42 had a BIMS score of 15. During an observation on 10/21/24 at 12:18 p.m., in the B-wing hallway, the carts carrying the…

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

Based on observation, interview, and record review, the facility failed to follow its policy and procedure (P&P) titled, Dietary Department-Infection Control when one of one Dietary Aide (DA) 1 did not wash his contaminated hands before returning to food service. This failure had the potential to contaminate food and cause food borne illness. Findings: During a concurrent observation and interview on 10/22/24 at 11:30 a.m. with Dietary Aide (DA) 1 in the facility kitchen, DA 1 changed the red bucket sanitizer solution and placed the bucket back on the counter. DA 1 immediately went back to handling the food without performing hand hygiene. DA 1 stated he should have washed his hands before returning to handling the food. During a review of the facility's policy and procedure (P&P) titled, Dietary Department-Infection Control, dated 2024, the P&P indicated, Proper Hand Washing: g. During food preparation, as often as necessary to remove soil and contamination when changing tasks.

Based on observation, interview, and record review, the facility failed to ensure four of 41 sampled resident's (Resident 337, Resident 70, Resident 10, and Resident 41) call lights were within reach. This failure had the potential for residents to be unable to call for assistance and had the potential for delayed care provision. Findings: During a concurrent observation and interview on 10/21/24 at 9:25 a.m. with Certified Nursing Assistant (CNA) 6 in Resident 337's room, Resident 337's call light was on the floor on the right side of her bed. CNA 6 stated Resident 337's call light was on the floor and the call light should be within Resident 337's reach. During a concurrent observation and interview on 10/21/24 at 9:34 a.m. with Director of Nursing (DON), in Resident 70's room, Resident 70's call light was on top of the bed frame behind the head of the bed. Resident 70 was unable to reach the call light. DON stated call light was not within Resident 70's reach and call light should be clipped to the sheet. During a concurrent observation and interview on 10/21/24 at 9:47 a.m. with…

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

Based on interview and record review, the facility failed to follow their policy and procedure (P&P) titled, Advance Directive [legal document indicating resident's decision for end-of-life treatment and care] when one of two sampled residents' (Resident 41) request for more information on advanced directives was not provided. Findings: During a concurrent interview and record review on 10/24/24 at 8:56 a.m. with Administrator, Resident 41's AHCD dated 6/7/24 was reviewed. The AHCD indicated, I would like receive more information. Administrator stated, Nothing from social services and nothing in the progress notes for more information on advance directives. During a review of Resident 41's face sheet (provides relevent resident information), dated 5/31/24, the face sheet indicated the facility admitted Resident 41 on 5/31/24. During a review of Residents 41's Brief Interview for Mental Status, (BIMS, cognition assessment tool, 15-point scale: 0-7 severe impairment, 8-12 moderate impairment, 13-15 cognitively intact) dated 5/31/24, Resident 41's Bims Score indicated 13. During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their policy and procedure (P&P) titled Disclosure of PHI [protected health information] for one of one sampled residents (Resident 61) when one of Resident 61's medical diagnoses was disclosed to Resident 61's roommate. This failure resulted in the Former Director of Nursing (FDON) revealing Resident 61's PHI to another resident. Findings: 1. During an interview on 10/21/24 at 4:07 p.m. with Resident 61's family member (FM 1), FM 1 stated Resident 61's roommate (Resident 15) asked FM 1 if Resident 61 had [medical condition]. FM 1 stated he responded by saying no, even though Resident 61 did have the medical diagnosis Resident 15 mentioned. During an interview on 10/23/24 at 8:19 a.m. with Resident 15, Resident 15 stated the old boss (FDON) told him, Resident 61 had [medical condition]. Resident 15 stated FDON was no longer working at the facility and was now working in a neighboring city. During an interview on 10/23/24 at 8:28 a.m. with…

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

Based on observation, interview, and record review, the facility failed to follow their policies and procedure titled Pressure Injury Prevention for one of seven sampled residents (Resident 75) did not receive preventative interventions for a pressure ulcer/injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence). This failure resulted in Wound Care Provider (WCP) performing a surgical excisional procedure to remove non-living tissue in Resident 75's pressure wound and had the potential for Resident 75 to continue to develop further skin breakdown and the Stage 3 pressure injury to worsen. Findings: During an interview on 10/21/24 at 11:19 a.m. with Resident 75, Resident 75 stated, I have wounds on my tailbone both upper and lower. During a review of Resident 75's Wound Evaluation & Management Summary (WEMS), dated 10/15/24, the WEMS indicated, Resident 75's had a Stage 3 (full thickness tissue loss) Pressure Wound for more than 19 days. The wound size was 1 centimeter (cm, unit of measurement) by 0.4 cm by 0.1 cm with a surface…

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

Based on observation, interview, and record review, the facility failed to follow its policies and procedures (P&P) titled, Gait Belt dated 9/16 and Ambulation when Physical Therapy Assistant (PTA) ambulated one of three sampled residents (Resident 438) without a facility provided gait belt, and supported Resident 438 by holding onto her pants waistband. This failure had the potential for Resident 438 to fall and sustain injuries. Findings: During an observation on 10/22/24 at 11:25 a.m. in the hallway, a Physical Therapy Assistant (PTA) was assisting Resident 438 to walk. PTA was holding onto Resident 438's pants' waistband. The gait belt on Resident 438 was fraying (coming apart) During an interview on 10/22/24 at 11:35 a.m. with PTA, PTA stated he did not use a gait belt (transfer belt used to help a resident move safely and maintain their balance). PTA stated, I felt like she (Resident 438) was steady, but the gait belt does help out. The gait belt does reduce falls. PTA stated the facility provides gait belts, but this gait belt was his own. PTA stated the gait belt on Resident…

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

Based on interview and record review, the facility failed to follow physician orders (PO) for pain management for one of one sampled residents (Resident 75) when: 1. Physician ordered pain medications were not given as ordered for one of one sampled residents (Resident 75). 2. Physician ordered non-pharmacological (not using non-medication) interventions were not implemented for one of one sampled residents (Resident 75). These failures resulted in Resident 75 refusing to eat, pain not being managed and had the potential for more pain medication to be used. Findings: 1. During an interview on 10/21/24 at 11:20 a.m. with Resident 75, Resident 75 stated, I have pain on my knees, feet, and back. Resident 75 stated her pain scale was 8/10 [1 to 10 numeric pain scale. 0 no pain, 1 to 4 = (equal to) mild pain, 5 to 7 = moderate pain, 8 - 9 = severe pain, 10 = excruciating pain]. During an interview on 10/21/24 at 11:32 a.m. with Licensed Vocational Nurse (LVN) 6, LVN 6 stated she was covering for LVN 11's lunch break, but she did not have the keys to the narcotic (strong pain medication)…

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

Based on observation, interview, and record review, the facility failed to reorder medication timely for one of 13 sampled residents (Resident 28) This failure resulted Resident 28 not receiving his physician ordered medication and had the potential for Resident 28's glaucoma to worsen. Findings: During a review of Resident 28's Order Summary Report (OSR), dated active orders as of 10/22/24, the OSR indicated, on 8/28/24 Brinzolamide [used to treat glaucoma, an eye disease] Ophthalmic [eye] Suspension 1% (Brinzolamide) Instill (drop) 1 drop in both eyes three times a day for glaucoma . During a concurrent observation and interview on 10/22/24 at 11:52 a.m. with Licensed Vocational Nurse (LVN) 6, in D-wing, LVN 6 was administering medication to Resident 28. LVN 6 stated, Resident 28's 12 p.m. dose of Brinzolamide was not available to give. During a review of Resident 28's Medication Administration Record (MAR), dated 10/24, the MAR indicated Resident 28 was not given his Brinzolamide doses on 10/22/24 at 12 p.m. or 5 p.m. During a review of Resident 28's Progress Notes, dated…

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

Based on observation, interview, and record review, the facility failed to follow its: 1. Policy and procedure (P&P) titled, Medication Storage in the Facility for three of 22 sampled residents (Resident 1, Resident 24, and Resident 43) when medications were found at residents' bedside. This failure had the potential for medication to be accessed by unauthorized staff and residents. 2. P&P titled Medication Storage in the Facility and the Manufacturer's Instructions for use (IFU) for one of one medication. This failure had the potential to result in a loss of medication potency (strength), inaccurate test results and adversely affect the residents' health. 3. P&P titled Medication Storage in the Facility was not followed when two of two medication carts stored topical medications (eye drops, injectable medications, creams, ointments, lotions and patches) with oral medications. This failure had the potential for medications to be cross contaminated. Findings: 1. During an observation on 10/21/24 at 10:07 a.m. in Resident 1's room, an open, single use vial of eye drops with liquid…

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

Based on observation, interview, and record review, the facility failed to ensure one of seven sampled residents (Resident 27) had a follow-up dental appointment. This failure had the potential to result in decreased appetite and weight loss due to difficulty eating. Findings: During a concurrent observation and interview on 10/21/24 at 10:15 a.m. with Resident 27, in her room, Resident 27 's dentures were found next to her bedside table. Resident 27 stated, My lower denture is loose. I'm not wearing it. During a concurrent interview and record review on 10/24/24 at 10:05 a.m. with Minimum Data Set Coordinator (MDSC), Resident 27's Dental Notes (DN), dated 6/4/24 was reviewed. The DN indicated, doesn't wear dentures, [dentures are] 5-6 years old. MDSC was unable to find follow-up dental notes with Resident 27's dentist since her last dental appointment on 6/4/24. MDSC stated there should have been a follow-up appointment with the dentist regarding realignment.

Based on observation, interview, and record review, the facility failed to ensure meal preferences were honored for two of 41 sampled residents (Resident 55 and Resident 1). This failure had the potential for Resident 55 and Resident 1's nutritional needs to not be met and the potential for unintended weight loss due to the food not meeting their nutritional needs. Findings: 1. During a concurrent observation and interview on 10/21/24 at 12:17 p.m. with Certified Nursing Assistant (CNA) 10, in Resident 55's room. CNA 10 delivered Resident 55's lunch tray. Resident 55's tray was missing his juice. CNA 10 stated the juice was not on Resident 55's lunch tray. During a concurrent interview and record review on 10/21/24 at 12:18 p.m. with CNA 10, Resident 55's Meal Tray Ticket (MTT), dated 10/21/24 was reviewed. The MTT indicated, Resident 55 should have 4 ounces (oz) of juice on his tray. CNA 10 stated the MTT indicated Resident 55 should have had juice on his tray. During an interview on 10/21/24 at 12:19 p.m. with Resident 55, Resident 55 stated he did not receive the juice he…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 obtain a therapeutic diet order for one of three sampled residents (Resident 388). This failure had the potential for Resident 388 to not obtain sufficient calories and nutrients. Findings: During a concurrent observation and interview on 10/21/24 at 12:25 p.m. in Resident 388's room, with Resident 388, Resident 388 had no teeth and no dentures. There was a plate with an uneaten half of zucchini. Resident 388 stated the uncut zucchini was difficult to eat. Resident 388 stated he preferred for the zucchini to be cut up. During a review of Resident 388's Care Plan (CP), dated 10/14/24, the CP indicated, The resident [Resident 388] has nutritional problem or potential nutritional problem. Interventions: NAS [No Added Salt] diet, Regular texture, Regular/Thick consistency. During a review of Resident 388's CP, dated 10/22/24, the CP indicated, The resident [Resident 388] has oral/dental health problems r/t [related to] edentulous [having no teeth], no dentures per preference. Interventions: Diet as Ordered. Consult…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow the facility's policy and procedure (P&P) titled, Completion & Correction when two of 4 sampled residents' (Resident 27 and Resident 36) medical record were not accurate. This failure had the potential to negatively impact the interventions and treatments for Resident 27 and the continuity of care for Resident 36 Findings: 1. During a concurrent interview and record review on 10/24/24 at 10:41 a.m. with Minimum Data Set Coordinator (MDSC), Resident 27's MDS [assessment tool] Assessment (MDSA),was reviewed. The MDSA dated 12/21/23 under the Oral/Dental Status indicated, No natural teeth or tooth fragment(s) [edentulous - all teeth are missing]. No [should have been marked Yes]. MDSC stated Resident 27 was edentulous, the MDS Assessment under the Oral/Dental Status was inaccurate. During a concurrent interview and record review on 10/24/24 at 10:41 a.m. with MDSC, Resident 27's Order Summary Report (OSR), dated 10/24/24 was reviewed. The OSR…

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

Based on interview and record review, the facility failed to ensure previous employment and personal reference checks were completed for two of two sampled employees (Registered Nurse [RN] 1 and RN 2) prior to being hired. This failure had the potential to put residents at risk for abuse. Findings: During a review of RN 1's Employee Information Sheet (EIS) dated 7/11/24, the EIS indicated, Hire Date 7/11/24. During a review of RN 2's Employee Information Sheet (EIS) dated 8/1/24, the EIS indicated, Hire Date 8/1/24. During a review of RN 1's Previous/Current Employment Verification (PCEV) form undated, the PCEV indicated, RN 1's previous employment and personal references were not verified prior to hire. During a review of RN 2's PCEV undated, the PCEV indicated, RN 2's previous employment and personal references were not checked prior to hire. During a concurrent interview and record review, on 9/18/24 at 10:30 a.m. with Administrator, Administrator reviewed RN 1 and RN 2's personnel record. Administrator stated the previous employment, and personal references were not checked…

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

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was monitored every 30 minutes after eloping from the facility. This failure had the potential for Resident 1 to be at risk for further elopement and at risk for harm. Findings: During a review of Resident 1's Progress Notes (PN) dated 9/13/24 at 7:37 p.m., the PN indicated, 5 p.m. staff noticed resident was not to be found in facility. Resident was found on Prosperity Ave in Tulare, CA on his wheelchair by staff member. Staff member redirected resident back to facility.Recommendations: Q (every) 30 (minutes) monitoring. During a review of Resident 1's Q 30 minute checks (QMC), dated 9/13/24-9/24/24, the QMC indicated, Resident 1 was monitored one time on 9/13, two times on 9/14, 9/15, 9/21 and 9/24, and three times a day on 9/16, 9/17, 9/18, 9/19, 9/20, 9/22, and 9/23. During a concurrent interview and record review, on 9/26/24 at 9:11 a.m. with Director of Nursing (DON), Resident 1's QMC dated 9/13/24- 9/24/24 was reviewed. DON stated the documentation indicated the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a safe discharge was provided for one of two sampled resident (Resident 1) when Resident 1 was discharged home with Resident 2's prescribed medications. This had the potential for Resident 1 to take the wrong medication and potential for adverse effects. Findings: During an interview on 7/31/24 at 10:40 a.m. with Resident 1, Resident 1 stated she was discharged home on 7/23/24 with her roommates (Resident 2's) prescribed medication. Resident 1 stated, What if I didn't look and I didn't know and I took them (Resident 2's prescribed medication). During an interview on 7/31/24 at 12:09 p.m. with Registered Nurse (RN), RN stated upon Resident 1's discharge on [DATE], Licensed Vocational Nurse (LVN) handed Resident 1 a bag filled with medications. RN stated she did not double check or triple check to ensure all medications inside the bag were prescribed for Resident 1. RN stated Resident 1 was discharged home with Resident 2's prescribed medication.…

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

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 1) was treated with respect. This failure resulted in Resident 1's rights being violated. Findings: During a review of Resident 1's Cognitive Patterns (CP), dated 4/14/24, the CP indicated, Should brief Interview for Mental Status be Conducted? .No (resident is rarely/never understood) . During a review of Resident 1's Transfer/Discharge Report (TDR), dated 7/3/24, the TDR indicated, Resident 1 was a [AGE] year-old admitted on [DATE] and had diagnoses of Unspecified Dementia (progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), anxiety (characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities.) During a review of the Facility Reported Event (FRE), dated 6/8/24, the FRE indicated, Describe the…

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

Based on interview and record review, the facility failed to notify one of three sampled residents (Resident 1) Physician when Resident 1 had a significant change in condition requiring hospitalization. This failure resulted in a delay of care. Findings: During an interview on 5/15/24 at 10 a.m. with Resident 1's Responsible Party (RP), RP stated Resident 1 was transferred to the acute hospital on 5/11/24. During a review of Resident 1's medical record, there was no documented evidence Resident 1's Physician was notified of Resident 1's significant change of condition and transfer to the acute hospital. During an interview on 5/15/24 at 1:37 p.m. with the Administrator, Administrator stated Resident 1 was transferred to the acute hospital on 5/11/24. Administrator was unable to find documented evidence Resident 1's Physician was notified of Resident 1's significant change in condition. Administrator stated she was not aware what type of change of condition Resident 1 had that required transfer to the acute hospital. During an interview on 5/15/24 at 1:47 p.m. with Director of Nurses…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 assess one of three sampled residents (Resident 1) when Resident 1 had a significant change in condition. This failure has the potential for unmet care needs. Findings: During an interview on 5/15/24 at 10 a.m. with Resident 1's Responsible Party (RP), RP stated Resident 1 was transferred to the acute hospital on 5/11/24. During a review of Resident 1's medical records, there was no documented evidence an assessment was completed when Resident 1 had a significant change in condition and was transferred to the acute hospital. During an interview on 5/15/24 at 1:37 p.m. with the Administrator, Administrator stated Resident 1 was transferred to the acute hospital on 5/11/24. Administrator stated the nurse on-duty failed to assess and document when Resident 1 had a change of condition. Administrator stated because there was no documentation made by the nurse on-duty, Adminsitrator was not aware what type of change of condition Resident 1 had that required transfer to the acute. During an interview on 5/15/24 at 1:47 p.m. with…

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

Based on interview and record review, the facility failed to ensure wound care was provided for one of three sampled residents (Resident 1) according to physician's order. This failure has the potential to result in worsening of Resident 1's wounds. Findings: During a review of Resident 1's Order Summary Report (OSR) , dated 4/6/24 thru 5/11/24, the OSR indicated Resident 1 had the following treatments: Stage 2 pressure ulcer (lesion caused by unrelieved pressure that results in damage to the underlying tissue) to coccyx (tail bone area) was to be cleanse with a wound cleanser, apply calmoseptine (wound ointment) topically, and leave open to air every shift (day and night). Surgical sutures and scarring to abdomen, cleanse with wound cleanser, pat dry, leave open to air every shift. Dehisced (reopen) surgical wound to abdomen, cleanse with wound cleanser, apply medi honey (wound gel), cover with dressing every shift. During a review of Resident 1's Treatment Administration Record (TAR), dated 4/6/24 thru 5/11/24, the TAR for the stage 2 pressure ulcer wound and surgical sutures and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify one of two sampled residents (Resident 1) Responsible Party (RP) after a fall resulting with a black left eye and a cut to left lower lip. This failure resulted Resident 1's RP not being notified of the fall incident. Findings: During a concurrent interview and record review on 5/9/24 at 1:16 p.m. with Assistant Director of Nurses (ADON), Resident 1's medical records was reviewed. ADON stated Resident 1 was admitted to the facility on [DATE], under respite care (temporary care). ADON stated Resident 1 had a fall incident on 5/6/24 and sustained a black eye and a cut to left lower lip. During an interview on 5/9/24 at 3:05 p.m. with Licensed Vocational Nurse (LVN), LVN stated on 5/6/24, Resident 1 was in the front lobby when she had fallen off her wheelchair when she attempted to stand. LVN stated Resident 1 sustained a cut to her left lower lip and left black eye. LVN stated she notified the hospice (type of care that focuses on the relief 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.

Based on interview and record review, the facility failed to ensure physician ' s orders were followed for one of three sampled residents (Resident 1). This failure resulted in Resident 1 not receiving an antibiotic as ordered for an infection. Findings: During a review of Resident 1 ' s Examination Notes (performed by Physician 1) (EN), dated 2/8/23, the EN indicated, Diagnosis and Plan.continue Cipro (antibiotic) 500 mg [milligrams] PO (by mouth) BID (twice a day). During a concurrent interview and record review, on 2/21/24 at 4:22 p.m., with Director of Nursing (DON), Resident 1 ' s Medication Administration Record (MAR), dated 2/2023 was reviewed. The MAR indicated, Cipro Oral Tablet 500 mg.give 1 tablet by mouth two times a day .for 14 days.start date 1/25/23. The last dose of Cipro was administered to Resident 1 on 2/8/23 (same day Physician 1 gave new order to continue Cipro). DON stated, Resident 1 received the last dose of Cipro on 2/8/23 and the Cipro should have been continued as ordered by Physician 1. During a review of the facility ' s policy and procedure (P&P)…

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

Based on observation, interview, and record review the facility failed to implement infection control and prevention practices according to facility ' s policy and procedure for 18 of 18 residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, Resident 9, Resident 10, Resident 11, Resident 12, Resident 13, Resident 14, Resident 15, Resident 16, Resident 17, Resident 18) during an outbreak of Covid (a highly contagious easily spread viral infection) infection in the facility. This failure had the potential to result in spread of Covid infection and other infectious diseases to residents, staff, and visitors. During an observation on 11/8/23 at 11:14 a.m. at the facility entrance, Central Supply Clerk (CSC) was observed amongst Resident 1, Resident 2 and Resident 3 with her N95 face mask (a mask that covers the nose and mouth used to prevent the spread of infection) hanging below her chin. During an interview on 11/8/23 at 11:15 a.m. with Director of Nursing (DON), DON stated the facility had positive cases of Covid infection with…

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

Based on observation, interview, and record review, the facility: 1.Failed to implement plan of care for one of four sampled residents (Resident 2). 2. Failed to develop a plan of care for one of four sampled residents (Resident 1). These failures had the potential for Resident 1 and Resident 2 to have further falls. Findings: 1. During a review of Resident 2 ' s Progress Notes (PN), dated 11/22/23 at 12:15 p.m., the PN indicated, IDT (Interdisciplinary Team-members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) Fall Follow UP: Unwitnessed fall on 11/12/2023 at 1:15 a.m. [Resident 2] was observed by the CNA (Certified Nursing Assistant) to be on the floor by her bedside.IDT recommendations. nonskid strips place on floor by bed. During a review of Resident 2 ' s Care Plan (CP), dated 10/25/23, the CP indicated, The resident is high risk for falls r/t [related to] .H/O [history of] falls, weakness, attempts to transfer without assistance, episodes of forget fullness,…

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

Based on interview and record review the facility failed to implement their policy titled Transfer and Discharge for one of three sampled residents (Resident 1). This failure resulted in a delay in return to facility from an acute hospital and had the potential for an adverse outcome due to an unsafe discharge. Findings: During an interview with on 11/7/23 at 10:34 with Complainant, Complainant stated on 11/6/23 the facility sent Resident 1 to the hospital and was ready to go back to the facility on the same date 11/6/23. Complainant stated the hospital attempted to send Resident 1 back to the facility via ambulance, but the facility refused to take Resident 1 back stating she was discharged . During an interview on 11/8/23 at 1:33 p.m. with admission Coordinator (AC), AC stated Resident 1 was a private pay resident (not covered by insurance) and the facility could no longer meet her needs once she was sent out to the acute hospital. AC stated Resident 1 had been in the facility for approximately 20 days. AC stated the facility told the hospital staff they could no longer meet the…

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

Based on interview and record review, the facility failed to ensure a criminal background check was completed prior to hire for one Licensed Vocational Nurse (LVN) 1. This failure had the potential for residents to be at risk for abuse. Findings: During a review of the Background Screening Report (BSR) dated 3/13/23. The BSR indicated, the report was completed on 3/13/23. During an interview on 10/31/23 at 2:30 p.m., with Director of Nursing (DON), DON stated, background checks should be completed prior to hire. During a concurrent interview and record review, on 10/31/23 at 1:51 p.m. with Director of Staff Development (DSD), LVN 1's Personnel Change Notice (PCN), dated 3/1/23 was reviewed. The personnel file indicated, LVN 1 was hired on 3/1/23 (12 days prior to the BSR being completed). DSD stated, the BSR was completed on 3/13/23, and it should have been done prior to LVN 1 being hired. During a review of the facilty's policy and procedure (P&P) titled, Abuse-Prevention, Screeining, & Training Program dated 7/18, the P&P indicated, The facility conducts criminal background checks…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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. Maintain food storage and food handling practices in a safe and sanitary manner. 2. Keep the ice machine in the kitchen clean and sanitary. 3. Dispose food beyond used-by-date. These failures had the potential for transmission of food-borne illness. Findings: 1. During a concurrent observation and interview on 11/7/22, at 9:48 AM, with Food and Nutrition Services Director (FNSD), inside the kitchen walk-in refrigerator, one plastic container with cheese-like substance and two plastic containers with a mixture of canned fruits were observed unlabeled and undated. FNSD confirmed the findings and stated, the cheese-like substance was cottage cheese and the fruit mix was fruit cocktail. FNSD stated, usually a sticker with the date of preparation and used-by date is placed on the tray with the food items, this identifies the foods that were prepared and the food items were good for two days once prepared. During a concurrent observation…

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

Based on observation, interview, and record review, the facility failed to implement infection prevention and control practices when: 1. Hand-held nebulizer (a device that turns liquid medications into a fine mist, allowing for easy absorption into the lungs) mouthpiece and facemask connected to a continuous positive airway pressure (CPAP machine- used in the treatment of sleep apnea) were left exposed and unlabeled on the shelf located on the wall behind Resident 37's bed. 2. Oxygen tubing/connector was on the floor. 3. Certified Nursing Assistant (CNA) 1 did not properly dispose of her gown and gloves when exiting Resident 36's room, which was on transmission-based precaution (used to help stop the spread of germs from one person to another), and touched the doorknob with used and contaminated gloves to open the door. 4. Licensed Vocational Nurse (LVN) 1 did not use aseptic technique (standard healthcare practice that helps prevent the transfer of germs to or from an open wound and other susceptible areas) during tracheostomy care (a surgically created hole [stoma] in one'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.

Based on interview and record review, the facility failed to ensure the residents or residents' representatives participated in the care planning conferences for four of five sampled residents (Resident 4, Resident 29, Resident 34, and Resident 176). This failure had the potential for unmet care needs. Findings: During an interview on 11/7/22, at 3:46 PM, with Resident 29, Resident 29 stated, she had not participated in care planning conferences. Nobody has invited me. During a concurrent interview and record review, on 11/9/22, at 3:35 PM, with Assistant Director of Nursing (ADON), Resident 29's Care Conference Record dated 2/4/22, was reviewed. ADON stated, care conferences occur quarterly. Social Services Director is responsible for arranging the meeting with the resident or the resident's representative. ADON stated, the last completed care conference for Resident 29 was on 2/4/22. ADON was unable to provide documentation Resident 29 or the resident's representative was present in the meeting. ADON stated, We talked about the overall care of the resident and their concerns. It…

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

Based on interview and record review, the facility failed to: 1. Re-evaluate and document current condition for Level 1 Preadmission Screening and Resident Review (PASARR-a federal requirement to ensure residents with mental disorder or intellectual disabilities are not inappropriately placed in a nursing home) for one of four sampled residents (Resident 29). 2. Refer and coordinate with the appropriate State-designated authority for three of four sampled residents (Resident 4, Resident 18, and Resident 36) with positive Level 1 PASARR for Level ll PASARR (filled out if Level I is positive) determination. These failures had the potential for Resident 4, Resident 18, Resident 29, and Resident 36 to not receive the appropriate services related to their mental disorder, intellectual disabilities, or other related cognitive impairment. Findings: 1. During a concurrent interview and record review on 11/9/22, at 10:17 AM, with Assistant Director of Nursing (ADON), Resident 29's Level 1 PASARR, dated 9/11/17, was reviewed. Resident 29's PASARR Level 1 indicated negative, resident has 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.

Based on interview and record review, the facility failed to ensure a baseline care plan (initial plan of care for newly admitted residents completed within 48 hours of admission) was completed for four of eight sampled residents (Resident 237, Resident 240, Resident 235, Resident 241) within 48 hours of admission. This failure had the potential to result in unmet care needs. Findings: During a review of Resident 237's Baseline Care Plan (BCP), dated 10/17/22, the BCP indicated, only section 4: dietary, therapy, and social services were completed. Section 1: general information and initial goals, section 2. functional status, section 3. health conditions, and section 5. summary and signatures were incomplete and left blank. During a review of Resident 240's BCP, dated 11/10/22, the BCP indicated, only section 4: dietary, therapy, and social services were completed. Section 1: general information and initial goals, Section 2. functional status, Section 3. health conditions, and Section 5. summary and signatures were incomplete and left blank. During a review of Resident 235's BCP,…

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

Based on interview and record review, the facility failed to ensure residents' Informed Consents (process in which patients are given important information, including possible risks and benefits, about a medical procedure or treatment) for psychoactive medications (drugs that cause changes in mood, thoughts, feelings, or behavior) were signed appropriately for two of three sampled residents (Resident 4 and Resident 36). This failure had the potential for Resident 4 and Resident 36 to not fully understand the treatment/intervention and consequences of the decisions regarding the use of psychoactive or psychotropic medications (drugs/medications use to manage symptoms of anxiety, depression, psychological distress, and/or insomnia [difficulty sleeping]). Findings: During a concurrent interview and record review, on 11/9/22, at 2 PM, with Nursing Consultant (NC), Resident 4's Medication Administration Record (MAR), dated 11/2022 was reviewed. The MAR indicated, Buspirone (medication to treat anxiety disorder) 15 mg (milligram, a unit of measure) give one tablet three times a day,…

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

Based on interview and record review, the facility failed to ensure two of two sampled residents (Resident 36 and Resident 37) had physician's orders and were determined to self-administer medications safely. This failure had the potential for adverse consequences. Findings: During a concurrent observation and interview, on 11/7/22, at 12:43 PM, in Resident 36's room, with Certified Nursing Assistant (CNA) 1, two tubes of Terrasil Ringworm Ointment were on top of Resident 36's nightstand. Resident 36 stated, I have ringworms all over my body and I use and apply this cream. Resident 36 stated, the nurses were aware I am applying this cream by myself. Sometimes, the nurses help me. CNA 1 confirmed the findings. During a concurrent interview and record review, on 11/7/22, at 12:55 PM, with Licensed Vocational Nurse (LVN) 2, Resident 36's Physician's Orders (PO), dated November 2022, was reviewed. The PO indicated, On 11/2/22, Terrasil cream to be applied PRN as needed for ringworm treatment, every 6 hours for 14 days. LVN 2 was unable to provide documentation a physician's order was…

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

Based on interview and record review, the facility failed to ensure personal property for one of one sampled resident (Resident 176) was secured and free from theft or loss. This failure resulted in Resident 176's feeling deeply upset from the loss of her personal cell phone. Findings: During an interview on 11/7/22, at 4:14 PM, with Resident 176, Resident 176 stated, she lost her personal cell phone on 10/5/22 and she reported it to the facility. Resident 176 stated, the cell phone was inside her bear pouch and was taken from it. Resident 176 stated, I know a facility staff member took my cell phone because she told my niece, I got your aunt's phone and she is not going to get it back. During a concurrent interview and record review, on 11/9/22, at 3:33 PM, with Social Services Director (SSD), the Theft and Loss Log, [undated] was reviewed. The Theft and Loss log indicated, Resident 176 reported her missing cell phone on 10/5/22. The log did not indicate the description of the phone, date and time of loss, or any other pertinent information. SSD stated, [Resident 176's] niece knew…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 conduct further investigation of an alleged theft by facility staff for one of one sampled resident (Resident 176)'s personal cell phone. This failure had the potential for more incidents of theft and loss in the facility when further investigations are not completed. Findings: During an interview on 11/7/22, at 4:14 PM, with Resident 176, Resident 176 stated, she lost her personal cell phone on 10/5/22 and she reported it to the facility. Resident 176 stated, the cell phone was inside her bear pouch and was taken from it. Resident 176 stated, I know a facility staff member took my cell phone because she told my niece, I got your aunt's phone and she is not going to get it back. During a concurrent interview and record review, on 11/9/22, at 3:33 PM, with Social Services Director (SSD), the Theft and Loss Log, [undated], was reviewed. The Theft and Loss Log indicated, Resident 176 reported her missing cell phone on 10/5/22. SSD stated, [Resident 176's] niece knew one facility staff member is in possession of Resident 176'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.

Based on interview and record review, the facility failed to develop and implement comprehensive care plans for two of eight sampled residents (Resident 235 and Resident 241). This failure had the potential to result in unmet care needs. Findings: 1. During an observation on 11/7/22, at 11 AM, in Resident 235's room, Resident 235 had a indwelling Foley catheter (a tube held in place in the bladder to collect urine) with drainage bag hanging on left side of bed. During a concurrent interview and record review, on 11/9/22, at 3 PM, with Minimum Data Set (Resident assessment tool) Coordinator (MDSC), Resident 235's Comprehensive Care Plans (Person-Centered Plan of Care), dated 11/4/22 were reviewed. The comprehensive care plans indicated, there was not one developed for Resident 235's Foley catheter. MDSC was unable to provide documentation there was a comprehensive care plan developed for Resident 235's Foley catheter and stated there should have been one initiated. 2. During an interview on 11/8/22, at 1:44 PM, with Resident 241, Resident 241 stated, he wishes he could be more…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 evaluate the effectiveness of the fall care plan and update the care plan with physician participation for the care of one of one sampled resident (Resident 29) who had fallen seven times during the course of her stay at the facility. This failure resulted in Resident 29's reoccurrence of multiple falls with the same plan of care. Findings: 1. During an observation on 11/7/22, at 3:38 PM, in Resident 29's room, Resident 29 was in her bed, in low position, with floor mats on each side of the bed. Resident 29 responded when greeted. Resident's right eye was noted to have opacity (cloudy) of the cornea (clear front layer of the eye). Resident 29 stated, she's blind in her right eye. During a concurrent interview and record review, on 11/10/22, at 10:42 AM, with Assistant Director of Nursing (ADON), Resident 29's Progress Notes of fall incidences, dated 2/24/22, 5/3/22, 6/8/22, 6/14/22, 8/29/22, 10/3/22, and 10/26/22, were reviewed. The Progress Notes indicated Resident 29 fell on these dates. ADON confirmed these findings.…

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

Based on interview and record review, the facility failed to provide an ongoing activity program to meet the needs and interests for one of eight sampled residents (Resident 241. This failure resulted in Resident 241 feeling socially isolated and depressed. Findings: During an interview on 11/8/22, at 1:44 PM, with Resident 241, Resident 241 stated, he is severely depressed. Resident 241 stated, I would love to participate in activities but I don't know what they have. Resident 241 stated, he is really sad that he doesn't get to participate in church every Sunday and would love to participate in mass at the catholic church. Resident 241 asked if there was someone he could do bible study with. Resident 241 stated, activity staff does not come to see him and that he is not offered activities to do in his room. Resident 241 stated, he liked board games such as Mexican train, chess, checkers, writing poetry, and playing bingo. Resident 241 stated, he has never seen an activity calendar to see what they offer. Resident 241 stated, he feels isolated to his room. Resident 241 stated, staff…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the necessary care and services to maintain skin integrity related to wound healing in accordance with the comprehensive assessment and plan of care for one of one sampled resident (Resident 237). This failure resulted in increased swelling and pain for Resident 237. Findings: During a review of Resident 237's admission Record (AR), dated 10/14/22, the AR indicated, Resident 237 was admitted for surgical aftercare following surgery of cutaneous abscess (a collection of pus that has built up within the tissue of the skin) of his right foot. During a concurrent observation and interview on 11/7/22, at 11:30 AM, with Resident 237, in Resident 237's room, Resident 237 had a wound dressing that was closely wrapped around his right foot and ankle exposing part of the wound and causing the toes and ankle to be discolored and swollen. The wound exposed had bloody and yellow drainage seeping through the wound dressing. Resident 237 stated, he informed the nurse who did his dressing change last night that his…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 eight sampled residents (Resident 241) received services to meet the resident's behavioral health care needs. This failure resulted in Resident 241's increase episodes of sadness and feelings of depression causing decreased appetite. Findings: During a concurrent observation and interview on 11/8/22, at 1:46 PM, with Resident 241, in Resident 241's room, Resident 241 had flat affect and looked sad. Resident 241 stated, he feels hopeless and has been depressed for a long time. Resident 241 stated, I don't know why God is keeping me alive. Resident 241 stated, he has been depressed for a long time and that he saw a Psychiatrist (Doctor that treats mental illness) regularly before coming to this facility. Resident 241 stated, he told staff he would like to see a Psychiatrist and states he has not seen one yet. Resident 241 stated, he does not have an appetite and does not have a lot of interest in daily activities. Resident 241…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 make a dental referral for two of two sampled residents (Resident 18 and Resident 49 ) with cracked, broken, and missing teeth. This failure had the potential to result in unplanned weight loss due to poor dentition affecting residents' ability to eat. Findings: During an interview on 11/8/22, at 2:03 PM, with Resident 49, Resident 49 stated, I have bad teeth, broken, and I have dental caries. I told the nurse it's affecting my ability to eat. During a review of Resident 49's MDS (Minimum Data Set-a resident assessment tool) Section L, Oral/Dental Status, dated 9/30/22, the MDS indicated, D. Obvious or likely cavity or broken natural teeth. During an interview on 11/8/22, at 4:31 PM, with Resident 18, Resident 18 stated, she had cracked teeth and needed to see a dentist. During a review of Resident 18's MDS Section L, Oral/Dental Status, dated 10/19/22, the MDS indicated, B. No natural teeth or teeth fragments (edentulous). During an interview on 11/9/22, at 3:57 PM, with Social Services Director (SSD), SSD stated, I…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 medical records were accurate for one of one sampled resident (Resident 34). This failure had the potential to affect resident's care when information, progress, and condition of the resident were not properly documented in accordance with Resident 34's health condition. Findings: During a review of Resident 34's admission Record (AR), dated 8/28/22, the AR indicated, Resident 34 is an [AGE] year-old female, re-admitted to the facility on [DATE]. Resident 34's diagnoses were Type 2 Diabetes Mellitus (chronic disease characterized by high levels of sugar in the blood), End-Stage Renal Disease (chronic kidney disease in which the kidneys no longer function, leading to a need for a regular course of dialysis), Dependent on Dialysis (a procedure that uses a machine to remove waste products and excess fluid from the blood when the kidneys stop working properly), Moderate Protein Calorie Malnutrition (lack of protein and low caloric intake leading to…

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