Solano Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement an effective pest control program for 20 out of 32 sampled residents (Resident 37, Resident 133, Resident 97, Resident 98, Resident 22, Resident 91, Resident 135, Resident 31, Resident 111, Resident 16, Resident 129, Resident 30, Resident 1, Resident 67, Resident 29, Resident 63, Resident 83, Resident 81, Resident 142, and Resident 9) when gnats (tiny flying insects) and flies were observed in their rooms.This deficient practice had the potential to create unsanitary conditions for the residents, staff, and visitors.Findings: During an observation on 12/2/25, the following were observed:- At 10:48 a.m., room [ROOM NUMBER] was observed with gnats flying around back and forth.- At 10:54 a.m., room [ROOM NUMBER] was observed with gnats flying back and forth.- At 11a.m., room [ROOM NUMBER] was observed with gnats flying.- At 11:30 a.m., room [ROOM NUMBER] was observed with gnats flying around.- At 12: 34 p.m., room [ROOM NUMBER] 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 provide treatment and services to maintain mobility and prevent further decrease in range of motion for one of 32 sampled residents (Resident 134), when Resident 134 did not receive restorative nursing assistant (RNA, exercises to improve or maintain resident's functional abilities) services per her care plan interventions.This failure placed Resident 134 at risk for further complications and decline in their physical functioning and mobility.Findings:During a review of Resident 134's admission record, the admission record indicated Resident 134 was admitted to the facility July 2024 with multiple diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) affecting the right side.During a review of Resident 134's Care Plan initiated 7/15/25, the care plan indicated, .Interventions.Restorative Nursing Program: Active Range of Motion - Right Upper Extremity. RNA will assist resident with AROM [Active Range of Motion] to Right Upper Extremities, 3 times a week.During an interview…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an environment free from accident hazards for one resident (Resident 93) when two beds in the room were situated side by side and put together, for a census of 161.This failure increased the risk of Resident 39 getting caught between beds risking injury and had the potential to cause blocked access for the staff when providing resident care.Findings:Review of Resident 93's admission Record, indicated Resident 93 was admitted to the facility in December 2022, with several diagnoses including, aphasia (a disorder that makes it difficult to speak) following a cerebral infarction (a condition that causes decreased blood flow to part of the brain), monoplegia (paralysis restricted to one limb) of upper limb affecting right dominant side, need for assistance with personal care, and muscle weakness (generalized).Review of Resident 93's MDS (Minimum Data Set-A federally mandated resident assessment tool), dated 9/20/25 indicated Resident 93 had severe cognitive impairment.Review of Resident 93's care plan dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that pharmacy services were maintained when:1. Controlled drug (medication that may be abused or cause addiction) record form for Resident 63 was not signed immediately after medication administration, and;2. LN did not follow the correct dilution protocol for the intravenous (IV antibiotic for Resident 61). These failures resulted in Resident 61 not receiving the correct dose of IV antibiotic and had the potential to result in diversion of the resident's medication.Findings:1. During an inspection of medication cart 400 Even with Licensed Nurse (LN) 5 on 12/3/25 at 1:31 p.m., a controlled drug count for Resident 63's hydrocodone acetaminophen (pain medication) 5/325 milligram (mg-unit of measurement) was not accurate. There were five tablets of hydrocodone acetaminophen 5/325 mg in the medication bubble pack and the controlled drug log indicated there should be six. LN 5 stated she had administered the hydrocodone acetaminophen…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 report an alleged abuse within the prescribed time frame within two hours for one of four residents (Resident 1), when the resident's allegations of inappropriate touching by another resident and a staff member was not reported to the state agency after the charge nurse was notified.This failure resulted to the delayed investigation of the allegation and had the potential to result in Resident 1's emotional and psychological distress.Resident 1 was admitted to the facility in the summer of 2025 with multiple diagnoses which included left and right hemiplegia (left and right-side paralysis) and dysarthria (difficulty speaking).During a review of the Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 6/29/25, the MDS indicated Resident 1 had no memory impairment.During a review of Resident 1's SBAR (Situation, Background, Assessment, Recommendation) Communication Form and Progress Notes (PN), dated 8/5/25, the SBAR and PN indicated that on 8/3/25, Resident 1 reported that a male resident allegedly…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 timely investigate and report the results of investigation of abuse allegations within five days for one of four sampled residents (Resident 1), when Resident 1 complained of being inappropriately touched by another resident and by a staff member.This failure resulted to the delayed investigation of the allegation and had the potential to result in Resident 1's emotional and psychological distress and further abuse. Resident 1 was admitted to the facility in the summer of 2025 with multiple diagnoses which included left and right hemiplegia (left and right-side paralysis) and dysarthria (difficulty speaking).During a review of the Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 6/29/25, the MDS indicated Resident 1 had no memory impairment.During a review of Resident 1's SBAR (Situation, Background, Assessment, Recommendation) Communication Form and Progress Notes (PN), dated 8/5/25, the SBAR and PN indicated that on 8/3/25, Resident 1 reported that a male resident allegedly…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 free from accident hazards when Resident 1 eloped (the act of leaving a facility unsupervised and without prior authorization) from the facility. This failure had the potential for Resident 1 to be at risk of injury including heat or cold exposure, dehydration, medical complications, and being struck by a motor vehicle. Findings: During a review of Resident 1's admission record (AR), the AR indicated, Resident 1 was admitted to the facility September 2016 with multiple diagnoses which included schizophrenia (a mental illness that can affect thoughts, mood, and behavior). During a review of Resident 1's care plan (CP), revised 5/30/24, the CP indicated, .the resident has behaviors r/t [related to] schizophrenia .currently with delusions .Interventions .anticipate . resident's needs . During an interview with Director of Nursing (DON) on 7/2/25 at 9:35 a.m., the DON stated Resident 1 eloped from the facility on 6/29/25 at approximately 2:00 p.m. The DON acknowledged there…

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

Based on observation, interview and record review, the facility failed follow their policy and procedures (P&P) and to assure that services being provided met professional standards of quality for one of four residents, (Resident 1), when a Licensed Nurse (LN 1) administered medication four hours late, improperly disposed of medication and incorrectly documented these errors. These deficient practices had the potential to cause harm and have a negative impact on the intended therapeutic effect of the medications. Findings: A review of Resident 1 ' s admission Record, the admission Record indicated, Resident 1 was admitted in January of 2025, with diagnoses that included Rhabdomyolysis (rare muscle injury where your muscles break down), Bariatric surgery status, (patient had undergone a bariatric procedure, such as gastric banding or bypass), and Hypomagnesemia (low magnesium levels in the blood. Magnesium is an essential mineral for energy production, muscle and nerve function, bone health and blood pressure regulation). During a concurrent observation and interview with LN 1 at…

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

Based on interview and record review, the facility failed to ensure an injury of unknown source was reported within the required timeframe for one of five sampled residents (Resident 2) when an injury of unknown source was reported to the California Department of Public Health (CDPH) the following day. This failure of timely reporting had the potential to cause a delayed response by enforcement agencies to ensure resident safety. Findings: A review of a facility document, dated 3/21/25 and received by the CDPH on 3/21/25, indicated an injury of unknown source occurred when Resident 2 obtained a broken left wrist on 3/20/25. During an interview, on 3/28/25 at 1:00 p.m., with the Director of Nursing (DON) and Administrator (ADM), DON and ADM stated they did not know an injury of unknown source, that resulted in serious bodily injury, should have been reported within two hours. During a review of the facility ' s policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating, undated, the P&P indicated injury of unknown source should be…

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

Based on observation, interview, and record review, the facility failed to ensure respect and dignity for two of seven sampled residents (Resident 4 and Resident 7), when staff did not label Resident 4 and Resident 7's clothing. This failure had the potential to result in the residents' clothing being lost. Findings: During a review of Resident 4's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated, Resident 4 was admitted to the facility October 2024 with multiple diagnoses which included atrial fibrillation (a heart rhythm disorder that causes an irregular heartbeat). Resident 4's Minimum Data Set (MDS – a federally mandated resident assessment tool), dated 10/24/24, indicated Resident 4 was cognitively intact. During a review of Resident 7's face sheet, the face sheet indicated, Resident 7 was admitted to the facility December 2021 with multiple diagnoses which included osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) of left hip. During an interview on 3/21/25…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 safely administer medications in accordance with acceptable professional standards of quality for one of five sampled residents (Resident 1), when Resident 1 was found in his room with unattended medications at his bedside table. This failure decreased the facility's potential to prevent medication errors. Findings: A review of Resident 1's admission record, dated 3/5/25, indicated Resident 1 was admitted to the facility in the fall of 2024. A review of Resident 1's Minimum Data Set (MDS – a federally mandated resident assessment tool), dated 1/25/25, indicated Resident 1 was cognitively intact and had no memory issues. A review of Resident 1's care plan, dated 3/5/25, indicated no care plans related to self-administration of medications. A review of Resident 1's Order Summary Report (OSR, a summary of all physician and care-related orders), dated 3/5/25, indicated no orders for self-administration of oral medications. During a concurrent observation and interview on 3/5/25 at 10:11 a.m. with Resident 1 in…

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

Based on observation, interview, and record review, the facility failed to implement infection control practices for a census of 150 residents, when Licensed Nurse 1 (LN 1) did not conduct hand hygiene after leaving Resident 1's room. This failure decreased the facility's potential to prevent the spread of infections among residents. Findings: A review of Resident 1's admission record, dated 3/5/25, indicated Resident 1 was admitted to the facility in the fall of 2024. During an observation on 3/5/25 at 10:11 a.m. two medication cups were placed unattended on top of Resident 1's bedside table. During a concurrent observation and interview on 3/5/25 at 10:32 a.m. with Licensed Nurse 1 (LN 1), LN 1 was observed bringing eight medication bubble packs to Resident 1's room then placing them on top of Resident 1's bed. LN 1 compared the bubble packs' medications to the contents of medication cups on the bedside table; then left Resident 1's room without conducting hand hygiene and returned the medication bubble packs back into the medications cart. LN 1 confirmed she did not conduct hand…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and maintain an effective infection prevention and control program for a census of 153 residents when: 1. A facility staff exited a droplet isolation precaution room (an isolation precaution implemented when a patient infected with a pathogen which is transmittable through air droplets by coughing, sneezing, talking, and close contact with an infected patient's breathing) and removed his used gloves and isolation gown in the hallway where staff and residents were passing by; 2. Two facility staff did not change their N95 mask respirator (a type of mask that filters up to 95% of particles in the air) upon exiting a droplet isolation precaution room; and, 3. A facility staff entered a droplet isolation precaution room and assisted a COVID19 positive resident without using eye protection. These failures resulted in an increased risk for cross-contamination (movement or transfer of harmful bacteria from one person, object, or place to another), potential exposure of residents to germs, and may cause…

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

Based on interview and record review, the facility failed to ensure that residents' medical care was supervised by a physician for one out of eight sampled residents (Resident 5) when the facility did not notify Resident 5's physician when Resident 5 refused blood draw and diagnostic test. This failure had the risk for Resident 5's physician to not be aware about Resident 5's condition and for Resident 5 to not receive appropriate and timely treatment. Findings: A review of Resident 5's clinical record indicated Resident 5 was admitted January of 2024 and had diagnoses that included metabolic encephalopathy (a condition where the brain does not function properly due to an underlying metabolic imbalance), diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), and dementia (a progressive state of decline in mental abilities). A review of Resident 5's Minimum Data Set (MDS– a federally mandated resident assessment tool) Cognitive Patterns, dated 5/13/24, indicated Resident 5 had a Brief Interview for Mental Status (BIMS- a tool 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 interview and record review, the facility failed to provide quality and timely laboratory services for one out of eight sampled residents (Resident 5) when Resident 5's laboratory tests ordered on l/8/24 and 2/16/24 were not done. This failure had the risk for the facility to be not aware about critical laboratory values of Resident 5 and for Resident 5 to not receive appropriate and timely treatment. Findings: A review of Resident 5's clinical record indicated Resident 5 was admitted January of 2024 and had diagnoses that included metabolic encephalopathy (a condition where the brain does not function properly due to an underlying metabolic imbalance), diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), and dementia (a progressive state of decline in mental abilities). A review of Resident 5's Minimum Data Set (MDS– a federally mandated resident assessment tool) Cognitive Patterns, dated 5/13/24, indicated Resident 5 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 6 out of 15 which…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 quality of care and treatment for one of four sampled residents (Resident 1) when Resident 1 was not informed of medication changes and didn't receive her diuretic (treatment for edema and swelling) medication per assessment, plan of care and physician's order. This failure had the potential to result in a negative outcome. Findings: Resident 1 was admitted to the facility May 2012 with multiple diagnoses which included congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). Resident 1's Minimum Data Sheet (MDS - a federally mandated resident assessment tool), dated 1/12/25, indicated Resident 1 had intact cognition. The MDS also indicated Resident 1 was receiving a diuretic, a high-risk drug medication. During a concurrent observation and interview on 2/18/25, at 11:42 a.m., Resident 1 was sitting in her wheelchair receiving oxygen. Resident 1 stated, I was not informed about my [brand name] [diuretic 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 follow the physician's order for a dressing change around an Intravenous Central Line (IVCL, flexible tube inserted into a vein to the heart and used to administer medications or nutrition) every 7 days for one of four sampled residents, Resident 1. This deficient practice may potentially cause a life-threatening infection to Resident 1. Findings: A review of Resident 1's admission Record, indicated, Resident 1 was admitted in the facility on 1/24/25 with diagnoses that included Necrotizing Fasciitis (flesh eating bacteria), severe sepsis with septic shock (life-threatening condition when an infection spreads throughout the body and causes a dangerously low blood pressure) and gangrene (a serious condition where tissue dies due to a lack of blood supply). A review of Resident 1's Brief Interview for Mental Status, (BIMS, tool used to identify cognitive conditions) Section C, showed a score of 14, which indicated he was cognitively intact. During a concurrent observation and interview in Resident 1's room on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to properly discard a used syringe for one of four sampled Residents (Resident 1), when the used syringe was observed on Resident 1's bedside table. This failure had the potential for Resident 1 and facility staff to accidentally poke themselves and cause injury. Findings: A review of Resident 1's admission Record, indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis that included Necrotizing Fasciitis (flesh eating bacteria), severe Sepsis with septic Shock (life-threatening condition when an infection spreads throughout the body and causes a dangerously low blood pressure) and gangrene (a serious condition where tissue dies due to a lack of blood supply). A review of Resident 1's Brief Interview for Mental Status, (BIMS, tool used to identify cognitive conditions) Section C, indicated Resident 1 was cognitively intact. During a concurrent observation and interview at resident 1's room, with Licensed Nurse 1 (LN 1), on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure resident needs were accommodated for four of 31 sampled residents (Resident 11, Resident 96, Resident 28, and Resident 234), when the residents did not have their call lights within reach. This failure had the potential to result in residents not attaining their highest practicable physical, psychosocial, and emotional well-being. Findings: 1. During a review of Resident 11's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated, Resident 11 was admitted to the facility May 2012 with multiple diagnoses which included Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements) and Macular Degeneration (a disease that causes central vision loss). During a review of Resident 11's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 11/15/24, the MDS indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure three of 31 sampled residents (Resident 11, Resident 254, and Resident 280) received respiratory care consistent with professional standards of practice, physician orders, and care plans, when: 1. Resident 11 did not receive oxygen as ordered and as care planned; 2. Resident 280's nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) was not in place; and 3. Resident 254 had no physician's order for oxygen therapy and nasal cannula was not in place. These failures caused Resident 11 to experience shortness of breath and had the potential to result in respiratory distress for Resident 11, Resident 254, and Resident 280. Findings: 1. During a review of Resident 11's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated, Resident 11 was admitted to the facility May 2012 with multiple diagnoses which included…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 safe and effective pharmaceutical services for a census of 155 residents when: 1. Resident 71 and Resident 255's controlled drug (drug with potential for abuse) use and removal signed out from Controlled Drug Record (CDR- a paper log of controlled drug removal for administration to resident) was not documented in their Medication Administration Record (MAR-a legal document that list administered drugs) and Resident 53's controlled drug use documented in the MAR was not accurately signed out in Resident 53's CDR, 2. Resident 11 received 15 doses of insulin (a medication used to treat high blood glucose level) past the discard date and Resident 71 received 16 doses of expired medication, 3. Hazardous medications (drugs that can cause harm to the body when handled unsafely) were stored in the medication carts with no hazardous drug and warning label on how to be handled by nursing staff and, 4. Resident 8's medication was not administered for two days. These failed practices may contribute to unsafe…

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

Based on observation, interview, and record review, the facility failed to ensure medications were properly labeled and stored in accordance with the facility's policies and procedures (P&P), and accepted professional principles for a census of 155 when: 1. A total of 5 loose pills were found in 100 hallway medication cart, 700 hallway medication cart, and 400-Odd Hallway med cart; 2a. Two opened insulin medication (a medication used to treat high blood glucose level) passed the discard date were found stored in 100 hallway medication cart; 2b. An expired bubble pack (a form of packaging where an individual pushes individually sealed tablets through the foil to remove the medication) of buspirone (a medication used to treat feeling of fear, dread, and uneasiness) was found stored in 300 hallway medication cart; 3. An unused insulin medication was found stored in 100 hallway medication cart; and, 4. Five eye medications, an insulin, and three semaglutide medications (a medication used to treat high blood sugar and for long term weight management) were found stored in 300 hallway…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 11 of 31 sampled residents' (Resident 1, Resident 8, Resident 50, Resident 57, Resident 77, Resident 91, Resident 96, Resident 97, Resident 238, Resident 239, and Resident 240's) meal tray ticket (guidance to staff on what to serve for a meal to a resident) was accurate and followed. This failure had the potential to negatively impact all 11 residents' nutritional status, and not provided meals consistent with their preferences. Findings: During a review of Resident 1's admission Record, the admission Record indicated, Resident 1 was admitted in the facility on 12/1/23 with diagnosis that included Hypertensive Heart and Chronic Kidney Disease (damage kidney) with Heart Failure. During a review of Resident 8's admission Record, the admission Record indicated, Resident 8 was admitted in the facility on 10/3/24 with diagnosis that included Severe Sepsis with Septic Shock (life-threatening condition that occurs when a severe infection causes organ damage). During a review of Resident 50's admission Record,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide palatable, attractive, and appetizing food at preferred temperatures for eight of 31 sampled residents (Resident 1, Resident 8, Resident 15, Resident 39, Resident 60, Resident 83, Resident 121, and Resident 130), when, residents stated the food was cold, bad, and late. These failures resulted in residents' dissatisfaction with their meals and had the potential for decreased food intake leading to unplanned weight loss, nutritional deficiencies, and delayed healing from illness or injury. Findings: 1. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted late 2023 with diagnoses which included hypertensive heart (high blood pressure that affects the heart) and chronic kidney disease (damaged kidney). During a review of Resident 1's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 8/26/24, the MDS indicated Resident 1 had intact cognition (mental process…

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

Based on observation, interview and record review the facility failed to store, and distribute food in accordance with professional standards for food service safety for a census of 155 residents when: 1. Several staff did not wear hair nets and did not perform hand hygiene upon entering the kitchen: a. Maintenance Director (MDir); b. Registered Dietician (RD); c. [name of company] food delivery driver; and e. Dietary Manager Assistant (DMA) 2. Assorted expired food products were found in the walk-in freezer and dry storage room: a. Opened container of mayonnaise with net contents of 3.78 lbs., unlabeled with open and use by date; b. Expired cilantro in a plastic bag dated 11/25/24; c. Expired corn meal in bag with a net weight of 25 lbs. with use by date 8/13/24; d. Expired [brand name] Iced Tea in a box with a net weight of 6 lbs. with use by date 10/17/24; and e. Expired 2 plastic containers of raisins with use by date 11/1/24. These failures had potential to cause food-borne illness in a highly susceptible residents who received food from the kitchen. Findings: 1. a. During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure infection prevention measures were implemented for a census of 155 when: 1.Personal Protective Equipment (PPE- clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) was not worn by housekeeping staff when cleaning a room with Enhanced Barrier Precautions (EBP) (infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs- bacteria that resist treatment with more than one antibiotic] that requires gown and glove use); 2.Staff was observed putting dirty linen into the clean linen storage closet; 3. Resident 1, 36, and 58 urinals were observed stored on the floor with no date or resident label; 4. Residents' non-pharmaceutical (not medication related) personal belongings were found stored in the medication carts next to pharmaceutical products; and, 5. A shared glucometer (a device which measures blood sugar using blood from 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 an accurate Minimum Data Set (MDS - an assessment tool used to guide care) assessment for one out of 31 sampled residents (Resident 254), when Resident 254's admission MDS oxygen (O2) therapy assessment was inaccurate. This failure resulted in inaccurate health status data for Resident 254 and the potential for Resident 254 to not achieve his highest practicable well-being. Findings: During a review of Resident 254's clinical record, Resident 254 was admitted November of 2024 and had diagnoses that included pneumonitis (a general inflammation of the lungs that makes it difficult to breathe), need for assistance with personal care, hemiplegia (complete loss of the ability to move one side of the body), hemiparesis (partial weakness of one side of the body), and congestive heart failure (a condition in which the heart cannot pump oxygen-rich blood efficiently to the rest of the body). During a review of Resident 254's MDS Cognitive Patterns, dated 11/29/24, Resident 254 had moderately impaired cognition (mental…

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

Based on observation, interview and record review, the facility failed to ensure two of 31 sampled residents (Resident 97 and Resident 103) received care which met professional standards when: 1. Family reported to licensed nurse that Resident 103 had an injury of unknown origin on 12/2/24 and was not documented in the nursing notes until 12/3/24; and 2. The facility did not obtain authorization for physical therapy treatment. These failures resulted in inaccurate assessment documentation and had the potential to result in unmet nursing needs for Resident 103 and had the potential to cause a decline in Resident 97's activities of daily living (ADLs - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) and worsening weakness. Findings: 1. During a review of Resident 103's admission Record indicated she was admitted in early 2023 with diagnosis of Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities). During a review of Resident 103's clinical record included the following documents: A…

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

Based on observation, interview, and record review, the facility failed to provide food that accommodates resident's needs and preferences for two out of 31 sampled residents (Resident 130 and Resident 240) when: 1. Resident 130 was not served coffee during the 12/3/24 breakfast meal; and, 2. Facility did not accommodate Resident 240's preference of decaffeinated (decaf) coffee. These failures had the potential to negatively affect Resident 130 and Resident 240's meal intake. Findings: 1. During a review of Resident 130's clinical record indicated Resident 130 was admitted November of 2024 and had diagnoses that included diabetes mellitus (a chronic condition causing too much sugar in the blood), need for assistance with personal care, and muscle weakness. During a review of Resident 130's Minimum Data Set (MDS- an assessment tool used to guide care) Cognitive Patterns, dated 11/11/24, indicated Resident 130 had an intact cognition (mental process of acquiring knowledge and understanding). During a concurrent observation, interview, and meal ticket review on 12/3/24 at 9:55 a.m.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 clean and non-soiled privacy curtains and failed to ensure the windows were clean and washed, in one of three resident rooms occupied by Residents 2 and 3. These failures resulted in Residents 2 and 3 living in an unclean environment. Findings: During an interview on 8/30/24, at 10:35 a.m., Resident 2 stated Resident rooms are not cleaned daily, and that, you are lucky if your room gets cleaned twice a week. Resident 2 further reported the windows were not washed regularly and were dirty. During a concurrent observation, the windows in Resident 2's room were visibly dirty. During the same interview, Resident 2's roommate, Resident 3, endorsed Resident 2's complaints about the cleanliness of their room. During an observation on 8/30/24, at 1:55 p.m., the privacy curtains around Residents 2's and 3's beds were dirty and stained. During a concurrent interview, Resident 2 stated the privacy curtains had not been washed in months. A review of the Resident Council's minutes for the month August 2024, 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 report an allegation of abuse within two hours to the Department and failed submit an investigative summary of the abuse allegation within five working days to the Department, for one of two abuse allegations. These failures had the potential to delay the Department's investigation of the abuse allegation. Findings: A review of Form SOC 341 - Report of Suspected Dependent Adult/Elder Abuse (SOC 341), dated 10/16/23, indicated Certified Nursing Assistant (CNA) A verbally abused Resident 1 on 10/12/23. The SOC 341 indicated the facility reported the incident to the Department on 10/14/23, via voicemail. The SOC 341 further indicated a fax transmission sheet reflected the SOC 341 was faxed to the Department on 10/16/23 at 12:16 p.m. A review of the facility's investigative report of the abuse allegation, dated 10/20/23, indicated the facility became aware of the abuse allegation on 10/12/23. A review of the investigative report indicated a fax transmission sheet showing it was faxed to the Department on 10/25/23 at 1:45 p.m.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 records review, the facility failed to complete a Fall Risk Assessment for one (Resident 4) of four residents (Resident 4, Resident 5, Resident 6, Resident 7) prior to developing interventions to reduce the risk of falls. This failure had the potential for facility staff not knowing what appropriate and personalized interventions to implement to prevent residents from falls that may result in injuries. Findings: On 7/8/24, the Department received a report from the facility on Resident 4's fall with resulting injury, on 7/6/24. A review of Resident 4's facesheet indicated she was admitted to the facility on [DATE], for an after effect of stroke, encephalopathy (group of medical conditions causing brain dysfunction), history of fall from slipping, tripping, and stumbling without striking against an object, need for assistance with personal care, and difficulty in walking amongst other disease conditions. Further review of facility documents, titled: Progress Notes, dated 7/6/24,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to implement its smoking policy (a facility's set of ideas or a plan for action for smoking) and failed to follow the smoking interventions identified in the Smoking Risks Assessment form (an assessment carried out for people who smoke) and smoking care plan (CP, a formal process that correctly identifies existing needs and recognizes a client's potential needs or risks created for individual residents), for two out of two sampled residents (Residents 1 and 2), to promote safety while they were smoking. These failures were a safety hazard and could result in accidents, burns and smoke inhalation injuries. Findings: A review of Resident 1's face sheet (demographics) indicated she was initially admitted to the facility on [DATE], with the diagnoses of Bipolar disorder (a disorder that causes extreme mood swings which include emotional highs-mania or hypermania and lows-depression), Heart Failure (HF, occurs when the heart muscle does not…

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

Based on interviews and record reviews, the facility did not ensure: 1. Resident 1 got to her medical appointment for one out of three sampled residents (Resident 1). 2. Resident 1 and her Responsible Party (RP, an appointed person who could act on behalf of the resident) was notified the facility was not able to procure transportation going to and from the medical appointment, for one out of three sampled residents (Resident 1). These failures could lead to miscommunication, frustration and could be a safety risk due to delayed care and treatment. Findings: A review of Resident 1's face sheet (demographics) indicated an admission date of 6/6/21. Her diagnoses included Hyperlipidemia (HLP, an elevated level of lipids -- fats, like cholesterol and triglycerides, in your blood), Major Depression (a serious mental disorder that negatively affects how you feel, think, act, and perceive the world) and Anxiety (a feeling of fear, dread, and uneasiness). Resident 1's Brief Interview for Mental Status (BIMS, a mandatory tool used to screen and identify the cognitive condition of residents),…

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

Based on interviews and record reviews, the facility failed to ensure for one out of two sampled residents (Resident 2): 1. An abuse allegation was reported timely. 2. Staff were aware of the abuse allegation reporting time frame. 3. The alleged staff was suspended after an abuse allegation was made. These failures were a safety risk and could result in the abuse to continue and had Resident 2 feeling scared and upset. Findings: A review of Resident 2 ' s face sheet (demographics) indicated an admission date of 6/6/21. Her diagnoses included Hyperlipidemia (HLP, an elevated level of lipids (fats, like cholesterol and triglycerides, in your blood), Major Depression (a serious mental disorder that negatively affects how you feel, think, act, and perceive the world) and Anxiety (a feeling of fear, dread, and uneasiness). Resident 2 ' s Brief Interview for Mental Status (BIMS, a mandatory tool used to screen and identify the cognitive condition of residents), dated 3/15/24, score was 14, indicating intact cognition (a term for the mental processes that takes place in the brain,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide adequate supervision during resident smoking sessions to reduce the risk of elopement. This failure resulted in one of one sampled residents (Resident 10) from being able to elope from the facility, potentially causing great bodily injury. Findings: During a review of Resident 10 ' s, admission Record, dated 12/19/23, indicated Resident 10 had been admitted to the facility on [DATE], with a history of chronic obstructive pulmonary disease (a group of diseases that block airflow and make it difficult to breathe), acute respiratory failure with hypoxia (a condition where you do not have enough oxygen in the tissues in your body), congestive heart failure (a long-term condition that happens when your heart cannot pump blood well enough to give your body a normal supply) and moderate dementia (a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities). A review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to arrange for the appropriate mode of transportation service for one of two sampled residents, Resident 1, when she needed a consult with an OB/GYN (Obstetrics/ Gynecology- An OB/GYN, meaning obstetrician gynecologist, is a medical doctor who combines two disciplines: obstetrics and gynecology. Gynecology is the care of a woman's reproductive organs and health. Obstetrics involves the treatment of pregnant women, including the delivery of babies), as ordered by Physician A, due to vaginal bleeding. This failure had the potential to result in an undiagnosed cause of the bleeding and could affect the health and well-being of Resident 1. Findings: A review of Resident 1's, Order Summary Report, active orders as of 1/5/24, indicated a prescriber (doctor) wrote an order on 12/9/23, to monitor Resident 1 for vaginal bleeding. A review of Resident 1's, Electronic Medical Records, indicated that on 12/9/23, at 11:36 a.m., LVN B (Licensed Vocational Nurse B)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 records review, the facility failed to ensure one of 12 residents (Resident 1) was free from abuse when Resident 2 hit Resident 1 during an altercation. This failure had the potential to cause pain, physical harm, or mental anguish to Resident 1. Findings: On 2/5/24 at 12:07 PM, the Department received a report of a resident-to-resident altercation between Resident 1 and Resident 2 at the facility. A review of SOC 341 (a report of suspected dependent adult/elder abuse) dated 2/5/24 sent by the Social Services Director (SSD), indicated the incident happened in the evening of 2/3/24 when Resident 1 reported he was yelling for his nurse when Resident 2 came into his room and told him to shut up. Both residents had exchange of words and Resident 2 hit Resident 1 ' s face. During an interview on 4/12/24, at 1:21 PM Resident 1 stated he does not remember the incident with Resident 2. During a review of the annual Minimum Data Set (MDS - a federal required clinical assessment of all residents '…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to: 1. document and perform a root cause analysis on how one out of two sampled residents (Resident 1) sustained the bruising (an injury that doesn't break the skin but results in some discoloration) on her eye; and, 2. ensure it provided immediate notification and consult with the physician, when one out of two sampled residents (Resident 1) was noted with bruising on her eye area. These failures could result in serious outcomes, medical complications, transfer to hospital and death. Findings: A review of Resident 1's face sheet indicated she was admitted to the facility on [DATE], with diagnoses of Chronic Pain, Fracture of the left humerus (left upper arm bone) and Repeated Falls. Her Minimum Data Sheet Assessment (MDS, a federally-mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes), dated 1/29/24, Brief Interview for Mental Status (BIMS, a mandatory tool used to screen and identify 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 interviews and record reviews, the facility failed to ensure residents' needs were anticipated and frequently needed items, such as water, was within reach for one out of two sampled residents (Resident 1), which resulted in Resident 1's fall on 1/31/24. This fall incident resulted in a small cut on her left index finger. This fall could also put Resident 1 at risk for further fracture (a break in the bone) and pain. Findings: A review of Resident 1's face sheet indicated she was admitted to the facility on [DATE], with a diagnosis of Chronic Pain, Fracture of the left humerus (left upper arm bone) and Repeated Falls. Her Minimum Data Sheet Assessment (MDS, a federally-mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes), dated 1/29/24, Brief Interview for Mental Status (BIMS, a mandatory tool used to screen and identify the cognitive condition of residents) score was 14, indicating intact cognition (the mental action or process of acquiring…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure one five sampled residents (Resident 5), with excessive weight loss, was provided with adequate care to prevent further weight loss. This resident lost 19% of her admission body weight in less than four months. This had the potential to result in harm and could have contributed to Resident 5 ' s death at the facility. Findings: Record review indicated Resident 5 was admitted to the facility on [DATE], with medical diagnosis including Chronic Respiratory Failure (A condition that results in the inability to effectively exchange carbon dioxide and oxygen, and induces chronically low oxygen), Severe Protein-Calorie Malnutrition (A condition that occurs when someone loses weight, due to inadequate protein and calorie intake) and Anemia (A condition in which the body does not have enough healthy red blood cells to carry oxygen through the body), according to the facility Face Sheet (Facility demographic). Record review of Resident 5's weights indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure clinical documentation for one of three sampled residents (Resident 3) was complete and accurate, when activities of daily living (ADLs-Activities related to personal care such as dressing, bathing and toileting) were not documented for Resident 3 several days of December 2023. The documentation did not reflect Resident 3 ' s care and services provided by unlicensed staff to ensure information was available to facilitate communication among the Interdisciplinary Team. This finding had the potential to result in inability for administrative and regulatory staff to monitor the provision of essential ADLs to Resident 3. Findings: Record review of a report received by the DEPARTMENT on 12/20/23, indicated, SSD (Social Services Director) was asked to interview roommate of [Resident 3], who has verbalized today that on Sunday, 12/17/2023, she witnessed that her roommate (Resident 3) was laying in feces from 11:00 pm until 2:30 am without being…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not ensure one of three sampled residents (Resident 1) was treated with respect and dignity, when one staff member (Licensed Staff A) refused to wait for Resident 1 to be ready for medication administration and attempted to pull away the prepared medication before Resident 1 could take it. Resident 1 stated Licensed Staff A grabbed and squeezed her right arm, in an act of anger, while trying to remove the medication cup from Resident 1 ' s hand, although the veracity of this act was inconclusive. This finding had the potential to result in serious harm, and feelings of impotence, frustration, and sadness to Resident 1. Findings: Record review indicated Resident 1 was admitted to the facility on [DATE], with medical diagnoses including Diabetes Mellitus (A chronic disease characterized by high levels of blood sugar) and Chronic Pain Syndrome (Ongoing pain lasting longer than three months), according to the Facility Face Sheet (Facility…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 thoroughly investigate an alleged violation, in response to an allegation of staff-to-resident abuse, for one of three residents (Resident 1). This finding had the potential to result in incidents of abuse to other residents of the facility. Findings: Record review indicated Resident 1 was admitted to the facility on [DATE], with medical diagnoses including Diabetes Mellitus (A chronic disease characterized by high levels of blood sugar) and Chronic Pain Syndrome (Ongoing pain lasting longer than three months), according to the Facility Face Sheet (Facility demographic). Record review of Resident 1 ' s MDS (Minimum Data Sheet-An assessment tool), dated 1/06/24, indicated her BIMS (Brief Interview of Mental Status-A cognition [the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses] assessment) score was 15, which indicated her cognition was intact (A score of 1-7 indicates the cognition is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 3) was provided with activities of daily living (ADLs Activities related to personal care such as dressing, bathing and toileting), when Unlicensed Staff C did not provide incontinence care (Cleaning the skin and changing the soiled undergarments and clothing of people with bowel or bladder incontinence [inability to control urination and defecation]), and repositioning, for more than two hours during the night shift of 12/17/23-12/28/23, even though she had been notified that Resident 3 needed to be cleaned-up. This finding had the potential to result in shame, impotence, and the development of pressure ulcers (Injuries caused by pressure on the skin) to Resident 3. Findings: Record review of a Facility-Reported Incident received by the DEPARTMENT on 12/20/23, indicated, SSD (Social Services Director) was asked to interview roommate of [Resident 3], who has verbalized today that on Sunday, 12/17/2023,…

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

Based on observation and interview, the facility failed to ensure food items were stored in a manner that complied with food handling practices to prevent food-borne illness (illness caused by the ingestion of contaminated food or beverages), when two expired items (cereals and onions), beyond their, Use by dates, were not removed from the dry storage area of the kitchen. This failure had the potential to result in the rapid growth of pathogenic (capable of causing disease) microorganisms (e. g. bacteria, virus etc.) that could cause food-borne illnesses and could affect the residents of the facility. Findings: During an observation on 12/8/23, at 12:20 p.m., inside the facility ' s dry storage area of the kitchen, two food items (cereals and onions) stored in bins (large containers), with, Use by dates of 12/1/23, were not removed from the dry storage area. (Pictures taken of the, Use by dates). During an interview on 12/8/23, at 12:20 p.m., with the Assistant Dietary Manager, he stated he expected the kitchen staff to change the stickers when new supplies were delivered. He 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 interviews and record reviews, the facility failed to report an abuse allegation to the law enforcement agency for one out of two sampled residents (Resident 1). This failure could lead to risk of ongoing abuse and could put residents ' safety at risk. Findings: During a review of Resident 1 ' s face sheet (demographics), it indicated she was 73 years-old with diagnoses of Dysphagia (difficulty swallowing), Hyperlipidemia (HLP, your blood has too many lipids (or fats), such as cholesterol and triglycerides) and Type 2 Diabetes Mellitus (DM, a condition that happens because of a problem in the way the body regulates and uses glucose or sugar as a fuel). Her Minimum Data Sheet Assessment (MDS, a standardized assessment tool that measures health status in nursing home residents), dated 9/6/23, Brief Interview for Mental Status Assessment (BIMS, a screen used to assist with identifying a resident's current cognition and to help determine if any interventions need to occur) score was 15, indicating intact cognition (the conscious and unconscious processes involved in thinking,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and records review, the facility failed to provide verbal or written notice to three of three sampled residents (Resident 1, 3, and 4) or their representatives before changing rooms for Residents 1, 2, and 3. This failure prevented the Residents or their representatives to exercise their right to agree or disagree with the room change or choose a room according to their preference. Findings: Resident 1 Review of the Face sheet (A one-page summary of important information about a resident) indicated, Resident 1 was admitted on [DATE], with diagnoses including but not limited to: Right Femur Fracture (a break in the thigh bone); Fracture of the orbital floor (bones of the rim of your eye socket push back); and Need For Assistance with Personal Care. Review of the Minimum Data Set (MDS -health status screening and assessment tool used for all residents). dated 7/09/23. indicated Resident 1 had a BIMS score of 04 out of 15 points (Brief Interview for Mental Status - a 15-point…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and records review, the facility failed to follow its policy and report an alleged violation of abuse within two hours to the California Department of Public Health (CDPH), when Licensed Staff A witnessed Resident 2 kick Resident 1 ' s left leg. This failure had the potential to prevent the State Department to ensure a complete investigation was initiated timely. Findings: Review of the Face sheet (A one-page summary of important information about a resident) indicated Resident 2 was admitted on [DATE], with diagnosis including but not limited to: Major Depressive Disorder (a mental disorder characterized by a persistently depressed mood and long-term loss of pleasure or interest in life); and Schizophrenia (a serious mental illness that interferes with a person's ability to think clearly, manage emotions, make decisions, and relate to others). Review of the Minimum Data Set (MDS -health status screening and assessment tool used for all residents). dated 7/30/23. indicated Resident 2 had 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 observations, interviews and record reviews, the facility failed to ensure it provide needed care and services that were resident-centered, in accordance with the residents' preferences, and professional standards of practice, for four out of six sampled residents (Residents 1, 5, 6 and 7) when: 1. staff would leave medications at residents ' bedside, would crush medications without a physician order and would not notify residents of medication changes (Residents 1 and 6); 2. the facility did not have an adequate supply of towels and linens readily available for residents' use (Residents 1, 5, 6 and 7); 3. staff were not providing consistent oral care for the residents (Residents 1 and 5); and, 4) staff were on their phones or using an ear bud while providing care to the residents (Resident 1, 5 and 7). These failures led residents to feel annoyed, upset and frustrated. It also led to Resident 1 feeling like her rights were not honored. Findings: During a review of Resident 1 ' s face sheet…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility failed to ensure there were sufficient Certified Nursing Assistants (CNAs) to provide nursing care to the residents for 27 out of 31 days, for the month of 8/2023. This insufficient staffing led to complaints of four out of four sampled residents (Resident 1, 2, 3 and 4 ) about not receiving showers, delayed provision of care, late response to call lights (an alerting device for nurses or other nursing personnel to assist a patient when in need), residents being left soaked in urine and feces and residents feeling upset, angry, humiliated and frustrated. Findings: During a review of Resident 1 ' s face sheet (demographics), it indicated she was 61 years-old with a diagnoses of Sacrum (the bottom of the spine and is a triangular-shaped bone) Pressure Ulcer stage 4 (PU, the most serious type of pressure ulcer. These ulcer extend below the subcutaneous fat into your deep tissues, including muscle, tendons, and ligaments and in more severe cases, they can extend as far down as the cartilage or bone),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record reviews, the facility failed to provide consistent showers, per facility schedule, for four out of four sampled residents (Residents 1, 2, 3 and 4). This failure resulted in residents looking unkempt, dirty and feeling frustrated. It also put residents at risk for feeling anxious, itchy and irritable and residents could develop skin infections, wounds and skin disease. Findings: During a review of Resident 1 ' s face sheet (demographics), it indicated she was 61 years-old with a diagnoses of Sacrum (the bottom of the spine and is a triangular-shaped bone) Pressure Ulcer stage 4 (PU, the most serious type of pressure ulcer. These ulcer extend below the subcutaneous fat into your deep tissues, including muscle, tendons, and ligaments and in more severe cases, they can extend as far down as the cartilage or bone), Epilepsy (a brain disorder in which a person has repeated seizures- a sudden change in the electrical and chemical activity in the brain, over time) and Anxiety…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 reviews, the facility failed to provide care and services to 6 of 14 residents (Resident 3, Resident 5, Resident 6, Resident 9, Resident 10, and Resident 14) according to professional standards, when Resident 3, Resident 5, Resident 6, Resident 9, and Resident 10 were left sitting in their wheelchairs or in their wet adult diapers for long periods or told to go in their adult diapers while waiting to be helped or cleaned; and Resident 14's call light button was left inaccessible to call for assistance. This failure resulted in a skin breakdown, restricting a resident from participating in activities she loved to attend, making her feel, cranky, and another resident having difficulty dealing with being told to go in her diapers, and other residents feeling insulted, horrible, upset, feeling alone and the only one dealing with staff problem, and putting another resident in danger of accidents and other untoward incidents. Findings: During an observation and subsequent…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide appropriate services to maintain or improve mobility when the Restorative Nursing Program (RNA program - nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible) did not provide gait training (training to improve the ability to stand and walk) using a wide based quad cane (cane with a metal base with four feet attached) with the left upper extremity to ambulate (walk) 20 feet with minimum to moderate assistance and close wheelchair follow (pushing a wheelchair closely behind a resident who is training to improve the ability to walk), to maintain the strength of Resident 10's right arm and lower legs. This failure resulted to Resident 10 not getting out of bed for more than three weeks and feeling furious and frustrated. Findings: During an interview on 6/7/23, at 11:49 a.m., Resident 10 stated she was furious about the fact that for four weeks a cane and wheelchair were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to practice infection prevention and control, when two Certified Nursing Assistants (CNAs) did not handle soiled linens and practice hand gloving properly. These failures had the potential to result to spread infections, disease outbreak, further deterioration of clinical problems or death among facility residents. Findings: During an observation on 6/19/23, at 11:26 a.m., CNA B was in room [ROOM NUMBER] walking towards the door of the room holding soiled linens she took from room [ROOM NUMBER]. CNA B was holding the soiled linens against her chest before she dumped the soiled linens in the soiled linen barrel by the door of room [ROOM NUMBER]. During an interview on 6/19/23, at 11:29 a.m., CNA B, when asked how she was supposed to properly handle soiled linens, CNA B stated she realized she was supposed to bag the soiled linens, hold the soiled linens away from her body and deposit it in the soiled linen bin. During an observation on…

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

Based on observations, interviews, and record reviews, the facility failed to implement measures to reduce the risk of disease and infection transmission when the surrounding area of the trash compactor across the kitchen had puddle of brownish-yellow water and trash accumulation with a dead rat under the trash compactor. This failure had the potential to contaminate the foods prepared in the kitchen that could result to a widespread infection/disease for residents. Findings: During an observation on 6/6/22 at 12:57 p.m., a strong sewer-like smell noted while this writer was walking by outside of the kitchen. A puddle of brownish-yellow water and trash accumulation with a dead rat visible under the trash compactor across the kitchen door was observed. Dried water tracks also observed from the compactor through the parking lot at the right side of the building. During an observation on 6/6/22 at 5:10 p.m. a strong sewer-like smell noted while this writer was walking by outside of the kitchen. A puddle of brownish-yellow water trash accumulation with a dead rat visible under the trash…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY During a review of the intake received on 12/21/21 at 4:13 p.m. indicated Resident 275 stated staff never responded to the call light. Resident 275 stated he was left sitting in his own feces for hours. During an interview on 4/04/22 at 11:40 a.m. with Resident 1, Resident 1 stated CNAs took a long time to answer her call light. Resident 1 stated she asked her CNA to change her adult brief on 4/3/22 at around 10:30 p.m. but she was not changed until 2:00 a.m. Resident 1 stated she had incontinence rashes from the past. Resident 1's MDS (an assessment tool completed by clinical staff to identify potential resident problems, strengths, and preferences) dated 3/14/22, indicated Resident 1 had a BIMS score of 13 (Brief Interview for Mental Status - a 15-point cognitive screening measure that evaluates memory and orientation. A score of 13 - 15 is cognitively intact, 08 - 12 is moderately impaired, and 00 - 07 is severe impairment). During an interview on 4/04/22 at 11:48 a.m. with Resident 85, Resident 85 stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide appropriate hygiene to two residents (Resident 37 and 89) out of five sampled residents. This failure resulted in residents having dirty fingernails and not being provided showers per their individual preferences. Findings: 1.During a review of Resident 37's, admission Record, dated 4/7/21, indicated Resident 37 was admitted to the facility on [DATE], with a history of stroke (damage to the brain from interruption of its blood supply), aphasia ( a language disorder caused by damage in a specific area of the brain that control language, effecting a person's ability to communicate) and diabetes (a group of diseases that result in too much sugar in the blood). During a review of Resident 37's, quarterly Minimum Data Set (MDS, clinical assessment process which provides a comprehensive assessment of the resident's functional capabilities and helps staff identify health problems.), dated 11/24/21, indicated Resident 37's, Brief Interview…

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

Based on interviews and record review, the facility failed to ensure two signatures were documented on the controlled drug count sheet for one of three months record of disposed controlled drugs. This failure had a potential to result in diversion (the transfer of a controlled substance or other medication from a lawful to an unlawful channel of distribution or use) of controlled drugs. Findings: During an interview and concurrent record review and with the Director of Nursing (DON) on 04/07/22 at 9:03 a.m. regarding process of controlled drug (drug that may be abused or cause addiction) disposition, the DON stated she and the pharmacist did the drug destruction and both signed the drug count sheets. Review of the narcotic count sheets for March indicated pharmacist signed on 3/24/2022, there was no DON signature. The DON stated she was popping the medications after pharmacist verified numbers of meds to be destroyed. DON stated she did not have the time to co-sign the count sheets. During an interview with the Pharmacist on 04/12/22 at 11:12 a.m. regarding controlled drug…

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

Based on interview and record review, the facility failed to develop and implement policies and procedures to address the steps in the Medication Regimen Review (MRR) process (a review conducted by the Consultant Pharmacist of all medications given to all residents in order to identify incidents of adverse consequences, potential drug interactions, ineffective therapy and duplicate therapy). These failures resulted in the Consultant Pharmacist's recommendations for 2 out of 5 residents selected for review due to potential unnecessary medications (Resident 12 and Resident 39) were not acted on and had the potential to result in ineffective treatment, overdose, and increased incidents of adverse consequences for all 145 residents in the facility. Findings: During an interview with the Director of Nursing (DON), on 4/07/22, at 5:10 p.m., she stated she was responsible for overseeing the facility's MRR (a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure 2 out of 5 residents selected for mediation review (Resident 12 and Resident 39) were free from unnecessary medications (any medication when used in excessive dose, for excessive duration, without adequate monitoring, without adequate indications for its use, in the presence of adverse consequences, or any combinations of the reasons stated) when the facility did not document adequate indications for the use of the medication, did not monitor adverse side effects or residents' behaviors for one medication, and did not act on the pharmaceutical recommendations. This failure had the potential to result in increased risk for movement disorders, falls with injury, cerebrovascular adverse events (commonly referred to as stroke), and increased risk of death. Findings: During a review of the Electronic Medical Record (EMR) for Resident 12, the admission Record, printed 4/11/22, indicated Resident 12 was admitted to the facility on [DATE]. The record…

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

Based on observations, interviews, and record reviews, the facility failed to ensure that one of one sampled resident, Resident 110, was given prior notice in writing that he was going to have a new roommate. This failure resulted in Resident 110 feeling angry and being disrespected. This failure also had the potential to result in physical or psychological harm to Resident 1 because the new roommate, Resident 120, had a history of physically aggressive behavior. Findings: During a review of Resident 110's clinical record, the MDS (Minimum Data Set) quarterly review assessment, dated 12/27/21, indicated on Section C, that Resident 110 had a BIMS (Brief Interview for Mental Status) score of 15, indicating that he had no cognitive impairment. The MDS indicated on Section I that Resident 110 had quadriplegia (Quadriplegia refers to paralysis from the neck down, including the trunk, legs, and arms). During a review of Resident 110's Care Plan, initiated on 8/3/21, the care plan indicated, Resident 110 had the potential to experience psychological distress due to physical altercation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 performance review of every nurse aide at least once every 12 months and provide regular in-service training that comply with the requirement education for Unlicensed Staff H. This failure had the potential to result in poor quality of work, lack of job knowledge and injury to residents due to lack of training. Findings: During an interview on 6/7/2022 at 11:25 a.m., Management Staff G stated Unlicensed Staff H (CNA) was hired on 4/3/2018. Management Staff G stated, Unlicensed Staff H was on leave from 10/18/21 through 3/1/2022. Management Staff G stated, Unlicensed Staff H did not have a reorientation or retraining before starting to work as a CNA on 4/10/22. During a telephone interview on 6/7/2022 at 11:30 a.m., Management Staff J (Senior Regional Human Resource) stated when a staff went on leave, it was not a separation from employment even the staff did not return on a designated date. Management Staff J stated, Unlicensed Staff H did not require an orientation or background check prior to working 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 observations, interview and record review, the facility failed to ensure medication error rate was below 5% when Nurse G did not follow the doctor's order regarding administration of medication for Resident 29 which resulted to two medication administration errors out of 28 administration opportunities (7.14%). This failure had the potential to compromise the absorption of the medication and the risk of developing localized infection of the mouth for Resident 29. Findings: 1. During an interview and concurrent observation in Resident 29's room on 04/06/22 at 9:20 a.m., Resident 29 was in bed, her breakfast tray was on top of her overbed table. Resident 29 stated she just had breakfast. Nurse G handed Resident 29 her medicines that included Levothyroxine (thyroid medicine) in a medicine cup. Resident 29 took all her pills with water. During a clinical record review of the Doctor's order dated 12/31/21, indicated to give Levothyroxine thirty minutes before breakfast. During record review and concurrent interview with Nurse G on 04/06/22 at 3:39 p.m. Nurse G verified 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.