Berkley Post-Acute

Based on interview and record review, the facility failed to ensure licensed nurses provided non-pharmacological interventions (treatments or therapies that do not involve the use of medications) prior to administering as needed (prn) opioid ([narcotic- used to treat moderate to severe pain) pain medication to a resident for one of four sampled residents (Resident 147). This deficient practice had the potential to place the resident at an increased risk of experiencing adverse side effects (undesired harmful effect resulting from a medication or other intervention) from the use of opioids. Findings: During a review of Resident 147's admission Record, the admission Record indicated the facility admitted the resident on 7/25/2025 with diagnoses including cardiomegaly (also known as an enlarged heart, is not a disease itself, but rather a sign of an underlying heart condition) and difficulty in walking.During a review of Resident 147's History and Physical (H&P) dated 7/27/25, the H&P indicated that the resident has the capacity to understand and make decisions.During a review of…

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

Based on observation, interview, and record review, the facility failed to:1. Ensure the licensed nurse documented the administration of Tramadol (a controlled substance with the potential for addiction- can treat moderate to severe pain) in the Medication Administration Record (a vital document in healthcare that accurately tracks and records all medications administered to a patient) right after the medication was administered to one of three residents (Resident 16) reviewed under the Medication Storage and Labeling task.2. Ensure the licensed nurse documented the administration of Norco (a controlled substance with the potential for addiction- used to relieve pain severe) right after the medication was administered for one of three (Resident 67) residents investigated under the Medication Storage and Labeling task.This deficient practice increased the risk of diversion (any use other than that intended by the prescriber) of controlled mediations and that Residents 16 and 67 could have received too much or too little medication due to lack of documentation possibly resulting in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that all drugs and biologicals used in the facility were properly stored and labeled in accordance with professional standards in two of three inspected medication carts by:1. Failing to label a box of Artificial Tears (eye drops that moisten dry eyes) with a resident's name but instead used a last name, during the investigation of Medication Cart 1, Station 1.2. Medication Cart 1, Station 2 had four loose, unlabeled pills left in the medication cart. These deficient practices had the potential for a resident to receive medication not intended for that resident or incorrect, contaminated, or expired medication.Findings: 1. During a review of Resident 98’s admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated the resident was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included hypertension (high blood pressure).…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 menu and did not meet nutritional needs of residents when the Swedish meat ball portions were four (4) ounces (oz, a unit of measurement) instead of three (3) oz portions.This failure had the potential to decrease nutrient intake of protein resulting in unplanned weight loss to 78 of 122 residents on regular texture (texture of food with no restrictions and modifications) diet and ineffective diet therapy of 38 of 122 residents on consistent carbohydrate (CCHO, diet consisting of the same amount of carbohydrate each meal), renal diet (diet consisting of food with limited amount of protein, sodium, potassium and phosphorus) getting food from the kitchen.Findings:During a review of the facilities' daily spreadsheet (a list of food, amount of food that each diet would receive) titled Summer Menus, dated 7/28/2025, the spreadsheet indicated residents on regular texture diet would include the following foods on the tray: Swedish meatballs 2 pcs Gravy 1-2 oz Over egg noodles 1/2 cup (c, household…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 prepare food by methods that conserve temperature when raspberry parfait was at 52 degrees Fahrenheit ( F, a degree of temperature) and puree raspberry parfait was at 59 F.This deficient practice placed 121 of 122 facility residents on regular (texture of food with no modifications and restrictions) and modified texture diet at risk of unplanned weight loss, a consequence of poor food intake, getting food from the kitchen.Findings:During a review of the facilities' daily spreadsheet (a list of food, amount of food that each diet would receive) titled Summer Menus, dated 7/28/2025, the spreadsheet indicated residents on regular texture diet would include the following foods on the tray: Swedish meatballs 2 pcs Gravy 1-2 oz Over egg noodles 1/2 cup (c, household measurement) Fresh zucchini and carrots 1/2 c Orange slice Wheat roll 1 Margarine 1 teaspoon Raspberry parfait square 2x2 1/2 inches Milk 4 oz During a review of the facility's daily spreadsheet titled Summer Menus, dated 7/28/2026, the spreadsheet…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 sanitary food storage and food preparation practices in the kitchen when: 1. Kitchen equipment and kitchen areas were not cleaned and sanitized.a. Reach in freezer bottom shelves had boxes particles and dirt debris.b. The ice cream reach-in freezer had dirt and dust debris.c. The bread refrigerator had dried juice and milk sticky food spill.d. Reach in refrigerator vent had dust buildup.e. Walk in refrigerator vent had dust buildup.f. Ice buildup in the walk-in freezer door.g. [NAME] particles on the dry storage room floorh. Can opener container have had dust and dirt buildup.i. The condiment container had salt, pepper, sugar, artificial sweetener and dust debris.j. Hood and hood light where the staff cook food had dust and dirt particles.k. Mixer had dust and was not cleaned after use. l. The rack for clean pans storage had dust particles. m. The vending machine used for residents had dust particles.2. There is no thermometer inside the bread reach-in refrigerator.3. One (1) dented can 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 observation, interview, and record review, the facility failed to dispose garbage and refuse properly when two (2) of 2 dumpsters (a movable waste container designed to be brought and taken away by a special collection vehicle, or to a bin that a specially designed garbage truck lifts) were not covered while not actively being used and there were soiled gloves and food juices on the floor. This failure had potential to attract birds, flies, insects, pests and possibly spread infection to 121 of 122 facility residents. Findings:During a concurrent observation and interview on 7/29/2025 at 9:54 a.m. of the dumpster with the Dietary Supervisor (DS), observed one dumpster was overfilled with trash, not completely covered, the other dumpster's lid was opened and there were liquid drippings and soiled gloves on the dumpster floor. The DS stated the dumpsters were full of trash and it was not completely closed and covered. The DS stated there were flies going in and out already and it needed to be closed to prevent flies and pest. The DS stated flies and insects could spread…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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:a. Ensure pain assessments were accurately documented for two out of three residents investigated under the pain care area (Residents 11 and 111) when the site of pain was not correctly documented as a part of the pain assessment. This failure resulted in Residents 11 and 111 having incorrectly and incompletely documented pain assessments.b. Clarify hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) orders were clear and accurate for one of five sample residents (Resident 12).This deficient practice placed Resident 12 at risk for unnecessary dialysis treatment and potential for electrolyte imbalance. c. Ensure accuracy of records when Licensed Nurse 3 (LVN 3) who did not sign controlled drug count sheet at the shift change time on 7/29/2025, signed afterwards, but did not document the entry as a late entry (documentation made after the time of the event).This had the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to:1. Ensure facility staff donned (put on) and doffed (took off) an isolation gown (type of personal protective equipment [PPE- specialized clothing or equipment worn by an employee for protection against infectious materials] used in healthcare settings to protect healthcare personnel from the spread of infection or illness, particularly from contact with blood and body fluids) when entering and exiting a resident's room who was on enhanced barrier precautions (EBP -a set of infection control practices that use PPE to reduce exposure to reduce the spread of multidrug-resistant organisms [MDROs -microorganisms that are resistant to multiple classes of antibiotics and antifungals] in nursing homes) for one of seven sampled residents (Resident 6).This deficient practice had the potential to increase the risk of spreading infection to other residents and staff. 2. Ensure the nebulizer (changes medication from a liquid to a mist so you can…

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

Based on observation, interview, and record review, the facility failed to ensure the resident environment remains as free of accident hazards as is possible to two of four sampled residents (Resident 148 and Resident 18) reviewed under the accidents care area by:a. Failing to ensure Resident 148 was provided with a tab alarm (refers to a type of fall prevention device that utilizes a pull-string or cord to activate an alarm when a patient attempts to move, such as getting out of bed or a chair) while in bed as ordered by the physician. b. Failing to ensure Resident 18's side rails were the correct size as ordered by the physician.These deficient practices had the potential to result in increased risk of injuries for Resident 148 and Resident 18. Findings: a. During a review of Resident 148's admission Record, the admission Record indicated the facility admitted the resident on 7/24/2025 with diagnoses including history of falling and chronic kidney disease (kidneys are damaged and can't filter blood properly, leading to a buildup of waste in the body). During a review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to prevent significant medication errors (the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards) by giving hydralazine HLC (blood pressure medication) outside of the prescribed parameters (a fixed limit/range by the doctor to either give or hold a medication) for one of five sample Residents (Resident 12). This deficient practice placed Resident 12 at risk for potential hypovolemic shock (a critical condition resulting from a significant decrease in blood volume, leading to inadequate blood flow to the body's organs) or other adverse effects (unwanted, unintended result). Findings:During a review of Resident 12's admission Record, the admission Record indicated the facility originally admitted Resident 12 on 1/18/2023 and re-admitted the resident on 7/20/2025, with diagnoses including end stage renal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 that facility failed to implement their policy on homelike environment by failing to provide documented evidence that the facility checked residents ' room temperatures daily from 1/26/2025-1/28/2025. This deficient practice had the potential to keep residents from being provided a homelike environment and having comfortable room temperatures. Findings: During an interview with the Maintenance/Housekeeping Director (MHD) on 1/28/2025 at 11:52 am, the MHD stated that the facility checks the temperatures of residents ' room, three times a day. The first temperature should be taken by 9:00 a.m. The MKD stated that the facility temperatures are then documented in the facility ' s temperature log. During an interview and concurrent facility records review with the MHD on 1/28/2025 at 12:02 p.m., the MHD reviewed the facility documents titled, Air Temperature Monitor Log, dated 11/1/2024-1/25/2025. The MHD stated that there is no documented evidence that facility temperatures were checked on 1/26/2025-1/28/2025, for three (3) days. 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 remove two unidentified and unlabeled medication tablets found in one of five medication carts (Nursing Station 1 Medication Cart Two [2]). This deficient practice had the potential for the residents to receive medications with improper efficacy due to improper storage condition of medications. Findings: During a concurrent medication storage observation and interview on 8/28/2024 at 12:29 p.m. with the Infection Prevention Nurse (IPN), observed one unidentified and unlabeled pink tablet and one unidentified and unlabeled white tablet in Nursing Station 1 Medication Cart Two. The IPN stated that all medications must be labeled indicating the name of the resident, name of medication, medication dose, and the expiration date of the medication. During an interview on 8/28/2024 at 1:13 p.m., Licensed Vocational Nurse 1 (LVN1) stated unlabeled and contaminated medications should have been immediately removed from the medication cart to prevent any medication error. LVN 1 further stated that she forgot to discard…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were kept safe from injury and accident hazards for three of six sampled residents (Resident 163, Resident 164, and Resident 29) by failing to: 1. Ensure residents' medications, who had no self-administration assessment, were not left unattended at the bedside for Resident 163 and Resident 164. This deficient practice had the potential for other residents to enter the room and take another resident's medication and could experience adverse side effects (undesired harmful effect resulting from a medication or other intervention). 2. Ensure Resident 29 had bedside floor mats (cushioned foam mats which reduce the risk of injury from a fall) placed next to the resident's bed as indicated in the care plan. This deficient practice placed Resident 29 at an increased risk of sustaining an injury from a fall. Findings: 1.a. During a review of Resident 164's admission Record, the document indicated the facility admitted the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure licensed nurses provided non-pharmacological interventions (any type of healthcare intervention which is not primarily based on medication) prior to administering as needed (PRN) opioid medication (powerful pain-reducing medications) on multiple days for two of 27 sampled residents (Residents 11 and 83). This deficient practice had the potential to place the resident at increased risk of experiencing adverse side effects (undesired harmful effect resulting from a medication or other intervention) from opioid pain medication. Findings: a. During a review of Resident 11's admission Record, the record indicated the facility admitted the resident on 4/27/2024 with diagnoses including encephalopathy (a general term for a group of conditions that affect the brain's function or structure, such as diseases, disorders, or damage), migraine headache (a type of headache that cause moderate to severe, throbbing pain on one side of the head or behind the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement infection control policy and procedure by failing to: 1. Ensure two visitors were for two of four days screened for signs and symptoms of Coronavirus disease-2019 (COVID-19, a highly contagious viral infection that can trigger respiratory tract infection). This deficient practice had the potential to spread COVID-19 to residents in the facility. 2. Ensure Dietary Aide 1 (DA 1) washed their hands after touching a trash can lid. These failures had the potential to result in harmful bacteria growth and cross contamination (a transfer of harmful bacteria from one place to another or one object to another) that could lead to foodborne illness (illness caused by food contaminated with bacteria, viruses, and other toxins) in 110 of 114 residents who received food from the kitchen. 3. Ensure a resident's oxygen nasal cannula tubing (a device that gives additional oxygen through the nose) was labeled for one of one sampled resident…

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

Based on interview and record review, the facility failed to ensure a facility staff knocked and asked permission prior to entering a resident's room for one of five sampled residents (Resident 413). This deficient practice violated the resident's rights to be treated with respect and dignity which had the potential to affect the resident's sense of self-worth and self-esteem. Findings: During a review of Resident 413's admission Record, the document indicated the facility admitted the resident on 8/8/2024 with diagnoses including muscle weakness, history of falling, and chronic kidney disease (kidneys are damaged and can't filter blood the way they should). During a review of Resident 413's History and Physical (a formal assessment that a physician performs on a resident, which includes a medical history, physical exam, and documentation of findings) dated 8/9/2024, the document indicated that the resident had the capacity to understand and make decisions. During a concurrent observation and interview on 8/20/2024 at 8:49 a.m., with Registered Nurse 1 (RN 1), observed RN 1 enter…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Certified Nursing Assistant 1 (CNA 1) fully closed a resident's privacy curtain while providing care for one of 27 sampled residents (Resident 96). This deficient practice violated the resident's right to privacy. Findings: During a review of Resident 96's admission Record, the document indicated the facility admitted the resident on 3/17/2024 with diagnoses including difficulty in walking, generalized muscle weakness, and glaucoma (a chronic eye disease that can cause vision loss and blindness). During a review of Resident 96's History and Physical (H&P - a formal assessment by a healthcare provider that involves a resident interview, physical exam, and documentation of findings), dated 3/18/2024, the document indicated the resident had the capacity to understand and make decisions. During a review of Resident 96's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 7/10/2024, the document indicated the resident had intact cognition (thought processes) and required…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of two sampled resident rooms (Room A) occupied by four residents (Resident 100, Resident 167, Resident 168, and Resident 363) was within the temperature range of 71 degrees Fahrenheit (F, a unit of measure for temperature) to 81 F. This deficient practice had the potential to create an uncomfortable environment and for the residents to become dehydrated (condition occurring when a harmful reduction in the amount of water in the body). Findings: a. During a review of Resident 100's admission Record, the document indicated the facility admitted the resident on 5/21/2024 and re-admitted the resident on 7/15/2024 with diagnoses that included end stage renal disease (chronic irreversible kidney failure) and dependence on dialysis (a medical procedure to remove waste from the body when the kidneys are unable to). During a review of Resident 100's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act by failing to report to the State Survey Agency (SSA) an allegation of physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) by one of three sampled residents (Resident 364). This deficient practice resulted in a delay of an onsite inspection by the SSA to ensure the safety of the other residents and had the potential to result in unidentified abuse. Findings: During a review of Resident 364's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe) and respiratory failure (when not enough oxygen passes from the lungs to the blood) with hypoxia (low levels of oxygen 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 interview and record review, the facility failed to ensure a water pitcher was not left at bedside for one of one sampled resident (Resident 317) who was on strict fluid restrictions. This failure placed Resident 317 at an increased risk for injury and or hospitalization related to hypo-osmolality (a condition where the levels of electrolytes [substances that have a natural positive or negative electrical charge when dissolved in water], proteins, and nutrients in the blood are lower than normal) and hyponatremia (a condition where the level of sodium in your blood is lower than normal). Findings: During a review of Resident 317's admission Record, the document indicated the facility admitted the resident on 7/3/2024 with diagnoses that included hypo-osmolality and hyponatremia, hypokalemia (a condition where the level of potassium [a type of electrolyte] in your blood is lower than normal), kidney failure (when the kidneys [organ that filters waste and extra water from the blood and turns it into urine] are not able to filter any more), and muscle weakness. During a review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident was provided a scheduled toileting plan (or bladder [a sac-shaped muscular organ that stores the urine secreted by the kidneys] training, which can involve assisting a resident to the restroom at specific timed intervals) for one of two residents (Resident 4). This deficient practice has the potential for Resident 4 to not to achieve or restore normal bowel (a tube-shaped organ in the abdomen that helps the body digest food and absorb nutrients) and bladder function. Findings: During a review of Resident 4's Face Sheet (admission record), the face sheet indicated the resident was admitted to the facility on [DATE] with diagnoses that included adult failure to thrive (a general decline in health in older adults) and extrarenal uremia (increased waste products in the blood that is normally removed by the kidney but caused by conditions outside of the kidneys). During a review of Resident 4's Minimum Data Set (MDS, a standardized…

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

Based on interview and record review, the facility failed to complete a post-dialysis (the removing of waste and excess fluid to prevent build up in the body for residents who have loss of kidney [organs that remove waste products from the blood and produce urine] function) assessment for one of one sampled resident (Resident 102). This deficient practice placed Resident 102 at risk for complications of dialysis such as redness at the dialysis access site (way to reach the blood for hemodialysis), edema (too much fluid trapped in the body's tissues), excessive bleeding, and a change in vital signs (clinical measurements that indicate the state of a patient's essential body functions). Findings: During a review of Resident 102's admission Record, the document indicated the facility admitted the resident on 6/23/2024 with diagnoses including end stage renal disease (ESRD - a condition when the kidneys cannot filter blood anymore), dependence on renal dialysis, and muscle weakness. During a review of Resident 102's History and Physical (H&P- a formal assessment by a healthcare provider…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 meet professional standards of quality of care by failing to ensure a lidocaine patch (eases pain by numbing the nerves and making them less sensitive to pain) was removed after 12 hours from application as per physician's order for one of five sampled residents (Resident 413). This deficient practice had the potential in excessive dosing and a potential to cause adverse reaction (undesired harmful effect resulting from a medication or other intervention). Findings: During a review of Resident 413's admission Record, the document indicated the facility admitted the resident on 8/8/2024 with diagnoses including muscle weakness, history of falling, and chronic kidney disease (your kidneys are damaged and can't filter blood the way they should). During a review of Resident 413's History and Physical (a formal assessment that a physician performs on a resident, which includes a medical history, physical exam, and documentation of findings) dated 8/9/2024, indicated that the resident had the capacity to understand and make…

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

Based on interview and record review, the facility failed to ensure licensed nurses monitored for side effects while a resident received an anticoagulant medication (medications that prevent and treat blood clots in the heart and blood vessels) for two of 27 sampled residents (Resident 73 and Resident 364). This deficient practice had the potential to result in the residents experiencing adverse side effects (undesired harmful effect resulting from a medication or other intervention) from the anticoagulant. Findings: a. During a review of Resident 73's admission Record, the record indicated the facility originally admitted the resident on 8/17/2021 and readmitted the resident on 3/12/2024 with diagnoses including atherosclerotic heart disease (a vascular disease that occurs when arteries thicken and stiffen, restricting blood flow to the heart and other organs). During a review of Resident 73's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 8/2/2024, the MDS indicated the resident had moderately impaired cognition (thought processes) and required…

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

Based on observation, interview and record review, the facility failed to ensure a vial of insulin (hormone that lowers the level of glucose [sugar] in the blood) that was past the discard date, was not stored in one of three medication carts (Medication Cart A) for one of one sampled resident (Resident 85). This deficient practice had the potential for an expired insulin to be administered to Resident 85 which could result in uncontrolled blood glucose (the primary sugar in the blood and the body's main source of energy). Findings: During a review of Resident 85's admission Record, the document indicated the facility admitted the resident on 7/19/20204, with diagnosis of diabetes mellitus (DM - a chronic condition that affects the way the body processes blood glucose [sugar]). During a review of Resident 85's Minimum Data Set (MDS - a standardized assessment and screening tool) dated 7/26/2024, the document indicated the resident had the ability to sometimes understand others and the ability to sometimes make self-understood. The MDS indicate that Resident 85 required assistance…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff (Cook 1) failed to check the temperature of all of the food items on the tray line (a system of food serving in which a tray is moved along an assembly line to ensure a resident gets their prescribed diet) during mealtime service on 8/21/2024 at 1:25 p.m. This deficient practice had the potential to result in harmful bacteria growth and cross contamination (a transfer of harmful bacteria from one place to another or one object to another) that could lead to foodborne illness (illness caused by food contaminated with bacteria, viruses, and other toxins) in 110 of 114 medically compromised residents who received food from the kitchen. Findings: During a kitchen tray line observation on 8/21/2024 at approximately 12 p.m., observed [NAME] 1 check the temperatures of the food on the tray line. Observed [NAME] 1 fail to check the temperature of the following food trays : 1. Puree (a very smooth, crushed, or blended food) potato 2. Chopped Turkey 3. Chicken During an interview with [NAME] 1 on 8/21/2024 at 1:25 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 interviews and record review, the facility failed to ensure Registered Nurse 1 (RN 1) transcribed a physician order accurately and administered the prescribed dose of lisinopril-hydrochlorothiazide (a combination of medication used to treat hypertension) as ordered by the physician for one of three sampled residents (Resident 1) between 3/30/2024 to 3/31/2024 and 4/1/2024 to 4/16/2024. Resident 1 was administered a total of 13 incorrect doses of lisinopril-hydrochlorothiazide. This deficient practice placed Resident 1 at risk for serious health complications as a result of being administered lisinopril-hydrochlorothiazide when the blood pressure (BP - pressure of circulating blood against the walls of blood vessels, normal range less than 120/80 millimeters of mercury [mmHg - unit of measure]) was less than 140/80 mmHg. This can lead to low blood pressure, lightheadedness, dizziness, and weakness. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a copy of the Notice of Proposed Transfer or Discharge (NPTD) Form for facility-initiated transfer (the resident expects to return to the facility) or discharge (when return to the facility is not expected) was sent to a representative of the Office of the State Long-Term Care (LTC) Ombudsman Program (advocates for residents in nursing homes) before transfer, discharge or in emergency situations as soon as practicable for 14 of 23 sampled residents (Residents 5, 6, 7, 8, 9, 10, 11, 12, 13, 16, 17, 18, 22, and 24). As a result, Residents 5, 6, 7, 8, 9, 10, 11, 12, 13, 16, 17, 18, 22, and 24 were denied protection and advocacy in the event residents were inappropriately or involuntary transferred or discharged from the facility. Findings: 1. A review of Resident 5 ' s admission Record indicated the facility originally admitted the resident on 12/4/2022 and re-admitted Resident 5 on 12/28/2022. A review of Resident 5 ' s Physician ' s Order 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 ensure that one of three sampled residents (Resident 1) had a physician ' s order to administer supplemental oxygen (O2- a treatment that provides you with extra oxygen to breathe in) prior to providing the resident with oxygen. This deficient practice had the potential to result in complications from lack of sufficient oxygen level in the body and lead to shortness of breath (SOB), rapid breathing, confusion, and loss of consciousness and irregular heartbeats. Findings: A review of Resident 1 's admission Record indicated the facility admitted the resident on 2/13/2020 and readmitted the resident on 6/25/2020 with diagnosis including cerebral infarction (damage to tissues in the brain due to a loss of oxygen) and hypoxia (low levels of oxygen in your body tissues). A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 11/11/2023, indicated the resident is able to understand others and is understood by others. The MDS further indicated that Resident 1 needed moderate…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 one of two sampled residents (Resident 4) received prescribed pain management by failing to administer pain medication as ordered by the physician. This deficient practice had the potential to result in confusion on the delivery of care and services rendered and may lead to inadequate management of resident ' s pain. Findings: A review of Resident 4 ' s admission Record indicated the facility admitted the resident on 9/10/2023 with diagnoses that included intervertebral disc disorder (a condition characterized by the breakdown of one or more of the discs that separate the bones of the spine, causing pain in the back or neck and frequently in the legs and arms) with myelopathy (compression of the spinal cord and nerve roots) of the lumbar region ( the lower end of the spinal column). A review of Resident 4 ' s Minimum Data Set (MDS - an assessment and care screening tool) dated 9/16/2023 indicated the resident had the ability to make self-understood and had the ability to understand others. A review of Resident…

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

Based on interview and record review, the facility failed to ensure the Medication Administration Record (MAR- the report that serves as a legal record of the drugs administered to a resident of a facility by a health care professional) and Controlled Drug Record (CDR - an accountability log signed by the nurse with the date and time each time a controlled substance [medications with a high potential for abuse] is administered to a resident) coincided and were accurately documented per facility policy for one of two sampled residents. (Resident 4). This deficient practice of failing to accurately account for the use of controlled substances increased the risk that medications may not be available for Residents 4 when needed, and also puts the facility at increased risk for the potential loss, diversion (transfer of a medication from a legal to an illegal use), or accidental exposure to controlled substances. Findings: A review of Resident 4 ' s admission Record indicated the facility admitted the resident on 9/10/2023 with diagnoses that included intervertebral disc disorder (a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a resident ' s responsible party was informed of and explained any changes in Medi-Cal (a public health insurance program that provides free or low-cost medical services) share of cost (the amount you agree to pay for health care before Medi-Cal starts to pay) for one of three sampled residents (Resident 1). This deficient practice had a potential to result in the resident ' s responsible party inability to make an informed decision regarding payments, incurring late fees, and having a delinquent account. Findings: A review of Resident 1 ' s admission Record indicated Resident 1 was originally admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD- a group of lung diseases that block airflow and make it difficult to breathe), hemiplegia (partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) and hemiparesis (muscle weakness on one side of the body that can…

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

Based on observation, interview, and record review, the facility failed to ensure a resident ' s call light (device used by residents that when pressed informs facility staff that assistance is being requested) was placed within reach for one of five sampled residents (Resident 2). On 10/12/2023, observed Resident 2 ' s call light placed on the resident ' s bed and covered with the bed sheet, out of reach from Resident 2 who was sitting by the bed. This deficient practice had the potential to result in a delay with resident care, and residents not receiving assistance with activities of daily living (ADL- fundamental skills required to independently care for oneself, such as eating, dressing, getting into or out of a bed or chair, taking a bath or shower, and using the toilet). Findings: A review of Resident 2 ' s admission Record indicated the facility admitted the resident on 9/22/2023 with diagnoses including dementia (a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and osteoporosis (a condition in…

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

Based on interview and record review, the facility failed to provide oral hygiene (cleaning the mouth, teeth, and tongue) to one of five sampled residents (Resident 3), who required extensive assistance from staff with activities of daily living (ADL- describes fundamental skills required to independently care for oneself, such as eating, bathing, and mobility). This deficient practice had the potential to place Resident 3 at risk for diseases of the mouth, gums, and teeth. Findings: A review of Resident 3 ' s admission Record indicated the facility admitted the resident on 7/12/2023 with diagnoses including epilepsy (a long-term disease that causes repeated seizures [a sudden, uncontrolled burst of electrical activity in the brain] due to abnormal electrical signals produced by damaged brain cells). A review of Resident 3 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 7/17/2023, indicated, the resident was able to understand others, and was able to make self-understood. The MDS further indicated that Resident 3 required extensive assistance…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 administer tramadol (medication to treat pain) as prescribed by the physician to one of five sampled residents (Resident 1) who had a diagnosis of right shoulder replacement survey. This deficient practice had the potential to result in ineffectively managed pain for the resident and could result in unrelieved pain. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 8/12/2023. A review of Resident 1 ' s History and Physical Examination (H&P) dated 8/14/2023, indicated, the resident ' s right shoulder dislocated ( when your upper arm bone comes out of place from your shoulder socket) after a fall incident on 8/10/2023. A review of Resident 1 ' s General Acute Care Hospital ' s (GACH) Progress Note dated 9/1/2023, indicated, the Resident 1 had surgery a surgery known as right shoulder open reduction (surgeons reposition the pieces of your fractured bone surgically so that your bones are back in their proper alignment) and reverse total shoulder arthroplasty (joint…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 call lights were within residents' reach while in bed for two out of three sampled residents (Resident 3 and Resident 5). This deficient practice had the potential to result in resident falls and residents not being able to summon health care workers for assistance when needed. Findings: a. A review of Resident 3's admission Record indicated the facility admitted the resident on 4/7/2023 with diagnoses that included malignant neoplasm (cancer) of head, face and neck, sepsis (life-threatening complication of an infection), and respiratory failure (serious condition that makes it difficult to breathe on your own). A review of Resident 3's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 7/7/2023, indicated Resident 3 had moderately impaired cognitive (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills for daily decision making. The MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement infection control policy and procedures by failing to ensure a staff member (Certified Nursing Assistant 1 [CNA 1]) doffed (took off) their gown and gloves prior to exiting a Coronavirus disease-2019 (COVID-19, a highly contagious viral infection that can trigger respiratory tract infection) isolation room for two of two sampled residents (Resident 6 and Resident 7). CNA 1 was observed exiting a COVID-19 isolation room wearing gown and gloves, and then observed walking across the hallway to dispose of the used gown and gloves. This deficient practice had the potential for the spread of infection and cross contamination among residents. Findings: a. A review of Resident 6 ' s admission Record indicated the facility admitted the resident on 5/23/2023 with diagnoses that included cellulitis (a common and potentially serious bacterial skin infection) of right lower limb (leg), malaise (a general feeling of discomfort, illness, or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement the facility's pneumococcal vaccine (prevents infection from pneumonia [infection that infects one of both lungs]) policy by failing to ensure residents were provided education regarding the pneumococcal vaccine for two of five sampled residents (Resident 2 and Resident 4). This deficient practice had the potential for residents to not be aware of the risks and benefits of the pneumococcal vaccine. Findings: a. A review of Resident 2's admission Record indicated the facility admitted the resident on 8/1/2023 with diagnoses that included malignant neoplasm (cancer) of colon (large intestine) and coronavirus disease-2019 (COVID-19, a highly contagious viral infection that can trigger respiratory tract infection). A review of Resident 2's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 8/7/2023, indicated Resident 2 had intact cognitive (refers to conscious mental activities including thinking, reasoning,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 residents written material with information regarding formulating an Advance Directive (a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor), for three out of 14 sampled residents (Residents 504, 250 and 252) investigated for Advance Directives. These deficient practices violated the resident's right to be fully informed of the option to formulate an Advance Directive and had the potential to cause conflict due to a lack of communication regarding the resident's wishes about his medical treatment and delay care in an emergency. Findings: a. A review of Resident 504's admission Record indicated the resident was admitted to the facility on [DATE] with a diagnosis that included alcohol dependence with intoxication (a disturbance in behavior or mental functioning during or after alcohol…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 menu as written for residents on pureed diet (food that residents cannot normally chew) as evidenced by: 1. The residents on pureed diet received less food than residents on regular diet. 2. The residents on pureed diet received five ounces of the lasagna instead of eight ounces per menu. This deficient practice had the potential to result in weight loss due to inadequate caloric intake and delay recovery from illness or injury for 11 residents who were on puree diet. Findings: During a concurrent observation and interview, on 6/1/2021 at 11:36 a.m., [NAME] 2 was observed using a white handle scoop for puree lasagna. [NAME] 2 stated the white scoop was scoop size number six. During an interview with Dietary Supervisor (DS) on 6/1/21 at 11:57 a.m., the DS stated scoop size number six was five ounces. During an concurrent interview and record review, on 6/1/21 at 12:25 p.m., [NAME] 2 looked at the diet spreadsheet (meal serving size guide) for the puree entree and stated pureed diet should receive eight…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety as evidenced by: 1. Frozen foods and nutrition supplements thawing in the walk-in refrigerator with no thaw (frozen to liquid state) date or use by date. 2. Expired milk cartons in the walk-in refrigerator and expired boxes of food items in dry storage area was not properly disposed. 3. Unknown food items with no labels and date in the walk-in freezer and unknown items with no label and date in the residents' refrigerator. 4. One fruit cocktail can with side dented in the dry storage room was not properly disposed. 5. The can opener blade had dried black residue with the potential to harbor harmful bacteria that were not easily cleanable. 6. The ice machine parts were not maintained in a sanitary manner and proper sanitation practice not followed to prevent rust color residue surrounding the ice dispensing area. 7. Dietary Aide (DA…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program by: 1. Failing to clean and disinfect the glucometer (a small, portable machine that's used to measure how much glucose [a type of sugar] is in the blood) before and after using with one (Resident 18) of two sampled residents observed during medication administration. 2. Failing to clean and disinfect the blood pressure monitor (a device used to measure blood pressure, composed of an inflatable cuff to collapse and then release the artery under the cuff in a controlled manner) before and after use for one (Resident 14) of two sampled residents observed during medication administration. 3. Failing to ensure a resident's oxygen tubing was not on the floor for one (Resident 505) out of four sampled residents investigated for infection control. 4. Failing to ensure there were no two 8 ounce (oz) plastic cups, undated and unlabeled, filled with A & D ointment (a moisturizer to treat or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure there was a dignity bag (a cover for a catheter bag, used to protect one's dignity) to cover a resident's indwelling catheter (a tube inserted into the bladder allowing urine to drain from the bladder) drainage bag (bag used to collect urine) for one (Resident 84) out of one resident sampled for dignity. This deficient practice had the potential to affect the resident's sense of self-worth and self-esteem. Findings: A review of Resident 84's admission Record indicated the resident was originally admitted to the facility on [DATE] and was readmitted on [DATE] with a diagnosis that included retention of urine (a condition in which one's bladder does not empty completely). A review of Resident 84's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 05/04/2021, indicated the resident had severe impairment in cognition (the mental action or process of acquiring knowledge and understanding through thought,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to protect Resident 21's back brace (device used to support the lower back) from loss or theft, for one of one sampled residents. This deficient practice had the potential to result in limited functional movement and restricted participation in activities for Resident 21. Findings: A review of the admission Record indicated Resident 21 was originally admitted to the facility on [DATE], with diagnoses that included difficulty in walking, muscle weakness, and fracture of the backbone. A review of the Minimum Data Set (MDS - a standardized assessment and screening tool), dated 9/28/2020, indicated Resident 21 had intact cognition (mental action or process of acquiring knowledge and understanding) for decision-making. The MDS indicated Resident 21 required supervision to extensive assistance with activities of daily living (ADLs - routine activities people do every day). A review of Resident 21's Inventory of Personal Effects, dated 9/22/2020,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 Registered Nurse 2 (RN 2) verified gastrostomy tube (g-tube - a tube inserted through the belly that brings nutrition directly to the stomach) placement before administering medications, as indicated in the policy, for one (Resident 507) out of six sampled residents observed for medication administration. This deficient practice had the potential to result in the resident not receiving his medications. Findings: A review of Resident 507's admission Record indicated the resident was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included dysphagia (difficulty swallowing) and gastrostomy status (resident has a gastrostomy tube [g-tube - a tube inserted through the belly that brings nutrition directly to the stomach]). A review of Resident 507's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 03/25/2021, indicated the resident had severely impaired…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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: 1. Failed to provide a resident with heel protectors (a medical device usually constructed of foam, air-cushioning, gel, or fiber-filling, and is designed to minimize or remove weight on the heel) and failed to offload (minimize or remove weight placed on the foot to help prevent and heal ulcers) the resident's heels, as ordered by the physician, for one (Resident 43) out of four sampled residents investigated for pressure ulcer/injury (injury to skin and underlying tissue resulting from prolonged pressure on the skin). This deficient practice had the potential to increase the resident's risk of developing a pressure ulcer. 2. Failed to ensure the resident's low air loss mattresses (LALM - a pressure-relieving mattress used to prevent and treat pressure ulcers was set according to the resident's weight per manufacturer's guidelines, for one (Resident 39) out of four sampled residents investigated for pressure ulcer/injury. This deficient practice…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 monitor nutritional parameters for Resident 1's insidious weight loss (gradual, unplanned progressive weight loss over time) for one of one sampled resident (Resident 1). This failure had the potential to result in continued undesirable weight loss. Findings: During a review of the admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease (a disease that causes obstructed airflow from the lungs), generalized muscle weakness, essential hypertension (high blood pressure), and asthma (a condition where a person's airways become inflamed that causes difficulty in breathing). During a review of the Minimum Data Set (MDS- a standardized assessment and care-planning tool, dated 5/14/2021, indicated Resident 1 had severe cognitive impact function. The MDS indicated Resident 1 required one person physical assistance for bed mobility, limited assistance with one…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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: 1. Failed to provide a resident with a sack lunch while at the dialysis (the process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally) center for one (Resident 40) out of two sampled residents investigated for dialysis. This deficient practice had the potential to cause discomfort to the resident and increase the resident's risk of not getting enough nutrients. 2. Failed to ensure a reliable transportation to the dialysis center was available for one (Resident 252) out of two sampled residents reviewed under the care area of dialysis. This deficient practice resulted in Resident 252's missing two scheduled dialysis treatment with the dialysis center and may have contributed to resident's transfer to the general acute care hospital. Findings: a. A review of Resident 40's admission Record indicated the resident was originally admitted to the facility on [DATE] and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure it was free of medication error rate of five percent (5 %) or greater, as evidenced by the identification of five medication administration errors out of 29 opportunities (observations during medication pass) for error, to yield a cumulative error rate of 17.24 % for one (Resident 507) out of six sampled residents observed during medication administration. Registered Nurse 2 (RN 2) crushed all five medications and administered them all together at once when giving medications via gastrostomy tube (g-tube -a tube inserted through the belly that brings nutrition directly to the stomach) for Resident 507. This deficient practice had the potential to result in medication interactions, rendering them less effective for the resident. Findings: A review of Resident 507's admission Record indicated the resident was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included dysphagia (difficulty…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident's vancomycin (antibiotic medication used to kill bacteria in the intestines) was stored inside a refrigerator, as indicated on the label, for one (Resident 507) out of ten residents on antibiotics (medicines that fight infections caused by bacteria in humans and animals by either killing the bacteria or making it difficult for the bacteria to grow and multiply). This deficient practice had the potential to render the resident's antibiotic less effective. Findings: A review of Resident 507's admission Record indicated the resident was originally admitted on [DATE] and was readmitted on [DATE] with diagnoses that included sepsis (a life-threatening complication of an infection) and urinary tract infection (an infection in any part of your urinary system - your kidneys, ureters, bladder and urethra). A review of Resident 507's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 03/25/2021,…

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