Sequoia Vista

Based on interview and record review, the facility failed to ensure care conferences were conducted at least quarterly for one of four sampled residents (Resident 6). This failure had the potential for care needs to go unmet.Findings:During a concurrent interview and record review on 6/3/26 at 11:24 a.m. with Assistant Director of Nursing (ADON) and Social Services Director (SSD), Resident 6's documented care conferences were reviewed. ADON stated Resident 6's last two care conferences were conducted on 3/8/24 and 10/22/25. SSD stated care conferences should be conducted quarterly and for Resident 6 they were not.A care conference policy was requested, and not was provided.

Based on observation, interview, and record review the facility failed to ensure medication was available to administer for one of four sampled residents (Resident 8). This failure had the potential for Resident 8 to experience symptoms of anxiety (a feeling of worry).Findings:During a review of Resident 8's physician orders (PO), the PO, dated 5/13/26, indicated, BusPIRone HCl [medication used to relieve the symptoms of anxiety and anxiety disorders] Tablet 5 MG [milligram]. Give 2 tablet [sic] by mouth two times a day for m/b [manifested by] inability to relax related to ADJUSTMENT DISORDER WITH MIXED ANXIETY AND DEPRESSED MOOD 2 tablets = 10 mg.During a concurrent observation and interview on 6/3/26 at 9:42 a.m. with Licensed Vocational Nurse (LVN) 5, outside of Resident 8's room, LVN 5 prepared to give Resident 8 his morning medications. LVN 5 stated she was unable to find Resident 8's BusPIRone HCl in the medication cart.During a concurrent observation and interview on 6/3/26 at 9:44 a.m. outside of Resident 8's room, LVN 5 called the facility's pharmacy to re-order 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 observation, interview, and record review, the facility failed to ensure one of 15 sampled residents (Resident 20) received a diet as ordered by the physician. This failure had the potential to result in choking, difficulty chewing and swallowing, and inadequate nutritional intake.Findings:During a review of Resident 20's Order Summary Report (OSR), dated 6/3/26, the OSR indicated, on 5/8/26 Resident 20's physician ordered a no added salt, soft and bite sized diet. During a review of Resident 20's Care Plan Report (CPR), dated 3/23/26, the CPR indicated, [Resident 20] has nutritional problem or potential nutritional problem r/t [related to]. poor PO [by mouth] intake. Interventions. Licensed nurse to check trays for accuracy every meal. Provide and serve diet as ordered.During an observation on 6/1/26 at 12:28 p.m. in the dining room, Resident 20 was served a lunch plate that had a quesadilla (melted cheese in a toasted flour tortilla) cut into approximately 3-inch triangles. Resident 20 was not eating the quesadilla.During a concurrent observation and interview on 6/1/26…

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

Based on interview and record review, the facility failed to implement an effective antibiotic stewardship program (a coordinated healthcare initiative that ensures antibiotics are prescribed only when necessary and used correctly) for one of five sampled residents (Resident 35). This failure had the potential for Resident 35 to receive inappropriate antibiotics and had the potential for untreated infections.Findings: During a review of the facility's Infection Prevention and Control Surveillance Log (IPCSL), dated 4/18/26, the IPCSL indicated, Resident 35 had signs and symptoms. Dysuria [pain, burning, or discomfort during urination] .the organism on culture. not completed. treatment.Bactrim DS [antibiotic] twice a day for seven days. During a review of Resident 35's Lab [laboratory] Results Report (LRR), dated 4/17/26, the LRR indicated, 1) Please specify the test that was not performed: urine culture [a laboratory test that grows bacteria or yeast from a urine sample to diagnose urinary tract infections (UTIs). It identifies the exact type of germ causing the infection and…

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

Based on interview and record review, the facility failed to develop a plan of care for the refusal of immunizations (the process by which a person's immune system becomes fortified against an infectious disease through vaccination) for one of five sampled residents (Resident 18). This failure had the potential for staff to be unaware of monitoring the risks for the Resident 18, who did not receive immunizations.Findings: During a review of Resident 18's Resident Vaccine Consent Form (RVCF), dated 3/25/26, the RVCF indicated, Resident 18 refused immunization for Pneumococcal (bacterial infection of the lungs), RSV (Respiratory Syncytial Virus-serious lung disease), and TDAP (Tetanus- a life-threatening bacterial disease that affects the nervous system, causing painful muscle contractions and spasms, and Diphtheria - a highly contagious, serious bacterial infection and Pertussis-contagious respiratory infection). During a concurrent interview and record review on 6/3/26 at 10:43 a.m. with Infection Preventionist (IP), Resident 18's Clinical Record (CR) was reviewed. IP stated she…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 51 sampled residents (Resident 7) call light system was functioning properly. This failure had the potential to place Resident 7 at risk for delayed staff response to urgent needs and medical emergencies.Findings:During a review of Resident 7's Minimum Data Set (MDS, a standardized assessment tool), dated [DATE]. The MDS, section GG functional abilities indicated, Resident 7 needed staff assistance with activities of daily living, including transfers and toileting.During a concurrent observation and interview on [DATE] at 11:23 a.m. with Resident 7 in Resident 7's room, Resident 7 stated that the call light system had not been working for months. Resident 7 stated that she had informed multiple staff of this issue. Resident 7 stated that she had to go out to the hallway to call for help. Resident 7 pushed the call light that was on her bed to call for assistance. The call light did not light up in the hallway and did 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 interview and record review, the facility failed to verify one of four sampled respiratory therapists (RT 1) were licensed by the state, prior to hiring and performing respiratory care. This failure resulted in RT 1 providing respiratory care to residents without a state license and the potential to put residents at risk for harm. Findings:During a review of RT 1's New Hire Form (NHF) dated 7/14/25, the NHF indicated, Date of Hire.7/14/25.Position Title.RT.During a review of RT 1's Termination Form (TF) dated 4/14/26, the TF indicated, (RT 1) .termination date.4/14/26.failure to possess the licensure/certification required by the position.During an interview on 4/21/26 at 12:48 p.m. with Human Resources (HR), HR stated RT 1 was hired on 7/14/25 and worked as an RT. HR stated when an RT was hired their license was to be verified with the Department of Consumer Affairs prior to being employed. HR was unable to provide evidence of RT 1's state licensure being verified prior to hire. HR stated RT 1 did not have a state license prior to being hired or at time of termination.…

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

Based on interview and record review, the facility failed to notify the physician when one of three sampled residents (Resident 1) was refusing multiple doses of medications. This failure resulted in the physician being unaware of Resident 1's refusals and the potential for Resident 1 to experience adverse side effects.Findings:During a review of Resident 1's Order Summary Report (OSR-physician's orders) dated 4/1/26, the OSR indicated, buspirone (medication used to treat anxiety).give one tablet by mouth two times a day.start date 12/25/25.citalopram (medication used to treat depression).give one tablet by mouth one time a day.start date 3/4/26.Valporic acid (used to treat psychiatric disorders).give 10 ml (milliliters-unit of measurement) by mouth two times a day.start date 3/31/26.During a review of Resident 1's Medication Administration Record (MAR) dated 4/1/26-4/30/26, the MAR indicated, citalopram was refused on 4/1, 4/5, 4/7, 4/8 and buspirone and valproic acid were refused on 4/1, 4/2, 4/4, 4/5, 4/6, 4/7 and 4/8.During a concurrent interview and record review on 4/13/26 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 the physician was notified when one of three sampled residents (Resident 1) anti-psychotic medication (used to manage psychotic symptoms such as delusions [false belief], hallucinations [perception of something not present], paranoia [irrational and excessive mistrust], and disordered thought [disruption in the ability to organize, process, and articulate thoughts] was not available. This failure had the potential to result in Resident 1 experiencing an adverse reaction and/or an increase in behaviors.Findings:During a review of Resident 1's Psych (psychological) Eval (evaluation), & Medication Recommendation (PEMR) dated 3/30/26, the PEMR indicated, The patient (Resident 1) was evaluated following two recent episodes of significant aggressive acting out behavior within the facility.Recommendation for Medication Adjustments. increase Risperdal Consta (anti-psychotic medication) to 37.5 mg (milligrams-unit of measurement)/IM (intramuscularly) every 2 weeks.During a review of Resident 1's Order Summary Report…

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

Based on interview and record review, the facility failed to follow the physician's order and notify the physician when one of three sampled residents (Resident 1)'s blood sugar was above 250. This failure had the potential for Resident 1 to experience adverse side effects from an elevated blood sugar.Findings:During a review of Resident 1's Order Report (OR-physician's orders) dated 2/1/26-2/28/26, the OR indicated, Insulin Degludec (medication used to lower blood sugar) Inject 23 unit subcutaneously (injected in the fat layer between the skin and muscle) two times a day related to type 1 diabetes mellitus (disorder causing high blood sugar) with hyperglycemia (high blood sugar).hold if BS (blood sugar) less than 90, notify MD (doctor of medicine) if BS is greater than 250.start date 2/3/26.During a review of Resident 1's Medication Administration Record (MAR) dated 2/2026, the MAR indicated, Insulin Degludec.hold if BS less than 90, notify MD if BS is greater than 250 start date 2/3/26. The BS results were as follows:2/6 at 6 p.m. BS result 3302/7 at 6 p.m. BS result 3422/9 at 10…

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

Based on interview and record review, the facility failed to follow its policy and procedure when annual Performance Evaluations (PE) were not completed for two of six sampled staff (Certified Nursing Assistant [CNA 1, CNA 2]). This failure resulted in overdue performance evaluations. FindingsFindings:a. During a review of the facility's Employee Roster (ER) undated, the ER indicated CNA 1 was hired on 5/1/19.During a concurrent interview and record review on 3/9/26 at 1:04 p.m. with Human Resource/Payroll Manager (HRPM), CNA 1's employee file was reviewed. The last PE was completed 7/17/2024. HRPM stated CNA 1 should have had a PE completed in July of 2025.b. During a review of the facility's ER undated, the ER indicated CNA 2 was hired on 5/1/19.During a concurrent interview and record review on 3/9/26 at 1:06 p.m. with HRPM, CNA 2's employee file was reviewed. The last PE was completed 7/17/2024. HRPM stated CNA 2 should have had a PE completed in July of 2025.During an interview on 3/9/26 at 1:10 p.m. with Administrator, Administrator stated PE's should be done yearly.During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure an allegation of abuse was reported to the abuse coordinator for one of two sampled residents (Resident 1). This failure had the potential for the residents to be at risk for abuse.Findings:During a review of Resident 1's admission Record (AR) undated, the AR indicated, Resident 1 was admitted on [DATE] with diagnoses including metabolic encephalopathy (brain dysfunction caused by illness), difficulty in walking and cognitive (mental processes involved in gaining knowledge, understanding, and comprehension, including thinking, knowing, remembering, judging, and problem-solving) communication deficit.During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool) dated 1/30/26, the MDS indicated, Cognitive Patterns.BIMS (Brief Interview for Mental Status).13 (cognitively intact).Functional Limitation in Range of Motion.2 (impairment on both sides) lower extremity.mobility devices.wheelchair.Functional abilities.01…

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

Based on observation, interview, and record review the facility failed to follow its own policy and procedure (P&P) titled, Resident and Family Grievances, when no investigation was done for one of six sampled residents' (Resident 1) grievance. This failure resulted in no resolution in Resident 1's grievance and violation of Resident 1's rights.Findings:During an interview on 12/1/25 at 2:16 p.m. with Director of Staff Development (DSD), DSD stated on 11/15/25 Resident 1's Responsible Party (RP) had filed a grievance regarding Resident 1 not being provided with a personal bag and a sack lunch when transported to dialysis center (outpatient clinic that provide life-sustaining treatment) and bandage on Resident 1's dialysis port site (surgical access point) was not removed after returning from dialysis center. DSD stated Director of Nurses (DON) was made aware of the grievance. DSD stated, I did tell DON about it, and she said she was going to follow up on it.During a review of the facility report titled Concern/Grievance Log dated 11/15/25 indicated unhappy w/ [with] nursing staff.…

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

Based on observation, interview, and record review, the facility failed to:1. notify the responsible party (RP) when one of three sampled residents (Resident 1) was involved in a resident-to-resident altercation.2. assess, treat, monitor and notify the physician and the responsible party (RP) when one of three sampled residents (Resident 1) had a cut under his left eye, bruising on his left cheek and scabs to the left side of his nose and under his left eyebrow.These failures resulted in the physician and the RP being unaware of the wounds and the RP being unaware of the resident-to-resident altercation. Findings:During an interview on 11/14/25 at 8:59 a.m. with Family Member (FM/RP) 1, FM 1 stated when she was visiting Resident 1 on 11/12/25, and noted Resident 1 had a black eye and she was not made aware of the black eye or the resident-to-resident altercation Resident 1 was involved in.During a review of Resident 1's S (situation) B (background) A (appearance) R (Review and Notify) (SBAR-used to notify the physician of a change of condition) dated 11/11/25, the SBAR indicated,…

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

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), was treated with respect and dignity. This failure resulted in Resident 1 feeling intimidated and bullied.Findings:During an interview on 8/26/25 at 10:35 a.m. with Licensed Vocational Nurse (LVN), LVN stated she was in Resident 1's room during a conversation between Resident 1 and the Social Worker (SW). LVN stated SW gave attitude when responding to Resident 1's questions on 8/18/25. LVN stated SW's demeanor during her responses to Resident 1, was snarky.During an interview on 8/26/25 at 11:32 a.m. with Resident 1, Resident 1 stated she was talking with the Social Worker (SW) in her room on 8/18/25. Resident 1 stated SW intimidated and bullied her during their conversation.During a review of Resident 1's BIMS (Brief Interview for Mental Status- cognitive assessment tool used to evaluate a resident's mental status), dated 8/2/25, the BIMS indicated Summary Score - 15 (score of 13-15 means cognitively intact).During a review of the facility's policy and procedure (P&P)…

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

Based on interview and record review, the facility failed to follow its policy and procedure for one of three sampled residents (Resident 1) when an alleged misappropriation of resident property was not reported to Department of Public Health, Ombudsman, Adult Protective Services and Law Enforcement Officials within 24 hours. This failure resulted in a delay of the investigation.Findings:During a review of the Theft & Loss Form (TLF) dated 8/10/25, the TLF indicated Date & Time of Report.8/10/25.Description of missing items.money 600 dollars.During a review of Resident 1's Progress Notes (PN) dated 8/10/25 at 2:32 p.m., the PN indicated, CNA (Certified Nursing Assistant) approached writer and stated that the resident said she was missing personal belongings. Upon arrival RN (registered nurse) supervisor was in residents' room helping look for belongings. Writer called daughter (daughter name) and notified. Inventory sheet was reviewed. Resident filled out theft and loss form and turned into SS (Social Services). SS aware.During a review of the Report of Suspected Dependent…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 permit one of three sampled residents (Resident 1) to return to the facility after hospitalization. This resulted in Resident 1 having an unnecessary stay in the hospital and violated Resident 1's rights.Findings:During an interview on 8/6/25 at 10:38 a.m. with acute care hospital Social Worker (SW), SW stated Resident 1 was ready to return to the facility, but facility was not permitting Resident 1 to return.During a review of Resident 1's admission Record (AR), dated 3/20/25, the AR indicated Resident 1 was a female resident, admitted to the facility on [DATE] with diagnoses of Dementia (a progressive state of decline in mental abilities), Psychotic Disturbance (severe mental health condition), and Schizophrenia (a mental illness that is characterized by disturbances in thought).During a review of Resident 1's Minimum Data Set (MDS-a federally mandated resident assessment tool), dated 7/4/25, the MDS indicated Resident 1 had a BIMS (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 interview and record review, the facility failed to implement its policy and procedure (P&P) for one of three sampled residents (Resident 1) when the Inventory of Personal Effects (IPE) was not signed by the resident upon admit. This failure had the potential to result in missing personal effects.Findings:During a review of Resident 1's Inventory of Personal Effect (IPE) dated 4/10/25, the IPE indicated, Certification of Receipt.on admission.signed resident or resident representative. (blank indicating the resident did not sign the IPE).During a concurrent interview and record review on 7/15/25 at 1:10 p.m., with Social Service Director (SSD), Resident 1's IPE was reviewed. SSD stated when Resident 1 was admitted the IPE should have been signed by Resident 1, indicating all of Resident 1's belongings were inventoried.During a review of the facility policy and procedure (P&P) titled Resident Personal Belongings dated 2/2025, the P&P indicated, All resident personal items will be inventoried at the time of admission by the social services designee, or another designated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) choice to stay in room during a routine deep cleaning was respected and followed. This failure resulted in Resident 1 being forced out of her own room, in her bed and into the hallway for approximately one hour and resulted in Resident 1 feeling anxious (feeling of unease), almost in tears and violation of Resident 1's rights. Findings:During a review of Resident 1's admission Record (AR), dated 7/2025, the AR indicated Resident 1 was initially originally admitted on [DATE]. The AR indicated, Diagnosis.Major Depressive Disorder (mood causes persistent feeling of sadness and loss of interest) disorder that .social anxiety (intense fear of social situations), .During a review of Resident 1's annual Minimum Data Set (MDS-a federally mandated resident assessment tool) dated 6/10/25, the MDS indicated Resident 1 had a BIMS (Brief Interview for Metal Status-an assessment tool used by facilities…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an advance written notice of a new roommate assignment for one of six sampled residents (Resident 2).Monitor compatibility (being a good match, getting along well) for one of six sampled residents (Resident 2) when Resident 3 was moved into Resident 2's room.These failures resulted in a resident-to-resident altercation between Resident 2 and Resident 3, Resident 2 unable to sleep and violation in Resident 2's rights.Findings:During a concurrent observation and interview on 6/24/25 at 12:29 p.m. with Resident 2, Resident 2 was in his room lying in bed. Resident 2 stated he was not given notification prior to Resident 3 moving into his room on 6/10/25.During an interview on 6/24/25 at 1:47 p.m. with Social Service Assistant (SSA), SSA stated on 6/10/25 Resident 3 was moved to Resident 2's room. SSA reviewed Resident 2's clinical record and was unable to find documented evidence that a notice of a new roommate was provided to Resident 2.During an interview on 6/24/25 at 2:30 p.m. with Director of Nurses…

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

Based on observation, interview, and record review the facility failed to provide written grievance decision for one of six sampled residents (Resident 1). This failure resulted in violation of Resident 1's rights.Findings:During an interview on 6/23/25 at 9:59 am with Resident 1's Responsible Party (RP), RP stated a grievance was filed on 6/14/25 regarding Resident 1 having soiled gown. RP stated she has not received a written notice of decision.During a review of the facility log titled, Grievance/Concern Log the log indicated a grievance report was filed by RP on 6/14/25.During a concurrent interview and record review on 6/24/25 at 4:13 p.m. with Administrator, Administrator reviewed the grievance log and confirmed a grievance was filed on 6/14/25 by Resident 1's RP. Administrator stated the grievance has been resolved but was unable to find documented evidence that a written decision was given to Resident 1's RP.During a review of the facility's policy and procedure (P&P) titled, Resident and Family Grievances, dated 7/2022, the P&P indicated, g. In accordance with 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 supervision was provided for one of six sampled residents (Resident 5) with a known behavior of attempting to leave the facility unsupervised. This failure resulted in Resident 5 eloping from the facility without staff knowledge and having the potential for injury. Findings:During a review of Resident 5's Minimum Data Set (MDS-resident assessment tool) dated 5/13/25, the MDS indicated, Cognitive Patterns.BIMS (brief interview for mental status-evaluates residents cognitive ability (mental processes involved in acquiring knowledge and understanding through thought, experience, and the senses).12 (moderate cognitive function).Functional abilities.walk 50 feet with two turns.05 (helper assist only prior to or following the activity).During a review of Resident 5's S (situation) B (background) A (appearance) R (review and notify) (SBAR-used to communicate with physician) dated 6/17/25 at 4:20 a.m., the SBAR indicated, Came out from break room during lunch break and was notified by CNAs [Certified Nursing Assistant] that…

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

Based on interview, and record review, the facility failed to address one of three sampled residents' (Resident 1) change in condition when Resident 1 had below normal blood pressure (BP-the force of blood pushing against artery walls as your heart pumps) (normal BP is around 120/80 mm Hg {unit of measurement-millimeters of mercury} and low BP is a reading of lower than 90/60 mm Hg). This failure had the potential for Resident 1 experiencing adverse health outcomes. Findings: During an interview on 4/15/25 at 4:20 p.m. with Family Member (FM), FM stated Resident 1 would come back from dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) and would not be feeling good and would ask for his BP to be checked and it (BP) would be low, and they would do nothing about it (low BP). During a concurrent interview and record on 4/16/25 at 12:41 with Social Services Director (SS), the facility Grievance Log (GL) dated April 2025 was reviewed. The GL indicated Resident 1 filed a grievance complaint that Resident 1…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 two of three sampled resident's (Resident 1 and Resident 2) were provided nail care. This failure resulted in Resident 1 and Resident 2 having debris under their fingernails and untrimmed fingernails. Findings: During a concurrent observation and interview, on 1/27/25 at 10:38 a.m. with Resident 1 and Certified Nursing Assistant (CNA) 1, in Resident 1's room, Resident 1 was observed with untrimmed fingernails and dark brown debris under his fingernails. CNA 1 stated Resident 1's fingernails needed trimming and there was a little bit of everything (XXXis it food) under his fingernails. CNA 1 stated nail care was supposed to be provided to the residents on Sundays and Resident 1's nails should have been cleaned and trimmed yesterday. During a concurrent observation and interview, on 1/27/25 at 11:17 a.m. with Resident 2 and CNA 2, in Resident 2's room, Resident 2 was observed with untrimmed fingernails and dark brown debris under his fingernails. CNA 2 stated Resident 2's fingernails were untrimmed and had brown debris…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 Registered Nurse (RN) was scheduled and on duty eight hours a day, seven days a week. This failure had the potential for resident care to be negatively impacted. Findings: During a concurrent interview and record review on 12/5/24 at 2:28 p.m. with Human Resource Payroll Manager (HR), facility's staff schedule dated November 2024 were reviewed. The staff scheduled indicated, on 11/9/24, 11/23/24, and 11/24/24 there was no RN for 8 hours a day. HR stated there was no RN present in the building for 8 hours a day on these days. During a review of the facility's policy and procedure (P&P) titled, Nursing Services-Registered Nurse (RN), dated [DATE], the P&P indicated, The facility will utilize the services of a Registered Nurse for at least 8 consecutive hours per day, 7 days per week.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure Performance Evaluation (PE-a process to give employees feedback on their job performance) for three of eight sampled employees (Certified Nursing Assistance [CNA] 54, CNA 88, Terminated [T]CNA) were completed. This failure had the potential for staff not being aware of their need improvement in certain areas, which could affect patient care. Findings: During a concurrent interview and record review on 12/5/24 at 11:30 a.m. with Human Resources Payroll (HR), CNA 54's PE was reviewed. CNA 54 was hired on 6/22/21 and there were no PEs found in her file. HR stated no PE was done. During a concurrent interview and record review on 12/5/24 at 11:40 a.m. with HR, CNA 54's PE was reviewed. CNA 54 was hired on 4/5/22 and there were no PEs found in her file. HR stated no PE was done. During a concurrent interview and record review on 12/5/24 at 11:50 a.m. with HR, TCNA PE was reviewed. TCNA was hired on 6/11/23 and there were no PEs found in her file. HR…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 there was adequate communication to and from the Dietary Manager and RD for proper guidance to ensure food safety when a one of two sampled refrigerator unit (Refrigerator 1) that was not in good working condition remained in use to store TCS foods (Time Temperature Control for Safety - food that requires time-temperature control to prevent the growth of bacteria.) This failure had the potential to result in residents nutritional need not being met in safe manner. Findings: During an observation on 12/2/24 at 9:57 a.m. in the kitchen, there was a reach in refrigerator (Refrigerator 1) located in the middle of the kitchen next to trayline area and cook station (stove range). The inside of refrigerator 1 did not feel cold. Refrigerator 1 had an internal thermometer indicated 38 degrees F (Fahrenheit) with two individual sized yogurt containers, unopened, three cartons of butter milk, several trays of individually served containers of pudding, and 12 gallon containers of milk on the right hand side of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure proper storage, preparation, and distribution of food was in accordance with professional standards for food service safety when: 1. Kitchen had unsanitary food preparation conditions. 2. Facility only had non pasteurized eggs available for use. 3. Certified Nursing Assistant (CNA) 81 walked an uncovered salad to a resident's room down the hallway. 4. Did not ensure cold food storage refrigerator maintained a minimum temperature of 41 degrees. These failures had the potential for residents in the facility to develop foodborne illnesses. Findings: 1. During a concurrent observation and interview on 12/2/24 at 3:41 p.m. with Lead [NAME] (LC) 1 in the kitchen, there was an extensive amount of dry old egg debris on the stove range area. LC 1 stated it was dried up leftover egg from the morning breakfast. During an observation on 12/3/24 at 9:56 a.m. in the kitchen, there was a # (number) 8 scooper that had dry old food debris on it and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure two of two sampled residents (Resident 13 and Resident 22) smoking assessment was completed timely. This failure resulted in residents not being assessed for safety while smoking and had a potential for residents to be burned while smoking. Findings: During a concurrent interview and record review on 12/4/24 at 10:31 a.m. with Director of Nursing (DON), Resident 13's Smoking Safety Evaluation, (undated) was reviewed. Resident 13's admission record indicated, Resident 13 was admitted on [DATE] and there were no quarterly assessments completed after 9/13/23. DON stated Resident 13 should have had smoking assessment completed on 6/5/23, 12/6/23, 3/6/24, 9/6/24 but there were none completed during those dates. During a concurrent interview and record review on 12/4/24 at 10:42 a.m. with DON, Resident 22's Smoking Safety Evaluation, (undated) was reviewed. Resident 22's admission record indicated, Resident 22's initial admission date was 5/1/22 and…

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

Based on observation, interview, and record review, the facility failed to ensure medication error rate was five percent or less when five medication errors were observed out of 43 medication administration opportunities, which yielded a medication error rate of 11.63 percent. These failures had the potential for residents to not receive the therapeutic effects of the medications. Findings: During an observation on 12/3/24 at 9:20 a.m. in the 100-unit hallway, Licensed Vocational Nurse (LVN) 3 was preparing Resident 32's morning medications. LVN 3 crushed one tablet of chewable aspirin (lowers risk of heart attack, or blood clots) 81 milligram (mg), one tablet docusate sodium (stool softener) 100 mg, one tablet of metformin (helps lower blood sugar) 500 mg, two tablets of Keppra (used to treat seizures) 500 mg, and one tablet of Januvia (helps lower blood sugars) 100 mg and mixed them into a plastic medicine cup of pudding. During an observation on 12/3/24 at 9:40 a.m. in Resident 32's room, LVN 3 orally administered Resident 32's medications that had been crushed and mixed with…

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

Based on observation, interview, and record review, the facility failed to ensure five of eight sampled residents (Resident 82, Resident 79, Resident 238, Resident 239, Resident 241) with indwelling devices (device inserted into the body) had Enhanced Barrier Precautions (infection control intervention designed to reduce transmission of bacteria) in place. This failure had the potential to cause infection and adverse outcomes. Findings: During an observation on 12/2/24 at 10:58 a.m. in Resident 82's room, Resident 82 had an indwelling Foley catheter (collection bag with tubing going into resident's bladder) hanging from the side of her bed. During an observation on 12/3/24 at 9:52 a.m. in Resident 82's room, Resident 82 was not on Enhanced Barrier Precautions. No signage or Personal Protective Equipment (PPE-gown, gloves, mask, goggles) cart seen. During an interview on 12/4/24 at 8:52 a.m. with Licensed Vocational Nurse (LVN) 5, LVN 5 stated she was unaware if a resident with an indwelling device should be on Enhanced Barrier Precautions. During an interview on 12/4/24 at 8:54 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 interview and record review, the facility failed to have accurate informed consent (IC- process that ensures a person is provided the risks and benefits of treatment) for a psychotropic (medication to treat mental disorders) medication for one of six sampled residents (Resident 49). This failure had the potential for Resident 49 not being aware of the risks and benefits of taking psychotropic medications. Findings: During a review of Resident 49's Minimum Data Set (MDS- assessment tool) section C- Cognitive Patterns, dated 10/1/24, the MDS indicated Resident 49's Brief Interview of Mental Status (BIMS, 1-7 Severe cognitive impairment, 8-12 Moderate cognitive impairment, 13-15 Intact cognitive impairment) score was 2. During a review of Resident 49's History and Physical (H&P), dated 9/26/24, the H&P indicated, Due to recent admission and chronic illness and condition change this patient is at increased risk for losing a decision making capacity. During a concurrent interview and record review on 12/4/24 at 10:01 a.m. with Director of Nursing (DON), Resident 49's 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 observation, interview, and record review, the facility failed to promote care for one of 44 sampled residents (Resident 10) to maintain dignity and respect. This failure had the potential to affect Resident 10's individuality and psychological needs. Findings: During a review of Resident 10's admission Record (AR), dated 5/1/22, the AR indicated, Resident 10 was admitted on [DATE] with a diagnosis of Schizophrenia (chronic mental illness that affects a person thoughts, feelings, and behavior) and Dementia (decline in mental abilities). During a review of Resident 10's, Minimum Data Set- Section C-Cognitive Patterns (MDS- assessment tool), dated 9/7/24, the MDS-Section C indicated, Resident 10 had a Brief Interview for Mental Status (BIMS, 1-7 Severe cognitive impairment, 8-12 Moderate cognitive impairment, 13-15 Intact cognitive impairment) score of 8. During a review of Resident 10's, MDS- Section GG- Functional Abilities and Goals, dated 9/7/24, The MDS-Section GG indicated, Resident 10 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 44 sampled resident's (Resident 75) choices were being accommodated to get out of bed daily. This failure resulted in Resident 75 not participating in group activities and had a potential to result in psychosocial harm and a reduction in quality of life. Findings: During a review of Resident 75's Minimum Data Set (MDS, a Resident assessment screening tool), dated 9/27/24, the MDS indicated, in Section GG-Functional Abilities and Goals, Resident 75's lower extremities (hip, knee, ankle and foot) had Impairment on both sides, is dependent with care, and needs the use of a mobility device. During an interview on 12/2/24 at 11:08 a.m. with Resident 75, Resident 75 stated she would like to go to activities, but she was not able to get into a wheelchair because her knees were unable to bend. Resident 75 stated she needed a Geri-Chair (a large, padded chair that reclines and allows people with limited mobility sit comfortably while…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Responsible Party (RP) for one of five sampled residents (Resident 22) was notified when Resident 22 had a change of condition and had to be admitted to an acute care hospital setting. This failure resulted in Resident 22's RP being unaware of Resident 22's health status. Findings: During a concurrent interview and record review on 12/4/24 at 11 a.m. with Director of Nursing (DON), Resident 22's Change in Condition Evaluation -V 5.1 (COC), dated 2/27/24 was reviewed. The COC indicated, Stayed [Resident] unresponsive and was took by [Emergency Medical Technician] EMT to [Hospital]. The COC indicated, Resident is own RP. DON stated there was no family notified and family should have been notified. During a concurrent interview and record review on 12/4/24 at 11:08 a.m. with DON, Resident 22's COC, dated 9/5/24 was reviewed. The COC indicated, At time of transfer FSBS [Fasting Blood Sugar] was 100, but patient [Resident] not responding 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: 1. Give one of five sampled residents (Resident 192) the Advanced Beneficiary Notice (ABN- a form which gives the resident the choice to continue services under private pay if Medicare does not provide payment) with the appeal contact information. 2. Accurately complete the ABN for one of five sampled residents (Resident 195) when form was left incomplete and Resident 195 signed the form. These failures resulted in Resident 192 and Resident 195 not having the choice to appeal the decision or have knowledge of the costs to continue treatment in the facility. Findings: 1. During a concurrent interview and record review on 12/5/24 at 11:42 a.m. with Admissions Coordinator (AC), Resident 192's, Notice of Medicare Non-Coverage [NOMNC-Notification that Medicare will not pay for your current skilled nursing services] dated 9/11/24 was reviewed. The NOMNC indicated, Pt [Patient] asked to be off therapy [Occupational Therapy] on 9/3/24. Pt family member needed to be notified, [sic] that patient will be placed on RNA [Restorative…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 accurately complete the annual pre-admission screening assessment and resident review (PASRR-federal requirement to help ensure that individuals are not incorrectly placed in nursing homes or long-term care instead of a psychiatric setting) for two of six sampled residents (Resident 13, Resident 42). This failure had the potential for Resident 13, and Resident 42 to be placed in an inappropriate setting and not receive required services. Findings: During a review of Resident 13's Preadmission Screening Resident Review (PASRR) Level I Screening, dated 10/15/24, the PASRR indicated, Level I positive for SMI [Serious Mental Illness]/negative for ID [Intellectual Disability]/DD [Developmental Disability]/RC [Related Condition]. During an interview on 12/4/24 at 9:27 a.m. with Director of Nursing (DON), DON stated Resident 13 was positive for Level I SMI but there was no Level II PASRR performed on Resident 13. During a review of Resident 42's Preadmission Screening Resident Review (PASRR) Level I Screening, dated 6/23/24, 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 obtain a diet order upon admission to the facility for one of one sampled residents (Resident 22). This failure had the potential to resulted in unmet nutritional needs. Findings: During a review of Resident 22's admission Record (AR), (undated), the AR indicated, Resident 22 was admitted on [DATE]. During a concurrent interview and record review on 12/4/24 at 2:12 p.m. with Director of Nursing (DON) and Assistant Director of Nursing (ADON), Resident 22's Order Summary Report (OSR), dated 11/12/24, was reviewed. The OSR indicated, Diet; Controlled Carb [carbohydrate] diet [to manage diabetes (a blood sugar disorder)] thin pureed [a paste or thick liquid] texture, thin consistency. DON and ADON stated this was Resident 22's first diet order by the facility's physician and was completed four days after admission. During a concurrent interview and record review on 12/4/24 at 2:31 p.m. with ADON, Resident 22's nursing progress notes, dated 11/8/24 to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of four residents (Resident 10) was given the appropriate care and services to improve hearing and communication. This failure resulted in Resident 10 not having her communication needs met. Findings: During a review of Resident 10's admission Record (AR), dated 5/1/22, the AR indicated, Resident 10 was admitted on [DATE]. During a concurrent interview and observation on 12/3/24 at 9:37 a.m. with Resident 10 in Resident 10's room, Resident 10 was having a hard time hearing and required this surveyor to get close to her ear and speak loud and clear for her to understand. Resident 10 stated, I wish I had some hearing aids so I could hear you better. During an interview on 12/4/24 at 3:16 p.m. with Resident 10 and Social Service Designee (SSD), Resident 10 stated I can't hear, and I think my ears need to be cleaned out. I would like some hearing aids. SSD stated, she was not sure if Audiology (hearing specialist) Services had been…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 document the quantity consumed of a nutrition beverage supplement ordered to address significant weight loss for one of one sampled residents (Resident 22) ensuring the accuracy of nutrition assessments and ability to monitor effectiveness. This failure had the potential to ineffectively evaluate and delay timely revision of nutrition interventions needed to meet residents' nutrition needs. Findings: During a concurrent observation and interview on 12/2/24 at 12:56 p.m. with Certified Nursing Assistant (CNA) 9 and Resident 22 in Resident 22's room, Resident 22 had an unopened four (4) ounce (oz.) carton of chocolate flavored sugar free health shake (to increase calorie and protein intake) on her lunch meal tray. LN 1 translated in Spanish to Resident 22 to ask if she liked the health shake. Resident 22 stated she does not drink the health shake because she does not like it at all, even if it was a different flavor. Resident 22 stated she feels bad about her weight loss because it occurred too fast and that she…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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, one of four sampled Licensed Vocational Nurses (LVN 2) failed to: 1. Ensure a controlled medication was not accessible to staff and residents during medication pass. 2. Ensure a controlled medication was properly disposed of. These failures had the potential to result in diversion of a controlled medication. Findings: 1. During a concurrent observation and interview on [DATE] at 8:26 a.m. with LVN 2 in Resident 189's room, LVN 2 dropped a plastic medication cup containing Resident 189's Vitamin B12 (vitamins that help keep blood and nerve cells healthy) 1000 milligram (mg), Docusate (stool softener) 100 mg, Eliquis (blood thinner used to prevent and treat blood clots) 5 mg, Neurontin (used to treat seizures and nerve pain) 100 mg, Reglan (used for stomach and esophageal problems; nausea, vomiting, and heartburn) 5 mg, Jardiance (used to improve blood sugar levels in patients with diabetes) 10 mg, Prilosec (used to treat stomach acid) 20 mg, Iron (supplement…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 meal tray ticket and/or planned menu for two out of three sampled residents (Resident 62 and Resident 83). This failure had the potential for Resident 62 and Resident 83's nutritional goals not being met. Findings: During a concurrent observation and interview on 12/3/24 at 12:10 p.m. with the Registered Dietitian (RD) in the kitchen, Resident 62's lunch meal tray was placed onto a meal delivery cart and Meal Tray Ticket (MTT) indicated large portions. There was only one slice of garlic bread on the meal tray. RD stated two slices of garlic bread should have been served per the planned menu for large portion diet. During a review of Resident 62's Physician Diet Order (PDO), dated 7/12/24, the PDO indicated, Resident 62 had large portion for diet order type. During a concurrent observation and interview on 12/3/24 at 12:15 p.m. with the RD in the kitchen, Resident 83's MTT under standing orders indicated 4 oz [ounce], 2% [percent] milk. RD stated Resident 83's meal tray did not have the 4 oz, 2%…

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

Based on observation, interview, and record review, the facility failed to ensure the therapeutic diet was served in accordance with the diet order for one of three sampled residents (Resident 22). This failure had the potential for Resident 22 to choke. Findings: During an observation and record review on 12/2/24 at 12:56 p.m. in Resident 22's room, Resident 22's meal tray consisted of corn bread and chili (regular texture). Resident 22's meal ticket diet order indicated regular texture, CCHO (Consistent, constant, or controlled carbohydrate), thin liquid was crossed out and replaced with a handwritten notation of puree. During a review of Resident 22's Physician's Diet Order (POD) dated 12/2/24, the POD indicated, Resident 22 had puree as the diet texture order. During a concurrent interview and record review on 12/3/24 at 3:25 p.m. with Registered Dietitian (RD), RD reviewed a photo picture of Resident 22's lunch meal tray ticket dated 12/2/24. Resident 22's lunch meal tray ticket indicated diet order regular texture, CCHO, thin liquid was crossed out and replaced with 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 follow their policy and procedure (P&P) titled, FOOD FOR RESIDENTS FROM OUTSIDE SOURCES for one of one resident designated refrigerator (RDR). This failure resulted in undated and unlabeled food and had the potential for food contamination. Findings: During a concurrent observation and interview on 12/3/24 at 10:27 a.m. with Certified Nursing Assistant (CNA) 81 in the employee break room, the RDR had undated and unlabeled foil covered plated food items stored inside. CNA 81 stated all food stored inside the RDR should have been dated and labeled with the residents name. During an interview on 12/3/24 at 9:23 a.m. with Licensed Vocational Nurse (LVN) 5, LVN 5 stated the food stored in the RDR for residents should have the resident name and the date the food item was received. During a review of the facility's P&P titled, FOOD FOR RESIDENTS FROM OUTSIDE SOURCES, dated 2023, the P&P indicated, 5. Prepared foods, beverages, or perishable food that requires refrigeration, can be stored for the resident in the…

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

Based on interview and record review, the facility failed to ensure staff treated one of three sampled residents (Resident 1) with respect when Certified Nursing Assistant (CNA) 1 was using profanity when providing care. This failure resulted in Resident 1 not being treated with respect and had the potential for emotional distress. Findings: During a review of the facility's Report of Suspected Dependent Adult/Elder Abuse (SOC341) dated 11/6/24, the SOC 341 indicated, While providing care to resident it was alleged that CNA (Certified Nursing Assistant) [1] was verbally aggressive.Reported Types of Abuse.Verbal. During a review of Resident 1's Minimum Data Set (MDS-a federally mandated resident assessment tool) dated 11/15/24, the MDS indicated, BIMS (Brief Interview for Mental Status) Summary Score.05 (indicating severe cognitive impairment) During a review of Resident 1's S (Situation) B (Background) A (Appearance) R (Review) (SBAR-document used to notify physician of a change of condition), dated 11/7/24 at 7:00 p.m., the SBAR indicated, Staff members walking by residents room…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 facility's policy and procedure was followed when employment references were not checked prior to hiring for one of three sampled employees' (Certified Nursing Assistant - CNA 1). This failure had the potential to put residents at risk for abuse. Findings: During a review of CNA 1's Application for Employment (AFE) dated 10/8/24, the AFE indicated, CNA 1 listed two previous employers, [Facility 2] and [Facility 3], and three personal references. During a concurrent interview and record review on 11/18/24 at 12:05 p.m., with Director of Staff Development (DSD), CNA 1's Pre-Employment Reference Check (PERC) dated 10/8/24 was reviewed. The PERC indicated the employment reference check for Facility 2 and two personal references were verified. There was no reference check done for Facility 3. DSD stated the employment reference check for Facility 3 was not verified and should have been. During an interview on 11/18/24 at 12:32 p.m. with Assistant Administrator (AA), AA stated both of CNA 1's employment references…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 four sampled residents (Resident 1) responsible party (RP) was notified of Resident 1's redness to bilateral buttocks. This resulted in Resident 1's responsible party not being aware of the resident's redness on bilateral buttocks. Findings: During a review of Resident 1's Progress Notes, dated 8/7/24, indicated Resident 1 was admitted to the facility on [DATE], with redness to bilateral buttocks. There was also no evidence the facility notified the RP regarding Resident 1's redness to bilateral buttocks. During an interview on 8/26/24 at 1 p.m. with the RP, RP stated the facility did notify her of Resident 1's redness to bilateral buttocks. During an interview on 9/17/24, at 3 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 reviewed the medical record for Resident 1. LVN 1 confirmed she did not notify the RP of Resident 1's redness to bilateral buttocks. During an interview on 9/18/2024, at 1:30 p.m. with Director of Nursing (DON),…

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

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was treated with respect and dignity. This failure resulted in Resident 1's rights being violated. Findings: During a review of the facility's Five day Report (FDR), dated 7/26/24, the FDR indicated, On July 22, 2024.Resident 1 explained he needed a pillow and when CNA (Certified Nursing Assistant) came was delivering the pillow he heard her state, another pillow for your stinky butt or stinky butt pillow. During an interview on 7/26/24 at 11:21 a.m. with Director of Nursing (DON), DON stated Resident 1 reported while CNA 2 and CNA 1 were providing care to him, he asked for a pillow and CNA 2 made a comment to CNA 1 asking if it was for his stinky ass. DON stated Resident 1 reported the comment was made to CNA 1 and not directly to Resident 1 but Resident 1 did not like it. During an interview on 7/26/24 at 11:33 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated while CNA 2 was assisting her with providing incontinent care to Resident 1, CNA 2 said…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 in-service training was provided for one of two sampled Certified Nursing Assistant (CNA 1) before returning back to work when one of two sampled resident (Resident 1) had alleged CNA 1 and CNA 2 of having bad attitude and rushed care . This failure had the potential for CNA 1 to continue providing Resident 1 with a bad attitude and rushing while providing care. Findings: During a concurrent observation and interview on 7/17/24 at 10:15 a.m. with Resident 1 in her room, Resident 1 stated while providing care, some staff are sometimes a little bit rough. Resident 1 stated she felt staff just want to hurry up and get their job done so they can go to the next person. During a review of Resident 1's Interdisciplinary Team (IDT) noted dated 7/11/24 at 4:20 p.m., the IDT note indicated, resident alleged incident of potential abuse reported 7/11/24.family [name] reported statement of staff providing rushed care and bad attitude. During an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the physician was notified when medication was not administered as ordered for one of three sampled residents (Resident 1). This failure had the potential for Resident 1 to experience an adverse health outcomes. Findings: 1. During a review of Resident 1's Order Summary Report (OSR), dated 5/30/24, the OSR indicated, Lovenox [blood thinner used to prevent blood clots] injection. Inject 0.4 ml [milliliter] subcutaneously [injected beneath the skin] one time a day for blood clot prevention related to unspecified fracture [broken] of shaft of left tibia [leg bone].for 30 days.start date 5/10/24.end date 6/9/24. During a review of Resident 1's Medication Administration Record (MAR), dated May 2024, the MAR indicated Lovenox was not administered on 5/11/24, 5/12/24, 5/13/24, 5/14/24, 5/26/24, 5/27/24, 5/28/24, 5/29/24, and 5/30/24. There was a documentation of 9 in the box, meaning other/see nurses notes. During a review of Resident 1's Progress…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 two sampled resident ' s (Resident 1) ' s personal belongings were not taken by a staff member. This failure resulted in misappropriation of Resident 1 ' s property. Findings: During a review of the Facility Reported Incident (FRI), dated 2/2/24, the FRI indicated, On January 30th, 2024, [Resident 1] reported that she let an employee use her shoes and they did not bring them back. During investigation it was identified that an employee did. During a review of the Report of Suspected Dependent Adult/Elder Abuse (used by health facilities to report suspected abuse) (SOC341), dated 1/30/24, the SOC341 indicated, [Resident 1] stated that the staff member [Housekeeper (HSK) 1 name] stole her shoes.Reported Types of Abuse.Financial. During a review of the Termination Form (TF), dated 2/6/24, the TF indicated, [Housekeeper (HSK) 1] Termination.Involuntary Termination.Employee is not rehireable. 1. Theft, attempted theft, fiduciary malfeasance…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 supervision for one of three sampled residents (Resident 1). This resulted in the staff being unaware Resident 1 had eloped from the facility and was sent to the acute hospital. Findings: During a review of Resident 1 ' s History and Physical Reports (completed by Hospital 1) (H&P), dated 1/13/24 at 6:11 p.m., the H&P indicated, BIBA (brought in by ambulance) for fall, rolled out of wheelchair while going down the street, disoriented to year, no injury, no loc (loss of consciousness). During a review of Resident 1 ' s Progress Notes (PN), dated 1/15/24 at 4:30 p.m., the PN indicated, Resident left facility unsupervised 1/13/23. Upon identifying resident as out of facility nursing staff and social services immediately began looking for resident, called Visalia PD (police department) and notified RP (responsible party). Social Services received call back from Visalia police department who stated resident was located and taken to acute for further eval (evaluation). During an interview on 2/5/24 at 2:38 p.m., with…

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

Based on interview and record review, the facility failed to develop a care plan for one of three sampled residents (Resident 1) when Resident 1 was receiving wound care. This failure had the potential for staff to be unaware of how to care for Resident 1's wounds. Findings: During a review of Resident 1's Physician Orders (PO), undated, the PO indicated, Cleanse right heel with DWS (Dermal Wound Solution-helps prevent bacterial contamination), pat dry, swab with betadine (applied to wound to prevent bacterial growth) and leave open to air.Start date 11/29/23.Cleanse full thickness (extends through two layers of skin) surgical wound to the right distal (away from the center) abdomen proximal (nearer to the center) thigh with DWS.start date 11/28/23.cleanse incisional line above the open wound with DWS.start date 11/28/23. During a concurrent interview and record review, on 12/27/23 at 12:25 p.m., with Director of Nursing (DON), Resident 1's Care Plans (CP), were reviewed. There was no care plan developed for the wound care that was being provided. DON stated, the care plans for…

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

Based on observation, interview, and record review, the facility failed to ensure a TDC (Tunneled Dialysis Catheter- used to remove blood and return blood to the blood stream during dialysis) was monitored for signs and symptoms of infection after it was no longer in use for one of three sampled residents (Resident 1). This failure had the potential for Resident 1 to experience complications. Findings: During a concurrent observation and interview, with Resident 1, on 11/29/23 at 1:22 p.m., in the hallway, Resident 1 had a tunneled dialysis catheter (TDC-catheter used to removing blood and returning blood to the blood stream during dialysis) to the right side of his chest. There was no dressing on the TDC. Resident 1 stated, he no longer went to dialysis. Resident 1 stated, the nurses at the facility did not monitor, flush, or apply dressings to the TDC. During an interview on 11/29/23 at 1:23 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, she was unaware that Resident 1 no longer had dialysis and had not monitored or provided care to the TDC. During a concurrent…

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

Based on interview and record review, the facility failed to follow up on a medical appointment for one of three sampled residents (Resident 1) when Resident 1 no longer required dialysis and was to have a tunneled dialysis catheter (TDC-used to remove blood and return blood to the blood stream during dialysis) removed. This failure resulted in a delay in the removal of the TDC and had the potential to result in Resident 1 acquiring an infection. Findings: During a review of Resident 1's Progress Notes (PN), dated 10/16/23 at 10:50 p.m., the PN indicated, Dialysis order given to discontinue dialysis.[Facility 2 Name] to remove tunnel catheter (TDC). Appt (appointment) scheduled for Friday, Oct (October) 20th @ (at) 1:30pm. During a review of Resident 1's PN, dated 10/30/23 at 3:58 p.m., the PN indicated, Spoke with [Resident 1's] RP.updated with current health status and plan to d/c (discontinue) CVC (TDC). Resident is aware that consent is needed to d/c CVC (TDC) port. During a review of Resident 1's PN, dated 11/6/23 at 9:07 a.m., the PN indicated, Resident will be rescheduled for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents completed an Advance Directive (AD- legal document which specifies a person's health care related choices and what actions should be taken when the person is no longer able to make decisions for themselves because of illness or incapacity) Acknowledgement (ADA- asks if resident had or did not have an advanced directive) or were given the option to formulate an AD, for 16 of 20 sampled residents (Resident 63, Resident 16, Resident 66, Resident 4, Resident 21, Resident 5, Resident 45, Resident 19, Resident 51, Resident 14, Resident 1, Resident 44, Resident 55, Resident 81, Resident 10, and Resident 11). This failure had the potential for health care decisions to not be honored. Findings: During a review of Resident 63's medical record, no ADA was found. During a review of Resident 16's medical record, no ADA was found. During a review of Resident 66's medical record, no ADA was found. During a review of Resident 4's medical record, no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a notice of transfer was sent to the Ombudsman (representative who assist residents in long-term care [LTC] facilities with issues related to day-to-day care, health, safety, and personal preferences) for six of six sampled residents (Resident 2, Resident 19, Resident 36, Resident 56, Resident 84 and Resident 91). This failure had the potential to result in residents being discharged inappropriately and for their admission, discharge, and transfer rights to not be honored. Findings: During an interview on 11/7/23 at 11:47 a.m. with Social Services Director (SSD), SSD stated she is the only staff member that sends the Notice of Transfer/Discharge forms to the Ombudsman and notification should have been sent to the Ombudsman within 24-48 business hours of the transfer. During a review of Resident 2's Order Summary (OS), dated 9/20/23, the OS indicated, Resident 2 was transferred to the hospital. During a concurrent interview and record review 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: 1. Accurately complete the Minimum Data Set (MDS - comprehensive assessment tool identifying resident specific healthcare needs) assessment for two of two sampled residents (Resident 8 and Resident 61). 2. Ensure Brief Interview for Mental Status (BIMS- assessment to evaluate memory and orientation) assessments for two of two sampled residents (Resident 85 and Resident 91) were accurately completed. These failures had the potential to result in residents' health and mental status to not be appropriately incorporated into their plan of care. Findings: 1. During a concurrent interview and record review on 11/9/23 at 9:53 a.m. with Dietary Services Supervisor (DSS), Resident 8's quarterly MDS assessment, dated 10/25/23, was reviewed. DSS stated Resident 8 was admitted on [DATE] and weighed 170 lbs (measure of weight) and on 10/3/23 weighed 147 lbs which indicated a 13.5% weight loss. DSS stated Resident 8's quarterly MDS was inaccurate and indicated that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure Preadmission Screening and Resident Review (PASRR or PASSARR- screening potential residents for developmental or intellectual disabilities and/or serious mental illness and determine if a Level II evaluation is necessary to ensure the facility can provide necessary services for the resident) Level 1 Screening was accurately completed or revised as needed for six of 17 sampled residents (Resident 66, Resident 45, Resident 11, Resident 44, Resident 40 and Resident 68). This failure had the potential for residents to be placed in an inappropriate setting and not receive necessary services to meet their needs. Findings: During a concurrent observation and interview on 11/6/23 at 10:54 a.m. with Social Services Director (SSD), outside of Resident 66's room, Resident 66 was walking around his room. SSD stated Resident 66 only speaks Portuguese and his brother will sometimes come in and translate for him. During a review of Resident 66's PASRR, dated…

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

Based on observation, interview, and record review, the facility failed to: 1. Develop a care plan to include safe swallow strategies for one of one sampled residents (Resident 64). 2. Develop a care plan to address the residents preference of keeping his bed in a high position despite being a high risk for falls for one of one sampled residents (Resident 73). These failures had the potential to result in negative health outcomes for vulnerable residents. Findings: During a concurrent interview and record review on 11/07/23 at 9:24 a.m. with Director of Rehabilitation (DOR), Resident 64's medical record was reviewed and indicated: 1. There was no care plan addressing Resident 64's difficulty swallowing. DOR stated there should have been an care plan completed. During an interview on 11/7/23 at 9:41 a.m. with occupational therapist (OT), OT stated Resident 64 did not have a care plan for safe swallowing interventions and should have one. During an interview on 11/7/23, at 10:03 a.m. with DOR, DOR confirmed OT had not developed a care plan per DOR expectation to communicate 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 care conferences (Interdisciplinary meeting to plan resident's care) were conducted at least quarterly for one of six sampled residents (Resident 4). This failure resulted in Resident 4's right to be informed of and participate in his care planning to not be honored and had the potential for care needs to go unmet. Findings: During a concurrent interview and record review on 11/9/23 at 12:13 p.m. with Director of Nursing (DON) and Minimum Data Set Coordinator (MDSC), Resident 4's Care Conference Summary [CCS] dated 10/5/22 was reviewed. The CCS indicated the conference type was Quarterly and Resident 4 attended but there was no physician in attendance. MDSC stated Resident 4 had no other Care Conference since 10/5/22. DON stated care conferences have been missed due to staffing issues. During an interview on 11/9/23 at 4:03 p.m. with Clinical Resource Nurse (CRN), CRN stated the facility expectation is for care conferences to be completed on admission, quarterly, and as needed for changes in resident condition.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to complete resident assessments timely and accurately for seven of seven sampled residents (Resident 63, Resident 4, Resident 11, Resident 91, Resident 40, Resident 2 and Resident 73). This failure resulted in residents not being assessed, not being assessed accurately, appropriate care not being provided, and had the potential to result in other changes in residents status which could impact their quality of care to go undetected. Findings: During an observation on 11/6/23 at 10:58 a.m. in Resident 4's room, Resident 4 was observed to be coughing continuously. Resident 4's fingernails were long with dark debris under the nails. During an interview on 11/6/23 at 11:07 a.m. with Certified Nursing Assistant (CNA) 2, CNA 2 stated she was unsure how long Resident 4 had been coughing. During a concurrent observation and interview on 11/6/23 at 11:12 a.m. with CNA 2, in Resident 4's room, CNA 2 stated Resident 4's fingernails were not only long…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the controlled substance (highly addictive drug or chemical regulated to prevent abuse) count was being completed before and after each shift for two of five sampled medication carts (100 hall medication cart and 200 hall medication cart). This failure had the potential to result in loss or diversion (concept involving the transfer of any legally prescribed controlled substance from the individual for whom it was prescribed to another person for any illicit use) of controlled substances. Findings: During a concurrent interview and record review on 11/8/23 at 9:03 a.m. with Licensed Vocational Nurse (LVN) 1, the 100 hall's Shift Verification Of Controlled Drug Count (SVCDC), dated October 2023 was reviewed. The SVCDC indicated, the controlled substance count for the following dates was not completed or was only partially completed at the change of shift: 10/25/23, 10/26/23, 10/27/23, 10/28/23, 10/29/23, 10/30/23, and 10/31/23. LVN 1 stated blanks in the record mean the count wasn't completed. During a concurrent…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: 1. Implement infection control standards for three of four sampled residents (Resident 63, Resident 12, and Resident 195). 2. Follow their infection prevention and control program when: Certified Nursing Assistant (CNA) 11 was observed not performing hand hygiene after coming out of a resident's room and before entering another resident's room, and not performing hand hygiene after removing her gloves. These failures had the potential to place residents, staff, and visitors at risk for the spread of infectious diseases. Findings: During an observation on 11/6/23 at 10:30 a.m. in the bathroom shared by rooms [ROOM NUMBERS], a toilet seat riser (a device placed on top of a toilet bowl to increase its height used by people who may have trouble sitting down in seats that are as low as a toilet, such as older people) was observed on the toilet. [NAME] stains were noted in smearing patterns on the back top and back inside of the riser device.…

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

Based on interview and record review, the facility failed to complete a fall risk assessment quarterly for one of one sampled resident (Resident 73). This failure had the potential to not reflect Resident 73's most recent fall risk status. Findings: During a concurrent interview and record review on 11/8/23 at 7:03 a.m. with Director of Nursing (DON), Resident 73's Fall Risk Evaluation (FRE), dated 4/13/23 was reviewed. The FRE indicated, INSTRUCTIONS Upon admission and quarterly (at minimum) thereafter, assess the resident status in the eight clinical condition parameters. DON stated the FRE should be completed quarterly. DON stated the FRE is overdue because the last one completed for Resident 73 was done 4/13/23. During an interview on 11/8/23 at 7:34 a.m. with DON, DON stated she had to work two weekends last month to provide Registered Nurse (RN) coverage. She stated it is difficult for her to complete her DON duties such as auditing to ensure assessments are completed. During a review of the facility's policy and procedure (P&P) titled Fall Risk Assessment, dated 6/1/22, the…

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

Based on observation, interview, and record review, the facility failed to ensure the needs of one of five sampled dependent residents (Resident 4) were met. This failure resulted in Resident 4's fingernails being long and dirty. Findings: During an observation on 11/6/23 at 10:58 a.m. in Resident 4's room, Resident 4's fingernails were long with dark debris under the nails. During a concurrent observation and interview on 11/6/23 at 11:12 a.m. with Certified Nursing Assistant (CNA) 2, in Resident 4's room, CNA 2 stated Resident 4's fingernails were not only long but dirty. During an interview on 11/6/23 with Licensed Vocational Nurse (LVN) 2, LVN 2 stated she had not been made aware of Resident 4's fingernails being long. LVN 2 stated it would typically be communicated via the Shower Sheets documented by CNAs. During a concurrent interview and record review on 11/6/23 at 12:31 p.m. with Director of Nursing (DON), Resident 4's Clinical and Order Alerts Listing Report [COALR] dated 10/21/23 through 10/30/23 was reviewed. The COALR indicated CNAs made licensed nurses aware 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 ensure one of four sampled residents (Resident 31), was treated for constipation (difficulty in emptying the bowels, usually associated with hardened stool). This failure resulted in a delay of diagnosis and treatment for Resident 31 and had the potential to result in other complications of bowel obstruction (a partial or complete blockage of the intestine) like perforation (a hole that develops through the wall of a body organ) and peritonitis (when the thin layer of tissue inside the abdomen becomes inflamed, usually infectious, and often life-threatening). Findings: During an interview on 11/7/23 at 9:30 a.m. with Resident 31, Resident 31 stated, I had to go to the hospital and have surgery. The doctor told me he had to remove [2 feet] of [hard stool]. During a concurrent interview and record review on 11/7/23 at 3:47 p.m. with Licensed Vocational Nurse (LVN) 3, Resident 31's Progress Note (PN), dated 10/22/23 was reviewed. The PN indicated,…

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

Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 17) received proper treatment and care for Resident 17's toenails. This failure resulted in Resident 17's toenails to become long and thick. Findings: During a concurrent observation and interview on 11/7/23 at 9:51 a.m. with Administrator in Resident 17's room, Resident 17's toenails were observed. Administrator stated, Resident 17's right big toenail was approximately ¼ of an inch (a unit of measure) beyond the tip of the toe, and that all of Resident 17's toenails were very thick. During an interview on 11/7/23 at 9:53 a.m. with Administrator, Administrator stated, the facility has contracted with a new Podiatrist (medical specialist that treats foot disorders) because the previous Podiatrist had failed to visit the facility. During a concurrent observation and interview on 11/7/23 at 11:24 a.m. with Administrator in Resident 17's room, Administrator measured Resident 17's right big toenail with a tape measure. Administrator stated, the toenail measured ½ inch…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Foley catheter (A small flexible tube that helps drain urine from the bladder) care in accordance with professional standards of practice for one of one sampled resident (Resident 11). This failure had the potential to result in trauma, infection, and other complications. Findings: During a concurrent observation and interview on 11/6/23 at 12:31 p.m. with Minimum Data Set (assessment tool) Coordinator (MDSC) in the small dining room, Resident 11's Foley catheter drainage bag (used to collect urine that is drained from the bladder) was dragging on the floor under his wheelchair. The drainage bag was attached to a bar near the left wheel. Resident 11's shoe was on the Foley catheter tubing (tube that connects the foley catheter to the drainage bag). MDSC stated the foley catheter bag should not be like that. MDSC stated it posed a risk of infection, trauma if it gets pulled, and falls because it posed a tripping hazard. During an interview on 11/7/23 at 8:31 a.m. with Infection Preventionist (IP), IP…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 one sampled resident (Resident 8) had a timely weight variance committee meeting conducted when Resident 8 had a 6.63% (percentage- parts of a whole) unplanned weight loss. This failure had the potential for Resident 8 to have adverse health outcomes. Findings: During a review of Resident 8's Food and Nutrition - Nutritional Evaluation (NE), dated 4/24/23, the NE indicated, Resident 8 was admitted to the facility on [DATE], weighed 165 pounds on 4/21/23, and was on a mechanical soft texture, fortified (additional calories) diet. The NE indicated, Res [resident] had sig [significant] wt [weight] loss of 5# [pounds] (-2.9%) x [within] 3 days. 1) Add Boost Breeze [oral liquid nutrition supplement to increase calories and protein] 8 oz [ounce] with breakfast .will not have significant changes in weight. During a review of Resident 8's Weights and Vitals Summary (WVS), Resident 8's weights included (not all inclusive) the following: 4/18/23…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 adequately monitor identified behaviors for one of one sampled resident (Resident 68). This failure had the potential to negatively impact the care provided to meet the behavioral needs of Resident 68. Findings: During a review of Resident 68's admission Record (AR), dated 11/7/23, the AR indicated, Resident 68 was admitted on [DATE] with a diagnosis of Schizophrenia (mental disorder that affects a person's ability to think, feel, and behave clearly). During a concurrent observation and interview on 11/6/23 at 12:10 p.m. with Resident 68, Resident 68 was in the hallway in front of the dining room. Resident 68 was in her wheelchair rolling back and forth in front, and stated, I ain't talking to you. During an interview on 11/6/23 at 12:37 p.m. with Resident 68, Resident 68 stated, Don't talk to me, I don't care what you are lying about. During an interview on 12:40 p.m. with Certified Nursing Assistant (CNA) 1, CNA stated Resident 68 has 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 ensure the Dietary Aide (DA) followed the policy and procedure (P&P) titled, Dish Washing when she did not correctly check the dishes for effective sanitization. This failure had the potential for residents to acquire foodborne (resulting from unsafe food practices) illnesses. Findings: During a concurrent observation and interview on 11/6/23 at 10:26 a.m. with DA in the kitchen by the dish machine, DA dipped the chlorine test strip (strip that detects chlorine (disinfectant) to verify dishes have been effectively sanitized after washing) into the dish machine's well water and it was 100 ppm (parts per million - unit of measure). DA stated she was responsible for checking the sanitizer concentration, and she always dips the chlorine test strip in the well water, and she has never been told otherwise. During an interview on 11/6/23 at 10:27 a.m. with Dietary Services Supervisor (DSS), DSS stated staff should be placing the chlorine strip at the plate/dish/utensil level to ensure effective sanitization. During…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 three of three sampled residents (Resident 13, Resident 63 and Resident 11) planned 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 result in a negative health outcome. Findings: During a concurrent observation and interview on 11/6/23 at 12:05 p.m. with Dietary Services Supervisor (DSS) by the meal tray cart, Resident 13's thickened health shake supplement was missing from the meal tray. DSS stated the health shake was missing. During a review of Resident 13's Meal Tray Ticket (MTT), (undated), the MTT indicated Resident 13 has a Supplement Shake (Honey Think). During a review of Resident 13's Nutrition Status (NS), (undated), the NS indicated, Resident 13 had an order for House Supplement with meals, Honey-thick liquids consistency. During an observation on 11/6/23 at 12:16 p.m. outside the small dining room, Resident 63's meal tray contained ice cream, the MTT indicated, Resident 63 had a Renal Diet (diet…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 raw turkey, chicken, and pork were stored correctly to prevent cross-contamination. This failure had the potential to cause foodborne (resulting from unsafe food practices) illness to the residents currently residing in the facility. Findings: During a concurrent observation and interview on 11/6/23 at 9:44 a.m. with Dietary Services Supervisor (DSS) in the kitchen, inside the reach-in refrigerator thawing from top to bottom: raw turkey was pulled from the freezer on 11/5/23 with a use by date of 11/7/23, chicken was pulled from the freezer on 11/4/23 with a use by date of 11/7/23 and pork was pulled from the freezer on 11/4/23 with a use by date of 11/6/23. DSS stated the meats were arranged only by the dates they were taken out of the freezer and there was no other criteria for the arrangement. During a review of the facility's policy and procedure (P&P) titled, Food Preparation, dated 2018, the P&P indicated, 5. Store raw meat, poultry, and fish in the order from top to bottom. This order is based…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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: 1. Ensure wound care was provided for one of three sampled resident (Resident 1). 2. Provide one of three sampled resident (Resident 1) with a Low Air Loss (LAL) mattress (help prevent skin breakdown) as ordered by the physician. These failures had the potential to result in the worsening of Resident 1's wounds. Findings: 1. During a review of Resident 1's Progress Notes (PN), dated 3/24/23, the PN indicated, Resident 1 was admitted to the facility with 2 unstageable [stage of wound is not clear] openings to coccyx [tailbone], center one measuring 4 cm [centimeter], 2 cm and other one located to the left measuring 2 cm x 2 cm. During a review of Resident 1's Order Summary Report (OSR), dated 3/24/23, the OSR indicated, Resident 1's unstageable wounds to coccyx area were to be treated with a wound cleanser, apply med honey (wound gel), cover with dry dressing daily. During a review of Resident 1's Treatment Administration Record (TAR), dated 3/24/23…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 allegation of abuse was reported timely for one of three sampled residents (Resident 1). This failure had the potential to place all residents at risk for further abuse. Findings: During a review of the Reported of Suspected Dependent Adult/Elder Abuse (SOC 341-used by facility to report an abuse allegation) dated 9/6/23, the SOC 341 indicated, Resident stated that the C.N.A (Certified Nursing Assistant 1) was yelling at her when she went to her room. She stated that the CNA told her not to go to her room alone.Date/Time of Incident(s).9/3/23 During a review of Resident 1's Progress Notes (PN), dated 9/3/23 at 5:38 p.m., the PN indicated, Resident told staff another staff member (CNA 1) yelled at her on 9/02/23. During a review of Resident 1's S [situation] B [background] A [appearance] R [review and notify] (SBAR), dated 9/6/23, the SBAR indicated, Resident is making allegations that staff (CNA 1) used loud voice while taking care of resident.Time started on: 9/3/23. During an interview on 9/13/23, at 3:08 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 interview and record review, the facility failed to re-admit one of two sampled residents (Resident 1) back to the facility when a male bed became available. This failure resulted in violation of Resident 1's rights and unnecessary hospitalization stay for 21 days. Findings: During a review of Resident 1's Progress Notes (PN) dated 7/22/23, at 10:23 a.m., the PN indicated, Resident [Resident 1] was transferred out to hospital c/o [complain of] severe back pain. During an interview on 9/13/23 at 3:03 p.m. with Administrator, Administrator stated she was aware Resident 1 was ready to return to the facility from the hospital (8/13/23) but Resident 1's seven-day bed hold was up and therefore was not priority to re-admit back to the facility. Administrator stated Resident 1 was not re-admitted back to the facility until 9/11/23. During an interview on 9/13/23 at 3:21 p.m. with admission Personnel (AP), AP stated she received an inquiry from the acute hospital on 8/13/23 indicating Resident 1 was ready 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 ensure the care plan was implemented for one of two sampled residents (Resident 2) when Resident 2 was not provided orange juice as requested. This resulted in Resident 2 becoming upset and striking Resident 1. Findings: During a review of Resident 2's S [Situation] B [Background] A [Appearance] R [Recommendation] (SBAR), dated 6/8/23, the SBAR indicated, Resident-to-Resident altercation.this started on 6/8/23.Nurse was notified by CNA (Certified Nursing Assistant) at approx. (approximately) 1200 that [Resident 2] had physically assaulted another [Resident 1] by slapping her face with an open hand, while both parties were at main dinning [sic] area. During a review of Resident 2's Progress Notes (PN), dated 6/9/23, the PN indicated, IDT [[Interdisciplinary Team-a group of health care professionals with various areas of expertise who work together toward the goals of their clients] met to discuss this resident's continuous aggressive behavior. Resident has a 24-hour direct supervision from staff. On June 8th, 2023 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.