Walnut Creek Skilled Nursing & Rehabilitation Cent

Based on observation, interview and record review the facility did not respect the right to maintain personal belongings securely for one of 18 sampled residents (Resident 53) when Resident 53's transfer sling, wheel chair and shoes had been missing. This created unnecessary distress for Resident 53's family. Findings: Record review of the document admission Record showed the facility admitted Resident 53 on 4/14/2017. Diagnoses included Intracranial Injury (brain injury). During an interview on 6/11/2025 at 2:25 p.m. Family Member 1 stated she had concerns regarding her son's missing items. She stated she had purchased a personal transfer sling for her son which was missing. In the past, he was missing a shoe which she also replaced for him. Family Member 1 stated she had not been reimbursed by the facility for these items. She stated the money wasn't important but she found it frustrating that staff could not keep her son's belongings in his room. During an interview on 6/12 at 9:20 a.m. Resident 53 was observed in bed nodding to questions, making audible sounds but 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, for one of four sampled residents (Resident 23) who were transferred to the hospital for acute care, the facility failed to notify Resident Representative (RR) 2 when Resident 23 vomited on 4/5/25. Resident 23's condition worsened and was transferred to the hospital the same day for fever and weakness. This failure had the potential to result in delayed interventions. Findings: During a review of Resident 23's admission Record (AR), the AR indicated Resident 23 was admitted to the facility in August 2022 with diagnoses that included senile degeneration of the brain (age-related cognitive decline, often used interchangeably with dementia) and major depressive disorder (persistent sadness, loss of interest, and difficulty functioning in daily life). The AR indicated Resident Representative (RR) 2 as Resident 23's emergency contact and guarantor. During a telephone interview on 6/9/25 at 9:55 a.m. with RR 2, RR 2 stated Resident 23 became very sick in the evening of 4/5/25. RR 2 stated receiving a call from facility staff when Resident 23 developed…

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

Based on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Residents 60 and Resident 142) received necessary care to maintain good grooming and personal hygiene when Resident 60 and Resident 142 had long fingernails. This failure resulted in Residents 60 and Resident 142 at risk for skin irritation and infection. Findings: During a review of Resident 60's admission Record (AR), printed on 6/12/25, the AR indicated, Resident 60 was admitted to the facility in July 2024 with diagnosis that included hemiplegia (a condition caused by brain damage or spinal cord injury that leads to paralysis on one side of the body) and hemiparesis (a condition characterized by weakness on one side of the body, making it hard to perform everyday activities like eating or dressing) following cerebral infarction (occurs when blood flow to a part of the brain is blocked, depriving brain cells of oxygen and nutrients, leading to tissue damage or death) affecting right dominant side. During a record review of During a review of Resident 60's Activities…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 appropriate treatment and services to prevent further decrease in range of motion when Restorative Nursing Assistant (RNA) services ( RNA program, focuses on nursing interventions that help residents in long-term care maintain or regain their ability to perform activities of daily living (ADLs) and improve their overall well-being) to three of four sampled residents (Residents 60, 120 and 126) who were reviewed for range of motion/mobility needs, as indicated in the physician orders and comprehensive care plan. This failure had the potential to result in further decline in range of motion. Findings: 1. During a review of Resident 60's admission Record (AR), printed on 6/12/25, the AR indicated, Resident 60 was admitted to the facility in July 2024 with diagnosis of hemiplegia (a condition caused by brain damage or spinal cord injury that leads to paralysis on one side of the body) and hemiparesis (a condition characterized by weakness on one side of the body, making it hard to perform everyday…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 reviews, the facility did not provide immediate necessary care and investigate potential self-harm for two of 18 sampled residents (Residents 101 and 210). Staff did not implement safety measures when Residents 101 and 210 expressed feeling suicidal. Staff did not investigate the cause of Resident 210's wrist wound. These failures have the potential to not ensure the residents' safety and/or promote and maintain the residents' highest practicable physical, mental, and psychosocial well-being. Findings: Record review of the document admission Record showed the facility admitted Resident 101 on 11/29/2024. Resident 101's diagnoses included depression. Record review of the document MDS 3.0 Nursing Home Quarterly (NQ) Version 1.19.1 (resident assessment) dated 5/29/2025, showed Resident 101 was alert and oriented to the day, month, and year. Record review of the document Progress Notes dated 6/13/2025, showed Resident 101 required some assist with ADLs (activities of daily living), was able to move all extremities and could feed herself.…

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

Based on observation, interview and record review, the facility failed to implement their infection prevention and control program for two of three sampled residents (Residents 125 and Resident 46) when two staff members did not wear appropriate Personal Protective Equipment (PPE, protective items or garments worn to protect the body or clothing from hazards that can cause injury and to prevent the transmission of infectious agents from one person to another, also known as cross-contamination) while providing care to Resident 125 and Resident 46, who were placed on enhanced barrier precaution (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities). This failure had the potential to result in spread of infection. Findings: During a record review of Resident 125's admission Record (AR), printed on 6/13/25, the AR indicated Resident 125 was admitted to the facility in November 2024 with diagnoses of quadriplegia (a loss of motor function can present as…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Resident 1 had privacy during care when staff transferred Resident 1, who was not wearing clothes and uncontrollably yelling fuck repeatedly, from a shower chair into his room without adequately covering his genitals. This failure had the potential for psychosocial harm when Resident 1 ' s genitals were exposed and viewable to anyone in the hallway when Resident 1 was being transferred from the shower chair into the room and was yelling uncontrollably. Findings: A review of Resident 1 ' s admission record indicated Resident 1 was admitted with diagnoses for vascular dementia (loss of mental function due to loss of brain tissue from reduced blood supply), Tourette syndrome (disorder involving repetitive movements or unwanted sounds which a person has little or no control over), seizures (changes in brain electrical activity), intracranial injury (injury in the head) and need for assistance with personal care. During a record review of Resident 1 ' s minimum data set (MDS, an assessment tool to guide…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure medications were administered as ordered by the physician, for one of three sampled residents (Resident 1) when Resident 1's Midodrine HCL (medication used to treat low blood pressure, helps prevent symptoms of dizziness when a Residents or person move from a sitting to a standing position) was held and not administered on multiple occasions, on 2/16/2025, 2/20/2025, and 2/21/2025. This failure resulted in Resident 1 not getting medication to treat his low blood pressure (BP) and potential return of symptoms to manage low blood pressure such as dizziness, lightheadedness, fainting spells, including decrease or limitation in Resident 1's activities of daily function, participation in his physical therapy treatment care, increased fall risk, injury and possible hospitalization. Findings: During a review of the facility's policy and procedure (P&P), titled, Administrating Medications dated 2001, the P&P indicated, Medication shall be administered…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure one of three sampled residents (Resident 1) received medications as ordered by the physician and was free of significant medication error (one which cause the resident discomfort or jeopardizes his or her health and safety), when Resident 1's Midodrine HCL (medication used to treat low blood pressure, helps prevent symptoms of dizziness when a Residents or person move from a sitting to a standing position) was held and not administered on multiple occasions, on 2/16/2025, 2/20/2025, and 2/21/2025. This failure resulted in Resident 1 not getting medication to treat his low blood pressure (BP) and potential return of symptoms to manage low blood pressure such as dizziness, lightheadedness, fainting spells, including decrease or limitation in Resident 1's activities of daily function, participation in his physical therapy treatment care, increased fall risk, injury and possible hospitalization. Findings: During a review of Resident's 1 Facesheet…

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

Based on interviews and record review, the facility failed to ensure Resident's right to choose health care and providers of health care services was honored for one of three sampled residents (Resident 3), when Registered Nurse (RN) 1 proceeded to administer medications to Resident 3, after Resident 3 had already refused to receive care from RN 1. This failure resulted in emotional distress for Resident 3. Findings: During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was initially admitted to facility during 11/23, and had multiple diagnoses that included, dependence on ventilator (breathing machine), chronic respiratory failure with hypoxia (a long-term condition that makes it difficult for the body to exchange oxygen and carbon dioxide), amyotrophic lateral sclerosis (nervous system disease that weakens muscles and impacts physical function, causes nerve cells in the brain and spinal cord to die, eventually causes the brain to lose ability to control voluntary movements and breathing), anxiety disorder (persistent and excessive worry 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 ensure to meet the interests of and support the physical, mental, and psychosocial well-being of one of three sample selected residents (Resident 1), when Resident 1 was not able to be out of her bed due to Mechanical Lifting Device (MLD) sling (a flexible strap or belt used in the form of a loop to support or raise a weight) not being available at the facility. This failure resulted in Resident 1 staying in her bed for two days and possibility of developing pressure ulcer and mental health issues. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility with multiple diagnoses including multiple mclerosis (an autoimmune disease that has a potentially disabling disease of the brain and spinal cord [central nervous system]). A review of Resident 1's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan) section GG, indicated Resident 1 has impairment on upper and lower extremity on both…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 manage pain for one out of four sampled residents (Resident 1), when Resident 1 did not received pain medication as desired for 13 hours. This failure resulted in Resident 1 suffering from severe pain and a feeling of neglect. Findings: During a review of Resident 1's admission Record, dated May 2024, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with active diagnosis that included thoracic fusion (an operation in the middle region of the spine) and chronic pain. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated April 2024, the MDS indicated Resident 1's Brief Interview for Mental Status (BIMS, a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information) was 15 out of 15, indicating cognitively…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, for one of three sampled residents (Resident 1), the facility failed to provide emergency basic life support, including Cardiopulmonary Resuscitation (CPR, any medical intervention used to restore blood circulation or breathing functions that have ceased) to Resident 1 who was found with no pulse and no spontaneous respiration. This failure resulted in the delayed provision of emergency basic life support for Resident 1. Resident 1 was pronounced deceased by emergency personnel at 5:52 a.m., 42 minutes after Resident 1 was found with no pulse. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility in [DATE] with diagnoses that included anoxic brain damage (brain injuries that are caused by a complete lack of oxygen to the brain), dependence on respirator status and chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon…

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

Based on interviews and record review the facility failed to ensure one (1) of four (4) sampled residents (Resident 1) was treated with dignity and respect when Resident 1, who is dependent on staff for eating, was not aided with eating during the candlelight dinner. This deficient practice negatively impacted Resident 1's sense of self-worth and self-esteem and made her feel neglected and left out. Findings: During a review of Resident 1's, admission Record, printed on 3/12/24, the admission Record indicated Resident 1 was originally admitted to the facility in June 2012 and readmitted in March 2021 with a diagnoses of multiple sclerosis (a disease wherein the body's immune system attacks the insulation and support around nerve fibers resulting in impaired nerve function. This damages the nerves that are involved in sensory, movement, cognition, and involuntary processes such as heart rate, breathing, digestion) and paraplegia (a specific pattern of paralysis [which is when you can't deliberately control or move your muscles] due to a problem affecting the nervous system that…

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

Based on observation, interview, and record review, the facility failed to ensure one (1) of four (4) sampled residents (Resident 1) received assistance with Activities of Daily Living (ADLs, Activities of daily living are those needed for self-care and mobility and include activities such as bathing, dressing, grooming, oral care, ambulation, toileting, eating, transferring, and communicating) when the assigned Certified Nursing Assistant (CNA) did not help Resident 1 in a timely manner. This failure resulted in Resident 1 waiting for a long time for ADL care and her urinary catheter bag (container or collector for the urine as it leaves the body and passes through the catheter tube) overflowing and soaking her wet in the wheelchair compromising Resident 1's dignity and comfort. Findings: During a review of Resident 1's, admission Record, printed on 3/12/24, the admission Record indicated Resident 1 was originally admitted to the facility in June 2012 and readmitted in March 2021 with diagnoses to include multiple sclerosis (a disease wherein the body's immune system attacks 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 complete and submit the quarterly and annual comprehensive Minimum Data Set (MDS, an assessment tool) assessments for 13 of 13 sampled residents. This failure placed residents at risk for not being assessed in a timely manner resulting in potential for inappropriate care planning and interventions. Findings: During a concurrent interview and record review on 1/25/24 at 9:41 a.m. with MDS coordinator (MDSC), Resident 97's quarterly MDS, with an assessment reference date (ARD, the last day of the observation or lookback period facilities use when filling out the MDS) of 11/21/23, was reviewed. The MDSC stated Resident 97's assessment was completed on 1/17/24 and transmitted on 1/22/24. Calculation of days between the ARD and MDS completion indicated 57 days elapsed. During a concurrent interview and record review on 1/25/24 at 9:42 a.m. with MDSC, Resident 71's annual MDS, with an ARD of 11/23/23, was reviewed. The MDSC stated Resident 71's assessment was completed on 1/18/24 and transmitted on 1/22/24. Calculation of days…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 develop and implement comprehensive-centered care plans for four of 31 sampled residents (Resident 120, Resident 12, Resident 69, Resident 219) when: 1. The facility did not develop an individualized care plan that includes current treatment, preventive measures, and services to manage Resident 120's deep tissue injury. 2. The facility did not monitor Resident 12's urine output according to the care plan. 3. The facility did not implement a care plan for Resident 69's diabetes. 4. The facility did not implement a care plan for Resident 219's antipsychotic medication. This failure had the potential for each resident to not have their specific needs met and result in inappropriate and inaccurate provision of care that could negatively impact the quality of care and services. Findings: 1. A review of the clinical record indicated Resident 120 was admitted in February 2023 with diagnoses that included diabetes (too much sugar in the blood), high blood pressure, and stroke with severe right sided weakness, seizure…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 3. During a review of Resident 24's undated Face Sheet, the Face Sheet indicated Resident 24 was admitted in the facility on 1/2011 with diagnoses that included dementia (memory loss which can interfere with activities of daily living). During a review of Resident 24's MDS, dated [DATE], the assessment indicated Resident 24 required substantial/maximal assistance (helper does more than half the effort) with personal hygiene. During a record review of Resident 24's ADL Care Plan, dated 4/28/23, the care plan indicated Resident 24 had a self-care performance deficit related to dementia. The care plan indicated for staff to check nail length and trim and clean on bath day and as necessary and report any changes to the nurse. During a concurrent observation and interview on 1/22/24 at 12:48 p.m. with CNA 5, Resident 24 was sitting in bed and eating lunch. Resident 24's fingernails for both hands were long and had dark brown matter underneath. CNA 5 stated the risk for Resident 24 with long dirty fingernails was…

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

Based on observation, interview, and record review, for two of three sampled residents reviewed for catheter care, the facility failed to; provide appropriate care and services to prevent urinary tract infections (UTI) when: 1. Resident 12's urinary output from nephrostomy tube (a small tube that helps drain urine from the kidneys) was not consistently monitored and documented per physician's order. This failure had the potential to result in urinary tract infections. 2. Resident 160's urine sample was not collected per physician's order. This failure resulted in delayed intervention that could potentially lead to worsening urinary tract infection symptoms. Findings: 1. During a review of Resident 12's admission Record, undated, the admission Record indicated Resident 12 was admitted to the facility on 1/2022 with diagnoses that included tubulo-interstitial nephritis (inflammation that affects the kidneys and the tissues that surround them), displacement of nephrostomy catheter and malignant neoplasm (an abnormal growth of tissue, especially a characteristic of cancer) of the…

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

Based on observation, interview, and record review, the facility failed to ensure there was sufficient licensed nursing staff, leading to late administration of high-risk medications for four of four sampled residents (Resident 93, 2, 72, 77). The late administration of medications included medications to manage high blood pressure, seizures, and pain. This failure resulted in Resident 93 to experience severe pain; and placed Resident 2 at risk for seizures; and Resident 72 and 77 at risk for high blood pressure. Findings: During an observation and interview on 1/22/24 at 10:13 a.m. in Resident 93's room, Resident 93 was sitting in the wheelchair. Resident 93 stated he was concerned about his medication for back pain because he did not receive it on time especially when a new nurse was working few days ago. Resident 93 did not specify the day or time when this incident occurred. During an interview on 1/25/24 at 10:54 a.m., Resident 93 stated he recalled receiving his scheduled morning Percocet late over the weekend, and his pain was nine out of 10 on the pain scale (indicating…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, for three of six sampled residents (Resident 51, Resident 69, and Resident 93), the facility: 1. Failed to ensure monthly drug regimen for Resident 51, Resident 69 and Resident 93 were reviewed monthly. 2. Failed to ensure Consultant Pharmacist recommendation was acted upon for Resident 93. These failures had the potential to result in unnecessary medications. Findings: 1. During a review of Resident 51's admission Record, undated, the admission Record indicated Resident 51 was admitted to the facility on 9/2021 with diagnoses that included chronic kidney disease (condition in which the kidneys are damaged and cannot filter blood as well as they should), aphasia (loss of ability to understand or express speech, caused by brain damage), and ventricular intracranial shunt (helps drain excess cerebrospinal fluid, liquid that surrounds the brain and spinal cord). During a review of Resident 51's Order Summary Report, dated 1/24/24, the Order Summary Report indicated Resident 51 was to receive amoxicillin (antibiotic to treat infection) 500…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medications were labeled in accordance with currently accepted professional principles and include the appropriate accessory and cautionary instructions and the expiration date, when multiple expired medications and multiple medications for discharged residents were found together with non-expired, active medications for other residents on the same shelf. This failure had the potential to result in using expired medications for the residents and medications for discharged residents would be taken by the staff for personal advantage. Findings: During a concurrent observation and interview on 01/22/24 at 12:20 p.m. with Director of Nursing (DON) and Licensed Vocational Nurse (LVN) 1 in the medication storage room, at nursing station number one, the following medications belonging to a discharged resident were found on the shelf with other active medications for active residents: Nystatin (anti-fungal infection), Metformin (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 safe and sanitary food preparation and storage practices were followed in the kitchen when: 1. Conveyor Toaster was not clean. 2. Floor underneath the wire shelf and staff's personal locker in dry storage room contained food debris, and dust. 3. Expired test strip was used to test sanitizer concentration for the dish machine. These failures had the potential to result in harmful bacteria growth and cross contamination that could lead to foodborne illness (illness caused by food contaminated with bacteria, viruses, parasites, or toxins) for 147 of 153 medically compromised residents who received food from the kitchen. Findings: 1. During an initial tour accompanied by Dietary Manager (DM) on 1/22/24 at 9:10 a.m. in the kitchen, a countertop conveyor toaster positioned towards one end of the island was noted. The conveyor toaster consisted of visible parts from top to bottom as follows: feed ramp, crumb tray, control panel (adjusting toasting process), mesh filter, and discharge chute (part of the…

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

Based on observation, interview, and record review the facility failed to ensure resident's appearance was in a manner to maintain dignity and self-esteem for one of one sampled resident (Resident 24) when Resident 24 was observed with long facial hair. This failure had the potential to result in Resident 24 not feeling good about herself and low self-esteem. Findings: During a review of Resident 24's undated Face Sheet, the Face Sheet indicated Resident 24 was admitted in the facility in January 2011 and the diagnoses included dementia (a loss of brain function that occurs with certain diseases, affecting one or more brain functions such as memory, thinking, language, judgment, or behavior). During a review of Resident 24's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan.), dated 1/5/24, the assessment indicated Resident 24 required substantial/maximal assistance (helper does more than half the effort) with personal hygiene. During a concurrent observation and interview on 1/22/24 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 family representative (FR) was informed of a significant change in condition for one of one sampled resident (Resident 138) when Resident 138 had a significant weight loss of 13.68% in six months from 7/2023 until 1/2024. This failure resulted in FR to be unaware of Resident 138's condition and not being able to participate in her plan of care. Findings: During a review of Resident 138's undated Face Sheet, the Face Sheet indicated Resident 138 was admitted to the facility on 7/2023. Resident 138's diagnoses included chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should), vitamin B12 deficiency and iron deficiency anemia. The record also indicated FR 1 was listed as a responsible party for Resident 138. During a review of Resident 138's Minimum Data Set (MDS- an assessment used to guide plan of care), dated 1/5/24, the assessment indicated Resident 138's Brief Interview for Mental Status (BIMS- brief screener that aids in detecting cognitive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, for one of one sampled resident (Resident 8), the facility failed to develop and implement written polices and procedures that included re-training and re-education of staff who was accused of abuse before returning to work with residents. This failure had the potential to result in exposing vulnerable residents to abuse. Findings: During a review of Resident 8's admission Record, the admission Record indicated Resident 8 was admitted to the facility on 11/2023 with diagnoses that included Alzheimer's disease (a form of dementia, loss of brain function that occurs with certain diseases, affecting one or more brain functions such as memory, thinking, language, judgment, or behavior), depressive disorder (persistent feeling of sadness and loss of interest and can interfere with your daily life), type 2 diabetes mellitus (abnormal blood sugar levels), hemiplegia (paralysis of one side of the body), and hemiparesis (weakness of one side of the body) following cerebral infarction (also called stroke, result of disrupted blood flow to the brain due 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 accurately complete the Preadmission Screening and Resident Review (PASARR) assessment for one of four sampled residents (Resident 121) to reflect the accurate medical diagnosis. This failure placed Resident 121 at risk to not receive care and services appropriate to his needs. Findings: During a review of Resident 121's admission Record, printed on 1/24/24, the admission Record indicated Resident 121 was originally admitted to the facility in June 2022. During a concurrent interview and record review on 1/24/24 at 10:53 a.m. with Director of Nursing (DON), Resident 121's PASARR Level 1 Screening Document, submitted on 2/13/23, was reviewed. Resident 121's PASSAR indicated the facility answered No to Question 10: Does the individual have serious diagnosed mental disorder such as Depressive Disorder, Anxiety Disorder, panic Disorder, Schizoaffective Disorder, or symptoms of psychosis, and/or mood Disturbance? During a concurrent interview and record review on 1/24/24 at 10:53 a.m. with Director of Nursing (DON), Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of 31 sampled residents (Resident 156) had skin assessments completed for the bilateral arm skin discolorations. This failure had the potential to result in ineffective monitoring and ineffective plan of care and treatment of the skin conditions. Findings: A review of Resident 156's Face Sheet, undated, indicated Resident 156 was admitted on [DATE] with diagnoses that included diabetes, dependence on respirator (breathing machine) status, PEG tube (tube placed through the abdominal wall directly into the stomach to deliver nutrition and medication), and acute kidney failure. During a concurrent observation and interview on 1/22/24 at 9:15 a.m. with Resident 156 in his room, Resident 156 was lying in bed and able to talk softly. Resident 156 stated he had concerns about his bruises and lab blood draws, especially the blood draws of about a week ago. Resident 156 had purplish red discolorations, appeared like bruises on bilateral…

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

Based on observation, interview, and record review, the facility failed to provide a therapeutic diet to one of one sampled resident (Resident 138) when they did not follow the physician's order. This failure had the potential to contribute to continued, unplanned weight loss for Resident 138. Findings: A review of the undated Face Sheet indicated that Resident 138 was admitted to the facility in 7/2023. Resident 138's diagnoses included chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should), vitamin B12 deficiency, and iron deficiency anemia. A review of the Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan.), dated 1/5/24, indicated Resident 138's Brief Interview for Mental Status (BIMS, is a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information. A BIMS score of eight to twelve is an indication of intact cognitive status.) was 9.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 scheduled pain medication was provided for one of one sampled resident (Resident 93) in a timely manner. Resident 93 did not receive one tablet of Percocet (a controlled medication to treat moderate to moderately severe pain) 5/325 milligrams (mg) until four hours later from the scheduled time. This failure resulted in Resident 93 to experience nine (severe pain) out of 10 pain in his lower back. Findings: During a review of Resident 93's undated Face Sheet, the Face Sheet indicated Resident 93 was admitted to the facility n 2/2020. Resident 93's diagnoses included traumatic brain injury (TBI), left elbow contracture, and right hip replacement. During a review of Resident 93's Minimum Data Set (MDS- an assessment used to guide plan of care), dated 11/2/23, the assessment indicated Resident 93's Brief Interview for Mental Status (BIMS- brief screener that aids in detecting cognitive impairment) score was 15 out of 15 (a score of 13-15 represents intact cognition). During a record review of Resident…

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

Based on interview and record review, for one of one sampled resident (Resident 51), the facility failed to ensure Resident 51 was free from unnecessary drugs when amoxicillin (antibiotic, treats infection) was administered without adequate monitoring for side effects. This failure had the potential to result in delayed management of adverse effects from the medication. Findings: During a review of Resident 51's admission Record, undated, the admission Record indicated Resident 51 was admitted to the facility in 9/2021 with diagnoses that included chronic kidney disease (condition in which the kidneys are damaged and cannot filter blood as well as they should), aphasia (loss of ability to understand or express speech, caused by brain damage), and ventricular intracranial shunt (helps drain excess cerebrospinal fluid, clear liquid that surrounds the brain and spinal cord). During a review of Resident 51's Order Summary Report, dated 1/24/24, the Order Summary Report indicated Resident 51 was to receive amoxicillin 500 milligrams (mg) two capsules twice daily for VP (ventricular…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, for one of five sampled residents (Resident 219) reviewed for unnecessary medications, the facility failed to ensure psychotropic (any drug that affects brain activities associated with mental processes and behavior) medications were administered for specific condition as diagnosed and documented in the clinical record. Resident 219 was administered ziprasidone (treats schizophrenia and bipolar disorder, types of mental illnesses) without a specific indication and was administered fluoxetine, mirtazapine, and trazodone (all anti-depressants) for the same indication. This failure had the potential to result in unnecessary medications and had the potential to result in multiple adverse reactions from duplicate therapy (Duplicate therapy refers to multiple medications of the same pharmacological class/category or any medication therapy that substantially duplicates a particular effect of another medication that the individual is taking.) Findings: During a review of Resident 219's admission Record, undated, the admission Record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement their policy and procedure related to food brought from the outside to one of five sampled residents. Residents' food refrigerator had expired food that was not discarded. This failure had the potential to expose the facility's residents to unsafe food storage practices which could lead to foodborne illness (food poisoning). Findings: During a concurrent observation and interview on 1/26/24 at 9:15 a.m. of the residents' refrigerator inside the storage room in nursing station three with Licensed Vocational Nurse (LVN) 9, an open flavored blend juice bottle [BRAND] was observed. The bottle had a ¼ juice left, labeled with a handwritten date, room number, and name of Resident 4. On the bottle there was a label that read enjoy by [DATE]. LVN 9 stated, the handwritten date was the opening date. LVN 9 also stated, the flavored blend juice was already expired as indicated on the bottle, it could have been an oversight of the expired…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, for one of one sampled resident (Resident 8), the facility failed to ensure Resident 8 was protected from further potential abuse when Certified Nursing Assistant (CNA) 7, who was the alleged abuser, continued to work in resident care areas, with access to Resident 8 and other residents after an abuse allegation was reported. This failure had the potential to result in retaliation and further occurrences of abuse. Findings: During a review of Resident 8's admission Record, the admission Record indicated Resident 8 was admitted to the facility on 11/2023 with diagnoses that included Alzheimer's disease (a form of dementia, loss of brain function that occurs with certain diseases, affecting one or more brain functions such as memory, thinking, language, judgment, or behavior), depressive disorder (persistent feeling of sadness and loss of interest and can interfere with your daily life), type 2 diabetes mellitus (abnormal blood sugar levels), and hemiplegia (paralysis of one side of the body) and hemiparesis (weakness of one side of the body)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide necessary respiratory care and services consistent with professional standards for four of four sampled residents (Resident 1, Resident 2, Resident 3, and Resident 4), when: 1. Respiratory Therapy Consultant (RTC) changed Resident 1's tracheostomy tube with an incorrect tube type and size. (Tracheostomy, also used interchangeably with trach or Tracheotomy is a surgical opening created through the neck into the trachea [windpipe] to allow direct access to the breathing tube and is commonly done in an operating room under general anesthesia. A tube is placed through this opening to provide an airway and to remove secretions from the lungs. A patient breathes through this tube rather than through the nose and mouth). This failure potentially contributed to Resident 1 going into respiratory distress. Resident 1 expired on [DATE] at 12:29 p.m., 20 minutes after a routine tracheostomy tube change. 2. Resident 1, Resident 2, Resident 3,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 complete documentation of medical records for one of three residents (Resident 1) involving: 1. missing seven weekly skin reports 2. missing twenty-six ADL (activities of daily living) entries This failure resulted in Resident 1 having incomplete medical records which potentially may affect Resident 1 ' s care and well-being. Findings: A review of Resident 1 ' s face sheet, undated, indicated Resident 1 was admitted to the facility in January 2023, with diagnoses of aphasia (loss of ability to understand or express speech) following cerebral infarction (or stroke – brain damage due to interruption of blood supply), hemiplegia (paralysis to one side of body) and hemiparesis (muscle weakness) following cerebral infarction. A review of Resident 1 ' s facility document quarterly Minimum Data Set (MDS, an assessment tool used to guide care) dated 7/5/23, indicated Resident 1 rarely understood others or makes self-understood, severely impaired daily decision making, total dependence on toilet use and personal hygiene,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 showers were provided to maintain grooming and personal hygiene for one of two sampled residents (Resident 2), who was totally dependent on staff for Activities of Daily Living (ADLs, such as transfers from bed to chair, bathing/showers, eating, personal hygiene). This failure had the potential to result in poor grooming and personal hygiene and potentially result in skin irritation. Findings: During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included convulsions (rapid, involuntary muscle contractions that cause uncontrollable shaking and limb movement), tremors (unintentional trembling or shaking movements in one or more parts of the body), need for assistance in personal care, cognitive communication deficit, autistic disorder (a developmental disability caused by differences in the brain), and anxiety (feelings of worry or fear that are…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medically related social services for one of two sampled residents (Resident 1) when transportation going to and from dialysis treatments was not provided. Resident 1 went to the dialysis center with a staff member pushing Resident 1 in a wheelchair. This failure had the potential to result in an avoidable accident. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility in February 2023 with diagnoses that included hypertensive heart and chronic kidney disease (means gradual loss of kidney function over time) with heart failure and Stage 1 through Stage 4 chronic kidney disease, morbid obesity, chronic pulmonary edema (fluid collects in the air sacs of the lungs, making it difficult to breathe), anemia, and unspecified asthma, and dependence on renal dialysis (a treatment for people whose kidneys are failing). During a review of Resident 1's Minimum Data Set (MDS, an assessment tool used to direct resident care), dated…

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

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) care plans were reviewed and revised by the interdisciplinary team after each assessment when Resident 1 had multiple new wounds at the facility and the facility did not start a new care plan nor update the existing care plan for skin damage prevention for Resident 1. This failure resulted in repeated skin damage and new wounds for Resident 1 at the facility. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility with multiple diagnosis including hemiplegia (one-sided muscle paralysis or weakness). During a concurrent interview and record review on 12/21/23 at 11:30 a.m. with the Director of Nursing Assistant (ADON), ADON reviewed Weekly Skin Check, Progress Note*New*, and Care Plan. ADON confirmed Resident 1 was found with new skin damages on the following dates: 6/4/23, 6/17/23, 5/10/23, 5/27/23, and 6/23/23. ADON confirmed that the wound care plan initiated for coccyx's wound on 4/21/23 and revised once on 5/11/23 with no…

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

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from accidents while residing at the facility, when Resident 1 had a skin tear to his right hand while being transferred to the shower. This failure resulted in Resident 1 had a skin damage, bleeding, and pain. Findings: During a concurrent interview and record review on 12/21/23 at 11:30 a.m. with the Director of Nursing Assistant (ADON), ADON reviewed and confirmed, Resident 1 ' s Progress Notes *NEW*, dated 6/28/23 indicated . Floor nurse was notified by CNA (Certified Nurse Assistant) after shower given around 0800 that patient got skin tears on the back of his R (Right) hand during taking him to the shower room. CNA stated, patient moved his hand and hit the wall while carrying him to shower room, assessed then measured the site (4cmX2.5cmX2cmX0.5cm), the site was bleeding .patient c/o (complained) pain . Furthermore, ADON reviewed the care plan and stated there was no care plan for the injury on 6/28/23 and stated making care plan is very important for 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, all drugs and biologicals were stored in locked compartments for one of three sampled residents (Resident 1), when medication was found at Resident 1 ' s bedside unattended. This failure had a potential in Resident 1 not receiving the medication in the right dose and right time. Findings: A review of Resident 1 ' s admission Records indicated Resident 1 was admitted to the facility with multiple diagnosis including diabetes. During an interview on 12/29/23 at 3:35 p.m. with the complainant, Complainant stated she found the medication in the cup at Resident 1 ' s bedside unattended, and she notified the Director of Nursing (DON). DON removed the medication from Resident 1 ' s bedside. During an interview on 12/22/23 at 10:30 a.m. with the DON, DON stated she was informed by Resident 1 ' s representative that the staff left medication at Resident 1 ' s bedside. DON stated she went to Resident 1 ' s room, found a cup of medication on the bedside, and removed it. DON stated the nurse confirmed she had left it there 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, for one of one sampled residents (Resident 1), the facility failed to provide a bed hold (holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization) notice to Resident 1 or Resident 1's Representative (RR) during transfer to the hospital. This failure had resulted in violation of Resident 1's right to return to his previously assigned bed. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility in August 2023 with diagnoses that included anxiety disorder (feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), history of falling, need for assistance with personal care, unspecified sequelae of nontraumatic intracerebral hemorrhage (bleeding inside the skull or brain), and tracheostomy (surgically created hole [stoma] in your windpipe [trachea] that provides an alternative airway 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 allow one of one sampled resident (Resident 1), to return to the facility when Resident 1 was discharged from the hospital on [DATE]. This failure resulted in an unnecessary hospital stay. As of 12/22/23 (37 days), Resident 1 continued to stay at the hospital pending the facility's approval to return. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility in August 2023 with diagnoses that included anxiety disorder (feelings of worry or fear that are strong enough to interfere with one's daily activities), history of falling, need for assistance with personal care, unspecified sequelae of nontraumatic intracerebral hemorrhage (bleeding inside the skull or brain), and tracheostomy (surgically created hole [stoma] in your windpipe [trachea] that provides an alternative airway for breathing) status. During a review of Resident 1's Progress Notes, dated 11/12/23, the Progress Notes…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 three showers per week as ordered by physician for one of two residents (Resident 1). This failure resulted in Resident 1's inability to exercise his rights in how he receives care causing emotional distress. Findings: During a review of Resident 1's face sheet, undated, the face sheet indicated Resident 1 was admitted to the facility in March 2023, with diagnoses of cerebral infarction (a stroke where blood circulation in the brain is suddenly disrupted), Guillain-Barre syndrome (a condition in which the immune system attacks nerves) and need for assistance with personal care. During a review of Resident 1's Order Information Report, dated 9/1/23, indicated an order, dated 7/25/23, for Resident 1 to have a shower three times a week; Monday, Wednesday, and Saturday a.m. shift. During a concurrent interview and record review on 10/26/23 at 9:00 a.m. with Assistant Director of Nursing (ADON), the Order Information Report was reviewed. ADON stated Resident 1 received showers two times a week. ADON was…

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

Based on interview and record review the facility failed to ensure the Minimum Data Set (MDS, an assessment tool used to guide care in skilled nursing facilities) was completed within 14 calendar days for five of five sampled residents (Residents 110, 105, 108, 109, and 107). This failure resulted in delayed completion and submission of Residents 110, 105, 108, 109 and 107's MDS assessments, and had the potential to result in delay of care plan development and implementation. Findings: During an interview and record review on 12/8/21, at 12:28 p.m., with the MDS Coordinator (MDSC), Resident 110's Annual MDS with an assessment reference date (ARD, a date set to establish a uniform look-back period for all responses to MDS coding items) of 10/29/21, was reviewed. The MDSC stated Resident 110's the assessment was completed on 11/27/21. Calculation of days between the ARD and MDS completion indicated 29 days elapsed. During an interview and record review on 12/8/21, at 12:30 p.m., Resident 105's Quarterly MDS with an ARD of 10/19/21, was reviewed. The MDSC stated Resident 105's…

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

Based on observation, record review, and interview, the facility failed to assist one (Resident 14) of one sampled resident with insertion of hearing aids. This failure resulted in Resident 14 not being able to use her hearing aids and feeling anxious and upset from difficulty hearing. Findings: A review of Resident 14's admission Record indicated Resident 14 was admitted to the facility in 2019 with a diagnosis of anxiety and bilateral (both sides) hearing loss. A review of Resident 14's Minimum Data Set (MDS, a resident assessment tool used to guide care) dated 8/13/21, indicated Resident 14 had moderate difficulty hearing and used hearing aids. During a concurrent observation and interview on 12/6/21 at 10:05 a.m., with Resident 14, Resident 14's lay in bed; her hands were shaky. Resident 14 stated she was having difficulty hearing because she did not have her hearing aids on; she depended on staff to assist her in putting them on and she did not know where they were stored when she was not wearing them. During an interview on 12/7/21 at 9:25 a.m., with Certified Nursing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 that food was stored, prepared, and served under sanitary conditions when: 1. The Dry Storage Room had two full cases of apple juice on the shelf 45 days past the used-by-date. 2. The Reach-in refrigerator had five glasses of individually served drinks and two food items in small individually served containers one day past the used-by-dates. 3. The kitchen work area had seven boxes of juice. The boxes had been opened and had dispensing nozzles with attached tubing; the tubing was full of liquid; the boxes were not labeled with date of opening or used-by date. These failures had the potential to result in food-borne illness for residents consuming the products. Findings: During an observation on 12/6/21, at 9:45 a.m., with the Dietary Supervisor (DS) and Registered Dietitian (RD) in the kitchen: 1. The Dry Storage Room had two unopened full cases of apple juice on the shelf, labeled with a received date of 10/23/20 and a used-by-date of 10/23/21 2. The Reach-in Refrigerator had the following items 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 notify the responsible party for three days of a change in the skin condition of one (Resident 56) of 27 sampled residents. The failure to notify Resident 56's responsible party of the development of a bluish discoloration on Resident 56's right wrist prevented RP from being informed about Resident 56's total health condition, and any possible treatment or care options. Findings: A review of Resident 56's admission Record, undated, indicated she was admitted to the facility in 2018 with a diagnosis of high blood pressure. The admission Record indicated Resident 56 had a family member for a Responsible Party (RP) with Power of Attorney for health care decisions. During an observation on 12/07/21, at 11:30 a.m., Resident 56 had a round, bluish discoloration the size of a quarter on her right wrist. During a concurrent observation and interview on 12/9/21, at 12:13 p.m., of Resident 56's right wrist, with Certified Nursing Assistant 1 (CNA 1), CNA 1 confirmed Resident 56 had a round, bluish discoloration 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, record review, and interview, the facility failed to meet the needs of one (Resident 119) of nine residents when Resident 119 received half of the prescribed dosage for furosemide (medication used to increase urination and decrease body fluids to decrease the workload on the heart), and metformin (medication used to decrease blood sugar levels). This failure had the potential to result in inadequate treatment of Resident 119's medical conditions, and lead to complications of heart failure (the heart does not pump enough blood to meet the body's needs), and diabetes (a condition of unstable blood sugar levels). Findings: A review of Resident 119's admission Record indicated Resident 119 was admitted to the facility in 2021, with a diagnosis of diabetes and heart failure. A review of Resident 119's, Order Summary Report, Active Orders as of 12/10/21, indicated a physician order for 40 mg furosemide in the evening for heart failure, start date 11/2/21; and an order for 1,000 mg metformin ER tablet once a day for diabetes, start date 10/20/21. A review of Resident…

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

Based on observation, interview, and record review, the facility failed to provide a sanitary environment when staff did not perform hand hygiene between glove changes when administering medication to Resident 52. This failure had the potential for infection of Resident 52. Findings: During a concurrent observation and interview on 12/8/21 at 12:20 p.m., in Resident 52's room, Registered Nurse 1 (RN 1) administered medication into Resident 52's gastrostomy tube (G-tube, a plastic or rubber tube that is surgically inserted through the abdomen and into the stomach to provide fluids, medications, and nutrition for people unable to chew or swallow safely). After administration, RN 1 removed her used gloves, and without performing hand hygiene, placed new gloves on her hands. RN 1 then performed a blood glucose fingerstick (a small lancet is used to prick a fingertip to get a drop of blood to measure the blood sugar level) on Resident 52. During an interview on 12/10/21 at 9:48 a.m., with Infection Preventionist (IP), IP stated staff are expected to perform hand hygiene by washing hands…

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