West Covina Medical Center D/P SNF

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to act upon the pharmacist's Medication Regimen Review (MRR, a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences associated with medication) recommendation for one of five sampled residents (Resident 1) to specify the behavior manifestation to be monitored for Resident 1's routine Xanax (a medication used for the short-term treatment of anxiety disorders and panic disorders) 0.5 milligrams (mg- unit of measurement) QHS (every night at bedtime) for anxiety, ordered on 9/13/2025, for the months of October and November 2025. This deficient practice had the potential for Resident 1 to receive unnecessary medications and result in undesirable or non-therapeutic effect of the medication to the resident. Findings: During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, Licensed Vocational Nurse 5 (LVN 5) failed to ensure medications were kept secure by failing to lock one of one medication cart (MedCart) that was left unattended and outside of LVN 5's view while providing medication to Resident 3. This deficient practice had the potential for the residents' medications to be accessible to others not authorized to have access to drugs (medications) and biologicals (drugs derived from natural sources) and increased the risk for loss and medication diversion (illegally redirecting prescription medications from intended patient for personal use). Findings: During medication pass observation on 12/18/2025 at 8:25 AM with LVN 5 in the hallway outside Resident 3's room, LVN 5 left the MedCart in the hallway unlocked. During an interview with LVN 5 on 12/18/2025 at 8:38 AM, LVN 5 stated, I did not lock my MedCart when I went inside the resident's room (Resident 3) to give medications. I should have locked the MedCart and not left it…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement and follow infection prevention procedures to prevent the transmission of infectious organisms for one of five sampled residents (Resident 24) by failing to wear proper personal protective equipment (PPE, equipment that protects people from injury or illness in hazardous environments) while providing care to Resident 24 who was placed on Enhanced Barrier Precaution (EBP, precautions that involve using a glove and gown during high-contact resident care activity for residents who are colonized or infected with an multidrug-resistant organisms [MDRO, bacteria that is resistant to many types of antibiotics] and those at a higher risk of developing a MDRO, such as, residents with wounds or indwelling medical devices). This deficient practice had the potential to transmit infectious microorganisms and increase the risk of infection for Resident 24 and staff that could result in a widespread infection in the facility.Findings: During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide reasonable accommodation of needs for two of two sampled residents (Residents 2 and 123) by failing to ensure the residents' call lights were within reach and appropriate to the resident's physical ability. These deficient practices had the potential for Residents 2 and 123 not to receive necessary care or received delayed services to meet their needs. Findings: a. During a review of Resident 123's Face Sheet (FS), the FS indicated Resident 123 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included chronic respiratory failure (a long-term condition that occurs when the lungs could not exchange enough oxygen and carbon dioxide in the body) and dependence on ventilator (a medical device to help support or replace breathing). During a review of Resident 123's Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 8/22/2024, the MDS indicated Resident 123 had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide information on Advance Directive (AD- a process of communication between individuals and their healthcare agents for future healthcare decisions when individuals are no longer able to make their own healthcare decisions) for three of three sampled residents (Residents 6,14, and 20) in accordance with the facility's policy on Advance Directives. These failures had the potential for facility staff to provide medical treatment against the residents' will. Findings: a. During a review of Resident 20's Face sheet (FS), the FS indicated the facility initially admitted Resident 20 on 8/23/2024 and readmitted on [DATE] with diagnoses that included chronic respiratory failure (a condition in which not enough oxygen passes from the lungs into the blood) and encounter for attention to tracheostomy (surgical opening in the throat in which a tube is placed for the resident's breathing). During a review of Resident 20's Minimum Data Set Minimum Data Set (MDS,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide necessary care and services for gastrostomy tube (GT, a tube inserted through the abdomen that delivers nutrition directly to the stomach) site as ordered by the physician and as indicated in the plan of care for two of three sampled residents (Residents 2 and 123 ). These failures had the potential for complications related to tube feedings for Residents 2 and 123. Findings: a. During a review of Resident 123's Face Sheet (FS), the FS indicated Resident 123 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included chronic respiratory failure (a long-term condition that occurs when the lungs could not exchange enough oxygen and carbon dioxide in the body), dependence on ventilator (a medical device to help support or replace breathing) and gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach) malfunction. During a review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: a. Ensure the oxygen cannula (tubing used to deliver oxygen) was connected to the tracheostomy (a surgical procedure that creates an opening in the neck into the windpipe to help a person breathe) with a T-Bar (a T shaped device) for one of one sampled resident (Resident 4). b. Follow the physician's order for tracheostomy care for one of one sampled resident (Resident 16) These deficient practices placed Residents 4 and 16 at risk for complications of shortness of breath and infection. Findings: a. During a review of Resident 4's Face Sheet (FS), the FS indicated the facility admitted Resident 4 on 3/26/2024 with diagnoses that included encounter for attention to tracheostomy and pneumonia (an infection/inflammation in the lungs). During a review of Resident 4's Physician Order (PO) dated 3/26/2024, the PO indicated an order for licensed staff to apply continuous oxygen at two (2) liters per minute (L/min) via T-bar with humidifier.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 it's policy and procedure on storing, preparing, distributing and serving food in accordance with professional standards for food service safety, proper sanitation and food handling practices by failing to ensure: 1. Thawed meat was stored on the top shelf in one of one refrigerator. 2. Stored food items were labeled and dated when it was first opened, in one of three kitchen freezers. These deficient practices had the potential risk for food borne illnesses (infections caused by ingesting contaminated food or beverages). Findings: 1. During an initial tour of the kitchen on 10/15/2024 at 9:34 am, together with Dietary Aid 1 (DA 1), one bag of uncooked meat and one bag of uncooked sausage being thawed were placed on the top shelf of the refrigerator. There were16 pieces of uncovered sliced bread placed on a tray on the second shelf immediately below the uncooked meat and sausage being thawed. The DA 1 stated, thawed meat should not be placed or thawed on top of the bread because blood from the thawed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the resident's indwelling catheter (foley catheter - thin, sterile tube inserted into the bladder to drain urine into a bag outside the body) bag was covered and provided the resident privacy in accordance with the facility's policy on Urinary Catheter, Insertion and Care for one of one sampled resident (Resident 17). This deficient practice had the potential to result in psychosocial (mental and emotional well-being) decline and lowered self-esteem and self-worth for the resident. Findings: During a review of Resident 17's Face sheet (FS), the FS indicated the facility initially admitted Resident 17 on 12/10/2018 and readmitted on [DATE] with diagnoses that included bladder (stores urine) disorder and urinary tract infection (UTI- infection that affects any part of the urinary tract). During a review of Resident 17's Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 9/17/2024, the MDS indicated Resident…

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

Based on interview and record review, the facility failed to notify the State Long Term Care Ombudsman (public advocate) of the Notice of Proposed Transfer and Discharge for one of three sampled resident's (Resident 22) transfer to the General Acute Hospital (GACH) on 8/8/2024 in accordance with facility's policy on Transfer and Discharge (Including Against Medical Advice [AMA].) This deficient practice had the potential to violate Resident 22's right to ensure for an appropriate discharge/transfer from the facility. Findings: During a review of Resident 22's Facesheet (FS), the FS indicated the facility admitted Resident 22 on 4/8/2024 with diagnoses that included encounter for attention to tracheostomy (an opening surgically created through the neck into the windpipe to allow air to fill the lungs) and pneumonia (an infection/inflammation in the lungs). During a review of Resident 22's Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 7/18/2024, the MDS indicated Resident 22 had moderately impaired cognition (mental action or process of acquiring…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide care and services to promote healing of pressure ulcer/injury (PU/PI, localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) for one of one sampled resident (Resident 14), as ordered by the physician. This failure had the potential to result in worsening or re occurrence of pressure injury. Findings: During a review of Resident 14's Face Sheet (FS), the FS indicated Resident 14 was readmitted to the facility on [DATE] with diagnoses that included chronic respiratory failure (a long-term condition that prevents the body from exchanging oxygen and carbon dioxide) and gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach). During a review of Resident 14's Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 9/27/2024, the MDS indicated Resident 14 had no speech, rarely/never understood others, and made…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Restorative Nurse Assistant (RNA, a specialized role for certified nursing assistants that involves training in rehabilitation skills) services was provided to one of one sampled resident (Resident 123) as ordered by the physician. This deficient practice had the potential for a decline in range of motion (ROM, measure of joint flexibility and functionality), stiffness and contractures (a stiffening/shortening at any joint, that reduces the joint's range of motion) for Resident 123. Findings: a. During a review of Resident 123's Face Sheet (FS), the FS indicated, Resident 123 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included chronic respiratory failure (a long-term condition that occurs when the lungs could not exchange enough oxygen and carbon dioxide in the body), and dependence on ventilator (a medical device to help support or replace breathing). During a review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 14) received care and service for parenteral antibiotic (a drug used to treat infections caused by bacteria and other microorganisms) consistent with professional standards of practice to label and date a peripherally inserted intravenous (IV) catheter. This failure had the potential to result in infection to the resident and worsen the resident's overall health condition. Findings: During a review of Resident 14's Face Sheet (FS), the FS indicated Resident 14 was readmitted to the facility on [DATE] with diagnoses that included chronic respiratory failure (a long-term condition that prevents the body from exchanging oxygen and carbon dioxide) and gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach). During a review of Resident 14's Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 9/27/2024, the MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to act upon the consultant pharmacist's Medication Regimen Review (MRR) recommendation for one of five sampled residents (Resident 8). This failure had the potential to result in undesirable or non-therapeutic effect of the medication to the resident. Findings: During a review of Resident 8's Face Sheet (FS), the FS indicated Resident 8 was admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure (a long-term condition that prevents the body from exchanging oxygen and carbon dioxide) and gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach). During a review of Resident 8's Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 9/26/2024, the MDS indicated Resident 8 had unclear speech, sometimes understood others, and made self-understood. Resident 8 was dependent (helper does all of the effort) for personal hygiene and showering/bathing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the facility staff used Personal Protection Equipment (PPE- protective clothing, helmets, goggles, or other garments or equipment designed to protect the wearer's body from injury or infection) in accordance with the facility's Policy and Procedure (P&P) on infection prevention and control for one of five sampled residents (Resident 14). This deficient practice had the potential to spread infection and transmission of communicable diseases. Findings: During a review of Resident 14's Face Sheet (FS), the FS indicated Resident 14 was readmitted to the facility on [DATE] with diagnoses that included chronic respiratory failure (a long-term condition that prevents the body from exchanging oxygen and carbon dioxide) and gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach). During a review of Resident 14's Physician Orders (PO) dated 8/13/2024, the PO indicated Resident 14 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to keep an electric fan (a powered machine used to create a flow of air to cool and ventilate rooms and control humidity) in a safe, operating, and sanitary condition for one of one sampled resident (Resident 123). This failure had the potential to affect Resident's 123 quality of life and overall health. Findings: During a review of Resident 123's Face Sheet (FS), the FS indicated Resident 123 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included chronic respiratory failure (a long-term condition that occurs when the lungs could not exchange enough oxygen and carbon dioxide in the body) and dependence on ventilator (a medical device to help support or replace breathing). During a review of Resident 123's Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 8/22/2024, the MDS indicated Resident 123 had severely impaired cognition (ability to understand). The MDS…

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

Based in interview and record review, three of four sampled staff (Pharmacy Technician 1[PTech 1], Licensed Vocational Nurse 1 [LVN 1] and Registered Nurse 1 [RN 1]) did not know to report allegation of abuse to the state agency as indicated in the facility's Policy and Procedure titled Elder and Dependent Adult Abuse. This deficient practice had the potential for employees not to report an abuse incident to the state agency, which could lead to possible harm and risk of further abuse of the residents. Findings: During an interview on 11/21/2023 at 9:31 am, with PTech 1, PTech 1 stated she worked full time for 30 years in the facility. PTech 1 stated she was a mandated reporter and she had to report to Ombudsman if an abuse was witnessed in the facility. RN 1 stated she did not remember that she needed to report any kind of abuse to the State Agency or California Department of Public Health (CDPH) and local law enforcement agency. PTech 1 stated it was important to report to CDPH and enforcement agency because they investigate abuse cases. During an interview on 11/21/2023 at 9:40…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 b. During a review of Resident 1's admission record, the admission record indicated the facility admitted Resident 1 on 4/22/2022 with diagnoses that included elevated white blood cell count (WBC - part of body's immune system that helps to fight infection), and dementia (long term and often gradual decrease in the ability to think and remember, severe enough to affect a person's daily functioning). During a review of Resident 1's MDS dated [DATE], the MDS indicated, Resident 1's cognition for daily decision making was severely impaired. The MDS indicated Resident 1 required total dependence with two-person physical assistance with bed mobility, transfer (how resident moves between surfaces including to or from bed, chair, wheelchair, standing position), dressing, and toilet use. During a review of Resident 1's Physician order, dated 6/15/2022, the physician's order indicated to give Resident 1 Lorazepam (antianxiety [medication to treat anxiety [emotion characterized by feelings of tension, worried thoughts and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to assess and monitor the presence of white sediments (visible particles in the urine that may contain red or white blood cells, casts, bacteria, fungi, parasites in the urine that could indicate infection or dehydration [fluid deficit]) in the urine for two of two sampled residents (Residents 8 and 22 ) with indwelling catheter (foley catheter - a tube inserted in the bladder to drain urine into a drainage bag), as indicated in the facility's Policy and Procedure, titled Urinary Catheter, Insertion and Care and the resident's care plan for foley catheter. This deficient practice had the potential for Residents 8 and 22 to receive no care or delayed care and treatment for urinary tract infection (UTI, condition in which bacteria invade and grow in any part the urinary system). Findings: a. During a review of Resident 22's Face Sheet, the face sheet indicated Resident 22 was admitted on [DATE], with diagnoses that included neuromuscular…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 care and services for gastrostomy tube (GT, a tube inserted through the abdomen that delivers nutrition directly to the stomach) feeding as ordered by the physician and as indicated in the facility's Policy and Procedure (P&P) and plan of care for two of five sampled residents (Residents 11 and 12) by failing to: a. Ensure Resident 11 received the recommended tube feeding formula and amount of gastrostomy tube feeding. b. Ensure to apply drain sponge to the gastrostomy site and anchor the gastrostomy tube of Resident 12. These failures had the potential for complications related to tube feedings for Residents 11 and 12. Findings: a. During a review of Resident 11's Face Sheet, the face sheet indicated Resident 11 was readmitted to the facility on [DATE] with diagnoses that included dependence on ventilator (a machine that support or replace the breathing of an ill or injured person) and dysphagia (difficulty swallowing).…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 label and date intravenous catheter (IV, a thin plastic tube inserted into a vein using a needle allowing for the administration of medications, fluids and/or blood products.) for three out of three sampled residents (Resident 21, 20 and 7). These failures had the potential to result in infection to the residents and worsen the residents' health condition. Findings: a. During a review of Resident 21's Face Sheet, the face sheet indicated Resident 21 was admitted on [DATE], with diagnoses that included type 2 diabetes mellitus (a disease that occurs when blood glucose/blood sugar is too high.) and heart failure (a condition that develops when the heart doesn't pump enough blood for the body's needs). During a review of Resident 21's Minimum Data Set (MDS, a resident assessment and care screening tool) dated 10/17/2023, the MDS indicated Resident 21 had no speech, rarely/never understood others, and rarely/never made self-understood.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 competent nursing staff for two of five staff (Licensed Vocational Nurse 7 [LVN 7], and Registered Nurse Supervisor 3 [RN Sup 3]) by failing to ensure the Department Manager completed and validated the performance evaluation as indicated in the facility's Policy and Procedure titled Evaluation Process. This deficient practice had the potential for residents not to receive appropriate nursing care and services. Findings: During a concurrent record review and interview on 11/20/2023 at 2:04 pm with the Director of Staff and Development (DSD), LVN 7's employee file was reviewed. The DSD stated LVN 7 worked full time in the facility since 4/22/2021. During a concurrent record review and interview on 11/20/2023 at 2:10 pm with the DSD, RN Sup 3's employee file was reviewed. The DSD stated RN Sup 3 worked full time in the facility since 4/9/2015. During a concurrent record review of the licensed staff's Performance Evaluation and interview on 11/20/2023 at 3:28 pm with the DSD, the DSD stated the Assistant Director of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to obtain a consent for psychotropic medication (any drug that affects behavior, mood, thoughts, or perception) use for two of five sampled residents (Residents 1 and 18). This failure had the potential for Resident 1 and 18 to receive unnecessary medications. Findings: a. During a review of Resident 18's Face Sheet, the face sheet indicated Resident 18 was admitted on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD- type of obstructive lung disease characterized by long-term poor airflow) and hypertension (increased blood pressure). During a review of Resident 18's Minimum Data Set (MDS, a resident assessment and care screening tool) dated 8/10/2023, the MDS indicated Resident 18 had unclear speech, sometimes understood others, and sometimes made self-understood. Resident 18 was totally dependent (full staff performance) for bed mobility, dressing and personal hygiene. During a review of Resident 18's Physician Order…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 safe, and sanitary environment to help prevent the development and transmission of communicable diseases (one that is spread from one person to another) for three of three sampled residents (Residents 1, 20 and 21) by failing to ensure: a. Registered Nurse Supervisor 2 (RN Sup 2) performed hand hygiene before contact with Resident 1. b. Licensed Vocational Nurse 2 (LVN 2) performed hand hygiene before contact with Resident 20. c. Resident 21's nasal cannula ( tube which on one end splits into two prongs which are placed in the nostrils to deliver oxygen) tubing was labeled and dated. These deficient practices placed the residents at risk for infection. Findings: a. During a review of Resident 1's admission record, the admission record indicated the facility admitted Resident 1 on 4/22/2022 with diagnoses that included elevated white blood cell count (WBC - part of body's immune system helps to fight infection), and dementia (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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain patient care equipment in safe operating condition for one of two beds inspected and the facility staff did not communicate with the facility Maintenance Department when the bed indicators flashed. This failure had the potential to result in compromised resident's safety. Findings: During an observation of the facility on 11/20/2023 at 8:48 am, while in Resident 6's room, Resident 6 was lying in a bed with multiple LED (light-emitting diode) indicators flashing that included [NAME] 30+(patient's head is elevated more than 30 degrees), low height, bed exit and side rails. During an observation on 11/20/2023 at 3:37 pm, in Resident 6's room, Resident 6's bed had the LED flashing with the same indicators observed from this morning at 8:48 am. During an observation on 11/21/2023 at 9:38 am, in Resident 6's room, Resident 6's bed had the LED flashing with the same indicators observed from yesterday (11/20/2023). 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.