Socal Post-Acute Care

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow physician ordered parameters for required monitoring prior to medication administration for one of six sampled residents (Resident 63). During a medication pass, Licensed Vocational Nurse (LVN) 1 was observed preparing and about to administer Resident 63's ordered Doxazosin Mesylate (a medication used to lower blood pressure) via the gastrostomy tube (G tube). The surveyor stopped the administration when LVN 1 did not check Resident 63's blood pressure and heart rate as required by the physician's order. The order directed staff to hold the medication if the systolic blood pressure (SBP) was less than 110 or if the heart rate (HR) was below 60. This deficient practice had the potential to result Resident 63's risk for adverse outcomes (undesired effect of medication) such as severe hypotension (dangerously low blood pressure where blood flow to vital organs-like the brain, heart, and kidneys are severely reduced) that could cause…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of one sampled resident (Resident 10)'s psychotherapeutic drug (medications that affects mood and behavior) Informed Consent Form (a written document ensuring voluntary participation in research or medical procedures, detailing the study's purpose, duration, procedures, risks, and benefits) was completed. This failure had the potential to result in Resident 10 or the responsible party to receive information such as side effects about the medication Rexulti (an antipsychotic medication used to treat agitation). Findings: During a review of Resident 10's admission Record (face sheet), dated 3/5/2026, the face sheet indicated the resident was admitted to the facility on [DATE] with diagnoses including but not limited to Alzheimer's disease (an irreversible brain disorder that destroys memory and thinking skills over time), dementia (a general term for loss of memory, language, problem-solving and other thinking abilities), and anxiety disorder…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 kitchen freezer was maintained at a temperature of 0 degrees Fahrenheit ( F) and below, per facility's policy and procedure (P&P). This failure had the potential to result in widespread foodborne illnesses with the residents. Findings: During an observation on 3/2/2026 at 8:39 a.m. in the kitchen, the thermometer inside the freezer read 18 F and the digital thermometer on the exterior of the freezer read 22 F. During an observation on 3/3/2026 at 8:13 a.m. in the kitchen, the thermometer inside the freezer read 30 F. During a concurrent interview and record review on 3/3/2026 at 8:21 a.m. with the Director of Food Services (DFS), the Cold Storage Temperature Log, dated 3/3/2026 was reviewed. The log indicated the freezer's readings are to be 0 F or lower. During a concurrent interview and record review on 3/5/2026 at 10:22 a.m. with DFS, the facility's policy and procedure (P&P) titled, Food Receiving and Storage, dated October 2017 was reviewed. The P&P indicated the freezer must keep frozen foods…

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

Based on observation and interview, the facility failed to ensure two of four sampled residents (Resident 17 and Resident 33), had their call light within reach. This failure had the potential to affect the residents' ability to request assistance when needed.Findings: During an observation on 3/2/2026 at 9:32 a.m. in Resident 17's room, Resident 17 was lying in bed with a sling on her right arm. The call light was behind the resident, tied to the bottom right side of the bed, not within reach. During an observation on 3/2/2026 at 9:51a.m. in Resident 33's room, Resident 33 was lying in bed in with their head elevated at a 45degree angle. The call light was behind the resident, on the floor not within reach. During a concurrent interview and record review on 3/5/2026 at 12:38 p.m. with Registered Nurse (RN) 1, the facility's policy and procedure (P&P) title, Answering the Call Light, dated September 2022 was reviewed. The P&P indicated the call light is to be accessible to the resident when in bed, from the toilet, from the shower or bathing and from the floor. RN 1stated it is the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and records reviews, the facility failed to ensure certified nursing assistants (CNA) were competent in providing appropriate care and services during resident transfers, to and from the bed, for two of three sampled residents (Resident 1 and Resident 2) who underwent orthopedic surgery (a procedure on the musculoskeletal system [a complex of network of bones, muscles, joints, tendons, and ligaments that work together to provide support, movement, and protection to the body) This deficient practice had the potential to place residents at risk for further injury and delay healing process.A review of Resident 1's general acute care hospital (GACH) records, dated 10/13/24, prior to the admission to the facility, indicated Resident 1 was status post fall with left femur fracture, status post (s/p) surgery on 10/10/24. The record indicated the diagnosis was open femur fracture. A review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 10/23/2024 with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to account for and administer medications as ordered by the physician for two of two sampled residents (Resident 1 and Resident 2), by failing to: 1. Account for Resident 1 ' s Dilaudid 4 mg tablet bubble pack (also known as a blister pack, a card that packaged doses of medication within small, clear plastic bubbles [or blisters] for easy and safe administration) and the Controlled Medication Count Sheet (CMCS, form used to keep track of how much of a controlled medication was on hand, how much was given to a resident, and how much remained) for the bubble pack. 2. Administer Resident 2 ' s Alprazolam 0.25 mg tablet on 5/4/2025 at 3:30 AM (55 minutes earlier than what was ordered by the physician). 3. Document Resident 2 received Alprazolam 0.25 mg tablet on 5/4/2025 at 3:30 AM in the Medication Administration Record (MAR). 4. Implement Resident 2 ' s Care Plan interventions to administer anti-anxiety medications as ordered by the physician.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 care and services as ordered by the physician and as indicated in the facility's policy and procedure for one of three sampled residents (Resident 1) after experiencing a fall on 4/4/25 and reported having pain on 4/6/25. Resident 1's x-ray (a medical imaging test that creates images of the inside of the body) that was ordered by the physician 4/6/25 at 7:48 AM due to the resident's complaint of pain on the ankle and x-ray was taken on 4/7/25 at 10:59AM. The facility did not follow up to with the Radiology (company that specialize in x-rays) company of the resident's x-ray to obtain the x-ray result. As a result of this deficient practice the X-ray result was not received until 4/9/25 that showed ankle fracture (broken bone) which delayed Resident 1's care and hospitalization after a fall to receive care which could potentially result in long term functional limitation, persistent pain, and limited of range of motion affecting the resident's quality of life negatively. Findings: During a review of…

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

Based on observation, interview and record review, the facility failed to ensure the facility's trash bin was not overflowing. The facility disposed trash in a bin with overflowing trash and the trash was on the ground of the facility's parking lot. These deficient practices had the potential to attract pest and rodents, that could spread infection and create an uncomfortable environment for residents, staff and the public. Findings: During a concurrent observation and interview on 1/10/2025 at 7:56 PM with the Dietary Director (DD), a variety of trash (open boxes, broken containers, wooden pallets, broken decorations and other scattered items) was observed within the view of residents ' windows in the facility ' s parking lot. The DD stated, The trash should be disposed in the trash can, not on the parking lot floor (ground). We don't know if it's hazardous, it can attract animals, bugs. During a concurrent observation and interview on 1/10/2025 at 8:35 PM with the Maintenance Director (MNTD) a variety of trash (open boxes, broken containers, wooden pallets, broken decorations and…

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

Based on observation, interview and record review, the facility failed to put an opening date on an open pack of ground beef in the facility's one of one freezer. These deficient practices had the potential to cause food-borne illnesses to 54 residents residing in the facility who receives their daily meals prepared in the facility's kitchen. Findings: During a concurrent observation and interview on 1/10/2025 at 6:25 PM with the Dietary Director (DD) an open pack of ground beef was observed without an opening date. The DD stated, We don't know how long something has been opened if there is no opening date. This pack of ground beef does not have an opening date on it. It might be old and cause a resident to get sick if they eat it. During a concurrent interview and record review on 1/12/2025 at 10:28 AM with the Director of Nursing (DON), the facility ' s policy and procedure (P&P) titled, Labeling and Dating of Foods dated 2023, indicated, All food items in the storeroom, refrigerator and freezer need to be labeled and dated. Newly opened food items will need to be closed and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that Resident 53's Advance Directive Acknowledgment Form (a written instruction, such as a living will or durable power of attorney for health care, recognized under State law [whether statutory or as recognized by the courts of the State], relating to the provision of health care when the individual is incapacitated) was completed upon admission to the facility on 1/7/2025. This deficient practice had the potential to result in misinformation of medical care and treatment and not honoring resident's wishes in cases where the resident and/or responsible party was unable to participate in making healthcare decisions. Findings: During a review of Resident 53's admission Record (AR), the AR indicated the resident was admitted on [DATE] with diagnoses that included hemiplegia (paralysis that affects only one side of the body) and hemiparesis (weakness or the inability to move on one side of the body) following other nontraumatic intracranial…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and the facility's policy for one of one sampled resident (Resident 53) with a diagnosis of diabetes mellitus (a disease in which the blood sugar levels are too high). The facility failed to ensure all appropriate discharge orders from General Acute Care Hospital (GACH) 1 were verified with the attending physician (Physician 1) upon readmission to the facility on [DATE]. This deficient practice resulted to Resident 53 not receiving the care and services to continue diabetic management and/or medications for the resident ' s diagnosis of diabetes mellitus, while in the facility from 12/8/2024 to 1/12/2024 (36 days). Cross Referenced to F641, F657, and F692 Findings: During a review of facility's admission Record indicated Resident 53 was initially admitted on [DATE] but readmitted back to the facility from GACH 1 on 12/8/2024, with diagnoses that included…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS - a federally mandated resident assessment tool) was accurate for one of one sampled resident (Resident 53) who had a diagnosis of diabetes mellitus (a disease in which the blood sugar levels are too high) with no physician orders for Diabetes Management. This deficient practice had the potential to result in Resident 53 not to receive appropriate treatment and/or services. Cross Referenced to F635, F657, and F692 Findings: During a review of Resident 53's Facility Physician Progress Notes from GACH 1 dated 12/1/2024 indicated a diagnosis of Diabetes Mellitus with blood sugar control per protocol. During a review of facility's Facility admission Record indicated Resident 53 was initially admitted on [DATE] and readmitted back to the facility on [DATE], with diagnoses that included acute pulmonary edema (condition caused by excess fluid in the lungs), Type 2 diabetes mellitus, and end stage renal disease (ESRD- condition…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the care plan was revised for one of one sampled resident (Resident 53) who had an active care plan for a diagnosis diabetes mellitus (a disease in which the blood sugar levels are too high) with no physician orders for Diabetes Management. This deficient practice had the potential to result in Resident 53 not receiving appropriate treatment and/or services for the Diabetes. Cross Referenced to F635, F641, and F692 Findings: During a review of Resident 53's Physician Progress Notes from GACH 1 dated 12/1/2024 indicated a diagnosis of Diabetes Mellitus with blood sugar control per protocol. During a review of facility's admission Record (AR), the AR indicated Resident 53 was initially admitted on [DATE] and readmitted back to the facility on [DATE], with diagnoses that included acute pulmonary edema (condition caused by excess fluid in the lungs), Type 2 diabetes mellitus, and end stage renal disease (ESRD- condition in which the kidneys lose the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a comprehensive approach in regard to resident's diet for one of one sampled resident (Resident 53) by failing to ensure an accurate nutritional assessment was completed for Resident 53 ' s diagnosis for diabetes mellitus (DM- a disease in which the blood sugar levels are too high). This deficient practice had the potential to result in Resident 53 to not receive the appropriate diet and nutritional needs that addressed her DM. Cross Referenced to F635, F641, and F657 Findings: During a review of Resident 53's Physician Progress Notes from GACH 1 dated 12/1/2024 indicated a diagnosis of Diabetes Mellitus with blood sugar control per protocol. During a review of facility's admission Record indicated Resident 53 was initially admitted on [DATE] and readmitted back to the facility on [DATE], with diagnoses that included acute pulmonary edema (condition caused by excess fluid in the lungs), Type 2 diabetes mellitus, and end stage renal disease…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to ensure one (1) of 1 sampled resident (Resident 15) was receiving the appropriate oxygen flow rate in liters per minute (LPM; measurement of volume delivered, used to measure delivery of oxygen) for chronic respiratory failure (when not enough oxygen passes from your lungs to your blood) as ordered by the attending physician and in accordance with the resident's plan of care. This deficient practice had the potential for Resident 15 not to receive enough oxygen or receive too much oxygen which can lead to oxygen toxicity (a condition that occurs when someone breathes in too much oxygen, damaging the lungs and other organs). Findings: During a review of Resident 15's admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE], with diagnoses that included chronic respiratory failure and pulmonary embolism (PE; when a blood clot blocks and stops blood flow to an artery in the lung). 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 interview and record review, the facility failed to ensure that the attending physician responded to a recommendation made by the consultant pharmacist (CP) regarding laboratory monitoring for one of four residents (Residents 18) sampled for medication regimen review between 1/9/2024 and 1/9/2025. This deficient practice had the potential to cause a negative impact on the resident ' s overall physical, mental, and psychosocial well-being. Findings: During a review of facility's admission Record indicated Resident 18 was initially admitted on [DATE] and readmitted back to the facility on 3/16/2019, with diagnoses that included Type 2 diabetes mellitus (a disease that occurs when there are high levels of sugar in the blood)with unspecified diabetic retinopathy(a complication of diabetes that damages the blood vessels in the eyes), Major depressive disorder(a mood disorder that consist of feelings of sadness, hopelessness and loss interest) During a review of Resident 18 ' s History and Physical Assessment…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a safe, sanitary environment to help prevent the spread of transmission of infections to residents, staff members, visitors in accordance with the facility's policy and procedure on infection control by failing to: 1. Ensure Licensed Vocational Nurse (LVN) 1 was aware when to wear personal protective equipment (PPE) in an Enhanced Barrier Precaution (EBP- an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes) room for one of one sampled resident (Resident 49) who had an EBP. 2. Ensure LVN 1 disposed of soiled PPE in a disposable bin inside of Resident 49 ' s room. These deficient practices had the potential to increase the risk of the spread of infection to the residents, staff, and other visitors in the facility. Findings: 1. During a review of Resident 49's admission Record (AR), the AR indicated the resident was admitted on [DATE] with diagnoses that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide adequate supervision to one of four sampled residents (Resident 1) who has a diagnosis of dementia (a progressive state of decline in mental abilities), Guillain-Barre syndrome (a neurological condition causing muscle weakness or paralysis [the loss of the ability to move some or all of the body]) and was assessed as a high risk for falls by failing to: 1. Increase the residents ' need for supervision, including the development of an individualized care plan indicating the frequency of supervision to be provided to the resident after the first fall at the facility on 10/22/24, as indicated in the facility ' s policy and procedure [P&P] titled Safety and Supervision of Residents. 2. Implement Resident 1 ' s care plan titled Witnessed Fall Care Plan to monitor Resident 1 ' s whereabouts and frequent visual monitoring after sustaining a fall on 10/22/24 [3 days after admission to the facility]. 3. Analyze the risk in identifying the trends 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 provide necessary care and services to ensure the resident's ability to perform activities of daily living (ADL) do not diminish for one of three sampled residents (Resident 1) who was dependent with staff on personal hygiene, toilet use and ADL. Resident 1 was left wet with urine for a long period of time, not kept clean and dry as indicated in the resident's care plan and the facility's policy and procedures. As a result of this deficient practice Resident 1 was placed at risk for skin breakdown, infection and feeling frustrated that could result in a decline in ability to perform activities of daily living. Findings: During a review of an admission record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included Cerebral Infarction (an area of necrotic [dead] tissue in the brain resulting from a blockage or narrowing in the arteries supplying blood and oxygen to the brain). During a review of Resident 1'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 interview and record review, the facility failed to implement the facilities policy and procedure titled, Abuse Prevention Management, and Reporting Policies by failing to complete in the facility's employment application (reference section) regarding the previous employer(s), and the facility did not contact the employee's previous employer or references for the employee's character or any history of abuse prior hiring five of five randomly selected employees (Registered Nurse 2 [RN 2], Licensed Vocational Nurse 4 (LVN 4), LVN 3, Certified Nurse Assistant 2 [CNA 2], and CNA 1). This deficient practice had the potential to hire employees with history of abuse, and result in abuse, neglect or mistreatment of residents which could lead to harm and abuse of residents. Findings: During a concurrent review of the employee file of RN 2 and interview with the Director of Nursing (DON) on 1/14/2024 at 11:59 am, the DON stated RN 2 was hired on 11/12/2020, but there was no documented evidence in RN 2's employee file that the facility's employment application section was answered 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 observation, interview, and record review the facility failed to ensure the Minimum Data Set (MDS: a standardized assessment and care-screening tool) was accurate for two of three sampled residents (Resident 4 and Resident 56) for the use of physical restraints (any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body). 1. For Resident 56, Minimum Data Set (MDS) dated [DATE] reflected an accurate assessment of the resident's discharge destination. Resident 56, who was discharged home was coded in the MDS assessment as being discharged to a general acute care hospital (GACH). 2. For Resident 4 the MDS was coded incorrectly for hospice (a type of health care that focuses on the palliation of a terminally ill patient's pain and symptoms) services. These deficient practices had the potential to result in Resident 4 and Resident 56 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. A review of Resident 34's Face sheet (a document that gives a patient's information at a quick glance) indicated an admission to the facility on [DATE] with diagnoses that included aftercare following joint replacement, anxiety disorder, and major depressive disorder. A review of Resident 34's History and Physical assessment dated [DATE], indicated Resident 34 had the capacity to understand and make decisions. A review of Resident 34's Order Summary Report (a physician's order) indicated the following: a. On 2/9/2023, the physician ordered Resident 34 to receive Bupropion (Wellbutrin) Hydrochloride (HCl) Tablet Extended Release 24 Hour 150 milligrams (mg-a unit of measure) one tablet by mouth one time a day for depression manifested by self-report of feeling sad. b. On 2/9/2023, the physician ordered Resident 34 to be monitored for depression behavior as evidence by self-report of feeling sad for Wellbutrin use. c. On 12/9/2023, the physician ordered Resident 34 to be monitored for hours of sleep every…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the necessary care and services for two of two sampled residents (Resident 4 and Resident 159 ) who are high risk for developing pressure injuries (areas of damaged skin caused by staying in one position for too long which reduces blood flow to the area and cause the skin to die and develop a sore) by failing to set the Alternating Pressure Mattress (mattress that provides pressure redistribution by filling and un-filling air cells within the mattress so that contact points with the body are reduced) according to the resident's weight as indicated in the manufacturer's recommendation. Resident 4's body weighs 170 pounds (lbs.-a unit of measurement) Resident 159's body weight of 220 pounds. This deficient practice has the potential for Resident 4 and Resident 159 to develop worsened or new pressure ulcer or injury (skin injury due to prolonged unrelieved pressure or skin friction) and/or delay the resident's wound to heal. Findings:…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 3 of 3 sampled residents (Resident 7, 108 and 47) receiving oxygen therapy were provided respiratory care and resident safety in accordance with the facility's policy and procedure and professional standard of practice by failing to: 1. Ensure proper placement of Resident 7's oxygen tubing and nasal cannula tubing (flexible plastic tubing used to deliver oxygen through nostrils and the tubing is fitted over the patient's ears) was administered continuously and not placed in a storage bag. 2. Ensure Resident 108's nasal cannula was placed properly by placing both nasal prongs in the resident's nostrils; one prong of the nasal cannula was observed in the resident's nostril. In addition, there was no cautionary sign posted on the resident's door indicating oxygen in use in accordance with the facility's policy and procedure. 3. Resident 47's nasal cannula tubing (NC-flexible plastic tubing used to deliver oxygen through nostrils 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 3. A review of Resident 11's admission Record indicated Resident 11 was admitted to the facility on [DATE] with diagnoses that included chronic pulmonary edema (a condition caused by too much fluid in the lungs), essential primary hypertension (a condition in which the force of the blood against the artery walls is too high). A review of Resident 11's History and Physical Assessment, dated 12/23/2023, indicated Resident 1 has the capacity to understand and make decisions. A review of Resident 11's Order Summary Report dated 1/14/2024, indicated a physical order for the resident to receive Apixaban (a medication known as blood thinner and reduce blood clot formation) oral (by mouth) Tablet 5 milligrams (mg, unit of measure), give one tablet by mouth two times day for A-fib with a start date of 12/19/2023. During a concurrent interview and record review of Resident 11's Medication Administration Record (MAR) and Order Summary Report with Director of Nursing (DON) on 1/14/2024 at 4:29 PM, DON stated she could 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 observation, interview, and record review the facility failed to follow proper sanitation and safe food handling based on the facilities policy and procedure by failing to ensure: 1. The Dietary Supervisor wore hair net while in the kitchen. 2. The opened bag of five dozen corn tortillas found in refrigerator were dated on when it was opened. 3. The Main [NAME] 1 changed gloves while preparing grilled cheese sandwich, opening drawer to grab spatula, and then proceeding to touch grilled cheese sandwich with the same gloves. These deficient practices had the potential to put residents at risk for foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins). Findings: On 1/12/2024 at 6:14 PM, during the initial observation of the kitchen, Dietary Supervisor (DS) was observed in the kitchen putting away utensil and not wearing a hair net. On 1/12/2024 at 6:18 PM, during a concurrent interview with DS, DS stated she was getting ready to go home and was doing last minute checks for the next day's meals, and she forgot she was not wearing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a safe, sanitary environment to help prevent the spread and transmission of infections to residents, staff members, visitors in accordance with the facility's policy and procedure on infection control by failing to: 1. Ensure Registered Nurse (RN) 2 wore the N95 respirator mask (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of air particles) that covered the nose and mouth while in the facility during an active Coronavirus (COVID-19, an infectious disease caused by the severe acute respiratory syndrome corona virus 2 (SARS-CoV-2 virus)) outbreak. 2. Ensure used face shields (a plastic covering the face) by staff were disposed after use. These deficient practices had the potential to increase the number of infected residents and spread the infection to the residents, staff, and other visitors in the facility. Findings: 1. During an observation on 1/12/2024 at 6:12 PM, RN 2…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to promote and treat one of two sampled residents (Resident 159) with respect, privacy and dignity by failing to ensure Resident 159's foley catheter bag (a small flexible, rubber tube that is placed through your skin into the kidney to drain your urine) was left covered to provide resident privacy. These deficient practices had the potential to cause Resident 159 to feel embarrassed that could lead to a psychosocial (mental and emotional well-being) decline, resident's individuality, self-esteem, and self-worth. Findings: A review of Resident 159's Face Sheet (an admission record) indicated Resident 159 was admitted to the facility on [DATE], with diagnoses including cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), obstructive and reflux uropathy (a condition in which the flow of urine is blocked). A review of Resident 159's History and Physical dated 1/10/2024 indicated Resident 159 does not have…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 reasonable accommodation of need for one (1) of 14 sampled resident (Resident 2) who was at risk for fall, by failing to ensure the resident's call light (a device used to call for assistance) was within reach as indicated in Resident 2's Care Plan and the facility's policy and procedure, titled Answering the Call Light. This deficient practice had the potential for Resident 2 not to receive or received delayed care to meet the necessary care and services that could result in fall and accident. Findings: During a review of Resident 2's admission Record, indicated the facility initially admitted Resident 2 on 12/5/2023 with diagnoses that included muscle weakness and history of falling. During a review of Resident 2's History and Physical (H&P) dated 12/6/2023, the record indicated, Resident 2 did not have the capacity to understand and made decision. During a review of Resident 2's Care Plan, indicated Resident 2 was risk for falls or injury initiated on 12/6/2023. The care plan interventions indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 159) with suprapubic catheter (a hollow flexible tube that is used to drain urine from the bladder.) had an active physician's order for the indication of placement for suprapubic catheter and the necessary care and treatments while in use. This deficient practice had the potential for Resident 159 with a suprapubic catheter to experience UTIs and had the potential to cause actual harm. Findings: A review of Resident 159's Face Sheet (an admission record) indicated Resident 159 was admitted to the facility on [DATE], with diagnoses including cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), obstructive and reflux uropathy (a condition in which the flow of urine is blocked). A review of Resident 159's History and Physical dated 1/10/2024 indicated Resident 159 does not have the capacity to understand and make decisions. A review of Resident 159's Minimum…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to prevent unnecessary use of medication by failing to assess for depression (depression, mood disorder that causes a persistent feeling of sadness and loss of interest that can interfere with daily life) and monitor the side effects (undesired effect of medication) for one (1) of 1 resident (Resident 1) who was receiving Duloxetine (a type of antidepressant medication, used to treat depression and anxiety). As result of this deficient practice, Resident 1 and other residents receiving psychotropic medications (any medication that affects behavior, mood, thoughts, or perception) could develop side effects that are not detected or continues to receive the medications even when the indication for the use of psychotropic medications had been resolve. Findings: A review of Resident 1's admission Record indicated a readmission to the facility on [DATE] with diagnoses that included transient cerebral ischemic attack (stroke, occurs when there is a lack of blood…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 prompt efforts were made to resolve grievances verbalized by a family member (Family 1) by one of two sampled residents (Resident 1) and keep Family 1 appropriately apprised of progress towards resolution. In addition, the facility failed to issue a written grievance decision to Resident 1 and Family 1, in accordance with the facility ' s policy on Grievance/Concern. This deficient practice increased the risk for negative psychosocial impact on Resident 1 ' s quality of life. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 11/02/2023 with diagnoses of urinary tract infection (an infection in any part of the urinary system, the kidneys, bladder, or urethra), difficulty walking, and muscle weakness . A review of Resident 1 ' s History and Physical Examination dated 11/16/2023, indicated Resident 1 can make needs known but could not make medical decisions. A review of Resident 1 ' s Minimum Data Set (MDS, an assessment and screen tool) dated 11/06/2023,indicated…

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