Whittier Hills Health Care Ctr

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two of three residents (Resident 35 and Resident 8) received services in the facility with reasonable accommodation of resident needs to ensure that the call light (device used by residents to communicate needs to the nursing staff) was within reach and accessible to the resident, specifically placed on the resident's non-dominant side and out of reach. This deficient practice had the potential to limit Resident 35 and Resident 8's ability to request assistance, safety, and timely access to care. Findings: 1.During a review of Resident 35's admission Record (AR), the AR indicated the facility admitted the resident on 11/17/2022, with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (partial weakness or reduced motor function affecting one entire side of the body, including the arm, leg, and sometimes the face), contracture (a stiffening/shortening at any joint,…

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

Based on observation, interview, and record review, the facility failed to provide one of 29 sampled residents (Resident 17) with an admission agreement (legally binding contract between a resident and a nursing facility, detailing the rights, responsibilities, services, and costs for care) in Resident 17's preferred language. This deficient practice had the potential for preventing Resident 17 from being informed of their rights, including contact information for the Ombudsman (trained advocates who investigate complaints, protect rights, and improve quality of life for residents) and the State agency. Findings: During a review of Resident 17's Face Sheet (summary of a resident's information), the Face Sheet indicated the facility admitted Resident 17 on 9/7/2025 with diagnoses including difficulty walking, dysphagia (difficulty swallowing) following a cerebral infarction (brain damage due to a loss of oxygen to the area), and hemiparesis (weakness of the arm, leg, and trunk on the same side of the body). During a review of Resident 17's Minimum Data Set ([MDS] a 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 notify the physician when two of three sample residents (Resident 8 and 194) with significant change in condition by failing to: 1.Resident 8 had pain and discoloration on her left foot's second toe and pain from her hemorrhoid (swollen veins in the anus and lower rectum [temporary storage chamber for stool before allowing the stool to pass through the anal canal to exit the body]). These failures resulted in the lack of and delay in Resident 8 medical management and coordination which did not address Resident 8 issues regarding her left foot second toe pain and discoloration and her hemorrhoid pain and follow up until the recertification survey team (from 2/23/2026 to 2/26/2026) conducted an investigation on 2/24/2026 into Resident 8's medical care. 2. For Resident 194 the facility failed to inform the Medical Director when the primary physician did not respond to the call or text when the resident complained of 3 out of 10 right hip 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 the reason for resident's discharge and notice of proposed discharge was completed for one of three sampled residents (Resident 193) reviewed for closed records as indicated in the facility's policy and procedure titled Criteria for Transfer and Discharge, This deficient practice had the potential to result in inappropriate information communicated to the receiving health care institution or provider. Findings: During a review of Resident 193's admission Record (AR), the AR indicated the resident was admitted on [DATE] with diagnoses that included type 2 diabetes mellitus (chronic condition where the body resists insulin [hormone produced by the pancreas that regulates blood sugar by moving glucose [sugar] from the bloodstream into cells for energy] or fails to produce enough, causing high blood sugar), other schizoaffective disorders (chronic mental health condition combining schizophrenia symptoms [hallucinations, delusions, disorganized…

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 standardized assessment and care screening tool) was completed and transmitted to Centers of Medicare and Medicaid Services (CMS) timely for 2 of 3 sampled residents (Resident 32 and Resident 71). This deficient practice failed to provide CMS specific resident information for quality care measure purposes and had the potential to affect the quality of care provided to the resident. Findings: During a review of Resident 32's admission Record (AC), the AC indicated the resident was admitted to the facility on [DATE] with diagnoses that included Type 2 Diabetes Mellitus (your body does not use insulin properly), muscle weakness ( when muscles aren't as strong as they should be). During a review of Resident 32's History and Physical (H&P) dated 11/14/2025 indicated Resident 32 has the capacity to understand and make decisions. A review of Resident 32's MDS, dated [DATE] indicated this was a 5-day scheduled assessment. A…

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

Based on observation, interview, and record review, the facility failed to provide care and services to prevent skin injury (a skin damage due to prolonged unrelieved pressure and friction) to ensure the resident's low air loss mattress was set according to the physician's order and within the appropriate weight range for one of two sampled residents (Resident 75). This deficient practice had the potential to place Resident 75 at risk for developing pressure injuries, impaired pressure redistribution, and potential skin breakdown. Findings: During a review of Resident 75's admission Record (AR), the AR indicated the facility admitted the resident on 7/21/2024, with diagnoses including pressure ulcer (localized, damaged areas of skin and underlying tissue caused by prolonged, unrelieved pressure - or pressure combine with shear - that cuts off blood flow) of right hip, abnormal posture, and adult failure to thrive (a decline caused by chronic diseases and functional impairments which could cause weight loss, decreased appetite, poor nutrition, and inactivity). 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 provide range of motion ([ROM] full movement potential of a joint) intervention for two of four sampled residents (Resident 8 and 96) reviewed for ROM limitations. 1. For Resident 8, the facility failed to: -Measure Resident 8's left hand during the Occupational Therapy ([OT] profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]) Evaluation, dated 1/19/2026, in accordance with professional standards of practice. -Provide Resident 8 with ROM exercises for both legs from 1/24/2026 to 2/25/2026. -Perform AAROM to Resident 8's left arm in accordance with the physician's orders, dated 1/30/2026. 2. For Resident 96, the facility failed to provide ROM exercises to both arms and legs from 2/18/2026 to 2/26/2026 (nine days) following Resident 96's admission to hospice (interdisciplinary care that is designed to provide physical, emotional, social, and spiritual comfort of an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not ensure that two of three sample residents' (Resident 70 and Resident 204) fluid intake was not monitored to restrict fluid intake at 1000 milliliters (mL, unit of weight) per 24 hours while on hemodialysis (dialysis, a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) as ordered by the physician and in accordance with the facility's policy and procedures titled Licensed Nurse Procedures: Fluid Restrictions, 1.Resident 70's total fluid intake was within the fluid restrictions parameters on 2/3/2026, 2/4/2026, 2/17/2026, 2/18/2026, and 2/24/206. 2.Resident 204's total fluid intake was accurately documented and fluid restrictions parameters on 2/13/2026 to 2/25/2026. These failures had the potential to place Resident 70 and Resident 204 at risk for altered hydration status which may lead to severe dehydration or fluid overload which may result in a hypotensive (low 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to assess the pain level for one of two sampled residents (Resident 203), who verbalized pain during medication pass. This has the potential to result in Resident 203's unmet needs affecting the residents' quality of life. Findings: During a review of Resident 203's admission Record (AC), the AC indicated the resident was admitted to the facility on [DATE] with diagnoses that included During a review of Resident 203's History and Physical (H&P) dated 2/12/2026, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 203's Order Summary Report dated 2/26/2026, the Order Summary Report indicated a medication order for: 1.Acetaminophen/Tylenol (a medication used to treat pain) oral tablet 325 milligrams (mg a unit of measurement), give 2 tablet by mouth every 6 hours as needed for mild pain (1-3) with an order start date of 2/17/2026. 2.Tramadol HCL (a medication used to treat pain) oral…

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 follow physician's orders for one of one sampled resident (Resident 4) who was receiving Hydrocodone (medication used to treat severe, chronic pain) as needed for moderate and severe pain. This deficient practice increased the risk of Resident 4 to experience adverse effects (unwanted and dangerous side effect of medications) that could lead to health complications, such as severe respiratory depression [breathing problems], coma, addiction, and severe low blood pressure. Findings: During a review of Resident 4's admission Record (AR), the AR indicated the resident was admitted on [DATE] with diagnoses that included toxic encephalopathy (brain dysfunction caused by exposure to toxins like solvents, heavy metals, industrial chemicals, drugs, or poisons), specified disorders of urinary system (include urinary tract infections, kidney stones, bladder control) , and extended spectrum beta lactamase (enzymes produced by bacteria that breakdown and 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 observation, interview, and record review, the facility failed to provide adequate hospice (interdisciplinary care that is designed to provide palliative care, alleviate the physical, emotional, social, and spiritual discomforts of an individual in the last phases of life due to a terminal disease) services to one of one residents (Resident 96) on hospice care by failing to: 1. Designate a member of the interdisciplinary team fully aware of the role as the hospice coordinator. 2. Ensure Resident 96 received a hospice physician assessment upon admission to hospice on 2/16/2026. 3. Ensure a physician signed the physician's orders, dated 2/16/2026, for Resident 96's admission to hospice. 4. Ensure Resident 96 received chaplain and Certified Home Health Aide ([CHHA] certified nursing assistants who are trained specifically for hospice care) services as indicated in Resident 96's admission Orders/Hospice Certification, dated 2/16/2026. 5. Ensure Resident 96 had a 60-day hospice certification (hospice medical…

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 therapy equipment was maintained in safe operating condition for one of two adjustable height therapy mats. An adjustable therapy mat in the Occupational Therapy ([OT] profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]) room was observed with a slanted, uneven surface due to a malfunctioning height adjustment mechanism. This failure had the potential to create a safety hazard for residents using the mat for therapy interventions. Findings: During a concurrent observation and interview on 2/24/2026 at 9:01 a.m. in the OT room with the Director of Rehabilitation (DOR), a therapy mat was observed in a slanted position. The DOR stated the therapy staff did not report any problems with the therapy mat. The DOR was observed lowering and increasing the height of the therapy mat. The side of the therapy mat, which was closer to the wall, did not lift as the DOR increased the height of the therapy mat, creating a slanted position. The DOR…

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 call light system (a communication tool that allows residents to immediately signal for assistance) was maintained in proper functioning for two of four sample residents (Resident 8 and Resident 96) in accordance to the facility's policy and procedure titled Physical Environment: Equipment Maintenance. Resident 8 call light (a button that allows the resident to communicate their need of assistance from the nursing staff) did not light up when pressed. In addition the nurse call dome light indicator (a visual signaling device above the resident's room in the hallways to immediately alert nursing staff for assistance) above the room and centralized call light panel (an audio and visual central display in the nursing station that lights up to indicate which resident needs assistance) located at the nursing station was not functioning properly. This deficient practice had the potential for unmet resident's needs especially in an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to accommodate needs for one of one sampled resident (Resident 1) who had a physician's order for a bariatric bed (specialized bed made specifically to accommodate larger and heavier patients) with bilateral 1/2 bed side rails (a structural support attached to the frame of a bed and intended to prevent a patient from falling) to maintain or achieve independent functioning and well-being. As a result of this deficient practice, Resident 1 was discovered on the floor, lying unconscious on [DATE]. The resident was later pronounced deceased , with the cause of death determined to be natural causes.Findings: During a review of Resident 1's admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included obesity due to excess calories, hyperlipidemia (an excess of lipids or fats in the blood), and major depressive disorder (mood disorder that causes a persistent…

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 (1) of 1 sampled resident (Resident 1) was safely provided with her own routine medications from the pharmacy or cubex (automated medication management system to securely store, track, and dispense medications) as ordered by the physician and in accordance with the Policy and Procedure (P&P) titled, Six Rights of Medication Administration. This deficient practice resulted in Resident 1 to miss one dose of albuterol (bronchodilator medicine that relaxes airway muscles to treat and prevent wheezing, shortness of breath, and chest tightness) and to receive one dose of Heparin (an anticoagulant medication that prevents blood from clotting) that belonged to another resident (Resident 3). This had the potential to negatively impact Resident 1's medical conditions resulting in fall with injury, coma, or death. During a review of Resident 1's admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to develop a person-centered care plan (a treatment plan that focused on the needs and preferences of a resident or individual) for two of three sampled residents (Resident 1 and Resident 2) incident on 12/3/2025 by failing to:1. Implement a care plan for Resident 1 after multiple facility staff stated the resident was scared of Resident 2.2. Implement a care plan for Resident 2 after the resident experienced right arm numbness and vision loss.These deficient practices had the potential for a lack of individualized care and to not address Resident 1's well-being and Resident 2's care needs effectively.Findings: a. During a review of Resident 1's admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE], with diagnoses that included hemiplegia and hemiparesis following cerebral infarction, affecting left non-dominant side (paralysis [the loss of the ability to move some or all parts of the body, resulting from damage to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain comfortable and safe room temperature levels between 71- and 81-degree Fahrenheit ( F, unit of measurement) in the resident's rooms as for three of five sampled residents (Resident 1, 2, and 3) as indicated by the facility's policy and procedures (P&P) titled Comfortable & Safe Air Temperature Levels This deficient practice resulted in the residents' increased level of discomfort and the potential to result in loss of body heat that could negatively impact the resident's quality of life.1. During a review of Resident 1's admission Record (AR), the AR indicated the facility originally admitted Resident 1 on 11/12/2019 and readmitted on [DATE] with diagnoses that included congestive heart failure (CHF, a condition when the heart cannot pump blood well enough to the body) and type II diabetes mellitus (a disease of inadequate control of blood sugar level). During a review of Resident 1's Minimum Data Set (MDS, a resident 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 follow physician's orders and care plan for two of three sampled residents (Resident 1 and Resident 2) by failing to:1. Follow Physician's Order to limit the resident's sitting to one to two hours at a time with gel cushion on the wheelchair for Resident 1.2. Follow Physician's Order to adjust Alternating Pressure Mattress Replacement System with Low Air Loss (APMRS, mattress that provided pressure redistribution by filling and un-filling air cells within the mattress so that contact points with the body were reduced) settings according to Resident 1's height and weight.3. Implement Resident 1's care plan to limit the resident's sitting to one to two hours at a time with gel cushion on the wheelchair and adjust the APMRS settings according to the resident's height and weight.4. Follow Physician's Order to adjust APMRS settings according to Resident 2's weight.5. Implement Resident 2's care plan to adjust APM settings according to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe and secured environment for one of two sampled residents (Resident 1) who has a diagnosis of Dementia (loss of memory, language, problem-solving and other thinking abilities) by mistakenly sending Resident 1 without supervision to a Physicians (Orthopedic- a medical specialty that focuses on the musculoskeletal system, which includes bones, joints, ligaments, tendons, and muscles) appointment outside the facility that was scheduled for another resident (Resident 2) on 11/12/2025. This deficient practice resulted in Resident 1 leaving the facility, unsupervised, to the Orthopedic physician's office, which was eleven (11) miles away from the facility, and had the potential for Resident 1 to be at risk for accidents and/or injuries.FINDINGS:During a review of Resident 1's admission Record (AR), the AR indicated the resident was originally admitted to the facility on [DATE]. The AR indicated the resident's diagnoses including…

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 physician failed to accurately document in the physician ' s readmission order and facility failed to record on the Medication Administration Record (MAR) for one of three sampled residents (Resident 1) with gastrointestinal tube (GT- a tube surgically inserted used to deliver medications in fluid form and nutritional formula) to receive medications via GT and not by oral (mouth) when the resident was readmitted to the facility. Resident 1 was receiving medications via GT and the physician ordered the resident to be NPO (nothing per oral) and receive medication per oral. This deficient practice resulted in inaccurate documentation of Resident 1 to receive medications through the wrong route which could result in complication such as aspiration (inhalation of fluid or food into the lungs). Findings: During a review of Resident 1 ' s admission Record indicated the resident was admitted on [DATE] with diagnoses that included cerebral infarction (result of disrupted 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to promote dignity and respect for two of two sampled residents (Resident 18 and Resident 100) by: 1. Leaving the privacy curtain opened while Resident 100 was being assisted with dressing change. 2. Leaving indwelling catheter drainage bag (a flexible tube used to empty the bladder and collect urine in a drainage bag) uncovered for Resident 18 who required the use of an indwelling catheter. As result of the failure, Resident 100 verbalized being hurt and potentially resulted in emotional distress. These deficient practices had the potential to cause a decline in Resident 18's dignity, self respect, self-esteem, and self-worth. Findings: 1. During a review of Resident 100's admission Record, indicated Resident 100 was admitted to the facility on [DATE] with diagnosis that included pneumonia (severe lung infection [the invasion and growth of germs in the body]), sepsis (the body's extreme response to an infection), acute respiratory failure…

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 2a. During a review of Resident 3's Face Sheet (front page of the chart that contains a summary of basic information about the resident) indicated Resident 3 was readmission to the facility on [DATE] with diagnoses that included of metabolic encephalopathy (a problem in the brain caused by a chemical imbalance), chronic obstructive pulmonary disease ( a diseases that blocks airflow and make it hard to breathe) and risk for fall. During a review of Resident 3's History and Physical (H&P), dated 12/24/2024, the H&P indicated the resident has the capacity to understand and make decisions. During a review of Resident 3's care plan for falls, initiated on 12/24/2024, indicated Resident 3 was at risk for falls. The care plan interventions included be sure the call light is within reach and encourage to use it to call for assistance as needed. The care plan also indicated to keep the resident needed items within reach, such as water,etc. During an observation in Resident 3's room on 1/6/2025 at 10:17 AM, Resident 3 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 interview and record review, the facility failed to ensure the quarterly Minimum Data Sets (MDS - a federally mandated resident assessment tool) were completed and submitted in the CMS (Centers for Medicare and Medicaid Services- Long-Term Care) data base within the required time frame for three (3) out of four sampled residents (Residents 85, 98, and 116). This deficient practice had the potential for Residents 85, 98, and 116 to not receive care and services that could negatively affect the provision of necessary care and services. Findings: a. During a review of Resident 85's admission Record, indicated the facility initially admitted Resident 2 on 2/21/2022 and readmitted on [DATE] with diagnosis that included difficulty walking, muscle weakness (generalized), and type 2 diabetes mellitus ((DM2 - condition that results in too much sugar circulating in the blood). During a review of Resident 85's quarterly comprehensive MDS, indicated 11/18/2024 as the assessment reference date (ARD- last day of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a personal centered individualized care plan (a healthcare plan specifically tailored to an individual's unique needs, preferences, and values) that included interventions to prevent elopement (an incident where a resident leaves the facility unsupervised and without staff knowledge) for four out of four sampled residents (Residents 29, 56, 89, and 154), who were at risk for elopement. This deficient practice put Resident 29, 56, 89, and 154 to not receive appropriate care, supervision, treatments, and/or services from staff, compromises the safety and potentially put these residents at risk of elopement and the danger that associated with elopement. Findings: a. During a review of Resident 56's admission Record indicated the resident was admitted on [DATE] with diagnoses that included Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks),…

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 interventions for safety and supervision for four of four sampled residents (Residents 29, 56, 89, and 154), who were at risk for elopement (an incident where a resident leaves the facility unsupervised and without staff knowledge). These deficient practices put Resident 29, 56, 89, and 154 at risk of elopement and potentially lead to serious injury and irreversible harm. Findings: a. During a review of Resident 56's admission Record indicated the resident was admitted on [DATE] with diagnoses that included Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks), hypothyroidism (condition in which the thyroid gland doesn't produce enough thyroid hormone, can disrupt heart rate, body temperature and all aspects of metabolism), and generalized anxiety disorder (severe, ongoing anxiety that interferes with daily activities). During a review of Resident 56'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure three (3) of 3 sampled residents (Resident 27, 201, and 202) were provided with safety and comfort while receiving oxygen therapy, in accordance with the facility's policy and procedure by failing to: 1. Ensure Resident 27's oxygen tubing (flexible plastic tubing used to deliver oxygen through nostrils and the tubing is fitted over the patient ' s ears) and nasal cannula did not touch the floor. 2. Ensure Resident 201's humidifier bottle (a water bottle that aids in preventing patients' airways from becoming dry) was not empty for Resident 201. 3. Ensure Resident 202's oxygen tubing did not touch the floor. These deficient practices had the potential for Resident 27, 201, and 202 to contract infection while receiving oxygen therapy and increase the risk of the spread of infection to other residents, staff, and the visitors in the facility. Findings: 1. During a review of Resident 27's admission record indicated the resident 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 reseal one intramuscular emergency kit (IM e-kit, a collection of supplies of medications that administered into the muscle in an emergency) for one of three sampled IM e-kits and replace the e-kit within 72 hours for Medication room [ROOM NUMBER]. The deficient practice had potential to result in an insufficient number of medications on hand in case of emergency and the potential to result in the inability to identify drug diversion (when a medication is taken for use by someone other than whom it was prescribed or for an indication other than what is prescribed) or misuse. Findings: 1. During a review of Resident 251's admission Record indicated the facility originally admitted Resident 251 on 4/16/2024 and readmitted him on 12/2/2024 with diagnoses that included diabetes mellitus (a group of diseases that result in too much sugar in the blood) and hyperlipidemia (a condition where there are high levels of fat in the blood). 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.

Based on observation and interview, the facility failed to ensure the daily refrigerator temperature logs was completed as required by its policy, compromising its ability to monitor food storage temperatures effectively. This deficiency created a risk of unsafe food storage conditions and potential foodborne illness (caused by consuming contaminated foods or beverages) for residents. Findings: During initial kitchen tour with the Dietary Director (DD) on 1/6/2025 8:30 AM, observed that the refrigerator temperature logs located in the kitchen in a binder were incomplete. No temperature entries were documented for 1/4/2025 for AM and PM shift for Freezer #1. During a concurrent interview and record review on 1/7/2025 at 8:35 AM with the DD, the Refrigeration and Freezer Temperature Log for January 2025 was reviewed. The log had missing entries were noted for the AM and PM shift on 1/4/2025. The DD stated she should have followed up the completion of the log. During an interview on 1/7/2025 at 8:35 AM with the DS stated, Staff are expected to record refrigerator Temperatures 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility ' s Quality Assessment and Assurance (QAA) committee (a group of facility staff responsible in developing and approving and evaluating established policies and procedures of resident ' s quality of care) failed to develop a policy and procedure related to admission process. Resident 301 was admitted to the facility with diagnosis of Diabetes Mellitus (a condition of having high blood sugar) at General Acute Care Hospital (GACH) 1, which was not monitored for signs and symptoms of high or low blood sugar levels. This failure had a potential for the residents not to receive the care and services for DM and other health concerns that could lead to a decline in the resident's well being. Cross reference to F684, F711 Findings: During a review of Resident 301's admission Record, indicated Resident 301 was admitted to the facility on [DATE] with diagnosis that included hemiplegia (a condition that causes weakness or loss of the ability to move on one side of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. During a review of Resident 3's Face Sheet (front page of the chart that contains a summary of basic information about the resident) indicated a readmission to the facility on [DATE] with diagnoses that included of metabolic encephalopathy (a problem in the brain caused by a chemical imbalance), chronic obstructive pulmonary disease ( a diseases that blocks airflow and make it hard to breathe). During a review of Resident 3's History and Physical (H&P) dated 12/24/2024, the H&P indicated the resident has the capacity to understand and make decisions. During a review of Resident 3's Order Summary Report dated 1/10/2025, indicated a physician order for a right lower quadrant abdomen urostomy (a surgical procedure which creates an opening in the abdomen through which urine drains from the body) attached to a drain foley bag (a collection bag that receives urine drained through a catheter), and change the bag on the 3rd day and as needed if dislodged. During a concurrent observation and interview on 01/08/2025 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: 1. Provide sanitary environment for Resident 122 by ensuring an unknown black back brace (a braced used when moving or lifting residents from sitting to standing) was not found in the resident's room on 1/7/2025. This deficient practice had a potential to result in cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) when used by Resident 122 and other facility's residents. 2. Maintain a safe, functional door with locks that latch which leads to the patio area to maintain a safe environment for all residents and staff. This deficient practice had a potential to put the facility's residents and staffs at risk of injury and harm. Findings: 1. During a review of Resident 122's admission Record, indicated Resident 122 was admitted to the facility on [DATE] with diagnosis that generalized epilepsy (a chronic disorder of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review for one of three sampled residents (Resident 3), the facility failed to ensure Resident 3's Advance Directive (living will, legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity) was in Resident 3's chart. These deficient practices 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 3's Face Sheet (front page of the chart that contains a summary of basic information about the resident) indicated a readmission to the facility on [DATE] with diagnoses that included of metabolic encephalopathy (a problem in the brain caused by a chemical imbalance), chronic obstructive pulmonary disease ( a diseases that blocks airflow and make it hard to breathe.…

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 comprehensive Minimum Data Sets (MDS - a federally mandated resident assessment tool) were completed and submitted in the CMS (Centers for Medicare and Medicaid Services- Long Term Care) data base within the required time frame for one (1) out of four sampled residents (Resident 22). This deficient practice had the potential for Resident 22 to not receive care and services that could negatively affect the provision of necessary care and services . Findings: During a review of Resident 22's admission Record, indicated Resident 22 was admitted to the facility on [DATE] with diagnosis that included hemiplegia (a condition that causes weakness or loss of the ability to move on one side of the body) and hemiparesis (a condition that causes weakness or an inability to move on one side of the body) following cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area) affecting left non-dominant side, abnormal posture…

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 follow the facility's policy and procedure titled, Physician visits, by failing to ensure Nurse Practitioner (NP) 1 thoroughly reviewed the overall care needed including the hospital record for one of thirty sampled residents (Resident 301) who had a history of type 2 Diabetes Mellitus (DM, a condition of having high blood sugar) that was not monitored for blood sugar levels. The failure had a potential to result in the resident to have uncontrolled blood sugar level that could lead to hospitalization or death. Cross reference to F684, F867 Findings: During a review of Resident 301's admission Record, indicated Resident 301 was admitted to the facility on [DATE] with diagnosis that included hemiplegia (a condition that causes weakness or loss of the ability to move on one side of the body) and hemiparesis (a condition that causes weakness or an inability to move on one side of the body) following cerebral infarction (damage to tissues in the brain due…

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 Cross reference to F711, F867 Based on interview, and record review, the facility failed to provide care and services to one of – sampled residents (Resident 301) with diagnosis of Diabetes Mellitus (DM, condition that results in too much sugar circulating in the blood) by failing to: 1. Ensure Resident 301 ' s blood sugar was monitored for high or low blood sugar level. 2. Ensure Admitting Registered Nurse (RN) clarified with Resident 301 ' s physician for blood sugar monitoring and treatment. 3. Ensure Nurse Practitioner (NP) 1 thoroughly reviewed Resident 301 ' s General Acute Hospital (GACH) 1 ' s discharge packet when NP 1 took over the care of Resident 301 to clarify Resident 301 ' s history of type 2 Diabetes Mellitus as documented in Resident 301 ' s GACH 1 ' s H&P and justified the need to continue or discontinue blood sugar monitoring and treatment. These deficient practices had a potential to result in Resident 301 ' s to developed uncontrolled blood sugar level that could lead to complication such 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility failed to provide a properly place and sized knee immobilizer (a device typically used for injuries that benefit from immobilization but can tolerate brief periods without immobilization to help relief pain and healing) for one (Resident 351) out of three sample residents. As a result of this failure Resident 351 was at risk for injury, discomfort, and complications, such as impaired mobility and skin breakdown. Findings: During a review of Resident 351's admission Record (Face Sheet), indicated the resident was admitted to the facility on [DATE], with diagnoses including fracture (a break in a bone) of the right patella (kneecap), and history of falling. During a review of Resident 351's History and Physical (H&P), dated 12/13/2024 indicated, Resident 351 had the mental capacity to make medical decisions. During a review of Resident 351's Minimum Data Set (MDS-a federally mandated resident assessment tool), dated 12/13/2024, indicated 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 one out of three sampled residents (Resident 136) who was identified as at risk for weigh loss, received the prescribed health shake (a nutritional supplement) TID (three times a day) as ordered by the physician. This failure had the potential to result in further weight loss and dehydration (fluid deficit) that could lead to compromised nutritional status and overall, well being. Findings: During a review of Resident 136 ' s admission Record, the facility admitted Resident 136 on 10/23/2024, with diagnoses including hypertension (a long-term medical condition in which the blood pressure in the arteries is persistently elevated), and difficulty in walking. During a review of Resident 136 ' s History and Physical (H&P), dated 10/23/2024 indicated, Resident 132 can make needs known but cannot make medical decisions. During a review of Resident 136's Minimum Data Set (MDS-a federally mandated resident assessment tool), dated 10/25/2024, indicated the cognitive (the ability to think and process…

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 smoking policy and procedure for one of three sampled residents (Resident 97) by failing to provide a smoke free environment as indicated in the facilities policy. This deficient practice had the potential to place Resident 97 at risk associated with inhaling secondhand smoke that can potentially lead to diseases such as lung cancer, stroke, heart disease and death. Findings: During a review of Resident 97's Face Sheet (front page of the chart that contains a summary of basic information about the resident) indicated admission to the facility on [DATE] with diagnoses that included stress fracture (a small crack in a bine caused by repetitive force or over use) of the left femur (left thigh bone), morbid obesity due to excess calories (a condition of having to much body fat) . During a review of Resident 97's History and Physical (H&P) dated 11/23/2024, the H&P indicated the resident has the capacity to understand and make…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to follow the faciltys' policy and procedure to prevent developement and worsening of pressure ulcer (skin injury due to prolonged unrelieved pressure or skin friction) by failing to: 1. Resident 90 was not weigh for 90 days to ensure the low air mattress settings (mattress designed to distribute resident's body weight over broad surface to prevent skin breakdown [damage to the skin that can result in redness, tenderness, or an open wound]) was at the correct settings. 2. Resident 78 was not turned and repositioned every two hours as ordered by physician and as indicated in the resident's care plan. Resident 78 was at 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). 3. For Resident 137, the facility failed to set the Alternating Pressure Mattress (mattress that provides pressure redistribution by…

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 appropriate treatments and services to minimize decline in joint range of motion (ROM, full movement potential of a joint) for three out of seven sampled residents (Residents 125, 86, and 82) who was assessed at risk for decline in joint ROM, as indicated in the resident's care plans. The facility failed to: 1. Ensure Resident 125 received Restorative Nursing Aide (RNA) program (nursing aide program to help residents maintain their function and joint mobility) treatments for active assist range of motion (AAROM, movement at a given joint with a person's own effort and assistance from an external force or another person) exercises to both upper extremities (BUE, shoulder, elbow, wrist, fingers) five (5) times a week as ordered by the physician. 2. Ensure Resident 86 received RNA treatments for donning (put on) of left elbow and left resting hand splints (rigid material or apparatus used to support and immobilize a broken bone or…

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

Based on observation, interview, and record review, the facility failed to promote resident safety in administering oxygen for two (2) of 2 sampled residents (Resident 262 and 261) who were receiving continuous oxygen therapy, in accordance with the facility's policy and procedure by failing to: 1. Ensure the oxygen tubing (flexible plastic tubing used to deliver oxygen through nostrils and the tubing is fitted over the patient's ears) was not touching the floor for Resident 262. 2. Ensure the humidifier bottle (a water bottle that aids in preventing patients' airways from becoming dry) was labeled with open date for Resident 262. 3. Ensure the oxygen tubing was labeled with an open date for Resident 262 and 261. This deficient practice had the potential for Resident 262 and 261 to contract infection when receiving oxygen therapy which could increase the risk of the spread of infection to the residents, staff, and other visitors in the facility. Findings: 1. A review of Resident 262's Face Sheet (a document that gives a patient's information at a quick glance) indicated an admission…

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 pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of four of six sample residents (Resident 65,26,310,90) by failing to: 1. Clarify physician orders with overlapping pain scale for Resident 65, which created a potential for duplication of opioid (a class of drugs associated with high potential for abuse) therapy. This failure had the potential to result in opioid overdose and increased risk for adverse consequences such as respiratory depression (trouble breathing) for Resident 65. 2. Accurately account for the use of controlled substances (medications with a high potential for abuse) for Residents 26 and 310) in medication carts (Medication Cart 1A and Medication Cart 2C). These failures had the potential to result in unintended use of discontinued order of Zolpidem (a controlled substance used to treat sleep problems) for Resident 26, and Methadone (a controlled substance used to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure two of two residents (Resident 90 and 154) were free of unnecessary medications in accordance to the facility's policy and procedure and residents care plan. The facility failed to: 1a. For Resident 90, there was no clinical justification in the resident's medical record for the physician's order that GDR (Gradual Dose Reduction-a process to lower dose of medication to determine if symptoms can be managed at a lower dose) was not attempted due to contraindication for Ambien (a medication to treat insomnia [the inability to fall asleep]) that Resident 90 has been receiving Ambien since 3/23/2023. 1b. Ensure Resident 90 who was receiving Xanax (medication to treat anxiety) and Norco (a medication to treat pain) were monitored for side effects ( undesired effect of medication). These failures had the potential for Resident 90 to experience adverse side effects related to Ambien, Xanax, and Norco such as increased sleepiness, drowsiness, lower 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure licensed nursing staff did not administer expired insulin (a medication used to treat high blood sugar) to at least four out of 11 residents (Resident 43, 65, 103 and 113) whose insulin was found to be expired during the inspection of three of five medication carts (Medication Cart 2A, Medication Cart 2B and Medication Cart 1B). These failures resulted in residents (Resident 43, 65, 103 and 113) receiving expired insulin doses that could affect the effectiveness of the medication to lower the blood sugar level and the potential to result in serious health complications due to uncontrolled blood sugar levels possibly resulting in hospitalization or death. Findings: a. During a review of Resident 43's admission Record, (a document containing demographic and diagnostic information), dated 1/8/2024, the admission record indicated that the resident was admitted on [DATE] with diagnoses including Type 2 Diabetes Mellitus (a medical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: 1. Ensure expired insulin (a medication used to treat high blood sugar) was removed and discarded for 11 residents (Residents 3, 27, 31, 43, 65, 86, 103, 113, 127, 260, and a discharged resident) in three of five inspected medication carts (Medication Cart 2A, Medication Cart 2B and Medication Cart 1B). 2. Ensure safe, secured, and limited access to prescription medication Keppra ([Generic name- Levetiracetam], medication used to treat seizure condition) for Resident 116. These failures increased the risk that: Residents 3, 27, 31, 43, 65, 86, 103, 113, 127, 260, and a discharged resident could have received medication that had become ineffective or toxic due to improper storage or labeling possibly leading to health complications resulting in hospitalization or death; Resident 116's seizure medication may not be administered as ordered, and increase the risk of unintended access, potential for misuse, and medication errors. Findings: 1.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop an plan, implement and evaluate its Quality Assurance and Performance Improvement Program (QAPI, a program that is focused on action plan to correct identified quality deficiencies [a deviation in performance resulting in an actual or potential undesirable outcome, or an opportunity for improvement]) for identified quality of care deficiencies to pharmacy services. Cross reference to F755, F760, F761 and F757 The facility failed to: 1. Ensure licensed nursing staff administering the medications did not administer expired insulin (a medication used to treat high blood sugar) to at least four out of 11 residents (Resident 43, 65, 103 and 113) whose insulin was found to be expired during the inspection of three of five medication carts (Medication Cart 2A, Medication Cart 2B and Medication Cart 1B). These failures resulted in residents (Resident 43, 65, 103 and 113) receiving expired insulin doses with the potential to result in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility staff failed to promote dignity and respect for one of three sampled residents (Resident 46). Certified Nursing Assistant (CNA) 12 was observed standing next Resident 46, who was seated in a wheelchair, while assisting the resident to eat lunch. This deficient practice violated the resident's rights to maintain and enhanced their self-esteem, self-worth, and the right to be treated with dignity and respect. Findings: A review of Resident 46's Face Sheet indicated a readmission to the facility on 7/26/2022 with diagnoses that included cerebral infraction (refers to damage to tissues in the brain due to a loss of oxygen), dementia (loss of cognitive functioning, thinking, remembering, and reasoning) A review of Resident 46's History and Physical assessment dated [DATE], indicated Resident 46 does not have the capacity to understand and make decisions. A review of Resident 46's Minimum Data Set (an assessment and screen tool) dated 12/19/2023,…

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, interviews, and record review the facility failed to notify the resident's primary physician for one of one sampled resident (Resident 87) who refused glucose monitoring (a test that measures the amount of sugar in a resident's blood). These failures have the potential to result in the decline of Resident 87's medical status which included hypoglycemia (low blood sugar; can cause weakness, confusion, and coma), hyperglycemia (high blood sugar; can lead to blindness and heart problems) and possible hospitalization. Findings:? During a review of Resident 87's Face Sheet, the Face Sheet indicated Resident 87 was admitted to the facility on [DATE], with diagnoses that included Type 2 Diabetes Mellitus (a disease that causes a problem in the way the body uses sugar as a fuel). During a review of Resident 87's History and Physical dated 8/11/2023, the History and Physical indicated Resident 87 has the capacity to understand and make decisions. During a review of Resident 87's Care Plan History…

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 take reasonable steps to protect three of eight sampled resident's (Resident 9, 59, 115) personal property from loss or theft in accordance with the facility's policy and procedure titled, Personal Effects, Inventory of, for by failing to provide accurate and updated inventory of personal belongings. This deficient practice had the potential to result in the loss or theft of resident's belongings that has importance in their lives. Findings: 1. A review of Resident 9's admission Record indicated the facility admitted Resident 9 on 7/25/2023 and then readmitted on [DATE] with diagnoses that included dysphagia (difficulty swallowing), dementia (a group of thinking and social symptoms that interferes with daily functioning), and diabetes (a disease that result in too much sugar in the blood). A review of Resident 9's History and Physical dated 11/14/2023 indicated that Resident 9 did not have the capacity to make decisions. During an interview…

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

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 46) was free from physical restraints (the use of a device that restrict freedom of movement of all or part of a person's body), by failing to ensure: 1. Resident 46 who had impaired cognition (ability to think and reason) was able to release the self-release belt (a belt that is placed around the residents waist while seated in the wheelchair which could restrict the resident's freedom to move or mobilize) without assistance. 2. A less a less restrictive measure was used to prevent Resident 46 from fall. 3. Identify the Self Release Belt as a restraint since Resident 46 could not release the self-release belt without assistance. This deficient practice had the potential for Resident 46's rights being violated, not treated with respect and dignity and being held against her will. Findings: 1. A review of Resident 46's Face Sheet (an admission record) indicated the resident was readmitted to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to evaluate one of three sampled residents (Resident 125) using the Preadmission Screening and Resident Review (PASRR- a federal requirement to help ensure that individuals with mental illness or disability are not inappropriately placed in nursing homes for long term care) level I to identify suspected mental illness, intellectual/developmental disability, or related condition. Resident 125 had a diagnoses of mental illness such as schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), psychosis (when people lose some contact with reality), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities) and generalized anxiety disorder (can't control the worrying) and receiving psychotropic (drugs that affect a person's mental state) medication. This deficient practice resulted in delayed the PASRR Level II evaluation by the mental…

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 develop a comprehensive, resident specific plan of care for two of two sampled residents (Resident 24 and Resident 46) who were placed on self-release/self-administer seat belt (a belt placed on a resident while seating on a wheelchair) due to resident making unassisted attempts of getting out of the wheelchair. This deficient practice had the potential to resulted in facility staff not monitoring the specific needs and care regarding the use of self-release belts for Resident 24 and Resident 46. Findings: 1. A review of Resident 24's Face Sheet (a document that gives a patient's information at a quick glance) indicated the resident was readmitted to the facility on [DATE] with diagnoses that included dementia (loss of cognitive functioning - thinking, remembering, and reasoning), schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves) A review of Resident 24's History and Physical Assessment, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to review, revised and update the care plan for one of eight sampled residents (Resident 25) who was discharged from hospice services (care services specialized for end-of-life care and needs) and continued to have a care plan regarding hospice care. These deficient practices placed Resident 25 at risk for not receiving necessary services and treatment which could impact quality of care and quality of life. Findings: A review of Resident 25's admission Record indicated the facility admitted Resident 25 on 2/8/2023 with diagnoses that included dysphagia (difficulty swallowing), aphasia (a language disorder that affects a person's ability to communicate), and diabetes (a group of diseases that result in too much sugar in the blood. A review of Resident 25's MDS, dated [DATE] indicated Resident 25 was independent in movement of the upper extremities (shoulder, elbow, wrist, hand) but required substantial/maximal assistance (helper does more than half the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow care plan to ensure safe medication administration for one of five residents (Resident 70) with diagnosis of dysphagia (a medical term for swallowing difficulty). This failure resulted in Resident 70 not receiving resident centered care and had the potential for the resident to choke and aspirate (a condition in which food, liquid or medicine go down the wrong airway while swallowing) during medication administration. Findings: During a review of Resident 70's admission Record, (a document containing demographic and diagnostic information), dated 1/11/2024, the admission record indicated that the resident was originally admitted to the facility on [DATE] and readmission date of 4/10/2023, with diagnoses including dysphagia, acquired absence of other specified parts of digestive tract and aphasia (a language disorder that affects a person's ability to communicate) following cerebral infarction (stroke that happens where there is a…

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

Based on interview and record review the facility failed to do a pain reassessment after one hour of administering Norco (prescribed medication to treat moderate to severe pain) and Tylenol (medication to treat mild to moderate pain) for one of one sampled resident (Resident 56). This failure had the potential to result in not identifying the effectiveness of pain medications. Findings: During a review of Resident 56's admission Sheet, undated, it indicated Resident 56 was admitted to the facility in 9/2023 with diagnoses including but not limited to the following: chronic obstructive pulmonary disease (COPD, condition that does not allow the lungs to fully expand and exchange oxygen and carbon dioxide) with acute exacerbation (sudden worsening of symptoms), purapura (purple-colored spots that occur on the skin), and atherosclerotic heart disease (a buildup of cholesterol in artery walls). During a review of Resident 56's History and Physical (H&P), dated 9/5/2023, it indicated Resident 56 has the ability to make medical decisions. During a review of Resident 56's Minimum Data Set…

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 serve lunch meal service at 12PM as indicated in the facility's policy and procedure titled, Mealtime Service to three of six sampled residents (Residents 25, 59, and 124). These deficient practices resulted in three residents not receiving meals at regularly scheduled time, in which the resident's complained of hunger. In addition, the residents who are receiving medications that lowers the blood sugar level could cause dangerously low blood sugar levels or not receive medications with meals as prescribed by the physician, which could compromise the resident's wellbeing. Findings: 1. A review of Resident 25's admission Record indicated the facility admitted Resident 25 on 2/8/2023 with diagnoses that included dysphagia (difficulty swallowing), aphasia (a language disorder that affects a person's ability to communicate), and diabetes (a group of diseases that result in too much sugar in the blood. A review of Resident 25's comprehensive…

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, interviews, and record review the facility failed to: 1. Separate dented cans on the shelf in the dry food storage area. 2. Label used or opened food items with an expiration date and remove expired food items in the resident refrigerator, kitchen refrigerator, kitchen freezer and dry goods storage. 3. Ensure staff used gloves or utensils when handling and preparing food. 4. Ensure the top exterior of the ice machine was clean. These failures have the potential to expose the residents to a food borne illness (illness caused by eating dirty food; symptoms include: nausea, vomiting, diarrhea). Findings: 1. During a concurrent observation and interview on 1/8/24 at 8:48 AM with Dietary Supervisor (DS) in the dry food storage room, two dented food cans were observed on the dry food shelf. DS stated the two dented cans should be placed in the dented cans area. DS also stated having dented cans on the shelves can compromise the quality of the food and be at risk for bacteria growth. During a review of the facility's P&P titled, Food Storage-Dented Cans, undated,…

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 implement a physical therapy (PT, a type of treatment to help manage movement and reduce pain in people) order for one of one sampled resident (Resident 6). This failure had the potential to result in a decline of Resident 6's mobility, activities of daily living, and overall physical and psychosocial well-being. Findings: During a review of Resident 6's Face Sheet (undated), it indicated Resident 6 was admitted on [DATE] with diagnoses that included but not limited to the following: chronic obstructive pulmonary disease (lung disease causing restricted airflow and breathing problems), abnormal posture, and generalized muscle weakness. During a review of Resident 6's quarterly Minimum Data Set (MDS, a standardized resident assessment and care screening tool) assessment dated [DATE], the MDS indicated Resident 6's cognition was intact. It indicated Resident 6 required the assistance of two or more helpers for bed mobility, toilet use, and personal…

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 follow their policy and procedure titled Physician Orders for Life Sustaining Treatment (POLST, a physician order form that complements an advance directive by converting an individual's wishes regarding life-sustaining treatment and resuscitation in physician orders) for two (2) of three (3) sample residents (Resident 1 and 3). 1. Resident 1 did not have a POLST during the entire stay at the facility from 6/14/2023 to 10/24/2023. 2. Resident 3 did not have a POLST readily accessible in the resident's records. This deficient practice had the potential to result in a delay in treatment and life sustaining emergency during an emergency situation. Findings: A review of Resident 1's admission Record indicated an initial admission to the facility on 6/14/2023, and a readmission on [DATE] with diagnoses of pneumonia (infection that inflames air sacs in one or both lungs, which may fill with fluid), diabetes mellitus (disease that results in too…

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 the facility ' s policy on Reporting Alleged Violations of Abuse, Neglect, Exploitation Policy and Procedure duringthe provision of care and services of one of three sampled licensed nurses for 151 residents (facility census) residing in the facility, when the facility received an allegation of abuse from the Board of Vocational Nursing and Psychiatric Technicians (BVNPT) on 10/20/2023. The facility failed to: 1. Support an environment in which staff and others freely and without hesitation report situations which may be or are consistent with abuse, neglect, mistreatment, exploitation, or misappropriation of resident property. 2. Conduct a prompt, thorough and complete investigation in response to received report of alleged abuse towards a resident (unknown) during medication administration by Licensed Vocational Nurse (LVN) 1. 3. Depending on the nature of allegation, immediately put effective measures in place to ensure that further potential abuse, neglect, mistreatment. Exploitation or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to identify hazards and maintain a safe environment for one of two sampled residents (Resident 1) with diagnosis of seizures (a sudden, uncontrolled electrical disturbance in the brain) by failing to: 1. Ensure a comprehensive, resident-centered care plan was developed and implemented for Resident 1, who had history of active seizures and was on seizure precautions that included the necessary precautions Resident 1 required, to be free from injury due to seizure activity. Resident 1 ' s care plans for seizure precautions did not include padded bed side rails. Resident 1 ' s bedside rails was not up as indicated in the resident ' s care plan for Risk for Falls. 2. Ensure resident equipment was maintained in good working order to prevent potential for accidents and injury. As a result, Resident 1 had a seizure witnessed by the Registered Nurse (RN) Supervisor and fell from the bed on 9/8/23. Resident 1 was transferred to the acute hospital via…

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, interviews and record review, the facility failed to report an injury of unknown source to the Department and other officials immediately, but not later than two hours for one of three sampled residents (Resident 1) who had a discoloration on the right eye. This deficient practice had the potential for the facility to under report allegations of abuse, neglect, exploitation or mistreatment, including injuries of unknown source, which could lead to failure to investigate in a timely manner. Findings: A review of Resident 1's admission Record indicated an admission date on 2/8/2023 with diagnoses including cognitive social or emotional deficit following cerebral infarction (ischemic stroke, occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), aphasia (loss of ability to understand or express speech, caused by brain damage), and dysphagia (impairment in the production of speech resulting from brain disease or damage). A review of Resident 1's History and Physical Examination dated 3/31/2023, 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.