Whittier Pacific Care Center

Based on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 46) received oxygen therapy at two liter per minute (L/mi) continuously according to the physician's order. This deficient practice had resulted in Resident 46 receiving less oxygen than prescribed and had the potential to cause respiratory distress. Findings: During a review of Resident 46's admission Record (AR), the AR indicated the facility originally admitted Resident 46 on 9/10/2012 and readmitted her on 4/3/2025 with diagnoses that include respiratory failure (a serious condition that happens when the lungs cannot get enough oxygen into the blood or remove waste gas from the body) with hypoxia (a condition not enough oxygen to the body) and dementia (a progressive, irreversible decline in cognitive function, including memory, thinking, and reasoning, and can become severe enough to interfere with daily life). During a review of Resident 46's Minimum Data Set (MDS, a standardized assessment and care planning screening tool), dated 1/15/2026, the MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide pharmaceutical services for one of three residents sampled for medication administration (Resident 112) by failing to reorder Resident 112's routine Olmesartan Medoxomil (a blood pressure medication), Isosorbide Dinitrate (another blood pressure medication), and Raloxifene Hydrocholoride (a medication used to treat osteoporosis- weak and brittle bones due to lack of calcium and Vitamin D) three (3) days prior to the last dosage being administered per the facility's policy and procedure (P&P). This deficient practice resulted in Resident 112 missing her medications as scheduled and placed Resident 112 at risk of complications related to hypertension (HTN- high blood pressure) and osteoporosis. Findings: During a review of Resident 112's admission Record, the record indicated Resident 112 was admitted to the facility on [DATE] with diagnoses including HTN (hypertension-high blood pressure), osteoarthritis (a progressive disorder 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 maintain the medication error rate was less than five percent (%). During medication pass four (4) medication errors out of a total of 30 opportunities contributed to 13.33% medication error rate affecting one of three residents observed for medication administration (Resident 112). 1.Failure to check Resident 112's pulse rate prior to administering Metoprolol Succinate (a blood pressure medication that lowers both blood pressure and pulse rate) with parameters to hold the medication for a pulse rate less than 60 beats per minute (bpm). 2.Failure to administer Olmesartan Medoxomil (another blood pressure medication) due to failing to refill Resident 112's medication after it ran out. 3.Failure to administer Isosorbide Dinitrate (another blood pressure medication) due to failing to refill Resident 112's medication after it ran out. 4.Failure to administer Raloxifene Hydrocholoride (a medication used to treat osteoporosis- weak and brittle…

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 safe provision of pharmaceutical services for one of two medication storage areas (MSA 1) by failing to discard an opened vial of Aplisol (Tuberculin Purified Protein Derivative, PPD) within 30 days as required by the manufacturer's instructions. The Aplisol vial, opened on [DATE], remained stored in the facility's medication refrigerator until [DATE], exceeding the 30 day discard date by 11 days. This failure had the potential to result in inaccurate test results, misuse of expired medication, and compromised resident safety. Findings: During an observation of the facility's Medication Storage Area 1 on [DATE] at 2:30 PM, and a concurrent interview with the Assistant Director of Nursing (ADON), an opened Aplisol vial dated [DATE] was observed inside of the refrigerator in the medication room. The manufacturer's label on the Aplisol bottle indicated, Once entered, vial should be discarded after 30 days. The ADON stated the vial 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 ensure one of four sampled residents (Resident 1), who was at risk for skin breakdown, was provided standards of quality care and services while using a low air loss mattress (LALM - a specialized therapeutic support surface that uses a constant flow of air through micro-vents to reduce skin moisture and heat, preventing and treating Stage I-IV pressure ulcers) As a result, Resident 1 had an alteration of skin and a reopening of the right trochanter (thigh bone) fragile scar tissue. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was initially admitted to the facility on [DATE] with diagnoses that included sepsis, contracture of right and left knee, and muscle weakness. During a review of Resident 1's History and Physical (H&P) dated 12/6/2025, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's Order Summary dated 12/4/2025, 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 care and services specific to the needs required for one of two sampled residents (Resident 1) who had a nephrostomy tubes (a thin, flexible tube that is inserted through the skin of the lower back directly into the kidney that is used to drain urine when the normal flow through the ureter to the bladder is blocked or impaired) by failing to: 1.Initiate and revise Resident 1's care plan to indicate actual and preventative measures for nephrostomy tube dislodgement. 2. Conduct an Interdisciplinary Team (IDT a group of professionals from different disciplines who work together to create and update a resident's individualized care plan) meeting to assess the root causes for Resident 1's nephrostomy tube dislodgement. This failure to perform a root cause analysis of Resident 1's recurring nephrostomy tube dislodgement and failure to initiate appropriate, individualized interventions to prevent future dislodgement of Resident 1's…

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

Based on observation, interview and record review, the facility failed to ensure that accurate staffing information was posted in a visible and prominent place on a daily basis, as required by the facility's policy and procedure (P&P) titled Posting Direct Care Daily Staffing Numbers. This failure had the potential to prevent residents and visitors from being informed of the facility's accurate daily staffing levels. Findings: During an observation on 11/21/2025 at 10:23 AM the staffing information postings at both Skilled Nursing and Subacute Nursing stations were found to be not easily visible to residents who use wheelchairs. At the Skilled Nursing unit, the staffing information was posted approximately five feet above the ground making it difficult for wheelchair bound residents to view. Additionally, the information posted at both the Skilled Nursing and Subacute stations reflected projected staffing information rather than the actual staffing for each shift (7:00 AM - 3:00 PM, 3:00 PM - 11:00 PM, and 11:00 PM - 7:00 AM). Inaccurate data was noted on the following dates: -For…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) who was assessed with contractures (permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff) received treatment and care services in accordance with the resident's care plan for by failing to: 1. Ensure facility staff implemented Resident 1's care plan developed on 7/21/25 to immobilize the resident's right arm, to hold Range of Motion (ROM - a type of exercise designed to maintain and improve the flexibility and movement of joints) exercises as evidence by documentation survey report indicating exercises to the right arm was performed on 7/21/25, 7/22/25.2. Ensure facility staff follow physician's orders to hold range of motion exercises and [elbow extension] splinting to the right arm as evidence by documentation survey report indicating ROM by CNA daily care was conducted on 7/21/25, 7/22/25, 7/23/25. This deficient…

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 one of one sampled resident (Resident 4), when Resident 4 ' s indwelling Foley catheter (a thin, flexible tube inserted into the bladder to drain urine continuously) urinary drainage bag (urine drainage bag to collect urine) was observed without a urinary drainage bag cover. This deficient practice had the potential to violate resident rights to maintain and enhance self-esteem, self-worth, and the right to be treated with dignity and respect. Findings: A review of Resident 4 ' s, admission Record (AR), dated 5/30/2025, indicated Resident 4 was admitted to the facility on [DATE], with diagnoses that included dementia (the loss of cognitive functioning — thinking, remembering, and reasoning), benign prostatic hyperplasia (BPH) (enlarged prostate, is a non-cancerous condition where the prostate gland grows larger than normal, leading to urinary problems), and acute kidney failure (kidneys suddenly stop…

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

Based on interview and record review, the facility failed to ensure nurse staffing information that was indicated on the Daily Skilled Nursing Facility (SNF) Staffing for certified nurse assistants (CNA) was accurate. This deficient practice had the potential to misinform residents and visitors of the number of CNA's providing care to the residents. Findings: A review of the facility provided document for Daily Skilled Nursing Facility (SNF) Staffing Posting, dated 5/23/2025, 5/24/2025, 5/28/2025 and 5/29/2025 for the 11 PM to 7 AM shift, the document indicated the staff posting for actual hours worked for CNAs for the 11 PM to 7 AM shifts was 32 hours, and that the staffing total for CNAs was four (4). A review of the facility documents titled Nursing Staffing Assignment and Sign-In Sheet, dated 5/23/2025, 5/24/2025, 5/28/2025 and 5/29/2025 for the 11 PM to 7 AM shift, the document indicated, three (3) CNAs worked on 5/23/2025, 5/24/2025, 5/28/2025 and 5/29/2025 for the 11 PM to 7 AM shift, which should total 24 hours. During a concurrent interview and record review on 5/30/2025 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.

Based on observation, interview, and record review, the facility failed to ensure two of four outdoor refuse containers (a waste container that a person controls that includes dumpsters, trash cans, garbage pails, and plastic trash bags) was closed with a tight-fitting lid and kept covered. This failure had the potential to attract insects and harbor pests in the refuse area that can cause a wide spread of diseases and affect the residents, staff, and visitors. Findings: During a concurrent observation and interview on 1/28/2025 at 9:17 AM with the Dietary Supervisor (DS) at the facility ' s courtyard, two outdoor refuse containers were observed with no secured lid covered and no other staff was around throwing trash into the refuse containers. The two open refuse containers were full and overflowing with the closed plastic bags of garbage hanging outside the contains. One open refuse container had a red stick propped the lid open. The DS stated the lid of the refuse containers should be closed at all times. During a concurrent observation and interview on 1/28/2025 at 9:20 AM with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. During a review of Resident 72 ' s admission Record (Face Sheet), indicated the facility admitted Resident 72 on readmitted on [DATE] with diagnoses that included diabetes mellitus (DM: long-term metabolic disorder that is characterized by high blood sugar, insulin resistance, and relative lack of insulin), epilepsy (a brain disorder that can cause people to suddenly become unconscious and have violent, uncontrolled movements of the body) and hypertension (a long-term medical condition in which the blood pressure in the arteries is persistently elevated). During a review of Resident 72 ' s History and Physical (H&P), dated 9/12/2024 indicated, Resident 72 does not have the mental capacity to make medical decisions. During a review of Resident 72's MDS dated [DATE], indicated the cognitive (the ability to think and process information) skills for daily decisions making was moderately impaired, and needed supervision to extensive assistance from the staff for the activities of daily living. During A review of…

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

Based on observation, interview and record review the facility failed to ensure sufficient staffing were provided to perform RNA (Restorative Nursing Assistant) assisted services and exercises as ordered by the physician to the residents in the facility that had limited range of motion (ROM). Two of Two RNA's (RNA 1 and 2) assigned to perform RNA services and exercises reported they were reassigned to perform Certified Nursing Assistant (CNA) duties when the facility had no sufficient CNA to attend to residents in the facility. This deficient practice had the potential to result in a decline in the resident's quality of care and further decline in mobility and ROM. Findings: During a review of the facility ' s Daily Staffing Assignment, dated 8/3/2024, 8/4/2024, 8/5/2024, 10/23/2024, 10/25/2024, 11/21/2024, 12/6/2024, 12/16/2024, 12/30/2024, 12/31/2024, 1/24/2024, indicated only one RNA was assigned to provide exercises to the residents with limited ROM and the RNA did not work overtime to attend to RNA duties. During a review of the facility ' s Daily Staffing Assignment, 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 observation, interview, and record review, the facility failed to ensure the facility ' s error rate was less than five percent (5%). During a medication pass observation License Vocational Nurse (LVN )1 did not flush in between each medication administration via gastrostomy tube [GT- a tube inserted into the stomach through a surgical incision use for feeding and administration of medication for a resident unable to swallow] to one of three sampled residents (Resident 86) resulting in 33.3% medication error rate for nine medications out of 27 opportunities. These deficient practices had the potential to result in inconsistent medication administration, risks of physical and chemical incompatibilities between the medications, that could alter drug therapeutic effectiveness, and stomach irritation. Findings: During a review of Resident 86 ' s admission Record (Face Sheet), the facility admitted Resident 86 on 11/8/2023 and readmitted on [DATE] with diagnoses including metabolic encephalopathy (a broad…

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 ' s Quality Assessment and Assurance (QAA) committee failed to maintain an effective system to identify, monitor and evaluate implementation of a plan of correction for the deficient practice previously cited on 8/1/2024 related to insufficient Restorative Nursing Assistant (RNA, a certified nurse assistant [CNA] with specialized training in rehabilitation skills who assists the restorative team with supervised and delegated restorative programs) and CNA and residents not RNA services o provide exercises and devices as ordered by the physician to prevent decline in the mobility. As a result of these deficient practices, the residents who required RNA services are at risk for further decline in range of motion, mobility and contractures (a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff that prevents normal movement of a joint or other body part. Contractures may be caused by not using the muscles). Crossed Reference to F725 and F688…

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 implement the facility's policy and procedure on infection control to prevent spread of infection for five of five sampled residents ( Resident 62, 67, 92, 78 and 77) by failing to: 1. For Resident 62, the resident's Suprapubic Catheter (a medical device that drains urine from the bladder directly through the abdominal wall) attached to a drainage bag that was found of the floor. 2. For Resident 67 and Resident 92, Certified Nursing Assistant (CNA) 1 did not perform hand hygiene before and after providing care between the residents. 3. For Resident 78's the feeding tubing (a tubing attached to the feeding bag with nutritional formula that connects to the Gastrostomy Tube [GT- a tube inserted into the stomach through a surgical incision use for feeding and administration of medication for a resident unable to swallow]) was on the floor. 4. For Resident 77's family member (FM) 2 and FM 3 were not following the Enhanced Barrier Precautions…

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 two of eight sampled residents (Resident 16 and 39) was offered to formulate and received information related to Advance Directive (a legal document indicating a resident's preference on end-of-life treatment decisions) information during their initial admission and subsequent re-admission to the facility. This failure had the potential to result in Resident 16 and 39 not having their wishes met regarding end-of-life treatment decisions. Findings: 1. During a review of Resident 16 ' s admission Record, dated 1/31/2025, the admission Record indicated Resident 16 was initially admitted to the facility on [DATE] and most recently re-admitted on [DATE]. The admission Record also indicated Resident 16 ' s diagnoses include, but not limited to, ventilator dependence (relying on a medical device to help support or replace breathing), epilepsy (brain condition that results in uncontrolled jerking, blank stares, and loss of consciousness),…

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 Discharge Minimum Data Set (MDS-a resident assessment and care-screening tool) was transmitted timely and within 30 days, to the Centers for Medicare and Medicaid Services (CMS) system for one of 19 sampled residents (Resident 87) MDS Assessments. This deficient practice had the potential to affect the quality-of-care monitoring system to ensure safe, efficient, resident centered care in a timely manner. Findings: During a review of Resident 87's admission Record (AR), the AR indicated the facility originally admitted Resident 87 on 1/30/2024 and readmitted him on 7/14/2024 with diagnoses that included metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), heart failure (a condition where the heart muscle is weakened and cannot pump blood efficiently), 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…

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 professional standards of practice in nursing care for one of two sampled residents (Resident 86) by failing to: 1. Check for gastric residual volume (refers to the volume of fluid remaining in the stomach) using a syringe to suction out the stomach fluids via Gastrostomy Tube (G Tube-a tube surgically inserted into your stomach through your abdomen) before medication administration. 2. Flush (rinse) the G-tube with water in-between each medication administration. This failure had the potential to cause complications, including aspiration (inhalation of foreign materials) and pneumonia (a lung infection), and clogged GTube needing a surgical replacement thta could negatively impact the resident's care and health outcomes. Findings: During a review of Resident 86's admission Record (Face Sheet), indicated the facility admitted Resident 86 on 11/8/2023, and readmitted on [DATE] with diagnoses including metabolic encephalopathy (a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to initiate routine Bowel and Bladder training programs to prevent a fall (refers to unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force) for one of one sampled resident (Resident 198) who was assessed at being high risk for fall. Resident 198 was observed walking out of his room and falling on top of plastic Wet Floor sign placed in front of his room door when attempting to use the restroom unassisted by facility staff. This deficient practice had the potential to result in unmet resident ' s needs, which can result in Resident 198 to sustain serious injuries from a fall. Finding: During a review of Resident 198's admission Record indicated the facility admitted Resident 198 on 1/16/2025 with diagnoses that included spinal stenosis (the spaces inside the bones of the spine get small),lack of coordination (a condition that makes it difficult to control your bodies movements).…

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 adequate supervision and safety measures to prevent a fall (refers to unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force) for one of one sampled residents (Resident 198) with high risk for fall. Resident 198 was observed walking out of his room and falling on top of plastic Wet Floor sign placed in front of his room door. This deficient practice had the potential for Resident 198 to sustain serious injuries from the fall. Cross reference F677 Findings: During a review of Resident 198 ' s admission Record indicated the facility admitted Resident 198 on 1/16/2025 with diagnoses that included spinal stenosis (the spaces inside the bones of the spine get small), lack of coordination (a condition that makes it difficult to control your bodies movements). During a review of Resident 198's History and Physical [H&P] dated 1/17/2025, the H&P 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 provider appropriate assessments, treatments, and services for one of one sampled residents (Resident 82) who was incontinent (involuntary loss of urine) of bladder and had an indwelling foley catheter (a thin, flexible tube inserted into the bladder to drain urine and left in place for a set amount of time) for wound care management. Resident 82's foley catheter was not strapped properly to her leg to prevent dislodgement (removal) and had sediment (particles free floating in urine) in the urine. This had the potential to result in Resident 82 sustaining a UTI (an infection in the bladder/urinary tract) unable to maintain patency of the foley catheter drainage system (a closed system containing the foley catheter to a drainage bag that collects urine) that may result in urosepsis (life threatening blood infection because of a UTI spreading to the kidneys), trauma in the catheter site and hospitalization. Findings: During a review of Resident 82's admission Record, the facility admitted Resident 82 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.

Based on observation, interview, and record review, the facility failed to use appropriate alternative interventions before installation of bilateral upper half side rails (metal or plastic bars attached to the side of the bed) for one of one sampled resident (Resident 298). This failure had the potential for Resident 298 to be at risk for entrapment (when a resident can get caught by the head, neck, chest, or other body parts in the tight spaces around the side rails) and physical injuries Findings: During a review of Resident 298's admission Record, the facility admitted Resident 298 on 1/8/2025 and the facility readmitted Resident 298 on 1/28/2025 with the diagnoses of acute respiratory failure (the inability for the body to maintain adequate oxygen to the tissues), hemiplegia (one-sided paralysis) and hemiparesis (one-sided weakness) following other cerebrovascular disease (decrease blood flow to the brain) affecting right dominant side, and surgical aftercare following surgery on the nervous system. During a review of Resident 298's Informed Consent (when the physician educated…

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

Based on interview and record review, the facility failed to ensure one out of three sampled Licensed Vocational Nurses (LVN 2) and one out of three sampled Certified Nursing Assistants (CNA 3) in the facility completed their annual competency assessment and evaluation (a process that assess and evaluates an employees skills, knowledge and performance) for the appropriate job category when providing quality care. As a result of this deficient practice placed the residents at risk for not receiving competent/quality of care services, treatments, and risk for infection from daily care. Findings: During a review of LVN 2's employee file records indicated the facility hired LVN 2 on 4/03/2020. LVN 2 ' s employee records included a Licensed Nurse Competency Check List dated 11/17/2023. During a review of CNA 3's employee file records indicated the facility hired CNA 3 on 1/28/2005. CNA 3's employee records included a Certified Nursing assistant Competency Check List dated 12/3/2023. During an interview and concurrent record review on 1/29/2025 at 11:15 AM with the Director of Nursing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide required specialized rehabilitation services (services that included but is not limited to physical therapy [provide exercises to help injured or ill people improve movement and manage pain] and occupational therapy [helps people to have physical, sensory, or cognitive problems] and promoting independence for individuals with complex rehabilitation needs in accordance with facility policy and professional standards of care for one of four sampled residents (Residents 14). For Resident 14 was not assessed and addressed for potential joint mobility concerns annually and quarterly since 2024. This deficient practice had the potential to negatively impact the resident's physical and mobility function including contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints), pain and discomfort. Findings: During a review of Resident 14 ' s admission Record…

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

Based on interview and record review, the facility failed to explain the arbitration agreement (a provide agreement that allows individual parties to resolve disputes rather than in a lawsuit) to one of three sampled residents (Resident 198) in a form and manner that his responsible party understands. Resident 198 ' s responsible party reported not understanding the arbitration agreement and the rights to make informed decisions and choices about important aspects of Resident 198 ' s health, safety, and welfare. This failure resulted in the resident's responsible party not to make an informed decision about the resident's care to ensure the resident received care according to his rights. Findings: During a review of Resident 198's admission Record, the facility admitted Resident 198 on 1/16/2025 with diagnoses that included dementia (a progressive state of decline in mental abilities), and cognitive communication deficit (trouble communicating due to problems with thinking skills such as attention, memory, organization, or reasoning). During a review of Resident 198's 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain a resident ' s call light in operating condition for three of four residents sampled (Resident 5, 48 and 62). This deficient practice had the potential for unmet resident ' s needs and calls for assistance that, may cause negative outcomes such as accidents/injury and/or anxiety (fear of the unknow) and depression (a severe feeling of hopelessness and sadness). Findings: 1. During a review of Resident 5 ' 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 Chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), Alzheimer disease (a progressive disease that destroys memory and other important mental functions). During a review of Resident 5 ' s History and Physical [H&P] dated 10/27/2024, the H&P indicated the resident does not have 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 accommodate the needs of four of five sampled residents (Residents 1, 3, 4 and 5) by failing to answer the call light (a device used by patients to call for assistance from staff) in a timely manner. This deficient practice had the potential to increase the risk for falls, delay medical attention for urgent needs, increase residents discomfort, frustration, and potentially contribute to residents' harms or irrversalble injuries. Findings: A review of Resident 1's admission Record indicated that the facility admitted Resident 1 on 10/25/2023 and readmitted the resident on 5/10/2024 with diagnoses that included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) affecting the left nondominant side and the right dominant side. A review of Resident 1's Minimum Data Set (MDS, a resident assessment and care-screening tool), dated 12/24/2024, indicated that Resident 1 ' s cognition (the mental process of acquiring knowledge…

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

Based on interview, and record review, the facility failed to follow the facility ' s policy and procedure for influenza immunization for one of five sampled residents (Resident 1) by failing to: 1. Offer the influenza vaccine (a vaccine to protect against the influenza virus, or flu. 2. Provide education regarding the benefits and potential side effects of the medication. 3. Indicate Resident 1 ' s refusal to receive the influenza vaccine with the resident ' s name and signature. This deficient practice increases the risk of Resident 1 ' s potential to be infected with the influenza virus that could lead to severe illness, hospitalization, or death. Findings: A review of Resident 1's admission Record indicated that the facility admitted Resident 1 on 10/25/2023 and readmitted the resident on 5/10/2024 with diagnoses that included an acute respiratory failure (a life-threatening condition that occurs when the lungs can't exchange enough oxygen with the blood) and cerebral aneurysm (a bulge or ballooning in a blood vessel in the brain that can cause serious health problems). A review…

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

Based on interview, and record review, the facility failed to follow the facility ' s Covid-19 policy and procedure for one of five sampled residents (Resident 1) by failing to: 1. Offer the Covid-19 2024/2025 vaccine (a vaccine intended to provide acquired immunity against the coronavirus disease) to Resident 1. 2. Provide Education to Resident 1 about the benefits of receiving the Covid-19 vaccine and risks of refusal. 3. Document Resident 1 ' s refusal of the Covid-19 vaccine with the resident ' s name and signature This deficient practice put Resident 1 at risk to infected with COVID-19 virus that could lead to severe illness, hospitalization, and/or death. Findings: A review of Resident 1's admission Record indicated that the facility admitted Resident 1 on 10/25/2023 and readmitted the resident on 5/10/2024 with diagnoses that included an acute respiratory failure (a life-threatening condition that occurs when the lungs can't exchange enough oxygen with the blood) and cerebral aneurysm (a bulge or ballooning in a blood vessel in the brain that can cause serious health…

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 that facility staff implement the facility ' s policies and procedures on Abuse, Neglect , Exploitation and Misappropriation Prevention Program and Abuse, Neglect, Exploitation and Misappropriation -Reporting and Investigating during the provision of care and services for one of two sampled residents (Residents 1). The facility failed to: Identify and investigate all possible incidents of abuse when Resident 1 reported she did not want Certified Nursing Assistant (CNA)1 providing her pericare (the practice of washing the genital and anal areas of the body) on 10/27/2024. Investigate and Report all alleged possible incidents of abuse immediately to the Administrator, state licensing agency within two hours, in accordance with the federal regulations. These deficient practices resulted in Resident 1 being assigned again to CNA 1 on 10/28/2024, a day after (10/27/2024) she had reported to RN 1, not wanting CNA 1 to care for Resident 1.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to document resident ' s belongings and prevent personal items from being lost for one of four sampled resident (Resident 1) by failing to document the resident ' s rosary as indicated in the facilities policy and procedure (P&P). This deficient practice resulted in Resident 1 ' s rosary being lost. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 5/10/2024 and re-admitted the resident on 6/11/2024, with diagnoses including anoxic brain damage (occurs when the brain was completely deprived of oxygen), restlessness and agitation, gastrostomy status (a surgical procedure that involves placing a feeding tube through the skin and into the stomach wall). A review of Resident 1 ' s history and physical exam (H&P) dated 5/12/2024, indicated the resident did not have capacity to understand and make decisions. A review of Resident 1 ' s MDS dated [DATE], indicated the resident had severe cognitive impairment. 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 provide medically related social services for one of four sampled resident (Resident 1) by failing to follow up on an x-ray (invisible electromagnetic energy beams to produce images of internal tissues, bones, and organs on film or digital media) recommended by the dentist for Resident 1 ' s bottom left aching tooth to further evaluate and treatment as indicated in the facility ' s policy and procedure (P&P). This deficient practice had the potential for delay in care and services lead to the potential for Resident 1 to suffer pain from the aching tooth and loss of tooth. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 5/10/2024 and re-admitted the resident on 6/11/2024, with diagnoses including anoxic brain damage (occurs when the brain was completely deprived of oxygen), restlessness and agitation, gastrostomy status (a surgical procedure that involves placing a feeding tube through the skin 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 an interview, and record review the facility failed to follow infection prevention and control practices and implement interventions to prevent and control the spread of infections in the facility by failing to transport and store dirty linen in accordance with the facility ' s policy and procedure for six of six sampled residents (Resident 3, 4, 5, 6, 7, and 8). This deficient practice had the potential to result in an increased spread of infection in the facility leading to serious illness and death. Findings: A review of Resident 3 ' s admission Record indicated the facility admitted the resident on 1/17/2024 and re-admitted the resident on 7/23/2024, with diagnoses including candidiasis (a fungal infection caused by an overgrowth of a type of yeast that lives on your body), carrier of carbapenem-resistant enterobacterales (CRE - a group of bacteria that were resistant to one or [NAME] carbapenems, a class of antibiotics), and personal history of other infectious and parasitic (an organism that lives 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.

Based on interview and record review, the facility failed to notify the physician after one of three sample residents (Resident 1) fell from a shower chair (a plastic chair with wheels used for resident to shower) on 8/1/2024. This deficient practice had the potential for the resident not to receive the necessary care, monitoring and supervision need to prevent recurrent fall. In addition this had the potential for the resident not to receive or receive delayed interventions after a fall. Cross reference to F689 Findings: During a review of Resident 1's admission Record (Face Sheet), indicated the facility admitted Resident 1 on 1/25/2019 and readmitted her on 8/9/2024 with diagnoses that included muscle weakness, osteoarthritis (tissue in the joints break down over time) of the left ankle and foot, and unspecified dementia (a decline in mental function that affects a person's ability to think, remember, make decisions, and can interfere with their daily activities). During a review of Resident 1's History Physical Examination (HPE, a comprehensive physician's note regarding 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 develop and implement a comprehensive care plan for two of two sampled residents: 1. For Resident 1 with history of falls by ensuring interventions are deveopled to prevent recurrent fall. Resident 1 had a fall on 8/1/24 and there was no documented evidence the incident was documented Resident 1's clinical record. These failures had the potential to result in Residnet 1 to have a recurrent fall due to the lack knowledge of the staffs to know the interventions needed to prevent Resident 1 from falsl that could result in injuries and death. Cross reference to F689 2, For Resident 5 a care plan was not developed to ensure the resident was monitored for the behavior or opening and closing curtains and keeping the television volume loud, including the intervention to have the nursing supervisor conduct rounds to ensure safety measures are being followed and noise levels are within an adequate range in Resident 4 and 5 ' s room. This deficient…

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 services to promote wound healing by failing to follow the facility ' s policies and procedures on Prevention of Pressure Injuries, and Wound Care, when providing incontinent care to residents with a pressure ulcers in the Sacrococcyx (the fused sacrum and coccyx, or tailbone) and Coccyx (the small bone at the bottom of the spine) area for two of four sampled residents (Resident 1 and Resident 2). This deficient practice had the potential to place the residents at risk for poor wound healing and discomfort. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 5/10/2024 and re-admitted the resident on 6/11/2024, with diagnoses including pressure ulcer of sacral region (skin injuries that occur in the sacral region of the body, near the lower back and spine) – stage 4 (involves full-thickness skin loss that extends through the fascia and into the muscle, tendon, or bone), anoxic brain…

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

Based on observation, interview, and record review, the facility failed to ensure one of two sampled resident ( Resident 1) with a history of fall and had a recurrent fall on 8/1/24 was investigated for cause of fall and implemented interventions that addresses resident ' s risk factors for falls to prevent recurrent fall. This failure had the potential for Resident 1 to have a recurrent fall and have a significant change in condition that is not monitored and result in delayed or not receive the necessary care and interventions to prevent a recurrent fall that could lead to injury and death. Findings: During a review of Resident 1 ' s admission Record (Face Sheet), indicated the facility admitted Resident 1 on 1/25/2019 and readmitted her on 8/9/2024 with diagnoses that included muscle weakness, osteoarthritis (tissue in the joints break down over time) of the left ankle and foot, and unspecified dementia (a decline in mental function that affects a person ' s ability to think, remember, make decisions that interfere with the daily activities). During a review of Resident 1 ' s…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide sufficient staffing to the residents by ensuring the Restorative Nursing Assistant (RNA-a certified nursing assistant (CNA) with specialized training in rehabilitation skills who assists the restorative team with supervised and delegated restorative programs) was not assigned to perform Certified Nursing Assistant duties ( to perform Activities of Daily Living- such as bathing, feeding and repositioning residents) instead of performing range of motion (ROM) exercises (Movement of joint exercise) to 19 to 19 of residents on RNA program, including Resident 6. This deficient practice had the potential to for the resident with a physician's order to receive RNA assisted exercises to not receive services and result in a decrease the residents' range of motion and mobility which could result in contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints).…

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 staffing information was posting was updated and placed in a visible and prominent place daily that indicated the total number of staff and the actual hours worked by the staff was not readily accessible to residents and visitors to. On 7/31/24 the nursing posting was not observed for residents, responsible party to review if the facility had adequate staffing for the day. This deficiency had the potential to result in the lack of the staff providing care to the facility without the responsible party and resident ' s awareness and result in the resident ' s not receiving quality of care. Findings: During an observation on 7/31/24 at 1:32 PM, the daily staffing information posting in front of the Subacute ( an area of nursing care that require a lower level than acute care hospital and higher level than a skilled nursing care) Nursing Station (Station and area divided from Skilled Nursing [SNF] in the facility) dated 7/25/24, verified with Registered Nurse (RN) 1. During an interview and record review on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain accurate clinical records in accordance with acceptable professional standards and practices for one of three sampled residents (Resident 6). Restorative Nurse Assistant (RNA-a Certified Nursing Assitant with specialised training in providing range of motion exercises) 1 admitted that she willfully documented in Survey Report for RNA tasks for Resident 6 ' s that RNA exercises were provided to Resident 6 on 7/10/24 and 7/22/24 even though she was not at the facility, off duty and did not provide the exercises to Resident 6. The deficient practice had the potential for the resident and other residents not to receive necessary RNA assisted exercisied to improve or maintain range of motion of the extremities and the body that results in the deterioration of rehabilitative condition. Findings: During a review of Resident 6 ' s admission Record indicated the facility originally admitted Resident 6 on 2/20/24 and readmitted him on 4/25/24 with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the physician was notified for one of two sampled residents (Resident 1), who had a history of self-decannulation (process to remove tracheostomy [procedure to help air and oxygen reach the lungs by creating an opening into the trachea [windpipe] from outside the neck] tube). This deficient practice had the potential for residents to not receive appropriate care, treatment and/or services. As a result, Resident 1 self-decannulated three times while a resident at the facility. Findings: A review of Resident 1 ' s admission Record indicated a readmission to the facility on 6/6/2024 with diagnoses that included cerebral infarction (also called ischemic stroke, occurs when the blood supply to part of the brain is blocked or reduced), aphasia (language disorder that affects how you communicate), respiratory failure (condition that makes it difficult to breathe on your own), and encounter for surgical aftercare following surgery on the respiratory…

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 implement a care plan consistent with professional standards of practice for a resident with trachoestomy (procedure to help air and oxygen reach the lungs by creating an opening into the trachea [windpipe] from outside the neck), that included specific behaviors and interventions to monitor tracheostomy self-decannulation (process to remove tracheostomy tube) for one of two sampled residents (Resident 1) who had a history of self-decannulation. This deficient practice had the potential for residents to not receive appropriate care, treatment and/or services. Resident 1 had self-decannulated three times while a resident at the facility on 6/9/2024 at 10:15 AM, 6/23/2024 at 3:30 AM and 11:30 AM. Findings: A review of Resident 1 ' s admission Record indicated a readmission to the facility on 6/6/2024 with diagnoses that included cerebral infarction (also called ischemic stroke, occurs when the blood supply to part of the brain is blocked or reduced),…

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 necessary care and services to one of 3 residents (Resident 3) with Gastrostomy tube (G-tube a soft plastic tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications) by ensuring an abdominal binder (fitted elastic material that goes around abdomen to support muscle and or keep bandage in place) was in use as ordred by the physician order to prevent from pulling out or dislodge ( accidental removal). This deficient practice had the potential to result in G-tube dislodgement that can lead to complications including trauma, infection of G-tube site and delayed nutritional feeding. Findings: During an observation on 7/31/24 at 10:35 AM in Resident 3 ' s room, Resident 3 was awake, able to make some eye contact and talks in incomprehensible sounds, G-tube was not anchored (device to secure device) and without an abdominal binder in use. During an interview on 7/31/24 at 10:45 AM with Licensed Vocational Nurse (LVN) 5, LVN 5 stated,…

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 that the prescribing physician document the rationale for extending the use of two PRN (as needed-not given on a regular schedule) psychotropic medications for two out of fourteen sampled residents as indicated in the facility ' s policy and procedure titled Psychotropic Medication use. These deficient practices increased the risk of Residents 1 and 2 to experience adverse effects of the psychotropic medications including, but not limited to, dizziness, drowsiness, leading to an overall negative impact to their physical, mental, and psychosocial well-being. Findings: 1. A review of Resident 1 ' s Face Sheet (admission record) indicated an admission to the facility on [DATE] with diagnoses including unspecified psychosis ( mental condition in which thought and emotions are so affected that contact is lost with external reality anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to review and investigate the allegations made by a resident ' s representative (RP 1) for one of three sampled residents (Resident 1) and submit a written report of such findings to the administrator and RP 1, in accordance with the facility ' s policies and procedures. RP 1 complained that Resident 1 ' s specialized wheelchair had been missing, but the facility did not make prompt efforts to resolve the problem and provide a written response to RP 1 regarding the resolution of the grievance. This deficient practice had resulted to Resident 1 ' s rights to have grievances resolved, in accordance with the regulations and the facility ' s policy and procedure. Findings: A review of Resident 1 ' s admission Record indicated the facility initially admitted the resident on 9/28/12 and readmitted the resident last on 3/16/21, with diagnoses including chronic respiratory failure (a long-term respiratory problem that causes shortness of breath,…

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 update and revise the care plan for two of three sampled residents (Resident 1 and Resident 3) by failing to: 1. For Resident 1, revise and update the care plan after the resident tested positive for Carbapenem-resistant Acinetobacter baumannii (CRAB, a type of bacteria commonly found in the environment, especially in soil and water) that requires isolation (a condition where a resident has to be isolated to prevent the spread of the infection). 2. For Resident 3, revise and update the activity care plan after the facility identified the type of music the resident enjoys listening. This deficient practice has the potential to diminish the quality of life of the resident by not providing the staff the right information the resident needs that the staff follows in the care plan, to reach the resident ' s highest practicable physical, mental, and psychosocial well-being. Findings: 1. A review of Resident 1 ' s admission Record indicated the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement the care plan for the resident to clear the area of any obstruction during a transfer with the use of mechanical lift for two of three sampled residents (Resident 6 and Resident 7). These deficient practices had the potential to place the residents at risk for injuries and fall. Findings: 1. During a review of Resident 6 ' s admission Record indicated the facility originally admitted Resident 6 on 1/27/2021 and readmitted on [DATE] with diagnoses that included diabetes mellitus (a group of diseases that result in too much sugar in the blood) and Hemiplegia (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles). During a review of Resident 6's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 2/28/2024, indicated Resident 6 had severely impaired cognitive (ability to think and reasonably) skills for daily decision making. The MDS indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure medications were not left at the bedside for one (1) of one (1) sampled residents (Resident 5) in accordance with the facility policy and procedure. This deficient practice had the potential for an inaccurate accounting and administration of medications for Resident 5 as indicated on the physician's order. It also had the potential for other residents to access the unattended medication and cause possible harm if ingested. Findings: A review of Resident 5's admission Record dated 2/27/2024, indicated the facility originally admitted the resident on 11/22/2007, and was readmitted on [DATE], with the diagnosis of generalized muscle weakness, difficulty in walking, and chronic obstructive pulmonary disease with (acute) exacerbation (COPD - worsening of respiratory symptoms associated with a variable degree of physiological deterioration). During a review of Resident 5's History and Physical (H&P), dated 2/1/2024, indicated Resident 5…

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 Physical Therapy (PT, medical treatment used to restore functional movements, such as standing, walking, and moving different body parts) per physician (MD) order for one of three sampled residents (Resident 1). This failure had the potential to result in Resident 1 to experience a decline in mobility and range of motion (ROM), and tightening and weakness to the resident's muscles. Findings: During a review of Resident 1's admission Record, Resident 1 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including but not limited to cerebral palsy (caused by damage to the brain that affects a person's ability to control muscles), rhabdomyolysis (occurs when muscle tissue breaks down and leaks into the bloodstream), and muscle weakness. During a review of Resident 1's History and Physical (H&P), dated 2/13/2024, it indicated Resident 1 does not have the capacity to understand and make decisions.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to promote and treat one of two sampled residents (Resident 1) with respect and dignity preventing staff from making inappropriate comments regarding care to Resident 1. This deficient practice had the potential to affect Resident 1's self esteem and to feel embarrassed that could lead to a psychosocial (mental and emotional well-being) decline, resident ' s individuality and self-worth. Findings: A review of Resident 1 ' s Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and then readmitted on [DATE], with diagnoses including heart failure (condition that develops when your heart doesn ' t pump enough blood for your body ' s needs), hemiplegia (a paralysis that affects only one side of your body) and hemiparesis (one side muscle weakness) following unspecified cerebrovascular disease (a group of conditions that affect blood flow and the blood vessels in the brain) affecting left non-dominant side. A review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide safe, accident and hazard free environment for five of 24 residents (Residents 37, 87, 92, 149, 150) with impaired cognition (mental action or process of acquiring knowledge and understanding) who were observed with improperly fitting mattresses and bed frames with gaps between the mattresses and footboard. This deficient practice had the potential to negatively affect the safety of Residents 37, 87, 92, 149 and 150, that placed the residents at risk for accidents or entrapment (trapped or entangled in the spaces in or about the bed rail, mattress, or hospital bed frame) and trap the resident's head, body, arms and legs between the rails and mattress which could result in injuries and death. Findings: 1. A review of Resident 37's admission Record indicated the resident was originally admitted to the facility on [DATE], and was readmitted on [DATE], with diagnoses that included, epilepsy (a disorder in which nerve cell activity in the brain is…

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 maintain a system-wide method of accountability for controlled medications (medication with a high risk of abuse or theft) and maintain a system to ensure accountability of controlled medications to track compliance with its policy on Controlled Substances. The change of shift narcotics reconciliation records titled Narcotic Key Control, the facility uses for the controlled medication reconciliation on (a process of counting all the controlled medication in the medication cart between the nurse leaving and the nurse coming on duty to determine if there are any discrepancies) were not signed by two nurses during shift change between for one of two medication carts (Station 1 Cart1) inspected. This deficient practice had the potential for the diversion (illegal distribution or abuse of prescription drugs or their use for unintended purposes) of controlled substance medications. Findings: On 1/25/24 at 3:06 PM, a review of the facility's Station 1 Cart 1's change of Shift Narcotics Reconciliation records titled,…

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 observations, interviews, and record reviews, the facility failed to store and prepare food under sanitary conditions in accordance with the facility's policy and procedure by failing to: a. Ensure open food items stored in the refrigerators were labeled and dated. b. Discard the expired food items and were not stored in the dry goods storage area. c. Failed to complete QUAT Sanitizer (QUATSL-agent used to kill germs and disease causing organism) Log for January 2024 and Dish Machine Temperature Log (DMTL) for January 2024. The deficient practice had the potential to result in the growth of bacteria and transmission of foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever which could lead to other serious medical complications and hospitalization. Findings: During a concurrent observation and interview on 1/23/24 at 8:12 AM, during an initial Kitchen tour in the present of the [NAME] (CK), several opened items without label of opened date were observed in the reachable refrigerator. a. One (1)…

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

Based on interview and record review, the facility failed to have measures to prevent the growth of Legionella (bacteria found in water, including groundwater, that causes severe pneumonia [severe infection in the lungs] that is transmitted through breathing in Legionella-contaminated, aerosolized [the form of a fine spray] water, soil and water borne pathogens (an organism that can cause disease) in the buildings water system. This deficient practice had the potential to result in widespread infection in the facility and could negatively impact all residents and staffs, and visitors. Findings: During an interview on 1/26/2024 at 8:49 AM, Infection Prevention Nurse (IPN) stated that water management for the facility was handled by the Maintenance Department and that she did not have any of the information regarding the water management. IPN stated that the purpose of a water management program was to prevent Legionnaires disease (a disease spread by water) by water testing. During an interview on 1/26/2024 at 10:20 AM, Maintenance Supervisor (MS) stated that Legionella tested had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the bed frames, mattresses and bedrails were checked for compatibility and size prior to use and the staff, routinely inspects all beds and related equipment to identify risks and problems including potential entrapment (trapped or entangled in the spaces in or about the bed rail, mattress or hospital bed frame) risk for five of 24 residents (Residents 37, 87, 92, 149, 150) who were observed with 5 to 6 inches gaps between the mattress and footboard. This deficient practice had Residents 37, 87, 92, 149 and 150 to have their arms, legs, foot, legs and head to entrap between the bed mattress and foot board and result in injury and death. Findings: 1. A review of Resident 37's admission Record indicated the resident was originally admitted to the facility on [DATE], and was readmitted on [DATE], with diagnoses that included, epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures [episodes causing temporary…

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 two of two sampled residents (Resident 26 and 4), were treated with respect and dignity as indicated in the facility's policy and procedure, by failing to: 1. Provide privacy and honor Resident 26's preference to keep gown and incontinent brief on before going to the shower room. This failure resulted in Resident 26's emotional distress manifested by crying, reported feeling embarrassed and frustrated which could potentially result in the resident not able to enhance her sense of well-being, level of satisfaction with life, and feeling of self-worth and self-esteem. 2. Cover Resident 4's indwelling catheter bag (drainage bag that collects urine from the tube inserted in the bladder into the bag outside of the body). This failure has the potential for Resident 4 to develop feelings of shame, embarrassment, and violate Resident 4's right to privacy. Findings: 1. A review of Resident 26's admission Record, dated 1/26/24 indicated,…

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

Based on observation and interview, the facility failed to provide a string attached to the call light in the bathroom located in Room A that could be reached and used to call for assistance when needed by one of one sampled resident (Residents 247). This deficient practice had the potential to result in a delay in provision of care and assistance in the bathroom or in an event of emergency that could and lead to falls, accidents, and injuries. Findings: During an observation in the bathroom of Room A, on 1/23/24 at 12:17 PM, there were two (2) wall switches which were about four (4) feet (ft- measurement unit for height) above ground level. One of the wall switches (WS 1), was observed by the bathroom door and the other wall switch (WS 2) was between the sink and the toilet. During a concurrent interview and observation in the bathroom of Room A, with the Registered Nurse Supervisor (RNS) 1 on 1/23/24 at 1:20 PM, RNS 1 was asked if there an emergency call light in the bathroom, RNS 1 identified WS 2 as an emergency call light. RNS 1 stated WS 2 was not reachable if 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.

Based on interview and record review, the facility failed to maintain a current copy of the resident's advance directive (legal document that provide instructions for medical care and only go into effect if you cannot communicate your own wishes) in the resident's medical record for one of one sampled residents (Resident 77). This deficient practice had the potential for Resident 77 to not have their wishes met regarding life-sustaining treatment (any treatment that serves to prolong life without reversing the underlying medical condition). Findings: During a review of Resident 77's admission Record Face Sheet dated 1/25/2024, the admission Record Face Sheet indicated the facility admitted the resident on 1/02/2024, with the diagnosis of hemiplegia (muscle weakness or partial paralysis on one side of the body), encephalopathy (group of conditions that cause brain dysfunction such as confusion or memory loss), and muscle weakness. During a review of Resident 77's History and Physical (H&P) dated 1/3/2024, the H&P indicated Resident 77 does not have 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.

Based on observation, interview, and record review, the facility failed to provide a safe, clean, and homelike environment by ensuring the three of 3 clothes dryer's lint trap (a part of the dryer that collects lint) in the laundry room were removed and cleaned after each dryer cycle and/or cleaned on the scheduled times. This deficient practice had the potential to cause fire in the facility and endanger the lives of the residents, staffs, and visitors. Findings: During a concurrent observation in the facility laundry room and interview with Laundry Staff (LS) 1 on 1/23/24 at 10:51 AM, LS 1 was observed taking out linens from dryer 1 and started folding the linens. LS did not remove lint from dryer 1's lint trap after removing the linens before proceeding to fold the linens. When asked why she did not remove the lint from the lint trap, the LS stated she forgot to remove lint from the dryer 1 after drying the linens. During a concurrent observation in the laundry room and interview with LS 1 and Infection Preventionist Nurse (IPN) on 1/23/24 at 11:02 AM, three dryers were observed…

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 a resident one of three (3) sample residents (Resident 24) was provided a communication device (a tool used to communicate with someone) that was readily available in a language that the resident could understand, and the resident's primary language. This deficient practice may result in the resident not to effectively communicate her care needs with the staffs, which could lead to a delay in receiving appropriate care/treatment when needed. Findings: A review of the admission Record (AR, face sheet) indicated Resident 24 was initial admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses that included hyperlipidemia (a condition in which there are high levels of fat particles (lipids) in the blood) and hypertension (high blood pressure). The AR indicated Resident 24 's primary language was a foreign language. A review of the Minimum Data Set (MDS - a comprehensive assessment and screening tool), dated 10/16/23,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Residents 74) with low air loss (LAL) mattresses (a mattress used to provide alternating pressure to the bony part of the body) was set according to the residents' weights to ensure effective prevention and/or worsening of pressure ulcers (areas of damaged skin caused by staying in one position for too long) in accordance to the manual for Med-Aire Essential 8-inch Alternating Pressure Mattress Replacement System with Low Air Loss. Resident 74, who weighed 165 pounds (lbs.), was observed with the LAL mattress setting at the highest setting for a person weighing 350 lbs. This deficient practice placed Resident 74 at risk for development of new pressure ulcer, delayed and worsening of the pressure ulcer. Findings: A review of Resident 74's admission Record, indicated the resident was admitted to the facility on [DATE] and was re-admitted [DATE] with diagnoses that included hyponatremia (low blood sodium)…

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

Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 4), who was not assessed for cognitive status (ability to think and process information) , vital signs (measurrement of the blood pressure, heart rate, breathing rate and body temperature), and the dialysis access site (sugically inserted catheter into the body [usually arms, chest groin] and connects to the dialysis machine that removes excess fluids and toxins in the blood) after returning to the facility from the dialysis center (treatment for people whose kidneys are failing). This deficient practice had the potential to delay the detection of complications including infections and bleeding for Resident 4. Findings: During a review of Resident 4's admission Record Face Sheet dated 1/25/2024, the admission Record Face Sheet indicated the facility admitted the resident on 9/17/2023, with the diagnosis of end stage renal disease (ESRD - permanent kidney failure that requires a regular course of dialysis), dependence of renal dialysis (treatment for people whose kidneys 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 failed to ensure two of five Nursing Assistants hired by the facility had current and active Certified Nursing Assistant (CNA) certifications to demonstrate competency skill sets and techniques necessary to care for and identify the need of the residents. CNA 1 continued to be assigned to work at the facility for three shifts (48 days after her CNA certificate expired) and CNA 2 continued to be assigned to work at the facility for 33 shifts (41 days after her CNA certification expired). This failure had a potential to result in facility's residents not to attain or maintain their highest practicable physical, mental, and psychosocial well-being. Findings: During a current interview and record review on [DATE] at 9:10 a.m. with Director of Staff Development (DSD), the Staff Competency binder was reviewed. The DSD stated, Certified Nursing Assistant (CNA) 1's CNA certification expired on [DATE] (48 days ago) and CNA 2's CNA certification expired since [DATE] (41…

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

Based on interview and record review the facility failed to provide Resident 1 with written notice of a room change before the resident ' s room in the facility was changed, in accordance with the facility ' s policy on Room Change/Roommate Assignment for one of two sampled residents. This deficient practice resulted in a delay of notification of room change for Resident 1. Findings: A review of Resident 1 ' s admission Record indicated the facility readmitted the resident on 3/16/2021, with diagnoses including chronic respiratory failure (occur when your blood has too much carbon dioxide or not enough oxygen), tracheostomy ) a procedure to help air and oxygen reach the lungs by creating an opening into the trachea (windpipe) from outside the neck) status, and quadriplegia (a symptom of paralysis that affects all a person's limbs and body from the neck down). A review of Resident 1 ' s History and Physical Examination dated 3/23/2023, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1 ' s Minimum Data Set (MDS, an assessment 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 facility developed a resident centered comprehensive care plan for the care and maintenance of three (3) of three (3) sampled residents with a peripheral venous/central catheter (Resident 1, 2, and Resident 3) These deficient practices had the potential to put the residents at risk for intravenous complications without appropriate intervention or preventive measures. Findings: 1. A review of Resident 1's admission Record indicated that the facility readmitted Resident 1 on 8/14/2023, with diagnoses that included chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), dependence on respirator (ventilator, machine that act as bellows to move air in and out of your lungs) status, and gastrostomy (a surgical operation for making an opening in the stomach) status. A review of Resident 1's History and Physical assessment dated [DATE], indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain a safe, sanitary environment to prevent the spread and transmission (transfer form one person or thing) of Carbapenem-resistant enterobacterales (CRE, a type of germs that cause infections which are resistant [not easily treated by many antibiotics which are medications designed to kill germs]) for three (3) of three (3) sampled residents (Resident 1, 2, and 3) by failing to: 1. Ensure the Certified Nurse Assistant (CNA) 1 performed hand hygiene before and after entering and exiting Resident 1, 2 and 3's room and providing resident care. 2. Ensure that CNA 1 don (put on) personal protective equipment (PPE) before entering the shared room of Resident 1, 2 and 3 who were placed on contact isolation precautions (infectious agents, including epidemiologically important microorganisms which are spread by direct or indirect contact with the residents or resident's environment). These deficient practices had the potential to increase…

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.