Valencia Hills Health And Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review the facility failed to ensure medication error rate was not greater than 5%. A total of 27 opportunities were observed with 2 errors constituting an error rate of 7.41%. Findings included:1. On 04/29/2026 at 8:34 AM a medication observation was conducted with Staff C, Licensed Practical Nurse (LPN) for Resident #131. Staff C dispensed the following medications:-Amlodipine 2.5 mg (milligram) -1 tablet-Aspirin 81mg chewable -1 tablet-Zyrtec 10mg -1 tablet-donepezil 5 mg -1tablet-Famotidine 10mg -4 tablets-Losartan 25 mg -1 tabletStaff C, LPN confirmed the tablets prior to administration.Review of Resident #131's admission Record showed she was admitted to the facility on [DATE] with diagnoses to include: cerebral atherosclerosis, vascular dementia, dementia, and hypertension. Review of Resident #131's active orders showed:-Donepezil HCl (hydrochloride) Tablet 5 mg; Give 10 mg by mouth one time a day for dementia.2. On 04/29/2026 at 4:30 PM a medication…

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 record reviews and interviews, the facility failed to provide timely laboratory services for one (Resident #130) of three residents reviewed.Findings included: Review of Resident #130's admission record revealed an admission date of 5/2/2024. Diagnosis includes but not limited to fracture of the lower end of right radius, nondisplaced fracture of right ulna styloid, chronic diastolic heart failure, and convulsions. Review of Resident #130's progress notes revealed a nursing note on 3/13/2026 at 10:11 p.m. showing Resident #130 had swelling of the right arm and right hand, felt hard and a little warm to touch. The resident's cast was removed from this arm on 2/19/2026 from a previous fracture. The note also said Resident #130 had range of motion within normal limits (ROM WNL), hospice and facility physician were notified. Review of Resident #130's progress notes revealed a nursing note on 3/14/2026 at 6:15 a.m. that a new order was placed for a venous ultrasound of the right upper extremity. Review of Resident #130's progress notes revealed a nursing note on 3/15/2026 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to ensure supervision was provided to residents identified as requiring enhanced monitoring (EM), one to one (1:1) supervision, and/or continuous monitoring (CM) for six residents (#1, #3, #4, #6, #22, and #24) out of six residents sampled. Findings included:1. A review of Resident #1's admission record revealed an admission date of 4/15/25, with diagnoses to include unspecified dementia, unspecified severity, with other behavioral disturbance, major depressive disorder, recurrent, moderate, unspecified psychosis not due to a substance or known physiological condition, and adjustment disorder with anxiety.A review of Resident #1's physician orders revealed the following:- Device: Wander Management Bracelet - Check Function with machine every night shift for elopement risk, with a start date of 9/1/25.A review of the facility's reportable incident log showed the following:- Date of Incident 2/23/26 [Resident #1] + [and] [Resident name] Type…

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

Based on interviews and record reviews, the facility failed to notify the physician of abnormal laboratory (lab) values for three residents (#7, #18 and #26) out of eight residents sampled. Findings Included:During an interview on 3/10/26 at 12:58 p.m. the Director of Nursing (DON) said for abnormal laboratory test values the nursing staff are expected to notify the doctor as soon as possible and the notification should be documented in the medical records.1) A review of Resident #7's admission record showed an admission date 2/4/26 with a primary diagnosis of left ilium (pelvic) fractureA review of Resident #7's lab report results revealed on 3/7/26 reported at 5:55 p.m. a TSH (thyroid stimulating hormone) level was 26.99, reference range 0.45-5.33 uI/ml (units/milliliter).A review of Resident #7's nursing note, dated 3/9/26 at 3:32 p.m. showed Received order to increase Levothyroxine to 200 mcg (micrograms) daily and repeat lab in a week.A review of Resident #7's nursing note dated 3/9/26 at 6:53 p.m. showed son made aware of increase on Levothyroxine and lab to be repeated in a…

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

Based on interviews, and record review, the facility failed to ensure the comprehensive care plan was implemented related to one to one supervision/enhanced monitoring for one resident (#24) out of ten residents sampled. Findings included: A review of Resident #24's admission record revealed an admission date of 1/14/25 with diagnoses to include cerebral atherosclerosis, Alzheimer's disease, vascular dementia, severe, with anxiety, major depressive disorder, recurrent, moderate, unspecified dementia, unspecified severity, with other behavioral disturbances, restlessness and agitation, and other specified anxiety disorders.A review of the facility's reportable incident log showed the following:- Date of Incident 3/3/26 [Resident #24] /+ [Resident name] Type of Allegation * Sexual .A review of Resident #24's comprehensive care plan revealed the following: - [Resident #24] can be sexually inappropriate at times r/t dx [diagnosis] of Dementia. Date Initiated: 03/10/2026, with interventions to include, Enhanced monitoring by staff as necessary. Revision on: 3/11/2026. 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 observations, interviews and record review, the facility failed to provide incontinence care for one resident (#12) out of three sampled for activities of daily living. Findings includedAn interview conducted on 3/10/26 at 12:13 PM with Resident #12 revealed the resident had many concerns with staff coming timely to provide incontinence and toileting care. The resident stated there had been many instances where the resident had a bowel movement (BM) and no staff would come timely to provide care when it was needed.A review of Resident #12's admission record revealed an admission date of 7/31/25 with diagnoses to include: Type 2 Diabetes Mellitus, anemia, paroxysmal atrial fibrillation, legal blindness, gastrointestinal hemorrhage, and adjustment disorder with anxiety.A review of Resident #12's Bowel and Bladder- Bowel Elimination Task documentation revealed the following:March no care marked on:Shift 11 PM-7 AM: 3/3Shift 3 PM-11 PM: 3/9February no care marked on:Shift 11 PM-7 AM: 2/28Shift 7 AM-3 PM: 2/3, 2/19January no care marked on:Shift 11 PM-7 AM: 1/10, 1/31Shift 3…

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

Based on observations, interviews and record review of the facility's Shift to Shift Controlled Medication count sheets, the facility did not ensure accurate documentation of controlled substances count logs for three carts (200-A, 100A - and100-B) out of ten medication carts. On 02/03/2026 at 9:25 a.m., an observation was made of the medication cart identified as cart 200-A. A review of cart 200 -A's narcotic book showed the Shift-to-Shift Controlled Medication Count with no entry for this morning's count. Staff G, Licensed Practical Nurse (LPN) who was assigned to the 200-A medication cart stated she forgot to mark the number of total narcotic cards, but the count was correct. On 02/03/2026 at 9:59 a.m., an interview was conducted with Staff C, LPN. Staff C, LPN, stated during shift change, two nurses, the off coming shift nurse and the oncoming nurse, must count the narcotic cards in the Shift-to-Shift Controlled Medication Count as well as each individual residents' narcotic medication. Both nurses will sign the Shift-to-Shift Controlled Medication Count. Staff C, LPN, stated if…

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, record review, and review of the facility's Plan of Correction (POC), the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) Committee effectively implemented and monitored corrective actions to prevent recurrence of deficient practices. The facility had previously been cited under F 755 during a complaint survey conducted on 2/3/26 and developed a Plan of Correction with a completion date of 3/2/26. The review showed the facility did not fully implement or sustain the corrective actions identified in the Plan of Correction.Findings Included:A review of in-service/training by the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) showed education with the following objectives was started on 2/3/26.:-Narcotic shift to shift documentation (count sheet)-Add and remove in the comment section.-Must be signed at the time of the count-Narcotic count when received from pharmacy.The in-service training record showed the education was provided between 2/3/26 and 3/2/26 for all nurses except the nurses 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 interviews and record reviews, the facility failed to accurately reconcile an anti-psychotic medication per their policy, for one resident (#5) out of three residents sampled.Findings included: A record review of Resident #5's admission record showed an original admission date of 01/27/2023 with a readmission date of 01/12/2026 with diagnoses to include but not limited to major depressive disorder, generalized anxiety disorder and other specified persistent mood disorders.A record review of Resident #5's hospital discharge medication list dated 01/12/2026 at 08:46 a.m., revealed a current order of an antipsychotic medication Lurasidone, (also known as Latuda) 20 milligram (mg) oral tablet to be given with supper.Review of Resident #5's electronic medical record (EMR) revealed on date 01/12/2026 when the resident readmitted to the facility, there was no new medication listed on the Order Summary Report signed by the facility doctor on 01/13/2026. An admission progress notes dated 01/12/2026 on page thirty-seven under medication reconciliation and the hospitals recommended…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews the facility failed to promptly notify the physician of laboratory testing results for two (Residents #1 and #2) of two residents sampled. Findings included: Review of Resident #2's admission Record revealed the resident was admitted on [DATE] and included diagnoses of unspecified fracture of left acetabulum subsequent encounter for fracture with routine healing, unspecified fracture of right talus subsequent encounter for fracture with routine healing, and essential (primary) hypertension. Review of the primary care physician note dated, 10/2/25, for Resident #2 showed the resident had been in a motor vehicle accident resulting in a left acetabulum fracture and right talus fracture. The objective data gathered by the physician showed bilateral lungs were clear to auscultation (CTA), no shortness of breath (SOB) or dyspnea on exertion (DOE). The plan was for Staff to report any new or worsening issues, complications, or symptoms to provider via SBAR (Situation,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, and record reviews, the facility failed to maintain a safe, clean, comfortable and homelike environment related to pest sightings in five Wings (100, 200, 300, 400, and 500) of the five facility Wings toured. Findings included: During a tour of the dining room across from the therapy gym on 7/22/25 at 1 p.m., a live small eight-legged insect was observed crawling on the floor. An unidentified staff member confirmed the observation and stated it was a spider. (Photographic Evidence Obtained). On 7/22/25 at 12:00 p.m. in the 400-wing, an observation was made of approximately five live insects, flattened, oval-shaped body, long antennae and six legs coming out of the 400-wing linen closet. The insects crawled underneath the base boards when the light was turned on. Multiple interviews were conducted on 7/21/25 from 1:50 p.m. to 2:20 p.m. with alert and oriented residents revealing the following:Resident #7 who was admitted to the facility on [DATE] and had a BIMS (Brief…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews the facility failed to inform the family of changes in condition for one resident (#6) of three sampled residents. Findings included:Review of admission record showed Resident #6 was admitted to the facility on [DATE] and discharged on 07/12/2025 with diagnoses included but not limited to Transient Ischemic Accident, congestive heart failure, Cerebrovascular accident, Stage 4 chronic kidney disease and hypertension. Review of the physician orders for Resident #5 showed:Complete Metabolic Profile (CMP), Basic Metabolic Profile (BMP) ordered on 07/07/2025 and 07/08/2025Lasix 20 mg (milligrams) daily as a diuretic as of 07/06/2025Potassium 10 meq. (milliequivalents) daily for hypokalemia as of 07/08/2025Review of the July 2025 Medication Administration Record showed Potassium 10 meq. (milliequivalents) daily for hypokalemia as of 07/08/2025 was given on 07/09, 07/10, 07/11, and 07/12 2025. Review of the Lab Results Report showed on 07/07/2025 Potassium was 2.98 acceptable…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews, the facility failed to ensure one (#3) of three sampled residents was free from the abusive behavior of a staff member. Findings included: On 10/30/24 at 9:30 a.m., Resident #3 was observed with Staff C, Certified Nursing Assistant (CNA) lying in bed, dressed, and with eyes closed. The staff member stated the resident would be up (awake) for days then sleep. Staff C reported being educated on abuse approximately 6 months ago and had not witnessed any type of abuse. Review of Resident #3's admission Record revealed the resident was admitted on [DATE] and included diagnoses not limited to unspecified severity unspecified dementia with other behavioral disturbance, unspecified depression, unspecified anxiety disorder, unspecified psychosis not due to a substance or known physiological condition, and unspecified mood (affective) disorder. Review of six months of the facility's Abuse Logs showed one abuse allegation perpetrated by a staff member against 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 record reviews and interviews, the facility failed to screen one (#4) of three sampled residents for trauma-informed care following allegations of abuse. Findings included: Review of the Abuse Log, containing allegations from 5/3/24 to 10/23/24 revealed an allegation made by Resident #4 on 7/23/24 at 11:45 a.m. of a volunteer that had molested the resident. Review of Resident #4's admission Record showed the resident had been admitted on [DATE] and 9/26/23. The record included diagnoses not limited to Parkinson's disease without dyskinesia without mention of fluctuations, unspecified severity unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, and generalized anxiety disorder. Review of the Significant Change in Status assessment completed on 6/24/24, approximately one month prior to the allegation, revealed a Brief Interview of Mental Status (BIMS) score of 10 of 15, which indicated moderate cognitive impairment. The quarterly BIMS score, 9/23/24,…

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

Based on observation, record review, and interview, the facility failed to ensure food was labeled and dated in the walk-in refrigerator, temperature logs were completed per facility policy, and dinnerware was properly sanitized. Findings included: An observation on 03/05/24 at 9:05 a.m., revealed a walk-in refrigerator that contained food items that were not labeled or dated. The items consisted of: - One 4-quart (qt) container of a pureed yellow substance that was identified by Staff E, Dietary Clerk (DC) as apple sauce. - One 4-quart (qt) container of squared yellow substance that was identified by Staff E, DC as pineapples. - One 4-quart (qt) container of squared white substance that was identified by Staff E, DC as pears. - 2 long metal pans of yellow substance that was identified by Staff E, DC as macaroni and cheese. - An opened package of orange shredded substance re-wrapped in plastic wrap that was identified by staff E, DC as shredded cheddar cheese. Photographic evidence obtained. During an interview on 03/05/24 at 9:05 a.m., Staff E, DC stated all food items in 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 and interview, the facility failed to ensure one of one walk in refrigerator was free from ice buildup and was maintained in safe operating conditions. Findings included: An observation on 03/04/24 at 9:10 a.m., showed a walk-in refrigerator with lots of ice on the floor. A huge icicle located on the walk-in refrigerator ceiling above the ice on the floor was dripping. Photographic evidence obtained. In an interview on 03/04/24 at 9:10 a.m., Staff E, Dietary Clerk (DC) stated yes, this walk-in refrigerator has been like this for a while. Staff E, DC stated she heard it accumulated ice because the walk-in refrigerator ran too cold. Staff E, DC stated the facility was aware of the concern and in the past talked about getting a new walk-in refrigerator. During an interview on 03/06/24 at 12:08 p.m., Staff J, Environmental Services (ES) stated he was aware of the ice buildup in the walk-in refrigerator as the maintenance department was scheduled to go into the kitchen two times a week to remove the ice buildup. Staff J, ES stated he did not think the walk-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 observations, record reviews, and interviews, the facility failed to ensure the accuracy of the Preadmission Screening and Resident Review (PASRR) for seven (Residents #38, #3, #1, #149, #151, #177,and #189) out of 44 initially sampled residents. Findings included: 1. An observation and interview was conducted on 3/4/24 at 11:27 a.m. with Resident #38. The resident voiced not wanting to discuss a diagnosed condition. A review of Resident #38's admission Record showed the resident was admitted on [DATE] with diagnoses including but not limited to unspecified bipolar disorder, unspecified schizoaffective disorder, unspecified single episode major depressive disorder, paranoid schizophrenia, unspecified anxiety disorder, unspecified obsessive compulsive disorder (OCD), borderline personality disorder, and unspecified paraphilia. The Psychotherapy note, dated 12/7/23, showed the resident continued with anxiety and depression and the interventions used would be cognitive behavioral therapy. The Psychotherapy…

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, record review, and interview, the facility failed to ensure laboratory testing and anticoagulant medications were completed and administered per physician orders for one (Resident #182) of one resident sampled for anticoagulant use, failed to obtain orders for management of a Peripherally inserted central catheter (PICC) for one (Resident #86) of one resident sampled for the use of a PICC, failed to obtain physician orders and document the treatment of one (Resident #271) of one resident sampled for undocumented skin condition, and failed to complete dressing changes as ordered for one (Resident #162) of two residents sampled for dressing changes. Findings included: 1. An observation and interview was conducted on 3/4/24 at 11:33 a.m., with Resident #182. The observation revealed the resident's urinary catheter tubing was draining dark red liquid. The resident stated the catheter was not normally like that and the facility was working on it. (Photographic evidence was obtained) An…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure it had a functioning Quality Assurance Committee. The facility was actively involved in the creation, implementation, and monitoring of the plan of correction for deficient practice identified during a recertification survey on 03/04/24 to 03/07/24 and was cited for F 812 and F908. During the revisit on 04/29/24, the facility was recited for F 812 and F908. The facility had developed a Plan of Correction with a completion date 04/06/24. The facility had not comprehensively implemented the plan of correction for the identified deficiencies. Findings included: Review of an undated facility policy titled, Quality Management revealed the following: Guiding Principles: -The facility will use QAPI to make decisions and improve the day-to-day operations. -QAPI will include all employees, every department and all services provided. -QAPI focuses on systems and processes rather than individuals. -The facility will have a culture that…

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

Based on observation, policy review, and interview, the facility failed to ensure dignity and respect during the dining experience for four (2 unknown, #56, and #322) out of four residents requiring supervision on the 300-unit as evidence by not removing dinnerware from meal trays, not serving one (#56) out of three residents seated at the common area table together, removing two (one unknown female and #56) out of two residents from the table until their meals arrived, and standing up while assisting one resident (#273) out of one resident observed for needing dining assistance. Findings included: An observation on 3/4/24 at 12:15 p.m. was conducted of meal service in the 300-unit common area. The observation revealed three residents (Residents #322, #56, and another female resident) sitting at the table in the common area, the two female residents had meal trays, while Resident #56 did not. The observation showed the dinnerware for the two females were not taken off the tray. Staff Q, Licensed Practical Nurse (LPN), informed Resident #56 that it (meal) was coming soon. An…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure one (Resident #180) of one sampled resident was free from restraints and was not evaluated for a restraint. Findings included: On 3/4/2024 at 10:33 a.m., Resident #180 was observed lying in a sitting position in his bed. His head was on the upper right side of mattress; legs were at a 90-degree angle (sitting position) over the edge of the left side of the head of the bed. Resident #180's side rails were up in the raised position on both sides. His legs were in front of the top of the rail on the left side. The side rails went from just below the head of the bed to just above the foot of the bed. The bed was approximately 2 feet off the floor. A blue mat was on each side of the bed. The resident was observed moving about in the bed. The privacy curtain was pulled for privacy. The resident was not visible from the hallway. (Photographic evidence obtained of the side rail). On 3/6/2024 at 9:01 a.m., the resident was observed lying…

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 obtain physician orders for one (Resident #525) of one resident to ensure a resident who entered the facility with a indwelling catheter was assessed and received appropriate physician orders, treatment, and services. Findings Included: On 03/04/2024 at 9:38 a.m., Resident #525 was observed sitting in his bed, with a cast on his right arm and a [Brand name]catheter over his left leg to a drainage bag hanging on the frame of the bed facing the door, no privacy bag present. There was cloudy yellow urine in the tubing and drainage bag. Resident # 525 stated he had the catheter as he had multiple sclerosis (MS) and a neurogenic bladder. Resident #525 stated he had a fall at home which resulted in him having a broken right arm. The resident stated when he first arrived at the facility, they had to change the catheter because the one they put in was too small, was not draining, his bladder felt full, and after they changed to a larger size, he…

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

Based on observation and interview, the facility failed to ensure one of one garbage dumpster was maintained in a sanitary condition and free from debris. Findings included: An observation of the facility's garbage area on 03/05/24 at 11:15 a.m., revealed multiple items on the ground around the garbage dumpster. The items were as follows: Photographic evidence obtained. - plastic cup - blue gloves - hamburger buns - plastic spoon - 2 recliners During an interview on 03/05/24 at 11:15 a.m., Staff F, Dietary Manager (DM) stated he was responsible for the dumpster and confirmed the items found around the dumpster should not be there. Staff F, DM stated he tried to come out daily to keep the area around the dumpster cleaned up.

Based on observations and interviews, the facility failed to maintain a safe and homelike environment related to two (500 hall and 200 hall) of two resident shower rooms observed. Findings included: An observation was conducted on 12/18/23 at 12:25 p.m. of the 500-hall, secured unit, shower room. The shower room was observed to have missing plaster on the lower portion of the wall and a hole at the bottom of the shower room door. There was a clear plastic bag full of soiled linen and resident clothing on the floor I the shower room. There were 4 wheelchairs, and all of them had unlabeled resident clothing draped over them along with hangers and plastic bags. In the shower room there were also two walkers, one resident lift, and a large plastic storage rack with labeled bins which were observed to have items overflowing out of the bins and the items were not what the bin was labeled as. The large plastic storage rack was not covered. There were two different sneakers on the bottom of large plastic storage rack along with multiple wheelchair legs rests. There was one shoe under 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 observations, interviews, and record review, the facility failed to ensure prompt efforts were made to resolve grievances for through to their conclusion for three residents (#1, #5, and #8) out of three residents sampled for grievances. Findings included: The Grievance Logs from September 2023 to November 20, 2023 were reviewed. Three grievances were randomly chosen for review from October 2023 and November 2023. Review of a grievance, dated 10/13/2023 for Resident #8, revealed the grievance was filed by a family member related to not changing the resident's linen when they were soiled with urine, and leaving the urine-stained sheets on the bed. The investigative section of the report was blank. Review of a grievance, dated 10/30/2023 for Resident #1, revealed the resident filed the grievance related to not being dressed for therapy, not receiving a bed pan when requested, long response time to call light, and blood sugar levels too low. The investigative section of the report was blank. Review of a grievance,dated 11/3/2023 for Resident #5, revealed the resident filed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure documentation was complete and accurate for two residents (#1 and #3) of three sampled residents for resident record documentation. Findings included: Resident #1 was admitted to the facility on [DATE], with a diagnosis included but not limited to, fracture of the T7 (thoracic vertebrae 7), T8, T11, and T12, Chronic Obstructive Pulmonary Disease (COPD), Diabetes Mellitus Type 2 (DM), respiratory failure, congestive heart failure (CHF), atrial fibrillation (A-Fib), depression, Bipolar disorder, GERD (Gastro-esophageal reflux disease), and hypertension (HTN). Review of the physician orders and Medication Administration Record (MAR) for October 2023 showed the following documentation missing: Gabapentin 300 milligrams (mg) at bedtime for neuropathy on 10/27/23 Pantoprazole Sodium delayed release 40 mg daily for GERD on 10/26 and 10/27/23 Risperidone 3 mg at bedtime for Bipolar disorder on 10/27/23 Trazodone HCL 50 mg at bedtime for depression 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 observations, interviews, and record review, the facility failed to develop and maintain an effective infection prevention and control program to control the spread of infection by: 1) failing to ensure staff donned appropriate personal protective equipment (PPE) before entering the rooms of residents under transmission based precautions for one resident (#2) of two residents sampled for transmission based precautions, 2) failing to ensure appropriate signage was posted outside of a resident room under transmission based precautions for one resident (#2) of two residents sampled for transmission based precautions, and 3) failing to ensure physician's orders for transmission based precautions were in place in a timely manner for one resident (#3) of two residents sampled for transmission based precautions. Findings included: An observation was conducted on 11/20/2023 at 10:05 AM outside of Resident #2's room. An isolation caddy was observed outside of Resident #2's room with signage posted on the caddy…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and policy review the facility did not ensure residents were treated with dignity during dining related to knocking on the door or announcing oneself prior to entering the room with lunch meals on one hallway of eleven halls on one of five nursing units, during two of two dining services observations. Findings included: On 10/26/21 at 12:52 p.m., an observation was conducted during dining services on the 200 nursing unit A hallway. Staff A, LPN (Licensed Practical Nurse) and Staff H, CNA (Certified Nursing Assistant) entered room [ROOM NUMBER] with lunch trays without knocking or announcing themselves. After setting up the trays both staff members exited the room after performing hand hygiene, and each removed a tray from the dining cart. At 12:56 p.m. on 10/26/21, an observation was conducted. Staff A, LPN and Staff H, CNA both entered room [ROOM NUMBER] with the lunch trays, without knocking or announcing themselves. On 10/27/21 at 12:38 p.m., an observation was conducted…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interview, the facility failed to provide a safe, clean, comfortable, and homelike environment for five (Residents #12, #37, #72, #97, #307) of 58 sampled residents, related to maintaining resident equipment in good repair for Resident #12 and providing a clean and homelike environment for Residents #37, #72, #97 and #307. Findings included: 1. Review of Resident #12's medical record revealed that she was re-admitted to the facility on [DATE], had diagnoses that included Spastic Hemiplegic Cerebral palsy and had a Basic Interview For Mental Status (BIMS) dated 10/6/21 which indicated a score of 15 (Cognitively intact). On 10/26/21 at 12:24 p.m., Resident #12 was observed sitting in a Geri chair. The chair had a left sided head rest which was noted to be ripped with jagged edges, exposing the internal material of the device. (Photographic evidence obtained) On 10/28/21 at 8:46 a.m., an observation was made of the resident sitting up in bed listening to music. 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, record review, and interview, the facility failed to ensure treatment and care in accordance with professional standards of practice related to a surgical wound for one (Resident #21) of one sampled resident. Findings included: 1. An interview with Resident #21 on 10/27/21 at 10:04 a.m., revealed that he had a surgical wound to his left leg which was not healing. Review of resident #21's record revealed that he was admitted to the facility on [DATE], had a Brief Interview For Mental Status (BIMS) with a score of 14 (Cognitively intact), and had diagnoses that included Cellulitis of left lower limb; acute embolism and Thrombosis of deep veins of left lower extremity; bilateral fem-pop bypass; Recent hospital admission for non-healing surgical wound on the left thigh. Review of the the resident's current physician orders revealed the following: -10/23/21-Weekly skin observations -10/6/21-Mupirocin Oint 2% TID (three times a day) for wound related to infection. Apply to left groin topically…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to provide necessary respiratory care and services related to storage of nebulizer equipment, consistent with professional standards of practice for one (Resident #183) of one resident investigated for respiratory therapy. Findings included On 10/26/21 at 10:45 a.m., Resident #183 was observed seated in a wheelchair next to the bed in her room. The resident had oxygen running at 4 liters per minute via a nasal cannula from a concentrator in the room. The resident stated she used oxygen at home. A nebulizer machine was observed sitting on the bedside nightstand with a nebulizer mask and tubing noted sitting on top of nightstand in front of the machine. An empty plastic bag was noted on the resident's bed. A Wixela inhaler medication was noted on the over bed table. Resident #183 stated the inhaler medication was from her morning medications and the nebulizer treatment was from the same time. Resident #183 stated the nurse would come back…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not ensure that prescribed medications were stored in a locked container for two (Residents #21 and #182) of 58 sample residents. Findings included: 1. On 10/28/21 at 10:30 a.m., wound care was observed with Staff I, LPN (licensed practical nurse) for Resident #21. She gathered her supplies, knocked on the door, and asked Resident #21 if she could enter the room. After walking in the room, she grabbed 5 paper towels from the paper towel dispenser and put them on the resident's side table, she then put her supplies on the paper towels and performed hand hygiene with soap and water. Staff I, LPN asked the resident if he had his ointment, and he said yes. Resident #21 pulled a tube of Mupirocin from a large cloth tote bag that was hanging off the arm of a chair in his room. He handed it to the nurse, who then put it on the paper towel barrier. Staff I, LPN then performed Resident #22's wound care using the tube of mupirocin he had handed her.…

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.