California Terrace

Based on observations, interviews, and record reviews, the facility failed to follow a resident's (R2) plan of care and failed to recognize potential accident/hazard in the patio. This has the potential to affect all residents who go out to the patio.Findings include: R2's 'admission Report' documents, in part, muscle wasting and atrophy in multiple sites, repeated falls, need for assistance with personal care, lack of coordination, abnormal posture, left hemiplegia, muscle weakness, and lack of coordination. R2's 6/24/2025 Minimum Data Set assessment documents R2 is cognitively intact. R2 has an impairment to one side of lower and upper extremity. R2 is dependent on staff when using the wheelchair. 'Facility Incident Investigation Report' documents on 7/10/2025 R2 complained of left ankle pain. Facility conducted an x-ray which resulted in closed left ankle fracture. Facility investigation reads R2 believes the injury occurred when left leg fell off the leg rest while propelling in the wheelchair. Facility intervention included to place a leg strap on R2's left leg to keep leg from…

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 foods were stored and/or prepared under sanitary conditions. These failures have the potential to affect all 229 residents residing at the facility. Findings include:1. On 08/11/2025 at 10:12 AM, during the initial tour with V31 (Dietary Manager), the Surveyor observed boxes of cheese (5lbs), pork loins (50lbs), and deli turkey (20lbs) boxes placed in the middle of the floor of the walk-in refrigerator. There were several boxes of other products placed above the ones on cement floor. Also, the entire floor of the walk-in refrigerator was covered with water due to a leak in the ceiling.There were also cartons of milk in thin (so thin that the milk cartons were exposed to the concrete floor) plastic crates were set on top of puddle of water. This includes four crates directly on the floor. According to V31, each crate contained 50 cartons of milk. There were 15 subsequent crates on top of the 4 bottom crates of milk. According to V31, the puddle of water in the walk-in refrigerator was probably due…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that the dumpster grounds were free from food related trash and that the dumpster lid was closed. These failures have the potential to affect all 231 residents residing at the facility.Facility Ray, Carlyn (36383) - KitchenFindings include:On 8/11/2025, V1 (Administrator) stated that the resident census was 231 residents at the facility.On 8/13/2024 at 11:00 am, Surveyor and V31 (Dietary Manager) inspected the facility outside dumpster area and observed dietary trash covering the grounds and one dumpster lid open. Trash items surrounding the dumpster grounds included open individual-sized milk cartons, used paper plates, foam drinking cups, dietary napkins, and other dietary related trash. V31 stated that all garbage and refuge should be disposed of properly by kitchen staff and referred me to the facility's maintenance director for further guidance.On 8/13/2024 at 11:10 am, Surveyor and V26 (Maintenance Director) inspected 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 interview and record review, the facility failed to implement a facility wide system to monitor the use of antibiotics. This failure has the potential to affect all 231 residents that reside in the facility. Findings include:On 08/11/25 at 3:07pm V10 (Infection Preventionist/IP) handed surveyor a list with three residents in the facility are currently receiving antibiotics.On 08/11/25 at 3:07pm V10 (IP) stated the list with the three residents was just typed to give to surveyor. V10 stated he delegated the antibiotic stewardship monitoring to V2 (Director of Nursing/DON). V10 (IP) stated V2 (DON) has not been keeping up with monitoring residents on antibiotics because V2 (DON) has a lot of personal things going on. V10 (IP) stated he is unable to provide previous months monitoring of residents who received antibiotics.On 08/13/25 at 9:49am V2 (DON) stated she assists the IP nurse with some of the IP duties. V2 (DON) stated she is not up to date with the antibiotic stewardship monitoring log. V2 (DON) stated it is important to keep up with the log to track the residents 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 upon observation, interview and record review, the facility failed to maintain an effective pest control program to ensure that the facility free of insects. This failure has the potential to affect all 231 residents at the facility. Findings include:R114's has a diagnosis of but not limited to Type 2 Diabetes Mellitus, Muscle Wasting and Atrophy, Difficulty in Walking, Abnormal Posture and Hypertension.R114 has a Brief Interview of Mental Status score of 15 that indicates resident's cognition is intact.On 8/11/2025 at 11:06am surveyor observed a brown bug (roach) crawl from behind the activities calendar taped to R114's wall.On 8/11/2025 at 11:06am R114 said between the roaches and the gnats it's quite scary for her to go to sleep and she doesn't know how many gnats she has swallowed because she sleeps with her mouth open. R114 stated the exterminator did recently come but he did not spray any areas and he just applied bait in the dresser draws and put down some traps.On 8/12/2025 at about 8:35am…

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 an order for two residents (R136 and R138) to self-administer medications. This failure affected two residents and has the potential to affect all 55 residents residing on the 3rd floor and all 56 residents residing on the 4th floor.Findings include: 1. R136's diagnoses include but are not limited to dementia, paranoid personality disorder, delusional disorders, alcohol abuse. R136's Minimum Data Set, dated [DATE] has a Brief Interview for Mental Status score of 8, indicating R136's cognition is moderately impaired. On 08/11/25 at 10:55am observed one large pill inside medication cup on top of R136's light fixture. On 08/11/25 at 10:56am V22 (Licensed Practical Nurse/LPN) stated that the pill observed in R136's room is a nighttime medication. V22 stated that the medication should not be left at R136's bedside because anyone can take it. On 08/13/25 at 9:49am V2 (Director of Nursing/DON) stated that medication should not be left 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 a resident's environment was free from hazard. This failure affected 1 (R138) resident reviewed for accident hazard and has the potential to affect all the 25 residents in Unit 3A. Findings include: The (08/11/2025) census documented there are 25 residents in Unit 3A.R138's admission Record documents that R138 resides in Unit 3A.On 08/11/2025 at 10:39am, during the initial tour of the facility, V13 (Registered Nurse) stated Unit 3 has more psyche residents than dementia residents. On 08/11/2025 at 10:52am, there is a razor at R138's nightstand.On 08/11/2025 at 10:56am, this observation is pointed out to V13 (Registered Nurse). V13 stated there is a razor blade at his (R138) bedside. V13 picked up the razor and stated razors should never be at bedside because anybody who walks inside the room may grab it and harm themselves or the resident.On 08/12/2025 at 11:13am, V2 (Director of Nursing) stated the razor should be disposed of appropriately by putting the razor in the sharps container. Other resident 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.

Based on observation, interview, and record review the facility failed to dispose of loose pills in the bottom of the medication cart (Team 2) on the 2nd floor. This failure has the potential to affect all 33 residents receiving medications from cart 2 on the 2nd floor.Findings include:Findings include:On 8/11/2025 at 11:43am surveyor observed 18 loose pills of different sizes, shapes and color at the bottom of medication cart for Team 2 on the second floor.On 8/11/2025 at 12:11pm V18 (Registered Nurse) stated the 11:00pm-7:00am shift (3rd shift) are supposed to clean the medication cart.On 8/13/2025 at 9:37am V2 (Director of Nursing-DON) stated the nurses that are working the carts are supposed to clean the cart, and the cart is expected to be free of loose pills, spills and should be checked on a regularly basis. V2 stated the 3rd shift is responsible for making sure medication carts are kept clean. Storage of Medication Policy with an effective date of 10/25/2024 documents, in part, Medications and biologicals are stored safely, securely, and properly, following manufacturer'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 observations, interviews and record review, the facility failed to perform appropriate hand hygiene after contact with residents during tray pass, prior to entering and after exiting resident room on Enhanced Barrier Precautions (EBP), and between residents medication pass; failed to ensure staff does not touch a resident's oral medications; failed to ensure staff sanitize shared medical equipment between each resident's use; failed to ensure EBP sign was posted and Personal protective equipment (PPE) bin available for residents on EBP; and failed to ensure staff do not store soiled linen on clean linen cart in an effort to prevent the spread of infectious microorganism. These failures affected six (R10, R129, R141, R157, R228, and R237) residents reviewed for infection control and have the potential to affect all 180 residents on 2nd, 3rd and 4th floors.Findings include: Review of the facility's provided census (dated 8/11/2025), 231 residents live within the facility (69 residents live on 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 interview and record review, the facility failed to ensure that a code status physician's order was in a resident's electronic medical record (EMR). This failure affected two residents (R5 and R114) in a sample of 54 residents reviewed for advance directives.Findings include: 1. R5 face sheet shows R5 has diagnosis which include but not limited to bacterial infection, other bacterial infection unspecified site, venous insufficiency, and chronic obstructive pulmonary disease. R5'S Physician Order Sheet (POS) shows active order dated 08/11/25 with no orders for R5's code status. On 08/12/25 at 11:57 am, V11 (Director of Social Services) stated the social service department is responsible for ensuring all residents have a code status on the residents POS. V11 stated every resident should have a code status order for full code or DNR (Do not resuscitate) so everyone knows what to do if the residents codes at the facility. On 08/13/25 at 9:23 am, V2 (Director of Nursing, DON) stated the importance of the code status is to follow the residents wishes if something was to occur…

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 ensure a resident with new diagnoses of schizoaffective disorder was referred to the appropriate state-designated agency for a new Preadmission Screening and Resident Review (PASRR). This failure affected 1 (R9) resident reviewed for PASRR in the total sample of 54 residents.Findings include:R9's admission Record documented that R9's Original admission Date was on 10/05/2020 and was readmitted to the facility on [DATE]. That R9 has a diagnoses of schizoaffective disorder with onset date of 05/08/2023. R9's State Department on Aging Care Coordination Unit - Choices for Care Screening Verification Form was dated 10/02/2020. R9's (06/10/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 11. Indicating R9's mental status as moderately impaired. Delirium. C1310. Signs and symptoms of Delirium. B - Inattention: 2 - Behavior present, fluctuates. C. Disorganized Thinking: 2…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that residents who depend on staff's assistance for their ADL (Activities of Daily Living) care received grooming and shaving. This failure affected two residents (R64 and R186) out of 54 residents reviewed for ADL care. Findings include: 1. Review of R64, Minimum Data Sheet, Section GG – Activities for Daily Living (ADL) dated 7/11/2025 documents Partial/moderate assistance – helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort. This ADL function applies to both Upper Body Dressing and Lower Body Dressing. Review of R64 Care Plan dated 7/12/2025 indicates that Resident #64 has a self-care deficit (ADLs/Mobility) and requires one assist with dressing/hygiene tasks. On 08/11/2025 at 10:20 AM, R64 stated They do not wash my clothes. This started about 6 months ago. And the clothes that they do wash, they have not returned them. I have no clothes. R64 was wearing…

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

Based on observation, interviews, and record review, the facility failed to ensure the low air loss mattress was set on the recommended setting. This failure affected 1 (R238) resident reviewed for the prevention of pressure injury in the total sample of 54 residents. Findings include:On 08/11/2025 at 11:59am, R238 is lying on a low air loss mattress. The low air loss mattress is set at firm. The 'Static' button is also turned 'On'. On 08/11/2025 at 12:00pm, these observations were pointed out to V17 (Licensed Practice Nurse). V17 stated the setting is at firm and the 'Static' button is on. V17 also stated she is a new nurse. On 08/11/2025 at 12:15pm, V5 (Wound Care Nurse) stated the setting of the low air loss mattress is according to resident's weight so the air flows evenly preventing pressure ulcer. The setting should not be higher than the resident's weight because setting the low air loss mattress higher than the resident's weight defeats the purpose of the low air loss mattress. On 08/11/2025 at 12:17pm, V5 checked the setting of R238's low air loss mattress and stated 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 contain oxygen equipment (nebulizer masks and nasal cannula tubing) per facility's policy. This failure affected three residents (R30, R165 and R205) reviewed for oxygen equipment, in a total sample size of 54 residents.Findings include: 1. R30's face sheet shows R30 has diagnosis which includes but not limited to unspecified asthma. R30 Physician Order Sheet (POS) shows active order dated 08/11/25 documents, in part: Albuterol Sulfate Nebulization Solution (2.5mg (Milligram)/3ml (Milliliter) 0.083% 3 ml inhale orally via nebulizer every 6 hours as needed for Shortness of Breath related to Other Chronic Obstructive Pulmonary Disease. On 08/11/25 at 10:20 am, R30 was observed in bed with a nebulizer mask not contained hanging from R30's nightstand drawer. R30 stated, I use my mask every day. On 08/11/25 at 10:24 am, this observation was brought to V6 (Licensed Practical Nurse, LPN) and V6 stated that nebulizer mask should be contained when not in use to avoid dusk, bacteria, and germs from entering 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 observations, interviews and record review, the facility failed to prepare insulin syringe dosage according to the prescribed sliding scale order. This failure affected one resident (R220) reviewed for medication administration and has the potential to affect all 10 residents receiving insulin products, that are residing on the second-floor unit of the facility. Findings include:Review of the facility's provided census (dated 8/12/2025), 231 residents live within the facility (10 residents receiving insulin on the second-floor unit). On 8/12/2025 at 10:30 AM, at R220's room's door entrance, V19 (Licensed Practical Nurse/LPN), measured R220's blood sugar and stated the blood sugar was 258. V19 stated, according to the active order for insulin sliding scale, R220 should receive 7 units of insulin subcutaneously.On 8/12/2025 at 10:40 AM, observed V19 (LPN) at the rim of R220's room to perform hand hygiene, and prepared R220's insulin injection. Observed 6 units of insulin inside of the prepared syringe.…

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 monitor personal refrigerator temperature logs; and failed to ensure that a residents personal refrigerator had a thermometer. These failures affected two residents (R2 and R109), and out of 54 residents in the total sample. Findings include: 1. R109 has a diagnosis which includes but not limited to unspecified protein-calorie malnutrition and muscle wasting and atrophy, not elsewhere classified, multiple sites. On 08/12/25 at 1:00 pm, V25 (Housekeeping Supervisor) stated the residents personal refrigerators are not monitored by the housekeeping department. V25 explained that V25 does not know what department is responsible for monitoring the residents personal refrigerator. On 08/13/25 at 9:24 am, V2 (DON) stated it is the responsibility of housekeeping department to monitor the residents personal refrigerators. V2 explained that the Nursing department only monitors the medication and specimen refrigerators on each unit. On 08/13/25 at 1:15 pm, V1 (Administrator) stated the residents personal refrigerators…

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 a resident had a privacy curtain which extended around the bed. This failure affected one resident (R15), out of 54 residents in the total sample. Findings include: R15's face sheet documents R15 has diagnoses include but not limited to depression, hypertension, syncope, and collapse.R15's Brief Interview for Mental Status (BIMS) dated 6/13/25 documents R15 has a BIMS score of 12. R15 has moderate cognitive impairment.On 8/11/25 at 11:00 am, observed R15's room without privacy curtains. R15 stated, I been here for 2 months and have not had any privacy curtains. I know I should have the curtains whether I use them or not.On 8/13/25 at 9:32 am, V2 DON (Director of Nursing) Privacy curtain should be with every resident because if provides privacy while rendering service. It's a dignity issue.On 8/13/25 at 1:20 pm V1 Administrator stated every resident should have privacy curtains in their rooms, to ensure privacy during care and as needed. On 8/13/25 at 1:24 pm, V25 Housekeeping Supervisor 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 F600: Abuse:Based on interview and record review the facility failed to prevent resident to resident physical assault for two (R1, and R2) out of three residents reviewed for abuse. This failure resulted to R1 sustaining a head injury with staples. Findings Include:R1's Minimum Data Set (MDS) dated [DATE], Brief Interview Score/BIMS (14) indicates he is cognitively intact.R2' MDS dated [DATE], BIMs score (15) indicates he is cognitively intact.On 7/30/25 at 10:02 AM, R1 stated he has been in this facility for over a year. R1 stated, on 7/1/25 around 1pm, he was watching a program on his television (TV) and listening to his radio. R1 got up to assist R2 to pick up his lunch tray when R1 accidentally fell on R2. R2 then hit the back/side of R1's head with a dumbbell. R1 stated staff came into his room to attend to his bleeding head. The paramedics picked R1 up to the hospital to treat his bleeding head with two staples. R1 returned to the facility same day, R2 had been moved to another room. R1 had no further…

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 protect one resident (R5) out a sample of 3 from verbal and emotional abuse. This failure has the potential to affect one resident (R5) out of a sample of 3.Findings include:R1 has a diagnosis of but not limited to Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation, Primary Insomnia, Major Depressive Disorder, and Paranoid Schizophrenia.R1 has a Brief Interview of Mental Status score of 15.R5 has a diagnosis of but not limited to Chronic Obstructive Pulmonary Disease, Undifferentiated Schizophrenia, Type 2 Diabetes Mellitus, Anxiety Disorder, Hypertension, and Syncope and Collapse. R5 has a Brief Interview of Mental Status score of 13.On 7/14/2025 at 12:53 PM, R1 stated on 7/03/2025 he (R1) was yelling, in the dining room, at R5 about continuously taking his stuff.On 7/14/2025 at 1:43 PM, V9 (LPN/Unit Manager) stated R1 was upset with R5 and R1 was 'pumped up' (mad and aggressive) with R5 on 7/03/2025.On 7/14/2025 at 1:59 PM, R5 stated R1 was yelling at him saying, You took my cigarettes. He said some other…

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 supervise a confused wandering male resident from wandering in female rooms during smoke times causing resident mental abuse. This failure affected 2 (R2 and R6) residents in a sample of 57. The facility failed to prevent residents from smoking inside the facility (R7, R10) per policy. Findings include: 1. R2 has a diagnosis of but not limited to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS, MUSCLE WASTING AND ATROPHY, NOT ELSEWHERE CLASSIFIED, MULTIPLE SITES, DIFFICULTY IN WALKING, NOT ELSEWHERE CLASSIFIED, OTHER LACK OF COORDINATION, ABNORMAL POSTURE, ACQUIRED ABSENCE OF RIGHT LEG ABOVE KNEE, UNSPECIFIED ASTHMA, UNCOMPLICATED, OSTEOMYELITIS, UNSPECIFIED, SUICIDAL IDEATIONS, MAJOR DEPRESSIVE DISORDER, RECURRENT.R2 has a BIMS (Brief Interview Mental Status) of 15 which is an indication of an intact cognition. R4 has a diagnosis of but not limited to UNSPECIFIED DEMENTIA, OTHER FORMS OF SCOLIOSIS, LUMBAR REGION, UNSPECIFIED PSYCHOSIS NOT DUE TO A…

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

Based on interview, observation and record review the facility failed to ensure reasonable accommodations of residents needs by failing to ensure nurse calls are assessable to the residents and answered in a timely manner in 7 (R1, R2, R3, R6, R7, R8, R9) of a sample of 20 residents. Findings include: On 2/7/25 at 10:25am R2 was observed in his room in bed. R2 had a strong urine odor. R2's nurse call was on the floor and not in reach. R2 stated they don't answer the nurse calls when I pull it. When they do it takes a long time. This happens on all shifts. I need to be changed now. On 2/7/25 at 10:33AM R3 stated they don't answer the nurse calls. I press the button and it takes a very long time for someone to show up to give me assistance. R3 pushed the nurse call button during the interview. The room light outside the room lit. The light next to the 3rd floor nurses station on the ceiling lit. Two nurses, V3 (Registered Nurse/RN) and V4 (Licensed Practical Nurse/LPN) were at the nurses station conducting computer and paper work. The nurse call system registers at the nurse station…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the call light system was functional and failed to monitor its call light system. These failures have the potential to affect 121 residents residing on the third and fourth floors of the the facility. Findings include: On 01/25/2025, at 11:01 AM, R8's call light is observed illuminated above his room door, no audible sound is heard. On 01/25/2025, at 11:02 AM, V8 (RN) and V9 (LPN) observed sitting at the third-floor nurse's station. On 01/25/2025, at 11:03 AM, surveyor located at the third-floor nurses' station and observes that R8's call light is not visible from the nurse's station. On 01/25/2025, at 11:05 AM, surveyor asks V8 (Registered Nurse/RN) how does staff know when a resident has activated their call light and need their call light answered. V8 states there is a phone at the nurse's station and when the resident pushes their call light button, the phone displays the resident's room number and makes an audible alert sound.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to prevent and protect a resident from resident-to-resident physical abuse. This failure affects one (R1) resident out of three residents reviewed for abuse. Findings include: On 01/25/2025, at 10:23 AM, R1 observed lying in bed inside of his room in a left lateral position. R1 is noted with confusion and unable to give an account of the altercation that occurred. On 01/25/2025, at 10:25 AM, R3 states, I know what happened. R3 then states they were located in the dining room on the second floor and a gray-haired male hit R1 in the face and gave R1 a puffy eye. R3 states he is not sure of the resident's name who hit R1. On 01/25/2025, at 10:57 AM, R2 states he was involved in an altercation with R1 in the dining room on the second floor. R2 states R1 was talking too much and R1 told R2 your mother. R2 states he does not know why R1 said that to him. R2 states he then hit R1 in the face. R2 states he was sent to the hospital after hitting R1 in the face. R2…

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 the third and fourth floor shower rooms were clean and sanitary. This has the potential to affect all 33 residents residing on the third floor and all 60 residents residing on the fourth floor. Findings include: On 1/06/2025 at 11:53am, during a tour of the fourth floor, surveyor requested the fourth floor housekeeper to unlock the door to the fourth-floor east side shower room. Upon entering the fourth-floor east side shower room, surveyor observed a small circle of a brown colored substance on the floor in front of the shower stall. On 1/06/2025 at 12:15pm, during a tour of the third floor, surveyor requested the third floor staff person to unlock the door to the third-floor east side shower room. Surveyor observed a blue soiled diaper on the floor in the third-floor east side shower room. On 1/08/2025 at 11:55am, R9 stated, I have observed feces on the shower room floor every now and then. On 1/08/2025 at 12:00pm, R2 stated, one day I went into the shower room and there was poop all over 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, interviews and record review, the facility failed to ensure that the residents'common shower room was without debris and dirt on the floor. This failure has the potential to affect all 66 residents that reside on the second floor. Findings include: During investigation on 11/25/2024 at 12:45 PM, Surveyor walked into 2nd floor shower room with V20 (CNA/ Certified Nurse Assistant) to observe the resident shower room. At that time, the resident's shower room was observed with debris and dirt on the floor. Surveyor observed plastic bottles, gloves, paper, plastic bags, clothes and towels on the floor. On 11/25/2024 at 12:50 PM, V5 (Nurse Manager) went with surveyor to observe the condition of the resident's shower room. At that time, V5 said that the shower room was unkempt and that it poses and infection control concern for the residents. On 11/25/2024 at 1:10 PM, V21 (Housekeeping) was observed on the 2nd floor near social service office. Surveyor inquired about the expectations regarding residents' shower rooms. At that time, V21 said, that the shower room…

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 that residents' rooms were free of cockroaches. This failure has the potential to affect all 66 residents that reside on the 2nd floor. Findings include: R2 is a [AGE] year old with diagnosis including but not limited to: Cellulitis, spinal stenosis, acquired absence of left leg above the knee, weakness, muscle wasting and atrophy. R2's BIMS (Brief Interview of Mental Status) score is 13, which indicates cognitively intact. R5 is a [AGE] year old with diagnosis including but not limited to: Gastric ulcer, acute pancreatitis without necrosis or infection, anemia, hypomagnesemia, and periorbital cellulitis. R5's BIMS (Brief Interview of Mental Status) score is 13, which indicates cognitively intact. R6 is a [AGE] year old with diagnosis including but not limited to: Obstructive sleep apnea, type 2 diabetes mellitus, epilepsy, essential hypertension, obesity and hyperlipidemia. R6's BIMS (Brief Interview of Mental Status) score is 12,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure that one resident with documented skin issues (R2) did not develop maggots in his foot wound. This failure has affected one of three residents reviewed for wound care. Findings include: R2 is [AGE] year old with diagnosis including but not limited to: Cellulitis, spinal stenosis, acquired absence of left leg above the knee, weakness, muscle wasting and atrophy. R2's BIMS (Brief Interview of Mental Status) score is 13, which indicates cognitively intact. On 11/25/2024 at 12:18 PM, R2 was observed lying in bed in his room. R2 said that he informed V5 (Nurse Supervisor) of his painful ingrown toe nail that he had months ago and was told that he (R2) would be assessed by the podiatrist. R2 said that V5 never took off his footie to assess his foot and that when he asked for his soiled wound bandage to be changed, V17 (Wound care nurse/LPN) refused to change his bandage. R2 began to become tearful during interview and said that he was hurt and pissed…

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 follow their policy by not reporting an allegation of abuse to V1 (Administrator) and reporting it to the (State Agency) for two of R1's incidents. This affected 3 (R1, R11, R12) out of 13 residents reviewed for abuse. Findings include: During a telephone interview with V21 (Former Nurse) on 10/23/2024 at 10:22 AM, V21 stated when V21 arrived for work one morning, R1 was already irate and fighting another resident at first. V21 saw R1 and R11 tussling back and forth over a cane. V21 stated R11 struck R1 twice in the face with a closed fist. V21 stated facility called a code to have additional staff assist with the incident. V21 stated V1 (Administrator), V3 (Assistant Director of Nursing), V6 (Certified Nurse Aide, CNA), V9 (CNA), and V27 (Medical Records Director) were present that morning. V21 stated V1 came after staff separated R1 and R11. On 10/23/2024 at 11:25 AM, V27 stated during the morning of 9/27/2024, facility assigned V27 to work as receptionist at the front lobby. R12 ran out the front door in the lobby…

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 ensure the temperature of the walk-in cooler and walk in freezer were checked daily, failed to ensure the scoop for dry food was contained, failed to ensure Dietary staff wore appropriate beard guard, and failed to ensure facility staff used unexpired test strips in checking the concentration of chemical used to sanitize kitchen utensils in an effort to prevent food borne illnesses. These failures have the potential to affect all residents at the facility. Findings include: On 10/06/2024 at 9:18am with V9 (Dietary Aide) during the initial tour of the Kitchen, V9 has a beard and was not wearing a beard guard. On 10/06/2024 at 9:18am, the walk-in freezer and walk in cooler temperature log had missing entries. These were pointed out to V9. V9 stated the temperature for whole day of 10/5 are missing. On 10/06/2024 at 9:25am inside the dry storage room with V9, a scoop was lying on the lid of the OATS bin. V9 stated we use the scoop to get sugar, oats, or breadcrumbs from the bin. The scoop should be by 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 reviews, the facility failed to ensure the dumpsters were not overflowing with trash, failed to ensure the dumpster lids were close, and failed to ensure there was no gap between the two doors which led to the loading dock of the facility in an effort to maintain an effective pest control program. These failures have the potential to affect all the residents at the facility. Findings include: On 10/06/2024 at 9:45am with V11 (Dietary Aide) during the initial tour of the dumpster area. Each of the 2 big dumpsters have 3 lids and each of the big dumpsters have one open lid. V11 stated the lids should not be open to prevent the animals from migrating to the dumpsters. On 10/06/2024 at 9:48am on the way back to the Kitchen area and upon closing the door that led to the loading dock noted a gap between the two doors. V11 stated that's maintenance. On 10/07/2024 at 10:21am with V23 (Assistant Maintenance) by the loading dock area, pointed out to V23 the hole between the doors. V23 stated there is a gap on the door. There should be no gap 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 observations, interviews, and record reviews, the facility failed to provide a homelike environment to 8 (R71, R73, R104, R172, R178, R179, R193, and R202) residents reviewed for home-like environment in the total sample of 67 residents. Findings include: 1. The (10/06/2024) midnight census documented the following number of residents by floor: 1st floor = 56 residents 2nd floor = 68 residents 3rd floor = 64 residents 4th floor = 65 residents On 10/06/24 at 10:58 AM, R202 stated I shower every day, sometimes I don't get to dry myself because there's no available towel to use. I ask the CNA (Certified Nursing Assistant) to bring me towels; sometimes they bring me towels and sometimes they don't. They (staff) said because there's none available. The same with the linens; sometimes they do bring them and sometimes they don't because the linens are not available. Of course, it is upsetting if the linens and towels are not available. On 10/06/24 at 11:58 AM, R193 was lying on bed; R193's pillowcase was only covering half of R193's pillow. The pillow and pillowcase had dark brown…

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 the environment was free from hazards for one resident (R189). This failure has the potential to affect all 64 residents on the third-floor unit. Findings include: On 10/06/24 V2 (Director of Nursing, DON) presented a facility census of 64 residents on the third-floor unit. R189's face sheet shows that R189 has a diagnosis which includes but not limited chronic obstructive pulmonary disease and acute respiratory failure with hypoxia. R189's Brief Interview for Mental Status (BIMS) dated 09/08/24 shows that R189 has a BIMS score of 7 which indicates that R189 has some cognitive impairments. On 10/06/24 at 11:02 am, R189 was observed in bed, awake, with a portable oxygen tank on the floor not in a holder, next to R189 dresser. R189 stated that R189 uses oxygen continuously to help R189 to breathe. R189 stated that R189's portable oxygen tank had been on the floor in R189's room for several days. On 10/06/24 at 11:07 am, Surveyor brought this observation to V18 (Registered Nurse, RN) and V18 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.

Based on observations, interviews, and record review, the facility failed to properly label and date oxygen equipment (humidifier bottled, and nebulizer mask) and failed to properly contain oxygen equipment (nebulizer mask) per the facility policy. These failures affected four residents (R48, R78, R135 and R205) reviewed for respiratory care in a sample of 67 residents. Findings include: 1. R78's diagnoses include but not limited to asthma, atherosclerotic heart disease, and epilepsy. R78's Brief Interview for Mental Status (BIMS) dated 9/3/24 shows R78 has a BIMS score of 13, which indicates R78 is cognitively intact. On 10/6/24 at 12:02 pm, surveyor observed R78's nebulizer mask laying on back of the oxygen machine not contained and dated 8/17/24. Humidify bottle dated 6/24/24. R78's (Active orders as of 10/08/24) Order summary Report documents in part, Ipratropium-Albuterol Inhalation Solution (3) MG/3ML(Milligram/Milliliter) 1 vial inhale orally every 6 hours for short of Breath. R135's diagnoses include but not limited to COPD (Chronic Obstructive Pulmonary Disease), atrial…

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 maintain an accurate account of the controlled substance record and failed to dispose expired medication. These failures affected four residents (R165, R202, R203, and 456) reviewed for controlled substance and medication storage in a sample of 67 residents. Findings include: On 10/7/24 at 10:30 am, Surveyor reviewed the 1st floor medication cart for rooms 101-114 with V32 License Practical Nurse (LPN). On 10/7/24 at 10:40 am, R202's Controlled Drug Receipt/Record/Disposition Form documents in part, Lorazepam Tablet 1 mg (milligram) document a total of 26 left, but actual count was 25 on the medication dispensing card. On 10/7/24 at 10:50 am, V33 (LPN) reviewed 1st floor medication cart 2 for rooms 115-129. On 10/7/24 at 10:55 am, R203's Controlled Drug Receipt/Record/Disposition Form documents in part, Lacosamide tablet 100 mg documents a total of 24 left, but actual count was 23 on the medication dispensing card. On 10/7/24 at 10:56 am, R456's Controlled Drug Receipt/Record/Disposition Form 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.

Based on observation, interview, and record review the facility failed to ensure that four residents (R5, R118, R174, and R556) was placed on Enhanced Barrier Precautions (EBP); failed to ensure staff appropriately [NAME] and Doff gloves and change wash clothes during ADL (Activities of Daily Living) care for one resident (R61). These failures affected one resident (R61) and has the potential to affect all 56 residents on the first floor, all 68 residents on the second floor and 64 residents on the third-floor unit. Findings include: 1. On 10/08/2024 at 10:13am, V36 (Certified Nursing Assistant) donned gloves. V36 washed and towel dried R61's whole body in sections starting from R61's face, then to R61's torso and lower abdomen, then to R61's bilateral upper extremities, then to R61's bilateral lower extremities and between thighs, then to R61's back and buttock including R61's anus with only one wet wash cloth and one dry washcloth without doffing and donning new gloves. On 10/08/2024 at 10:25am, this surveyor inquired how many times V36 changed her gloves while performing ADL care…

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

Based on observation, interview and record review, the facility failed to ensure the fourth floor resident pantry was clean and sanitary. This has the potential to affect the 65 residents residing on the fourth floor. Findings include: Facility document titled, (Facility) Midnight Census Report 10/6/2024, shows that 65 residents are currently residing on the fourth floor. On 10/6/24 at 11:25am, while on the 4th floor, this surveyor observed the following in the fourth floor resident pantry: 1. There was multiple areas of a brown substance on the base and the walls of the inside of the microwave and multiple areas brown, green and white substances on the walls of the outside of the microwave. 2. The garbage was overflowing with trash and the trash was observed on the floor surrounding the garbage can. 3. Dried brown substances on the walls of the residents' pantry. 4. Dried brown substances on the floor of the residents' pantry. On 10/6/24 at 11:29am, this surveyor inquired about the fourth floor resident pantry and V4 (Nursing Supervisor) said, All the residents on the fourth floor…

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 nail care is provided for one resident (R75). This failure has the potential to affect all residents in the sample size of 67. Findings include: R75 has a diagnosis of but not limited to Chronic Obstructive Pulmonary Disease, Vascular Dementia, Major Depressive Disorder, Metabolic Encephalopathy and Lack of Coordination. R75 has a Brief Interview of Mental Status score of 03. A score of 03 indicates severe cognitive impairment. On 10/06/2024 at 11:31am surveyor observed R75's fingernails to have a greyish black substance under the fingernails on both hands. On 10/06/2024 at 11:32am R75 stated he would like his fingernails cleaned. On 10/06/2024 at 11:34am V39 (Licensed Practical Nurse-LPN) stated I would think it (nailcare) should be done daily. On 10/08/2024 at 9:20am V2 (Director of Nursing-DON) stated the nursing staff are responsible for providing nail care when ADL care is done and when showers (twice a week) are given. V2 also stated for independent residents' staff should be offering assistance…

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 monitor personal refrigerator temperature logs for two residents (R98 and R174). This failure affected two residents (R98, R174) out of 67 residents in the total sample. Findings include: R98 has a diagnosis which includes but not limited to dysphagia following cerebral infarction, aphasia, dysphagia, muscle wasting, and mixed hyperlipidemia. R98 Brief Interview for Mental Status (BIMS) dated 07/10/24 documents that R98 has a BIMS score of 15 which indicates that R98 is cognitively intact. R174 has a diagnosis which includes but not limited to type 2 diabetes mellitus with other specified complication, dysphagia oropharyngeal phase, end stage renal disease and essential hypertension. R174 BIMS dated 07/07/24 documents that R174 has a BIMS score of 8 which indicates that R174 has some cognitive impairments. On 10/06/24 at 10:58 am, Surveyor observed R174's personal room refrigerator with a temperature log sheet dated April 2024. R174 was not able to answer surveyor regarding how often R174's personal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that resident's call device was functioning to allow resident to call for staff assistance. This failure affected 1 resident (R250) reviewed for functioning resident call device in a total sample of 67 residents. Findings include: On 10/06/24 at 11:07am, this surveyor requested R250 to activate his (R250) call device. R250 stated what for, it does not work anyway. On 10/06/2024 at 11:09am, this surveyor requested V13 (Social Service Director) to activate R250's call device; no light on the box of R250's call device and on overhead call device indicator outside of R250's room were noted. V13 stated it is not working. On 10/07/2024 at 10:54am, R80 stated the call light (referring to R250 call light) has been broken the day I came in this room. I got here 4 months ago. On 10/07/2024 at 10:55am, R250 stated I got here the first week of September and my call light has been broken. On 10/08/2024 at 2:44pm, V2 (Director of Nursing) 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.

Based on observation, interview, and record review, the facility failed to ensure medication was not left inside the room of a resident whose ability to safely self-administer medications was not assessed. This failure affected one (R4) resident reviewed for self-administration in the total sample of 7 residents. Findings include: On 06/10/2024 at 11:28am, there were 2 half pills in a med cup by R4's television stand. R4 stated I (R4) don't remember who gave me (R4) medication. I (R4) am not sure if it is the morning shift or the night shift. I (R4) don't remember the name of the nurse. All I (R4) know is that I (R4) took the med cup with meds (medications) from the nurse and the nurse just left them to me. The medication in the med cup is my potassium. I (R4) split it in half because I (R4) cannot swallow the whole pill. On 06/10/2024 at 11:30am, this surveyor requested V8 (Assistant Director of Nursing) to describe the medication in the med cup. V8 stated I (V8) am not going to tell you because I (V8) did not give that pills to her (R4). On 06/10/2024 at 11:30am for the second…

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 who required assistance with incontinence care received necessary services in a timely when requested for one (R6) resident out of three residents reviewed for improper nursing care in the sample. Findings include: On 05/01/2024 at 11:13 AM, observed V12 (Certified Nursing Assistant/CNA) take R3's soiled clothes to laundry out of R3's room. On 05/01/2024 at 11:17 AM surveyor informed V12 that R3 states that she is ready to get up from the bed. V12 states that she has assisted R3 on the bedpan already and V12 states that first thing first she must get the dirty clothes and take it to the laundry. V12 states that R3 is going to have to wait. V12 states that she has a resident that she must clean first. V12 states that R6 is the resident that she will change. On 05/01/2024 at 11:24 AM observed V12 take down the dirty linen down the elevator. On 05/01/2024 at 11:28 AM observed V12 stepped outside from the elevator. R6'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 maintain a functioning call light that is accessible to one resident (R7) to allow the residents to call for staff assistance and failed to provide a specialized call light for one resident (R2) who is unable to use standard call light out of three residents reviewed for call lights in the sample. Findings include: 1. 04/30/2024 at 1:47 PM during hallway observation, surveyor observes outside call light of R7's room blinking with the door closed. 04/30/2024 at 1:50 PM continued to observe R7's room call light blinking outside of the room with door closed. 04/30/2024 at 1:53 PM continued to observe R7's call light blinking outside with door closed. 04/30/2024 at 1:56 PM continued to observe call light blinking, observed V7 (Business office Manager) walk by call light blinking. V7 informed surveyor that the call light is broken. V7 states that she did not know how long the call light was broken for, but she will find out. V7 states that there is no resident in the room and in the restroom. 4/30/24 at 2:15 PM V8…

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 ensure food items were covered, labeled and dated and failed to ensure staff appropriately wear beard restraints in an effort to prevent food borne illness. These failures have the potential to affect all residents receiving oral nutrition at the facility. Findings include: The (03/11/2024) facility census was 251. The (03/14/2024) email correspondence with V2 (Director of Nursing) documented that one resident was not taking oral nutrition at the facility. On 03/11/2024 at 10:06am inside the facility kitchen, V17 (Dietary Supervisor) has a beard and mustache and was not wearing beard restraint. This surveyor inquired about the beard restraint. V17 stated I (V17) am not aware that I (V17) need to wear one. On 03/11/2024 at 10:10am, V19 (Dietary Aide) has a beard and was not wearing beard restraint. On 03/11/2024 at 10:11am, V20 (Dietary Aide) has a beard and was not wearing beard restraint. This surveyor inquired about beard restraint. V20 stated I (V20) am not wearing a beard restraint. On 03/11/2024 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 observations, interviews, and record reviews, the facility failed to ensure the dumpsters were not overflowing with trash, failed to ensure the dumpsters were closed and failed to ensure the ground surrounding the dumpster was free of trash in an effort to prevent pest and rodents migration to the facility. These failures have the potential to affect all residents at the facility. Findings include: On 03/11/2024 at 10:35am, the 2 outside dumpsters were overflowing with trash and the lids were open. The ground surrounding the dumpster were with trash. V18 (Dietary Manager) stated the dumpsters are overflowing with trash that's why the dumpsters are not closing. These is all trash; we don't have recyclables. There is also trash on the grounds. It is everywhere. On 03/11/2024 at 10:38am, there was small gap between the delivery door and door frame. This observation was pointed out to V18. V18 stated the little mice could fit in there. On 03/11/2024 at 10:39am, there was a gap at bottom of the kitchen doors. V18 stated I know what you're pointing out, the mice could go to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure 4 residents (R7, R25, R175, R299) received nail care to preserve their dignity and increase self-esteem. This failure affected 4 out of 71 residents in the sample. Findings include: R7 has a diagnosis of but not limited to Nontraumatic Chronic Subdural Hemorrhage, Weakness, Abnormal Posture, Hypertension, and Dementia. R7's has a Brief Interview of Mental Status score of 99. R7's care plan focus on self-care dated 2/11/2024 documents, in part, substantial/max assist x 1 (one person) with dressing/grooming tasks. R25 has a diagnosis of but not limited to Sequelae of Cerebrovascular Disease, Lack of Coordination, Flaccid Hemiplegia affecting Right Dominant side, and Abnormal Posture. R25 has a Brief Interview of Mental Status score of 07. R25's Minimum Data Set (MDS) dated [DATE] documents, in part, Personal Hygiene: 01. 01 is for dependent: Helper does all of the effort. R25's care plan focus Self Care Deficit dated 2/08/2024…

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 safety for 4 residents (R27, R111, R163, R173) by removing disposable razors from the resident's room and failed to provide supervision for 2 residents (R27 and R131) by leaving oral medicine and eye drops at the resident's bedside. The failure has the potential to affect all 5 residents out of a sample of 71. Findings include: R27 has a diagnosis of Chronic Obstructive Pulmonary Disease, Venous Insufficiency, Type 2 Diabetes Mellitus, Blepharitis [NAME] Upper Eyelid, and Blepharochalasis. R27 has a Brief Interview of Mental Status score of 15. R27's Active Orders as of 3/12/2024 documents, in part, Fluorometholone Acetate Suspension 0.1% (eye drops for Blepharochalasis) and Maxitrol Ointment 3.5-10000-0.1 (eye drops for Cellulitis of Left Orbit). R27 has no order to self-administer eye drops. On 3/11/2024 at 11:27am surveyor observed two boxes of eye drops and one disposable razor on R27's dresser. R131 has a diagnosis 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 two licensed personnel conducted a physical inventory of controlled substances at each change of shift. This failure has the potential to affect 3 residents on the 4th Floor Team 2 medication cart who are prescribed controlled substances and 5 residents on the 4th Floor Team 1 medication cart who are prescribed controlled substances. Findings include: On 03/13/2024 at 9:21 am review of the 4th Floor Team 2 medication cart with V11(RN/Registered Nurse) surveyor observed the controlled substances check form for March 2024. The Nurse's Off box was left blank for March 03, 2024 (11pm-7am shift). The Nurse's Off box was left blank for March 04, 2024(3pm-11pm shift). On 03/13/2024 at 9:25pm review of the 4th Floor Team 1 medication cart with V10(LPN/Licensed Practical Nurse) surveyor observed the shift change accountability record for controlled substances for March 2024. The Nurse's Initials on box was left blank for March 8, 2024(1st shift). The Nurse's Initials off box was left blank for March 12, 2024(2nd…

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 a bedside table was accessible when being served lunch in resident's room, which affected one resident (R449) in the sample of 71 reviewed for accommodation of needs. Findings include: R449's admission diagnoses documents in part, diabetes, wound right foot, osteomyelitis, hypertension, gastro esophageal reflux and schizophrenia. R449's Brief Interview of Mental status (BIMS) score is 14. A BIMS score of 14 indicates R449 is cognitively intact. On 3/11/24 at 12:00 pm, surveyor observed R449 in room sitting next to bed in a wheelchair. V31, CNA (Certified Nursing Assistant), came into R449's room and put R449's lunch tray on R449's bed and walked out of the room. R449 stated that the staff always put the meal trays on the bed. Surveyor inquired to R449 how R449 feels about the staff putting the meal trays on the bed? R449 stated, I don't have a choice but to eat on the bed because I don't have a table. On 3/12/24 at 2:50 pm, V1 (Administrator) stated that it is not acceptable for staff to put a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide clean linen for 2 residents (R27, R175) out of a sample of 71 residents. Findings include: R27 has a diagnosis of Chronic Obstructive Pulmonary Disease, Venous Insufficiency, Type 2 Diabetes Mellitus, Blepharitis [NAME] Upper Eyelid, and Blepharochalasis. R27 has a Brief Interview of Mental Status score of 15. R175 has a diagnosis of Hemiplegia and Hemiparesis affecting Left Side, Hypertension, Atherosclerosis, Muscle Weakness and Adjustment Disorder. R27 has a Brief Interview of Mental Status score of 11. On 3/11/2024 at 11:20am surveyor observed R27's sheet with a brownish stain on the right side of the foot of the fitted sheet. R27 also had a reddish stain on the left side of the top of the fitted sheet. On 3/11/2024 at 11:25am R27 stated he asked for clean sheets a couple of days ago but was told they did not have any clean sheets to give him. On 3/12/2024 at 10:45am V39 (Laundry Aide) stated that there is not enough laundry to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure new skin alteration was reported to the nurse and failed to ensure the low air loss mattress was set appropriately. These failures affected 1 (R67) resident reviewed for prevention and treatment of pressure ulcer/injury in the total sample of 71 residents. Findings include: On 03/11/24 at 11:41am, R67 was lying on a low air loss mattress (IHE 395 True Low Air Loss). The setting of R67's low air loss mattress was [PHONE NUMBER]lbs, max inflate, static on. On 03/11/24 at 11:44am, this observation was pointed out to V23 (Licensed Practice Nurse). V23 stated the setting of her (R67) mattress is at [PHONE NUMBER] lbs., max inflate, and static on. On 03/11/24 at 11:45 AM, V24 (Certified Nursing Assistant) checked R67's buttocks upon the request of this surveyor and turned R67 to left side. Noted a skin opening on the coccyx area approximately 1inch x 0.4inch with no dressing. V24 stated there is no dressing on the wound. On 03/13/2024…

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 ensure the feeding tube was disconnected and flushed after the completion of feeding. This failure affected 1 (R46) resident reviewed for tube feeding in the total sample of 71 residents. Finding include: On 03/11/24 at 12:35 PM, R46's tube feeding bag was hanging on a pole. The feeding bag was dated 3/10. The feeding pump was off. The line of the tube feeding from the feeding pump was under R46's blanket. On 03/11/2024 at 11:36am, this surveyor requested V23 (Licensed Practice Nurse) to check R46's feeding tube. The feeding tube was still hooked on R46's gastrostomy tube and feeding formula was still present on the feeding tube. V23 stated I (V23) stopped the feeding this morning. I (V23) will turn it back on at 2pm. On 03/11/2024 at 11:37am, surveyor inquired about flushing and disconnecting of tube feeding after completion of the feeding. V23 stated I (V23) should have done it, but I (V23) did not. On 03/13/2024 at 11:38am, V2 (Director of Nursing) stated the expectation of the staff stopping 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 properly log refrigerator temperatures for two resident's (R98 and R180) personal refrigerators and failed to provide a thermometer in one resident's refrigerator(R180). This failure has the potential to affect all 71 residents in the sample. Findings include: On 3/11/2024 at 11:34am observed a black refrigerator sitting on top of a stand in R98's room. Surveyor observed missing documentation of temperatures on the refrigerator temperature log. Surveyor asked R98 if it was okay to open the refrigerator and R98 responded yes. Surveyor observed 2 cartons of 2% milk, 3 bottles of water and 3 plastic bottles of soda in the refrigerator. On 3/11/2024 at 11:40am observed a white box refrigerator on top of a stand in R180's room, observed R180's refrigerator with no thermometer in the inside of the refrigerator and no refrigerator temperature log affixed to the personal refrigerator. The following foods were located inside the refrigerator at the time of observation: 2 cartons of two percent milk and four plastic…

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 upon observation, interview and record review the facility failed to ensure that call lights were accessible for two of four residents (R1, R2) reviewed for call lights. Findings include: 1. R1's diagnoses include generalized weakness, reduced mobility and lack of coordination. R1's (12/20/23) functional assessment affirms supervision and/or touching assistance is required for transfers. R1's (12/20/23) BIMS (Brief Interview Mental Status) determined a score of 15 (cognition intact). On 2/27/24 at 11:34am, R1 was observed seated in a wheelchair (adjacent the bed), the call light was on the floor (behind the head of bed) and out of reach. Surveyor inquired if R1's able to walk, R1 stated No. Surveyor inquired if residents need help, how do they request for help. R1 responded I gotta go and see em (staff). Surveyor inquired if R1 was lying in bed needing help, how does R1 request help R1 replied It's the same thing. R1's care plan (12/22/23) Resident is able to use call light, intervention: provide frequent monitoring. (12/20/23) Resident is at risk for fall related to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based upon observation, interview and record review the facility failed to follow the abuse prevention policy, failed to report required information, and failed to report accurate information and/or injury to the State Agency for two of four residents (R4, R5) reviewed for abuse. Findings include: R4 is [AGE] years old with diagnoses which include bipolar disorder and paranoid schizophrenia. R4's progress notes include the following behaviors (6/19/23) resident presented with physical and verbal aggression toward staff and peers stating that he was going to Kill all of the black people. (10/20/23) Resident began threatening nurse saying, I will f* you up, come on, right here, right now. Resident threw his fist up in the position to fight. (11/25/23) Resident was standing in front of the nurse's station and another resident asked him to stay out of his room. Resident turned and looked at this person and put his face close to this person and this person reacted by putting his hand to resident's upper chest area,…

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 upon observation, interview, and record review the facility failed to follow the smoking safety policy and failed to provide supervision to one of five residents (R1) reviewed for hazards. These failures have the potential to affect 251 residents. Findings include: The (2/27/24) census includes 251 residents. R1's (12/20/23) smoking risk assessment determined a score of 5, may not be capable of handling/carrying any smoking materials and requires supervision when smoking. On 2/27/24 at 11:34am, surveyor(s) entered R1's room and a strong odor of cigarette smoke was noted. R1 was observed in the room sitting in a wheelchair and a cigarette butt was noted on the dresser in front of R1. A cigarette pack was also observed on R1's bed at this time. On 2/27/24 at 11:39am, surveyors inquired about the odor in R1's room V3 (Licensed Practical Nurse) stated There's a odor, it's kind of musky. Surveyor inquired if cigarettes should be in R1's possession V3 stated No, it should be downstairs with the activity and subsequently removed the cigarette pack from R1's bed at this time. 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, interviews and record review the facility failed to ensure that resident's meals were the proper portion size. This failure has the potential to affect 245 residents that currently depend on the facility to meet their nutritional needs. Findings include: On 12/18/2023 during kitchen visit, Surveyor observed tray line in progress for lunch. On 12/18/2023 at 11:30 AM, V8 (AM Cook) was observed preparing resident's meal trays. At that time, V8 placed a slice of Ham, ½ cup of mashed potatoes, ½ cup of peas and slice of cake on each tray. On 12/18/2023 at 11:34 PM, Surveyor asked V5 (Dietary Manager) to weight a slice of ham. At that time, V5 weighed a slice of ham on a mechanical food scale. The scale indicated that the slice of ham weighed between .75 and .8 ounce. (Not even one ounce) Surveyor inquired about the amount of ham that is supposed to be served on each resident's meal tray. On 12/18/2023 at 11:34 PM, V5 said, They (residents) are supposed to get 3 ounces of ham. Surveyor inquired about who cut the ham for lunch. On 12/18/2023 at 11:40 AM, V8 (Cook)…

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 that one dependent resident (R1) was clean and dry within two hours of requesting incontinent care; and the facility failed to ensure that one resident (R1) with scaly feet and overgrown toe nails received foot care. This failure affected one of three residents reviewed for Activities of Daily Living. Findings include: R1 is [AGE] year old with diagnosis including but not limited to: Contracture of Muscle, Lack of Coordination, Weakness, Reduced mobility, Rheumatoid Arthritis and Contracture of unspecified joint and Diabetes Mellitus. R1 has a BIMS (Brief Interview of Mental Status) score of 11 which indicates moderate impairment. On 12/18/2023, at 1:23 PM, R1was observed lying in bed. At that time, R1 said, I am waiting on my CNA (Certified Nurse Assistant) to come and change me. I've been waiting for over an hour now. On 12/18/2023 at 1:25 PM, Surveyor observed V9 (CNA) at the 2nd floor Nurse's station (outside of R1's room)…

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 provide reasonable accommodation of needs by not supplying enough linen for five (R7, R9, R10, R11,12) residents out of a total sample of 12 residents. Finding include: On 11/14/2023 at 11:54 AM, surveyor interviewed R9. R9 was alert and oriented to person, place, and time. R9 stated the facility did not have enough linens and are always running low. One of R9's pillows did not have a pillowcase. Fitted bed sheet had tan stains on it. At 12:01 PM, one of R10's pillows did not have a pillowcase. At 12:04 PM, R11 stated staff needed to change R11's bed linens. R11 could not recall the last time the staff changed R11's linens. R11 stated staff have not changed them this week. At 12:07 PM, R12 was sitting up in a motorized wheelchair. R12 had a pillow behind R12's back that did not have a pillowcase. At 12:18 PM, surveyor observed one, small linen cart in the hall. Linen cart had less than ten pieces of linen and there were no pillowcases. At 12:21 PM, V5 (CNA, Certified Nurse Aide) took surveyor into 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 observations, interviews, and record reviews, the facility failed to maintain an effective Pest Control Program for two resident rooms and a hallway. Findings include: On 11/14/2023 at 11:54 AM, surveyor interviewed R9 in the bedroom. R9 was alert and oriented to person, place, and time. There were two black, flying insects flying around R9's bed. R9 stated they can't control no flies. At 12:07 PM, R12 (R9's roommate) stated facility needs to have the exterminators come and spray more often. R12 stated I'm looking at a fly right now. R12 stated also finding roaches in the room. At 12:10 PM, V4 (Housekeeper) stated [V4] sees fruit flies when the residents leave out food or when the CNAs (Certified Nurse Aides) don't collect the meal trays right away. V4 reported seeing flies and fruits flies last week. At 12:12 PM, surveyor observed a black, flying insect outside of room [ROOM NUMBER]. At 12:27 PM, surveyor interviewed R7 in the bedroom. R7 was alert and oriented to person, place, and time. R7 stated 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 observations, interviews, and record reviews, the facility failed to keep two residents (R6, R8) free from abuse for 2 of 12 residents reviewed for abuse. Findings include: R6's admission Minimum Data Set assessment dated [DATE] documents in part that R6 has severe cognitive impairment. During the one week look back period, R6 had wandering behaviors. R6's comprehensive care plan initiated 9/18/2023 documents in part that R6 may be at risk for potential abuse related to confusion and wandering. Intervention initiated 9/18/2023 documents in part: Monitor resident behaviors. On 11/15/2023 at 1:45 PM, V22 (Nurse) stated finding R6 ambulating in the hallway injured. After investigating, V22 found out that R6 went into R5's bathroom. When R6 exited the bathroom, R6 startled R5. '[R5] reached out and slapped [R6].' V22 stated R6 is a little bit confused and needs redirection. V22 did not know why R6 was using R5's bathroom instead of R6's bathroom. V22's incident progress note dated 9/18/2023 7:10 AM…

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 (a) provide all 244 residents residing in the facility with needed supplies for Activities of Daily Living care items(bedsheets, gowns, towels, incontinence briefs) (b) failed to provide appropriate eating utensils to accommodate 241 residents that eat from the kitchen. Findings include: On 09/21/2023 at 12:40pm, R1 said the facility does not have enough bath and wash towels, incontinence pads, adult briefs, soap, toothpaste, and other daily use supplies, and R1 had to get these supplies from his insurance company for him to use at the facility. On 09/21/2023 at 1:07pm, during observation of clean linen cart on the hallway near R1's room with V12 (Certified Nursing Assistant), observed on the linen cart were four incontinence diapers, three hospital gowns, one flat sheet, and two face towels cut from a bath towel, with frayed sides. On 09/21/2023 at 1:07pm, V12 said that CNAs do not have enough supplies to perform resident ADL (Activities of Daily Living) care, and linen such as bath towels, face towels,…

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 residents received food in the acceptable amount to maintain nutritional values. This failure has the potential to affect the 241 residents receiving food from the kitchen. Findings include: On 9/21/23 at 4:45 PM, observed kitchen staff plating dinner: one slice of riblette per bun, tater tots grabbed by hand, not measured. Each tray had a sandwich and tater tots on a plate, a bowl of mixed fruit cocktail in juice, 1 fork, 1 ketchup packet. The trays were on the cart to be delivered to the floor. Staff took the cart of trays to the elevator for delivery to the resident floors. Survey team did not observe a spoon on the trays to eat the fruit cocktail with. On 9/21/23 at 12:03 PM, R5 was observed sitting on the bed eating lunch. R5s lunch ticket did not have the names of the foods served. Observed on the food tray were steamed green beans, carrots, and a type of mashed potatoes with ham. R5 said R5 did not know if it was mashed potatoes and ham, because R5 could not tell what the food was. R5 said 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 records review, the facility failed to follow their call light system policy by failing to maintain a properly functioning call light system that allows residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area. This deficient practice has the potential to affect all 244 residents residing in the facility. Findings include: On 09/21/2023 at 2:16pm, R2 said before she fell last Wednesday on 09/13/2023, she had put on the call light and no staff come to her assistance. R2 suffered a fractur on the humerus and middle finger of her left hand from the fall. On 09/21/2023 at 12:40pm, R1 said he has not been changed since last night, and he has been lying down like this all morning, and he has been putting the call light on for a long time without an answer, R1 put his call light on. R1's urinal was observed with urine at 850cc and almost full. R1 said he was afraid his urinal would overflow if staff did not empty it soon. R1 also stated he had soiled…

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 records review, the facility failed to follow their activities of daily living and dignity policy to provide one resident (R1) of 3 reviewed for activities of daily living(the necessary services to maintain, grooming, and personal hygiene of three residents reviewed). Findings include: On 09/21/2023 at 12:40pm, R1 was observed lying on his bed. His food tray was observed on the bedside table. R1 said he was waiting for staff to change him because he had a bowel movement earlier today, about 10:00am, and no-one is answering his call light or checking on him, and he cannot eat his lunch when he is soiled. R1 further said that said he has not been changed since last night, and he has been lying down soiled like this all morning, and he has been putting the call light on for a long time without any staff answering his call light. R1 put his call light on, no staff came to R1's room. R1 said now they will come they know you are here. R1's urinal was observed with urine at 850cc…

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 food was served at a palatable temperature. This deficient practice has the potential to affect all 240 residents receiving food prepared in the facility's kitchen. Findings include: On 09/13/23 at 8:25 AM, surveyor entered kitchen while breakfast tray line service was still in progress. Observed three plastic meal trays stacked on top of each other each containing uncovered non-insulated bowls of hot cereal from which the diet aide was taking the bowls of hot cereal and placing onto the non-disposable plastic plates and covering the plates with a dome lid. There was no plate warmer under the non-disposable plastic plates. On 09/13/23 at 8:31 AM, observed V27 (Food Service Manager) take temperatures on the tray line as follows: pancakes 149 degrees Fahrenheit(F), sausage patty 138 degrees F, hot cereal 80 degrees F. On 09/13/23 at 8:40 AM, V21 (Dietary Aide/Prep Cook) stated that V21 portioned out the hot cereal this morning between 6:45-7:00 AM at the start of the tray line. V21 stated V21 has not 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 observation, interview and record review the facility failed to maintain an effective pest control program to keep pests out of the facility. This deficient practice has the potential to affect all 243 residents residing at the facility. Findings include: On 09/13/23 at 9:05 AM, observed gnats in R11 and R12's room near R12's bed. On 09/13/23 at 9:27 AM, surveyor observed light brown oval shaped insect crawling up and down the outside of the garbage can in the Maintenance Room located in the basement. Surveyor pointed to the insect and V20 (Maintenance Director) stated, that's a roach! On 09/13/23 at 10:02 AM, during inspection with V19 (Housekeeping Director) of Soiled Linen [NAME] Room on basement level observed 30-32 dark brown pellets which were larger than a grain of rice concentrated in one area behind a red isolation container. V19 stated that the pellets are rodent droppings and that the droppings looked larger than mice droppings so they might be from a rat. On 09/13/23 at 11:42 AM, 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, interviews, and review of records the facility failed to follow pain assessment and management program by not addressing and documenting pain for 1 out of 3 residents (R1) reviewed for pain management. These failures have the potential to affect 1 resident (R1) daily pain status and comfort. Findings include: R1 was admitted to the facility on [DATE]. R1's medical diagnosis includes but not limited to pressure ulcer, muscle wasting. R1's Cognitive Patterns dated 08/ 14/ 2023, documents R1's Brief Interview for Mental Status (BIMS) of 13/15, indicating R1 has intact cognation. On 09/12/2023 at 1:14pm R1 said observed in her bed. Surveyors introduced themselves to R1. R1 started crying and said she was in a lot of pain on her legs, and she cannot move her legs because of the pain. R1 said all she offered for pain is Tylenol, which does not help her. R1 said before she came to the facility, her pain was managed with Norco and gabapentin to help control her pain. V4(Wound Nurse-RN) came into…

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.