Glenoaks Senior Living Campus

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to ensure a thorough investigation was completed and protect residents after 2 of 2 allegations which included rushed and harsh cares in addition to physical abuse were reported by unknown residents which effected (R1, R4, R6, and R7) who reported on going inappropriate behavior and treatment by nursing assistant (NA)-P. Findings include:Review of NA-P's employee record included a written warning dated 8/1/25, that was authored by assistant director of nursing (ADON)-A. The ADON wrote- residents complained of nursing assistant (NA)-P being harsh and rushed, staff have complained about tone and verbiage coming from NA-P that is demeaning and lacked appropriate bedside manner. NA-P's employee record nor did the disciplinary action document identify which residents were involved that led to NA-P's written warning. Further, there were no recorded grievances and/or documentation of the concerns voiced by residents, there was no indication of an investigation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 performance evaluations for 4 of 4 nursing assistants (NA-P, NA-D, NA-S, and NA-L) were provided within the past 12 months.Findings include:Review of nursing assistant (NA)-P employee record identified a hire date of 10/25/23 and did not include a performance evaluation since NA-P's hire date. During interview on 9/12/25, nursing assistant (NA)-P could not remember receiving a performance evaluation since she was hired. Review of (NA)-D's employee record identified a hire date of 11/10/22 and included a performance evaluation dated 3/13/23; there were no subsequent performance evaluations included in her record.Review of NA-S employee record identified a hire date of 4/15/22 and included a performance review dated 3/13/23; there were no subsequent performance evaluations included her the record. During interview on 9/12/25 at 8:27 a.m., NA-S could not remember receiving a performance evaluation since 2023. Review of NA-L's employee file identified a hire date of 2/18/20, a performance evaluation for 2022 was found…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 document review the facility failed to report an allegation of abuse timely to the State Agency for 1 of 1 resident (R1) who reported staff to resident physical abuse. Findings include:A facility five-day investigation submitted by the administrator to the State Agency on9/3/25 indicated on 8/28/25, R1 had clinic appointment and had become upset with the physician. The report included a statement R1 made to the physician then we should talk about Glen Oaks and the staff that is beating me up. In review of facility reported incidents to the State Agency there was no indication R1's allegations of abuse were reported to the State Agency. R1's significant Minimum Data Set (MDS) dated [DATE], indicated R1 did not have cognitive impairment. R1 had verbal behaviors and rejection of cares.During an interview on 9/11/25, at 10:17 a.m., Administrator confirmed she submitted the five-day report to the State Agency that included the allegation of abuse R1 had made. On 8/28/25, she was told 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 interview and record review, the facility failed to provide a Quality Assurance and Performance Improvement (QAPI) plan that identified necessary policies and procedures describing how the facility will identify and correct quality deficiencies. This had the potential to affect all 29 residents residing in the facility. Findings include: When interviewed on 4/23/25 at 1:29 p.m. the administrator indicated there was no formalized QAPI plan in place to track and measure performance, no goals established to measure performance, and no development or implementation of corrective action or performance improvement activities. The administrator stated although there were attendance rosters available for quarterly QAPI meetings from the past year, the facility lacked any documentation to reflect the QAPI process. The administrator stated awareness of the need for and importance of the QAPI process, however, was new to the facility and this had not yet been implemented. During follow up interview on 4/24/25 at 4:54 p.m., the administrator stated she had again reviewed all…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 document review the facility failed to ensure the quality assurance (QA) team developed, and revised, a quality improvement program to correct infection control concerns identified through tracking and trending and the infection control process as presented by the director of nursing (DON) during routine QAPI meetings. This had the potential to affect all 28 residents residing in the facility. Findings include: On 4/23/25, at 8:28 a.m., the administrator provided information for review related to the Quality Insurance Performance Improvement (QAPI) meeting attendance rosters, and meeting minutes for the current QAPI program. A review of the attendance roster and meeting minutes lacked indication as to what the overall program focused on, as well as what the Performance Improvement Plan (PIP) focus was. The information following the attendance roster of 1/17/24 included hand written notes, however, these notes provided no context as to what the QAPI program was focusing on, benchmarks and goals, or information regarding the current PIP programs. The minutes did…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 document review, the facility failed to have a current, ongoing system of infection control (IC) surveillance to identify potential outbreaks of infectious disease, analyze data, and track infections through to resolution or identify the need to alter treatment. The facility also failed to ensure employee illnesses were tracked to identify when staff last worked and the criteria for when they would be allowed to return to work. The facility also failed to ensure staff appropriately wore a gown (personal protective equipment (PPE)) and/or bagged soiled linen during transport. This had the potential to affect all 29 residents in the facility. In addition, the facility failed to appropriately disinfect 1 of 1 resident's (R7) glucometer prior to returning it to the medication cart, Findings include: RESIDENT INFECTION SURVEILLANCE Review of the infection surveillance logs from January 2025 through March 2025 identified the columns for name, room #, infection date, site of infection, culture taken, causative agent, antibiotic treatment, isolation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 document review, the facility failed to ensure the infection preventionist had the appropriate time allotted to have oversight of the facility infection control program and was deemed competent in providing that oversight. This had the potential to affect all 29 residents. Findings include: RESIDENT INFECTION SURVEILLANCE Review of the infection surveillance logs from January 2025 through March 2025 identified the columns for name, room #, infection date, site of infection, culture taken, causative agent, antibiotic treatment, isolation precautions and center acquired (obtained while in the facility). In January 2025, three residents (R100, R101, and R18) were listed with active infections as follows: 1) R100 was listed twice with two separate infections, COVID and a urinary tract infection (UTI). An antibiotic was given for each infection. COVID (a virus) was treated with amoxicillin (an antibiotic) 500 milligrams (mg) x three days. Isolation was marked yes. R100 second infection, identified to start the same day, was a UTI. No culture was…

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

Based on observation and interview the facility failed to ensure hazardous chemicals were appropriately secured in 1 of 2 unlocked soiled utility rooms located in hall A. This had the potential to affect 16 of 29 residents residing in that hall. Findings include: Observation on 4/21/25 at 1:49 p.m., of the unlocked soiled utility room a bottle of Lysol toilet bowl cleaner was sitting on the counter next to the sink. Some of the cleaner was spilled on the countertop. Interview on 4/21/25 at 1:54 p.m., with the maintenance director confirmed the above findings. He does walk through the building but was unable to recall the last time he had checked the utility rooms. He identified they have a locked closet off the nursing floor that is supposed to be used to store cleaning supplies and other hazardous chemicals. He was not certain who had left the toilet bowl cleaner in the unlocked utility room. Interview on 4/24/25 at 4:58 p.m., with the nurse consultant and administrator identified they would expect staff to ensure all hazardous chemicals are always kept in a locked closet away 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure medications were administered in accordance with physicians orders and manufacturers guidelines for 2 of 7 (R24 and R30) residents observed to receive medications. A total of seven (7) errors out of 26 errors were identified, resulting in a 26.9% (percent) facility error rate. Findings include: On 4/22/25 at 3:56 p.m., licensed practical nurse (LPN-A) was observed to prepare medications at a mobile medication cart in the hallway of the unit. R24 was in the hallway and approached the medication cart for medication administration. LPN-A proceeded to set up medications, including topical medication Voltaren External Gel 1 % (Diclofenac Sodium). The label for this prescription cream directed staff to apply two gm (grams). LPN-A stated she did not have the dispensing film to measure out the two grams as ordered, however, R24 only wished to receive a pea sized amount. LPN-A was unsure how much this was comparative to the two grams amount…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 document review, the facility failed to have an antibiotic stewardship program to identify appropriate antibiotic use for 10 of 10 sampled residents (R1, R100, R18, R30, R18, R23, R15, R16, R5, and R101). Findings include: Review of the infection surveillance logs from January 2025 through March 2025 identified: In January 2025, two residents (R100 and R18) were listed with active infections as follows: 1) R100 was listed twice with two separate infections, COVID and a urinary tract infection (UTI). An antibiotic was given for each infection. COVID (a virus) was treated with amoxicillin (an antibiotic) 500 milligrams (mg) x three days. R100's second infection, identified to start the same day, was a UTI. No culture was marked as having been taken, but R100 was also prescribed amoxicillin clavulanate potassium (a combination antibiotic) 875/125 mg, x six days, given twice per day. There was no information to identify what R100's symptoms were, if an antibiotic time out (ATO) was performed (done to ensure the resident is on the correct antibiotic or if the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to provide complete information upon transfer to the receiving facility for 1 of 2 residents (R18) reviewed for hospitalization and discharge. Findings include: R18's quarterly Minimum Data Set (MDS) dated [DATE], indicated R18 had impaired cognition and was noted to exhibit inattention and disorganized thinking. R18 was also noted to have intermittent behavioral symptoms including physical behavioral symptoms directed towards others, verbal behaviors, and other symptoms not directed at others. R18 was noted to receive assistance with activities of daily living, although was able to ambulate independently. R18's medical diagnoses included acute kidney failure, renal insufficiency, heart failure, hypertension (high blood pressure), Alzheimer's disease, dementia, and depression. A review of Resident Census was completed and it was noted R18 was hospitalized on [DATE], however, R18's narrative notes lacked indication as to reason for transfer or what…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 document review, the facility failed to ensure nail care was provided for 2 of 5 residents (R20 and R26) Findings include: R20's 3/27/25, quarterly Minimum Data Set assessment identified he admitted to the facility in September of 2021, his cognition was severely impaired, and he was dependent on staff for activities of daily living (ADL)'s. R20 had diagnoses of Alzheimer's disease, cerebral palsy, bipolar disorder, and arthritis. Interview on 4/21/25 at 12:35 p.m., with family member (FM)-A reported she has asked the facility staff to clean and trim R20's nails several times. She states his nails look terrible. Observation on 4/21/25 at 12:36 p.m., of R20's nails on both hands were observed to be untrimmed and extended beyond the tip of his fingers with an unknown black substance observed under each nail from edge to edge. Observation on 4/22/25 at 1:23 p.m., of R20's nails identified they remained the same as above. Observation on 4/23/24 at 2:34 p.m., R20's nails remain overgrown with an unknown black substance under the nail of each finger.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 document review the facility failed to ensure the hospice plan of care had been integrated with the facility care plan for 1 of 1 resident (R)17 to delineate services provided between the facility and hospice. Findings include: R17's 2/20/25, significant change Minimum Data Set (MDS) identified his cognition was severely impaired, and he was dependent on staff for activities of daily living (ADL)s. R17 had diagnoses of Parkinson's disease, respiratory failure, and diabetes. Review of R17's current care plan identified he was on hospice. The care plan lacked any indication what services hospice was to provide during their visits to the facility. Interview on 4/24/25, at 5:05 p.m., with the nurse consultant identified she agreed with the above findings and would expect nursing staff to ensure the hospice care plan is integrated with the facility care plan. Review of the facilities 2017 Hospice Care policy identified residents receiving hospice services would have coordinated care plans that would include the most recent hospice plan of care and 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 document review, the facility failed to ensure pharmacy consultant recommendations were followed up on in a timely manner for 1 of 5 residents (R13) reviewed for pharmacy recommendations Findings include: R13's 3/12/25, quarterly Minimum Data Set (MDS) assessment identified his cognition was intact, he had no behaviors, and he was independent with activities of daily living (ADL)'s. R13 had diagnoses of adjustment disorder with depressed mood, hypertension, diabetes, anxiety, orthostatic hypotension, repeated falls, and stroke. Review of R13's pharmacy consultants monthly drug regimen review identified the following: 1. October 2024 pharmacy consultant recommendation: Please assess for continued use of divalproex 250 mg twice daily, CMS guidelines recommend periodic reassessment of psychotropic medication for trial dose reduction consideration in attempts to eventually discontinue unnecessary psychotropics or find lowest effective dose. If current dose is still appropriate for patient, please provide clinical rationale for continuing current dose in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure prescribed medications were labeled with current physician-ordered administration instructions to reduce the risk of administration error for 1 of 6 residents (R24) observed to receive medication during the survey. Findings include: R24's quarterly Minimum Data Set (MDS), dated [DATE], identified R24 had intact cognition with several medical diagnoses which included a medically complex condition, restless leg syndrome, muscle weakness, and difficulty walking. On 4/22/25 at 3:56 p.m., licensed practical nurse (LPN-A) was observed to prepare medications at a mobile medication cart in the hallway of the unit. R24 was in the hallway and approached the medication cart for medication administration. LPN-A proceeded to set up medications, including obtaining the med card for Tramadol from the locked box. LPN-A stated R24 received Tramadol HCl 50 mg one tablet every eight (8) hours, and this was given on a routine basis A review of the…

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

Based on observation, interview, and document review, the facility failed to assure cleanliness and monitoring of temps, and undated foods in 1 of 2 refrigerators in dining rooms, and 5 of 5 residents'(R7, R11, R13, R16, and R29) personal refrigerators located in resident rooms. Findings include: R16's 3/3/22, quarterly Minimum Data Set (MDS) assessment identified her cognition was intact, she had verbal behaviors towards others two-three days a week, and she was independent with meals and hygiene but required assistance with set up for dressing. R16 had diagnoses of morbid obesity, vascular disease, chronic kidney disease, adjustment disorder, and history of stroke. Observation on 4/22/25 at 5:03 p.m., of R16's room identified she had a small dorm style refrigerator. Inside the refrigerator she had 7 plastic containers with left over foods in them. The containers were not labeled and did not have dates on them. One container had tuna, one container had chicken, and one container had rice. The refrigerator also had condiments and cans of pop. The refrigerator did not have a log to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure 5 of 5 residents (R3, R8, R11, R13 and R19) reviewed for immunizations were offered and/or provided the pneumococcal vaccine series as recommended by the Centers for Disease Control (CDC) to help reduce the risk of associated infection(s). Findings include: A CDC Pneumococcal Vaccine Timing for Adults feature, dated 3/15/2023, identified various tables when each (or all) of the pneumococcal vaccinations should be obtained. This identified when an adult over [AGE] years old had received the complete series (i.e., PPSV23 and PCV13; see below) then the patient and provider may choose to administer Pneumococcal 20-valent Conjugate Vaccine (PCV20) for patients who had received Pneumococcal 13-valent Conjugate Vaccine (PCV13) at any age and Pneumococcal Polysaccharide Vaccine 23 (PPSV23) at or after [AGE] years old. R3's face sheet dated 3/6/24, indicated she was [AGE] years old. The immunization record dated 3/6/24, indicated she received a PPSV23…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 document review, the facility failed to ensure advanced directives for emergency care and treatment were accurately reflected in all areas of the resident's medical record to ensure residents wishes would be implemented correctly in case of an emergency for 1 of 17 residents (R15) reviewed for advanced directives. Findings include: R15's admission Minimum Data Set (MDS) dated [DATE], identified R15 had severe cognitive impairment and required assistance with all activities of daily living (ADL)'s. R15's diagnoses included cerebral infarction, coronary artery disease, heart failure, aphasia, hemiplegia/hemiparesis, depression, restless leg syndrome, muscle weakness, difficulty in walking, unspecified lack of coordination and abnormal posture. Review of R15's electronic medical record (EMR) identified the following: -R15's Order Summary Report identified Advance Directive: DNR (do not resuscitate) -R15's dashboard profile (viewed on computer screen) identified Advance Directive: DNR -R15's…

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

Based on interview and document review, the facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) to 1 of 3 residents (R94) reviewed whose Medicare A coverage ended and then remained in the facility. Findings include: R94's Centers for Medicare and Medicaid Services (CMS)-10123 signed as received on 10/23/23, identified a last covered day (LCD) of 10/23/23. R94's undated Census Records listing identified on 10/24/23, R94's payer source changed from Medicare Part A to Private Pay, and remained in the facility. R94's medical record was reviewed and lacked any evidence a SNFABN had been provided to explain the estimated cost per day or provide rationale or explanation of the extended care services or items to be furnished, reduced, or terminated. When interviewed on 03/05/24 at 4:16 p.m., the social services designee (SSD)-A stated she was responsible for providing the Medicare non-coverage notices within the facility but had missed providing the SNFABN to R94 at the time Medicare payment was ending. The SSD-A stated the importance of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to complete neurological assessments following falls for 2 of 3 residents (R15 and R21) who had unwitnessed falls. Findings include: R15's admission Minimum Data Set (MDS) dated [DATE], identified R15 had severe cognitive impairment and required assistance with all activities of daily living (ADL)'s. R15's diagnoses included cerebral infarction, coronary artery disease, heart failure, aphasia, hemiplegia/hemiparesis, depression, restless leg syndrome, muscle weakness, difficulty in walking, unspecified lack of coordination and abnormal posture. R15's record lacked evidence neurological assessments were initiated and completed after R15's unwitnessed falls on: 1/17/24, 1/19/24, 1/19/24, 1/25/24, 1/26/23, 2/1/24. 2/1/24, 2/8/24, 2/12/24, 2/13/24, and 2/23/24. R21's admission Minimum Data Set (MDS) dated [DATE], identified R21 had intact cognitive impairment and required assistance with all activities of daily living (ADL)'s. R21's diagnoses…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 document review, the facility failed to monitor orthostatic blood pressures with the use of an antipsychotic medication for 1 of 3 resident (R12) reviewed for unnecessary medications. Findings include: R12's quarterly Minimum Data Set (MDS) dated [DATE], identified R12 had moderate cognitive impairment and required assistance with activities of daily living (ADL)'s. R12's diagnoses included schizoaffective disorder, diabetes mellitus, seizure disorder, anxiety disorder, depression, bipolar disorder, and obsessive-compulsive disorder. R12's medication and treatment record, print date of 3/5/24, indicated R12 had a potential for psychotropic drug adverse drug reaction (ADR's) related to daily use of psychotropic medications, and included to monitor for postural hypotension (blood pressure drops when you go from lying down to sitting up, or sitting to standing). R12's physician orders included orders for Risperidone (antipsychotic) 2 milligram (MG) by mouth two times daily 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.

During a complaint survey exited on 9/21/23, the state survey agency cited deficiencies in the areas of safe functional sanitary/comfortable environment and sufficient nursing staff. While the facility was in substantial compliance on 4/27/23, the Quality Assurance and Performance Improvement (QAPI) program committee was unable to sustain compliance as evidence by the following repeated deficiencies: Findings include: F725- Based on observation, interview and document review the facility failed to provide sufficient nursing staff to meet assessed needs for 5 of 5 residents (R8, R1, R29, R5 and R23) reviewed for activities of daily living (ADLs); quality of care for 1 of 1 (R35) residents reviewed for nursing assessement; 9 of 9 residents (R7, R10, R11, R15, R16, R17, R18, R22 and R25) reviewed for supervision in a memory care unit; RN coverage; and as expressed by Resident Council, Staff, and 2 family members (FM-D and FM-E) who had concerns about the lack of sufficient nursing staff at the nursing home. F921- Based on observation, interview, and document review, the facility failed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 document review the facility failed to provide sufficient nursing staff to meet assessed needs for 5 of 5 residents (R8, R1, R29, R5 and R23) reviewed for activities of daily living (ADLs); quality of care for 1 of 1 (R35) residents reviewed for nursing assessement; 9 of 9 residents (R7, R10, R11, R15, R16, R17, R18, R22 and R25) reviewed for supervision in a memory care unit; RN coverage; and as expressed by Resident Council, Staff, and 2 family members (FM-D and FM-E) who had concerns about the lack of sufficient nursing staff at the nursing home. Findings include: ASSESSED NEEDS NOT MET: R1's significant change Minimum Data Set (MDS) dated [DATE], indicated R1 was moderately cognitively impaired, required extensive assist of two with bed mobility and total assist of two with transfers. The MDS indicated R1 had limited mobility in upper and lower extremity and used a wheelchair for mobility. R1's care plan dated 8/17/23, identified R1 was bariatric had peripheral vascular…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 document review the facility failed to take immediate action to prevent further potential violations, immediately report alleged violations, ensure written grievance documentation decisions to included; dates, grievance summary, investigation summary, statements, findings, action taken, conclusion, and communication by facility for 1 of 1 resident (R7) who was alleged to have not received staff care for an extended period of time and filed a grievance with facility. Findings include: R7's quarterly MDS dated [DATE], indicated R7 was severely cognitively impaired had Alzheimer's disease, dementia, anxiety, and depression. R7's Care Plan dated 8/23/23, indicated R7 requires assist of two with activities of daily living, requires two person assist with toileting and peri-care with every incontinent episode as necessary. During interview on 9/12/23 at 8:12 p.m., family member (FM)-F stated she had a camera put in R7's room two to three months ago due to noticing bed wetting and had concerns…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 document review, the facility failed to ensure allegations of neglect was reported immediately, within two hours, to the State Agency (SA) for 1 of 1 resident (R7) who was alleged to have not received staff care for an extended period of time. Findings include: R7's quarterly MDS dated [DATE], indicated R7 was severely cognitively impaired had Alzheimer's disease, dementia, anxiety, and depression. R7's Care Plan dated 8/23/23, indicated R7 requires assist of two with activities of daily living, requires two person assist with toileting and peri-care with every incontinent episode as necessary. Review of facility Resident Grievance Form's on R7 indicated the following: -On 8/18/23 Resident Grievance Form filled out by FM-F indicated, R7 was changed on 8/17/23 at 8:00 p.m. to 8:30 p.m. and not again until 8/17/23 in the morning she was not touched or changed for nine hours. The grievance form further indicated FM-F stated this was very concerning because she could have fell or passed away…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 document review the facility failed to thoroughly investigate allegations of neglect for 1 of 1 residents (R7) who was alleged to have not received staff care for an extended period of time. Findings include: R7's quarterly MDS dated [DATE], indicated R7 was severely cognitively impaired had Alzheimer's disease, dementia, anxiety, and depression. R7's Care Plan dated 8/23/23, indicated R7 requires assist of two with activities of daily living, requires two person assist with toileting and peri-care with every incontinent episode as necessary. During interview on 9/12/23 at 8:12 p.m., family member (FM)-F stated she had a camera put in R7's room two to three months ago due to noticing bed wetting and had concerns she was not getting changed after incontinent episodes of bowel and bladder. FM-F stated she had filled out a grievance forms and gave them to the director of nursing (DON) and the administrator and received no follow up on any of them. FM-F stated the only thing she noticed was 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 document review the facility failed to provide timely incontinence care for 1 of 1 residents (R8) and bathing as care planned for 4 of 4 residents (R1, R29, R5 and R23) who were dependent upon staff for assistance with activities of daily living (ADL). Findings include: R8's annual MDS dated [DATE], indicated R8 was cognitively intact, needed extensive assist of two with toileting and always incontinent of bowel and bladder. The MDS further indicated she was not on a toileting plan. R8's Care Plan dated 9/08/23, indicated R8 needed assist of one with toileting, provide peri-care with every incontinent episode as necessary. During observation and interview on 9/11/23 at 4:50 p.m., licensed practical nurse (LPN)-B stated R8 was last checked and changed at 1:50 p.m. and on the evening shift they like to toilet her every two hours or she was usually very wet with urine. LPN-B stated they only have two nursing assistants (NA) working on the floor and they are both very busy. LPN-B…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 document review, the facility failed to assess 1 of 1 resident (R35) for change of condition upon family request. Findings include: R35's significant change Minimum Data Set (MDS) dated [DATE], indicated diagnosis of severe cognitive impairment, atrial fibrillation, coronary artery disease, end stage renal disease and hypertension. The MDS indicated R35 required extensive assist of two with dressing, bathing, and grooming. R35's care plan dated 7/15/23, indicated at risk for fluid overload, chest pain, weakness and cardiovascular disease. The care plan directed staff to monitor for increased blood pressure, shortness of breath, signs of acute renal failure and to monitor/document and report to the physician. The care plan also indicated R25 had a staph infection to his right knee and was on antibiotics. During interview on 9/11/23 at 7:05 p.m., family member (FM)-B stated on 8/25/23, R35 was not acting like himself and was very confused and was normally alert. FM-B stated R35 stated to her…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to assess, develop and implement a person centered dementia care treatment plan for 1 of 2 residents (R10) reviewed who had behaviors related to dementia and multiple resident to resident abuse incidents. Findings include: R10's significant change Minimum Data Set (MDS) dated [DATE], indicated R10 had dementia and was severely cognitively impaired, had physical, verbal, and other behavioral symptoms such as hitting toward others or scratching and pacing. The MDS indicated rejection of care and wandering. R10's care plan dated 8/22/23, indicated R10 had potential for episodes of alteration in mood as evidenced by persistent anger with staff or others, unrealistic fears, sad, crying and hallucinations and delusions. The care plan directed for behavioral psychological consults as indicated, monitor document mood to determine external cause, observe for signs of depression, hopelessness, mania, hypomania, increased irritability, frequent mood…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 document review, the facility failed to ensure an antiparkinson medication was administered in accordance with physician orders for 1 of 1 residents (R5) who was provided Carbidopa-Levodopa (assists to relieve Parkinson's disease symptoms) outside of ordered parameters during a medication pass observation. Findings include: R5's quarterly Minimum Data Set (MDS), dated [DATE], indicated R5 was moderately cognitively impaired with a diagnosis of dementia and Parkinson's. R5's Order Recap Report identified R5 was ordered the following: -Carbidopa-Levodopa 25/100 mg (milligrams), give two tablets by mouth before meals related to Parkinson's Disease. 1 hour prior to MEALS. R5's September Medication Administration Record (MAR) identified the carbidopa-levodopa was scheduled for AM Pa (morning medication pass), Noon, and PM Pa (evening medication pass). During a medication pass observation on 9/18/23 at 12:15 p.m., registered nurse (RN)-A reviewed R5's electronic MAR (eMAR) orders,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 document review, the facility failed to fix damaged tile, leaking shower, broken tub in Maple Lane (the only tub that was working in the entire facility). The facility received a citation for this on 3/23/23, and the citation still remains un-fixed. This had the potential to affect all 34 residents who resided in the facility who potentially would use the Maple Lane shower/tub room. Findings include: R19's quarterly minimum data set (MDS) dated [DATE], indicated R19 was cognitively intact, required limited assistance with personal hygiene and assist of one with bathing. During interview on 9/13/23 at 5:35 p.m., R19 stated she has not received her shower in the past few days and has not received a bath and it would feel really nice to have a bath if the facility had a bathtub. R5's quarterly MDS dated [DATE], indicated R5 was moderately cognitively impaired required extensive assist with ADL's and one person physical assist with bathing. During interview on 9/13/23 at 5:40…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 document review the facility failed to implement a comprehensive care plan for 1 of 1 resident's (R192) reviewed for accidents. Findings Include: Significant change Minimum Data Set (MDS) dated [DATE], identified R192 was cognitively intact and was able to clearly communicate needs and wishes. Further, R192 required extensive assistance of two or more persons for her activities of daily living (ADL's) including bed mobility, transfer, and toileting. R192's care plan revised on 12/27/22, identified self-care deficit requiring assistance with ADL's, and non-weight bearing to left lower extremity, The care plan indicated R192 required two persons assistance for toileting, transfers, bathing, and showering. The Nursing Home Incident Report (NHIR) read as follows: the care plan was being followed correctly at the time of the incident/event. However, the NHIR also read C.N.A took resident to her room after supper. They were doing her normal routine of getting ready for bed brushed teeth 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.