Ladera Center

Based on record review and interview, the facility failed to ensure 1 (R #107) of 1 (R #107) resident was treated with respect and dignity when the facility failed to ensure that R #107 was not put to bed at night with her shoes on and fully clothed.This deficient practice is likely to result in residents feeling as if they were unimportant and that their preferences do not matter. The findings are: A. On 01/21/23 at 12:40 pm during an interview with R #107's sister (FM) #1, she stated she had been told by her sister (R #107) that she had been put to bed a fully clothed and with her shoes on and she had been upset about it. FM #1 stated that her sister (R #107) likes to be put to bed in her pajamas every night. FM #1 thought this was a concern and her sister was upset that is why she brought it to the facilities attention. B. Record review of R #107's care plan dated 10/02/24 revealed: it is important that she (R #107) has the opportunity to engage in daily routines that are meaningful relative to her preferences. Intervention: It is important for me to choose what clothing 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 record review, and interview, the facility failed to complete an accurate Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) assessment for 1 (R #132) of 1 (R #132) resident reviewed for assessments. This deficient practice could likely result in the residents' preferences and care needs not being met.The findings are:A. Record review of R #132's facesheet revealed she was admitted on [DATE] and discharged to community on 04/15/23 with the following diagnoses (including but not limited to): 1. Unspecified intracapsular fracture of right femur (a type of bone fracture that occurs within the joint capsule, often affecting the hip). 2. Type 2 diabetes mellitus (condition in which the body [NAME] use insulin correctly and sugar builds up in the blood) without complications. 3. Systemic lupus erythematosus (an autoimmune disease in which the body's immune system mistakenly attacks its own healthy cells and tissues, leading to inflammation and damage in various…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide an ongoing program of activities designed to meet the interests for 1 (R #11) of 6 (R #11, R #12, R #48, R #118, R #122, and R #131) residents reviewed for activities by not providing meaningful individualized activities based upon residents' interests. If residents are not provided or encouraged to attend/participate in activities that meet their interests, then they are likely to experience an increase in boredom, isolation, and depression. The findings are: A. Record review of R #11's admission record, no date revealed an admission date of 10/02/25 with the following diagnoses: 1. Hemiplegia and Hemiparesis following Cerebral Infarction affecting left dominant side (is a symptom that involves one-sided paralysis. A left-sided stroke is a stroke that damages the left side of the brain). 2. Essential (primary) Hypertension (high blood pressure, is a common condition where the force of blood against the artery walls is consistently too high).…

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

Based on record review, and interview, the facility failed to meet the professional standards of practice required to prevent skin breakdown for 1 (R #132) of 1 (R #132) resident reviewed for skin assessments when the facility failed to:Ensure a Braden Scale assessment was completed upon admission-Accurately utilize standardized tools such as the Braden Scale (nursing assessment tool used to estimate a patient's risk of developing pressure injuries (pressure ulcers)).-The lack of documented off-loading (Offloading is crucial for preventing pressure ulcers, particularly in individuals with limited mobility or those confined to a bed or wheelchair. By redistributing pressure away from vulnerable areas, offloading helps mitigate the risk of pressure ulcer development) coccyx (tailbone, the last bone at the end of the spine) directly contributed to the tissue necrosis (death of body tissue).These deficient practices led to the development of pressure injury to the coccyx area.The findings are:A. Refer to F0641 for related findings.B. Record review of R #132's Electronic Medical Records…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 preferences were honored for 1 (R #104) of 1 (R #104) resident reviewed when:-the facility served green peas despite the resident's dietary profile indicating a preference for no peas.The findings are: A. Record review of R #41's facesheet revealed she was admitted on [DATE] with the following diagnoses (including but not limited to): 1. Parkinson's Disease (progressive neurodegenerative disorder that primarily affects movement and is characterized by symptoms such as tremors, stiffness, and balance difficulties) with dyskinesia (involuntary or uncontrolled movements of the body, which can range from mild tremors to severe, erratic motions). 2. Presence of intraocular lens (artificial lens implanted in the eye to replace the natural lens). 3. Presbyopia (the gradual loss of your eyes' ability to focus on nearby objects). B. On 01/27/26 at 12:40 pm, during on observation in the dining room, R #104 was served beef chili…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 stored foods are not left open to air.Ensure staff wore beard nets in the kitchen. These deficient practices are likely to affect all 107 residents listed on the census provided by the Administrator on 05/12/25 and may lead to foodborne illnesses in residents if proper food storage and safe food handling practices are not adhered to.The findings are: A. On 01/20/26 at 12:13 pm during an observation of the kitchen revealed one ten-pound box of frozen hamburger patties stored in freezer open to air.B. On 01/20/26 at 12:15 pm during an interview, Dietary Manager (DM) confirmed the ten-pound box of frozen hamburgers was open to air and should not have been left open.C. On 01/27/2026 12:27 pm during an observation of the kitchen revealed that Dietary Aide (DA) #1 was not wearing a beard guard and was serving lunch.D. On 01/27/26 at 12:38 am during an interview, the DM confirmed that DA #1 was not wearing a beard guard and stated that he should have been.

Based on observation and interviews, the facility failed to ensure the facility had sufficient staff to meet the needs of all 110 residents who resided in the facility when staff failed to: 1. Offer baths or showers to the residents as scheduled and per residents' preference. 2. Offer substantial/maximal eating assistance for residents that require activities of daily living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating) assistance. 3. Maintain fingernail length and cleanliness for residents who are dependent on the facility for ADL's. 4. Maintain dignity of residents who are dependent on the facility for ADLs. These deficient practices are likely to affect the comfort, dignity and health of the residents. The findings are: A. Refer to F0658 and F0677 for related findings. B. On 05/01/25 at 3:44 pm during an interview with Certified Nursing Assistant (CNA) #1, she stated the facility needs extra staff to complete daily tasks. She stated there isn't always enough staff to help with the Hoyer (resident moving device)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 that meals were served to residents at the posted serving times (Breakfast 7:30 am, Lunch 12:30 pm and Dinner 5:30 pm). This deficient practice is likely to result in the disruption of residents' dining experience. The findings are: A. On 05/01/25 at 9:49 am during initial walkthrough of the dining room and kitchen, lunch time was posted to be served at 12:30 pm. B. On 05/01/25 at 10:06 am during an interview with R #13, she stated that breakfast, lunch and dinner trays are always late. C. On 05/01/25 at 11:03 am during an interview, R #13 stated breakfast comes out late, sometimes at 9:00 am. Lunch comes to the rooms at 1:45 pm and dinner comes to the rooms at 6:45 pm. D. On 05/01/25 at 12:36 pm during an observation of lunch time in the dining room, the first resident meal tray was served at 12:51 pm. The last resident meal tray was served at 1:11 pm. E. On 05/01/25 at 1:15 pm during an observation of lunch time, the first lunch trays were delivered to north hall from kitchen. The Certified Nurse Aid (CNA)'s started…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to conduct an in-depth investigation and correct the grievance allegation for 2 (R #13 and 14) of 2 (R #13 and 14) residents reviewed for the outcomes and resolutions of their grievances. This deficient practice could likely result in the facility not considering the needs of the residents or adequately resolving their grievances and could likely lead to a decrease in resident quality of life. The findings are: A. Record reveiw of the facility's policy dated 10/15/24 regarding resident grievances. The policy stated in brief: -Resident/patients have the right to voice grievances to the center or other agency without fear of discrimination or reprisal. Service location (the facility residence of the resident/patient) will inestigate, document and follow up on all concerns and grievances registered by any patient or patient representative. Social services personnel will serve as patient advocates. The facility administrator will serve as the Grievance…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview, the facility failed to provide showers, eating assistance, skin assessments and grooming care for 1 (R # 5) of 1 (R #5) resident when the facility failed to assist resident with ADL (Activities of Daily Living) care in accordance with Physician approved POC (Plan of Care). This deficient practice is likely to affect the dignity, health and comfort of the residents. The findings are: A. Record review of R #5's face sheet revealed R #5's was admitted on [DATE]. B. Record review of R #5's plan of care dated 04/03/25, revealed R #5 requires assistance/is dependent for ADL care. Dependent care includes: bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, and toileting. Facility interventions are: -Provide resident with substantial/maximal assistance for personal hygiene. -Provide resident with substantial/maximal assistance for showering/bathing. -Provide resident with substantial/maximal assistance for oral hygiene. -Provide R…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide activities of daily living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating) assistance for baths and showers by the facility staff for 2 (R #5 and R #12) of 2 (R #5 and R #12) residents reviewed for ADLs (activities of daily living). This deficient practice is likely to affect the dignity and health of the residents. The findings are: R #5 A. Record review of R #5's face sheet revealed R #5 was admitted on [DATE] with the following diagnoses: -Epilepsy, (a brain condition that causes recurring seizures). -Multiple Sclerosis, (the immune system attacks the protective sheath that covers nerve fibers). Symptoms include: lack of coordination, loss of muscle control, weakness, loss of bladder and or bowel control. -Hemiplegia, (paralysis of muscles of the lower face, arm, and leg on one side of the body). -Unspecified dementia, (a group of symptoms dealing with affecting memory, thinking…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure residents had a written, signed, and dated progress note from their physician after each visit for 3 (R #'s 4, 7 and 8) of 3 ( R #'s 4, 7 and 8) residents reviewed for current physician progress notes and documentation. This deficient practice is likely to result in resident's records being incomplete and resident care not being documented and reviewed. The findings are: R #4 A. Record review of R #4's face sheet dated 05/05/25 revealed she was admitted to the facility on [DATE] with the following diagnoses: -Cerebral Infarction (stroke). -Dysphagia (difficulty swallowing). -Epilepsy (a chronic condition that is characterized by seizures). The face sheet also states that R #4's primary care provider is a Medical Doctor (MD) who is part of a local primary care service (PCS) that is not associated with the facility. The face sheet further revealed that R #4 was discharged on 03/06/25 due to her death. B. Record review of R #4's electronic medical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide quality of care for 1 (R #4) of 3 (R #'s 4, 7, and 8) residents reviewed for change in condition when care was not provided in a timely manner. This deficient practices likely resulted in worsening condition and unnecessary discomfort for the residents. The findings are: A. Record review of R #4's face sheet revealed she was admitted to the facility on [DATE] with the following diagnoses: -Cerebral Infarction (stroke). -Dysphagia (difficulty swallowing). -Epilepsy (a chronic condition that is characterized by seizures). The face sheet also confirmed that R #4's primary care provider is a Medical Doctor (MD) who is part of a local primary care service (PCS) that is not associated with the facility. B. Record review of R #4's daily care notes revealed the following: -03/01/25 at 5:26 pm, R #4 is reported to have chills, a measured body temperature of 99 degrees (normal body temperature is 98.6) and a cough. The reporting nurse indicated she…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to effectively manage pain for 1 (R #1) of 1 (R #1) resident reviewed for pain when staff did not provide pain treatment. This deficient practice likely resulted in R #1 experiencing long periods of pain without sufficient relief. The findings are: A. Record review of R #1's face sheet revealed R #1 was admitted into the facility on [DATE]. B. Record review of R #1's physician orders revealed the following: 1. 01/29/25: Acetaminophen 325 MG (milligram) every six hours as needed. Notify physician/midlevel provider if discomfort persists. 2. 01/29/25: Lidocaine External Cream 4 % (percent) every twenty four hours for pain (one patch each shoulder). 3. 04/21/25: Oxycodone 5 MG every six hours as needed for pain for two weeks (on hold as of 05/02/25) 4. 05/01/25:Acetaminophen 325 MG (milligram) every six hours. 5. 05/02/25: Excedrin Migraine Oral Tablet 250-65 MG, give two tablets by mouth only for one day. C. Record review of R #1's nursing progress notes…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 serve food under sanitary conditions when staff did not use proper handling techniques of glasses, bowls, and drinks while distributing meals to residents in the dining room. This deficient practice is likely to affect all 117 residents listed on the resident census list provided by the administrator on 10/21/24; and could likely lead to foodborne illnesses in residents if safe food handling practices are not adhered to. The findings are: A. On 10/21/24 at 12:56 pm during an observation of the lunch meal service revealed an activity staff member assisted with meal service to the residents. The activity staff handled the resident's cups and and bowls by the rims. He did not perform hand hygiene between serving the resident trays. Observation revealed that these residents consumed these food and beverages. B. On 10/21/24 at 12:59 pm, an observation of the lunch meal service revealed an unknown female staff member assisted with meal service to the residents. The unknown staff handled resident bowls of food with her thumb…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 observation the facility failed to ensure staff served meals that were attractive and palatable (pleasant to taste) for 3 (R #'s 10 , 52, and 54) of 5 (R #'s 10, 52, 54, 97 and 107) residents reviewed for meal quality. This deficient practice reduces residents' ability to eat and enjoy meals, may decrease their quality of life, and could likely lose weight. The findings are: R #10 A. On 10/22/24 at 3:31 pm, during an interview, R #10's Power of Attorney (POA; legal authorization for a designated person to make decisions about another person's property, finances, or medical care) stated she witnessed on numerous occasions while visiting with R #10, staff delivered the resident's food being last and cold. She stated R #10 often did not eat because the food was unrecognizable and tasted horrible. B. On 10/23/24 at 2:40 pm, during an interview, R #10 stated his meals were often cold by the time staff served him. He stated staff forget to deliver his meals to his room on several occasions. He stated he ate all his meals in his room. R #52 C. On 10/23/24 at 10:04 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure care plans included comprehensive medical history information for 1 (R #112) of 1 (R #112) residents reviewed for comprehensive care plans. This deficient practice could likely result in staff not understanding and implementing the needs and treatments of residents. The findings are: A. Record review of R #112's facesheet revealed R #112 admitted to the facility on [DATE] with the following list of diagnoses (not all-inclusive): -Diabetes mellitus (a chronic disease in that occurs when the body is unable to control blood sugar levels). -Sepsis (a life-threatening extreme immune system response to infection or injury which can cause inflammation, blood clots, and damaged blood vessels reducing the blood flow and oxygen delivered to the body's organs). -Acute respiratory failure (inability to maintain adequate oxygenation in the body). -Atrial fibrillation (Afib: a type of irregular heartbeat that occurs when the electrical signals in the heart'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 record review, the facility failed to ensure that activities of daily living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating) were maintained for 1 (R #10) of 3 (R #'s 10, 97, and 107) residents sampled for ADLs when staff failed to provide assistance with toileting needs for R #10 when staff told him to use the restroom in his brief instead of assisting him up to the toilet. This deficient practice could likely result in residents' experiencing a decline in their ability to perform activities of daily living (ADLs) and to feel embarrassed and undignified. The findings are: A. Record review of the face sheet for R #10 dated 09/28/24, revealed an initial admission date of 09/20/2011 and included the following diagnoses: -Orthopedic aftercare following surgical amputation, -Dehiscence of amputation stump (condition where the wound along the surgical line opens up), -Morbid obesity (severely overweight), -Need for assistance with personal care, -Limitation of activities due to disability, -Acquired…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 follow dietary orders regarding food allergies for 1 (R # 77) of 1 (R #77) resident reviewed with food allergies. This failure had the potential to affect residents with food allergies. This deficient practice could likely cause a resident to have a medical emergency due to food allergies. The findings are. A. On 10/22/24 at 10:00 am, during an interview with R #77, she stated she had received a strawberry banana yogurt today (10/22/24) and another time she received strawberry banana yogurt. On 10/02/24, R #77 stated that she got an actual banana with her meal. R #77 stated she is worried that she could be in danger as she has a banana allergy, even if it is banana-flavored. R #77 stated the allergy is documented on her meal ticket. Although she avoids eating bananas, she finds it strange that she still experiences allergic reactions to food containing banana flavor. She confirmed that she has photographic evidence from the three days she received…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure there was enough staff available to operate a Hoyer lift (mechanical device used to transfer patients from one surface to another) for 2 (R #1 and R #3) of 3 ( R #1, R #3, and R #4) residents reviewed for Hoyer lift usage. This deficient practice could likely result in residents experiencing issues while being transferred, including being bumped into walls, developing bruises, and feelings of frustration. The findings are: A. Record review of NM complaint #73644 revealed family member of R #1 reported . Staff that use the Hoyer lift to transfer her mother and are too rough with her. They also only use one person to transfer her while using the hoyer lift. As a result, the staff push on her mother while transferring her and not using the Hoyer which has left her mom with bruising . B. Record review of R #1's face sheet revealed R #1 was admitted to the facility on [DATE] with the pertinent diagnosis of morbid obesity (a disorder that involves…

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

Based on observation and interview, the facility failed to provide a comfortable, homelike environment for 2 (R #5 and R #7) of 3 (R #5, R #6, and R #7) residents reviewed for resident rights by failing to ensure the hallway remained free of a persistent urine smell. This deficient practice could lead to residents feeling disrespected, uncomfortable, and embarrassed. The findings are: A. On 03/19/2024 at 9:45 AM during an observation, the facility's north hallway near the nurse's station had a strong smell of urine. B. On 03/19/2024 at 11:05 AM during an interview with R #5, she stated the hallways of the facility always smelled like urine, and it got much stronger on the weekends. She stated it felt gross to smell that. C. On 03/19/2024 at 1:29 PM during an interview with R #7's family member, she stated, that during R #7's stay at the facility from 02/24/24 to 03/07/24, there was constantly a very strong smell of urine and feces in the facility, especially on the right (north) hall. She added she and her family member felt very uncomfortable and disgusted by the smell. D. On…

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

Based on observation, interview, and record review, the facility failed to provide an activities program designed to meet the interest and preferences of each resident for 3 (R #4, R #5, and R #6) of 3 (R #4, R #5, and R #6) residents reviewed for activities. This deficient practice could result in residents feeling less connected to their peers, having lower self-esteem, and experiencing a decline in psychosocial well-being. The findings are: R #4 A. Record review of R #4's Recreation Comprehensive Assessment, dated 11/15/2023, revealed the resident felt it was very important that he participated in his favorite activities, but the assessment did not include a list of the resident's preferred activities. B. On 03/19/2024 at 9:55 AM, an observation of the facility's day room revealed a large whiteboard where staff list the current month's activities. Further observation revealed the whiteboards was blank. C. On 03/19/2024 at 10:16 AM during an interview, R #4 stated he enjoyed socializing with other residents, but he did not know when or what the next group activity would be. He…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to: 1. Monitor blood sugar levels, and; 2. Notify the physician when a resident's blood sugar dropped below 70 milligrams (mg) / decilitre (dL; A blood sugar reading below 70 mg/dL is considered low and dangerous. A a normal level is 90 to 130 mg/dL.) This deficient practice affected 2 ( R #6 and R #11) of 3 (R #6, R #8, and R #11) residents reviewed for diabetic management. This deficient practice could likely result in residents feeling physically ill and unsatisfied with the care received. The findings are: Findings for R #11: A. Record review of R #11's face sheet revealed R #11 admitted to the facility on [DATE] with the pertinent diagnosis of type 2 diabetes mellitus (a condition in which the body has trouble controlling blood sugar and using it for energy) with hyperglycemia (when blood sugar falls below a healthy level). Further review revealed R #11 discharged on 01/18/24. B. Record review of a grievance submitted by R #11's husband, dated…

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

Based on record review and interview, the facility failed to prevent resident-to-resident physical abuse and to protect multiple residents from physical altercations for 2 (R #3 and 4) of 3 (R #3, 4 and 6) residents reviewed for abuse. This deficient practice could likely result in residents feeling unsafe in their home. The findings are. A. Record review of a complaint submitted to the state agency on 09/15/23 alleged that R #3 was targeted during smoking breaks and experienced repeated physical assaults by R #4. B. Record review of the nursing progress note for R #3, dated 01/19/23 at 12:18 am, revealed R #4 slapped R #3 while smoking outside of the facility. R #3's right cheek was red and tender after slap. Staff rechecked an hour or so after incident and did not note any redness. C. Record review of the nursing progress note for R #3, dated 06/22/23 at 6:17 am, revealed R #3 reported being hit in the face by another resident (R #4), because she would not give him a cigarette. Resident's left cheek was reddened at time of the incident. D. Record review of the nursing progress…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility failed to: 1. Serve food according to the presented menu; 2. Communicate menu changes with residents; 3. Follow Dietary Orders regarding food allergies. These deficient practices have the potential to affect all residents listed on the census presented by the Center Executive Director on 08/27/23 and could likely result in resident frustration and/or dissatisfaction with meal options and having a medical emergency due to food allergies. The findings are: A. On 08/28/23 at 10:14 am, during an interview, R #94 stated, They always change the menu at the last minute. B. On 08/30/23 at approximately 3:15 pm, during an interview, R #87 stated, What is on the menu is not what is being served frequently, and they are not informed when the menu changes. She further stated sometimes the next days' menu is not available for them, and they often do not know what they are getting until it is served. C. On 08/31/23 at 9:31 am during an interview, Dietary Manager…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and interview, the facility failed to serve food under sanitary conditions by: 1. Not dating food packages in reach-in refrigerator and walk-in refrigerator and freezer; 2. Not using proper handling techniques of glasses, bowls and drinks while distributing meals to residents in the dining room; and 3. Not storing or not disposing individual salsa and individual butter servings, after meal service. These deficient practices are likely to affect all 117 residents listed on the resident census list provided by the Administrator on 08/27/23; and could likely lead to foodborne illnesses in residents if safe food handling practices are not adhered to. The findings are: A. On 08/27/23 at 5:02 pm, during the initial tour of the kitchen, an observation of the walk-in freezer and walk-in refrigerator revealed the following: 1. Five bags of undated 40 ounce (oz) corn in freezer, 2. One undated bag of whole California 32 oz blend vegetable; 3. One undated, opened bag of blueberries, 4. One ear of corn…

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

Based on record review and interview, the facility failed to ensure that residents or the guardians were aware of and understood the risks and benefits of medication and the reason they were receiving the medications for 2 (R #63 and R #67) of 3 (R #2, R #63, R #67) residents reviewed for unnecessary medications. If the residents or their guardians are not informed of the risks of benefits of the medication, they are not able to make informed decisions. The findings are: R #63 A. Record review of R #63's physician's orders revealed: 1. Order start date of 01/28/23. Fluoxetine HCI (used to treat major depressive disorder). 40 MG (milligrams). Give one capsule by mouth at bedtime for depression, tearfulness, and feelings of hopelessness. 2. Order start date of 03/31/23. Depakote (used for bipolar disorder-a mental health condition that causes extreme mood swings) tablet delayed reaction. 500 MG. Give one tablet by mouth two times a day for delusion (false belief that conflicts with reality) with agitation (state of excitement, disturbance or worry). B. Record review of R #63's medical…

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

Based on observation and interview the facility failed to safeguard (secure or protect) clinical record information by leaving Protected Health Information (PHI) unattended. This deficient practice has the potential to affect all 25 residents residing on the south middle hall (residents were identified by the Resident Census List provided by the Administrator on 08/27/23). If resident's clinical information is not adequately safeguarded, resident's PHI is likely to be accessed (obtained or examined) by unauthorized (not having permission or approval) residents, visitors, and/or staff. The finding are: A. On 08/28/2023 at 12:54 PM, observation revealed Registered Nurse (RN) #2 walked away from the south middle hall medication cart and into a resident's room to deliver medications. RN #2 left the computer unlocked with residents' identities visible and accessible. B. On 08/28/23 at 1:00 PM, during an interview, RN #2 stated they should lock their medication cart and computer whenever they leave their cart.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview, the facility failed to accurately complete the Minimum Data Set (MDS - assessment tool used to facilitate resident care in nursing homes) of 3 (R #22, R #94 and R #225) of 4 (R #22, R #94, R #224 and R #225) residents reviewed for current and up-to-date comprehensive assessments of residents. The facility failed to comply with the requirement to thoroughly assess and plan care for the residents by not completing the MDS in a timely manner. This deficient practice is likely to result in residents not receiving the optimal care needed to live and thrive within their environment. The findings are: Findings for R #22: A. Record review of R #22's face sheet, dated 03/28/23, revealed an initial admission date of 03/28/23 and a discharge date of 07/31/23. B. Record review of R #22's MDS log revealed staff completed the Entry MDS on 03/28/23, the admission MDS completed on 04/03/23, and the Discharge MDS completed on 07/31/23. The completed Quarterly MDS was due by…

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

This is a repeat deficiency. Based on observation, record review, and interview, the facility failed to revise the care plan for 2 (R #55 and R #94) of 2 (R #55 and R #94) residents reviewed for care plan revisions. This deficient practice could likely result in staff being unaware of residents' healthcare care needs, durable medical equipment (a medically necessary device that helps improve residents' quality of life) needs, and may present safety hazards (objects or situations that could cause harm, injury or illness). The findings are: Findings for R #55: A. Record review of R #55's electronic medical record (EMR) revealed the following diagnoses related to mobility (ability to move freely and easily): - Hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke) affecting left non-dominant side, - Acquired absence of right leg below knee [amputation (surgical removal) of the right leg leaving the knee in tact], - Acquired absence of left leg below knee [amputation (surgical removal) of the left leg…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to provide activities to promote the mental and psychosocial well-being for 2 (R #23 and R #43) of 9 (R #23, R #29, R #34, R #40, R #43, R #46, R #50, R #52, and R #62) residents reviewed for activities. This deficient practice has the potential to result in residents becoming depressed and feel like they have no quality of life. The findings are: R #23 A. Record review of R #23's facility face sheet revealed initially admitted to the facility on [DATE] with a diagnosis of: - Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement, chiefly affecting middle-aged and elderly people); - Dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain) in other diseases classified elsewhere, moderate…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview, the facility failed to offer sufficient fluid for hydration (the replacement of body fluids lost through sweating, exhaling, and eliminating waste) for 1 (R #23) of 1 (R #23) resident sampled for hydration. This deficient practice could likely result in the resident feeling dehydrated (occurs when a person uses or loses more fluid than taken in, and the body doesn't have enough water and other fluids to carry out its normal functions), the body lacking adequate hydration for highest practicable well-being, and low blood pressure. The findings are: A. Record review of R #23's facility face sheet revealed initially admitted to the facility on [DATE] with a diagnoses of: - Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement, chiefly affecting middle-aged and elderly people), - Dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially…

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

Based on observation, record review, and interview, the facility failed to meet professional standards of care for 6 (R #9, R #17, R #75, R #88, R #111, and R #279) out of 6 (R #9, R #17, R #75, R #88, R #111, and R #279) residents reviewed for respiratory care by: 1. Not properly dating and monitoring the oxygen delivery tubing for residents and not dating the humidifier bottle (bottle of water that provides water to the oxygen to prevent the air from being too dry) for residents; 2. Not ensuring that R #9 had his oxygen (O2) machine turned on and the tubing was placed in his nostrils and that R #75 had his O2 tubing in his nostrils and; 3. Not providing written physician orders for the administration of oxygen therapy for R #279. These deficient practices could likely lead to hypoxia (decreased oxygen to the body) and/or could likely lead to respiratory infections by the oxygen tubing becoming clogged due to condensation (process where water vapor becomes liquid), or becoming dirty leading to the reduced flow of oxygen. The findings are: R #88: A. On 08/27/23 at 8:08 PM, R# 88 was…

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

Based on interview and record review, the facility failed to ensure ongoing communication and collaboration with the dialysis (clinical purification of blood as substitute for normal kidney functioning) facility regarding dialysis care and services for 1 (R #55) of 1 (R #55) resident reviewed for dialysis. If the facility is unaware of residents status, current condition, or any barriers or complications, then residents are likely to not receive the appropriate monitoring and care they need. The findings are: A. Record review of the medical record for R #55 indicated the resident went to dialysis on Tuesdays, Thursdays, and Saturdays. B. Record review of the care plan, dated 04/14/22, indicated R #55 had impaired renal function and was at risk for complications related to hemodialysis, renal insufficiency. One of the interventions on the care plan indicated to send communication book to dialysis and review book upon return. C. Record review of the physician orders indicated the following: Post Dialysis Weight: Enter post dialysis weight from dialysis communication sheet when…

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

Based on record review and interview, the facility failed to provide a drug regimen (prescribed systematic form of treatment) that was free from unnecessary psychotropic medication (psychotropic medication is a type of medication that affects the mind, emotions) by not responding to the pharmacy recommendations for 2 (R #9 and R #63) of 6 ( R #9, 11, 31, 35, 63 and 224) residents reviewed for unnecessary medication. This deficient practice could likely have lead to residents receiving antipsychotic medication that they may not need which could cause increased risk of adverse drug effects, including falls and cognitive impairment and harmful drug interactions. The findings are: R #9 A. Record review revealed that R #9 had a physician order for lorazepam oral tablet, 0.5 mg (milligrams). Give one tablet by mouth, two times a day, for anxiety. Start date 03/21/23. B. Record review revealed that R #9 had a physician order for sertraline (Zoloft used for depression) tablet, 25 mg. Give one tablet by mouth, one time a day, for depression, tearfulness, refusal of care/food. Start date…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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: 1. Properly store medications in a medication cart; 2. Document the daily medication refrigerator internal temperatures and daily medication storage room temperatures; 3. Lock medications carts when they were unattended. These deficient practices have the likelihood to result in the residents in the south back and north back hall, that were identified on the census list provided by the Centers Executive Director (CNE) on 08/27/23, to receive improperly temperature-controlled medications that have either lost their potency (strength of a drug) or effectiveness; allow residents medications to be accessed by unauthorized (not having permission or approval) staff or residents. The findings are: Findings for Medication Cart: A. On 08/27/23 at 5:26 PM, during an observation of the south back medication cart, a loose white oval pill, with the letters APO imprinted on one side, was observed in the top drawer of the medication cart. B. On 08/27/23 at 5:27 PM, during an interview, Licensed Practical Nurse (LPN) stated that loose…

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

Based on record review and interview, the facility failed to ensure a resident received dental services for 1 (R #30) of 1 (R #30) resident reviewed for dental services. This deficient practice can result in the resident not receiving dental care and services to meet the resident's needs. The findings are: A. On 08/27/23 at 7:32 pm, during an interview, R #30 stated he did not have dentures and had asked for them a while ago. B. Record review of R #30's electronic health record revealed a progress note, dated 03/09/23, indicated an oral health evaluation had been completed for R #30 and identified R #30 had 1-3 decayed or broken teeth. C. Record review of R #30's care plan, with a review date of 06/04/23, revealed the following: Resident exhibits or is at risk for oral health or dental care problems. Obtain dental consult as needed. Date initiated: 03/09/23. D. Record review of R #30's electronic health record revealed the following: - Record review of the clinical physician orders listed for R #23 revealed the record did not contain orders written for a dental consult as needed. -…

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

Based on record review and interview, the facility failed to accurately document in resident's records the Administration Disclosures (also referred to as a consent form - consent explaining risks and benefits of psychotropic medication) when they failed to document antidepressant medications, and anti-anxiety medication on the consent form for 1 (R # 67) of 1 (R #67) resident reviewed for psychotropic medication (a type of medication that affects the mind, emotions and behavior). This deficient practice could likely result in residents and/or resident healthcare decision makers not being informed about the risks and benefits of using Psychotropic Medications. The findings are: A. Record review of R #67's consent form revealed: Psychotropic medication administration disclosure, dated 03/23/23, did not list vilazodone (used to treat depression), hydroxyzine pamoate (an antihistamine used to treat insomnia), and risperdal (used to treat bipolar disorder).The only medication the POA (Power of Attorney) consented to was ativan (an anti-anxiety medication). B. Record review of R #67'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 and interview, the facility failed to ensure a resident was treated with dignity and respect when staff did not provide privacy for 1 (R #75) of 1 (R #75) resident. This deficient practice could likely cause the resident to feel embarrassed and disrespected. The findings are: A. On 08/29/23 at 11:35 am, an observation of R #75's room revealed the door was open, the curtain was not pulled to provide privacy, and R #75 used his portable urinal (container used to collect urine). A maintenance staff member stood in the doorway, and Certified Nursing Assistant (CNA) #4 assisted R #75 with using his portable urinal. CNA #4 peeked her head out of the room, and surveyor asked if the door should be closed. CNA #4 did not answer but closed the door to R #75's room. B. On 08/29/23 at 4:30 pm, during an interview, CNA #4 stated she should have closed the door before R #75 started using his portable urinal. CNA #4 stated the Maintenance staff member stood in the doorway to translate since R #75 speaks Spanish, and she does not.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This is a repeat deficiency. Based on interview and record review, the facility failed to ensure a current copy of a resident's advance directive [a document, also known as the New Mexico Medical Orders For Scope of Treatment (MOST) form indicating a person's wish whether or not to receive CPR (cardiopulmonary resuscitation: an emergency lifesaving procedure performed when the heart stops beating) when they have no pulse or are not breathing] was present in the resident's medical record for 1 (R #81) of 1 (R #81) resident reviewed for advance directives. This deficient practice could likely result in a resident's wishes not being honored. The findings are: A. Record review of R #81's EMR (electronic medical record) indicated the resident's advanced directive status was full code (attempt Cardiopulmonary resuscitation (CPR)). B. Record review of R #81's MOST form, dated [DATE], revealed full code as his advanced directive status. C. Record review of R #81's care plan meeting note, dated [DATE], revealed, Advance…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 written grievance (complaints over something believed to be wrong or unfair) decisions included whether or not the grievance was confirmed and the date the grievance was resolved for 1 (R #31) of 1 (R #31) resident reviewed for grievances. This deficient practice could likely result in residents feeling unimportant and/or unsatisfied with the results of the grievance process. The findings are: A. On 08/30/23 at 3:00 pm, during an interview, R #31 stated staff do not keep them (residents) informed of the actions taken to resolve grievances filed. B. Record review of the facility policy titled OPS204 Grievance/Concern, revision date 07/19/23, revealed: - Upon receipt of the 'Grievance/Concern Form', the administrator or designee will document the grievance/concern on the 'Grievance Concern Log;' - The completed 'Grievance/Concern Forms' will be reviewed and retained by the Administrator. C. Record review of the grievances filed by R #31, dated 7/30/23, 08/07/23 and 08/21/23, revealed the grievances did not contain…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 keep residents free from physical restraints for 1 (R #23) of 1 (R #23) resident, when staff used the resident's geriatric chair as a side rail to keep resident from getting out of bed for R #23. This deficient practice could likely result in physical restraints being used for discipline or staff convenience; therefore, unnecessarily preventing residents from freedom, movement, or activity. The findings are: A. Record review of R #23's face sheet revealed he was initially admitted to the facility on [DATE], with a diagnosis of: - Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement, chiefly affecting middle-aged and elderly people); - Dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease 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 record review and interview, the facility failed to create an accurate Baseline Care Plan (minimum healthcare information necessary to properly care for a resident immediately upon their admission to the facility) within 48 hours of admission for 1 (R #224) of 3 (R #'s 94, 224 and 225) residents reviewed for Baseline Care Plans. This deficient practice could likely result in a decline in the residents' condition due to staff not being aware of the care residents' need and residents not being able to attain or maintain their highest practical level of well-being. The findings are: A. Record review of Face Sheet dated 08/25/23 revealed this as an initial date and included the following diagnoses: - Sepsis (an infection in the blood); - Enterocolitis (inflammation of the large and small intestines) due to C-diff (Clostridioides difficile - bacterial infection of the large intestine); - Muscle weakness; - Abnormalities of gait (how a person walks) and Mobility; - Type 2 diabetes (high blood sugar) with Diabetic Neuropathy (nerve damage caused by high blood sugar); - Type 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 record review, observation, and interview, the facility failed to develop and implement a comprehensive person-centered care plan for 2 (R #38 and R #94 ) of 3 (R #s 38, 94, 224 and 225) residents reviewed for comprehensive person-centered care plans. This deficient practice could likely result in staff's failure to understand the needs and implement the appropriate treatments for residents, possibly resulting in decline in abilities and a failure to thrive. The findings are: A. Record review of Face Sheet dated 04/08/22 for R #94 revealed this as an initial admission date and included the following diagnoses: - Alcoholic cirrhosis of the liver (when healthy liver tissue is replaced with scar tissue due to heavy alcohol use), - Acute respiratory failure with hypoxia (a life-threatening condition where the lungs cannot provide enough oxygen to the blood and organs), - Chronic obstructive pulmonary disease (lung disease that causes difficulty breathing and persistent cough), - Chronic viral hepatitis C…

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

Based on record review, interveiws and observations, the facility failed to provide services that meet professional standards for 1 (R #38) of 1 (R #38) residents by: 1. Staff did not follow physician's orders for R #38. 2. Staff did not document compression stockings being placed on the resident. These deficit practices may cause edema (swelling) in bilateral extremities if staff do not follow physician's orders. This can cause build up of fluid, pain, and swelling due to lack of care. Findings for #38 A. On 08/27/23 at 8:23 pm, during an observation, R #38 sat up in his wheelchair. He (resident) had red socks on his (resident) feet. R #38's legs and feet were swollen, and the socks left an indention in his ankle. R #38 did not have compression stockings on. B. On 08/28/23 at 2:30 pm, during an observation, R #38 sat up in his wheelchair. The resident did not have on compression stockings. C. Record review of R #38's physician orders dated 03/31/23, revealed an order for compression stockings, bilateral lower extremity during up hours. D. Record Review of R #38's care plan,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility failed to provide podiatry (the medical care and treatment of the human foot) services for 1 (R #40) of 1 ( R #40) resident reviewed for toenail care. This deficient practice could likely result in functional decline, pain, and infections. A. Record review of the facility's policy titled Foot Care, last reviewed 08/07/23, revealed Centers will provide foot care and treatment in accordance with professional standards of practice and state scope of practice, as applicable, including to prevent complications from the patient's medical condition(s) such as diabetes, peripheral vascular disease (the reduced circulation of blood to a body part other than the brain or heart.), or immobility (the state of someone or something that is not moving or not able to move) Further review revealed Patients who have complicating disease processes requiring foot care including, but not limited to, infections/fungus, ingrown toenails, diabetes mellitus (a group of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure urine collection bags did not touch the floor for 1 (R #279) of 1 (R #279) residents with indwelling urinary catheters (plastic tubing that allows urine to come from the body and into a collection bag). This deficient practice could lead to urinary tract infections (UTIs-an infection in any part of the urinary system, the kidneys, bladder, or urethra) and possibly sepsis (an infection of the blood stream that can be life-threatening). The findings are: A. Record review of R #279's facility face sheet revealed he was admitted to the facility on [DATE] with the following diagnoses: benign prostatic hyperplasia [a condition in men in which the prostate gland (located just below the bladder in men and surrounds the top portion of the tube that drains urine from the bladder) is enlarged and not cancerous] with lower urinary tract symptoms and retention of urine unspecified. B. Record review of R #279's admission Minimum Data Set [MDS-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 record review and interview, the facility failed to provide a drug regimen that was free from unnecessary medication by not responding to the pharmacy recommendations for 1 (R #9) of 5 (R #9, 11, 31, 35 and 224) residents reviewed for unnecessary medication. This deficient practice could have likely led to R #9 receiving medication he no longer needed. The findings are: A. Record review R #9's physician order revealed an order for atorvastatin (also known as Lipitor is a statin medication used to prevent cardiovascular disease in those at high risk) calcium tablet, 10 milligrams (mg). Give one tablet by mouth at bedtime for hyperlipidemia (high cholesterol). Start date 03/21/23. B. Record review R #9's physician order revealed an order for aricept [also known as Donepezil is a medication used to treat dementia of the Alzheimer's type (is a progressive and irreversible condition that affects the brain and causes dementia)] tablet, 10 mg. Give one tablet by mouth at bedtime for dementia (memory loss and a loss of other cognitive abilities that interfere with daily life).…

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