Northridge Rehabilitation and Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of resident immunizations, review of personnel records, staff interview, and policy review, the facility failed to ensure residents and staff were educated on the risks, benefits, and side effects of the COVID-19 vaccine. This affected five (#14, #42, #53, #57, and #64) of five residents reviewed for immunization and seven of seven employees reviewed for immunization and had the potential to affect all residents. The facility census was 74. Findings include 1) Review of the medical record for Resident #57 revealed an admission date of 01/11/24. Diagnoses included anoxic brain injury, and sudden cardiac arrest. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment Review of Resident #57's undated consent form for the pneumococcal vaccine revealed a hand written note stating the resident would like the COVID-19 vaccine. There was no information sheet for the COVID-19 vaccine and no documentation the resident/representative had been…

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 resident and staff interview, record review, and review of the facility policy, the facility failed to have routine/scheduled care plan meetings for the residents and/or resident representative in 2024. This affected one (Resident #51) of one resident reviewed for care plan meetings. The facility identified all residents residing at the facility with the exception of 18 residents admitted after November 2024 (Residents #17, #18, #23, #24, #29, #34, #45, #51, #53, #59, #61, #66, #65, #135, #179, #181, #182, and #183) did not have care conferences in 2024. The facility census was 74. Findings include: Record review for Resident #51 revealed an admission date of 12/13/22. Diagnoses included displaced midcervical fracture of the left femur, atrial fibrillation, and hemiplegia and hemiparesis following cerebral infarction. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #51 was moderately cognitively impaired. Resident #51 had impairment on both sides of the lower…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident, family, and staff interviews, and record review, the facility failed to ensure medical records were accurate and factual. This affected eight (Residents #26, #35, #38, #53, #53, #55, #57, and #177) of 27 residents medical records reviewed during the annual survey. The facility census was 74. Findings include: 1 Review of the medical record for Resident #26 revealed an admission date 12/09/21. Diagnoses included left hand contracture. Review of the physician orders for February 2025 revealed palm protective splint to left hand on in the PM and off in the AM, activated 01/20/23. Review of the plan of care revealed assistance needed for activities of daily living (ADL) related to decreased range of motion to left hand. Interventions included palm protective splint to left hand on in the PM and off in the AM. Review of the Treatment Administration Record (TAR) for February 2025 revealed treatment for palm protector splint to left hand was marked that it was put on 02/04/25 and signed…

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 medical record review, and resident and staff interview, the facility failed to ensure residents were treated with dignity and respect. This affected two (Resident #13 and #74) of four residents reviewed for dignity. The facility census was 74. Findings include: 1. Review of the medical record for Resident #13 revealed an admission date of [DATE]. Diagnoses included psychosis, depression, anxiety, delusional disorders, altered mental status, heart failure, chronic kidney disease. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #13 was cognitively intact. Interview on [DATE] at 1:22 P.M. with Resident #13 stated Licensed Practical Nurse (LPN) #346 was always saying things that were sarcastic and rude. Resident #13 also reported being pretty sure LPN #346 cursed at her on an unknown date. 2. Review of the medical record for Resident #74 revealed an admission date of [DATE]. The resident expired in the facility on [DATE]. Diagnoses included hypertensive heart…

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 medical record review, observation, resident and staff interviews, and policy review, the facility failed to ensure all residents' call lights were within reach. This affected three (Residents #14, #34, and #42) of 74 residents reviewed for call lights within reach. The facility census was 74. Findings include: 1) Review of the medical record for Resident #42 revealed an admission date of 07/28/20. Review of the plan of care dated 04/19/21 revealed Resident #42 was at a potential risk for falls related to dementia, bipolar and decreased safety awareness. Interventions included to ensure call light was within reach. Observation on 01/28/25 at 11:10 A.M. revealed Resident #42's call light laying on floor at the bottom of bed. Resident #42 was unable to reach the call light. Interview on 01/28/25 at 11:15 A.M. with Certified Nursing Assistant (CNA) #334 verified Resident #42's call light was at the bottom of bed and out of reach. CNA #334 stated staff were to ensure call lights were within reach and residents were able to use the call light. 2) Review of the medical record for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the medical record, staff interview and policy review, the facility failed to ensure a resident's family was notified of a resident's decline in condition. This affected one (#178) of four residents reviewed for change in condition. The facility census was 74. Findings include: Review of the closed medical record for Resident #178 revealed an admission date of [DATE], a readmission date of [DATE] and a discharge date of [DATE]. Diagnoses included pneumonia, hypertension, and acute and chronic respiratory failure with hypoxia. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #178 had impaired cognition. Review of a physician order dated [DATE] revealed Resident #178's code status was Do Not Resuscitate Comfort Care (DNRCC). Review of nurse's note dated [DATE] at 11:16 A.M. revealed the nurse went to assess and provide resident medication and resident was noted with respiratory distress. The resident's pulse oximetry level was 80 percent on four liters via…

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 staff interview, record review, and review of the facility policy, the facility failed to ensure a care plan was completed for Resident #61 to include depression, anxiety, and the use of psychotropic medications. This affected one (Resident #61) of 27 residents reviewed for care plans. The facility census was 74. Findings include: Review of the medical record for Resident #61 revealed an admission date of 11/04/24. Diagnoses included delirium, dementia without behavioral disturbance, psychotic disturbance and mood disturbance, and major depressive disorder. Review of Resident #61's care plan initiated on 11/13/24 revealed the resident's anxiety, depression, behaviors, and use of antipsychotic and psychotropic medications were not addressed in the comprehensive care plan. Review of the physician orders revealed the following psychotropic medications: on 11/04/24, an order for quetiapine 50 milligrams (mg) at bedtime for anxiety. On 11/09/24, an order for Zoloft 25 mg in the morning for dementia and anxiety and Depakote sprinkles 125 mg at bedtime for delirium, dementia and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and staff interview, record review, and review of the facility policy the facility failed to ensure a resident who required assistance from staff with activities of daily living received the care and services with bathing/showers. This affected one (Resident #182) of three residents reviewed for bathing/showers. The facility census was 74. Findings include: Record review for Resident #182 revealed an admission date of 11/21/24 and a discharge date of 12/30/24. Diagnoses included presence of right artificial hip joint and encounter for orthopedic aftercare. Review of the Medicare five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #182 was cognitively intact. Resident #182 had impairment on one side of the lower extremity. Resident #182 was dependent on staff for showering/bathing. Review of the care plan dated 11/21/24 revealed Resident #182 had no care plan for activities of daily living (ADL). Review of the physician orders for Resident #182 dated 11/24/24 revealed skin…

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, family and staff interview, record review, and review of the facility policy, the facility failed to ensure physician ordered compression socks were implemented for Resident #55 and failed to timely provide care and treatment to treat a resident's excessive sweating causing skin issues. This affected two (Residents #54 and #55) of seven residents reviewed for care and services. The facility census was 74. Findings include: 1. Record review for Resident #55 revealed an admission date of 05/15/23. Diagnoses included Parkinson's disease, dementia, and muscle weakness. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #55 was severely cognitively impaired. Resident #55 had impairment on both sides of the upper and lower extremities. Resident #55 was dependent on staff for personal hygiene. Review of the care plan for Resident #55 dated 05/15/23 and revised 07/17/24 revealed an intervention was to apply TED (thrombo-embolic deterrent; type of compression…

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 medical record review, observation, and resident and staff interview, the facility failed to ensure a resident received the appropriate treatment and services to maintain/improve mobility according to physician orders. This affected one (Resident #26) of one resident reviewed for range of motion. The facility census was 74. Findings include: Review of the medical record for Resident #26 revealed an admission date 12/09/21. Diagnoses included left hand contracture. Review of the physician orders for February 2025 revealed palm protective splint to left hand on in the PM and off in the AM, activated on 01/20/23. Review of the plan of care revealed Resident #26 required assistance with needed for activities of daily living (ADL) related to decreased range of motion to left hand. Interventions included palm protective splint to left hand on in the PM and off in the AM. Observation and interview on 01/28/25 at 2:51 P.M. revealed Resident #26 was propelling self in her wheelchair down the hall and her left hand was contracted and no splint was on. Interview with Resident #26…

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, staff interview, record review and review of the facility policy, the facility failed to prevent an avoidable fall with minor injury for Resident #54, failed to ensure fall interventions were in place for Resident #54 who was at a fall risk, and did not complete a thorough fall investigation into Resident #173' fall. This affected two (Residents #54 and #173) of three residents reviewed for falls. The facility census was 74. Findings include: 1) Record review for Resident #54 revealed an admission date of 05/30/23. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left non dominant side, aphasia, muscle weakness, tracheostomy, cerebral infarction, and acute respiratory failure. Review of the care plan created 06/05/23 revealed Resident #54 was totally dependent on staff for ADLs and does not participate in any aspect of the task for bed mobility. Interventions included to use two persons assistance for repositioning, hygiene and bathing. The care plan was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, resident, family, and staff interview, and policy review, the facility failed to ensure the resident's indwelling catheter tubing was secured to the resident to prevent dislodgement of the urinary catheter. Additionally, the facility failed to ensure residents receive timely incontinence care. This affected two (Resident #5 and #47) of three residents reviewed for indwelling catheters and two (Residents #55 and #181) of three residents reviewed for incontinence care. The facility identified seven residents who have an indwelling catheters. The facility census was 74. Findings include: 1) Record review for Resident #181 revealed an admission date of 01/15/25. Diagnoses included atrial fibrillation, atherosclerotic heart disease of native coronary artery, and chronic kidney disease. Review of the care plan dated 01/16/25 revealed Resident #181 experienced bowel and/or bladder incontinence. Interventions included to provide incontinence care every two hours and 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 review of the medical record, staff interview, and policy review, the facility failed to ensure residents on psychotropic medications were monitored for adverse consequences and behaviors were routinely monitored. This affected three (Residents #13, #42, and #61) of five residents reviewed for unnecessary medications. The facility identified 48 residents receiving psychotropic medications. The facility census was 74. Findings include: 1. Review of the medical record for Resident #61 revealed an admission date of 11/04/24. Diagnoses included delirium, hypertension, unspecified dementia without behavioral disturbance, psychotic disturbance and mood disturbance, urinary tract infection, pneumonia, and major depressive disorder. Review of the care plan initiated 11/13/24 revealed no plan of care was in place for anxiety, depression, behaviors, use of antipsychotic and psychotropic medications. Review of the physician orders revealed the following psychotropic medications for Resident #61: on 11/04/24, an orders for quetiapine 50 milligrams (mg) at bedtime for anxiety. 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 record review, observation, staff interview, review of Medscape guidance, and policy review, the facility failed to prime an insulin pen per manufacturer instructions prior to administration, resulting in a significant medication error. This affected one (Resident #30) of five residents reviewed for medication administration. The facility identified 14 residents who receive insulin via a pen-injector. The facility census was 74. Findings include: Review of the medical record for Resident #30 revealed an admission date of 11/06/23. Diagnosis included type two diabetes mellitus with hyperglycemia. Review of the plan of care dated 11/07/23 revealed Resident #30 was at risk for hyper/hypoglycemia related to diabetes mellitus. Intervention included to administer medications as ordered. Review of the physician orders revealed Resident #30 was ordered Lantus Solostar 50 units subcutaneously via a pen-injector, two times a day and Novolog 10 units via a pen-injector before meals. Observation on 01/29/25 at 6:46 A.M. revealed Licensed Practical Nurse (LPN) #353 administered 20…

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, resident and staff interviews, and record review, the facility failed to ensure all medications were stored appropriately and residents were watched when taking medications. This affected two of sevens (Resident #24 and #181) for medication storage. The facility census was 74. Findings include: 1. Review of the medical record for Resident #181 revealed an admission date 02/01/25. Diagnosis included pain management. Review of the physician orders for February 2025 revealed an order for Tylenol 325 milligrams (mg) give 650 mg by mouth every four hours as needed for pain. Observation and interview on 02/03/25 at 4:35 P.M. of Resident #181 revealed there was a pill cup sitting on the bedside table with two round tablets in it. Resident #181 stated she did not know what was in the pill cup, the nurse just set them down and left the room. There were no staff in the room or insight of Resident #181. Interview on 02/03/25 at 4:40 P.M. with Registered Nurse (RN) #358 stated she though Resident #181…

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 staff and resident interviews the facility failed to ensure narcotic pain medication was available for administration. This affected one (#32) of the three residents reviewed for receiving narcotic pain relief. The facility identified 28 residents receiving narcotic pain medications. The facility census was 80. Finding Include: Review of the medical record for Resident #27 revealed an admission date of 08/09/22. Diagnoses included acute kidney failure, lymphedema, obesity, cerebral infarction, obstructive sleep apnea, chronic ulcer of the left lower leg, chronic pain, and cellulitis. Review of the physician order dated 04/15/24 for Resident #27 revealed an order to administer oxycodone five milligram (mg) every four hours as needed (PRN) and an order to administer cyclobenzaprine 10 mg PRN for spasms. Review of Resident #27's Controlled Drug Record/Disposition Form, dated 05/13/24 for oxycodone five mg, revealed the last pill was administered on 06/14/24 at 7:00 A.M. The record revealed the resident was taking the medication consistently in the evenings.…

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, staff interview and review of facility policy, the facility failed to ensure a narcotic pain medication was accurately documented in the resident's Medication Administration Record (MAR). This affected one (#27) of three residents reviewed for pain medications. The facility census was 80. Finding Include: Review of the medical record for Resident #27 revealed an admission date of 08/09/22. Diagnoses included acute kidney failure, lymphedema, obesity, cerebral infarction, obstructive sleep apnea, chronic ulcer of the left lower leg, chronic pain, and cellulitis. Review of the physician order dated 04/15/24 for Resident #27 revealed an order to administer oxycodone 5 milligram (mg) every four hours as needed (PRN). Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 05/29/24, revealed the resident had intact cognition and required substantial assistance for transfers, bed mobility and was dependent on staff for toileting and showering. Review of Resident #27's Controlled Drug Record/Disposition Form, dated 5/13/24 revealed the resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews and review of facility policy, the facility failed to ensure resident call lights were in reach of residents. This affected two (#32 and #69) of the three residents reviewed for call lights. The facility census was 80. Finding Include: 1)Review of the medical record for Resident #32 revealed an admission date of 01/18/24. Diagnoses included acute respiratory failure, paraplegia, traumatic brain injury (TBI), epilepsy, and type II diabetes. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/25/24, revealed Resident #32 had intact cognition and was dependent on staff for bed mobility, transfers and hygiene. Review of Resident #32's Care Plan dated 05/09/24 revealed the resident required assistance for activities of daily living (ADLs) related to immobility. Intervention included to keep the call light in reach. 2)Review of the medical record for Resident #69 revealed an admission date of 08/09/22. Diagnoses included hemiplegia, cerebral infarction,…

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 medical record review, interview and review of policy the facility failed to ensure residents were invited to participate in care conference meetings regarding their care. This affected two of two residents (#20, #56) reviewed for care planning. The facility census was 87. Findings include 1. Review of the medical record revealed Resident #20 had an admission date of 12/05/21. Diagnoses included depressive disorder, delusional disorder, anxiety disorder, type two diabetes mellitus, hypertension, chronic obstructive pulmonary disease and chronic kidney disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. Review of the resident's Care Conference Summary dated 09/22/23 revealed the resident's last care plan meeting was held on this date. There were no care conference meeting notes since 09/22/23. Interview on 02/26/24 at 8:52 A.M., Resident #20 would like a care plan meeting and had not been invited to one recently. Interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, resident and staff interviews, the facility failed to ensure skin assessments were completed accurately and the facility failed to follow physician orders for oxygen administration. This affected one of one resident (#45) reviewed for skin assessments and oxygen administration. The facility census was 87. Findings Include: 1. Review of Resident #45 medical records identified Resident #45 was admitted into the facility on [DATE] with diagnoses of unspecified dementia, psychotic disturbance, mood disturbance, anxiety, chronic respiratory failure with hypoxia ,legal blindness, and personal history of traumatic brain injury. Review of the most recent annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #45 was severely cognitively impaired and required substantial to maximal assistance from staff to aide in completing his activities of daily living. A. Review of Resident #45 current physician orders identified skin checks were to be completed weekly…

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, medical record review and staff interview, the facility failed to administer tube feeding formula according to directions for use. This affected one of two residents (#78) reviewed for enteral tube feedings. The facility census was 87. Findings include: Review of the medical record for Resident #78 revealed an admission date of 05/30/23. Diagnoses included but were not limited to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, history of pneumonitis due to inhalation of food and vomit, dysphagia, aphasia, tracheotomy, chronic obstructive pulmonary disease, stage three chronic kidney disease, and neuromuscular dysfunction of bladder. Review of 1/18/24 significant change Minimum Data Set (MDS) 3.0 for Resident #78 revealed a Brief Interview of Mental Status (BIMS) score of 03 which indicated the resident had severely impaired cognition. Review of activities of daily living (ADLs) revealed Resident #78 was dependent for all ADLs, was noted to have a history of pocketing food, coughing with meals, used oxygen, and was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, resident and staff interviews, the facility failed to ensure a resident's medications were kept secured against unauthorized access. This affected one of one resident (#50) reviewed for medication administration. The facility census was 87. Findings Include: Record review revealed Resident #50 was admitted into the facility on [DATE] with diagnoses of arteriosclerotic heart disease, heart failure, benign prostatic hyperpiesia with lower urinary tract symptoms, muscle weakness, difficulty in walking. Review of the most recent annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #50 was cognitively intact and required moderate assistance from staff to aide in completing his activities of daily living. Review of the Medication Administration Policy (dated 08/22/22) stated under number 15: observe resident consumption of medication. Observation on 02/26/24 at 11:05 A.M. revealed a small plastic medication cup containing six (6) pills sitting on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical records review, facility policy review and staff interview, revealed the facility failed to ensure the Preadmission Screening and Resident Review (PASARR) was current and up to date. This affected two (#28 and #54) of two residents reviewed for PASARR. The facility census was 75. Findings include: 1. Review of medical record for Resident #28 revealed an admission date of 01/29/21. Diagnoses included paranoid schizophrenia, insomnia, major depressive disorder, schizoaffective disorder, generalized anxiety disorder, and schizophrenia unspecified. Review of Resident #28's quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #28 was cognitively intact. Resident #28 was independent with bed mobility, transfers, eating and toileting. She required extensive assistance with one person assist with dressing, supervision with set up assistance for personal hygiene and was total dependent for bating. Review of the PASARR dated 01/29/21 revealed a check mark denoted the resident had 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 medical record, staff and resident interviews and review of facility policy revealed the facility failed to provide showers per resident preferences. This affected two (#53 of #67) three of residents reviewed for Activities of Daily Living. The facility census was 75. Findings included: 1. Review of the medical record for Resident #53 revealed an admission date of 09/25/15 and re-admitted on [DATE]. Diagnoses included hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting unspecified side, localization-related symptomatic epilepsy and epileptic syndrome with simple partial seizures, major depressive disorder, insomnia, and unspecified sequelae of unspecified cerebrovascular disease. Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/10/21, revealed Resident #53 had intact cognition. The resident required limited assistance with one person for bed mobility, transfers, and personal hygiene. He required extensive assistance with one person for dressing,…

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, observations, staff interview and review of the facility policy, the facility failed to ensure an anchoring device for the Foley catheter was implemented to prevent accidental pain or injury from excessive tension and/or removal of a Foley catheter. This affected one (#41) of one resident reviewed for catheter care. The facility identified 11 residents with catheters. The facility census was 75. Findings Include: Review of Resident #41's medical record revealed the resident was admitted on [DATE]. Diagnoses included cerebral infarction, acute respiratory failure with hypoxia, tracheostomy, hypertension, and urinary retention. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed extensive assist of two person for bed mobility and has an indwelling Foley catheter. Review of the most recent plan of care revealed a potential for complications related to the use of a Foley catheter and assist with Foley catheter care as needed. Observation on 07/21/21 at 8:52 A.M., 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.