Menlo Park Post Acute

Based on observation, interview, and record review it was determined the facility failed to provide appropriate foot care for 2 of 5 sampled resident (#42 and 45) reviewed for ADL care. This placed residents at risk for complications and discomfort. Findings include: Resident 42 was admitted to the facility in 8/2025 with diagnoses including diabetes. The 11/24/25 Modified Quarterly MDS indicated Resident 42 had a BIMS score of 15 which indicated the resident was cognitively intact. The 9/5/25 Care Plan indicated the nursing staff completed nail trimming for Resident 42 and staff monitored skin conditions when care was provided and staff notified the nurse of any open areas or red skin areas. A review of Resident 42's Physician Orders on 2/2026 indicated the nurses checked fingernails and toenails once a week on bath days and trimmed the residents nails as needed. Resident 42 was scheduled for evening showers on Sunday and Wednesday. The 3/10/25 Skin & Wound Evaluation indicated Resident 42's right plantar foot wound was healed. An attached picture of Resident 42's right plantar…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to ensure trauma informed care was assessed to ensure proper practices were provided for 2 of 2 resident (#s 3 and 10) reviewed for mood and behavior. This placed residents at risk for triggered responses and re-traumatization. Findings include: A facility Trauma-Informed Care policy dated 8/2024 included the focus of four areas when care interventions are developed and strategies to support resident with trauma history. Those four areas include: -Realize the prevalence of trauma through education and training of care staff, -Recognize how trauma affects individuals through evaluation and identification of triggers, -Responding and putting knowledge into practice through development of resident=centered care planning, and -Resisting re-traumatization through avoiding identified triggers and making empathetic, reasonable modifications to the care approach and environment. 1. Resident 10 was admitted to the facility in 1/2026 with diagnoses…

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

Based on interview and record review it was determined the facility failed to ensure adequate indications for medication use for 1 of 1 sampled resident (#10) reviewed for unnecessary medications. This placed residents at risk for adverse side effects. Findings include:Resident 10 was admitted to the facility in 1/2026 with diagnoses including paraplegia (paralysis of the legs and lower body) and wounds. The 1/10/26 Care Plan identified Resident's 10's pain would be relieved to a tolerable level as indicated by the resident. A 1/11/26 Physician's Order was in place for Morphine Sulfate 10 MG/5 ML every six hours as needed for pain. The 1/16/26 admission MDS revealed a BIMS score of 14 indicating the resident was cognitively intact. The resident received scheduled and PRN pain medications. The 1/2026 and 2/2026 MARs showed Staff 27 (CMA) administered PRN Morphine with a pain rating of zero seven times in the two-month period on 1/21/26, 1/22/26, 1/28/26, 1/29/26, 2/4/26, and 2/5/26.The 1/2026 and 2/2026 Progress Notes contained no additional assessment or justification for the dates…

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 it was determined the facility failed to provide emergency dental services for 1 of 1 sampled resident (#42) reviewed for dental care. This placed residents at risk for acute dental pain and poor appetite. Resident 42 was admitted to the facility in 8/2025 with diagnoses including diabetes.The 9/5/25 Care Plan indicated Resident 42 had her/his own teeth and required assistance setting up when oral hygiene was performed. The 11/24/25 Modification of Quarterly MDS indicated Resident 42 had a BIMS score of 15 which indicated the resident was cognitively intact and Resident 42 did not have dental pain, discomfort and difficulty chewing. The 11/2025 Documentation Survey Report indicated Resident 42 was not verbally or physically aggressive to other residents or staff. A 11/21/25 Progress Note indicated Resident 42 was verbally aggressive with staff and reported toothache. A 11/25/25 Progress Note indicated Staff 31 (Social Services Assistant) called to make an emergent dental appointment but the clinic advised her to call back the…

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

Based on interview and record review it was determined the facility failed to ensure CNAs received annual performance reviews for 5 of 5 randomly selected CNA staff (#s 6, 7, 8, 9 and 10) reviewed for sufficient and competent staffing. This placed residents at risk for lack of care by competent staff. Findings include: A review of personnel records on 11/6/24 at 12:01 PM with Staff 23 (Human Resources/Payroll) indicated the following employees had not received their annual performance evaluations: -Staff 6 (CNA), hire date 9/17/15: no annual performance review was completed. -Staff 7 (CNA), hire date 9/16/14: no annual performance review was completed. -Staff 8 (CNA), hire date 9/15/17: no annual performance review was completed. -Staff 9 (CNA), hire date 8/1/08: no annual performance review was completed. -Staff 10 (CNA), hire date 6/24/14: no annual performance review was completed. On 11/6/24 at 12:01 PM Staff 23 confirmed annual performance reviews for Staff 6, Staff 7, Staff 8, Staff 9 and Staff 10 were not completed.

Based on interview and record review it was determined the facility failed to ensure CNA staff received 12 hours of in-service training annually for 5 of 5 randomly selected staff members (#s 6, 7, 8, 9, and 10) reviewed for evidence of in-service training. This placed residents at risk for lack of quality care. Findings include: On 11/6/24 at 1:19 PM Staff 23 (Human Resources/Payroll) provided a list of annual training hours for CNA staff which revealed the following: -Staff 6 (CNA): 0 annual training hours; -Staff 7 (CNA): 8 annual training hours; -Staff 8 (CNA): 11 annual training hours; -Staff 9 (CNA): 0 annual training hours and -Staff 10 (CNA) 8 annual training hours. On 11/6/24 at 1:19 PM Staff 23 confirmed Staff 6, Staff 7, Staff 8, Staff 9 and Staff 10 did not complete the required 12 hours of annual in-service training. On 11/8/24 at 11:09 AM Staff 1 (Administrator) acknowledged CNA staff were required to have 12 hours of annual in-service training.

Based on observation and interview it was determined the facility failed to ensure a homelike environment for 1 of 1 facility reviewed for dining. This placed residents at risk for a lessened quality of life. Findings include: Observations on 11/5/24 through 11/8/24 between the hours of 8:00 AM and 12:35 PM revealed meals were served with plastic spoons, plastic glasses and Styrofoam cups. On 11/5/24 at 12:38 PM Resident 66 was eating lunch. Resident 66 held up a plastic spoon and stated, they give us this crap to eat with. On 11/6/24 at 1:38 PM Staff 29 (CNA) stated residents usually received regular forks and knives but were given plastic spoons, plastic glasses and Styrofoam cups for at least the past month. Staff 29 stated this was not homelike. On 11/6/24 at 1:42 PM Staff 30 (Dietary Manager) stated the facility did not have enough glasses, cups or silverware for all of the meal service. Staff 30 stated plasticware and Styrofoam cups were not homelike. On 11/8/24 at 9:17 AM Staff 13 (Activities Director) confirmed multiple residents complained about paper and Styrofoam cups,…

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 interviews it was determined the facility failed to ensure medications and biologicals were maintained within secured (locked) locations, accessible only to designated staff for 3 of 6 medication and treatment carts reviewed for safe medication storage. This placed residents at risk for unsafe access to medications and diversion of medication. Findings include: The facility's 1/2023 Storage of Medication Policy stated: In order to limit access to prescription medications, only licensed nurses, pharmacy staff, and those lawfully authorized to administer medications (such as medication aides) are allowed access to medication carts. Medication rooms, cabinets and medications supplies should remain locked when not in use or attended by persons with authorized access. 1. On 11/6/24 at 1:38 PM a treatment cart was observed to be unlocked on Hall 1. The nurse was not in view of the cart. On 11/6/24 at 1:47 PM Staff 12 (LPN) confirmed the cart was unlocked. 2. On 11/7/24 at 9:53 AM a medication cart was observed to be unlocked and unattended on Hall 3. On 11/7/24 at…

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

Based on observation, interview and record review it was determined the facility failed to ensure the ice machine and ice machine scoop were cleaned adequately to maintain sanitary conditions in 1 of 1 kitchen reviewed for sanitary kitchen services. This placed residents at risk of foodborne illness. Findings include: 1. On 11/4/24 at 9:34 AM the ice machine adjacent to the kitchen was observed to have a pink/black substance on a plastic shield inside the machine. Condensation was observed dripping over the substance onto the ice. On 11/4/24 at 9:39 AM Staff 18 (Maintenance Director) stated the ice machine was cleaned every month. Staff 18 acknowledged the presence of the pink/black substance and confirmed the ice machine should be free of any debris or contaminants. On 11/4/24 at 9:58 AM Staff 1 (Administrator) acknowledged the existence of pink/black substance inside the ice machine and stated the ice machine needed to be cleaned. 2. On 11/4/24 at 9:34 AM the ice machine scoop located on the wall next to the ice machine was observed to be stored in a clear plastic container with a…

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

Based on interview and record review it was determined the facility failed to inform residents and/or the residents' responsible party of the risks and benefits, and to ensure consent was obtained for the use of psychotropic medications for 2 of 5 sampled residents (#s 34 and 66) reviewed for unnecessary medications. This placed residents at risk for lack of informed consent. Findings include: The facility's Psychoactive Medications policy, dated 8/1/24, indicated risks and benefits of drug use and revealed informed consent was to be obtained from the resident/resident representative prior to administration of any psychoactive medication. 1. Resident 34 was admitted to the facility in 3/2023 with diagnoses including major depressive disorder. Resident 34's 10/2024 MAR revealed the resident received the following psychotropic medications as ordered by her/his physician: -Buspirone (a medication to treat anxiety), three times a day for anxiety. -Sertraline (a medication to treat depression), one time a day for major depression. -Clonidine (a medication to treat anxiety), every 6 hours…

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 it was determined the facility failed to protect the resident's right to be free from verbal abuse by a resident for 1 of 1 sampled residents (#19) reviewed for abuse. This placed residents at risk for abuse. Findings include: Resident 19 admitted to the facility in 3/2024 with diagnoses including infection and anxiety disorder. A 10/10/24 Quarterly MDS revealed Resident 19 had moderate cognitive impairment. Resident 17 admitted to the facility in 10/2024 with diagnoses including amputation and obesity. A 10/23/24 admission MDS revealed Resident 17 was cognitively intact. On 11/6/24 at 11:55 AM Resident 17 was observed to enter the doorway of Resident 19's room where she/he proceeded to yell and swear at Resident 19. Resident 17 told Resident 19 to stop fucking yelling out and to turn her/his damn tv down. The interaction was observed by Staff 13 (Activities Director), Staff 22 (Physical Therapy Assistant), Staff 21 (CMA) and Witness 1 (Family Member). On 11/6/24 at 12:02 PM Staff 22 stated he was doing a therapy session with…

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 it was determined the facility failed to timely report an allegation of sexual abuse to the State Agency (SA) for 1 of 3 sampled residents (# 60) reviewed for abuse. This placed residents at risk for abuse. Findings include: The facility's 8/2024 Abuse Screening, Training, Identification, Investigation, Reporting and Protection policy directed the following: -Any suspicion of a crime requires notification of law enforcement and the State survey agency immediately by the person who first forms the suspicion of the crime for sexual abuse. -If, with the suspicion of a crime, there is abuse or a serious injury, the staff member must report the incident within 2 hours of forming the suspicion to law enforcement and the State survey agency. Resident 60 was admitted to the facility in 7/2024 with diagnoses including C-difficile infection (a bacterial infection in the colon). Resident 60's 10/15/24 Quarterly MDS indicated the resident had intact cognition. Resident 13 was admitted to the facility in 6/2024 with diagnoses including diabetes and alcohol…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to ensure transfer notices with appeal rights were provided in writing to residents and their representatives, and to ensure the Office of the State Long-Term Care Ombudsman was notified of resident hospitalizations for 1 of 1 sampled resident (#73) reviewed for hospitalizations. This placed residents at risk for lack of information regarding their options, rights, and lack of advocacy from the Ombudsman Office. Findings include: Resident 73 was admitted to the facility in 9/2024 with diagnoses including complications of a foreign body accidentally left in the body following heart catheterization (a procedure that uses a catheter to diagnose and treat heart conditions). A review of Resident 73's health record revealed she/he was transferred to the hospital on [DATE]. No evidence was found in Resident 73's health record to indicate a transfer notice with appeal rights was provided in writing to the resident or their representative upon…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to provide residents with a written notice of the facility's bed hold policy at the time of transfer to the hospital for 1 of 1 sampled resident (#73) reviewed for hospitalization. This placed residents at risk for lack of knowledge regarding their choices and potential financial responsibilities. Findings include: Resident 73 was admitted to the facility in 9/2024 with diagnoses including complications of a foreign body accidentally left in the body following heart catheterization (a procedure that uses a catheter to diagnose and treat heart conditions). A review of Resident 73's health record revealed she/he was transferred to the hospital on [DATE]. No evidence was found in Resident 73's health record to indicate a written bed hold policy with reserved bed payment was provided to the resident or their representative upon transferring to the hospital on [DATE]. On 11/7/24 at 2:50 PM Staff 2 (Interim DNS) stated the charge nurse 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 it was determined the facility failed to ensure physician orders were followed for 3 of 5 sampled residents (#s 8, 34 and 66) reviewed for unnecessary medications. This placed residents at risk for adverse medication consequences. Findings include: 1. Resident 34 was admitted to the facility in 3/2023 with diagnoses including major depression and diabetes. a. A 10/28/24 Physician Order indicated Resident 34 was prescribed clonidine (an anti-anxiety medication) one tablet every six hours as needed. Hold if systolic blood pressure (SBP-the maximum pressure in your blood vessels when your heart contracts and pumps blood) was less than 110. Resident 34's 10/2024 MAR indicated the resident received clonidine one time on 10/29/24, three times on 10/30/24 and one time on 10/31/24. A review of Resident 34's health record revealed no evidence the resident's blood pressure was assessed prior to administering clonidine. On 11/7/24 at 8:33 AM Staff 12 (LPN) reviewed Resident 34's MAR and stated the resident's SBP was not assessed prior to administering…

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 it was determined the facility failed to assist in vision care needs for 1 of 1 sampled resident (#34) reviewed for vision. This placed residents at risk for impaired vision. Findings include: Resident 34 was admitted to the facility in 3/2023 with diagnoses including major depression and diabetes. A 12/27/23 Request for Medical Eye Care, resident authorization form, indicated Resident 34 consented to have a vision examination on 12/27/23. The 9/14/24 Quarterly MDS indicated Resident 34 had intact cognitive functioning and the resident wore glasses. A review of Resident 34's heath record revealed no evidence a vision examination was scheduled or completed. Observations from 11/5/24 through 11/7/24 between the hours of 10:14 AM and 9:01 PM revealed Resident 34 was not wearing glasses. On 11/5/24 at 9:23 AM, Resident 34 stated she/he was supposed to get glasses last year around Christmastime but nothing happened. Resident 34 stated she/he asked for an appointment several times but was yet to be scheduled for a vision examination. 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 interview and record review it was determined the facility failed to ensure residents who were trauma survivors received trauma-informed care for 1 of 1 sampled resident (# 39) reviewed for mood. This placed residents at risk for re-traumatization and decreased quality of life. Findings include: The facility's 8/2024 Trauma-Informed Care Policy and Procedure revealed the following: -Realize the prevalence of trauma: Through education and training of care staff, -Recognize how trauma affects individuals: Through education and identification of triggers, -Responding/putting knowledge into practice: Through development of resident-centered care planning, and -Resisting re-traumatization: Through avoiding identified triggers and making empathetic, reasonable modifications to the care approach and environment. Resident 39 was admitted to the facility in 7/2022 with diagnoses including Post-traumatic stress disorder (PTSD) and major depressive disorder. Resident 39's 7/25/22 Social Services Assessment revealed the resident was not assessed for her/his diagnosis of PTSD. Resident…

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 it was determined the facility failed to ensure residents were appropriately supervised while smoking for 1 of 3 sampled residents (#106) reviewed for smoking safety. This placed residents at risk for injury from fire hazards. Findings include: The facility's Smoking Policy, revised 10/2023 stated residents who wished to smoke were evaluated for their ability to smoke safely. Residents who did not meet the safety criteria established by the facility to smoke independently were aided or supervised by facility staff during smoking activities. Resident 106 admitted to the facility in 2016, with diagnoses including diabetes mellitus and stroke. Resident 106's MDS Quarterly dated 7/11/24 revealed a BIMS score of 11, indicating the resident had moderate cognitive impairment. Resident 106's Smoking Safety Evaluation dated 8/14/24 revealed Resident 106 did not have adequate cognitive skills or memory recall, did not recognize designated smoking areas and could not identify proper smoking receptacles. The IDT decision stated observations [of…

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

Based on interview and record review it was determined the facility failed to ensure residents were free from misappropriation of property for 1 of 2 sampled residents (# 106) reviewed for misappropriation. This placed residents at risk for loss of property. Findings include: Resident 106 was admitted to the facility in 2022 with diagnoses including chronic kidney disease and heart failure. Resident 106's MDS Quarterly dated 5/7/24 revealed she/he was cognitively intact with a BIMS score of 15. The facility submitted a report to the state agency on 5/30/23 which stated Resident 106 had loaned Staff 4 (Former CNA) money and the facility started an investigation which included suspending Staff 4. On 5/30/24 at 12:48 PM, Resident 106 confirmed she/he loaned Staff 4 money on several occasions prior to May 2023 and Staff 4 had paid back the money. Resident 106 stated in May 2023 she/he loaned Staff 4 $700.00 for new tires and was not paid back. Staff 4 was unable to be interviewed due to no longer working at the facility. On 6/6/24 at 11:00 AM, Staff 1 (Administrator) and Staff 2 (DNS)…

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 it was determined the facility failed to follow appropriate hand hygiene while preparing and serving food for 1 of 1 kitchen reviewed. This placed residents at risk for cross contamination and foodborne illness. Findings include: On 7/27/23 at 11:39 AM during the kitchen inspection, Staff 14 (Dietary Aid) was observed touching a kitchen door and handle. The door was white in color with numerous dark brown markings on front and back. Afterwards Staff 14 resumed preparing trays. Staff 14 did not change his gloves and perform hand hygiene. On 7/28/23 between 11:31 AM and 12:08 PM Staff 14 was observed with gloved hands touching a white kitchen door with numerous dark brown markings on front and back, cart handles, refrigerator handles, his clothing, facemask and silverware during lunch food service without changing his gloves and performing hand hygiene. On 7/28/23 between 11:31 AM and 11:50 AM Staff 13 (Cook) and Staff 14 were wearing facemasks pulled down below their noses. Staff 13 and Staff 14 touched their facemasks to adjust them with their…

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 it was determined the facility failed to maintain a safe, clean and homelike environment on 4 of 4 resident halls and 1 of 1 resident outside courtyard patio reviewed for environment. This placed residents at risk for tripping and living in an unkept and unhomelike environment. Findings include: Observations of the facility's outside resident courtyard patio and resident rooms from 7/25/23 through 7/28/23 found the following issues: -Numerous deep cracks, lifted and uneven cement surfaces and areas of missing cement were observed on the resident courtyard patio which posed a tripping hazard. Multiple residents were observed utilizing the outside courtyard patio on a frequent basis. -room [ROOM NUMBER] had a hole in the wall, chipped paint on the walls, the flooring in front of the window was cracked and non-skid strips in front of the toilet were lifted and peeling which were a tripping hazard. Urine was observed on the far wall to the left of the toilet, a wash cloth with 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 interview and record review it was determined the facility failed to develop and implement care plans for 1 of 2 sampled residents (#18) reviewed for hospitalization. This placed residents at risk for unmet needs. Findings include: Resident 18 admitted to the facility in 2022 with diagnoses including schizoaffective disorder (a mood disorder) and anxiety disorder. The 6/12/23 Quarterly MDS indicated Resident 18 was cognitively intact and was not exhibiting behaviors at that time. A closed care plan from a prior admission to the facility dated 5/11/22 indicated Resident 18 had a history of expressing suicidal ideations in an attempt to be admitted to the hospital. The closed care plan also included extensive resident centered interventions for identified behaviors. Resident 18's current care plan reviewed on 7/30/23 did not include a history of expressing suicidal ideations identified on the 5/11/22 closed care plan, specific behaviors, nor interventions to manage these behaviors. Resident 18's [NAME]…

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 it was determined the facility failed to follow physician orders for 1 of 5 sampled residents (#4) reviewed for unnecessary medications. This placed residents at risk for adverse medication consequences. Findings include: Resident 4 was admitted to the facility in 2018 with diagnoses including diabetes and chronic kidney disease requiring dialysis. 1. A 6/13/23 and revised 7/10/23 physician order indicated Resident 4 was prescribed lispro insulin (a rapid acting insulin that lowers blood glucose) before meals. A review of Resident 4's 7/1/23 through 7/26/23 DAR (diabetic administration record) indicated the resident's lispro insulin was not administered according to physician orders on the following days: -7/4 lunch dose missed; -7/6 lunch dose missed; -7/8 lunch dose missed; -7/11 lunch dose missed; -7/15 lunch dose missed; -7/18 lunch dose missed; -7/20 lunch dose missed; -7/22 lunch dose missed; -7/23 lunch dose missed. On 7/27/23 at 11:07 AM Staff 7 (RNCM) reviewed Resident 4's lispro insulin DAR and stated the resident's lispro insulin…

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 it was determined the facility failed to accurately assess and provide or offer pressure ulcer wound care for 1 of 2 sampled residents (#117) reviewed for pressure ulcers. This placed residents at risk for worsening pressure ulcers or delayed healing. Findings include: Resident 117 was readmitted to the facility in 2022 with diagnoses including malnutrition. On 12/13/22 at 10:47 AM Witness 1 (Complainant) stated Resident 117 reported the facility should have done more to prevent the resident's pressure ulcers from worsening. Resident 117's Progress Notes from 8/1/22 through 12/12/22 revealed extensive documentation of the resident's refusals of care including pressure ulcer treatment and pressure off-loading. The notes also included frequent education provided to the resident regarding the risks of refusing treatments and off-loading. Resident 117's 9/2022 TAR revealed the resident had wound treatments ordered for pressure ulcers to the left and right buttocks three times per week. The TAR indicated wound care was completed three times out of…

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

Based on observation, interview and record review it was determined the facility failed to ensure smoking care plan interventions were followed and smoking materials were stored in a safe manner for 3 of 3 residents (#s 11, 14 and 33) reviewed for smoking. This placed residents at risk for burns and smoking related accidents. Findings include: The facility's Smoking Policy and Procedure for Independent smokers, last revised 3/2020, indicated the following: -The smoking policy was communicated to the resident prior to or upon admission to the center. -Residents who were safe to smoke independently and safely manage their smoking materials were allowed to do so in a manner that was safe according to the assessment. -Residents who did not adhere to smoking policies were subject to additional interventions and safety measures, including but not limited to, revocation of their ability to smoke while a resident at the center and discharge from the center. 1. Resident 11 was admitted to the facility in 2022 with diagnoses including COPD (a lung disease causing breathing problems) 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.

Based on interview and record review it was determined the facility failed to ensure gradual dose reductions (GDRs) were attempted for residents on psychotropic medications for 1 of 5 sampled residents (#18) reviewed for unnecessary medications. This placed residents at risk for adverse medication consequences. Findings include: Resident 18 admitted to the facility in 2022 with diagnoses including schizoaffective disorder (mood disorder) and anxiety disorder. The 6/12/23 Quarterly MDS indicated Resident 18 was cognitively intact. Resident 18's current active physician orders indicated the following: - Zyprexa (antipsychotic) 20mg by mouth at bedtime. Order last updated 10/17/22 - Invega (antipsychotic) 3mg extended release one time a day. Order last updated 10/17/22 - Sertraline (antidepressant) 150mg one time a day. Order last updated 9/3/2022 A review of Resident 18's clinical record from 9/2022 through 7/2023 revealed no documentation to support or rationalize gradual dose reductions not being attempted. On 7/31/23 at 10:08 AM Staff 7 (RNCM), Staff 9 (LPN), Staff 10 (RNCM)…

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.