Fallbrook Rehabilitation and Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents (Resident #1) reviewed for infection control. The facility failed to ensure CNA L and CNA T followed appropriate infection control, hand hygiene and PPE procedure during incontinent care for Resident #1. This failure could place residents at risk for infection. Findings include: Record review of Resident #1's face sheet revealed a [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had diagnoses which include morbid (severe), obesity (A BMI of 40 plus), diabetes mellitus (high blood sugar), hypertension (high blood pressure), and cerebral infraction (brain attack caused by a blockage in a blood vessel). Record review of Resident #1'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, interview and record review the facility failed to ensure they were adequately equipped to allow residents to call for staff assistance through a communication system which relayed the call directly to a staff member or to a centralized staff work area from each resident's bedside, and toilet and bathing facilities for 1 of 5 residents (Resident #1) reviewed for call light systems. The facility failed to ensure Resident #1' s call light was properly functioning. These failures could place residents at risk of not being able to call for assistance when needed. Findings include: Record review of Resident #1's face sheet revealed a [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had diagnoses which included morbid (severe) obesity (A BMI of 40 plus), diabetes mellitus (high blood sugar), hypertension (high blood pressure), and cerebral infraction (brain attack caused by a blockage in a blood vessel). Record review of 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain nutrition, grooming and personal and oral hygiene for 2 of 4 residents (Resident #21and Resident #31) reviewed for ADLs. - The facility failed to ensure Resident #21was provided personal grooming (dry patches and flaky skin) by facility staff. - The facility failed to ensure Resident #31 was provided personal grooming (brown substance in the resident fingernails) by facility staff. These failures could place residents at risk for not receiving the assistance needed for daily care and services. Findings included: RESIDENT #21 Record review of Resident #21's face sheet dated 04/09/225 revealed a [AGE] year-old male was admitted to the on 02/17/25. Resident #21 diagnosis included: cerebral infraction (blockage in blood vessel stops blood flow to the brain), hypertension (force of blood against the walls of the arteries…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 2 of 4 residents (Resident #31 and Resident #14) observed for infection control. The facility failed to ensure EBP sign was posted on Resident #31 door and ensure PPE was set up at the residents door. The facility failed to ensure clean uncovered linen cart with linens was not stored in Resident # 14 room. These failures could place the residents at risk for infection. Findings included: Record review of Resident #31's face sheet dated 04/10/25 revealed a [AGE] year-old male was admitted to the on 03/05/25. Resident #31 diagnosis included: end stage renal disease (kidneys have stopped working well enough to support the body), hypertension (force of blood against the walls of the arteries is consistently too high), atrial fibrillation (an irregular heartbeat) and coronary artery disease (arteries that supply blood to the heart become…

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 accommodate the needs and preferences reviewed for accommodation of needs. for one resident (Resident #28) of 15 residents. The facility failed to ensure Resident #28's call light was within reach of the resident. This failure could place residents at risk of being unable to obtain assistance for activities of daily living or in the event of an emergency. Findings included: Observation and interview on 4/8/25 at 10:18 AM revealed Resident #28's call light was under his dresser on the right side of his bed. Resident #28 was observed lying in bed, he said that he just woke up and his leg hurts. The surveyor asked him to press his call-light for assistance and he said he did not even know he had a call-light. Surveyors searched for the call-light which was found under the dresser. The DON came to assist, he removed the call-light from beneath the dresser and attached the call-light to Resident #28's blanket. Resident #28 pressed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to respect the resident's right to personal privacy during care, for 1(Resident # 777) of 6 residents reviewed for privacy, in that: -LVN F failed to lock her computer during medication pass on 04/09/25, leaving Resident #777's medical records disclosed on the hallway. This failure could place resident at risk for economic harm, embarrassment, and not maintaining their individual autonomy and individuality. The findings included: Record review of Resident # 777's face sheet dated 04/11/25 revealed a [AGE] year-old female admitted to the facility on [DATE]. Resident # 777 diagnoses included the following: staphylococcal (bacteria) arthritis (swelling or tenderness in one or more joints causing pain or stiffness) of the right knee, chronic pain, anemia (low count of red blood cells {cells that carry oxygen from the lungs to the rest of the body}), hypertension (high blood pressure), heart failure, and kidney disease stage 3 (moderate loss 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 interview and record review, the facility failed to develop a person-centered baseline admission care plan for 2 of 6 residents (Resident #45 and Resident #31 ) reviewed for baseline care plans in that: -The facility failed to develop a 48-hour baseline care plan with goals, interventions, treatments, and psychosocial needs addressed in a resident specific care plan for Resident #45. - The facility failed to develop a 48-hour baseline care plan with goals, interventions, treatments, and psychosocial needs addressed in a resident specific care plan for Resident #31. This failure could affect new admissions residents reviewed for 48-hour baseline care plans of not having their individual, medical, functional, and psychosocial needs identified and cause a physical or psychosocial decline in health. Findings included: Resident #45 Record review or Resident #45's admission record dated 4/11/25 revealed a [AGE] year-old male admitted to the facility on [DATE]. Resident #45's diagnoses included hemiplegia 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 interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 7 residents (Resident #53, Resident #31) reviewed. The facility failed to ensure that Resident #53's status of hospice were a focus area in the resident's comprehensive care plan and no intervention was in place. The facility failed to ensure Resident #31 status on ADL care were a focus area in the resident's comprehensive plan and intervention was in place. This deficient practice could affect residents by contributing to inadequate care. The findings included: Resident #53 Record review of Resident #53's facility admission Record dated 4/10/25 revealed that Resident #53 was a [AGE]…

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 a resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 1 (Resident #158) of 6 residents reviewed for range of motion. -Resident #158 did not receive preventive care measures to prevent further contractures of the resident's hands. This failure placed resident at risk for impaired skin integrity, of further decline and decrease in their quality of life and quality of care. Findings include: Record review of Resident #158's face sheet dated 04/09/25 revealed a [AGE] year-old-female admitted to the facility on [DATE]. Resident diagnoses included the following: bipolar disorder (mood swings ranging from depressive lows and elevated energy), seizures, quadriplegia (loss of function in arms legs that could include the chest, abdomen, pelvis, and back). Record review of Resident #158's annual MDS dated [DATE] reflected 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 observations, interviews, and record reviews, the facility failed to ensure the resident environment remained as free of accident hazards as was possible for 1 of 3 residents (Resident #45) reviewed for accident hazards, in that: The facility failed to ensure there was no unattended container micro - kill germicidal wipes on top of the housekeeper's cart in 100 hall. These deficient practices could place residents at risk of an accidental injury. The findings were: Record review of Resident #45's face sheet dated 04/09/25 revealed a [AGE] year-old male was admitted to the on 02/15/25. Resident #45 diagnosis included: hemiplegia (paralysis that affects only one side of the body), hypertension (force of blood against the walls of the arteries is consistently too high), atrial fibrillation (an irregular heartbeat) and diabetes mellitus (body cannot regulate blood sugar levels properly). Record review of Resident #45's admission assessment dated [DATE] revealed BIMS of 13 indicating intact cognition.…

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 a resident who enters the facility with an indwelling catheter received appropriate treatment and services to prevent urinary tract infections for 2 (Resident #17, Resident #158) of 6 residents reviewed for catheters, as evidenced by: -Resident #17 did not have a STATLOCK to secure Foley catheter. -Resident #158 did not have a STATLOCK to secure Foley catheter. These failures placed the residents at risk of their Foley catheters getting dislodged, unwanted pain, trauma, infections, and decreasing their quality of life. Findings included: Resident # 158 Record review of Resident #158's face sheet dated 04/09/25 revealed a [AGE] year-old-female admitted to the facility on [DATE]. Resident diagnoses included the following: acute (illness that develops quickly) and chronic (lasting for a long time) respiratory failure with hypoxia (lack of oxygen to sustain bodily functions), neuromuscular (affecting the nerves controlling the…

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

Based on observation, interview and record review, the facility failed to ensure that drugs and biologicals used in the facility were stored properly in accordance with professional standards of practice in one of two medication rooms (Hall 100), reviewed for labeling and storage of drugs and biologicals, in that: -Medication room on hall 100 had expired medications. These failures placed residents on Hall 100 at risk of receiving expired medications and adverse reactions. Findings Include: Observation on 04/09/25 at 7:15AM on Hall 100 medication storage room revealed there were 3 expired hydrocortisone acetate 25mg suppositories. The expiration date on the medication was dated 03/2025. Interview on 04/09/25 at 7:25AM with LVN H said it was the DON that was supposed to be checking the medication rooms for any expired medications. LVN H said if a resident is administered an expired medication, it placed the resident at risk of not receiving the full intended dose of the medication or it could place the resident at risk for unwanted adverse side effects. Interview on 04/09/25 at…

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

Based on observation, interview and record review, the facility failed to dispose of garbage and refuse properly for 1 out of 3 dumpsters, dumpster A. -On 4/8/2024 at 8:08am, one of the facility's dumpster was observed with no lid attached or on it and was a quarter full. This failure has the potential to affect 54 residents in the facility, staff, and visitors by placing them at risk for infection and a decreased quality of life due to having an exterior environment which could attract pests, rodents and other animals. Findings included: Observation on 4/8/25 at 8:08am, Surveyor A and [NAME] A observed the facility dumpster area, which was in the lot behind the dietary department. The facility stand-alone dumpster was not covered. The lid was detached and placed on the side next to the dumpster. Observation on 4/9/25 at 8:47am, the right lid to the same dumpster was open. It was marked in white chalk 4/09. Interview with [NAME] A on 4/8/25 at 8:08am, she said she did not know why the dumpster was open. [NAME] A said that not closing the lids could attract rodents because of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation for 1 (CR #1) of 7 residents reviewed for controlled drugs in that: -The facility failed to appropriately store CR #1's Norco oral tablet 5-325mg (Hydrocodone -Acetaminophen- medication classified as a schedule II drug (high potential for addiction and abuse) used to treat pain and also used as a cough suppressant) in the DON's office under double lock when CR #1 was discharged to the hospital on [DATE] and returned to the facility 06/21/24. It was discovered on 06/29/24 that the medication was missing after CR #1 requested pain medication. -The facility Nursing staff failed to have completed signatures on their Controlled Drugs-Count Record for the month of June 2024 regarding 7am oncoming nurse and 7pm off going nurse for 6/18/24, 6/20/24, 6/24/24, 6/25/24, and 6/28/24. This failure could place residents at risk…

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 Resident #16 Review of Resident #16's face sheet dated 02/06/24 reflected a [AGE] year-old female who was initially admitted to the facility on [DATE] and 12/23/23 with diagnoses including quadriplegia (paralysis of all four limbs), hypoxia (a condition in which the human body tissues are not oxygenated sufficiently to maintain adequate homeostasis), muscle weakness (generalized), seizures( sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain), familial dysautonomia ( a nervous system disorder that disrupts autonomic body processes), bipolar disorder ( mental illness that causes unusual shifts in a person's mood, energy) unspecified, aphasia ( unable to speak), tracheostomy( a procedure to help air and oxygen reach the lungs by creating an opening into the trachea( windpipe) from outside the neck), tachycardia ( a heart rate over 100 beats a Minute), gastrostomy( a surgical procedure used to insert a tube, often referred to as a G-tube).…

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 a resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent decrease in range of motion for 1 of 5 residents (Resident #16) reviewed range of motion. -The facility failed to ensure Resident #16, with contractures to both hands, was wearing a hand rolls on both hands and off load bilateral heels. as care planned and ordered by the physician. - This failure could place resident at risk for further contractures of the hands and fingers, pain, and a decrease in quality of life. Findings included: Review of Resident #16's face sheet dated 02/06/24 reflected a [AGE] year-old female who was initially admitted to the facility on [DATE] and 12/23/23 with diagnoses including quadriplegia (paralysis of all four limbs), hypoxia (a condition in which the human body tissues are not oxygenated sufficiently to maintain adequate homeostasis), muscle weakness (generalized),…

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 Residents who are incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 2 of 2 residents ( Resident #16 and Resident #89) reviewed for incontinent care, in that: CNA B did not separate Resident #16's labia to clean during incontinent, clean arround the buttocks and did not perform appropriate hand hygiene with glove changes throughout the care CNA A did not separate Resident # 89's labia to clean during incontinent, clean arround the buttock and did not perform appropriate hand hygiene with glove changes throughout the care. This deficient practice could affect residents who received perineal care( the skin in between your genital and your anus) and place them at-risk of increased urinary tract infections due to improper care. The findings included: Review of Resident #16's face sheet dated 02/06/24 reflected a [AGE] year-old female who was initially admitted to the facility 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, interview, and record review the facility failed to ensure that a resident who needed respiratory care and services was provided such care, consistent with professional standards of practice for 1 of 4 residents (Resident #6) reviewed for respiratory therapy in that: The facility failed to ensure Resident # 6's concentrator filter was not covered with a substantial amount of dust. This failure placed residents who received oxygen therapy at risk of respiratory complications. Findings include: Record review Resident #6's face sheet dated 01/03/24 revealed a [AGE] year-old male initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #6 had diagnoses which included cerebral infarction (disrupted blood flow to the brain), aphasia(a language disorder caused by damage in a specific area of the brain that controls language expression), hypertension (blood vessels have persistently raised pressure) and chronic obstructive pulmonary disease(group of diseases that cause…

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

Based on observation, interview, and record review the facility failed to ensure that drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 2 of 4 medication carts (skilled unit MA cart, 300 hall nurse cart, and 200 hall nurse cart) reviewed for medication storage. - The 300-hall nurse's cart contained an opened fluticasone propionate nasal spray with no discard date. Cyclosporine ophthalmic emulsion 0.05% was not in the complete original packet. A box of quality choice original eyelid cleansing wipes did not have a visible expiration date. -The 200-hall nurse's cart contained a box of quality choice original eyelid cleansing wipes without a visible expiration date. These failures could place residents at risk of adverse medication reactions. Findings included: During observation and interview on 02/07/24 at 4:40 p.m., the 300-hall nursing cart with RN B revealed a bottle of fluticasone propionate nasal spray…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain an infection control program designed to prevent the development and transmission of infections for 2 of 2 residents (Resident #16 and #89) reviewed for infection control. 1.CNA B failed to perform hand hygiene appropriately while providing incontinent care for Resident #16 by not changing gloves and washing hands. 2.CNA A failed to perform hand hygiene appropriately while providing incontinent care for Resident #89 by not changing gloves and washing hands. These failures could place residents at risk for transmission of diseases and organisms. The findings included: Review of Resident #16's face sheet dated 02/06/24 reflected a [AGE] year-old female who was initially admitted to the facility on [DATE] and 12/23/23 with diagnoses including quadriplegia (paralysis of all four limbs), hypoxia (a condition in which the human body tissues are not oxygenated sufficiently to maintain adequate homeostasis), muscle weakness (generalized),…

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 accurately assess each resident's status for 1 of 5 Residents (Resident #1) reviewed for assessment accuracy in that: 1. Resident #1's quarterly MDS assessment dated [DATE] did not correctly assess his diagnoses. This failure could place residents at risk of not receiving the proper care treatments, and interventions due to inaccurate records. Findings include: Record review of Resident #1 admission record revealed he was a [AGE] year-old male. He was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included cerebral infarction (disrupted blood flow to the brain), unspecified, acute respiratory failure (impairment exchange between gas and lungs) with hypoxia (insufficient amount of oxygen), type 2 diabetes (body not producing enough insulin) mellitus (excess amount of sugar passing through blood and urine) without complications, essential (primary) hypertension (elevated blood…

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 The facility did not ensure Resident #64's care plan addressed her pain management, her high risk for developing pressure ulcers, or her developement of a pressure ulcer. Based on observation, interview, and record review the facility failed to accurately list Resident #1's C. auris diagogois for 1 of 5 Residents (Resident #1) reviewed for isolation precuasion: 1. The facility failed to care plan Resident #1's C. auris diagnosis. This failure could place the census of 56 residents at risk for unmet care needs. Finding include: Record review of Resident #1's admission record revealed he was a [AGE] year-old male. He was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included cerebral infarction (disrupted blood flow to the brain), unspecified, acute respiratory failure (impairment exchange between gas and lungs) with hypoxia (insufficient amount of oxygen), type 2 diabetes (body not producing enough insulin) mellitus (excess amount of sugar passing…

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 accurately assess each resident's status for 1 of 5 Residents (Resident #1) reviewed for assessment accuracy in that: 1. Resident #1's Facesheet dated 08/18/2023 did not correctly assess his diagnoses. 2. Resident #1's Diagnosis dated 08/18/2023 did not correctly assess his diagnoses. This failure could place residents at risk of not receiving the proper care treatments, and interventions due to inaccurate records. Finding include: Record review of Resident #1's admission record revealed he was a [AGE] year-old male. He was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included cerebral infarction (disrupted blood flow to the brain), unspecified, acute respiratory failure (impairment exchange between gas and lungs) with hypoxia (insufficient amount of oxygen), type 2 diabetes (body not producing enough insulin) mellitus (excess amount of sugar passing through blood and urine)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection for 1 (Resident #1) of 5 resident reviewed for infection control in that: Licensed Vocational Nurse (LVN) failed to properly remove her gown and wash or sanitize her hands when moving from a dirty area to a clean area after she had changed the gastrostomy tube (g-tube) feeding machine tubing and pulling back the resident's sheet for Resident #1 who was on the isolation precaution. This deficient practice could place 5 residents at risk for cross contamination and/or spread of infection. Finding include: Record review of Resident #1's admission record revealed he was a [AGE] year-old male. He was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included cerebral infarction (disrupted blood flow to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain a safe, comfortable, and homelike environment for 4 residents of 20 residents (Resident #10, #49, #19 and #7), reviewed for environment, in that: The facility failed to maintain an ambient air temperature range of 71 degrees to 81 degrees Fahrenheit in the 300 hallway, the dining room and in resident rooms. The failure could place residents at risk of loss of body heat and of a decrease in quality of life. Findings included: Resident #10 Record review of Resident #10's admission Record revealed a [AGE] year-old-male admitted on [DATE] and originally admitted on [DATE]. His diagnoses included: stroke, muscle weakness, bipolar disorder, thyroid disorder, hypertension, obesity, psychosis, manic episode, mood disorder, paralysis of limbs, nerve damage, edema, diabetes, GERD and BPH. Record review of Resident #10's annual MDS dated [DATE] revealed a BIMS score of 15 indicating he was cognitively intact. He required extensive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 1 of 10 residents (Resident #1 ) and 4 of 4 medication storage areas (100 Hall Med Cart 1, 200 Hall Med Cart 1, 200 Hall Med Room, and 300 Hall Med Cart #2) reviewed for pharmacy services. - The facility failed to ensure the medication carts and med rooms did not include expired insulin for Resident #3, Resident #14, Resident #41, Resident #100 and Resident #105 - LVN D administered Heparin ( a blood thinner) to Resident #1 that had no open date. These failures could place residents at risk of not receiving the therapeutic benefit of medications and/or adverse reactions to medications. Findings Included Resident #1 Record review of Resident #1's Face Sheet dated 09/06/22 revealed, a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which…

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

Based on observation, interview, and record review, the facility failed to ensure that the medication error rate was not five percent (%) or greater. The facility had a medication error rate of 9 percent based on 3 errors out of 31 opportunities, which involved 3 of 5 residents (Resident #1, Resident #2 and Resident #11); and 3 of 5 staff (LVN A, LVN B and LVN D ) reviewed for medication errors. - LVN D failed to ensure medication administered to Resident #1 had a Physician's order. - LVN A failed to administer the correct eye drop to Resident #2. - LVN B failed to administer the correct multivitamin to Resident #11. These failures could place residents at risk of inadequate therapeutic outcomes, increased negative side effects, and a decline in health. Findings included: Error #1 An observation on 12/13/22 at 08:53 AM revealed, LVN D preparing medication for administration to Resident #1 via G-tube, she prepared the solid medications and poured 15 ml of Chlorohexidine 0.12% in individual cops and entered into the resident's room. After administering the medications via G-tube 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 observation, interview, and record review, the facility failed to ensure that drugs and biologicals were labeled in accordance with professional principles and stored in locked compartments under proper temperature controls for 4 of 4 medication carts. (100 Hall Nursing Cart 1 , 200 Hall Med Cart 1 ,300 Hall Nursing Cart 1 and 300 Hall Med Cart 2) and 1 of 2 Medication Rooms (200 Hall Medication Room) reviewed for medication storage. - The facility failed to ensure the 100 Hall Nursing Cart did not contain inappropriately labeled insulin, and pudding without an open date - The facility failed to ensure the 200 Hall Med Cart 1 was locked when not in use and did not contain medications without an open dates and prescription medications without pharmacy labeling - The facility failed to ensure the 300 Hall Med Cart 1 was locked when not in use and did not contain insulin without an open date. - The facility failed to ensure the 300 Hall Med Cart 2 did not contain insulin without an open date. These…

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 accurately assess each resident's status for 1 of 17 Residents (Resident #24) reviewed for assessment accuracy in that: -Resident #24's Quarterly MDS dated [DATE] did not accurately assess his absence of natural teeth. -This failure could affect residents at the facility who had been assessed and place them at risk of not receiving the proper care and services due to inaccurate assessments. Findings Include: Resident #24 Record review of Resident #24's face sheet revealed he was a [AGE] years old male admitted to the facility on [DATE] with diagnoses that included Peripheral Vascular Disease(slow and progressive circulation disorder), Chronic Obstructive Pulmonary Disease(inflammatory lung disease), Cerebral Infarction(ischemic stroke), Hypercholesterolemia (high cholesterol), Hypothyroidism, Hypertension(high blood pressure), Unspecified Atrial Flutter(heart rhythm disorder), Hemiplegia (lack of control in one side of the body), 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 interview and record review, the facility failed to ensure they coordinated with the appropriate, State-designated authority, to ensure that individuals with a newly diagnosed mental disorder received care and services in the most integrated setting appropriate to their needs for 1 (Resident #10) of 2 residents reviewed for PASSR. The facility failed to complete and submit an accurate PASRR Level 1 for Resident #10 when he was newly diagnosed with a mental illness. This failure could place residents who had a positive PASRR Level 1 or residents with a diagnosis of mental illness at risk for not receiving care and services to meet their needs. Findings included: Record review of Resident #10's admission Record revealed a [AGE] year-old-male admitted on [DATE] and originally admitted on [DATE]. Record review of Resident #10's PASRR Level 1 Screening dated 01/14/2020 completed by the facility revealed Section C was answered No for mental illness, intellectual disability and developmental disability. Record…

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 develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 (Resident #38) of 20 residents reviewed for care plan in that: The facility failed to develop an individualized care plan for activities for Resident #38. This failure could place residents at risk of a diminished quality of life leading to a variety of emotional and physical problems/issues. Findings included: Record review of resident #38's face sheet revealed a [AGE] year-old female who was initially admitted on [DATE] and readmitted on [DATE]. Her diagnosis was dementia (a condition characterized by progressive or persistent loss of intellectual functioning), behavioral disturbances, and mood disorders with major depression (depression is 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, the facility failed to maintain a quality assessment and assurance committee consisting at a minimum the required committee members for 1 of 2 quarters reviewed for committee attendance, in that: The infection preventionist was not present for QAPI meetings from May 2022 to August 2022. This failure could place residents at risk of infections. Findings included: Record review of the QAPI Committee sign-in sheets revealed the IP never signed in for their meetings from May 2022 - August 2022. In an interview on 12/16/22 at 3:29PM, the Administrator stated the IP was hired as an IP staff in the month of February 2022. When asked if she was required to be present for the meetings, she said she would need to check the policy to see what it said. In an interview on 12/16/22 at 3:35PM the HR staff stated the IP was their only staff with an IP certification and she was hired this year. Record review of the QAPI meeting notes from May, June, July, August of 2022 revealed during those…

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.