Valley Center

Based on record view and staff interview, the facility failed to ensure informed consent was obtained for psychotropic medications. This was found true for two (2) of five (5) residents reviewed. Resident #12 and Resident #46. Facility census: 122. a) Resident #12 A record review for Resident #12 revealed a physician order for Buspirone HCl 5 mg (milligram), to be administered as one (1) tablet by mouth. Further review of the clinical record revealed no documented evidence of informed consent for the use of Buspirone. Documentation indicated the medication was initiated on 03/01/26; however, there was no evidence that informed consent had been obtained prior to initiation of the medication. This finding was confirmed with the Director of Nursing (DON) on 04/01/26 at approximately 3:45 PM. Findings included: b) Resident #46 A record review for Resident #46 on 04/06/26 found the following physician order: Olanzapine oral tablet disintegrating 5 MG (Olanzapine) Give one (1) tablet by mouth at bedtime for antipsychotic. On 04/06/26 at 11:11 AM the surveyor asked the Director of Nursing…

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 observation, the facility failed to ensure call lights were within reach for dependent residents. This failed practice had the potential to affect a limited number of residents. Resident Identifiers: #19 and #47. Facility Census: 125.Findings included: a) Resident #19 On 06/03/26 at 12:25 PM, Resident #19's call light was not in reach. The call light was on the opposite side of the bed across from the resident who was sitting in her wheelchair. The Administrator confirmed the call light was not in reach and moved it within the resident's reach. The call light had been placed out of reach across the bed on the resident's paralyzed side. b) Resident #47 On 06/03/26 at 6:30 PM, Resident #47's call light was observed on the floor. At 6:35 PM, Activities Director #166 confirmed the call light was on the floor and picked it up, placing it within reach of the resident. The facility's policy and procedure for Call Lights stated, 4. Staff will ensure the call light is within reach of the patient and secured as needed.

Based on record review and interview, the facility failed to honor Resident #49's bathing choices from 03/23/26 to 03/31/26. This was true of one (1) of five (5) residents sampled for choices during the Long-Term Care Survey Process. Census: 122 Resident identifier: #49Findings include: a) Resident #49 Resident #49's care plan from 02/03/26 stated the resident prefered to take a shower.The bathing task for the month of March shows Resident #49 had a shower twice per week by Nurse Aide (CNA) #15 from 03/01/26 through 03/22/26. After that date, Resident #49 only had bed baths. Further, the bathing tasks showed there were no refusals of showers during that time frame. In an interview with Resident #49 and her son on 03/31/26 at 10:02 AM, she stated she only gets showers when NA #15 is working. She further stated she had not been asked if she wanted a shower since 03/22/26. An interview with Director of Nursing (DON) confirmed that according to documentation, Resident #49 has not been offered a shower since 03/22/26.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Number of residents sampled: Number of residents cited: Based on record review and staff interview, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs. This was true for one (1) of five (5) residents reviewed under the Unnecessary Medications Pathway throughout the Long-Term Care Survey Process. Resident identifier: #46. Facility Census: 122 Findings included: a) Resident #46 A record review, completed on 04/06/2026 at 10:00 AM, revealed:-The following physician order, dated 03/19/2026: Olanzapine Oral Tablet Disintegrating 5 MG Give 1 tablet by mouth at bedtime for antipsychotic.-On 03/20/2026 at 2:32 PM, the consulting pharmacist recommended a Gradual Dose Reduction of Resident #46 (Olanzapine). A Gradual Dose Reduction (GDR) refers to the stepwise tapering of a medication dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued.-On 03/20/2026, the attending physician agreed to and signed off 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 record review and staff interviews, the facility failed to ensure the Minimum Data Set (MDS) accurately reflected the residents' current condition. This was true for two (2) of 39 residents sampled for accuracy of assessments during the Long-Term Care Survey Process. Census: 122 Resident identifier: #31, #57Findings included: A) Resident #31 A1) Section GGThe significant change Minimum Data Ser (MDS) dated [DATE] section GG, shows resident is ambulating 10 feet with supervision. A physical therapy Discharge summary dated [DATE] reveals Resident #31 was able to stand without moving in the parallel bars, but unable to take steps at that time.In an interview with Physical Therapist Assistant (PTA) #122 on 04/06/26 at 3:04PM, he stated Resident #31 has not been able to walk since the fractures occurred. A2) Section IThe same MDS, section I, does not have other fractures box checked indicating that Resident #31 does not have any fractures at the time of the MDS.Resident #31's diagnosis list includes fourth…

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 interview the facility failed to coordinate with the appropriate State-designated authority, to ensure that individuals with a mental disorder, intellectual disability or a related condition received care and services in the most integrated setting appropriate to their needs when completing/revising a Pre-admission Screening and Resident Review (PASARR). This was true for 1 of 30 residents sampled. Resident Identifier: #66. Facility census: 122. Findings Included:a) Resident #66On 04/01/26 at 11:00 AM record review found Resident #66 had the following medical diagnosis:Psychoactive Substance AbuseReview of the PASARR dated 04/01/26 found that this diagnosis was not identified on the PASARR.The above information was confirmed with The Social Worker on 04/02/26 at 10:00AM, who agreed that the additional medical diagnosis should have been on the PASARR.

Based on record review, staff interview and resident interview, the facility failed to develop a baseline care plan for a resident ordered oxygen therapy by the physician. This failed practice had the potential to affect a limited number of residents. Resident Identifier: #29. Facility Census: 125.Findings included: a) Resident #29 On 06/03/26, Resident #29's medical record was reviewed for oxygen therapy. Oxygen therapy orders were reviewed by the state surveyor. The resident's orders stated, Incentive Spirometer - encourage patient to use as often as tolerate, every day shift Pre tx: Evaluate heart rate, respiratory rate, Pulse Oximetry and Lung sounds in supplementary documentation. and Oxygen at 2 L/min Nasal Cannula, every shift for Shortness of Breath. The resident's baseline care plan was reviewed for oxygen therapy. No focus, goals or interventions were listed on the baseline care plan for oxygen therapy. The care plan was reviewed and confirmed with Corporate Registered Nurse #19 and the Director of nursing (DON). The federal regulatory guidelines for a baseline care plan…

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

Based on resident interview, staff intervew and record review, the facility failed to revise a care plan to indicate Resident #24's preference for night time care. This was true for one (1) of 39 residents reviewed during the survey process. Resident Identifier: #24. Facility Census: 122. Findings Include: a) Resident #24 On 04/06/2026 at 2:00 PM, a record review was completed for Resident #24. Also, a review of a facility-reported incident (FRI) dated 12/08/25 was reviewed. The allegation of neglect was noted in the FRI for Resident #24 regarding incontinence care at night time. The resident was interviewed on 04/06/26 at approximately 3:00 PM regarding the allegation of neglect. The resident stated, you know how it is .I don't remember that but I'm sure if I said it .it must have happened. An interview was held with the Social Services Director (SSD) on 04/06/26 at 3:00 PM. The SSD was asked, did you find any evidence the allegation of neglect was verified? The SSD stated, let me look over it. On 04/06/26 at 3:30 PM, an interview was held with the Administrator. The Administrator…

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, staff interview, and family interview, the facility failed to ensure necessary activities of daily living (ADL) care, including personal hygiene and grooming, for two (2) of eight (8) of sampled residents. This was found true for Resident #87 and Resident #96. Facility census 122.a) Resident #87 On 03/31/2026 at approximately 2:24 PM, an interview was conducted with the resident's wife, who reported observing the resident with a dirty face, neck, and hands, as well as soiled bedding. She further stated that the resident's fingernails were long and untrimmed and reported observing scratches behind the resident's right ear, which she attributed to the resident scratching. The resident's wife indicated she personally trimmed the resident's fingernails, cleaned his face and neck, and requested staff assistance to change the resident's shirt and bedding. The reported observations indicate the resident was not maintained in a clean and well-groomed condition, and grooming needs, including nail care, were not adequately addressed by facility staff. The presence 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 and staff interview, the facility failed to ensure access to fluids at bedside for one (1) resident, placing the resident at risk for inadequate hydration. This was found at a random opportunity for discovery. This was found true for one (1) resident. Resident identifier: #77. Facility census: 122. a) Resident #77On 03/31/2026 at 3:07 PM, observation of the resident's room revealed no water present at the bedside. At approximately 3:15 PM, the observation was reviewed with LPN #16, who confirmed that no water was present at the bedside at the time of observation. There was no evidence to indicate that fluids had been recently offered or were readily accessible to the resident.Water was subsequently provided to the resident following surveyor intervention.

Based on record review and staff interview, the facility failed to ensure an ongoing assessment of Resident #17's condition before, during and after dialysis treatment. This was true for one (1) of one (1) residents sampled for dialysis. Census: 122 Resident Identifier: #17Findings include: a) Resident #17 A policy titled Dialysis: Hemodialysis (HD)-Communication and Documentation, states following completion of the HD, the dialysis facility should complete and return the form and/or other communication to the Center with the patient. Upon return of the patient to the Center, a licensed nurse will:-Review the certified dialysis facility communication;-Evaluate/observe the patient; and -Complete the post-hemodialysis treatment evaluation using the Hemodialysis Communication Record.-Notify the certified dialysis facility if information about the patient is not returned with the patient and ask that it be faxed to the Center.-Document notification of certified dialysis facility regarding return of the form or other communication. Upon reviewing the Hemodialysis Communication Records…

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

Based on observation and staff interview, the facility failed to ensure that the resident was served foods consistent with the prescribed diet order, placing the resident at risk for choking and aspiration. This was found true of two (2) of two (2) residents reviewed. Resident #110 and Resident #114. a) Resident #114During dining observation, on 3/31/26 at approximately 12:30 PM it was noted that Resident #114, who was ordered a Dysphagia Advanced (Dys Adv) diet, was served whole grapes. The facility's diet guidelines indicate that foods should be provided in an appropriate consistency for a Dysphagia Advanced diet, such as applesauce or other modified textures, to reduce the risk of choking.Through surveyor intervention, whole grapes were removed from resident access and applesauce was substituted. This observation was confirmed with, Dietary Manager (DM), at 12:43 PM on 03/31/2026.b) Resident #110On 04/02/2026 at 12:25 PM, the surveyor observed that Resident #110, who was prescribed a Dysphagia Advanced (Dys Adv) diet, was served whole orange slices. Review of the dietary…

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 policy, observation, and resident and staff interviews, the facility failed to provide services to ensure Resident #49's physical needs were met by failing to provide lunch to Resident #49. This was true for one (1) of 13 residents sampled for abuse during the Long-Term Care Survey Process. Census: 122 Resident Identifier: #49Findings include: A policy titled Resident Rights Under Federal Law, states Patients/Residents (hereinafter resident) have the fundamental right to considerate care that safeguards their personal dignity along with respecting cultural, social, and spiritual values. At 12:43PM on 04/07/26, State Surveyor went in to Resident #49's room to observe lunch. Resident #49's son was present and stated that no one had been in the room yet to offer lunch to Resident #49. Interview with Certified Nurse Aide (CNA) #86 at 12:45PM, confirmed the aides were done passing trays on that particular hall. State Surveyor went to the lunch cart and found resident's tray on the cart with the ticket torn. A torn ticket indicates a refusal of a tray. In interviews with CNA #86,…

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

Based on observation and interview, the facility failed to ensure accurate pain assessment, timely reassessment, administration of medications in accordance with physician orders, and maintenance of an accurate medical record for one (1) of four (4) resident reviewed (Resident #48). Facility census: 122. a) Resident #48On 03/31/26 at approximately 10:30 PM, surveyors observed Resident #48 in his room. During this observation, the resident verbalized, I am in pain and My legs are hurting, A review of the clinical record revealed that Nurse #13 administered Tylenol 325 mg orally at 10:24 PM. Documentation further indicated that Nurse #13 completed a pain assessment at 10:24 PM, with the resident's pain level recorded as zero (0) at that time. This documented pain level is not consistent with the resident's subsequent verbal reports of pain observed at 10:30 PM. There is no documented evidence that a follow-up pain assessment or reassessment was completed after the resident voiced complaints of pain.Additionally, review of physician orders indicated Ativan 1 mg was prescribed 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.

Based on family interview, record review and staff interview, the facility failed to notify the resident's representative of two (2) significant changes for Resident #123. This was true for one (1) of one (1) residents reviewed during the survey process. Resident identifier: #123. Facility Census: 122. Findings Include: a) Resident #123 On 05/14/25 at 10:39 AM, an interview was held with Resident #123's representative. The representative stated, They (the facility) didn't call me when two (2) different incidents happened to (Resident #123). I was very upset and felt someone should have called me. On 05/14/25 at 11:35 AM, a record review was completed. The review found a physician determination of capacity dated 05/27/23, which indicated the resident lacked capacity due to Alzheimer's disease. The review, also, found the resident representative was not notified about two (2) changes in conditions. The first change in condition was on 02/12/25, when the resident was noted with an elevated pulse/heart rate while resting. The second change in condition was on 02/21/25, when the 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 record review and staff interview, the facility failed to ensure an accurate MDS assessment in the area of discharge destination. This deficient practice had the potential to affect one (1) of four (4) residents reviewed for the care area of hospitalization. Resident identifier: #117. Facility census: 124. Findings included: a) Resident #117 Review of Resident #117's medical records showed the resident was discharged home with home health on 08/21/24. Resident #117's Discharge Return Not Anticipated Minimum Data Set (MDS) Assessment with Assessment Reference Date (ARD) 08/21/24 stated the resident was discharged to the hospital. On 10/08/24 at 3:18 PM, the Administrator confirmed the discharge destination on the MDS was incorrect. The Administrator confirmed the resident was discharged home instead of to a hospital. She stated the MDS was corrected.

Based on record review and staff interview the facility failed to identify Bipolar Disorder on one (1) of three (3) Preadmission Screening and Resident Review (PASARR) reviewed during the Long Term Care Survey Process. Resident identifier: #48. Facility Census: 123. Findings Include: a) Resident #48 During record review, on 10/08/24 09:10 AM, a review of Resident #48's medical diagnoses revealed the following: - UNSPECIFIED DEMENTIA, UNSPECIFIED SEVERITY, WITH OTHER BEHAVIORAL DISTURBANCE -DELUSIONAL DISORDERS -BIPOLAR DISORDER, CURRENT EPISODE MIXED, MODERATE -ANXIETY DISORDER, UNSPECIFIED -MAJOR DEPRESSIVE DISORDER, RECURRENT, UNSPECIFIED -UNSPECIFIED DEMENTIA, UNSPECIFIED SEVERITY, WITH AGITATION Further review of Resident #48's medical record showed the PASARR completed on 08/20/24 did not identify Bipolar Disorder. An interview, on 10/08/24 at 9:20 AM, with the administrator and Director of Nursing (DON) confirmed bipolar disorder was not coded on the PASARR.

Based on record review and staff interview, the facility failed to revise a care plan regarding the discontinuation of an anticoagulant. This was true for one (1) of three (3) residents reviewed under the care area of hospitalizations. Resident Identifier: #74. Facility Census: 124. Findings Include: a) Resident #74 On 10/09/24 at 9:30 AM, a record review was completed for Resident #74. The review found a focus area on the care plan noted as Resident is at risk for injury or complications related to the use of anticoagulation therapy lovenox. Upon further review, the anticoagulation medication (Lovenox) was discontinued on 09/29/24. The care plan had not been revised to indicate the Lovenox had been discontinued. On 10/09/24 at 10:50 AM, the Director of Nursing (DON) confirmed the medication had been discontinued and the care plan had not been revised.

Based on observation, staff interview and record review, the facility failed to document the refrigerator and room temperatures in the South medication room. This was a random opportunity for discovery. Facility Census: 124. Findings Include: a) South Medication Room On 10/08/24 at 10:05 AM, a tour of the South medication room was completed. During the tour, the medication refrigerator and room temperatures were not documented for the following dates: --10/01/24 AM room temperature --10/03/24 PM refrigerator temperature --10/07/24 PM room temperature --10/08/24 AM room temperature On 10/08/24 at 10:22 AM, the Director of Nursing (DON) was notified and confirmed the refrigerator and room temperatures should be documented.

Based on record review and staff interview, the facility failed to maintain accurate and complete medical records for Resident #222. This is true for one (1) of 27 residents reviewed under the care area of advance directives. Resident identifier: #222. Facility Census: 124. Findings Include: a) Resident #222 On 10/08/24 at 8:30 AM, a record review was completed for Resident #222. The review found that the Physician's Order for Scope of Treatment (POST) was not complete. The signature of the Medical Power of Attorney (MPOA) was not dated. On 10/08/24 at 8:58 AM, the Director of Nursing (DON) was notified and confirmed the POST form was missing the date of the MPOA's signature.

Based on observation, record review and staff interview, the facility failed to maintain an appropriate infection control program for blood glucose monitoring. This was a random opportunity for discovery. Facility Census: 124. Findings included: a) Resident #76 On 10/07/24 at 12:06 PM, an observation was made of Registered Nurse (RN) #3 monitoring a blood glucose for Resident #76. RN #3 was not wearing gloves while checking the blood glucose and did not perform hand hygiene prior to or after the blood glucose was obtained. On 10/07/24 at 12:12 PM, an interview was held with RN #3. RN #3 stated, I've been a nurse for a long time, and I never wear gloves when I check blood sugars. On 10/07/24 at 12:20 PM, the Director of Nursing (DON) and the Administrator were notified. Both the DON and Administrator confirmed RN #3 should be wearing gloves and performing hand hygiene while completing the task of monitoring a blood glucose test. b) Centers for Disease Control and Prevention (CDC) Guidelines On 10/07/24 at 12:30 PM, the CDC guidelines were reviewed regarding wearing gloves and 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 Based on record review, observation and staff interview the facility failed to ensure the environment was free of accident hazards. Medicated items were identified to be left out accessible to wandering residents during a complaint survey. This was determined for more than an isolated number of residents identified to be at risk for wandering in the facility. Twenty-five (25) residents were identified to have wandering tendencies. had wandergards. Census: 121. Findings included: a) During a tour of the facility on 09/23/24 at approximately 11:45 AM the following rooms were identified to contain items intended for medical use that were readily visible and easily accessible in the residents' rooms as well as numerous personal hygiene items that were not labeled and or stored within reach of wandering residents. - room [ROOM NUMBER] Medline Aplicare Hydrogen Peroxide 3% was readily visible and easily accessible on the bed side nightstand. There was not a name marked on the container to identify who it belonged to.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview the facility failed to ensure residents received treatemt and care in accordance with professional standards of pratcie, the comprehensive care plan and resident choices. Resident #49's medication was not available. Resident #33 did not receive insulin as ordree for elevated blood sugar. For Resident #125 the facility failed to ensure the residents wishes according to the Physician Orders for Scope of Treatment (POST) forms orders that were followed. The facility failed to ensure Resident #26's physician orders were followed for skin integrity and fracture stability. Advanced Directive orders did not match the POST for Resident #71 and Resident #44. Insulin administration was not documented for Resident #33. These failed practices had the potential to affect more than a limited number of residents. Resident identifiers: #125, #26, #71, #44, #49 and #33. Facility census: 129. Findings included: a) Resident #49 During medication pass observation on [DATE] at 8:53 AM,…

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

Based on observation, and staff facility failed to ensure the environment was free of accident hazards. Resident #41's medication was left unattended in Resident room. A treatment cart and mediation cart were found unlocked and unattended. This failed practice was a random opportunity for discovery and had the potential affect more than a limited number of residents. Resident identifier: #41. Facility census: 129. Findings included: a) Resident #41 On 04/08/24 at 1:11 PM, Surveyor observed a Spiriva inhaler on Resident #41's over the bed table. Resident #41 stated, The nurse left it here this morning. It's probably not supposed to be here, they usually take it with them. Charge Nurse Supervisor Registered Nurse (RN) #9 answered call light and verified the medication in the room belonged to Resident #41 and removed it. RN #9 stated, I wasn't the one the one passed medications this morning and left it here, but I'll take it and put it up. RN #9 verified the Resident did not have an order for the inhaler to be left at bedside. Record review showed an order for Spiriva Handi-Haler…

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 interview, the facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) form to two (2) of three (3) residents reviewed for the facility's beneficiary protection notification practice during an annual survey. This failure placed residents at risk of not being informed of their rights prior to the end of Medicare Part A covered services. Resident Identifiers: #28 and #19. Facility census: 129 Findings included: a) Beneficiary Notice Review On 04/10/24 at 2:22 PM, a review was completed regarding the beneficiary protection notification liability notices given for the following two (2) residents who remained at the facility following their last covered day of Medicare Part A services: - Resident #28 began Medicare Part A skilled services on 10/18/23. The last covered day of Part A service was 11/10/23. Notice of Medicare Non-Coverage (NOMNC) was signed and dated on 11/08/23. There was no evidence a SNF ABN form had been provided and signed. - Resident #19 began Medicare Part A skilled service…

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, resident interview, and staff interview, the facility failed to ensure that all alleged violations involving verbal abuse were reported to the appropriate state agencies. This was true for one (1) of five (5) residents reviewed under the abuse pathway in the Long-Term Care Survey Process. Resident identifier: 95. Facility census: 129. Findings included: a) Resident #95 Review of the facility grievance log, completed on 04/09/24 at 9:30 AM, found a grievance dated 01/15/24. Review of the grievance form revealed, Nurse informed resident that she had an odor and that she needed a shower in front of her friends. Actions taken to investigate the grievance were listed as, NHA (Nursing Home Administrator) and DON (Director of Nursing) addressed and interviewed those around and the CNA (Certified Nursing Assistant) that was around. Corrective action taken was to re-educate the nurse with an individual performance improvement plan (IPIP). The description of event on the IPIP was listed as, Resident had complaint that she was addressed in front of other residents in…

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.

c) Resident 116 An observation on 04/08/24 at 1:18 PM, of Resident #116's lunch tray in front of her showed Resident #16 had not taken a bite of her food. During A record review on 04/08/24 at 3:00 PM, of Resident #116's medical record revealed the following weights: 04/5/24 8:39 AM, 80.6 P pounds (Lbs) with Mechanical Lift (ML) 03/27/24 4:18 PM, 80.8 Lbs with Wheelchair (WC) 03/20/24 5:37 PM, 82.4 Lbs with WC. 03/13/24 5:26 PM, 85.4 Lbs with WC. 03/6/24 9:06 PM, 84.4 Lbs with WC. 02/29/24 9:22 PM, 82.4 Lbs with WC. 02/19/24 3:44 PM, 84.4 Lbs with WC. 02/13/24 9:58 AM, 86.4 Lbs with WC. 01/18/24 8:29 AM, 90.0 Lbs with WC. 01/12/24 8:18 AM, 92.4 Lbs with WC. 01/3/24 9:24 AM, 94.8 Lbs with WC. 12/29/23 7:39 PM, 89.9 Lbs with ML. 12/21/23 10:49 PM, 92.4 Lbs with ML. 12/20/23 6:59 AM 92.4 Lbs admission weight. The weights equaled a 12.5% weight loss in 3.5 months. Further record review showed that the last quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/27/24, section K, question K0300, is marked no for weight loss of 5% or more in the last month or loss…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to complete a new Pre-admission Screening and Resident Review (PASARR) for residents with newly evident or a possible serious mental disorder. This was true for three (3) out of seven (7) residents reviewed under the category of PASARR, during the Long-Term Care Survey Process. Resident identifiers: #49, #44, and #81. Facility census: 129. Findings included: a) Resident #44 On 4/08/24 at 1:50 PM a review of Resident # 44 medical record revealed a Preadmission Screening and Resident Review form (PASRR) was completed on 08/01/19. A diagnosis of delusional disorder added on 04/21/20. It was noted Resident #44 was hospitalized on two (2) occasions. The facility failed to complete a new PASRR with the diagnosis of delusional disorder upon Resident # 44's readmission to the facility. A record review of Resident # 44's care plan revealed the facility failed to revise the interventions when a change occurred. On 4/10/24 at 11:01 AM and interview with the…

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

Based on record review and staff interview the facility failed to revise the care plans for two (2) of 38 residents when their needs changed. Resident #71's care plan was not revised to reflect pain management. Additionally, the facility failed to include Resident #44's delusional disorder diagnosis in her care plan. Resident identifiers: #71 and #44. Facility census: 129. Findings included: a) Resident #44 On 4/08/24 at 1:50 PM a review of Resident #44's medical record noted a diagnosis of delusional disorder added on 04/21/20. A record review of Resident # 44's care plan revealed the facility failed to revise the interventions when a change occurred. On 4/10/24 at 11:01 AM an interview with the Social Worker #154 was completed. Social Worker #154 acknowledged Resident #44's PASRR was incorrect and had not been completed prior to readmission to facility from hospitalizations with a diagnosis of delusional disorder and that the care plan had not been revised to reflect changes. b) Resident #71 -On 4/08/24 at 12:32 PM an interview was conducted with Resident #71. Resident #71 stated,…

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, the facility failed to effectively evaluate pain level and effectiveness for pain medication given for two (2) of five (5) residents reviewed for pain. This failed practice had the potential to affect more than a limited number of residents. Facility census: 129 Resident identifiers: #71 and #81. Findings included: a) Resident #81 Record review on 04/15/24 at 03:12 PM revealed Licensed Practical Nurse (LPN) #28 signed out an oxycodone 5-325 tablet at 9:56AM on the controlled medication utilization record. The medication was documented on the Resident's Medication Administration Record (MAR) as administered. Further record review on 04/15/24 at 03:20 PM revealed no documentation showing the effectiveness of the pain medication that was signed out at 9:56 AM given was completed by LPN #29 On 04/15/24 at 3:20PM Clinical Operation Lead (COL) #164 confirmed effectiveness of the pain medication given was not completed by LPN #28.

Based on staff interview and record review, the facility failed to ensure monthly Medication Regimen Reviews (MRR) were being reviewed/signed by the attending physician. This was true for one (1) of five (5) residents reviewed in the unnecessary medication review pathway during the Long-Term Care Survey Process. Facility Census: 129. Resident identifier: #6 Findings included: a) Resident #6 On 04/15/24 at 11:59 AM, a record review revealed the pharmacist had completed a monthly medication regimen review for Resident #6 on 12/26/23 with the following recommendation, Please reassess the existing A1C goal, and if appropriate, initiate Januvia 25 mg PO (by mouth) daily. Close monitoring (e.g., glucose) should accompany any change in diabetic therapy and guide further adjustments. Treatment intensification is recommended for those individuals not meeting therapy goals, to avoid the consequences of prolonged hyperglycemia. There was no evidence the physician had reviewed and acted on the recommendation. The attending physician did not sign the MRR for 12/26/24. During a staff 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.

Based on resident interview, staff interview, and record review the facility failed to obtain routine and/or emergency dental services for Resident #75. This failed practice was found true for (1) one of (4) four residents during the Long-Term Care Survey Process. Resident identifier #75. Facility Census 129. Findings Include: a) Resident #75 During an interview on 04/08/24 at 2:00 PM, Resident # 75 indicated to the surveyor that she had a loose tooth. A record review on 04/10/24 at 2:08 PM revealed that Resident # 75 has an active order dated 02/07/24 for a dental referral for loose cap to upper front tooth Further record review showed no referral to the dentist had been made. During an interview on 04/10/24 at 9:30 AM, the Interim Director of Nursing (IDON) stated, I'm not going to lie to you, there is not a dental referral in (Resident #75 name's) chart. I will get her an appointment made.

Based on observation, and staff interview the facility failed to maintain appropriate infection control procedures during medication pass for Resident #49. This failed practice was a random opportunity for discovery and had the potential to affect a limited number of residents. Resident identifier: #49. Facility census: 129 Findings included: a) During medication pass observation, on 04/10/24 at 8:54 AM, Licensed Practice Nurse (LPN) #105 removed the following pills from blister pack with ungloved hand and touched the medication with bare fingers. LPN #105 had been opening medication cart doors and touching over the counter pill bottles with her bare hands prior to removing the pills from blister pack and placing them into a plastic medicine cup to be administered to Resident #49: Gabapentin 100 mg (milligram) capsule Lisinopril 2.5 mg tablet Oyster Shell 500/200 mg tablet On 04/10/24 at 10:01 AM the administrator was informed of the infection control issue observed by surveyor. The Administrator stated, This surprises me, she [LPN #105] told me med pass went well. So she gave dirty…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to develop and/or implement a comprehensive care plan for Resident #126. This is true for one (1) of six (6) residents reviewed during the survey process. Resident Identifier: #126. Facility Census: 125. Finding Included: a) Resident #126 On 09/26/23 at 11:30 AM, a record review was completed for Resident #126. The record review found the care plan had not been developed and implemented for Resident #126. Resident #126 was admitted on [DATE] and had been sent to the emergency department on 09/07/23. The care plan had incomplete focus areas, interventions and goals in the areas of at risk for decreased ability to perform ADL(s), risk for falls, may not smoke per smoking evaluation and exhibits or is at risk for alterations in comfort. The care plan was void of any information. The sections listed were all blanks .nothing was added to the above focus areas. On 09/26/23 at 1:50 PM, the Director of Nursing (DON) was notified and confirmed the care plan…

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

Based on medical record review and staff interview the facility failed to ensure one (1) of five (5) residents had a care plan revised when a resident's advanced directive had changed. Resident identifier: #28. Facility census: 125. Findings included: a) Resident #28 Medical record review revealed Resident #28 had an advanced directive care planned as comfort care. A progress note dated 08/17/23 stated the resident's medical power of attorney had changed the resident's advance directives from Do Not Resuscitate (DNR)/Selective Measures to DNR Comfort Care. A Physician Orders for Scope of Treatment (POST) form dated 08/17/23 also reflected the MPOA's signature and the box was checked for Comfort Focused Treatments. A progress note dated 09/02/23 stated the resident was now DNR/Comfort and would no longer be having labs obtained or following up with specialists. A care plan provided by the Director of Nursing (DoN) dated 09/26/23 under the focus Activities of Daily Living (ADL) the resident would at times refuse care and lab draws. Another care plan focus area stated the resident 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 medical record review and staff interview the facility failed to ensure they developed an ongoing program to support residents in their choice of individual activities for (1) resident. Resident #87 was reviewed at random for activities. Resident identifier: #87. Facility census: 125. Findings included: a) Resident #87 The medical record review for Resident #87 revealed the resident received MediTelecare. MediTelecare provides behavioral telemedicine services to residents of skilled nursing and assisted living facilities. A therapy note dated 07/09/23 stated the resident felt bored at times. He stated he liked attending physical therapy and he enjoyed listening to country music and watching television. A therapy note dated 08/07/23 revealed the resident had a primary symptom of depression and sadness. The note also stated the resident enjoyed reading but was unable to due to problems with his vision. During an interview with the Administrator and Director of Nursing on 09/27/23 at 2:11 PM they both stated the resident had been sexually inappropriate with female residents in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to maintain an accurate and complete record for Resident #126's smoking status and 15 minute observations for Resident #86. This was true for two (2) of six (6) residents reviewed during the survey process. Resident Identifiers: #126 and #86. Facility Census: 125. Findings Included: a) Resident #126 On 09/26/23 at 1:45 PM, a record review was completed for Resident #126. The review found a smoking evaluation dated 08/31/23. The smoking evaluation indicated the resident was not allowed to smoke. Upon reviewing the hospital records prior to the admission to the facility, the documentation stated the resident had never smoked. The admission Minimum Data Set (MDS) dated [DATE] section J, indicated the resident did not use tobacco. On 09/26/23 2:57 PM, the Director of Nursing (DON) confirmed the smoking assessment was completed in error upon admission. b) Resident #86 On 09/27/23 at 12:45 PM, a record review was completed for Resident #86. The review…

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.