Ceres Postacute Care

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide Physical Therapy (PT - a healthcare specialty that aims to improve and restore physical function, reduce pain, and prevent future injuries) treatment and services to increase range of motion (the full movement potential of a joint to flex and extend in any direction) and mobility (the ability to move, change, or control their body position independently and comfortably) to prevent further decrease in range of motion and mobility for one of three sampled residents (Resident 1), when Resident 1 was not provided PT treatment and services on 4/13/26, 4/14/26, and 4/15/26. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the required State Agency (SA) within ten (10) days when there was a Change in Administrator (CHOA) on 11/13/2023. This failure had the potential for the facility information to not be up to date and had the potential for the old Administrator (ADM) to receive communication from the SA that was intended for the current ADM.

Inspectors wroteBased on observation, interview, and record review, the facility failed to post the results of the most recent survey in a place readily accessible for 41 of 41 residents, families, and their legal representatives. This failure had the potential to violate the rights of residents and their representatives to be informed of previous survey deficiencies.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow an infection prevention and control program designed to provide a safe and sanitary environment for three of the eight (Residents 1, 2 and 14) sampled residents when: 1. The facility's written policies and procedures (P&P) for infection prevention and control program (IPCP) did not include the list of communicable diseases (infectious illnesses that spreads from one person to another or from surface to a person), when and to whom possible incidents of communicable disease or infections should be reported, and COVID-19 (Coronavirus disease 2019 -an illness caused by a virus) infection prevention and control was not updated. These failures had potential risk in the development and transmission of communicable diseases and infections for all residents. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure cold food storage was stored under sanitary conditions in accordance with professional standards for food service safety when refrigerator A was observed at 42 degrees Fahrenheit (F) (unit of measure for temperature) which was above the recommended safe temperature range of 32 to 40 degree F for cold food storage. This failure had the potential to contribute to the growth of foodborne pathogens (a tiny organism, like a germ, that could cause disease. Pathogens included things like bacteria, viruses and fungi) and posed a risk of foodborne illness (any illness resulting from eating contaminated/spoiled foods) symptoms which could range from nausea, vomiting, diarrhea, abdominal pain, fever, headache, and confusion to residents who received meals and nourishment from refrigerator A. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the accuracy of assessments for one of one sampled residents (Resident 10) when they did not accurately assess the condition of an area of excoriation (injury to the skin caused by scratching or wearing away the surface) on Resident 10's left buttock. This failure to assess Resident 10's left buttock resulted in an inability to monitor the progression of the condition- and determine if it was improved or had worsened.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement person-centered care plans for two of five sampled residents (Resident 5 and Resident 9) when: 1. Resident 5 who was dependent on a wireless call light system, did not have one accessible. This failure had the potential to result in unmet personal care needs, inconsistent care and compromised dignity and safety for Resident 5; 2. Resident 9 who had been refusing snacks and meal alternatives and was on meal monitoring due to weight loss did not reciece supplimental snacks or meal alternatives. This failure had the potential to result in continued or worsening weight loss, compromised quality of life and failure to meet therapeutic goals.

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise a fall care plan for one of four sampled residents (Resident 24) when, Resident 24 had a fall on 1/3/25, a post fall assessment recommended interventions to monitor proper wearing of shoes when up walking with a front wheeled walker (FWW) and Resident 24's care plan interventions indicated for him to wear nonskid socks when up walking with a FWW. This failure had the potential to result in Resident 24 not receiving the care and services from nursing staff and the potential for subsequent falls and injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet professional standards of quality by not following facility's policy and procedure (P&P) for Administering Medications for two of nine sampled residents (Residents 1 and 3) when, 1. Licensed Vocational Nurse (LVN) 1 and LVN 3 used one resident identifier (name, date of birth , photograph, wrist band [containing resident information of name and date of birth for proper resident identification], and staff verification) before medication administration for Resident 1 and Resident 3. This failure had the potential for medication errors and negative drug interactions (occur when the effects of one drug are altered by another drug that can lead to decreased effectiveness of medication) for Residents 1 and Resident 3. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident environment remains free of accident hazards (a danger or risks) as possible for one of four sampled residents (Resident 31) when, Resident 31's room was cluttered (filled with disorganized items, making it difficult to move around and find things) with multiple boxes at the back of Resident 31's room blocking the door from opening fully and the carpet on the floor had curled edges. These failures placed Resident 31 at risk for an avoidable accident including falling and fall related injuries.

Inspectors wroteBased on interview and record review, the facility failed to ensure a staff member was aware of their job duties when Restorative Nurse Aide (RNA) 1 did not have a signed job description prior to her working as an RNA. This failure had the potential to cause RNA 1 to be unaware of her job duties.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident's drug regimen was free from unnecessary drugs for one of six sampled residents (Resident 19) when Resident 19 was administered oxycodone hydrochloride (medication used to treat intense pain) without adequate monitoring. This failure had the potential to cause Resident 19 to experience side effects such as constipation, decreased respirations, dizziness, and increased fall risk.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate was less than five percent when the facility's medication error rate was 5.88 % percent. There were 34 opportunities for errors and two medication errors occurred for two of nine sampled residents (Resident 1 and Resident 2) when: 1. Resident 2 did not receive the inhaler medication Salbutamol (medication used to treat asthma (a condition in which person's airways become inflame, narrow , and swell, and produce extra mucus, which makes it difficult to breathe) and exercise-induced bronchospasm (a life-threatening emergency that occurs when the muscles surrounding the lungs' small airways tighten, narrowing the airways) at the prescribed time of administration of 8:00 a.m. on 5/14/25. 2. [...]

Inspectors wroteBased on observation and interview during the survey period of 5/12/25 to 5/16/25, the facility failed to provide the minimum of at least 80 square feet per resident in multiple residents rooms (Rooms 1, 2, 3, 4, 5, 6, 11, 12, 13, 14, 15, 16, 17 and 18), when the amount of usable living space was not adequate for residents. This failure had the potential for residents in Rooms 1, 2, 3, 4, 5, 6, 11, 12,13, 14, 15, 16, 17 and 18 to not have reasonable privacy or adequate space.

Inspectors wroteBased on interview and record review, the facility failed to ensure licensed nurses assessed and provided interventions in accordance with professional standards of practice as outlined in the comprehensive care plan for one of four residents (Resident 1), when Resident 1 did not receive a complete and accurate initial wound assessment on readmission [DATE]) and did not have weekly wound monitoring, assessments and wound measurements for Resident 1's left inner ankle (wound #8) and right outer ankle (wound #9) from 4/25/2024 to 5/9/2024 and licensed nurses did not assess, measure and notify a physician of changes to wound #8 and wound #9 from 5/9/2024 to 6/27/2024. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) received treatment and care in accordance with professional standards of practice when Resident 1 did not receive a complete and accurate initial wound assessment on readmission [DATE]) and did not have weekly wound monitoring, assessments and wound measurements for Resident 1's left inner ankle (wound #8) and right outer ankle (wound #9) from 4/25/2024 to 5/9/2024 and licensed nurses did not assess, measure and notify a physician of changes to wound #8 and wound #9 from 5/9/2024 to 6/27/2024. And Resident 1 did not have a comprehensive person-centered care plan (an individual summary of a person's health conditions, specific care needs, and current treatments) for wounds #8 and #9. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to post the results of the most recent abbreviated survey document titled, Statement of Deficiencies in a place readily accessible to residents and their representatives. This failure had the potential to violate the rights of the residents and their representatives to be informed of abbreviated survey deficiencies and the facility's plan of correction.

Inspectors wroteBased on observation, interview, and record review the facility failed to have an air gap (an unobstructed vertical space between the water outlet and the flood level of a fixture), under the food preparation sink. This failure had the potential to result in 36 of 36 residents being exposed to contaminated water (when substances pollute the water and make it unusable for cooking and drinking) which could ultimately result in food born illness from eating contaminated food.

Inspectors wroteBased on observation, interview and record review, the facility failed to cover one of one outside trash bin with a lid. This failure had the potential to harbor and feed pests. This failure had the potential for an infestation of pests which could lead to unsanitary conditions and the spread of disease.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a safe clean comfortable homelike environment was provided for four of 21 residents when: 1. One third of the floor in Resident 10, 18, 19, and 26's rooms had yellow and brown stains. This failure resulted in Residents 10, 18, 19 and 26 not being provided a clean comfortable homelike environment. 2. In Resident 6 and Resident 23 room red tape was used to attach the call light cord to the call light socket. This failure resulted in a potenial fire hazard and Resident 6 and 20 not being provided a safe, comfortable homelike environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement comprehensive person-centered care plans (CP - a detailed approach to care customized to an individual resident's needs) for four of 13 sampled residents (Residents 4, 18, 30, and 138) when Residents 4 and 138 did not have an individualized care plan developed and implemented for the use of side rails. This failure had the potential for Residents 4 and 138 to be injured while using the side rails.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective infection control program when one of four sampled residents' (Resident 1) oxygen concentrator (a device that concentrates the oxygen from the ambient air) filters were found covered with lint and dust. This failure placed Resident 1 at an increased risk to develop respiratory and healthcare-associated infections.

Inspectors wroteBased on observation and interview during the survey period of 5/20/24 to 5/23/24, the facility failed to provide the minimum of at least 80 square feet per resident in multiple residents rooms (Rooms 1, 2, 3, 4, 5, 6, 11, 12, 13, 14, 15, 16, 17 and 18), when the amount of usable living space was not adequate for residents. This failure had the potential for residents in Rooms 1, 2, 3, 4, 5, 6, 11, 12, 13, 14, 15, 16, 17 and 18 to not have reasonable privacy or adequate space.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat residents with respect and dignity when staff spoke with each other in a foreign language not understood or spoken by three of four sampled residents (Residents 1, 2, and 3). This failure made Residents 1, 2 and 3 feel uncomfortable and believed staff spoke about them in a language they did not understand and Resident 3 felt disrespected when staff spoke in a language she did not understand.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the chemical sanitizing solution used for dishes, utensils and kitchen working surfaces met the recommended sanitation concentration when expired chemical test strips were used. This practice failed to ensure the required level of sanitation was followed and placed the residents and staff of the facility at risk for food borne illness.

Inspectors wroteBased on interview and record review, the facility failed to conduct a facility wide assessment specific to the facility needs when the facility assessment did not include a water management plan. This practice failed to establish an individualized facility assessment to meet the requirement for a water management plan which had the potential for waterborne bacteria exposure to the residents including Legionella (disease is a severe form of pneumonia - lung inflammation usually caused by infection, caused by bacterium known as legionella, most people get legionnaires' disease from inhaling the bacteria in showers, water faucets, water fountain) in an event of an outbreak.

Inspectors wroteBased on interview and record review, the facility failed to have an effective Quality Assurance and Performance Improvement (QAPI) program that had a data driven approach to maintain safety and quality when the facility's QAPI program did not develop and implement a water management program as part of the infection Control Program. These failure resulted in the facility not having a program in place to reduce the risk of waterborne illnesses including Legionella (a severe form of pneumonia) (lung inflammation usually caused by infection, caused by a bacterrium known as legionella, most people get legionnaires'disease from inhaling the bacteria in showers, water faucets, water fountain).

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an effective infection prevention and control program when: 1. The facility water management plan was not created or implemented to reduce the risk of Legionella (waterborne bacteria which can cause life threatening pneumonia) (a lung infection) and other waterborne pathogens (germs that cause disease) in accordance with Centers for Medicare and Medicaid Services (CMS). These failures placed the residents at risk for cross contamination, infection and had the potential for not identifying the risk of waterborne illnesses such as Legionella. 2. The Infection Surveillance Logs (to track residents with infections) was not completed in accordance with the facility policy and procedure titled, Infection Control Plan. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were provided with comfortable sound levels for three of three sampled residents (Resident 15, 13 and 20) when: Resident 17's television (TV) sound was so loud, it was heard in the hallways and adjacent rooms and disrupted Resident 15,13 and 20. This failure violated the residents' rights to a comfortable and homelike environment that would respect the residents' dignity, privacy and well-being.

Inspectors wroteThe facility failed to ensure residents' Minimum Data Set (MDS) (an assessment of memory, recall and functional abilities) assessment accurately reflected the residents functional status for three of three sampled residents (Resident 17, 30 and 33) when: 1. Resident 17's hard of hearing status was not coded in the MDS assessment. 2. Resident 30's dialysis (filters a patient's blood to remove excess water and waste products when the kidneys are damaged, dysfunctional, or missing) treatment was not coded in the MDS assessment. 3. Resident 33 ate by mouth and the MDS assessment coding indicated nasogastric feeding or percutaneous endoscopic Gastrostomy (PEG-tube) (tube inserted by was of the nose or stomach for administration of nutrition, fluids and/or medications) instead. These failures had the potential for the residents' needs to be unmet.

Inspectors wroteBased on interview and record review, the facility failed to operationalize their policy and procedure to investigate abuse when the Director of Nursing (DON) and the Administrator (ADM) did not conduct an investigation after one of three sampled residents (Resident 23) engaged in disruptive yelling and abusive verbal behavior toward Resident's 13 and 26. This failure resulted in the missed opportunity to provide Resident 13 and Resident 26 emotional support and counseling during and after the investigation, as needed. This failure had the potential for all allegations of abuse to continue.

Inspectors wroteBased on interview and record review, the facility failed to implement the abuse prohibition policy and procedure for two of two residents (Resident 26 and 13) when Certified Nursing Assistant (CNA) 3, CNA 4, CNA 5, Licensed Vocational Nurse (LVN 1), Director of Staff Development (DSD), Director of Nursing (DON) and Administrator (ADM) failed to report an incident of verbal abuse from Resident 23 toward Resident 26 and 13 in accordance with the State law. These failures subjected the staff and the residents' safety at risk and had the potential for these incidents to continue endangering the well-being of the residents.

Inspectors wroteBased on observation, staff interview and record review, the facility failed to ensure residents were assisted in gaining access to hearing services for one of three sampled residents (Resident 17). This failure resulted in not meeting Resident 17's functional hearing needs necessary to improve her quality of life.

Inspectors wroteBased on observation, staff interview and record review, the facility failed to ensure one of three sample residents (Resident 27) received routine dental care when a follow-up with dental recommendations for Resident 27 to have an upper partial denture fitting was not done. This failure resulted in Resident 27 feeling embarrassed and inability to eat regular textured food.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide one of three sampled residents (Resident 21) with eating equipment necessary to facilitate drinking and reduce fluid spillage when two nosey cups (designed with a cut out on the non-drinking side enabling tilting without interference by the nose) were not included in Resident 21's lunch tray. This failure had the potential for Resident 21's fluids to spill and difficulty to drink fluids.

Inspectors wroteBased on observation, and interview, the facility failed to assure full visual privacy for one of 23 sampled residents (Resident 7) when Resident's 7's cubicle curtain (material suspended from the ceiling to circle around the bed to provide privacy during resident personal care) was removed and not replaced. This failure had the potential for Resident 7 to receive personal care with out being afforded privacy.

Inspectors wroteBased on observation and interview, during the annual recertifiction survey period of 6/3/19 to 6/7/19, the facility failed to provide the minimum of at least 80 square feet per resident in multiple residents rooms (Rooms 1, 2, 3, 4, 5, 6, 11, 12, 13, 14, 15, 16, 17 and 18). This failure had the potential for residents to not have reasonable privacy or adequate space.