Alameda Healthcare & Wellness Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record reviews, and review of facility policy, the facility failed to ensure side rails were used appropriately for three of four sampled residents (Resident (R)4, R30 and R99). This failure increased the risk for entrapment or injury for the three residents. Findings include: Review of the facility's policy titled Bed Rails revised 11/16/22, stated .A bed rail is an assistive device and must be used in accordance with the following regulations: a. Only permissible if they are used to treat a Resident's medical symptoms .d. Bed rails cannot be used for staff convenience or as discipline, such as prevention of falls when less restrictive methods have not been attempted or ruled out . 1. Review of R30's undated admission Record located in the electronic medical record (EMR) under the Resident tab revealed an original admission date of 03/30/16 and readmission on [DATE]. R30's primary diagnosis was chronic respiratory failure with hypoxia. Comorbidities included encephalopathy,…

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, record reviews, and facility policy reviews the facility failed to provide administration of medication according to physician orders for nine of nine residents (Resident (R)16, R29, R33, R37, R38, R44, R45, R73 and R90) reviewed for medication administration. Specifically, the facility failed to properly document medication administration, failed to administer medication to one resident (R16), and failed to administer medications on time to eight of nine residents reviewed for medication administration (R29, R33, R37, R38, R44, R45, R73, and R90). These failures had the potential to result in decreased therapeutic results of the medications prescribed for the effected residents. Findings include: Review of the facility policy titled, Medication-Administration, revised 01/01/12 stated .Medications may be administered one hour before and after the scheduled medication administration time .The time and dose of the drug or treatment administered to the patient will be recorded 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.

Based on interview, observation, and facility policy review, the facility failed to ensure the two of two dumpsters located in a fenced area located behind the building was not propped open as well as failed to ensure there was no bagged trash or refuse loose on the ground in the dumpster area. These failures could lead to vermin gathering around the dumpsters and potentially entering the facility. Findings include: Review of the facility policy titled, Waste Management, last revised on 04/21/22 revealed the purpose was, To reduce risk of contamination from regulated waste and maintain appropriate handling and disposable [sic] of all waste. The policy stated, . The Center's waste disposal system includes separate methods, for handling regulated, non-regulated and recycle waste. On 08/05/24 at 8:55 AM, the dumpster area was observed to have a several bags of trash on the ground, a stack of wooden pallets, broken down cardboard boxes, the blue dumpster was filled with items preventing the lid from closing properly, and the large green dumpster had one-half of the lid propped open by 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, record review, and policy review, the facility failed to ensure that three of three residents (Resident (R) 21, 77, and 89) reviewed for dignity out of a sample of 47 residents, did not have signs hanging above bed with medical information on them. Findings include: Review of facility policy titled, ''Resident Rights-Quality of Life,'' revised 03/2017, revealed ''To ensure that each resident receives the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing, consistent with the resident's comprehensive assessment and plan of care. Procedure: .Facility staff treats cognitively impaired residents with dignity and sensitivity.'' 1. Review of R21's ''admission Record,'' located under tab ''Profile'' in the electronic medical record (EMR) indicated that R21 was re-admitted to the facility with a diagnosis of cerebral palsy (CP), and malignant neoplasm of prostate. During observation on 08/05/24 at 12:35 PM, there was 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, record review, and policy review, the facility failed to ensure residents who self-administered medications had a self-administration of medication assessment, a physician's order, and a care plan completed for two of two residents (Resident (R) 44 and R73) reviewed for self-administration of medications. This failure to assess and care plan residents for self-administration of medications increases the potential risk of medication errors for residents. Findings include: Review of facility's policy titled, ''Medication-Self Administration,'' revised 01/01/12, revealed, ''To provide residents with the opportunity to self-administer medications when determined they are capable to do so by the attending physician and the Interdisciplinary team (IDT). Procedure: . 3. For a final determination of the resident's ability to self-administer medications, the Assessment for Self-Administration of Medications will be presented to the resident's attending physician. A. The resident may not…

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, record review, and policy review, the facility failed to provide privacy during care in the resident's room for one of 45 sampled residents (Residents (R) 108). This failure could potentially have a negative impact on the quality of life for the affected resident. Findings include: Review of R108's Face Sheet located in the Profile tab of the electronic medical record (EMR), revealed R30 was admitted to the facility on [DATE] with the following diagnoses: unspecified dementia, unspecified severity, without behavioral, disturbance, psychotic disturbance, mood disturbance, and anxiety, moderate protein-calorie malnutrition, Alzheimer's disease, unspecified disorder involving the immune mechanism, unspecified, essential (primary) hypertension difficulty in walking, Review of R108's Quarterly, MDS with an ARD of 6/17/24 located in the resident's EMR under the MDS tab revealed a BIMS score of eight out of 15 which indicated R108 was moderately impaired for decision-making. During an…

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 observations and interviews, the facility failed to maintain air conditioning filters for one of four residential units. This failure had the potential to negatively affect the respiratory system of 21 residents residing on the subacute unit, 11 of 21 residents were on ventilators. Findings include: Review of the facility's policy titled, Heating and Air Conditioning System Inspection revised on 01/01/12 indicated the purpose of the policy was To protect the health and safety of residents, visitors, and Facility Staff .Inspections are the responsibility of the Maintenance Department . During an observation on 08/07/24 at 1:00 p.m., the portable air conditioner at the end of the subacute resident hall had three filters with a thick, gray film caked on all three filters. During an interview on 08/07/24 at 1:48 p.m., with the Maintenance Supervisor, Maintenance Supervisor stated maintenance was responsible for maintaining and cleaning the portable air conditioner. He stated they last cleaned the filters in July 2024 and after looking at the filters today they need to be done…

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 interviews, record review and policy review, the facility failed to ensure that an allegation of physical abuse was reported to the State survey agency (SSA) for one of one resident (Resident (R) 23) reviewed for abuse out of a sample of 47 residents. Findings include: Review of facility's policy titled, ''Abuse Prevention and Management,'' revised on 05/30/24, revealed, ''The facility does not condone any form of resident abuse, neglect, misappropriation of resident property, exploitation, and/or mistreatment. The facility develops policies, procedures, training programs, and screening and prevention systems. The facility will report all allegations of abuse and criminal activity as required by law and regulations to the appropriate agencies .7. Notification of Outside Agencies for All Allegations of Abuse. a. The Administrator or designated representative will notify law enforcement, by telephone immediately, or as soon as practicably possible, but no longer than (2) hours of an initial report 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 interviews, record reviews, and policy review, the facility failed to ensure one of three residents (Resident (R) 30) reviewed for hospitalization out of a total sample of 46 were given a written notice prior to or as soon as practical following transfer to the hospital. Additionally, there was no documentation that the Ombudsman was notified of the transfer for R30. This failure created the potential for residents or their responsible party to not have the information needed to understand their transfer to the hospital. Findings include: Review of the facility's policy titled, Discharge and Transfer of Residents revised 02/2018 indicated .Upon transfer to the acute hospital the resident/resident representative will be given an opportunity to execute a Bed Hold .The Facility may transfer or discharge a resident with an order from the resident's physician for .The discharge is necessary for the welfare of the resident, and needs cannot be met in the facility .Prior to discharge, Social Service Staff or…

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, record review, and policy review, the facility failed to ensure two out of two sampled residents who were reviewed for hospitalization (Residents (R)30 and R100) were provided with a bed hold notice within 24 hours of emergent transfer to the hospital. This failure increased the potential that residents would not know to request a bed hold and may be unable to return to the facility. Findings include: Review of the facility's policy titled, Bed Hold, revised 07/2017,indicated , To ensure that the resident and/or his/her representative is aware of the Facility's bed-hold policy, and that such policy complies with state and federal law and regulations .The Facility notifies the resident and/or representative, in writing, of the bed hold, option, any time the resident is transferred to an acute care hospital or requests therapeutic leave. 1. Review of R30's admission Record, located in the electronic medical record (EMR) under the Resident tab revealed an original admission date of 03/30/16 and…

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

Based on record review, interview, and review of the Resident Assessment Instrument (RAI manual) the facility failed to ensure that one resident (Resident (R) 86) out of 47 sampled residents' Minimum Data Set (MDS) assessments were transmitted in a timely manner. Findings include: Review of Center for Medicare and Medicaid Services (CMS) Long-term Care Facility Assessment Instrument 3.0 User's Manual, version 1.18.11, dated 10/23, revealed, .Chapter 2: Assessments for the Resident Assessment Instrument, 2.6: Required OBRA Assessments for the MDS .RAI OBRA-required assessment summary for discharge assessment .MDS completion date (Z0500B) no later than no later than discharge date + 14 calendar days .Transmission date no later than MDS completion date + 14 calendar days. Review of ''admission Record,'' located under tab ''Profile'' in the electronic medical record (EMR) indicated that R86 was admitted to the facility 02/02/24 with a diagnosis including fracture of unspecified part of neck of right femur, subsequent encounter for closed fracture with routine healing, spinal stenosis,…

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 interviews, record reviews, and facility policy review, the facility failed to ensure two of three residents (Resident (R)4 and R99) had accurate care plans which were reviewed and revised on a quarterly basis. Additionally, the facility failed to ensure that one of three residents (R101) was invited to participate in care conferences. This failure increased the risk of the residents' preferences and concerns not being included in the plan of care. Findings include: Review of the facility's policy titled Comprehensive Person-Centered Care Planning revised 08/24/23, indicated, .changes or updates to the resident's comprehensive care plan will be made based on the assessed needs of the resident .The comprehensive care plan will be periodically reviewed and revised by IDT [interdisciplinary team] after each assessment which means after each MDS assessment as required, except discharge assessments .The Facility must provide the resident and representative if applicable, reasonable notice of care planning…

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 interviews, record reviews, and facility policy review, the facility failed to develop, assist, and follow through to completion with discharge plans for one of 46 sampled residents (Resident (R)101) reviewed for discharge planning. The facility did not have a person-centered discharge plan for R101. Findings include: Review of the facility's policy titled Discharge and Transfer of Residents, revised 02/2018, stated, .When a resident is admitted to the Facility, Facility Staff will initiate a discharge plan .Discharge planning will begin on the residents' admission to the Facility .The Attending Physician will review the resident's progress and determine a possible discharge date with information from the IDT . Review of the facility's policy titled Resident Rights, revised 01/01/12, stated, .State and federal laws guarantee certain basic rights to all residents of the facility. These rights include, but are not limited to, a resident's right to: .participate in decisions and care planning . Review 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 make an ophthalmologist referral order for one out of one resident (Resident (R)100) who needed cataract surgery. This failure effected one of 45 sampled residents. Findings include: Review of R100's Face Sheet located in the Profile tab of the electronic medical record (EMR), revealed R100 was admitted to the facility on [DATE] with the following diagnoses: diabetes mellitus with diabetic chronic kidney disease, and unspecified affecting left nondominant side. , Review of R100's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/07/24, located in the resident's EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated R100 was moderately intact for decision-making. Review of R100's Physician Orders located in the physician order tab of the EMR last order review: 08/05/24, revealed there was no physician order for R100 to receive cataract surgery. Review of R100'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 record review, observation, and interviews, the facility failed to follow physician orders for enteral feeding for one resident (Resident (R) 38) out of 24 residents with feeding tubes. This failure increased the risk for dehydration and weight loss for the resident. Findings: Review of R38's admission Record located in the electronic medical record (EMR) under the Resident tab revealed an original admission date of 09/23/16 and readmission on [DATE]. R38's primary diagnosis was chronic respiratory failure with hypoxia (lack of sufficient circulating oxygen). Review of R38's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 07/19/24, located in the EMR under the MDS tab did not include a BIMS due to inability to participate. Review of R38's Physician Orders located in the EMR under the Orders tab included orders dated 01/10/22, lorazapem 0.5 milligrams (mg), give one tablet via gastrostomy tube (g-tube, a tube inserted through a surgically created opening through the abdomen…

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 interviews, record review and policy review, the facility failed to ensure that dialysis communication sheets were complete for one of one resident (Resident (R) 16) reviewed for dialysis out of a total sample of 47 facility residents. This failure placed all residents that receive dialysis at this center in potential risk of impaired continuity of care. Findings include: Review of facility policy titled, ''Dialysis Care,'' revised 10/01/18, revealed, ''To provide dialysis care for residents in renal failure and those residents who require ongoing dialysis treatments .Procedure .4. Communication and Collaboration: A. The nursing staff, dialysis provider staff, and the attending physician (''Dialysis Staff'') will collaborate on a regular basis concerning the resident's care as follows: i. Nursing staff will communicate the following information in writing to the dialysis staff: a. The resident's current vital signs; b. Weight; and c. Any changes of conditions specific to the resident with each…

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, record review, staff interviews, and policy review, the facility failed to ensure the facility provided appropriate treatment and services for one of one resident (Resident (R) 89) reviewed for suicidal ideations (SI). This failure had the potential to contribute to continued suicidal thoughts that could result in self-harm for R89. Findings include: Review of facility policy titled, ''Referrals to Outside Services,'' revised 12/01/13, revealed, ''To provide residents with outside services as required by physician orders or the care plan. Policy: 1. The Director of Social Services coordinates the referral of residents to outside agencies/programs to full fill resident needs for services not offered by the facility .2 .Examples of service provider contracts that the Director of Social Services may coordinate include but are not limited to psychiatric services.'' Review of ''admission Record,'' located under the ''Profile'' tab in the electronic medical record (EMR) indicated that R89 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 observations, staff interview, and policy review, the facility failed to remove expired medications, treatment, and intravenous supplies and topicals stored in one (Sub-Acute Medication Room) of four medication rooms. Findings include: Review of the facility's policy titled, Storage of Medications with an effective date of April 2008, indicated, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier Under M indicated, Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order exists. Observation of the Sub-Acute Medication storage room with the Director of Nursing (DON) on 08/08/24 at 10:33AM, revealed the following medications were expired: Erythromycin (an antibiotic) 200mg[milligram]/5ml [milliliter] liquid suspension with a filled date of 08/22/23. There was no open date…

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 interviews, record review and policy review, the facility failed to ensure that a contract was completed for a dialysis facility for one of one resident (Resident (R) 16) reviewed for dialysis out of a sample of 47 total facility residents. This failure placed all residents that receive dialysis at this center in potential risk. Findings include: Review of facility policy titled, ''Service Agreements,'' 01/01/12, indicated, ''To ensure consistency and uniformity when contracting with vendors and service providers, including physicians, in accordance with state and federal laws and regulations .Procedure: 1. The facility/Administrator will use approved Service Agreements contracting with vendors/consultants/providers whenever possible .4. Service Agreement Management: A. The Administrator will keep an original signed and dated copy of all service agreements with vendors/consultants/providers at the facility.'' Review of ''admission Record'' under the ''Profile'' tab in the electronic medical record (EMR)…

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 Social Services Department staff failed to provide medically related social services for one of three sampled residents (Resident 1) when Resident 1 did not have social services follow through documentation, comprehensive care plan development, and 72-hour resident monitoring following an alleged theft and loss abuse incident between Resident 1 and Resident 2. This deficient practice failed to ensure that sufficient and appropriate social services were provided to meet Resident 1's physical, mental, and psychosocial needs. Findings: A review of Resident 1's admission Record, printed on 4/3/24, indicated resident was admitted to the facility on [DATE], with diagnoses of respiratory failure, Schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), and hemiplegia (paralysis on one side of the body). A review of Resident 1's Minimum Data Set (MDS, an assessment tool used to direct care), dated 10/17/23, indicated Resident 1 was able 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 maintain proper storage of medications including controlled medications (substances that have an accepted medical use, medications which fall under US Drug Enforcement Agency (DEA) Schedules II-V, and have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence) when: 1. Medication room [ROOM NUMBER] ' s door was left ajar by staff allowing unauthorized access to medications and syringes with needles, 2. The medication room for the sub-acute area was ajar allowing access to an unlocked open, cabinet containing an emergency kit (e-kit, kit containing doses of emergency medication) which contained one vial of valium (a controlled medication which is used for sedation), 3. A treatment cart containing topical treatment medications was left unlocked and unattended by nursing station 3. This failure to adequately secure medications had the potential for drug diversion and unauthorized access 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.

Based on interview and record review the facility failed to ensure the responsible party (RP 1) of one (Resident 1) of three residents consented to COVID-19 vaccination before vaccinating Resident 1. This failure resulted in denial of the right to refuse vaccination, and the vaccination caused swelling and probable pain, of Resident 1 ' s vaccinated arm. Findings: During a review of Resident 1's admission Record, undated, the admission Record indicated the facility admitted Resident 1 in 2016 with diagnoses which included dependency on a ventilator (breathing machine) due to respiratory failure, tracheostomy (artificial opening in the airway to facilitate breathing), inability to swallow correctly requiring feedings via a gastrostomy tube (GT, a surgically created opening through the abdomen to the stomach for direct administration of food, fluids, and medications), anoxic brain damage (brain damage as the result of lack of adequate oxygen to the brain cells), generalized muscle weakness. The admission Record indicated RP 1 had Durable Power of Attorney for healthcare decisions (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 have the ordered medication Sinemet (used for treatment of symptoms of Parkinson ' s disease) for one of two residents (Resident 1). This failure of not having this medication on 7/19/23 resulted in Resident 1 ' s delayed treatment and potential worsening of symptoms of Parkinson ' s disease (disease of nervous system with symptoms of tremors, muscle stiffness and unsteady movement). Findings: During a review of Resident 1 ' s face sheet, undated, the face sheet indicated Resident 1 was admitted to the facility November 2013, with a diagnosis of Parkinson ' s disease. A review of Resident 1 ' s Order Information Report as of 7/31/23, indicated an order, start date on 2/2/23, for Sinemet tablet 25-100 mg; give two tablets by mouth three times a day for Parkinson ' s disease. During an interview on 10/12/23, at 8:35 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated if a resident did not receive an ordered medication, this could cause mood swings, nausea, blood pressure elevation, and other…

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 one of three sampled residents (Resident 1), had medical records that accurately documented insulin administration on July 16, 2023 and July 25, 2023. This failure had the potential to result in Resident 1 getting his insulin twice and having a low blood sugar. Findings: A review of Resident 1's face sheet, undated, indicated Resident 1 was admitted to the facility in July 2023 with diagnoses of Type 2 diabetes (elevated blood sugar). A review of Resident 1's Medication Administration Record (MAR) with a start date of 7/6/23, indicated insulin glargine (long acting) inject 30 units subcutaneously (fatty tissue) one time a day for diabetes. A review of Resident 1's MAR with a start date of 7/6/23, indicated Insulin aspart (rapid-acting) inject per sliding scale (dose varies depending on blood glucose level) subcutaneously with meals. During an interview with Licensed Vocational Nurse (LVN) 1 on 8/8/23, at 2:20 p.m., LVN1 stated not receiving insulin affected blood sugar level, affected the health, 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, for six (Residents 122, 38, 123, 130, 58, and 62) of 31 residents, the facility failed to implement a care plan when: 1. Resident 122 did not have an antidepressant and antianxiety medications careplan; 2. Resident 38 did not have an antidepressant medication careplan; 3. Resident 123 did not have a range of motion (ROM) and mobility careplan; 4. Resident 130 did not have an inhaler medication self administration careplan; 5. Resident 58 did not have an edema careplan, and; 6. Resident 62 did not have a suprapubic catheter careplan. These failures had the potential to result in Residents 122, 38, 123, 130, 58, 26, 62, and 114 not receiving needed care. Findings: 1. Review of Resident 122's Minimum Data Set (MDS - an assessment tool used to guide care), dated 6/8/19, indicated Resident 122 had diagnoses that included depression and anxiety. Review of Resident 122's Physician Orders (PO), dated July 2019, indicated Resident 122 had an order, dated 5/19/19, to receive 10…

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 interview, for three (Residents 16, 114, and 63) of six residents with limited range of motion (ROM - a joint or body part cannot move through its normal range of motion), the facility failed to ensure Residents 16, 114, and 63 received services and assistance to maintain or improve mobility when: 1. Resident 16 did not receive physical therapy (PT) and occupational therapy (OT) evaluations; 2. Resident 114 did not receive PT, OT, and speech therapy (ST) evaluations, and; 3. Resident 63 was without Restorative Nursing Assistant (RNA) services. For Residents 16, 63, and 114, this deficient practice resulted in the delay of care. Findings: 1. A review of the Face Sheet, printed 7/17/19, indicated Resident 16 was re-admitted to the facility on [DATE] with diagnoses that included generalized muscle weakness and other abnormalities of gait and mobility. During a review of Resident 16's Minimum Data Set (MDS - an assessment tool used to guide resident care), dated 3/20/19, indicated Resident…

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

Based on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service safety when: 1. In the dry storage room, there were bulk food items stored in containers with partially opened lids that also had cracks and big gaps. 2. Resident Food Refrigerators in Nursing Station 2 and Nursing Station 3 had multiple food items that were not labeled and dated, and the refrigerator's freezer section did not have a thermometer. These deficient practices had the potential to result in foodborne illness. Findings: 1. During an observation of the kitchen and concurrent interview with the Dietary Manager (DM) on 7/15/19, at 8:25 a.m., the food thickener bin had partially opened lid that had a crack and a big gap. The lids for flour bin, bread crumbs bin, and white rice bin were also noted with big cracks and gaps. The DM stated that lids should be tightly closed and sealed for food safety because if there were pests present, they could get inside the bins. Review of the facility's undated policy titled, Storage of Food and…

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

Based on interview and record review, the facility failed to employ a qualified social worker on a full-time basis and the two social service assistants functioning as the social worker did not meet the regulatory specified qualifications. This deficient practice had the potential to result in the residents' inability to attain or maintain their highest practicable psychosocial wellbeing by not receiving medically needed social services. During an interview with the Director of Nursing (DON) on 7/16/19, at 12:55 p.m., DON stated the facility did not have a full-time social worker. During an interview with the Administrator (ADM) on 7/17/19 9:03 a.m., ADM stated the facility did not have a social worker full time, but had two social service designees (SSDs). ADM stated the facility should have a full time social worker, but the former social worker resigned in March 2019. ADM stated the facility had not been able to find a qualified social worker since March 2019. See F 740 for additional information.

Based on observation, interview, and record review, for one (Resident 142) of two residents with dignity concerns, the facility failed to ensure Resident 142's right to privacy during personal care when Treatment Nurse (TN) 1 and Licensed Vocational Nurse (LVN) 1 performed a skin assessment that involved Resident 142's chest area and took a picture without providing privacy for Resident 142. This failure had the potential to result in Resident 142 feeling bad. Findings: During an interview on 7/15/19, at 10:35 a.m., Resident 142 stated TN 1 took photograph of her left under breast while she was in the Rehabilitation gym with other staff around. Resident 142 stated she felt bad. Review of Resident 142's Face Sheet, printed 6/29/19, indicated Resident 142 was admitted to the facility with multiple diagnoses that included pain in the left arm, abscess (swollen area with accumulation of pus) on the left upper limb and muscle weakness. Review of Resident 142's Minimum Data Set Assessment (MDS - an assessment tool used to direct resident care), dated 7/2/19, indicated Resident 142 had a…

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

Based on interview and record review, for one (Resident 305) of three sampled residents, the facility failed to implement their Personal Property policy and procedure to prevent the misappropriation of resident property when Registered Nurse (RN) 1 and Certified Nursing Assistant (CNA) 1 did not do an inventory and document Resident 305's personal property upon her transfer to the acute hospital. This deficient practice resulted in the facility's inability to account for Resident 305's missing purse, money, credit cards, automatic teller machine (ATM) cards, and checkbook. Findings: Review of the Resident Face Sheet, dated 7/19/19, indicated Resident 305 was admitted to the facility with diagnoses that included dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning). Review of a document titled Resident Inventory, dated 6/6/19, indicated that Resident 305 had a brown purse, checkbook, credit cards, one set of keys and an ATM cards. Review of a document titled…

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, for one of 31 sampled residents (Resident 130), the facility failed to complete a Minimum Data Set (MDS - an assessment tool used to direct resident care) admission assessment within 14 days of Resident 130 admission to the facility. For Resident 130, this failure had the potential to result in unassessed and unmet care needs. Findings: Review of Resident 130's Face Sheet, printed 6/6/19, indicated Resident 130 was admitted to the facility with diagnoses that included difficulty in walking, need for assistance in walking, and chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe). During an interview and concurrent record review on 7/18/19, at 2:21 p.m., Resident 130 was admitted to the facility on [DATE] and discharged home on 5/1/19. Director of Nursing (DON) stated Resident 130 returned to the facility on 5/31/19 and there was no MDS admission assessment completed for Resident 130, but there should have been…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a significant change of status Minimum Data Set (MDS-an assessment tool used to guide care) was completed within 14 days after one (Resident 302) of 31 sampled residents was placed on hospice (care for the terminally ill). This deficient practice had the potential for Resident 302 not to receive appropriate care and services. Findings: Review of the Face Sheet, dated 7/17/19, indicated Resident 302 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident 302's physician's order, dated 6/20/19, indicated Resident 302 was admitted to hospice care on 6/20/19. Review of a document titled MDS Assessment Manager, not dated, indicated Resident 302's significant change of status (SCSA) MDS was opened but not completed on 6/20/19. During a joint interview with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) on 7/16/19 12:57 p.m., they stated when Resident 302 started hospice care on 6/20/19, a…

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

Based on interview and record review, for two (Resident 2 and 4) of two sampled residents, the facility failed to transmit Resident 2's Annual Minimum Data Set (MDS - an assessment tool used to direct care) Assessment and Resident 4's Quarterly MDS Assessment in a timely manner. These deficient practices resulted in the delay of resident-specific information to reflect residents' overall status, necessary for the provision of care. Findings: 1. Review of the Face Sheet, printed 7/19/19, indicated Resident 4 was admitted to the facility with diagnoses that included hemiplegia (paralysis or weakness on one side of the body following) and dysphagia (difficulty swallowing). Review of Resident 4's Quarterly MDS Assessment showed an Assessment Reference Date of 6/3/19. In an interview on 7/19/19, at 9:42 a.m., Director of Nursing (DON) (currently doing MDS during the absence of an MDS Coordinator), confirmed he did not check the Final Validation Report after the transmission of Resident 4's Quarterly MDS Assessment on 6/3/19. Review of the Final Validation Report, undated, for 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 interview and record review, the facility failed to provide assistance in arranging vision services for one (Resident 60) of one sampled residents. This deficient practice resulted in Resident 60 having a delay in treatment. Findings: Review of the Resident Face Sheet, dated 7/17/19, indicated Resident 60 was admitted to the facility on [DATE] and readmitted on [DATE]. This document also indicated Resident had multiple diagnoses that included hypertension (high blood pressure) and Stage 4 chronic kidney disease (an advance kidney disease that alters kidney functions). Review of Resident 60's physician's telephone order, dated 7/3/19, indicated the physician had ordered Ophthalmology referral for seeing gray spots on left eye. During an interview with Resident 60 on 7/15/19, at 8:40 a.m., Resident 60 stated she told Licensed Vocational Nurse (LVN) 1 she was having eye problems about two weeks ago. Resident 60 stated her dialysis (a process that purifies the blood, a substitute for the normal function 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 observation, interview and record review, for one of one resident (Resident 130) who was triggered for accident hazard, the facility failed to provide supervision to prevent accidents when Resident 130 was allowed to keep and administer inhaler by herself without proper instructions. For Resident 130, this failure had the potential to result in unwanted side effects and accidental overdose of medications. Findings: Review of Resident 130's Face Sheet indicated Resident 130 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (group of lung diseases that made it hard to breathe). Review of Resident 130's Minimum Data Set (MDS - an assessment used to direct resident care), dated 6/28/19, indicated a Brief Interview for Mental Status (BIMS, an assessment tool for resident's orientation to time, and capacity to remember) score of 14. The BIMS score range is from 0-15, with zero as the most impaired. Review of Resident 130's Physician's Orders for July…

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, for one (Resident 62) of one residents with a urinary catheter (a tube placed in the body to drain and collect urine from the bladder), the facility failed to ensure Resident 62 received care and services to prevent urinary tract infection when Resident 62's: a. suprapubic catheter was positioned over his hip and under his right shoulder; b. suprapubic catheter site care was not provided, and; c. suprapubic catheter was not changed as ordered. For Resident 62, this failure had the potential to result in recurring urinary tract infection. Findings: Review of Resident 62's Face Sheet indicated Resident 62 was admitted to the facility on [DATE] with diagnoses that included malignant neoplasm of the prostate, and dementia (memory loss and impaired judgment). Review of Resident 62's Treatment Administration Record (TAR), dated June 2019, indicated Resident 62 had a physician's order for a suprapubic catheter (catheter that is inserted into the bladder to drain…

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, for two (Residents 26 and 304) of six residents on a feeding tube, the facility failed to provide care and services to promote nutrition when licensed staff did not manage the tube feeding pumps properly and Residents 26 and 304 did not receive the calculated amount of tube feedings that were ordered by the physician. This failure had the potential to result in weight loss. Findings: 1. Review of Resident 26's Face Sheet indicated Resident 26 was admitted to the facility with diagnoses that included bacteremia (presence of bacteria in the blood), convulsions (seizure), catatonic disorder (behavioral syndrome marked by inability to move normally) and dysphagia (difficulty swallowing). Review of Resident 26's Minimum Data Set (MDS - an assessment tool used to direct resident care), dated 7/15/19, indicated Resident 26 received more than 50 percent of total calories through a feeding tube (a medical device used to provide liquid nourishment, fluids, and medications…

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

Based on interview and record review, for one (Resident 203) of one residents with behavior symptoms, the facility failed to ensure Resident 203 received behavioral health services when a psychiatric evaluation was not completed as ordered by the Attending Physician. For Resident 203, this failure had the potential to result in exacerbation of behavioral symptoms without appropriate treatment. Findings: Review of Resident 203's Face Sheet, printed 6/14/19, indicated Resident 203 was admitted to the facility with diagnoses that included major depressive disorder. Review of Resident 203's Medication Administration Record (MAR), dated June 2019, indicated Resident 203 received 25 milligrams of seroquel (medication that treats psychosis) daily as needed for mood disorder manifested by agitation and yelling. Resident 203 received seroquel once daily for 4 days from 6/14/19 to 6/17/18. Monitoring for episodes of yelling indicated Resident 203 had up to nine episodes of yelling mostly during the afternoon/evening shift. Review of Resident 203's Physician's Telephone order, dated 6/18/19,…

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 when: 1. Resident 204's medication suboxone (controlled substance that treats pain and addiction to narcotic pain killers) was not available for administration for two days. This failure had the potential to result in unwanted withdrawal symptoms. 2. Resident 61's medications hydrochlorothiazide (controls blood pressure) and plavix (prevents blood clot) were not available for administration during medication pass. This failure had the potential to result in uncontrolled high blood pressure. Findings: 1. Review of Resident 204's Face Sheet indicated Resident 204 was admitted to the facility on [DATE] with diagnoses that included osteoarthritis (type of arthritis that occurs when protective tissue at the end of the bone wears down), diabetes mellitus (abnormal levels of blood sugar) and chronic pain syndrome. During an interview on 7/17/19 at 11:10 a.m. and concurrent review of Resident 204's clinical 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 ensure its medication error rate did not exceed five percent. There were three medication errors out of 27 opportunities for error that totaled 11.11 percent (%) when: a. For Resident 204, Homology 15 units (a fast acting insulin, lowers blood sugar) was administered an hour after the time frame ordered by the physician. This failure had the potential to result in untreated high blood sugar; b. For Resident 204, Suboxone 2 milligram (mg) per 0.5 mg. sublingual film (controlled substance that treats pain as well as addiction to narcotic pain relievers) was not administered as ordered by the physician. This failure had the potential to result in unpleasant withdrawal symptoms, and; c. For Resident 61, hydrochlorothiazide (medication that lowers blood pressure) 12.5 mg capsule was not administered as ordered. This failure had the potential to result in uncontrolled high blood pressure. Findings: a. Review of Resident 204's Face Sheet…

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 clinical records were complete and accurately documented for two (Resident 93 and Resident 35) of 31 sampled residents when: 1. Resident 93's July 2019 physician's order indicated Resident 93 had an order to receive 100 milliliters (ml) of MedPlus (a nutritional supplement) three times a day, which did not reflect the original order, dated 5/25/19, for Resident 93 to receive 180 ml of MedPlus three times a day. This deficient practice had the potential for Resident 93 not to receive the required amount of calories and to potentially have weight loss. 2. Resident 35's clinical record had both old and new Restorative Nursing Assistance (RNA) orders. This deficient practice had the potential for Resident 35 not to receive needed care, services and treatments. Findings: 1. Review of Resident 93's physician's order, dated 5/25/19, indicated Resident 93 had an order for MedPlus NSA (no added salt) 180 ml by mouth three times a day. 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 observe infection control practices for one (Resident 304) of one sampled residents when a Licensed Nurse did not wash her hands between glove changes during wound care and left a soiled brief (disposable diaper) under the resident during a wound care treatment. This deficient practice had the potential to result in the spread of infection. Findings: Review of the Resident Face Sheet, dated 7/17/19, indicated Resident 304 was admitted to the facility on [DATE] and readmitted on [DATE]. This document also indicated Resident 304 had a Stage 4 (affects the muscles and/or bone) pressure ulcer (opening over the bony area caused by pressured) of the sacral ( a triangular bone in the lower back between the two hip bones) region During an interview with the treatment nurse (TN) 1 on 7/18/19 at 9:01 a.m., TN 1 stated Resident 304's sacral wound order was cleanse with Normal Saline ( a cleaning solution), pat dry, loosely pack wound with wet…

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 maintain the facility's kitchen convection oven in proper working condition when the Dietary Staff (DS) did not clean the oven according to manufacturer's guidelines. This failure had the potential to result in food borne illnesses. Findings: During an observation on 8/28/18, at 8:12 a.m., in the presence of the Kitchen Supervisor (KS), there was a blackish-brown residue inside the convection oven. In an interview on 8/28/18, at 10:21 a.m., the Dietary Staff (DS) stated that when he cleaned the oven he sprayed the oven with water and Ecolab grease express. The DS stated he did not know about the manufacturer's instructions for cleaning the oven. Review of the facility's policy and procedure titled Oven-Convection-Operation and Cleaning, dated 10/1/04, indicated .Sanitation of Equipment .Weekly tasks .Spray the sides, interior, and oven doors with the oven cleaner according to the manufacturer's guidelines Review of the oven manufacturer's Owner's Manual, undated, indicated .Never spay water at or near equipment…

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 one of 29 sampled residents (Resident 201) maintained their dignity when Resident 201 waited for 35 minutes in her soiled undergarment before Certified Nursing Assistant (CNA) 2 changed it. This failure resulted in Resident 201 not feeling good about waiting in her soiled undergarment. Findings: Record review of the document titled Facesheet, indicated Resident 201 was admitted to the facility with diagnoses that included a urinary tract infection (UTI - an infection in any part of the urinary system). Review of Resident 201's Minimum Data Set (MDS - resident assessment tool used to guide care), dated 8/19/18, indicated Resident 201 was alert and could identify the correct day, year and month. The MDS also indicated Resident 201 required the extensive physical assistance of two or more staff persons for bed mobility and toileting. Review of Resident 201's care plan, dated 8/5/18, indicated Resident 201 was to be kept dry, clean, and comfortable. In an interview on 8/29/18, at 10:25 a.m., Resident 201…

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, for one (Resident 123) of 29 sampled residents, the facility failed to notify the physician of the need to alter treatment when Resident 123 developed an open area on the left great toe. This failure had the potential to result in infection and a delay in treatment. Findings: Review of the clinical record indicated Resident 123 was admitted to the facility with diagnoses that included paraplegia (paralysis of both lower extremities) and Type 2 diabetes mellitus (abnormal levels of blood sugar). According to the National Institute of Diabetes and Digestive and Kidney Diseases, diabetes can lower blood flow to the feet, and thus making it hard for a sore to heal, sometimes, a bad infection will never heal and may lead to gangrene (death of tissues due to decreased blood flow) [Reference: https://www.niddk.nih.gov/]. Review of Resident 123's Weekly Summary dated 8/4/18 indicated Resident 123 was alert and oriented to time, place, and person. During an observation and concurrent interview on 8/28/18 at 11:06 a.m., Resident 123's left…

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, for one (Resident 145) of 3 sampled residents, the facility failed to develop and implement a baseline care plan to address Resident 145's use of CPAP (Continuous Positive Airway Pressure - a machine that forces air through the airways to treat sleep apnea to maintain good blood oxygen levels during sleep. Apnea is a sleep disorder, when a person's breathing stops or is interrupted during sleep). This failure had the potential to result in Resident 145 not having restful sleep and decreased levels of oxygen. Findings: Review of the clinical record indicated Resident 145 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive lung disease (a group of lung diseases that block airflow and make it difficult to breathe) and obstructive sleep apnea (sleep disorder that is caused when the airway is blocked repeatedly during sleep, stopping airflow). Review of Resident 145's physician orders, dated 6/18/18, indicated Resident 145 was to have a CPAP…

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

Based on interview and record review, the facility failed to develop and document a discharge care plan for one of 29 sampled residents (Resident 70) when the discharge care plan for Resident 70 was not developed and discussed with Resident 70's Responsible Party (RP). This failure had the potential to cause the residents and responsible parties emotional distress. Findings: Record review of the Minimum Data Set (MDS - a resident assessment tool used to guide care), dated 7/2/18, indicated Resident 70 was admitted to the facility with that included Alzheimer's dementia. The MDS also indicated Resident 70 never made decisions, had difficulty in hearing, had slurred speech, and difficulty communicating with others. Review of Resident 70's Face Sheet, dated 8/30/18, indicated RP was Resident 70's responsible party. In an interview on 8/28/18, at 10:54 a.m., the RP stated that the facility did not discuss Resident 70's discharge plan with him and he just wanted to know what was going on In an interview and concurrent record review on 8/30/18, at 10:46 a.m., the Social Services Director…

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, for one (Resident 123) of 29 sampled residents, the facility failed to ensure Resident 123 received treatment and services when Resident 123 developed an open area on the left great toe without assessment and initiation of treatment. For Resident 123, this failure had the potential to result in the delay of treatment and infections. Findings: Review of the clinical record indicated Resident 123 was admitted to the facility on [DATE] with diagnoses that included Type 2 diabetes mellitus (abnormal levels of blood sugar) and paraplegia (paralysis of both lower extremities). According to the National Institute of Diabetes and Digestive and Kidney Diseases, diabetes can lower blood flow to the feet, and thus making it hard for a sore to heal, sometimes, a bad infection will never heal and may lead to gangrene (death of tissues due to decreased blood flow). Review of Resident 123's Weekly Summary, dated 8/4/18, indicated Resident 123 was alert and oriented to time,…

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, for one (Resident 70) of 29 sampled residents the facility failed to ensure Resident 70 received treatment and services to maintain her highest practicable level of functioning and well-being when Licensed Vocational Nurse (LVN) 2 did not implement the facility's Behavior Management policy and procedure. For Resident 70, this failure had the potential to result in increased episodes of crying, yelling, and screaming. Findings: Review of Resident 70's Minimum Data Set (MDS - a resident assessment tool used to guide care), dated 7/2/18, indicated Resident 70 was admitted to the facility with diagnoses that included Alzheimer's dementia (progressive disease that destroys memory and other important mental functions). The MDS also indicated Resident 70 never made decisions and had no behaviors. The MDS also indicated Resident 70 had difficulty hearing, had slurred speech, and had difficulty communicating with others. During an observation on 8/28/18, at 9:09 a.m., Resident 70 was in her wheelchair in her room and cried, screamed, and…

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

Based on interview and record review, for one of 13 sampled residents (Resident 69), the facility failed to ensure Resident 69 was free of significant medication error when Resident 69 did not receive Renvela (a phosphate binder that helps lower increased levels of phosphorus in residents with kidney disease) with meals, as ordered by the physician. This failure had the potential to result in increased phosphorus levels which may lead to bone disease, vascular calcification (accumulation of calcium deposits in major arteries) and cardiovascular disease. Findings: Review of the clinical record indicated Resident 69 was admitted to the facility with diagnoses that included diabetes mellitus (a group of diseases that result in too much sugar in the blood) and end stage kidney disease (the last stage of chronic kidney disease where the kidneys are unable to filter waste and excess fluid from the blood). Resident 69 underwent dialysis (a treatment where a machine cleans and filters the blood of toxins when the kidneys are not healthy enough to do this adequately). Review of Resident 69'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.