Bay View Rehabilitation Hospital, LLC

Based on interview and record review, the facility failed to follow its policy and procedure to immediately report alleged abuse allegations to the facility Administrator and to California Department of Public Health (CDPH) within 2 hours, for one of three sampled residents (Resident 1), when Resident 1 alleged Certified Nursing Assistant 1 (CNA 1) slapped them in the face. This failure had the potential to cause a delay in investigations and affect physical and psychological well-being of Resident 1. A review of Resident 1's admission Record printed 7/27/24, indicated Resident 1 was admitted to the facility in 2020 with multiple diagnosis including: Major Depressive Disorder, Single Episode (a serious mood disorder that can affect how a person feels, thinks, and behaves). During an interview on 7/9/24, at 2:35 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, on 4/7/24 at around 10:00 a.m., Resident 1 told them CNA 1 hit them in the face in the morning. LVN 1 stated Resident 1 had redness on their face. LVN 1 stated they did not report the alleged abuse or complete 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 observation, interview, and record review, the facility failed to keep one of three residents (Resident 1) free from physical abuse when Certified Nursing Assistant 1 (CNA1) deliberately poked Resident 1 in the right cheek, smacked Resident 1 in the hand and then forced Resident 1 down in her wheelchair causing her to cry out. This abuse resulted in Resident 1 crying out in pain, hyperventilating (breathing rapidly) and visibly shaking, and had the potential to instill fear in Resident 1 which could result in psychosocial harm. This abuse also had the potential to result in further physical abuse towards Resident 1 and/or other vulnerable residents under CNA1 ' s care. (Cross Reference F610) Findings: During a review of Resident 1's admission Record dated 5/13/24, the admission Record showed Resident 1 was admitted to the facility on [DATE] and primarily spoke Tagalog (a language spoken by people of Filipino descent) for communication. During a record review of Resident 1's admission Minimum Data Set…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a safe and functional environment for residents and staff when: 1. Sliding doors in multiple residents' rooms did not have a working lock. 2. Screen doors in all resident's rooms did not have locks. This failure had the potential to result in residents and staff being unsafe from neighborhood crimes such as theft and physical assault because of unlocked doors. Findings: During an observation and concurrent interview on 5/1/24 at 10:59 a.m. with Resident 1 in Resident 1's room, Resident 1 stated the screen door did not have a lock. Resident 1's sliding door was left ajar, there were multiple personal items at the bedside that included a motorized scooter and a big manual wheelchair that was placed inside the closet. During an observation and concurrent interview on 5/1/24 at 11:31 a.m. with Maintenance Director (MD), the sliding doors in the residents' rooms were inspected. MD stated all screen doors inside all residents' rooms did…

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 follow its policy and procedure to immediately report an alleged abuse allegation to the California Department of Public Health (CDPH) within two hours, for two of three sampled residents (Resident 1 and 2), when Resident 1 and Resident 3 allegedly hit each other, and Resident 2 alleged Certified Nursing Assistant 1 (CNA 1) hit him on the side of his stomach. These failures had the potential to cause a delay in investigations and affect physical and psychological well-being of residents. Findings: A review of Resident 1's admission Record printed 1/16/24, indicated Resident 1 was admitted to the facility in 2021 with a diagnosis of Pneumonia (lung inflammation caused by bacterial or viral infection). A review of Resident 2's admission Record printed 2/23/24, indicated Resident 2 was admitted to the facility in 2023 with a diagnosis of End Stage Renal Disease (ESRD, the final stage of long-term kidney disease when the kidneys are no longer sufficiently able to remove waste products and excess water to support the body'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.

The facility failed to ensure the competency of the Dietary Manager (DM) when: 1. the DM did not ensure the cleanliness and maintenence of equipment in the kitchen (Cross-reference F812 and F908); and 2. the DM did not adequately oversee the safe cooling of meat. This failure to maintain equipment and a clean kitchen environment had the potential to result in cross-contamination of food and lead to foodborne illness for 129 residents who received food from the kitchen out of a facility census of 141. Findings: 1. During the recertification survey from 6/21/21 to 6/24/21, various areas in the kitchen were found dirty and not maintained including the walk-in refrigerator which had exposed electical wires which were meant to be enclosed, ice build-up on pipes and electical wires, black residue on conduit and a wall, fuzzy residue build-up on pipes, conduit, wires, and the unit cooler which the DM and the Maintenence Director (MD) idendified as dust; the freezer which had peelng paint around the entire door frame to the freezer, a significant amount of dried paint bits and black 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 observation, interview, and facility document review, the facility failed to ensure the competency of Food and Nutrition Services staff when: 1. Dietary [NAME] 1 (DC1) did not correctly date thawing chicken stored in a refrigerator; and 2. DC1 and Dietary [NAME] 2 (DC2) did not follow standardized recipes when preparing food. The failure to ensure staff competency for food related tasks had the potential to cause contamination of food resulting in food borne illness; provide food for residents which did not meet the nutrients according to the planned menu resulting in nutritional related medical issues; and provide food to residents with an inappropriate texture for medical needs resulting in choking or death for 129 residents who received food from the kitchen out of a census of 141. Findings: 1. On 6/21/21 at 11:12 a.m., observation in the walk-in refrigerator and concurrent interview with DC1 and the Dietary Manager (DM), showed a container of pieces of raw chicken stored on a shelf. The chicken pieces were sitting in chicken juice as a result of the thawing process.…

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 store, prepare, and serve food safely when: 1. A dirty food tray was placed on a clean food preparation table, and an open cart containing dirty trays was left in a hallway. 2. 2 racks of clean food covers were stored beside the handwashing sink at a distance where splash from the sink could easily reach the clean covers. 3. Electric fan in the food preparation area was dirty. 4. Baking pans were stored dirty and sticky in an area for clean utensils. 5. A rack beside the stove where pots and pans were stored was sticky and dirty. 6. The big mixer stored ready to use was sticky. 7. Drawers were lined with colored tape, which made the storage surface rough with crevices, and not easily cleanable. 8. Door gaskets around the two doors of refrigerator 2 had black residue in its grooves along the entire surface of the gaskets. 9. The walk-in freezer had a dirty floor, peeling paint from the door frame, and a metal threshold (for closing a gap…

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 facility document review, the facility failed to ensure nursing staff were knowledgeable about safely storing food for residents brought in by family and visitors. This failure had the potential for residents to not receive food from family and visitors leading to a decrease in food intake and weight loss for 129 residents who ate food by mouth out of a facility census of 141. Findings: In an interview and observation on 6/23/21 at 11:03 a.m., two nursing staff, Certified Nursing Assistant 3 (CNA 3) and Licensed Vocational Nurse 5 (LVN 5), were interviewed on the policy and procedure for food brought in by family and visitors. CNA 3 stated the facility did not accept food brought to residents in from outside (visitors and family). She stated before the pandemic, food was allowed to be brought in and it could be stored for the resident for 1 day then discarded. LVN 5 stated any food brought in for residents was stored in the resident food refrigerator located in the medication room on Fernside unit. An observation of the refrigerator showed 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 facility document review, the facility failed to store food-related garbage in a dumpster with a tight-fitting lid. This failure had the potential to attract pest to the facility and lead to pest related spread of disease to 141 residents out of a census of 141. Findings: On 6/21/21 at 12:03 p.m., an observation and concurrent interview with the Dietary Manager (DM), showed a dumpster outside in the parking lot with the lid more than 12 inches open with the contents preventing the lid from closing tightly. The dumpster was filled with broken down cardboard boxes and transparent garbage bags containing used cardboard beverage containers. DM stated it was okay for the lid of the dumpster to be open because the dumpster was for recycling. She stated the open beverage containers in the transparent garbage bags were from the kitchen and they were in the recycle dumpster because the containers were recyclable. On 6/23/21 at 1:35 p.m., in interviews with the Infection Preventionist (IP) and the Environmental Manager (EM), the IP stated she did not know…

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, the facility failed to follow doctor's orders for two (Resident 88 and Resident 91) of five residents with a feeding tube (medical device used to provide liquid nourishments, fluids and medications by bypassing oral intake) when the staff did not document performing tube site care. This deficient practice may result in an increased risk for skin breakdown at Resident 88 and Resident 91's tube site. Findings: A review of the document titled, admission Record, dated 6/23/21 indicated Resident 88 was admitted to the facility on [DATE] with a diagnosis of cerebral infarction (damage to tissues in the brain due to a loss of oxygen in the area). A review of the document titled, admission Record, dated 6/23/21 indicated Resident 91 was admitted to the facility on [DATE] with a diagnosis of generalized muscle weakness. A review of the comprehensive Minimum Data Set (MDS- an assessment tool), dated 5/2/21 indicated Resident 88 is on a feeding tube. A review of the comprehensive MDS,…

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 provide food that accommodated the preferences of three unsampled residents: Resident 95, Resident 127 and Resident seven who were on a physician prescribed fortified diet. This failure had the potential for inadequate food intake and altered nutritional status for these three of three residents who were interviewed about their prescribed fortified diet out of a census of 141. Findings: On 6/22/21 at 11:58 a.m., an observation and concurrent interview with Dietary [NAME] 1 (DC1) and the Dietary Manager (DM), showed resident tray tickets on resident food trays food trays that read fortified. The trays that indicated fortified received a scoop of mashed potatoes in addition to what was listed on the menu. DC1 and the DM stated all residents who were on a fortified diet received a scoop of mashed potatoes on every lunch and dinner tray. The main entrée for lunch that day was spaghetti with meat sauce, so the residents on a fortified diet received spaghetti, and a scoop of mashed potatoes. Review of the Policy…

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 implement their infection prevention policies and procedures when: 1. Licensed Vocational Nurse (LVN) 4, did not wash hands or use an alcohol-based hand rub after performing blood sugar check using Glucometer (device use to check for blood sugar level using blood sample) for Resident 30. 2. Certified Nursing Assistant (CNA) 5, did not wear proper personal protective equipment (PPE, protective items or garments such as gloves and gown, worn to protect the body or clothing from germs that can cause spread of infection) when feeding Resident 82, who was on droplet and contact precautions (droplet and contact precautions are measures intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment). 3. Resident rooms did not have waste containers with lids for disposing of used PPE (Personal Protective Equipment - clothing and equipment that is worn or used 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 observation, interview and record review, the facility failed to ensure the walk-in refrigerator/freezer was maintained when there was grime, and ice build-up on the unit cooler (equipment within the refrigerator to regulate and maintain temperature and air flow), pipes and electrical wires; the unit cooler was missing a part to enclose electrical wires; an electrical box was missing a cover; and a metal floor threshold (for closing a gap between the bottom of the door and the floor so there is a good seal) to the entrance of the freezer was not in good repair. This failure had a potential for the walk-in refrigerator/freezer to malfunction and increase the risk for food contamination for 129 residents who received food from the kitchen out of a census of 141. Findings: On 6/21/21 at 11:30 a.m., during the initial tour of the kitchen, an observation of the inside of a walk-in refrigerator and freezer and concurrent interview with the Dietary Manager (DM), showed dirty areas that the DM stated maintenance was responsible for (Cross-reference F812). These areas included the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the privacy and dignity for two of five sampled residents (Residents 89 and 30) was protected when urinary drainage bags were left uncovered and visible to other residents, as well as visitors. This failure had the potential to negatively affect the emotional well-being of the residents. Findings: 1. During a review of Resident 89's admission Record, dated 6/22/21, indicated, Resident 89 was admitted to the facility in 2021. According to Resident 89's admission Minimum Data Set (MDS, an assessment tool used to guide care), dated 5/4/21, indicated, Resident 89 had a Brief Interview for Mental Status (BIMS, a tool used to assess mental function) score of 15, meaning Resident 89 was cognitively intact. The MDS also indicated Resident 89 had an indwelling urinary catheter (a tube that drains urine from the bladder into a bag outside the body). During a concurrent observation and interview on 6/21/21, at 1:15 p.m., Resident 89 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 observation, interview, and record review, facility failed to ensure one of 28 sampled residents (Resident 594) received nail care which resulted in Resident 594's nails on both hands being long with black matter underneath them. This failure had the potenial for Resident 594 to scratch himself. Findings: During an observation, on 06/21/21, at 1:05 p.m., Resident 594 had long nails on both hands and feet with black substance underneath them. During a concurrent interview and record review, on 6/22/2021, at 12:00 p.m. with the Certified Nursing Assistant (CNA 6), Resident 594's Activities of Daily Living (ADL) flow sheet dated 06/2021 was reviewed. CNA 6 stated Resident 594 was totally dependent on staff for maintaining personal hygiene, including nail care. CNA 6 stated staff provided nail care to the residents during showers when nails were softer. CNA 6 stated Resident 594 were hard, and she needed a special nail clipper. CNA 6 stated she notified Registered Nurse (RN 3) of the need for special nail clippers on 6/21/2021. During an interview, on 6/22/21, at 12:15 p.m.,…

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 an interview and record review, the facility failed to provide restorative nursing services (nursing care used to improve or maintain physical function) to one of nine residents (Resident 1). This failure had the potential to result in physical decline and development of contractures (shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). Findings: During an interview on 6/22/21, at 10:59 a.m., with Resident 1, Resident 1 stated they were not receiving rehabilitation services to help with right sided weakness after a stroke (interruption of blood flow to brain). During a review of Resident 1's Order Summary Report (OSR), dated 6/2021, the OSR indicated, Resident 1 has order to receive restorative nursing assistance every day for 90 days starting 4/26/21. During a review of Resident 1's Restorative Nursing Administration Record (RNAR), dated June 2021, the RNAR indicated services were provided two out of 22 days. The RNAR dated May 2021 indicated services were provided eight of 31 days. The RNAR dated April 2021…

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, the facility failed to provide care for two (Resident 109 and 695) of two Residents that require dialysis (treatment for kidney failure that rids your body of unwanted toxins, waste products and excess fluids by filtering your blood) when the staff did not do an assessment after their dialysis treatments. These deficient practice may result in staff being unaware of any abnormal vital signs that can happen after dialysis treatments. Findings: 1. A review of the document titled, admission Record, dated 6/24/21 indicated Resident 109 was admitted to the facility on [DATE] with a diagnosis of End Stage Renal Disease (ESRD, longstanding disease of the kidneys leading to renal failure). A review of Resident 109's Minimum Data Set (MDS- an assessment tool) dated 6/6/21 indicated Resident 109 is on dialysis. A review of Resident 109's Order Summary Report dated 5/25/21 indicated a doctor's order on 1/26/21 to check shunt site every hour for 6 hours for bleeding, pain, redness, 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 observation, interview and record review the facility failed to obtain a doctors order or determine if one of 38 sampled residents (Resident 160) was able to self-administer medications, when Resident 160 had eye drops at the bedside. This deficient practice had the potential to result in Resident 160 using the eye drops against safe dosing recommendations. It also had the potential to result in the use of the medications by other residents, who could potentially come into the room and obtain them from the drawer where it was stored. According to the Minimum Data Set (MDS, an assessment tool used to guide care) dated 3/5/19, On the Brief Interview for Mental Status (BIMS), Resident 160 scored 15/15 or cognitively intact. Resident 160 was diagnosed with glaucoma (increased pressure in the eye). During an observation on 3/26/19 at 10:55 a.m., Resident 160 had two bottles of eye drops in an unlocked drawer at his bedside, brinzolamide 1% and latanoprost 0.005%. In an interview on 3/26/19 at 10:55 a.m., Resident 160 stated he kept his eye drops at his bedside because the staff…

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 three of 38 sampled residents (Residents 117, 148, and 91) had a call light within reach. This deficient practice has a potential for residents to have unmet needs. Findings: 1. According to the Minimum Data Set (MDS, an assessment tool used to guide care) dated 9/23/18, Resident 148 required extensive assistance in positioning in bed, toilet use, and personal hygiene. During an interview and observation on 3/26/19 at 9:30 a.m., Resident 148 stated he had a bowel movement and needed to be changed and could not find his call light. Upon observation, Resident 148's call light was seen on the floor, out of his reach. During an interview with Certified Nursing Assistant (CNA) 2 on 3/26/19 at 9:35 a.m., CNA 2 stated the call light was on the floor and he would fix it and assist the resident. 2. According to the MDS dated [DATE], Resident 91's was totally dependent for positioning and toilet use. In an interview and observation on 3/26/19…

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.

Based on observation and interview, the facility failed to ensure residents had bedside curtains which assured full visual privacy in multiple occupancy rooms. This deficient practice resulted in no visual privacy for residents in eight rooms (302, 305, 306, 360, 362, 363, 364, and 366). in an observation on 3/27/19 between 10:30 a.m. and 2:00 p.m., bed curtains did not provide for complete privacy in rooms 302, 306, 360, 362, 363, 364, and 366. In an interview on 3/27/19 at 9:30 a.m., Licensed Vocational Nurse (LVN) 3 stated the curtain was pulled to give privacy to one resident at a time. In an interview on 3/27/19 at 10:30 a.m., the Director of Nursing (DON) stated she did not realize the curtains were like that and they were possibly in the laundry.

Based on observation, interview and record review, for one (Resident 265) of one sampled resident, the facility failed to ensure the oxygen humidifier (a device to that helps the nose from drying out by humidifying administered oxygen) had water in it. This failure had the potential to cause sore, dry, bloody nose. Findings: During an observation on 3/26/19 at 9:15 a.m. with the Registered Nurse (RN 1), Resident 265 was in bed and was receiving oxygen via nasal cannula ( nose tube) connected to a concentrator (air concentrator that increased the level of oxygen and delivered it via the nasal cannula) During a concurrent interview on 3/26/19 at 9:16 a.m., Licensed Vocational Nurse (LVN) 1 stated The humidifier should not be empty. Registered Nurse (RN) 2 stated the nurses were supposed to check the humidifier every shift to make sure it was full of water so the oxygen was humidified. The facility policy and procedure titled Oxygen Administration dated October 2010 indicated Check the mask, tank humidifying jar, etc, to be sure they are in good working order . be sure there is water…

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, expired medication and equipment was found in a medication room and expired and open dressing supplies were found in two treatment carts. This failure could result in unsuccessfully treatment of residents' medical conditions with ineffective medications and unclean supplies. Findings: During an observation on [DATE] at 1:33 p.m. the following medication and equipment were found: One bottle 180 ml magic mouthwash (used to treat and soothe mouth sores) which expired on [DATE]. Two bottles of 150 ml vancomycin (a strong antibiotic) which expired on [DATE]. Ten lancets (used to prick finger tips for blood samples) which expired on [DATE]. During an observation on [DATE] at 2:24 p.m. of Gold coast Treatment Cart #2, one package of Optifoam non-adhesive 6 inch x 6 inch wound dressing was open. During an observation on [DATE] at 2:30 p.m. of the Fern side Treatment Cart #2 the following was found: Four six-inch x eight inch Mepilex Transfer dressing with Safetec…

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, interviews and record reviews, the staff failed to follow infection control practice when contrary to the facility policy, the treatment nurse brought back unused disposable treatment supplies from Resident 71's room and returned the unused supplies back to the treatment cart for others to use. This deficient practice placed other residents at risk for developing infection form contaminated disposable supplies. Findings: On 3/27/19 at 8:45 a. m. the Treatment Nurse (TN) was observed doing a bedsore dressing change to Resident 71's left buttock. When the TN finished the dressing change, she brought the unused disposable supplies back and put them in the treatment cart. During an interview with TN on 3/27/19 at 9:38 a. m. she stated she should have only brought the needed wound care supplies in the resident's room. Review of the facility wound care policy and procedure indicated only disposable supplies necessary for treatment should be taken inside the room and disposable supplies cannot be returned to the cart.