West Shore Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure two of 25 sampled residents (Residents 47 and 370), received the necessary services of bathing when the residents were not offered a shower as scheduled. This failure had the potential to affect the residents' dignity and their quality of life. Findings: a. During a concurrent observation and interview on 4/28/25, at 10:56 a.m., Resident 47 was observed to be lying in bed. Resident 47's family member who was at the resident's bedside stated resident did not get showers as scheduled. Review of Resident 47's Facesheet (information containing contact details, brief medical history at-a-glance) indicated he was admitted to the facility on [DATE] with diagnoses that included muscle weakness, need for assistance for personal care and depression (a persistent feeling of sadness). Review of Resident 47's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 1/24/25 under Section C, indicated a score of 7, meaning…

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 an ongoing program of activities to meet the interests and psychosocial well-being for two of 25 sampled residents (Residents 112 and 115). These deficient practices had the potential to affect the quality of life of the residents by placing the residents at risk of sensory deprivation and social isolation. Findings: a. During an interview on 4/28/25, at 12:44 p.m., with Resident 112, the resident stated she was not being offered activities. On observation, the resident only had a TV and her cellphone. Review of Resident 112's Facesheet (information containing contact details, brief medical history at-a-glance) indicated she was admitted to the facility on [DATE]. Review of Resident 112's Minimum Data Set (MDS, an assessment tool) dated 3/18/25, indicated she had a Brief Interview for Mental Status or BIMS of 15 (BIMS score of 13-15 suggests intact cognition). Review of Resident 112's Activities care plan dated 3/12/25 indicated…

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 care and services to six of 25 sampled residents who were dependent on the staff for their care when their call lights were not answered by the facility staff on a timely manner (Residents 4,8, 48,88,113 and 370). This deficient practice had the potential to negatively affect the residents' physical comfort and psychosocial well-being Findings: a. During a concurrent observation and interview on 4/28/25 at 12:30 p.m., Resident 4 was lying in bed and resident stated his call lights took an hour or more to be answered. Stated his needs were sometimes not met. Review of Resident 4's Facesheet (information containing contact details, brief medical history at-a-glance) indicated, Resident 4 was admitted to the facility on [DATE] with diagnoses that included muscle wasting and atrophy (muscle wasting, also known as muscle atrophy, refers to the loss of muscle mass and strength). During a review of Resident 4's Minimum Data Set (MDS, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, for one of three sampled residents (Resident 45), the facility failed to developed and implement adequate person-centered interventions to prevent Resident 45 with dementia from wandering into the rooms of other residents. Dementia is a general term to describe a group of symptoms related to loss of memory, judgment, language, complex motor skills, and other intellectual function, caused by the permanent damage or death of the brain's nerve cells, or neurons. However, dementia is not a specific disease. There are many types and causes of dementia with varying symptom and rates of progression. (Adapted from: About Dementia. Alzheimer's Foundation of America. 30). This failure cause Resident 45 falls, injuries, and had the potential to cause residents increased confusion and emotional distress. Findings: During a review of Resident 45's Annual Minimum Data Set (MDS), Resident Assessment and care guide tool, dated 3/17/25, indicated Resident 45's Basic Interview…

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 facility did not ensure the standardized recipes for the regular diet were followed as printed, in accordance with menu guidance and facility policy. This failure had the potential to alter the palatability and nutritional value of the food, which could decrease food intake and compromise the nutritional status of the facility residents. The facility census was 114. Cross reference F801 and F803 Findings: During a review of the facility's Lunch Menu titled Daily Spreadsheet- Wednesday Day 25, Week 4 Day 4, indicated Main Regular Diet NAS (4-5 grams): 3 oz. Tomato Braised Pot Roast, 1/2 cup Lyonnaise potatoes, 1/2 Steamed spinach, 1 Bread or roll, 1 cup of choice of beverage, 1 slice of 7-up Cake . During a concurrent kitchen observation, interview and record review on 4/29/25 at 2:38 PM with the evening [NAME] (CK) 2 and Dietary Services Manager (DSM), a large metal pot was found in the walk-in refrigerator with foil on it labeled Pot roast 4-29-25 Use by 5-1-25. CK 2 stated the morning [NAME] made the pot roast and placed…

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 staff did not follow their infection control prevention policy and standards of practice during med pass for (two of twenty-five residents,) Resident 50 and Resident 86, when: 1. The facility staff did not clean and sanitize the medication cart in between resident's care, (Resident 50 and Resident 86), after placing soiled medication cup used by Resident 50, into the medication cart. 2. An uncapped and exposed lancet (a small needle used to poke the skin, [usually on a finger for Residents with diabetes] to get a small drop of blood) was left in med storage room B with no name or identifier. 3. The facility staff did not keep medication pill crusher (used to crush medications during medication administration), on the medication cart, clean and sanitized. The failure to practice universal precaution and infection control during medication administration had the potential to result in infection or spread of infection for Resident 86 and increased…

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 sampled resident (Resident 45), Minimum Data Set (MDS-Resident Assessment and Care Screening tool used to guide care), was accurate when Resident 45 MDS section E was not coded accurately to reflect Resident 45's wandering behavior. This failure had the potential for residents to not received appropriate care. Findings: During an observation on 4/28/25 at 10:52 a.m. Resident 45 wandered in hallways with a front wheeled walker looking into other residents rooms. During an interview on 4/30/25 at 8:33 a.m. with Certified Nursing Assistant (CNA1), CNA1 stated Resident 45 wandered around the facility goes into other residents rooms . CNA1 stated Resident 45 was very confused, wanders into other residents rooms, switch off the light in the room and get agitated when redirected. During a review of Resident 45's Annual Minimum Data Set (MDS), Resident Assessment and care guide tool, dated 3/17/25, indicated MDS section E wandering presence and frequency was coded zero meaning wandering behavior was 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, and record review the facility failed to provide wound care treatment and services for one of 25 sampled residents, Resident 80's left heel deep tissue injury (DTI, serious type of pressure ulcer where the underlying tissue is damaged), not following the Physician orders and not consistent with the facility's policy and professional standards of practice. This failure has the potential for Resident 80 to develop worsening of his wound, increase deep pressure ulcer, slow wound healing process, pain, infection and possibly hospitalization. During a review of Resident 80's Face sheet (FC), the FC indicated Resident 80 is [AGE] years old newly admitted to the facility, less than 30 days. The FC indicated Resident 80 has a diagnosis of Type 2 Diabetes (adult onset diabetes, characterized by high blood sugar and insulin resistance) with foot ulcer (open sores or wound), Essential Primary Hypertension (high blood pressure), End Stage Renal disease (a condition in which the kidneys lose…

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 manage, label and store medications for one of one sampled resident, Resident 90, in an accurate, secure, and safe manner according to their facility's policy and procedures and standards of practice, when: 1. facility staff administered Amlodipine Besylate (drug used to treat high blood pressure) to Resident 90 from a medication package that was inaccurately labeled as Amlodipine Besylate 2.5 M instead of administering Amlodipine Besylate 2.5 mg as per physician orders. 2. Facility staff left one loose pill exposed in one of the drawers in medication storage room [ROOM NUMBER]. Findings 1: During a review of Resident 90's face sheet (FC), the FC indicated Resident 90 is [AGE] years old, admitted to the facility in 2023. The FC further indicated Resident 90 has diagnosis of Essential Hypertension (high blood pressure), Calculus (presence of kidney stones, which are hard mineral deposits that form inside the kidneys) of the kidney, 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 ensure the vegetarian menu was followed in accordance with the menu guidance and facility policy. This failure had the potential to decrease the food intake of three unsampled residents (50, 38, and 26) on vegetarian diets, which could further compromise their nutritional status. Cross reference F801, F804 Findings: During a review of the facility's Lunch Menu titled Daily Spreadsheet- Monday Day 23, Week 4 Day 2, the menu indicated .Regular Diet: 1-1/2 cup Penne with Mushroom sauce, 1/2 cup seasoned fresh broccoli florets, 1 slice Garlic bread, 1 cup of choice of beverage, 1 slice of key lime pie.Vegetarian: Select vegetarian item to serve . During a review of the facility's Lunch Menu titled Daily Spreadsheet- Tuesday Day 24, Week 4 Day 3, the menu indicated .Regular Diet: 4 oz. Honey baked ham, 1/2 cup Roasted sweet potatoes, 1/2 Parslied Fresh Cauliflower, 1 Bread or roll, 1 cup of choice of beverage, 1- 3x2 slice of turtle brownie.Vegetarian: Select vegetarian item to serve . During a concurrent…

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 Arbitration Agreement (a binding agreement by the parties to submit to arbitration (a private process where disputing parties agree that one or several other individuals can make a decision about the dispute after receiving evidence and hearing arguments) all or certain disputes which have arisen or may arise between them in respect of a defined legal relationship, whether contractual or not. The decision is final, can be enforced by a court, and can only be appealed on very narrow grounds.) was explained in a manner that one of three sampled residents (Resident 520) understood. This failure resulted in Resident 520 signing the facility's arbitration agreement without full understanding. Findings: During a review of Resident 520's Face Sheet, the Face Sheet printed on 4/30/25 indicated, Resident 520 was admitted in the facility on 4/18/25 with a diagnosis that included multiple fractures of ribs and chronic obstructive pulmonary disease (COPD, a lung disease that makes it difficult to breathe.) During a review…

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

Based on observation , interview and record review, the facility failed to protect one of three sampled residents (Resident 2) the right to be free of physical abuse, when Resident 1 slapped Resident 2's in the face. This failure caused repeated resident to resident altercations, emotional distress and potential to result in injuries. Findings: During a review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment and care guide tool), dated 1/24/25, the MDS indicated Resident 1's Basic Interview of Mental status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) Resident 1's score was 07 meaning impaired cognition. Resident 1 exhibited physical behavioral symptoms directed toward others e.g., hitting, kicking, pushing that put others at significant risk for physical injury. MDS indicated Resident 1 has a serious mental illness. Resident 1's diagnoses included schizophrenia…

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 Resident 1 was free from physical abuse when: 1) Resident 1 was hit by another resident and sustained a bloody right lower lip, 2) Resident 1 was touched on the face by another resident (Resident 2) while in Activity room. This failure resulted to Resident 1 being the recipient of physical abuse which affected Resident 1's physical and psychosocial well-being. Findings: A review of Resident 1's Face Sheet, printed 3/3/25, indicated Resident 1's diagnoses of Alzheimer's (a disease characterized by a progressive decline in mental abilities) disease and dementia (a progressive state of decline in mental abilities). 1. During an interview on 2/27/25, at 11:00 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated on 2/13/25 at 4:15 a.m., LVN 1 was notified by Licensed Vocational Nurse (LVN) 2 that Resident 1 was found in the hallway in her wheelchair with blood coming down from Resident 1's cheek. During an interview on 3/3/25, at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide a written notice of rights and services prior to or upon admission for three of three sampled residents (Resident 1, Resident 2 and Resident 3), when: - For Resident 1, the admission agreement was provided more than nine months after Resident 1's admission to the facility. - For Resident 2 and Resident 3, there was no admission agreement provided during the residents' stay. This failure had the potential to result in Residents 1, 2 and 3 ' s lack of information and awareness of their rights and how to use them as residents of the facility. Findings: During a review of Resident 1's, Face Sheet, the Face Sheet indicated, Resident 1 was admitted to the facility in [DATE] with diagnoses that included fracture of one rib on the right side, unspecified dementia (a progressive state of decline in mental abilities) mild with other behavioral disturbance, major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of…

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

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) or Resident Representative (RR), was provided written information that specified the duration of the state bed-hold policy (Bed-hold, holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization), how reserve bed payments would be made (if applicable), and the conditions upon which the resident would return to the facility. This failure had the potential to result in the lack of awareness of Resident 1's right to hold a bed during hospitalization. Findings: During a review of Resident 1's, Face Sheet, the Face Sheet indicated, Resident 1 was admitted to the facility in January 2024 with diagnoses that included fracture of one rib on the right side, unspecified dementia (a progressive state of decline in mental abilities) mild with other behavioral disturbance, Major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), Hypertension (HTN-high blood pressure),…

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 resident environment was safe and comfortable when the patio area had refrigerator parts, a circular concrete pad approximately two feet across, two pieces of broken concrete, and two leaking water hoses puddling water by two resident patio doors. The failure to maintain the facility patio without clutter and hose-generated puddles had potential to cause ambulatory residents using the patio to trip and fall. Findings: During an observation on 8/28/24 at 11:32 a.m., there was a green hose (hose 1) leaking a small amount of water, eight feet away was a puddle approximately 12 inches by 12 inches on the ground approximately 4 feet away from a resident door which exited onto the patio. There was a black hose (hose 2) leaking water which had puddled directly in front of another resident door which exited onto the patio. Hose 2 continued to drain from the puddle area for 20 feet down the patio to a drain. On the other side of the patio there were several square pieces of plastic, approximately 3 feet…

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 one of two sampled residents (Resident 2) received the correct medications and instructions upon discharge. The failure to follow discharge orders for medications had the potential to result in Resident 2 attempting to self-administer an injectable medication for prevention of blood clots without instruction on side effects or administration. This had the potential to result in injury and excessive bleeding. Findings: During a review on 8/28/24 at 3:40 p.m., Resident 2 ' s facility Facesheet was reviewed. The Facesheet indicated Resident 2 was admitted to the facility in July 2024 and discharged [DATE]. Resident 2 had diagnoses of diabetes mellitus (Diabetes is a chronic (long-term) disease in which the body cannot regulate the amount of sugar in the blood.) and chronic kidney disease (when the kidneys are no longer sufficiently able to remove waste products and excess water to support the body ' s needs). A review of Resident 2 ' s facility…

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 for one (Resident 1) of two sampled residents who made reports of lost items. The failure to investigate or assist with replacement of the reported loss of Resident 1 ' s hearing aids resulted in Resident 1 not having use of hearing aids, potentially causing difficulties with medical and social interactions. Findings: During a review of Resident 1 ' s Facesheet, printed 8/28/24, the Facesheet indicated Resident 1 was initially admitted to the facility in July 2024, with a diagnosis of hypertension (high blood pressure). The Facesheet indicated Resident 1 was his own responsible party, with three family members as alternate responsible parties. During a review of Resident 1 ' s facility documents titled, Inventory Lists, dated 7/31/24, 8/2/24, 8/10/24, 8/28/24, the Lists dated 7/31/24, 8/2/24, 8/10/24 all indicated Resident 1 had hearing aids. The List dated 8/28/24 had no listing of hearing aids for Resident 1. During a 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.

Based on interview and record review, the facility failed to ensure the treatment for scabies (a contagious, itchy skin rash caused by a tiny burrowing mite called Sarcoptes scabiei.) for one of two sampled residents (Resident 1) was carried out according to the physician order and instructions when Permethrin topical cream (used to treat scabies) was washed off two hours after application. There was no evidence the medication error was reported to the physician. This failure had the potential for Resident 1's scabies treatment to be ineffective and could lead to spread of Scabies to other residents and staff at the facility. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted in April 2024 and readmitted in July 2024, with multiple diagnoses including dementia (a loss of brain function that occurs with certain diseases, affecting one or more brain functions such as memory, thinking, language, judgment, or behavior). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment instrument used to identify…

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 a Certified Nursing Assistant (CNA) 1 followed infection control protocols for one of one sampled Resident (Resident 1) when CNA 1 did not perform hand hygiene prior to feeding lunch to Resident 1. This failure had the potential for contaminating Resident 1's food with pathogens from a variety of dirty sources. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted in April 2024 and readmitted in July 2024, with multiple diagnoses including dementia (a loss of brain function that occurs with certain diseases, affecting one or more brain functions such as memory, thinking, language, judgment, or behavior). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 5/23/24, the MDS Section C indicated Resident 1 had severe cognitive impairment. During a review of MDS Section GG, the MDS indicated Resident 1 required substantial/maximal assistance for showers/bath. During 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 observation, interview, and record review, the facility failed to follow infection prevention and control procedures when Certified Nursing Assistant (CNA) 1, did not wear Personal Protective Equipment (PPE, protective items or garments worn to protect the body or clothing from hazards that can cause injury and to prevent the transmission of infectious agents from one person to another, also known as cross-contamination) while providing care to Resident 1 who was on contact isolation). This failure had the potential to result in spread of infection. Findings: During a review of Resident 1's Face Sheet, the Face Sheet indicated Resident 1 was admitted to the facility in March 2024 with diagnoses that included scabies (a parasitic infestation caused by tiny mites that burrow into the skin and lay eggs, causing intense itching and a rash). During an interview on 5/15/24 at 11:09 a.m. with Licensed Vocational Nurse-Infection Preventionist (LVN-IP), LVN-IP stated Resident 1 was confirmed to have scabies on 4/16/24 and was isolated in a single room right away. During a 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.

Based on observation, interview and record review, the facility failed to ensure the Registered Dietitian (RD) and/or Dietary Manager (DM) were competent to comprehensively evaluate and manage the food service operation for 118 of 118 residents, as evidenced by: 1. Lack of guidance and oversight of the DM. 2. Staff competency did not meet professional standards for food safety related to: (a) Time/Temperature Control Foods. (b) Recording refrigerator temperature readings. (c) [NAME] bucket with cleaning solution contained dirty cloth. 3. Nutritional values of food and menu not evaluated and approved by RD. 4. Lack of oversight of dietetic services physical environment. This failure put residents at risk for compromised nutritional status and potential transmission of food borne illness. Findings: 1. During an interview on 8/07/23 at 2:03 p.m. with the DM, the DM stated the RD does not come into the facility, but works remotely. During a phone interview on 8/09/23 at 8:18 a.m., with the RD, the RD stated she worked completely remote and didn't provide any oversight of the DM 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.

Based on observation, interview and record review, the facility failed to ensure staff were competent to meet professional standards for food safety for 118 of 118 residents when Dietary Aide (DA2): 1. Did not cool down a cucumber salad according to established time/temperature control guidelines or record it neither in the cool down log nor the tray line temperature record. 2. Did not record internal temperature readings for the reach-in refrigerator. 3. [NAME] bucket with cleaning solution contained dirty cloth. This failure put the facility at increased risk for food contamination and foodborne illness. Findings: 1. During a concurrent observation and interview on 8/07/23 at 2:17 p.m. with the Dietary Manager (DM) in the kitchen, the temperature of the cucumber salad stored in the reach-in refrigerator was 60.8. The DM stated, the salad was made at lunch time and was in the process of cooling. During a concurrent interview and record review on 8/08/23 at 2:23 p.m. with the DM and Dietary Aide (DA2), DA2 stated, she made the cucumber salad, and it was served at dinner on 8/07/23.…

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 and prepare food in accordance with professional standards for safety when: 1. A resident food refrigerator contained items that were not labeled and/or dated. 2. Stored equipment and utensils that were dirty. 3. Food items in dry storage were left open. These failures put the facility at increased risk for food contamination and foodborne illness for 118 residents who received food from the kitchen. Findings: 1. During a concurrent observation and interview on 8/07/23 at 2:37 p.m. with Licensed Vocation Nurse 2 (LVN2) at the front nursing station medication room counter-top refrigerator. The resident food refrigerator contained an unopened Santa Fe Style Salad that was unlabeled and had a partially erased date of 8/7/23 written in black ink. The refrigerator also contained a partially used, unlabeled, and undated container of Lakewood Organic Pure Black Cherry juice. LVN2 stated, nursing is responsible for checking the refrigerator temps and removing old food. She also stated, contents of the…

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

Based on observation, interview, and record review, the facility failed to ensure the outside garbage storage area was maintained in a sanitary condition when refuse and dark liquid waste was found on the ground surrounding the garbage receptacles. This failure put the facility at increased risk for attracting pests and potentially causing pest related disease in 118 of 118 residents. Findings: During a concurrent observation and interview on 8/07/23 at 2:42 p.m. with the Dietary Manager (DM), the Environmental Supervisor (ES), and Maintenance (M1), the outside garbage area included garbage, green waste, and recycling dumpsters. On the ground, just behind the dumpster on the left, and to the right of the dumpster was debris such as discarded pallets, a shopping cart, a blue rubber garbage can, a patio umbrella, wood, plastic containers and lids, latex gloves, food packaging and paper napkins. There was also a significant amount of dark, gelatinous, liquid waste on the ground in front of the green waste dumpster. The dark liquid was leaking from the bottom corner of the green waste…

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 following kitchen equipment was maintained in good repair when: 1. Reach-in refrigerator: the rubber gasket (a rubber piece that surrounds the inside perimeter of the door to help keep the cold air in) around the interior perimeter of all three the doors was torn or peeled away from the doors. 2. Reach-in freezer: the bottom right side of the rubber gasket on the left door was torn and peeled away from the door. 3. Chest freezer: the lid was broken off the hinges, the rubber gasket was torn across the top of the lid and there was ice buildup on the inside walls. This failure had the potential for the refrigerator and freezers to not maintain appropriate temperatures and put the facility at risk for decreasing the quality of food stored in the freezer and/or affecting the safe storage of food leading to foodborne illness for 118 residents who received food from the kitchen. Findings: 1. During a concurrent observation and interview on 8/07/23 at 9:47 a.m., during the initial kitchen tour, the rubber…

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 complete and submit quarterly Minimum Data Set (MDS- an assessment tool used to plan care) assessments for nine of nine (9) sampled residents (Residents 25, 57, 65, 14, 18, 73, 60, 21 and 78). This failure placed Residents 25, 57, 65, 18, 73, 60, 21 and 78 at risk for unidentified changes in health conditions and potentially outdated plans of care for over a three (3) month period. Findings: During a concurrent interview and record review with the MDS Coordinator (MDSC 1) and the MDS Assistant Coordinator (MDSC 2) on 8/8/23 at 1:16 p.m., Residents 25, 57, 65, 18, 73, 60, 21 and 78's MDS assessments in Electronic Health Records (EHR) were reviewed. The MDSC 2 stated, Residents 25, 57, and 14 were not assessed since 4/2023, indicating there were no MDS assessments for four (4) consecutive months. The MDSC 2 then stated, Residents 65, 18, 73, 60, 21 and 78 had not received an MDS assessment since 3/2023, indicating there were no assessments completed for five (5) consecutive months. The MDSC 2 continued by stating, all…

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 nail care services to four of ten residents (Resident 50, Resident 54, Resident 199 and Resident 400 ). This deficient practice had the potential to result in complications related to a nail infection. Findings: 1. During a review of Resident 199's admission record dated, 6/20/23, indicated, Resident 199 was admitted to the facility in 2023. Resident 199's admitting diagnoses included idiopathic peripheral neuropathy (nerve damage - an individual with idiopathic peripheral neuropathy is at higher risk for developing a toenail infection). During a concurrent observation and interview on 8/7/23 at 11:35 a.m. Resident 199's toenails were observed to be overgrown, thick and dirty. Resident 199 stated, he prefers to keep his toenails short because it was not comfortable. During a concurrent observation and interview, on 8/7/23 at 11:40 a.m. with Registered Nurse (RN) 1, RN1 acknowledged Resident 199's toenails to be overgrown, thick…

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 removal of expired biological supplies that were stored in a medication room. This failure had the potential to result in resident using the expired testing supplies. Findings: 1) During a concurrent observation and interview on [DATE], at 1:29 PM, with LVN 1, in medication room A on nursing station 1, a cabinet drawer was opened and observed there were 5 Puritan UniTranz-RT transport system kits (test kits for the collection and preservation of Virus, Chlamydia, Mycoplasma and Ureaplasma), and 23 tubes of BD-Vacutainer (tubes used for transporting and processing blood for testing serum, plasma or whole blood in the clinical laboratory) to have been expired since [DATE] and [DATE] respectively. The LVN 1 confirmed, and stated both of these biological supplies had been expired. During a review of the facility's policy and procedure (P&P) titled, Medication Storage in the facility dated [DATE], the P&P indicated, Medications 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 ensure one of three sampled residents (Resident 400) was provided with facial hair care when Resident 400 had long, uneven (in length), white facial hair. This failure resulted in Resident 400 feeling unclean and not presentable. Findings: Review of Resident 400's Face Sheet, dated August 2023, indicated, Resident 400 was admitted to the facility on [DATE], with a diagnosis of Anxiety Disorder (excessive feelings of fear or worry) and Depression (persistent feelings of sadness or hopelessness). Review of Resident 400's Minimum Data Set (MDS - An assessment tool used to direct resident care) dated 2/21/23, indicated Resident 400's Brief Interview for Mental Status (BIMS - an indication of a persons ability to understand and be understood) was scored at 13, indicating Resident 400's ability to understand and be understood is intact. The MDS assessment also showed Resident 400 required one staff's limited assistance with his personal…

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 complete a performance review for two of three CNA's (Certified Nurse Assistant) at least once every 12 months. This failure had the potential to result in inadequate care and services provided to residents. Findings: During a concurrent interview and record review on 8/9/23 at 12:12 p.m. with the Director Of Staff Development (DSD), a review of the following CNA records revealed: a. CNA 4 was hired on 11/7/13. b. CNA 5 was hired on 9/7/21. The DSD confirmed CNA 4 did not have performance review for the following years: 2019, 2020, 2021, 2022, and 2023. The DSD also confirmed, there was no performance review for CNA 5 in 2022. The DSD stated, annual performance reviews were important to ensure CNAs providing direct care to the residents, are competent and able to perform tasks correctly. The DSD further added, failure to perform tasks correctly can cause discomfort, pain and/or injury to residents. During a concurrent interview and record review on 8/9/23 at 2:57 p.m. with the Director Of Nursing (DON), the DON stated, 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 thoroughly investigate an alleged abuse violation and submit the results of their complete investigation to the State Agency (SA), for one of two residents (Resident 72). These failures had the potential for further abuse violations and the potential to result in emotional and psychosocial distress to Resident 72. Findings: During a review of Resident 72's Face Sheet, dated 8/10/23, showed, Resident 72 was admitted to the facility in 2021 with multiple diagnoses that included Dementia (loss of memory and other thinking abilities) and Alzheimer's Disease (brain disease). During a review of Resident 72's Minimum Data Set (MDS - A standardized assessment and screening tool used to guide/plan care), dated 5/1/23, indicated, Resident 72 had a Brief Interview for Mental Status (BIMS - An assessment of the ability to understand and be understood) score of 11, meaning Resident 72 had moderate impairment of her ability to understand and be understood. By observation and while in the presence of the Director of Nursing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the pharmaceutical services were provided to assure accurate administering of the pain medications for one of two sampled residents (Resident 1). This deficient practice had the potential for Resident 1's pain to increase and the prescribed treatment to be ineffective. Findings: During an interview on 7/26/23, at 11:10 am., with Resident 1's family member, the family member stated the facility staff administered pain medications to Resident 1 about three hours late on 4/3/23 upon admission. The family member also indicated the facility delayed in giving pain medications to Resident 1 on several occasions while Resident 1 was in the facility. During a review of Resident 1's admission record, the admission record indicated Resident 1 was admitted on [DATE] with diagnoses that included Right hip fracture status post-surgical repair, weakness, and malignant neoplasm of brain (cancerous brain tumors). During a review of Resident 1's Physician order…

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 five of 27 sampled residents, the facility failed to: 1. a. For Resident 276, there was no care plan developed to address purplish skin discoloration on the dialysis site. This failure had the potential to result in delayed management. b. For Resident 276, fall care plan was not implemented when bathroom floor was left wet with a puddle of fluid. This failure had the potential to result in fall accidents. 2. For Resident 114, hearing care plan was not implemented when audiology consult was not provided. This failure had the potential to result in decreased social interaction. 3. For Resident 81, smoking care plan was not implemented when supervision was not provided. This failure had the potential to result in burn and fire hazards. 4. For Resident 12, a care plan was not developed after Resident 12 repeatedly refused podiatry consult. This failure had the potential to result in infection. 5. For Resident 115, there was no care plan developed to address…

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 of one sampled resident (Resident 114) who had difficulty hearing, the facility failed to provide treatment to maintain hearing abilities when facility did not arrange audiology consult as indicated. For Resident 114, this failure resulted in the inability to hear telephone conversations with family members had also the potential to result in social isolation while in the facility. Findings: Review of Resident 114's face sheet indicated Resident 114 was admitted to the facility with diagnoses that included hearing loss. Review of Resident 114's Minimum Data Set Assessments (MDS - an assessment tool used to direct resident care), dated 1/16/19, 4/2/19, 7/16/19, and 10/22/19 all indicated Resident 114 had moderate difficulty hearing (speaker had to increase volume and speak distinctly). Review of Resident 114's hearing impairment care plan, initiated on 1/7/15, indicated Resident 114 was hard of hearing and did not have hearing device. Planned approaches included for Resident 114 to have an audiology consult and to evaluate…

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 1. Review of the Dental Progress Notes, on 11/21/19 at 9:30 a.m., indicated Resident 178 was seen by the dentist (DDS) on 8/13/19. The progress note showed submitting for relines. During an interview, on 11/21/19 at 1:15 p.m., the Social Services Director (SSD) explained Resident 178's dentures were not properly aligned. In a telephone interview, on 11/21/19 at 1:20 p.m., the Dentists' office manager (DOM) stated the DDS received approval from Medi-Cal in mid-August to do the reline work for Resident 178's dentures. During an interview, on 11/22/19 at 3 p.m., the SSD stated she would get a copy of the dentist's visit with the residents. She stated sometimes it would take three to six weeks for denture reline work. The SSD stated the follow up process for a dental visit was to ask the dentist when the next visit would be and to alert the resident on how long it would be for the next visit. When asked if the SSD documented follow up information, she replied not all of the time. The SSD was unable to provide any…

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. This deficient practice resulted in the residents' inability to attain or maintain their mental and psychosocial health by failing to identify the required services needed by the residents and ensure that these services were provided. Findings: During an interview with the Social Services Director (SSD) on 11/22/19 at 10:38 a.m., SSD stated she was the facility's social worker. During an interview with SSD on 11/22/19 at 1:16 p.m., SSD stated she had a bachelor's degree in advertising. SSD stated she was a trained Social Service Designee for long term care facilities. SSD stated the facility had a social worker consultant. SSD stated she was hired by the facility in October 2018 for the social worker position. During an interview with the Administrator (ADM) on 11/22/19 at 1:26 p.m., ADM stated the facility had a capacity of 135 beds and needed a (full-time) social worker. ADM stated he thought SSD had a degree in one of the social sciences. ADM stated the facility 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 observation, interview, and record review, the facility failed to maintain infection control practices when: 1. Manufacturer's directions were not followed for the disinfection of three of three glucometers. 2. Resident 57's personal cup was placed on Resident 80's tray table during lunch. 3. Resident 50 was served meals on Resident 54's over bed table. These failures had the potential for the spread of germs and infections. Findings: 1. During an observation on 11/22/19 at 9:35 a.m., the glucose meter stored in Medication Cart 1B was wrapped in a moist sani-cloth. LVN 1 stated the blood glucose meter was stored this way and that was how she received it from the previous shift. LVN 1 stated that after she uses it, she disinfects it and wraps it with the sani-cloth for storage. During an observation on 11/22/19 at 9:55 a.m., the glucose meter stored in Medication Cart 1A was wrapped in a moist sani-cloth. LVN 2 stated she received the cart with the blood glucose monitor this way from the previous shift. LVN 2 stated this is how the blood glucose monitor is stored. LVN 2…

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 document review, for one of three residents (Resident 80), the facility failed to provide a dignified dining experience when Certified Nursing Assistant (CNA) 1 remained standing while assisting Resident 80 with eating. This failure did not promote respect or dignity in dining for Resident 80 who required assistance during a meal. Findings: Review of Resident 80's Minimum Data Set (MDS - a resident assessment tool used to guide care), dated 10/2/19, indicated Resident 80 was totally dependent on the assistance of staff to eat meals. Review of Resident 80's speech therapy summary, dated 4/18/19 indicated Resident 20 required the assistance of staff to eat. During an observation on 11/18/19 at 12:38 p.m., Resident 80 sat in her wheelchair with a food tray on the table in front of her. CNA 1 arrived and stood with one hand on her hip in front of Resident 80 and used her the other hand to feed Resident 80. At one instance, CNA 1 sat high on Resident 80's roommate's bed and continued to feed Resident 80. During an interview on 11/18/19 at 1:02 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, for one of two sampled residents (Resident 275), the facility failed to inventory all of Resident 275's personal belongings upon readmission to the facility. For Resident 275, this failure had the potential to result in the unrecognized loss or theft of personal belongings. Findings: Review of Resident 275's Physical Examination, dated 11/7/19, indicated Resident 275 had the capacity to understand and make decisions. During an interview with Resident 275 on 11/19/19 at 9:40 a.m., Resident 275 stated she did not know what personal items she had when she returned to the facility on [DATE]. Resident 275 stated she did not know if she had personal items that went missing. During an observation, interview, and concurrent review of Resident 275's personal inventory sheet with Registered Nurse 2 (RN 2) on 11/19/19 at 9:41 a.m., there were items that included; one piece of purple blanket, one piece of purplish black floral sweater, one pair of white and blue fuzzy…

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 comprehensive Minimum Data Set (MDS - an assessment tool used to direct resident care) assessments were completed accurately and within the regulated timeframes for one (Resident 179) of 27 sampled residents. Resident 179's annual MDS was not completed within 14 days of the Assessment Reference Date (ARD - the date the signifies the end of the look back period). For Resident 179, this deficient practice had the potential to result in unassessed and unmet care needs. Findings: Review of Resident 179's Face Sheet, printed 11/22/19, indicated Resident 179 was admitted to the facility on [DATE]. During an interview and concurrent record review with the Minimum Data Set Coordinator (MDSC) 1 on 11/19/19, at 8:37 a.m., indicated Resident 179's annual MDS, dated [DATE], had an ARD of 9/19/19. Further review of this document, indicated Section Z was completed on 10/06/19. MDSC 1 stated Resident 179's annual MDS should have been completed within 14 days…

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 transmit an Annual Minimum Data Set (MDS - an assessment tool used to direct care) Assessment within the regulated timeframes for one (Resident 178) of 27 sampled residents. Resident 178's Annual MDS was not transmitted within 14 days of completion. For Resident 178, this deficient practice had the potential to result in unassessed and unmet care needs. Findings: Review of the Face Sheet, printed 11/22/19, indicated Resident 178 was admitted to the facility on [DATE]. Review of Resident 178's Annual MDS Assessment, indicated an Assessment Reference Date (the date that signifies the end of the look back period) of 9/5/19. During an interview with the Minimum Data Set Coordinator (MDSC) 1 on 11/18/19, at 8:46 a.m., she stated Resident 178's Annual MDS needed to be transmitted with 14 days of completion, but it was not. Review of the Final Validation Report, dated 10/4/19, indicated Resident 178's Annual MDS was transmitted late. Review of the facility's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, for one of one sampled resident (Resident 276) who was on dialysis (process when a machine filters the blood of wastes when the kidneys are not healthy enough to do it), the facility failed to develop a baseline care plan to address presence of peritoneal catheter (a small flexible, hollow tube that is surgically placed in the lower abdomen to withdraw excess fluid, a small piece of the tubing if left outside of the body that can be covered when not in use). For Resident 2796, this failure had the potential to result in infection around the catheter site without appropriate intervention. Findings: Review of Resident 276's face sheet indicated Resident 276 was admitted to the facility on [DATE] with diagnoses that included end stage kidney disease. Resident 276 underwent hemodialysis. During an observation and concurrent joint interview with Resident 276 and Director of Nursing (DON) on 11/22/19 at 7:46 a.m., there was a tube taped to Resident 276's left lower…

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 of six residents (Resident 275) who were at risk of developing pressure ulcers, the facility failed to provide preventive skin treatment for Resident 275 when licensed nurses did not apply Dermaseptine as ordered to Resident 275's skin as ordered by the physician. For Resident 275, this failure had the potential to result in skin breakdown. Findings: Review of Resident 275's clinical record indicated Resident 275 was admitted to the facility with diagnoses that included muscle weakness. Review of Resident 275's Braden Scale (score for predicting one's pressure sore risk), signed and dated 11/7/19, indicated Resident 275's score was 12 (total score of 10-12 is high risk). Review of Resident 275's baseline care plan dated 11/7/19 indicated Resident 275 was at risk for pressure ulcer development. Interventions planned included for staff to monitor skin every shift and provide Preventative skin care per policy. Review of Resident 275's November 2019 Physician Order Sheet indicated an order, dated 11/16/19, to apply Dermaseptine…

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 of four sampled residents (Resident 81 and 175) who were investigated for accident hazards, the facility failed to provide safe environment when: 1. Resident 81 was allowed to smoke unsupervised with two oxygen tanks on the back of his wheelchair. 2. Resident 81 was found in the middle of the driveway at the facility's north side parking lot unsupervised. For Resident 81, these failures had the potential to result in injury from fire or motor vehicle accidents. 3. Resident 175 had O2 being administered at 2 liters per minute (lpm) via nasal cannula (nc - a plastic tube with prongs that is inserted into the nose to deliver oxygen), but there was no O2 sign at the resident's door. Findings: 1. Review of Resident 81's face sheet indicated Resident 81 was admitted to the facility with diagnoses that included chronic obstructive pulmonary disease (a group of progressive lung diseases that causes increasing breathlessness), dementia (impaired memory 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, for one (Resident 175) of two sampled residents who were observed receiving oxygen (O2), the facility failed to ensure Resident 175 received the necessary respiratory care in accordance with professional standards of practice when Resident 175's oxygen saturation (amount of oxygen in the bloodstream) level was measured while Resident 175 was receiving O2. This failure had the potential to result in Resident 175 receiving incorrect amounts of oxygen. Findings: Review of the Face Sheet, printed 11/22/19, indicated Resident 175 was admitted to the facility with multiple diagnoses that included chronic obstructive pulmonary disease (chronic obstruction of lung airflow that interferes with normal breathing). Review of Resident 175's physician's orders, dated November 2019, indicated Resident 175 was to receive O2 at 2 lpm via nc as needed if O2 saturation was below 92% on room air. Review of Resident 175's treatments record, dated November 2019, indicated Resident 175's O2 saturation on 11/21/19 was 97%. During an interview with Licensed…

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 Residents 74 and 76 had their medication regimen reviewed monthly by the consulting pharmacist. This failure had the potential for missed opportunities to prevent, identify, report, and resolve medication-related problems, medication errors, or other irregularities for Residents 74 and 76. Findings: 1. During a concurrent interview and review of the medial record on 11/20/19 at 1:31 p.m., Registered Nurse (RN) 2 stated Resident 74 was taking Celexa for depression and Ativan for anxiety. RN2 stated Resident 74's Celexa was last reviewed by the consulting pharmacist on 8/13/19 and 9/24/19. RN 2 also stated Resident 74's Ativan was last reviewed by the consulting pharmacist on 7/13/19. During an interview on 11/21/19 at 1:17 p.m., Director of Nursing (DON) stated she could not verify with their consulting pharmacist whether Resident 74's Celexa was reviewed for the months of October and November. DON further stated she could not verify with their consulting pharmacist that Resident 74's Ativan was reviewed for 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 provide a safe and sanitary environment when a bathroom floor had a puddle of fluid that had strong unpleasant odor. This failure had resulted in an unsanitary environment and had the potential to result in accidents from a wet floor. Findings: Review of Resident 276's Fall Risk Assessment, dated 11/4/19, indicated a score of 12 (if total score is 10 or higher, the resident should be considered at high risk for falls and a fall prevention care plan is then implemented). Review of Resident 276's Potential for Fall care pla,n dated 11/9/19, indicated interventions to prevent falls that included keeping the environment free from safety hazards (i.e., wet floors, appropriate lighting). During an observation on 11/18/19 at 11:20 a.m., Resident 276's bathroom had fluid on the floor. During an observation and concurrent interview with Maintenance Supervisor (MS) on 11/22/19 at 8:43 a.m., there was a puddle of fluid on the bathroom floor around…

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.