Anaheim Healthcare Center, LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the respiratory care and services were provided for three of three final sampled residents (Residents 74, 81, and 83) and one nonsampled resident (Resident 70) reviewed for respiratory care. * The facility failed to ensure Resident 74's nebulization mask, tubing, and canister were labeled. * The facility failed to ensure the suction canister with tubing and Yankauer suction tip (an oral suctioning tool) at Resident 81's bedside were labeled and stored in a set-up bag. The facility failed to ensure the physician's order for the oxygen therapy was followed for Resident 81. In addition, there was no documentation of the oxygen administration. * Resident 83 received oxygen therapy without a physician's order. * The facility failed to ensure the oxygen humidifier was labeled for Resident 70. These failures had the potential for these residents to not receive appropriate respiratory care and increase risks of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure pharmaceutical services were provided to meet the needs for one final sampled resident (Resident 59) and two nonsampled residents (Residents 118 and 574) reviewed. * The facility failed to ensure the narcotic medication for Resident 118 was accurately signed out, documented and disposed of per the facility's P&P. * The facility failed to ensure Resident 574's order for docusate sodium (bowel movement medication) was followed as ordered by the physician. * The facility failed to ensure Resident 59's hypertension medication was held when the SBP below 130 mmHg. These failures had the potential to result in medication diversion (the illegal use or distribution of a prescription medication that was not originally intended by the prescriber), unsafe handling of the narcotic medications, and the risk for negative health outcomes to the residents. Findings: Review of the facility's P&P titled Controlled…

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, medical record review, and facility P&P review, the facility failed to ensure four of 35 final sampled residents (Resident 65, 76, 81, and 197) reviewed were free from unnecessary medications. * The facility failed to ensure the non-pharmacological interventions were implemented for Resident 197 use of aripiprazole medication. * The facility failed to ensure the non-pharmacological interventions were implemented for the depression and anxiety behaviors exhibited by Resident 81. * The facility failed to ensure the non-pharmacological interventions, AIMS assessment, and specific side effects monitoring for Abilify were assessed for Resident 65. * The facility failed to ensure Resident 76 was properly assessed and monitored related to the use of antipsychotic medication. These failures had the potential to place the residents for receiving unnecessary medication and increased risk of serious medication adverse reactions. Findings: Review of the facility's P&P titled Use of Psychotropic…

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, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure the proper storage and disposal of the medications as evidence by the following: * The facility failed to ensure the arformoterol (medication used to treat chronic obstructive pulmonary disease) medication found in Medication Cart E and Medication Cart F were stored as per the manufacture's storage instructions. * The facility failed to ensure the medical supplies/items that were expired in Medication Carts G and H, and Medication Storage Room B were discarded and/or properly disposed. * The facility failed to ensure Medication Carts B and C was maintained in clean sanitary condition. These failures had the potential to negatively impact the residents' well-being and the potential for the medications to lose the stability and effectiveness. Findings: Review of the facility's P&P titled Medication Storage revised on 12/2022 showed it is…

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, facility document review, and facility P&P review, the facility failed to ensure the facility's posted meal Week at A Glance menus met Resident 17's needs. * The facility failed to follow Resident 17's item request of tuna melt during lunch meal was served. This failure placed Resident 17 at risk of not receiving the meal as planned. Findings: Review of the facility's Diet Count by Modification dated 4/10/25, showed 196 of 216 residents residing in the facility received food prepared in the kitchen. Review of the facility's P&P titled Initial Resident Visitation/ Nutritional Screening dated 9/2021 showed to obtain food preferences, allergies, or intolerances and note on Dietary interview/Pre-screen (form 101) or other designated form and tray card. Review of the facility's posted meal spreadsheet titled Week at a Glance Long Term Care Regular Diet dated between 4/6/25 to 4/12/25, showed the lunch on a date of 4/7/25, included a meal of braised pork shoulder, pork and beans,…

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, medical record review, and facility P&P review, the facility failed to ensure the food preference was honored for one nonsampled resident (Resident 173). This failure had the potential for poor meal intake and negatively impact Resident 173's psychosocial well being Findings: Review of the facility's Diet Count by Modification dated 4/10/25, showed 196 of 216 residents residing in the facility received food prepared in the kitchen. Review of the facility's P&P titled Promoting/Maintaining Resident Dignity During Mealtime revised 12/19/22, showed it is the practice of this facility to treat each resident with respect and dignity and care for each resident in a manner and in an environment that maintains or enhanced his or her quality of life, recognizing each resident's individuality and protecting the rights of each resident. Resident request will be honored during meals to the extent possible. Medical record review for Resident 173 was initiated on 4/7/25. Resident 173 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review and facility P&P review, the facility failed to ensure the complete and accurate medical records for five of 35 final sampled residents (Residents 50, 106, 117, 574, and 674) and two nonsampled residents (Residents 75 and 193). * Residents 75, 117, and 193's H&P examinations showed the residents had no capacity to make medical decisions; however, their face sheets showed they were self-responsible. * Resident 117's Physician Progress Note showed the resident's cognitive level was reevaluated and showed they had capacity, and to update the H&P examination. However, the H&P examination was not updated. * The facility failed to ensure the hold parameters of Resident 574's metoprolol tartrate (blood pressure medication) were accurate. * The facility failed to ensure the urine output was documented post removal of a indwelling urinary catheter for Residents 106 and 674. * Resident 50's Advance Directive Acknowledgment showed Resident 50 had not executed a POLST; however,…

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, medical record review, and facility P&P review, the facility failed to ensure the arbitration agreement was explained and agreed with the appropriate IDT members for three of three residents reviewed for arbitration agreements (nonsampled residents, Residents 75 and 193; and final sampled resident, Resident 117). This failure posed the risk for the resident to not have the right to file an appeal if there was any issue of medical malpractice. Findings: Review of the facility's P&P titled Binding Arbitration Agreement reviewed/revised 12/19/22, showed when explaining the arbitration agreement to the resident or their representative, the facility shall explain the form in a manner that he or she understands, and ensure they understand, and that it is their right not to sign the agreement. Review of the facility's P&P titled Bioethics Committee reviewed/revised 12/19/22, showed the Bioethics Committee is composed of the Administrator, DON, Medical Director, resident's Primary Care Physician,…

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 facility P&P review, the facility failed to implement their infection control program in accordance with the facility's P&P and accepted standards of care. * LVN 11 and CNA 1 failed to follow proper infection control when entering and leaving resident rooms under contact/droplet precautions. * There was a piece of paper trash and staff personal item observed in the clean linen area. * The facility's infection control surveillance did not include residents with signs/symptoms of infection. * The facility failed to ensure the staff wore proper PPE for a COVID-19 isolation room. * The facility failed to ensure the staff wore proper PPE when administering medications via GT. * The facility failed to ensure the staff sanitized the stethoscope after use. * The facility failed to ensure Resident 676's urinal was properly stored. * The facility failed to ensure the urinal observed in Room C's restroom shared by Residents 170 and 674 was properly labeled and stored. * The 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, facility document review, and facility P&P review, the facility failed to maintain the accurate and complete antibiotic stewardship program designed to reduce the use of unnecessary antibiotics. * The facility failed to properly assess and document signs and symptoms of infection in their infection screening evaluation component of their antibiotic stewardship review. The infection screening evaluation component of antibiotic stewardship also lacked clear guidelines as to how many criteria must be met to be considered true infection and escalate those instances where true infection may be undiagnosed or showing no clinical improvement. This failure has the potential to impair the physiological well being of the residents in the facility. * The facility failed to ensure the Resident 81's prescribed antibiotic for the hepatic encephalopathy specified the duration of the antibiotic therapy as per the facility's antibiotic stewardship program. This failure posed the risk of the residents'…

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, medical record review, facility document review, and facility P&P review, the facility failed to ensure two of five final sampled residents (Residents 127 and 160) reviewed for Influenza and pneumococcal immunizations were administered with the vaccine. * The facility facility did not administered the pneumococcal vaccine (a vaccine to protect against infection by pneumococcal bacteria) to Resident 127) * The facility facility did not administered the influenza vaccine to Resident 160. These failures posed the risk for the residents of contracting pneumococcal disease and influenza. Findings: Review of the facility's P&P titled Pneumococcal Vaccination revised 9/2022 showed guidelines to ensure that all eligible residents receive the pneumococcal vaccine in a timely manner, all the residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections, and pneumococcal vaccines will be administered to residents (unless medically contraindicated, already given,…

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, medical record review, facility document review, and facility P&P review, the facility failed to ensure the COVID vaccine was administered to one of five final sampled residents (Resident 160) reviewed for immunization. * The facility failed to ensure COVID -19 vaccine was administered to Resident 160. This failure had the potential to put the resident and staff at risk for increased infection and transmission of COVID-19 infection. Findings: Review of the facility's P&P titled COVID Vaccination revised 12/2022 showed the guidelines to ensure that all eligible patients receive the COVID vaccine in a timely manner, all the residents will be offered COVID vaccines to aid in preventing COVID-19 infections, and COVID vaccines will be administered to residents (unless medically contraindicated, already given, or refused) per facility's physician's approved COVID vaccination protocol. Medical record review for Resident 160 was initiated on 4/9/25. Resident 160 was admitted to the facility on…

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

Based on observation and interview, the facility failed to ensure the accuracy of documentation on the Blood Glucose Monitoring System Quality Control Record for Medication Cart C. This failure had the potential risk of inaccuracy for the glucose test results. Findings: On 4/9/25 at 1011 hours, an inspection of Medication Cart C, review of the blood glucose quality control record, and concurrent interview was conducted with RN 2. Review of the Assure Platinum Meter Serial Number of the Blood Glucose Monitoring System Quality Control Record was observed blank. RN 2 was asked if the form should have been completed. RN 2 verified it should have been with the documentation of the serial number of the meter and completed for accuracy. On 4/11/25 at 0915 hours, an interview was conducted with the DON. The DON verified the above findings.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to develop the comprehensive plan of care to address the IV hydration and clogged nephrostomy tube for one of two sampled residents (Resident 1). This failure posed the risk of not providing appropriate individualized care to Resident 1. Findings: Review of the facility's P&P titled Hydration dated 12/19/22, showed the facility will utilize a systematic approach to optimize the resident's hydration status: developing and consistently implementing pertinent approaches, and monitoring the effectiveness of interventions and revising them as necessary. The resident's goals and preferences regarding hydration will be reflected in the resident's plan of care, and the interventions will be individualized to address the specific needs of the resident. Review of the facility's P&P titled Nephrostomy and Cystostomy Tube Care and Maintenance dated 12/19/22, showed the resident's goals and preferences for care and treatment 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 facility P&P review, the facility failed to maintain the comfortable temperatures for seven of 83 resident rooms (Rooms A, B, C, D, E, F, and G) housing 19 residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, A, B, C, D, E, F, G, H, I, J, and K). This failure had the potential to negatively affect the residents' health and well-being. Findings: Review of the facility's P&P titled Safe and Homelike Environment revised 12/19/22, showed in accordance with the resident's rights, the facility will provide a safe, clean, comfortable, and homelike environment. The facility will maintain comfortable and safe temperature levels. The facility should strive to keep the temperature in common resident areas between 71 and 81 degrees Fahrenheit. On 8/5/24 at 1429 hours, an observation and concurrent interview was conducted with Resident 1 in Room F. Resident 1 was observed to be sitting at her bedside. A personal fan was observed on her bedside table and turned on. Resident 1 stated her room got warm and the hallway got very hot. Resident 1 stated sometimes she could…

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, medical record review, and facility P&P review, the facility failed to ensure the personal property for one of two sampled residents (Resident 1) was protected from theft or loss. This failure had the potential for the resident's property to get lost or stolen. Findings: Review of the facility's P&P titled Theft and Loss Program dated 9/2/22, showed a resident property inventory will be completed to identify the personal property the resident brought with him/her to the facility. The items will be listed on a two (2) part form; Resident's Clothing and Possessions. In addition, the policy showed the admission staff will explain to the resident/surrogate at the time of admission that all personal property is to be clearly marked with the resident's name and listed on the Resident's Clothing and Possessions form. Review of the facility's P&P titled Resident Personal Belongings dated 9/2/22, showed the facility will ensure the resident's belongings are kept in a neat and orderly…

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, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to one of two sampled residents (Resident 2) as ordered by the physician. * The facility failed to notify the physician regarding Resident 2's continuous refusal of medications. This failure had the potential to negatively affect the residents' health condition and well-being. Findings: Review of the facility's P&P titled Medication Administration revised 9/2/22, showed to report and document anyadverse side effects or refusals. Medical record review for Resident 2 was initiated on 6/18/24. Resident 2 was admitted to the facility on [DATE]. Resident 2 had diagnoses of COPD and duodenal ulcer. Review of Resident 2's H&P examination dated 12/4/23, showed Resident 2 had the capacity to understand and make decisions. Review of Resident 2's Order Summary Report showed a physician's order to administer the following medications: - omeprazole DR (medication used for indigestion, heartburn,…

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, medical record review, and facility P&P review, the facility failed to ensure the resident was free from the medication errors for one of five sampled residents (Residents 5). * The facility failed to provide the correct insulin medication to Resident 5 as ordered. This failure had the potential to negatively affect the resident's health. Findings: Review of the facility's P&P titled Medication Errors revised 12/19/22, showed the following: - medication error means the observed or identified preparation or administration of a medication or biologicals which is not in accordance with the physicians' order; manufacturer's specifications (not recommendations) regarding the preparation and administration of the medication and biological; or accepted professional standards and principles which apply to professionals providing the services - the facility shall ensure medications will be administered as follows: a. according to the physician's orders; b. per manufacturer's specification regarding…

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 medical record review, the facility failed to ensure the physician's visits were conducted for three of four sampled residents (Residents 1, 3, and 4) and six nonsampled residents (Residents 5, 6, 8, 9, 10, and 11). This failure had the potential for not addressing the residents' health conditions and care needs. Findings: Review of the facility's Alphabetical Roster dated 3/5/24, showed a list of all residents in the facility and their physicians. The roster showed Physician 1 had 81 residents under their care. Review of the facility's P&P titled Physician Visits and Physician Delegation reviewed 12/19/22, showed the following: - The physician should see the resident within 30 days of initial admission to the facility - The resident must be seen at least every 30 days for the first 90 days after admission and at least every 60 days thereafter by physician or physician delegate. The P&P also showed the Medical Director should visit the resident who are not seen by their attending physician…

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, medical record review and facility P&P review, the facility failed to evaluate the resident to determine if the resident was safe to self-administer the medications for one of four sampled residents (Resident 2). This failure had the potential for unsafe self-administer medication. Findings: Review of the facility's P&P titled Resident Self-Administration of Medication revised 12/19/22, showed a resident may only self-administer medications after the facility's IDT has determined which medications the resident can self-administer safely. Medical record review for Resident 2 was initiated on 2/15/24. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's Order Summary Report dated 2/16/24, showed a physician's order dated 12/11/23, for insulin glargine (long-acting insulin) 62 units to be administered subcutaneously daily. Review of Resident 2's SBAR Communication Form dated 1/26/24, showed a medication error occurred. The document showed around 1039 hours, the LVN drew up a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and facility P&P review, the facility failed to ensure Shower Room A was maintained in a sanitary condition. This failure had the potential for not providing clean home like environment for the residents in the facility. Findings: Review of the facility's P&P titled Resident Rights reviewed/revised 9/22/22, showed the residents have the right to a clean, safe, homelike environment. Medical record review for Resident 2 was initiated on 2/15/24. Resident 2 was admitted to the facility on [DATE]. On 2/16/24 at 1439 hours, an interview was conducted with Resident 2 at the bedside. Resident 2 stated the shower room was dirty and the privacy curtain had what looked like dried feces on it. On 2/16/24 at 1140 hours, an observation of Shower Room A was made. Three shower stalls were observed. The shower stall closest to the door had the following: - The shower curtain had a visible brown discoloration on the middle of the curtain and a small brownish-black discoloration at the bottom hem…

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, medical record review, and facility P&P review, the facility to provide the appropriate supervision for one of four sampled residents (Resident 3). This failure resulted in Resident 3 leaving the facility unsupervised, which could put the resident at risk of injury while out on pass. Findings: Review of the facility's P&P titled Therapeutic Leave reviewed/revised 12/19/22, showed a therapeutic leave is when the resident leaves the facility for a non-medical visit. The policy showed the nurse will obtain an order from the practitioner specifying approval of the leave, and the facility will document in the resident's medical record the resident's leave of absence. Medical record review for Resident 3 was initiated on 2/15/23. Resident 3 was admitted to the facility on [DATE]. Review of Resident 3's MDS dated [DATE], showed Resident 3 used a manual wheelchair and required supervision. Resident 3's BIMS Evaluation showed the resident was cognitively intact. On 2/21/24, at 0839 hours, an 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review and facility P&P review, the facility failed to ensure the residents were free from the medication errors for two of four sampled resident (Residents 2 and 4). * Resident 2 was administered glucose gel outside of the physician's ordered parameters. * Resident 4's nurse failed to ensure the correct dose of medication was prepared before going to administer the medication to the resident. These failures had the potential for undesirable outcomes. Findings: Review of the facility's P&P titled Medication Errors reviewed/revised 12/19/22, showed a medication error is the observed or identified preparation or administration of a medication not in accordance with the physicians' orders. 1. Medical record review for Resident 4 was initiated on 2/21/24. Resident 4 was admitted to the facility on [DATE]. Review of Resident 4's History and Physical examination dated 5/18/23, showed the resident had capacity to understand and make decisions. Review of Resident 4's Order Summary…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility P&P review, the facility failed to ensure the resident was free from the significant medication error when one of four sampled residents (Resident 2) received the incorrect insulin prepared by the licensed nurse. This failure had the potential for poor health outcomes due to adverse effects of the medication. Findings: Review of the facility's P&P titled Medication Errors revised 12/2022, showed a significant medication error, is one that causes the resident discomfort or jeopardizes their health and safety. The P&P showed the facility will ensure medications are administered according to the physician's orders. Lexicomp, an online resource, showed hypoglycemia, low blood sugar levels, can occur from taking too much insulin. Early symptoms of hypoglycemia include sweats, trembling, feeling hungry, feeling worried. If blood sugar levels are not treated, severe symptoms can occur such as trouble walking, being confused, passing out or having a seizure. Medical record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility P&P review, the facility failed to ensure the resident to have access to a refrigerator for storing the resident food brought from outside for one of four sampled residents (Resident 2). This had the potential for the resident not able to obtain or store perishable food of their liking. Findings: Review of the facility's P&P titled Use and Storage of Food Brought in by Family or Visitors, copyright 2023, showed it is the right of the resident to have food brought in by family or visitors. The P&P showed the facility may refrigerate labeled and dated prepared items in the nourishment refrigerator. Medical record review for Resident 2 was initiated on 2/25/24. Resident 2 was admitted to the facility on [DATE]. Resident 2's room was on Nurses' Station A. Review of Resident 2's MDS dated [DATE], showed the resident was cognitively intact. On 2/15/24 at 1202 hours, an interview was conducted with Resident 2 at the bedside. Resident 2 stated she did not always like 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 interview, medical record review, and the facility's P&P review, the facility failed to ensure the accurate and complete medical records for one of four sampled residents (Resident 2) and eight nonsampled residents (Residents 5, 6, 7, 8, 9, 10, 11, and 12). * Insulin administration for Residents 2, 5, 6, 7, 8, 9, 10, 11, 12 were documented past the administration time. * Medication administration documented in the MARs were incomplete for Residents 2 and 6. These failures had the potential for not having an accurate information in the residents' medical record. Findings: 1.a. Medical record review for Resident 2 was initiated on 2/15/24. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's MAR for February 2024 showed the orders dated 12/4 and 12/5/23, for insulin lispro injection to be administered subcutaneously before meals and at bedtime. The scheduled times were at 0630, 1100, 1600 and 2100 hours. Review of Resident 2's Location of Administration Report dated 2/16/24, showed…

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 medical record review, the facility failed to ensure Resident 1 was free from physical abuse when Resident 2 yelled at and pushed Resident 1 to the floor, resulting in Resident 1 sustaining a cut to his left thumb. This failure had the potential for not protecting the resident and negatively impact the resident's well-being. Findings: Review of the facility's 5-day Investigation Summary dated 11/1/23, showed on 10/29/23, Resident 2 hit Resident 1, yelled at, and pushed Resident 1 to the floor. The incident was witnessed by CNA 1. Resident 2 stated he was not happy Resident 1 was using the bathroom while Resident 2 was eating. The facility substantiated the incident. a. Medical record review for Resident 1 was initiated on 11/8/23. Resident 1 was admitted on [DATE]. Review of Resident 1's History and Physical examination dated 10/23/23, showed Resident 1 had the capacity to understand or make medical decisions. Review of Resident 1's progress note dated 10/29/23, showed…

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 medical record review, the facility failed to ensure one of five sampled residents (Resident 1) received the appropriate care and services related to the use of an indwelling urinary catheter. * Resident 1 had a physician's order to discontinue the use of the indwelling urinary catheter; however, the physician's order was not carried out for a period of greater than three weeks. This failure put Resident 1 at risk of complications such as infection. Findings: According to the CDC, the most important risk factor for developing a catheter-associated UTI is prolonged use of the urinary catheter. Therefore, catheters should only be used for appropriate indications and should be removed as soon as they are no longer needed. On 10/17/23 at 1046 hours, an observation and concurrent interview was conducted with Resident 1. Resident 1 was observed in bed with an indwelling urinary catheter draining to a drainage bag withprivacy bag to the right side of the bed. The urine was dark…

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, medical record review, and facility P&P review, the facility failed to ensure the appropriate infection control practices were implemented for one of five sampled residents (Resident 2). * Resident 2 had a history of organ transplants and had a central line (CVC) in place but was not placed on the enhanced standard precautions as per the facility's P&P. This failure put Resident 2 at increased risk for infection transmission. Findings: Review of the facility's P&P titled Enhanced Barrier Precautions dated 9/2022 showed enhanced barrier precautions refer to the use of gown and gloves for use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at risk for MDRO acquisition (e.g., residents with wounds or indwelling medical devices). An order for enhanced barrier precautions will be obtained for residents with any of the following: - Wounds, and/or indwelling medical devices (e.g., central lines .) even if 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 medical record review, the facility failed to ensure the proper storage and label of the medications as evidenced by: * The oral medication was stored together with the suppository medication and nail polish remover and expired supplies were found in Medication Storage 1. * The oral medications were stored with wound supplies in Medication Carts 4 and 8. * The medication bottles with stick residues were found in Medication Carts 1, 5, 6, and 7. * The quality control for a glucometer in Medication Cart 5 was not performed daily and the log was not maintained with the test strip lot number, expiration dates, and normal high lot number. * An expired medication was found in Medication Storage room [ROOM NUMBER]. * Insulin vials in the plastic bags stored in Medication Storage rooms [ROOM NUMBERS] had two different expiration dates on the vials and bags. * The facility failed to ensure the safe storage of an unlabeled medication cup containing a white pasty cream found at the bed…

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.

9.a. Review of the facility's P&P titled Nourishment Refrigerator/ Freezer Storage Guide revised 5/2023 showed the food from outside sources for residents must be labeled with the resident's name, date item placed, and a use-by date. Monitor for freshness. Review of the facility's P&P titled Use and Storage of Food Brought in by Family or Visitors revised 6/2023 showed it is the right of the residents of the facility to have brought in by family or other visitors. However, the food must be handled in a way to ensure the safety of the resident. All food items that are already prepared by the family or visitor brought in must be labeled with content and dated. The facility may refrigerate labeled and dated prepared items in the nourishment refrigerator. The prepared food must be consumed by the resident within two hours. If not consumed within two hours, food will be thrown away by the facility staff. All food items brought in that are manufactured and does not require refrigeration, may be kept in the resident room inside a lock tight container that is provided by the resident.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of 35 final sampled residents (Resident 78) was informed of the changes in the psychotropic medication (medication affecting brain activities associated with mental processes and behavior) dosage. * The facility failed to ensure the informed consent was obtained prior to administering the increased dosage of buspirone hcl (antianxiety medication) for Resident 78. This failure had the potential for Resident 78 not being informed of his medication and potential effects of increased dosage of buspirone hcl. Findings: Review of the facility's P&P titled Use of Psychotropic Medication dated 12/19/22, showed the residents and/or representatives shall be educated on the risks and benefits of psychotropic drug use, as well as alternative treatments/nonpharmacological interventions. Medical record review for Resident 78 was initiated on 10/4/23. Resident 78 was admitted on [DATE], and readmitted to the facility on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure two of 35 final sampled residents (Residents 135 and 171) and two nonsampled residents (Residents 194 and 810) were assessed to safely self-administer the medications prior to performing the self administration of medications. This failure had the potential to negatively impact the residents' physiological well-being and could administer the medications inaccurately. Findings: Review of the facility's P&P titled Resident Self-Administration of Medication revised 12/2022, showed the facility to support each resident's right to self-administer medication. A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely. The results of the interdisciplinary team assessment are recorded on the electronic health record. The policy also showed all nurses and aides are required to report to the charge nurse on duty 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the reasonable accommodations to meet the needs of four of 35 final sampled residents (Residents 62, 82, 136, and 195) and four nonsampled residents (Residents 3, 8, 36, and 127). * The facility failed to ensure Resident 3's bed light cord was within the resident's reach. * The facility failed to ensure Residents 8 and 136's call light and bed remote control were within the residents' reach. * The facility failed to ensure Residents 36, 82, 127, and 195's call light was within the resident's reach. * The facility failed to ensure the staff emptied Resident 62's urinal as per the resident's request. These failures had potential to negatively impact the residents' psychosocial well-being or result in a delay to provide care to these residents. Findings: Review of the facility's P&P titled Call Lights: Accessibility and Timely Response revised 12/19/22, showed the staff will be educated on the proper use…

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, medical record review, and facility P&P review, the facility failed obtain and maintain the copy of the advance directives (legal document that states a person's wishes about receiving medical care if that person is no longer able to make medical decisions) for one of 35 final sampled residents (Resident 9). This failure had the potential for the resident's decisions regarding their healthcare and treatment options not being honored. Findings: Review of the facility's P&P titled Physician Orders for Life Sustaining Treatment (POLST) revised 9/23/20, showed the facility will provide resident/ surrogate decision-maker the option to complete or honor a POLST or Preferred Intensity of Care from at the time of admission. The admission or Social Services staff will ask the resident/healthcare surrogate if the resident has completed a POLST form, and if yes to provide a copy for the medical record. The admission or Social Services staff will review the POLST for completeness (e.g. signed by resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to send a copy of the notice of transfer/discharge to the representative of the Office of the State Long-Term Care (LTC) Ombudsman for one of 35 final sampled resident (Resident 104) and one closed record sampled resident (Resident 49). These failures posed the risk of the LTC Ombudsman not being aware of the circumstances of the resident's transfer/discharge should an appeal be filed or requested by the resident or their representatives regarding the transfer. Findings: Review of the facility's P&P titled Transfer and Discharge (including AMA) revised 12/2022 showed the Social Services Director, or designee, will provide copies of notices for emergency transfers to the Ombudsman, but they may be sent when practicable, such as in a list of residents on monthly basis, as long as the list meets all requirements for content of such notices. 1. Medical record review for Resident 104 was initiated on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to develop the comprehensive plans of care to reflect the individual care needs for three of 35 final sampled residents (Residents 75, 115, and 134). * The facility failed to develop a comprehensive person-centered care plan to address Resident 75's use of antibiotic for treatment of infection and isolation precaution. * The facility failed to develop a comprehensive person-centered care plan to address Resident 115's weight loss. * The facility failed to develop a comprehensive person-centered care plan to address Resident 134's use of antibiotic medication for the treatment of infection. These failures had the potential risk of not providing appropriate, consistent, and individualized care to these residents. Findings: Review of the facility's P&P titled Comprehensive Care Plans dated 12/19/22, showed the comprehensive person-centered care plan that includes measurable objectives and timetables to meet 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 medical record review, the facility failed to ensure the comprehensive plan of care for one of 35 final sampled residents (Resident 191) was revised to reflect the residents' current care needs and interventions. * Resident 191's care plan for tube feeding was not revised to address current continuous tube feeding order. This posed the risk of not providing the resident with individualized and person-centered care. Findings: During the initial tour of the facility on 10/3/23 at 1002 hours, Resident 191 was observed in bed with a tube feeding machine observed at bedside. The tube feeding pump was turned off, and a Diabetisource AC (a tube feeding formula made with a unique blend of carbohydrates that includes pureed fruits and vegetables) feeding bag was observed hanging on the pole. Medical record review for Resident 191 was initiated on 10/3/23. Resident 191 was admitted to the facility on [DATE]. Review of Resident 191's physician's order dated 9/14/23, showed to provide…

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, medical record review, facility P&P review, and facility document review, the facility failed to provide the necessary care and services for two of 35 final sampled residents (Residents 23 and 151) and one of three closed record sampled residents (Resident 199). * Resident 199 was provided with only one shower on 9/14/23, while she was on isolation from 9/4 to 9/14/23. * Resident 151 was provided with only one bed bath on 9/18/23, while the resident was on isolation from 9/14 to 9/24/23. * Resident 23's long fingernails were not trimmed for a month. These failures posed the risk of the residents not being provided with the appropriate care which could negatively impact their psychosocial well-being. Findings: 1. Review of the facility's P&P titled Resident Showers revised date 12/19/22, showed the residents will be provided showers as per request or as per the facility schedule protocols and based upon resident safety. On 9/29/23 at 1314 hours, a telephone interview was conducted with…

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 facility document review, the facility failed to provide an individualized and ongoing activity program to meet the needs and interests of one of 35 final sampled residents (Resident 120). * The facility failed to provide activities and initiated a care plan for Resident 120 to meet the resident's identified interests. This failure had the potential for the resident to experience feelings of social isolation and frustration. Findings: On 10/3/23 at 0916 hours, 10/5/23 at 1053 hours, 10/09/23 at 0827 hours, and 10/10/23 at 0802 hours, Resident 120 was observed in bed and awake. There was no in-room sensory stimulation observed. The TV was turned off, and there was no radio inside the room. On 10/5/23 at 0806 and 0849 hours, and 10/6/23 at 0852 hours, Resident 120 was observed sitting in the wheelchair in front of the nurses' station. Medical record review for Resident 120 was initiated on 10/3/23. Resident 120 was readmitted to the facility on [DATE]. Review of the MDS dated…

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, medical record review, facility record review, and facility P&P review, the facility failed to provide the necessary services to attain or maintain the highest practicable well-being for four of 35 final sampled residents (Residents 78, 86, 171, and 195) and one close record sampled resident (Resident 199). * The facility failed to ensure the necessary care and services were provided timely for Resident 195 who had a fall, including the assessment of the resident's condition and neurological assessments after a fall, developing a care plan to address the actual fall, and notifying the physician and resident's representative of the incident. The resident sustained an acute left hip fracture and was transferred to the acute care hospital where the resident had a left hip hemiarthroplasty (surgical procedure where half of a joint is replaced). * Resident 171 sustained an unwitnessed fall on 9/20/23. The facility failed to ensure the monitoring for the neurological assessment and documenting…

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 medical record review, the facility failed to ensure the elbow splints were applied as per the physician's orders for one of 35 final sampled residents (Resident 191). * The facility failed to ensure the elbow splints for Resident 191 was applied for three to six hours daily per the physician's order. This failure had the potential for the resident's contractures (abnormal shortening of muscle tissue, rendering the muscle highly resistant to stretching; this can lead to permanent disability) and range of motion to worsen. Findings: Medical record review for Resident 191 was initiated on 10/3/23. Resident 191 was admitted to the facility on [DATE]. Review of Resident 191's Order Summary Report showed a physician's order dated 9/1/23, for a prosthetic and orthotic company to provide bilateral elbow orthosis and bilateral knee orthosis to correct/control contractures. However, Resident 191 was observed in bed without bilateral elbow and knee splints applied on 10/3/23 at 1002…

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, medical record review, and facility P&P review, the facility failed to ensure two of 35 final sampled residents (Residents 195 and 710) remained free from accident hazards. * The facility failed to implement safety interventions for Resident 710 who smoked. * The facility failed to complete the assessment, notify the primary care physician, obtain the informed consent from the resident's representative, and develop a plan of care prior to the use of bolster pillows in bed for Resident 195. These failures had the potential for the residents to sustaint accidents and/or injuries. Findings: 1. Review of the facility's P&P titled Resident Smoking revised on 12/2022 showed it is the policy of the facility to provide a safe and healthy environment for residents, visitors, and employees, including safety as related to smoking. The policy also showed smoking is prohibited in all areas except the designated smoking area. Safety measures for the designated smoking area will include 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, medical record review, facility document review, and facility P&P review, the facility failed to ensure the nursing staff provided care for three of 35 final sampled residents (Residents 9, 75, and 113) with the indwelling urinary catheters (a flexible tube that drains urine from the bladder) as evidence by: * The facility failed to ensure Resident 113's indwelling urinary catheter, physician's order for the indwelling urinary catheter, and the care plan for the indwelling urinary catheter were accurate. In addition, the facility failed to obtain a physician's order for clarification when RN 2 was observed changing the indwelling urinary catheter order without first calling the physician or nurse practitioner for clarification. * The facility failed to ensure Resident 9 was educated and monitored when the resident was disconnecting and reconnecting the catheter system to her urostomy bag. * The facility failed to ensure Resident 75 received the appropriate care and services for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and medical record review, the facility failed to provide hydration for one of 35 final sampled residents (Resident 120). * The facility failed to provide a water pitcher and monitor the hydration status of Resident 120 when her fluid restriction order was discontinued on 3/14/23. This failure had the potential for Resident 120 to be at risk for dehydration. Findings: On 10/3/23 at 0916 hours, during the initial tour of the facility, Resident 120 was observed in bed. Resident 120 stated she was always thirsty. There was no water pitcher observed at Resident 120's bedside. Medical record review for Resident 120 was initiated on 10/3/23. Resident 120 was readmitted on [DATE]. Review of Resident 120's plan of care showed a care plan problem dated 1/11/22, addressing Resident 120's dehydration or potential fluid deficit. Another care plan problem dated 1/16/22, addressing monitoring of Resident 120 for status-post of discontinuing current fluid restriction. Both care plan problem had…

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 medical record review, the facility failed to provide the necessary GT care and services for one of 35 final sampled residents (Resident 191). * The facility failed to ensure Resident 191 was administered the total amount of enteral feeding as ordered by the physician. In addition, the facility failed to ensure the GT bag was not empty and there was no air in the feeding tube while connected to Resident 191's GT feeding. These failures posed the risk for developing complications related to GT. Findings: Medical record review for Resident 191 was initiated on 10/3/23. Resident 191 was admitted to the facility on [DATE]. Review of the Order Summary Report showed the following physician's orders: - On 8/26/23, to check tube feeding placement every shift; - On 8/26/23, to flush enteral tube with 15-30 ml water before and after medication and 5 ml water in between each medication; - On 9/14/23, to flush enteral tube at 30 ml/hr for 20 hours, starting at 11 AM until 600 ml/day…

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, medical record review, and facility P&P review, the facility failed to ensure the respiratory services were provided as ordered for five of 35 final sampled residents (Residents 82, 135, 118, 171, and 191) and four nonsampled residents (Residents 6, 112, 146, and 203). * The facility failed to ensure Resident 6 received 4 liters per minute oxygen via nasal cannula as per the physician's order. In addition, the facility failed to ensure the bag containing the nebulizer mask and tubing was not on the floor. Furthermore, the facility failed to ensure the oxygen tubing was changed weekly. * The facility failed to ensure the nebulizer medication cup (the container which holds liquid medication to be converted into mist for inhalation) and tubing for Resident 146 were not on the floor. * The facility failed to ensure the oxygen tubing in a set-up bag and concentrator belonged to another resident were not in Resident 112's bedside. * The facility failed to ensure the Yankauer suction…

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, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary care and services to attain the highest physical wellbeing for one of 35 final sampled residents (Resident 809). * The facility failed to ensure Resident 809 was accurately monitored for the intake and output. This failure had the potential for Resident 809 not being provided the appropriate care and treatment, which could lead to medical complications. Findings: Review of the facility's P&P titled Hydration dated 12/19/22, showed the facility offers sufficient fluid, including water and other liquids, consistent with resident needs and preferences to maintain proper hydration and health. The physician will be notified of the following: 1. Signs and symptoms of dehydration, fluid overload, electrolyte imbalance, or conditions that may increase fluid needs; 2. Lack of improvement toward goals; and 3. Any complications associated with interventions. Documentation: a. Record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the assessment for the risk for entrapment and informed consent were obtained prior to the use of side rails for one of 35 final sampled resident (Resident 129). This failure had the potential to put Resident 129 at risk for serious injury. Findings: Review of the facility's P&P titled Proper Use for Bed Rails revised 7/2023 showed as part of the resident's comprehensive assessment, the following component will be considered when determining the resident's needs, and whether or not the use of bed rails meets those needs: (a) medical diagnosis, conditions, symptoms, and/or behavioral symptoms; (b) size and weight; (c) sleep habits; (d) medications; (e) acute medical and surgical interventions; (f) underlying medical conditions; (g) existence of delirium; (h) ability to toilet self safely; (i) cognition; (j) communication; (k) mobility; and (l) risk of falling. On 10/3/23 at 1035 hours, and 10/5/23 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 observation, interview, medical record review, and facility P&P review, the facility failed to ensure the staff properly communicated with the pharmacy to refill the narcotic pain medication for one nonsampled resident (Resident 125). This failure created the risk for not having the pain medication available to meet the resident's needs. Findings: Review of the facility's P&P titled Medication Ordering and Receiving from Pharmacy dated 04/2008 showed medications included in the Drug Enforcement administration (DEA) classification as controlled substances, and medications classified as controlled substances by state law, are subject to special ordering, receipt, and record keeping requirements in the facility, in accordance with federal and state laws and regulations. The P&P further showed scheduled II controlled medications prescribed for a specific resident are delivered to the facility only if a written prescription has been received by the pharmacy prior to dispensing. In an emergency situation, 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 medical record review, the facility failed to ensure one of 35 final sampled residents (Resident 163) was free from the unnecessary drugs. * Resident 163 was administered metoprolol (used to treat high blood pressure), furosemide (used to treat fluid retention) and hydralazine (used to treat high blood pressure) medications without checking the heart rate and blood pressure parameters as per the physician's orders. This failure had the potential for Resident 163 to develop significant side effects such as bradycardia (slower than normal heart rate) and hypotension (low blood pressure). Findings: According to Lexicomp, an online reference for clinical drug information, the warnings/precautions and concerns related to the adverse effects of metoprolol, furosemide and hydralazine included bradycardia and hypotension. Medical record review for Resident 163 was initiated on 10/3/23. Resident 163 was admitted to the facility on [DATE]. Review of Resident 163's Order Summary Report…

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, medical record review, and facility P&P review, the facility failed to ensure seven of 35 final sampled residents (Residents 9, 26, 75, 78, 87, 151, and 206) were free from unnecessary psychotropic medications (medication affecting brain activities associated with mental processes and behavior). * The facility failed to ensure Resident 78's use of psychotropic medications were accurately monitored to identify a specific behavior manifestation associated with the use of trazadone hcl for in order to determine the effectiveness of the medication. Additionally, the monitoring of adverse reactions of the psychotropic medications were not specific to the drug classifications for antidepressant and antianxiety. In addition, the facility also failed to follow up with the psychiatrist's recommendation to discontinue Resident 78's antidepressants. * The facility failed to ensure Resident 26 had accurate specific behavior manifestation monitoring summaries for venlafaxine hcl and temazepam in order to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 12.5%. * LVN 2 failed to accurately follow a physician's order and administered an expired medication to Resident 859. * The staff failed to notify the physician of Resident 78's refusal of paroxetine HCl. These failures had the potential to compromise the health and safety of the residents. Findings: 1. During the medication pass observation on [DATE] at 0812 hours, LVN 2 administered docusate sodium 100 mg one tablet and Vitamin B1 Thiamine Mononitrate one tablet to Resident 859. Medical record review for Resident 859 was initiated on [DATE]. Resident 859 was admitted to the facility on [DATE]. Review of Resident 859's physician's orders for [DATE] showed the following: - dated [DATE], docusate sodium oral cap 100 mg one cap PO TID for BM, hold if with loose stool - dated [DATE], Vitamin B1 oral tablet (Thiamine HCl) one tablet by mouth in…

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

Based on observation, interview, and facility document review, the facility failed to ensure the recipes were followed. This failure had the potential for the residents to not receive adequate nutrition to meet their individual needs. Findings: 1. Review of the facility's menu daily spreadsheet for Thursday dated 10/05/23, for lunch meal showed to serve braised beef tips, rice pilaf, zucchini and yellow squash, bread or roll with butter or margarine, lemon pudding with whip topping and choice of beverage. Review of the facility's recipe number P17 for Pureed Potatoes, Pasta, [NAME] and other Grains ingredients include ½ (half) cup, and two Tbsp of margarine. On 10/5/23 at 1004 hours, during the puree preparation observation, the Assistant [NAME] did not include the margarine in the puree preparation of the rice. The Assistant [NAME] verified it was missed. On 10/9/23 at 1038 hours, an interview was conducted with the RD. The RD was shown the recipe for pureed rice and according to the recipe, margarine would be added as part of the puree process. The RD stated the margarine added…

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 facility document review, the facility failed to ensure the food served was palatable. * The cooked vegetables were mushy and watery in texture. This failure had the potential for the residents to not eat the food served and could affect their nutritional status. Findings: Review of the CMS 672 Resident Census and Conditions of Residents completed by the facility dated 10/06/23, showed 195 of 210 residents in the facility received food prepared in the kitchen. On 9/29/23 at 1314 hours, a telephone interview was conducted with Resident 199's friend. Resident 199's friend stated Resident 199 was served with overcooked food while at the facility. Resident 199's friend stated Resident 199 was served with mashed or pureed textured food even though Resident 199 was on a regular diet. Closed medical record review for Resident 199 was initiated on 10/3/23. Resident 199 was admitted to the facility on [DATE], and discharged on 10/22/23. On 10/5/23 at 1301 hours, a test tray inspection…

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, facility document review, and facility P&P review, the facility failed to ensure the dietary texture guidelines were followed for the residents on pureed diet. * The pureed rice was observed with grains of rice in the serving container. This failure had the potential to lead to choking or aspiration (a condition in which food, liquids, saliva, or vomit is breathed into the airway) and posed the risk for residents to receive inadequate nutrition. Findings: Review of the facility's P&P titled Puree Food Preparation (undated) showed the pureed food should be prepared in such manner to prevent lumps of chunks. The goal is a smooth, soft, homogenous consistency similar to soft mashed potatoes. Review of the facility's menu daily spreadsheet for Thursday dated 10/5/23, for lunch meal showed to serve braised beef tips, rice pilaf, zucchini and yellow squash, bread or roll with butter or margarine, lemon pudding with whip topping and choice of beverage. On 10/5/23 at 1004 hours, a puree preparation observation was conducted with the Assistant Cook. 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 medical record review, the facility failed to ensure the medical records for one of 35 final sampled residents (Resident 189), one closed record sampled resident (Resident 207), and one nonsampled residents (Resident 709) were complete and accurate as evidenced by: * The facility failed to ensure Residents 709 and 189's medical records had the complete POLST Forms. * The facility failed to ensure Resident 207's Record of Death was complete and accurate. These failures had the potential for not having the information to provide necessary care and services. Findings: 1.a. Medical record review of Resident 709 was initiated on [DATE]. Resident 709 was admitted to the facility on [DATE]. Review of Resident 709's POLST Form dated [DATE] showed Section D regarding advance directive was left blank. On [DATE] at 1520 hours, an interview and concurrent medical record review was conducted with SSA 3. SSA 3 verified the POLST Form, Section D, was not completed. The SSA 3 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, facility document review, and facility P&P review, the facility failed to implement their infection control surveillance program in accordance with the facility's P&P and failed to maintain the infection practices to help prevent the development and transmission of diseases and infection. * The facility failed to maintain the accurate infection surveillance program for August, September, and October 2023. * The facility failed to ensure the clean personal clothing rack was covered during transportation. * The facility failed to ensure the infection control practices were implemented in the facility's laundry room. * The facility failed to ensure Resident 189's urinal was properly labeled and stored to maintain infection control. These failures posed the risk for not identifying resident infections and thereby, preventing the implementation of interventions to control the potential transmission of communicable diseases to other residents in the facility. Findings: 1. 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 interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the COVID-19 vaccination information was documented for one of 35 final sampled residents (Resident 195). This failure posed the risk of not tracking the resident's COVID-19 vaccination status accurately. Findings: Review of the facility's P&P titled COVID-19 Vaccination revised 3/2023 showed the resident's medical records will include documentation of the following: Each dose of the vaccine administered to the resident. Medical record review for Resident 195 was initiated on 10/3/23. Resident 195 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 195's H&P examination dated 8/18/23, showed Resident 195 did not have the capacity to understand and make decisions. Review of Resident 195's COVID-19 Vaccine Booster Dose Consent Forms dated 8/17 and 9/7/23, showed Resident 195 was vaccinated with the COVID-19 vaccines. Further review of the COVID-19 Vaccine…

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, medical record review, facility document review, and facility P&P review, the facility failed to ensure the residents' entrapment assessments were accurate, complete; and the measurements were recorded during the bed inspection when identifying areas of possible entrapment with the use of bed side rails for four of 35 final sampled residents (Residents 9, 86, 129, and 134) and four nonsampled residents (Residents 172, 711, 712, and 713). These failures had the potential to negatively impact the residents resulting in possible entrapment, serious injury, and death. Findings: According to the Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, the term entrapment describes an event in which a patient/resident is caught, trapped, or entangled in the space in or about the bed rail, mattress, or hospital bed frame. Patient entrapments may result in deaths and serious injuries. These entrapment events have occurred in openings within the bed rails, between 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 and interview, the facility failed to provide the clean, sanitary, homelike environment for five of five shower rooms. This failure had the potential to negatively impact the residents' well-being. Findings: On 9/29/23 at 1314 hours, a telephone interview was conducted with Resident 199. Resident 199 stated the shower rooms in the facility were dirty. When asked to elaborate, Resident 199 stated there were used items in the shower rooms, and the shower rooms were not sanitized. Closed medical record review for Resident 199 was initiated on 10/3/23. Resident 199 was admitted to the facility on [DATE], and discharged on 10/22/23. Review of the H&P Examination dated 8/28/23, showed Resident 199 had the capacity to understand and make decisions. On 10/6/23 at 0836 hours, an inspection of the shower rooms was conducted with Maintenance Assistants 1 and 2. Maintenance Assistants 1 and 2 stated there were five shower rooms in the facility and the following was observed: - A razor was observed on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of three closed record sampled residents (Resident 199) was discharged safely. * The facility failed to ensure the Notice of Non-Coverage and Termination of Services forms were given and explained to the resident while in the facility, and the Notice of Proposed Transfer/Discharge contained the reason for the resident's discharge. his posed the risk for Resident 199 to be deprived of her rights regarding the transfer and discharge, which included their right to file an appeal to the correct and appropriate agency within 10 days of being notified. Findings: Closed medical record review for Resident 199 was initiated on 10/3/23. Resident 199 was admitted to the facility on [DATE], and discharged on 10/22/23. Review of the H&P Examination dated 8/28/23, showed Resident 199 had the capacity to understand and make decisions. Review of a physician's order dated 9/19/23, showed Resident 199's last coverage date (LCD)…

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 medical record review, the facility failed to provide the reasonable accommodations to meet the needs for two sampled residents (Residents 1 and 2). * The facility failed to ensure Residents 1 and 2 were provided with assistance in a timely manner. This failure had the potential to negatively impact the resident's physical and psychosocial well-being. Findings: 1. On 8/22/23 at 1300 hours, an interview was conducted with Resident 1. Resident 1 stated he used the urinal or an incontinence brief for his toileting needs. When asked about the response time for the call lights, Resident 1 stated there were times he pressed the call light and had waited up to an hour for assistance. Resident 1 stated the slow response time occurred during the afternoon and night shifts. Resident 1 described a time when he pressed his call light for the staff to empty his urinal. Resident 1 stated his bed sheet and clothes were soaked in his urine after he spilled the urinal while waiting for help.…

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, medical record review, and facility P&P review, the facility failed to remove a staff (CNA 1) from resident care areas pending an alleged violation of abuse for one of three sampled residents (Resident 1) as per the facility ' s P&P. This failure had the potential to expose Resident 1 to abuse. Findings: Review of the facility ' s P&P forCompliance with Reporting Allegations of Abuse/Neglect/Exploitation revised 12/19/22, showed upon report of abuse, the facility will remove and suspend the accused employee from resident care areas pending completion of an abuse investigation. Review of the SOC 341 (a form to report suspected abuse) dated 7/27/23, showed the facility reported Resident 1 incurred a bruise after a CNA showered her on 7/23/23 at 1100 hours. Medical record review for Resident 1 was initiated on 7/27/23. Resident 1 was admitted to the facility on [DATE], with diagnoses of acute on chronic back pain and lumbar stenosis (a condition that results in pressure in the spinal cord and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of three sampled residents (Resident 1) was provided the appropriate pain management as evidenced by: * The facility failed to administer the pain medication as ordered when Resident 1 received acetaminophen (a pain medication) for a pain level of 7 (on a 0-10 pain scale with 0= no pain and 10 = worst pain). * The facility failed to assess and monitor the pain levels for Resident 1 during hydrocodone-acetaminophen (a combination opioid and non-opioid pain medication used to treat moderate to severe pain) administration. These failures put Resident 1 at risk for ineffective pain management. Findings: Review of the facility ' s P&P for Pain Management revised 12/19/22, showed the facility must ensure pain management is provided to the residents who require such services, consistent with professional standards of practice. Medical record review for Resident 1 was initiated on 7/27/23. Resident 1 was admitted to 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 medical record review, the facility failed to ensure one of 35 final sampled residents (Resident 198) remained free from accident hazards. * The facility failed to ensure Resident 198 received two or more persons' physical assistance during ADL care. This had the potential for injury to both the resident and staff. Findings: On 7/12/21 at 1021 hours, CNA 1 was observed changing Resident 198's incontinence briefs by himself. CNA 1 stated he was a one-to-one with the resident and verified he was providing ADL care by himself. CNA 1 stated the resident was heavy, hard to turn, and combative. Medical record review for Resident 198 was initiated on 7/15/21. Resident 198 was admitted to the facility on [DATE]. Review of Resident 198's plan of care showed a care plan problem dated 3/17/21, addressing ADL/physical functions. The care plan problem showed Resident 198 required extensive assistance from two staff members for bed mobility, transfers, and personal hygiene. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to ensure one of 35 final sampled residents (Resident 191) received the IV hydration as ordered. This posed the risk for Resident 191 to develop complications including dehydration. Findings: On 07/12/21 at 0805 hours, Resident 191 was observed with an IV solution bag of D5 1/2 NS (dextrose 5% in 0.45% sodium chloride, indicated for parenteral replenishment of fluid) connected to the left wrist peripheral IV. The IV bag was dated 7/11/21 at 1500 hours, and had 500 ml remaining in the bag. The IV fluid was not infusing. Medical record review for Resident 191 was initiated on 7/12/21. Resident 191 was admitted to the facility on [DATE]. Review of the Order Summary Report showed a physician's order dated 6/21/21, to infuse dextrose-sodium chloride solution 5-0.45% (D5 1/2 NS) at 50 ml per hour for malnutrition. On 07/12/21 at 1218 hours, the same bag of IV fluid was observed hanging with 500 ml still remaining in the bag. The IV fluid…

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, medical record review, and facility P&P review, the facility failed to provide proper respiratory care for four of 35 final sample residents (Residents 82, 45, 108, and 202). * The facility failed to ensure Resident 108's oxygen humidifier bottle was labeled with the date when it was last changed and oxygen tubing was not touching the floor. * The facility failed to ensure Resident 82's oxygen humidifier bottle was changed as scheduled and oxygen tubing was not on the floor. * Residents 405 and 202's nasal cannula tubing were observed touching the floor. These had the potential for increased risk of infection. Findings: According to the facility's P&P titled Oxygen Therapy dated 7/30/18, the licensed nurse should replace the oxygen humidifier bottle every seven days, or sooner if the bottle is empty. The licensed nurse should label and date the humidifier bottle after changing and connecting the humidifier to the outlet of the flow meter. 1. On 7/12/21 at 0946 and 1130 hours,…

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, medical record review, and facility P&P review, the facility failed to ensure one of 35 final sampled residents (Resident 125) remained free from accident hazards due to the use of elevated grab bars in bed. The facility failed to conduct the assessment for the risk of entrapment from elevated grab bars and failed to obtain the informed consent prior to the use of the grab bars. These had the potential to place the resident at risk for entrapment and serious injury. Findings: Review of the facility's P&P titled Proper Use of Bed Rails dated 5/20/21, showed the purpose of this guideline is to ensure the use of bed rails is appropriate and safe for the resident and that bed rails are properly installed and maintained. The P&P defined entrapment as an event in which a resident is caught, trapped, or entangled in the space in or about the bed rail. The P&P defined bedrails as adjustable metal or rigid plastic bars that attach to the bed; available in a variety of types, shapes, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure two of 35 final sampled residents (Residents 53 and 99) were free from unnecessary medications. * The facility failed to monitor Resident 99 who was on an antipsychotic medication for the orthostatic hypotension, medication side effects, behavior manifestation, and psychopharmaceutical behavior summary. This posed the risk of not identifying the potential harmful side effects associated with the medication. * The facility failed to inform the physician when Resident 53 who was on the antipsychotic medications had a significant increase in the behavior manifestations of paranoid delusions and irrational fear by verbalizing someone was trying to kill/harm her. Failure to inform the physician of the increased behaviors posed the risk of Resident 53 not receiving the optimized therapeutic benefits of the medication therapy and a delay in necessary medical interventions for the resident. Findings: Review 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, medical record review and facility document review, the facility failed to ensure the residents received meals based upon their nutritional needs, allergies, and personal preferences. * The facility failed to develop and follow the puree recipes for beef patties and lasagna casserole to ensure nutritional consistency and adequate portions. * The facility failed to ensure the correct meal portions were provided as ordered by the physician to Residents 81 and 95 during lunch. These failures posed the risk of the residents' nutritional needs not being met. Findings: Review of the facility's P&P titled Food Preparation dated 2018 showed the facility will use approved recipes, standardized to meet the resident census. Recipes are specific as to portion yield, method of preparations, amount of ingredients, and time and temperature guide. Review of the Consistency Census Report dated 7/14/21, showed four residents were to have pureed beef patties and 30 residents were to have the pureed lasagna casserole. 1.a. On 7/14/21 at 0955 hours, an observation 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, facility document review, and facility P&P review, the facility failed to provide meals at a proper temperature for 39 of 186 residents. This failure had the potential to decrease food intake which may lead to weight loss and compromise the health of already vulnerable residents. Findings: Review of the facility P&P tiled Food Preparation dated 2018 showed foods should be hold prior to serve for as short a time as practical. A maximum one hour holding time is recommended. Hot foods should be held prior to service at 140 degrees F or above and cold foods at 41 degrees F or below. Review of the facility's CMS 672-Resident Census and Conditions of Residents showed 39 of 186 residents received meals prepared in the kitchen. On 7/13/21 at 0926 hours, an interview was conducted with Resident 3. Resident 3 stated the soup was always cold when he got the tray. Resident 3 stated he had to ask the staff to warm the soup. Resident 3 stated sometimes it took 10 to 15 minutes for the staff to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and the facility document review, the facility failed to ensure 53 of 186 residents were provided the prescribed therapeutic diet. This failure posed the risk of choking for residents and the residents' nutrition needs not being met. Findings: Review of the Consistency Census Report and the facility's CMS 672-Resident Census and Conditions of Resident dated 7/12/21, showed 53 of 186 residents received mechanical soft diet's servings prepared in the kitchen. Review Resident 114's medical record was initiated on 7/13/12. Resident 114 was admitted to the facility on [DATE]. Review of the Order Summary Report dated 6/29/21, showed a physician's order dated 1/1/21, to provide NAS ( No Added Salt) diet, mechanical soft texture, regular thin consistency, finely chopped. On 7/13/21 at 1035, an interview was conducted with Resident 114. Resident 114 stated her diet was changed to the mechanical soft diet when she was admitted to the facility. Resident 114 stated she did not like 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 ensure the sanitary conditions were maintained at the kitchen during food storage and preparation. * The facility failed to label the food items with the open or use by dates. * The facility failed to label the food items with the received date as per their first-in, first-out process. These failures posed the increased risk of cross-contamination and created the potential for pathogens to cause food-borne illnesses to the residents in the facility. Findings: Review of the CMS-672 Resident Census and Conditions of Residents completed by the facility dated 7/12/21, showed 186 of 210 residents residing in the facility received food prepared in the kitchen. According to the facility's P&P titled Storage of Food and Supplies, Procedures for Dry Storage dated 2020, food stores should be arranged in food groups to facilitate storing, locating, and taking inventories. All food will be dated with month, day, and year. According to the facility's P&P title Procedure for Refrigerated Storage dated 2020, 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 interview, medical record review, and facility document review, the facility failed to ensure the medical records for four of 35 final sampled residents (Residents 97, 125, 147, and 208) were accurately maintained. * Resident 125's POLST (Physician Orders for Life-Sustaining Treatment) showed Section A was to Attempt Resuscitation/CPR. The POLST form showed Selecting CPR in Section A required selecting Full Treatment in Section B. However, Section B of the POLST showed Selective Treatment. * Residents 147 and 208's physician documentation of informed consent forms were not signed and dated by the physician. * Resident 97's weight was incorrectly entered into the electronic health record. These deficient practices put the residents at risk for errors in medical care and delays in treatment. Findings: 1. Review of the facility's P&P titled Physician Orders for Life Sustaining Treatment (POLST) dated 10/2014 showed the admission or Social Services staff will review the POLST form for completeness (e.g.…

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, medical record review, facility document review, and facility P&P review, the facility failed to ensure the appropriate infection control practices designed to provide a safe and sanitary environment. * The facility failed to ensure the staff were monitored and screened for symptoms of COVID-19 prior to working the assigned shift. LVN 7, CNAs 5, 6, 7, 8, and 9 were not screened for COVID 19 before their shift. This failure posed the risk of infection and the transmission of COVID 19 in the facility. Findings: Review of the facility's P&P titled Infection Control Manual-Coronavirus (COVID-19) revised 6/30/21, showed the facility will actively verify the absence of fever and respiratory symptoms when employees report to work, at the beginning and at the end of their shift, documenting temperature, absence of shortness of breath, new or change in cough and sore throat and other criteria as identified by State guidance. Review of the facility's Projection Sheet Form for staff dated 7/14/21, showed LVN 7, CNAs 5, 6, 7, 8, and 9 were scheduled to work for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility document review, the facility failed to ensure the COVID-19 vaccination was documented for one of 35 final sampled residents (Resident 53). * The facility failed to document Resident 53's refusal for the second dose of COVID 19 vaccination. This failure posed the risk of not tracking the residents' COVID 19 vaccination status accurately. Findings: Review of the facility's Fact Sheet for Recipients and Caregivers: Emergency Use Authorization (EUA) of the Pfizer-BioNTech COVID-19 Vaccine to Prevent Coronavirus Disease 2019 (COVID-19) in Individuals [AGE] years of age and Older revised 06/25/21, showed the Pfizer-BioNTech COVID-19 Vaccine is administered as a two-dose series, three weeks apart, into the muscle. Medical record review for Resident 53 was initiated on 7/12/21. Resident 53 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 53's COVID-19 Vaccination Record Card showed the first dose of Pfizer COVID-19 vaccination…

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, medical record review, and facility P&P review, the facility failed to ensure inspection of bed frames, mattresses, and bed rails was completed as part of a regular maintenance program for two of 35 final sampled residents (Residents 89 and 125). This failure put the residents at risk for serious injury or possibly death due to entrapment. Findings: Review of the facility's P&P titled Proper use of Bed Rails dated 5/20/21, showed when bed rail usage is appropriate, the facility will assess the space between the mattress and bed rails to reduce the risk for entrapment. 1. Medical record review for Resident 89 was initiated on 7/13/21. Resident 89 was readmitted to the facility on [DATE]. Review of Resident 89's Order Summary Report showed an order dated 11/25/20, for bilateral one-half side rails to improve current bed mobility. On 7/13/21 at 1515 hours, Resident 89 was observed in bed with bilateral one-half side rails in place. On 7/15/21 at 1326 hours, an observation 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.