Anaheim Point

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and P&P review, the facility failed to develop the comprehensive plan of care to reflect the individual care needs for three of 29 final sampled residents (Residents 8, 79 and 126). * The facility failed to implement the care plan to address Resident 8's head of bed while the resident was on continuous oxygen. * The facility failed to develop a care plan problem to address Resident 79's use of bed bolster (a raised foam edges along the sides of bed mattress to support positioning and prevent patient from rolling out of bed) for safety. * The facility failed to develop a care plan problem to address Resident 126's self-use of suction equipment. 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 Person-centered care planning revised 8/24/23, showed the facility will provide person-centered, comprehensive, and interdisciplinary…

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 comprehensive person-centered care plan was revised to reflect the residents' current care needs and interventions for one of 29 final sampled residents (Resident 11) and one nonsampled resident (Resident 133). * The facility failed to ensure Resident 11's care plan interventions for the alprazolam (antianxiety) and duloxetine (antidepressant) medications were revised to show the nonpharmacological interventions were included as per physician's order. * The facility failed to ensure the care plan for Resident 133 was updated to reflect Resident 133's dislike of the facility food, and the food brought daily from home. These failures increased the risk for the residents to not receive an individualized and person centered care in accordance with their assessed needs. Findings: Review of the facility's P&P titled P-NP04-Person-Centered Care Planning revised 4/24/25, showed the facility must develop and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to provide the necessary care and services for one of 29 final sampled residents (Resident 51) and one nonsampled resident (Resident 149) reviewed for ADL care. * The facility failed to ensure Resident 51 was provided with showers on her scheduled shower days. * The facility failed to ensure Resident 149 was provided with oral care. Resident 149's tongue was observed covered with thick white residue. These failures had the potential for the residents' need not met and for the residents to experience physical discomfort. Findings: Review of the facility's P&P titled Oral Care revised 1/1/12, showed the following: - All residents receive appropriate oral care, including denture care if applicable, daily; - It is the responsibility of each staff member within the nursing department is to ensure good oral care for each resident; - For debilitated residents, use suction toothbrush to brush teeth, gums, tongue, cheeks, and palate; and -…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to provide the necessary services to attain or maintain the highest practicable well-being for one of 29 final sampled residents (Resident 61). * The facility failed to ensure Resident 61 was administered midodrine (antihypotensive) medication when Resident 61's systolic blood pressure (SBP) was less than 110 mmHg as prescribed by the physician. This failure had the potential to negatively affect Resident 61's health condition and well-being.Findings: Medical record review for Resident 61 was initiated on 6/16/26. Resident 61 was admitted to the facility on [DATE]. Review of Resident 61's Order Summary Report showed the following physician's orders dated 6/2/26:- to administer midodrine 10 mg one tablet by mouth every eight hours as needed for hypotension. Give if the systolic blood pressure is less than 110 mmHg; and- to monitor blood pressure every shift for the midodrine medication use. Review of Resident 61's MAR for June 2026…

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 P&P review, the facility failed to monitor the fluid intake accurately for one of one final sampled resident (Resident 126) and one nonsample resident (Resident 25) reviewed for hydration and nutritional status. * The facility failed to provide Resident 25's Nephro (nutritional supplements) oral liquid 237 ml as ordered by the physician. * The facility failed to ensure Resident 126's fluid intake was monitored accurately by the charge nurses and CNAs. The CNAs fluid intake documentation did not match the charge nurses' documentation, and often exceeded the volume documented by the charge nurses. In addition, the daily fluid intake documentation was inconsistent and incomplete. These failures placed the residents at risk for undetected fluid imbalances or weight loss and negatively impact the resident's well-being. Findings: 1. Review of the facility's P&P titled Intake and Output revised 2/27/25, showed the fluid intake and output shall be recorded 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, medical record review, and facility P&P review, the facility failed to provide the necessary pain management care and services for two of 29 final sampled residents (Residents 13 and 90) reviewed for pain management. * The facility failed to ensure Resident 13's pain was assessed prior to the administration of hydrocodone (narcotic analgesic) medication. * The facility failed to accurately document the pain level for Resident 90 according to the physician's order when the resident was administered with hydrocodone (narcotic analgesic) medication. These failures posed the risk for the residents not to receive the appropriate and necessary interventions to manage the residents' pain.Findings: 1. Medical record review for Resident 13 was initiated on 6/16/26. Resident 13 was admitted to the facility on [DATE]. Review of Resident 13's H&P examination dated 6/9/26, showed Resident 13 had the capacity to participate in medical decision-making. Review of Resident 13'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 observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for one of three final sampled residents (Resident 62) reviewed for hemodialysis. * The facility failed to ensure Resident 62's fluid intake related to dialysis was monitored accurately. In addition, the facility failed to monitor Resident 62 and notify the physician when his access site was assessed with redness, pain, swelling, or tenderness. These failures had the potential to result in accurate assessment of fluid status, complications associated with fluid overload, and delayed intervention to the resident in the event of a dialysis access emergency.Findings: Review of the facility's P&P titled Dialysis Management revised 1/25/24, showed the following:- Diet and fluid restriction will be followed as ordered; and - Assessing, observing and documenting care of access sites daily, as applicable, such as evidence of infection at the surgical site, such as drainage,…

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 two of two licensed nurses (RN 1 and LVN 2) reviewed for competency had specific competencies and standard of practice skill sets needed to provide safe and efficient nursing care. * The facility failed to ensure RN 1 and LVN 2 were able to competently administer the medications via GT. These failures had the potential to put the residents at risks to receive care not provided in a safe and competent manner.Findings: Review of the facility's document titled RN Staff Nurse Job Description (undated) showed the general duties and responsibilities of the RN are to provide nursing care as prescribed by physician/health care professional in accordance with the legal scope of practice, any Board of Licensing restrictions, and within established standards of care, policies, and procedures, and to administer professional services and provide care consistent with allowing residents to attain or maintain his or her highest practicable physical, mental, and emotional well-being…

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 nurse staffing information was posted in a prominent place and readily accessible to residents and visitors. * The facility failed to post the DHPPD, CDPH Form 612 in a prominent place and readily accessible to residents and visitors. This deficient practice had the potential for residents and visitors to not have facility staffing information available at any given time.Findings: On 6/18/26 at 1041 hours, a facility observation was conducted and there was no CDPH Form 612, Nurse Staffing Information with actual hours worked for licensed and unlicensed nurses posted in any prominent areas in the facility that was accessible to residents and visitors. On 6/18/26 at 1109 hours, an interview and concurrent observation of the posting of actual nursing hours worked by the licensed and unlicensed nurses was conducted with the DSD. The DSD stated the facility had only the posting of the daily projected hours for licensed and unlicensed nurses. The DSD verified there was no posting of the actual…

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 necessary pharmacy services to ensure proper storage of medication for one of 29 final sampled residents (Resident 13) reviewed for self-administration of medication. * The facility failed to ensure a box containing fluticasone propionate (corticosteroid) nasal spray was not left at Resident 13's bedside table. This failure had the potential to negatively impact on the resident's well-being, unsafe administration of the medications, and the potential for the other residents, staff, and visitors to have access to the medication.Findings: Review of the facility's P&P titled Medication - Self Administration revised 7/31/25, showed the following:- Self-administration of medications refers to a resident's ability to independently take their own prescribed medications without assistance from licensed nursing staff. This includes preparing, consuming, or applying the medication as directed by a…

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

Based on observation, interviews, facility P&P review, and facility document review, the facility failed to ensure one of 12 kitchen employees (Dietary Aide 1) had the appropriate competency and skill set to perform daily kitchen duties. These failures posed the risk of cross contamination in the kitchen which could lead to food-borne illness in the 127 residents who received food prepared in the kitchen.Findings: Review of the facility's matrix dated 6/16/26, showed 127 residents received food prepared in the kitchen. Review of the facility's P&P titled Dietary Department Infection Control for Dietary Employees dated 2022 showed, II. Proper Hand Hygiene A. Upon entering the kitchen, F. After handling soiled equipment or utensils. III. Hand Washing Facilities A. Kitchen sinks shall not be used for hand washing. Separate hand-washing facilities with soap, running water and individual towels shall be provided. Review of the employee file signed by Dietary Aide 1 on 7/7/25, showed Dietary Aide 1 was responsible to maintain a safe and sanitary work environment. a. Review of the employee…

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 nutritional needs were met for one of 127 residents (Resident 133) who had an option to received a vegetarian meal. * The facility failed to ensure Resident 133 was provided the vegetarian meal with the same amount of protein as the regular diet. This failure posed the risk for the resident's nutritional needs not be met which could lead to medical complications. Findings: Review of the facility's document titled Cooks Spreadsheet dated 6/17/26, showed for the lunch meal a Regular diet would receive taco casserole, seasoned fresh zucchini, fiesta salad and tangy glazed fresh fruit and milk. The Vegan Alternative Menu dated 6/17/26, showed for the lunch meal Regular diet would receive baked beans, seasoned fresh zucchini, fiesta salad and fresh fruit. On 6/16/26 at 1145 hours, an interview was conducted with the DSS. When asked about the vegetarian diets, the DSS stated three residents received a vegetarian diet. Tofu or…

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

Based on observation, interview, and facility P&P review, the facility failed to ensure visitors who brought food from the outside to the facility residents, and the staff who handled the food brought from the outside were educated on safe food handling practices. These failures posed the risk for unsafe food handling for the 127 facility residents who received an oral diet.Findings: Review of the facility's P&P titled Food Brought by Visitors dated 2022 showed for the staff to assist the family/visitors to understand safe food handling practices (such as safe food cooling/reheating processes, hot/cold holding temperatures, preventing cross contamination, hand hygiene etc.). On 6/16/26 at 0935 hours, an interview was conducted with Resident 133 and her family member. Resident 133's family member had brought into the facility ethnic food from outside for Resident 133 to eat. Resident 133's family member stated he brought food for Resident 133 every day and got the food from his church. The food from outside was stored in a previously used plastic butter container and three additional…

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 the facility P&P review, the facility failed to ensure four nonsampled residents (Residents 38, 103, 110, and 144) were safe to self-administer the medications. * The facility failed to ensure a bottle of Refresh eyedrops (used to relieve dry and irritated eyes) was not in Resident 110's nightstand. Resident 110 stated she administered the eyedrops by herself; however, Resident 110 was not assessed for the safe self-administration of the medication. * The facility failed to ensure a container of Biofreeze pain relief cream (a topical rubefacient used to ease muscle and joint aches and pain) was not in Resident 103's nightstand drawer. Resident 103 stated he administered the cream by himself; however, Resident 103 was not assessed for the safe self-administration of the medication. * The facility failed to ensure a bottle of Bactine pain-relieving cleansing spray (a maximum strength antiseptic with 4% lidocaine used to help prevent bacterial…

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 one of 29 final sampled residents (Resident 20) needs and preferences were accommodated. * The facility failed to provide the properly fitted diaper to Resident 20. This failure posed the risk to negatively affect the resident's physical and emotional well-being. Findings: On 3/3/25 at 930 hours, during the initial tour of the facility, an observation and concurrent interview was conducted with Resident 20. Resident 20 stated the diaper she wore was too small, and the facility's vendor did not carry the Prevail diapers any longer. Resident 20 stated, the diaper does not fit me and my bed was soaked three times a day. Resident 20 showed her diaper and was observed to have the current diaper's waist band below her mid abdominal area and just above the pubic area. Resident 20 further stated, I'm just upset because of my diaper, I have asked them for two weeks, and I feel like I'm wearing a thong. Medical record review 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, medical record review, and facility P&P review, the facility failed to ensure the personal property of one nonsampled residents (Resident 100) was protected from loss or theft. * The facility failed to ensure Residents 100's personal items were labeled with the resident's name and included in the resident's inventory list. These failures had the potential for the resident's property to get lost or stolen. Findings: Review of the facility's P&P titled Personal Property revised 7/14/17, showed the following: - The facility will make every effort to maintain the security of the resident's property while helping to create a home-like environment; - During the admission process, the Admissions staff will inform the resident/resident representative of the need to mark the resident's belongings with the resident's name and to notify nursing when additional items are brought to the facility so that they can be added to the resident's inventory list; - A copy of the written inventory…

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 documents review, and facility P&P review, the facility failed to ensure the abuse P&P was implemented for one of five sampled residents (Resident 120) investigated for abuse. * The facility failed to ensure two alleged perpetrators (LVNs 2 and 7) were immediately suspended pending the outcome of the investigation for the abuse allegation for Resident 120. This failure had the potential for the resident to be vulnerable for further abuse, mistreatment, and injury. Findings: Review of the facility's P&P titled Abuse Prevention and Management revised 5/30/24, showed the facility does not condone any form of resident abuse, neglect, misappropriation of resident property, exploitation, and/or mistreatment. Reports of resident abuse, mistreatment, neglect, exploitation, injuries of an unknown source, and any suspicion of crimes are promptly reported and thoroughly investigated. If the suspected perpetrator is an employee, remove the employee immediately from the care of the resident(s)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to ensure the comprehensive care plan was implemented for one of 29 final sampled residents (Resident 82). * The facility failed to implement the bilateral floor mats in accordance with Resident 82's fall risk care plan. This failure placed the resident at risk of not receiving the appropriate, consistent, and individualized care. Findings: Medical record review for Resident 82 was initiated on 3/3/25. Resident 82 was admitted to the facility on [DATE]. Review of Resident 82's Care Plan titled At Risk for Falls/Injuries initiated on 5/17/23, showed Resident 82 was at risk for falls related to dementia, impaired cognition, and poor safety awareness. The care plan further showed Resident 82 had a long history of ongoing falls. The interventions included to provide the bilateral floor mats. On 3/3/25 at 0900 hours, an observation was conducted of Resident 82. Resident 82 was observed lying in bed. Resident 82's bed was observed with 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 observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for one of two sampled residents (final sampled resident, Resident 66) reviewed for IV antibiotic use and one of eight sampled residents (final sampled resident, Resident 394) reviewed for advance directives to attain and maintain their highest practicable well-being. * The facility failed to continuously monitor Resident 66 for the adverse reactions related to the IV antibiotics use and ESBL in the urine. * The facility failed to clearly identify the current code status for Resident 394. These failures had the potential for residents to not receive the necessary care and services in accordance with the resident's needs and treatment wishes. Findings: 1. Review of the facility's P&P titled Change of Condition Notification revised [DATE] showed a licensed nurse will notify the resident's attending physician and legal representative or an appropriate family member when…

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 one of 29 final sample residents (Resident 82) and one nonsampled resident (Resident 643) remained free from accident hazards. * The facility failed to update the plan of care and provide the adequate supervision and necessary services for Resident 643 to prevent elopement. This failure had the potential for Resident 643 leaving the facility premises undetected. * The facility failed to implement the bilateral floor mats per the physician's order for Resident 82 who was at risk for falls. These failures had the potential to place the residents at risk for serious injury. Findings: Review of the facility's P&P titled Wandering and Elopement revised on 1/31/23, showed the facility will identify the residents at risk for elopement upon admission and when there is a change in condition to minimize the risk of elopement, to enhance the safety of the residents of 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 observation, interview, medical record review, and facility P&P review, the facility failed to ensure the dialysis care was provided for one of three final sampled residents (Resident 4) reviewed for dialysis as evidenced by: * The facility failed to ensure Resident 4's dialysis access site was assessed and monitored appropriately and consistently. This failure had the potential for Resident 4 not being provided with the appropriate care and treatment and the possibility of medical complications related to the resident's dialysis access site. Findings: Review of the facility's P&P titled NP37 Dialysis Management revised 1/25/24, showed the facility should assure that each resident receives care and services consistent with professional standards of practice. The vascular access site should be assessed, observed and document care of access sites daily, as applicable, such as auscultation/palpation for pulse, bruit and thrill to assure adequate blood flow. On 3/3/25 at 1005 hours, during the initial tour…

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 five sampled residents (final sampled resident, Resident 394) reviewed for side rail use remained free from accident hazards due to the use of side rails. * The facility failed to ensure Resident 394 who was assessed for no indication for the use of side rails was not provided with the side rails. Resident 394 was provided with bilateral upper ½ (half) side rails. In addition, Resident 394's plan of care showed a care plan problem to address grab bars, not ½ side rails. These failures had the potential to place Resident 394 at risk for entrapment and serious injury from side rail use. Findings: Review of the facility's P&P titled Bed Rails dated 6/12/24, showed the licensed nurse will complete the Bed Rail Evaluation prior to the use and/or installation of any bed rail, upon admission, readmission, change in bed or mattress, and a change in mobility status. On 3/4/25 at 1405 hours, Resident 394…

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 pharmacy services as per the facility's P&P for one nonsampled resident (Residents 34). * The facility failed to ensure the accurate and complete documentation of the controlled medication administered to Resident 34 was maintained. This failure had the potential to pose the risk for the diversion of the medications. Findings: Review of the facility's P&P titled Medication Administration revised 1/1/12, showed the licensed nurse will chart the drug, time administered and initial his/her name with each medication administration. The time and dose of the drug administered to the patient will be record in the patient's individual medication record by the person who administers the drug. Medical record review for Resident 34 was initiated on 3/4/25. Resident 34 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 34's H&P examination dated 2/10/25, showed Resident 34 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, medical record review, and facility P&P review, the facility failed to ensure the medications were not stored at the bedside for one of 29 final sampled residents (Resident 104). In addition, the facility failed to ensure the proper disposal of the expired treatment supplies for one of five medication/treatment carts inspected for the medication storage and labeling. * The facility failed to ensure the expired culture swabs and dressing were removed from Treatment Cart 1. * Resident 104 was observed with sealed, unopened Wallgreens Redness Relief eye drops (eye redness relief) at bedside. These failures had the potential to result in unsafe medication administration and posed the risk for inaccurate test results and treatments. Findings: Review of the facility's P&P titled Medication Storage in the Facility effective date 4/2008 showed the medications and biologicals are stored safely, securely, and properly, following the manufacture's recommendation or those of the supplier.…

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 document review, the facility failed to follow the menu when preparing food for one of 29 final residents (Resident 88). * The facility failed to ensure the recipe for chef salad was followed. Resident 88 requested a chef salad and received only lettuce with shredded carrots and purple cabbage. This failure had the potential for the resident to not receive adequate nutrition based on their diet orders. Findings: Review of the facility's Diet Count dated 3/6/25, showed 123 of 140 residents residing in the facility received food prepared in the kitchen. On 3/3/25 at 0907 hours, an observation and concurrent interview was conducted with Resident 88. Resident 88 was sitting up in bed watching TV. Resident 88 stated she was ordering more salads for her meals because she was trying to lose weight to qualify for her knee surgery. Resident 88 stated she was not receiving enough protein on her salads and did not feel like with enough food. Medical…

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 necessary adaptive equipment was provided for one of 29 final sampled residents (Resident 8). * Resident 8 was not provided with built-up utensils per the physician's order. This failure had the potential for Resident 8 not having an appropriate assistive device to consume her food. Findings: Review of the facility's P&P titled Restorative Dining Program revised January 2012 showed the residents will be provided a tray with their respected diet. The special adaptive equipment may be recommended by the OT and will be provided by the facility. The equipment may include, but may not be limited to built-up handled utensils, weight utensils, large handled utensils, and angled utensils. The facility staff should consistently place the adaptive equipment in the same position on the tray and encourage use of the adaptive equipment by the resident during the meal. On 3/3/25 at 1315 hours, during the dining…

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 ensure the hair restraints were worn by the staff while in the kitchen and failed to ensure kitchen dry storage guidelines were implemented. * The DSS failed to donn a hair restraint while in the kitchen, in accordance with the facility's P&P. * A canister containing brown rice was observed without a lid inside of the dry storage room. These failures had the potential for unsafe food storage and infection control practices in a medically vulnerable resident population. Findings: Review of the facility's Diet Count dated 3/6/25, showed 123 of 140 residents residing in the facility received food prepared in the kitchen. 1. Review of the facility's P&P titled Dietary Department - Infection Control for Dietary Employees revised on 11/9/16, showed personal are required to have clean hair covered with an effective hair restraint while in all kitchen and food storage areas, and beard/mustache covering when applicable. On 3/3/25 at 0745 hours, during the initial tour of the kitchen, the kitchen staff 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 provision of hospice services for two of three residents (final sampled residents, Residents 79 and 394), reviewed for hospice services. * Resident 79 was scheduled to receive care from a certified hospice aide twice per week; however, the medical record failed to show documentation the certified hospice aide provided care to Resident 79 twice per week as scheduled. * The facility failed to clarify the frequency of the hospice agency staff visits and to ensure the hospice aide visited and provided care to Resident 394. The facility failed to ensure the flowsheet and clinical notes from the hospice nurses and hospice aides were completed. In addition, the facility failed to ensure Resident 394's POLST and hospice agency's consents were completed. These failures had the potential to delay hospice care for the residents. Findings: Review of the facility's P&P titled Hospice Care of Residents revised 1/1/12, 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.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to maintain the infection control program and practices designed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases. * The facility failed to implement the testing, monitoring, and establishment of acceptable ranges of disinfectant chemicals levels throughout the facility's water supply in accordance with the facility's water management P&P for water management, and the facility's plan for Legionella control. * The laundry room and equipment were not maintained to ensure a clean area, and free from potential contamination. These failures had the potential for the spread of infection to the residents, staff and visitors in the facility. Findings: 1. According to the CMS QSO-17-30 titled Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaire's Disease dated 6/2/17, the facilities must develop and adhere to the policies and procedures that inhibit…

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 (Policy and Procedure) review, the facility failed to implement the antibiotic stewardship program. * The facility failed to ensure the infection control data gathered in the surveillance log was accurately documented in the Infection Control Report for January 2025. * The facility failed to provide documentation of the McGeer's criteria used to determine if the residents met the criteria for true infection. * The facility failed to ensure Resident 54 was accurately assessed for true infection when an Ampicillin (antibiotic medication to treat infection) was prescribed. These failures had the potential for inappropriate use of antibiotics and increased risk of drug-resistant organisms. Findings: According to the CDC, the antibiotics are among the most frequently prescribed medications in nursing homes, with up to 70% of residents in a nursing home receiving one or more courses of systemic antibiotics over a year. Studies have shown that 40-75% 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, facility document review, and facility P&P review, the facility failed to ensure the bed inspection and entrapment assessment were conducted for one of five final sampled residents (Resident 394) reviewed for side rail use. These failures had the potential to negatively impact the resident's well-being 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 bed rails and mattresses, under bed rails, between split rails, and between the bed rails and head or foot boards. The population most vulnerable to entrapment are elderly patients…

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, medial record review, and facility P&P review, the facility failed to conduct an inventory of a resident's personal property in accordance with the facility's P&P for one of five sampled residents (Resident 2). * The facility failed to conduct the inventory of Resident 2's personal property when he was admitted and discharged from the facility. This failure had the potential for the resident's property to get lost or stolen. Findings: Review of the facility's P&P titled Personal Property revised 7/14/17, showed the residents are encouraged to retain and use personal possessions, as space permits. During the admission process the admissions staff will inform the resident of the need to mark the resident's belongings with the resident's name and to notify nursing when additional items are brought to the facility, so they can be added to the resident's inventory list. Admissions staff will also inform the resident that items removed from the facility need to be removed from the inventory list.…

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 implement their P&P related to abuse reporting for one of five sampled residents (Resident 1). * The Activities Assistant failed to report the abuse allegation to the Administrator when Resident 1 informed the Activities Assistant that a CNA was mad and threw towels on Resident 1's bed. This failure had the potential for the abuse allegation not investigated thoroughly and posed a risk of not providing appropriate actions to prevent further abuse. Findings: Review of the facility's P&P titled Abuse Reporting and Investigations revised 3/2018 showed the purpose of the facility's policy is to protect the health, safety, and welfare of facility residents, by ensuring that all reports of resident abuse are promptly reported and thoroughly investigated. Allegations of abuse are to be reported to the Administrator or designated representative immediately. When the Administrator or designated representative receives a report of an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility document review, the facility failed to ensure the routine changes of indwelling urinary catheter order were clarified with the physician for one of two sampled residents (Resident 2). This failure had the potential to put Resident 2 at risk for UTI. Findings: Review of the CDC's resource for Infection Control - Catheter-Associated Urinary Tract Infections (CAUTI) dated 2009 showed the Proper Techniques for Urinary Catheter Maintenance include changing indwelling urinary catheters or drainage bags at routine, fixed intervals is not recommended. Rather, it is suggested to change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised. Review of the facility's P&P titled Catheter – Care Of revised on 6/2021 showed the indwelling urinarycatheters will not be changed at the arbitrary fixed intervals. The entire system will be changed when it functions poorly, is obstructed, or is the source of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and the facility P&P review, the facility failed to provide the written information regarding the rights to formulate the advance directives for one of ninesampled residents (Residents 1). In addition, facility failed to ensure the POLST was completed for Resident 1. These failures had the potential for the residents' decisions regarding their healthcare and treatment options not being honored. Findings: Review of the facility's P&P titled Advanced Directive revised July 2018 showed upon admission, the admission staff or designee will provide written information to the resident concerning his or her right to make decision concerning medical care, including right to accept or refuse medical or surgical treatment, and the right to formulate advance directive. The P&P further showed during the social services assessment process, the Director of Social Service designee will also ask the resident whether he or she has a written advance directive. Closed medical record review…

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

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 nine sampled residents (Resident 1) was provided the necessary treatment and services to maintain and improve his ROM functions. * The facility failed to ensure the physician was notified of Resident 1's refusal of the PT and OT services and failed to develop the care plan problem to address Resident 1's refusal of the PT and OT services. These failures posed the risk for Resident 1 to develop complications from immobility leading to muscle atrophy and contractures (shortening of the tendons and muscles causing the joints to become stiff and unable to fully function). Findings: Review of the facility's P&P titled Refusal of Treatment revised 1/1/12, showed the facility will honor a resident's request not to receive medical treatment as prescribed by their attending physician, as well as care services outlined on the resident's assessment and care plan. Under the section for procedure showed the attending…

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 maintain the accurate medical record for one of four final sampled residents (Resident 1). * The facility failed to ensure the licensed nurse documented the initials in the MAR when the medications were administered to Resident 1. * The facility failed to document when Resident 1 went out on pass and returned to the facility. * The facility failed to ensure the weekly skin/wound assessments were completed weekly in December 2023 for Resident 1. These failures had the potential for the resident's care not being met as the clinical information were not complete. Findings: Review of the facility's P&P titled Medication-Administration revised 1/2012 showed the licensed nurse will chart the drug, time administered and initial his/her name with each medication administration and sign full name and title on each page of the Medication Administration Record (MAR). Review of the facility's P&P titled Out on Pass revised 1/2016,…

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 four sampled residents (Resident 1) received the pain medication as prescribed in accordance with physician ' s orders. * Resident 1 had a physician ' s order for oxycodone-acetaminophen (a narcotic medication used to treat pain) 5-325 mg two tablets by mouth every four hours as needed for moderate pain; however, Resident 1 received the medication on multiple occasions outside of the ordered parameters. This failure had the potential for Resident 1 to not have their pain adequately addressed and adverse effects. Findings: Review of the facility ' s P&P titled Pain Management revised date 11/2016showed the following: - The licensed nurse will administer pain medication as ordered; and - The licensed nurse will assess the resident for pain and document results on the Medication Administration Record (MAR) each shift using the 0-10 pain scale. Closed medical record review for Resident 1 was initiated on 11/7/23.…

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

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 medications were administered in accordance with the standards of practice for one of four sampled residents (Resident 4). * Resident 4's medications were not administered in a timely manner as prescribed by the physician. This failure had the potential for medication errors and to negatively affect Resident 4's health conditions. Findings: Review of the facility's P&P titled Medication – Administration revised 1/1/12, showed it is the facility's policy to ensure the accurate administration of the medications for residents in the facility. The medications may be administered one hour before or after the scheduled medication administration time. Medical record review for Resident 4 was initiated on 9/14/23. Resident 4 was admitted to the facility on [DATE], and readmitted on [DATE]. On 9/14/23 at 1051 hours, an observation was conducted with Resident 4 in Room A. Resident 4 was observed sitting 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 medications were stored properly for one of four sampled residents (Resident 4) when a medication cup filled with multiple tablets were observed at the bedside table in Resident 4's room. This failure had the potential for the residents, staff, and visitors to have access to the medication and unsafe administration of medications. Findings: Review of the facility's P&P titled Medication Storage in the Facility dated April 2008 showed the medications and biologicals are stored safely, securely, and properly following the manufacturer's recommendations or those of the supplier. Medical record review for Resident 4 was initiated on 9/14/23. Resident 4 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 4's Self-Administration of Medication form dated 7/18/23, showed Resident 4 was not capable to self-administer his medications. Further review of the 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.

Based on interview, facility document review, and facility P&P review, the facility failed to ensure the CNAs' performance evaluations were completed every 12 months for the CNAs' competency evaluations reviewed. The lack of CNAs' performance review had the potential for the staff to not maintain competencies to provide the residents with needed and appropriate care and services. Findings: Review of the facility's P&P titled Staff Competency Assessment revised 3/2022 showed competency assessment would be preformed upon hire during employee's 90-day employment period, annually, or anytime new equipment or a procedure introduced and as needed. On 4/21/23 at 1506 hours, the employees' files review was conducted with the DSD. The DSD stated she was not able to find the performance evaluation records for all CNAs who were in the facility for more than a year for 2022 and 2023. The DSD stated she started to work for the facility in September 2023 and was verbally told the performance evaluations for the CNAs were completed in June 2022; and the next performance evaluations were due 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 P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen. * The facility failed to ensure the food preparation equipment was air dried. * The facility failed to ensure the meal trays were in good condition. * The facility failed to ensure the food service spatulas were in good condition. * The facility failed to ensure the food items in the resident refrigerator were labeled and dated. * The facility failed to ensure the backflow prevention of one food preparation sink was maintained. * The facility failed to ensure the door frame of the kitchen walk-in refrigerator was free from residue and in good condition. * The facility failed to ensure the kitchen cleaning equipment were stored off the floor. These failures had the potential to expose the residents who consumed food prepared in the kitchen to foodborne illnesses. Findings: Review of the CMS 672 form completed by the facility on 4/17/23, showed 118 of 127 residents consumed food prepared from the facility's kitchen. 1. Review of the facility's P&P…

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 ensure multiple waste bins were properly maintained. This failure had the potential to cause unsafe and unsanitary conditions in the facility. Findings: Review of the facility P&P titled Garbage and Trash Can Use and Cleaning revised 10/2014, showed garbage and trash cans must be covered. On 4/17/23 at 1125 hours, during the facility rounds, two large dumpsters and two small trash cans located outside of the building next to the laundry room were observed overfilled with their lids open. Additionally, four large plastic bags of garbage were observed on the floor next to the large, overfilled dumpster. On 4/17/23 at 1133 hours, Housekeeper 1 was observed discarding additional bags of garbage on the floor next to the large, overfilled dumpster. On 4/17/23 at 1140 hours, a tour of the facility's garbage disposal area and concurrent interview was conducted with the Housekeeping Supervisor. The Housekeeping Supervisor stated in total, the facility had five large garbage dumpsters and two small trash cans.…

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 25 final sampled residents (Resident 101) participated in the development and planning of their care. * Resident 101 was not invited to participate in the care plan conference. This posed the risk of violating Resident 101's rights in choosing the treatment options and making the decisions in care planning. Findings: Review of the facility's P&P titled Resident Rights Operational Manual-Resident Rights revised 1/1/12, showed the facility will promote and protect those rights. Residents have freedom of choice, as much as possible, about how they wish to live their everyday lives and receive care, subject to the facility's rules and regulations and applicable state and federal laws governing the protection of resident health and safety. Review of the facility's P&P titled Comprehensive Person-Centered Care Planning Nursing Manual- General, undated, showed the facility must provide the resident and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 25 final sampled residents (Resident 48) who was not a candidate for self-administered medication had an ointment medication at the bedside and self-administered it. * Resident 48 pulled out an Aquaphor Itch Relief Ointment (anti-itch ointment) from her drawer which she self-administered to her feet. Resident 48's Self-Administration of Medication Assessment showed Resident 48 was not a candidate for self-administration of medication. Resident 48 did not have a physician's order to self-administer the Aquaphor Itch Relief Ointment. This failure had the potential for poor health outcomes to Resident 48. Findings: Review of the facility's P&P titled Medication- Self Administration Nursing Manual- General revised 12/1/12, showed all self-administered medication will have pharmacy labels with complete directions for use of the medication. No labels may read as directed. Non-prescription (over 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 six of 25 final sampled residents (Residents 57, 75, 727, 777, 779, and 782) had the rights to receive reasonable accommodation of needs and preferences. * The facility failed to ensure Resident 57's call light was within reach. * The facility failed to ensure Residents 75, 727, 777, and 782's call lights were answered in a timely manner. * The facility failed to ensure Resident 779's bariatric mattress had proper fitted sheets. These failures had the potential to negatively impact the residents' well-being. Findings: Review of the facility's policy and procedure titled Communication- Call System revised 1/2012 showed the facility will provide call system to enable residents to alert the nursing staff from their rooms and toileting/bathing facilities. Call cords will be placed within the residents' reach in the residents' room. Nursing staff will answer call bells promptly in courteous manner. Review of the facility's P&P…

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's advanced directive was obtained and maintained in the medical record for one of 25 final sampled residents (Resident 4). This failure had the potential for the resident's decisions regarding her healthcare and treatment options to not be honored. Findings: Review of the facility's P&P titled Advance Directives revised 7/2018 showed the purpose of an advance directive is to ensure the facility respects advance directives. At the time of admission, the admission staff will obtain a copy about the existence of an advance directive. A copy of the advance directive is maintained as part of the resident's medical record. Medical record review for Resident 4 was initiated on 4/17/23. Resident 4 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of the Advance Healthcare Directive Acknowledgement Form dated 8/28/19, showed Resident 4 received an information regarding her right to make an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility P&P review, the facility failed to report the potential abuse for one of nonsampled resident (Resident 57) when Resident 57 was found with a skin discoloration below the left eye. This failure created the risk for a delay in protecting Resident 57 and delay investigation of the alleged abuse. Findings: Review of the facility's P&P titled Abuse: Reporting and Investigations dated 3/2018 showed the facility will report allegations of abuse and criminal activity as required by law and regulations to the appropriate agencies. The facility promptly reports and thoroughly investigates allegations of resident abuse, mistreatment, neglect, exploitation abuse facilitated or enabled by the use of technology, misappropriation of resident property, or injuries of unknown source, and suspicion of crimes. On 4/17/23 at 0843 hours, Resident 57 was observed lying in bed and had a skin discoloration below the left eye. Medical record review for Resident 57 was initiated on 4//17/23.…

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

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 notify one of three closed record sampled residents (Resident 126) and their representative of their transfer/discharge and the reasons for the move in writing. In addition, the facility failed to send a copy of the transfer/discharge to the representative of the Office of the State Long-Term Care Ombudsman (a person who routinely visits the facility and advocated for the residents). These posed the risk for Resident 126 and the representative not aware of the appeal process for discharge. Findings: Review of the facility's P&P titled Discharge and Transfer of Residents Nursing Manual-General revised date 2/2018 showed the resident/resident representative will be provided with a Notice of Proposed Transfer and Discharge 30 days prior to discharge or as soon as practicable. Review of the Notice of Proposed Transfer/discharge date d 5/4/22, showed, If you believe that the proposed transfer/discharge…

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 accurately complete the MDS for one of 25 final sampled residents (Resident 529). This posed the risk of the resident not receiving an individualized plan of care based on the resident's specific needs. * Resident 529 was a smoker. The facility failed to code the use of tobacco in the admission MDS dated [DATE]. Findings: Medical record review for Resident 529 was initiated on 4/17/23. Resident 529 was admitted to the facility on [DATE]. On 4/17/23 at 1652 hours, Resident 529 was observed in her room lying in bed, pointed to the pillow on top of her wheelchair, and stated to look underneath; and two pieces of cigarettes and a lighter were observed under the pillow. Review of Resident 529's plan of care showed a care plan problem dated 4/17/23, addressing Resident's 529's smoking. The care plan focus showed Resident 529 was an identified as a smoker. Review of Resident 529's admission MDS dated [DATE], showed the tobacco use 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 observation, interview, and medical record review, the facility failed to develop the plan of care to reflect the individual care needs for six of 25 final sampled residents (Residents 29, 52, 55, 57, 59, and 777). * The facility failed to ensure Resident 29's care plan problem addressing dialysis included Resident 29's fluid restriction. * The facility failed to develop a care plan problem to address Resident 777's dialysis catheter site care. * The facility failed to develop a care plan problem to address Resident 57's skin discoloration below the left eye. * The facility failed to ensure a care plan problem addressing smoking included the safe storage of cigarettes materials for Resident 52. * The facility failed to ensure a care plan problem addressing smoking included the safe storage of cigarettes materials for Resident 55. * The facility failed to develop a care plan problem for Resident 59's right arm swelling. These failures posed a risk of not providing appropriate, consistent, 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 care plans were updated and revised for four of 25 final sampled residents (Residents 42, 59, 100, and 777 ) as evidenced by: *For Resident 100, the care plans for dialysis to administer epoetin (used to treat anemia (a lower than normal number of red blood cells) in people with chronic kidney failure) were not revised timely. * The facility failed to revise the care plan intervention of Resident 59 for the dialysis access care. * The facility failed to revise the care plan of Resident 777 to address the dislodged femoral dialysis catheter. * The facility failed to revise the care plan intervention of Resident 42 for the use of indwelling catheter. These failures had the potential for inadequate treatment and management of residents' medical and health conditions. Findings: Review of the facility's P&P titled Comprehensive Person-Centered Care Planning revised 11/2018 showed the comprehensive care plan will be…

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 care and services for one of 25 final sampled residents (Resident 48). * Resident 48 did not have the follow-up appointment for an ENT consult for decreased hearing. This failure had the potential for Resident 48's hearing needs to not be met. Findings: Review of the facility's P&P titled Referrals to Outside Services Operational Manual- Social Services revised 12/1/13, showed to provide residents with outside services as required by physician orders or the Care Plan. The Director of Social Services coordinates the referral of residents to outside agencies/programs to fulfill resident needs for services not offered by the facility. To facilitate this process, the facility maintains service provider contracts with variety of providers. The Director of Social Services is responsible for locating agencies and programs that meet the needs of residents, facilitating the execution of service provider…

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 25 final sampled residents (Residents 48 and 69) received adequate care. * The facility failed to ensure a change of condition and care plan problem were documented when Resident 69 was prescribed erythromycin (antibiotic used to treat infections) ointment to both eyes. * The facility failed to ensure Resident 69 with positive ESBL in urine (urinary tract infection) had a contact isolation order. There were no care plans developed to address prescribed antibiotic medication, Bactrim DS (antibiotic used to treat infections), positive ESBL, and contact isolation for positive ESBL. * The facility failed to address a change of condition and notify the physician when Resident 48 was observed having redness and rashes to bilateral feet. These failures had the potential to not providing necessary care and services to the residents with a change of condition, prescribed antibiotics, and infection that…

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 RNA services for one of 25 final sampled residents (Resident 100). This failure had the potential to negatively affect the residents' health. Findings: Review of the facility's P&P titled Restorative Nursing Program Guidelines dated 9/19/19, showed the RNA carries out the restorative program according to the care plan. The RNA documents the frequency of the program, the amount of time the resident spent in the activity and their tolerance to the program. In addition, the RNA completes a written weekly summary for all residents on a Restorative Nursing Program. The Restorative Nursing Program Coordinator co-signs the weekly progress notes. Medical record review of Resident 100 was initiated on 4/17/23. Resident 100 was admitted to the facility on [DATE]. Review of Resident 100's H&P examination dated 2/21/23, showed the resident had the capacity to understand and make decisions. Review of the Order…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 25 final sampled residents (Resident 42) received the appropriate care and services for an indwelling urinary catheter. This failure had the potential for the resident to develop complications associated with the use of indwelling urinary catheter. Findings: Review of the facility's P&P titled Indwelling Catheter revised 9/1/14, showed the drainage system will be maintained and will be changed when it is obstructed or is leaking according to physicians order. On 4/17/23 at 1019 hours, Resident 42 was observed to have an indwelling urinary catheter connected to a urinary drainage bag placed at the side of the bed with cloudy and lot of sediments in the tubing, with no label of when the bag was changed. Medical record review for Resident 42 was initiated on 4/19/23. Resident 42 was readmitted to the facility on [DATE]. Review of Resident 42's Order Summary Report dated 4/19/23, showed the…

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

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 offer or provide adequate and appropriate pain management for two of 25 final sampled residents (Residents 777 and 779). * The facility failed to ensure Resident 777 was administered pain medication per the physician's order. * The facility failed to consistently provide non-pharmacological interventions for pain prior to administration of a narcotic pain medication to Residents 777 and 779. * The facility failed to monitor Resident 779's implanted pain pump. These failures had the potential for not effectively managing these residents' pain. Findings: Review of the facility's P&P titled Pain Management revised 11/2016 showed the licensed nurse will administer pain medication as ordered and document medication administered on the MAR. Additionally, the P&P showed the nursing staff will also utilize non-pharmacological interventions to address possible issues contributing to pain. Interventions include but are…

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 implement the fluid restrictions for one of 25 final sampled residents (Resident 29). This failure had the potential to negatively impact Resident 29's health and complication associated with fluid deficit and overload. Findings: Review of the facility's P&P titled Dialysis Care revised 10/1/18, showed dialysis residents are given fluid based on the fluid restriction as ordered by the physician and a water pitcher will be provided at bedside, unless contraindicated. Review of the facility's P&P titled Fluid Restrictions revised 4/21/22, showed for each resident on fluid restriction, complete the fluid restriction guidelines, and keep in the resident's medical record. The Licensed Nurse will initiate strict intake measurement per the Attending Physician order, remove the water pitcher, and notify caregivers of the fluid restriction, and record any fluids given on the intake and output record. CNAs will 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 competency of the licensed nurses in assessing the dialysis access site for one of 25 final sampled resident (Resident 59). LVN 9 was unable to demonstrate competency in the assessment of the AV shunt site of Resident 59. This failure had the potential to put residents at risk for care not provided in a safe and competent manner. Findings: Review of the facility's P&P titled Staff Competency assessment dated [DATE], showed competency assessments will be performed upon hire during the employee's 90-day employment period, annually, or anytime new equipment or a procedure is introduced and as needed. Medical record review for Resident 59 was initiated on 4/17/23. Resident 59 was admitted on [DATE], and readmitted to the facility on [DATE]. Review of Resident 59's Order Summary Report showed a physician order dated 4/1/23, to monitor presence of bruit and thrill every shift. Review of Resident 59's plan…

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 pharmaceutical services for two of 25 final sampled residents (Residents 529 and 779) and one nonsampled resident (Resident 35) to meet the needs of each resident as evidenced by: * The facility failed to ensure Resident 529's oxycodone-acetaminophen (pain medication) was accurately reconciled. The number of tablets of oxycodone-acetaminophen removed showing on the Individual Narcotic Record did not match the number of tablets in the electronic MAR as administered to Resident 529. This failure had the possibility of diversion of controlled medications. * LVN 2 failed to provide the necessary instructions to Resident 35 for the proper technique on how to rinse her mouth after fluticasone-salmeterol inhaler (medication to decrease the inflammation of the airways) use. This failure had the potential for the resident to experience side effects including fungal infection in 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 and medical record review, the facility failed to ensure one of 25 final sampled residents (Resident 4) was free from unnecessary psychotropic medications. * The facility failed to ensure Resident 4's orthostatic blood pressure (measure the blood pressure while laying down or sitting and again upon standing up) was monitored as ordered by the physician related to the use of an antipsychotic medication. This failure had the potential for the resident to experience adverse consequences from the psychotropic medication. Findings: Medical record review for Resident 4 was initiated on 4/18/23. Resident 4 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of the Order Summary Report showed the following physician's orders: - a physician's order dated 12/23/22, for Risperdal (antipsychotic medication) 1 mg one tablet by mouth once a day; - an order dated 12/23/22, for Zyprexa (antipsychotic medication) 10 mg one tablet by mouth in the evening, and - an order dated 12/21/22, to…

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

Based on observation and interview, the facility failed to ensure the medications and influenza test kits were appropriately stored. * The unopened insulin bottle and insulin pen were stored at room temperature in Medication Cart 1 instead of storing in the refrigerator as per the pharmacy labels. * The facility failed to ensure proper storage of influenza test kits. These failures had the potential to alter the efficacy of the stored medications and cause inaccurate influenza results. Findings: 1. On 4/20/23 at 1112 hours, an observation of Medication Cart 1 and concurrent interview was conducted with LVN 5. A vial of unopened Novolin R (medication used to lower blood sugar) and an unopened insulin glargine pen (medication used to lower blood sugar) were stored at room temperature in Medication Cart 1. The pharmacy label on the Novolin R vial showed to refrigerate the unopened bottle and may store at room temperature after opening. The pharmacy label on the insulin glargine pen showed to refrigerate the unopened cartridges or pens and store the cartridge or pen in use at room…

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 provide one nonsampled residents (Resident 44) an entree substitute of similar nutritive value when Resident 44 was served a cheese quesadilla for lunch. This failure posed the risk for Resident 44's nutritional needs to not be met. Findings: Review of the facility's P&P titled Menu revised 4/2014 showed a substituted food item should be comparable in nutritional value. On 4/18/23 at 1155 hours, a concurrent observation and interview with Dietary Staff 3 was conducted during kitchen rounds. Dietary Staff 3 was observed cooking a cheese quesadilla. Dietary Staff 3 stated she was preparing the cheese quesadilla as a menu substitute for the lunch meal. Dietary Staff 3 further stated she prepared the cheese quesadilla with one tortilla and two ounces of shredded cheese. On 4/18/23 at 1215 hours, during the lunch meal tray line observation, Resident 44's meal tray was observed plated with one serving of cheese quesadilla, carrots, and potato salad. Resident 44's meal ticket 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, facility document review, and facility P&P review, the facility failed to ensure the policy on resident food brought by visitors was followed. * The facility failed to ensure the staff were aware of the process for storing and discarding the resident food brought by the visitors. * The facility failed to ensure the staff were educated on safe food handling practices when handling the resident food brought in by the visitors. * The facility failed to ensure the policy, guidelines, and safe food handling practices were communicated to the resident's family/visitors who brought the resident food from the outside. These failures had the potential to cause foodborne illness to the residents who received food brought by the visitors. Findings: 1. Review of the facility's P&P titled Food Brought in by Visitors revised 6/2018 showed food brought from the outside must be labeled, dated, and discarded after 48 hours. On 4/17/23 at 1045 hours, a tour of the resident food storage area and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medical records for two of 25 final sampled residents (Residents 75 and 100) were accurate and complete. * Resident 75's and 100's MARs had multiple entries of medication and treatment missing initials of the license nurses. This failure created the risk of not knowing if the medications administered. Findings: Review of the facility's P&P titled Medication Administration dated 1/1/12 showed the license nurse will chart the drug, time administered and initial his or her name with each medication administration and sign full name and title on each page on the MAR. Holding medication: whenever a medication is held for any reason, the hours it was held must be initiated and circled in the MAR by the responsible license nurse. The license nurse will document on the back of MAR, noting the time and reason the medication was held. Refusing medication: if the resident is refusing to take medications, time…

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