Anaheim Point

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 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 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility document review, the facility failed to ensure the Consultant Pharmacist's identified drug irregularities and medication recommendations were addressed for four of 29 final sampled residents (Residents 24, 55, 62, and 124) and four nonsampled residents (Residents 32, 34, 71, and 90). * The facility failed to ensure the Pharmacy Consultant's recommendation to add folic acid supplement for Resident 124 to reduce possible toxicity from methotrexate (arthritis medication) was communicated to the physician. * The facility failed to ensure the Pharmacy Consultant's recommendations for Residents 2 and 35 were carried out since they were recommended on 10/1/19. * The facility failed to ensure the Pharmacy Consultant's recommendations for Residents 24, 34, 62, 71, and 90 were carried out since they were recommended on 12/17/19. These failures had the potential for the residents to experience adverse drug reactions and unnecessary medications. Findings: Review of the…

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

Based on observation, interview, and facility P&P review, the facility failed to follow proper sanitation, food handling, and storage practices. * The expired food was found in the freezer. * The facility failed to ensure the kitchen stove hood was clean. * The facility failed to ensure kitchenware and tableware were presented so only the handles were touched by the dietary staff. * The facility failed to ensure four muffin pans were maintained in sanitary and safe condition. * The trash receptacle with a foot peddle was not provided by the handwashing sink in the kitchen. * The food blender was not allowed to air dry. These had the potential to result in foodborne illnesses in the highly susceptible resident population. Findings: Review of the CMS 672 Resident Census and Conditions of Residents signed by the DON dated 1/28/2020, showed 133 of the 147 residents residing in the facility received food prepared in the kitchen. 1. Review of the facility's P&P titled Freezer Storage Guidelines (undated) showed all foods which need to be kept in the freezer could be stored frozen for six…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to provide the written information regarding the advance directives and/or obtain and maintained copies of the advance directives in the medical records for four of 29 final sampled residents (Residents 45, 62, 527, and 528). These failures had the potential for confusion or failure to provide care and life sustaining measures in accordance with the residents' treatment wishes. Findings: 1. Review of the facility's P&P titled Advance Directives revised July 2018 showed the admission staff or designee will provide written information to the resident concerning his or her right to make decisions including the right to formulate advance directives. The admission staff or designee will obtain a copy of a resident's advance directive upon admission. A copy of the advance directive will be included in the resident's medical record. Medical record review for Resident 45 was initiated on 1/28/2020. Resident 45 was admitted to the…

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

Based on interview and facility document review, the facility failed to provide three of three nonsampled residents (Residents 98, 582, and 583) with the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) CMS-10055 and/or the Notice of Medicare Non-coverage CMS-10123 (NOMNC) forms. The SNF ABN CMS-10055 and the NOMNC CMS-10123 forms are used to inform residents of their potential financial liability, appeal rights, and protections, should they decide to receive care and services that may not be covered by Medicare. This posed the risk of these residents not being allowed to make an informed decision concerning their Medicare services. Findings: On 1/31/20 at 1000 hours, an interview and concurrent facility document review was conducted with the Business Office Manager who provided and verified the following information: 1. Resident 98's Medicare Part A skilled services episode start date was 11/1/19, and the last covered day of Part A service was 12/20/19. Resident 98 was currently residing at facility. The Business Office Manager verified Resident 98 did…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to complete the comprehensive MDS assessments timely for two of 29 final sampled residents (Residents 527 and 428). * Resident 527's admission assessment dated [DATE], was not completed. This was 23 days past the required completion date of 1/7/2020. * Resident 428's admission comprehensive assessment was not completed within 14 days from the date of admission to the facility, and was four days past due. These failures had the potential for the staff not identifying the residents' preferences and goals of care, functional and health status, and strengths and needs. Findings: Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual dated October 2019 showed a comprehensive MDS assessment (admission, annual, and significant change) must be completed on an annual basis (at least every 366 days). Also, the completion date must be no later than 14 days after the assessment reference date. Federal statute and regulations…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 3. Medical record review for Resident 9 was initiated on 1/28/2020. Resident 9 was admitted to the facility on [DATE]. On 1/29/2020 at 1008 and 1136 hours, Resident 9 was observed lying in bed with her eyes closed. The television was off and there was no sensory stimulation in the room. An indwelling urinary catheter was observed attached to a drainage bag by the side of the bed. Review of the Order Summary Report showed a physician's order dated 1/13/2020, for an indwelling urinary catheter for wound management. Review of Resident 9's plan of care failed to show comprehensive care plan problems were developed to address Resident 9's activities and use of an indwelling urinary catheter. A care plan problem to address Resident 9's incontinence of bowel and bladder was created on 1/13/2020. On 1/29/2020 at 1120 hours, an interview and concurrent medical record review was conducted with LVN 5. LVN 5 reviewed Resident 9's medical record and verified the above findings. LVN 5 stated Resident 9's care plan problem for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to ensure a communication book (a book with symbols or pictures and words in the resident's native language used to communicate basic care needs between nonverbal or non-English speaking residents and the staff) was provided for one of 29 final sampled residents (Resident 578) who did not speak English. This failure had the potential for Resident 578 to not have the ability to communicate her needs to the healthcare staff. Findings: On 1/28/2020 at 0802 hours, during the initial tour of the facility, Resident 578 was observed seated on the side of her bed fully dressed and was well groomed. When asked about the facility, Resident 578 stated she did not speak English, she only spoke her native language. Bulletins observed posted in Resident 578's room advertising group events within the facility were in English. During the interview with Resident 578, Resident 578 pushed her call light. CNA 3 who responded to Resident 578's call light…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an ongoing activities program to meet the needs and interests of two of 29 final sampled residents (Residents 9 and 124). This had the potential to negatively impact the residents' well being. Findings: On 1/28/2020 at 0816, 0920, 1036, and 1624 hours, Resident 9 was observed lying in bed in the dark, with the curtains by the window closed and the visual privacy curtain drawn. The television was observed turned off. There was no in-room stimulation observed. Medical record review for Resident 9 was initiated on 1/28/2020. Resident 9 was admitted to the facility on [DATE]. Review of Resident 9's Activity Participation Review assessment dated [DATE], showed Resident 9 enjoyed watching television and movies including action, comedies, and soap operas, and listening to the radio. Review of Resident 9's plan of care failed to show a comprehensive care plan problem was developed to address Resident 9's activities. On 1/29/2020…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 four of 29 final sampled residents (Residents 17, 20, 61, and 115) and two nonsampled residents (Residents 23 and 581) to ensure the residents maintained their highest physical well-being. * The facility failed to follow the physician's order to monitor Resident 581's blood sugars before meals and to administer insulin as needed. * The insulin injection sites were not consistently rotated for Residents 20, 17, and 61. * The facility failed to follow the physician's order to obtain laboratory studies of renal function and Keppra (anti-seizure medication) levels for Resident 115. * Resident 23 had a physician's order written on 8/25/19, for a daily multivitamin with minerals. From 8/25/19 through 1/28/2020, the facility failed to administered the supplement to Resident 23. These failures posed the risk of the residents not being provided appropriate care and treatment. Findings: 1. 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 follow the physician's orders to provide daily restorative nursing treatment and apply a hand splint, daily, for one of 29 final sampled residents (Resident 24), who had a hand contracture. This failure had the potential for Resident 24 to not receive necessary care and services to prevent the worsening of an existing hand contracture. Findings: 1. Review of the facility's P&P titled Restorative Nursing Program Guidelines revised 9/19/19, showed restorative nursing is the delivery of services by nursing personnel designed to encourage and enable individuals to be as independent as possible based on their condition, resources, and desires. It includes nursing interventions that promote a patient's ability to attain, and maintain their optimal functional potential. Restorative care implies that the possibility for progress exists and that improvement can be expected, or there is a risk of imminent decline which…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 29 final sampled residents (Residents 27 and 80) remained free from accident hazards. * The facility failed to repair Resident 27's broken night stand drawers which had two exposed nails protruding outward. * The facility failed to ensure Resident 80 was accurately assessed for smoking. Resident 80 was observed smoking in the patio, but was assessed as a non-smoker. These failures posed the risk for injury to both residents. Findings: 1. Medical record review for Resident 27 was initiated on 1/28/2020. Resident 27 was admitted to the facility on [DATE]. On 1/28/2020 at 0910 hours, Resident 27 was observed in bed between two nightstands. Both nightstands were observed with a broken drawer. Resident 27 voiced concern about her inability to place her items in the broken drawers. Resident 27 stated she had told the nurses about the drawers, but the drawers had not been repaired and she could not use…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to ensure one of 29 final sampled residents (Resident 43) remained free from accident hazards due to the use of elevated side rails. * The facility failed to obtain informed consent prior to the use of elevated side rails for Resident 43. This failure had the potential to put the resident at risk for entrapment and serious injury. Findings: The FDA issued a Safety Alert entitled Entrapment Hazards with Hospital Bed Side Rails. Residents most at risk for entrapment are those who are frail or elderly or those who have conditions such as agitation, delirium, confusion, pain, uncontrolled body movement, hypoxia, fecal impaction, acute urinary retention, etc., that may cause them to move about the bed or try to exit from the bed. Entrapment may occur when a resident is caught between the mattress and bed rail or in the bed rail itself. Inappropriate positioning or other care related activities could contribute to the risk of entrapment.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to ensure the availability of prescribed medications for one of 29 final sampled residents (Resident 428). * Resident 428 had a physician's order for clopidogrel bisulfate (medication used to prevent blood clots) for CVA prophylaxis. The licensed nurse was unable to administer clopidogrel bisulfate as ordered due to the unavailability of the medication. This failure posed the risk for inhibiting the therapeutic effects of the medication and had the potential to negatively affect the resident's health. Findings: Medical record review for Resident 428 was initiated on 1/28/2020. Resident 428 was admitted to the facility on [DATE]. Review of the Order Summary Report showed a physician's order dated 1/13/2020, to administer clopidogrel bisulfate 75 mg orally once a day (at 0900 hours) for CVA prophylaxis. On 1/29/2020 at 0750 hours, an interview was conducted with LVN 3. LVN 3 stated Resident 428 had an order for clopidogrel bisulfate 75 mg orally…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 two of 29 final sampled residents (Residents 22 and 124) were free from unnecessary medications. * Resident 124 was administered blood pressure medications when the resident's blood pressure was below the parameters prescribed by the physician. The facility failed to ensure Resident 124 was administered the PRN (as needed) pain medication according to the physician's order. * The facility failed to ensure Resident 22 was administered Depakote (antiseizure medication, also used as mood stabilizer) with appropriate indication for its use. These failures posed the potential of complications related to unnecessary medications. Findings: 1. Medical record review for Resident 124 was initiated on 1/28/2020. Resident 124 was admitted to the facility on [DATE]. a. Review of Resident 124's Order Summary Report showed a physician's order dated 3/27/19, to administer one tablet of losartan potassium (blood pressure medication) 100 mg by mouth one…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 two of 19 final sampled residents (Residents 22 and 58) were free from unnecessary psychotropic medications. * Resident 22 was receiving Risperdal (antipsychotic medication) for behavior manifestation of aggressive behavior. The Psychiatrist doubled the dose of the Risperdal despite the resident not exhibiting any episode of behavior for which the Risperdal was prescribed. In addition, the facility failed to ensure the as needed order for a psychotropic medication for Resident 22 was limited to 14 days or had a documented rationale from the physician for the appropriateness of extending the medication beyond 14 days. * The facility failed to show a documented rationale from the physician for the continuation of the duplicate antipsychotic therapy for Zyprexa and Risperdal for Resident 58. In addition, the facility failed to attempt a GDR for Resident 58's antipsychotic medications Zyprexa, Risperdal, and Buspirone Hcl. These failures 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.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 13.79%. Two of two licensed nurses (LVN 3 and RN 1) were found to have made errors during the medication administration observations. * Resident 428 had a physician's order for clopidogrel bisulfate (medication used to prevent blood clots) for CVA prophylaxis. LVN 3 failed to administer the clopidogrel as ordered due to unavailability of the medication. * Resident 23 had a physician's order for multivitamins with minerals; however, LVN 3 failed to administer the supplement. * RN 1 failed to check whether Resident 73 had loose stool prior to administering docusate sodium (stool softener medication) and failed to administer artificial tears solution (eye drops medication) to Resident 73 during the medication administration observation. These failures had the potential to negatively affect the residents' health. Findings: Review of the facility's P&P titled Medication Administration revised date…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure one nonsampled resident (Resident 581) was free from significant medication errors when the licensed nurses did not administer insulin as ordered by physician. This deficiency placed the resident at risk for hypoglycemia (abnormally low blood sugar levels). Findings: Review of the facility's P&P titled Medication Administration revised 1/1/12, showed the licensed nurse may administer medications one hour before or after the scheduled medication administration time. On 1/29/2020 at 1030 hours, during the resident council meeting, Resident 581 stated the nurses checked her blood sugar levels while she ate her meals. Resident 581 stated she found it annoying. Medical record review for Resident 581 was initiated on 1/29/2020. Resident 581 was admitted to the facility on [DATE]. Review of the History and Physical Examination dated 1/6/2020, showed Resident 581 had the capacity to make decisions. Review of the MDS dated…

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

Based on interview and medical record review, the facility failed to notify one of 29 final sampled residents' (Resident 115) physician of the resident's laboratory results. This had the potential for the resident not receiving appropriate care. Findings: Review of Resident 115's laboratory results, collection date of 1/22/2020, showed Resident 115's hemoglobin A1c (test measuring the amount of blood sugar attached to hemoglobin, used to check for diabetes or prediabetes) results were above the normal range of 4-6%. There was no documentation to show Resident 115's physician was notified of the abnormal hemoglobin A1c results. On 1/30/2020 at 1547 hours, an interview and concurrent medical record review was conducted with the Medical Records Director. The Medical Records Director verified there was no documentation to show Resident 115's physician was notified of the abnormal hemoglobin A1c results.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to ensure dental services were provided for one nonsample resident (Resident 581). Resident 581 did not have any natural teeth or dentures. The facility failed to assist Resident 581 in obtaining routine dental care. This deficient practice resulted in Resident 581 experiencing unnecessary pain. Findings: Medical record review for Resident 581 was initiated on 1/30/2020. Resident 581 was admitted on [DATE]. Review of the History and Physical dated 1/6/2020, showed Resident 581 had the capacity to make decisions. Review of the MDS dated [DATE], under Section L, showed Resident 581 did not have natural teeth or tooth fragments. Review of the Order Summary Report showed a physician's order dated 12/26/19, for a dental consultation and treatment follow-up as needed. Another physician's order dated 12/26/19, showed for social services to arrange dental consultations as needed. On 1/29/2020 at 1244 hours, an interview was conducted with Resident 581.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 tray line staff followed the menu for the residents participating in the RNA feeding program. The residents on the RNA feeding program did not receive the parsley garnish on their plates. This failure had the potential for the residents on the RNA feeding program not have an appetizing, attractive meal, which could cause them not to eat. Findings: Review of the CMS-672 Resident Census and Conditions of Residents signed by the DON and dated 1/28/2020, showed 133 of the 147 residents residing in the facility received food prepared in the kitchen. Review of the facility's P&P titled Dietary Department - General revised date 6/1/14, showed the primary objective of the dietary department included to provide nutritionally adequate and attractive meals, which are consistent with physician's orders. Review of the facility's document titled Winter Menus, Week 4 Wednesday dated 1/29/2020, showed all the plates served were to be provided with a parsley garnish. On 1/29/2020, starting at 1130 hours,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to ensure the medical record for one nonsampled resident (Residents 581) was accurate. This deficient practice resulted in incorrect information regarding Resident 581's healthcare. Findings: On 1/29/2020 at 1244 hours, an interview was conducted with Resident 581. Resident 581 stated she did not have teeth and forgot to bring her dentures to the facility. Resident 581 stated she informed the nurse who admitted her to the facility of this. On 1/29/2020 at 1452 hours, a follow-up interview was conducted with Resident 581. Resident 581 stated the food was too hard for her to chew without teeth. Resident 581 stated she complained to the staff it was difficult for her to chew her food, but nothing was done. Medical record review for Resident 581 was initiated on 1/29/2020. Resident 581 was admitted to the facility on [DATE]. Review of Resident 581's Dietary Profile dated 12/31/19, showed Resident 581 had her own teeth and did not have…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 bed remote control cord for one nonsampled resident (Resident 98) was maintained in safe operating condition. This had the potential to compromise the resident's safety when using the bed remote control. Findings: On 1/29/2020 at 1140 hours, Resident 98 was observed in bed and stated her bed remote control cord was broken. The cord attached to Resident 98's bed remote control was observed broken and frayed with wires exposed in three different areas. Resident 98 stated she was afraid she might get hurt from the exposed wires. Resident 98 stated she did not want to use her bed remote control because it was damaged. On 1/29/2020 at 1145 hours, an observation of Resident 98's bed remote control and the attached cord was conducted with CNA 1. CNA 1 verified the the cord attached to Resident 98's bed remote control was damaged and stated it was not safe for Resident 98 to use. CNA 1 stated she would inform the maintenance department. On 1/29/2020 at 1209 hours, The Maintenance Supervisor…

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