Anaheim Terrace Care Center

Based on interview and medical record review, the facility failed to ensure a physician's order for the orthostatic blood pressure monitoring while standing was clarified for one of 21 final sampled residents (Resident 31). This failure placed the resident at risk of receiving services not appropriate for his functional level. Findings: Review of Resident 31's Order Summary Report showed a physician's order dated 2/21/25, to monitor the resident's BP for orthostatic hypotension weekly while lying, sitting, and standing. Review of Resident 31's MAR for May 2025 showed the weekly monitoring of the resident's BP while standing were not completed. On 5/19/25 at 1402 hours, an interview and concurrent medical record review was conducted with the ADON. The ADON stated Resident 31 was not able to stand without two facility staff supporting the resident, and checking the resident's BP while standing was not appropriate for the resident. The ADON stated the physician's order should have been clarified with the physician.

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 nonsampled residents (Residents 25 and 42) remained free from accident hazards. * The facility failed to ensure the bilateral floor mats were implemented in accordance with the physician's order for Resident 42. * The facility failed to ensure Resident 25 had a physician's order prior to going out on pass. These failures had the potential to place the residents at risk for injury. Findings: 1. Medical record review for Resident 42 was initiated on 5/18/25. Resident 42 was admitted to the facility on [DATE]. Review of Resident 42's physician's orders showed an order dated 10/25/24, for the use of the bilateral floor mats. Review of Resident 42's care plan titled At Risk for Falls initiated 10/25/24, showed Resident 42 was at risk for falls due to cognitive loss and lack of safety awareness. On 5/19/25 at 0853 hours, an observation of Resident 42 was conducted. Resident 42 was observed lying in her…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 two of two final sampled residents (Residents 61 and 493) and one nonsampled resident (Resident 59) reviewed for respiratory care were provided the appropriate respiratory care. * The facility failed to ensure Resident 59's oxygen order was carried out as ordered by the physician. * The facility failed to ensure Resident 61's oxygen order was carried out as ordered by the physician. * The facility failed to ensure Resident 493 received oxygen administration as ordered by the physician. These failures had the potential to affect the respiratory health and well-being of the residents in the facility. Findings: Review of the facility's P&P titled Oxygen Administration (undated) showed the purpose of this procedure is to provide guidelines for safe oxygen administration. The P&P further showed to verify that there is a physician's order for this procedure and review the physician's orders or facility protocol for oxygen…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 appropriate pain management for three of three final sampled residents (Residents 10, 30, and 45) reviewed for pain management. * The facility failed to accurately document the monitoring of pain for Resident 45 and administer the pain medications according to the physician's order. In addition, the facility failed to ensure the non-pharmacological interventions for pain were provided to Resident 45 prior to the administration of the pain medications as per the physician's order. * Resident 10 was administered pain medication outside of the ordered pain level parameters. * Residents 10 and 30's pain level was not monitored and documented as ordered. These failures had the potential to put Residents 10, 30, and 45 at risk for ineffective pain management and adverse effects related to the use of unnecessary pain medication. Findings: Review of the facility's P&P titled Pain Assessment and Management revised…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, medical record review, and facility P&P review, the facility failed to ensure the ongoing assessment before, during, and after dialysis treatments for two of two final sampled residents (Residents 45 and 61) reviewed for dialysis was conducted as evidence by: * The facility failed to ensure Resident 45's Hemodialysis Communication Records were complete, and ensure accurate documentation for the monitoring for Resident 45's fluid restriction. In addition, the facility failed to ensure Resident 45 was administered the blood pressure medications after dialysis as per the physician's orders. * The facility failed to ensure Resident 61's Hemodialysis Communication Records were complete and accurate. These failures had the potential of not identifying negative outcomes for dialysis residents. Findings: Review of the facility's P&P titled Dialysis Care dated 8/2021 showed for fluid restrictions dialysis residents are given fluid based on the fluid restriction…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 pharmacy services to meet the resident needs for one of 21 final sampled residents (Resident 22), and two nonsampled residents (Residents 70 and 74). * Residents 70 and 74's controlled medication log did not match the MAR. * The facility failed to ensure the BP medication was held as per the physician's ordered hold parameters for Resident 22. These failures had the potential for poor health outcomes related to a potential unstable BP, and a delay in identifying potential diversion of the controlled medications. Findings: Review of the facility's P&P titled Controlled Substances revised November 2022 showed the controlled substance inventory will be monitored and reconciled to identify loss and potential diversion. Reconciliation, dispensing, and disposition of controlled medications includes medication administration records. 1. Medical record review for Resident 70 was initiated on 5/20/25. Resident 70 was…

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

Based on observation, interview, 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 5.13%. One of three licensed nurses (LVN 1) was found to have made errors during the medication administration observation. * LVN 1 failed to administer the complete dose for two of Resident 22's medications when significant residual of the medications were observed in the medication cups after administering the zinc (supplement) medication and vitamin D3 (supplement) medication via GT to Resident 22. This failure had the potential to negatively affect the resident's health conditions and posed the risk for possible complications or delay in interventions. Findings: Review of the facility's P&P titled Administering Medications revised 4/2019 showed medications are administered in accordance with prescriber orders. Review of the facility's P&P titled Administering Medications through an Enteral Tube (also known as a feeding tube, is a flexible tube inserted into the digestive tract to deliver…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 store the drugs and biologicals in a safe manner for two of two medications rooms (Medication Rooms A and B) and three of three medication carts (Medication Carts A, B, and C). * The facility failed to remove the expired medications after the discard after or use-by date. * The facility failed to ensure proper labeling of the eye drop medication with the opened date. * The facility failed to remove the discontinued medications from the medication cart for Residents 10 and 50. * The facility failed to ensure the orally administered medications were stored separately from externally used medications. These failures had a potential to negatively impact residents' physiological well-being and posed the risk of unauthorized access, drug diversion, and medication administration errors; and posed the risk for cross contamination of the medications. Findings: Review of the facility's P&P titled Medication Storage in the Facility revised 1/2025 showed orally administered medications are kept separate from…

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

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the menu was followed when preparing food for the residents. * The facility failed to ensure [NAME] 1 followed the recipe when preparing pureed spaghetti. This failure had the potential for not providing nutritional meals to meet the needs of the residents who were on pureed diet. Findings: Review of the facility's document titled Diet Type Report dated 5/18/25, showed six residents received pureed food prepared from the kitchen. Review of the facility's diet Menus dated 5/19/25, showed the lunch menu included spaghetti/meat sauce, tossed salad dressing, garlic bread, banana strawberry cup, and milk 2%. Review of the facility's P&P titled Food: Quality, Palatability dated 2/2023 showed food will be prepared by methods that conserve nutritive value, flavor. and appearance. Food will be palatable, attractive and served at a safe and appetizing temperature. Food and liquids are prepared and served in a manner, form, and texture to meet resident's needs. The P&P further…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 implement their P&P to ensure proper storage of food in the residents' refrigerator as evidenced by: * Residents' refrigerator for food brought from the outside was not maintained in a proper temperature. In addition, the food items were in the residents' refrigerator not labeled with the current date and use by dates as per the facility's P&P. These failures had the potential to result in foodborne illnesses in a highly susceptible resident population. Findings: Review of the facility's P&P titled Food Brought by Family/Visitors revised 3/31/25, showed the facility to provide the residents with the option of having food prepared by the resident's family brought into the facility. When the food items are intended for later consumption, responsible staff member will label food with the resident's name, and the current date and use by date. Items will be thrown out after 48 hours. Further review of the P&P showed refrigerator/freezer for storage of foods brought in by visitors will be properly maintained…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 properly dispose of the unused items. This failure had the potential to attract rodents and pests that carried a disease. Findings: Review of the facility's P&P titled Pest Control dated 5/2008 showed the garbage and trash are not permitted to accumulate and are removed from the facility daily. Review of the facility's P&P titled Grounds dated 5/2008 showed facility grounds shall be maintained in a safe and attractive manner. Maintenance shall be responsible for keeping the grounds free of litter. On 5/19/25 at 0857 hours, an observation and concurrent interview was conducted with the Maintenance Director. A big pile of items including five plastic storage drawers, wheelchair, laundry cart in despair, soiled laundry bin, bed wires, plastic bags, metal boxes, front wheel walker, bed side commode, two trash bins, etc., with the dust on and around of the above items were observed in the facility compound at the left side of the facility's building. The Maintenance Director verified the observation and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. Medical record review for Resident 3 was initiated on 5/18/25. Resident 3 was admitted to the facility on [DATE]. On 5/20/25 at 1032 hours, an interview and concurrent medical record review for Resident 3 was conducted with the ADON. A review of Resident 3's EHR was conducted with the ADON. Resident 3's EHR contained Resident 343's PASRR Level 1 screening. The ADON verified Resident 343's PASRR Level 1 screening was uploaded to Resident 3's EHR in error. Based on interview, medical record review and facility P&P review, the facility failed to ensure the complete and accurate medical records for four of 21 final sampled residents (Residents 3, 9, 10, and 19). * The facility failed to ensure Residents 9 and 19's MAR documentation for months of April and May 2025 were accurate regarding monitoring for the side effects for apixaban use (a medication used to prevent blood clots). * The facility failed to ensure Resident 19's facesheet listed accurate diagnoses. The facility included a diagnosis of unspecified…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ensure the QAPI committee implemented and monitored the effectiveness of their plan of correction for improvement of repeated deficient practice cited at F552, F812, and F883. This failure had the potential to affect the quality of care for all the residents in the facility. Findings: Review of the facility's Quality Assurance Performance Improvement Program showed the QAPI will develop monitoring tools that provide an effective mechanism to ensure residents receive the necessary care. The QAPI will develop plans of correction and evaluate corrective actions taken to obtain desired results. Review of the POC submitted by the facility to the CDPH, L&C Program from the last recertification survey completed on 6/13/24, showed the following: - For cited F552, the Medical Records staff and Medical Records Director will audit the informed consents and medication records for compliance for three months. Findings will be brought to the monthly QA committee. - For cited F812, the District Manager will perform monthly…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 appropriate infection control practices designed to provide the safe and sanitary environment were implemented as evidenced by: * The facility failed to ensure the basins found inside the shared restrooms in Rooms A, B, C, and D were properly labeled and stored. * The facility failed to ensure Resident 595's personal food items maintained infection control. These failures had the potential to spread communicable diseases to the vulnerable residents in the facility. Findings: 1.a. On 5/18/25 at 0836 hours, an observation of the shared restroom for Rooms A (occupied by Residents 4 and 29) and B (occupied by Residents 13 and 15) and concurrent interview was conducted with LVN 7. An unlabeled basin was observed on top of the toilet tank. When LVN 7 was asked which resident that the unlabeled basin was belonged to, LVN 7 stated he did not know since the unlabeled basin was placed in the shared…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure one of five final sampled residents (Resident 12) reviewed for influenza vaccinations was offered the influenza vaccination. This failure placed Resident 12 at risk for increased risk of infection and the transmission of influenza. Findings: Review of the facility's P&P titled Influenza Vaccine revised 3/2022 showed all residents and employees who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccinations against influenza. Between October 1st and March 31st each year, the influenza vaccine shall be offered to residents and employees, unless the vaccine is medically contraindicated or the resident or employee has already been immunized. The P&P further showed a resident's refusal of the vaccine shall be documented on the informed consent for influenza vaccine and placed in 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, medical record review, facility document review, and facility P&P review, the facility failed to ensure one of five final sampled residents (Resident 12) reviewed for COVID-19 vaccination was offered the COVID-19 vaccination. This failure placed Resident 12 at risk for increased risk of infection and transmission of COVID-19. Findings: Review of the facility's P&P titled Coronavirus Disease (COVID-19) - Vaccination of Residents COVID-19 Protocol, undated, showed each resident is offered the COVID-19 vaccine unless the immunization is medically contraindicated or the resident has already been immunized. Residents who are eligible to receive the COVID-19 vaccine are strongly encouraged to do so. The resident (or resident representative) has the opportunity to accept or refuse a COVID-19 vaccine, and to change his/her decision. Residents are screened for contraindications to the vaccine, medical precautions and prior vaccination before being offered the vaccine. Furthermore, the P&P showed if…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary care and services to ensure two of 13 sampled residents (Residents 8 and 13) attained and maintained the highest practicable physical well-being. * On 12/22/24, Resident 8 requested to continue the Ciprodex Otic suspension (used to treat middle ear infections) for continued ear pain after completing the seven-day treatment on 12/20/24. Resident 8 received the requested Ciprodex Otic suspension on 1/7/25, 16 days later. * The facility to ensure Resident 13's ceftriaxone sodium (antibiotic) intravenous medication was administered as per the physician's order. These failures had the potential to negatively affect residents' health condition and well- being. Findings: 1. Review of the facility's P&P titled Change in Condition dated 8/25/21, showed the facility must immediately inform the resident, consult with resident's physician and/ or nurse practitioner, and notify,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 pharmaceutical services for one of 13 sampled residents (Resident 8) to meet the needs of each resident as evidenced by: * The facility failed to ensure the medication was administered as ordered to Resident 8. This failure had the potential for poor health outcome to Resident 8. Findings: Review of facility's P&P titled Medication Orders dated 4/2008 showed the medication orders specify the following: a. Name of medication b. Strength of medication, where indicated c. Dose and dosage form d. Time or frequency of administration e. Route of administration (If facility policies allow, orders are assumed to be PO unless otherwise specified) f. Quantity or duration (length) of therapy. If not specified by prescriber on a new order, the duration is limited by automatic stop order policy, when applicable. g. Diagnosis or indication for use Review of facility's P&P titled Administering Medications revised 4/2019…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 sevensampled residents (Residents 6) could self-administer the medications safely. * Resident 6 had a bottle of sealed Motrin (medication to relieve pain) 200 mg, a plastic medication cup containing one tablet of Oscal 500/200 with vitamin D (supplement), and two capsules of Docu Soft (stool softener) 100 mg inside the drawer of Resident 6's bedside table for self-administration. Resident 6 was not assessed for self-administration of medications. This failure had the potential to negatively impact the resident's physiological well-being, and administer the medications inaccurately. Findings: Review of the facility's P&P titled Self Administration of Medications (undated) showed the residents have the rights to self-administer themedications if the interdisciplinary team has determined that it is clinically appropriate and safe for the residents to do so. If it is deemed safe and appropriate for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility document review, the facility failed to ensure one of seven sampled residents (Resident 2) was free from the physical abuse by another resident. * Resident 2 was hit on the left shoulder and left side of the face by Resident 1. This failure had the potential to negatively impact the resident's well-being. Findings: Review of thefacility's P&P titled Abuse Prohibition Policy and Procedure reviewed 2/23/21, showed the facility prohibit abuse, mistreatment, neglect, misappropriation of resident property, and exploitation for all residents. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the patient's medical symptoms. The purpose of the policy is to ensure that Center staff are doing all that is within their control to prevent occurrences of abuse, mistreatment, neglect, exploitation, involuntary seclusion, injuries of unknown source, and…

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

Based on observation, interview, and facility document review, the facility failed to ensure the oversight of food service operations when the facility did not employ a full-time qualified individual, defined as 35 hours per week, to manage and oversee food operation services for the skilled nursing facility. This failure had the potential to jeopardize the health and well-being of the 82 residents who received food prepared in the kitchen. Findings: Review of the facility's matrix showed 82 of 87 residents who consumed food prepared in the kitchen. According to the California Code, Health, and Safety Code - HSC § 1265.4: A licensed health facility shall employ a full-time, part-time, or consulting dietitian. A health facility that employs a registered dietitian less than full time, shall also employ a full-time dietetic services supervisor who meets the requirements of subdivision (b) to supervise dietetic service operations. Review of the untitled facility document provided by the Administrator showed the DSS's scheduled facility assignments for May 2024. The document showed the…

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

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food safety and sanitation requirements were met in the kitchen when: * The facility failed to properly monitor for Time/Temperature Control for Safety (TCS) foods (food that require time and temperature controls to limit the growth of illness causing bacteria) to ensure proper cool down process was followed, as per the facility's P&P. * The facility failed to ensure the refrigerated pasta salad was labeled with a prepared date and a use by date, as per the facility's P&P. * The facility failed to label and properly cover the thawing meat in the refrigerator. * The facility failed to ensure the food past the use-by date was discarded. * The facility failed to properly air-dry the kitchen equipment. * The facility failed to ensure the kitchen utensils and equipment were stored or kept in sanitary conditions. * The facility failed to ensure the kitchen utensils were in good condition. * The facility failed to ensure the cutting boards were kept in sanitary condition…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 establish and maintain the infection control program and practices designed to help prevent the development and transmission of diseases and infections as evidenced by: * The facility failed to ensure the EBP (Enhanced Barrier Precautions) was practiced for Resident 71. * The facility failed to ensure hand hygiene was performed after adjusting the resident's bed control using a gloved hand and proceeding to perform care for Resident 8. * The licensed nurse failed to ensure a contaminated equipment was not disinfected prior to use on Resident 793. * The facility failed to ensure infection control was maintained in the laundry room. * The facility failed to ensure the staff and visitors followed the contact precautions before entering Resident 93's room. * The facility failed to ensure the trash can containing soiled PPE was closed and not overflowing. * The facility failed to show…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, medical record review, facility document review, and facility P&P review, the facility failed to ensure the antibiotics were prescribed and administered to the residents under the guidance of their antibiotic stewardship program. * The facility failed to monitor and address the use of antibiotics when the resident's condition did not meet the McGeer's criteria (a set of specific definitions to identify true infections in long term nursing facilities) for six nonsampled residents (Residents 38, 63, 71, 593, 594, and 595). * The facility failed to ensure their antibiotic surveillance tracking forms included outcome and adverse events during the months of January 2024 through May 2024. These failures had the potential for antibiotics to be used when it was not indicated and the development of antibiotic-resistant bacteria. Findings: According to the CDC's guidances, an estimated 70% of nursing home residents receive one or more courses of antibiotics during a year. Studies have shown that 40% to 75% of the antibiotics prescribed in nursing homes may be unnecessary…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, equipment instruction manual review, and facility P&P review, the facility failed to maintain the essential equipment in safe operating condition. * The facility failed to ensure the ice machine was cleaned and sanitized according to the manufacturer's specification. This failure had the potential for the equipment to not function in the way it was intended, which could cause food-borne illnesses for the residents. Findings: Review of the facility's Matrix showed 83 of 87 residents who consumed food prepared in the kitchen. According to USDA Food Code 2022, Section 4-501.11, Good Repair and Proper Adjustment, showed the proper maintenance of equipment to manufacturer specifications helps ensure that it will continue to operate as designed. Failure to properly maintain equipment could lead to violations of the associated requirements of the Code that place the health of the consumer at risk. Review of the facility's P&P titled Equipment revised 9/2017 showed all food service equipment will be clean, sanitary, and in proper working condition. All…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of five final sampled residents (Resident 55) reviewed for psychotropic use was informed of the use of psychotropic medications (medication affecting brain activities associated with mental processes and behavior). * The facility failed to ensure Resident 55's informed consent was obtained prior to administering the increased dosage of mirtazapine (antidepressant medication). This failure had the potential for Resident 55 to not be informed of the medication and potential side effects of mirtazapine. Findings: Review of the facility's P&P titled Psychotropic Medication Use dated 6/2021 showed the facility shall verify informed consent prior to administration of a psychotropic medication for a resident. Review of the facility's P&P titled Informed Consent revised on 3/2024 showed prior to initiating the administration of a psychotherapeutic medication or physical restraint or a device, licensed nursing staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the reasonable accommodations to meet the needs for two of 22 final sampled residents (Residents 5 and 55). * The facility failed to ensure Resident 5's head of bed was elevated to allow the resident to reach her meal tray. * The facility failed to ensure Resident 55's call light was within the resident's reach. These failures had the potential to negatively impact the residents' psychosocial well-being or result in a delay to receive care. Findings: 1. On 6/10/24 at 0815 hours, during the initial tour of the facility, Resident 5 was observed lying in bed with head of bed elevated at 45 degrees and was waving for assistance. Residenr 5 was pointing to the breakfast tray on the table. The table was observed too high for the resident to see and reach her food. Medical record review for Resident 5 was initiated on 6/10/24. Resident 5 was admitted to the facility on [DATE]. Review of Resident 5's MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to provide two nonsampled residents (Residents 394 and 395) with the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN) Form CMS-10055. This failure had the potential for not allowing the residents or their representatives to make informed decisions regarding their healthcare. Findings: Review of the facility's P&P titled Medicare Advanced Beneficiary Notice dated 4/2021 showed the residents are informed in advance when changes will occur to their bills. Review of the SNF ABN Form CMS-10055 dated 2018 showed the SNF ABN Form CMS-10055 provided information to allow beneficiaries to decide whether to receive care that may not be paid for by Medicare and allow for the beneficiary to assume the financial responsibility. 1. Medical record review for Resident 394 was initiated on 6/10/24. Resident 394 was admitted to the facility on [DATE]. On 6/13/24 at 0910 hours, an interview…

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

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the privacy was provided for three of 22 final sampled residents (Residents 3, 8, and 244). * The privacy curtain was not pulled completely in Resident 8's room when the license nurse administered the medications via GT. Additionally, Resident 8's window had the missing blind slats showing a walkway outside the window during the medication administration via GT. * The computer screen on Medication Cart 3 was left unattended showing Resident 3 and other residents' names and care information. * The computer screen was left on unattended with no privacy screen in Nursing Station 2 showing Resident 244's personal information. These failures had the potential to negatively affect the dignity of the residents and violate the resident's rights to privacy. Findings: Review of the facility's Policy Statement on Dignity revised in February 2021 showed under paragraph 11, the staff promote, maintain and protect resident privacy, including bodily privacy during assistance with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility P&P review, the facility failed to maintain a clean and homelike environment for four of 22 final sampled residents (Residents 14, 65, 74, and 75) and two nonsampled residents (Residents 8 and 71). * Residents 65 and 74 complained about the condition of the carpet in the resident hallways throughout the facility, stating the carpets were dirty. * Two resident's rooms (Residents 14 and 75) were observed with missing paint and scrapes on the walls. * Resident 8's window was observed with missing blind slats. * Resident 71's room was observed with an improperly hung curtain. These failures had the potential to negatively impact the residents' quality of life. Findings: Review of the facility's P&P titled Homelike Environment revised 2/2021 showed the residents are provided with a safe, clean, comfortable, and homelike environment. The facility staff and management maximize, to the extent possible, homelike setting. 1. Medical record review for Resident 74 was initiated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 notify the resident's representatives of the transfer and reasons for the transfer to the acute care hospital in writing and send a copy of the notice of transfer to the representative of the Office of the State Long-Term Care (LTC) Ombudsman for two of three sampled residents (Residents 55 and 72) reviewed for hospitalization. This failure posed the risk of the resident's representatives not being aware of their appeal rights and the Ombudsman not being aware of the circumstances of the resident's transfer/ discharge should an appeal be filed or requested by the resident or their representatives regarding the transfer. Findings: Review of the facility's P&P titled Transfer or Discharge, Facility Initiated dated 10/2022, showed notice of transfer is provided to the resident and representative as soon as practicable before the transfer and to the LTC ombudsman when practicable. When a resident is transferred or discharged…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 or the resident's representative was provided a written bed hold policy upon transfer to the acute care hospital for two of three sampled residents (Resident 55 and 72) reviewed for hospitalization. This failure had the potential for the resident or the resident's representative to not be informed of their rights to return to the facility following a hospitalization. Findings: Review of the facility's P&P titled Transfer or Discharge, Facility Initiated dated 10/2022 showed the notice of facility bed-hold and returns policies are provided to the resident and representative within 24 hours of emergency transfers. 1. Medical record review for Resident 55 was initiated on 6/10/24. Resident 55 was admitted to the facility on [DATE], transferred to the acute care hospital on 5/23/24, and readmitted to the facility on [DATE]. Review of Resident 55's H&P examination dated 5/28/24, showed Resident 55 had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to coordinate an assessment with Pre-admission Screening and Resident Review (PASRR) program for one of 22 final sampled residents (Resident 15) when the resident had a newly evident mental disorder for level II review. This failure posed the risk for Resident 15 not receiving the necessary specialized services specific to treat mental illness and had the potential for inappropriate placement in a long-term nursing home. Findings: Medical record review for Resident 15 was initiated on 6/10/24. Resident 15 was admitted to the facility on [DATE]. Review of Resident 15's History and Physical examination dated 4/24/24, showed Resident 15 had no diagnosis of mental illness. Review of Resident 15's level I PASRR dated 4/20/24, showed Resident 15 had no diagnosis of mental illness and had not been prescribed of a psychotropic medications. Review of Resident 15's Order Summary Report dated June 2024 showed a physician's order dated 4/30/24, for quetiapine…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 level 1 PASRR Screening was conducted after an acute care hospital discharge exemption lapsed for one of four residents (Resident 65) reviewed for PASRR. * Resident 65's Level I PASRR Screening dated 4/3/24, showed Resident 65 had a diagnosed mental illness and had been prescribed psychotropic medications. Resident 65's Level 1 Screening was negative, and a Level II mental health evaluation referral was not required due to an exempted hospital discharge. Further review of Resident 65's Level 1 PASRR Screening dated 4/3/24, showed if Resident 65 remained in the facility longer than 30 days, the facility should resubmit a new Level 1 PASRR Screening on the 31st day. However, the facility failed to resubmit a new Level 1 PASRR Screening when Resident 65 had remained in the facility longer than 30 days. This failure posed the risk for Resident 65 not receiving a Level II Mental Health Evaluation, which had the potential for the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to ensure three of 22 final sampled residents (Residents 25 and 93) attained and maintained their highest practicable well-being. * The facility failed to ensure Resident 93's medication order for Insulin Regular Human (Regular Insulin is a short-acting type of insulin) Injection Solution per sliding scale was administered as ordered by the physician. This failure posed risk for Resident 93 to have hyperglycemic episode and to receive unnecessary short acting insulin dose. * Resident 25's change in skin integrity were not assessed and documented. This failure posed the risk of Resident 25 not receiving appropriate care. Findings: 1. Medical record review for Resident 93 was initiated on 6/3/24. Review of Resident 93's H&P examination dated 6/3/24, showed the resident had a capacity to understand and make decisions. Review of Resident 93's Physician Order Summary Report…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of one resident (Resident 25) reviewed for accident hazards remained free from accident hazards. * The facility failed to ensure two persons transferred Resident 25 with the mechanical lift. This failure had the potential for injury to Resident 25. Findings: Review of the facility's P&P titled Lifting Machine, Using a Mechanical undated showed the purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device. At least two nursing assistants are needed to safely move a resident with a mechanical lift. Mechanical lifts may be used for tasks that require: transferring a resident from bed to chair and toileting or bathing. Medical record review for Resident 25 was initiated on 6/10/24. Resident 25 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 25's H&P examination dated 10/9/23, showed Resident 25 was alert and oriented and…

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

Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure one of three sampled residents (Resident 8) reviewed for GT care received adequate care as evidenced by: * The facility failed to ensure the GT patency and placement were properly checked before the medication was administered for Resident 8. This failure had the potential for negative outcomes for the residents with GT. Findings: Review of the facility's P& P titled Administering Medications through Enteral Tube revised 11/2018 showed to verify the placement of the feeding tube. Review of the facility's document titled Gastrostomy and Jejunostomy Placement and Patency Check, dislodging: Pulling Out undated showed using a 60 ml syringe, pull syringe plunger back and fill with 10-20 ml of air, connect the syringe to the end of the feeding tube, put on the stethoscope and place bell or diaphragm of the stethoscope over the left upper quadrant of the abdomen while rapidly injecting the air. On 6/11/24 at 0943 hours, during the medication…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, medical record review, and facility P&P review, the facility failed to ensure one sampled resident (Resident 93) reviewed for IV therapy was administered parenteral flushes in accordance with the physician's order. * The facility failed to flush Resident 93's IV every 12 hours as ordered by the physician. This failure posed the risk for complications related to the IV therapy. Findings: Review of the facility's P&P titled General Policies for IV Therapy dated 3/2023, showed the intermittent IV medications should be separated by saline flushes to avoid incompatibilities. Medical record review for Resident 93 was initiated on 6/10/24. Review of Resident 93's H&P examination dated 6/3/24 showed Resident 93 had capacity to understand and make decisions. Review of Resident 93's Physician Order Summary Report as of 6/10/24, showed the following physician orders: - On 6/3/24, Ertapenem Sodium (antibiotic) Injection Solution Reconstituted 1 gram intravenously one time a day for 10 Days. Flush IV with 10 ml Normal Saline (sodium chloride Flush) before and after giving…

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

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the pharmaceutical services including accurate acquiring, receiving, dispensing, and record keeping were maintained to meet the needs of each resident as evidenced by: * The facility failed to ensure the medications removed from the emergency kit were replaced in a timely manner. * The facility failed to ensure the controlled drug count reconciliation logs were properly accounted for and documented. These failures had the potential for not having the medications available for use in case of emergency and drug diversion. Findings: Review of the facility's P&P titled Controlled Medication Storage effective 8/2014 showed at each shift change, a physical inventory of all controlled medications, including the emergency supply is conducted by two licensed nurses and is documented on the controlled medication accountability record. Any discrepancy in controlled substance medication count is reported to the Director of Nursing immediately. The Director or designee investigates…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 22 final sampled resident (Resident 25) was free from the unnecessary medications. * The facility failed to clarify Resident 25's physician's order for no other narcotics and muscle relaxants while on methadone (narcotic). Resident 25 was prescribed narcotics pain medications and muscle relaxant with methadone. This failure had the potential for Resident 25 to receive unnecessary medications and develop significant adverse effects, and risk adverse effects from prolonged use of medication. Findings: Medical record review for Resident 25 was initiated on 6/10/24. Resident 25 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 25's H&P examination dated 10/9/23, showed Resident 25 was alert and oriented and had independent decision-making capabilities. Review of Resident 25's Order Summary Report dated 6/12/24, showed the following physician's orders: - dated 4/15/20, no other narcotics…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, medical record review, and facility P& P review, the facility failed to ensure one of 22 final sampled residents (Resident 15) was free from the unnecessary psychotropic medications (medication that affects the brain activity). * The facility failed to ensure the Psychotropic Medication Administration Disclosure (informed consent) was completed prior to the administration of Resident 15's psychotropic medications. This failure posed the risk of not evaluating the need and effectiveness of Resident 15's psychotropic medications use, Findings: Review of the facility's P&P titled Informed Consent dated June 2021 showed the information to be included in obtaining consent for Psychotherapeutic Medications are as follows: the reason for the treatment and the nature and seriousness of the resident's illness, and the nature of the medication to be used including the dose, frequency, and duration. Prior to initiating the administration of a psychotherapeutic medication, the licensed nursing staff shall verify with the resident or the surrogate decision maker that he/she…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 facility's medication error rate was below 5%. * The facility's medication error rate was 16.12%. One of three licensed nurses (LVN 3) was observed administering the medications to one of 22 final sampled residents (Resident 8) and was found to have errors. The facility failed to ensure Resident 8 received the prescribed medications as ordered. This failure had the potential for the resident to not receive the effective therapeutic effects of the medications and may negatively affect the resident's health. Findings: Review of the facility's P&P titled Administering Medications revised April 2019 showed medications are administered in a safe and timely manner as prescribed. Medications are administered in accordance with the prescriber orders, including any required time. The medications are administered within one hour of their prescribed time, unless otherwise specified. Medication administration times are determined by the resident's need and benefit, and not for the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 22 final sampled resident (Resident 8) was free from the significant medication errors. This failure placed Resident 8 at risk for medical complications. Findings: Medical record review for Resident 8 was initiated on 6/11/24. Resident 8 was admitted to the facility on [DATE], with diagnoses including essential (primary) hypertension and heart failure (unspecified). Review of Resident 8's Nursing Documentation Evaluation dated 6/10/24, showed weakness to both upper extremities in the musculoskeletal system review. Review of Resident 8's Order Summary Report as of: 6/11/24, showed the following orders: - amlodipine besylate (antihypertensive, medication to control blood pressure) oral tablet 5 mg one tablet daily - hydralazine hcl (antihypertensive) oral tablet 25 mg one tablet enterally two times a day - lisinopril (antihypertensive) oral tablet 20 mg enterally one time a day - enulose (laxative,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 P&P review, the facility failed to ensure the medications were labeled and stored safely, securely, and properly. * The facility failed to ensure the medications were stored and labeled properly. * The facility failed to ensure the discontinued medications were removed from the medication cart. * The facility failed to ensure the oral medications were stored separate from externally used medications. These failures had the potential for medication errors. Findings: 1. Review of the facility's P&P titled Administering Medications revised 4/2019 showed the individual administering the medications checks the label three times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. On [DATE] at 1449 hours, the treatment cart inspection was conducted with LVN 9. A triamcinolone acetonide cream 0.1% for Resident 85 did not have a clear label. LVN 9 stated she tried…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 offer and provide education for COVID-19, influenza, and pneumococcal immunizations for three of 22 final sampled residents (Resident 2, 15, and 75). * The facility failed to provide education and offer the COVID-19 and influenza immunizations to Resident 75. * The facility failed to offer and provide education for PCV 15/20 (PCV 15 protects against two additional serotypes and PCV 20 protects against seven additional serotypes involved in cases of invasive pneumococcal disease (IPD) and pneumonia) for Residents 2, 15, and 75. These failures increased the risk for residents to be inadequately vaccinated for COVID-19, influenza, and pneumococcal disease and not be informed of its associated complications. Findings: Review of the new CDC guidelines titled Morbidity and Mortality Weekly Report (MMWR) dated 1/28/22, for the use of 15-Valent Pneumococcal Conjugate Vaccine (PCV15) and 20-Valent…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 maintain the documentation if the staff received the COVID-19 vaccinations, were provided the education regarding the benefits and risks of COVID-19 vaccines, and were offered to receive the COVID-19 vaccine. This failure placed the staff and residents at risk of COVID-19. Findings: Review of the facility's P&P titled Coronavirus Disease (COVID-19) Vaccination of Staff revised June 2022 showed all staff are required to be fully vaccinated for COVID-19. Under the section for Documentation and Reporting showed the Infection Preventionist maintains a tracking worksheet of staff members and their vaccination status. The tracking worksheet provides the most current vaccination status of all staff who provide any care, treatment, or other services for the facility and/or its residents. The worksheet includes: staff name (and/or employee ID), initial start of employment or service, termination of employment or service, job title, work area, brief description of how they interact with residents,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to follow up on the grievance for one of 22 final sampled residents (Resident 25). This failure had the potential for violating the resident's rights to have their grievances resolved. Findings: Review of the facility's P&P titled Grievance/Concern effective 8/25/21, showed the grievances are documented and tracked through to their conclusion. Also, the grievances are to be resolved promptly. On 6/11/24 at 0935 hours, a concurrent observation and interview was conducted with Resident 25. Resident 25 verbalized he had talked to the Administrator months ago about his Sketchers brand shoes being shrunk after being washed in the facility's laundry. Resident 25 stated he had also talked to the Administrator about wanting a reimbursement for his shrunken Sketchers shoes, but the Administrator still had not resolved his grievance. Resident 25 verbalized he also wanted a replacement for his two pairs of socks that were missing.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 sampled residents (Resident 35) reviewed for dialysis treatment received the dialysis treatment at the prescribed time. * Resident 35's transportation issues were not followed up on with the resident's insurance carrier. This failure had the potential for negative health outcomes for the resident. Findings: On 6/11/24 at 0813 hours, an interview was conducted with Resident 35. Resident 35 stated on 6/11/24, Resident 35 had an appointment to change his dialysis access site to a shunt. Resident 35 further stated his appointment was at 0800 hours on 6/11/24, and the transportation did not arrive to the facility until 0750 hours. Resident 35 stated he cancelled the appointment because the transportation was too late since his appointment was at 0800 hours and there was not enough time to get Resident 35 to his appointment location by 0800 hours. Resident 35 further stated last Friday, he did not get his dialysis until 1300 hours, 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, and facility P&P review, the facility failed to ensure the privacy for one sampled resident (Resident 4) was provided during care. * The privacy curtain was not pulled while providing ADL care to Resident 4. This failure had the potential to violate the resident's rights to privacy. Findings: Review of the facility's P&P titled Quality of Life-Dignity revised February 2020 showed the staff to promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during procedures. On 4/25/24 at 0947 hours, CNA 1 was observed speaking to CNA 2 from Shower Room A while providing a shower to Resident 4. The door of the shower room was open with the privacy curtain pulled back by CNA 1, and Resident 4 was observed completely undressed and visible from the hallway. Other residents and staff were observed in the hallway at that time. Medical record review for Resident 4 was initiated on 4/24/24. Resident 4 was admitted to the facility on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility document review, the facility failed to follow the COVID-19 isolation precautions for one of five sampled residents (Resident 1). This failure had the potential to put other residents and staff at risk of contracting COVID-19. Findings: Review of the CDC's Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2109 (COVID-19) Pandemic updated 5/8/23, showed the following: - Source control (the use of masks covering the nose and mouth to prevent spread of respiratory secretions) is recommended for residents with confirmed COVID-19 infection. - Residents with confirmed COVID-19 infection should be placed in a room with the door kept closed. Staff entering the resident's room should use a NIOSH Approved particulate respirator with N95 filters or higher. Review of the facility's P&P titled Coronavirus Disease (COVID-19) - Identification and Management of Ill Residents - F880 revised…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and food storage practices. * The facility failed to ensure the opened food items were dated and not stored beyond the use by date. * The facility failed to ensure the dietary staff performed proper hand hygiene when preparing food. * The facility failed to ensure hair restraints were worn in the kitchen. * The facility failed to ensure personal belongings were stored away from the kitchen preparation area and away from dishware. * The facility failed to replace the cutting boards that were marred and did not have cleanable surfaces. These failures had the potential to cause the foodborne illnesses in a medically vulnerable resident population who consumed food prepared in the kitchen. Findings: 1. During an initial tour of the kitchen on 7/19/21 at 0741 hours, an observation of the walk-in refrigerator, dry storage area and kitchen preparation area was conducted with Dietary Aide 1. The following items were opened and undated: - three cartons of thickened lemon-flavored water;…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to provide the necessary care and services for one of 20 final sampled residents (Resident 686). The facility failed to ensure Resident 686's call light was answered in a timely manner when she needed to go to the bathroom. This failure led to the resident feeling upset and posed a risk to the residents' physical and emotional well-being. Findings: Review of the Resident 686's medical record was initiated on 7/19/21. Resident 686 was admitted to the facility on [DATE]. Review of the physician's H&P examination dated 7/11/21, showed Resident 686 needed assistance with her ADL care. On 7/19/21 at 0956 hours, during an initial tour, Resident 686 was observed sitting on her bed with a plaster cast on her left leg. Resident 686 stated she was not able to ambulate by herself when she needed to go to the bathroom. Resident 686 stated she had concerns about the facility staff not answering her call light in a timely manner. Resident 686…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medical record review, the facility failed to provide a homelike environment for one of 20 final sampled residents (Resident 63). A blank wall and cork board were observed by Resident 63's bedside. This failure posed the risk for Resident 63 to develop emotional distress. Findings: On 7/19/21 at 1057 hours, during an initial tour, Resident 63 was observed lying in bed, awake, and staring at the ceiling. A cork board at Resident 63's bedside was observed with no posting. There were no personal belongings observed at Resident 63's bedside. On 7/21/21 at 1658 hours, Resident 63's room was observed with the bare wall and board, no pictures and no personal belongings or mementos at bedside. On 7/22/21 at 1435 hours, a concurrent observation and interview was conducted with the Activities Director. Resident 63 was observed lying in bed and staring at the ceiling. The Activity Director acknowledged the absence of personal items like pictures and mementos from home to ensure a homelike environment was provided to Resident 63.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical records review, the facility failed to ensure the baseline care plans related to the specific care needs were provided to two of the 20 final sampled residents (Residents 686 and 687). This had the potential for the residents to not receive the necessary care and services in accordance with their care needs. Findings: 1. Review of the Resident 686's medical record was initiated on 7/19/21. Resident 686 was admitted to the facility on [DATE]. Review of the medical record did not show any documentation of a baseline care plan provided to Resident 686. On 7/19/21 at 1035 hours, during initial tour, an interview was conducted with Resident 686. Resident 686 stated she was not aware of her plan of care and did not know when she would be discharged back to her home. Resident 686 stated she did not receive a copy of her plan of care. 2. Review of the Resident 687's medical record was initiated on 7/19/21. Resident 687 was admitted to the facility on [DATE]. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to develop a comprehensive care plan for one of 20 final sampled residents (Resident 61). Resident 61 was readmitted to the facility with an unstageable pressure ulcer (an ulcer with full thickness tissue loss covered by extensive dead tissue) on the sacrococcyx (sacrum and coccyx region). The facility failed to develop a care plan problem to address Resident 61's pressure ulcer. This posed the risk of the resident not receiving the necessary care and services. Findings: Medical record review for Resident 61 was initiated on 7/19/21. Resident 61 was readmitted to the facility on [DATE]. Review of Resident 61's Skin Check assessment form dated 4/6/21, showed Resident 61 had an unstageable sacrococcyx pressure ulcer, measuring 7 cm (length) x 7 cm (width). Review of Resident 61's Order Summary Report showed a physician's order dated 6/25/21, to provide treatment to an unstageable sacrococcyx pressure ulcer by cleansing with normal saline, patting…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 revise the plan of care for one of 20 final sampled residents (Resident 63). Resident 63's care plan problem addressing GT feeding was not updated to reflect the resident's current care needs. This had the potential to affect the provision of care. Findings: Review of Resident 63's medical record was initiated on 7/19/21. Resident 63 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of the MDS dated [DATE], showed Resident 63 had impaired cognition. Resident 63 was on GT feeding. Review of the Order Summary Report dated 7/21/21, showed a physician's order dated 6/21/21, for enteral feed to administer Glucerna 1.5 at 40 ml/hour via pump from 12 pm to 8 am. Review of the care plan problem addressing the enteral feeding dated 2/9/18, showed an intervention to administer Jevity 1.2 Cal via pump. On 7/19/21 at 1052 hours, during an initial tour, Resident 63 was observed in bed with the bottle of Glucerna 1.5…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an individualized activity program to meet the needs and interests of one of 20 final sampled residents (Resident 63). Resident 63 was observed on multiple occasions to be inside her room without any type of activity. This failure had the potential for the residents to experience feelings of social isolation and depression. Findings: According to the facility's P&P titled Recreation Services Policies and Procedures Manual revised on 4/1/18, showed recreation services will be designed to meet the individual's interest, abilities, and preferences through group and individual programs. Review of Resident 63's medical record was initiated on 7/19/21. Resident 63 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of the MDS dated [DATE], showed Resident 63 had impaired cognition. Resident 63 was totally dependent on staff for her ADL care. Resident 63 considered music as important.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 necessary treatment and services were provided to maintain or improve ROM functions and prevent further development of contractures for one of 20 final sampled residents (Resident 63). The facility failed to ensure the OT evaluation was conducted for Resident 63 when it was ordered on 11/15/20. In addition, Resident 63 was not provided RNA services when her plan of care included RNA services as interventions to address her risk for developing contractures and limited range of movements. These failures posed the risk for residents to develop complications from immobility and not achieve their highest practicable level of independence. Findings: Review of Resident 63's medical record was initiated on 7/19/21. Resident 63 was admitted on [DATE], and readmitted on [DATE]. Review of the MDS dated [DATE], showed Resident 63 had impaired cognition. Resident 63 was totally dependent on staff for her ADLs. Resident 63 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 and interview, the facility failed to ensure the environment remained free from accident hazards. * The railing attached to the wall adjacent to the entrance of the resident's shower room was observed with structural damage resulting in exposed sharp edges. This failure had the potential to cause skin tears or cuts on the skin of the residents who utilized the railing. Findings: On 7/21/21 at 1420 hours, an observation and concurrent interview was conducted with the DON. The railing attached to the wall adjacent to the entrance of Shower Room A was observed with structural damage, resulting in exposed sharp edges. The DON stated the residents utilized the railing and Shower Room A. The DON verified the findings and stated the facility would repair the railing.

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 20 final sampled residents (Resident 84) remained free from accident hazards due to the use of elevated side rails as evidence by: * The facility failed to conduct the assessment for the risk of entrapment from elevated side rails and failed to obtain the informed consent prior to the use of side rails for Resident 84. This had the potential to place the resident at risk for entrapment and serious injury. Findings: Review of the FDA issued Safety Alert titled Entrapment Hazards with Hospital Bed Side Rails showed the 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…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure accurate accountability, documentation, and reconciliation of the controlled medications (medications that can cause physical and mental dependence, whose use and distribution is tightly controlled due to its potential or risk for abuse) as evidenced by: * The facility staff failed to follow their P&P on reconciling and reporting the narcotic medication discrepancies for one controlled medication. * The facility failed to ensure accurate drug accountability and documentation when administering the controlled medication for one nonsampled resident (Resident 55). * The facility failed to ensure the physical inventory of the controlled medications was conducted during every shift change as per the facility's P&P for one of three medication carts (Medication Cart A) inspected. This failure posed the risk for the diversion (illegal transfer of any legally prescribed controlled substance) 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 2. Medical record review for Resident 64 was initiated on 7/19/21. Resident 64 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of the physician's order dated 3/18/20, showed to administer carvedilol 3.125 mg orally two times per day for hypertension and to hold the medication for a systolic blood pressure (the top number in a blood pressure measurement) less than 110 mmHg. Review of Resident 64's Medication Administration Records for 12/2020, 2/2021, and 3/2021 showed carvedilol 3.125 mg was administered on the following dates/times when Resident 64's systolic blood pressure was less than 110 mmHg: - 12/20/20 at 1700 hours; 2/19/21 at 0900 hours; and 3/5/21 at 1700 hours. On 7/21/21 at 1236 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified the findings and stated the antihypertensive medications administered outside of the ordered hold parameters could potentially cause negative health outcomes associated with hypotension. Based on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to ensure one of 20 final sampled residents (Resident 40) was free from unnecessary psychotropic medications (any medication that affects brain activity). * The facility failed to ensure Resident 40's order for alprazolam (medication treating anxiety and panic disorder) PRN (as needed) was limited to 14 days. This had the potential to negatively impact the resident's well-being. Findings: Medical record review for Resident 40 was initiated on 7/19/21. Resident 84 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of the physician's order dated 2/3/21, showed to administer alprazolam 0.5 mg by mouth every 24 hours PRN for anxiety. The physician's order for alprazolam failed to show a duration for use. On 7/21/21 at 0930 hours, and interview and concurrent medical record review was conducted with the DON. The DON verified Resident 40's physician's order for alprazolam had no end date for duration of use.

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 medication error rate was below 5%. The facility's medication error rate was 8%. One of two licensed nurses (LVN 2) observed was found to have made errors during the medication administration observations. * LVN 2 gave a dose of a medication to Resident 72 that had been previously modified by the physician to a lower dose and reduced frequency. * LVN 2 failed to give the full dose of the medication to Resident 9. These failures created the risk for the residents to not receive the therapeutic dose or response of the medications and could negatively affect the residents' health. Findings: 1. On 7/21/21 at 0848 hours, an observation of the medication administration for Resident 72 was conducted with LVN 2. LVN 2 prepared and administered the following seven medications to Resident 72 by mouth: - sevelamer carbonate (lowers high blood phosphorus) 0.8 grams one packet, - Eliquis (treats and prevents…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility P&P review, the facility failed to ensure the medications were accurately stored and labeled. * The opened Glucose Quality Control Solution (a liquid used to validate the performance of the glucometer) bottle with an open date of [DATE], was in use 62 days beyond the manufacturer's recommended use date. This failure posed the risk for inaccurate blood sugar level results and inaccurate insulin dosing for residents. * The facility failed to ensure Resident 70's insulin pen (medication to decrease blood sugar level) was discarded 28 days after it was opened. This failure posed the risk for a decrease in the effectiveness of the medication. Findings: 1. Review of the facility's P&P titled Glucose Meter revised [DATE], showed staff must check the expiration date on the glucose control solution and discard the bottle of glucose control solution according to the manufacturer's guidelines. Review of the manufacturer's guidelines titled Assure Dose for the glucose control…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 follow the menu for one of 20 final sample residents (Resident 4) and two nonsampled residents (Residents 538 and 539). This failure posed the risk of the residents' nutritional needs not being met and/or residents' preference not being honored. Findings: 1. On 7/21/21 at 1353 hours, an observation and concurrent interview was conducted with the Dietary Manager. Resident 4's meal ticket showed he was to receive Italian sausage, garlic and rosemary roasted red skin potatoes, broccoli florets, parsley dinner roll, and lemon bar. Resident 4's tray was observed to have Italian sausage, mashed potatoes, chopped broccoli and parsley dinner roll. Resident 4 did not receive the lemon bar. The Dietary Manager verified the finding. 2. On 7/21/21 at 1354 hours, an observation and concurrent interview was conducted with the Dietary Manager. Resident 538's meal ticket showed she was to receive Italian sausage, garlic and rosemary roasted red skin potatoes, broccoli florets, parsley dinner roll, and lemon bar.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 follow proper food storage practices. * The facility failed to ensure the food items brought from outside the facility by Resident 84's family were labeled with the expiration dates. * The facility failed to ensure the food items were stored in a sanitary manner. Resident 84's Ginger Ale cans were stored in the same drawer with her bed pan. These failures had the potential to cause the foodborne illnesses in a medically vulnerable resident population. Findings: 1. Review of the facility's P&P titled Food Brought in for Residents revised 6/15/18, showed food items must be labeled with resident's name and dated. Foods considered unsafe for consumption or beyond the expiration date will be discarded by staff upon notification of resident. On 7/19/21 at 0915 hours, an observation and concurrent interview was conducted with the DSD. A plastic container with approximately 50 assorted individually wrapped chocolates and mints was observed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 garbage and refuse were properly stored. Failure of the facility to keep the garbage covered had the potential to attract pests/rodents that carried diseases. Findings: 1. On 7/19/21 at 0734 hours, an observation and concurrent interview was conducted during the initial tour of the kitchen with Dietary Aide 1. A garbage bin was observed uncovered at the food preparation area. A closer inspection of the garbage bin showed food waste inside. Dietary Aide 1 verified the above findings. 2. On 7/22/21 at 0704 hours, an observation and concurrent interview was conducted with the Maintenance Supervisor. Two of the four dumpsters located outside of the facility adjacent to the kitchen were observed to have the lids propped open. The Maintenance Supervisor verified the findings. On 7/22/21 at 1440 hours, an interview was conducted with the RD. The RD stated the garbage bins and dumpsters should always be covered. 3. On 7/20/21 at 0715 hours, an observation and concurrent interview was conducted with the Administrator. Four…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 infection control practices were followed to prevent the potential transmission of microorganisms * The facility failed to ensure a visitor removed her isolation gown before exiting the room of a resident (Resident 288) housed on the facility's COVID-19 observation unit. The visitor then walked through the facility's non-observational unit (COVID-19 negative unit). This failure posed the risk for transmission of COVID-19 to staff and residents. * The facility failed to maintain the sanitary condition in the laundry area. A thick layer of black and grey dust and debris was observed along the plumbing system, the back wall of the sink, and floor just behind the washing equipment. This failure posed the potential for the contamination of the clean linens provided to the residents which were processed just adjacent to the washing equipment. Findings: On 7/21/21 at 1300 hours, an observation and concurrent interview was conducted with Visitor 1. Visitor 1 was observed exiting Resident 288's room (Room A) without removing…

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