Beach Creek Post-Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary pharmacy services. * The facility failed to ensure orally administered medications were stored separate from the externally used medications in Medication room [ROOM NUMBER]. *The facility failed to ensure the expired supplies were removed from the current treatment supply in Treatment Cart A. * The facility failed to ensure there were no medications left at bedside. * The facility failed to ensure RN 4 and LVN 7 did not leave medications on top of medication cart during medication pass observation. * The facility failed to ensure a medication cup with white paste was not left on Resident 1's overbed table. These failures had the potential to negatively impact the residents' well-being, and the potential for the medications to lose the stability and effectiveness.Findings: Review of the facility's P&P titled Storage of Medications revised on 4/2007 showed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility document review, the facility failed to ensure the menu to meet the resident's nutritional needs was followed for one of 85 residents (Resident 82) who received food from the kitchen. * The facility failed to ensure Resident 82 was served the corn on the cob or street corn, as per the menu. Resident 82 was served green beans. This failure posed the risk for negatively impacting the residents' satisfaction and dietary compliance. Findings: Review of the facility document titled Order Listing Report dated 1/20/26, showed 85 residents had regular diets and received food from the kitchen. Review of the facility's document titled Week at a Glance- Menu showed the menu for 1/20/26, for the lunch meal was BBQ pork loin, Spanish rice, corn on the cob, bread or roll with margarine, apple pie, street corn, and choice of beverage. Further review of the menu showed the menu items were for the regular diet. Medical record review for Resident 82 was initiated on 1/20/26. Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, facility document review and facility P&P review, the facility failed to ensure the food preference was honored for one of 27 final sampled residents (Resident 3). * The facility failed to ensure Resident 3 was served white bread per the resident's meal ticket. This failure had the potential for the resident to not receive a meal to meet the resident's needs and preferences.Findings: Review of the facility's P&P titled Therapeutic Diets dated 10/2017 showed therapeutic diets are prescribed by the physician to support the residents' treatment and plan of care and in accordance with the residents' goals and preferences. On 01/20/26 at 1212 hours, a dining observation was conducted in the dining room. The meal cart arrived and LVN 1 was observed checking the meal trays against the residents' diet list. The meal trays were then distributed to the residents by the facility staff in the dining room. On 1/20/26 at 1225 hours, an observation and concurrent…

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

Based on observation, interview, facility document review, and facility P&P review, the facility failed to accommodate the drink preferences for one of 27 final sampled resident (Resident 111). * The facility failed to ensure Resident 111 was served two milk cartons, as per the meal ticket, for his lunch meal. This failure had the potential to affect the resident's overall meal intake and nutritional status.Findings: Review of the facility's P&P titled Food and Nutrition Services revised 10/2017 showed each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. Reasonable effort will be made to accommodate resident choices and preferences. On 1/20/26 at 1220 hours, a lunch observation and concurrent interview was conducted with Resident 111 in the dining room. Resident 111 was observed eating his lunch with one eight-ounce carton of non-fat milk. Review of Resident 111's lunch meal ticket showed under Standing Orders, to send two eight-ounce…

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

Based on observation, interview and facility P&P review, the facility failed to ensure the garbage and refuse were properly stored for one of three dumpsters. * The facility failed to ensure one of three dumpster's lid was fully closed. This failure had the potential to attract pests and rodents that carried diseases.Findings: According to the USDA Food Code 2022, Chapter 5 Water, Plumbing, and Waste, Section 5-501.113 Covering Receptacles showed outside garbage receptacles shall be kept covered with tight-fitting lids or covers. Review of the facility's P&P titled Food related Garbage and Refuse Disposal dated 10/2017 showed all garbage and refuse containers are provided with tight- fitting lids or covers and must be kept covered when stored or not in continuous use, and outside dumpsters provided by garbage pick-up services will be kept closed and free of surrounding litter. On 1/22/25 at 0917 hours, an observation of the facility's outside dumpsters was conducted with the Maintenance Supervisor. One dumpster lid was not fully closed with visible bags of trash on the left side of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to ensure the medical records were accurately completed for four of 27 final residents (Residents 3, 5, 8 and 135). * The facility failed to ensure Resident 3's MAR for [DATE] was completed and signed. * The facility failed to ensure Resident 5's POLST Section D was completed. * The facility failed to ensure Resident 135's POLST Section D was completed. * The facility failed to ensure Resident 8's POLST Section D was completed. These failures posed a potential risk for residents to not be provided with the care and treatment since their medical record information was incomplete.Findings: Review of the facility's P&P titled Charting and Documentation dated 7/2017 showed the following information is to be documented in the resident medical record as follows - objective information - medication administered - treatment or services performed - changes in residents' condition - events, incidents or accidents involving the resident and -…

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

Based on interview and facility document review, the facility failed to implement their QAPI plan of action. * There was no documentation to show the facility had provided an in-service for medication storage, specifically storing internally administered medication separately from externally administered medications for one repeated deficient practice cited at F761 in accordance with their POC from the last recertification survey completed on 1/9/25. This failure had the potential for medication errors and negatively impact the residents' well-being.Finding: On 1/26/26 at 1443 hours, an interview and concurrent facility document review was conducted with the Administrator and DSD. Review of the POC submitted by the facility to the CDPH, L&C Program for F761 cited from the last recertification survey completed on 1/9/25, showed the DON in-serviced the licensed nursing staff on 1/7/25, regarding medication storage and labeling. The Administrator and DSD failed to show documented evidence the DON in-serviced the licensed nursing staff regarding medication storage and labeling,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 abuse investigation protocol was followed for one of three sampled residents (Resident 1) reviewed for abuse. * The facility failed to ensure CNA 1 was suspended immediately when Resident 1 reported to the facility staff of allegation of abuse against CNA 1. Resident 1 reported CNA 1 being rough during the provision of care. * The facility failed to report the result of the investigation to the CDPH, L&C Program, Orange District Office within five working days. These failures had the potential to put vulnerable residents at increased risk for abuse and/or delay in providing the necessary care.Findings: Review of the facility's P&P titled Abuse Investigation and Reporting dated 10/2022 showed all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to implement the comprehensive care plan for one of 27 final sampled residents (Resident 13). * Resident 13's At Risk for Respiratory Distress care plan showed to administer the oxygen as ordered by the physician (a rate of two liters per minute); however, Resident 13 was receiving oxygen at a rate of four and a half liters per minute. This failure posed the risk for not providing appropriate an individualized care to the resident. Findings: Review of the facility's P&P titled Oxygen Administration revised 6/5/23, showed the resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders such as, but not limited to: The type of oxygen delivery system, equipment setting for the prescribed flow rates, monitoring of oxygen saturation levels as ordered, and monitoring for complications associated with the use of oxygen. Medical record review for Resident 13…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 two sampled residents (final sampled, Resident 13) reviewed for respiratory care, was provided with the appropriate respiratory care when: * The facility failed to follow the physician's order for the administration of continuous oxygen for Resident 13. This failure had the potential to result in negative health outcomes for the resident. Findings: Review of the facility's P&P titled Oxygen Administration revised 6/5/23, showed oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. Oxygen is administered under orders of a physician. Medical record review for Resident 13 was initiated on 1/6/25. Resident 13 was admitted to the facility on [DATE]. Review of Resident 13's H&P examination dated 11/7/24, showed Resident 13 had a diagnosis of COPD. Review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to attain and maintain the highest well-being for one of three residents (final sampled resident, Resident 106) reviewed for hemodialysis (treatment to remove waste and extra fluid from the blood using a filtering machine). * The facility failed to monitor Resident 106's fluid restriction as per the physician's order. This failure had the potential to negatively impact the resident's well-being. Findings: Review of the facility's P&P titled Fluid Intake and Output revised July 2017 showed the facility will monitor the intake and output as ordered by the physician. Maintaining intake and output for residents on restricted fluid diets, according to specific fluid restriction in the resident's plan of care. Medical record review for Resident 106 was initiated on 1/6/25. Resident 106 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 106's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the pharmacy services as per the facility P&P for four nonsampled residents (Residents 63, 77, 85, and 118). * LVN 6 failed to ensure Residents 63 and 77's scheduled morning medications (at 0900 hours) were administered timely within 60 minutes of the scheduled time. * The facility failed to ensure the accurate and complete documentation of the controlled medications administered to Resident 85. * The facility failed to ensure the administration of the controlled medication for Resident 118 was documented in the narcotic and hypnotic record. These failures had the potential to place the residents at risk for delays in treatment and increased risk for adverse events and posed the risk for diversion of medications. Findings: 1. Review of the facility's P&P titled Medication Administration revised 12/19/22, showed to administer resident's medications within 60 minutes prior to or after scheduled time,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on 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 8.33%. * Resident 4 had a physician's order for vitamin B12 5000 micrograms orally to be administered one time a day for supplement; however, the LVN administered vitamin B12 1000 micrograms to Resident 4. In addition, the LVN applied a nicotine 21 mg transdermal patch to Resident 4's lower back; however, Resident 4 did not have a physician's order for a nicotine transdermal patch. * Resident 63 had a physician's order for a multi-vitamin/minerals tablet to be administered orally for supplement; however, the LVN administered a multi-vitamin without minerals to Resident 63. These failures had the potential to negatively affect the residents' health. Findings: Review of the facility's P&P titled Medication Administration revised 12/19/22, showed medications are administered by licensed nurses as ordered by the physician and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure proper storage, labeling, and disposal of medications. * The facility failed to ensure the orally administered medications were stored separately from the rectally administered medication in Medication Cart 5. * The facility failed to ensure the medication drawer was kept clean and free of dried white residue in Medication Cart 5. * A package which contained nicotine 21 mg transdermal patches was not labeled with a resident's name, prescribing physician's name, prescription number, or prescribed dose. Subsequently a LVN applied the nicotine 21 mg transdermal patch to a resident (Resident 4) without a physician's order for the nicotine 21 mg transdermal patch. * Resident 63's carvedilol (antihypertensive medication) medication order and carvedilol medication packaging had conflicting hold parameters specific to the systolic blood…

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

Based on observation, interview, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen when: * The facility failed to ensure the ice machine was maintained in a sanitary condition. * The facility failed to ensure the raw meat was stored in a sanitary manner. * The facility failed to ensure the kitchen equipment was clean. These failures posed the risk for food borne illnesses in highly susceptible resident population of 125 facility residents who received food prepared in the kitchen. Findings: Review of the CMS 672 Resident Census and Conditions of Residents completed by the facility dated 1/6/25, showed 125 of 134 residents in the facility received food prepared in the kitchen. 1. According to the USDA Food Code 2022, Section 4-601.11 Equipment, Food- Contact Surfaces, Nonfood Contact Surfaces, and Utensils. (A) Equipment, food-contact surfaces and utensils shall be clean to sight and touch. Review of the facility's P&P titled Food Safety and Food Storage revised on 11/4/24, showed cleaning and sanitizing the internal component of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to maintain the infection prevention and control practices to help prevent the development and transmission of communicable diseases and infections when: * CNA 1 did not follow the EBP when providing incontinence care for Resident 58. * The facility failed to ensure the CNA donned the appropriate PPE when providing care to Resident 50. * There was no receptacle readily available to discard used gowns for the resident on EBP. These failures had the potential to spread infection in the facility. Findings: Review of the facility's P&P titled Infection Control revised October 2018 showed the facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. The objectives of our infection control practices are to: Prevent, detect, investigate, and control infections in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the respiratory services were provided as ordered for two of five sampled residents (Residents 1 and 2). * The facility failed to ensure Resident 1 received oxygen 2 liters per minute via nasal cannula as per the physician's order. In addition, the facility failed to ensure the nebulizer (used to deliver vaporized medicine into the airway) mask was stored properly. * The facility failed to ensure Resident 2's nebulizer mask and BiPAP (bilevel positive airway pressure, a machine used to provide pressurized air into the airways while asleep) mask were stored properly. These failures had the potential to affect the residents' health and well-being. Findings: Review of the facility's P&P titled Administering Medications Through a Small Volume (Handheld) Nebulizer revised October 2010 showed the purpose of this procedure is to safely and aseptically administer aerosolized particles of medication into the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to develop a care plan for one of two sampled residents (Resident 1) to address Resident 1's behavioral concerns with Resident 2. This failure posed the risk of not providing appropriate and consistent care to Resident 1. Findings: Review of the facility's P&P titled Care Plans, Comprehensive Person-Centered reviewed 3/2023 showed the facility will update the resident's care plan when there has been a significant change in the resident's condition. Medical record review for Resident 1 was initiated on 08/23/23. Resident 1 was admitted to the facility on [DATE],with a diagnosis of schizophrenia. Review of Resident 1's Progress Notes showed Resident 1 reported concerns of Resident 2's inappropriate social skills as follows: - The progress note dated 6/27/23, showed Resident 1 complained to the staff of Resident 2 touching him. Resident 1 stated he was uncomfortable. - The progress note dated 7/3/23, showed Resident 1 complained…

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

Based on observation, interview, and facility document review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by the following: * The facility failed to ensure the cutting boards were in sanitary condition and with cleanable surface. * The facility failed to ensure the robot coupe blender used for puree preparation was air dried prior to storing. * The facility failed to ensure the silver metal chopper was clean and free of food particles. * The facility failed to ensure the kitchen utensils had a smooth cleanable surface and not worn out. These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food prepared in the kitchen. Findings: Review of the CMS-672 Resident Census and Conditions of Residents completed by the facility dated 2/27/23, showed 118 of 131 residents residing in the facility received food prepared in the kitchen. 1. According to the 2017 FDA Food Code Section 4-202.11, multi-use food contact surfaces shall be smooth; free of breaks, open seams, cracks,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medications were safely administered to one of 26 final sampled residents (Resident 34). Resident 34 had a bottle of inhalant, decongestant observed at the bedside. This failure had a potential to negatively impact the resident's physiological well-being, and administer medications inaccurately. Findings: Review of the facility's P&P titled Medication Administration General Guidelines Policy showed the medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Review of the facility's P&P titled Self-Administration of Medications revised December 2016 showed the residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. The policy also showed self-administered medications must be stored in a safe and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to follow the policy for advance directives for two of 26 final sampled residents (Residents 34 and 50). * The facility failed to obtain a copy of the advance directive for Resident 50. * The facility failed to to ensure an assistance was provided to formulate an advance directive for Resident 34. These had the potential for the resident's decisions regarding their healthcare and treatment options not being honored. Findings: Review of the facility's P&P titled Advance Directives revised 12/2016 showed if the resident indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives. The resident will be given the option to accept or decline the assistance, and care will not be contingent on either decision. Nursing staff will document in the medical record the offer to assist and the resident's decision to accept or decline assistance. 1. Medical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain a clean home-like environment for one of 26 final sampled residents (Resident 50). Resident 50's floor fan in her room was observed with dust build-up on the vents of the fan. This placed the resident at risk for living in an unkempt environment. Findings: Medical record review for Resident 50 was initiated on 2/27/23. Resident 50 was admitted to the facility on [DATE] and readmitted on [DATE]. On 3/2/23 at 1540 hours, an observation and concurrent interview was conducted with Resident 50 and LVN 6. Resident 50's floor fan was on. The fan was noted with dust build-up on the vents of the fan. LVN 6 acknowledged and verified the findings. When asked who was responsible to clean the floor fan, LVN stated it was the housekeeping. On 3/2/23 at 1545 hours, a follow-up interview was conducted with Resident 50. Resident 50 stated she has had the floor fan since she was admitted to the facility. When asked who cleaned the floor fan and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one nonsampled residents (Resident 103) was free from unnecessary restraints. * Resident 103 was diagnosed with dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) and had behaviors of hitting, kicking, pushing, scratching, and grabbing directed towards others. Resident 103's bottom portion of the top sheet was observed tied down onto the low air loss mattress straps in a manner which restricted Resident 103's ability to freely move his legs. * The facility utilized an abdominal binder on Resident 103. The facility failed to complete the comprehensive assessments, provide the appropriate medical diagnoses for the use of the restraint, determine the least restrictive interventions before the abdominal binder (compression belt that encircle the abdomen, used to help protect the gastrostomy tube 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to develop and implement the comprehensive person-centered care plans for three of 26 sampled residents (Residents 6, 38, and 95) and one nonsampled resident (Resident 103). * The facility failed to develop the care plan problem for the use of floor padding for Resident 38 who was at high risk for falls. In addition, Resident 38's care plan problem showed Resident 38 should be provided with two-person assistance for transfers; however, Resident 38 was transferred with the assistance of one person from her wheelchair to her bed. * The facility failed to develop the care plan problem for the use of abdominal binder for Resident 103. * The facility failed to ensure the care plan problem for Ativan use for Resident 6 was specific and individualized. * Resident 95's care plan problem showed to administer oxygen as ordered. The facility failed to follow the physician's order for the administration of continuous oxygen for Resident 95.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to ensure the comprehensive care plan was revised to reflect specific care needs for one of 26 sampled resident (Resident 50). This failure posed the risk for not providing the resident with individualized and person-centered care. Findings: Medical record review for Resident 50 was initiated 3/6/23. Resident 50 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of coccyx (triangular bony structure located at the bottom of the vertebral column) wound stage 2 (partial thickness skin loss involving epidermis, dermis, or both). On 3/07/23 at 1013 hours, an interview was conducted with Resident 50. Resident 50 stated she preferred laying on her back and repositioned every few hours on back with once a day on the right side. On 03/06/23 at 0906 hours, an observation and concurrent interview was conducted with CNA 6. When asked how often Resident 50 was repositioned, CNA 6 responded every two hours. When asked…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 implement the safety interventions and provide the padded side rails for one of 26 sampled resident (Resident 87) who had a diagnosis of seizure disorder (neurological disorder causing sudden, uncontrolled burst of electrical activity in the brain that leads to convulsions or uncontrollable shaking that is rapid and rhythmic). This failure put Resident 87 at risk for serious injuries during a seizure episode. Findings: Medical record review for Resident 87 was initiated on 2/28/23. Resident 87 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 87's H&P Examination dated 12/5/22, showed Resident 87 had seizure disorder and did not have the capacity to understand and make decisions. Review of Resident 87's MDS dated [DATE], showed Resident 87 had severe cognitive impairment and needed staff assistance for all her activities of daily living. Review of Resident 87's Order Summary Report…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure two of 26 sampled residents (Residents 50 and 87) and one nonsampled resident (Resident 103) who received enteral (refers to the intake of food through a gastrostomy tube) feeding were provided appropriate treatment and services to prevent complications of the enteral feeding. * The facility failed to ensure Resident 87 was administered the enteral feeding at the infusing rate as ordered by the physician. * The facility failed to ensure Residents 87 and 103's head of bed elevated when administering the enteral feeding. * The facility failed to ensure the enteral feeding mechanical pump was operated by a licensed staff while providing care for Residents 50 and 103. These failures posed the potential risk for aspiration during feeding and the potential for not meeting the residents' nutritional needs. Findings: Review of the facility's P&P titled Enteral Nutrition revised November 2018 showed adequate…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 respiratory care for two of 26 final sampled residents (Residents 34 and 95). * The facility failed to follow the physician's order for the administration of continuous oxygen for Resident 95. Resident 95 had an order to receive continuous oxygen at 2 liters per minute; however, Resident 95 received continuous oxygen at 4 liters per minute. * The facility failed to label the oxygen tubing for Resident 34. These failures had the potential to negatively impact Residents 34's and 95's medical conditions. Findings: 1. Review of the facility's P&P titled Oxygen Administration revised October 2010 showed preparation for oxygen administration includes a review of the physician's order for oxygen administration. Medical record review for Resident 95 was initiated on 2/27/23. Resident 95 was admitted to the facility on [DATE]. Review of the physician's order dated 9/18/22, showed an order 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.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided for one of 26 final sampled residents (Resident 34). * The facility failed to ensure the dialysis shunt site (a passage made to allow blood or other fluid to move from one pat of the body to another) was monitored every shift and documented in the medical record. * The facility failed to ensure the pre and post dialysis communication forms were completely filled out. * The facility failed to ensure the physician's order for a 1200 ml fluid restriction (a diet which limits the amount of daily fluid consumption) was followed and carried out accordingly. These failures had the potential to negatively impact the resident's well-being. Findings: Review of the facility's P&P titled Hemodialysis Access Care revised September 2010 showed the general medical nurse should document in the resident's medical record every shift as follows: 1. Location of catheter. 2. Condition of dressing (interventions if needed). 3. If dialysis was done during shift.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 accurate administration and documentation of the controlled medications (medications that have some potential for abuse or dependence) for one nonsampled resident (Resident 104). This failure had the potential for exposing residents to ineffective treatment, medication errors, and the potential for diversion of controlled medications. Findings: Review of the facility's contracted pharmacy P&P titled Controlled Medications undated showed when a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and MAR: date and time of administration, amount administered, and signature of the nurse administering the dose, completed after the medication is actually administered. Medical record review for Resident 104 was initiated on 2/27/23. Resident 104 was admitted to the facility on [DATE], and readmitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and P&P review, the facility failed to follow their P&P for drug regimen review for one of 26 final sampled residents (Resident 55) and one nonsampled resident (Resident 66). * The facility's Pharmacy Consultant made multiple recommendations on the Medication Regimen Review (MRR) reports for Residents 55 and 66; however, the facility failed to follow up on the recommendations for the month of January 2023. This failure put the residents at risk for complications and adverse effects from the medications. Findings: Review of the facility's contracted pharmacy P&P titled Pharmacist Medication Regimen Review (undated) showed the consultant pharmacist documents potential or actual medication therapy problems and communicates them to the responsible physician and the director of nursing. A written report is provided to the physician within seven working days, with a copy to the facility .The consultant pharmacist medication regimen review and nursing medication documentation…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to ensure two of five unnecessary medication sampled residents (Residents 55 and 66) were free from unnecessary drugs. * The facility failed to monitor for signs and symptoms of bleeding related to Resident 55's use of Pradaxa (medication used to treat and prevent blood clots). * The facility failed to ensure Resident 66 was free from duplicate therapy as two antiulcer medications (famotidine and omeprazole) were ordered without evidence or a documented clinical rationale. These failures had the potential for the residents to receive unnecessary medication and develop significant side effects. Findings: 1. Medical record review for Resident 55 was initiated on 3/1/23. Resident 55 was admitted to the facility on [DATE]. Review of the Physician Order Summary Report dated 3/1/23, showed a physician's order dated 10/30/22, for Pradaxa 110 mg one capsule by mouth two times a day. Review of Lexicomp, an online reference for clinical drug information,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to ensure two of five unnecessary medication sampled residents (Residents 6 and 55) free from unnecessary psychotropic (drug that affects brain activities associated with mental processes and behavior). * For Resident 6, the Ambien PRN order did not have specific duration and exceeded 14 days without prescriber-documented rationale for extending the medication duration. There was no nonpharmacological interventions prior to Ativan use and no physician's clinical rationale documented for renewing the Ativan (antianxiety medication) PRN order. In addition, there were no side effect monitoring for the use of psychotropic medications. * For Resident 55, the clinical rationale for not attempting gradual dose reduction (GDR) for psychotropic medications were not documented. The monthly behaviors monitoring was not completed for the Seroquel (antipsychotic medication)use. In addition, there were no side effects monitoring for the use of psychotropic…

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

Based on observation, interview, facility P&P review, and medical record review, the facility failed to ensure the medication error rate was less than 5%. The facility's medication error rate was 12.5%. * LVN 1 failed to administer Symbicort (bronchodilator) and ferrous sulfate (supplement) for Resident 40 as per the physician's order. * LVN 2 failed to administer vitamin C (supplement), vitamin D, and aspirin to Resident 112 as per the physician's order. These failures had the potential to expose the residents to significant adverse reactions and complications. Findings: 1. Review of the Premier Pharmacy Services's P&P titled Specific Medication Administration Procedures under the Oral Inhalation Administration not dated showed, Wait one minute between puffs for multiple inhalations of the same medication. Have resident rinse his/her mouth and spit out the rinse water. On 2/27/23 at 0831 hours, a medication observation pass was conducted for Resident 40 with LVN 1. LVN 1 prepared and administered Resident 40's medications which included the following: - one small container of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility P&P review, the facility failed to store the drugs and biologicals in a safe manner. * Multiple opened medications containers with no open dates were observed in Medication Cart 1. * Two discontinued unopened medication bottles of Lactulose (medication used to treat constipation or high levels of ammonia in the blood) oral solution were stored in Medication Cart 1 instead of being disposed. * Multiple missing temperature log entries were observed in the refrigerator temperature log book in Medication room [ROOM NUMBER]. * One IV E-Kit with opened date [DATE], was observed in Medication room [ROOM NUMBER]. * Expired wound care supplies were observed in Treatment Cart 2. * Expired IV supplies were observed in the IV Cart. * Expired sunscreen and inhaler medications were observed in the TRC Medication Pass Cart. These failures had the potential to result in unsafe medication administration. Findings: Review of the Premier Pharmacy Services's P&P titled 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.

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 maintain the infection control program and practices to help prevent the development and transmission of diseases and infections. * The facility failed to ensure the Monthly Infection Surveillance Reports were completed. For example, the information such as the residents' symptoms of infection, type of organisms when a culture was obtained, when the antibiotic was ordered, the duration of the antibiotics, and any laboratory/diagnostic tests were not documented. This had the potential for the antibiotics used were not indicated and the development of the antibiotic resistant bacteria. * The facility failed to ensure the Sani Hands wipes used on the residents had not expired. This posed the risk for not adequately sanitizing the residents' hands prior to receiving their meals, cross contamination, and spread of infection. Findings: According to the Centers for Disease 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.

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 antibiotic stewardship program designed to provide the safe and sanitary environment and help prevent the development and transmission of diseases and infections. * The facility failed to identify CAIs and HAIs and failed to address the use of antibiotics for residents whose symptoms did not meet the McGeer's Criteria in the infection control meeting for one final sampled resident (Resident 38). These failures posed the risk of inaccurately identifying if the residents met the criteria for a true infection and inappropriate antibiotic usage. Findings: According to the CDC, unnecessary antibiotic use promotes development of antibiotic-resistant bacteria. Every time a person takes antibiotics, sensitive bacteria are killed, but resistant germs may be left to grow and multiply. Repeated and improper use of antibiotics is the primary cause of the increase in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, facility P&P review, and facility document review, the facility failed to ensure the foot panel attached to the resident's bed was assembled in accordance with the bed manufacturer's User-Service Manual for one of 26 final sampled residents (Resident 24). * Resident 24's bed foot panel was observed to be loose as evidenced by moving back and forth. Upon inspection by the Maintenance Director, it was determined the foot panel was not attached to the bed as per the bed manufacture's User-Service Manual. This failure posed the risk for entrapment between the bed foot panel and bedframe and/or mattress, potentially causing serious injury to the resident. Findings: Review the facility's P&P titled Bed safety revised 12/07 showed to prevent deaths/injuries from the beds and related equipment (including the frame, mattress, footboard, and bed accessories), the facility will promote the following approaches: Inspection by maintenance staff of all beds and related…

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