Coventry Court Health Center

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the competency of two licensed nurses (LVNs 7 and 8) and the DSD interviewed regarding the facility's glucometer operation and protocols. * LVNs 7 and 8, and the DSD were not aware of how long the glucose control solutions used to do Quality Control checks for the glucometers are good for from the date they were opened. In addition, LVNs 7 and 8, and the DSD were not able to verbally state the facility's protocol on when to conduct the quality control checks and the process to conduct quality control checks for the glucometer. These failures had the potential of not providing care to the residents in a safe and competent manner. Findings: Review of the facility's P&P titled Performance Evaluations revised 7/2010 showed it is the policy of the company that employees are to be given regular performance evaluations. The Supervisor/Department Head will evaluate the employee's performance using the applicable performance evaluation form. Review of the glucometer…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medication was administered as ordered by the physician for one of two residents (Resident 84) investigated for dialysis. * The facility failed to administer Resident 84's furosemide (a diuretic medication) as per the physician's order. This failure had the potential for the resident to have an adverse outcomes related to the diuretic not being administered as ordered. Findings: Medical record review for Resident 84 was initiated on 7/22/25. Resident 84 was admitted to the facility on [DATE]. Review of Resident 84's Order Summary Report showed the following physician's order:- dated 5/21/25, for the resident's dialysis appointments every Tuesday, Thursday, and Saturday at 0900 hours,- dated 11/6/24, to hold all the blood pressure medications prior to dialysis on Tuesdays, Thursdays, and Saturdays, and - dated 11/14/25, for furosemide 40 mg by mouth daily for edema (swelling). Review of Resident 84's MAR for July 2025 showed a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure the pharmacist consultant performed a monthly MRR (Medication Regimen Review) to identify potential irregularities for two of five sampled residents (Residents 4 and 7) reviewed for unnecessary medications. * The facility failed to ensure Resident 4 had a monthly MRR completed by the pharmacist consultant for May 2025. * The facility failed to ensure Resident 7's MRR for June and July 2025 conducted by the pharmacist consultant addressed the use of two antidepressant medications (mirtazapine and bupropion) for the same manifested behavior of verbalization of sadness. These failures put the residents at risk for adverse outcomes related to the medications the residents were receiving. Findings: Review of the facility’s P&P titled Medication (Drug) Regiment Review (MRR) reviewed January 2022 showed the pharmacist will review each resident's medication regimen at least once a month to identify irregularities and to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, 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 7.14%. One of the two licensed nurses (LVN 7) observed during the medication administration was found to have made errors. * LVN 7 failed to ensure the sevelamer medication (phosphate binder) was administered to Resident 84 on time and with a meal as per the physician's orders. LVN 7 failed to ensure the furosemide medication (diuretic) was administered to Resident 84 as ordered. These failures created the risk for the resident to have potential side effects or complications related to the medications.Findings: Review of the facility's P&P titled Administration of Medications (undated) showed the following:- Medication shall be administered as prescribed by the resident's physician, nurse practitioner, or physician's assistant.- Medications must be administered in accordance with the written orders of the attending…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure the proper storage, labeling, and disposal of medications. * The facility failed to ensure the expired medications were removed from the Medication Room. In addition, the facility failed to ensure medications used for different routes were not stored together in one container, and the medications were labeled. * The facility failed to ensure the expired medications were removed from Medication Carts B and C. * The facility failed to ensure the supplies were labeled for Medication Cart C. * The facility failed to ensure the three sachets of Calazinc body shield (skin protectant) were not kept at Resident 24's bedside. These failures posed the potential risk for the residents to receive the expired medications and treatments, and for the unauthorized access to unsecured supplies.Findings: Review of the facility's P&P titled Medication Storage in 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.

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 ensure the kitchen staff were wearing hair restraints and clothing that covers body hair. * The facility failed to ensure the pitchers and pitcher covers were properly air dried. * The facility failed to ensure one of the multiple pitchers was clean and free of particle. * The facility failed to ensure the sanitary condition of the kitchen hood over the stove was maintained. These failures had the potential to cause foodborne illnesses in a highly susceptible residents population of 88 facility residents who consumed food prepared in the kitchen.Findings: Review of the facility's document titled Diet Type Report dated 7/22/25, showed 88 of 90 residents in the facility received food prepared in the kitchen. 1. According to the USDA Food Code 2022, Section 2-402.11 Effectiveness, (A) Except as provided in (B) of this section, food employees shall wear hair restraints such as…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 one glucometer (Glucometer A) from one of two medications carts (Medication A) inspected with the glucometers, was maintained in safe operating condition. This failure had the potential for residents requiring glucose checks to have inaccurate readings. Findings: Review of the glucometer manufacturer's manual titled Assure Platinum Blood Glucose Monitoring System User Instruction Manual under When to Perform a Control Solution Test showed:- Before testing with the Assure Platinum System glucometer for the first time- When you open a new bottle of test strips- Whenever you suspect the meter or test strips may not be functioning properly- If test results appear to be abnormally high or low or are not consistent with clinical symptoms- Use the control solution within 90 days (3 months) of first opening On 7/24/25 at 1425 hours, an inspection of Medication Cart A and concurrent interview and review of the form titled Quality Control Record Assure Platinum Blood Glucose Monitoring System was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were coordinated to meet the resident's needs when discharged from the facility for one of two sampled residents (Resident 1). This failure resulted in Resident 1 not having appropriate care at home, which had the potential to negatively affect Resident 1's health. Findings: Review of the facility's P&P titled Criteria for Transfer and Discharge revised 2/2023 showed upon a resident's discharge the facility must provide information to the receiving provider, which must include a minimum of the following: contact information of the practitioner responsible for the care of the resident, resident representative information including contact information, advance directive information, all special instructions or precautions for ongoing care as appropriate, comprehensive care plan goals, and all other necessary information, including a copy of the resident's discharge summary, and any…

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

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 ensure the kitchen utensils and equipment were clean and stored in sanitary conditions. * The facility failed to ensure the kitchen utensils were in good condition. * The facility failed to ensure the personnel entering the kitchen donned hair covering in the kitchen. * The facility failed to ensure the proper labeling and dating of the foods in the kitchen was utilized once the food item was opened. * The facility failed to ensure the fan unit inside the walk-in refrigerator was clean and free of buildup. These failures had the potential to cause foodborne illnesses in a highly susceptible resident population of 88 facility residents who consumed food prepared in the kitchen. Findings: Review of the facility document titled Diet Type Report dated 7/29/24, showed 88 of 92 residents in the facility received food prepared in the kitchen. 1. According to the USDA Food Code…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 infection control practices designed to provide a safe and sanitary environment and help prevent the development and transmission of infections were implemented as evidenced by: * The facility failed to implement their infection control surveillance program for August 2023 through June 2024. The facility conducted surveillance of resident infections based on whether the residents were prescribed antimicrobials. Residents who were not prescribed antimicrobials were not included in the facility's infection control surveillance program. * The facility failed to accurately track and monitor for the infections for April and May 2024. * The facility failed to ensure the staff performed hand hygiene before and after meal tray distribution. * The facility failed to ensure the infection control practices were implemented in the facility's laundry room. These failures posed the risk for not identifying…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 implement their antibiotic stewardship program when the facility failed to conduct an assessment for the McGeer's criteria to determine the true infection. This failure had the potential for inaccurately identifying for true infections and potentially inhibited the residents' physicians from discontinuing the unnecessary antimicrobials. Findings: Review of the facility's P&P titled Antibiotic Stewardship, undated, showed it is the policy of the facility to implement an Antibiotic Stewardship Program (ASP) that is incorporated in the overall Infection Prevention and Control Program which will promote appropriate use of antibiotic while optimizing the treatment of infections, at the same time reducing the possible adverse events associated with antibiotic use. This policy has the potential to limit antibiotic resistance in the post-acute setting, while improving treatment efficacy and resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to obtain the informed consent for the use of psychotropic medication (medications affecting brain activity) for one of five final sampled residents (Resident 37) reviewed for unnecessary medications. * The facility failed to ensure an informed consent was obtained when alprazolam (antianxiety medication) was prescribed for an extended period for Resident 37. This failure posed the risk for Resident 37 and her responsible party to not be informed of the potential risks and benefits of the alprazolam medication. Findings: According to AFL 24-7 titled Assembly [NAME] (AB) 48 - Nursing Facility Resident Informed Consent Protection Act of 2023 dated 2/28/24, with an effective date of 1/1/24, the facilities must obtain a resident's written informed consent for treatment using psychotherapeutic drugs. Medical record review for Resident 37 was initiated on 7/29/24. Resident 37 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to provide and document in the medical record the information regarding their rights to formulate the advance directives and to ensure the POLST was accurate for three of 20 final sampled residents (Residents 2, 54, and 74). * Resident 2's POLST showed DNR status; however, the resident's medical record showed full code status. * Resident 74's responsible party had not been provided the information regarding their rights to formulate the advance directive. * Resident 54's POLST and code status did not match the resident's advance directive. These failures had the potential for the residents' decisions regarding their healthcare and treatment options not being honored. Findings: Review of the facility's P&P titled Advance Directives and Associated Documentation revised 12/2023 showed it is the policy of the facility to inform and provide written information to all adult residents concerning the right to accept or refuse medical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 20 final sampled residents (Resident 2) was free from the physical restraints. * The facility failed to obtain the informed consent and the restraint assessment was conducted prior to applying a compression glove (helps provide support, relief and recovery from sore muscles andpainful joint stiffness in the wrists, palms, and fingers. It also helps to push the excess fluid out of the hand) on Resident 2's right hand. This failure posed the risk of compromising the resident's independence and psychosocial well-being. Findings: Review of the facility's P&P titled Restraint, Physical revised 2/2023 showed physical restraints for behavior control shall only be used with a written order designed to lead to a less restrictive way of managing, and ultimately elimination of, the behavior for which the restraint is applied. If it is determined that a resident requires the use of a restraint, a thorough…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 report the allegation of sexual abuse between two nonsampled residents (Residents 19 and 21) to the CDPH L&C and LTC Ombudsman Programs as per the facility's P&P. This failure had the potential for the residents to be vulnerable for further abuse. Findings: Review of the facility's P&P titled Abuse: Prevention of and Prohibition Against dated 10/2022 showed if resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the Administrator and to other officials according to state law. The Administrator or the individual making the allegation immediately reports his or her suspicion to the appropriate State or Federal agencies in the applicable timeframes. On 7/31/24 at 0901 hours, the CDPH, L&C Program received the OSLTCO S223 form dated 7/31/24, regarding Resident 19's family member complaint about Resident 21 exposed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the comprehensive care plan was implemented to reflect the individual care needs for one of 20 final sampled residents (Resident 54). * The facility failed to ensure Resident 54's left ½ (half) side rail was elevated as an enabler as per the care plan. This failure had the potential for Resident 54 to not be provided with appropriate, consistent, and individualized care. Findings: Review of the facility's P&P titled Comprehensive Resident Centered Care Plan revised 1/2021 showed the IDT shall develop and implement a comprehensive person-centered care plan for each resident consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs. Medical record review for Resident 54 was initiated on 7/29/24. Resident 54 was admitted to the facility on [DATE], with a diagnosis of hemiplegia and hemiparesis following…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 provide the services to attain or maintain the highest practicable well-being for one of five sampled residents (Resident 69) reviewed for unnecessary medications. * Resident 69 was administered midodrine (antihypotensive medication used to treat low blood pressure) medication when Resident 69's systolic blood pressure was above the parameter prescribed by the physician. This failure had the potential to negatively affect Resident 69's health condition and well-being. Findings: Medical record review for Resident 69 was initiated on 7/29/24. Resident 69 was admitted to the facility on [DATE]. Review of Resident 69's Order Summary Report showed a physician's order dated 4/26/24, to administer midodrine 2.5 mg one tablet by mouth every eight hours for hypotension; and to hold if systolic blood pressure more than 120 mmHg. Review of Resident 69's MAR for July 2024 showed Resident 69 was administered the midodrine medication when the resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure one of one final sampled resident (Resident 28) and two nonsampled residents (Residents 21 and 47) reviewed for Wander Guard use were remained free from the accident hazards. * The facility failed to monitor the Wander Guard for functionality for Residents 21, 28, and 47. This failure had the potential to place the residents at risk for serious injuries and posed the risk for not having accurate information documented to prevent further accidents and or injuries to the residents. Findings: Review of the facility's P&P titled Wander System Monitoring Program dated 1/2023 showed the residents identified to be at risk for wandering will be evaluated for a wander-monitoring device. Each monitoring device will be tested for placement and function per manufacturers recommendation. According to the Wander Guard Universal Tester Operating Instructions (undated), to test the bracelets…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 to maintain the IV access for one of one final sampled resident reviewed for IV care (Resident 79). * The facility failed to ensure the initial PICC line external catheter measurement was documented in the medical record and failed to confirm baseline measurements of the PICC line external catheter and arm circumference measurements prior to administration of IV antibiotics. These failures had the potential to delay the identification of catheter related complications for this resident. Findings: On 7/29/24 at 0951 hours, Resident 79 was observed in bed with a PICC line to the right upper arm with a two-port external catheter. A transparent dressing dated 7/24/24, was observed on the PICC line site. When asked about the PICC line, Resident 79 stated the PICC line was inserted at the acute care hospital. Medical record review for Resident 79 was initiated on 7/29/24. Resident 79 was admitted…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 safe respiratory care for three of three final sampled residents (Resident 8, 50, and 61) and one nonsampled resident (Resident 687) reviewed for respiratory care. * The facility failed to ensure Resident 8's CPAP machine was cleaned as per the manufacturer's user cleaning guidelines. * The facility failed to ensure Resident 61's oxygen tubing was not touching the floor. * The facility failed to ensure Resident 50's nebulizer tubing was dated and mask was stored in a bag when not in use. * The facility failed to ensure Resident 687 was administered the oxygen as ordered by the physician. Additionally, the facility failed to ensure the nebulizer tubing and oxygen tubing were changed and labeled as per the facility's P&P. These failures had the potential to adversely affect the health, well-being, and posed the risk for equipment contamination and respiratory complications. Findings: 1. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to provide the adequate and appropriate pain management for one of five final sampled residents (Resident 69) reviewed for unnecessary medication use. * The facility failed to ensure the pain medication was administered as per the physicians' orders for Resident 69. This failure had the potential for Resident 69 to not receive effective treatment for pain. Findings: Medical record review for Resident 69 was initiated on 7/29/24. Resident 69 was admitted to the facility on [DATE]. Review of Resident 69's Order Summary Report showed the following physician's orders: - dated 3/4/24, to administer acetaminophen (over the counter pain medication) 325 mg two tablets by mouth every four hours as needed for general discomfort for pain levels of 1-3 (on a 0-10 pain scale with 0 = no pain and 10= worst pain); - dated 4/9/24, to administer Norco (hydrocodone-acetaminophen, a narcotic analgesic medication) 5-325 mg one tablet by mouth every four hours as…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 nine final sampled residents reviewed for side rail use (Residents 50 and 54) remained free from the accident hazards associated with the use of elevated side rails. * The facility failed to obtain a physician's order and informed consent and failed to conduct a side rail evaluation prior to the use of the right half side rail for Resident 54. * The facility failed to ensure the proper assessment for Resident 50 prior to the use of the side rails. These failures have the potential to put Residents 50 and 54 at risk for serious injuries. Findings: The FDA issued a Safety Alert entitled Entrapment Hazards with Hospital Bed Side Rails. Residents most at risk for entrapment are those who are frail or elderly or those who have conditions such as agitation, delirium, confusion, pain, uncontrolled body movement, hypoxia, fecal impaction, acute urinary retention, etc., that may cause them to move about…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 final sampled residents (Residents 14 and 37) reviewed for unnecessary medications were free from the unnecessary psychotropic medications. * The facility failed to ensure the physician's documentation of the rationale for extending the use of alprazolam (antianxiety medication) beyond the 14-day duration for Resident 37. * The facility failed to monitor Resident 14 for signs of orthostatic hypotension for the use of antipsychotic medication. These failures had the potential to place Residents 14 and 37 at risk for receiving unnecessary medication and increased risk of serious adverse reactions from the medications. Findings: 1. Review of the FDA black box warning for alprazolam showed the continued use of benzodiazepines, including Xanax (brand name for alprazolam), may lead to clinically significant physical dependence. The risks of dependence and withdrawal increase with longer treatment duration and higher daily dose.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 proper storage and disposal of medications for one of one medication storage room, three of four medication carts inspected for medication storage and labeling. In addition, the facility failed to ensure the medications were not stored at the bedside for one of 20 final sampled residents (Resident 35) and one nonsampled resident (Resident 66). * The facility failed to ensure the oral medications were stored separate from externally used medications in the medication room. * The facility failed to ensure the medications in the bubble packs (type of pre-formed, plastic packaging that seal individual tablets until they are taken) were secured, sealed and free from tears or damage for two nonsampled residents (Residents 1 and 88). * The facility failed to ensure Medication Cart C was not left unlocked and unattended. * The facility failed to ensure the medication for one…

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

Based on interview, facility document review, and facility P&P review, the facility failed to ensure the education was provided to the staff and family/visitor on safe food handling of outside food as per the facility's P&P. This failure had the potential to cause foodborne illnesses to the medically vulnerable resident population who consumed food brought from outside sources. Findings: Review of CMS S&C-09-39 dated 5/29/09, showed the residents have the right to choose to accept food from visitors, family, friends, or other guests according to their rights to make choices. The CMS guideline further shows the facility has the responsibility under the food safety regulation to help the visitors to understand safe food handling practices such as not holding or transporting foods containing perishable ingredients at temperatures above 41 degrees Fahrenheit. Review of the facility's P&P titled Food Brought by Family and Visitor revised 7/21/21, showed the resident and or resident representative will be informed of the policy and provided safe food handling guidance in the form of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medical records for four of 20 final sampled residents (Residents 14, 17, 20, and 50) were accurate and complete. * The facility failed to ensure Resident 50's RNA documentation was complete. * The facility failed to ensure Resident 17's Smoking Evaluation was accurately completed. * The facility failed to ensure Resident 50's RNA documentation was complete. * The facility failed to ensure Resident's TARs regarding the indwelling urinary catheter securement and monitoring Resident 14's edema were completed. * The facility failed to ensure Resident 14's medical record did not contain another resident's health information. These failures had the potential for the residents' care needs not being met as their medical information were inaccurate. Findings: Review of the facility's P&P titled Charting and Documentation undated showed the purpose is to provide the following: 1. A complete account of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to offer and provide the education for influenza and pneumococcal immunizations for two of five final sampled residents (Residents 20 and 35) reviewed for immunizations. * The facility failed to obtain the consent and provide education on the influenza vaccine to Residents 20 and 35. * The facility failed to ensure Resident 35's Immunization Record was accurate for receiving the pneumococcal vaccine. These failures had the potential for the residents to be uninformed of the risks and benefits of receiving the influenza vaccine and potentially affect care provided. Findings: Review of the facility's P&P titled Infection Prevention- Immunizations, Influenza and Pneumococcal (Resident), undated, showed it is the policy of this facility to ensure that before entering the influenza and or pneumococcal immunization, each resident's legal representative receives education regarding the benefits 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 ensure the residents' entrapment assessments were accurate and complete for six of nine sampled residents (Residents 14, 20, 37, 50, 54, and 69) reviewed for side rails use. * The facility failed to ensure Residents 14, 20, 37, 50, and 69's entrapment assessments were accurate. * The facility failed to ensure Resident 14's bed entrapment assessment was complete. * The facility failed to ensure Resident 54's bed entrapment assessment was completed for the right half side rail prior to use. These failures had the potential to negatively impact the residents resulting in possible entrapment, serious injury, and death. Findings: According to the Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, the term entrapment describes an event in which a patient/resident is caught, trapped, or entangled in the space in or about the bed rail, mattress, or hospital bed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 arrange for the transportation to and from ophthalmology appointments for one of two sampled residents (Resident 1). This posed the risk of the resident not receiving the necessary vision related care and treatment. Findings: On 1/30/24 at 0922 hours, a telephone interview was conducted with Family Member 1. Family Member 1 stated Resident 1 missed her ophthalmology appointments in December 2023 and January 2024 because the facility did not arrange for the transportation. Family Member 1 stated the ophthalmology appointments were crucial as Resident 1 had diabetes and glaucoma and needed to have her eyes examined and eye pressure checked. Medical record review for Resident 1 was initiated on 1/30/24. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's History and Physical Note dated 8/11/23, showed Resident 1's diagnoses included diabetes and glaucoma. Review of Resident 1's Physician Order dated 6/15/23, showed Resident 1…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 plan of care to reflect the individual care needs for one of three sampled residents (Resident 2). * Resident 2's care plan for hearing had an incorrect intervention. This failure had the potential risk of not providing the appropriate and individualized care for Resident 2. Findings: Review of the facility's P&P titled Care Plan and Care Plan Update revised 2/2022 showed the facility will assure the completion of the resident assessment process enabling the development of an individualized comprehensive care plan for the resident. Medical record review for Resident 2 was initiated on 9/20/23. Resident 2 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 2's History and Physical examination dated 5/5/23, showed Resident 2 had blindness and hearing loss. Review of Resident 2's MDS dated [DATE], showed Resident 2 had severely impaired vision and minimal difficultly for hearing.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 provide the necessary care and services to ensure one of three sampled residents (Resident 1) maintained his highest practicable physical well-being. * The facility failed to administer acetaminophen (a fever and pain reducing medication) as prescribed by the physician for Resident 1. This failure had the potential to negatively impact Resident 1's well-being. Findings: Medical record review for Resident 1 was initiated on 9/20/23. Resident 1 was admitted to the facility on [DATE], and readmitted [DATE]. Review of Resident 1's History and Physical examination dated 7/25/23, showed Resident 1 was recently hospitalized for sepsis (a condition where the body is responding to an infection). Review of Resident 1's Order Summary Report dated 6/29/23 through 7/26/23, showed the following orders: - dated 7/6/23, to administer acetaminophen 325 mg two tablets by mouth every six hours as needed for the body temperatures > 99.9 degrees F. - dated 7/18/23,…

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

Based on observation, interview, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by: * The facility failed to ensure the proper labeling and dating of the foods in the kitchen was utilized once the food item was opened. * The facility failed to ensure the ice machine's ice maker was free from black residue. * The facility failed to ensure the quaternary sanitizing strips to measure the concentration of ammonium compound the sanitizing solution for the manual ware washing and sanitization buckets were not expired. * The facility failed to ensure the kitchen equipment was clean. These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food prepared from the kitchen. Findings: Review of the CMS 672 Resident Census and Conditions of Residents completed by the facility on 7/18/23, showed 78 of 82 residents in the facility received food prepared in the kitchen. 1. Review of the facility's P&P titled Storage of Food and Supplies dated 2023 showed the Food…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 implement the infection control practices designed to provide a safe and sanitary environment; and prevent the transmission of diseases and infections to all residents. * The facility failed to ensure the infection control practices were implemented in the facility's laundry room. * The facility failed to ensure RN 4 provided the sanitary condition during the medication administration. * The facility failed to ensure RN 3 performed hand hygiene during the medication administration. * The facility failed to ensure CNAs 4 and 5 performed hand hygiene when passing the lunch trays and assisting in between the residents. These failures posed the risk for transmission of disease-causing microorganisms. Findings: 1. Review of the facility's P&P titled Laundry Personnel revised 2/2023 showed no personal belongings would be kept in the laundry area. The facility had a designated employee cabinet. Review of the facility's P&P titled Dryer, Lint Trap Cleaning revised 1/2020 showed laundry…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the residents' entrapment assessments were accurate, complete; and the measurements were recorded during the bed inspection when identifying areas of possible entrapment with the use of bed side rails for all 80 residents with side rails. These failures had the potential to negatively impact the residents resulting in possible entrapment, serious injury, and death. Findings: According to the Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, the term entrapment describes an event in which a patient/resident is caught, trapped, or entangled in the space in or about the bed rail, mattress, or hospital bed frame. Patient entrapments may result in deaths and serious injuries. These entrapment events have occurred in openings within the bed rails, between the bed rails and mattresses, under bed rails, between split rails, and between the bed rails and head…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, medical record review, and interview, the facility failed to ensure resident care was provided in a manner to promote dignity and respect for one of 18 final sampled residents (Resident 82) and one nonsampled resident (Resident 71). * The facility failed to ensure the staff sat next to Residents 71 and 82 while assisting them to eat. This had the potential to negatively impact the residents' feelings of self-worth and well-being. Findings: 1. On 7/20/23 at 0805 and 0809 hours, Resident 71 was observed being assisted to eat by CNA 5. CNA 5 was observed standing over Resident 71 who was seated in a wheelchair. On 7/20/23 at 1016 hours, an interview was conducted with CNA 5. CNA 5 acknowledged she was standing over Resident 71 when assisting the resident with eating. CNA 5 stated she was standing over Resident 71 so she could focus on what the resident was eating. When asked about the facility's policy for assisting the residents with meals, CNA 5 stated she did not know she had to sit down…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 one nonsampled resident (Resident 28) trust fund statements quarterly. This failure had the potential for loss and misuse of Resident 28's personal funds. Findings: Review of the facility's P&P titled Resident Trust Fund revised 3/1/23, showed the facility will send out the Resident Trust Fund statement to the resident or the resident's legal representative within 30 days from the end of the quarter. The facility Executive Director will be responsible to ensure quarterly statements are submitted in a timely manner and in accordance with the State or Federal regulations. On 7/18/23 at 0857 hours, a telephone interview was conducted with the Ombudsman. The Ombudsman stated Resident 28 had concerns about not receiving her quarterly statements for her funds at the facility. On 7/21/23 at 1154 hours, a follow-up telephone interview was conducted with the Ombudsman. The Ombudsman…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 information on how to formulate an advanced directive and maintain a copy of the resident's advance directives in the medical record for four of 18 final sampled residents (Residents 4, 16, 18, and 38) and one nonsampled resident (Resident 7). These failures have the potential for the residents' decision regarding their healthcare and treatment options not being honored. Findings: Review of the facility's P&P titled Advance Directives and Associated Documentation revised January 2022 showed prior to, upon, or immediately after admission, a facility staff member shall: - Provide the resident/family or responsible agent written information regarding the right to accept or refuse medical treatment and the right to formulate Advance Directives - Document in the resident health record that, at the time of admission, the resident/family has been provided with written information regarding advance directives - Inquire…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 MDSs for two of 18 final sampled residents (Residents 4 and 16) and one nonsampled resident (Resident 85) were accurate. This posed the risk of the residents not receiving an individualized plan of care based on the residents' specific needs. Findings: 1. Medical record review for Resident 16 was initiated on 7/19/23. Resident 16 was readmitted to the facility on [DATE]. Review of Resident 16's MAR for the months of June and July 2023 showed Resident 16 was administered quetiapine (a medication use to treat symptoms of schizophrenia or bipolar disorder) 25 mg one-half tablet daily at bedtime for other schizophrenia manifested by auditory hallucinations as evidence by hearing voices not present. Review of Resident 16's MDS dated [DATE], showed the following: - Resident 16's BIMS score was 14 which indicated Resident 16 was cognitively intact. - The anticoagulant section showed Resident 16 was administered an anticoagulant for seven…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to develop the comprehensive plans of care to reflect the individual care needs for two of 18 final sampled residents (Residents 15 and 42). These failures had the potential risk of not providing appropriate, consistent, and individualized care to these residents. Findings: Review of the facility's P&P titled Care Plan and care plan update revised February 2022 showed each resident receives quality of care and services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The facility's P&P also showed individualized comprehensive person-centered care plan includes all problems, goals, and interventions will be documented. 1. On 7/18/23 at 0955 hours, and 7/20/23 at 1558 hours, an observation and concurrent interview was conducted with Resident 15. Resident 15 was observed in bed and stated she always stayed in bed. When Resident 15 was asked if she attended any…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to provide the necessary care and services to ensure two of 18 final sampled residents (Residents 33 and 82) and one nonsampled resident (Resident 12) attained and maintained their highest practicable well-being. * The facility failed to consult the physician when Resident 33 was administered the following medications at the same time: midodrine (antihypotensive or medication used to treat low blood pressure) medication and metoprolol (antihypertensive or medication used to treat high blood pressure), diltiazem (antihypertensive) and isosorbide dinitrate (used to prevent chest pain and lowers blood pressure). In addition, the parameters for midodrine, metoprolol, and diltiazem were not followed when administering these medications. These failures had the potential for Resident 33 to not receive necessary therapeutic effect of the medications and to experience adverse effects. * The facility failed to coordinate the care 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 maintain the intravenous accesses for one of 18 sampled residents (Resident 336). The facility failed to ensure the PICC line external catheter and arm circumference measurements were performed and documented in the medical record for Residents 336. This failure had the potential to delay identification of catheter related complications for the resident. Findings: Review of the facility's P&P titled Care of Peripheral Inserted Central Lines (PICC) - dressing change and site care, undated, showed the dressing were routinely changed every seven days or when the dressing becomes loose, wet or soiled. The documentation in the medical records includes the appearance of the insertion site. Medical record review for Resident 336 was initiated on 7/20/23. Resident 336 was admitted to the facility on [DATE]. Review of Resident 336's IV Administration Record for July 2023…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 one of 18 final sampled residents (Resident 336). * The facility failed to ensure Resident 336's nasal cannula (flexible tube to deliver oxygen into the nose) tubing was dated as per the facility's P&P. In addition, a CNA was observed turning on and off the concentrator machine. These failures posed the risk for the resident's oxygen equipment to become contaminated which had the potential to negatively affect the residents' medical conditions. Findings: Review of the facility's P&P titled Oxygen, Use of, revised October 2021 showed oxygen nasal cannula tubing and humidifiers will be changed every seven days with identifiable date. Review of the facility's P&P titled Oxygen Administration revised July 2017 showed the oxygen therapy is administer by licensed nurses as ordered by the physician. On 7/17/23 at 1037 hours, 7/19/23 at 1347 hours, and 7/20/23 at 1349 hours,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure dialysis care was provided for two of 18 final sampled residents (Residents 4 and 33). * The facility failed to implement and monitor the fluid intake for Resident 33 as per the physician's order. There were two physician's orders for fluid restrictions for Resident 33 with different fluid breakdowns for nursing and dietary. There was no documentation by the nursing staff for the actual fluid intake by Resident 33, and the CNA's documentation of the resident's fluid intake showed the resident took more than the prescribed fluid intake. * The facility failed to ensure the physician's order for 1000 ml fluid restriction (a diet which limits the amount of daily fluid consumption) was followed and carried out accordingly for Resident 4. These failures had the potential for Residents 4 and 33 not being provided with the appropriate care and treatment, and the possibility of medical complications related to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 18 final sampled residents (Resident 51) remained free from accident hazard due to the use of side rails. * The facility failed to ensure the assessments for the risk for entrapment were completed for Resident 51 prior to the use of bilateral half side rails. In addition, the facility failed to obtain informed consent for the use of the side rails. This failure had the potential to put the resident at risk for entrapment and serious injury. Findings: Review of the facility's P&P titled Bed Rails revised January 2022 showed after the facility has attempted alternatives to bed rails and determined that these alternatives failed to meet the resident's assessed needs, the facility's IDT will assess the resident for risks of entrapment and possible benefits of using bed rails. It the use of bed rails is recommended by the IDT, the facility must obtain informed consent from the resident, or 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.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the pharmaceutical services to ensure the accurate administration and storage as evidenced by: * The facility failed to ensure the electronic MAR for Resident 636 was not signed prior to the medication administration. * The facility's medication error rate was 3.45%. One of two licensed nurses (LVN 1) who were observed during the medication administration was found to have an error. LVN 1 failed to administer one of Resident 12's medications. * The narcotic medication was not properly stored. These failures had the potential to negatively impact the residents' health outcomes. Findings: 1. On 7/19/23 at 0902 hours, a medication administration observation for Resident 636 was conducted with RN 4. RN 4 prepared and signed the electronic MAR before giving the following medications to Resident 636: - one tablet of aspirin (antiplatelet medication) enteric coated 81 mg - one drop of brimonidine tartate (eye drop used to lower pressure inside the eye) 0.15% to both eyes - one…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility document review, the facility failed to ensure the Pharmacy Consultant's recommendations were acted upon for one of 18 final sampled residents (Resident 33). * The Pharmacy Consultant recommended to verify the diagnosis and behavior for the prescribed risperidone (antipsychotic) medication for Resident 33 was not acted upon. This failure had the potential to put Resident 33 at risk for adverse consequences related to the medication. Findings: Medical record review for Resident 33 was initiated on 7/18/23. Resident 33 was initially admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 33's Order Listing Report showed the following physician's orders dated: - On 5/17/23, to administer risperidone 1 mg every 12 hours for unspecified psychosis manifested by mood swings -On 6/21/23, to administer risperidone 1 mg every 12 hours for schizoaffective disorder manifested by mood swings Review of the Consultant Pharmacist's 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, and facility P&P review, the facility failed to ensure three of 18 final sampled residents (Residents 16, 33, and 43) was free from unnecessary psychotropic medications. * The facility failed to ensure Resident 16's episodes of behaviors for the use of quetiapine (a medication use to treat symptoms of schizophrenia or bipolar disorder (a mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions) and clonazepam (antianxiety medication) were summarized and made available to the prescriber on a monthly basis to serve as reference for gradual dose reduction. * The facility failed to ensure Resident 43's episodes of behaviors for the use of Cymbalta (medication to treat depression and anxiety), mirtazapine (antidepression medication), and temazepam (medication to treat sleeping problems) were summarized and made available to the prescriber on a monthly basis to serve as reference for gradual dose…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff implemented the proper disposal and storage of medications in a safe manner as evidenced by: * The facility failed to ensure the discontinued medications were properly disposed. * The facility failed to ensure the oral and suppository medications were properly stored in the medication cart. * The facility failed to ensure the medication carts were properly locked and secured. Medication Cart 2 was left unlocked and unattended. This had the potential for unauthorized persons to have access to the medications inside the medication cart. These failures had the potential for the drug diversion and to result in an unsafe handling and storage of the residents' medications. Findings: 1. On 7/19/23 at 1207 hours, an observation and concurrent interview was conducted with RN 1 in Medication room [ROOM NUMBER]. One of three waste disposal bins with a blue top was noted with whole pills not fully dissolved. RN 1 acknowledged…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 for the pureed garlic bread sticks was followed when the wrong scoop size was used to serve the pureed bread for the residents on pureed diet. This failure had the potential for the residents to not receive adequate nutrition and appropriate servings to meet their individual needs. Findings: Review of the facility's P&P titled Menu Planning dated 2023 showed the menus are planned to meet the nutritional needs of the residents in accordance with the established national guidelines, physician's orders, and, to the extent medically possible, in accordance with the recommended dietary allowances of the Food and Nutrition Board of the National Research Council and National Academy of Sciences. Review of the facility's document titled List of Puree Patients on 7/19/23, showed there were nine residents on pureed diet. Review of the facility's menu spreadsheet Cycle 2 2023 for Week 4 dated 7/19/23, for noon meal showed to serve lasagna, California blend vegetable,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 preferences were followed for one of 18 final sampled residents (Resident 4) and one nonsampled resident (Resident 12) as evidenced by: * Resident 4 disliked broccoli and cauliflower but was served with California vegetable blend with broccoli and cauliflower. * Resident 12 liked a double portion of salad and fruit but was only served a single serving of salad and fruit. These failures had the potential to negatively impact the residents' well-being. Findings: Review of the facility's P&P titled Food Preferences dated 2023 showed the resident's food preferences will be adhered within reason. Substitutes for all foods disliked will be given from the appropriate food group. Review of the facility's menu spreadsheet Cycle 2 2023 for Week 4 dated 7/19/23, for the noon meal showed to serve lasagna, California blend vegetable, garlic bread stick, marbled sour cream pound cake with whole milk, and water. In addition, pureed garlic bread will be served for the residents…

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