Harbor Villa Care Center

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 four final sampled residents reviewed for nutrition (Resident 8) received the appropriate services needed to maintain acceptable parameters of nutritional status. * The facility failed to follow up when Resident 8 refused CNA Helping Hands assistance, as recommended by the dietician and as ordered by the physician, after the resident experienced a weight loss of more than 5 (five) pounds in one month. This failure had the potential to result in inadequate monitoring and evaluation of the effectiveness of nutritional interventions and increase the risk for further weight loss and nutritional decline.Findings: Review of the facility P&P titled Nutrition (impaired)/ Unplanned Weight Loss Clinical Protocol (undated) showed the staff will report to the physician significant weight gains or losses or any abrupt or persistent change from baseline appetite or food intake. The staff and physician will…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 PICC line assessments were performed and documented for one of one final sampled resident (Resident 58) reviewed for the IV management. * The facility failed to obtain and document the external catheter length measurement upon admission for Resident 58's PICC line. This failure posed the risk for the resident developing complications related to PICC line displacement, malfunction, or infection.Findings: Review of the facility's P&P titled PICC Dressing Change dated 3/2023 showed the length of external catheter is obtained upon admission. Medical record review for Resident 58 was initiated on 4/7/26. Resident 58 was admitted to the facility on [DATE]. Review of Resident 58's H&P examination dated 3/23/26, showed the resident had the capacity to make medical decisions. Review of Resident 58's PICC line insertion documentation (undated) showed the PICC was inserted on 3/22/26, at the acute care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 necessary respiratory care and services were provided for one of three sampled resident (Resident 44) reviewed for respiratory care. * The facility failed to ensure Resident 44 received the correct amount of oxygen via nasal canula per the physician's order. This failure had the potential to negatively affect Resident 44's medical conditions. Findings: Review of the facility's P&P titled Oxygen Administrator (undated) showed to verify that there is a physician's order; review the physician's order or facility protocol for oxygen administration. On 4/7/26 at 0744 hours, an observation of Resident 44 was conducted in the resident's room. Resident 44 was observed with a nasal canula tubing in her nose connected to the oxygen concentrator, which was on and set at 2.5 liters per minute. On 4/7/26 at 1009 hours, an observation of Resident 44 and concurrent interview was conducted with the DON inside the…

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

Based on observation, interview, facility document review, and facility P&P review, the facility failed to provide the pharmaceutical services to meet the needs of the residents. * One of four LVNs (LVN 4) observed for medication administration discarded the liquid medication in the medication cart's trash bin. This failure had the potential for the medications to be administered in error and opportunities for drug misuse.Findings: Review of the facility's P&P titled Discarding and Destroying Medications (undated) showed non-controlled and Schedule V (non-hazardous) controlled substances are disposed of in accordance with state regulations and federal guidelines regarding disposition of non-hazardous medications. Review of the facility's document titled Lesson Plan- Course Subject: Medication Admin/Blood Pressure Medication Parameters dated 1/8/26, showed the medications would be disposed in the red container located inside each nurse cart, not in the trash can or resident personal trash. Review of the facility's document titled Inservice Lesson Plan and Attendance Record dated…

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

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 drugs, biologicals, or medical supplies were stored in a safely for one of 19 final sampled residents (Resident 6) and one nonsampled resident (Resident 91). * The facility failed to ensure Resident 6's Inhaler medication (ciclesonide) was not left at unattended at the resident's bedside. * The facility failed to ensure a packet of Vitamins A&D (skin protectant) ointment was properly stored for Resident 91. These failures had the potential to result in medications being contaminated, misused, or accidentally administered to the wrong resident.Findings: Review of the facility's P&P titled Medication Labeling, and Storage (undated) showed the nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manner. Medications are stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medications are assigned to an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the menu and recipes were followed for one of 81 residents (Resident 14) who consumed food prepared in the kitchen. * The facility failed to ensure Resident 14 was served the braised cabbage as per the menu. This failure posed the risk of negatively impacting Resident 14's satisfaction and dietary compliance.Findings: Review of the facility's Diet Type Report dated 4/7/26, showed 81 of 87 residents consumed the food prepared in the kitchen. Review of the facility's P&P titled Menus (undated) showed menus are developed and prepared to meet resident choices including religious, cultural and ethnic needs while following established national guidelines for nutritional adequacy. Menus for regular and therapeutic diets are written at least two (2) weeks in advance and are dated and posted in the kitchen at least one (1) week in advance. The dietitian reviews and approves all menus. Review of the facility'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.

Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the infection control practices were followed. * The facility failed to conduct a facility-wide risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in facility water system. This failure posed a risk of exposure and potential illness to the residents, staff, and visitors by allowing unidentified and uncontrolled areas within the water system where Legionella and other opportunistic waterborne pathogens could grow. Findings: Review of the facility's P&P titled Legionella Water Management Program (undated) showed the facility was committed to the prevention, detection and control of water-borne contaminants, including legionella. The purpose of the water management program are to identify areas in the water system where legionella bacteria can grow and spread, and to reduce the risk of legionnaires…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 required education on the benefits and potential side effects for the seasonal influenza and pneumococcal immunizations for two of five residents (Residents 8 and 14) reviewed for the immunizations. * The facility failed to ensure Resident 8 was offered pneumococcal and seasonal influenza vaccinations and provided with education regarding their benefits and potential side effects. * The facility failed to ensure Resident 14 was offered seasonal influenza vaccination and provided with education regarding its benefits and potential side effects. These failures had the potential for the residents and/or their representatives not being informed of the benefits and risks of the seasonal influenza and pneumococcal vaccines to make an informed decisions and put the residents at increased risk of infection and transmission of influenza and pneumococcal vaccination.Findings: Review of the…

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

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 residents were offered and provided education regarding the benefits and potential side effects of seasonal COVID-19 vaccine for two of five residents (Residents 8 and 14) reviewed for the COVID-19 immunization. * The facility failed to offer and provide education regarding the benefits and potential side effects of seasonal COVID-19 vaccine for Residents 8 and 14. This failure placed the residents at risk for increased risk of infection and transmission of COVID-19 and had the potential for the residents and/or their representatives not being informed of the seasonal COVID-19 vaccines.Findings: Review of facility P&P titled Coronavirus Disease (COVID-19) - Vaccination of Residents dated May 2023 showed each resident is offered COVID-19 vaccine unless the immunization is medically contraindicated or the resident is fully vaccinated. The resident (or resident representative) has the opportunity to accept or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to ensure the residents' care equipment was maintained in a safe operating condition. * One of four LVNs (LVN 1) observed for medication administration used a non-facility issued BP automatic machine to obtain Resident 6's BP prior to medication administration. The facility failed to ensure the calibration for the personal BP machine was conducted. This failure had the potential for the essential equipment not to function in the way it was intended and the risk of resulting in inaccurate resident BP measurements.Findings: Review of the Omron BP5100 (automated BP machine) Instruction Manual (undated) showed Home as the environment of use. On 4/8/26 at 0938 hours, a medication administration observation for Resident 6 was conducted with LVN 1. Prior to administering the medications for Resident 6, LVN 1 obtained the resident's BP reading using a non-facility issued automatic BP machine (Omron BP5100) and the resident's BP reading was 103/68 mmHg and heart rate…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an environment free of accident hazards was provided for two of three sampled residents (Residents 1 and 2). * Resident 1 used a razor to self-inflict harm. * Resident 2 had two razors and two scissors in an unlocked bag inside Resident 2's closet, easily accessible to other residents. * The razors used to shave the male residents were unlocked and unsecured at Nurse Station A and inside a supply closet. These failures posed the risk of the residents accessing the sharp devices and resulting in injuries to the residents.Findings: 1. On 1/23/26, CDPH received a complaint about Resident 1 verbalizing thoughts of committing suicide. Closed medical record review for Resident 1 was initiated on 1/23/26. Resident 1 was admitted to the facility on [DATE], and was sent out to an acute hospital on 1/22/26, due to self-inflicted wounds. Review of Resident 1's Psychiatric Progress Note dated 12/4/25, showed the resident had 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 provide the necessary care and services to prevent accidents for three of six sampled residents (Residents 1, 2, and 3). * The facility failed to ensure the risks of leaving the facility unsupervised without informing the staff were explained to Resident 1. * The facility failed to ensure Resident 1's smoking assessment was accurate and complete. * Resident 2 and 3's post fall neuro checks were not completed per their care plans. These failures had the potential to negatively affect Resident 1, 2, and 3's health condition and well-being.Findings: 1. a. Review of the facility's P&P titled Care Plans - Comprehensive (undated) showed each resident's care plan is designed to:- incorporate identified problem areas- incorporate risk factors associated with identified problems- build on resident's strengths- reflect the resident's expressed wishes regarding acre and treatment goals- reflect treatment goals, timetables 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 implement their P&P on Abuse Investigation and Reporting by failing to report an allegation involving the resident to resident physical altercation between two sampled residents (Residents 1 and 2) when Resident 1 alleged Resident 2 had hit him on the right cheek and Resident 1 had allegedly hit back Resident 2. This failure had the potential to put Residents 1 and 2 and other residents at risk of not being protected against the alleged abuse. Findings: Review of the facility's P&P titled Abuse Investigation and Reporting (undated) showed all the reports of the 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 by current regulations), and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. 1. Medical record review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P reviewed, the facility failed to thoroughly investigate an alleged incident involving the resident to resident physical altercation between two sampled residents (Residents 1 and 2) when Resident 1 alleged Resident 2 had hit him to the right cheek and Resident 1 had allegedly hit back Resident 2. This failure had the potential to put Residents 1 and 2 and other residents at risk of not being protected against the alleged abuse. Findings: Review of the facility's P&P titled Abuse Investigation and Reporting (undated) showed all the reports of the resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse ) shall be thoroughly investigated by facility management. Findings of abuse investigations will also be reported. 1. Medical record review forResident 1 was initiated on 6/12/25. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 1's H&P…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and the facility P&P review, the facility failed to ensure the discharge process was properly followed for Resident 1. * Resident 1's closed medical record failed to show the physician's documentation to show Resident 1 was ready for discharge. This failure had the potential for Resident 1 to unsafely discharge from the facility. Findings: Review of the facility's P&P titled Transfer or Discharge, Facility Initiated dated 10/22 showed should the resident be transferred or discharge for any of the following reasons, the basis for the transfer or discharge is documented in the resident's clinical record by the resident's attending physician: 1. The transfer or discharge is necessary for the resident's welfare, and the resident's needs cannot be met in the facility; or 2. The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility. Closed medical record review for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medial record review, and facility P&P review, the facility failed to provide an environment free from the physical restraint (physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body) for one of three sampled residents (Resident 2). * The facility failed to obtain the orders to place a soft mitten on Resident 2's left hand. * The facility failed to ensure the appropriate assessment was completed prior to placing a soft mitten restraint on Resident 2. * The facility failed obtain the consent for the application of the soft mitten restraint for Resident 2. * The facility failed to monitor Resident 2 for the use of restraints. * The facility failed to ensure the comprehensive plan of care for Resident 2 was revised to reflect the current resident assessment for restraints. These failures had the potential to negatively affect 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, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to maintain the highest practicable well-being for two of three sampled residents (Residents 1 and 2). * The facility failed to assess the resident for the use of supplemental oxygen and failed to obtain a physician's order for Resident 1's use of the oxygen as per the facility's P&P. * The facility failed to follow up with the pharmacy services for Resident 1's delivery of the breathing treatment medications. * The facility failed to ensure Resident 2's humidifier was labeled, dated, and changed when it was empty. These failures had the potential to negatively affect the resident's well-being as the necessary care and services were not provided. Findings: 1. Review of the facility's P&P titled Oxygen Administration revised 10/2010 showed the following: 1. Verify that there is a physician's order for this procedure. 2. Before administering oxygen, and while the resident is receiving…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 necessary care and services to ensure one of three sampled residents (Resident 1) attained and maintained the highest practicable physical well-being. * The facility failed to ensure the physician was timely notified when Resident 1 had a change in condition to theright leg. This failure posed the risk for Resident 1 to not receive the necessary care and services timely to maintain the resident's highest physical well-being. Findings: Review of the facility's P&P titled Change in Resident's Condition or Status revised February 2021 showed the facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/ mental condition and/ or status. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) 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 observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to treat and prevent the development of pressure injuries for one of three sampled residents (Resident 2). * The facility failed to provide the skin treatment to Resident 2 as ordered by the physician and developed a care plan to address Resident 2's Stage 3 pressure injury to the lumbosacral spine. These failures had the potential for Resident 2 to not receive the appropriate care and services to promote healing of the pressure ulcer. Findings: Review of facility's P&P titled Pressure Ulcers/ Skin Breakdown – Clinical Protocol revised February 2024 showed the nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers; for example, immobility, recent weight loss, and a history of pressure ulcer(s). The physician will assist the staff to identify the type (for example, arterial or stasis…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 five of five final sampled residents (Residents 5, 19, 64, 84, and 745) reviewed for unnecessary medications were free from the unnecessary psychotropic medications. * There was no evidence of non-pharmacological interventions for Resident 745's use of quetiapine (antipsychotic medication), Ativan (antianxiety medication), duloxetine (antidepressant medication) and divalproex sodium (mood stabilizer medication). Additionally, the facility failed to monitor behavior and side effects for the use of Ativan and failed to reassess the resident for use of quetiapine as needed more than 14 days. * The facility failed to show the Xanax (antianxiety medication) medication was only limited to 14 days for Resident 84. Additionally, the informed consent for the use of the Xanax medication was not completed prior to administration, and there was no evidence of non-pharmacological interventions for use of Remeron (antidepressant…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 implement the infection control practices designed to provide a safe and sanitary environment and help prevent the development and transmission of diseases and infections. * The facility failed to ensure the facility had monthly Infection Prevention and Control Surveillance logs for July, September, and December 2024. * The facility failed to ensure the facility's infection surveillance log for August through November 2024 included if the resident met the Loeb's criteria for true infection. * The facility failed to ensure the October and November 2024 Infection Prevention and Control QA Reports were accurate. * The facility failed to ensure the facility had a surveillance log to show the residents who met and not met the Loeb's criteria. * The IP failed to include residents with signs and symptoms of infection but were not prescribed with antibiotic on the infection surveillance report. * The facility failed to ensure Resident 694'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 ensure two of 19 final sampled residents (Residents 24 and 394) and one nonsampled resident (Resident 74) were safe to self-administer the medications found at bedside. * Resident 394 was observed with a bottle of dorzolamide (medication used to treat glaucoma) eyedrops at bedside. Resident 394 stated she administered the eyedrops herself. Resident 394 did not have the assessment and physician's order addressing the resident's self-administration of medication. * Resident 74 was observed with a medication cup containing a gabapentin (anticonvulsant medication) capsule at bedside. Resident 74 stated the charge nurse left the medication for her to self-administer the medication later. Resident 74 did not have the assessment, and physician's order addressing the resident's self-administration of medication. * Resident 24 was observed to have a Vicks VapoRub (cough suppressant and topical analgesic) ointment at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the reasonable accommodations to meet the needs for two of 29 final sampled residents (Residents 5 and 48) and four nonsampled residents (Residents 9, 29, 35, and 38). * The facility failed to ensure the call lights were within reach and accessible for Residents 5, 9, 29, 35, 38, and 83. This failure had the potential to result in a delay in the provision of care and the potential to negatively impact the residents' psychosocial well-being. Findings: Review of the facility's P&P titled Answering the Call Lights (undated) showed the purpose of this procedure is to ensure timely responses to the resident's requests and needs, and to ensure the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility, and from the floor. 1. On 1/7/25 at 0837 hours, Resident 9 was observed in bed, yelling, and pointing to the window. The call light was observed clipped on…

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

Based on interview, facility document review and facility P&P review, the facility failed to respond to the concerns brought up by the residents during the Resident Council meetings. * The facility failed to show what facility administrative actions were taken to address the concerns from the Residents Council meetings on 7/11, 9/12, and 10/10/24, regarding the medications, snacks, and CNA interactions with the residents. This failure had the potential for the residents' identified issues to not be resolved, a delay in the provision of care, and a decline in quality of life for the residents. Findings: Review of the facility's P&P titled Grievances Complaint, Filing revised 4/2017 showed the following: - The Administrator and the staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative; - All grievances, complaints or recommendation stemming from resident or family groups concerning issues of resident care in the facility will be considered. Actions on such issues will be responded to in writing, including a rationale for the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility document review, the facility failed to provide the individualized and ongoing activity program to meet the needs and interests for two of 19 final sampled residents (Residents 5 and 22) and two nonsampled residents (Residents 9 and 35). * The facility failed to provide the activities for Residents 9 and 22 which met the residents' identified interests. * The facility failed to ensure the bingo game was not cut-off by the activity department to supervise the smokers as per the concerns of Residents 5 and 35. These failures had the potential for the residents to experience feelings of social isolation and depression. Findings: Review of the facility's P&P titled Activity Programs revised 6/2018 showed the following: - Activities offered are based on the comprehensive resident-centered assessment and the preferences of each resident; - The activities program is ongoing and includes facility-organized group activities, independent individual…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility document review, the facility failed to ensure one of 19 final sampled residents (Resident 64) was provided with the prescribed liquid consistency diet per the physician's order. This failure had the potential to negatively affect Resident 64's health condition and well- being. Findings: On 1/7/25 at 0901 hours, during initial tour to the facility, a cup of thin clear liquid with a straw and a pitcher labeled with Resident 64's name and room number, Nectar, and dated 12/30/24 was observed on Resident 64's bedside table. CNA 5 was observed entering Resident 64's room and verified both the cup with thin liquid and the pitcher labeled Nectar was on Resident 64's bedside table. CNA 5 was then observed removing the cup with the thin liquid from the resident's bedside table. CNA 5 stated the thickened liquid with the nectar consistency was being given to the resident and proceeded to point at the pitcher labeled as Nectar. CNA 5 then opened 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 provide the necessary care and services for two of 19 final sampled residents (Residents 44 and 20) and two nonsampled residents (Residents 97 and 99) reviewed for respiratory care. * The facility failed to ensure Resident 44's nasal cannula was applied properly. * The facility failed to ensure the oxygen cannula for Resident 97 was stored in a set-up bag when not in use, and ensure a physician's order was obtained prior to administering oxygen to the resident. In addition, the facility failed to ensure a No Smoking/Oxygen in Use sign was posted outside the resident's door per the facility's P&P. * The facility failed to ensure the nebulizer mask and canister for Resident 99 was stored in a set-up bag when not in use. * The facility failed to ensure Resident 20's nebulizer mask and canister was stored in a sanitary manner. These failures had the potential to affect the respiratory health and well-being 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, and facility P&P review, the facility failed to accurately monitor the fluid intake and output for one final sampled resident (Resident 394) reviewed for hemodialysis care. This failure had the potential for Resident 394 to experience life threatening conditions associated with fluid deficit/overload. Findings: Review of the facility's P&P titled Intake and Output, Monitoring revised 1/2024 showed the following: - It is the policy of the facility to ensure the intake and output is monitored and accurately documented when it is ordered by the resident's physician or implemented by the licensed nurse or IDT to evaluate hydration, fluid restrictions, or assist in assessment and management of fluid needs; - Nursing personnel are responsible for recording on the Intake and Output Record as appropriate for each resident under their care; and - Nursing personnel are responsible are responsible to add intake and output amounts to the UDA Task throughout their shift. Other staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the IP had specific competencies and standard of practice skill sets needed to provide the safe and efficient nursing services to the residents as evidenced by: * The IP failed to identify the six moments of EBP. * The IP failed to document the meeting minutes on the Infection Control Committee Meeting Minutes form. * The IP failed to correctly identify HAI and CAI. * The IP failed to identify what the infection onset date was for. * The IP failed to provide accurate information on the Antibiotic Time Out to Resident 694's physician. * The facility failed to ensure CNA 8 and LVN 6 were competent about EBP. CNA 8 and LVN 6 were not able to identify when to use EBP and were not provided with training on EBP. These failures had the potential to put the residents at risk for services not provided in a safe and competent manner. Findings: Review of the Position Summary section of the IP's job description…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of five final sampled residents (Residents 84) reviewed for unnecessary medications was properly monitored related to the use opioid medication. * The facility failed to ensure Resident 84 was monitored for the side effects of receiving Norco (narcotic) medication. This failure had the potential for Resident 84 to receive unnecessary medications and develop significant side effects. Findings: Review of the facility's P&P titled Pain - clinical protocol dated 10/2022 showed the staff and physician will monitor for adverse effects of pain medications such as gastrointestinal bleeding from NSAIDs, and anorexia, confusion, lethargy, and severe constipation related to opioids. Medical record review for Resident 84 was initiated on 1/7/25. Resident 84 was admitted to the facility on [DATE] and was readmitted on [DATE]. Review of Resident 84's H&P examination dated 12/2/24, showed the resident had capacity to make…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 23.33%. Three of three licensed nurses (LVNs 1, 2, and 3) were found to have made errors during the medication administration observation for one sampled resident (Resident 745) and two non-sampled residents (Residents 29 and 32). This failure had the potential to negatively impact the resident's heal outcomes. Findings: Review of the facility's P&P titled Medication Administration dated 4/2019 showed the medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame. Review of the facility's P&P titled Administering Medication through a Metered Dose Inhaler revised 10/2010 showed the purpose of this procedure is to provide guidelines for the safe administration of inhaled medication. Assess the resident, if…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of three sampled residents (final sampled resident, Resident 745) was free from the significant medication errors. This failure placed Resident 745 at risk for medical complications. Findings: Review of the facility's P&P titled Medication Administration dated 4/2019 showed the medications are administered in a safe and timely manner, and as prescribed. The medications are administered in accordance with prescriber orders, including any required time frame. Review of the facility's P&P titled Medication Ordering and Receiving from Pharmacy date 4/2008 showed to reorder medication five days in advance of the need to assure for an adequate supply is on hand. Medical record review for Resident 745 was initiated on 1/7/25. Resident 745 was admitted to the facility on [DATE]. Review of Resident 745's Order Summary Report dated 1/7/25, showed the following physician orders: - dated 12/19/24, for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. On 1/7/25 at 0834 hours, during the initial tour of the facility, a bag containing several wound dressings, a tube of CalProtect topical ointment and two tubes of Triad hydrophilic wound ointment was observed on Resident 82's nightstand. Resident 82 stated she did not know anything about the wound dressing and wound care ointments, and the nurse applied those to her right leg wound. Medical record review for Resident 82 was initiated on 1/7/25. Resident 82 was admitted to the facility on [DATE]. Review of Resident 82's Order Summary Report dated 1/8/25, showed the following physician's orders: - dated 12/13/24, for the left lower leg with dry and scaly skin, cleanse with normal saline, apply with moisturizing cream and leave open to air; - dated 12/13/24, for the right lower leg with dry and scaly skin, cleanse with normal saline, apply with moisturizing cream and leave open to air; - dated 12/26/24, for the right posterior/ lateral lower leg peripheral arterial disease wound, cleanse with normal saline,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 guidelines were followed when: * The facility failed to ensure two coffee pots were not stored wet. * The facility failed to ensure the kitchen equipment and utensils were maintained in a sanitary condition. * The facility failed to ensure the food preparation sink had a back flow prevention in place. These failures had the potential to result in foodborne illnesses for residents receiving kitchen services in the facility. Findings: Review of the facility's document titled Diet Type Report dated 1/7/25, showed 89 of 92 residents were receiving food prepared from the kitchen. 1. According to the USDA Food Code 2022, Section 4-901.11, Equipment and Utensils, Air-Drying Required, items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items prevents them from drying and may allow an environment where microorganism can begin to grow. On 1/7/25 at 0800 hours, an observation and concurrent interview 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 document review, the facility failed to ensure one of one resident (final sampled, Resident 52) reviewed for hospice services had received the necessary care and services. * The facility failed to ensure the hospice visit calendar was available in Resident 52's residents' medical record. * The facility failed to ensure for an accurate documentation of the hospice staff visits were available for Resident 52. * The facilty failed to ensure the hospice staff visited the resident as scheduled in the hospice calendar for Resident 52. These failures posed the risk for the delay in communication and provision of hospice care between the hospice provider and facility . Findings: Review of the facility's document titled Hospice Services Agreement with Hospice Provider A dated 2/23/23, showed: - The hospice provider will ensure that patient's visit will be made at a time mutually agreed upon by provider and patient. - The hospice provider will ensure complete…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, facility document review, and facility P&P review, the facility failed to implement their Antibiotic Stewardship Program when the IP was not able to show the documentation she notified the physician of the residents who were prescribed antibiotics and did not meet the Loeb's Criteria. This failure had the potential for inaccurately identifying for true infections and potentially inhibited residents from receiving the appropriate treatment and care. Findings: According to the CDC, the antibiotics are some of the most commonly prescribed medications in nursing homes. Over the course of a year, up to 70% of nursing home residents get an antibiotic. Roughly 40% to 75% of antibiotics are prescribed incorrectly. In nursing homes, high rates of antibiotics are prescribed to prevent urinary tract infection (UTI) and respiratory tract infection (RTI). Prescribing antibiotics before there is an infection often contributes to misuse. Often residents are given antibiotics just because they are colonized…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 protect the resident's rights to be free from physical abuse by a staff for one of two sampled residents (Resident 1). * CNA 2 was observed by her colleague slapping Resident 1 on the face,resulting in redness to Resident 1's face. Resident 1 stated the incident made him feel embarrassed. This failure had the potential to cause serious injury and physical and/or psychological harm to the resident. Findings: Review of the facility's P&P titled Resident Rights revised 2/2021 showed employees shall treat all residents with kindness, respect, and dignity. Federal and State laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to be treated with respect, kindness, dignity and be free from abuse. Medical record review for Resident 1 was initiated on 7/17/24. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's MDS dated [DATE], showed Resident 1 had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of three closed record sampled residents reviewed for discharges (Resident 1) was properly discharged from the facility after his elopement. * Resident 1 was found after his elopement from the facility and transported to an acute hospital for evaluation. Resident 1 was cleared to transfer back to the facility; however, the facility denied Resident 1's readmission. This failure had the potential to place Resident 1 at risk for decline in his health condition if placed inappropriately. Findings: Review of the facility's P&P titled Transfer or Discharge Documentation revised 12/2026 showed when a resident is transferred or discharged from the facility, the following information will be documented in the medical record: a. the basis for the transfer or discharge; if the resident is being transferred or discharged because his or her needs cannot be met at the facility, documentation will include: the specific…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of three sampled residents reviewed for elopement (Resident 1) was provided adequate supervision and necessary services to prevent elopement. * The facility failed to monitor Resident 1's whereabouts, resulting in Resident 1 leaving the facility undetected twice. * The facility failed to reassess Resident 1 for elopement risk as per the IDT's recommendations after an elopement episode. * The facility failed to monitor Resident 1 for his exiting behaviors. These failures placed Resident 1 at risk to not receive the appropriate care and services and placed the resident at risk for harm or injury. Findings: Review of the facility's P&P titled Wandering and Elopements (undated) showed the facility will identify the residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for the residents. Review of the facility P&P titled Tab Alarms, Bed Alarms,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to coordinate the transportation for one of two sampled residents (Resident 1)'s ortho surgery appointment. * Resident 1's physician ordered an ortho surgery appointment; however, the facility failed to coordinate the transportation services in a timely manner. This failure resulted in Resident 1 having missed his ortho surgery appointment, which had the potential to delay Resident 1's plan of care. Findings: Medical record review for Resident 1 was initiated on 2/7/24. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's Occupational Therapy Evaluation and Plan of Treatment dated 12/24/23, showed Resident 1 had a recent history of right tibia/fibula fracture status post ORIF with external fixator. Review of Resident 1's Order Summary Report showed a physician's order dated 1/17/24, for an ortho surgery appointment on 1/23/24 at 1030 hours. Review of Resident 1's Social Service Note dated 1/19/24 at 1717 hours, showed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide reasonable accommodations to meet the needs for two sampled residents (Residents 1 and 4). * The facility failed to ensure Residents 1 and 4 were provided with assistance in a timely manner. This failure had the potential to negatively impact the resident's physical and psychosocial well-being or would result in delayed provision of care. Findings: Review of the facility's P&P titled Accommodation of Needs revised 3/2021 showed the facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity, and well-being. The resident's individual needs and preferences are accommodated to the extent possible, except when the health and safety of the individual or other residents wound be endangered. Review of the facility's P&P titled Answering the Call Light revised 9/2022 showed the purpose of the procedure is to ensure…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 sampled resident (Resident 1) remained free from accident hazards. * The facility failed to ensure Resident 1's smoking materials were not stored at the resident's bedside. This failure had the potential for the resident to sustain accidents and/or injuries. Findings: Review of the facility's P&P titled Smoking Policies and Procedures (undated) showed residents without independent smoking privileges may not have or keep any types of smoking articles, including cigarettes, tobacco, etc., except when they are under direct supervision. On 9/28/23 at 1323 hours, an observation and concurrent interview was conducted with Resident 1. Resident 1 was observed lying in bed with the nasal cannula (device used to provide supplemental oxygen therapy) inside his nostrils and the oxygen concentrator was on and set at 4 liters per minute. Resident 1 was observed with two boxes of cigarettes and one lighter inside…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 protect one of two sampled residents' (Resident 1) rights to be free from the physical abuse when Resident 2 had punched Resident 1's face after an altercation, resulting in Resident 1's abrasion on his nose to reopen and bleed. This failure had the potential to negatively impact the residents. Findings: Review of the facility's P&P titled Abuse, Neglect, Exploitation, and Misappropriation Prevention Program dated 2001, showed the residents have the rights to be free from abuse, neglect, misappropriation of resident property, and exploitation, and must protect residents from abuse by anyone, including other residents. Review of the facility's Report of Suspected Dependent Adult/Elder Abuse (SOC 341) form dated 8/12/23, showed Resident 1 was physically abused by Resident 2. Review of the facility's Resident Abuse Investigation Report Form dated 8/12/23, showed the housekeeping staff had witnessed Resident 1 and 2's altercation 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, and medical record review, the facility failed to develop and implement the plan of care for assessing, monitoring, and intervening aggressions towards other residents for one of two residents (Resident 2) who had a reported allegation of resident-to-resident abuse. This failure had the potential to delay providing the safeguard measures to protect the residents in the facility. Findings: Review of the facility's investigation conclusion dated 8/17/23, showed Residents 1 and 2 had an altercation on 8/12/23. Resident 1 hit Resident 2 in the arm, and then Resident 2 hit back by punching Resident 1's face, causing Resident 1's nose to bleed. Review of Resident 2's medical record was initiated on 8/21/23. Resident 2 was initially admitted on [DATE], and readmitted on [DATE]. Resident 2 was transferred out on 8/18/23, to the acute care hospital for physical aggression towards staff and others. Review of Resident 2's H&P exam dated 7/12/23, showed Resident 2 was competent and able to…

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

Based on observation and interview, the facility failed to ensure the sanitary condition in the kitchen as evidenced by: * The facility failed to ensure safe storage of food items. * The facility failed to ensure the kitchen equipment was maintained in sanitary condition. 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 form CMS-672 Resident Census and Conditions of Residents completed by the facility dated 8/16/22, showed 93 of the 96 residents residing in the facility received food prepared in the kitchen. 1.a. On 8/16/22 at 0819 hours, an initial observation of the freezer and concurrent interview was conducted with the DSS. On the third shelf from the top, a plastic bag of barbeque ribs was observed with the use by date of 7/25/22. The DSS verified the observation and stated the barbeque ribs had expired. The DSS stated it should have been discarded. b. On 8/16/22 at 0835 hours, during the initial kitchen observation and concurrent interview with the DSS,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 appropriate 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 ensure eye protection was worn by the staff as PPE during all resident care in accordance with the Orange County Health Care Agency's Guidance on COVID-19 in long-term care facilities. This failure posed the risk of a COVID-19 outbreak at the facility. * The facility failed to ensure LVN 5 performed hand hygiene and changed gloves when administering the eye drops for one of 19 final sampled residents (Resident 16) as per the facility's P&P. This failure had the potential for the resident to acquire an eye infection. Findings: 1. Review of the Orange County Health Care Agency Guidance on COVID-19 in long-term care facilities titled Some Reminders and Updates From your Local Health Department dated 8/9/22, showed Important IP (infection prevention) Reminders: Eye protection…

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

Based on observation and interview, the facility failed to ensure the staff provided care in a manner that promoted dignity and respect for one of 19 final sampled residents (Resident 54). CNA 1 was observed standing over Resident 54 while assisting the resident with her meal. This failure had the potential to negatively impact the resident's well-being. Findings: On 8/16/22 at 1224 hours, CNA 1 was observed assisting Resident 54 with her lunch meal in the resident's room. Resident 54 was observed lying in the bed with the head of bed elevated. The bed was observed in a low position. Resident 54's lunch tray was observed on top of the resident's night stand. CNA 1 was observed standing over Resident 54 while spoon-feeding the resident. Resident 54's eye level was at CNA 1's waist area. Resident 54 was observed looking up, trying to make eye contact with CNA 1 as she was being fed. CNA 1 lifted the plate with one hand and continued feeding Resident 54 while standing over the resident. An over bed table and a chair were observed on the opposite side of the resident's bed. CNA 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 observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 19 final sampled residents (Resident 16) was assessed to determine if the resident was safe to self-administer the medications. This failure had the potential for medication interactions and inappropriate use of medications. * Aspercreme Lidocaine dry spray (pain reliever medication) with an expiration date of 08/2021 and Icy Hot Max-maximum strength/Lidocaine roll on (pain reliever medication) with an expiration of 12/2023 were unlabeled and observed at Resident 16's bedside table. Findings: Review of the facility's P&P titled Self-Administration of Medications revised 2/2021 showed the residents have the right to self-administer medications if the interdisciplinary team has determined that is was clinically appropriate and safe for the resident to do so. If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 call light was kept within reach for one of 19 final sampled residents (Resident 73). This failure resulted in Resident 73 not being able to use the call light to call for assistance, which had the potentail to negatively impact the resident's well-being. Findings: Review of the facility's P&P titled Answering the Call Light revised March 2021 showed when the resident is in bed or confined to a chair, be sure the call light is within easy reach of the resident. On 8/16/22 at 0820 hours, during the initial tour of the facility, Resident 73 was overheard moaning while lying in bed. Resident 73's call light was observed on the floor, not within the resident's reach. Resident 73 was observed asking for help. On 8/16/22 at 0823 hours, CNA 2 who was observed sitting at the nurse's station was summoned to Resident 73's room. CNA 2 verified the call light was on the floor and not within the resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to offer assistance to formulate an advance directive, and/or maintain a copy of the resident's advance directive in the medical records for five of 19 final sampled residents (Residents 18, 29, 38, 54, and 595). This failure put the residents at risk of not having their wishes for treatment known and 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 revised December 2016 showed upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. Information on whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. 1. Medical record review for Resident 38 was initiated on 8/16/22. Resident 38 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to ensure one of 19 final sampled residents (Resident 594) was provided with comfortable and homelike environment. This failure had the potential to prevent Resident 594 from getting a restful sleep and be free unwanted noise in his room. Findings: On 08/22/22 at 1000 hours, during observation and concurrent interview was conducted with Resident 594. Resident 594 stated his roommate had the TV on at an uncomfortable sound level from 0700 hours to midnight since his admission to the facility on [DATE]. When asked if he had informed anyone regarding his concern of the loud TV, Resident 594 stated he had told, 10 plus nurses, on 8/4/22. Resident 594 stated no one had done anything about it; he added, I just gave up on it and stopped complaining to the staff. When asked how the TV sound level made him feel, Resident 594 stated, I feel like a nervous wreck. Medical record review for Resident 594 was initiated on 8/16/22. Resident 594 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to develop a plan of care to reflect the individual care needs for two of 19 final sampled residents (Residents 74 and 78). * The facility failed to develop a care plan problem to address Resident 74's risk for developing pressure ulcers. * The facility failed to ensure a care plan problem was developed to address Resident 78's use of the PRAFO boots for wound management. These posed the risk of not providing appropriate, consistent, and individualized care to the residents. Findings: 1. Medical record review for Resident 74 was initiated on 8/16/22. Resident 74 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of the Order Summary Report showed a physician's order dated 4/4/22, to offload Resident 74's bilateral lower extremities using pillows while he was in bed. Review of the Braden Scale for Predicting Pressure Ulcer Risk dated 7/22/22, showed Resident 74 was at risk for developing pressure injuries. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to provide the necessary care and services to maintain the highest physical well-being for two of 19 final sampled residents (Resident 74 and 78). * The facility failed to ensure the PRAFO boots was applied to Resident 78 as per physician's order. * The facility failed to ensure Resident 74's right arm sling was applied when he was out of bed as ordered by the physician. These failures had the potential to affect Residents 74 and 78's well being. Findings: 1. Medical record review was initiated for Resident 78 on 8/16/22. Resident 78 was admitted to the facility on [DATE]. Review of the Order Summary Report for the month of August 2022 showed an order dated 8/11/22, to apply PRAFO boot to Resident 78's right heel while in bed for wound management. On 8/16/22 at 0831 hours and 8/18/22 at 0812 hours, Resident 78 was observed in bed with a dressing on the right heel and his leg was elevated on a pillow. There was no heel protector or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to ensure the necessary care and services were provided to prevent the development of pressure ulcers for one of 19 final sampled residents (Resident 74). * The facility failed to offload Resident 74's heels from pressure as ordered by the physician. This had the potential of Resident 74 not receiving the appropriate care and services to promote healing or prevent the development of the pressure ulcers. Findings: On 8/16/22 at 1444 hours, Resident 74 was observed lying in bed. Resident 74's heels were not offloaded and were observed resting directly on the mattress. Medical record review for Resident 74 was initiated on 8/16/22. Resident 74 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of the Order Summary Report showed a physician's order dated 4/4/22, to offload Resident 74's bilateral lower extremities using pillows while he was in bed. Review of Resident 74's history and physical examination dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of 19 final sampled residents (Resident 594) was provided appropriate pain management. This created the risk of not effectively manage pain for this resident. Findings: Review of the facility's P&P titled, Pain Assessment and Management, revised date March 2020, showed pain management interventions shall reflect the sources, type and severity of pain and monitor for the presence of adverse consequences to treatment. Medical record review for Resident 594 was initiated on 8/16/22. Resident 594 was admitted to the facility on [DATE], with the diagnosis of lower limb cellulitis. On 08/17/22 at 1332 hours, during an interview, Resident 594 was asked about his pain levels. Resident 594 stated he had pain during dressing changes and had been given Ibuprofen (nonsteroidal anti-inflammatory medication). However, Resident 594 stated he could not sleep when he took it and had told the nurse. Review of Resident 594's MAR…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 complete a comprehensive bed/side rail assessment for one of 19 final sampled residents (Resident 44). This failure had the potential to cause physical harm to Resident 44. Findings: Review of the facility's P&P titled Proper Use of Side Rails revised December 2016 showed the guidelines to ensure the safe use of side rails included the consent, assessment, and care planning of the resident. Medical record review for Resident 44 was initiated on 8/16/22. Resident 44 was admitted to the facility on [DATE]. On 8/22/22 at 1458 hours, during the tourof the facility, Resident 44 was observed with an upper bilateral half side rails up on his bed. Resident 44 was asked about the purpose of his side rails and stated he used the side rails to transfer in/out of bed. Review of Resident 44's Side Rail Utilization assessment dated [DATE], showed Resident 44 had had the side rails in place since 6/29/22, for transfers 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 provide the pharmaceutical services to meet the needs of one of 19 final sampled residents (Resident 16). * The facility failed to ensure the physician's orders were obtained for the use of the topical analgesics found at Resident 16's bedside table. This failure had the potential to cause Resident 16's pain not to be managed completely and could lead to the resident's decreased concentration or sleep disturbance. Findings: Review of the facility's P&P titled Administering Medications revised 4/2019 showed the medications are administered in a safe and timely manner, and as prescribed. Medical record review for Resident 16 was initiated on 8/18/22. Resident 16 was admitted to the facility on [DATE]. Review of Resident 16's Order Summary Report dated 7/6/22, failed to show the physician's orders for Aspercreme Lidocaine spray and Icy Hot max-maximum strength/Lidocaine roll on. On 8/18/22 at 0849 hours, a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medication prescription inserts review, the facility failed to ensure the medications were stored and labeled properly in one of four medication carts (Medication Cart 1); and failed to ensure an expired medication was not stored at the bedside for one of 19 final sampled residents (Resident 16). * Three inhalers with no opened dates were stored in Medication Cart 1. * An expired medication was observed at Resident 16's bedside table. These failures had the potential to negatively impact the residents' well-being. Findings: 1. Review of the medication prescription inserts for Advair Diskus (medication to prevent symptoms of asthma and COPD) from www.drugs.com showed to discard Advair Diskus one month after opening the foil pouch or when the counter reads 0 (after all blisters have been used), whichever comes first. Review of the medication prescription inserts for Breztri Aerosphere (medication to treat COPD) from www.drugs.com showed to discard the medication when the 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 medical record review, the facility failed to ensure the medical records for two of 19 final sampled residents (Residents 16 and 54) were accurate and complete. * Resident 54's POLST was incompletely filled out. * Resident 16's medical record contained Resident 56's Order Summary Report. These failures had the potential for the residents' care needs not being met as their medical information was inaccurate and incomplete. Findings: 1. Medical record review for Resident 54 was initiated on [DATE]. Resident 54 was admitted to the facility on [DATE]. Review of the History and Physical examination dated [DATE], showed Resident 54 was not competent and not able to enter into a contract, including admission agreement. Review of Resident 54's POLST dated [DATE], showed the attempt resuscitation/CPR (cardiopulmonary resuscitation) option was checked off. The physician signed the POLST. However, all other areas including medical interventions (selecting the treatment when the patient…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 two glucometers (Glucometers A and B) from one of four medication carts (Medication Cart 1) were maintained in safe operating condition. This had the potential for residents requiring glucose checks to have inaccurate readings. Findings: Review of the Assure Platinum Blood Glucose Monitoring System Instruction Manual, under Quality Checks, showed to use Assure Dose Control Solutions to check if the meter and test strips are working correctly as a system, and if the test is correct. A control solution test is performed when a new bottle of test strips is opened. On 8/23/22 at 1057 hours, Medication Cart 1 inspection was conducted with LVN 6. Two glucometers were observed inside the top drawer labeled Glucometer A and Glucometer B. The bottle of Assure Platinum Blood Glucose Test Strips was observed with an opened date of 8/22/22, and Lot No. 051622A. A bottle of control solution was observed with the control solution range for normal was 86-107 mg/dL, and the control solution range for high…

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