La Palma Nursing Center

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 five final sampled residents (Resident 34) reviewed for unnecessary medications received appropriate pharmacological recommendations. * The facility's Pharmacist Consultant failed to make recommendations based on Resident 34's elevated hemoglobin A1c (a blood test that measures the average blood sugar (glucose) level over the past 2-3 months) results and insulin use for diabetic management. This failure had the potential for the resident's diabetic regimen not being promptly re-evaluated by the physician. Findings: Medical record review for Resident 34 was initiated on 9/9/25. Resident 34 was readmitted to the facility on [DATE]. Review of Resident 34's admission MD/NP/PA Progress Note dated 3/7/25, showed the resident had Type 2 diabetes (a chronic condition characterized by high blood sugar levels due to the body's inability to use insulin effectively or produce enough insulin.). Review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to ensure two of five final sampled residents (Residents 3 and 34) reviewed for unnecessary medications were free from the unnecessary medications. * The facility failed to ensure Resident 3 was monitored for signs and symptoms of bleeding for the use of clopidogrel bisulfate (medication used to prevent dangerous blood clots). * The facility failed to ensure Resident 34 was monitored for bleeding related to clopidogrel bisulfate medication use. These failures had the potential for the residents to receive unnecessary medications and develop significant adverse effects.Findings: According to the FDA the approved Highlights of Prescribing Information for clopidogrel bisulfate revised 3/2021 showed the most common adverse reaction in adult patients are related to bleeding including life-threatening and fatal bleeding. 1. Medical record review for Resident 3 was initiated on 9/9/25. Resident 3 was admitted to the facility on [DATE].…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on 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 39.29%. Two of two licensed nurses (LVNs 2 and 3) were found to have made errors during the medication administration. * Resident 10 had a physician's order for metoprolol (antihypertensive medication) with parameter to hold if HR (heart rate) is less than 60 beats per minute (bpm). LVN 3 failed to check the resident's HR prior to administering the medication. In addition, Resident 10 did not receive the full dose of vitamin D3 (supplement) and Rena Vite (supplement) medications when there was residual left in the medicine cups after LVN 3 administered the medications via GT. * LVN 2 failed to ensure seven medications were not left in pill pouches used for crushing Resident 62's medications. * LVN 2 failed to administer Resident 63's calcium (supplement) 500 mg tablet. These failures resulted in the residents not 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 observation, interview, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen. * The facility failed to ensure two plastic containers with clean scoops were free from dust and dry food crumbs. * The facility failed to ensure safe storage of food items. * The facility to ensure complete hair restraint was done by the dietary staff inside the kitchen. * The facility failed to ensure Resident 47 did not store food from the kitchen at the bedside. These failures had the potential to cause foodborne illness for residents who consumed food prepared in the kitchen.Findings: Review of the facility's document titled Diet Type Report dated 9/10/25, showed 56 of 64 residents were receiving food from the kitchen. 1. According to FDA Food Code 2022, 4-601.11, Equipment, Food-Contact Surfaces, Nonfood Contact Surfaces, and Utensils, the equipment food-contact surfaces and utensils shall be clean to sight and touch, the food-contact surfaces of cooking equipment and…

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

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the P&P was followed regarding outside food brought into the facility for one nonsampled resident (Resident 76). * There were unlabeled food items observed at Resident 76's bedside. * The facility failed to ensure the staff, residents, and/or their responsible party were educated on safe food handling guidelines. These failures had the potential to expose the residents who received food brought from the outside to food borne illnesses. Findings: Review of the facility's P&P titled Food from Outside Sources dated 4/2017 showed food brought in by the visitors for the residents is discouraged due to problems of infection control and conflicts between diets and consistency. Food brought in for residents should not be served by the dietary department, food brought into the facility by family members or visitors should be checked to confirm that the food is not in conflict with the residents prescribed diet. The P&P further showed visitors are discouraged from bringing 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 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 maintain an accurate infection control surveillance program for August 2025 when the IP classified the infections as CAIs, HAIs, and those who did not meet the McGeer Criteria. In addition, the facility failed to ensure the monthly infection surveillance mapping included all infections in the facility. * The facility failed to ensure the residents' blankets, wedge pillows, and splints in the laundry area were stored in a clean and sanitary manner. * CNA 7 failed to wear a gown when providing care and changing the linens for Resident 16 who was on EBP precaution. * The facility failed to ensure the blood sugar machine was properly cleaned after LVN 2 used the machine to check Resident 22's blood sugar. In addition, LVN 2 failed to perform…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the regular inspection for all the facility beds was conducted as part of the regular maintenance program. * The facility failed to conduct a regular inspection of Residents 2, 3, and 5's beds, bed frames, and mattresses, as part of the regular maintenance program. These failures had the potential to compromise residents' safety, health, and well-being.Findings: Review of the facility's P&P titled Bed Safety revised 7/2018 showed the following: - The resident's sleeping environment shall be assessed by the interdisciplinary team, considering the resident's safety, medical conditions, comfort, and freedom of movement, as well as input from the resident and family regarding previous sleeping habits and bed environment; - To try to prevent death/injury from the beds and related equipment (including the frame, mattress, side rails, grab bar, headboard, footboard, and bed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure one of three sampled residents (Resident 1) received the necessary care and services to prevent accident hazards. * The facility failed to thoroughly investigate and document Resident 1's subacute closed fracture (a broken bone that has started to heal and is not breaking the skin) of multiple ribs of the left side. In addition, the facility failed to request the physician to complete the fracture progress report and failed to conduct the root cause analysis by IDT as per the facility's P&P when the subacute fracture of Resident 1's left multiple ribs was identified after the fall incident. * The facility failed to ensure the change in condition and neurological evaluations were conducted and documented the physician's recommendations after the unwitnessed fall incident on 10/25/24, for Resident 1. These failures had the potential to negatively impact the residents' wellbeing. Findings:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the comprehensive care plans were developed to reflect the individual care needs for 13 of 16 final sampled residents (Residents 15, 17, 20, 32, 33, 34, 35, 40, 44, 45, 48, 59, and 366). * The facility failed to ensure the comprehensive person-centered care plans for the use of grab bars were in place for Residents 15, 17, 20, 32, 33, 34, 35, 40, 44, 45, 48, 59, and 366. This failure had the potential for residents to not be provided with appropriate, consistent, and individualized care. Findings: Review of the facility's P&P titled Comprehensive Care Planning dated on 1/2017 showed the facility developed a comprehensive care plan for each resident. The plan of care must include measurable objectives and time frames and describe services that are to be furnished to attain or maintain the resident's practicable level of well-being. During a concurrent observation, interview, medical record review, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure 13 of 16 final sampled residents reviewed for side rail use (Residents 15, 17, 20, 32, 33, 34, 35, 40, 44, 45, 48, 59, and 366) remained free from the accident hazards associated with the use of elevated side rails. * The facility failed to ensure the accurate and complete assessments and evaluations for the grab bars use for Residents 15, 20, 32, 33, 34, 35, 40, 44, 45, 48, 59, and 366. This failure had the potential to put the residents at risk for entrapment and serious injuries. Findings: The FDA issued a Safety Alert entitled Entrapment Hazards with Hospital Bed Side Rails. Residents most at risk for entrapment are those who are frail or elderly or those who have conditions such as agitation, delirium, confusion, pain, uncontrolled body movement, hypoxia, fecal impaction, acute urinary retention, etc., that may cause them to move about the bed or try to exit from the bed. Entrapment may occur when…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 sanitary requirements were met in the kitchen as evidenced by: * The facility failed to ensure the cutting boards were kept in a sanitary condition and with cleanable surface. * The facility failed to ensure the scoops used for food portioning were air dried and clean prior to storing. * The facility failed to ensure the kitchen utensils had a smooth cleanable surface and were in good conditions. * The facility failed to ensure the kitchen utensils were clean and free of food particle or residue. * The facility failed to ensure the heavy-duty blenders used for puree preparation, the clear measuring containers, and the pink plastic drinking cups were air dried prior to storing. * The facility failed to ensure the sanitary condition of the hood over the stove was maintained. * The facility failed to ensure the microwave utilized to warm up the residents' food was in sanitary condition and free of food residue. * The facility failed to ensure the ice machine utilized…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the residents' entrapment assessments were accurate and complete for 13 of 16 final sampled residents (Residents 15, 17, 20, 32, 33, 34, 35, 40, 44, 45, 48, 59, and 366) reviewed for grab bar use. This failure had the potential to negatively impact the residents resulting in possible entrapment, serious injury, and death. Findings: According to the Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, the term entrapment describes an event in which a patient/resident is caught, trapped, or entangled in the space in or about the bed rail, mattress, or hospital bed frame. Patient entrapments may result in deaths and serious injuries. These entrapment events have occurred in openings within the bed rails, between the bed rails and mattresses, under bed rails, between split rails, and between the bed rails and head or foot boards. The population most…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one nonsampled resident (Resident 28) was provided with the necessary care in the manner that promoted dignity and respect. * The facility failed to ensure an effective communication with Resident 28 in a language understood by the resident. This failure had the potential to negatively impact the resident's emotional well-being, and risk for not providing the appropriate treatment of Resident 28. Findings: Review of the facility's P&P titled Translation or Interpretation Services dated 9/2014 showed the following: - To ensure those residents with limited English proficiency and those residents who have hearing issues have access to facility services. - The facility provides assistance to resident with limited English proficiency and those resident with hearing deficiencies, through translation and interpretation. Medical record review for Resident 28 was initiated on 8/27/24. Resident 28 was admitted to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure the psychotropic medication informed consent for one of 16 final sampled residents (Resident 366) was signed by the physician. This failure posed the risk for Resident 366 to not be informed of their care and treatment for the psychotropic medication use. Findings: Review of the facility's P&P titled Informed Consent Policy revised on 4/2024 showed the attending physician, PA (Physician Assistant) or NP (Nurse Practitioner) must obtain the informed consent of the resident or their responsible party for purposes of prescribing, ordering, or increasing an order for a psychotherapeutic medication. The facility shall verify that informed consent has been obtained prior to the administration of psychotherapeutic medication, use of siderails as a restraint, enabler, or assistive device of the use of anything attached to a normal bed, wheelchair, or Geri chair. The P&P further showed it is the responsibility 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 observation, interview, medical record, and facility P&P review, the facility failed to determine if it was safe for one of 16 final sampled residents (Resident 316) to safely self-administer the medications. This failure had the potential for Resident 316 to administer the medications inaccurately. Findings: Review of the facility's P&P titled Medication: Self- Administration revised 1/2017 showed the facility supports the residents right to self-administer medications if the Interdisciplinary Team (IDT) determines this practice is clinically appropriate. The policy also showed on admission or shortly thereafter, each resident will be assessed to determine if they want to self- administer their medications. On 8/27/24 at 0900 hours, during the initial tour of the facility, Resident 316 was observed with the following medications at the bedside: - one bottle of Synthroid (thyroid hormone replacement to treat a condition called hypothyroidism- enlarged thyroid gland and thyroid cancer) 125 mcg tablets; -…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 accommodation to meet the needs of one nonsampled resident (Resident 60). * The facility failed to ensure the call light button was within Resident 60's reach. This failure had the potential to hinder Resident 60's ability to communicate with facility staff. Findings: Review or the facility's P&P titled Call Lights dated 1/2017 showed when the resident is in bed or in the wheelchair or chair in the room, staff should make sure that the call light is within easy reach of the resident. On 8/27/24 at 0805 hours, during the initial tour of the facility, Resident 60 was observed lying in bed. Resident 60's call light was observed on the floor and not within the resident's reach. Medical record review for Resident 60 was initiated on 8/27/24. Resident 60 was admitted to the facility on [DATE]. Review of Resident 60's MDS dated [DATE], showed Resident 60's cognition was intact. On 8/27/24 at 0907…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure one nonsampled residents (Resident 43) had copy of her advance directive in her medical record. This failure had the potential for the resident's decisions regarding her healthcare and treatment options to not be honored. Findings: Review of the facility's P&P titled Advance Directives revised 4/2017 showed the resident or their responsible party will be asked if the resident has completed an advance directive, and to provide a copy of the document for the resident's clinical record. Medical record review for Resident 43 was initiated on 8/27/24. Resident 43 was admitted to the facility on [DATE]. Review of Resident 43's H&P examination dated 2/21/24, showed Resident 43 had no capacity to understand and make decisions. Review of the Quarterly MDS assessment dated [DATE], showed Resident 43 had moderately impaired cognition. Review of the Physician Orders for Life Sustaining Treatment (POLST) form prepared on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure the recommendations from the Preadmission Screening and Resident Review (PASARR, a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) Level II determination was followed up and incorporated into the resident care for one of one final sampled resident (Resident 44) reviewed for PASARR. This failure had the potential for Resident 44 not receiving the adequate care and services that were recommended by PASARR Level II determination and evaluation report assessed by a appropriate state-designated authority. Findings: Review of the facility's P&P titled Comprehensive Care Planning revised 1/17 showed a comprehensive care plan would be developed for each resident. The comprehensive care plan would provide specific information to include resident strengths, goals, life history and preferences, discharge planning and would be completed within seven days of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care for three of 16 final sampled residents (Residents 15, 34, and 59) and one nonsampled resident (Resident 55). * The facility failed to ensure Resident 55 was administered the oxygen as per the physician's order. This failure posed the risk to negatively affect Resident 55's medical condition. * The facility failed to ensure Resident 15's oxygen tubing was dated. * The facility failed to ensure the oxygen tubing was placed in a clear plastic bag when not in use and the nebulizer tubing were not touching the floor for Resident 34. * The facility failed to ensure accurate documentation of the monitoring of Resident 59's oxygen saturation level on room air. These failures had the potential to put the residents at risk for adverse effects of the inaccurate administration of oxygen and improper care of oxygen equipment. Findings: 1. On 8/28/24 at 0920 hours, Resident 55 was…

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

Based on observation, interview, and facility document review, the facility failed to ensure the DHPPD nurse staffing forms were accurately posted as per AFL (All Facility Letter) 18-27. This failure had the potential to result in inaccurate staffing information provided to the public. Findings: Review of the AFL 18-27 dated 6/29/18, showed beginning 7/1/2018, the facility shall either create a census and DHPPD form or use the Census and Direct Care Service Hours per Patient Day (CDPH 612 and instructions) to report daily DHPPD. The DON or designee must sign the form verifying the information is true and accurate. The census and DHPPD form must be typed or printed legible. If the facility chooses to create a form, it must contain substantially similar information to the attached CDPH 612 and instructions. The form must include: 1. Facility name, address, and license number 2. Patient day date and the patient day start time 3. Total licensed SNF beds 4. Name of administrator and the DON or designee 5. Patient census at start of patient day 6. Scheduled nursing hours and the scheduled…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the pharmaceutical services to ensure accurate reconciliation, and disposal of medications. * The facility failed to ensure administration of the controlled medication for Resident 66 was documented in the controlled drug record and MAR. * The facility failed to ensure non-controlled medications were discarded by two licensed nurses. These failures posed the risk for diversion of medications. Findings: 1. Review of the facility's P&P titled Preparation and General Guidelines dated 8/2014, under the Controlled Medications section, showed when a controlled medication is administered, the license nurse administering the medication immediately enters the following information on the accountability record and the MAR: - Date and time of administration; - Amount administered; - Signature of the nurse administering the dose on the accountability record at the time the medication is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure three of five residents reviewed for unnecessary medications (Residents 15, 36, and 44) were free from the unnecessary psychotropic medications. * The facility failed to ensure a specific behavior manifestation was identified for Resident 15 related to the use of divalproex (antipsychotic medication). The facility failed to ensure accurate monitoring for Resident 15's orthostatic blood pressure (measurement of the blood pressure while laying down and sitting) as ordered by the physician related to the use of an antipsychotic medication, when the blood pressure readings for Resident 15 had the same results for sitting and lying. In addition, the facility failed to ensure accurate monitoring for Resident 15's meal intake related to the use of mirtazapine (antidepressant) medication. Resident 15's meal intake monitoring documented in the MAR by the licensed nurses did not match the meal intake monitoring…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 7.14%. One of two licensed nurses (LVN 5) who were observed during the medication administration was found to have made errors. * LVN 5 failed to administer the metoprolol (antihypertensive medication) and diltiazem (antihypertensive medication) as per the physician's order when LVN 5 failed to ensure Resident 16's heart rate was taken prior to administering the medications. This failure had the potential for Resident 16 to develop significant side effects from the medications and affect Resident 16's health condition. Findings: Review of the facility's P&P titled Preparation and General Guidelines dated 10/2017, under the Medication Administration- General Guidelines section, showed the medications are administered in accordance with written orders of the attending physician. On 8/28/24 at 0943 hours, a medication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review the facility failed to ensure one nonsampled resident (Resident 16) was free from the significant medication error. * The facility failed to ensure Resident 16's heart rate was taken prior to administering the metoprolol (antihypertensive medication) and diltiazem (antihypertensive medication) medications. This failure had the potential to cause Resident 16 to have abnormally slow heart rate and negatively affect the resident's health. Findings: Review of the facility's P&P titled Preparation and General Guidelines dated 10/2017 under the Medication Administration- General Guidelines section, showed medications are administered in accordance with written orders of the attending physician. On 8/28/24 at 0943 hours, a medication administration observation for Resident 16 was conducted with LVN 5. LVN 5 prepared and administered Resident 16's medications including one tablet of metoprolol 25 mg and one capsule of diltiazem 120 mg. LVN 6…

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

Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure proper storage, labeling, and disposal of medications. * The facility failed to ensure the medications for Residents 22 and 53 who were discharged to home, Resident 2 who was transferred out of the facility, and Resident 63 who had expired was removed from the current medication supply in Medication Room A and Medication Cart A. * The facility failed to ensure the expired medications had been removed from the current medication supply in Medication Cart B. * The facility failed to ensure the opened foil pouches of inhalation solution medications for Residents 5, 15, and 40 in Medication Cart A were labeled with an opened date. * The facility failed to ensure the bubble packs (a form of tamper-evident packaging where an individual pushes individually sealed tablets through the foil to take the medication) containing medication tablets for Residents 2, 16, 37, and 45 remained intact and free from tears. *…

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

Based on interview, facility document review, and facility P&P review, the facility failed to ensure the infection control practices designed to provide the safe and sanitary environment and help prevent the development and transmission of infections were implemented as evidenced by: * The facility failed to ensure the water management program was implemented to include an assessment of the facility water systems to identify where Legionella (a bacterium commonly found in natural and man-made aquatic environments, warm stagnant water) and other opportunistic pathogens can grow and spread. * The facility failed to ensure the infection control practices were implemented in the facility's laundry room. These failures posed the risk for transmission of communicable diseases to other residents in the facility. Findings: 1. Review of the facility's P&P titled Legionnaire's Disease revised dated 6/2017 showed the facility to have a plan for the prevention of Legionnaire's disease, recognize the signs and systems of the disease, test as appropriate with a physician's order and report…

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

Based on observation, interview, and facility document review, the facility failed to ensure the essential equipment was maintained in safe operating condition. * The facility failed to ensure the staff performed calibration before using a new glucometer (a device which measures the amount of sugar in the blood). This failure had the potential for residents requiring glucose checks to have inaccurate readings. * The facility failed to ensure the freezer compartment inside the refrigerator used for medications in Medication Room A was free of ice buildup. This failure had the potential to affect the refrigerator's functionality and the potential to affect the potency of the medications stored inside the refrigerator. Findings: 1. Review of the Assure Platinum Blood Glucose Monitoring System Quality Assurance/ Quality Control Reference Manual, revised 8/2023, under Performing a Control Solution Test section, showed the following: - Check the meter and test strips using Assure dose control solutions to confirm the meter and test strips are working properly; - Before using a new meter…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, medicalrecord review, and facility P&P review, the facility failed to ensure the controlled substance medications (medications with high risk for abuse andaddiction) were appropriately accounted for one of two sampled residents (Resident 1). This failure had the potential to negatively affect the health and safety of the resident. Findings: Review of the facility's P&P titledControlled Medications dated 8/2014 showed the medications included in the Drug Enforcement Administration (an agency which enforces the United States' controlled substance laws and regulation) classification as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility, in accordance with federal and state laws and regulations. When a controlled medication is administered, the license nurse administering the medication immediately enters the following information on the accountability record and the medication administration record (MAR): A. Date and time of administration…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 send a copy of the transfer/discharge notice to the Long-Term Care Ombudsman for one of three closed record sampled residents (Resident 54). This posed the risk of the Ombudsman not being aware of the circumstances should an appeal be filed by the resident or their representative regarding the transfer/discharge. Findings: On 8/4/21, closed medical record review was initiated for Resident 54. Resident 54 was admitted to the facility on [DATE], and discharged on 6/4/21, to the general acute care hospital. Review of the Notice of Transfer/discharge date d 6/4/21, showed the section to document if a copy of the notice was sent to State Long-Term Care Ombudsman was not checked off and the date was blank. On 8/4/21 at 1538 hours, an interview was conducted with the SSD. The SSD was asked if the facility provided a copy of the Notice of Transfer/Discharge to the Long-Term Care Ombudsman when the resident was sent to the acute care hospital. The SSD…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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. Review of the facility's P&P titled Change of Condition dated 3/2021 showed it is the policy of this facility that any significant changes in a resident's condition be thoroughly assessed and evaluated with physician notification for early clinical management to avoid unnecessary readmissions to acute hospitals. The facility may use the SBAR process to access and evaluate the resident's change of condition. Medical record review for Resident 24 was initiated on 8/2/21. Resident 24 was was initially admitted to the facility on [DATE], and readmitted on [DATE]. On 8/2/21 at 0800 hours, Resident 24 was observed with a dried blood clot on the left side of his lips and had a small amount of blood dripping down his left cheek. On 8/2/21 at 0851 hours, the left side of Resident 24's lips was observed bleeding with a small amount of blood dripping down his left cheek. LVN 5 was asked to come to the resident's room. LVN 5 stated she did not see the bleeding this morning. LVN 5 cleaned the resident with a towel. 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 2. Medical record review for Resident 31 was initiated on 8/4/21. Resident 31 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of the MDS dated [DATE], showed Resident 31 was cognitively intact and totally dependent on two or more staff members for bed mobility. Review of the Braden Scale for Predicting Pressure Sore Risk dated 7/6/21, showed Resident 31 was at moderate risk for developing pressure ulcers. On 8/4/21 at 1044 hours, a wound treatment observation for Resident 31 was conducted with LVN 2 and CNA 1. Resident 31's left flank, from the left scapula to the left lower rib cage, was observed with a large area of opened skin, measuring 23 cm (length) x 15 cm (width). The flank area was red and had sanguineous drainage, and some areas had bleeding. The whole wound was observed covered in a white substance. The resident's linen was observed spotted with red blood. When asked about Resident 31's left flank, LVN 2 stated he was not aware Resident 31 had the skin breakdown on his left…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to provide the necessary care and services to ensure adequate assistance was in place for one of 14 final sampled residents (Resident 15). This posed the potential for Resident 15 to sustain a fall or injuries. Findings: Medical record review for Resident 15 was initiated on 8/2/21. Resident 15 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of the MDS dated [DATE], showed Resident 15 had severe cognitive impairment. Resident 15 required total assistance from two or more persons for bed mobility and transfers. The assessment showed Resident 15 had functional limitation of the upper and lower extremities. Review of Resident 15's plan of care showed a care plan problem revised 4/30/21, addressing Resident 15's risk for fall or injury related to poor safety awareness, impaired balance, gait problem, and required assistance with transfers. Further review of the plan of care showed a care plan problem revised…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to provide the necessary care and services to attain and maintain the highest physical well-being for one of 14 final sampled residents (Resident 152) who required dialysis. * The facility failed to ensure the physician's order for a 1000 ml fluid restriction (a diet which limits the amount of daily fluid consumption) was followed and carried out accordingly. This had the potential to result in Resident 152 having excess fluids which may affect other vital organs in the body due to impaired kidney function. Findings: Medical record review for Resident 152 was initiated on 8/5/21. Resident 152 was admitted to the facility on [DATE], with End Stage Renal Disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life) required hemodialysis (a process of purifying the blood of a person whose kidneys are…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 14 final sampled residents (Resident 103) and one nonsampled resident (Resident 21) were assessed for entrapment associated with the use of elevated grab bars and informed consent was obtained for the use of the grab bars. * The facility failed to ensure the assessments for the risk for entrapment were completed for Residents 21 prior to the use of grab bars. In addition, the facility failed to develop a plan of care addressing the use of grab bars. * The facility failed to ensure Resident 103 was assessed for the risk of entrapment nor an informed consent was obtained for the use of the grab bars. These failures had the potential to put the residents at risk for entrapment and serious injury. Findings: The FDA issued a Safety Alert entitled Entrapment Hazards with Hospital Bed Side Rails. Bed rails are adjustable metal or rigid plastic bars that attach to the bed and are available in a variety…

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

Based on observation, interview, and facility P&P review, the facility failed to ensure proper accounting and safeguarding of the controlled medications in order to prevent loss, diversion, or accidental exposure. * The facility failed to ensure the incoming and outgoing licensed nurses assigned to Medication Cart B consistently signed the Narcotic Count Sheet log. This failure created the risk of drug diversion in the facility. Findings: According to the facility's Policy and Procedure titled Controlled Medication Storage dated 8/2014, under the section Policy, showed medication included in the Drug Enforcement Administration classification as controlled substances are subject to special handling, storage, disposal and recordkeeping in the facility in accordance with federal, state and other applicable laws and regulations. Under the section Procedures, showed at each shift change, a physical inventory of all controlled medications, including the emergency supply, is conducted by two licensed nurses and is documented on the controlled medication accountability record. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to ensure the Pharmacy Consultant's recommendations were acted upon for one of 14 final sampled residents (Resident 15). The Pharmacy Consultant recommended for a lipid panel test (complete cholesterol test, a blood test that can measure the amount of cholesterol and triglycerides in the blood) for the use of simvastatin (medication used to treat high cholesterol and triglyceride levels) was not acted upon. The facility's failure to act upon the Pharmacy Consultant's recommendations had the potential to put Resident 15 at risk for adverse consequences related to the medication. Findings: Medical record review for Resident 15 was initiated on 8/2/21. Resident 15 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 21's Physician Order Report showed a physician's order dated 7/26/19, for simvastatin 10 mg to be given at bedtime. Review of the Medication Administration Record for June, July, and August 2021 showed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to ensure one of 14 final sampled residents (Resident 15) was free from unnecessary psychotropic drugs (any drug that affects brain activity). * The facility failed to ensure the side effects were monitored for the administration of valproic acid (anticonvulsant, medication used to treat seizures and bipolar disorder). This had the potential for Resident 15 to have adverse complications from the medication. Findings: Medical record review for Resident 15 was initiated on 8/2/21. Resident 15 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 15's Physician Order Report showed the following physician's orders dated: - 10/18/19, to monitor episodes of calling out for no apparent reason every shift and tally by hashmarks; and - 9/30/20, to administer valproic acid 125 mg at bedtime for schizoaffective disorder bipolar type manifested by episodes of calling out for no reason. Review of the Medication Administration…

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

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 28.57%. * LVN 3 failed to administer Resident 9's medications in a timely manner. This failure posed the risk of complications and ineffective therapeutic effects of the medications. Findings: According to the facility's policy titled Preparation and General Guidelines: Medication Administration General Guidelines dated October 2017, under administration, showed medications are administered within 60 minutes of scheduled time (one hour before and one hour after), except before or after meal orders, which are administered based on mealtimes. Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the facility. On 8/4/21 at 1112 hours, a medication administration observation was conducted with LVN 3 for Resident 9. LVN 3 stated Resident 9's medications were due at 0900. LVN 3 prepared the following…

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

Based on observation, interview, and facility P&P review, the facility failed to implement their infection control P&P designed to prevent the spread of infection in the facility. * The facility failed to ensure LVN 6 wore a faceshield in the resident care areas. In addition, the facility failed to ensure the faceshield was stored or discarded properly. * Multiple medication bottles in Medication Cart A had stains and sticky residues. The medication drawer holding the liquid medications in Medication Cart A had sticky residues. These failures had the potential for the spread of infection in the facility. Findings: Review of the facility's Corona Virus Disease 2019 (Covid 19) Mitigation Plan revised 7/30/21, under Personal Protective Equipment, showed to use universal face mask and eye protection while in the facility and resident care areas. 1. On 8/4/21 at 0833 hours, LVN 6 was observed going inside Room A. LVN 6 was observed wearing a mask but not wearing a faceshield. On 8/4/21 at 0838 hours, LVN 6 was observed going inside Room C. LVN 6 was observed wearing a mask but not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 maintain an effective pest control program. * The fire exit door at Nurses' Station B was observed to be left ajar. In addition, a gap was observed at the bottom portion of the fire exit door and floor threshold. An open cracked area on the left lower corner of the fire exit door was observed. These failures posed the risk for vermin entering the facility and potential safety hazard for the residents, staff, and visitors. Findings: On 8/2/21 at 0900 hours, a concurrent observation and interview was conducted with the IP. The fire exit door located at the end of the hallway in Nurses' Station B was observed to be left open. In addition, an open cracked area was observed on the left lower corner of the fire exit door. A gap was also observed between the bottom of the fire exit door and the floor threshold. The IP verified the findings and stated the exit door had to remain shut at all times. Review of the Orkin Pest Control Down to a Science Invoice dated 5/26/21, showed sightings of cockroaches in the employee bathroom 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.