Leisure Court Nursing 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 three final sampled residents (Resident 28) reviewed for elopement was free from accident hazards. * The facility failed to document Resident 28's wandering and/or exit-seeking behaviors and failed to conduct her elopement assessment accurately. Resident 28 was not assessed to be a high risk for elopement; however, the facility staff had observations of the resident verbalizing she wanted to go home or she wanted to leave the facility with her daughter, wandering around the facility, episodes of going outside the facility, and standing by the locked front door to wait for her daughter so she could leave the facility. In addition, the facility failed to provide Resident 28 with an ID bracelet as per the elopement assessment plan. This failure had the potential to not follow the elopement protocol for Resident 28, and the risk for Resident 28 to not be identified immediately and could result to 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, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services related to the GT feeding were provided for one of three final sampled residents (Resident 62) reviewed for tube feeding. * The facility failed to ensure Resident 62's GT feeding rate was updated according to the physician's orders and failed to ensure Resident 62's GT feeding care plans were revised. These failures posed the risk for not providing the necessary GT care and interventions to Resident 62. Findings: Review of the facility's P&P titled Gastrostomy Tube Feeding via Continuous Pump revised 1/2017 showed it is the policy of the facility to provide nourishment via continuous pump to the residents who are unable to obtain adequate nourishment orally, as ordered by the resident's attending physician. On 1/22/25 at 1413 hours, Resident 62's GT feeding formula was observed running at 60ml/hr via GT feeding pump. Medical record review for Resident 62 was initiated 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 provide the necessary care and services for one of one final sampled resident (Resident 37) reviewed for dialysis care. * The facility failed to ensure Resident 37's vital signs and weight were monitored post-dialysis. This failure had the potential for delay in the provision of care to Resident 37 for complications of the dialysis treatment. Findings: Review of the facility's P&P titled Dialysis Care revised 2/2018 showed the following: - The Pre-Dialysis Checklist will be completed by the facility each time the resident is scheduled for dialysis. This checklist includes the vital signs; - The Dialysis Unit Progress will accompany the resident to dialysis and requests that the dialysis unit complete with the pre- and post-dialysis weight and vital signs; and - The Post-Dialysis Checklist is to be completed by the facility upon the return of the resident. Information to be documented included the vital signs. 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 observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of four sampled residents (nonsampled resident, Resident 13) reviewed for side rail use remained free from accident hazards due to the use of side rails. * The facility failed to obtain the physician's order and informed consent, review the risks and benefits, provide the least restrictive alternatives, and develop the plan of care for Resident 13's use of the side rails. This failure had the potential to place the resident at risk for entrapment and serious injury. Findings: Review of the facility's P&P titled Side Rails or Bed Rails revised 8/2018 showed the following: - Informed consent for the physical restraint, including the use of bed or side rails even for episodic use is required to be obtained from the resident or legal representative. Potential negative outcomes and benefits should be discussed. The use of anything attached to a normal bed (i.e. one-fourth rails as an enabler, grab bar…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary pharmaceutical services to one final sampled resident (Resident 82) and one nonsampled resident (Resident 20). * The facility failed to ensure Resident 20's medications were administered as ordered by the physician and accurately documented in the MAR. * The facility failed to ensure the documentation for Resident 82's controlled medication administrations were accurate and complete. * The facility failed to ensure the narcotic sheets inventory were properly conducted showing the nurses' initials and signatures for Medication Cart B. Theses failures had the potential for the resident not to receive the necessary medications and posed the risk for diversion of the medications. Findings: Reviewed of the facility P&P titled Medication Administration revised on 5/2019 showed the following: -Medications must be administered in accordance with the physician orders;…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to ensure two of 24 final sampled residents (Residents 37 and 53) were free from unnecessary drugs. * The facility failed ensure Resident 37 was not administered metoprolol (medication to treat high blood pressure) and clonidine (medication to treat high blood pressure) medications when Resident 37's blood pressure was below the parameter prescribed by the physician. * The facility failed to ensure Resident 53 was administered with metoprolol medication when Resident 53's blood pressure was below the parameter prescribed by the physician. These failures had the potential for the residents to develop the significant side effects such as hypotension and negatively affect the residents' health condition and well-being. Findings: 1. According to DailyMed, the most common adverse effects of the metoprolol and clonidine medications included hypotension. Medical record review for Resident 37 was initiated on 1/21/25. Resident 37 was readmitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure 7 of 11 final sampled residents (Residents 12, 13, 28, 37, 44, 53, and 73) reviewed for unnecessary medications were free from unnecessary psychotropic drugs. * The facility failed to ensure Resident 37's was accurately monitored related to the use of Remeron (antidepressant medication). Resident 37's meal intake documentation was inconsistent, showing either a % or a hashmark, and did not match the CNA's Documentation Survey Report. In addition, the monthly behavior summary of the episodes of Resident 37's meal intake less than 50% did not match the MAR nor the CNA's Documentation Survey Report. * The facility failed to renew the informed consent related to the use of Depakene (mood stabilizer medication), Remeron (antidepressant medication), and risperidone (antipsychotic medication) for Resident 53. In addition, the facility failed to monitor Resident 53's blood pressure for orthostatic…

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 20) was free from the significant medication errors. * The facility failed to provide Resident 20's Zyprexa (antipsychotic medication) as ordered by the physician and accurately document the Zyprexa administration. This failure placed Resident 20 at risk for medical complications. Findings: Review of the facility's P&P titled Medication Administration dated 5/2019 showed the medications are administered in a safe and timely manner, and as prescribed. The medications must be administered in accordance with prescriber orders, including any required time frame. Review of the facility's P&P titled Physician Services and Orders dated 1/2017 showed: - Signed orders for drugs shall be transmitted to the issuing pharmacy within 48 hours of the receipt of the order; - The charge nurse or the DON shall place the order for all prescribed medications; and - Drugs and biologicals…

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 necessary pharmacy services to ensure proper storage of the medications for two of five Medication Cart (Medication Carts A and B) when: * The facility failed to ensure the orally administered medications were stored separate from externally used medications and supplies in Medication Cart A. * The facility failed to ensure Medication Cart B was not left unlocked and unattended by the licensed nurses while parked in the hallway. These failures had the potential to negatively impact the residents' well-being and opportunities for drug diversion or drug misuse. Findings: Reviewed of the facility's P&P titled Storage of Medications effective date 4/2008 showed the following: - Orally administered medications are kept separate from externally used medications. - Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. 1. On 1/23/25 at 1320 hours, a medication cart inspection for Medication Cart A was conducted with LVN…

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 kitchen staff were competent in their position related duties when: 1. Two of 13 kitchen employees (Dietary Aides 2 and 3) were unable to correctly test the sanitizing solution used to sanitize the food preparation surfaces in the kitchen and sanitize the food preparation equipment washed in the manual ware washing sink. 2. One of 13 kitchen employees (Cook 1) did not know the correct cutting board to be use when preparing raw poultry. These failures posed the risk for exposure to unsafe food handling practices which could lead to food borne illness in the 94 vulnerable residents who received food prepared in the kitchen. Findings: Review of the facility's undated matrix showed 94 residents received food prepared in the kitchen. 1. Review of the facility's document titled Employee Evaluation Form dated 10/3/24, signed by the CDM and Dietary Aide (DA) 2 showed DA 2 met expectations in quality of work; work was completed accurately (few or no errors) efficiently 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, and facility document review, the facility failed to ensure the nutritional needs were met for two of 82 nonsampled residents (Residents 11 and 70) who received a vegetarian diet preference when the lunch meal served provided nine grams of protein vs 28 grams of protein per the regular menu. This failure posed the threat of the nutritional needs; specifically the protein needs for Residents 11 and 70 to not be met which could lead to medical complications. Findings: 1. According to the California Health and Safety Code Section 1265.10: Effective 1/1/19, the skilled nursing facilities must make available wholesome, plant-based meals of such variety as to meet the needs of patients in accordance with their physicians' orders. Review of the facility's document titled Cooks Spreadsheet showed the following: Week 4 Wednesday dated 1/22/25, showed for the lunch meal, four ounces Old Fashioned Meatloaf for the entrée for regular diets. The lunch meal entrée served for 1/22/25, 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 P&P review, the facility failed to ensure food brought to the facility from family members or visitors was stored, prepared and safe food handling practices were followed. This failure had the potential for unsafe food handling which could lead to food borne illness in the 94 residents receiving an oral diet who resided in the facility. Findings: Review of the facility P&P titled Food and Liquids from Outside Sources or Other Than the Dietary Department revised 7/2019 showed the food and liquids brought in by visitors for the residents is discouraged due to problems of infection control and conflicts between diets and consistency .Visitors are discouraged from bringing in potentially hazardous foods, i.e. meat, fish, eggs, custards, milk products, etc. If such foods are brought to the resident, they should be consumed immediately and not shared with other residents within the facility .Food items brought into the facility for residents cannot be reheated or stored. They are to be consumed or discarded. On 1/21/25 at 1115 hours, 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 interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for one of one final sampled resident reviewed for hospice services (Resident 49). * The facility failed to ensure Resident 49 received the hospice care visits three times a week by the Certified Home Health Aid and one to three visits a week from the Skilled Nurse. * The facility failed to assign a designated hospice coordinator for Resident 49. These failures posed the risk for delays in the communication between the hospice provider and the facility which may affect resident care. Findings: Review of the facility's P&P titled Hospice Care revised 9/2018 showed the following: - The facility is responsible for ensuring that hospice services meet professional standards and the timelines of the services. - The facility must designate a member of the facility's interdisciplinary team who is responsible for working with hospice representatives to coordinate care to the resident provided…

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

Based on observation, interview, and facility P&P review, the facility failed to ensure the appropriate infection control practices were implemented as evidenced by: * The employees and residents' personal belongings were in the laundry room's clean folding area. * The facility failed to clean the spoon container on the Medication Carts for two of five medication carts inspected (Medication Carts B and C). These failures had the potential for spread of infection. Findings: Review of the facility's P&P titled Infection Control Program System revised 1/2023 showed the personnel must handle, store, process, and transport linens to prevent the spread of infection. Review of the facility's P&P titled Policy for Laundry - Nursing P&P Manual revised 8/2016 showed the linens are handled, stored, processed, and transported in such a manner as to prevent the spread of infection. 1. On 1/27/25 at 1245 hours, a concurrent observation of the laundry room and interview was conducted with the Environmental Services Director (ESD). The following items were observed in the clean folding area: - 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.

Based on observation, interview, and facility document and facility's P&P review, the facility failed to ensure the essential equipment was maintained in proper working order when: * The ice machine manufacturer's guidelines for cleaning and sanitizing were not followed. * The microwave located on Station 1 was not maintained in a safe operating condition. * Two medication refrigerators and one specimen refrigerator were observed with ice buildup. These failures had the potential for equipment hazards or unsafe practices which could affect the residents' well-being in the facility. Findings: 1. Review of the facility's P&P titled Cleaning the Ice Machine revised date of 4/2022 showed the ice machine shall be cleaned for maintenance of sanitary conditions in order to prevent food contamination and the growth of disease- producing organism and toxins. The ice machine shall be cleaned in accordance with the manufacturer's requirements. Review of the [Manitowoc] ice machine model 1-300/420/620 manufacturer's instructions located on the inside panel of the ice machine cover showed 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 3. On 1/21/25 at 0900 hours, during the initial tour of the facility, Resident 37 was observed in bed with bilateral grab rails elevated. Resident 37 stated she used the grab rails when turning and repositioning during incontinence care. Medical record review for Resident 37 was initiated on 1/30/25. Resident 37 was readmitted to the facility on [DATE]. Review of Resident 37's MDS dated [DATE], showed Resident 37 was cognitively intact, with impairment to the upper extremities, and required partial/moderate assistance for mobility. Review of Resident 37's Bedrail/ Grab bar use and Entrapment Risk Evaluation dated 1/3/25, showed the following: - The grab bars were requested by the resident, and the resident demonstrated the ability to use the grab bars; - The possible risks of entrapment were discussed, and verbalized understanding and agreement for continued use. - The Entrapment Zones 1 to 4, and the boxes for yes were checked off; and - The IDT recommended bilateral grab bars for bed mobility/repositioning.…

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 (Resident 1) remained free from the accident hazards. * CNA 1 had provided ADL care to Resident 1 in bed by herself instead of two or more persons to assist as per the resident's MDS and plan of care. When CNA 1 turned the resident to the right side, the resident rolled and fell off the bed to the floor sustaining multiple bruises and a skin tear to the right cheek. This failure had the potential for Resident 1 to sustain serious injury. Findings: Review of the facility's P&P titled Fall Risk/Prevention revised 7/2018 showed the policy of the facility is to identify the residents that are at risk for falls and to implement a plan of care in an attempt to prevent falls. Upon admission, a Fall Risk Assessment will be completed for all residents. If the Fall Risk Assessment score is 10 or above, the resident is at risk for falls and a plan of care will be developed with approaches in 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 interview, medical record review, and facility P&P review, the facility failed to develop and implement the individualized resident-centered plans of care for one of two sampled residents (Resident 2). * Resident 2's care plan interventions were not implemented as recommended in PASRR Level II evaluation. * Resident 2's desire to be discharged to a lower level of care was not assessed by the IDT team and reflected in the plan of care. These failures posed the risk of not providing appropriate and individualized care to Resident 2 to maintain her highest practicable physical well-being. Findings: Review of the facility's P&P titled Comprehensive Care Planning revised 3/2019 showed there should be coordination of the assessment with the Preadmission Screening and Resident Review (PASRR) to ensure that residents with a mental disorder, intellectual disability or a related condition receive care and services in the most integrated setting appropriate to their needs. Coordination includes incorporating…

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

Based on observation, interview, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by: * The facility failed to ensure the ice machine was maintained in sanitary condition. * The facility failed to follow proper sanitation and food handling practices to prevent a potential outbreak of foodborne illnesses during the preparation of pureed foods. These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food prepared in the kitchen. Findings: 1. Review of the form CMS-672 titled Resident Census and Conditions of residents completed by the DON dated 4/18/22, showed 106 of 106 residents residing in the facility received food prepared in the kitchen. According to the FDA Food Code, 2017 4-601.11, it is the standard of practice to ensure non-food contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. Review of the facility form titled Monthly Cleaning and Sanitation of the Ice Machine with multiple…

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 obtain a copy of advance directive for one of 22 final sampled residents (Resident 44). This had the potential for the residents' advanced care planning decisions regarding the health care and treatment options not being honored. Findings: Review of the facility's P&P titled Advance Directives revised 4/2017 showed prior to, or upon admission, the residents will be provided with written information concerning the residents' rights under State law to accept or refuse medical or surgical treatment and the residents' right to prepare an advance directive. 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 44 was initiated on 4/18/22. Resident 44 was admitted to the facility on [DATE]. Review of the POLST dated 2/12/22, showed Resident 44 had an advance directive…

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 DHCS PASRR guidelines review, the facility failed to ensure PASRR Level II Mental Health Evaluation was conducted as required for two of 22 final sampled residents (Residents 44 and 60). This failure had the potential for the residents to not receive the specialized care and services appropriate for their condition. Findings: 1. According to the DHCS, federal law requires all individuals seeking admission to a Medicaid Certified Nursing Facility (NF) to receive a Level 1 Screening. The Level 1 Screening identifies if an individual has a suspected Mental Illness (MI) or an Intellectual/Developmental Disability or Related condition (ID/DD/RC). If MI is suspected, then a Level II Mental Health Evaluation may be conducted to determine if the individual can benefit from specialized mental health services. This process is known as the Preadmission Screening and Resident Review (PASRR). Review of the facility's P&P titled PASRR (Preadmission…

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 the observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for one of 22 final sampled residents (Resident 36) and one nonsampled resident (Resident 35). * Resident 36's Floranex (probiotic supplement) was not administered as ordered by the physician. * Resident 35's florastor (probiotic supplement) and carbonyl iron (supplement) were not administered as ordered by the physician. These failures posed the risk for possible complications related to residents not receiving the prescribed medications. Findings: Review of the facility's P&P titled Preparation and General guidelines IIA2: Medication Administration - General Guidelines dated 10/2017, under the section for Administration, showed the medications are administered in accordance with the written orders of the attending physician. 1. On 4/20/22 at 0929 hours, a medication administration observation for Resident 36 was conducted with LVN 2. LVN 2 prepared and administered…

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 one of 22 final sampled residents (Resident 45). * Resident 45 who had bilateral ½ sides in bed was not assessed for risk for entrapment. This failure posed the risk for injury from side rail use. 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 a resident is caught between the mattress and ed rail or in the bed rail itself. Inappropriate positioning or other care related activities could contribute to the risk of entrapment. According to the facility's P&P titled Siderails or Bedrails revised…

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

Based on the observation, interview, medical record review, and facility P&P review, the facility failed to maintain the accurate medical record for one nonsampled resident (Resident 35). * LVN 1 documented on the MAR for Resident 35's Florastor (supplement) and carbonyl iron (iron supplement) as given when they were not administered during the medication administration observation. In addition, LVN 1 documented both of Resident 35's medications as administered even when they were not available. These failures had the potential for the resident's care not being met as his medication administration was inaccurate. Findings: According to the facility's P&P titled Preparation and General guidelines IIA2: Medication Administration - General Guidelines dated 10/2017, under the section for Documentation, it showed the following: - if a dose of a regularly scheduled medication is withheld, refused or given at other than the schedule time (e.g. the resident is not in the facility at scheduled dose time, or a started dose of antibiotic is needed, the space provided on the front of the 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.

Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the appropriate infection control practices designed to provide a safe and sanitary environment were implemented. * The facility failed to use the appropriate disinfectant to clean the porous foam on Resident 45's bilateral siderails. This posed the risk for not adequately cleaning and disinfecting the resident's equipment. Findings: Review of the facility's P&P titled Infection Control revised 5/2018 showed the facility has established infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Review of the manufacturer's information for Clorox Bleach Germicidal Wipes showed the recommended use is for hard, non-porous surfaces. On 4/20/22 at 0838 hours, Resident 45 bed was observed with the bilateral side rails padded with a gray porous (full of tiny holes or opening, where fluids could go through) material.…

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 regular inspection of all bed frames, mattresses, and side rails as part of the regular maintenance program to identify areas of possible entrapment. This had the potential to negatively impact the residents in the facility. Findings: According to the facility's P&P titled Siderails or Bedrails revised 8/2018, the facility will make sure the bed dimensions are appropriate for the resident's size and weight. The maintenance department will check side rails and bed rails prior to resident's use and monthly for proper installation and functioning. The maintenance department will maintain a log of the side rails check. On 4/18/22 at 1432 hours, and 4/20/22 at 0838 hours , Resident 45 was observed lying in bed. Resident 45 had ½ siderails up on both side of the bed. On 4/20/22 at 1610 hours, an interview was conducted with the Maintenance Supervisor. When asked what the process was for the residents who needed a side rail installed, the Maintenance Supervisor stated the licensed nurses would inform…

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 food safety and sanitation requirements were met in the kitchen. * The facility failed to ensure food in the walk-in freezer was free from contamination. * There was a lack of glaze observed on the dishware. * The facility failed to ensure a refrigerated food item was properly labeled and dated. These failures had the potential to contaminate the food which could lead to food borne illness in a medically vulnerable resident population who consumed food prepared in the kitchen. Findings: Review of the CMS 672 Resident Census and Conditions of Residents completed by the facility dated 12/13/19, showed 90 of 97 residents in the facility received food prepared in the kitchen. 1. According to the USDA Food Code 2017 Section 3-305.11 Food Storage, pathogens can contaminate and/or grow in food that is not stored properly. Drips of condensate .can be sources of microbial contamination for stored food. Review of the facility's P&P titled Food Storage (undated) showed proper food storage procedures 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, and medical record review, the facility failed to develop the comprehensive person-centered care plans for two of 21 final sampled residents (Residents 23 and 439). * Resident 23 was hearing impaired and required hearing aids. The facility failed to develop a care plan problem to address the resident's hearing deficit and use of hearing aids. This had the potential of Resident 23 not having their needs met due to inefficient communication. * The facility failed to develop a care plan problem to address Resident 439's use of an IV and increased sodium. This failure posed the risk of not providing appropriate, consistent, or individualized care to Resident 439. Findings: 1. Medical record review for Resident 23 was initiated on 12/13/19. Resident 23 was admitted to the facility on [DATE]. Review of Resident 23's history & physical examination dated 12/4/19, showed Resident 23 was hearing impaired. Review of the MDS dated [DATE], under Section B, showed Resident 23 had moderate…

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 a vascular access site was maintained and assessed as per the facility's P&P for one of 21 final sampled residents (Resident 76). This had the potential to place the resident at risk for developing a complication related to vascular access associated infections. Findings: Review of the facility's P&P titled IV Therapy dated 6/2018 showed peripheral IV sites will be rotated at least every 96 hours and as needed. Documentation of IV therapy should include IV site assessment. On 12/12/19 at 1540 hours, an observation was conducted of Resident 76. Resident 76 was observed lying in bed with a peripheral IV inserted into her right wrist. The IV site dressing was unlabeled. Medical record review for Resident 76 was initiated on 12/12/19. Resident 76 was readmitted to the facility on [DATE]. Review of Resident 76's medical record failed to show an order for IV therapy. On 12/12/19 at 1546 hours, a concurrent…

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

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 respiratory care and services for one of 21 final sampled residents (Resident 438). The facility failed to ensure the oxygen treatment was documented. In addition, the facility failed to develop a care plan for the oxygen and nebulizer treatment. These failures posed the risk for complications related to respiratory care. Findings: Medical record review for Resident 438 was initiated on 12/12/19. Resident 438 was readmitted to the facility on [DATE]. Review of Resident 438's Physician and Telephone Orders showed the following physician's orders: - 12/9/19, administer Duoneb (a bronchodilator, relaxes muscles in the airway) one unit dose every eight hours as needed for two weeks. - 12/10/19, apply oxygen inhalation 3 liters per minute via nasal cannula (flexible tube to deliver oxygen into the nose) to maintain the oxygen saturation above 90%. a. Review of Resident 438's Medication Record for December 2019…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to ensure ferrous sulfate (an iron supplement) was administered as per the physician's order for one nonsampled resident (Resident 72). * Resident 72 had a physician's order for ferrous sulfate delayed release/enteric coated (DR/EC) 325 mg orally twice a day for anemia. Resident 72 received the incorrect dose (330 mg) and the incorrect form (non DR/EC) of ferrous sulfate on 10 occasions. This posed the risk of Resident 72 not receiving the therapeutic effect of the prescribed supplement. Findings: Medical Record review for Resident 72 was initiated on 12/12/19. Resident 72 was admitted to the facility on [DATE]. Resident 72 had a diagnosis of anemia. On 12/17/19 at 0815 hours, LVN 3 was observed administering Resident 72's prescribed medications. LVN 3 stated Resident 72's medications needed to be crushed before being administered to Resident 72. Resident 72 had a physician's order dated 6/14/19, for ferrous sulfate DR/EC 325 mg…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to ensure two of 21 final sampled residents (Residents 53 and 438) were free from unnecessary psychotropic medications. * The facility failed to ensure two psychotropic medications had a specific behavior manifestation for Resident 53 and failed to accurately monitor the behavior. * The facility failed to ensure the behavior manifestations were monitored for Resident 438 related to the use of Ativan (antianxiety medication). These failures had the potential to negatively impact the residents' well-being. Findings: 1. Medical record review for Resident 53 was initiated on 12/13/19. Resident 53 was admitted to the facility on [DATE]. Review of Resident 53's Physician Order Report showed an order dated 7/29/29, for Depakene solution (a psychotropic medication used to treat mood disorders) 500 mg twice daily for yelling/screaming without provocation. Review of Resident 53's Physician Order Report showed another order dated 9/23/19, for buspirone (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.

Based on observation, interview, and facility P&P review, the facility failed to store the drugs and biologicals in a safe manner. The facility failed to ensure the proper labeling of an insulin medication. * The facility failed to ensure orally administered medications were stored separate from externally used medications and failed to ensure the alcohol wipes were stored separately from medications. This posed the risk for cross-contamination of the medications. * The facility failed to ensure an insulin medication was accurately labeled with an open date for one of 21 final sampled residents (Resident 67). Findings: 1. Review of the facility's P&P Storage of Medications dated 4/2008 showed orally administered medications are kept separate from externally used medications, such as suppositories, liquids, and lotions. Potentially harmful substances such as urine test reagent tablets, household poisons, cleaning supplies, and disinfectants are clearly identified and stored in a locked area separately from medications. On 12/13/19 at 1400 hours, an inspection of Station 2'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.