Park Anaheim Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and facility's P&P review, the facility failed to ensure the care plans were revised and updated for one of 23 final sampled residents (Resident 54) reviewed for care plans. * The facility failed to ensure Resident 54's activity care plan was revised to reflect the resident 's current condition and needs when Resident 54 was no longer on a mechanical ventilator. This failure posed the risk for the resident to not receive a current individualized and person-centered care.Findings: Review of the facility's P&P titled Care Plans, Comprehensive Person – Centered revised 3/2023 showed a comprehensive, person-centered care plan that include measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Assessments of residents are ongoing, and care plans are revised as information about the residents and the resident's conditions change. The interdisciplinary team reviews and updates the care plan:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to ensure two of 23 final sampled residents (Residents 11 and 13) attained and maintained their highest practicable well-being. * The facility failed to follow the physician's order to check and record the orthostatic blood pressure for Resident 11. * The facility failed to ensure to continuously monitor Resident 13 when the resident had a change in condition. These failures had the potential for the residents to not receive the necessary care and services when the residents had a change in condition. Findings: 1. Review of the facility's P&P titled Change in a Resident's Condition or Status revised 3/2023 under the Policy Interpretation and Implementation section showed: - Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility document review, the facility failed to ensure the necessary care and services were provided to prevent the development of pressure injuries or worsening of the existing pressure injuries for one of two final sampled residents (Resident 40) reviewed for pressure injuries. * The facility failed to ensure Resident 40's LAL mattress setting was appropriate to the resident's weight. This failure had the potential for Resident 40 to develop pressure injuries or worsening of the existing pressure injuries.Findings: Review of the facility's document titled Proactive Medical Products Operation Manual for Protekt Aire 4000DX/5000DX (undated) showed users can adjust air mattress to a desired firmness according to patient's weight. Medical record review for Resident 40 was initiated on 3/22/26. Resident 40 was admitted to the facility on [DATE]. Review of Resident 40's H&P examination dated 3/10/26 , showed the resident had the capacity to understand and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, facility document review, and facility P&P (Policy and Procedures) review, the facility failed to ensure the necessary care and services were safely provided using two person assistance for one of 23 final sampled residents (Resident 12) and three of three nonsampled residents (residents who are not included in the finalized survey sample, Residents 22, 49, and 70) reviewed for falls. * The facility failed to ensure the two person assistance was provided when providing ADL (Activities of Daily Living) care to Resident 12. Resident 12 sustained a fall when a one person assistance was provided during care which resulted to a right foot first metatarsal (big toe) fracture. In addition, the facility failed to ensure Residents 22, 49, and 70 were provided with two person assistance during care. These failures had the potential to affect Residents 12, 22, 49, and 70 care and safety, and may have contributed to Resident 12's fall which resulted to right foot first…

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 GT care and services for five of 23 final sampled residents (Resident 8, 12, 42, 54 and 104) with enteral feeding orders. * The facility failed to ensure Residents 8, 12, 42, and 104 were administered the total amount of enteral feedings as ordered by the physician. * The facility failed to ensure Resident 54 was positioned safely at 30 to 45 degrees during the enteral feeding via GT. In addition, the facility failed to follow Resident 54's physicians order to hold the enteral feeding one hour before the administration of phenytoin (a prescription anticonvulsant used to treat and prevent seizure). These failures had the potential for the residents to have undesirable outcomes, including aspiration and risk for weight loss.Findings: 1. According to Taylor's Fundamentals of Nursing seventh edition, Nursing Considerations with Tube Feeding, make sure the resident is as upright as possible…

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 record review, the facility failed to provide the respiratory care and services for one of two nonsampled residents (Resident 84) reviewed for respiratory care. * The facility failed to ensure Resident 84 was administered with the oxygen as prescribed by the physician. This failure had the potential to negatively impact the resident's health outcomes.Findings: Review of the facility's P&P titled Oxygen Administration dated 10/2010 showed:- under preparation: to verify there is a physician's order and to review the physician's order.- under procedure steps: to turn on the oxygen and unless otherwise ordered, start the flow of oxygen at the rate of two to three liters per minute. Medical record review for Resident 84 was initiated on 3/23/26. Resident 84 was admitted to the facility on [DATE]. Review of Resident 84's H&P examination dated 8/28/25, showed Resident 84 was too ill to make simple needs known due to her poorly responsive state and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure the dialysis care and services were provided for one of 23 final sampled residents (Resident 10) reviewed who was receiving dialysis (life sustaining medical treatment which filters waste, toxins, and excess fluids from the blood when the kidneys fail) care. * The facility failed to ensure the instructions from the dialysis center was addressed for Resident 10 on 11/27/25. This failure had the potential to result in health complications for Resident 10.Findings: Review of the facility's P&P titled Care of a Resident with End Stage Renal Disease (ESRD) dated 9/2010 showed agreements between this facility and the contracted ESRD facility included all aspects of how the resident's care will be managed , including but not limited to how the care plan will be developed and implemented, how transportation will be arranged and how the information will be exchanged between the facilities and the resident's care plan will…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided for the used of side rails for one of three final sampled residents (Resident 20) reviewed for the use of the bed rails. * The facility failed to ensure the physician's order and informed consent were obtained, the physical assessment was completed, and less restrictive alternatives were attempted prior to Resident 20's use of the bed rails. These failures had the potential for the resident to receive unnecessary measures and for the resident to not be aware of the risk and benefits of the side rails' use. Findings: Review of the facility's P&P titled Bed Safety and Bed Rails revised 3/2023 showed before using bed rails for any reason, the staff shall inform the resident or representative about the benefits and potential hazards associated with bed rails and obtain informed consent. The following information will be included in the consent:- The assessed…

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 an accurate nurse staffing information was posted daily for residents and visitors to view, for one of three nursing stations (Station A). * The facility's posted staffing information observed on 3/22/26, had a date of 3/18/26. This failure had the potential of not having the staffing information be available to the residents and the public to determine if sufficient staff were available to care for the residents.Findings: Review of facility's P&P titled Posting Direct Care Daily Staffing Numbers revised 8/2022 showed our facility will post on a daily basis for each shift nurse staffing data, including the number of nursing personnel responsible for providing direct care to residents; the information record on the form shall include the current date (the date for which the information is posted). On 3/22/26 at 0911 hours, the Daily Nurse Staffing information posting on the bulletin board in front of Station A, SNF side, next to the storage room was observed with the 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, and facility P&P review, the facility failed to ensure the drugs, biologicals, or medical supplies were stored in a safe manner. * The facility failed to ensure Resident 104's GT feeding was not left at the bedside unattended. This failure had the potential for the GT feeding to be accidentally administered or used inappropriately.Findings: Review of the facility's P&P titled Administering Medications revised 3/2023 showed the medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame. Medical record review for Resident 104 was initiated on 3/22/26. Resident 104 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 104's H&P examination dated 12/1/25, showed Resident 104 had no capacity to understand and make decisions. Review of Resident 104's Order Summary Report for 3/2026 showed the following physician's orders: - dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the nursing staff reported laboratory results to the physician in a timely manner for one of 23 final sampled residents (Resident 20). * The facility failed to ensure the UA C&S (Urinalysis with Culture and Sensitivity) laboratory results were reported to the physician in a timely manner. Resident 20's UA C&S laboratory results were available on 3/15/26; however, the results were not reported to the physician until 3/19/26. This failure had the potential to result in a delay of care and risk for adverse complications for Resident 20.Findings: Review of the facility's P&P titled Lab and Diagnostic Test Results - Clinical Protocol revised 3/2023 showed when the test results are reported to the facility, a nurse will first review the results. a. If staff who first receive or review lab and diagnostic test results cannot follow the remainder of this procedure for reporting and documenting the results 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 interview, medical record review, and facility P&P review, the facility failed to ensure complete and accurate medical records for one of 23 final sampled residents (Resident 7). * The facility failed to ensure the amount of GT feeding formula administered to Resident 7 was documented on the resident's Intake record. This failure had the potential for Resident 7's care needs not being met as the resident's medical information was inaccurate.Findings: Review of the facility's P&P titled Procedure: Measuring & Recording Fluid Intake & Output (undated) showed the facility will monitor intake or output as ordered; measure and record the amount of intake and output for every 24-hour period. Review of the facility's P&P titled Charting and Documentation revised 7/2017 showed documentation in the medical record will be objective (not opinionated or speculative), complete and accurate. Medical record review for Resident 7 was initiated on 3/24/26. Resident 7 was admitted to the facility on [DATE], and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care and services for one of four sampled residents (Resident 4). * The facility failed to ensure Resident 4's suction canister was changed. This failure had the potential to affect the respiratory health and well-being of the resident. Findings: Review of the facility's P&P titled Suction Canister Disposal dated July 2014 showed the suction canisters will be changed weekly, ¾ full, and PRN. Medical record review for Resident 4 was initiated on 5/7/25. Resident 4 was readmitted to the facility on [DATE]. Review of Resident 4's H&P examination dated 8/13/24, showed Resident 4 had the capacity to make and understand his own decision. Review of Resident 4's RT- Continuous Ventilator Flow Sheet dated 5/2/25 at 1800 hours, showed the suction canister was changed. On 5/7/25 at 1223 hours, Resident 4 was observed on the ventilator (medical device used to assist or take over the…

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

Based on observation, interview, and facility P&P review, the facility failed to ensure the resident equipment was maintained in a safe operating condition. * An air fryer (countertop appliance used to cook food) and Keurig coffee machine were observed in Resident 4's room. This failure had the potential for the equipment to not function in the way it was intended and exposed to potential fire hazards. Findings: Review of the facility's P&P titled Electrical Appliance revised January 2019 showed the following: 1. Residents may not maintain any electrical appliance (i.e., heating irons, cooking utensils, etc ) within their living areas unless approved by the administrator or his/her designee. 2. Should the electrical appliances be permitted, each must be in good working order, free of frayed cords, and UL approved. On 5/7/25 at 0747 hours, during the initial tour of the facility, an air fryer was observed on the bedside table close to the patio door in Room A. On 5/7/25 at 1115 hours, a follow-up observation of Room A and concurrent interview was conducted with LVN 2 and Resident 4.…

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

Based on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to ensure one of three sampled residents (Resident 1) attained and maintained the highest practicable physical well-being. * The facility failed to ensure the proper documentation was completed as per the facility's protocol for Resident 1 who had a change in condition. This failure had the potential for Resident 1 to not be provided with the appropriate care and monitoring. Findings: Review of the facility's P&P titled Change of Condition, under Section E, showed the documentation of the change in condition shall be performed by the Licensed Nurse accordingly: 1. Documenting for at least 72 hours, or longer if condition change warrants 2. Using appropriate form for daily charting 3. Documenting vital signs each shift 4. Care plan evident 5. Reassessing MDS (if change is significant) 6. IDT conference if indicated 7. Reassess resident condition as needed 8. COC/SBAR will be completed as indicated Medical Record review for Resident 1 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.

Based on observation, interview, facility document review, and P&P review, the facility failed to ensure the DSS was competent in the day-to-day supervision of the kitchen as evidenced by: 1. Fried eggs were not pasteurized or cooked thoroughly for one of three non-sampled residents (Resident 33). 2. The DSS did not know the correct procedure to calibrate a thermometer. 3. The DSS did not know the manufacturer guidelines for the health shakes. 4. The DSS did not ensure food preparation equipment was replaced when worn. 5. The DSS did not ensure beard coverings were available for kitchen staff with facial hair. 6. The DSS competency was not evaluated by the Administrator. These failures posed the risk for 62 vulnerable residents who received food prepared in the kitchen to be exposed to potential food borne illnesses. Findings: Review of the facility's document titled Order Listing Report dated 3/11/25, showed 62 residents received food prepared in the kitchen. Review of the job description titled Dietary Manager signed and dated by the DSS on 2/24/14, showed the Dietary Manager…

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 P&P review, the facility failed to ensure two of 10 kitchen employees (Cook 1 and DA 1) were competent in their daily job duties when: 1. [NAME] 1 failed to perform the following: - Follow proper hand hygiene, - Take food temperatures correctly during meal service, - Prepare resident meals according to the facility recipes, - Accurately test the sanitizing solution used to sanitize food preparation surfaces, and - Utilize the manual dishwashing process correctly. 2. DA 1 was unable to read the temperature dial of the dish machine. These failures posed the risk for unsafe food handling practices which could expose the 62 residents who received food prepared in the kitchen to food borne illnesses. Findings: Review of the facility's document titled Order Listing Report dated 3/11/25, showed 62 residents received food prepared in the kitchen. 1. Review of the facility's job description titled [NAME] signed by [NAME] 1 (undated) showed the [NAME] is responsible for the preparation of all dietary components in accordance with…

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 menus were followed when the recipes for puree meat, vegetables, and starch were not adhered to. This failure had the potential for the nutritional needs to not be met for 15 residents who received a puree diet. Findings: Review of the Order Listing Report dated 3/11/25, showed 15 residents had the physicians' orders for the pureed diet. 1. Review of the facility's document titled Recipe: Puree (IDDSI Level 4) Meats dated 2024 showed 12 servings mix 12 to 24 oz (1 ½ to 3 cups) warm fluid such as gravy, or low sodium both. If the meat is moist, you can start with only a few ounces of liquid. These amounts are only an average and may vary. If needed: Stabilizer: for 12 serving to mix 6 to 12 Tbsp (3/8 - ¾ cup) instant potato, non -fat dry milk, breadcrumbs, toast, instant cream of rice or farina, or commercial instant food thickener. On 3/12/25 at 1002 hours, an observation of the puree meat preparation and concurrent interview was conducted with [NAME] 1. [NAME] 1 stated he was preparing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, facility document and facility P&P review, the facility failed to ensure the food safety and sanitary requirements were met in the kitchen as evidenced by: * The facility failed to ensure the egg served was fully cooked when there were no pasteurized eggs were available. * The facility failed to ensure the proper hand hygiene was followed during the food preparation. * The facility failed to ensure the fish thawing process was followed. * The facility failed to the ensure the automatic dish washing water temperature reached the acceptable range. * The facility failed to ensure the manual dishwashing process was followed. * The facility failed to ensure the refrigerated food items were stored properly. * The facility failed to ensure the ice storage was in sanitary condition. * The facility failed to ensure the hair restraints were available and worn by staff in the kitchen. * The facility failed to ensure the kitchen equipment were maintained in a sanitary condition. * The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the care was provided in a manner which promoted dignity and respect for one of four final sampled residents (Resident 84) reviewed for indwelling urinary catheter and one of 24 final sampled residents (Resident 71) reviewed for privacy. * The facility failed ensure Resident 84's indwelling urinary drainage bag was fully covered. * Resident 71's body parts were exposed while being transferred to a shower bed. These failures have the potential to negatively affect the resident's emotional well-being. Findings: 1. Review of the facility's P&P titled Dignity revised 2/2021 showed the staff are expected to promote dignity and assist the residents; for example: helping resident to keep urinary bags covered. The P&P also showed each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, and feelings of self-worth and self-esteem.…

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 the informed consents for four of 24 final sampled residents (Residents 10, 44, 72, and 85) and one nonsampled resident (Resident 20) were completed as per the facility's P&P. * The facility failed to ensure the informed consents for Residents 10, 20, 72, and 85 were signed and dated by the physician. * The facility failed to ensure Resident 44's informed consent for the use of the Abilify (antipsychotic medication) was signed and dated by the physician. These failures posed the risk of residents and their responsible parties not to be informed of their treatments and the potential side effects. Findings: Review of the facility's P&P titled Informed Consent dated 12/2024 showed to ensure the residents and/or their representatives are fully informed of the benefits, risks, frequency/duration and alternatives before initiating the administration of the psychotherapeutic drugs or physical…

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 maintain a copy of an advance directive in the medical record for one of six final sampled residents (Resident 34) reviewed for advance directives. This failure had the potential for Resident 34's decisions regarding his healthcare and treatment options to not be honored. Findings: Review of the facility's P&P titled Advance Directive revised 9/2022 showed prior to or upon admission of a resident, the Social Service Director or designee will inquire of the resident, his/her family members and /or his or her legal representative about the existence of any written Advance Directives. Further review of the P&P showed if the resident or the resident's representative has executed one or more advanced directives, or executes one upon admission, copies of these documents are obtained and maintained in the same section of the residents' medical record and are readily retrievable by any facility staff. Medical record review for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the appropriate restraint use, including skin assessment, removal of restraint, and ROM exercises for three of three final sampled residents (Residents 41, 72, and 100) reviewed for the use of the restraints. * Resident 100 did not have a physician's order and consent for the use of the elbow restraint, and no documentation of the restraint removal, and if the arm was assessed and exercised every two hours. * Residents 41 and 72's medical records failed to show their hand mitten restraints were removed, and if their hands were assessed and exercised every two hours. These failures had the potential for the increased risk of resident's skin and soft tissue injury as well as the decrease in the ROM functions related to restraint use. Findings: Review of the facility's P&P titled Use of Restraints revised April 2017 showed the following: - Restraints will only be used with a physician's order and after…

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 notify the resident and/or their representative of the transfer and reasons for the transfer in writing when the resident was transferred to the acute care hospital for two of three final sampled residents (final sampled residents, Residents 11 and 84) reviewed for hospitalization. This failure had the potential for the resident and their representative of not knowing about the appeal process and the circumstances of the resident's transfer/discharge should the resident and their representative believe the transfer or discharge was inappropriate or involuntary. Findings: 1. On 3/11/24 at 1010 hours, an interview was conducted with Resident 11. Resident 11 stated she was transferred to the acute acre hospital on or around 7/20/24. Resident 11 was asked if the facility provided the written Notice of Transfer/Discharge when she was transferred to the acute care hospital. Resident 11 stated the facility did not provide Resident 11 or her…

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 resident and/or their representative were provided with the written information regarding the facility's bed-hold policy when the resident was transferred to the acute care hospital for two of three final sampled residents (Residents 11 and 84) reviewed for hospitalization. This failure had the potential for Residents 11 and 84 and/or their representative to be unaware of their rights to request a bed hold and return to the first available bed should the resident's hospital stay exceed the seven-day bed-hold period. Findings: Review of the facility's P&P titled Bed-Holds and Returns dated 3/2022 showed all the residents/representatives are provided written information regarding the facility bed hold policies, which address holding or reserving a resident's bed during period of absence (hospitalization or therapeutic leave). The residents are provided written information about this policy at least twice well in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to develop and implement the plan of care for one of 24 final sampled residents (Resident 100). * Resident 100's care plan failed to address the resident's ventilator use at night and left elbow restraint use. This failure had the potential for the resident's plan of care not being communicated to the interdisciplinary team. Findings: Medical record review for Resident 100 was initiated on 3/11/25. Resident 100 was readmitted on [DATE]. a. On 3/11/25 at 0854 hours, an observation was conducted at Resident 100's bedside. The resident had an elbow splint on his left arm, keeping the arm extended and preventing the arm from bending. On 3/12/25 at 0754 hours, Resident 100 was observed lying in bed, with their eyes closed. The elbow splint was observed applied to the resident's left arm, keeping it extended. On 3/13/25 at 0812 hours, an interview was conducted with CNA 6. CNA 6 stated Resident 100 had the elbow splint prior 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 observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure one of 24 final sampled residents (Resident 47) remain free from accident hazards. * The facility failed to apply the tab alarm (a fall prevention device designed to alert caregivers when a person attempts to get out of the bed, chair, or wheelchair) for Resident 47 as ordered by the physician. This failure had the potential to place Resident 47 at risk for serious injuries. Findings: Review of the facility's P&P titled Alarm Monitor (undated) showed the licensed nurse will complete the physical restraint assessment to determine whether the resident is a candidate for alarm monitor. The assessments will include but are not limited to : - The medical symptoms warrant the use of alarm monitor. - The less restrictive measures attempted prior to the alarm. - The type of alarm to be used: - Tab alarm; - Pad alarm (a fall prevention device designed to alert caregivers when a person…

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 verify the GT placement, patency, and gastric residuals prior to starting an enteral tube feeding for one of four residents investigated for tube feeding (final sampled resident, Resident 100). This failure had the potential for adverse outcome related to a dislodged GT or increased gastric residuals. Findings: Review of the facility's P&P titled Enteral Tube Feeding via Continuous Pump revised March 2023 showed to verify placement of the GT, and when placement has been verified, flush the tubing with at least 30 ml of water. Medical record review for Resident 100 was initiated on 3/11/25. Resident 100 was readmitted to the facility on [DATE]. Review of Resident 100's Order Summary Report showed the following physician's orders: - dated 1/3/25, to check the GT feeding residual every shift and hold the enteral feeding for one hour if the residuals are more than 100 ml. - dated 1/3/25, to run 40 ml of water…

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 three final sampled residents (Residents 52, 82, and 712) reviewed for respiratory care were provided the appropriate respiratory care. * The facility failed to ensure Residents 82 and 712's oxygen tubings were labeled and dated. * The facility failed to ensure Resident 52 was administered the oxygen as per the physician's order. These failures had the potential to affect the respiratory health and well-being of the residents in the facility. Findings: Review of the facility's P&P titled Oxygen Administration dated 10/2010 showed for the oxygen administration preparation, to verify that there is a physician's order for this procedure, review the physician's orders or facility protocol for oxygen administration, review the resident's care plan to assess for any special needs of the resident, and assemble the equipment and supplies as needed. Review of the facility's P&P titled Departmental…

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 non-pharmacological interventions for pain management was provided when one of one final sampled resident (Resident 34) reviewed for pain management. This failure had the potential to negatively affect Resident 34's well-being. Findings: Review of the facility's P&P titled Pain - Clinical Protocol dated 3/2018 showed the physician will order appropriate non-pharmacologic and medication interventions to address the individual's pain. Further review of the P&P showed the staff will provide the elements of a comforting environment and appropriate physical and complementary interventions; for example, positioning/repositioning, local heat or ice, and the opportunity to talk about chronic pain. On 3/11/24 at 0904 hours, Resident 34 was observed lying in her bed. Resident 34 stated she had pain on the right side of her body. RN 1 was observed entering the room of Resident 34. Resident 34 reported having…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to attain or maintain the highest physical well-being for one of one final sampled resident (Resident 10) reviewed for hemodialysis care. * The facility failed to ensure the licensed staff have the competency to assess the hemodialysis access site of Resident 10. This failure had the potential for the delay in hemodialysis site assessment and resident's poor health outcomes. Findings: Review of the facility's P&P titled Care of Resident with End-Stage Renal Disease (undated) showed the following: - Staff caring for residents with ESRD, including residents receiving dialysis care outside the facility, shall be trained in the care and special needs of these residents; and - Education and training of staff includes, specifically the nature and clinical management of ESRD, the type of assessment data that is to be gathered about the resident's condition on a daily basis or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure seven of eight final sampled residents (Residents 9, 45, 47, 51, 52, 89, and 99) reviewed for the side rail use remained free from the accident hazards associated with the use of the elevated side rails. * The facility failed to ensure the side rails assessment was accurate or completed, and/or the least restrictive measures were provided prior to the use of the side rails for Residents 9, 45, 47, 51, 52, 89, and 99. These failures had the potential to put the residents at risk for entrapment and serious injuries. Findings: Review of the facility's P&P titled Bed Safety and Bed Rails revised on 3/2023 showed the following: - The use of bed rails or side rails (including temporarily raising the side rails for episodic use during care) is prohibited unless the criteria for the use of bed rails have been met, including the attempts to use an alternatives, interdisciplinary evaluation, resident assessment,…

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 physician's orders matched the medication label provided by the pharmacy and medication was administered as ordered by the physician for two of three residents (nonsampled residents, Residents 18 and 48) reviewed during the medication administration as evidence by the following: * The facility failed to ensure Resident 18's physician's order for the digoxin (heart medication) matched the instructions shown on the medication label of the bubble pack provided by the pharmacy. * The facility failed to ensure Resident 48's metoprolol tartrate (blood pressure medication) medication was administered with food as ordered by the physician. These failures posed the risk for negative health outcomes to the residents. Findings: Review of the facility's P&P titled Administering Medications revised 3/2023 showed the medications are administered in a safe and timely manner, and as prescribed. The medication 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 interview, medical record review, and facility P&P review, the facility failed to ensure two of five final sampled residents (Residents 34 and 44) were free from the unnecessary psychotropic drugs (any drug that affects brain activity associated with mental processes and behavior). * The facility failed to ensure non-pharmacological interventions were implemented for the depression and anxiety behaviors exhibited by Resident 34. * The facility failed to ensure non-pharmacological interventions were implemented for the bipolar behaviors exhibited by Resident 44. These failures had the potential to place the residents at risk for receiving the unnecessary medications and increased risk of serious medication adverse reactions. Findings: Review of the facility's P&P titled Use of Psychotropic Medication use dated 3/2023 showed in part, a psychotropic drug is any drug that affects the brain activities associated with the mental processes and behavior, which includes the antipsychotics, anxiolytics,…

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 the proper storage and disposal of the medications. * The facility failed to store the external and internal medications separately in Medication Storage Room A and Medication Cart G. * The facility failed to ensure seven out of eight sampled Medication Carts (Medication Carts A, B, C, D, E, G, and H) were maintained in a clean and sanitary manner. * The facility failed to ensure Residents 19 and 98's Assure Platinum Meter Serial Number in the blood glucose monitoring system record were accurately documented. These failures had the potential to negatively impact the residents' well-being, and the potential for the medications to lose the stability and effectiveness. Findings: Review of the facility's P&P titled Storage of Medications dated 3/2023 showed the facility stores all the drugs and biologicals in a safe, secure, and orderly manner. The nursing staff is responsible for maintaining 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.

Based on observation, interview, and facility P&P review, the facility failed to ensure the nutrient content of pureed vegetables was preserved when pureed vegetables were prepared more than one hour prior to meal service and held in an oven at 500 degrees F. This failure posed the risk of 15 residents on a puree diet to not meet their nutritional needs. Findings: Review of the Order Listing Report dated 3/11/25, showed 15 residents had physician's orders for a pureed diet. During the review of the professional reference titled, https://www.healthline.com/nutrition/cooking-nutrient-content, dated 11/7/2019, the reference showed in part, . The following nutrients are often reduced during cooking: water-soluble vitamins: vitamin C and the B vitamins - thiamine (B1), riboflavin (B2), niacin (B3), pantothenic acid (B 5), pyridoxine (B6), folic acid (B9), and cobalamin (B12), fat-soluble vitamins: vitamins A, D, E, and K, and minerals: primarily potassium, magnesium, sodium, and calcium . On 3/12/25 at 1011 hours, an observation of the puree preparation and concurrent interview was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility document review, the facility failed to ensure two of 10 final residents reviewed for dining (Residents 11 and 85) received food prepared in a form to meet their individual dietary needs. * The facility failed to ensure Resident 11 was provided with the minced and moist diet as per physician's diet order. * The facility failed to ensure Resident 85 was provided with the mechanical soft snacks as per the resident's diet order. These failures placed Residents 11 and 85 at risk for aspiration (accidental breathing in of food or fluid into the lungs) or choking. Findings: 1. Medical record review for Resident 11 was initiated on 3/11/25. Resident 11 was readmitted to the facility on [DATE]. Review of Resident 11's SLP Evaluation and Plan of Treatment dated 3/12/24, showed Resident 11 was currently edentulous (toothless) per dentist recommendation and was awaiting a procedure on her gums to improve the ability to wear dentures. Further review of the SLP Evaluation and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, facility document review and facility P&P review, the facility failed to ensure the food preferences were honored for one of 24 final sampled residents (Resident 10). This failure had the potential for decreased meal intake, weight loss, and a negative impact on the resident's psychosocial wellbeing. Findings: Review of the facility's P&P titled Resident Food Preferences (undated) showed the DSS will meet with the resident or representative to go over food preferences, allergies, likes and dislikes upon admission and as needed. The DSS will visit the resident periodically to ensure food preferences are being honored. Medical record review for Resident 10 was initiated on 3/11/25. Resident 10 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of the facility's Resident Council minutes dated 1/14/25, showed Resident 10 requested the collard greens with meals. Review of the the Resident Council Response Form dated 1/14/25, showed the DSS would order…

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 food brought from the outside was stored for three nonsampled residents (Residents 57, 65, and 70). Additionally, the facility failed to ensure the visitors and staff were educated on safe food handling guidelines. These failures had the potential to expose 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 (undated) showed the food from outside sources is discouraged due to concerns with food safety and infection control and maintaining control of therapeutic diet orders. 1. While it is preferred that families and/or friends do not bring foods or beverages into the facility, it is within the resident's right to allow the resident to eat outside food, especially if an individual is eating poorly. If outside food is brought in, the facility is not liable for safety and infection control concerns. a. Review of Resident 70's…

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

Based on observation, interview, and facility P&P review, the facility failed to ensure the facility's garbage and refuse was properly disposed as evidence by: * The facility failed to ensure the waste dumpsters were properly closed. * The facility failed to ensure the organic waste and recycling refuse were handled as per state mandate SB1383. * The facility failed to ensure trash was placed in the appropriate containers and not stored in the trash bags placed on the ground or stacked on hand carts. These failures had the potential to cause unsafe sanitary conditions and potential to harbor pests and rodents. Findings: 1. According to the USDA Food Code 2022, Section 5-501.113 Covering Receptacles: Receptacles and waste handling units for refuse, recyclables, and returnables shall be kept covered. (B) With tight-fitting or doors if kept outside the food establishment, Review of the facility's P&P titled Waste Control and Disposal (undated) showed outside garbage bin should be keep closed at all times and surrounding area must be kept clean. On 3/11/25 at 0733 hours, during 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, document review, and facility P&P review, the facility failed to ensure the medical records were accurately maintained for eight of 24 final sampled residents (Residents 9, 40, 45, 47, 51, 52, 72, 89, and 99). * The facility failed to ensure the respiratory care documentation for Resident 72 were accurate. * The facility failed to ensure the side rails assessment for the risk for entrapment for Residents 9, 40, 45, 47, 51, 52, 89, and 99 were accurate. These failures posed the risk for residents not to receive the necessary care and services as their medical records were not accurate. Findings: 1. Review of the facility's P&P titled Charting and Documentation revised on 7/2017 showed all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the…

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

Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to maintain the infection control program and practices to help prevent the development and transmission of diseases and infections. * Two used mugs and a utensil were sitting on the laundry room's clean sink, and the clean linen shelf had staffs' personal belongings, hand sanitizers and lotion bottles next to the clean linen. * The facility was not cleaning and maintaining their decorative water feature, as well as maintaining logs per the facility's water management program. * Residents 28, 77, 88, and 98's (nonsampled residents) infections were incorrectly listed as meeting McGeer's Criteria on the facility's monthly infection control report. * The LVN failed to maintain infection control practices when initiating Resident 100's GT feeding. * Hand hygiene was not performed prior to the medication administration for Resident 6. * Basins were found in Rooms A, B and C's shared restrooms and were not labeled. These failures resulted in inaccurate infection…

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

Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to implement the antibiotic stewardship program to reduce the risk of unnecessary or inappropriate antibiotic use when one closed record sampled resident (Resident 1) and four nonsampled residents (Residents 28, 77, 88, and 98) were being treated for conditions which did not meet the McGeer's criteria. These failures had the potential of not accurately identifying true infections and exposing the residents to unnecessary antibiotic use. Findings: Review of the facility's P&P titled Antibiotic Stewardship - Review and Surveillance of Antibiotic Use and Outcomes revised 4/2023 showed the IP, or designee will review all antibiotic utilization and identify specific situations that are not consistent with the appropriate use of antibiotics, and the physician will be notified of the review findings. Review of the facility's P&P titled Infections - Clinical Protocol revised 3/2018 showed based on clinical review, the physician and staff will identify whether antibiotics 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.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to maintain the essential equipment in a clean and safe operating condition when: * The ice machine located in the kitchen was not clean and the manufacturer's guidelines for cleaning and sanitizing were not followed. * The walk-in refrigerator floor was not maintained in a clean/sanitary condition. * The microwave used to heat the resident's food was not maintained in a clean condition. These failures had the potential for the essential equipment to not function in the way it was intended and expose residents to unsafe practices, which could lead to food borne illnesses for the residents. Findings: 1. Review of the facility's P&P titled Ice Machine cleaning (undated) showed the ice machine bin will be cleaned and sanitized once a month. The maintenance staff will clean and sanitize the motor (evaporator) every three to six months, depending on manufacturer's recommendation. Review of the ice machine manufacturer guidelines titled [Hoshizaki] Model KML -325/500 Instruction Manual…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to maintain the infection prevention and control program designed to provide thesafe, sanitary comfortable environment to help prevent the transmission of communicable diseasesand infection. * CNA 5 failed to properly perform the proper hand hygiene after removing and disposing the PPE. * The facility failed to ensure the proper disposal of used gowns and gloves in the trash in Room A. These failures had the potential risk to spread and control the infection to the residents, staff personnel, and visitors. Findings: 1. Review of the facility's P&P titled Handwashing/ Hand Hygiene revised April 2023 showed the facility considers hand hygiene the primary means to prevent the spread of infections, all personnel shall follow the handwashing/hand hygiene procedure to help prevent the spread of infections to other personnel, residents and visitors, and the hand hygiene is the final step after removing and disposing or…

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

Based on record review, interviews, and review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to ensure the accuracy of a Minimum Data Set (MDS) assessment for 1 (Resident #60) of 3 sampled residents reviewed for Preadmission Screening and Resident Review (PASSR) requirements. Specifically, the facility failed to ensure Resident #60's annual MDS, with an Assessment Reference Date (ARD) of 07/07/2023, reflected that the resident was considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or related condition. Findings included: A review of the CMS Long-Term Care Facility RAI 3.0 User's Manual, version 1.18.11, dated October 2023, Chapter 3: Overview to the Item-By-Item Guide to the MDS 3.0, A1500: Preadmission Screening an Resident Review (PASRR), revealed, Code 1, yes: if PASRR Level II screening determined that the resident has a serious mental illness and/or ID/DD [intellectual disability/developmental disability] or…

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

Based on observations, record review, interviews, and facility policy review, the facility failed to ensure the use of a bilevel positive airway pressure machine (BiPAP, a machine used to provide noninvasive ventilation) was reflected on the care plan for 1 (Resident #60) of 2 sampled residents reviewed for respiratory care. Findings included: A review of a facility policy titled, Care Plans, Comprehensive Person-Centered, revised in March 2023, revealed, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The policy specified, The comprehensive, person-centered care plan: a. includes measurable objective and timeframes; b. describes the services that are to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being, including (3) which professional services are responsible for each element of care and e. reflects currently recognized standards of practice for problem areas…

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 observations, record review, interviews, and facility policy review, the facility failed to ensure staff assisted with oral care, including brushing teeth, for 1 (Resident #62) of 3 sampled residents reviewed for activities of daily living (ADLs). Findings included: A review of a facility policy titled, Activities of Daily Living (ADLs), Supporting, revised in March 2023, revealed, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). The policy specified, 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming, and oral care). A review of an admission Record revealed the facility admitted Resident #62 on 03/25/2021 with diagnoses that included cerebral palsy, Rett syndrome (a rare genetic neurological disorder), scoliosis, and functional quadriplegia.…

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 observations, record review, and interviews, the facility failed to ensure respiratory equipment was cleaned and stored appropriately between uses for 1 (Resident #60) of 2 sampled residents reviewed for respiratory care. Specifically, Resident #60's bilevel positive airway pressure machine (BiPAP, a machine used to provide noninvasive ventilation) mask was cleaned and stored in a plastic bag after each use. Findings included: A review of an admission Record revealed the facility most recently admitted Resident #60 on 04/06/2022 with diagnoses that included obstructive sleep apnea. A review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/03/2024, revealed Resident #60 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. According to the MDS, the resident utilized a non-invasive mechanical ventilator while a resident of the facility. A review of Resident #60's Order Summary Report, listing active orders as of 03/08/2024, revealed the following orders dated 07/19/2022: - BiPAP…

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 observations, record review, interviews, and facility policy review, the facility failed to ensure the medication error rate was less than 5 percent (%). Specifically, the facility had 2 errors out of 31 opportunities, resulting in a medication error rate of 6.45%, affecting 1 (Resident #6) of 5 residents reviewed during the medication administration task. Findings included: A review of a facility policy titled, Administering Medications, revised in March 2023, revealed, Medications are administered in a safe and timely manner, and as prescribed. The policy further indicated, 4. Medications are administered in accordance with prescriber orders, including any required time frame. A review of Resident #6's admission Record revealed the facility most recently admitted the resident on 09/22/2021 with diagnoses that included neuromuscular dysfunction of the bladder and calculus of the kidney. A review of Resident #6's March 2024 Medication Administration Record (MAR) revealed the transcription of an order started on 09/22/2021 for Florastor (a probiotic) capsule 250 milligrams…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility document review, the facility failed to provide the necessary care and services for one of three sampled residents (Resident 3) to ensure the resident maintained his highest physical well-being. * The facility failed to ensure the sling was applied appropriately to Resident 3's RUE as per the physician's order. This failure had the potential to affect Resident 3's well-being. Findings: Review of the facility's in-service titled Mobility Precautions, Right Shoulder Sling at All Times, No Right Shoulder Movement, 2 Person Assist, POP Precaution, Donning/Doffing RUE Sling provided by the DOR and DSD on 11/14 and 11/15/23, showed CNA 1 and LVN 2 were in attendance for the in-service. Medical record review of Resident 3 was initiated on 11/20/23. Resident 3 was readmitted to the facility on [DATE]. Review of Resident 3's Order Summary Report dated 11/22/23, showed a physician's order dated 11/14/23, to apply sling on the right shoulder for right…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the worsening of pressure injuries (areas of damaged skin caused by staying in one position for a long time which reduces blood flow to the area and causes the skin to die and develop a sore) and promote the healing of existing pressure injuries for two of three sampled residents (Residents 1 and 2). * The facility failed to provide the appropriate and necessary nursing services to ensure Residents 1 and 2 had no more than two layers of linen between the residents and low air loss mattress. This failure had the potential of Residents 1 and 2 not receiving the appropriate care and services to promote healing or prevent the development of new pressure injuries. Findings: Review of the facility's P&P titled Pressure-reducing Mattresses (undated) showed the objective of the policy was to provide mattresses that will prevent and/or minimize pressure on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P, the facility failed to ensure one of three sampled residents (Resident 3) who received enteral feedings via GT were provided the appropriate treatment and services to prevent complications. * The facility failed to ensure Resident 3 was administered the correct enteral feeding formula as ordered by the physician. In addition, the facility failed to ensure the enteral feeding mechanical pump was operated by a licensed staff for Resident 3. These failures posed the potential risk for not meeting the Resident 3's nutritional needs and potential risk for aspiration during feeding. Findings: Review of the facility's P&P titled Enteral Feedings- Safety Precautions revised 11/2018 showed the purpose of the policy is to ensure the safe administration of enteral nutrition. Under the section Preparation showed all personnel responsible for preparing, storing, and administering enteral nutrition formulas will be trained, qualified and competent in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the nursing staff performed hand hygiene during the wound care treatment for two of three sampled residents (Residents 1 and 2). This failure posed the risk of infection and the transmission of disease-causing microorganisms. Findings: Review of the facility's P&P titled Hand Washing (undated) showed hand washing must be performed in between performance of routine procedures i.e., handling urinals, bedpans, catheters, changing dressings, collecting specimens, etc. Review of the facility's P&P titled Wound Care revised 3/2023 showed the purpose of the policy is to provide guidelines for the care of wounds to promote healing. Under the section Steps in the Procedures showed: (a) put on exam gloves, loosen tape, and remove dressing, (b) pull gloves over the dressing and discard into appropriate receptacle, (c) wash and dry hands thoroughly, and (d) put on gloves. 1. Medical record review for Resident 1 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.