West Anaheim Medical Center D/P SNF

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to provide the necessary care and services to maintain the intravenous (IV) accesses for one of 12 final sampled residents (Resident 13) reviewed for IV care. * The facility failed to ensure a physician's orders were obtained for the IV fluid and peripheral IV access site rotation every 72 hours and as needed. This failure had the potential to delay the identification of intravenous complication of the resident.Findings: Medical record review for Resident 13 was initiated on 3/24/26. Resident 13 was admitted to the facility on [DATE]. On 3/24/26 at 0937 hours, Resident 13 was observed in bed with the normal saline (NS, sterile solution of 0.9 grams or salt per 100 ml of water) IV fluids infusing from the IV pump machine at 10 ml/hr, which was connected to Resident 13's right hand IV access with a transparent dressing dated 3/22/26. Reviewed Resident 13's physician's order dated 3/24/26, showed to administer cefepime (antibiotic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the pharmaceutical services to ensure the accurate administration of the medications when two of four licensed nurses were observed to have made errors. * LVN 5 failed to follow the administration instructions to dissolve the GlycoLax (laxative) for Resident 21. * During the medication administration observation, LVN 6 failed to administer the Pro-Stat (liquid protein supplement) medication to Resident 6. These failures had the potential to negatively affect the residents' health conditions and posed the risk of possible complications or delay in interventions. Findings: Review of the facility's P&P titled Medication Administration revised 3/2025 showed all dosing frequencies for inpatients will be administered at fixed times approved by nursing and the medical staff. The pharmacy information system would be programmed to include standard medication frequency abbreviations and administration times.…

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

Based on observation, interview, medical record review, and facility P&P review, the facility failed to implement their infection control program in accordance with the facility's P&P. * The facility failed to ensure LVN 1 donned the appropriate PPE during the medication administration observation for Resident 8 via the GT; additionally, LVN 1 failed to disinfect the stethoscope after use and prior to exiting Resident 8's room. * The facility failed to ensure RN 2 removed the gloves, performed hand-hygiene, and donned new gloves in between the administration of eye ointment medication for both eyes. These failures had the potential for the spread of infection to the residents, staff, and visitors in the facility.Findings: 1. Review of the facility's P&P titled Guidelines for Enhanced Barrier Precautions dated 4/2025 showed Enhanced Barrier Precautions refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in long-term care facilities. It involved gown and glove use during high contact resident care activities for residents…

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

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 care and services for the use of GT for one of 12 final sampled residents (Residents 12) and one nonsampled resident (Resident 13). * The facility failed to ensure Resident 12's enteral feeding formula was labeled with the time as per the facility's P&P. * The facility failed to ensure RN 2 checked for gastric residual prior to the administration of the GT medication for Resident 13, as per the facility P&P. These failures posed the risk for complications related to the use of the GT for Residents 12 and 13. Findings: Review of the facility's P&P titled Enteral Feeding, Administration revised 2/2023 showed the pump bags, syringe and tubing are to be changed every 24 hours and properly labeled with the date, time, and nurse's initials. Review of the facility's P&P titled Medication Administration Through a Feeding Tube revised 2/2023 showed medications will be administered via the feeding…

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

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by: * The facility failed to ensure the cutting boards were kept in a sanitary condition and with cleanable surface. * The facility failed to ensure the kitchen utensils were air dried prior to storage. * The facility failed to ensure the kitchen utensils were in good condition. * The facility failed to ensure the kitchen utensils were clean and free of food particle or residue. * The facility failed to ensure the sanitary condition of the hood over the stove was maintained. These failures had the potential for cross contamination and foodborne illnesses to the residents consuming the foods prepared in the facility's kitchen. Findings: Review of the facility's untitled document dated 1/6/25, showed two of 22 residents consumed the foods prepared in the kitchen. 1. Review of the facility's P&P titled Food Preparation revised 1/2023 showed non-porous cutting boards in good condition are used and sanitized…

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 maintain the infection control practices to prevent the development and transmission of diseases and infections. * RN 1 failed to disinfect the stethoscope after use on Resident 1 and prior to exiting the room. * RN 2 failed to disinfect the stethoscope after use on Resident 13 and prior to exiting the room. * CNA 1 failed to remove the gown and gloves and perform hand hygiene after touching Resident 1's surroundings and before touching Resident 10's environment. * Three linen cart covers were observed to be dirty, stained with black, white, and brown colors, and worn out. These failures had the potential to result in the transmission of infection to a vulnerable population of residents in the facility. Findings: Review of the facility's P&P titled Patient Equipment Use Maintenance and Cleaning dated 6/27/21, showed all reusable instruments and equipment will be thoroughly cleaned 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 administer the pneumococcal vaccines to two of five residents reviewed for vaccinations (final sampled residents, Residents 4 and 19). This failure had the potential to cause medical complications related to pneumococcal infections for the affected residents. Findings: Review of the facility's P&P titled Pneumococcal Vaccine, Administration and Guidelines dated 1/2024 showed under section procedure, all the patients will be assessed for prior vaccination history during admission, provide the resident or legal representative with the latest edition of the vaccine information statement developed by the CDC, administer the vaccine, and document in MAR. 1. Medical record review for Resident 4 was initiated on 1/6/25. Resident 4 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident 4's Pneumococcal Vaccine dated 7/8/24, showed Resident 4's RP consented for the resident to receive the pneumococcal…

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 take immediate action to prevent further potential abuse after the allegation of verbal and physical abuse was reported for one of two sampled residents (Resident 1). * The facility failed to immediately remove CNA 1 (alleged perpetrator) from the resident care assignment after the allegation of abuse was reported by Resident 1. The failure had the potential to negatively impact Resident 1's well- being. Findings: Review of the facility's P&P titled Abuse Recognition/ Reporting: Elder/Dependent Adult, reviewed on 2/2024 showed Protection/Reporting- if the incident is not witnessed but reported by a resident, take measures to protect the resident immediately. Remove/separate the resident from the area or ask the individual in question to leave the room or the area. On 11/17/24 at 1420 hours, an interview was conducted with RN 1. RN 1 stated on 10/27/24 between 2100 to 2130 hours, Resident 1 reported being physically and verbally abused by CNA 1. CNA 1 was removed from Resident 1's assignment…

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 medical record review, the facility failed to ensure the proper infection prevention and control measure as evidenced by: * Lack of surveillance, tracking and mapping of suspected and confirmed infection cases. The summary of the monthly infection snapshot did not reflect the accuracy of the actual McGeer's tool for individual resident assessments. The facility did not include the residents who did not meet the McGeer's criteria in the discussion during the quarterly infection control meeting. * The facility failed to provide a system in place to protect the residents, staff, guests, and outside vendors free from possible exposure to infectious diseases by comingling the isolation and non-isolation residents' soiled laundry throughout the facility. These failures posed the increased risk for spread of infectious diseases. Findings: 1. On 1/11/24 at 0901 hours, an interview with the Director of Performance Improvement was conducted. He stated his responsibilities included overseeing the quality assurance, patient safety, and regulatory compliance.…

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

Based on observation, interview, and facility document review, the facility failed to ensure two of two ice machines were not clean and maintained as per the manufacturer's guidelines. This failure posed the risk of ice contamination and equipment to not function in the way it was intended. Findings: 1. Review of the ice machine manufacturer guidelines located on the interior panel of the ice machine located in the kitchen showed, Cleaning and Sanitizing instructions, Cleaning solution, [Hoshizaki scale away] 9.6 ounces diluted with 1.6 gallons warm water . Sanitizing solution, 2.5 ounces of a sodium hypo-chlorite solution with five gallons of warm water. On 1/8/24 at 1356 hours, an observation of the facility's ice machine located in the kitchen and concurrent interview was conducted with IMTs 1 and 2. IMT 1 stated he used the ice machine cleaner and sanitizer produced by [Nu-Calgon] company to clean and sanitize all ice machines in the facility. IMT 1 stated some hard water deposits could not be removed. The interior of the ice chute (the part of the ice machine where ice was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to provide the written information regarding the rights to accept or refuse the medical or surgical treatments and formulate the advance directive for one of 14 final sampled resident (Resident 19). In addition, the facility did not have a written policy on advance directives. These failures had the potential for the residents' decision regarding the resident's healthcare and treatment options not being honored. Findings: According to the Code of Federal Regulations, Section § 483.10(g)(12), the facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives). (i) These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident ' s option, formulate an advance directive. (ii) This includes a written description of the facility's policies to implement advance…

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 plans of care for two of 14 final sampled residents (Resident 6 and 10) were developed, resident centered, and with measurable goals. This failure posed the risk of not providing appropriate, individualized care to Residents 6 and 10. Findings: Review of the facility's P&P titled Care Planning reviewed 10/23 showed in part, Purpose: to ensure a coordinated and comprehensive written plan is developed based on the resident assessment instrument and on the individual needs of the resident, Procedure: 4. (d) Problem statements should be followed with a related to or secondary phrase which relates to the problem when appropriate. (e) Objectives/goals are expectations, within the resident's abilities, which can be reached realistically. Each problem should have an objective/goal that is simple, specific and measurable within a specified time frame. 1. Medical record review for Resident 6 was initiated on 1/9/24 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to ensure the comprehensive plans of care for two of 14 final sampled residents (Residents 7 and 10) were revised to reflect the residents' current care needs and interventions. * The facility failed to revise the comprehensive plan of care for Resident 7's use of the bilateral knee braces. * The facility failed to revise the comprehensive plan of care for Resident 10's use of PICC line. These failures posed the risk of not providing the residents with individualized and person-centered care. Findings: 1. On 1/8/24 at 1048 hours, during the initial tour of the facility, Resident 7 was observed in bed with a rolled pillowcase on his left hand. Also observed during the tour were the knee braces stored on the cabinet. Medical record review for Resident 7 was initiated on 1/8/24. Resident 7 was admitted to the facility on [DATE]. On 1/10/24 at 1328 hours, an interview and concurrent medical record review for Resident 7 was conducted 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.

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 and worsening of pressure injuries for one of 14 final sampled residents (Resident 13). * The facility failed to ensure the licensed staff were trained and followed the manufacturer's guidelines on the LAL mattress settings. * The facility failed to ensure Resident 13 was repositioned every two hours per the physician's order. These failures put Resident 13's pressure injuries to reoccur and not heal. Findings: Medical record review for Resident 13 was initiated on 1/8/24. Resident 13 was admitted to the facility on [DATE]. The resident had a diagnosis of respiratory failure, traumatic brain injury, seizure disorder, and diabetes. a. Review of the facility's P&P titled Skin Integrity section Support Surfaces for Prevention and Treatment of Pressure Ulcers revised 3/2021 showed the nurses should consult manufactures guidelines for bedding needs. 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, medical record review, and interview, the facility failed to ensure the treatment was provided to one of 14 final sampled residents (Resident 7) to prevent a decline in the ROM functions. * The facility failed to follow a physician's order to apply a knee brace to Resident 7's both knees. This failure had the potential for Resident 7 to sustain a decline in ROM functions, leading to muscle atrophy and decrease in functioning. Findings: On 1/8/24 at 1048 hours, during the initial tour of the facility, Resident 7 was observed in bed with a rolled pillowcase on his left hand. Also, the knee braces were observed on the cabinet. Medical record review for Resident 7 was initiated on 1/9/24. Resident 7 was admitted to the facility on [DATE]. Review of Resident 7's Physician's Order dated 4/30/23, showed to apply knee braces to Resident 7's both knees eight hours daily, once a day five times per week as tolerated, with routine skin checks every two hours. Another physician's order showed for the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to prevent accidents for one of the 14 final sampled residents (Resident 22). * The facility failed to ensure Resident 22's bed alarm was on. This failure had the potential for the resident to sustain another fall. Findings: Review of the facility's P&P titled Fall Prevention/Reduction Program revised 02/2016 showed in part, to implement a program that prevents falls and /or reduces the number of times a resident falls .under the section Policy, showed an individualized interdisciplinary fall prevention/reduction plan of care will be developed and implemented for each resident identified as a fall risk and the plan of care for each resident will be accelerated post fall, as indicated, to enhance the preventive measures a decrease the risk of further falls in a manner that meets the individual needs of the resident. Medical record review for Resident 22 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 observation, interview, and medical record review, the facility failed to follow the physician's order for the indwelling urinary catheter (a tube placed in the body to drain and collect urine from) maintenance for one of 14 final sampled residents (Resident 13). This failure had the potential for not providing the necessary care and services to prevent adverse complications of obstruction or infections for residents with an indwelling urinary catheter. Findings: Medical record review for Resident 13 was initiated on 1/8/24. Resident 13 was admitted to the facility on [DATE]. Review of Resident 13's care plans showed the resident had UTI on 7/9/23, 10/21/23, 12/8/23, and 1/9/24. Resident 13's care plan showed a care plan problem addressing the alteration in urinary function related to the use of indwelling urinary catheter. The interventions dated 3/31/23, included to flush the indwelling urinary catheter with 60 ml of normal saline every four hours. Review of Resident 13's Physician's Order for January…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to ensure the physician's orders were clarified for one of 14 final sampled residents (Resident 13) for head of bed (HOB) elevation for aspiration precautions when the resident received a feeding tube. This failure had the potential to cause the resident to experience adverse reactions from GT feeding Findings: Medical record review for Resident 13 was initiated on 1/8/24. Resident 13 was admitted to the facility on [DATE]. The resident had a diagnosis of respiratory failure, traumatic brain injury, seizure disorder, and diabetes. On 1/8/24 at 0832 hours, during an initial tour, Resident 13 was observed lying on a LAL mattress in bed with tracheostomy tube, indwelling urinary catheter connected to a urinary drainage bag, and GT connected to a feeding pump. Resident 13 was nonverbal upon conversation initiation. On 1/10/24 at 1338 hours, LVN 1 was observed providing wound care to Resident 13. After completion of care, LVN 1 raised the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to maintain the intravenous accesses for one of 14 final sampled residents (Resident 10). In addition, the facility failed to ensure the PICC line external catheter and arm circumference measurements were performed and documented in the medical record for Residents 10. These failures had the potential to delay the identification of catheter related complications for the resident. Findings: Review of the facility's P&P titled Peripherally Inserted Central Line (PICC): Maintenance and Discontinuation with a revised date on 7/18 showed the care and maintenance should be performed by qualified persons knowledgeable of the risk for PICC line. Dressing changes every seven days, and document in medical records including the catheter integrity and arm circumference. Medical record review for Resident 10 was initiated on 1/9/24. Resident 10 was admitted to the facility on [DATE]. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the completion of side rails assessments for two of 14 final sample residents (Residents 6 and 8). * Resident 6 did not have two quarterly entrapment assessments completed. * Resident 8's assessments for bed side rails use were not completed. These failures posed the risk for the residents' safety associated with bedrails usage. Findings: Review of the facility's P&P titled Bed Rail Entrapment Assessment revised 5/2021 showed all residents are required to have fall and entrapment assessment upon admission to facility, followed by quarterly and as needed basis. The Bed Entrapment Risk Assessment tool consist of seven Safety Alert Zones approved by Food and Drug Administration. Zone 1: within the rail Zone 2: between the top of the compressed mattress and the bottom of the rail, between rails ports Zone 3: between the rails and mattress Zone 4: between the top of the compressed mattress and the bottom of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P, the facility failed to ensure the pharmaceutical services were provided to meet the residents' needs for two of 14 final sampled residents (Residents 6 and 16). * The nursing staff failed to ensure the physician's order not to crush paroxetine (antidepressant medication) tablet was clarified with the pharmacist or physician to obtain an alternate form of medication to administer via GT for Resident 16. * The medications ordered to administer with meals were administered when the GT feeding was not on for Resident 6. These failures had the potential to cause the adverse reactions due to improper medication administration to the residents. Findings: 1. Review of the facility's P&P titled Medication Administration revised on 5/16 showed medications shall be reviewed for appropriateness of crushing (see List of Medications Which Should Not Be Crushed or Chewed). Specific questions should be addressed to the pharmacist. Any medication which appears on 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's P&P review, the facility failed to ensure the necessary care and services were provided to prevent adverse reactions of a medication for experiencing active bleeding from multiple sources while receiving enoxaparin (a medication used to thin the blood) for one of 14 final sampled residents (Resident 13). This failure had the potential to result in Resident 13 to have more or active bleeding in his urine, and bleeding from his tracheostomy tubing (a tube inserted into the windpipe in front of the neck to assist in breathing). Findings: On 1/8/24 at 0832 hours, during an initial tour, Resident 13 was observed lying in bed with tracheostomy tube, indwelling urinary catheter in place draining dark red urine in tubing, and GT. Resident 13 was nonverbal upon conversation initiation. Medical record review for Resident 13 was initiated on 1/8/24. Resident 13 was admitted to the facility on [DATE]. The resident had a diagnosis of respiratory failure,…

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 14 final sampled residents (Resident 19) was free from the unnecessary psychotropic medications (medication that affects the brain activity). * The facility failed to provide non-pharmacological interventions to Resident 's 19's crying and constantly crying episodes due to depression and severe anxiety. * The facility failed to ensure a GDR was attempted for Resident 19's buspirone (medication to treat anxiety) and escitalopram (medication to treat depression) use. These failures had the potential for the physician to not have the necessary information and the residents to receive the unnecessary medications. Findings: Review of the facility's P&P titled Psychotropic Drug Therapy Monitoring revised 12/2023 showed patients who have psychotropic medication drug therapy initiated shall receive a comprehensive assessment to assure that psychotropic medication drug therapy is necessary to treat a specific…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility P&P review, the facility failed to ensure the medications were stored and labeled properly and failed to discard the expired supplies. * Medication Cart A had one open and unlabeled Lantus pen (an insulin medication to treat high blood sugar), and three expired supplies. * The facility failed to monitor the temperature of Medication room [ROOM NUMBER]. * Medication Cart B had two expired supplies. These failures posed the risk for negatively affect the resident's well-being. Findings: Review of the facility's P&P titled Floor Stock revised 10/2019 showed the policies and procedures are designed to ensure the safe and accurate dispensing of medications throughout the hospital . under the section Floor Stocks, showed medication contained in floor stock are stored under the condition listed by the medication manufacturer to ensure stability. Review of the facility's P&P titled Automated Medication Dispensing System revised 9/2020 under the section Patient-Specific…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary adaptive equipment was provided for one of 14 final sampled residents (Resident 10). * Resident 10 was not provided with a plate guard, non-slip table mat, and a suction cup as per the physician's order. This failure had the potential for Resident 10 not having an appropriate assistive device to consume her food and drinks. Findings: Review of the facility's P&P titled Nursing Care Restorative and Supportive revised 5/2016 showed the provision of supplies and equipment to support self-care of the residents. Restorative and supportive care includes the assessment of self-feeding skills, providing adaptive devices, and retraining program based on resident needs and capabilities. On 1/8/24 at 1156 hours, and 1/9/24 at 1157 hours, a concurrent observation and interview for Resident 10 with RNA 2 was conducted. Resident 10 was observed in bed and assisted by RNA 2 for the set up of Resident…

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

Based on observation, interview, and facility P&P review, the facility failed to ensure the food safety and sanitation requirements were met in the kitchen when: * The facility's P&P for dating foods was not followed. * The staff was not performing handwashing between soiled and clean tasks. * The food preparation equipment was not clean when stored. * The food preparation equipment was not air dried. * A handwashing sink was used for purposes other than handwashing. These failures posed the risk to cause food borne illnesses in a highly susceptible resident population of three residents who consumed food prepared in the kitchen. Findings: Review of the facility's matrix showed three of 21 residents consumed food prepared in the kitchen. 1. Review of the facility's P&P titled Food Labeling and Dating revised 8/2023 showed in part, 3. Stored foods are labeled to indicated type of product and dated prepared or dated the product is to be discarded .5. Prepared pudding .meat, tuna .are discarded after three days .16 .Non-perishable foods (flour, sugar, rice, beans and pasta) that 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 facility P&P review, the facility failed to ensure the facility staff responsible for handling food brought for residents from the outside and visitors who brought food for residents from the outside were educated on safe food handling procedures. These failures posed the risk for food borne illness for residents who consume food from the outside. Findings: Review of the facility's P&P titled Outside Food for Patients/Residents revised 1/2023 showed the following: * Food may be brought in from home or other sources to improve nutritional intake or provide supportive care. * For a patient to receive food from an outside source, a physician/LIP order is required and be compatible with the diet order and texture. * Food supplied to patients from outside sources must be stored in a manner which complies with infection control and food safety guidelines. * If perishable food is brought in but eaten right away it must be stored in the refrigerator with the following guidelines: C.…

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 interview, and facility P&P review, the facility failed to ensure the residents' entrapment assessments were accurate and complete including the measurements during the bed inspection when identifying areas of possible entrapment with the use of bed side rails for four of 14 final sampled residents (Residents 5, 7, 8, and 16). These failures had the potential to negatively impact the residents resulting in possible entrapment, serious injury, and death. Findings: According to the Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, the term entrapment describes an event in which a patient/resident is caught, trapped, or entangled in the space in or about the bed rail, mattress, or hospital bed frame. Patient entrapments may result in deaths and serious injuries. These entrapment events have occurred in openings within the bed rails, between the bed rails and mattresses, under bed rails, between split rails, and…

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.