Delta View Post Acute

Based on observation, interview and record review, the facility failed to provide routine medication, as ordered by the prescriber, and provide pharmaceutical services which includes procedures that assure the accurate acquiring, receiving, dispensing, and administering of medications to meet each resident's needs when: 1. Lisinopril (medication to treat high blood pressure) was not available for administration for one of five sampled residents (Resident 304). 2. One of two intravenous (IV, into the vein) drug emergency kits (E-kit) was opened and the IV Drug Emergency Kit Use Form had no accurate record of medication used and was not re-ordered timely. These failures resulted in Resident 304 not receiving the medication as prescribed and had the potential for facility residents with a census of 97 to not receive emergency IV medications when needed. Findings: 1. During a review of Resident 304's undated admission Record, the admission Record printed on 3/12/25 indicated, Resident 304 was admitted in the facility on 3/3/25 with a diagnosis of essential hypertension (a condition…

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, interviews, and record review, the facility failed to ensure a medication error rate below five percent for two of five sampled residents (Resident 75 and 304) when: 1. Resident 75 was administered multi-vitamin with minerals instead of multi-vitamins as prescribed by physician's order. 2. Resident 304's toprol xl (medication to treat high blood pressure) extended release (ER) was crushed and administered. 3. Resident 304's lisinopril (medication to treat high blood pressure) was not administered as ordered. These failures resulted in three medication errors out of 28 opportunities during observation of medication administration which resulted in the facility having a medication error rate of 10.71%. These failures also resulted in residents not receiving the correct medication or receiving the medication as prescribed or according to the manufacturer's specification. Finding: 1. During a review of Resident 75's undated admission Record, the admission Record printed on 3/12/25 indicated, Resident 75 was admitted in the facility on 10/26/24 with a diagnosis 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.

Based on observation, interview and record review, the facility failed to ensure food waste trash and garbage was disposed of in a sanitary manner when the lid of outside trash container was not closed. This failure had the potential of harborage and feeding of pest. Findings: During a concurrent observation and interview on 3/10/25 at 9:48 a.m. with Dietary Manager (DM) at the dumpster area located behind the kitchen building, the trash container overflowed with bags of trash and the lid of the container was not closed. DM stated the trash in the container was food waste. During an interview on 3/11/25 at 9:06 a.m. with [NAME] (CK), CK stated food wastes are disposed of into trash can after each shift. CK stated trash container lid was expected to be closed at all times. During a review of the facility's policy and procedure (P&P) titled, Sanitation and Infection Control, dated 2023, the P&P indicated, Outside trash compactors require a protective cover to prevent pests, animals, or debris from falling in. Keep lids of outside trash dumpster's closed.

Based on observation, interview and record review, the facility failed to maintain medical records that was accurately documented when: 1. One of five sampled residents (Resident 302) lidocaine patch (medicine that prevents pain by blocking the signals at the nerve endings in the skin) 5% was documented as administered in the Electronic Medication Administration Record (E-MAR) prior to administration. 2. Facility staff back dated Resident 47's discharge care planning notes. These failures resulted in Resident 47 and 302's medical record to reflect inaccurate clinical information. Findings: 1. During a review of Resident 302's undated admission Record, the admission Record printed on 3/12/25 indicated, Resident 302 was admitted in the facility on 2/28/25 with a diagnosis of cellulitis (bacterial infection of the skin and underlying tissues) of the left lower limb. During medication administration observation on 3/11/25 at 8:52 a.m., RN 1 was observed preparing and administering one lidocaine patch 5% to Resident 302's back. During a concurrent interview and record review, on 3/11/25…

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 record review, the facility failed to provide a safe, sanitary environment to prevent transmission of infections for three (Resident 21, 24 and 247) of eleven sampled residents when; 1. Resident 21's urinary drainage bag laid on the floor; 2. Resident 247's urinary bag was touching the floor without privacy cover. 3. Resident 24's tube feeding pole had dried light mater sticking on it; tube feeding pole is a portable, vertical pole used to support and hold the bag of formula or medication during tube feeding. This failure placed the residents at increased risk for healthcare associated infections. Findings: 1. During a review of Resident 21's Annual-Minimum Data Set (MDS - a federally mandated resident assessment and care guide tool), dated 9/19/24, the MDS indicated Resident 21's Basic Interview of Mental status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.)…

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 record review, the facility failed to provide a written discharge notice within the expected time frame to Resident, Resident Representative, and Ombudsman, for one of six sampled residents, Resident 95. Findings: During record review of Resident 95's Face Sheet (FC), the FC indicated that Resident 95 is [AGE] years old male, admitted to the facility in 2025. During record review of Resident 95's Progress Notes (PN), dated 12/22/2024, PN indicated, Patient sent out to the hospital from dialysis [NAME] due to 8/10 chest pain and short of breath .So they call on call MD [Medical Doctor, physician name redacted] for patient being sent out to the hospital. During an interview on 03/12/25 at 11:41 a.m., with Social Services Director (SSD), SSD stated she did not fill out the notice of transfer when Resident 95 was transferred to the hospital in December 2024. SSD stated she went back into Resident 95's chart in February 2025, and created a late entry document for the notice of transfer. During…

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 record review, the facility failed to provide services to meet professional standards of quality for one of one sampled resident (Resident 302) when Resident 302's lidocaine patch (medicine that prevents pain by blocking the signals at the nerve endings in the skin) 5% was not removed according to physician's order. This failure resulted in Resident 302 to receive excessive dose of lidocaine in a 24-hour period. Findings: During a review of Resident 302's undated admission Record, the admission Record printed on 3/12/25 indicated, Resident 302 was admitted in the facility on 2/28/25 with a diagnosis of cellulitis (bacterial infection of the skin and underlying tissues) of the left lower limb. During a concurrent medication administration observation and interview, on 3/11/25 at 8:52 a.m. with Registered Nurse (RN) 1, in Resident 302's room, RN 1 removed one lidocaine patch with handwritten letters JS and numbers 3/10 from Resident 302's back. RN 1 stated the lidocaine patch she removed was the patch she had applied yesterday morning. RN 1 stated…

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 record review, the facility failed to provide necessary care and services to maintain physical and psychosocial well-being for one of twenty four sampled residents (Resident 44) when Resident 44 was not positioned properly in the dining room prior to eating lunch. This failure had the potential to cause Resident 44 aspiration and emotional distress. Findings: During a review of Resident 44's Minimum Data Set (MDS - a federally mandated resident assessment and care guide tool), dated 1/8/25, the MDS indicated Resident 44's Basic Interview of Mental status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) Resident 44's score was 10 (meaning mild cognitive impairment). MDS indicated Resident 44 had clear speech, able to express ideas and wants, make self-understood and understood others. MDS indicated Resident 44 need helper assistance prior to or following eating…

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 record review, the facility failed to report a verbal abuse allegation made by one of four sampled residents (Resident 3) against a Certified Nursing Assistant (CNA 1) to the required agencies, including California Department of Public Health, Long Term Care Ombudsman and Local Law Enforcement agency. This failure resulted in facility not responding to abuse allegation appropriately and placed Resident 3 at risk for experiencing further unreported abuse. Findings: During a review of Resident 3 ' s admission Record printed on 1/12/24, the record indicated Resident 3 was admitted to the facility on [DATE] and discharged on 12/8/23. During a review of Resident 3 ' s Minimum Data Set (MDS, an assessment used to plan care), the assessment indicated Resident 3 had a BIMS (a tool used to assess a resident ' s level of awareness and thinking) score of 13 out of 15, indicating Resident 3 was cognitively intact and was able to make his needs known and understood. During a phone interview with CNA 1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to thoroughly investigate a verbal abuse allegation by one of four sampled residents (Resident 3) against Certified Nursing Assistant (CNA 1). Facility did not remove CNA 1 from resident care areas and did not complete and/or report the results of investigation to California Department of Public Health (CDPH) within 5 working days of the incident. This failure resulted in facility not responding to abuse allegation appropriately and placed Resident 3 and other residents residing at the facility at risk for experiencing further unreported abuse. Findings: During a review of Resident 3 ' s admission Record printed on 1/12/24, the record indicated Resident 3 was admitted to the facility on [DATE] and discharged on 12/8/2023. During a review of Resident 3 ' s Minimum Data Set (MDS, an assessment used to plan care), the record indicated Resident 3 had a BIMS (a tool used to assess a resident ' s level of awareness and thinking) score of 13 out of 15,…

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 record review, the facility failed to ensure infection control practices were implemented when the facility did not have oxygen tubing labeled for 2 of 6 residents (Residents 10 and 12) receiving oxygen. The facility did not have tubing or nasal cannula (pronged tubing that sits in nostrils to deliver oxygen) stored in a plastic bag when not in use for one of six residents (Resident 10) receiving oxygen, and the nasal cannula and tubing were on the floor. These failures placed Residents 10 and 12 at risk for healthcare-associated infections. Findings: During a review of Resident 10 ' s admission Record dated 12/15/23, the admission Record indicated Resident 10 was admitted to the facility in October 2023. During a review of Resident 10 ' s Order Summary Report dated 12/15/23, the Order Summary Report indicated an order, dated 10/24/23, for oxygen at 2 liters per minute via nasal cannula as needed. During a review of Resident 12 ' s admission Record dated 12/15/23, the admission Record indicated Resident 12 was admitted to the facility in May 2023.…

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 record review, the facility had four medication errors out of 28 medication pass observations which resulted in an error rate of 14.29%. Physician Orders were not followed during medication administration for Resident 67 and 63. For Resident 67, this had a potential to cause poor pain control when Lidocaine 5% patches (a patch with local anesthetic applied to skin to help control pain) were cut in half, and another 1/2 patch was applied on the left knee without physician orders. For Resident 63, Cozaar 50 milligram (mg) tablet (a type of medication that helps manage high blood pressure), was not given and could result in poor management of high blood pressure. Findings: 1. During an observation and interview on 11/15/22 at 08:40 a.m., with Registered Nurse (RN) 1, RN 1 stated they would prepare Resident 67's medications that included Lidocaine 5% patches. RN 1 removed two Lidocaine 5% patches for Resident 67 from the medication cart. RN 1 opened one Lidocaine 5% patch and cut it in half, then wrote the current date and initial. RN 1 opened the…

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

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 80) had an accurate discharge assessment. Resident 80 was discharged to the community. This deficient practice had the potential to cause improper planning for Resident 80's care upon discharge from the facility. Findings: During a review of Resident 80's face sheet on 11/17/22, the face sheet indicated Resident 80 was admitted to the facility in 2022. During a review of Resident 80's discharged summary, dated 9/3/22, the discharge summary indicated under disposition, Resident 80 was discharged to an Assisted Living (a type of housing in a community setting for people who need various levels of medical and personal care). During a review of Discharge Minimum Data Set (MDS - an assessment tool used to direct health care needs) dated, 9/3/22; Section A2100 indicated 03 which meant Resident 80 was discharged to an Acute Care Hospital. During a concurrent interview and record review, with the MDS Coordinator (MDSC), on 11/17/22, at 11:11 a.m., the MDSC stated, the Discharge MDS…

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 record review, for one of 18 sampled residents (Resident 75), the facility failed to develop an individualized nursing care plan to address Resident 75's right and left arm discolorations. This failure had the potential for Resident 75 to have delayed and or inappropriate care. Findings: During an observation on 11/14/22, at 12:13 p.m., observed Resident 75 with multiple purplish marks on their right and left arms. During a concurrent observation and interview on 11/15/22, at 10:33 a.m., with Assistant Director of Nursing (ADON), observed Resident 75's arms. ADON stated Resident 75 had multiple discolorations on their right and left arms. During a record review of Resident 75's Weekly Skin Assessment, dated 10/31/22, the assessment indicated Resident 75 had skin discolorations on both arms and hands. During a concurrent interview and record review on 11/17/22, a 10:12 a.m., with the ADON, reviewed Resident 75's care plans. ADON stated Resident 75 did not have a nursing care plan for their skin discolorations on their right and left arms. ADON…

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 record review, the facility failed to provide appropriate fingernail care for two of 18 sampled residents (Residents 19 and 26). This failure had the potential to cause Residents 19 and 26 injury, pain and infection. During a concurrent observation and interview on 11/15/22, at 10:42 a.m., with Resident 19, Resident 19's fingernails were observed long with dark gray matter under the fingernails of both hands. Resident 19 stated staff had never cut residents fingernails. Resident 19 stated it made them feel upset. During a concurrent observation and interview on 11/15/22, at 11:01 p.m. with Assistant Director of Nursing (ADON), Resident 19's fingernails were observed. ADON stated Resident 19's fingernails were, long and a little dirty. ADON stated Resident 19's fingernails needed to be cut. During an interview on 11/16/22, at 3:07 p.m., with ADON, ADON stated staff should have cleaned Resident 19's fingernails. ADON stated long and dirty fingernails were a risk for infection and pain. During a concurrent observation and interview on 11/15/22, 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.

Based on observation, interview, and record review, the facility did not destroy the controlled substance (CS - drug or other substance that is tightly controlled by the government because it may be abused or cause addiction), to render it unusable after removing them in their individual packaging. This deficient practice could result in a potential case of controlled substance diversion. Findings: During an observation and interview on 11/15/22 at 3:15 p.m., with Director of Nurses (DON) in the presence of Assistant Director of Nurses (ADON) in the DON's office, DON grabbed a gallon sized plastic container with gray colored top from behind their chair. Observed the inside of the container which contained a dark dry substance wrapped in thin plastic, dry whole capsules, and tablets. DON stated that the medications inside the container were the controlled substances that were Destroyed back in October by her and the pharmacist. DON stated when the pharmacist was in the facility, they verified the number of tablets/capsules from the bubble pack or bottle, removed them from 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 record review, the facility failed to follow proper sanitation and food handling practices by failing to wear hair restraints while inside kitchen. This deficient practice had the potential to spread food borne illnesses. Findings: During a follow up observation of the kitchen and concurrent interview, on 11/14/22, at 10:15 a.m., observed a dishwasher repair vender not wearing a hairnet. Vendor stated they have been inside facility kitchen many times to work on the dishwasher and was never asked to wear a hairnet by the kitchen staff. Also observed maintenance staff enter the kitchen without a hairnet. Maintenance staff walked through the kitchen and exited out of the rear door. Maintenance staff stated they did not wear a hairnet because they were never asked to wear hairnet inside kitchen. During an interview on 11/14/22, at 10:17 a.m., with Dietary Manager (DM), the DM stated, all staff are required to wear hairnets inside the kitchen. During a review of the facility's policy and procedure (P&P) titled, Food Safety and Sanitation, dated 2017,…

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 record review, the facility failed to ensure two (Resident 43 and 42) of 80 sampled residents received an accurate assessment when: 1. Resident 42's Minimal Data Set (MDS- an assessment tool) did not reflect ambulation and range of motion (ROM) services being provided during the Restorative Nurse Aide (RNA) program. 2. Resident 43's MDS was inaccurately coded for using no bed rails when bed rails were being used every day. This failure resulted in Resident 42 and 43's MDS's to reflect inaccurate clinical status. Findings: 1. Review of Resident 42's MDS dated [DATE] showed Resident 42 walked in corridor only once or twice and did not receive RNA services for ROM exercises and walking in 7-day look back period (reference period for the assessment). During a concurrent interview and review of Resident 42's Restorative Nursing Care Flow Record dated 9/2019 and 10/2019, with RNA 1 on 11/20/19 at 8:13 a.m., RNA 1 confirmed Resident 42 was receiving 15 minutes of ROM and 15 minutes of walking…

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 record review, for one (Resident 70) of 80 sampled residents, the facility failed to address resident's significant weight loss. This failure resulted in Resident 70's fifteen percent weight loss over six months. Findings: Review of the admission Record indicated Resident 70 was admitted on [DATE] with multiple medical history including, Diabetes (high blood sugar), Dysphagia and Muscle Weakness. During an observation and concurrent interview on 11/18/19 at 8:45 a.m., Resident 70 was awake in bed. Resident 70 stated that she did not like hard foods because it was hard to chew. Resident 70 added she had missing teeth. Review of physician's order dated 11/4/19 indicated, Consistent Carbohydrate, No Added Salt diet, Regular texture . Review of the MD orders dated 10/9/19 indicated, Dental evaluation and treatment as indicated. In an interview with SSD2 on 11/21/19 10:27 a.m., SSD2 stated dental consent was not completed and was overlooked since admission. SSD2 added Resident 70…

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 record review, the facility failed to assess, explain risks and benefits and obtain an informed consent prior to using bed rails for six of (Resident 43, 186, 79, 42, 47, and 36) of 80 sampled residents. This failure had the potential for the above listed 6 residents to suffer from avoidable and hazardous accidents such as entrapment, entanglement, skin injuries, and the feeling of isolation, agitation, due to being restrained. Findings: During an observation on 11/18/19 at 10:00 a.m., Residents 43, 186, 79, 42, 47, and 36 were noted with bilateral half/quarter bed rails up while they were lying in bed. During a concurrent interview and Resident 43's medical record review on 11/18/19 at 2:07 p.m., Infection Control Nurse (ICN) confirmed Resident 43 was not assessed and/ or had physician's orders, and/ or had informed consent for use of bed rails. During an interview on 11/18/19 at 2:18 p.m., the Licensed Vocational Nurse (LVN 3) stated We do not do bed rail assessment if it's not a full bed rail. During an interview with the Clinical Leader (CL1)…

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 record review, the facility failed to provide safe storage of laboratory test supplies when expired laboratory sample collection kits were found stored with currently used laboratory collection kits. This failure had the potential to jeopardize the quality of the collected data and could result in inaccurate result impacting physician's treatment decisions. Findings: During an observation on [DATE] at 11:01 a.m. the following laboratory biological test kits were found in the Dirty Utility Room: 1. Three E-Swabs Collection Transport System for Aerobic (requiring oxygen), Anaerobic (not requiring oxygen) and Fastidious (requiring specific nutrient) Bacteria test kits with expiration date of [DATE] were stored in the drawer mixed with currently used laboratory test kits. 2. Four Nasopharyngeal Sample Collection Kits for Viruses with Expiration date of [DATE] were stored in the drawer mixed with currently used laboratory test kits. In an interview with the Licensed Vocational…

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 record review, the facility failed to follow its policy and procedure for food storage, when following food items were stored in freezer section of Medication room [ROOM NUMBER]'s Medication Refrigerator: a. One undated and unlabeled brown colored drink frozen hard in a Jack in the Box plastic cup. b. One undated and unlabeled, with no open date, box of Fudgsicles with 11 fudgsicles left in the box. This failure resulted in facility not following its safe food handling practices. Findings: During a medication room [ROOM NUMBER] observation accompanied by Licensed Vocational Nurse (LVN) 3 on 11/18/19 at 10:30 a.m., one undated, unlabeled brown colored frozen hard drink in [NAME] in the Box plastic cup was stored in Medication Refrigerator's freezer section. LVN 3 stated she did not know who did the drink belong to and she threw it away. LVN 3 then took out a box of Fudgsicles from the freezer section. The box was unlabeled and undated and has 11 fudgsicles left inside. LVN 3…

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 record review, the facility failed to provide services to safely store and reheat residents' food brought in by family/visitors. This failure resulted in residents to waste the leftovers brought in families and/or visitors and feel left out at the facility. Findings: During medication room rounds with Licensed Vocational Nurse (LVN) 3 on 11/18/19 at 10:26 a.m., LVN 3 stated staff was not reheating residents' leftover foods brought in by family/visitors. LVN 3 stated Kitchen had told nursing staff to not reheat the food. During an interview with the Facility Manager (FM) on 11/18/19 at 11:30 a.m., the FM stated We do not have enough space to have residents' food, so we do not encourage them to keep the leftovers. We tell them to either finish the food or visitors should take the leftovers. Review of Resident Council Suggestion dated 10/29/19 showed, Resident are concerned that they no longer have a place to heat up their food. During the Resident Council Meeting on 11/19/19 at 11:07 a.m., Residents expressed Food would taste better if it was hot…

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 record review, the facility failed to follow infection prevention practices when following were observed: 1. Two sets of personal clothing items were stored in medication room [ROOM NUMBER] at the nursing station; 2. Resident 51's oxygen cannula attached to nebulizer was not changed for 15 days. This failure had the potential to spread infections to the residents whose medications were stored and/or prepared in the medication room [ROOM NUMBER] and Resident 51 to suffer from respiratory infections from using the oxygen cannula that was not changed per facility's policy. Findings: 1. During an observation of Medication room [ROOM NUMBER], accompanied by Licensed Vocational Nurse (LVN 3) on 11/18/19 at 10:26 a.m., One black jacket with hoodie and one blue colored full sleeve female top were hanging on a hook on the back of the medication room door. LVN 3 stated staff at nursing station 2 did not know who did the clothing items belonged to. LVN 3 further stated staff should not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to provide at least 80 square feet per resident for residents who occupied the following multiple resident bedrooms: Rooms 1, 3, 5.6, 9, 10, 11, 12, 14, 15, 16, 17, 18, 19, 20, 23, 24, 25, 26, 27, 29, 31, 32, 33, 34, 35, 37 and 39. This failure had the potential to result in a lack of sufficient space for the provision of care by facility staff and for the lack of sufficient space for residents to have personal belongings at the bedside. Findings: In an observation and concurrent interview with the Maintenance Supervisor (MS) on 11/19/19 at 10:30 a.m., MS measured the resident's bedrooms. MS stated that there were no complaints from the residents and staff regarding the size of the bedrooms. The following multiple resident rooms were identified having below the required 80 square feet requirement per resident: Room Activity Number of Beds Floor Area 1 Rt room [ROOM NUMBER] 75.75 sq.ft/bed 3 Rt room [ROOM NUMBER] 75.56 sq.ft/bed 5 Rt room [ROOM NUMBER] 76.23…

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 record review, the facility failed to ensure three (Resident 79, 48, 42) of 80 sampled residents were provided with a clean and sanitary environment, when thick, dark brown, dried matter was sticking all over the commode and toilet bowl in a shared bathroom between room [ROOM NUMBER] and 22. This failure resulted in Resident 79, 48 and 42 to not receive a clean, sanitary and homelike environment. Findings: During an observation of shared bathroom between room [ROOM NUMBER] and 22, accompanied by Certified Nursing Assistant (CNA 4) on 11/8/19 at 10:08 a.m. thick dark brown matter was sticking inside toilet bowl and all over a light blue colored commode placed over the toilet bowl. CNA 4 was unable to state what was sticking on the toilet bowl and the commode. During another observation of the bathroom with CNA 4 and Housekeeper (HK 1) on 11/8/19 at 10:12 a.m., HK 1 stated its pee (urine) pointing towards the stains on the toilet bowl. HK 1 then stated commode was old and should…

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 records review, for one (Resident 63) of 80 sampled residents the facility failed to monitor and develop a nursing care plan to address Resident 63's Left Lower Leg edema (swelling). This deficient practice had the potential for Resident 63's condition went unnoticed or delayed for treatment. Findings: Review of the admission Record indicated Resident 63 was admitted on [DATE] with multiple diagnosis including, Diabetes (high blood sugar). Review of the physician's (MD) order, dated 11/4/19, indicated, Ultrasound (a test that uses high-frequency sound waves to measure the amount of blood flow through the arteries and veins) Left Lower Extremity. In an observation and concurrent interview on 11/19/19 at 1:03 p.m., Resident 63 was awake sitting in a wheelchair by her bed. Resident 63 stated her left lower leg was swollen. Resident 63 stated that her leg hurts a little but she got pain medicine from the nurses. In an interview with the Licensed Vocational Nurse (LVN) 1 on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide quality of care to two (Resident 184 and 73) of 80 sampled residents, when: 1. the facility failed to reassess pain for Resident 184 after she was given Tylenol for pain due to a fall. 2. For Resident 73, an initial smoking assessment was not completed. This failure resulted in Resident 184 to stay in pain for four hours until she was transferred to Acute Care Hospital (ACH) 1 where she was diagnosed with bilateral lower extremities fractures. Findings: 1. Review of Resident 184's Minimal Data Set (MDS- An assessment tool used to guide care) dated 10/19/19 showed Resident 184 is cognitively intact. During a concurrent interview and record review on 11/20/19 at 10:23 a.m., LVN 3 stated at 9:55 a.m. on 11/4/19, Resident 184 was lying on her back on the floor between the bed and the sliding door stating her legs were hurting. LVN 3 stated Resident 184 had abrasions on both knees, and a skin tear on the right arm. LVN 3 stated she provided…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow the physician's order to provide routine dental services for two (Residents 19 and 70) of 81 sampled residents, when: 1. Resident 19 did not receive routine follow up dental services for broken and decayed teeth. 2. Resident 70 did not receive routine dental services since admission. These failures had the potential to cause resident avoidable dental issues and weight loss. Findings: 1. Review of the admission Record indicated Resident 19 was admitted on [DATE] with multiple diagnosis including, Dysphagia (difficulty swallowing) and Diabetes (high blood sugar). In an observation and concurrent interview with Resident 19 on 11/18/19 at 09:10 a.m., Resident 19 was awake in bed complaining that it has been awhile since she saw a dentist. Resident 19 added that she would like her broken teeth fixed. Review of the physician's order dated 4/1/16, indicated, Dental evaluation and Treatment as needed. Review of the Dentist progress notes…

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.