Sundance Creek Post Acute

Based on observation, interview, and record review, the facility failed to ensure one oral relief sore throat spray stored in a medication cart was properly labeled. This failure had the potential for the residents to receive unnecessary medications or for medication error to occur. Findings:On September 25, 2025, at 11:32 a.m. a concurrent observation and interview were conducted with Licensed Vocational Nurse (LVN) 9 at the medication cart located in the East Station.An unlabeled bottle of Phenol 1.4 % (medications that temporarily induce a loss of sensation) oral relief sore throat spray was found in the cart, available for use. The bottle was half-full, the cap was broken, and there was no resident name, identifier or pharmacy label. LVN 9 stated she was unable to identify which resident the spray belonged to or when it was last used. LVN 9 stated the bottle had been opened and used, as half of the fluid in the bottle was visible. LVN 9 state she was unsure of how long the medication had been in the cart. LVN 9 stated it was the medication nurse responsibility to check the carts…

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 the resident's food preference was honored for one of three residents reviewed for nutrition (Resident 120). This failure had the potential to result in the resident refusing meals and experiencing decreased nutritional intake.Findings: On September 22, 2025, at 11:21 a.m. an observation and interview were conducted with Resident 120. Resident 120 stated she was prescribed a regular diet with large portions and disliked milk to drink. Resident 120 stated, they keep bringing me milk and I keep telling them I don't like it. A large note was observed on the resident's table that read in capital letters, .NO MILK PLEASE. Resident 1's meal ticket was observed to list the following: .Notes.Milk for cereal only.Standing.4fl oz (fluid ounce a unit of measure) milk 2% 4 fl oz juice.Orders.8 fl oz. Milk 2% .Dislikes.Milk to drink. On September 24, 2025, Resident 120's record was reviewed. Resident 120 was admitted on [DATE], with a diagnosis…

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 the physician-ordered fortified diet (high calorie, high protein diet) were provided as prescribed for two of eight residents reviewed for nutrition (Residents 98 and 125).This failure had the potential to reduce calorie and protein intake, decrease palatability of meals, and negatively affect nutritional status for these residents, in a facility with a population of 140. Findings:A review of facility undated document titled Fortified Menu Plan, indicated .This plan provides an additional 300-400 calories and 3-4 grams of protein per day.Lunch and Dinner.Meat per menu.Possible Fortified Additions.Extra 1 oz (ounce- unit of measurement) of gravy or sauce. On September 24, 2025, at 1 p.m., during a lunch tray line observation, the meal trays for Resident 98 and Resident 125 were not provided with the required extra one ounce of gravy.On September 24, 2025, at 1:17 p.m., during a concurrent observation and interview with the Dietary…

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 required personal protective equipment (PPE - specialized clothing or equipment worn by staff to protect themselves and others from exposure to infectious agents) was readily available on the PPE cart for one of one resident reviewed for infection control (Resident 8).This failure increased the risk of transmission of infection to residents and staff. Findings:A review of Resident 8's admission Record indicated Resident 8 was re-admitted to the facility on [DATE], with diagnoses including ESBL infection (Extended-Spectrum Beta Lactamases - a highly contagious bacterial infection requiring the resident to be on contact precaution (a type of precaution used to prevent the spread of infections that are transmitted to through direct physical contact).On September 24, 2025, at 3:38 p.m., during a concurrent observation and interview with the Housekeeping Supervisor (HS), Resident 8's PPE cart was observed without disposable gowns. 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, interviews, and record review, the facility failed to make reasonable accommodations to meet the needs and preferences of two residents (Residents A and B) who required Hoyer lift (a mechanical device used to transfer residents who cannot bear weight) for transfers. This failure resulted in delays, missed activities, and disruption of established daily routines for two of three sampled residents (Residents A and B).Findings:On July 22, 2025, at 12:14 p.m., during an interview with Resident A, he stated everybody is fighting over two Hoyer lifts. Resident A stated, two Hoyer lifts were not enough to service more than 100 residents.1.A review of Resident A's admission Record indicated Resident A was admitted to the facility May 26, 2019, with diagnoses which included morbid obesity (extremely overweight), and chronic pain syndrome (persistent pain lasting longer than 3 months, often significantly impacting daily life and potentially leading to disability).On July 22, 2025, at 1:53 p.m.,…

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 assess and monitor one of four sampled residents (Resident 1) for signs and symptoms of circulatory insufficiency (decrease blood flow) in the right lower leg after testing positive for deep vein thrombosis (DVT - a blood clot). This failure had the potential to result in staff being unable to detect worsening circulatory insufficiency. Findings: A review of Resident 1's admission Record, indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included diabetes (high blood sugar), end stage renal disease (kidney failure) and hemodialysis (special procedure done to remove wastes and excess fluids from the body). A review of Resident 1's History and Physical, dated April 6, 2025, indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1's Radiology Results Report, dated May 1, 2025, indicated, .Venous Lower Extremity Unilat (unilateral - one side) .Interpretation .Significant findings .there…

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 resident's medical records were accurate and complete in accordance with the accepted professional standards and practices, for one of three sampled residents (Resident 1), when the nursing weekly summary and the skin evaluations did not reflect the skin changes from May 21, 2025, to May 31, 2025. These failures could negatively impact patient care and prevent staff or representatives from being aware of the potential changes in the resident's skin condition. Findings: On June 19, 2025, at 12:30 p.m., an unannounced visit was conducted to investigate a quality-of-care concern. Resident 1's record was reviewed. Resident 1 was admitted on [DATE] with diagnoses which included diabetes type two (inability to process and control glucose sugar levels in the body). A review of Resident 1's History and Physical, indicated, Resident 1 had fluctuating capacity to understand and make decisions. A review of Resident 1's skin/wound note, indicated: - 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 and record review, the facility failed to report an allegation of physical abuse within two hours to the California Department of Public Health (CDPH), for one of three sampled residents (Resident 1). This failure had the potential to place Resident 1 at continued risk of abuse and negatively impact her emotional and psychosocial well-being. Findings: On April 1, 2025, at 2:31 p.m., CDPH received a fax (facsimile - telephonic transmission of scanned-in printed material) report involving an allegation of physical abuse for Resident 1. On April 4, 2025, at 12:30 p.m., an unannounced visit to the facility was conducted to investigate an allegation of abuse. 1. A review of Resident 1's admission Record, indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses which included muscle weakness, pneumonia (a lung infection) and deaf nonspeaking. A review of Resident 1's History and Physical, dated December 31, 2024, indicated Resident 1 had 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 interview and record review, the facility failed for one of three sampled residents (Resident 1), to report Resident 1's total right shoulder prosthesis dislocation [the artificial component of a shoulder replacement entirely come out of their proper position], an injury of unknown source, within 2 hours to California Department of Public Health (CDPH) after the facility was made aware of the injury, for one of three sampled residents (Resident 1). This failure had potential to result in further injury for Resident 1, affecting the resident physical, emotional, and psychosocial well-being. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE]. A review of Resident 1's History and Physical, dated January 24, 2025, indicated Resident 1 had fluctuating capacity to make medical decisions. A review of Resident 1 Admission/readmission Evaluation/Assessment, dated January 21, 2025, indicated, .Extremities (arms and legs) .No limited ROM (range of motion…

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 for one of three sampled residents (Resident 1), to investigate how Resident 1's right shoulder prosthesis became dislocated [the artificial component of a shoulder replacement entirely come out of their proper position]. This failure had potential to result in further harm for Resident 1, affecting the resident physical, emotional, and psychosocial well-being. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE]. A review of Resident 1's History and Physical, dated January 24, 2025, indicated Resident 1 had fluctuating capacity to make medical decisions. A review of Resident 1 Admission/readmission Evaluation/Assessment, dated January 21, 2025, indicated, .Extremities (arms and legs) .No limited ROM (range of motion - a measure of joint function and flexibility) .No Edema (swelling) Present .Resident has no wounds or skin .concerns . A review of Resident 1 Nurse's Note, dated January 27, 2025,…

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 for one of three sampled residents (Resident 1) to: 1. Provide the resident and or resident representative a written copy of the transfer or discharge. This failure had the potential to deny the resident the opportunity to understand the reasons for the transfer and the right to appeal, and other pertinent information related to the discharge process; and 2. Ensure a copy of the transfer or discharge notice was sent to the representative of the Office of the State Long-Term Care Ombudsman (LTC Ombudsman - an advocate for residents of nursing homes to protect residents' rights and ensure quality care). This failure had the potential to delay advocacy and oversight of Resident 1's discharge plan, impacting continuity of care and resident rights. Findings: 1. A review of Resident 1's admission Record, indicated Resident 1 was admitted to the facility on [DATE]. A review of Resident 1's History and Physical, dated January 24, 2025, indicated Resident 1 had…

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 showers on scheduled shower days and bed baths on non-shower days, for one of three sampled residents (Resident A). This failure had the potential to negatively affect the resident ' s physical, emotional, and social well-being which included skin infections, body odor, and discomfort. Findings: Resident A ' s record was reviewed. Resident A was admitted to the facility on [DATE], with diagnoses which included bilateral lower extremities contractures (both legs experienced shortening of muscles leading to restricted movements) and history of cerebrovascular accident (stroke) with left-sided deficits (loss or impairment of function on the left side). A review of Resident A ' s care plan dated July 5, 2024, indicated, .ADL (activities of daily living)/Mobility: Resident .is at risk for ADL/mobility decline and requires assistance related to .HEMIPLEGIA (paralysis on one side of the body) AND HEMIPARESIS (weakness on one side of the body) .MUSCLE…

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 one of three sampled residents (Resident A) was repositioned and turned every two hours. This failure had resulted in the development of Resident A's pressure ulcer (bed sore). Findings: On December 4, 2024, at 8:40 a.m., an unannounced visit to the facility was conducted to investigate a quality care issue. A review of Resident A's admission Record, indicated, Resident A was admitted to the facility on [DATE], with diagnoses which included hemiplegia (complete paralysis) and hemiparesis (partial weakness) of left side of the body. A review of Resident A's history and physical examination dated July 3, 2024, indicated Resident A did not have the capacity to make decisions. A review of Resident A's BRADEN SCALE FOR PREDICTING PRESSURE CORE RISK, dated July 30, 2024, indicated, .Score: 12 .HIGH RISK .Activity .Bedfast: Confined to bed .Mobility .completely immobile .does not make even slight changes in body or extremity position without assistance…

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 an allegation of misappropriation of property (a type of financial abuse) to California Department of Public Health (CDPH) within 2 hours after the facility was made aware of the allegation, for one of three sampled residents (Resident 1). This failure had the potential to result in further financial abuse for Resident 1, affecting the resident 's emotional and psychosocial well-being. Findings: On October 10, 2024, at 3:23 p.m., CDPH received a fax (facsimile - telephonic transmission of scanned-in printed material) report of a complaint involving misappropriation of property for Resident 1. On October 24, 2024, at 9 a.m., an unannounced visit to the facility was conducted to investigate a misappropriation of property issue. A review of Resident 1's admission Record, indicated, Resident 1 was admitted to the facility on [DATE]. A review of Resident 1's History and Physical, dated October 4, 2024, indicated Resident 1 had the capacity to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure for one of three sampled residents (Resident 1) was monitored after an allegation of financial abuse. This failure had the potential to affect Resident 1 ' s emotional and psychosocial wellbeing. Findings: On October 24, 2024, at 9 a.m., an unannounced visit to the facility was conducted to investigate a misappropriation of property issue. A review of Resident 1's admission Record, indicated, Resident 1 was admitted to the facility on [DATE]. A review of Resident 1's History and Physical, dated October 4, 2024 indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1 ' s (city name) Police Department CAD Incident Report (police report), dated October 9, 2024 at 2:05 p.m., indicated, .Incident type: Theft .Caller Name: (Social Service Assistant [SSA] 1 ' s name) .Incident Comments: RP (sic) (Reporting Party) is Social Worker advised (Resident 1 ' s name) family member took his wallet .Patient is now saying his…

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 staff was observed not performing hand hygiene upon entry and exit of two transmission-based precaution (TBP - an infection control measure use in healthcare to prevent the spread of infection and diseases) rooms. This failure had the potential to increase the spread of pathogens (germs) and infections by staff to facility residents. Findings: On October 24, 2024, at 9:43 a.m., during a concurrent observation and interview in the hallway outside Resident 8's and Resident 9's rooms, a Droplet Precaution (a type of TBP) sign was observed outside the room doors. The Physical Therapy Assistant (PTA) was observed to not perform hand hygiene when exiting Resident 9's room and when entering and exiting Resident 8's room. The PTA stated droplet precaution requires facility staff and visitors to wear a mask and wash hands before entering and upon exiting the room. The PTA stated he did not perform hand hygiene when he exited Resident 9's room and when he entered…

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 that the resident and/or the family member (FM) were notified of the grievance investigation findings and result after a complaint, for one of one sampled resident (Resident 1). This failure had the potential for Resident 1's FM to be unaware if the complaint was investigated and addressed, which could lead to ongoing dissatisfaction. Findings: On September 18, 2024, Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which included muscle wasting (loss of muscle strength) and atrophy (thinning of muscles). A review of Resident 1's Minimum Data Set (an assessment tool) dated June 10, 2024, indicated Resident 1 ' s Brief Interview for Mental Status (tool to assess cognitive function in residents) score was 6 (six) (severe cognitive impairment). A review of facility Email Receipts, indicated the following: - Dated December 12, 2023, indicated, .My name is (Resident 1 ' s FM name) the son of (Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed for one of three residents reviewed for discharges (Resident 1) to provide a complete written notice of transfer/discharge that included the discharge location. This failure had the potential for Resident 1 to experience stress, and confusion due to lack of information about their future living arrangements. Findings: On August 08, 2024, at 1:25 PM, Resident 1 was interviewed. Resident 1 stated that he was issued a discharge noticed and he appealed. He added that he couldn ' t read the notice due to his poor eyesight and did not know where he was being discharged to. Resident 1 ' s record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which included diabetes mellitus (high blood sugar), and essential hypertension (high blood pressure). A review of Resident 1's Progress Notes, dated June 28, 2024, indicated, Resident was issued a 30-day notice and refused to sign stated he was told by the Ombudsman and CDP not to sign it,…

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 a follow-up ophthalmology consult was provided for one of three sampled residents (Resident 1). This failure increased the risk of the resident not receiving the necessary care to address their medical condition and had the potential to result in the progression of resident's altered visual functioning. Findings: On August 15, 2024, at 1:30 PM, Resident 1 was interviewed. Resident 1 stated that he needs to see an ophthalmologist, but the facility has not done anything for him. Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses that included: Type II Diabetes Mellitus (high blood sugar), and Essential Hypertension (high blood pressure). Resident 1's History and Physical Examination (H & P), dated July 12, 2024, indicated the resident has the capacity to understand and make decisions. A review of Resident 1's document titled, Order Summary Report, dated July 1, 2024, indicated the .Eye health 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 5. On August 21, 2024, Resident 23's admission RECORD, was reviewed. Resident 23 was admitted to the facility on [DATE], with diagnoses which included end-stage renal disease (ESRD - when the kidneys stop working) on hemodialysis (special procedure done by a trained professional to remove wastes and excess fluids from the body) and fracture (broken bone) on left fibula (long bone in the lower extremity) bone. A review of Resident 23's Order Summary Report, included a physician's order, dated May 6, 2024, indicated to give Tramadol HCL 1 tablet 50 mg by mouth every six hours as needed for moderate to severe pain. A review of Resident 23's Medication Count Sheet, for the month of August 2024, indicated eleven doses of Tramadol HCL 50 mg were signed out by the Licensed Nurse (LN) on the following dates and times: - August 2, 2024, at 9 p.m. - August 6, 2024, at (time illegible). - August 8, 2024, at 12 p.m. - August 8, 2024, at (time illegible). - August 9, 2024, at 8:05 a.m., 6 p.m., and 9:30 p.m. - August 13,…

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, which has more than 120 beds, failed to employ a full-time qualified social worker. This failure had the potential in residents not receiving the necessary treatment and health services provided by a qualified social worker. On August 23, 2024, at 4:30 p.m., the Administrator (ADM) was notified an extended survey would be conducted due to substandard quality of care issues. Findings: On August 23, 2024, at 12:27 p.m., during a concurrent interview and review of the social worker employment requirements with the (SSD), she stated she had been employed in the facility for one year and one month as a full-time Social Service Director for the facility. The SSD stated she did not have a bachelor's degree in social work, and she is not a licensed medical social worker. The SSD further stated she is not supervised by a qualified social worker. The SSD stated she is not qualified to perform psychosocial assessments to residents which had the potential to cause physical and psychosocial distress. On August 23, 2024, a review of the Social…

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 the Quality Assessment and Performance Improvement (QAPI) identified concern regarding narcotic (a controlled drug that can cause paralysis or loss of feeling) medication accountability and pain assessment before and after pain medication administration was monitored and evaluated. This failure had the potential for possible diversion of controlled medication and for residents to experience unrelieved and unmanaged pain which could compromise the resident's overall health and wellbeing. Findings: On August 23, 2024, at 4:53 p.m., a concurrent interview and record review of the facility QAPI meeting were conducted with the Administrator (ADM) and the Director of Nursing (DON). The DON stated the QAPI meetings on February 26, 2024 and April 30, 2024 identified the following concerns: - Narcotic medications being signed out on the narcotic count sheet by License Nurses (LN) but were not being documented as administered in the e-MAR (Electronic Medication Administration Record), and - Pain assessments, monitoring and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the residents' rights were promoted and respected for six of 11 residents (Residents 23,29, 59, 106, 112 and 126) when: 1. Residents 23, 29, 59, 106 and 126 complained that call lights (devices used by residents to signal a need for assistance from facility staff) were not answered promptly by staff. This failure had the potential for Residents 23, 29, 59, 106 and 126 to not receive timely care, which could lead to falls, injuries, and worsening of residents' condition. 2. Resident 112's lunch meal tray was not served at the same time as another resident's. This failure had the potential to decrease Resident 112's meal intake, which could lead to weight loss. Findings: 1. On August 20, 2024, at 10:25 a.m., during an interview with Residents 29, 59, 106, and 126, on the Resident Council meeting. Residents 29, 59, 106, and 126 stated when they call for assistance the staff did not respond timely. The residents further stated call…

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 an assessment was conducted for three of eight residents (Resident 49, 101, and 113) reviewed for safe self-administration of medication when: 1. One pink medication pill was found on the overbed table. 2. One opened bottle of 15ml (milliliters - unit of measurement) eyedrops (medication that relieved eye irritation) was found on the overbed table. 3. One opened black bottle of 15,250 MG (milligram - unit of measurement) dietary supplement was found on the overbed table. This failure had the potential for Residents 49, 101, and 113 to receive multiple doses of medication without proper monitoring, which could lead to harmful effects or death. Findings: 1. On August 19, 2024, at 8:33 a.m., during concurrent observation and interview with Resident 49 in his room, one pink medication tablet was oberved on top of his bedside table. Resident 49 stated the nurse placed the medication on his overbed table this morning and then left 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, and record review, the facility failed to ensure education and resources for Advance Directive (AD - written statement of a person's wishes regarding medical treatment) was provided for 15 of 25 residents (Residents 15, 60, 82, 57, 56, 53, 87, 104, 58, 49, 105, 107, 52, 113, and 101), and or the Resident Representative (RP). This failure had the potential for Residents 15, 60, 82, 57, 56, 53, 87, 104, 58, 49, 105, 107, 52, 113, 101 and the RP not to be educated and informed about AD and the facility unable to know and honor the residents wishes regarding their medical treatment. Findings: 1. On August 20, 2024, Resident 15's 'admission RECORD, was reviewed. Resident 15 was admitted to the facility on [DATE], with diagnoses which included dementia (loss of memory). A review of Resident 15's HISTORY AND PHYSICAL EXAMINATION, dated June 6, 2024, indicated, Resident 15 did not have the capacity to understand and make decisions. A review of Resident 15's Social History Assessment, dated May 16,…

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 for 20 of 20 residents reviewed for pain (Resident 3, 16, 18, 19, 23, 26, 30, 34, 58, 65, 76, 80, 83, 88, 95, 98, 99, 120, 278, 280): a. A pain assessment was conducted prior to the administration of PRN narcotic pain medication; and b. An evaluation was conducted after the administration of PRN narcotic pain medication. These failures had the potential for Residents 18, 58, 65, 19, 278, 23, 26, 34, 83, 99, 120, 76, 88, 95, 16, 80, 280, 3, 30, and 98, to experience unrelieved and unmanaged pain which could compromise the resident's overall health and wellbeing. In addition, failing to document the residents' pain levels before and after administration of the pain medication could disrupt effective pain management and result in a lack of individualized care. Findings 1. On August 20, 2024, Resident 18's admission RECORD, was reviewed. Resident 18 was admitted to the facility on [DATE], with diagnoses which included osteomyelitis 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 observations, interviews, and record reviews the facility failed to ensure Food and Nutrition Service employees were able to carry out their functions safely and effectively when: 1. Several Food and Nutrition Service employees were unable to properly clean used kitchen equipment; This failure had the potential to cause foodborne illness for 128 out of 129 sampled residents who received foods from the kitchen. 2. Two Diet Aide did not know the correct concentration of chlorine (sanitizer) for the dish machine. This failure had the potential to cause a strong chloride odor leading to cross-contamination of clean kitchenware for 128 out of 129 sampled residents who received foods from the kitchen. 3. [NAME] 1 did not follow the recipe for making pureed Bread Stuffing for lunch on 8/20/24; (Cross referred F 804) This failure resulted in eight out of eight residents receiving overly salty pureed Bread Stuffing, which may lead to decreased meal intake. Findings: 1. During a review of the facility's Policy and Procedure (P&P) titled, SHELVES, COUNTERS, AND OTHER SURFACES…

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 on MEAL SERVICE to provide appetizing food at appropriate temperatures according to residents' preferences for nine of 128 sampled residents (Resident 23, 26, 34, 35, 57, 62, 78, 97 and 426). This failure placed residents at potential risk to decrease nutritional intake and affect the resident's nutrition status. Findings: On August 19, 2024, at 9:41 a.m., an interview was conducted with Resident 35. Resident 35 stated, Food is cold during breakfast, lunch and dinner. On August 19, 2024, at 10:13 a.m., an interview was conducted with Resident 26. Resident 26 stated, Vegetables tasted old and no flavor; meat is tough, and they put too much dressing on salad. On August 19, 2024, at 10:47 a.m., an interview was conducted with Resident 97. Resident 97 stated, Food taste bad and is not good. On August 19, 2024, at 10:57 a.m., an interview was conducted with Resident 426's family. Resident 426's family stated provided foods…

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 safe and sanitary food preparation and storage practices in the kitchen when: 1. Mold, dust and hair were found in the walk-in refrigerator; 2. Calcium buildup was found on hot water spout; 3. Three wet plastic containers were stacked and stored with dried containers; 4. Dust was observed on several pieces of equipment in the kitchen; 5. Rust was found on several pieces of equipment in the kitchen; 6. Two pieces of equipments in the kitchen had chipped paint; and 7. An unsanitary microwave was found in the [NAME] pantry room These failures had the potential to cause foodborne illness (stomach illness acquired from ingesting contaminated food) in a medically vulnerable population of 128 out of 129 residents who received food prepared in the kitchen. Findings: 1. On August 20, 2024, at 9:35 a.m., a concurrent observation and interview were conducted with the Dietary Service Supervisor (DSS), at the walk-in refrigerator. Two out of two storage shelves were found to have whitish, grayish, and black fuzzy…

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 homelike environment for one of four residents reviewed for environment (Resident 107) when the resident complained of uncomfortable noise level during sleeping hours. This failure had the potential for Resident 107 to experience lack of sleep, discomfort, and irritability which could affect the resident's overall health and well-being. Findings: On August 22, 2024, Resident 107's record was reviewed. Resident 107 was admitted to the facility on [DATE], with diagnoses which included hypotension (low blood pressure). A review of Resident 107's Health Status Notes, dated August 20, 2024, at 9:19 a.m., indicated, .Two residents outside .One gardening .One sitting on bench .Today Patient states it happened again . A review of Resident 107's Care Plan, dated August 16, 2024, indicated, .Complained about another resident doing gardening early in the morning and it wakes him up . On August 19, 2024, at 10:20 a.m., during a concurrent observation 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 and record review, the facility failed to ensure an accurate smoking assessment was conducted for one of one resident reviewed for smoking (Resident 95), who smokes electronic cigarettes (battery powered device that heats liquids into an aerosol that users breathe in). This failure had the potential to result in Resident 95 sustaining an injury associated with the use of electronic cigarettes. Findings: On August 23, 2024, Resident 95's admission RECORD, was reviewed. Resident 95 was admitted to the facility on [DATE], with diagnoses which included pulmonary hypertension (blood pressure in the lungs higher than normal). A review of Resident 95's History and Physical Examination , dated July 12, 2024, indicated has the capacity to understand and make decisions. A review of Resident 95's Minimum Data Set (an assessment tool), dated March 18, 2024, indicated Resident 95 had a Brief Interview of Mental Status (a cognitive screening tool used to assess the mental state of residents) Score 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide respiratory care and treatment for one of two residents reviewed for respiratory care (Resident 52) when the physician's order for oxygen therapy was not implemented as ordered. This failure had the potential for Resident 52 to experience oxygen toxicity (harmful effects related to excessive oxygen in the lungs). Findings: On August 19, 2024, Residents 52's admission RECORD, was reviewed. Resident 52 was admitted on [DATE], with diagnoses which included other specified symptoms and signs involving circulatory (relating to the circulation of blood) and respiratory system (system allow oxygen in the air to be taken in and out of the body). A review of Resident 52's care plan dated July 2, 2024, indicated .Potential for SOB (shortness of breath) .Interventions .Oxygen at 2L/min . A review of Resident 52's Order Summary, dated, August 19, 2024, indicated, .Oxygen .at 2 L/min (LPM -liters per minute) via NC (nasal cannula - a plastic…

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 for two of three residents reviewed for dialysis (special procedure done by a trained professional to remove wastes and excess fluids from the body) (Residents 100 and 23) to ensure: 1. Resident 100 was assessed after dialysis; and 2. Resident 23's recommendation to discontinue fluid restriction (limited fluid consumption) was followed. In addition, Resident 23's Intake and Output (I&O) were monitored. These failures had the potential for Residents 100 and 23 to not be monitored which could lead to dialysis complications (e.g. heart failure, fluid overload, bleeding), harm and or death. Findings: 1. On August 19, 2024, Resident 100's admission RECORD, was reviewed. Resident 100 was admitted to the facility on [DATE] with diagnoses which included end-stage renal disease (ESRD - when the kidneys stop working) on dialysis. A review of Resident 100's Order Summary, date June 21, 2024, indicated, .Hemodialysis (a type of dialysis) .On Tues (Tuesday), Thursday,…

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 behavior monitoring was conducted for the use of Olanzapine (used to treat schizophrenia - a condition that affects a person's ability to think, feel. and behave clearly), for one of five residents reviewed for unnecessary medication (Resident 278). This failure to identify and monitor specific behavior manifested had the potential to put Resident 278 at risk of receiving unnecessary medication, which could result in serious harm. Findings: On August 23, 2024, Resident 278's medical record was reviewed. Resident 278 was admitted to the facility on [DATE], with diagnoses which included schizophrenia. On August 23, 2024, a review of Resident 278's Minimum Data Set (MDS - an assessment tool) was reviewed. Resident 278's MDS indicated under Section C, Resident 278's Brief Interview for Mental Status (a screening tool used to assess the mental state of residents) Score was 11 (cognition moderately impaired). On August 23, 2024, a review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure discontinued medications were stored properly and not readily available for use when two vials/bottles of Lorazepam (used to treat anxiety [feeling of fear]) and Insulin Lispro Injection (a rapid-acting insulin used to lower blood sugar level) were observed in the medication room refrigerator. This failure had the potential to result in the accidental administration of discontinued medication to residents. Findings: On [DATE], at 2:30 p.m., during a concurrent observation, interview, and record review with Registered Nurse (RN) 2 in the Westside medication room, two bottles/vials of lorazepam, one insulin (Humalog) lispro injection pen with d/c (discontinued) written on it were observed. RN 2 stated the facility's process for discontinued medication is to give the medicine to the resident at discharge or destroy the medication. RN 2 stated the medications should not be left in the refrigerator and was not sure why they were still…

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 the therapeutic diet order (diet ordered by a physician) and resident preferences were followed for one of 12 residents (Resident 23) when: 1. Resident 23's diet physician order was not implemented and/or provided to the resident. This failure had the potential for Resident 23 to not meet his nutritional needs and not honor his food preferences; and 2. The Registered Dietician's (RD) recommendation to fortify Resident 23's diet was referred to the physician and carried out. This failure had the potential for Resident 23 to have decreased calorie intake and compromise his nutritional status. Findings: 1. On August 19, 2024, at 10:57 a.m., an observation with a concurrent interview was conducted with Resident 23 in his room. Resident 23 stated, he did not like the food served during meals. Resident 23 further stated he did not like fish, pizza, and sandwiches but it was still being served to him. Resident 23 stated he had already…

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 infection control practices were implemented when: 1. Certified Nursing Assistant (CNA) 4 did not clean and disinfect (use of chemicals to reduce the number of bacteria or virus particles on surfaces) the Hoyer lift (mechanical device use for lifting) before and after resident use. 2. Registered Nurse (RN) 3 did not wear personal protective equipment (PPE - equipment use to protect against infection or illness) when taking care of a resident with Extended Spectrum Beta Lactamase (ESBL - a bacteria resistant to many antibiotics [medication use to treat infections]). These failures had the potential to increase the spread of pathogens (germs) and infections from staff to residents which could lead to illness or death. Findings: 1. On August 20, 2024, at 9:02 a.m., during a concurrent observation and interview with CNA 4, CNA 4 was observed coming out of Resident 105's room and entering Resident 18's room with the Hoyer lift. CNA 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 observation, interview, and record review, the facility failed to maintain an effective pest control program to ensure the facility remained free of pests when house flies were found in the kitchen and East activity room. This failure had the potential to spread bacteria from flies, which could cause illness in a medically vulnerable population of residents. Findings: On August 19, 2024, at 10:52 a.m., a concurrent observation and interview were conducted with the Dietary Service Supervisor (DSS) in the kitchen at the prep juice area. A house fly was observed landing on a cleaned plastic container. The DSS stated the delivery man propped the door open, which allowed the house fly to enter the kitchen. On August 20, 2024, at 12:41 p.m., a concurrent observation and interview were conducted with Certified Nurse Assistant (CNA) 3 in the East activity room. A house fly was observed landing on Resident 41's served food. CNA 3 stated the house fly entered the room when other residents opened the door to go outside to smoke. On August 21, 2024, at 9:19 a.m., an 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 record review, the facility failed to ensure facility policy and procedure for hand hygiene were followed for one of four sampled residents, (Resident 4), when the Treatment Nurse, (TN), did not perform hand hygiene after removing gloves, and before donning a new pair of gloves during wound care. This failure had the potential for contamination of Resident 4's wound. Findings: On July 23, 2024, at 10:40 a.m., an unannounced visit to the facility on a complaint investigation was initiated. On July 23, 2024, at 2:56 p.m., observed the TN providing wound care to Resident 4. The TN provided peri-care, removed her gloves, walked to the bathroom, and washed her hand with soap and water for 30 seconds. The TN walked back to the left side of Resident 4's bed, donned a new pair of gloves. She removed the wound cleanser from the clear plastic bag that was on the left side of Resident 4's mattress. The TN removed clean 4x4 gauze from the plastic bag and held the 4x4 gauze in her left…

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

Based on observation and interviews, the facility failed to provide a dedicated dietary manager (DM) to safely and effectively, carry out the functions of the food and nutritional services. This failure had the potential to result in a lack of oversight, leading to poor food safety practices including improper food storage. Findings: On July 18, 2024, at 8:10 a.m., an unannounced visit was made to the facility for a quality-of-care issue. On July 18, 2024, at 8:35 a.m., an interview was conducted with the Director of Staff Development (DSD). The DSD stated, the facility did not have a dedicated DM. The DSD further stated, the Dietary Corporate Consultant (DCC) and Registered Dietitian (RD), helped cover the duties of DM by filling in for the DM throughout the week. On July 18, 2024, at 8:55 a.m., an interview was conducted with the DCC, who confirmed, the facility does not have a dedicated DM. The DCC stated, she covers the DM duties for two days per week, the RD covers the duties for two days per week, and a DM from a sister facility covers the DM duties for the remaining days of…

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

Based on observation, interview, and record review, the facility failed to ensure food items were stored in accordance with the professional standards for food service safety when foods within the refrigerator were missing the use by dates or expiration dates. This failure had the potential that food may be consumed past its safe consumption, leading to foodborne illnesses due to spoilage or contamination. Findings: On July 18, 2024, at 9:00 a.m., a concurrent observation of the kitchen and interview with DCC were conducted. The DCC stated, the Italian dressing was missing a use-by date. The DCC stated all food items in the refrigerator should have received, open, and use-by dates. The DCC stated, the egg salad in the refrigerator, dated July 18, 2024, was missing an expiration date. The DCC stated, the dietary staff (DS) who prepared the egg salad, should have written the expiration date on the food container. On July 18, 2024, at 9:25 a.m., an interview was conducted with DS 1, who stated, she had prepared the egg salad that morning, and did not put an expiration date on the food.…

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 ascertain the current condition of one of three sampled residents (Resident 1), prior to refusing the resident's re-admission to the facility. The resident had been living at the facility for 11 years. This failure increased the potential for prolonged hospital stay and emotional distress to Resident 1 and his family. Findings: On May 13, 2024, at 9:05 a.m., an unannounced visit to the facility was conducted to investigate a complaint related to refusal to readmit. On May 13, 2024, Resident 1's medical record was reviewed. Resident 1 was admitted to the facility on [DATE], with a diagnoses which included history of traumatic brain injury (when a sudden external physical assault damages the brain) and adjustment disorder with mixed disturbance of emotions and conduct. The facility history and physical indicated Resident 1 did not have the capacity to understand and make decisions. Resident 1's medical record indicated that on April 9, 2024, resident 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, and record review, the facility failed to ensure information related to facility bed hold (holding or reserving a resident's bed while the resident was absent from the facility during hospitalization or therapeutic leave) was provided to one (Resident 1) of three sampled resident's family member. This failure had resulted in the family member not given the opportunity to ensure a facility bed would remain available for Resident 1's return to receive services needed. Findings: On May 7, 2024, at 8:25 a.m., an unannounced visit to the facility was conducted to investigate a complaint related to discharge and bed hold issues. On May 7, 2024, Resident 1's medical record was reviewed. Resident 1 was admitted to the facility on [DATE], with a diagnosis which included history of traumatic brain injury (when a sudden external physical assault damages the brain) and adjustment disorder with mixed disturbance of emotions and conduct. The facility history and physical indicated Resident 1 did not have…

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: 1. Provide accurate bookkeeping of Resident 1 ' s monthly Room & Board (R&B) charges. 2. Provide a Notice of private pay rate increase, prior to charging a (R&B) daily increase from $280/(per) day to $380/day, for Resident 1. These failures had the potential to result in confusion and overpayment for Resident 1 or Resident 1's representative. Findings: On January 11, 2024, at 1:10 p.m., an unannounced visit was made to the facility to investigate a billing issue. A record review of Resident 1 ' s admission records, indicated, resident was admitted to the facility on [DATE], with a primary diagnosis of emphysema (Air sacs of lungs are damaged and enlarged, causing breathlessness). On January 11, 2024, at 1:25 p.m., an interview was conducted with Resident 1's representative. The resident's representative verbalized frustration on the resident's monthly bill. The representative stated she pays the monthly bill, however; the statements had been…

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 interview & Record review the facility failed to consistently assess and monitor the changes of one of three sampled residents' (Resident 1) skin body rash. This failure has the potential to result in delayed provision of appropriate treatment which could cause worsening of the skin condition. Findings: On December 10, 2023, at 10 a.m., an unannounced visit was conducted at the facility to investigate a quality care issue. A review of Resident 1 ' s facility admission records, indicated the resident was admitted to the facility on [DATE], with diagnoses which included diabetes mellitus (chronicmetabolic disorder characterized by persistent high blood sugar). A review of Resident 1 ' s progress notes dated December 7, 2023, at 5:51 p.m., by Licensed Vocational Nurse (LVN 1), indicated, .Informed Dr (Doctor) . that Resident (1) have (sic) noted with episodes of scratching due to generalized itchiness . A review of Resident 1 ' s physician ' s orders dated, December 07, 2023, indicated, . Loratadine (used to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure monitoring was done and the physician was notified, for one of five residents reviewed, when Resident 1 was identified with a change of condition on October 25, 2023, at 8:25 a.m. This failure had the potential for Resident 1 to not be adequately monitored and assessed for worsening in his condition and potentially led to Resident 1's transfer to the General Acute Care Hospital (GACH) later in the day. Findings: On February 6, 2024, at 10:05 a.m., an unannounced visit was conducted at the facility. On February 6, 2024, Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which included hemiplegia (paralysis on one side of the body), cerebral infarction (stroke-decrease in blood flow to the brain which could affect the ability to talk and move), and urinary retention (unable to empty the bladder completely when voiding). A review of Resident 1's Physician Order Summary, dated October 25, 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 interview and record review, the facility failed to accommodate preferences for certain staff to assist during shower and baths for one of four residents (Resident 1). The facility failure had the potential for the resident to refuse routine personal care which could result in unmet needs. Findings: On December 21, 2023, at 8:00 a.m., an unannounced visit was conducted to investigate concern on residents rights. On December 21, 2023, the Staffing Assignment Sheet dated December 20 and 21, 2023, and the Shower and Bath schedule was reviewed. The Shower and Bath schedule indicated Resident 1 was assigned to receive shower and bath every Wednesday and Saturday of the week, and the Staffing Assignment Sheet had pre-arranged resident ' s schedule marked with pre-assigned Certified Nursing Assistant (CNA). On December 21, 2023, at 9:30 a.m., Certified Nursing Assistant 1 (CNA) was interviewed. CNA 1 stated Resident 1 had refused his shower on December 20, 2023, and had allowed her only to give a partial bed bath. CNA 1 stated Resident 1 had requested for a certain CNA who was 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 interviews and record review the facility failed to obtain orders from the physician for blood work (labs) and an ultrasound (an x-ray using special medical imaging) for one of three Residents, (Resident 1). This failure had the potential for a delay in care for Resident 1. Findings: On September 13, 2023, at 9:42 a.m., the Department received a complaint, indicating Resident 1 did not get labs and ultrasound (US-is a noninvasive imaging test) done as ordered by physician. On September 27, 2023, at 8:23 a.m., an unannounced complaint investigation was conducted at the facility. A review of Resident 1's Face Sheet (admission Record) indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnosis included asthma, hypertension, Parkinson's disease (a disorder that affects movement, often including tremors), Scoliosis (a sideways curvature of the spine) and Chronic Obstructive Pulmonary Disease (a group of lung diseases that block airflow and make it difficult to breathe). On 10/27/2023…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement fall intervention for one of three sampled residents (Residents B), when the resident was left unattended in the doorway. This failure resulted in the resident to fall. Findings: On June 14, 2023, at 2:15 p.m., an unannounced visit to the facility was conducted to investigate an accident issue. On June 14, 2023, at 2:26 p.m., Resident B, who was in a wheelchair, had the bedside table moved away from her and was attempting to get the magazine that had dropped on the floor. Resident B was seen by herself in the hallway without staff members present. A review of Resident B's record indicated Resident B was admitted to the facility on [DATE], with diagnoses which included dementia (memory loss). During a review of Resident B's Minimum Data Set (MDS - an assessment tool), dated March 30, 2023, the MDS indicated, the resident had a Brief Interview for Mental Status (a tool used to screen and identify the cognitive condition 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 store, prepare, and distribute food in accordance with professional standards for food service safety when: 1. The ice machine located in the East Wing was not cleaned and sanitized properly per manufacturer's guidance; 2. Several various size of metal pans was stacked and stored wet; 3. Dietary Aide (DA) 2 was not able to perform hand hygiene practices and glove use properly in between dirty and clean areas during the process of machine dishwashing; and 4. Facility had no system in place to review and monitor temperatures of the freezers in the pantries, for the resident's food refrigerators at the East and [NAME] Wings. These failures had the potential to cause food-borne illness in medically vulnerable resident population who consumed food in the facility. The facility census was 96. Findings: 1. During an observation on December 13, 2021, at 10:59 a.m., the ice machine at the East Wing had several visible black and brown residues on the side panel of the ice chute (area where the ice is dispensed) when 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, and record review, the facility failed to ensure residents received treatment and care for five of 21 residents reviewed for quality of care (Residents 29, 47, 67 and 69) when: 1. For Resident 47, an assessment and monitoring was not completed when the resident developed skin discolorations to lower extremities; 2. For Resident 67, an assessment and monitoring was not completed when the resident developed skin discolorations to lower extremities; 3. For Resident 69, a reassessment was not conducted to right upper extremity. In addition, an assessment and monitoring was not completed when resident developed edema to the left upper extremity; and 4. For Resident 29, a doctor's appointment was not rescheduled when the appointment was missed on November 23, 2021. These failures had the potential to result in the delay in treatment and further decline in residents' medical condition, affecting the psychosocial, mental, and physical well-being of the residents. Findings: 1. On December…

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 food service personnel was able to safely and effectively carry out the functions of the food and nutrition services when one Dietary Aide (DA 1) was unable to demonstrate and verbalized the process of manual dishwashing by using three-compartment sink. This failure had the potential to place 96 out of 96 highly susceptible residents who received food from the kitchen at risk for food-borne illness. Findings: During an interview on December 13, 2021, at 9:55 a.m., Dietary Aide (DA) 1 verbalized and demonstrated the process of manual dishwashing with the three-compartment sink. DA 1 stated he would first scrape off the food into the trash can and then put the dishes to wash bin with premixed detergent, then to rinse the dishes in the rinse bin. He did not mention the water temperature for the wash and rinse temperature, until the Dietary Service Manager (DSM) reminded him that both water temperature should be at 110 degrees Fahrenheit (F). He stated after washing and rinsing, the next step was to immerse 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 and record review, the facility failed to ensure the physician was notified when Resident 88 had an increase in respiratory rate above the baseline (15-20 breaths per minute). This failure had the potential for the resident not to receive the necessary care and treatment resulting in the decline of the resident's condition. Findings: Resident 88's record was reviewed. Resident 88 was re-admitted to the facility on [DATE], with diagnoses including acute respiratory failure with hypoxia (a deficiency of oxygen reaching the tissues of the body). The document titled, Respiration Summary, indicated: -Dated November 23, 2021, at 6:17 p.m., .Respiration 18 breaths/min . -Dated November 24, 2021, at 10:57 p.m., .Respiration 19 breaths/min . -Dated November 26, 2021, at 9:00 p.m., .Respiration 19 breaths/min . - Dated November 27, 2021, at 8:17 a.m., .Respiration 22 breaths/min . (manual) . - Dated November 27, 2021, at 6:20 p.m., .Respiration 18 breaths/min . (manual) . - Dated November 28, 2021, 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 interview and record review, the facility failed to ensure the care plan on skin issue was reassessed and revised to address the left arm discoloration for one of 21 residents reviewed, (Resident 47). This failure had the potential to result in providing interventions that was ineffective for the resident. Findings: On December 14, 2021, at 9:36 a.m., Resident 47 was observed with discoloration on his left wrist. In a concurrent interview with Resident 47, he stated he did not know what happened. Resident 47's record was reviewed. Resident 47 was admitted to the facility on [DATE], with diagnoses which included chronic kidney disease (gradual loss of kidney function which can cause dangerous levels of fluid, electrolytes and wastes to build up in the body). Resident 47's care plan titled, High risk for Skin Discoloration/Hematoma/Skin tears/Skin breakdown, developed on February 4, 2019, indicated, Handle gently during care .Monitor skin condition Q shift and PRN (as needed) . Resident 47's record titled…

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 meal time assistance was provided for one of three residents reviewed for Activities of Daily Living (ADL) (Resident 95). This failure has the potential to result in a decrease in resident's oral intake which could result in weight loss. Findings: On December 13, 2021, at 12:20 p.m., Resident 95 was observed in the room with lunch tray at bedside. and the resident was not eating the meal that was served. There was no staff observed feeding the resident. On December 13, 2021, at 12:38 p.m., Certified Nursing Assistant (CNA) 2 was interviewed. He stated Resident 95 ate 10-15% of the meal served. On December 13, 2021, at 3:40 p.m., the Resident Representative (RR) was interviewed, and the RR stated the resident needed encouragement, for him to eat. She stated Resident 95 would not eat if the staff would not encourage him to eat. On December 15, 2021, at 7:27 a.m., Resident 95 was observed in a wheelchair sleeping with breakfast tray…

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 room visits to meet the interests of and support the psychosocial well-being of one of four residents reviewed for activities (Resident 246). This failure had the potential for Resident 246 to not meet her highest physical, mental and psychosocial well-being. Findings: A review of Resident 246's record, indicated, Resident 246 was admitted to the facility on [DATE], with diagnoses which included fracture of lower end of left tibia (shin bone). Resident 246's history and physical examination dated November 6, 2021, indicated she had the capacity to make decisions about her health care. Resident 246 Care Plan for Activity, date-initiated November 13, 2021, indicated, .Goal .Resident will participate in preferred act's (activities) of interest .If group attendance is less than 2-3x/ week provide resident with a tailored activity program which allows resident to partake in preferred activities of choice . Resident 246's MDS (Minimum…

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 the post dialysis assessment was completed after receiving hemodialysis (process of removing waste from the blood with the use of a machine) treatment on November 5, 2021, for one of one resident reviewed for dialysis (Resident 16). This failure has the potential for the facility not to be aware of Resident 16's condition during and after dialysis treatment. Findings: A review of Resident 16's record indicated Resident 16 was admitted to the facility on [DATE], with diagnoses which included end stage renal disease (ESRD- kidney failure). Resident 16's history and physical examination dated June 28, 2021, indicated, Resident 16 has the capacity to understand and make decisions. On December 16, 2021, at 2:41 p.m., in a concurrent interview and record review with Registered Nurse (RN) 2, RN 2 stated dialysis care was coordinated thru the communication form sent to the dialysis facility. He stated it is the facility's practice to fill out 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 ensure pharmacy services were provided to meet the needs of the residents by not having a readily available vial of Lorazepam (medication used to treat anxiety) in the refrigerated eKIT (emergency medication kit) as indicated on the eKIT Content List, located in the medical storage room. This failure had the potential to result in medication not being available for emergency use. Findings: On December 13, 2021, at 4:03 p.m. an observation of the medication storage room at Station 2 was conducted. One small eKIT in the refrigerator was observed with a label read: (Name of Facility) eKIT #2 Daily exchange, had the following contents: - Humulin R U 100 Insulin x 1 (fast acting insulin to reduce blood sugar level) - Humulin N U Insulin x1 (longer acting insulin to reduce blood sugar level.) - Lorazepam 2mg/ml (milligrams per milliliter a unit of measure) x1 .expiration 6/22 (June 2022) dated: 9/20/2021 initials by RPH (registered pharmacist) dated: 2/18/2021 initials by TECH (pharmacy technician) . Upon opening…

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's pharmacist failed to provide the monthly medication regimen review timely. This failure had the potential to allow continuation of unnecessary medication regimen for one of five residents reviewed for unnecessary medication (Resident 16). Resident 16 continued to receive daily, two laxative medications (to prevent development of hard to pass stool) and one antidiarrheal (to prevent development of diarrhea), which work to counter each other. Findings: On December 15, 2021, at 1:40 p.m., an interview was conducted with Licensed Vocational Nurse (LVN 5). LVN 5 stated he had been providing Resident 16 with two scheduled laxative medications and one antidiarrheal medication during dialysis days. On December 15, 2021, at 3:22 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated a resident should not be taking two regularly scheduled laxatives in conjunction with an antidiarrheal because they could counter each other. On December 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 pharmacy services were provided to meet the needs of the residents by not labeling the open date sticker on the multi-dose injectable insulin pen (a device used to administer insulin) with the date it was initially opened. This failure had the potential for administering discontinued and below therapuetic concentration of medications to the residents. Findings: On December 14, 2021, at 11 a.m., during the inspection of Medication Cart 2, there was an open (the protective plastic top cap being removed and unrefrigerated) injectable pen of Lantus Insulin (Long acting insulin). The pen did not have an open date indicated on the open date sticker or a written open date on it. A concurrent observation and interview was conducted with Licensed Vocational Nurse (LVN) 6. LVN 6 stated there was no open date on the Lantus injection pen and she could not tell when it was opened. The manufacturer of Lantus recommends the following included in the prescribing information: .Open (In-Use) Vial: Vials must be…

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 residents' medical records were maintained in accordance with the professional standards and practices for two of 21 residents reviewed (Residents 47 and 69), when: 1. The licensed nurses did not document the presence of nephrostomy tube (a tube placed to kidney to drain urine) in the weekly progress notes for Resident 69; 2. Resident 47's skin discoloration on his left arm was not documented under skin observation and weekly progress note. These failures had the potential to result in inaccurate representation of the residents' condition and not reflecting the care and services provided to the resident. Findings: 1. On December 15, 2021, at 3:29 p.m., Licensed Vocational Nurse (LVN) 2 was observed providing a dressing change to Resident 69. Resident 69 was observed with a left nephrostomy tube and right urostomy tube (an opening in the belly made surgically to re-direct urine away from bladder). Resident 69's record was reviewed.…

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 implement infection prevention and control practices in preventing transmission of COVID-19 (corona virus-illness caused by a virus that can be transmitted from person to person) when: 1. Two visitors (Transport staff) were not screened for their vaccination status prior to entering the facility. 2. One unvaccinated staff was wearing surgical mask and not the N95 respirator (a mask used to filter particles), while working in the facility. These failures had the potential to result in the spread of COVID-19 infection to residents and staff. Findings: 1. On December 15, 2021, at 9:05 a.m., two transport staff went inside the facility to pick Resident 246 for dialysis (process of removing waste from the blood with the use of a machine). On December 16, 2021, at 9:11 a.m., in a concurrent interview and record review with the receptionist, she stated the transport staff were screened upon arrival. The receptionist was unable to provide documented evidence the two-transport staff were screened for their vaccination…

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.