Vista Real Post Acute

Based on observation, interview, and record review the facility failed to ensure Dietary staff were able to carry out the functions of food and nutrition services safely and effectively when: 1. The [NAME] used a slotted spoon to scoop out meatloaf without measuring the portion when preparing pureed meat during the lunch service on July 8, 2024. (Cross referred F 803) This failure had the potential for four out of four residents who received pureed meat prepared in the kitchen to not meet their nutritional needs, which could lead to nutrition-related health complications. 2. Diet Aide 2 served ice cream instead of diet cookies to Resident 7, who had a physician-ordered renal controlled carbohydrate during the lunch service on July 8, 2024. (Cross referred F 808) This failure had the potential for Resident 7, to receive a dessert prepared in the kitchen that did not meet their nutritional needs which may lead to nutrition-related health complications. Findings: On July 8, 2024, at 9:54 a.m., a concurrent observation and interview were conducted with [NAME] 1 (CK) in the kitchen. CK 1…

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

Based on observation, interview, and record review, the facility failed to ensure the menus were followed and resident nutritional needs were met when: 1. The [NAME] did not follow puree recipes when preparing pureed diet during the lunch service on July 8, 2024; (Cross referred F 802) This failure had the potential for 4 out of 4 residents who had physician ordered pureed diets, as the pureed food prepared in the kitchen did not meet their nutritional needs which may lead to nutrition-related health complications. 2. The [NAME] served biscuit instead of wheat roll for Carbohydrate Control diet Residents during the lunch service on July 8, 2024; This failure had the potential for 12 out of 12 residents who had physician-ordered Carbohydrate Control diets, as the food prepared in the kitchen did not meet their nutritional needs which may lead to nutrition-related health complications. 3. The [NAME] was not supposed to serve biscuits to Mechanical Soft diet residents during the lunch service on July 8, 2024. This failure had the potential for 14 out of 14 residents who 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 observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen when: 1. There was buildup found on the ice maker; 2. Wear and tear were observed on the mixer in the kitchen; 3. The milk refrigerator's gasket was found to have black grime; 4. [NAME] grime was found on equipment; 5. Open food items were found on exposed to the air; 6. Three serving scoops were stored wet with other dry scoops, and one plastic container was stacked wet with other dry containers; 7. The vent hoods were covered with grease and dust; 8. The ceiling above the steam table was covered with dust. These failures had the potential to cause foodborne illness (stomach illness acquired from ingesting contaminated food) in a medically vulnerable population of 51 out of 52 residents who received food prepared in the kitchen. Findings: 1. On July 8, 2024, at 2:19 p.m., a concurrent observation and interview were conducted with the Dietary Supervisor (DS)…

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: 1. Resident (55) was observed to have a pair of black shoes and blue pants on top of a commode (chair with a built-in toilet seat). 2. The Activity Director (AD) was observed to have long artificial nails when providing direct care to residents. These failures had the potential to increase the risk of transmission of infectious disease (disorders caused by organisms) to vurnerable residents in the facility. Findings: 1. On July 8, 2024, at 10:10 a.m., a concurrent observation and interview were conducted inside Resident 55's room. Resident 55's pair of black shoes and blue pants were on top of a commode. Resident 55 stated he asked the staff to placed it in his big closet this morning. On July 8, 2024, at 10:20 a.m., a concurrent observation and interview was conducted with Certified Nursing Assistant (CNA) 1 inside Resident 55's room. CNA 1 stated, Resident 55's shoes and pants should not be on top of a commode. CNA 1 stated all clean clothes should…

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

Based on observation and interview, the facility failed to contain waste in a closed container, and provide a comfortable homelike environment for three of six residents reviewed (Residents 30, 42, and 43) when: 1. Multiple discarded medical equipment and non-medical materials surrounding the outside disposal bins. This failure had the potential to attract insects and rodents, presenting a health risks to the vulnerable population in the facility. 2. The window blinds in resident rooms were damaged. This failure had the potential to cause disruption of sleep, inability to properly control sunlight leading to increased heat. Findings: 1. On July 8, 2024, at 1:15 p.m. the outside waste disposal bins were observed to have multiple scattered debris of discarded and broken medical equipment and waste. On July 10, 2024, at 09:13 a.m., a concurrent observation and interview were conducted with Maintenance Supervisor (MS). The MS was made aware of the buildup of scattered debris and discarded medical equipment outside near the large garbage bins. There were several broken medial equipment…

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 six residents reviewed for Advance Directive (AD - written statement of a person's wishes regarding medical treatment) (Residents 4 and 5) to: 1. Ensure a copy of the Advance Directive (AD - written statement of a person's wishes regarding medical treatment) was available in the resident's record; and 2. Verify if the resident did have an advance directive or if the resident representative was provided information regarding formulation of the advance directive. These failures had the potential for Residents 4 and 5's AD to not be readily retrievable by the staff and the physician, making them unaware of, and unable to honor the residents wishes regarding their medical treatment. Findings: 1. On July 8, 2024, at 3:50 p.m., Resident 5's record was reviewed. Resident 5 was admitted to the facility on [DATE]. A review of Resident 5's History and Physical dated December 29, 2023, indicated Resident 5 does not have the capacity to understand and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the resident representatives (RP) and Office of the State Long-Term Care Ombudsman (LTC Ombudsman) of a transfer for one of three residents (Resident 57) reviewed for closed records. This failure had the potential to result in the RP and LTC Ombudsman not to be informed about Resident 57's plan of care and condition. Findings: On July 10, 2024, at 12:00 p.m., Resident 57's record was reviewed. Resident 57 was admitted to the facility on [DATE], with a diagnosis which included anxiety disorder (excessive worry and feelings of fear, dread, and uneasiness). A review of the document titled, Physicians Discharge Summary, dated April 16, 2024, indicated, .Sent to hospital from Appointment . There was no documented evidence that the facility mailed or faxed a letter of transfer/discharge notice to Resident 57's RP and to the LTC Ombudsman. On July 10, 2024, at 2:04 p.m., a concurrent interview and record review was conducted with the Director of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the physician recommendation for wound treatment was transcribed to an actual physician order for one of two residents (Resident 23) reviewed. This failure resulted in a gap in the communication regarding the physician's recommendation which affected the implementation of the recommended care or treatment. Findings: On July 11, 2024, Resident 23's record was reviewed. Resident 23 was admitted to the facility on [DATE], with diagnoses that included wheelchair dependent and severe debility (state of being weak). A review of the facility document titled, COC (Change of Condition) Progress Notes, dated June 4, 2024, indicated, . resident has skin tear on the right hand .Primary Provider Feedback: Primary Care Provider responded with the following feedback. A.Recommendations: Cleanse area with NS (normal saline - a sterile souliton of salt in water); pat dry; apply Triple Antibiotic (a topical medication that inhibits the growth 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 provide nail care for one of six sampled residents (Resident 42). This failure had the potential to cause skin breakdown and infection for Resident 42. Findings: On July 8, 2024, at 9:49 a.m., a concurrent observation and interview was conducted with Resident 42 inside the room. Resident 42 was observed with long, untrimmed fingernails on both hands with black colored residue. Resident 42 stated my nails are dirty and needs to be trimmed On July 8, 2024, at 9:55 a.m., a concurrent observation and interview were conducted with Certified Nurse Assistant (CNA) 1. CNA 1 stated Resident 42 had long fingernails with black dirt under them. CNA 1 stated during daily body check, the resident's fingernails were checked, and when the fingernails were long, the CNA should have trimmed them. CNA 1 stated, Resident 42's fingernails should have been trimmed. On July 8, 2024 at 9:59 a.m., an interview was conducted with Registered Nurse (RN) 1. She stated Resident 42 had long fingernails, and if he scratched his skin, 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 observation, interview, and record review, the facility failed to follow the physician order for respiratory care and treatment for one of one resident reviewed for oxygen administration (Resident 56). This failure had the potential to result in ineffective oxygen therapy, respiratory distress, and a decline in Resident 56's health condition. Findings: On July 8, 2024, Resident 56's record was reviewed. Resident 56 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (COPD - lung disease that makes it difficult to breathe). A review of Resident 56's History and Physical dated June 26, 2024, indicated Resident 56 has the capacity to understand and make decisions. A review of Resident 56's Order Summary, dated June 24, 2024, indicated, .Titrate O2 (sic) (oxygen) between 1 LPM - 3 LPM (liters per minute) to keep saturation greater than or equal to 90% every shift for COPD via Nasal Cannula (a tube used to deliver oxygen through the nose) . On July 8,…

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 dental referral and dental care services for one of one resident reviewed for dental (Resident 55). This failure had the potential to negatively effect the resident's physical and psychosocial well-being. Findings: On July 8, 2024 at 9:55 a.m., a concurrent observation and interview were conducted with Resident 55 in his room. Resident 55 was observed to have missing upper and lower teeth. Resident 55 stated he needed dentures and he had not seen a dentist since he came to the facility. Resident 55 further stated, he was embarassed talking to others and he could not smile because he did not have teeth. Resident 55 stated he told a licensed nurse about his dental issues but was not being helped. On July 9, 2024, at 3:10 p.m., a concurrent interview and record review were conducted with Registered Nurse (RN) 1. RN 1 stated if dental issues were identified upon admission, the licensed nurse would notify the physician and 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 observation, interview, and record review, the facility failed to ensure the physician orders were followed for one of four sampled residents (Resident 7) during a dining observation when: 1. Resident 7, who had a physician order for thin liquid (liquids that take little or no effort to drink) received honey- thick (slightly thicker, like honey or a milkshake) liquid during lunch on July 8, 2024. This failure had the potential to result in Resident 7 becoming discouraged with his fluid intake, further compromising his nutritional and medical status. 2. Resident 7, who had a 120 ml fluid restriction (liquid allowed to drink) for the lunch meal per physician order, received 240 ml fluid during lunch on July 8, 2024. This failure had the potential to result in fluid overload (when there is too much fluid in your body), further compromising the nutritional and medical status of Resident 7 who is undergoing dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly). Findings: 1. A review of Resident 7's physician diet…

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 an effective pest control program was in place for the kitchen when house flies were observed flying and landing in the kitchen and dining hall. This failure had the potential to lead to food borne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins) among the facility residents who eat food prepared in the kitchen. Findings: On July 8, 2024, at 8:59 a.m. a concurrent observation and interview were conducted with the Dietary Supervisor (DS) in the kitchen. Two house flies were observed flying around the kitchen and one was seen landing on the post next to the handwashing station. The DS stated, Yes, that is a house fly. The DS further stated dietary staff noticed house flies in the kitchen one month ago. She stated, We shoo them away or kill them with a fly swatter. On July 8, 2024, at 11:01 a.m., a concurrent observation and interview were conducted with Dietary Aide (DA) 1 in the kitchen. DA 1 stated a house fly landed on a cleaned red cutting board surface. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a comprehensive care plan (specific interventions to provide effective and person-centered care to meet the resident's needs) was initiated, for one of four residents (Residents 1) when: Resident 1 had a documented social history assessment indicating the presence of experiencing trauma (severe emotional or mental distress caused by an experience). This failure had the potential to result in the re-traumatization (a relapse into a state of trauma, triggered by some subsequent event) of Resident 1. Findings: On May 14, 2024, at 11:05 a.m., an unannounced visit to the facility was initiated for a facility reported incident investigation. On May 14, 2024, at 11:25 a.m., Resident 1 was observed sitting in bed, with noise cancelling headphones over the ears. Resident 1 explained the noise cancelling headphones help block out loud voices or noises that increase anxiety, especially while sleeping. Resident 1 further explained waking up 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.

Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 1), was provided trauma informed care. This failure had the potential to result in re-traumatization of Resident 1. Findings: During a concurrent observation and interview on May 14, 2024, at 11:25 am with Resident 1, Resident 1 was observed to be wearing noise cancelling headphones. Resident 1 stated, the noise cancelling headphones help reduce the level of noise from the facility and the staff. Resident 1 stated she wears the headphones to sleep due to a history of abusive relationships, if she hears staff talking loudly in the room it scares her and makes her anxious. Resident 1 also has a fear of belongings being stolen and prefers keeping personal belongings locked due to the history of abuse. During an interview on May 14, 2024, at 12:40 p.m. with Certified Nurse Aide (CNA), CNA stated, when Resident 1 is woken up abruptly she responds angrily to whoever wakes her up and demands to know what the person wants from her. CNA also stated Resident 1 has 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 on interview and record review, the facility failed to report 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 3). This failure had potential to result in further injury for Resident 3, affecting resident's physical, emotional, and psychosocial well-being. Findings: On February 14, 2024, at 4:16 p.m., CDPH received a fax (facsimile - telephonic transmission of scanned-in printed material) report of a complaint allegation of abuse, neglect and a hip fractured for Resident 3. On February 29, 2024, at 9:00 a.m., an unannounced visit to the facility was conducted to investigate a complaint allegation incident. A review of Resident 3's Face Sheet, indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis which included osteoporosis (disease that can cause the bones to become weak.) A review of Resident 3's Minimum data Set (an assessment tool) dated January…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure an allegation of abuse was reported to the California Department of Public Health (CDPH) immediately, or not later than two hours after the allegation was made for six of nine sampled residents (Residents 1, 2, 3, 4, 5, and 6). This failure had the potential to place Residents 1, 2, 3, 4 , 5, and 6 at risk for further abuse. Findings: On December 28, 2023, an announced visit was conducted at the facility to investigate an allegation of abuse. On December 28, 2023, at 10:32 a.m., a concurrent observation and interview was conducted with Resident 1. Resident 1 was in her room, lying in bed and alert. Resident 1's response during the interview was unclear. A review of Resident 1's record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included right hemiplegia (paralysis on the right side of the body), cerebral aneurysm (a bulge in the wall of a blood vessel), and dysphagia (difficulty swallowing). Resident 1 ' s…

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

Based on interview and record review, the facility failed to implement infection control practices for COVID-19 (a highly infectious respiratory virus), for three of five sampled employees, when: 1. Two Certified Nursing Assistants were allowed to work after tested positive for COVID-19; and 2. One CNA (CNA 1) had not been fit tested with the N-95 (is a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) used during direct care for COVID-19 positive residents. These failures had the potential to increase staff and resident exposure and transmission of COVID-19 virus causing illness to vulnerable population. Findings 1. A review of the facility document titled, NURSING STAFFING ASSIGNMENT AND SIGN-IN SHEET, from December 14, 2023, to December 21, 2023, indicated, CNA 2 worked on December 15, 2023 and December 19, 2023, while CNA 3 worked on December 19, 2023, December 20, 2023, and December 21, 2023. On December 21, 2023, at 12:45 p.m., during a concurrent interview and record review with the Infection…

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

Based on 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: 1. Multiple food items in the dry storage room were not labeled with received by date or open date as per facility policy and procedure; 2. Five pounds thickener in a bucket was not labeled with an open date; 3. Multiple rotten food items were in the walk-in refrigerator available for use; and 4. Six loaves of bread and 6 pieces of bun were stored outside the walk-in refrigerator available for use. These failures had the potential to result in contamination of food, causing food-borne illnesses to vulnerable population of 46 residents. Findings: 1. On January 31, 2022, at 8:42 a.m., during the dry storage room inspection with the Dietary Staff (DS), the following food items were observed: a. One opened box containing one bag of pasta with the label ripped off. In a concurrent interview with the Dietary Staff (DS), he stated the label on the box of the pasta was ripped off. The DS stated he could not tell…

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 portion sizes were followed as indicated in the spreadsheet. This failure had the potential to result in not meeting the nutritional needs of the residents. Findings: A review of the facility document titled, Cooks Spreadsheet WINTER MENUS, dated February 2, 2022, was conducted. The menu indicated, Fish Italiano .Regular .3 oz .Be sure to weigh the meat to assure correct ounces . On February 2, 2022, at 12 p.m., during the trayline observation (serving of food onto plates), [NAME] 1 was observed serving regular diet. [NAME] 1 was observed serving broken-up fish in pieces for two residents, and a portion of the fish was cut for one resident. [NAME] 1 was not observed weighing the fish prior to serving. On February 3, 2022, at 7:42 a.m., [NAME] 1 was interviewed. [NAME] 1 stated the practice was to weigh one piece of the food item to determine the portion size before the start of trayline. He stated he would be able to approximate the portion size of the other pieces during the serving. [NAME] 1…

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

Based on observation, interview, and record review, the facility failed to ensure the puree meal was prepared at an appropriate consistency. This failure had the potential to result in decreased resident's satisfaction, decreased appetite, and decreased oral intake for six residents on puree diet. Findings: On February 2, 2022, at 11:42 a.m., [NAME] 1 was observed preparing puree food. [NAME] 1 put in five pieces of fish and two scoops of chicken broth in the blender. The puree was observed not pudding like in consistency. In a concurrent interview with [NAME] 1, he stated there was no recipe for puree. [NAME] 1 stated he estimated the amount of chicken broth to put in with the fish to come up with the puree consistency. On Febraury 2, 2022, at 12 p.m., the puree rice, puree vegetables, and puree fish were placed on the steam table. The puree was observed not pudding in consistency for the three items. On February 2, 2022, at 2:07 p.m., the Dietary Service Supervisor (DSS) was interviewed. The DSS stated the puree consistency of the rice was not right. On February 3, 2022, at 2:30…

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 that the call light was within reach for one of 46 residents (Resident 3). This failure has the potential to result in resident not being able to call for assistance. Findings: On January 31, 2022 at 11:17 a.m., Resident 3 was observed in bed with his call light dangling on the floor, on the left side of the bed. Resident 3 attempted but was unable to reach the call light. On January 31, 2022, at 11:28 a.m., Licensed Vocational Nurse (LVN) 1 was interviewed. She stated the call light was out of reach of Resident 3. LVN 1 stated the call light should be within reach of the resident. On February 2, 2022, at 2:59 p.m., Certified Nursing Assistant (CNA) 1 was interviewed. She stated Resident 3 required limited assistance with his activities of daily living (ADLs). CNA 1 stated the resident was using the call light to ask for assistance. Resident 3's record was reviewed. Resident 3 was admitted to the facility on [DATE], with a diagnoses…

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 incorporate the recommendations from the PASARR level II determination and evaluation in the care plan for one (Resident 41) of six residents reviewed for PASRR (Pre-admission Screening & Resident Review- a federal requirement to determine whether or not an individual who has an active diagnosis of mental illness or intellectual disability meets the criteria for admission to a nursing facility and identify what specialized services an individual needs). This failure had the potential for Resident 41's special needs not to be met in the facility. Findings: A review of record indicated Resident 41 was admitted to the facility on [DATE], with diagnoses which included schizophrenia (a mental disorder). Resident 41's PASRR report indicated, Your (Resident 41) Level I screening conducted at (name of facility) followed by a Level II Evaluation on August 17, 2021 .The facility staff will receive a copy of this Determination Report, .and will incorporate 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 follow-up on a Level II PASRR evaluation (Pre-admission Screening & Resident Review-a federal requirement to determine whether or not an individual who has an active diagnosis of mental illness or intellectual disability meets the criteria for admission to a nursing facility and identify what specialized services an individual needs), for one of six residents reviewed for PASRR (Resident 4). This failure had the potential to result in admitting residents that were not appropriate in the nursing facility and for Resident 4 not to receive the appropriate services. Findings: A review of medical record indicated Resident 4 was admitted to the facility on [DATE], with diagnoses that included psychosis (a mental disorder). Resident 4's PASRR report done on October 22, 2021, indicated, Positive for Level I Screening indicates a Level II Mental Health Evaluation is Required . Federal law requires all individual seeking admission to a Medicaid Certified…

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 comprehensive care plan was developed to address Activity of Daily Living (ADL's) for one of three residents reviewed for care planning (Resident 3). This failure had the potential for the resident not to be able to attain or maintain his mental, physical, and psychosocial needs. Findings: Resident 3's record was reviewed. Resident 3 was admitted to the facility on [DATE], with a diagnoses which included coronary artery disease (heart disease). Resident 3's Minimum Data Set (MDS-an assessment tool) comprehensive assessment dated [DATE], indicated Resident 3 required assistance with his activities of daily living. Further review of the MDS dated [DATE], indicated, Resident 3's care area assessment triggered the ADL functional/Rehabilitation Potential, and a care plan was necessary to address the problem. There was no careplan for ADL initiated for Resident 3. On February 2, 2022, at 3:45pm., the Registered Nurse Supervisor (RNS) 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 provide treatment and care in accordance with the professional standards of practice for two of 15 residents reviewed (Resident 18 & Resident 50), when: 1. Resident 50, receiving an Insulin Detemir (medication to control blood sugar), did not have blood glucose monitoring. This failure had the potential to result in not being able to track the effect of the medicine which could lead to unmanaged blood sugar increasing the risk for health complications. 2. Resident 18's skin condition was not appropriately assessed. This failure had the potential to result in delayed treatment leading to skin infection. Findings: 1. A review of medical record indicated Resident 50 was admitted to the facility on [DATE], with diagnoses which included type 2 diabetes mellitus (disease in which your blood glucose, or blood sugar, levels are too high.). Resident 50's Physician order indicated: - December 29, 2021, .Insulin Detemir solution inject 12 unit…

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 evaluate the need for the use of floor mat to ensure safety for one of one resident reviewed for fall (Resident 17). This failure had the potential to result in not being able to determine the appropriate intervention to ensure safety for Resident 17. Findings: Resident 17's record was reviewed. Resident 17 was admitted to the facility on [DATE], with diagnoses which included atherosclerotic heart disease (the buildup of fats, cholesterol, and other substances in and on your artery walls) and anxiety (intense, excessive, and persistent worry and fear about everyday situations). Resident 17's care plan dated August 6, 2021, indicated .History of fall(s), Chronic Pain Syndrome .Interventions .provide floor mat at bedside . The care plan indicated the floor mat intervention was created on September 5, 2021. Resident 17's physician order dated November 22, 2021, indicated, May use alarm while on bed and on WC (wheelchair) for safety. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the use of oxygen was prescribed by the physician for one of one resident ( Resident 20). This failure has the potential for the resident not to receive therapeutic benefit for oxygen use which could result in serious health complications. Findings: On January 31, 2022, at 9:29 a.m., Resident 20 was observed in bed with oxygen via nasal cannula ( a two prong plastic tubing used to deliver oxygen through the nose). Resident 20's oxygen was observed at 4 liters per minute (l/m). On January 31,2022, at 9:29 a.m, in a concurrent interview, Resident 20 stated she used the oxygen when she needed it. A review of Resident 20's medical record indicated she was admitted to the facility on [DATE], with diagnosis of transit ischemic attack (a stroke that last only a few minutes) and cerebral infarction (stroke) affecting right dominant side. In a review of Resident 20's medical record, there was no physician order for the use of oxygen. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to re-evaluate the effectiveness of the current pain medication regimen for one of one resident reviewed for pain (Resident 18). This failure had the potential for the resident's pain not to be managed which could affect the resident's physical and psychosocial functioning. Findings: On January 31, 2022, at 11:04 a.m., Resident 18 was interviewed and stated his left foot hurts. Resident 18 stated he was telling the staff every other day that his foot hurts. A review of Resident 18's record indicated, Resident 18 was admitted to the facility on [DATE], with diagnoses which included chronic pain syndrome (pain that is ongoing and usually lasts longer). Resident 18's HISTORY AND PHYSICAL EXAMINATION, indicated, Resident 18 had the capacity to understand and make decisions. The physician order indicated: - December 13, 2021, Lidocaine ointment 5% (a medication which causes loss of feeling in the skin) Apply to Left Foot topically every 8 hours as needed for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to act on the pharmacy consultant's recommendation for the use of gabapentin (treats seizures [uncontrollable shaking]), for one of five residents reviewed for unnecessary medications (Resident 30). This failure had the potential to result in adverse consequences for the use gabapentin. Findings: A review of Resident 30's record indicated he was admitted to the facility on [DATE], with a diagnosis of dementia (memory loss) and cerebral infarction (stroke). A review of the document titled, Consultant Pharmacist's Medication Regimen Review, dated December 23, 2021, indicated the following: Clarify with MD (medical doctor) if clinically indicated/appropriate to do labs, if not done recently: CBC (complete blood count- test which measures several components and features of your blood), CMP (comprehensive metabolic panel is a test that measures 14 different substances in the blood), lipid panel (a blood test that measures lipids-fats and fatty substances used…

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 their policy and procedure regarding food safety requirements when: 1. The resident's perishable food in the nursing station refrigerator was not date labeled. This failure had the potential to result in food borne illnesses to vulnerable population. 2. Food and drink at the bedside, brought by the family members/caregivers, were not consistently checked by the staff to ensure proper storage and consumption before the date indicated in the packaging for Residents 18 and 33. This failure had the potential for the resident to experience food poisoning such as stomach cramps, diarrhea, nausea, and vomiting. Findings: 1. On February 2, 2022, at 10 a.m., during inspection of the nursing station refrigerator with Certified Nursing Assistant (CNA) 4, a box of pizza was observed with no date. In a concurrent interview with CNA 4, she stated the food brought by the family member should have a received by date. She stated the food should have been dated. On February 2, 2022, at 10:08 a.m., the Registered…

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.