Buena Park Nursing Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility document review, the facility failed to provide the written Notice of Medicare Non-coverage (NOMNC) form CMS-10123 for one of three residents (Resident 139) reviewed for beneficiary notification. * The facility failed to make sure Resident 139 was provided with NOMNC form prior to discharge from the facility. This failure had the potential for Resident 139 and/or the representative to not be aware of the resident's rights and make informed decision regarding Resident 139's care and services.Findings: Medical record review for Resident 139 was initiated on 3/17/26. Resident 139 was admitted to the facility on [DATE]. Review of Resident 139's H&P examination dated 7/7/25, showed the resident had no capacity to make medical decisions. Review of the facility's Beneficiary Notice - Residents discharged Within Last Six Months showed Resident 139 was to be discharged from the Medicare Covered Part A stay on 9/25/25, and would be discharged home, or to a facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to address the resident's grievance in accordance with the facility's P&P for one of 25 final sampled residents (Resident 81). * The facility failed to address the concern when Resident 81 verbalized the staff was rude and giving attitude when answering his call light. This failure posed the risk for the resident's grievance not being thoroughly addressed, investigated, documented, and resolved.Findings: Review of the facility's P&P titled Grievance Procedure revised 1/2017 showed the resident has the right to and the facility must take prompt efforts to resolve grievances that the resident, responsible party, other family members, or advocates may have and any resident, their responsible party, family member or advocate may file a grievance or complaint concerning resident's treatment, medical care, behavior of other residents or staff members. Medical record review for Resident 81 was initiated on 3/13/26. Resident 81 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, medical record review, and facility P&P review, the facility failed to ensure one of 25 final sampled residents (Resident 98) was free from the physical restraints. * The facility failed to implement the least restrictive measures prior to applying a hand mitten to Resident 98's left hand. In addition, the facility failed to follow and document the release of the left hand mittens as per the physician's order. These failures posed the risk of compromising the residents' independence and psychosocial well-being.Findings: Review of the facility's P&P titled Physical Restraints dated 9/2017 showed the restraints will only be used after other alternatives have been tried unsuccessfully and only after a thorough assessment, informed consent from the resident or their responsible party, a physician's order and a care plan to address the use of the restraint. Least restrictive measures shall be assessed prior to the use of an actual restraint. Restraints must be used only as a last…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to ensure the MDS was accurate for one of 25 final sampled residents (Resident 11). * The facility failed to accurately code the functional limitation of the range of motion for Resident 11. This failure posed the risk for the resident to not receive an individualized plan of care based on their specific needs.Findings: On 3/11/26 at 1241 hours, an observation and concurrent interview was conducted with Resident 11. Resident 11 was observed sitting in a wheelchair and using an iPad with his left arm. Resident 11 was observed not moving his right arm. Resident 11 stated he had a stroke that affected the right side of his body, resulting in his inability to move his right arm and right leg. When asked if he had been receiving exercises in the facility to maintain range of motion for the affected areas, he stated he had been this way for a long time and did not want to receive any exercises. Resident 11 added that he did not want 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 medical record review, the facility failed to ensure coordination of PASARR and assessments for one of two final sampled residents (Resident 16). * The facility failed to ensure a follow-up was made regarding Resident 16's PASARR level II recommendation for a psychiatric consult and psychotherapy/counseling services for Resident 16 was completed. This failure posed the risk for Resident 16 to not receive the appropriate care.Findings: On 3/11/26 at 1011 hours, Resident 16 was observed in bed, sleeping. Medical record review for Resident 16 was initiated on 03/11/2026. Resident 16 was admitted to the facility on [DATE]. Review of Resident 16's H&P examination dated 9/14/24, showed Resident 16's diagnoses included a history of bipolar affective disorder. Review of Resident 16's PASRR Notice of Individual Determination Letter dated 4/12/25, showed the recommended specialized services included psychology consultation and psychotherapy/counseling services. On 3/13/26 at 928 hours, an interview…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure the level 1 PASRR contained accurate information for one of two final sampled residents (Resident 15) reviewed for PASRR. * Resident 15 had a diagnosis of psychosis; however, the level 1 PASRR showed Resident 15 had no diagnosis of serious mental illness. Additionally, the facility failed to complete a Resident Review when Resident 15's level 2 PASRR evaluation was inaccurate. These failures posed the potential risk for Resident 15 to not receive the necessary care and services as the assessments were inaccurate.Findings: Review of the facility's P&P titled PASRR (Preadmission Screening Resident Review) reviewed 3/2019 showed all admissions to the facility will receive a Preadmission Screening prior to the admission of the resident. If the resident had already been admitted to the facility and the PASRR is being updated because the resident had exceeded the 30-day exempted hospital discharge or there is a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and the facility P&P review, the facility failed to develop the comprehensive plans of care to reflect the individual care needs for two of 25 final sampled residents (Residents 6 and 21). * The facility failed to develop a care plan for Resident 6's use of the blood glucose monitoring device (Dexcom G7). * The facility failed to develop a care plan problem to address Resident 21's IV site. These failures posed the risk of not providing appropriate, consistent, and individualized care to these residents.Findings: Review of facility's P&P titled Comprehensive Care Planning dated 3/2019 showed a comprehensive resident-centered care plan be developed for each resident that includes measurable objectives and timeframes to meet each resident's medical nursing and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan will provide specific information to include resident strengths, goals, life history and preferences,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the comprehensive plan of care was revised to reflect the resident's current care needs and interventions for five of 25 final sampled residents (Residents 3, 4, 7, 73, and 98) reviewed for care plans. * The facility failed to ensure the care plan was revised to include the manufacturer's recommendations for cleaning and disinfecting the ventilator machines for Residents 3, 4, and 7. * The facility failed to ensure Resident 73's care plan interventions for weight loss were revised to reflect Resident 73's NPO status; and failed to ensure the care plan for hydration needs related to NPO status was revised to include the current IV hydration therapy. * The facility failed to ensure Resident 98's care plan for the use of the hand mittens was revised to include the use of least restrictive interventions when the left hand mittens was released every two hours for 15 minutes. These failures posed the risk of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the quality care and services were provided for three of 25 final sampled residents (Residents 3, 6, and 8). * The facility failed to ensure a physician's order was obtained, the assessment was completed, and appropriate instructions were obtained to maintain the appropriate care of a blood glucose monitoring device (Dexcom G7 - a discreet, all-in-one continuous glucose monitor (CGM) for diabetes management) for Resident 6. This failure posed a risk for the resident to not receive the necessary care and services to maintain their highest physical well-being. * The facility failed to ensure the injection sites for the insulin administration were rotated for Resident 3. This failure had the risk for lipodystrophy (buildup of fatty lumps) and decreased with insulin absorption. * The facility failed to ensure medication was held as per the physician's ordered parameters for Resident 8's metoprolol (blood…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of two sampled residents (Resident 11) reviewed for limited range of motion (ROM) received the appropriate treatment and services. * The facility failed to ensure the instruction for the RNA services for Resident 11 was accurate. In addition, the facility failed to ensure the risk of possible ADL decline was explained to the resident when Resident 11 requested to reduce the frequency of the RNA treatment. These failures had the potential to result in the decline in Resident 11's ROM which could lead to further deterioration in the resident's physical well- being.Findings:Review of the facility P&P titled Restorative Nursing Assistant Referrals dated 9/2016 showed facility to ensure ongoing communication and care giver training take place between Restorative Nursing Assistant (RNA) and therapy department. If the resident is screened and it is determined that the resident could benefit from referral for services…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary GT care and services for two final sampled residents (Residents 5 and 98) reviewed for tube feeding. * The facility failed to ensure Resident 98 was positioned safely at 30 to 45 degrees during the enteral feeding via G-Tube. * The facility failed to ensure Resident 5's water flush connected via feeding pump was labeled. These failures posed the risk for developing complications related to the residents' GT.Findings: Review of facility P&P titled Gastrotomy Tube Feeding Via Continuous Pump dated 1/2017 showed to always keep the resident's bed elevated more than 30 degrees or as directed by physician order. 1. Medical record review for Resident 98 was initiated on 3/11/26. Resident 98 was admitted to the facility on [DATE]. Review of Resident 98's H&P examination dated 8/18/25, showed Resident 98 was GT feeding dependent. Review of Resident 98's Order Summary Report dated 3/2/26, showed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility's P&P review, the facility failed to ensure professional standards of practice were followed for two of two final sampled residents (Residents 21 and 73) reviewed for the IV therapy. * The facility failed to ensure Resident 21's IV dressing was labeled with the date on when it was placed. * The facility failed to ensure Resident 73's IV tubing was discarded after 72 hours as per the physician's order. These failures posed the risk for the residents to experience complications related to the IV therapy.Findings: 1. According to Intravenous Infusion Therapy for Nurses, Principles and Practice, when the residents are on IV therapy, it is best practice to label the IV site dressing with information including the date, time, and staff initials. On 3/11/26 at 1039 hours, an observation was conducted with Resident 21. Resident 21 was observed in bed with an empty container of vancomycin (an antibiotic) medication hanging from Resident 21's IV pump.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure the appropriate pain management was provided for one of 25 final sampled residents (Resident 31) reviewed for pain management. * The facility failed to ensure the hydrocodone-acetaminophen (a narcotic pain medication) medication was administered per the physician's orders for Resident 31. In addition, the facility failed to ensure the nonpharmacological interventions were provided and documented prior to the administration of Resident 31's PRN hydrocodone-acetaminophen medications. These failures had the potential to put Resident 31 at risk for ineffective pain management and adverse effects related to the use of unnecessary pain medication.Findings: Review of the facility's P&P titled Pain Management Protocol reviewed 1/2017 showed documentation on the flow sheet should reflect every PRN administered, response to the medication and the nonpharmacological interventions. Review of the facility's P&P titled Medication…

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

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the nurse staffing information was posted in a prominent place accessible to residents and visitors. This failure has the potential of not having the staffing information be available to the residents and the public to determine if sufficient staff were available to care for the residents.Findings: Review of facility's P&P titled Staffing Nurse Information revised on 1/2017 showed it is the policy of the facility to post the nurse staffing information daily; and posted information will be in a prominent place readily accessible to residents and visitors. On 3/17/26 at 1330 hours, a concurrent observation and interview was conducted with the DSD. The Daily Nurse Staffing Information was observed posted and positioned sideways between a vase and other paperwork, making it not visible to the residents and visitor in station 2, SNF side. In addition, the staffing data was dated 3/16/26, and not the current date. The DSD stated the RN supervisor was supposed to post it but…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary pharmaceutical services. * The facility failed to ensure the administration of the controlled medication for one nonsampled Resident 99 was documented on the MAR. This failure had the potential for the medications to be administered in error and opportunities for drug diversion or drug misuse.Findings: Review of the facility P&P titled Controlled Medication (undated) showed when a controlled medication is administered, the licensed nursed administering the medication immediately enters the following information on the accountability record and the medication administration record (MAR): - Date and time of administration. - Amount administered. - Signature of the nurse administering the dose on the accountability record at the time the medication is removed from the supply. - Initials of the nurse administering the dose on the MAR after the medication is…

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

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the drugs and biologicals were stored, labeled, and/or disposed properly. * The facility failed to ensure the orally administered medications were stored separately from the externally used medications. This failure posed a risk for the medications to be used or improperly administered to the residents. * The facility failed to ensure the opened box of ipratropium-albuterol (breathing treatment medication) was labeled with the opened date for Residents 83 and 122. These failures posed a risk for the administration potentially contaminated or deteriorated medications. * The facility failed to ensure the vancomycin (an antibiotic) IV medication and supplies were properly disposed. This failure posed a risk for the residents and/or visitors to have access to a potential toxic substance. Findings: 1. Review of the facility's P&P title Storage of Medications dated 4/2008 showed orally administered medications are kept separate from external use medications, such as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure the American and Korean pureed preparation were prepared properly. * The facility failed to ensure the American and Korean pureed food preparation was not conducted too far in advance of the serving time. Also, the staff were not knowledgeable about the serving temperature for kimchi. These failures posed the risk of the foods served losing nutritive value and of the residents not being able to enjoy foods at a palatable temperature.Findings: Review of the facility's document titled Order Listing Report dated 3/12/26, showed a total of 48 of 124 residents (including 10 on puree diets) received meals prepared in the facility's kitchen. On 3/11/26 at 0840 hours, an interview was conducted with the Dietary Services Director. The Dietary Services Director stated lunch was served starting at 1130 hours. On 3/12/26 at 0757 hours, an interview was conducted with the Dietary Services Director. The Dietary Services Director stated the Korean food puree…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary adaptive equipment was provided for one nonsampled resident (Resident 33). * The facility failed to ensure Resident 33 was provided with the sippy cup as per the meal ticket and the physician's order. This failure had the potential for Resident 33 not having an appropriate assistive device to properly consume her drinks.Findings: Review of the facility's P&P titled Assistive Devices- Frequency of Meals, Assistive Devices & Food Safety reviewed 1/2017 showed the facility will provide eating equipment and utensils for residents who are assessed to require them. Residents who are assessed to require special eating equipment and utensils will be provided appropriate assistance to ensure that they can use the assistive devices when consuming meals and snacks. On 3/11/26 at 1134 hours, a lunch observation was conducted in the dining room. Resident 33 was observed sitting in a chair and 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.

Based on interview, facility document review, facility P&P review, and Title 22 review, the facility failed to ensure documented evidence of compliance with the State law. * The sign in sheet for the review of the facility's P&P related to pharmaceutical services failed to include the facility's pharmacist. This failure posed the risk of the P&Ps not being maintained and reviewed. Findings: Per Title 22 S 72525 - Required Committees showed under (a) Each facility shall have at least the following committees: patient care policy, infection control and pharmaceutical service (a) Each facility shall have at least the following committees: patient care policy, infection control and pharmaceutical service. (b) Minutes of every committee meeting shall be maintained in the facility and indicate names of members present, date, length of meeting, subject matter discussed and action taken. Review of the facility's provided document titled Policy and Procedure Review dated 10/9/25, failed to show the facility's pharmacist had attended this review as per Title 22, Chapter 3, Section 72525. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medical records were accurate for four of 25 final sampled residents (Residents 8, 11, 21, and 73). * The facility failed to ensure Resident 73's Nutrition Risk Assessment was completed accurately. The licensed nurse selected 0 for albumin level of 3.5 to 5.0 g/dL, instead of 3 for albumin level of less than 2.8 g/dL, when Resident 73's albumin level was 2.5 g/dL. * The facility failed to ensure Resident 11's POLST was accurate. The POLST showed Resident 11 had no advance directive, however Resident 11 had an advance directive. * The facility failed to ensure Resident 8's MAR for March 2026 was accurate. Resident 8's furosemide (diuretic) medication was held due to low blood pressure as per the physician' parameters, however, Resident 8's MAR showed the medication was administered. * RN failed to document Resident 21's IV site condition; IV site was no longer patent and had to be removed These…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the coordination of hospice services for one of two final sampled residents (Resident 31) reviewed for hospice. * The facility failed to ensure Resident 31's hospice visitation calendar showed the scheduled hospice staff visits; failed to ensure the hospice nurse, hospice aide, and hospice social worker progress notes were available in Resident 31's hospice binder; and failed to ensure the hospice plan of care was consistent with the actual hospice aide visits for Resident 31. These failures had the potential to put Resident 31 at risk for uncoordinated medical care between the facility and hospice agency.Findings: Review of the facility's P&P titled Hospice Care reviewed 9/2018 showed the facility is responsible for ensuring that hospice services meet professional standards and principles and the timeliness of the services. A care plan should be developed in coordination with the hospice,…

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, facility document review, and facility P&P review, the facility failed to accurately determine whether one final sampled resident (Resident 16) who was prescribed antimicrobial therapy and seven nonsampled residents (Residents 34, 45, 76, 78, 99, 117, and 143) met the criteria for true infection. * Residents 16, 34, 45, 76, 78, 99, 117, and 143 who did not meet the McGeer's (a standardized surveillance definitions used to detect infections in long-term care facilities, ensuring consistent reporting and monitoring) criteria were prescribed antimicrobial therapy. These failures resulted in continued use of unnecessary antibiotic therapy, potentially resulting in adverse reactions associated with antibiotics and the development of antibiotic-resistant bacteria. Findings: According to the Centers for Disease Control and Prevention (CDC), antibiotics are among the most frequently prescribed medications in nursing homes, with up to 70% of residents in a nursing home receiving one or more courses of systemic antibiotics over a year. Studies have shown that 40-75% of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review and facility P&P review, the facility failed to ensure the care plan was followed for the use of restraints for one of six sampled residents (Resident 6). * The facility failed to ensure Resident 6's left hand mitten was released every two hours as per the care plan. This failure had the potential to cause delays in identifying possible health risks associated with the use of hand mitten restraint including poor circulation and impaired skin integrity. Findings: Review of the facility's P&P titled Physical Restraints revised 1/2017 showed if the restraints are utilized, the opportunity for motion and exercise should be provided for a period of not less than 10 minutes during two hour period in which restraints are utilized. Medical record review for Resident 6 was initiated on 1/28/26. Resident 6 was admitted to the facility on [DATE]. Review of Resident 6's Order Summary Report showed a physician's order dated 3/10/25, to apply left hand mitten necessity…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the pharmaceutical services to one of six sampled residents (Resident 1) as ordered by the physician. * The facility failed to ensure Resident 1's Refresh Plus (eye lubricant), Timoptic ophthalmic solution (a prescription eye drop used to lower high fluid pressure within the eye) and Lumify (an eye drop used to reduce eye redness) were available for administration as ordered by the physician. In addition, the facility failed to ensure Resident 1's physician was made aware when the medications were not available for administration. These failures had the potential to affect resident's health status and wellbeing.Findings: Review of the facility's P&P titled Medication Administration revised 5/2019 showed it is the policy of the facility that medications for residents be administrated in a safe and timely manner and as prescribed. Medications must be administered in accordance…

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, medical record review, and facility document review, the facility failed to develop an individualized care plan for one of five sampled resident (Resident 1). *The facility failed to ensure a care plan was developed for Resident 1's Actual Fall Incident on 11/22/24. This failure posed the risk of not providing the appropriate and individualized care to Resident 1 to prevent another episode of fall.Findings: Review of the facility's P&P titled Comprehensive Care Planning revised 3/2019 showed the plan of care must include measurable objectives and timeframes and describe the services that are to be furnished to attain and maintain the resident's highest practicable level of well-being. Closed medical record review for Resident 1 was initiated on 10/23/25. Resident 1 was admitted to the facility on [DATE], and was discharged to the acute care hospital on 3/2/25. Review of Resident 1's H&P examination dated 10/14/24, showed Resident 1 had no capacity to understand and make decisions. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to maintain the highest practicable well-being for two of five sampled residents (Residents 1 and 2). * The facility failed to ensure the physician's recommendation was carried out as ordered for Resident 1. * The facility failed to ensure Residents 1 and 2's neurological checks (Neuro check -series of tests performed by healthcare providers to evaluate the function of the brain) were completed. * The facility failed to ensure the orthostatic hypotension monitoring was implemented for Resident 1 for the use of the Seroquel (antipsychotic medication). These failures had the potential to negatively affect the residents' well-being as the necessary care and services were not provided.Findings: Review of the facility's P&P titled Physician Services and Orders revised 1/2017 showed it is the policy of the facility that each resident remain under the care of a physician. Drugs,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility P&P review, the facility failed to implement effective infection control practices designed to prevent the development and transmission of diseases and infections for seven non-sampled residents (Residents A, B, C, D, E, F, and G) observed for infection control practices.*The facility failed to ensure appropriate enhanced barrier precaution (EBP) signs were posted for Residents A, B, C, D, E, F, and G. In addition, the facility failed to properly train staff to identify the appropriate PPE to don when caring for residents on EBP isolation.These failures posed the risk of not controlling the transmission of infection to the other residents throughout the facility.Findings: Review of the facility's P&P titled Infection Control Program System revised 1/2023 showed the following: -The facility has an established infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to ensure the POLST was signed and dated by the physician and failed to provide an advance directive Acknowledgement form for one of seven final sampled residents (Resident 104) reviewed for advanced directives. This failure had the potential of not following the resident's health wishes and not providing the resident and resident representative the information about the advance directive. Findings: Medical record review for Resident 104 was initiated on 11/18/24. Resident 104 was admitted to the facility on [DATE]. Review of Resident 104's H&P examination dated 7/24/24, showed Resident 104 did not have the capacity to understand and make decisions. Review of Resident 104's POLST dated 7/24/24, showed under Section D, the Information and Signatures portion was incomplete. The POLST failed to show documented evidence of the physician, NP, or PA's name and date signed. Further review of Resident 104's medical record failed to show documented…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the PASRR screening was completed as per the facility's P&P for two of two final sampled residents (Residents 61 and 76) reviewed for PASRR. * The facility failed to ensure Resident 76 had a Level 1 PASRR screening upon readmission back to the facility. * The facility failed to perform a PASRR Level 1 Screening Resident Review Status Change after Resident 61 was diagnosed with depression and prescribed a psychotropic medication. These failures had the potential of not providing the residents screened for mental illness or intellectual disabilities with additional resources if needed. Findings: Review of the facility's P&P titled PASRR (Preadmission Screening Resident Review) revised 3/2019 showed each resident is screened regardless of payment source, when applying for admission to, or residing in the facility, which is a Medicaid-certified facility, for mental illness and intellectual disability. Level…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to develop the comprehensive care plan to reflect the individual care needs for two of 26 final sampled residents (Residents 73 and 88). * The facility failed to develop a care plan to address the use of elevated side rails for Resident 73. * The facility failed to develop a care plan for a high bed for Resident 88. These failures posed the risk for not providing appropriate and individualized care to the residents. Findings: 1. Medical record review for Resident 73 was initiated 11/18/24. Resident 73 was admitted to the facility on [DATE]. Review of Resident 73's physician's order dated 8/7/24, showed an order for bilateral grab bars for bed mobility and repositioning. On 11/18/24 at 0835 hours, an observation and concurrent interview was conducted with Resident 73. Resident 73 was observed lying in bed with bilateral grab bars elevated. Resident 73 stated he utilized the grab bars to get up in bed. On 11/21/24 at 1357 hours, an interview and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the pressure ulcer for three final sampled residents (Residents 3, 102, and 103) and one nonsampled resident (Resident 334) reviewed for pressure injury and skin management. * Resident 334 was developing a new blister to the right underneath first and second toes. The facility failed to assess Resident 334's skin, inform the physician of new change of skin condition, and provide the treatment. * The facility failed to ensure the LAL mattress setting was consistently monitored to ensure the appropriate settings of the low air loss mattress for Resident 3. * The facility failed to ensure the LAL mattress setting was consistently monitored to ensure the appropriate settings of the low air loss mattress for Resident 102. * The facility failed to ensure Resident 103's LAL mattress setting was appropriate to the resident's weight. These failures had 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 medical record review, the facility failed to provide the necessary GT care and services for one of three residents (Resident 74) reviewed for tube feeding. * The facility failed to ensure Resident 74 was connected to the continuous infusing enteral feeding as ordered by the physician. This failure posed the potential risk for not meeting Resident 74's nutritional needs. Findings: Medical record review for Resident 74 was initiated on 11/18/24. Resident 74 was readmitted to the facility on [DATE]. Review of Resident 74's Order Summary Report dated 11/19/24, showed a physician's order dated 10/9/24, to administer Nepro 1.8 (type of enteral feeding) via enteral pump and infuse at 50 ml per hour over 16 hours or until volume limit was completed (800 ml), off at 0500 hours and on at 1300 hours. On 11/18/24 at 1400 hours, Resident 74 was observed laying in bed. Resident 74's GT feeding was connected via a feeding pump, which was turned on and infusing at 50 ml/hr. The GT feeding…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure four of seven final sampled residents (Residents 8, 44, 58, and 75) and one nonsampled resident (Resident 29) reviewed for respiratory care were provided the appropriate respiratory care. * The facility failed to ensure Resident 75's oxygen was administered as ordered and a No Smoking/Oyxgen in Use sign was outside the resident's door per the facility's P&P. In addition, the facility failed to ensure Resident 75 had a physician's order and care plan developed to address the use of the suction machine. The suction storage bag was also observed undated and unlabeled. * The facility failed to ensure Resident 8 who was on oxygen had a No Smoking/Oxygen in Use sign outside the resident's door as per the facility's P&P. In addition, the facility failed to ensure Resident 8's oxygen nasal cannula was stored in a sanitary manner. * The facility failed to ensure Resident 58's physician orders for the use of CPAP…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure the appropriate dialysis care was provided for one of two final sampled residents (Resident 82) reviewed for dialysis services. * The facility failed to ensure the dialysis communication forms were completed for Resident 82. This failure had the potential for the resident to experience medical complications. Findings: Review of the facility's P&P titled Dialysis Care Inhouse revised 1/2019, showed it is the policy of the facility that a resident admitted for dialysis care will receive quality care and quality of life from the dialysis nurse, dialysis staff, and facility nursing staff. There will be continuity of care and communication between nursing staff and the dialysis nursing staff. A pre-dialysis checklist will be completed by the facility each time the resident is scheduled for dialysis. This checklist includes information regarding the type of access site and the condition of the access site and 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 medical record review, the facility failed to ensure two of 26 final sampled residents (Residents 46 and 73) remained free from accident hazards. * The facility failed to attempt the alternatives and failed to obtain the informed consent prior to the use of side rails for Resident 73. * For Resident 46, the facility failed to asses for the risk of entrapment and failed to attempt alternatives prior to the use of side rails. Additionally, the facility failed to inform the responsible party of side rail use. These failures had the potential for placing the residents at risk for entrapment for the use of side rails. Findings: The FDA issued a Safety Alert entitled Entrapment Hazards with Hospital Bed Side Rails. Residents most at risk for entrapment are those who are frail or elderly or those who have conditions such as agitation, delirium, confusion, pain, uncontrolled body movement, hypoxia, fecal impaction, acute urinary retention, etc., that may cause them to move about the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the pharmaceutical services were provided to meet the needs of one of 26 final sampled residents (Resident 74). * The facility failed to ensure Resident 74's GT medication was administered via gravity. * The facility failed to ensure Resident 74's bowel pattern was checked for loose stool/diarrhea prior to administering docusate sodium (stool softener). These failures had the potential to result in poor health outcomes to the resident. Findings: Review of the facility's P&P titled Medication Administration via Enteral Tube revised 4/2017 showed the purpose of the policy was to safely and accurately administer oral medications through an enteral tube. The policy showed under the section Administering Medications, to allow each medication to flow down the tube by gravity. Medical record review for Resident 74 was initiated on 11/18/24. Resident 74 was readmitted to the facility on [DATE]. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to provide adequate monitoring of the blood pressure and heart rate to ensure one of 26 final sampled residents (Resident 73) was free from unnecessary drugs. * Resident 73 was administered amlodipine (blood pressure medication) and lozartan (blood pressure medication) when the resident's blood pressure and heart rate were not checked prior to administering the medications, as prescribed by the physician. This failure had the potential to negatively affect Resident 73's health condition and well-being. Findings: Medical record review for Resident 73 was initiated on 11/18/24. Resident 73 was admitted to the facility on [DATE]. Review of Resident 73's Order Summary Report showed the following physician's orders dated 8/7/24: - to administer amlodipine 5 mg one tablet by mouth two times a day for hypertension (high blood pressure), and to hold if the systolic blood pressure less than 110 mmHg, and if the heart rate less than 60 beats per minute; and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure two of 26 sampled residents (Residents 86 and 124) were free from unnecessary medications. * Resident 124 was prescribed zolpidem (hypnotic) as needed, but this medication was not only limited to 14 days. * The facility failed to ensure Resident 86 was not prescribed quetiapine fumarate (antipsychotic medication) unless the medication was necessary to treat a specific condition or diagnosis. These failures posed the risk of providing residents with unnecessary medications and the potential for development of significant side effects. Findings: Review of the facility's P&P titled Psychotherapeutic Drug Treatment revised 1/2017 showed the facility is to provide psychotherapeutic drug treatment for a resident with a specific condition as diagnosed and documented in the clinical record. The resident has the right to be free from unnecessary drugs/medications and protection from medication errors. Residents should not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility P&P review, the facility failed to ensure for the safe storage of the medications and supplies for one of three medication rooms (Medication Room A) and five of 10 medication carts (Medication Carts B, C, D, E, and F) inspected. In addition, the facility failed to ensure the medications were not stored at the resident's bedside. * Medication Room A contained multiple expired medications. This failure had the potential to result in the unsafe administration of medications. * The facility failed to ensure the antifungal cream was not kept at Resident 87's bedside. This failure had the potential for unauthorized persons having access to the medication. * Medication Cart D had external and internal medications, and bleach germicidal wipes stored together. This failure had the potential to result in the unsafe administration of medications. * Medication Cart E contained multiple expired vials of normal saline. This failure had the potential to result in the unsafe…

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

Based on observation, interview, facility document review, and facility P&P review, the facility failed to follow the food safety and sanitation guidelines in several areas as evidenced by: * The blender used for preparing the pureed food was not air-dried properly. * Two kitchen frying pans showed signs of corrosion. * Staff members (Cooks 1 and 2) lacked the knowledge on proper food cooling procedures. * The storage area for water pitchers and cups was not maintained in a sanitary condition. These failures had the potential to negatively impact the residents' well-being. Findings: Review of the facility's diet count dated 11/18/24, showed 53 of 129 residents received regular and mechanical soft meals prepared in the kitchen. 1. Review of the facility's P&P titled Electrical Food Machines dated 2023 showed to keep and maintain all food machines in good operating, sanitary condition. This includes mixers, grinders, slicers and toasters. Mixing machine: after washing and rinsing, allow beater and bowl to air dry. Then store in the proper place. On 11/19/24 at 0950 hours, [NAME] 1 was…

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

Based on observation, interview, facility P&P review, and facility document review, the facility failed to ensure the facility's P&P was updated and followed as evidenced by: * The facility failed to ensure the food items in the residents' refrigerator were labeled and dated for one of two resident refrigerators. This failure had the potential to cause foodborne illnesses to the medically vulnerable resident population who consumed food brought from outside sources. Findings: Review of the facility's P&P titled Bringing in Food for a Resident dated 2023 showed food or beverages should be labeled and dated to monitor for food safety. Food or beverages in the original containers marked with manufacturer expiration dates and unopened, need to be marked with resident's name. Food in unmarked or unlabeled containers will be marked with the current date and the resident's name. On 11/20/24 at 1015 hours, a concurrent observation and interview was conducted with RN 2 and LVN 13. The following items were observed in the resident refrigerator in Nursing Station 1: - One strawberry yogurt 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 medical record review, the facility failed to ensure three of 26 final sampled residents (Residents 73, 100, and 124) had accurate and complete medical records. * The facility failed to ensure the information on Resident 73's POLST was accurate and updated. * Resident 100 had conflicting information documented in the medical record as to whether Resident 100 had formulated an advance directive. * Resident 124 did not have a complete smoking assessment and accurate care plan problem for smoking. These failures had the potential of not following the residents' health wishes. Findings: 1. Medical record review for Resident 73 was initiated on 11/18/24. Resident 73 was admitted to the facility on [DATE]. Review of Resident 73's H&P examination dated 8/7/24, showed Resident 73 did have the capacity to understand and make decisions. Review of Resident 73's POLST dated 8/7/24, showed Section D, no advance directive. Further review of Resident 73's medical record showed an advanced…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to implement the safe and sanitary environment to help prevent the development and transmission of infection when: * The facility failed to ensure LVN 1 changed gloves in between administering medications through a different route. * The facility failed to ensure LVN 1 changed the PPE in between administering medications to two nonsampled residents (Residents 26 and 40) on EBP precautions. These failures posed the risk for transmission of disease-causing microorganisms. Findings: Review of the facility's P&P titled Infection Control revised 5/2018 showed the facility has an established infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Review of the facility's P&P titled Medication Administration revised 5/2019, showed staff shall follow infection control procedures…

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

Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to inform the physician of the residents who had not met McGeer's Criteria and were prescribed antibiotics for two of 26 final sampled residents (Residents 82 and 87) and five nonsampled residents (Resident 12, 25, 57, 83, and 99). This failure had the potential for the continued use of unnecessary antibiotics, potentially resulting in adverse reactions associated with antibiotics, and the development of antibiotic resistant bacteria. Findings: According to the CDC, an estimated 70% of nursing home residents receive one or more courses of antibiotics during a year. Studies have shown that 40% to 75% of the antibiotics prescribed in nursing homes may be unnecessary or inappropriate. Frail and older adults are at significant risk of harm from antibiotic overuse including increased adverse drug events, increased drug interactions and infection with antibiotic-resistant organisms. The WHO cites antibiotic resistance as one of the biggest threats to human health. Review of…

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

2. On 11/19/24 at 1552 hours, a concurrent inspection of Medication Cart F and interview was conducted with LVN 14. There were two glucometers with serial numbers 1040-4306940 and 1040-4381046 inside Medication Cart F. Review of the Quality Control Record for October 2024 showed a calibration log for glucometer with serial number 1040-4381046. However, the calibration log showed missing entries and no calibration was documented from 10/1 to 10/10, 10/12, 10/14, and from 10/20 to 10/28/24. In addition, there was no documented evidence the glucometer with serial numbers 1040-4306940 was calibrated in October. Review of the Quality Control Record for November 2024 showed a calibration log for glucometer with serial number 1040-4261376, which did not match the two glucometers stored in Medication Cart F. In addition, there was no documented evidence the two glucometers with serial numbers 1040-4306940 and 1040-4381046 inside Medication Cart F were calibrated in November. LVN 14 verified the above findings. Based on observation, interview, facility document review, and the facility P&P…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable well-being for one of three sampled residents (Resident 1). * The facility failed to ensure Resident 1 was assessed and monitored by a licensed nurse regarding bruises. In addition, the facility failed to ensure the physician or Resident 1's representative was notified of the bruises. This failure had the potential for not providing necessary care and services for the resident. Findings: Review of the facility's P&P titled Change in Condition dated 3/2021 showed it is the policy of this facility that any changes in a resident's condition be thoroughly assessed and evaluated with physician notification for early clinical management to avoid unnecessary readmissions to acute hospitals. If there is a significant change in the resident's physical or mental condition, a thorough assessment of the resident's condition must be done…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of four sampled residents (Resident 1) was free from the physical restraints. * The facility failed to obtain the informed consent prior to applying the hand mittens (mittens which look like boxing gloves that immobilize the resident's fingers) and physician's order for the hand mitten use; and develop a plan of care related to the use of the hand mittens. This failure posed the risk of compromising the resident's independence and psychosocial well-being. Findings: Review of the facility's P&P titled Physical Restraints revised 1/2017 showed the restraints will only be used with the informed consents from the residents, physicians, and/or representatives. Upon admission, the residents shall be assessed for the need or lack of physical restraints. Written orders for the use of restraints should specify the use of the restraints. An interdisciplinary assessment team in coordination with the residents and his/her…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to implement the P&P to ensure the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for one of two sampled residents (Resident 1). * The facility failed to report Resident 1's sexual abuse allegation to the CDPH L&C Program, Ombudsman office, and local law enforcement agency timely. This failure had the potential for abuse allegations to go unreported and uninvestigated timely. Findings: Review of the facility's P&P titled Abuse Reporting and Prevention revised 4/2024 showed the Administrator or his/her designee will report each alleged abuse to the Ombudsman office and CDPH immediately or within two hours as per the California Health and Safety Code, Section 1418.91 and all alleged violations and all substantiated incidents will be reported to the CDPH and all other agencies as required by State law, i.e., the local law enforcement agency, Certified Nursing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the allegation of abuse was investigated timely to prevent further potential abuse for one of two sampled residents (Resident 1). * The facility failed to investigate Resident 1's sexual abuse allegation against CNA 1 when the facility received the report of the sexual abuse allegation from Resident 1 on 5/25/24. This failure had the potential to put Resident 1 and other vulnerable residents at increased risk for further sexual abuse. Findings: Review of the facility's P&P titled Abuse Reporting and Prevention revised 4/2024 showed when incidents involving the health, welfare, or safety of residents, including suspected abuse are reported, the Administrator, or his or her designee, shall take the following steps: - provide a safe environment for resident(s) as indicated by the situation. - if the suspected abuser is an employee remove employee immediately from the care of all residents and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to conduct a resident change of condition assessment specific to dehydration for one of two sampled residents (Resident 1) whoexhibited signs and symptoms of dehydration as evidenced by: * On 11/27/23 and 12/1/23, Resident 1 ' s family notified the nursing staff of a change in Resident 1 ' s condition which included Resident 1 not wanting to open his eyes or answer questions and Resident 1 ' s family requesting Resident 1 receive hydration. Resident 1 ' s fluid intakes (during the months of November and December 2023) were below the RD ' s recommended daily estimated needs for Resident 1. However, the facility failed to conduct a resident assessment specific to dehydration to determine whether Resident 1 was dehydrated. * On 12/1/23, Resident 1 ' s family requested Resident 1 receive hydration and requested the facility obtain a CMP test. On 12/4/23, a CMP was obtained, and Resident 1 was subsequently transferred to the acute…

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

Based on observation, interview, and facility document review, the facility failed to ensure the sanitary conditions and proper storage of food items were maintained in the kitchen as evidenced by: * The facility failed to ensure the food items were not stored beyond the used by dates. This failure had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed affected food items in the kitchen. Findings: Review of the CMS 672 Resident Census and Conditions of Residents completed by the facility dated 6/22/22, showed 82 of 128 residents in the facility received food prepared in the kitchen. Review of the facility's document titled Freezer Storage Guidelines dated 2018 showed the length of time in the freezer for processed meats such as bacon, sausage, ham, hot dogs, and luncheon meat was one month. On 6/21/22 at 0735 hours, during the initial tour of the kitchen with the DSA, the following food items were observed inside the fresh produce refrigerator and freezer: - one bag of pepperoni slices dated 6/25/21, in the freezer - two containers…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure it was safe for one nonsampled resident (Resident 54) to self-administer the medications. * LVN 4 left Resident 54's oral medications at bedside unattended. Resident 54 then took the oral medications without LVN 4's supervision. Resident 54 was not a candidate to safely self-administer the medications. This failure had the potential for Resident 54 to administer the medications unsafely and inaccurately. Findings: Review of the facility's P&P titled Medication Self-Administration revised January 2017 showed it is the responsibility of the IDT to determine if it is safe for the resident to self-administer the drugs before the resident may exercise that right. Review of the facility's P&P titled Medication Administration revised May 2019 showed the residents may self-administer their own medications only if the resident's attending physician in conjunction with the IDT has assessed the resident to be able…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to ensure the MDS was accurate for one of 29 final sampled residents (Resident 60). The MDS failed to show Resident 60 had sustained a fall in the facility. This posed the risk of Resident 60 not receiving an individualized plan of care based on her specific needs. Findings: Medical record review for Resident 60 was initiated on 6/21/22. Resident 60 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 60's Progress Notes dated 3/2/22 at 1400 hours, showed Resident 60 sustained a fall, in which she fell from her bed. However, review of the MDS dated [DATE], showed Resident 60 had no falls since admission/entry or reentry or the prior assessment. On 6/23/22 at 0956 hours, an interview and concurrent medical record review was conducted with MDS Assistant 1. MDS Assistant 1 verified Resident 60 had a fall in the facility on 3/2/22. MDS Assistant 1 stated the MDS dated [DATE], should have been coded to reflect 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 medical record review, the facility failed to ensure the comprehensive care plans were implemented for two of 29 final sampled residents (Residents 48 and 60). * The facility failed to implement the bilateral floor mats for Resident 60 as per the fall risk care plan. * The facility failed to develop a care plan for the use of elevated side rails for Resident 48. These failures placed the residents at risk of not being provided appropriate, consistent, and individualized care. Findings: 1. Medical record review for Resident 60 was initiated on 6/21/22. Resident 60 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 60's Physician's Progress Notes dated 3/2/22, showed Resident 60 fell from her bed. Review of Resident 60's care plan problem titled Falls/Injury revised 4/21/22, showed Resident 60 was at risk for falls related to cognitive impairment, impaired vision, impaired hearing, and a history of falls. The care plan showed to implement…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to ensure one of 29 final sampled residents (Resident 60) remained free from accident hazards. * The facility failed to implement the floor mats as per the physician's order for Resident 60. This failure had the potential to place the resident at risk for serious injury. Findings: Medical record review for Resident 60 was initiated on 6/21/22. Resident 60 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 60's MDS 3.0 Notes Report dated 4/29/21, showed Resident 60 fell from her wheelchair on 4/3/21, while trying to reposition herself without assistance. Resident 60 sustained the left lower leg tibia and ankle fractures. Review of Resident 60's progress notes dated 3/2/22 at 1400 hours, showed Resident 60 sustained a fall, in which she fell from her bed. Review of Resident 60's Physician Order Report showed a physician's order dated 5/7/21, for bilateral floor mats. On 6/21/22 at 0751 hours, an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide safe respiratory care to meet the needs of six of 29 final sampled residents (Residents 5, 55, 64 78, 81, and 474). * The facility failed to ensure Residents 64 and 78 were placed on the ventilator settings ordered by the physician. This failure had the potential to result in poor health outcomes for the residents. * The facility failed to ensure Resident 474 had a manual resuscitation device (a hand-held device used to provide ventilation to residents who are not breathing or not breathing adequately) at the bedside. This posed the risk of delayed intervention in the event of an emergency. * The facility failed to obtain a physician's order for Residents 5 and 81's supplemental oxygen therapy. This failure posed the risk of the residents receiving unnecessary oxygen. * The facility failed to ensure Resident 81's nasal cannula tubings (a small, flexible tube that contains two open prongs for oxygen…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 29 final sampled residents (Residents 48) remained free from accident hazards related to the use of elevated bed side rails. * The facility failed to ensure Resident 48 was assessed for the risks of entrapment. Also, the facility failed to obtain the informed consent and physician's order prior to the use of bed side rails. This had the potential to place Residents 48 at risk for entrapment and serious injury. Findings: Review of the FDA (Food and Drug Administration) issued guidance titled Entrapment Hazards with Hospital Bed Side Rails showed the residents most at risk for entrapment are those who are frail or elderly or those who have conditions such as agitation, delirium, confusion, pain, uncontrolled body movement, hypoxia, fecal impaction, acute urinary retention, etc., have an increased likelihood of entrapment. Bed entrapment occurs when a resident is caught between the mattress and bed…

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

Based on observation, interview, and medical record review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 8.8%. * LVN 4 failed to administer the correct multivitamin tablet for Resident 54 as per the physician's order. * LVN 5 failed to administer Ciprofloxacin for Resident 67 as per the physician's order. * LVN 5 failed to administer artificial tears for Resident 56 as per the physician's order. These failures had the potential to expose the residents to significant adverse reactions and complications. Findings: 1. On 6/23/22 at 0825 hours, a medication pass observation for Resident 54 was conducted with LVN 4. LVN 4 prepared and administered Resident 54's medications which inluded the following: - one tablet of oyster shell calcium with vitamin D (supplement) 500 mg - one tablet of hydrocodone/APAP (pain medication) 5 mg/325 mg - one tablet of Augmentin (antibiotic) 875 mg - one tablet of multivitamin with minerals (supplement) Review of Resident 54's Order Summary Report showed a physician's order dated 4/6/22, 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 facility P&P review, the facility failed to store the drugs and biologicals in a safe manner. * A bottle of lorazepam (medication used to treat anxiety) oral solution was stored in the medication drawer of Medication Cart 1 instead of being refrigerated as per the manufacturer's instructions. * Multiple opened medication vials with no open dates were observed in Respiratory Cart 3. * One opened medication bottle with no open date was observed in Respiratory Cart 1. * Multiple opened medication containers with no open dates were observed in Treatment Cart 1. * Multiple opened medications containers with no open dates were observed in Medication Cart 1. * LVN 12 left the medication cart unlocked and unattended with the medicine cup containing multiple pills on top of the unlocked medication cart. These failures had the potential to result in the unsafe medication administration and unauthorized persons having access to the medications. Findings: According to the facility's P&P titled Medication Storage in the Facility dated April 2008, under 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 medical record review, the facility failed to ensure the medical records of two nonsampled residents (Residents 67 and 11) were accurate. These failures had the potential for the residents' care needs not being met as their medical records were inaccurate. Findings: 1. Medical record review for Resident 67 was initiated on 6/23/22. Resident 67 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 67's Telephone Order Sheet dated 6/23/22 at 0751 hours, showed a physician's order dated 6/23/22, to administer Ciprofloxacin 500 mg one capsule orally twice a day for five days for UTI. Review of Resident 67's Medication Administration Record for June 2022 failed to show any documented evidence Ciprofloxacin 500 mg was administered to Resident 67. The document also failed to show Ciprofloxacin 500 mg was transcribed into Resident 67's Medication Administration Record. On 6/23/22 at 1203 hours, an interview and concurrent medical record review 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.