Healthcare Center Of Orange County

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 adequate respiratory services. * The facility failed to ensure an adequate number of portable oxygen tanks were kept on site for use in an emergency for the residents with a physician's order for continuous supplemental oxygen therapy for 51 of 52 residents who resided in the subacute unit and four of 41 residents who resided in skilled nursing unit. * The facility's total number of portable oxygen tanks consisted of 46 tanks (43 E tanks and three H tanks). However, a total of 55 residents in the facility had a physician's order for a continuous supplemental oxygen. Failure to ensure an adequate number of portable oxygen tanks were available on site, for the residents who required continuous supplemental oxygen, posed the risk for negative health outcomes in the event of an emergency, in which the building was rendered unsafe and an evacuation of the residents from the facility was necessary. * The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and facility document review, the facility failed to determine the number of portable oxygen tanks needed to conduct an emergency evacuation of residents who required continuous supplemental oxygen therapy for 51 of 52 residents who resided in the subacute unit and four of 41 residents who resided in skilled nursing unit. * The total number of residents residing in the facility (subacute unit and skilled nursing unit) who had an active physician's order for continuous supplemental oxygen was 55. However, the facility had a total inventory of 46 full oxygen tanks on site. This posed the risk for negative health outcomes for the residents in the event of an emergent evacuation from the facility. Findings: Review of the Facility assessment dated [DATE], showed the central supply staff would monitor the availability of supplies in the facility. Emergency supplies were being monitored and replenished daily, weekly, and monthly. Further review of the Facility Assessment failed to show information…

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 respond to the concerns brought up by the residents during the Resident Council meetings on 3/19 and 5/5/25, regarding the call lights not being answered in a timely manner. This failure had the potential for the residents' identified issue to not be resolved and a decline in quality of care for the residents. Findings: Review of the facility's P&P titled Resident Council revised 4/2017 showed the following: - the purpose of the resident council was to provide a forum for discussion of concerns and suggestions for improvement; - a Resident Council Response Form should be utilized to track issues and their resolution. The facility department related to any issues should be responsible for addressing the items of concern. Review of the Resident Council minutes dated 3/19/25, under the Resident Interview and Nursing Department sections showed the call lights were not answered in a timely manner and nurses told the residents to turn off their call lights because they will return with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to maintain a homelike environment for one sampled resident (Resident 15). * Resident 15 resided in Room A. Resident 15 was observed sitting on her bed eating lunch. A pest was observed floating on the surface of Resident 15's milk. This failure had the potential to negatively impact the resident's quality of life. Findings: Medical record review for Resident 15 was initiated on 6/2/25. Resident 15 was admitted to the facility on [DATE]. On 6/2/25 at 1224 hours, a dining observation was conducted with Resident 15 in her room. Resident 15 was observed sitting on her bed eating lunch. A pest was observed floating on the surface of Resident 15's milk. Resident 15 stated she put her milk to the side because there was a bug in it. Resident 15 stated the bug in her milk made her feel nauseated and would not drink her milk anymore because of the bug. Resident 15 stated she has seen the bugs flying around but they have not landed on her food. On 6/2/25 at 1232…

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 2. Medical record review for Resident 15 was initiated on 6/2/25. Resident 15 was admitted to the facility on [DATE]. Review of Resident 15's H&P examination dated 5/11/25, showed Resident 15 had the capacity to understand and make decisions. Review of Resident 15's Order Summary Report dated 6/2/25, showed the following physician's orders: - dated 5/9/25, to administer aripiprazole oral tablet 5 mg, one tablet by mouth in the morning for bipolar disorder manifested by angry outbursts; and - dated 5/9/25, to administer trazodone oral tablet 50 mg, one tablet by mouth at bedtime for depression manifested by inability to sleep. - dated 5/11/25, for the use of the aripiprazole medication, to monitor for bipolar disorder manifested by angry outburst every day and night shift; - dated 5/9/25, for the use of the trazodone medication, to monitor for depression manifested by inability to sleep every day and night shift; - dated 5/9/25, for the use of aripiprazole and trazodone medications, to monitor orthostatic…

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 to failed to ensure the discharge instructions were documented for one of three sampled residents reviewed for closed records (Resident 100). This failure had the potential for Resident 100 to have an inappropriate discharge. Findings: Review of the facility's P&P titled Transfer or Discharge Documentation dated 12/2016 showed when a resident is transferred or discharged , details of the transfer or discharge will be documented in the medical record and appropriate information will be communicated to the receiving health care facility or provider. Closed medical record review for closed Resident 100 was initiated on 6/4/25. Resident 100 was admitted to the facility on [DATE], and readmitted to the facility on [DATE]. Review of Resident 100's Advance Directive Acknowledgement dated 12/19/24, showed Resident 100 had no decision making capacity. Review of Resident 100's H&P examination dated 1/23/25, 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 interview and medical record review, the facility failed to coordinate an assessment with the PASARR program for one of two final sampled residents (Resident 15) reviewed for PASARR when the resident had an updated diagnosis of depression, schizoaffective disorder, bipolar disorder, and anxiety disorder. This failure posed the risk for Resident 15 not receiving the necessary specialized services specific to treat mental illness. Findings: Medical record review for Resident 15 was initiated on 6/2/25. Resident 15 was admitted to the facility on [DATE], with diagnoses including depression, schizoaffective disorder, bipolar disorder, and anxiety disorder. Review of Resident 15's PASARR Level I Screening dated 5/9/25, showed the facility marked no when the question asked does the individual have a serious diagnosed mental disorder such as depressive disorder, anxiety disorder, panic disorder, schizophrenia and/or schizoaffective disorder, or symptoms of psychosis, delusions, and/or mood disturbance.…

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 plan was implemented for one of 22 final sampled residents (Resident 63). * The facility failed to implement the comprehensive plan for contact isolation precautions for Clostridium difficile, for Resident 63. This failure placed the resident at risk for not being provided appropriate, consistent, and individualized care. Findings: Medical record review for Resident 63 was initiated on 6/2/25. Resident 63 was admitted to the facility on [DATE]. Review of Resident 63's physician's order dated 5/27/25, showed an order to give Vancomycin (antibiotic) 125 mg via GT every 12 hours for Clostridium difficile colitis until 6/14/25. Review of Resident 63's care plan titled At Risk for Decrease Socialization due to Contact Isolation initiated 5/27/25, showed an intervention for contact isolation precautions for Clostridium difficile. On 6/5/25 at 0849 hours, an observation and 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY * The facility failed to ensure RNA services were provided as ordered by the physician for Resident 10. 4. On 6/2/25 at 1115 hours, Resident 10 was observed lying on his bed. Resident 10's left arm was observed in a flexed position. Medical record review for Resident 10 was initiated on 6/2/25. Resident 10 was admitted to the facility on [DATE]. Review of the Resident 10's Order Listing Report, showed the following physician's order dated 2/21/25: - for RNA for PROM (passive range of motion) exercise to bilateral upper and lower extremities every day for times a week as tolerated - for RNA to apply bilateral PRAFO (pressure relief ankle foot orthosis) four to six hours, every day five times a week, as tolerated. - for RNA to apply bilateral WHFO (wrist hand finger orthosis) four to six hours, every day five times a week, as tolerated. Review of Resident 10's Care Plan dated 2/21/25, showed the care plan problem addressing Resident 10's alteration in musculoskeletal status. The goal was to maintain the current…

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 monitor the onset of weight loss for one final sampled resident (Resident 33) reviewed for nutrition. * The facility failed to address Resident 33's weight loss of 28 lbs in two days after admission and another weight loss of 3 lbs after three days. This failure had the potential for Resident 33's condition to go unmonitored and cause delay in treatment. Findings: Review of the facility's P&P titled Weight Assessment revised dated 8/2008 showed the multidisciplinary team will strive to prevent, monitor, and intervene for desirable weight loss for our residents. The nursing staff will measure resident weights on admission, the next day, and the weekly for 2 weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly thereafter. Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will…

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 care and services for the use of GT for two of four final sampled residents (Resident 27 and 72) and one nonsampled resident (Resident 54) reviewed for GT use. * The facility failed to ensure the physician's orders for the route of medication administration for Resident 27 was accurate. The medication route was ordered to be oral instead of the GT. * The facility failed to ensure a diet order was obtained from the physician for Residents 27, 54, and 72. * The facility failed to ensure Resident 27 and 72's HOB (head of bed) was elevated at a minimum of a 30 degree angle during the enteral feeding via GT, to reduce the risk of aspiration. These failures posed the risk of complications related to the use of the GT for Residents 27, 54, and 72. Findings: Review of the facility's P&P titled Administering Medications revised 4/2019 showed to verify the right resident, right medication, right dosage, right…

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 maintain the IV accesses for one nonsampled resident (Resident 45) who had peripheral IV (PIV) access. * The facility failed to properly label Resident 45's PIV access and discontinue the PIV catheter per the facility's P&P. This failure posed the risk of Resident 45 developing complications related to the use of the peripheral IV catheter. Findings: Review of the facility's P&P titled Peripheral IV Catheter Insertion revised 4/2016 showed the label on the dressing should include date and time of dressing placement, initials, gauge size, and length of catheter. Remove the peripheral catheter if it has not been used for 24 hours or if therapy is discontinued. On 6/2/25 at 0918 hours, an observation of Resident 45 was conducted in Resident 45's room. Resident 45 was observed to have a PIV on his right arm. The PIV was not observed labeled. On 6/2/25 at 0927 hours, 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 facility P&P review, the facility failed to provide the pharmaceutical services to meet the resident's needs for one of five final sampled residents (Resident 78) reviewed for unnecessary medications. * The facility failed to ensure Resident 78's enoxaparin (anticoagulant medication) injection sites were rotated. This failure had the potential for poor health outcome for Resident 78. Findings: Review of the facility's P&P titled Subcutaneous Injections dated March 2011 showed the licensed nurses should verify the physician's order including the resident's name, drug name, dose, time, and route of administration. The procedures included the following: - To assist the resident to a comfortable position and asked to relax the arm, leg, or abdomen depending on the site chosen for the injection. Medical record review for Resident 78 was initiated on 6/5/25. Resident 78 was admitted to the facility on [DATE]. Review of Resident 78's Order Summary Report dated 6/4/25,…

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

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 identify and report a medication irregularity to the facility for one of 22 final sampled residents (Resident 42). * Resident 42 had a physician's order for docusate sodium medication; however, there was no specified dose indicated on the order. This failure posed the risk for Resident 42 to have adverse consequences from the medication. Findings. Review of the facility's P&P titled Medication Utilization and Prescribing- Clinical Protocol dated 4/2018 showed the consultant pharmacist should use the monthly and interim drug regimen review to help identify potentially problematic medications, including medications regimens that are not supported based on clinical signs and symptoms. On 6/3/25 at 0752 hours, a medication administration observation was conducted with LVN 1 for Resident 42. LVN 1 was observed preparing for the following medications in the medication cup for each medication. - one tablet 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 2. Review of the facility's P&P titled Administering Medication through an Enteral Tube dated 11/2018 showed under the section preparation showed to verify that there is a physician's medication order for this procedure. Further review of the P&P showed to check the label, confirm the medication name and dose with the MAR . to calculate the medication dose and to re-check the calculation. On 6/3/25 at 0752 hours, a medication administration observation was conducted with LVN 1 for Resident 42. LVN 1 was observed preparing for the following medications in the seperate medication cup for each medication: - one tablet of docusate sodium (stool softener), 100 mg; - one tablet of pepcid (medication that treats and prevents heartburn from acid indigestion and upset stomach) 20 mg; - 5 ml of iron syrup (supplement), 220 mg/5 ml; - one tablet of folic acid (supplement), 1 mg; - one tablet of metoprolol (medication that lowers the blood pressure), 100 mg; - one tablet of multivitamin with minerals (supplement); 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.

3. Review of the facility's P&P titled Storage of Medications revised 4/2019 showed the facility stores all the drugs and biologicals in a safe, secure, and orderly manner. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light, and humidity controls. On 6/2/25 at 0945 hours, a concurrent observation and interview was conducted with Resident 47 in her room. Resident 47 was observed with a clean dressing over her below the knee amputation stump. A clear medicine cup was observed filled with a dark liquid and placed on top of her nightstand. Resident 47 stated she did not know what was in the medicine cup. On 6/2/25 at 0950 hours, a concurrent observation and interview was conducted with the DON in Resident 47's room. The medicine cup was filled with a dark liquid was observed on Resident 47's nightstand. The DON was observed to pick up the medicine cup and smell the dark liquid. The DON stated it was Betadine (an antiseptic solution which helps prevent skin infections), it should not be kept at the bedside and proceeded to take…

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 food safety and sanitation guidelines were followed as evidenced by: * The can opener blade's coating was observed to be removed. * Two frying pans were observed to have grayish black residue. * Strainer was observed to be with white residue. * An opened box of gloves was placed on top of plates where clean plates were stored. * The roof surface of the microwave used by residents was observed to be scattered food residue. These failures posed the risk for food borne illnesses for the 39 residents who consumed food prepared in the kitchen. Findings: Review of the facility's Matrix dated 6/2/25, showed 39 of 93 residents who resided in the facility consumed food prepared in the kitchen. According to the USDA Food Code 2022, Section 4-601.11 Equipment, Food -Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES AND UTENSILS shall be clean to sight and touch. (C) NonFOOD -CONTACT SURFACES OF EQUIPMENT shall be kept free of 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.

Based on observation, interview, and facility P&P review, the facility failed to dispose and store the trash in a sanitary manner. Three of four dumpster were observed overflowing with trash which prevented the lids from fully closing. This failure had the potential to harbor pests and for pest contamination. * Two of five dumpster bins were observed to be overflowing with trash which prevented the lids from fully closing. * Seven sharps' disposal containers were not properly disposed in the biohazard waste dumpster bins in the Infectious Waste Matter Room. These had the potential to attract and harbor pests and/ or rodents and potentially cause spread of diseases. Findings: According to the US Food Code 2013, 5-501.113, Covering Receptacles, receptacle units for refuse shall be kept covered with tight fitting lids after they are filled. On 6/2/25 at 1056 hours, an observation of the trash disposal and concurrent interview was conducted with the Central Supply Supervisor. One recyclable dumpster bin and one regular trash dumpster bin were observed to be overflowing with trash which…

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 medical records for two of 22 final sampled residents (Residents 58 and 33) were complete and accurate. * The facility failed to ensure Resident 58's physician's order dated 1/29/25, on NPO diet, NPO texture, NPO consistency was discontinued (NPO stands for nil per os or nothing by mouth). * The facility failed to ensure Resident 33's blood pressure access site was accurately documented in the resident's medical record. These failures had the potential for the residents' care needs not being met as their medical information was incomplete and inaccurate. Findings: 1. Medical record review for Resident 58 was initiated on 6/2/25. Resident 58 was admitted to the facility on [DATE], and readmitted to the facility on [DATE]. Review of Resident 58's Order Summary Report dated 6/2/25, showed a physician's orders: - dated 1/29/25, for NPO diet, NPO texture, NPO consistency. - dated 5/13/25, for NAS (No added salt) diet pureed texture ,…

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 infection control program and practices designed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases, for one final sampled resident (Resident 63) and five nonsampled residents (Residents 8, 21, 42, 66 and 79). * The facility failed to follow the physician's order for contact isolation, for Clostridium Difficile colitis, for Resident 63, as evidenced by the following. The facility failed to place Resident 63 in a private room. The LVN failed to utilize a designated blood pressure cuff and thermometer for Resident 63 while obtaining vital signs. The CNA failed to donn PPE in accordance with contact isolation precautions. The facility failed to post a sign at the entrance to Resident 63's room showing Resident 63 had a physician's order for contact isolation. Additionally, the IP provided Resident 63's physician with incomplete…

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 offer the PCV 20, PCV 21, or PCV 15 (PCV 20 protects against 20 types of pneumococcal bacteria, PCV 15 protects against 15 types of pneumococcal bacteria, and PCV 21 protects against 21 types of pneumococcal bacteria), immunizations for one of five residents (Resident 15) reviewed for pneumococcal vaccination (a vaccine given to protect the resident from pneumococcal disease) in accordance with the CDC's recommendations. This failure increased the resident's risk for being inadequately vaccinated for the pneumococcal disease and its associated complications. Findings: Review of the facility's P&P titled Pneumococcal Vaccine revised October 2019 showed all residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Prior to or upon admission, the residents will be assessed for eligibility to receive the pneumococcal vaccine series and when indicated,…

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 6/3/25 at 1148 hours, an observation and concurrent interview was conducted with RN 1. The refrigerator in the facility to store the residents' medication located in Medication Room A was observed with thick ice buildup in the frozen storage area. The frozen storage area was observed inside medication refrigerator with no separate door for the frozen storage area. Multiple medications for multiple residents were observed stored in the refrigerator. RN 1 verified the observations and stated the above refrigerator was being defrosted every month and acknowledged refrigerator needed more frequent defrosting. On 6/5/25 at 0933 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. Based on observation, interview, and facility document review the facility failed to maintain the essential equipment in a clean and safe operating condition when: * The facility failed to ensure the quality control checks were performed for the glucometer in Medication Cart C. * The facility failed to ensure the frozen storage area inside the residents'…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Medical record review for Resident 19 was initiated on 6/2/25. Resident 19 was admitted to the facility on [DATE]. Review of Resident 19's Order Summary Report showed an order dated 7/3/23, for bilateral siderails as an enabler to promote independence and bed mobility. Review of Resident 19's care plan titled Use of Siderails dated 12/2/24, showed the risk and benefits of side rails including entrapment and other injury such as death, were explained to Resident 19 and her responsible party. On 6/2/25 at 0947 hours, an observation and concurrent interview was conducted with Resident 19. Resident 19 was observed lying in her bed with the bilateral side rails elevated. Resident 19 stated she utilized the siderails to reposition herself in bed. On 6/5/25 at 1418 hours, an observation was conducted of Resident 19. Resident 19 was observed lying in her bed with the bilateral side rails elevated. Review of Resident 19's Bed Safety Checklist for Residents with Bed Rails undated, showed Zone 1 gaps (within the side…

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 five sampled residents (Resident 3) was free from the unnecessary drugs. * The facility failed to ensure Resident 3's metoprolol tartrate (a beta-blocker, a medication a medication that works by affecting the nerve impulses in the body such as the heart and slows the heartbeat and decreases blood pressure) and hydralazine (medication used to treat high blood pressure) were administered as per the physician's orders. This failure had the potential for the resident to receive unnecessary medications and develop significant side effects. Findings: Review of the facility's P&P titled Administering Medications revised April 2019 showed the medications are administered in accordance with prescriber orders, including any required time frame. Medical record review for Resident 3 was initiated on 10/17/24. Resident 3 was readmitted to the facility on [DATE]. Review of Resident 3's Order Summary Report showed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to ensure one of four sampled residents (Resident 1) was free from accidents when the facility failed to follow their care plan requiring two-person assistance with bed mobility for Resident 1. * Resident 1 fell to the floor while being changed and turned in bed by one CNA. This failure resulted in Resident 1 falling to the floor with profuse bleeding from the head requiring Resident 1 to be transferred to the acute care hospital, which had the potential to negatively impact the resident's well-being. Findings: Review of facility's P&P tilted Activities of Daily Living (ADL), Supporting revised 3/2018 showed the appropriate care and services will be provided for the residents who are unable to carry out ADL care independently with the consent of the resident and in accordance with the plan of care, including the appropriate support and assistance with hygiene (bathing, dressing,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility P&P review, the facility failed to ensure the staff implemented the proper storage, labeling, and disposal of medications in a safe manner as evidenced by: * The facility failed to ensure the medications were properly stored in Medication Cart A. In addition, thexpired medications and two blood glucose strip bottles were found in Medication Cart A. * The facility failed to dispose the expired [NAME] luer lock caps (use as a protective cap on access ports on medical devices or intravenous sets when not in use) inside Medication Cart C. * The facility failed to ensure the medications were not stored with the odor eliminator spray in Medication Cart B. * The facility failed to dispose of the expired medication in Medication Cart D and failed to ensure the medications administered orally were stored separately from the externally used medications in Medication Cart D. * The facility failed to dispose of the expired BinaxNOW COVID-19 Ag card (test kit to check for…

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

Based on observation, interview, facility document review and facility P&P review, the facility failed to ensure 36 of 94 residents who received food from the kitchen received the proper diets and portion sizes when the facility's menus were not followed. * The facility failed to follow the menu for the BBQ Chicken puree recipe. * The facility failed to ensure the kitchen staff served the correct portion size as per the menu when serving the ground BBQ chicken and the potato salad. * The facility failed to ensure the residents who were on CCHO diets (diet for diabetics) received homemade BBQ sauce with their BBQ chicken as per the menu. These failures had the potential for the resident's nutritional needs not being met which could result in medical complications. Findings: Review of the CMS 802 Matrix For Providers completed by the facility 4/15/24, showed 36 of 94 residents in the facility received food prepared in the kitchen. Review of the facility's P&P titled Menus revised 10/2017 showed menus meet the nutritional needs of residents in accordance with the recommended dietary…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and facility document review, the facility failed to ensure the residents on mechanically altered diets received food in a form that met their individual needs when: 1. The pureed bread was not prepared according to the recipe. 2. One of 21 sampled residents (Resident 33) on a mechanical soft NAS (No added salt) CCHO (consistent carbohydrate- a diet to control blood sugar) diet received regular textured meat. 3. One of 73 nonsampled residents (Resident 29) on a mechanical soft finely chopped meat diet received a pureed diet. These failures posed the risk for complications such as choking for nine residents on mechanically altered diets: seven residents on a pureed diet and two residents on mechanical soft diets. Findings: 1. Review of the facility document titled Therapeutic Diet Count dated 4/16/24, showed seven residents were on a puree diet. Review of the facility's recipe titled pureed breads, cakes, cookies, pancakes, french toast, sweet rolls, waffles, tortillas, sandwiches…

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 document review, the facility failed to ensure the residents' entrapment assessments were complete and the measurements were recorded during the bed inspection when identifying areas of possible entrapment with the use of side rails for six of 21 final sampled residents (Residents 16, 18, 33, 61, 62, and 351). These failures had the potential to negatively impact the residents resulting in possible entrapment, serious injury, and death. Findings: Review of the facility's P&P titled Proper use of side rail dated 12/2016 showed an assessment will be made to determine the resident's symptoms, risk for entrapment. When side rail usage is appropriate, the facility will assess the space between the mattress and side rails to reduce the risk for entrapment (the amount of safe space may carry depending the type of bed and mattress being used). According to the Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, the term…

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 document review, the facility failed to provide the residents' care timely for the residents on the SNF unit and two nonsampled residents (Residents A and 32). * The residents on the SNF unit were not repositioned or provided their usual care when only two CNAs were on duty. * Residents A and 32 waited more than an hour for incontinent care. These failures resulted in a delay of the residents' care, putting them at risk for negative outcome and resulting in feelings of discomfort. Findings: 1. Review of the Nursing Staffing Assignment and Sign-In Sheet for 3/20/24, for the 2300 to 0700-hours shift, showed two CNAs were assigned to care for 43 residents. On 4/17/24 at 1614 hours, a telephone interview was conducted with CNA 4. CNA 4 stated they worked on 4/14/24 at night shift, when there was a sick call, so they only had two CNAs for 43 residents. CNA 4 stated they were not able to get to the residents timely and some of the residents got…

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 provide two of three final sampled residents reviewed for the Notice of Medicare Non-coverage (NOMNC) and Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) Form CMS-10055 (Residents 901 and 902). The NOMNC and SNF ABN Forms were used to inform the residents of their potential financial liability and appeal rights and protections should they wish to receive care and services that may not be covered by Medicare. This failure had the potential for not allowing Residents 901 and 902 to make an informed decision regarding their Medicare services. Findings: Review of the facility's P&P titled Medicare Non-Coverage Notice dated April 2018 showed a Medicare provider or health plan must give an advance, completed copy of the Notice of Medicare Non-Coverage (NOMNC) to beneficiaries/enrollees receiving skilled nursing, home health, comprehensive outpatient rehabilitation 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 observation, interview, medical record review, and facility P&P review, the facility failed to implement the restraint free periods for two of three final sampled residents reviewed for restraints (Residents 39 and 46). * The facility failed to ensure the mittens (mitten which look like boxing gloves with a Velcro or tie at the wrist to hold them in place and immobilize the resident's fingers) were released every two hours as per the resident's care plan and physician's order to release at least 10 minutes for Residents 39 and 46's both hands. These failures posed the risk of compromising the residents' independence and psychosocial well-being. Findings: Review of the facility's P&P titled Use of Restraints dated 4/2017 showed the following safety guidelines shall be implemented and documented while a resident is in restraints: A resident placed in restraint will be observed at least every thirty minutes by nursing personnel and an acoount of the resident's condition shall be recorded in the resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility P&P review, the facility failed to ensure the comprehensive resident centered care plan was developed for one nonsampled residents (Resident 40) when the perishable and nonperishable food items were stored in Resident 40's room. This failure posed the risk to not provide appropriate, consistent, and individualized care. Findings: Review of the facility's P&P titled Care Plans, Comprehensive Person-Centered revised 12/2016 showed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. Medical record review for Resident 40 was initiated on 4/5/24. Resident 40 was admitted to the facility on [DATE], and readmitted on [DATE]. On 4/5/24 at 1511 hours, an observation and concurrent interview was conducted with Resident 40. Resident 40's room had multiple nonperishable food items: chips, dehydrated soup, pastries, instant…

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

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the services provided met the professional standards of care when LVN 7 failed to properly administer the medication for one nonsampled resident (Resident 44). This failure had the potential to negatively impact the resident's health due to malabsorption and reduction in the effectiveness of the medication. Findings: Review of the facility's P&P titled Nasal Inhalers, Sprays, and Pumps Administration Procedure dated 03/2023 showed the following instructions: - have the resident keep upright, - press a finger against the side of the nose to close one nostril, - keeping mouth closed, tip of pump, spray or inhaler is inserted into the nostril, - have resident sniff in through open nostril while pump or inhaler is quickly and firmly squeezed or activated, - instruct resident to hold his/her breath for a few seconds and then breathe out through mouth, and - repeat for other nostril if indicated. On 4/17/24 at 0846 hours, a medication administration observation was conducted with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary care and services for one of 21 final sampled residents (Resident 33) to ensure the residents maintained their highest physical well-being. * The facility failed to ensure the heel protector boots were applied to Resident 33's BLEs as per the physician's order. This failure had the potential to affect the resident's well-being. Findings: On 4/17/24 at 0832 hours, a medical record review of Resident 33 was initiated. Resident 33 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 33's physician's order dated 3/3/24, showed an order to apply heel protector boots to the BLEs every shift for wound management and prevention while in bed. On 4/17/24 at 0832 hours, an observation and concurrent interview was conducted with CNA 8. Resident 33 was observed without the bilateral heel protectors while in bed. CNA 8 verified Resident 33 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to provide the RNA services as ordered by the physician for one of two final sampled residents reviewed for ROM functions (Resident 87). This failure had the potential for decline in the resident's range of motion and mobility. Findings: Review of the facility's P&P Charting and Documentation dated July 2017 shows documentation in the medical record may be electronic, manual, or a combination of both. The following information is to be documented in the resident's medical record: - treatments or services performed. Medical record review for Resident 87 was initiated on 4/15/24. Resident 87 was admitted to the facility on [DATE]. Review of Resident 87's Physician Orders List dated 9/1 to 9/30/23, showed the following orders dated 9/29/23, for RNA services: - RNA to provide PROM on BUE every day five times a week or as tolerated. - RNA to provide PROM on BLE every day five times a week or as tolerated. - RNA to apply RUE elbow…

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 one final sampled resident reviewed for fall risks (Resident 23) remained free from accident hazards. The facility failed to implement the bilateral floor mats as per the physician's order and plan of care. This failure had the potential to place Resident 23 at risk for serious injury. Findings: On 4/15/24 at 0857 hours, during the initial tour of the facility, Resident 23 was observed lying in bed with a yellow wrist band (indicating fall risk), and no fall matts were observed in place. Medical record review for Resident 23 was initiated on 4/15/24. Resident 23 was admitted to the facility on [DATE]. Review of Resident 23's H&P examination dated 4/15/23, showed Resident 23 could make her needs known but could not make medical decisions. Review of Resident 23's Physician's Orders for April 2024 showed a physician's order dated 8/28/23, to implement bilateral floor mats to prevent from injury in the event of a fall.…

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 maintain the IV accesses for two of two final sampled residents reviewed for IV care (Residents 53 and 67). * The facility failed to ensure the PICC line external catheter and arm circumference measurements were completed and documented in the medical record for Residents 53 and 67 upon admission to the facility. In addition, the facility failed to obtain a physician's order for care and maintenance of the PICC line, and failed to develop a plan of care for the use of PICC. These failures had the potential to delay the identification of catheter related complications for these residents. Findings: Review of the facility's P&P titled Peripheral and Midline IV Dressing Changes with a revised 3/22 showed for central line catheters, to measure arm circumference and compare to baseline when clinically indicated to assess for possible complications. The P&P also showed 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 observation, interview, medical record review, and facility P&P review, the facility failed to provide the safe respiratory care to meet the needs for three of four final sampled residents (Residents 10, 16, and 53) and one nonsampled resident reviewed for respiratory care (Resident 51). * The facility failed to ensure Resident 16's ventilator machine alarms were set for high pressure alarms. In addition, the facility failed to ensure the nebulizer machine tubing was labeled. * The facility failed to ensure Resident 53's ventilator machine alarms were set for high pressure alarms. In addition, the facility failed to ensure the oxygen tubing labeled. * The facility failed to ensure Resident 10 received the amount of oxygen as ordered by the physician. * The facility failed to ensure Resident 51's oxygen concentrator was clean. These failures had the potential to result in poor health outcomes to the resident and posed the risk of delayed intervention in the event of an emergency. Findings: Review of 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 dialysis care and services were provided for two of two final sampled residents reviewed for dialysis care (Residents 10 and 74). * The facility failed to ensure emergency supplies/kits were accessible at Resident 10's bedside in the event of dialysis (a treatment to rid the body of wastes and toxins when the kidneys fail to function) access bleeding/emergency. * The facility failed to ensure Resident 74's emergency dialysis kit was available at the bedside. These failures had the potential for Residents 10 and 74 not being provided appropriate care and treatment, and possibility of medical complications. Findings: Review of the facility's P&P titled Hemodialysis Catheters- Access and Care of revised 2/23, under the section for Care Immediately Following Dialysis Treatment, showed mild bleeding from site (post-dialysis) can be expected, and to apply pressure to insertion site and contact 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, facility document review, and facility P&P review, the facility failed to provide the pharmaceutical services to meet the resident's needs for one of 21 final sampled residents (Resident 39). * The facility failed to ensure Resident 39's lorazepam (antianxiety medication) was accurately reconciled. The lorazepam tablets removed as shown on the Record of Controlled Substances was not recorded as administered on the electronic MAR. This failure had the potential for drug diversion. Findings: Review of the facility's P&P titled Control Substances revised November 2022 showed controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up. Nursing staff count controlled medication inventory at the end of each shift, using these records to reconcile the inventory count. Review of the facility's P&P titled Documentation of 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.

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 five final sampled residents sampled reviewed for unnecessary medications (Residents 25 and 42) were free from unnecessary psychotropic drugs (any drug that affects brain activity associated with mental processes and behavior). * The facility failed to ensure the informed consent was obtained from Resident 42 for the use of Seroquel (quetiapine fumarate, an antipsychotic medication). In addition, the facility failed to ensure the non-pharmacological interventions were implemented prior to administering Resident 42's Seroquel. * The facility failed to ensure Resident 25's informed consent for diazepam (an antianxiety medication) was signed and dated by the physician. These failures had the potential for the residents receiving the unnecessary psychotropic medications. Findings: Review of the facility's P&P titled Psychotropic medication use dated 7/2022 showed non-pharmacological approaches are used (unless…

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

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 6.06%. Two of the four licensed nurses (LVNs 6 and 7) who were observed during the medication administration were found to have made errors. * LVN 6 failed to ensure Resident 12's vitamin B12 (supplement) was administered as ordered. * LVN 7 failed to ensure Resident 44's aspirin was administered as ordered. These failures had the potential to negatively impact the residents' health and safety and posed the risk for possible complications. Findings: Review of the facility's P&P titled Administering Medications revised April 2019 showed the medications are administered in accordance with prescriber orders, including any required time frame. 1. On 4/17/24 at 0814 hours, a medication administration observation was conducted with LVN 6 for Resident 12. LVN 6 prepared and administered Resident 12's medications which included the following: - one tablet of finasteride 5 mg (medication use to shrink…

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 document review, the facility failed to provide the food substitute of similar nutritive value when the meal alternate recipes were not followed for four of 36 sampled residents who received meals from the kitchen (Residents 13, 21, 32, and 80). This failure had the potential for Residents 13, 21, 32, and 80 who received a meal alternate from the kitchen to not meet their nutritional needs. Findings: 1. Review of the facility's document titled Standard Substitutes for Dinner and Supper undated showed a grilled cheese sandwich and a cheese quesadilla were available for a meal substitute. Review of the facility's document titled Spring Cycle Menus, Cook's Spreadsheet dated 4/15/24, showed the mechanical soft diet was to receive ground Roast Turkey #10 scoop (three ounces), ½ (half) cup of parsley and herb penne (pasta), ½ cup of green beans with garlic, one wheat roll, one teaspoon of margarine, one serving of apple crisp, and four ounces of milk. Review of the…

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

Based on observation, interview, and facility P&P review, the facility failed to ensure the food safety guidelines were met in the kitchen as evidenced by: * The facility failed to ensure Time Temperature Control for Safety (TCS) Food (food that require time and temperature controls to limit the growth of illness causing bacteria) were monitored with a cool down log. * Resident 40's room was observed with non-perishable and perishable food items brought from the outside. The food items were not labeled and dated and the mini fridge with perishable food was not being monitored by the facility. * The residents' food items brought from outside were not labeled and dated. * The facility failed to ensure the ice machine drainpipe located in the kitchen had an air gap. These failures had the potential to place the 34 residents who received food prepared in the facility kitchen at risk for foodborne illness. Findings: The facility had 36 of 94 residents receiving food from the kitchen. 1. According to the USDA Food Code 2022 Section 3-501.14 Cooling, (A) Cooked time/temperature control for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility P&P review, the facility failed to ensure the P&P regarding outside food for residents was followed. * The facility failed to ensure the facility staff responsible for handling food brought for the residents from the outside and visitors who brought food for residents from the outside were educated on safe food handling procedures. * The facility failed to provide appropriate equipment needed to reheat food items brought in for residents from the outside. These failures posed the risk for food borne illness in residents who consume food from outside sources. Findings: Review of the facility's P&P titled Foods Brought by Family/Visitors revised 3/2022 showed: - Foods brought by family/visitors for individual residents are not shared with or distributed to other residents. - Family/visitors are asked to prepare and transport food using safe food handling practices, including safe cooling and reheating processes, holding temperatures, preventing cross-contamination with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to ensure the medical records for three of 21 final sampled residents (Residents 23, 25, and 61) were complete and accurate. * The facility failed to ensure Resident 23's CNA flowsheet for meal percentages and nourishments were complete and accurately documented. * The facility failed to ensure Resident 25's Advance Directive Acknowledgment form was complete to reflect Resident 25's wishes; and failed to ensure Resident 25's informed consent for Xanax (an antianxiety medication) had the correct date as the physician's order date. * The facility failed to ensure Resident 61's POLST information had the same information with the Advance Directive Acknowledgement form. These failures had the potential for the residents' care needs not being met as their medical information was incomplete and inaccurate. Findings: 1. Medical record review for Resident 23 was initiated on 4/15/24. Resident 23 was admitted to the facility on [DATE]. Review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to ensure the appropriate infection control practices designed to provide a safe and sanitary environment and to prevent the spread of infections within the facility were implemented. * Resident 17's urinary tubing and Resident 81's indwelling catheter drainage bag were laying on the floor. * One of two clean linen wheeled bins had layers of peeling tape on the hard plastic cart. These failures posed the risk of transmission of nfectious organisms from the floor to the urinary tract and transmission of infection in the facility. Findings: Review of the facility's P&P titled Catheter Care, Urinary dated 9/2014 showed under the section for Infection Control, be sure the catheter tubing and drainage bag are kept off the floor. 1. Medical record review for Resident 17 was initiated on 4/15/24. Resident 17 was admitted to the facility on [DATE]. Review of Resident 17's Order Summary Report for April 2024 showed a physician's order dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the essential kitchen equipment was maintained in safe operation condition when the ice machine manufacturer cleaning and sanitizing instructions were not followed. This failure had the potential to result in the equipment to not function in the way it was intended which could affect the health status of the residents. Findings: Review of the facility's P&P titled Ice Machine Cleaning Procedures dated 2023 showed the ice machine needs to be cleaned and sanitized monthly. Clean inside of ice machine with a sanitizing agent per the manufacturer's procedures to clean and sanitize the machine. Review of the ice machine instruction manual titled LB Series Ice Machine Installation and maintenance instructions, undated, showed in part, in order to make the operation of the ice machine stable and efficient, the user is responsible for the operation according to the cleaning and disinfection requirements.…

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 kitchen was free of pests. This failure posed the risk for pests to transmit disease to residents by contaminating food and food contact surfaces for 36 residents who received food prepared in the kitchen. Findings: Review of the facility's P&P titled Pest Control revised 5/08 showed this facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. Review of the facility's pest control invoices showed the pest control company had performed pest control maintenance in the kitchen for cockroaches on 1/16, 2/20, and 3/20/24. During the initial tour of the kitchen on 4/15/24 at 0810 hours, with the DSS, a live bug which resembled a Jerusalem cricket (a large flightless insect) was observed under the manual ware washing sink. The DSS stated the pest control company came to treat the kitchen for pests monthly. The DSS confirmed the live bug observed under the manual ware washing sink. On 4/15/24 at 1622 hours, an observation of 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 a homelike environment by maintaining the comfortable sound levels for one of six sampled residents (Resident 3). * Resident 3's roommates (Residents A and B) had caused the disruption due to their noise levels and Resident 3 reported the noise issue to the staff and subsequently requested a room change; however, there was no resolution or follow up to Resident 3's concern. This failure had to the potential for Resident 3 to continuously have interruption of sleep and disrupting their homelike environment. Findings a. Medical Record Review for Resident 3 was initiated on 3/25/24. Resident 3 was admitted to the facility on [DATE]. Review of Resident 3's H&P examination dated 9/21/23, showed Resident 3 could make needs known but was unable to make medical decisions. b. Medical record review of Resident A was initiated on 3/26/24. Resident A was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to implement the P&P for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act when the facility did not report an allegation of verbal abuse to the CDPH, L&C Program, Ombudsman Office, and local law enforcement agency for one of two sampled residents (Resident 1). This failure had the potential for Resident 1 to be vulnerable to further abuse and emotional distress. Findings: Review of the facility's P&P titled Abuse Investigation and Reporting revised 7/2017 showed all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source shall be promptly reported to the local, State, and Federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. Further review of the P&P, 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, medical record review, and facility P&P review, the facility failed to ensure four of four nonsampled residents (Residents 51, 58, 73, and 80) were free from the physical restraints. The facility to ensure the least restrictive measures were attempted prior to the use of hand mittens. This failure had the potential to result in compromising Residents 51, 58, 73, and 80's independence and psychological well-being. Findings: Review of the facility's P&P titled Use of Restraints dated 4/2017 showed the physical restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. Examples of the devices that are/may be considered physical restraints include leg restraints, arm restraints, hand mitts, soft ties or vest, wheelchair safety bars, gerichairs and lap cushions and trays that the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to develop the plans of care to reflect the individual care needs for four of four nonsampled residents (Residents 51, 58, 73, and 80). This posed the risk of not providing appropriate, consistent, and individualized care to these residents. Findings: Review of the facility's P&P titled Care Plans, Comprehensive Person - Centered dated 12/2016 showed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The comprehensive, person - centered care plan is developed within the completion of the required comprehensive assessment (MDS). 1. Medical record review was initiated for Resident 73 on 4/03/23. Resident 73 was admitted to the facility on [DATE]. Review of Resident 73's plan of care showed a care plan problem dated 9/29/22, to address the resident's episodes of pulling out…

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 food safety and sanitation requirements were met in the kitchen as evidenced by: * The facility failed to ensure the ice machine drain pipe had an air gap and not touching the drain. * The facility failed to ensure the sanitary condition of the hood over the stove was maintained. * The facility failed to ensure the kitchen utensils had smooth cleanable surface. These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food prepared in the kitchen. Findings: Review of the form CMS-672 Resident Census and Conditions of Residents completed by the DON dated 4/3/23, showed 37 of 85 residents residing in the facility received food prepared in the kitchen. 1. According the USDA 2017 Food Code, Section 5-202.13, Backflow Prevention, Air Gap, an air gap between the water supply inlet and the flood level rim of the plumbing fixture, equipment, or nonfood equipment, shall be at least twice the diameter of the water supply inlet and may…

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 three of 19 final sampled residents (Residents 39, 46, and 340) were assessed to self-administer their medications. This had the potential for Residents 39, 46, and 340 to have medication administration errors. Findings: Review of the facility's P&P titled Self-Administration of Medications dated 12/2016, showed if the team determines a resident cannot safely self-administer the medications, the nursing staff will administer resident's medications. Nursing staff will review the self-administered medication record on each nursing shift and they will transfer pertinent information to the Medication Administration record (MAR) kept at the nursing station, appropriately noting that doses were self-administered. 1. Medical record review for Resident 46 was initiated on 4/5/23. Resident 46 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of the H&P examination dated 1/12/23, 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 interview, medical record review, and facility P&P review, the facility failed to determine whether one of 19 final sampled residents (Resident 49) wished to formulate an advance directive. This had the potential for the resident's decisions regarding his health care and treatment options not being honored. Findings: Review of the facility's P&P titled Advance Directives revised 12/2016 showed upon admission the Social Services Director or designee will inquire of the resident about the existence of any written advance directives. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive, if he chooses to do so. If the resident indicates he has not established an advance directive, the facility staff will offer assistance in establishing an advance directive. Staff will document in the medical record the offer to assist and the resident's decision to accept or decline assistance.…

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

Based on observation and interview, the facility failed to maintain a clean, safe, and homelike environment for two of 19 final sampled residents (Residents 49 and 62). * Residents 49 and 62 were roommates. The residents' room (Room A) was observed with stained areas on the ceiling above Resident 62's bed and the wall was observed in a state of disrepair with exposed sharp edges. * Resident Room B was observed with the wall baseboard protruding out from the wall. These failures had the potential to negatively impact the residents' safety and quality of life. Findings: 1. On 4/3/23 at 0902 hours, an observation and concurrent interview was conducted with Resident 62. Resident 62 was observed in his room. The wall adjacent to the head of Resident 62's bed was observed in disrepair with exposed sharp edges. Resident 62 stated the wall was in a state of disrepair for as long as he could remember. Resident 62 was observed with a bandage on his left knee. Resident 62 stated he ambulated independently and fell a few days ago. On 4/3/23 at 1200 hours, an observation and concurrent 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 and medical record review, the facility failed to accurately code the MDS for one of 19 final sampled residents (Resident 58). The facility failed to ensure Residents 58's diagnosis of schizophrenia (a severe brain disorder in which people interpret reality abnormally) was coded accurately. This failure posed the risk of the resident not receiving an individualized plan of care based on the resident's specific needs. Findings: Medical record review for Resident 58 was initiated on 4/4/23 . Resident 58 was admitted to the facility on [DATE]. Review of the admission Information Sheet for Resident 58 showed Resident 58's diagnosis including schizophrenia. However, there was no date when Resident 58 was diagnosed with schizophrenia. Review of Resident 58's admission MDS assessment dated [DATE], showed the resident's diagnosis when admitted to the facility. However, there was no diagnosis of schizophrenia coded. On 4/6/23 at 1001 hours, an interview and concurrent medical record review for Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to ensure the level 1 PASRR (used to ensure a resident with a mental illness is evaluated and receives care in a setting appropriate to meet their needs) contained accurate information for one of 19 final sampled residents (Resident 3). * Resident 3 had a diagnosis of depression and was prescribed citalopram (antidepressant medication); however, the level 1 PASRR screen showed Resident 3 had no diagnosis of mental illness and was not prescribed with psychotropic medications. This failure posed the risk for inappropriate placement in a long-term care nursing home if a PASRR level 2 (used to determine if residents with a mental disorder are placed in a appropriate setting and receive necessary recommendations for specialized services) was indicated, and the facility subsequently could not provide the resident with the necessary mental health services. Findings: Medical record review for Resident 3 was initiated on 4/3/23. Resident 3 was admitted 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 a care and services provided meeting the accepted standards of quality for one of 19 final sampled residents (Resident 58). * Resident 58 was diagnosed with schizophrenia (a severe brain disorder in which people interpret reality abnormally) without a complete clinical assessment and was prescribed with an antipsychotic medication. This failure posed the risk and the potential for the resident to suffer the adverse effects of the antipsychotic medication prescribed. Findings: Medical record review for Resident 58 was initiated on 4/4/23. Resident 58 was admitted to the facility on [DATE]. On 4/3/23 at 1009, 1242, and 1444 hours, Resident 58 was observed having a hand mitten on the left hand and able to moved her hands touching her face and body. Review of the MDS dated [DATE], showed Resident 58 had severe cognitive impairment. Review of the Physician Orders for April 2023 showed an order dated 10/22/22, to administer Seroquel…

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 accommodate the needs for one of 19 sampled residents (Resident 27). * A Vietnamese communication board was not available when required by Resident 27 for communication. This has the potential to impede the resident in maintaining and/or achieving independent functioning, dignity, and well-being. Findings: Medical record review of Resident 27 was initiated on 4/3/23. Resident 27 was admitted to the facility on [DATE]. Review of Resident 27' care plan dated 1/20/23, showed a care plan problem addressing Resident 27's communication problem related to moderate hearing difficulty and severe difficulty for altered ability to make self-understood rarely or never understood or sometimes understood, altered ability to understand others: sometimes understand, rarely/ never understands, and altered speech clarity clear speech. The intervention included to explore use of assistive device such as communication board, letterboard, and memory…

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 needed care and services for two of 19 sampled Resident (Residents 27 and 340). * Resident 340 had developed multiple skin discolorations; however, the direct care staff failed to report these skin discolorations to the licensed nurses to conduct a thorough assessments and obtain orders for appropriate treatment. Failure to report and assess areas of skin discoloration in a timely manner placed this resident at increased risk for further injury to their skin. * Resident 27 had reported to the licensed nurse about lower eyelids' discomfort and redness, but the license nurse did not communicate in timely manner with the hospice staff and other staff to address the issue. Failure to report the discomfort of the eyes in a timely manner placed this resident at risk for delay in the treatment. Findings: 1. Medical record review for Resident 340 was initiated on 4/5/23. Resident 340 was admitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the wound care in a manner to prevent infection of wound for one of 19 final sampled residents (Resident 17). LVN 7 failed to maintain a clean field during the preparation of Resident 17's wound care supplies and treatment. This posed the risk of cross contamination and the potential for wound infection. Findings: Review of the facility's P&P titled Dressings, Dry/Clean revised 9/2013 showed under the procedure section, to open the dry, clean dressings by pulling corners of the exterior wrapping outward, and touching only the exterior surface. Medical record review for Resident 17 was initiated on 4/5/23. Resident 17 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 17's H&P examination dated 12/30/22, showed Resident 17 did not have the capacity to understand and make decisions. Review of Resident 17's Physician Orders List dated 4/5/23, showed a wound care order for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to ensure one of 19 final sampled residents (Resident 62) remained free from accident hazards. * The wall located adjacent to the head of Resident 62's bed was observed in disrepair with exposed sharp edges. This failure had the potential to place the resident at risk for serious injury. Findings: Medical record review for Resident 62 was initiated on 4/3/23. Resident 62 was admitted to the facility on [DATE]. Review of Resident 62's care plan titled At Risk for Falls/Injury revised 3/23, showed Resident 62 had a history of falls, balance problems, and memory problems. The nursing interventions to address Resident 62's risk for falls and injury included maintenance of a safe environment. On 4/3/23 at 0902 hours, an observation and concurrent interview was conducted with Resident 62. Resident 62 was observed in his room (Room A). The wall adjacent to the head of Resident 62's bed was observed in disrepair with exposed sharp edges.…

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 maintain the highest practicable physical, mental, and psychosocial well-being for one of 19 sampled residents (Resident 43). * The facility failed to completely assess Resident 43 for pain prior to administering morphine (an opioid pain medication), creating the risk for the resident's pain not being properly managed. Findings: Review of the facility's P&P titled Pain assessment and Management dated 3/2020 showed to assess pain for location of pain, intensity of pain, characteristics of pain (aching, burning, crushing, numbness, burning, etc), pattern of pain and frequency, timing, and duration of pain. Medical record review of Resident 43 was initiated on 4/3/23. Resident 43 was admitted to the facility on [DATE]. Review of the care plan problem addressing the resident's alteration in comfort potential for pain diagnosis Chronic Obstuctive Pulmonary Disease,…

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 19 final sampled residents (Resident 26) remained free from accident hazards due to the use of elevated side rails. * The facility failed to attempt alternatives prior to the use of elevated side rails for Resident 26. This had the potential to place the resident at risk for entrapment and serious injury. 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 bed or try to exit from the bed. Entrapment may occur when a resident is caught between the mattress and bed rail or in the bed rail itself. Inappropriate positioning or other care related activities could contribute to the risk of entrapment. Medical…

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 individualized behavioral health care needs and services for one of 19 final sampled residents (Resident 58) were met. * Resident 58 was diagnosed with schizophrenia (a severe brain disorder in which people interpret reality abnormally) without a thorough clinical assessment and was prescribed a Seroquel (antipsychotic medication). The pharmacological interventions was used when the clinical psychological assessment was not thoroughly done. This failure had the potential for the resident not able to attain her highest practicable well being. Findings: Medical record review for Resident 58 was initiated on 4/4/23. Resident 58 was admitted to the facility on [DATE]. On 4/3/23 at 1009, 1242, and 1444 hours, Resident 58 was observed with hand mitten on the left hand and was able to moved her hands touching her face and body. Review of the MDS dated [DATE], showed Resident 58 had severe cognitive impairment. Review of 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 one of 19 final sampled residents (Resident 58) was free from unnecessary psychotropic medications. This failure had the potential for the resident to experience adverse consequences from the psychotropic medications. Findings: On 4/3/23 at 1009, 1242, and 1444 hours, Resident 58 was observed had hand mitten on the left hand and was able to moved her hands touching her face and body. Medical record review for Resident 58 was initiated on 4/4/23. Resident 58 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], showed Resident 58 had severe cognitive impairment. Review of the Physician Orders for April 2023 showed an order dated 10/22/22, to administer Seroquel 12.5 mg via GT at bedtime for Schizoaffective disorder manifested by pulling out medical devices. Review of the Psychiatric follow Up Note dated 2/17/23, showed the examination and assessment of the NP for Resident 58. The examination and assessment…

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

Based on observation and interview, the facility failed to ensure garbage was properly stored in three of three garbage dumpsters. The failure of the facility to ensure the garbage was contained and covered had the potential to attract pest/rodents that carried disease. Findings: According to the 2022 FDA (Food and Drug Administration) Food Code, outside garbage receptacles must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents. On 4/3/23 at 0820 hours, an observation of the facility's outside garbage dumpsters was conducted. Three of three garbage dumpsters were observed to have the lids propped open by garbage, preventing the lids from fully closing. The Maintenance Director verified the findings. On 4/4/23 at 1349 hours, an observation of the facility's outside garbage dumpsters was conducted. Three of three garbage dumpsters were observed with the lids propped open by garbage, preventing the lids from fully closing. The Maintenance Director verified the findings. The…

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

Based on interview and facility record review, the facility failed to comply with the State regulation for not submitting a written notice timely to the Stage Agency responsible for licensing the facility when the facility had a changes of the facility's Administrator. * The facility's new Administrator began employment at the facility on 3/1/23; however, the facility had yet to notify the State Agency. This failure had the potential to cause confusion specific to communication between the State Agency and facility's administrative staff. Findings: Review of Title 22 Chapter 3 (Skilled Nursing Facilities) Subsection 72211(b), showed when a change of Administrator occurs, the Department shall be notified within 10 days in writing by the licensee. Such writing shall include the name and license number of the new Administrator. On 4/3/23 at 0825 hours, an observation was made of the information posted at the facility's entrance. The facility posted a copy of the Administrator's license adjacent to the entrance to the facility; however, the Administrator was not present in the 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 and medical record review, the facility failed to ensure the medical records for two of 19 final sampled residents (Residents 19 and 70) were accurate and complete. This failure had the potential for the residents' care needs not being met as their medical information was incomplete. Findings: 1. Medical record review for Resident 70 was initiated on 4/3/23. Resident 70 was readmitted to the facility on [DATE]. Review of Resident 70's POLST dated 4/26/21, showed the sections for the physician's signature and license number were left blank and undated. The section for the patient's signature was left undated. On 4/10/23 at 1413 hours, an interview and concurrent medical record review was conducted with the SSD. The SSD verified the findings. On 4/10/23 at 1501 hours, an interview and concurrent medical record review was conducted with RN 2. RN 2 verified the findings and stated the incomplete POLST would cause confusion during transfer to the hospital. 2. Medical record review for Resident 19…

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 call light for Resident 43 was operable. This posed the risk for staff not knowing and answering the calls for the residents needed assistance in the room. Findings: Medical record review of Resident 43 was initiated on 4/3/23. Resident 43 was admitted to the facility on [DATE]. On 4/3/23 at 0930 hours, Resident 43's call light was observed not working when the resident pressed the call light. Resident 43 stated the call light was not working since four days ago, and she had been telling the staff about it. Resident 43 needed assistance from the staff to get water for her. Resident 43 was feeling upset and sometimes had to yell at staff when the call light did not work. On 4/3/23 at 0935 hours, the Central supply staff was summoned to the resident's room and Resident 43 pressed call light but the call light was functioned. The Central supply staff verified the finding. On 4/3/23 at 1000 hours, an interview was conducted with the Director of…

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