Peninsula Post-Acute

Based on observation, interview, and record review, the facility failed to ensure medications and biologicals were labeled and stored according to manufacturer's instruction and facility policy and procedure; expired biologicals were removed from the active storage area; and medication cart was locked when left unattended. These deficient practices had the potential to compromise the integrity and effectiveness of the drugs and biologicals; and may jeopardize the health and safety of residents. Findings: 1A. During an observation on 10/14/24 at 10:25 AM, in resident's room, a medicine bottle was observed in plain sight in Resident 52's bedside drawer. The medication bottle indicated, FETILIDE 500 MCG (Generic for Dofetilide) ., a medication used to treat an irregular heartbeat (arrhythmia). During concurrent interview, Resident 52 stated she had asked the doctor to have her keep this medication at the bedside so she can take it on time to prevent her heart rate to increase. During concurrent interview and record review on 10/16/24 at 3:31 PM, Licensed Vocational Nurse (LVN) 3…

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

Based on observation, interview, and record review, the facility failed to ensure meals were plated in accordance with the approved menu when the incorrect scoop size was used for serving green beans to residents for a lunch meal. This failure to follow the planned menu had the potential to result in residents' diets not being given in accordance with the prescriber's order and diet specifications, resulting in residents not receiving the amount of nutrients to meet their nutritional needs to 49 residents who received regular textured green beans according to the menu and the lunch tray tickets. Findings: Review of the facility provided document titled Fall Menus spreadsheet dated 10/14/24, showed the serving size for regular textured Southern [NAME] beans was ½ cup. According to the facility's lunch tray tickets dated 10/14/24, showed 49 residents had a diet allowing regular textured green beans and did not have a dislike for beans/green beans. Review of the undated facility document titled Scoop Measurements, showed the gray color scoop (number 8) measures ½ cup, and the green…

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 provide palatable food for a lunch meal including: 1. Meatballs; and 2. Pureed green beans. The failure to provide palatable food had the potential to reduce residents' food and nutrient intake leading to weight loss and/or nutritional medical complications for 34 residents who received meatballs or pureed green beans according to diet orders on the lunch meal tickets out of 56 residents who received food from the kitchen. Findings: 1. Review of the facility policy and procedure (P&P) titled Meal Service dated 2023, showed the Food and Nutrition Services staff member will take the food temperature prior to service of the meal with a thermometer. It may be necessary to take the temperature in more than one location on the food item to confirm the proper temperature has been reached. The food temperatures will be recorded. The minimum hot holding temperature on steam table is 140 degrees F. Temperatures of the food when the resident receives it is based on palatability. The goal is to serve hot food…

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

Based on interview and record review, the facility failed to furnish a completed written agreement for dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) services or transportation to dialysis that was being provided by an agency outside the facility. This failure has the potential for residents that require dialysis to not have services held to a standard agreed upon by the facility. Findings: During a concurrent interview and record review on 10/15/24 at 9:50 AM with the Administrator, a document titled INTERNAL AGREEMENT REQUEST PREP FORM NURSING HOME DIALYSIS TRANSFER AGREEMENT, dated 05/18/21. The documented indicated that This Agreement type is for nursing home residents who are transferred from a nursing home to a chronic dialysis facility for treatment .Once approved, agreement sent for signatures; you will receive a copy once all parties sign. The Administrator stated this is a request for an agreement but not an actual contract. During a concurrent interview and record review on 10/15/24 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a Physician Orders for Life-Sustaining Treatment (POLST, a written medical order that specifies the types of medical treatment a patient wants to receive in the event of a serious illness) was obtained on admission for one of 18 sampled residents (Resident 219). This failure had the potential to result in resident's wishes in an emergency situation and end-of-life choices not being honored. Findings: Review of Resident 219's admission record indicated, was admitted to the facility on [DATE] with diagnoses including fracture of head and neck of left femur (a break in the bone that connects the femoral head to the femoral shaft in the hip), abnormalities of gait and mobility (changes to a person's normal walking pattern), type 2 diabetes mellitus (high blood sugar), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and hypertension (high…

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

Based on interview and record review, the facility failed to accurately encode one of 18 sampled residents' (Resident 20) Minimum Data Set (MDS - a federally mandated resident assessment tool) when Resident 20 was encoded has being diagnosed with Depression, but the Resident had no current or past medical history of that diagnosis. This failure has the potential to result in MDS assessments that inaccurately captures quality metrics and a resident's condition over time. Findings: A review of Resident 20's face sheet (front page of the chart that contains a summary of basic information about the resident), dated 10/18/24, indicated that Resident 20 was admitted 2024 with multiple diagnoses including SPINAL STENOSIS (when the space inside the backbone is too small causing pressure and pain) and LOW BACK PAIN. During a concurrent interview and record review on 10/17/24 at 2:31 PM with the MDS Director (MDSD), Resident 20's list of active diagnoses, dated 10/17/24, was reviewed. The list of active diagnoses indicated all the conditions that Resident 20 was being treated or cared for.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop an accurate comprehensive care for two of 18 sampled residents (Resident 20 and Resident 31) when: 1. Resident 20's care plan for Duloxetine (an anti-depressant medication that can also be used to treat nerve pain) had the incorrect indication (reason to give a medication) 2. Resident 31's care plan for indefinite use of Cephalexin (an antibiotic) was not developed. These failures have the potential for residents' care plans to not be person-centered and specific enough for residents to meet their medical and physical needs. Findings: 2. A review of Resident 20's face sheet (front page of the chart that contains a summary of basic information about the resident), dated 10/18/24, indicated that Resident 20 was admitted 2024 with multiple diagnoses including SPINAL STENOSIS (when the space inside the backbone is too small causing pressure and pain) and LOW BACK PAIN. A review of Resident 20's Order Summary Report (a list of a medical provider's…

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

Based on observation, interview, and record review, the facility failed to provide care and treatment according to facility policies and procedures and professional standards of practice for two of 18 sampled residents (Resident 291 and Resident 24) when: 1. Insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) injection was not prepared and administered according to current professional standard of practice and facility's insulin administration policy and procedure for Resident 219 and Resident 24. 2. Glucose (blood sugar) reading for Resident 24 was obtained during meals. Additionally, insulin was administered without a prescribed glucose check for Resident 24. These failures resulted in a medication error and had the potential to affect the absorption rate and efficacy of the insulin which could result in serious complications for Resident 219 and Resident 24. Findings: During medication pass observation on 10/15/24 at 12:13 PM, Licensed Vocational Nurse (LVN) 3 prepared to administer 4 units of Humulin R…

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

Based on interview and record review, the facility failed to ensure that one of 18 sampled residents (Resident 26) had the necessary language systems for translation accessible when Resident 26 requested a translator but multiple staff were not aware of resources except for family or the use of a communication board (a tool that helps people with limited language skills express themselves by pointing to images or symbols). This failure has the potential for staff to not properly assess residents who speak a different language or make it difficult for a resident to make their unique needs known. Findings: A review of Resident 26's face sheet (front page of the chart that contains a summary of basic information about the resident), dated 10/18/24, indicated that Resident 26 was admitted in 2024 with a primary language of Japanese. During an interview on 10/15/24 at 12:10 PM with Resident 26, Resident 26 stated that their English was not good, and they requested an translator to continue the interview. A review of Resident 26's Medical Practitioner Narrative Note titled, PHYSICAL…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to monitor for behavioral symptoms, side effects and/or adverse consequences for one of 3 sampled residents (Resident 220) on psychotropic (drugs that affects brain activities associated with mental processes and behavior) medications. Additionally, the informed consent for the use of psychotropic medication was signed seven days after Resident was admitted to the facility. This failure had the potential to place residents on psychotropic medications at risk for adverse health consequences which could negatively impact the resident's mental, physical, and psychosocial well-being. Findings: Review of Resident 220's admission record indicated, was admitted to facility on 10/10/24 with diagnoses including osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) of right ankle and foot, schizophrenia, (a mental illness that is characterized by disturbances in thought), and type 2 diabetes mellitus (DM - high blood sugar).…

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

Based on observation, interview, and record review the facility failed to ensure that one of 18 sampled Residents (Resident 269) was free of significant medication errors when Resident 269 was given Acetaminophen (a pain medication) beyond the parameters ordered by the medical provider. This failure has the potential to lead to Acetaminophen adverse effects (undesired effect of a drug) including abdominal pain, nausea/vomiting, or liver damage. Findings: A review of Resident 269's face sheet (front page of the chart that contains a summary of basic information about the resident), dated 10/18/24, indicated that Resident 269 was admitted in 2024 for multiple diagnosis including Fracture, Left femur (break in the upper leg bone) and Fracture .of left humerus (break in the left upper arm bone). A review of Resident 269's medication administration record (MAR, a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 10/17/24, indicated that Resident 269 had two orders for Acetaminophen. The first order 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.

Based on observation, interview, and facility document review, the facility failed to ensure one kitchen staff competency for manual warewashing (warewashing: cleaning and sanitizing of utensils and food-contact surfaces of equipment) using the three-compartment sink. The failure to ensure staff competency for 1 of 8 kitchen staff regarding manual warewashing had the potential to result in contamination of food and/or utensils and equipment leading to illness caused by pathogens (harmful organisms). Findings: Review of the policy and procedure titled 3-Compartment Procedure for Manual Dishwashing, dated 2023, showed if the dish machine is not working properly manual dishwashing will be initiated. All items should be rinsed, scraped, or soaked before washing. The first compartment is used for washing. Fill the first compartment with detergent and hot water. The second compartment is used for rinsing. Fill the sink with clean, clear hot water, 110 -120 degrees Fahrenheit (F, temperature scale) and the temperature should be recorded. Items should be thoroughly rinsed to remove…

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

Based on observation, interview and record review, the facility failed to ensure the facility's electronic medical record was designed to provide physicians with diet order selections, for residents with renal (kidney) insufficiency/failure, that was consistent with current standards of practice and terminology used by the approved diet manual of the Food and Nutrition Services Department. This failure had the potential for 3 residents (Resident 34, 43, and 54), out of a facility census of 56, who were prescribed a Renal diet (a diet aimed at keeping levels of fluids, electrolytes, and mineral balanced in the body in individuals with chronic kidney disease or who are on dialysis) to receive inappropriate nutrient levels for their individual medical status. Findings: Review of the facility Policy and Procedure (P&P) titled Therapeutic Diets revised 2017, showed the terminology of physician ordered diets should match the terminology used by the Food and Nutrition Services department. Review of the facility's 2023 Diet Manual for Long Term Care Facilities showed it was approved by the…

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

Based on interview and record review, the facility failed to operate and provide services to residents of 62 beds when the facility exceeded that capacity and reached 63-64 beds for 13 days in September, 2024. The facility failed to provide services to 62 residents when they admitted 63-64 residents. Findings: Review of a Detailed Census Report for September, 2024 showed 63 residents were admitted on Sept. 1, and 2nd. 64 residents were admitted on Sept. 4, and 9th. 63 residents were admitted on Sept. 15, and 16th. 64 residents were admitted on Sept. 19, and 23rd. 63 residents were admitted on Sept. 24, and 25th. 64 residents were admitted on Sept. 26th. 63 residents were admitted on Sept. 27, and 29th. The facility had admitted 63-64 residents for 13 days in a facility licensed for 62 beds. Review of facility license titled, State of California, Department of Public Health in accordance with applicable provisions of the Health and Safety Code of California and its rules and regulations, the Department of Public Health hereby issues this License to facility, to operate and maintain…

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

Based on observation, interview, and record review the facility failed to follow infection control standards for one of 18 sampled residents (Resident 19) when Physical Therapist (PT) 1 and Occupational Therapist (OT) 1 were observed providing care without the necessary personal protective equipment (PPE, clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) used for a resident on enhanced barrier precaution (EBP, an approach where PPE is used during high contact resident care activities to reduce spread of drug-resistant organisms). This failure has the potential to spread infection in the facility or cause infection to a resident that is at higher risk for acquiring an infection. Findings: A review of Resident 19's face sheet (front page of the chart that contains a summary of basic information about the resident), dated 10/18/24, indicated that Resident 19 was admitted in 2024 with multiple diagnoses including QUADRIPLEGIA (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury) and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to respond in a timely manner to a request for medical records for Resident 1, 1 of 1 sample resident. Failure to provide requested medical records in a timely manner violated Resident 1's right to access her medical records. Additionally, the facility's policy of subjecting residents to a wait of 30-60 days before providing a copy of their medical records does not meet the regulatory definition of timely provision of medical records upon request. Findings: During an interview on 04/25/2024 at 12:16 PM, the Complainant stated she faxed a medical record request to the facility on [DATE] and followed up with two voicemails on 04/05/2024 and 04/08/2024 asking about the requested medical records. The Complainant stated as of today (36 days later), she still has not received the requested medical records for Resident 1. Nor has the facility contacted her regarding her request. The Complainant then provided this Department with a copy of a medical record…

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

Based on observation, interview and record review, the facility failed to ensure that a Registered Nurse (RN) completed an assessment to 4 of 4 sampled residents (Resident 1, 2, 3, and 4) when the residents had a change in condition. The deficient practice had the potential for harm on the resident's safety and well-being. Findings: A review of the face sheet indicated Resident 1 was admitted with diagnoses including left ankle wound, congestive heart failure (when the heart does not pump as strong as it should) and osteopenia (weakened bones). During an interview on 2/27/24, at 3:02 PM, Occupational Therapist (OT, help people recover from injuries to regain abilities to perform daily activities) she responded after hearing a scream and saw Resident 1 upside down, hanging from the hoyer lift. During an interview on 2/27/24, at 3:06 Vocational Nurse (LVN) 1 stated, I was called to the resident's room. The OT was already there, and the resident was already lowered on the floor. LVN further stated that after completing assessment to Resident 1, he decided that Resident 1 can be…

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

Based on observation, interview and record review, the facility failed to prevent an injury to one of one sampled resident (Resident 1) when Resident 1 hit her head during the transfer from the wheelchair to the bed. The facility failure resulted to resident to experience severe pain and sustain a bump on the back of her head. Findings: A review of the face sheet indicated Resident 1 was admitted with diagnoses including left ankle wound, congestive heart failure (when the heart does not pump as strong as it should) and osteopenia (weakened bones). A review of the Minimum Data Set (MDS, a standard assessment tool) dated 3/30/23, Brief interview of mental status (BIMS, a brief memory test to help determine cognitive functioning [thinking, learning, and decision- making abilities]) score of 5 indicated severe cognitive impairment (rarely/never make decisions). Resident 1 required extensive assistance with one-person physical assist to perform activities of daily living including bed mobility, transfer, personal hygiene, and toilet use. Resident 1 was non ambulatory (unable to walk).…

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

Based on observation, interview and record review the facility failed to ensure the hospital menu met the nutritional needs in accordance with the Medical Director (MD) approved diet manual, physician ordered diets and current standards of practice. This failure resulted in diets not given in accordance with the prescriber's order and diet specification which may result in resident's not receiving food to meet their nutritional needs and/or receiving food that may worsen their clinical conditions. The lack of comprehensive nutritional analysis, in general, affected 47 residents who were receiving meals from the kitchen. Additionally, of the 47 Residents receiving meals there were 19 Residents with physician ordered carbohydrate consistent diets and eight Residents with chopped diets who did not receive meals in accordance with standards of practice. There were also 14 Residents with physician ordered cardiac diets, however the cardiac diet was not part of the facility's Medical Director approved diet manual. Findings: Diet manuals establish a common language and practice 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 food production observations, dietary staff interview and dietary document review the facility failed to ensure food was stored and/or prepared in a sanitary manner when there were 1) lapses in infection control, 2) lack of comprehensive cooldown monitoring of potentially hazardous foods prepared from ingredients at room temperature; 3) improper washing/sanitation of food service equipment; 4) ineffective sanitizer strength; and 5) storage of unlabeled and/or undated items. This failure had the potential to put residents at risk for foodborne illnesses (any illness resulting from the consumption of foods contaminated by bacteria, viruses, or parasites). Findings: 1. During a tray line observation, on 2/14/22, at 12:15 PM, in the kitchen, [NAME] 1 (C1) was observed preparing meal trays. C1 was wearing a black smock (a loose garment worn over street clothing) unbuttoned in the front. Parts of C1's smock was observed touching the plated food when C1 was plating the food to the meal trays. During an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure staff upheld a resident's right to be treated with dignity for three of 13 sampled residents (Residents 53, 168, and 24) when: 1. Staff did not answer Resident 53's request for assistance in a timely manner and when staff did not assist Resident 53 with incontinence care. (Refer to F600) 2. Staff did not provide pain management intervention(s) to Resident 168 in a timely manner when requested by a family member and staff did not provide incontinence care in a timely manner. (refer to F600) 3. Staff did not to assist Resident 24 with incontinent care in a timely manner. Failing to treat each residents with dignity had the potential to make them feel unwanted, depressed, and not respected. Findings: A thorough review of staff response to request for assistance was initiated during this survey due to two factors: i. There were three prior complaints alleging delay in staff response and/or substandard response to requests for assistance. ii.…

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

Based on observation, interview, and record review, the facility failed to maintain a safe and homelike environment when the Communal Shower Room (CSR) 2 had peeled and torn non-skid strips. This failure posed a safety risk that may result in injuries to the residents and staff. Findings: During a concurrent observation and interview, with the Environmental Services Director (ESD) on 2/16/22 at 11:46 AM, there were dark-colored strips installed at the entrance, in front of the toilet bowl, and beside the bathtub in the CSR 2. The strips had areas that were torn and peeled off. The ESD stated, I want that removed (damaged strips) because it's hard to clean across the lifted areas. I feel like patients could trip if they come in with walker. The ESD also stated that the CSR 2 is used by the residents. During an interview, on 2/17/22 at 12:23 PM, the Maintenance Director (MD) stated that the dark-colored strips on the CSR 2 floor were non-skid strips. The MD stated he was aware of the torn and peeled non-skid strips. The MD also stated that if the non-skid strips were not fixed, It 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.

Based on observations, interview and record review the facility failed to ensure effective Registered Dietitian (RD) oversight of food services when there were lapses in safe food handling standards of practice, and independent evaluation of food service operations. Lack of a Registered Dietitian's oversight may result in 1. consumption of contaminated food, 2. provision of inadequate nutrition to residents, 3. Provision of incorrect food texture or 4. an increase in food related illnesses (Cross Reference F800, F812 and F880). Findings: 1. During observations, on 2/14/22, at 11:55 AM, C1 was seen using her right hand to open the door to the back of the kitchen. C1 then took off the glove on her right hand. C1 did not wash her hands and proceeded to put another glove on her right hand. During an observation, on 2/15/22, at 10:28 AM, in the kitchen, C1 was observed placing cucumber peels in the garbage can. After dumping the peels, C1 removed both her gloves. C1 did not wash her hands and proceeded to fold white towels. During an observation, on 2/15/22, at 10:40 AM, in the kitchen,…

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

Based on observations, interview and record review the facility failed to ensure meals were plated in accordance with the approved menu. This failure can result in diet not given in accordance with the prescriber's order and diet specification which may result in resident not receiving the full therapeutic effect of the resident nutritional need and/ or provision of inadequate nutrition to residents. Findings: During a tray line observation, on 2/14/22, at 12:15 PM, in the kitchen, Cook1 (C1) was observed plating resident lunch trays. The following was noted: a. Resident 61 with a physician ordered pureed liberal renal diet received mashed potatoes. Concurrent review of the therapeutic spreadsheet (a document used by kitchen staff to determine types and quantities of food to be plated for each diet) approved by the Registered Dietitian on 10/10/21 indicated renal diets should have received parslied noodles in place of potato. b. Resident 71 had a physician ordered carbohydrate consistent diet with twice the amount of protein at the noon meal. Resident 71's meal was plated as a diet…

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

Based on meal plating observations, speech therapy interview and departmental document review the facility failed to ensure meal production was consistent with standards of practice when residents with orders for a chopped diet were served a regular hamburger that was cut in half. Additionally, the facility lacked specific diet manual guidance on what constitutes a chopped diet. This deficient practice had the potential to negatively impact nutritional intake for residents with limited range of motion of their hands/arms, and residents with chewing and swallowing deficits. Findings: During a tray line observation, on 2/14/22, at 12:15 PM, in the kitchen, [NAME] 1 (C1) was observed preparing a meal tray for Resident 38. The tray had a meal ticket for a regular chopped diet. C1 was observed cutting the hamburger patty in a bun in half. During an interview, with the Registered Dietician (RD) and the Dietary Manager (DM) on 2/15/22, at 1:37 PM, the RD stated, regular chopped diet is for residents who cannot cut regular meat on their own, with fracture or surgery on the arm. RD and DM…

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

Based on observation, interview, and record review, the facility failed to implement infection control practices when: 1. Certified Nursing Assistant (CNA) 2 did not perform hand hygiene before putting on and after removing gloves during resident care activities, and did not remove his gown before leaving Resident 28's room, who was under observation for COVID-19 infection; 2. CNA 3 did not perform hand hygiene before putting on and after removal of gloves; and 3. Two kitchen staff did not perform hand hygiene before putting on and after removing gloves. These deficient practices had the potential to spread infection to the residents, staff, and visitors. Findings: 1. During an observation on 2/14/22 at 12:44 PM, Certified Nursing Assistant (CNA) 2 was inside Resident 28's room, assisting the resident in using the commode (a portable toilet). CNA 2 was wearing protective personal equipment (PPE - equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) that include gloves and a gown. During further observation, CNA 2 picked up the basin…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain patient care equipment in safe operating condition when: 1. Two drawers of infection control cabinet lack wheels and were resting on the floor, and one drawer had a cracked plastic top, which had the potential to contaminate the PPE (personal protective equipment) stored within the drawers and prevents staff from effectively sanitizing the outside of the drawers. 2. The water pressure gauge of the facility dishwashing machine did not exceed 12 PSI that was not within the manufacturer's recommended Pounds per Square Inch (PSI) of 15-25 PSI. This failure may decrease the dishwasher's effectiveness in cleaning dishes, utensils and other kitchen items. Findings: 1. During initial observation on 2/14/22 at 11:40 AM, an infection control plastic container/drawer was found without wheels on the floor outside room [ROOM NUMBER]. Another infection container was found without wheels on the floor outside room [ROOM NUMBER] on 2/14/22 at 2:52…

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

Based on interview and record review, the facility failed to ensure allegations of neglect for three of 13 sampled residents (Residents 53, 168 , and 24) were reported within the prescribed timeframes, when the alleged incidents on 2/16/22 was reported on 2/18/22 to the required authorities. This failure had put residents at risk for safety. Findings: During an interview on 2/16/22 at 3:13 PM, the Administrator and Director of Nursing (DON) were made aware of allegations of neglect regarding Residents 53, 168 and 24. The facility staff was made aware of the alleged residents' neglect on 2/16/22, and the facility reported the incident on 2/18/22 to the required authorities. Review of Resident 53's Progress Notes, dated 2/16/22 at 4:00 PM and 2/17/22 at 8:37 AM, indicated the facility was aware of allegations of neglect regarding call light response. During interview on 2/18/22 at 12:34 PM, the Administrator and Director of Nursing were asked to provide documented evidence these allegations of neglect were reported to the required authorities. The facility was unable to provide…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement policies and procedures for accurate provision of pharmaceutical services when: 1.Licensed staff failed to accurately reconcile metoprolol (a medication to treat blood pressure) for Resident 368, 2.Tramadol (a medication for pain that is regulated) 50mg (milligram) for Resident 60 was not accurately reconciled on control drug count sheet and medication administration record (MAR). These failures had a potential for Resident 368 to experience adverse effects, Resident 60 having unmedicated pain, and controlled substance discrepancy leading to diversion (stealing of medications). Findings: 1.During record review on 2/15/22, the MAR from Hospital 1 showed Resident 368 received metoprolol 25mg half a tablet by mouth two times a day or 12.5mg by mouth two times a day. A review of the Facility's MAR indicated Resident 368 had a physician order for metoprolol 25mg (milligram - a unit of measure) by mouth two times a day and had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and document review, the facility failed to ensure one of 13 sample residents (Resident 74) was free from unnecessary psychotropic (drugs that affects brain activities associated with mental processes and behavior) medications when: 1. Abilify (antipsychotic medication to treat mental health issues) was administered without a specific condition that was diagnosed and documented in the clinical record and without documented behavioral interventions (individualized non - pharmacological approaches). 2. Celexa (a medication used to treat depression, a persistent feeling of sadness and loss of interest) and Abilify were administered as duplicate therapy (multiple medications for same diagnosis) for depression. These failures had the potential for the resident to receive unnecessary medication which increased the risk of preventable side effects and death. Findings: 1.Review of Resident 74's clinical record indicated that she was [AGE] years old and admitted to the facility on [DATE]. Record…

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

Based on observation, interview and record review, the facility failed to label and store drugs in accordance with current professional standards for four of 13 sampled residents (70, 76, 81, and 82) when: 1.Ensure potentially expired medications were not available for use, 2.Properly label resident medications available for use with expiration date when applicable and in accordance with facility policy and procedures (P & P). These failures placed residents 70, 76, 81, and 82 at risk for receiving ineffective or expired medications and had the potential of exposing residents to infections due to cross contamination. Findings: 1.During a concurrent observation and interview on 2//14/22 at 12:11 PM of medication cart 3 at Station 3 with Registered Nurse (RN) 1, one opened vial of Lantus (medication for treating high blood sugar levels) 100 units/1ml (milliliter - a unit of measurement for liquid) 10 ml vial for Resident 76 was observed. The vial did not have a label attached that contained the date opened or an expiration date. RN 1 acknowledged the opened and undated vial and stated…

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

Based on observations, interview and record review the facility failed to ensure meals were palatable (refers to the taste and/or flavor of the food, acceptable to the taste) when the pureed entrée for the noon meal lacked flavor and was not like the regular entrée. This deficient practice had the potential to affect resident's appetite which may result in poor dietary intake that could potentially compromise their health and nutritional status. Findings: During general dining observation, on 2/14/21 at 12:56 PM, It was noted Resident 4's tray consisted of a plain hamburger; stir fried vegetables consisting of grilled peppers and onions; watermelon and grape juice. Resident 4 refused the grilled vegetables stating they were Not tasty, cold, don't want to eat it. They were tasteless (referring to the vegetables). During a concurrent observation and interview, on 2/16/22, at 1:15 PM, with Registered Dietician (RD), a test tray was conducted in the hallway by the activity room area. The pureed beef stew did not taste like the regular beef stew. The RD tasted the pureed beef stew 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.