East Bay Post-Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, facility failed to maintain accurate and complete medical records for four (Residents 6, 7, 75, and 76) out of twenty sampled residents. This deficient practice had the potential to cause inaccurate assessments of nutritional status, inappropriate care planning and unnecessary dietary restrictions, which could place residents at risk for unmet needs or avoidable decline. During a review of facility's document titled, admission Record, dated 9/12/25 for Resident 6, the admission Record indicated Resident 6 is a [AGE] year old woman initially admitted to the facility on [DATE] with multiple diagnoses, including unspecified protein-calorie malnutrition (a condition that occurs when an individual does not consume enough protein and calories to meet their nutritional needs), hypertension (high blood pressure), multiple sclerosis (a chronic disease of the brain and spinal cord characterized by changes in sensation, visual problems, weakness, depression, difficulties 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, and record review, the facility failed to ensure that one of two sampled residents ( Resident 35) was provided reading glasses as prescribed by the doctor. This failure resulted in Resident 35 to be unable to see things clearly, participate in activities fully and feeling frustrated. During a review of Resident 35's admission Record printed on 09/10/25, the record indicated Resident 35 was admitted to the facility on [DATE]. During a review of Resident 35's Minimum Data Set (MDS, an assessment used to guide care) assessment dated [DATE], the assessment indicated Resident 35 did not wear glasses at the time of assessment. The assessment indicated the Resident 35 was able to understand others and make her self understood. During a review of Resident 35's care plan for vision dated 6/20/25, indicated Resident 35 had altered visual ability related to visual loss, and may impact ability to participate in ADL (activities of daily living). The care plan indicated to perform eye exam as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that residents maintained adequate nutrition status in accordance with professional standards of practice and resident preferences for 2 out of 20 sampled residents (Resident 75 and 6).This deficient practice had the potential to result in unrecognized weight loss, inaccurate assessment of nutritional status, and failure to meet resident's dietary needs and preferences, placing residents at risk for avoidable weight loss and decline.During a review of facility's document titled, admission Record, dated 9/11/25 for Resident 75, the admission Record indicated Resident 75 is a [AGE] year old woman initially admitted to the facility on [DATE] with multiple diagnoses including acute respiratory failure (when lungs cannot provide enough oxygen to the blood), unspecified protein calorie malnutrition, and muscle weakness. During a review of Resident 75's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 7/12/25,…

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, and record review, the facility failed to ensure least restrictive alternatives were attempted for a reasonable amount of time, prior to installing bedrails (adjustable metal or rigid plastic bars attached to the bed) for one of one samples residents (Resident 70) upon admission to the facility. This failure placed the Resident 70 at risk for injury, entrapment, psychosocial harm, up to and including death.During a review of Resident 70's admission Record printed on 9/10/25, the record indicated Resident 70 was admitted to the facility on [DATE]. During a review of Resident 70's Minimum Data Set (MDS, an assessment used to plan care) assessment dated [DATE], the assessment indicated Resident 70's Brief Interview for Mental Status (BIMS) score was six out of 15, indicating severe cognitive impairment. The assessment indicated Resident 70 had impairment in range of motion on both sides of her extremities and was dependent upon staff for activities of daily living, indicating…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 procedures to ensure accurate accountability and replacement of drugs in the emergency intravenous (IV) kit for 1 of 1 kits reviewed. This deficient practice resulted in the lack of documentation, missing medications, and failure to follow required procedures for notifying the pharmacy, which placed residents at risk of not having necessary emergency medications available when needed.During an observation on 09/08/2025 at 11:15 AM of the emergency IV kit, it was noted that the kit was missing normal saline. When asked when the kit was last opened, LVN 4 stated that typically a form is left inside the kit and faxed to the pharmacy; however, no such documentation was present. LVN 4 stated she could not determine when the kit had last been opened. During an interview 09/08/2025 at 12:00 PM Minimum Data Set Coordinator stated that she found the Emergency Drug Kit usage slip. She acknowledged that the policy was to change the kits within 72 hours once they are opened. A review of the Emergency Drug Kit…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medications were administered in accordance with manufacturer instructions and accepted standards of clinical practice observed during medication pass. These failures included the administration of an expired inhaler and improper inhaler technique and potentially contaminating a syringe of Lispro prior to administration. As a result, 2 medication errors were identified out of 25 opportunities, resulting in a medication error rate of 8%. This placed residents at risk of reduced potency, diminished therapeutic benefit, and compromised clinical outcomes.1. During an observation on 09/08/2025 at 10:07 AM of medication administration by LVN 4 to Resident 79, LVN 4 administered Breo Ellipta inhaler, but failed to instruct the resident to fully exhale prior to inhaling the dose. During an interview after the medication pass on 09/08/225 at 10:20 AM, LVN 4 acknowledged that she had not instructed the resident to exhale before using the inhaler. She further stated she was unaware that Breo Ellipta inhalers…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medications were labeled and stored in accordance with accepted professional principles and manufacturer instructions for 3 of 4 medication carts observed. This deficient practice resulted in the presence of unidentifiable medications, expired drugs, and opened medications without required dating, which placed residents at risk of receiving unsafe or ineffective therapy.During a medication storage observation on 09/08/2025 at 11:00 AM, cart number 4, was reviewed. Multiple unidentifiable loose pills were observed in the cart. When asked if she was aware of what these pills were, LVN 4 stated she did not know and confirmed they should not have been present in the cart. During an interview on 09/082025 at 11:00 AM LVN 4 stated that she did not know what the loose pills were and she acknowledged that they should be removed because they were unidentifiable. A review on 09/09/2025 of the facility's Medication Labeling and Storage Policy revision date 02/2023 requires that medications be stored in the…

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

Based on observation, interview, and record review, the facility failed to maintain infection prevention and control practices during a medication administration for 1 of 1 residents (Resident 93) when RN 2 prepared Lispro Subcutaneous injection and left it on an uncleaned overbed table. This failure had the potential to expose residents to contamination and increased risk of infection.During a medication pass observation on 09/09/25 at 8:15 AM, RN 2 was observed drawing up Lispro insulin into a syringe at the medication cart. Prior to administering the injection, RN 2 placed the uncapped insulin syringe directly onto Resident 93's overbed table. This surface was observed at other times during the survey to hold personal food items and beverages. The syringe remained in contact with the table for approximately 20 seconds before the nurse picked it up and administered the dose. When interviewed on 09/09/25 at 8:20 AM, RN 2 stated, Yes, I did leave the syringe on the table. I forgot, and I should not have left it there, even for a short period of time. She further acknowledged the…

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

Based on observation, interview and record review, the facility failed to follow physician ' s order of supervised feeding for one (Resident 1) of two residents. This failure resulted in Resident 1 potentially choking and aspirating (accidental inhalation of food or liquid into the lungs) when eating. Findings: During a record review of Resident 1 ' s face sheet, undated, Resident 1 was admitted in July 2023 with dysphagia (difficulty swallowing). During an observation on 9/6/24, at 8:32 a.m., Resident 1 had his breakfast tray in front of him. Resident 1 had breakfast on his own with no staff assisting him with feeding. Resident 1 was observed with food particles on his beard. During a record review of Order Summary Report, a physician order with a start date of 8/5/23 indicated, 1:1 feeding assist; aspiration precautions. LUA (left upper arm) flaccid (a type of paralysis in which muscle becomes soft) due to stroke, with meals. During a record review of Resident 1 ' s care plan (how facility will help manage care), the care plan for activities of daily living (ADL-skills required 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, and record review, the facility failed to ensure one of two sampled residents (Resident 1), received treatment and care for a non-pressure ulcer (open area that is not caused by shear or pressure but may be caused by poor circulation) when: 1. Resident 1 developed redness to abdominal folds which became worse. 2. Resident 1's Treatment Administration Record (TAR), had multiple dates without initials/documentation that showed assigned licensed nurses had performed the resident's ordered wound treatments. These failures resulted in Resident 1's avoidable abdominal wound dehiscence which reopened and led to infection. Findings: A review of Resident 1's admission Record, printed on 6/24/24, indicated resident was admitted to the facility on [DATE] with multiple diagnoses that included diabetes mellitus (high blood sugar), morbid obesity, and heart disease with heart failure (a condition in which heart does not pump blood as well as it should). A review of Resident 1's Minimum Data…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of two sampled residents (Resident 2) when: 1. Treatment Nurse 2 (TN 2) and Certified Nursing Assistant 1 (CNA 1) did not wear a disposable gown during Resident 2's wound dressing change. Failure to wear the necessary personal protective equipment (PPE such as gloves, gown, face shield, masks, etc.) had the potential to place residents, staff, and visitors at risk for infection. 2. TN 2 did not perform hand hygiene (handwash with soap and water or alcohol-based hand rub) in between glove change during the wound dressing change. This failure had the potential to result in infection and spread of infection. Findings: A review of Resident 2's admission Record, printed 8/28/24, indicated resident was readmitted to 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.

Based on observation, interview, and document review, the facility failed to ensure garbage was stored properly when outside trash bins were leaking, over-filled, and the lids were open, letting waste spill onto the ground. This failure had the potential to attract insects, rodents, and other pests to the facility. Findings: During an observation and concurrent interview on 5/16/24, at 10:04 a.m., with the housekeeping supervisor (HS), the facility's outside trash cans and dumpsters were inspected. There were four large green plastic bins designated for organic food waste in the rear facility entrance. Two of these bins were cracked and leaking dark brown liquid, and the lids were not closed. Waste was piled over the tops of the bins, with open and closed plastic bags with food waste spilling over the tops. There was food waste and trash on the ground surrounding the bins, and dark brown liquid was running down the driveway away from the area. The HS confirmed that the area was unclean, and could result in infection due to insects, vermin and pests. During and observation and…

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

Based on staff interviews and review of facility documents, the facility failed to comply with Federal regulations related to the oversight of food service operations when the facility did not have a full-time dietitian and the requirements were not met as specified in established standards (California Code, Health and Safety Code - HSC § 1265.4) for food service managers which required, employment of a full-time, qualified dietetic supervisor when the dietitian was not full time. The lack of qualified, full time person to supervise the Food and Nutrition Services Department had the potential to result in unsafe food practices and food borne illness for 69 residents eating facility prepared foods. Findings: According to the California Code, Health, and Safety Code - HSC § 1265.4: A licensed health facility shall employ a full-time, part-time, or consulting dietitian. A health facility that employs a registered dietitian less than full time, shall also employ a full-time dietetic services supervisor who meets the requirements of subdivision (b) to supervise dietetic service…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 menu was followed when: 1. An entrée on the menu was not prepared because an ingredient was not purchased. 2. Diet salad dressing was not purchased and was on the lunch menu for residents on a Heart Healthy diet. This failure had to the potential to result in resident dissatisfaction of meals and/or the residents not receiving the appropriate nutrients as set forth by the planned menu for 69 residents who received food from the kitchen. Findings: A review of the facility policy and procedure (P&P) titled, Substitutions, revised 4/2007, indicated substitutions should only be made when unavoidable. A review of the job description titled, Dietary Supervisor, signed by the Dietary Supervisor (DS) on 10/1/23, indicated the DS will direct and assist the preparation of regular and therapeutic diets. The DS is responsible for meeting the quality and quantity of food to meet each resident's needs in accordance with physician order in compliance with approved menus. In addition, the DS is responsible 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, interviews, and record review, the facility failed to ensure food was palatable when recipes were not followed and foods were bland, as well as over-seasoned. This deficient practice placed 69 residents who received food from the kitchen at risk for decreased nutrient intake leading to nutrition related medical complications. Findings: During an interview on 1/8/24, at 10:50 a.m., Resident 10 stated the food at the facility was bad. During an interview on 1/8/24, at 10:55 a.m., Resident 41 stated the food sucks. During an interview on 1/8/24, at 3:00 p.m., Resident 48 stated the food is not good. During a record review of recipe titled, Chicken Teriyaki, dated 8/21/23, the ingredients for the sauce included pineapple juice, water, soy sauce (low sodium), garlic powder, ginger ground, brown sugar, cornstarch, and water. During a record review of recipe titled, Carrots with Dill, dated 12/6/23, the ingredients included sliced frozen carrots, dill weed, seasoned salt, and margarine. During a record review of recipe titled, Rice, Steamed, dated 12/6/23, the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and served in a safe and sanitary manner when: 1. A resident's (Resident 1) personal refrigerator was not monitored for temperature, food expiration dates, and cleanliness. 2. Unpasteurized (not heated to kill dangerous pathogens which can cause foodborne illness), undercooked eggs were served to a resident. 3. Two of two ice machines were not clean. 4. Prepared, leftover Time/Temperature Control for Safety (TCS) food (food requiring time and temperature controls to limit the growth of illness causing bacteria) was not monitored for cooldown. 5. Refrigerated TCS food was not labeled to show when it was to be used-by or discarded. 6. Frozen raw fish stored in the freezer was not covered and open to air. 7. A kitchen staff member did not follow hand hygiene practices. 8. Surface sanitizer solution was not at the appropriate temperature for testing the sanitizer strength. 9. Kitchen walls, ceilings,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 document review, the facility failed to have a refrigerator to store perishable food brought into the facility for residents by families and visitors. This failure to store perishable food belonging to residents had the potential for a decreased intake of food preferred by residents for 69 residents who ate food by mouth. Findings: In an interview on 1/10/24 at 2:35 p.m., Licensed Vocational Nurse (LVN) 5 stated when food was brought in by visitors and/or family members for a resident, staff encouraged the resident to eat the food and what was not eaten was trashed because there were no refrigerators to store resident food. She also stated there was not a microwave to heat resident food. In an interview on 1/10/24 at 3:14 p.m., the Director of Staff Development (DSD) stated food brought in for residents by family or visitors could be stored in a refrigerator for 72 hours. When she was asked which refrigerator the food was stored in, she stated the facility did not have a refrigerator to store resident food. The policy and procedure titled Food Brought by…

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

Based on interview and record review, the facility failed to ensure the Annual (comprehensive) Minimum Data Sets (MDS, an assessment tool used to guide resident care) were completed within the required time frames for four of 30 sampled residents (Resident 31, Resident 50, Resident 47, and Resident 53). Resident 31, Resident 50, Resident 47, and Resident 53's annual MDS' were not completed within 14 days of the Assessment Reference Date (ARD, a date set to establish a uniform look-back period for all the responses to MDS coding items). These deficient practices had the potential for Resident 31, Resident 50, Resident 47, and Resident 53 to not receive the appropriate care and services needed based on these residents' current health status. Findings: A review of Resident 31's admission Record, printed 1/10/24, indicated Resident 31 was admitted to the facility in 2018 with diagnosis of quadriplegia (a form of paralysis that affects all person's limbs and body from the neck down). A review of Resident 50's admission Record, printed 1/10/24, indicated Resident 50 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.

Based on interview and record review, the facility failed to ensure the quarterly Minimum Data Sets (MDS, an assessment tool used to guide resident care) were completed within the required timeframes for four of 30 sampled residents (Resident 67, Resident 51, Resident 13, and Resident 30). Resident 67, Resident 51, Resident 13, and Resident 30's quarterly MDS' were not completed within 14 days of the Assessment Reference Date (ARD, a date set to establish a uniform look-back period for all the responses to MDS coding items). These deficient practices had the potential for Resident 67, Resident 51, Resident 13, and Resident 30 to not receive the appropriate care and services needed based on their current health status. Findings: A review of Resident 67's admission Record, printed 1/10/24, indicated Resident 67 was admitted to the facility in 2023 with diagnosis of Diabetes Mellitus (high blood sugar). A review of Resident 51's admission Record, printed 1/10/24, indicated Resident 51 was admitted to the facility in 2021 with diagnosis of cerebral infarction (a stroke or lack of blood…

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

Based on interview and record review, the facility failed to ensure the Minimum Data Sets (MDS, an assessment tool used to guide resident care) were completed and submitted to the Centers for Medicare and Medicaid Services (CMS) within the required time frames determined by the Assessment Reference Date (ARD, a date set to establish a uniform look-back period for all the responses to MDS coding items) when: 1. For four of 30 sampled residents (Resident 31, Resident 50, Resident 47, and Resident 53), Annual MDS' were not completed and transmitted within 14 days of the ARD. 2. For four of 30 sampled residents (Resident 67, Resident 51, Resident 13, and Resident 30), Quarterly MDS' were not completed and transmitted within 14 days of the ARD. These deficient practices had the potential for Resident 31, Resident 50, Resident 47, Resident 53, Resident 67, Resident 51, Resident 13, and Resident 30 to not receive the appropriate care and services needed based on these residents' current health status. Findings: 1. A review of Resident 31's admission Record, printed 1/10/24, 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 record review, the facility failed to ensure its nursing staff was competent and knowledgeable about the proper disinfection of shared glucometers (medical equipment used to measure and display the amount of sugar [glucose] in the blood) according to the manufacturer's instructions and accepted professional standards of practice when: 1. Two out of three nurses observed during medication administration did not use appropriate disinfectant to clean and disinfect shared glucometers for two out of three sampled residents (Residents 24 and 52). 2. Record review for two out of two registry nurses (an individual licensed or certified by a regulatory agency who receives compensation from a third party agency to work at a nursing care institution) personnel training files did not have evidence of training or competency related to blood glucometer cleaning and disinfection from the agency or from facility. These failures had the potential for widespread transmission of bloodborne diseases (such as Hepatitis B [a serious liver infection caused 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure proper medication storage and labeling of medication for one of one sample medication room and two of two medication carts when: 1. A non-licensed staff had access to the main medication room; and 2. Multiple expired, unlabeled, and undated multi-dose vials, eye drops, and inhalers were identified. These failures had the potential for loss or diversion of medications; and residents to receive medication with unsafe and reduced potency from being used past their discard date. Findings: 1. During a concurrent observation and interview on [DATE], at 11:41 a.m., in Station 2/3 with the presence of the Director of Nursing (DON) and Licensed Vocational Nurse (LVN) 2, the Housekeeping/Central Supply (HSKG/CS) staff stated she had the key to the medication room and replenished medication and treatment supplies whenever a nurse is available. The DON and LVN 2 acknowledged HSKG/CS staff should not have access to the medication room. HSKG/CS…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 kitchen staff were competent regarding job duties when kitchen staff did not know the appropriate procedures for cleaning equipment and utensils using the three-compartment sink. This failure had the potential to result in contamination of kitchen equipment and/or utensils leading to illness caused by pathogens (harmful organisms) for 69 residents who received food from the kitchen. Findings: During a concurrent observation and interview in the kitchen on 1/9/24, at 9:57 a.m., [NAME] 1 stated the three-compartment sink would be used to clean dishes if the dish machine was not working. [NAME] 1 demonstrated the steps for manual dish washing using the three-compartment sink. She stated the first sink was filled with water and used for washing the dishes with soap. When she was asked what the water temperature should be for washing the dishes in the first sink, she stated that temperature of wash water should be warm, and stated she did not know the temperature. During the demonstration for use…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a food/drink substitute of similar nutritive value and/or provide an alternate means of meeting the residents' nutritional needs when: 1. Milk was indicated on the planned lunch menu and was not provided for 43 residents out of 69 residents who received food from the kitchen; and 2. An alternate of equal nutritional value was not provided during a lunch meal for residents who did not like chicken. These failures had the potential for residents who ate food from the kitchen to receive a diet that did not meet their nutritional needs. Findings: Review of the policy and procedure titled Menus revised 2017, showed menus provide a variety of foods from the basic daily food groups and indicate standard portions at each meal. If a food group is missing from a resident's daily diet (e.g., dairy products), the resident is provided an alternate means of meeting his or her nutritional needs (e.g., calcium supplementation or fortified non-dairy alternatives). 1. Review of the Daily Cook's Menu 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.

Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when: 1. Two out of three nurses failed to disinfect the blood pressure (BP) cuff before and/or after use for two of three sampled residents (Residents 28 and 52), 2. Two out of three nurses during medication administration were observed not using the appropriate disinfectant to clean and disinfect shared glucometers for two out of three sampled residents (Residents 24 and 52), and 3. Resident 25's foley catheter (tube inserted thru the urethra to drain bladder) equipment was lying on the ground. These failures had the potential for the spread of infections and communicable diseases among residents and placed Resident 25 at risk of urinary tract infection (UTI, infection of the urinary tract). Findings: 1. During a medication administration observation on 01/08/24, at 10:01 a.m., Licensed Vocational Nurse (LVN) 3 was observed taking the shared BP apparatus (BP monitor and BP cuff) from the hallway to Resident 28's room without disinfecting the blood pressure…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 essential kitchen equipment was in operational working condition when: 1. The right hand side of double oven unit was not operational. 2. A plate warmer was not operational. Findings: In a concurrent interview and observation on 1/9/24, at 09:20 a.m., [NAME] 1 stated that the right side of the oven was broken for about three months, making it difficult for her to cook all necessary food at times. [NAME] 1 also stated that the Dietary Supervisor (DS) was aware part of the oven was not working. [NAME] 1 stated that the plate warmer was broken for two days. In an interview on 1/10/24, at 10:50 a.m., with the Maintenance Supervisor (MS) in the kitchen, MS stated maintenance issues are communicated to him through a group chat via phone, and also via a maintenance binder located in two nursing stations. In a concurrent interview and observation on 1/10/24, at 11:47 a.m., in the kitchen, [NAME] 2 stated she told someone that the oven was not working about two weeks ago. DS stated an outside company came 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.

Based on observation, interview, and record review, for one of 30 sampled residents (Resident 32), the facility failed to provide the resident with an appropriate facility gown to wear according to her size and preference. This failure resulted in Resident 32 wearing tight clothing, feeling uncomfortable, and restricted to both her upper arms and chest area. Findings: Review of Resident 32's admission Record, printed 1/10/24, indicated resident was admitted to the facility in 2019 with diagnoses of multiple sclerosis (a disabling disease that impacts the central nervous system which controls everything a person does) and morbid obesity (excessive body fat). A review of Resident 32's Minimum Data Set (MDS, an assessment tool used to direct resident care), dated 12/9/23, indicated Resident 32 was able to understand others and be understood. The MDS indicated Resident 32 required substantial/maximal assistance (helper does more than half the effort) for personal hygiene including dressing. During a concurrent observation and interview on 1/8/24, at 10:42 a.m., in Resident 32's room,…

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

Deficiency Text Not Available

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide fingernail care to one of 30 sampled residents (Resident 13) when Resident 13's fingernails on both hands were long. This failure resulted in Resident 13 feeling bothered by the long fingernails and placed him at risk for scratching himself. Findings: A review of Resident 13's admission Record, printed on 01/10/24, indicated Resident 13 was originally admitted to the facility on [DATE]. During a review of Resident 13's Minimum Data Set (MDS, an assessment tool used to guide care) dated 8/25/2023, indicated Resident 13 required limited assistance with personal hygiene. The MDS assessment also indicated Resident 13 was able to understand others and was able to make himself understood. During a concurrent observation and interview on 01/08/24, at 1:39 p.m., Resident 13's fingernails on both hands were long. Resident 13 stated the length of his nails bothered him. During a concurrent interview and record review on 1/10/24, at 1:12…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 document review, the facility failed to ensure care provided to a resident (Resident 27) was in accordance with professional standards of practice when a staff who was not a nursing staff provided resident care by helping the resident sit up in bed, and serving her lunch tray. This failure had the potential for one resident to receive food not appropriate for her diet resulting in a negative outcome such as an allergy reaction. Findings: Review of the tray card on Resident 27's tray for lunch on 1/9/24 showed Resident 27 was on a Consistent Carbohydrate (a diet typically prescribed to a person to help regulate blood sugar), No Added Salt therapeutic diet. The tray card also showed she had gluten (a protein found in grains such as wheat, barley, and rye) and iodine (a mineral found in some foods) allergies. In the notes section of the tray card, it showed Resident 27 received small portions of starch foods and she disliked wheat bread. An observation on 1/9/24 at 12:37 p.m., showed a food tray delivery cart holding resident lunch trays parked in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a timely evaluation of one resident's (Resident 72) severe weight loss. This failure had the potential to result in further unintentional and/or undesirable weight loss for one resident. Findings: Review of the undated Policy and Procedure titled Weight Assessment and Intervention, Residents are weighed upon admission and at intervals established by the interdisciplinary team. Weights are recorded. Unless notified of a significant weight change, the dietitian will review the unit weight record monthly to follow individual weight trends over time. The threshold for significant unplanned and undesired weight loss will be based on the following criteria: a. 1 month - 5% weight loss is significant, greater than 5% is sever. b. 3 months - 7.5% weight loss is significant; greater than 7.5% is sever. c. 6 months - 10% weight loss is significant; greater than 10% is severe. Undesirable weight change is evaluated by the treatment team…

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

Based on interview and record review, the facility failed to ensure one of one sampled resident (Resident 43) was free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental process and behaviors). Resident 43 received aripiprazole (an antipsychotic medication, used to manage conditions such as psychosis) and sertraline (medication used to treat depression) without side effects and behavior monitoring. Resident 43's care plan did not have the correct side effect monitoring for the aripiprazole use. These failures resulted in inadequate monitoring for effectiveness and adverse effects of psychotropic medications. Findings: 1. A review of clinical record indicated Resident 43 was admitted to the facility with diagnoses including Schizoaffective disorder (a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania) and Depression. A review of Resident 43's physician's orders included the following: -Aripiprazole 2 mg…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 had a 7.41% error rate when two medication errors out of 27 opportunities were observed during the medication pass for two of six sampled residents (Residents 28 and 52 ). Resident 28 did not receive carvedilol (medication used to treat high blood pressure) as ordered and Resident 52 received a wrong calcium product. These failures resulted in medication not given in accordance with the prescriber's orders, which may negatively affect the resident's health.) Findings: 1. During medication administration observation on 01/08/2024, at 10:01 a.m., in Station 1, LVN (Licensed Vocational Nurse) 3 was observed preparing and administering 7 medications to Resident 28. These medications included 1 tablet of allopurinol (medication used to treat gout) , 1 capsule of docusate sodium (medication used to treat constipation), 1 tablet of duloxetine (medication used to treat depression), 1 tablet of finasteride (medication to treat symptoms of an enlarged prostate), one fluticasone inhaler (medication used to treat asthma), 1 tablet…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 accurately document entries for one of 30 sampled residents (Resident 24), when resident's current physician orders did not reflect oxygen (O2) and nebulizer (a device to take medication in the form of a mist that is inhaled into the lungs) use. This deficient practice resulted in incomplete and inaccurate records and had the potential for Resident 24 to not receive care, services, and treatments as needed. Findings: A review of Resident 24's admission Record, printed 1/10/24, indicated Resident 24 was admitted in March 2023, with diagnosis of chronic respiratory failure (a condition in which the lungs have a hard time loading the blood with O2 or removing carbon dioxide) with hypoxia (low levels of O2 in the body). A review of Resident 24's Care Plan titled, Difficulty Breathing related to Acute and Chronic Respiratory Failure with Hypoxia, undated, indicated, Administer medication/puffers as ordered. Monitor for effectiveness and side effects .Provide oxygen as ordered . Further review of Resident 24's care…

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

Based on observation, interview, and record review, the facility failed to ensure one of 30 sampled residents (Resident 34) had access to his call device. This failure resulted in Resident 34 not being able to get staff assistance when needed. Findings: A review of Resident 34's face sheet, undated, indicated Resident 34 was admitted in February 2019, with diagnoses of hemiplegia (paralysis) and hemiparesis (partial weakness) of left side of body following cerebral infarction (stroke - blood supply to the brain is cut off), arthritis (inflammation of joints), and muscle wasting (decrease in size of muscles). During a concurrent observation and interview on 1/8/24, at 10:47 a.m., with Resident 34, there was no call device found for Resident 34. Resident 34 stated he had no call light for the last 3 days. Resident 34 stated he needed the call light to call staff for any needs especially at nighttime but could not. During a concurrent observation and interview on 1/8/24, at 11:00 a.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 went to Resident 34's room, looked under the bed and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to contact a physician for a significant change of condition for eight hours and 40 minutes for one of two (Resident 400) sampled residents after Licensed Vocational Nurse 8 (LVN 8) administered multiple doses of unprescribed medications, including opioid medications (a group of medications which are federally regulated substances used for pain control with a potential for physical or psychological dependence) to Resident 400. This failure resulted in Resident 400's hospitalization for excessive sedation and respiratory failure (inadequate breathing efforts) requiring mechanical ventilation (machine used to provide artificial breathing) from the opioid medications overdose. Findings: During a review of Resident 400's admission Record dated 12/22/23, the admission Record indicated Resident 400 was admitted to the facility in 2008 for stroke (brain tissue death resulting in brain function impairment), hemiplegia (the loss of muscle function on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, for one of two sampled residents (Resident 1), the facility failed to ensure Resident 1's representative was allowed to obtain a copy of the medical records within the required time frame. This failure had the potential to result in Resident 1's representative undue concern and anxiety on behalf of Resident 1. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE]. During a review of the letter requesting medical records dated 8/23/23, the letter, addressed to the facility's Custodian of Records, indicated a request for Resident 1's medical records be sent through the following methods: -Contacting the requesting office at their phone number when medical records are located to schedule a copy appointment. -Emailing the records to the requesting office's email address. -Furnishing a copy via facsimile to the requesting office's fax number. -Mailing a copy of the records to the requesting…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 menu was followed for seven of seven residents when [NAME] 1 prepared white rice for residents on a pureed diet instead of the Spanish rice listed on the menu. This failure had the potential to result in less appetizing and nutritious food, and less food consumption, nutritional imbalance, and weight loss. Findings: A review of the posted facility menu for Week 1 from June 12 to June 18 for Tuesday (6/14/22), indicated lunch included Spanish rice. A review of the facility's Daily Cook's Menu for Week 1, Tuesday, indicated the facility was supposed to serve Spanish rice for pureed diet. During a concurrent observation and interview on 6/14/22 at 12:10 p.m., in the kitchen, [NAME] 1 pureed white rice for residents on a pureed diet. [NAME] 1 stated he thought white rice was the correct food. During an interview on 06/14/22 at 12:10 p.m., with Dietary Supervisor (DS), DS stated that residents on pureed diet should have the same menu as the regular diet, and to prepare the pureed food, Spanish rice,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 kitchen cabinets in good repair when an undercounter cabinet had doors with chipped and peeling paint (interior and exterior sides), unpainted wooden interior walls were chipped and peeling, the cabinet floor had chips of paint and wood and irregular white, green, yellow, and black stains. The failure to maintain the cabinets in good repair and sanitary conditions had the potential to result in food contamination and food borne illness for any resident eating food. Findings: During a concurrent observation and interview on 6/13/22 at 11:30 a.m., with Dietary Supervisor (DS) in the kitchen, there was a wooden cabinet under the dishwashing three-compartment sink. DS confirmed the condition of the wooden cabinet was as follows: the cabinet doors had chipped and peeling paint (interior and exterior sides), the unpainted wooden interior walls were chipped and peeling, the cabinet floor had chips of paint and wood and irregular white, green, yellow, and black stains. Inside the cabinet was a wooden shelf…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 arrange for a vision consult upon admission for one of 17 sampled residents (Resident 36). The failure to refer Resident 36 for eye care upon admission resulted in Resident 36 not receiving an eye exam on 3/30/22, during the routine eye care visit, with a subsequent delay in services for eleven additional weeks. This failure had the potential to result in impairment of Resident 36's vision. Findings: A review of Resident 36's face sheet, undated, indicated Resident 36 was admitted on [DATE], with a diagnosis of a fracture of nasal bones and a Le Fort I fracture (a horizontal facial fracture characterized by the separation of the hard palate from the upper jaw). The face sheet also indicated Resident 36 had a family member, RP, to act as a responsible party and emergency contact. A review of Resident 36's, Physician Order Report, dated 2/8/22, indicated, Consult-Vision for eye health with follow-up and treatment as indicated. A review of 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.

Based on observation, interview, and record review, the facility failed to follow the physician's orders to refer two of 17 sampled residents (Resident 2 and Resident 54) for podiatry (foot specialty) services. Resident 2 had no podiatry services for four months after one podiatry visit. Resident 54 had no referral for podiatry services for three weeks and three days following admission. These failures resulted in Resident 2 and Resident 54 developing long toenails which had the potential to result in skin breakdown/injury, infection, and amputation of toes and/or feet. Findings: A review of Resident 2's face sheet, undated, indicated an admission date in December 2021. The face sheet indicated Resident 2 had diagnoses of weakness of the left side following a stroke, general weakness, and impaired walking and mobility. A review of Resident 2's physician order, dated 12/15/21, indicated, Consult- podiatry as needed, for fungal infection, thick nails and/or skin lesions. A review of Resident 2's podiatry services note dated 2/18/22, indicated Resident 2 was a new patient with pain 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.

Based on interview and record review the facility failed to ensure one of eight sampled residents (Resident 39) received services to improve mobility and achieve maximum practicable independence when Resident 39 did not receive restorative nursing services for walking with a walker (an ambulation device with two to four wheeled legs, connected by handlebars to provide stability when walking). The failure to provide daily services to practice walking with a walker potentially contributed to muscle weakness and decreased mobility for ten weeks. Findings: A review of Resident 39's face sheet indicated he was admitted to the facility with diagnoses of generalized muscle weakness and difficulty walking. A review of Resident 39's Minimum Data Set (MDS, a resident assessment tool used to guide care) dated 5/20/22, indicated Resident 39 was understood and could understand others. The MDS indicated Resident 39 had not walked in his room or the unit but had used a wheelchair for locomotion. The MDS indicated Resident 39 needed extensive physical assistance from one person for transfer between…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 appropriate pharmaceutical services for two of eight sampled residents (Resident 42 and Resident 10) when: 1. Resident 42's had four medications left unattended on her bedside table; the administration of the medications was delayed for one hour and fifty minutes past the scheduled administration time. This failure resulted in Resident 42 not receiving her medications timely, and Resident 10 receiving a more concentrated dose of medication. For Resident 42, the one hour and fifty minutes delay in administration of hydroxyzine (an anti-anxiety drug) resulted in potential stacking of doses as the next dose of hydroxyzine was due in one hour and ten minutes. Stacking of doses had the potential to result in adverse side effects such as seizures. Resident 42's unsupervised medications also had the potential to result in diversion of the medications to other residents, with subsequent adverse side effects such as low blood pressure, fast heart rate, dizziness, drowsiness, seizures. 2. Resident 10's powdered…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 arrange for a dental consult upon admission for one of 17 sampled residents (Resident 36). The failure to refer Resident 36 for a dental exam upon admission resulted in Resident 36 not receiving a dental exam on 3/30/22 or 3/31/22, during the routine dental care visit, with a subsequent delay in services for eleven additional weeks. This failure had the potential to result in difficulty eating and weight loss. Findings: A review of Resident 36's face sheet, undated, indicated Resident 36 was admitted on [DATE] with multiple diagnoses including a fracture of nasal bones and a Le Fort I fracture (a horizontal facial fracture which is characterized by separation of the hard palate from the upper jaw). The face sheet also indicated Resident 36 had a family member as responsible party and emergency contact, RP. A review of Resident 36's Physician Order Report, dated 2/8/22, indicated, Consult-Dental for oral hygiene with follow-up 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.

Based on observation, interview, and record review, for one of 8 sampled residents (Resident 16), the facility failed to ensure Treatment Nurse 1 (TN 1) performed hand hygiene (wash hands with soap and water or use an alcohol-based hand rub) on two occasions during a wound dressing change. The staff failure to change gloves during a wound treatment when moving from wound care (a dirty procedure) to application of a new dressing (a clean procedure), and to sanitize hands after removing gloves had the potential to result in infection and spread of infection. Findings: A review of Resident 16's Face Sheet, dated 6/16/22, indicated Resident 16 was admitted to the facility in 2021 with diagnoses of dementia (a chronic progressive disease marked by memory loss, personality changes and impaired reasoning), and a stage IV pressure ulcer. (A pressure ulcer develops when one or more layers of skin and tissue are damaged as a result of continuous pressure to the area. The depth of skin and tissue damage determines the stage of the pressure ulcer, which is on a scale of stage I to stage IV,…

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