Arbor Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure all residents were treated with dignity and respect by direct care staff during activities of daily living for two out of five sampled residents when: 1. Resident 44's room door and privacy curtains were open, exposing her back and chest. 2. Resident 68 did not receive assistance with toileting and a request for a food preference at breakfast. This resulted in Resident 44's privacy and dignity to be violated and Resident 68 felt cold and uncomfortable. Findings: A review of the facility's Policy and Procedure (P&P) titled Dignity, dated 8/2024, indicated: 1. Residents shall be treated with dignity and respect at all times. 2. Residents shall be encouraged to dress in their own clothes daily. 3. If resident's preference is limited or no clothing, the preference will be respected if (a) the preference is care planned and (b) the resident has appropriate coverage or privacy, for example, use of bed linens or closure of the privacy…

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 direct care staff failed to place the call light within reach for two of four sampled residents, (Resident 39 and Resident 87). This failure had the potential for resident specific needs and requests to not be met in a timely manner, and the potential for negative clinical outcomes to include the potential for a fall. Findings: A review of the facility's policy revised 10/2024, titled, Answering the Call Light, indicated the purpose of this procedure is to respond to the resident's requests and needs. General guidelines include explain the call light to the new resident, demonstrate the use of the call light, be sure the call light is plugged in, and when the resident is in bed or confined to a chair, be sure the call light is within easy reach of the resident as much as practicable. 1. During a review of Resident 39's medical record, the admission Record, indicated Resident 39 was admitted to the facility on [DATE] with diagnoses that included…

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 protect the rights of one of four sampled residents' (Resident 22) to be free from sexual abuse when Resident 120 was observed by staff to hold Resident 22's hand in his unzipped pants. This failure placed all residents at risk for potential sexual abuse and/or mental anguish from Resident 120. Findings: A review of facility Policy and Procedure (P&P) titled Resident Rights, dated 10/2023, indicated federal and state laws guarantee certain basic rights to all residents of this facility, including: 1. A dignified existence, 2. To be treated with respect, kindness, and dignity, and 3. To be free from abuse, neglect, stolen property, and exploitation (treating someone unfairly for one's own benefit). A review of facility P&P titled Abuse, Neglect, Exploitation, and Misappropriation (stealing) Prevention Program, dated 8/2024, indicated residents have the right to be free from abuse - including but not limited to the freedom from verbal, mental, sexual, or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report sexual abuse to the State Agency (SA) and family in the mandated timeframes for one of four sampled residents (Resident 22). This failure delayed an investigation of the incident and created the potential for ongoing resident-to-resident sexual abuse for residents within the facility. Findings: A review of facility Policy and Procedure (P&P) titled Abuse, Neglect, Exploitation, and Misappropriation (stealing) Prevention Program, dated 8/2024, indicated residents have the right to be free from abuse - including but not limited to the freedom from verbal, mental, sexual, or physical abuse - by anyone: staff, other residents, family members, visitors, and any other individual. The P&P indicated the facility will: 1. Establish and maintain a culture of compassion and caring for all residents, particularly those with behavioral, cognitive, or emotional problems. 2. Provide staff training/orientation programs that include topics such as abuse…

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 accurate resident assessments for two of 29 residents (Resident 68 and 303) when: 1. Resident 68 was assessed as continent (able to control bladder which holds urine) when she was occasionally incontinent (not able to control her bladder). 2. Resident 303 was assessed as a non-smoker but was a smoker and was observed smoking. This failure had the potential for inaccurate resident care planning and adverse health outcomes for Resident 68 and Resident 303. Findings 1. A review of the facility's policy, Facility Assessment dated 8/6/24, indicated the purpose of the assessment is to determine what resources are necessary to care for residents competently both during day to day competencies and emergencies. Genitourinary is a section included in this Assessments Policy and under this section is bladder incontinence. A review of Resident 68's admission assessment dated [DATE], indicated Resident 68 was admitted for bilateral (right 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 ensure residents received services that met professional standards of quality for two of nine residents when: 1. Resident 69's physical needs were not accommodated when Durable Medical Equipment (DME) was not provided by the Therapy Department. 2. Resident 68 did not receive needed medical referrals. This failure had the potential to result in emotional stress, anger, depression, feelings of neglect, and the potential for negative clinical outcomes. Findings: During a review of the facility's policy revised 8/2024, titled, Assistive Devices and Equipment, indicated the facility provides and maintains the use of assistive devices and equipment for residents. Devices and equipment that assist with resident mobility, safety, and independence are provided for residents. The devices include but are not limited to wheelchairs (W/Cs.) During a review of a facility policy, revised 10/2024, titled, Activities of Daily Living (ADLs), Supporting,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide the necessary assistance for Activities of Daily Living (ADLs, activities related to personal care) for dependent residents for two of six sampled residents, (Resident 68 and Resident 69) when: 1. Resident 69 did not get out of bed (OOB) due to not having an appropriate wheelchair (W/C) to meet his specific needs; and 2. Resident 69 did not receive scheduled showers, or as needed showers for January 2025; and 3. Resident 68 did not receive assistance for toileting using a bed pan (device to collect urine while lying or sitting in bed) upon request. These failures had the potential to result in emotional stress, anger, depression, feelings of neglect, denial of resident rights, and prevent the residents from achieving their highest practicable level of physical and emotional well-being. Findings: 1. During a review of a facility policy revised 10/2024, titled, Activities of Daily Living (ADLs), Supporting, indicated residents will…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide 1 of 29 sampled residents (Resident 44) with quality of care that met their needs when Resident 44 did not receive adequate foot care (washing, applying lotion, and assessing the skin). This failure resulted in discomfort and dry, cracked, and peeling feet for Resident 44. A review of the facility's Policy and Procedure (P&P) titled, Activities of Daily Living (ADLs), Supporting, dated 10/2024, indicated: 1. Residents will be provided care, treatment, and services as appropriate to enable them to carry out ADLs, for example, bathing, dressing, oral hygiene, walking, transferring in bed, toileting, and eating. 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with resident consent and in accordance with the plan of care, including appropriate support and assistance. 3. A resident's ability to perform ADLs will be measured using clinical tools. 4. The resident's responses…

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 three sampled residents (Resident 123), was turned and repositioned as ordered to prevent skin break down, promote circulation, and provide pressure relief. This failure resulted in areas of redness to Resident 123's skin and wrinkles to her skin from the bed linens and the potential to contribute to Resident 123 developing a pressure ulcer (open area of the skin, or bedsore caused by prolonged pressure) which could lead to complications including pain, discomfort, and infection. Findings: During a review of the facility's policy revised 5/2013, titled, Repositioning, indicated the purpose of repositioning is to provide guidelines for the evaluation of resident's repositioning needs, to aid in the development of an individualized care plan for repositioning, to promote comfort for all bed or chair bound residents and to prevent skin breakdown, promote circulation and provide pressure relief for residents. Repositioning is a…

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

Based on interview and record review, the facility failed to do a performance evaluation every year for one out of two sampled Certified Nursing Assistant's (CNA) M employee file reviews. This had the potential for CNAs not to receive ongoing education/inservices based on the outcome of their annual review. Findings: A record review of CNA M's performance evaluations indicated she had a review on 11/10/21 and 7/15/22. There were no evaluations for the years 2023 and 2024 found in her employee file. During a concurrent interview and record review on 1/24/25 at 12:02 pm, Director of Staff Development (DSD) confirmed CNA M did not have an annual performance review since 2022, and that the facility was behind on CNA annual performance evaluations.

Based on observation, interview, and record review, the facility failed to be free of medication error rates of five percent (%) or greater when five medication errors were observed out of 26 opportunities. The medication error rate was 19.2 %. This failure resulted in multiple medication errors and had the potential for the residents not to receive medication as their physician's ordered. Findings: 1. A record review of facility policy titled, Administering Medications through a Small Volume (Handheld) Nebulizer revised October 2024, indicated, wash and dry hands .explain the procedure to the resident .wash and dry hands .turn on nebulizer and check the outflow port for visible mist .instruct the resident to take a deep breath, pause briefly and then exhale normally, encourage the resident to repeat the above breathing pattern until the medication is nebulized or until the designated treatment time is reached .monitor for side effects, including rapid pulse .encourage resident to cough and expectorate as needed .wash and dry hands. A review of an article found on American Lung…

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 properly store medications in two out of two sampled medication storage rooms. Disorganized storage of medications in a nursing home can lead to medication errors, delays in treatment, and potential adverse health effects. Findings: During a review of facility policy titled, Storage of Medications reviewed August 2024, indicated, The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Facility policy further indicated, Medications are stored separately from food and are labeled accordingly. During a website review of the American Society of Consultant Pharmacists https://www.ascp.com/page/policystatements 2016-2024, indicated medications must be stored separately from non-prescription items, including enteric food (liquid food that goes directly into the intestines and bypasses the stomach), and alcohol swabs to prevent contamination and reduce the risk of medication errors. During an observation on 1/21/2025 at 3:22 pm, medication room number three was found to have medications…

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: 1. Resident 98's perishable food was stored in the refrigerator rather than at his bedside, and his expired food was discarded. 2. Descaling (the process of removing a hard, white layer of limescale - a hard chalky buildup of calcium left over from water - from an object) and sanitizing (a process to reduce the number of microorganisms to safe levels) of the ice machine was performed per the manufacturer's instructions. These failures had the potential: 1. To place Resident 98, a medically vulnerable resident, at risk for foodborne illness related to the growth of microorganisms (bacteria or fungus that cause nausea, vomiting, and diarrhea). 2. For the facility ice machine to become contaminated with microorganisms, putting all residents consuming ice from the ice machine at risk for foodborne illness. Findings: 1. A review of the facility's Policy and Procedure (P&P) titled, Foods Brought by Family/Visitors, dated 2001, 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 policies were established and implemented regarding smoking safety for one of two sampled residents (Resident 303) when: 1. Resident 303 smoked on the sidewalk in front of the facility and the facility had not identifed him as a smoker because the facility had no policy or procedure to identify residents who smoked while off the facility property. 2. Resident 303 kept his cigarettes and lighters in his room unsecured because the facility had no policy or procedure to identify and manage resident smoking materials (cigarettes and lighters) for residents that smoked while off the facility property. 3. Resident 303's clothes had a cigarette burn holes (from smoking at home), but was not monitored for safety because the facility had no policy or procedure to do a smoking evaluation on residents who smoked off the facility property to ensure they were able to smoke safely. These failures resulted in an unsafe environment for Resident 303. Findings: A review of the facility's policy titled, Non-Smoking…

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 nursing staff provided competent nursing care for one of five sampled residents (Resident 1), who had a change in their condition and the physician was not notified. This failure resulted in Resident 1 being transferred out of the facility by ambulance and had the potential to negatively impact the safety, physical, and emotional well-being of any resident who experienced a change in their condition. Findings: A review of a facility policy titled, Change in a Resident's Condition or Status, with a revised date of March 2021, indicated, Our facility shall promptly notify the resident . his or her Attending Physician . of changes in the residents medical . status . This policy further indicated, The nurse will notify the resident's Attending Physician . when there has been a(an): significant change in the resident's physical/emotional/mental condition . need to transfer the resident to a hospital treatment center . specific instruction to notify…

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 was communicated with in a language that she could understand (Resident 1), when Resident 1 only spoke Spanish and the facility failed to provide an interpreter. This failure resulted in Resident 1 not understanding why she was moved to a new room and negatively impacted her emotional and psychosocial well-being, and had the potential to affect all residents who ' s primary language was not English. Findings: A review of a facility policy titled, Translation and/or Interpretation of Facility Services, with a revision date of November 2020, indicated, Competent oral translation of vital information that is not available in written translation . A staff member who is trained and competent in the skill of interpreting; a staff interpreter who is trained and competent in the skill of interpreting; contracted interpreter service; voluntary community interpreters who are trained and competent 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents was notified of a room/roommate change with a written notice that included the reason before the facility had the resident ' s room changed (Resident 1). This failure resulted in negatively impacting Resident 1 ' s emotional and psychosocial well-being due to being upset and without proper notification and/or understanding of the room change. Findings: A review of a facility policy titled, Room Change/Roommate Assignment, with a revised date of March 2021, indicated, Prior to changing a room or roommate assignment all parties involved in the change/assignment . are given at least a day advance written notice of such change. Advance written notice of a roommate change includes why the change is being made and any information that will assist the roommate in becoming acquainted with his or her new roommate. A review of a facility policy titled, Room Change/Roommate Notification, with a revised date of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that one of three residents sampled residents (Resident 1), had reasonable access to the use of a telephone in the facility without their calls being overheard. This failure resulted in the resident not having enough privacy to speak to the Ombudsman (an individual that assists residents with their concerns), on her own and voicing her concerns properly without facility staff being present. Findings: A review of a facility policy titled, Grievances/Complaints, Filing, with a revised date of April 2017, indicated, Residents and their representatives have the right to file grievances . to the agency designated to hear grievances (e.g., the State Ombudsman). A review of a facility policy titled, Telephones, Resident Use of, with a revised date of February 2021, indicated, Designated telephones are available to residents to make and receive private telephone calls. Telephones will be in areas that offer privacy . A private telephone line or cellular…

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 a clean, safe, comfortable homelike environment for eight residents (Residents 1, 2, 3, 4, 5, 6, 8 and 9) among a facility census of 134, when their bathrooms appeared dirty and in disrepair. This failure had the potential to threaten the residents ' health and well-being. Findings: A facility policy, titled, Bathrooms, revised 2/1/20, was reviewed. The policy indicated residents who could have used the bathroom independently (including chair-bound residents) would have been ensured access to a safe, clean, sanitary and accessible toileting facility. Bathrooms, including showers, sinks, commodes, etc., were cleaned and disinfected daily. During an interview, on 8/1/24, at 10:43 am, Housekeeper C stated the resident rooms and bathrooms were cleaned every day, and the supervisor inspected them every other day. Review of Resident 9 ' s clinical record indicated they were originally admitted to the facility on [DATE] with diagnoses…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to directly involve one of 22 sampled residents (Resident 1), and their Responsible Party (RP, a person designated to make decisions on behalf of a resident) in a treatment decision, when the RP was not notified of, and a consent for an Ear, Nose and Throat (ENT) consult was not obtained prior to treatment. This failure resulted in Resident 1 receiving treatment by an ENT that the RP was not informed of and did not approve of. Findings: A review of the facility policy titled Resident Rights revised February 2021, indicated, Employees shall treat all resident with kindness, respect, and dignity. 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: p. be informed of, and participate in, his or her care planning and treatment. A review of Resident 1's, undated, admission Record indicated Resident 1 was admitted on [DATE] with diagnoses including dementia, muscle weakness,…

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 maintain complete and accurately documented medical records in accordance with accepted professional standard for 1 of 1 sampled residents (Resident 1) when: 1. Resident 1 had a change of condition and medication was ordered by the physician but there were no nurses notes describing the condition of Resident 1. 2. An Ear Nose and Throat Practitioner (ENT, an outside provider) did rounds in the facility and saw Resident 1 and no documentation of the visit were in the residents' medical record. These failures had the potential to prevent accurate information for Resident 1 regarding medical care and condition to be available to the residents, their representatives and other care providers. Findings: A review of the facility's policy titled Charting and Documentation dated July 2017, indicated 2. The following information is to be documented in the resident medical record: a. Objective observations. b. Medications administered. c. Treatments or services…

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

Based on observation, interview and record review, the facility failed to ensure that resident shower rooms on Station 1 and Station 2 were safe, sanitary, and comfortable when floor tiles had black and brown areas in the grout (a mixture of water, cement, and sand used to fill voids and seal joints such as those between tiles), and the wall tiles in the shower corners were cracked and covered with a black substance. This failure placed residents at risk for being uncomfortable and exposed to possible infectious conditions while taking a shower. Findings: A review of the facility ' s policy titled, Safety of Employees dated January 2008, indicated As part of our efforts to provide a safe and healthful environment for all employees, residents, and visitors, the facility shall comply with applicable governmental health and safety requirements. A review of the facility ' s policy titled, Cleaning and Disinfection of Environmental Surfaces dated August 2019, indicated 10. Environmental surfaces will be disinfected (or cleaned) on a regular basis (e.g., daily, three time per week) 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 records review, the facility failed to provide a safe environment which was free from abuse for 1 of 5 samples residents (Resident 8, 10, 16, 27, and 38), when Certified Nursing Assistant 2 (CNA 2) verbally abused Resident 10 on 3/2/24. This failure caused Resident 10 to have feelings of fear and emotional distress, and affected their psychological well-being. This failure also had to potential for other Residents to be abused, when CNA 2 was allowed to continue working. Findings: During a review of Resident 10 ' s admission Record, it showed Resident 10 was admitted on [DATE], with diagnoses including Hemiplegia and hemiparesis following cerebral infarction (paralysis and weakness following a stroke), Type 2 Diabetes Mellitus (a disease where the pancreas doesn ' t work properly, causing high blood sugar), and Chronic Obstructive Pulmonary Disease (A disease that causes lung problems and trouble breathing). During an interview with Resident 10 on 3/7/24, they stated that over…

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 meet this requirement when its Dietary Supervisor (DS), the person responsible for the day to day management and supervision of the department, did not meet the federally required training qualifications for that position. This had the potential for inadequate purchasing of food and supplies, incorrect food preparation, service and storage, according to professional standards for sanitation and safety to avoid food borne illnesses. Findings: Facility document dated 9/2016 and titled, Job Description: Dietary Supervisor listed the general purpose of the position as .supervision of the Dietary Department The essential duties listed .Directs and supervises all dietary functions and personnel The job description also indicated the Dietary Supervisor will direct and assist the preparation and service of regular meals and therapeutic diets, order food and supplies, maintain area and equipment in sanitary condition, and assure the smooth operation with other nursing facilities departments. The position description also listed…

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, observation and record review, the facility failed to ensure dietary staff had the necessary competencies and skills when: 1. Staff did not prepare pureed food items in accordance with facility guidelines, recipes, and/or current standards of practice, and 2. One of two dishwashing staff was unfamiliar with the manufacturer's recommended test strips for ensuring dishwashing water was within a safe chlorine range, and had no record of being trained in using testing strips. This resulted in resident dissatisfaction with the flavor and consistency of purees and had the potential for foodborne illness. Findings 1. In a concurrent observation and interview on 1/23/24 at 9:30 AM, [NAME] A (CA) was observed adding what he stated was vegetable broth to what he stated was pureed zucchini. CA was observed pouring in unmeasured broth into the zucchini puree and then poured in an unmeasured amount of thickener. CA then poured into a 1/8 deep steam pan, with a resultant product that resembled a creamed soup consistency. The product was then placed into a hot steamer until…

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, observation and record review, this requirement was not met when the facility failed to store and prepare food in a sanitary environment as evidenced by: 1. Kitchen fixtures/equipment and appliances that were not clean to sight or touch. 2. Bare artificial nails were worn by a kitchen staff member during food production. This had the potential to cause foodborne illness and rodent or insect infestation. Findings: 1. In a concurrent observation and interview with Assistant Dietary Manager (ADM) A on 1/23/24 at 8:40 AM, large white plastic bins of oats approximately 2 feet tall were observed to be smudged and dirty on the outside. [NAME] spots were observed in the contents of a tall plastic tub containing white powder labeled thickener. In a concurrent interview ADM A confirmed that the particles were of something that doesn't belong in there. Dried-on food drips and other smudges were noted on the steamer and stove stainless-steel panels. In a concurrent interview and observation on 1/23/24 at 9:30 AM, [NAME] A (CA) pulled out a food processor bowl that was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to take actions aimed at performance improvement and, after implementing those actions, measure its success, and track performance to ensure that improvements were realized and sustained when: 1. Nurse staffing not sufficient to meet resident needs. 2. Building maintenance projects not identified or timely repaired. 3. Dietary staff not sufficient nor qualified. 4. Oxygen system to supply 129 of 143 residents in the facility who required respiratory support. This failure had the potential to affect all residents quality of life and care. Findings: A facility policy, titled, Quality Assurance and Performance Improvement (QAPI) Program, revised 2/1/2020, was reviewed. The policy indicated that the facility should have developed, implemented, and maintained an ongoing, facility-wide, data-driven program that was focused on indicators of the outcomes of care and the quality of life for the facility's residents. The objectives (goals) of the QAPI…

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 ensure the Director of Nursing (DON), was present during the Quality Assurance and Performance Improvement committee meeting (a meeting where managers discuss problems and improvement plans for the facility), for the last quarter of 2023. This had the potential for problems and concerns regarding resident care needs and the nursing department to go unheard. Findings: A facility policy titled, Quality Assurance and Performance Improvement (QAPI) Program - Governance and Leadership, revised 3/1/2020, was reviewed. The policy indicated that the QAPI program was overseen and implemented by the QAPI committee, which reported its findings, actions and results to the administrator and governing body. The following individuals served on the QAA Committee: a. Administrator, or a designee who was in a leadership role; b. Director of nursing (DON) services; c. Medical director; d. Infection preventionist; and e. Representatives of the following departments, as requested by the administrator. During a concurrent interview and 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure essential equipment was maintained and in an operating safely when: 1. A floor drain in the kitchen was backed up with dirty, stagnant water; 2.Various pieces of equipment in the kitchen were dirty and in poor repair; 3. Ice buildup was observed on a pipe above the fan in the walk-in freezer. 4. Two out of four water boilers were not functioning for a facility with 143 current residents. This had the potential to cause foodborne illness and resulted in residents to refuse showers due to uncomfortable cold water temperatures. Findings: 1. In a general observation on 1/23/24 at 8:50, a floor drain in the kitchen was backed up and filled with a green stagnant liquid that had what appeared to be white mold or bacteria on top. In a concurrent interview, Associate Dietary Manager A stated that the floor drain was backed up, and that she was not sure how long it was out of order. A pedal-operated handwashing sink was observed to 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 interview and record review the facility failed to ensure resident complaints were acted upon timely and implemented plans of action to correct the identified issues. This failure resulted in ongoing unresolved resident complaints. Findings: A review of a facility policy titled, Resident Council revised April 2023, indicated the purpose of the resident council is to provide a forum for discussion of concerns and suggestions for improvement. A resident council follow up form will be used to track issues and their resolution and that the facility department related to any issues will be responsible for addressing these issues. A review of the resident council meetings minutes, follow up forms, and in-service education documentation indicated: On 07/27/2023, complaints of missed showers/late showers and call lights not being responded to timely was discussed by residents. Staff education on responding to call lights was completed on 08/01/2023 with three staff members in attendance. On 08/29/2023, complaints of showers not being consistent, call lights during evening and night…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to maintain a clean, comfortable, homelike environment when: 1. Linoleum flooring was detached from the lower walls in bathrooms of rooms [ROOM NUMBER]. 2. Resident 118 had no overhead light to read in bed. 3. Shower Rooms on Station 1, 2 and 3 tiles were broken. This failure had the potential to negatively impact the residents' health and well-being. Findings: 1. During an observation, on 1/23/24, from 12:15 PM to 12:25 PM, in rooms 119, 121 and 123, the linoleum flooring that extended approximately four inches up the bottom edge of the walls was detached from the walls. Between the back of the linoleum and the walls was a one to two inch gap lined with brown, porous material. The linoleum appeared stained and dirty. During a concurrent observation and interview, on 1/23/24, 12:18 PM, in the bathroom of room [ROOM NUMBER], Laundry Staff A confirmed the linoleum flooring was detached from the bottom of the walls. During a concurrent 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement culturally competent care plans for two of four non-English speaking residents (Residents 33 and 64). This failure put all non-English speaking residents at risk for physical, mental, and emotional distress due to their lack of ability to communicate with staff and others. Findings: 1. During a review of Resident 64's admission Record, dated 5/19/2020, the record indicated Resident 64 was admitted with diagnoses of prior stroke, right-sided paralysis, contractures (tightening of muscles and tendons preventing normal movement) of both hands, difficulty walking, lack of coordination, and major depressive disorder. During a review of Resident 64's Minimum Data Set (MDS - a tool for assessing nursing home residents' functional capabilities), dated 12/2/2023, the record indicated Resident 64 had a Brief Interview for Mental Status (BIMS - a tool to measure ability to acquire and comprehend knowledge) Score of 7 (range 0-15),…

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 failed to ensure residents received the necessary care and services when: 1. A functional and effective communication system for four out of four sampled residents whose primary language was not English. (Resident 33, Resident 43, Resident 64, and Resident 286). This failure had the potential to impact the residents' right, care and lead to bias, misinformation, confusion, and physical harm. 2. Provide routine bathing (shower, bed bath) in accordance with standards for resident hygiene for 6 of 8 sample residents (Residents 21, 49, 130, 46, 800, 81). This failure had the potential to result in depression, poor self-esteem, skin breakdown, infection, and denial of resident rights, all of which could lead to negative clinical outcomes for Residents 21, 49, 130, 46, 800, 81. Findings: During a review of the facility's policy titled, Translation and/or Interpretation of Facility Services Policy Statement, revised 3/2022, indicated: a. This facility's language access…

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 dependent residents with dementia were provided meaningful activities to meet their needs for 3 of 4 sampled residents (Residents 64, 76 and 101). This failure had the potential for all residents to be at risk for decline in cognitive function and psychosocial well-being. Findings: During a review of Activity Programs (AP), revised 10/2023, the record indicated: - AP's are designed to meet resident interests and support the physical, mental, and psychosocial (relationship between social factors and individual thought/behavior) well-being of each resident. - Policy Interpretation and Implementation indicated: A. Activities offered are based on the assessment and the preferences of residents. B. The AP is ongoing and includes facility-organized group activities, independent individual activities, and assisted individual activities. C. Activities are considered anything in which the resident participates, other than routine activities…

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, interviews, and record review the facility failed to provide sufficient nursing staff to deliver the care and services to meet the needs of the residents when: 1. Call lights were not answered in a timely manner for five out of 28 sampled residents (Residents 81, 118, 92, and 28) and a confidential resident interview. 2. Residents were not assisted with meals for four out of five sampled residents (Resident 75, 96, 130, and 9) 3. Showers were not given as scheduled for six out of eight sampled residents (Resident 49, Resident 130, Resident 76, Resident 91, Resident 800, and Resident 81). This resulted in activities of daily living needs not to be met. Findings: A review of a facility policy titled, Activities of Daily Living (ADLs), Supporting revised March 2018 indicates residents will be provided care, treatment and services, appropriate for their needs and with the consent of the resident in accordance with the plan of care for the resident. 1. a. A review of the medical record for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: 1. Ensure medications were stored safely when multiple pharmaceutical products were found to be expired. 2. Ensure two intravenous (medication given in the veins), infusion medications were properly disposed after the residents were discharged . 3. Ensure the medication was labeled with currently accepted labeling requirements. 4. Ensure there is no discrepancy between the number of the oral medication stored in the emergency drug kit (drug supply for emergencies), and the number of the oral medication indicated on the label of the emergency drug kit. These failures had the potential for residents to receive expired wound care products, wrong and ineffective (expired) medications, and to not receive needed medications in an emergency. Findings: During a review of the facility's policy titled, Storage of Medications, revised 04/2019, indicated that Discontinued, outdated, or deteriorated drugs or biologicals are placed on designated…

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, observation and record review, the facility failed to meet this requirement when: 1. Dietary staff prepared foods hours before of mealtimes and kept food in a steamer (table with hot water bins to keep food hot), for several hours. 2. Pureed foods were alternately thickened and thinned without following a recipe. This resulted in food complaints and had the potential for food to have lost nutritive value, texture, and palatability (general edible appeal). Findings: 1. On 1/23/24 at 12:24 PM, it was observed that a piece of chicken was prepared for Resident 42 as an alternative menu choice. The chicken appeared stiff, dry and overcooked and was still being held over a pan on a lit burner. The chicken could not easily be penetrated with the thermometer when temperature was taken. During that time, dietary staff was also observed making a toasted cheese sandwich by placing what appeared to be a 1/3 stick of butter in a large pan, placing white bread slices in the resulting pool of butter, placing cheese slices on top, with the resultant product appearing heavy 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 maintain their infection prevention and control program when: 1. A Certified Nursing Assistant (CNA) assisted Residents 45 and 77 with eating lunch at the same time without sanitizing their hands in between handling the residents' utensils; 2. Linoleum flooring was separated from the walls in bathrooms of rooms 119, 121 and 123. This failure had the potential to spread germs to a vulnerable resident population which could have caused infections with negative clinical outcomes. Findings: 1. A facility policy titled, Assistance with Meals, revised 10/1/23, was reviewed. The policy indicated residents should have received assistance with meals in a manner that met the individual needs of each resident. Residents who could not have fed themselves would have been assisted with attention to safety, comfort, and dignity. A facility policy titled, Handwashing/Hand Hygiene, revised 10/1/23, was reviewed. The policy specified that hand hygiene was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed ensure a request for roommate change was accommodated for two of four residents (Resident 999 and 32). This failure resulted in loss of sleep and frustration. Findings: 1. During a review of facility policy Room Change/Roommate Assignment, dated 12/2022, indicated changes in room or roommate assignment shall be made when the facility deems it necessary or when the resident requests the change. The policy indicated residents have the right to refuse to move to another room in the facility if the purpose of the move is to (1) relocate a resident from skilled to non-skilled unit, (2) relocate from a non-skilled to a skilled nursing unit, or (3) solely for the convenience of the staff. During record review of Residence Grievance Form, dated 9/5/2023, by Resident 999 (admitted [DATE], discharged [DATE]), indicated: - Resident 999's complaint was a nearby resident was always yelling, pounding on her table with objects. I can't leave my door open because it's so…

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 assess and monitor one of five residents (Resident 72) for risk of elopement (leaving the building without notifying anyone) when a wander monitoring device (a device placed on a resident that caused an alarm to sound when a resident approached an exit door) was applied to Resident 72 with no physician's order, no Care Plan, and no follow-up. This failure had the potential to diminish Resident 72's quality of life. Findings: A facility policy, titled, Wandering and Elopements, revised 10/1/23, was reviewed. The policy indicated the facility would have identified residents who were at risk of unsafe wandering and strived to prevent harm while maintaining the least restrictive environment for residents. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan would have included strategies and interventions to maintain the resident's safety. A review of Resident 72's clinical record indicated they…

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 physician orders for oxygen were implemented for one of three residents (Resident 9) when her oxygen tank was found empty on two consecutive days in the morning. This failure had the potential for all oxygen dependent residents to be at risk for respiratory complications. Findings: During a review of facility Oxygen Administration policy, revised 10/2023, the policy indicated the purpose of the procedure was to provide guidelines for safe oxygen administration. The policy indicated Steps in the Procedure included turning on the portable oxygen cylinder to the physician-prescribed flow of oxygen and adjusting the oxygen delivery device to assure proper flow of oxygen is being administered. The policy indicated staff should check the tank to be sure it is in good working order and to observe the resident upon setup to be sure oxygen is being tolerated. During a review of Care Plans for Resident 9, last reviewed 11/21/2023, the record indicated Resident 9 was unable to perform activities of daily living…

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 that a pain assessment was done and that pain medications were aquired and available to be given for one of five sampled residents (Resident 92), when Resident 92 expressed that her pain level was 10.5 out of 10 (on a scale from 1 to 10, with 10 being the worst pain imaginable), upon admission to the facility. This failure to aquire pain medications for Resident 92 resulted in severe and uncontrolled pain for this resident and required that she be transferred back to the hospital within 7 hours after she was admitted to the facility. Findings: During a review of the facility's policy titled, Pain - Clinical Protocol, revised 10/2023 indicated: 1. The physician/Nurse Practitioner/ Physician Assistant and staff will identify individuals who have pain or who are at risk for having pain . 2. The nursing staff will assess each individual for pain upon admission to the facility . A review of Resident 92's admission record indicated that she was…

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

Based on interview and nursing schedule review, the facility failed to ensure that there was a Registered Nurse (RN) on duty 8 hours a day 7 days a week. This failure had the potential to adversely affect oversight and direction regarding resident's quality of care and quality of life directly impacting overall health and well-being. Findings: A review of the Payroll Based Journal (PBJ, an electronic system for facilities to submit staffing information), for Fiscal Year Quarter 4: (July -September 2023), indicated the facility had no RN on duty for: 7/29/23 Saturday (Sa), and 7/30/23 Sunday (Sa). During a review of the RN monthly schedule, dated July 2023, indicated there was no RN coverage for Saturdays or Sundays during the month of July. During an interview on 1/24/24 at 2:30 pm, the Assistant Director of Nursing (ADON) confirmed, We have had just a few shifts without a RN. During a concurrent interview and record review on 01/30/24 at 10:20 a.m., with the Administrator (Adm) confirmed the PBJ was correct on 7/29/23 and 7/30/23 there was no RN coverage. Requested staffing…

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 maintain medical records that were accurately documented for one of six residents (Resident 72) when a physician documented two antipsychotic (used to treat psychosis, or a loss of touch with reality) medications that the resident was not receiving. This failure had the potential to negatively impact Resident 72's care and treatment. Findings: A review of Resident 72's clinical record indicated they were admitted to the facility on [DATE]. Resident 72's diagnoses included dementia (a mental disorder that caused memory loss and confusion), depression, and anxiety. Resident 72 was not capable of making their own healthcare decisions. A physician's note, dated, 5/13/23 at 8 AM, by Medical Doctor (MD) A, was reviewed. MD A wrote, Chief complaint: monthly regulatory visit, and, Medication: none recorded, and, Plan: all medications reviewed. Continue risperidone (an antipsychotic medication). Record review of two Order Summary Reports, dated 5/1/23 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 ensure a call light system was functioning and accessible for four out of four residents (Residents 69, 96, 118, 127). This failure resulted in a delayed responses to resident care needs. Findings: During an observation on 1/23/2024 at 9 am, the bedside call light for Resident 96 was not within reach. During an interview with Resident 127 on 1/24/2024 at 9:30 am, Resident 127 stated that their call light was broken one evening and no one answered the light for about an hour. Resident 127 stated they were able to flag someone down from the hallway to assist them, and maintenance staff fixed it the next day. During an interview with Resident 118 on 1/25/2024 at 8 am, Resident 118 stated, My call light hasn't worked for days. Resident 118 stated they were given a bell to use, however Every time I use it, everyone around me gets upset, and some of them start yelling. Resident 118 stated they had to use the bathroom so bad I was in tears on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed ensure one of six residents (Resident 5) was supervised to keep him free from accidents and hazards when care plan interventions were not developed and implemented to prevent wandering/elopements, prevent falls, and injuries related to resident to resident altercations. This resulted in an elopement, wandering, falls, and resident to resident altercations. Findings: A review of Resident 5's records indicated he was admitted on [DATE], had a history of Traumatic Brain Injury (TBI, an injury that affects how the brain works), cognitive communication deficit (difficulty thinking and using language) and had partial amputations to both lower legs, and dementia with psychotic disturbance, and major depressive disorder. A record review of Resident 5's Interdisciplinary Team meeting (IDT) records dated 03/31/2023, the facility indicated that Resident 5's risk for Wandering/Elopement was high. A record review of Resident 5's nurse's note records 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 record review and interview the facility failed to recognize pain, assess pain, identify the cause of pain, and monitor and modify approaches to pain management for Resident 5. This failure resulted in uncontrolled pain and behaviors and altercations with other residents. Findings: A record review of policy and procedure last revised at an unknown date, titled, Pain Assessment and Management under General Guidelines #4 Cognitive, cultural, familial, or gender-specific influence on the resident's ability or willingness to verbalize pain are considered when assessing and treating pain. Comprehensive pain assessments are conducted upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain. Under Recognizing Pain #1 Observe the resident (during rest and movement) for physiologic and behavioral (non-verbal) signs of pain, and #2 (d) Possible Behavioral Signs of Pain: d. behavior such as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure social services were provided for four of six residents (Residents 1, 2, 3, and 5) when: 1. Resident 5 had behavior issues and resident-to-resident altercations with no psychiatric referrals, no social worker notes nor care conferences in the record. 2. Resident 1 had no social worker follow-up after a resident-to-resident altercation on 09/01/2023. Resident 2's records contained no social services follow-up after the resident-to-resident altercation, and no follow up with Resident 2 after room change. 3. Resident 3 had no social services progress notes following the resident-to-resident altercation occurring 08/28/2023. This resulted in ongoing psychosocial distress and continued resident-to-resident altercations. Findings: A review of job description titled, Social Services Director, prepared 10/16, under General Purpose, states, The responsibility of the Social Services Director is to act as advocates for the residents. Protect vulnerable…

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 two of six residents (Residents 1 and 7) were free from abuse when: 1. On 9/5/2023 at 10:11 am, it was reported Resident 2 slapped Resident 1 in his left eye. 2. On 10/04/2023 at 1:54 pm, Resident 5 hit Resident 7 in the face. These failures resulted in resident injuries and frustration. Findings: A review of the facility ' s policy titled, Abuse, Neglect, Exploitation or Misappropriation -Prevention Program, revised in 04/21, under Policy Statement, states, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident ' s symptoms. 1. A review of Resident 2 ' s records indicate she was admitted on [DATE], with diagnoses which include stroke with the loss of the of ability to understand or…

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 report allegations of abuse/neglect for two of six residents (Residents 1 and 2). This failure had the potential for all residents to be at risk for resident-to-resident altercations and abuse. Findings: A review of the facility ' s policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigation, revised 9/22, indicated that reporting must be done Immediately and defines Immediately as: within two hours of an allegation involving abuse or result in serious bodily injury. A review of a report of suspected elder abuse form dated 9/2/23, indicated Resident 1 reported to night shift Licensed Nurse (LN A) on 9/1/23 at 8 pm, that Resident 2 tried to get into bed with him. Resident 1 stated Resident 2 came back a second time, he put his hand out and asked her to leave, then she slapped him in the left eye. A review of a nurses note dated 09/02/2023 at 3:46 pm, Resident 1 reported to LN B that on 09/01/2023 around 8 pm, Resident 2 came in and tried to lay in his bed. Resident 1 stated to Resident 2…

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 investigative results for two of three facility reported incidents involving resident to resident altercations were sent to the state survey agency with 5 working days of the incidents. These failures resulted in ongoing resident-to-resident altercations, which could lead to negative clinical outcomes. Findings: A review of the facility's policy titled, Abuse, Neglect, Exploitation or Misappropriation -Reporting and Investigation, revised in 9/22, defined their follow-up report and what it is to include: 1. Within five (5) business days of the incident, the administrator will provide a follow-up investigation report. 2. The follow-up investigation report will provide sufficient information to describe the results of the investigation, and indicate any corrective actions taken if the allegation was verified. 3. The follow-up investigation report will provide as much information as possible at the time of submission of the report. 4. The resident and/or representative are notified of the outcome immediately upon…

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 obtain a Physician's order and arrange for recommended Home Health services (nursing and/or therapy provided in the home after discharge), when they discharged one of three sampled residents home (Resident 1). This failure had the potential for Resident 1 not to attain or maintain his highest practicable physical, mental, and psychosocial well-being and had the potential for a hospital readmission. Findings: During a review of the facility's policy and procedure (P&P) titled, Discharge Summary and Plan, revised 11/1/17, indicated, If the resident indicates an interest in returning to the community, he or she will be referred to local agencies and support services that can assist in accommodating the resident's post-discharge preferences. During a review of the facility's P&P titled, Discharging a Resident without a Physician's Approval, revised 10/1/22, indicated, An order for an approved discharge must be signed and dated by a physician and recorded…

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 maintain an environment safe and free from abuse for 1 of 5 sampled residents (Resident 2), when Resident 1 poked Resident 2, then followed Resident 2 to Resident 2's room and slapped Resident 2's face. This failure had the potential of causing harm, pain, and emotional distress which may result in a negative impact on the resident's health issues and overall wellbeing, both physically and psychologically. Findings: During a review of Resident 1's medical record, indicated, Resident 1 was admitted on [DATE] and deceased on [DATE], with diagnoses of dementia with severe anxiety (decline in cognitive abilities that impacts one's ability to perform everyday activities with anxiety), Diabetes Mellitus (DM), Psychotic with delusions (mental health problem that causes one to perceive or interpret things differently, and believes things that when examined rationally, are untrue). The facility's MDS (minimum data set, a standardized assessment tool), dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility's Administrator failed to administer the facility effectively and efficiently in a manner that ensured the needs of the residents were met when: 1. The Administrator falsely presented herself as a licensed Nursing Home Administrator and was not qualified to act in the capacity. 2. The Administrator had not ensured that there was a Director of Nursing (DON), to evaluate the delivery of clinical services, admissions and monitor resident outcomes. 3. The Administrator failed to ensure there were enough Registered Nurses (RNs) to administer physician ordered medications. 5. The Administrator failed to ensure all licensed nurses in the building had a current license. This had the potential to result in substandard quality of care to all the residents in the facility and negatively impact their quality of life and ability to attain or maintain their highest practicable level of physical, emotional and psychosocial well-being. Findings: The facility's job…

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, record and document reviews, the facility's Governing Body (facility owners, executives, or other individuals who are legally responsible for the management and operations of a facility), failed to ensure that the Administrator (individual who is responsible for the facility's operating budget, supplies, staff and any other services necessary for the care of the residents), they appointed had a valid Nursing Home Administrator's (NHA) license issued by the State of California's Nursing Home Administrator Program (NHAP, the State Department that ensures that resident's rights are safeguarded and that all qualifications and background checks are met before they will issue a NHA license). This had the potential for the facility to be inefficiently operated and managed by unqualified leadership that could potentially mishandle services necessary for the care of the residents resulting in an unfavorable outcome for the residents. Findings: On 8/21/23, the California Department of Public Health (CDPH), received a complaint that the facility's Administrator…

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 have an effective Quality Assurance Performance Improvement (QAPI), when the committee did not develop, implement, and identify performance improvement activities related to quality of care and life when: 1. Residents right to be comfortable in their home was not honored. This resulted in a decrease in quality of life when residents reported staying in their rooms, sleeplessness and frustration about the AC not working in the facility. 2. Ensure sufficient Registered Nurse and Director of Nursing staffing required for the oversight of care provided to residents in the facility. This resulted in missed doses of an antibiotics and had the potential to delay healing and discharge from facility. Findings: A review of a facility policy titled Quality Assurance and Performance Improvement (QAPI) Program revised February 2020, indicated this facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI Program that is focused on indicators of the outcomes of care and quality of life for our…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure the temperatures were at comfortable levels for resident rooms, hallways and common areas on Station 3 and Station 4. These failures resulted in residents to be uncomfortable, stay in their rooms, sleeplessness, and frustration. Findings: A review of an online weather resource on www.wunderground.com, indicated on 8/22/23 the outside temperature was 99 degrees Fahrenheit (F). During a concurrent observation and interview on 8/22/23 at 4:02 pm, Maintenance Facilities Director (MFD) confirmed the air temperature on Station 3 hallway was 82 degrees F. During an interview on 8/22/23 at 4:40 pm, Resident 3 in room [ROOM NUMBER]A stated Yes, I will talk to you. It stays hot out there; I feel so sorry for the staff. I never leave my room anymore because it is too hot in the dining room or in the halls. I just stay in my room now. It has been like this for about 2 months. I keep my door closed to stay cool, my air conditioner works, but not…

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

Based on observation, interview and record review the facility failed to ensure sufficient licensed nursing staff to meet the needs of the residents when: 1. A Registered Nurse (RN) was not available 8 hours a day This resulted in Resident 1 not to receive a antibiotic via a Peripherally Inserted Central Catheter (PICC, thin, soft, long tube that is inserted into a vein for medications). 2. Director of Nursing (DON) was not replaced timely for a planned leave of absence. This resulted in decreased RN coverage and oversight of daily resident admission screening to ensure residents needs were met. Findings: 1. A review of staffing and scheduling documents from 7/24- 8/13/23 indicated no RN coverage on: -7/24/23, LN H called off, and LN B was scheduled as the Minimum Data Set (MDS) office nurse for the day and was not listed nursing staffing assignment signature sheet. -7/29/23, LN I called off, and LN B was scheduled as MDS office nurse for the day and was not listed nursing staffing assignment signature sheet. -7/30/23, LN B was scheduled as MDS office nurse for the day and was not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure equipment in the facility was maintained when the Central Air Conditioning (AC) system and Packaged Terminal Air Conditioners (PTAC, a standalone AC/heater, self-contained, meaning they do not rely on ducts to operate) on Station 3 and 4 were not working. This resulted in an uncomfortable temperature during the summer months and resident discomfort. Findings: During a concurrent observation and interview on 8/22/23 at 4:02 pm, Maintenance Facilities Director (MFD) confirmed the air temperature on Station 3 hallway was 82 degrees Fahrenheit (F) and room [ROOM NUMBER] did not have a PTAC. MFD stated All I can do is report it, they all know. I have been checking the temperatures and reporting them. MFD stated, we need PTACs and three central AC roof top units to cool Station 3 and 4 nursing stations. MFD stated he has been talking to administrator about the high temperatures and cannot fix until approved. During an interview on 8/22/23…

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 medications were administered as per physician orders when Resident 1 did not receive a necessary antibiotic to treat a severe infection. This resulted in 3 missed doses of an antibiotics and had the potential to delay healing and discharge from facility. Findings: A review of a facility policy titled Adverse Consequences and Medication Errors Policy, dated February 2023, indicated the interdisciplinary team monitors medication usage in order to prevent and detect medication-related problems such as adverse drug reactions and side effects. A medication error'' is defined as the preparation or administration of chugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. Examples of medications errors include: Omission - a drug is ordered but not administered; Each incident report is forwarded to, Director of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) was free from physical abuse from a Certified Nursing Assistant, (CNA), when CNA E was witnessed by staff throwing a piece of bread at Resident 1. This failure resulted in physical abuse for Resident 1 and the potential for all residents to be at risk for physical abuse and loss of dignity. Findings: During a review of the facility's policy not dated, titled Abuse and Neglect Protocol, indicated Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual…

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 report the results of an investigation of staff to resident abuse to the California Department of Public Health (CDPH) within five days for one of two sampled residents (Resident 1) when the five-day report was not submitted to CDPH following . This had the potential to put all residents at risk for abuse from staff at the facility. Findings: A review of the facility's abuse policy revised December 2009, titled Reporting Abuse to State Agencies and other Entities/Individuals, indicated all suspected violations and all substantiated incidents of abuse will be immediately reported to appropriate state agencies and other entities or individuals as may be required by law. This facility's policy also indicated The Administrator, or his/her designee, will provide the appropriate agencies or individuals listed above with a written report of the findings of the investigation within five (5) working days of the occurrence of the incident. During a review of Resident 1's clinical record indicated a review of a document dated 8/4/23,…

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 3 of 4 sampled residents (Resident 1, 3, and 4) received physician ordered medications at prescribed scheduled times. This failure had the potential to for adverse side effects from uncontrolled blood sugar levels for Resident 1, 3 and 4. Findings: 1. A review of a facility policy titled Administering Medications, undated, indicated that medications .must be administered within one (1) hour of their prescribed time, unless otherwise specified. A review of Resident 1 ' s admission record indicated he was admitted on [DATE], with diagnoses which included diabetes and muscle weakness. Resident 1 was able to make his health care decisions. A review of Medication Administration Record (MAR) for July 2023, the Lantus SoloStar insulin was administered late (one hour after scheduled time) 8 out of 16 times on 7/3, 7/5, 7/7, 7/8, 7/9, 7/11, 7/12, and 7/16/23. Resident 1's Humalog insulin was administered late 9 out of 80 times on twice on 7/5, twice on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure the physician was notified of a change of condition for one out of four residents (Resident 1) when: 1. Resident 1 had signs and symptoms of high blood sugar levels. 2. Resident 1 was not participating in physician ordered physical and occupational therapy. This failure resulted in Resident 1 having nausea, weakness, blurred vision, excessive thirst, light headedness, frustration, anxiety, and caused him not to participate in therapy which delayed his discharge. Findings: A review of a facility policy titled Diabetes , (undated), indicated the staff will identify and report issues that may affect, or be affected by a resident's diabetes management such as skin ulcerations, increased thirst, or hypoglycemia (low blood sugar). The policy indicated how to manage hypoglycemia (low blood sugars) but not how to manage hyperglycemia (high blood sugar). A review of a facility policy titled Change in a Resident's Condition or Status , (undated),…

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 nursing staff had appropriate competencies necessary to care for one out of four residents, Resident 1, when: 1. Nursing staff failed to get a physician's order before changing an insulin sliding scale when Resident 1 was admitted . 2. Nursing staff failed to identify and document Resident 1's signs and symptoms of hyperglycemia (high blood sugar levels) and notify Medical Director with change of condition. 3. Nursing staff discontinued blood sugar level checks when the physician only discontinued the bedtime sliding scale insulin administration order. This failure caused Resident 1 to have weakness, blurred vision, extreme thirst, frequent urination, headache, stomachache, nausea, sleeplessness anxiety, frustration and inability to participate in therapy delaying discharge from facility. Findings: 1. During a review of a facility policy titled Diabetes, (undated), indicated the staff will identify and report issues that may affect, or be affected by a resident's diabetes management such as skin ulcerations,…

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 one of four residents (Resident 1) received physician ordered physical and occupational therapy due to hyperglycemia (high blood sugar levels). This failure delayed Resident 1 from being safely discharged home. Findings: A review of Resident 1's admission record indicated he was admitted on [DATE], with diagnoses which included diabetes and muscle weakness. Resident 1 was able to make his health care decisions. A review of therapy orders dated 7/4/23, indicated Resident1 to receive skilled physical therapy 5 times/week for 4 weeks and occupational therapy was ordered for 4 days/week for 4 weeks to safely discharge home. During an interview on 7/19/2023 at 8:40 am, Resident 1, stated he had signs of hyperglycemia (high blood sugar) throughout his stay. Resident 1 experienced weakness, blurred vision, extreme thirst, frequent urination, headache, stomachache, nausea, sleeplessness anxiety and frustration. Resident 1 stated the reason he was at 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 provide sufficient supervision to prevent accidents for two of 59 sampled residents (Residents 38 and 109) when the use of and documentation for fall alarms (a device that emitted a noise to alert staff that the resident got out of a bed or chair) were not consistent. This failure had the potential to contribute to an unsafe environment that put Residents 38 and 109 at risk for falls with injuries. Findings: A facility policy, titled, Falls and Fall Risk, Managing, undated, was reviewed. The policy indicated that based on previous evaluations and current data, the staff would have identified interventions related to the resident's specific risks and causes, to have tried to decrease the risk for falls and related complications. Resident conditions that may have contributed to the risk of falls included cognitive impairment, lower extremity weakness, and functional impairment. The staff, with the input of the attending physician, would have implemented fall prevention interventions to reduce the specific risk…

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 that all resident care plans were accurate and updated when one care plan for Resident 2 did not accurately reflect his physician's orders. This had the potential to impact staff response and monitoring for the resident's psychoactive (effects thoughts and feelings) medications. Findings: Resident 2 was admitted on [DATE] with diagnoses that included dementia with behavioral disturbances, psychotic disorder with delusions, and major depression. His physician's orders, dated 7/19/22, indicated Trazadone (an antidepressant) give 25 milligrams (mg) by mouth at bedtime for inability to sleep. A second physician's order, dated 9/1/22, indicated Risperdal (an antipsychotic) give 0.5 mg two times a day for psychotic disorder with delusions (as evidenced by) aggressive behaviors, screaming, yelling, hitting. During an interview and concurrent record review with Assistant Director of Nurses (ADON), on 9/14/22 at 11:45 am, she reviewed the Care Plans 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 ensure that all resident care plans were reviewed and revised for all residents when the care plans for 1 resident (Resident 116) did not consistently reflect his use of a G-Tube (gastrostomy tube, a device used to deliver nutrition, fluids, and medication directly into a resident's stomach.) This had the potential to confuse staff providing care and placed the resident at increased risk for aspiration (breathing food or fluids into the lungs) if staff administered anything to the resident orally. Findings: Resident 116 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included cerebral infarction (stroke) dysphagia following a cerebral infarction (difficulty or inability to safely swallow), and gastrostomy (an opening surgically created between the stomach and abdomen and placement of G-Tube) status. The record for Resident 116 was reviewed. The physician's order, dated 8/23/22 indicated the resident was strictly NPO (no 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Resident 116 was admitted on [DATE] and readmitted after a brief hospital stay on 9/12/22 with diagnoses that included cerebral infarction (stroke) dysphagia following a cerebral infarction (difficulty or inability to safely swallow), and gastrostomy (an opening surgically created between the stomach and abdomen, through which a G Tube is inserted). The record for Resident 116 was reviewed. A physician's order, dated 8/23/22, indicated the resident should have no food, fluids, or medications by mouth (NPO). A physician's order, dated 8/23/22 indicated Aspirin, give 81 milligrams (mg) via G-Tube one time a day. A physician's order dated 8/23/22 indicated, Atorvastatin (a medication to reduce cholesterol) give 40 mg via G tube. A physician's order, dated 8/31/22 indicated, Lasix give 20 mg via G-Tube one time a day. A physician's order, dated 8/23/22 indicated, FerrouSol (a liquid iron supplement) give 125 mg via G Tube. During an observation on 9/14/22 at 9:13 AM with Licensed Nurse (LN) C she was observed…

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 kitchen staff were competent to carry out the responsibilities of the Food and Nutrition Services when: 1. Staff did not prepare pureed foods according to the standardized recipe. 2. Staff were unclear regarding manual ware washing water temperature requirements. 3. Staff utilized non-food-safe chemicals in food areas. These failures had the potential to result in foodborne illness, decreased nutritional status, decreased meal satisfaction, and medical decline for residents consuming food prepared in the kitchen and food areas. Findings: 1. Staff did not properly prepare pureed foods. Review of job descriptions provided by Human Resources showed: Job Description: Cook dated 10-2016, Essential Duties included Prepare pureed foods. Job Description: Dietary Aide dated 10-2016, showed the Dietary Aide reported to the [NAME] and Dietary Supervisor. Essential Duties showed Dietary Aides assisted with serving meals, and prepared nourishments and snacks, but did not show that Dietary Aides prepared pureed…

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 menus were in place, prepared in advance and followed when: 1. Staff did not follow the menu for vegetarian diets and one (Resident 99) out of three (Residents 79, 99, 101) on vegetarian diets stated the menu was not followed and was not consistent. 2. Staff prepared pureed fruit instead of the pureed dessert indicated on the menu for all residents on pureed diets without prior approval from the Registered Dietitian. These failures created the potential for residents to receive food that did not meet their nutrient needs and or provide the variety in foods and flavors needed to encourage meal intakes and enhance resident's quality of life. Findings: 1. The vegetarian menu was not followed. During an observation in the cook's area on 9/12/22 at 11:25 AM, [NAME] A was cutting up and preparing tofu for lunch. In a concurrent interview [NAME] A stated she was preparing seasoned tofu for the vegetarian residents. She explained for the vegetarian diets she tried to mimic the flavors of the main dish served…

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

Based on observation, interview and record review, the facility failed to ensure food was stored, prepared and distributed in accordance with professional food safety standards when: 1) Two out of three observed nursing unit pantries were unsanitary and contained ants. 2) Chemicals that were not food-safe were used to clean food service areas. 3) Kitchen equipment was not maintained in a sanitary manner 4) Trash can in handwashing area was not emptied timely as needed. These practices had the potential to result in foodborne illness for residents consuming food in the facility. Findings: 1. Two out of three observed nursing unit pantries were unsanitary and contained ants. Review of a policy titled Sanitation, dated 2018, showed All utensils, counters, shelves and equipment shall be kept clean, and On a monthly basis, a pest control company will inspect and service the Food & Nutrition Services Department. If at any time additional servicing is needed, the pest control company will be notified. 1A. Station 3 Food Pantry During an observation in the nursing pantry on Station 3 on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to have an effective Governing Body (GB) when: 1. There were no policies for the use of fall alarms, documentation of fall alarms, and documentation of fall risk assessments by nursing. Refer to F689. 2. Community complaints about not being able to contact staff and residents via telephone were not resolved after nine months. This failure had the potential to threaten the well-being of residents and their family members. Findings: 1. A facility policy, titled, Quality Assurance Performance Improvement (QAPI) Plan, last annual review date of 7/15/22, was reviewed. The policy indicated its purpose was to have focus areas that included all systems that affected resident and family satisfaction, quality of care and services provided, and all areas that affected the quality of life for persons living and working in the organization. The outcome of QAPI was to improve the quality of care and the quality of life for the residents. Among the 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.

Based on observation, interview and record review, the facility failed to ensure that infection control measures were followed when a staff member was observed entering a Resident room without proper Personal Preventive Equipment (PPE). This failure had the possibility of spreading Covid - 19 (a very easily spread, severe viral infection) to all of the residents and staff in the facility as well as to the community. Findings: During an observation of the facility on 9/12/22 at 10:10 AM, a Restorative Nurse Assistant (RNA) 1, was observed going into a resident room, which housed two residents in a Yellow Zone, to weigh one of the two residents. A yellow zone is an area in the facility where residents are isolated due to being suspected of having Covid, having been exposed to Covid, or under observation for Covid. RNA 1 did not put a gown on upon entering the room. On exit from the room, RNA 1 stated that a gown should have been worn upon entering the room and stated she had not worn one. During an interview on 9/14/22 at 4:09 PM, Infection Preventionist (IP) stated that every room 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.

Based on interview and record review the facility failed to ensure that all staff were either fully vaccinated for COVID-19 or granted an approved exemption. This was not met when one facility staff was not fully vaccinated for COVID-19 and did not have a record of an exemption, one staff member had completed their vaccination, but this status was unknown, and one staff member had been granted an exemption but this status was unknown. This placed residents and staff at increased risk for exposure and had the potential for unvaccinated staff to be outside the testing parameters appropriate for their level of risk. Findings. On 9/15/22 the facility record of staff vaccination status for COVID-19 was reviewed. Three staff were noted to have been only partially vaccinated CNA (certified nursing assistant) E, CNA G, and DA (Dietary Aid) F. During an interview and concurrent record review with the IP (Infection Preventionist) on 9/15/22 at 3 PM, he confirmed that three staff (CNA E, CNA G, and DA F) had been partially vaccinated. IP confirmed that he did not have documentation of an…

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

Based on observation, staff interview and record review the facility failed: 1. To ensure kitchen floor drains and drainpipes were kept in good repair 2. To ensure the leaking plumbing at the kitchen hand-washing sink was repaired timely. 3. To ensure kitchen floors, walls, wall guard and one cabinet drawer were maintained in good repair. 4. To ensure an effective system was in place to report and track Food and Nutrition Services maintenance needs. These failures had the potential to result in compromise to kitchen sanitation, food safety, and staff safety. Findings: Review of an undated policy provided by the Facility's Director (FD) titled Maintenance Service, showed The Maintenance Department is responsible for maintaining the building, grounds and equipment in a safe and operable manner at all times .Functions of maintenance personnel include, but are not limited to: Maintaining the building in compliance with current federal, state and local laws, regulations, and guidelines .Maintaining the building in good repair and free from hazards .Maintaining .plumbing fixtures .in good…

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.