Chico Terrace Care Center

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) Fixed equipment (Fixed equipment is equipment that cannot be put thought a dish washer or washed in a sink, such as refrigerators, steamers, stoves, carts, counters, shelving, and small appliances) was not clean. 2) Apron was not changed between cleaning dishes and preparing food. Apron was not worn when soiled counter was cleaned. 3) Dietary staff touched face with gloved hands when trays were loaded onto cart and did not change gloves or wash hands. Dietary staff touched tops and bottoms of dessert bowls and scooped Jell-O into them without gloves. 4) Cabinets, floors and walls were uncleanable. 5) Evidence of roaches under one sink. 6) Chlorine concentration was outside of acceptable parameters. 7) Ice machine was not cleaned according to manufacturer recommendations. These practices had the potential to result in foodborne illness for residents from food prepared by the facility food 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 conditions essential to the sanitation of the kitchen were maintained when uncleanable surfaces were not repaired or replaced. This failure had the potential to result in cross contamination, the attraction of pests, and foodborne illness for all residents consuming food from the facility. Findings: A review of the Food and Drug Administration (FDA) 2022 Food Code, Section 4-202.16, Nonfood-contact surfaces shall be free of unnecessary ledges, projections, and crevices, and designed and constructed to allow easy cleaning and to facilitate maintenance. A review of facility policy titled Maintenance Service, dated 1/1/12, showed The Maintenance Department maintains all areas of the building, grounds, and equipment .in compliance with current federal, state and local laws, regulations, and guidelines. During an observation in the kitchen on 3/03/25 at 8:04 AM, the floor in the refrigerator/freezer room was damaged and uncleanable in three locations. In addition, the walls, doorways, and doors in multiple…

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

Based on observation, interview and record review the facility failed to maintain an effective pest control program when: *1. The facility did not have an effective system in place to track and monitor pest control issues in the facility. *2. Cockroach traps, and evidence of cockroach presence were found in a cabinet under a food preparation sink in the facility kitchen. These failures had the potential to result in transmission of disease, or to trigger allergies or asthma for 72 residents living at the facility. Findings: The Food and Drug Administration (FDA) Food Code 2022, 6-501.111 showed: The premises shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the premises by: (A) Routinely inspecting incoming shipments of food and supplies; (B) Routinely inspecting the premises for evidence of pests; (C) Using methods, if pests are found, such as trapping devices or, other means of pest control (D) Eliminating harborage conditions (conditions that encourage pests to live…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 two out of eight sampled residents (Resident 18 and Resident 370) received their showers as scheduled, and as needed. This failure had the potential to result in emotional stress, anger, depression, feelings of neglect, denial of resident rights, and not identifying altered skin integrity. Findings: During a review of the facility's policy revised 1/1/2012, titled, Showering and Bathing, indicated a tub or shower is given to the residents to provide cleanliness, comfort, and to prevent body odor. Observe the skin is performed during the bath. The facility's policy revised 3/2017, titled, Quality of Life-Dignity, indicated that each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. All residents shall be treated with dignity and respect at all times. The staff shall promote dignity and assist the residents as needed by promptly responding to the residents'…

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

Based on observation, interview, and record review the facility failed to ensure food was palatable and meat easy to cut with a knife when four out of four residents interviewed (Resident 15, 18, 59, 372) stated the food needed more seasoning or salt and/or the meat was difficult to cut with the provided knife. This failure had the potential to result in decreased resident meal intakes, weight loss, and decline in health status. Findings: During an observation on 3/4/25 at 9:26 AM, [NAME] B prepared a baking sheet of Ranch-style chicken for lunch. A concurrent review of the recipe titled Ranch Style Chicken Breast, dated 2025, called for baking sheet to be greased, chicken breasts to be baked for 15 minutes, removed from oven, covered in ranch dressing, and put back in oven. Observed [NAME] B pour cooking oil into baking sheet, placed chicken breasts on baking sheet, removed from oven after 15 minutes, temperature checked with thermometer, and placed back into oven. [NAME] B was not observed putting ranch dressing onto the chicken breasts. During an observation and concurrent…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 physician orders for a suprapubic (S/P, a thin tube inserted directed into the bladder at the abdomen to drain urine) catheter changes and site care were obtained upon admission to the facility for one of three sampled residents, (Resident 18) for a new admission. This failure had the potential for a negative clinical outcome, re-hospitalization, and Resident 18 had specific skin treatment needs that were not identified in a timely manner. Findings: The facility's policy revised 8/22/2019, titled, admission Criteria, indicated the facility admits residents upon the order of a physician who have medical needs that require skilled nursing care. The administrator or his or her designee responsible for screening resident for admission to the facility will ensure that the facility only admits residents whom it can provide adequate care. The facility's policy revised 1/25/2024, titled, Dialysis Management, indicated the facility should…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 eight sampled residents (Resident 43) received coordination of care to get out of bed daily, and at meals to improve quality of life, and to meet goals towards independence to discharge home. These failures had the potential to result in emotional stress, anger, depression, feelings of neglect, denial of resident rights, and prevent the resident from achieving their highest practicable level of physical and emotional well-being. Findings: During a review of a policy revised 8/21/2020, titled, Bowel and Bladder Training/Toileting Program, indicated the purpose for residents who are incontinent of bowel and/or bladder appropriate treatment and services to minimize urinary tract infections and to restore as much bowel and/or bladder function as possible to prevent skin breakdown and irritation, improve resident morale, and restore resident dignity and self-respect. The facility's policy revised 3/2017, titled, Quality of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the Certified Nursing Assistants (CNA)s, and the Licensed Nurses (LN)s had competent skills when: 1. CNAs and LNs did not provide Dementia care for Resident 35 when resident was left in the Dining room alone and fell. 2. LNs did not verbalize understanding of phosphorus binder medication administration for Resident 18 and Resident 373. 3. LN A was not able to verbalize instructions for use for an inhaler ordered for Resident 373. These failures had the potential to result in emotional stress, anger, depression, feelings of neglect, denial of resident rights, and prevent the resident from achieving their highest practicable level of physical and emotional well-being. These failures did result in a fall for Resident 35. Findings: 1. A review of the facility's policy revised 10/2017, titled, Dementia Care, indicated the purpose is to optimize the quality of life for individuals living with a diagnosis of dementia at the facility. It…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a Care Conference meeting, to determine that a resident may be appropriate for a facility initiated discharge, occurred with the Interdisciplinary Team (IDT, a group of healthcare professionals nurses, therapists, social workers, dietitians and activities staff who work together to plan the residents care), Physician, the resident and resident ' s responsible party (RP, an individual who assumes varying degrees of responsibility for the well-being of the resident) for one of two sampled residents (Resident 1) when Resident 1 ' s RP indicated she never had a meeting with the facility about Resident 1 ' s discharge therapy levels or training on how to assist Resident 1 with his mobility at home and Resident 1 was unable to make it into the house and could not stand or transfer. This failure had the potential for a decline in Resident 1 ' s physical, psychosocial, and mental well-being after discharge from the facility. Findings: A review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure they provided care and services for one of two residents (Resident 1) sampled for unplanned weight loss when: 1. Resident 1 was not weighed as per facility policy. 2. There was no weekly monitoring of Resident 1 ' s weight by an Interdisciplinary Team (IDT, a group of healthcare professionals nurses, therapists, social workers, dietitians and activities staff who work together to plan the residents care) the first 10 weeks after admission. 3. Care plan titled Nutritional problem or potential nutritional problem was not reviewed or revised to reflect an actual weight loss and no interventions were added to his care plan. These failures delayed care and services needed for Resident 1 to prevent weight loss and had the potential to add to the cause of Resident 1 ' s 18.8-pound weight loss in two months. Findings: A review of Resident 1 ' s admission record indicated Resident 1 was originally admitted on [DATE] with diagnoses that included two…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 food that is palatable (refers to the taste and/or flavor of the food), attractive, and nutritious. Complaints of food that is not appetizing or palatable for three of five (Residents 3, 5 and 6). This had the potential for all residents to receive an inadequate amount of nutrition required to aid in the recovery from illness or injury or maintain a healthy body weight. Findings: A review of a facility policy titled Menu Operational Manual Policy, revised 04/01/2014, The Dietary Manager will develop menus in collaboration with the Dietitian. Menus are to be designed in consideration of resident preferences, Dietary Department resources, and seasonal availability of food. A record review of monthly Resident Council Meeting minutes from 6/26/24 to 10/24/24, included complaint/concerns regarding food including not liking the new food, wishing they had a different menu, and the food being too cold to consume. A record review of a Food & Nutrition: Resident Satisfaction Survey completed on 9/3/24, had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a food was prepared in a safe and sanitary kitchen in accordance with professional food standards when: 1. Food was stored in a refrigerator that was not maintained at the required temperatures for storage. 2. Food storage containers were stacked wet and available for use. 3. A soiled towel was used around a floor drain to prevent splashing. This had the potential to put all residents at risk for food borne illness. Findings: 1. A record review of Facility Visit Report - Nutritional Services dated 09/26/24, the Registered Dietician (RD) kitchen audit identified an issue of concern that the [NAME] refrigerator inside temperature was 45 degrees F. During a concurrent observation and interview on 11/08/24 at 12:30 pm, Dietary Aide (DA) confirmed the [NAME] double door fridge inside temperature was 49 degrees Fahrenheit (F). During a concurrent observation and interview on 11/20/2024 at 9:55 am, the inside temperature of the double…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 identify and act upon a change in condition by notifying the physican of post fall pain for one out of six sampled residents (Resident 4). This resulted in delay of treatment which caused unnecessary pain and suffering. Findings A review of Resident 4 ' s admission record indicated he was admitted to the facility on [DATE], with diagnoses which included dysphagia and aphasia following a cerebral infarction (difficulty swallowing and talking following a stroke), muscle weakness, frequent falls at home and dementia. A review of Residents 4 ' s admission notes on 6/29/24 at 1:24 pm, by a Licensed Nurse (LN) indicated resident had no pain on admission. A review of Resident 4 ' s nursing progress note dated 7/1/24 at 5:06 am, indicated Resident 4 had an unwitnessed fall at 4:45 am on 7/1/24. Resident 4 was found on the floor with wet brief twisted around his feet. LN documented Resident 4 had a new injury of skin tear between left thumb and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to develop a Person-Centered baseline care plan within 48 hours of a resident's admission to meet the resident's immediate needs for one of the 6 sampled residents (Resident 4). This failure placed Resident 4's health at risk when resident's person centered care plan was not created upon admission. Findings: A review of Resident 4 ' s admission record stated he was admitted to the facility on [DATE], with diagnoses which include frequent falls, dysphagia and aphasia following a cerebral infarction (difficulty swallowing and talking following a stroke), muscle weakness, and dementia. A record review of Resident 4 ' s care plans, no baseline care plan was found in the record for the first admission on [DATE] for fall prevention, there was a baseline care plan on his readmission on [DATE]. During a concurrent interview and clinical record review for Resident 4 with the Director of Nursing (DON), on 12/18/24 at 10:10 am, DON was unable to find documented…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility to ensure one of six residents (Resident 4) had a plan of care to meet his pain management needs after a fall with substantial injury. This resulted in untreated severe pain and a delay in treatment. Findings: A review of the facility ' s policy titled, Pain management, revised November 2016, indicated: Facility staff will help the resident attain or maintain their highest level of well being while working to prevent or manage the resident ' s pain to the extent possible. Procedure includes a licensed nurse will assess each resident for pain upon admission, quarterly, when there is a new onset of pain, exacerbation of pain, or when there is a change in status. If the Licensed Nurse is unable to determine if the resident's nonverbal cures are related to pain, the nurse will advise the Attending Physician and Interdisciplinary Team {IDT), so that the Attending Physician can consider ordering a trial pain medication to alleviate symptoms or identify another…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 dietary staff followed the dietary menus and a recipe for a lunch meal when: 1. An unapproved substitute meal was provided without reasonable effort made to ensure nutritional adequacy. 2. A recipe was not followed for creamy rice. This had the potential for all residents not to receive their nutritional requirements to maintain normal body weight. Findings: A review of a facility policy titled Menu Operational Manual Procedure, revised 04/01/2014, indicated food service should adhere to the written menu. Substitutions to the menu should be comparable in nutritional value taking into consideration vitamins, minerals, and calories. Substitutions should also be reviewed by the Dietary Manager and Dietitian for appropriateness per the diet order and recorded on Form A - Substitution List. 1. During a concurrent observation, interview and record review on 11/08/24 at 12:10 pm, a meal tray line was observed. A review of the menu dated 11/08/2024, indicated baked tilapia, creamy rice, tartar sauce, mixed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 facility air temperatures were at a comfortable level for resident rooms and hallways on Station 2. These failures resulted in residents to feel uncomfortable, tired, horrible, and lost sleep. Findings: A review of a facility policy titled, Extreme Weather , revised on 01/01/12, indicated that the facility responds to extreme weather in a prompt manner to protect the health and safety of residents. The purpose is to provide residents, visitors, and staff with a comfortable and safe environment during extreme weather. A review of a facility policy titled, 4.6. Extreme Weather - Heat or Cold , undated, indicated it is the policy of the facility to protect residents, staff, and others who may be visiting from harm. The priority of the facility is to minimize stress that the residents could experience from extreme temperatures. To mitigate (to make less severe, serious, or painful), the facility rigorously maintains their systems…

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

Based on observations, interviews, record review, and facility policy, the facility failed to secure urinary catheter tubing for 1 (Resident #12) of 2 sampled residents reviewed for urinary catheter. Findings included: Review of the facility policy titled, Catheter Care, revised on 06/15/2011, revealed, The catheter will be anchored to prevent excessive tension on the catheter. Review of Resident #12's admission Record revealed the facility admitted the resident on 01/13/2023, with diagnoses to include neuromuscular dysfunction of the bladder and overactive bladder. Review of Resident #12's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/11/2024, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS revealed the resident had an indwelling catheter. Review of Resident #12's care plan initiated on 01/18/2023, revealed the resident had an indwelling urinary catheter related to a diagnosis of neurogenic bladder. On 03/25/2024 at 1:26 PM and on 03/26/2024 at…

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

Based on interviews, record review, and facility policy titled, the facility failed to ensure an as-needed psychotropic medication had a 14-day end date for 1 (Resident #1) of 5 sampled residents reviewed for psychotropic medications. Findings included: Review of the facility policy titled, Behavior/Psychoactive Drug Management, revised in November 2018, revealed, Any Psychoactive Medication ordered on a prn basis, must be ordered not to exceed 14 days. If the physician feels the medication needs to be continued, he/she must document the reason(s) for the continued usage, and write the order for the medication; not to exceed the 14 day time frame. Review of Resident #1's admission Record revealed the facility admitted the resident on 07/26/2019, with diagnoses to include anxiety disorder and insomnia. Review of Resident #1's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/14/2024, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS revealed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility failed to meet this requirement when one of three sampled residents (Resident 1) received no documented bathing between 12/8/23 and 12/15/23 (seven days). This potentially contributed to Resident 1's several areas of documented skin redness and breakdown. Findings: Resident 1 was admitted to the facility on [DATE] for repeated falls, encephalopathy (brain dysfunction), muscle weakeness, arthritis, and weakness. A review of the facility ' s record titled, Showers and Bathing, revised 1/1/12, indicated, a tub or shower bath is given to residents to provide cleanliness, comfort, and to prevent body odors. The record further indicated, Residents are given a tub or shower bath unless contraindicated, and observe the skin during the bath. A review of the facility ' s record titled, ADL report, looking back at the dates 12/7/23 to 12/18/23, indicated not applicable under bathing on the following dates: 12/8, 9, 10, 11, 12, 13, 14, and 12/15/23. Similarly,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 implement their Skin Integrity Management policy and procedure when two out of two sampled residents (Resident 1 and Resident 2), had wounds and the facility had not followed procedures as outlined in their policy. 1a. Resident 1 had a chronic (occurring for a long time, more than three months), infected chest wound and there were no wound measurements (written measurement that described the length, width, and depth of the wound) documented in the medical record; and 1b. Resident 1 had a chronic, infected chest wound and two weekly wound assessments did not include the effectiveness of the current treatment when the Licensed Nurse (LN) inaccurately documented there was no wound; and 1c. Resident 1 had a chronic, infected chest wound and there was no Interdisciplinary Team (IDT, a group of heath care professionals who met to discuss and make recommendations about resident care to evaluate if the resident was meeting their goals) meeting notes. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to respond timely to resident's request and treat resident with dignity and respect for one of three sampled residents (Resident 1). This failure resulted in Resident 1 lying in feces for a long period of time and upsetting Resident 1. Findings: During a review of Resident 1's clinical record, indicated that she was admitted to the facility on [DATE] with diagnoses which included heart disease, diabetes (high blood sugar), and difficulty in walking. Resident 1 was determined to be capable of making her own healthcare decisions on 7/22/2023. Resident 1 was discharged on 9/13/2023. During a review of Resident 1's Minimum Data Set (MDS - an assessment and care screening tool), dated 7/29/2023, the MDS indicated that Resident 1 had a brief interview for mental status (BIMS) score of 11, at section C Cognitive Patterns indicating that her cognition was moderately impaired. During a review of Resident 1's MDS at section G - Functional Status, 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 interview and record review, the facility failed to follow the facility's policy and the physician orders to prevent Pressure Ulcers/Injuries (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device), revise individualized care plan and provide treatment for the pressure injury wound for one of three sampled (Resident 1). These failures could have the potential to delay the wound healing and increased the risk of infection. Findings: During a review of the facility's policy and procedure (P&P) titled, Pressure Injury and Skin Integrity Treatment , dated 8/12/2016, the P&P indicated, Treatments to pressure injuries and other skin integrity problems will be provided as ordered by the physicians , Treatments administered will be documented on the Treatment Administration Record , and Update the resident's Care Plan as necessary. During a review of Resident 1's clinical record, indicated that she was admitted to the facility on [DATE]…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Resident 2 was free from abuse when Resident 1 yelled at him aggressively, threatened him verbally and grabbed his arm. This resulted in Resident 2 to fear further encounters with Resident 2 and had the potential to put all residents in the facility at risk for abuse. Findings: During a review of the facility's policy and procedure titled, Abuse, Prevention, Screening, and Training Program, dated July 2018, indicated that abuse was defined as the willful, deliberate infliction of injury, intimidation, mistreatment, punishment with resulting physical harm, pain, or mental anguish. It also indicated ' Willful ' , as related to abuse, is defined as the individual acting deliberately (not inadvertent or accidental) and not that the individual must have intended to inflict injury or harm. The Abuse policy outlined preventions for abuse, and The facility identifies, corrects, and intervenes in situations in which abuse, neglect,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interventions to address Resident 1's dementia behavior care needs. This failure resulted in resident-to-resident altercation when Resident 1 verbally and physically abused Resident 2. Findings: During a review of the facility's policy and procedure titled Behavior Management, dated 1/16/22, it indicated the facility will ensure that when a resident displays a mental disorder, psychosocial adjustment difficulties .they will receive appropriate treatment to address the problem and attain the highest practicable mental and psychosocial wellbeing. It also indicated possible non-pharmacological interventions for the IDT to consider, including Environmental conditions: adjust room temperature, decrease noise level, move resident from crowded room, offer soft music, approach resident calmly. During a review of admission record, indicated Resident 1 was admitted on [DATE] with diagnoses of dementia, mood disturbance, and anxiety.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 privacy and treat four residents (two confidential residents and Resident's 6 and 39) with dignity and respect. This caused the residents to feel humiliation, embarrassment, a loss of dignity, and frustration while using the toilet. Findings: During a confidential interview on 5/25/2021 at 10:35 am, two Residents stated a concern regarding shared bathrooms. A resident stated that the door cannot be locked in the bathroom, and that when the bathroom is being used, the door frequently gets opened, both by other residents and by staff. A resident stated that most often it is staff coming in to either get gloves or dump something down the sink. A different resident stated that when staff knocks on the door, it is frequently a knock on the door and then the door gets opened. The resident stated that sometimes they wait for a response before opening the door, but not always. The one resident stated a feeling of humiliation when having a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure residents were free from accidents and hazards when: 1. Door closures were not maintained or closing properly. This had the potential for residents to be injured in doorways if not prepared for the swift door closures. 2. Smoking area had multiple cigarette butts near dry leaves in 2 locations. This had the potential to result in a fire close to the building. 3. Resident 4 had more than 30 falls in the last 12 months and Resident 211 had five unwitnessed falls in a two month period. This had the potential to place these resident at risk for continued falls and serious life threatening injuries. Findings: 1. Resident injury caused by broken door closer During a review of a radiology report for Resident 29, dated 05/21/2021 at 1:16 pm, it was noted that Resident 29 had an x-ray (images of internal tissues, bones, and organs) of her left hand that indicated two fractures (partial or complete break in a bone) of her second and third…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff were provided to meet residents shower needs. This had the potential for residents to not receive showers as scheduled or requested which could negatively affect their physical and emotional well-being. Findings: During a record review of resident shower logs, dated 04/19/2021 on the evening shift, it was noted that a certified nursing assistant (CNA S) documented, Due to being short-staffed, CNAs did not have enough time on PM shift to get any showers done. During a concurrent observation and interview, on 05/24/21 9:30 am, Resident 7 was observed lying in bed under a blanket, without a shirt on. Resident 7 stated, I only have briefs on, I'm naked because I'm waiting for a shower. During an interview with a certified nursing assistant (CNA G), on 05/24/21 12:15 pm, CNA G stated she asked Resident 7 to remove his clothes in preparation for a shower at 8:00 am, but did not get around to giving the resident a shower until 11:00 am because she was busy taking care of other residents.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the safe and effective use of medication when the policy for Medication Storage was not implemented for two sampled Residents (11 and 410) as evidence by the following: 1. Insulin Pen, (a device for insulin administration; insulin is injected to control blood sugar for patients with uncontrolled blood sugar), for Resident 11, remained available for use, after the expiration date 5/13/2021. 2. Eye drops (a lubricant used to keep the eye moist also known as artificial tears) for Resident 410, also had the expiration date as 5/13/2021, and it was available for use. This failure resulted in putting both Resident (11 and 410) at increased risk of harm from receiving expired and potentially contaminated or ineffective medications. Findings: 1. A review of Resident 11's record, indicated, she was admitted on [DATE] with diagnoses including type 2 diabetes (it is a disease that occurs when the blood sugar is too high.), heart problem and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to identify the irregularity of significant medication error that continued for five months for one out of seven sampled residents (Resident 56). Pantoprazole 40 mg was administered instead of 20 mg to Resident 56 from 12/27/2020 to 5/26/2021 (refer to F 760). There was no documented evidence that the error was not identified or reported. This failure resulted in Resident 56 receiving double the dose of pantoprazole for more than five months. Findings: A review of Resident 56's record, indicated, she was admitted on [DATE] with diagnoses including heart , kidney and swallowing problems. She is her own health care decision maker. A review of the facility's policy and procedure titled Drug Regimen Review revised on 12/2016, indicated, Facility must ensure that a pharmacist reviews each resident's medical chart every month and perform a drug regiment review, including the following expanded requirements: A. Report any irregularities to the facility's medical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one out of seven sampled residents (Resident 56) was free from unnecessary drugs. Resident 56 received an excessive dose of medication intended to reduce stomach acid (pantoprazole). This failure resulted in Resident 56 was administered double the ordered does (40 milligrams instead of 20) of pantoprazole for five months and put this Resident at increased risk of harm. Findings: A review of Resident 56's record, indicated, she was admitted on [DATE] with diagnoses including heart, kidney and swallowing problem. She is her own health care decision maker. A review of the facility's policy and procedure titled Drug Regimen Review- Procedure - (IV). Unnecessary Drugs - revised on 12/2016, indicated: Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used - A. In excessive dose (including duplicate drug therapy); . A review of Resident 56's record on 5/26/2021 at 9:15 am, showed a physician order,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 seven residents (Resident 30) is free from unnecessary psychotropic drug, which affects brain activities associated with mental processes and behavior . Resident 30 continued to receive Lexapro (a medication used for depression) for six months, in the absence of clinical indication to do so. This failure resulted in Resident 30 receiving unnecessary psychotropic medication and put the resident at increased risk for drug related side effects and potential harm. Findings: A review of Resident 30's record, indicated, she was admitted on [DATE] with diagnoses including breast cancer, major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest) and heart problem. She is not her own health care decision marker. A review of the facility's policy and procedure titled Behavior/Psychoactive Drug Management - Intervention - (B), Psychoactive Drug Interventions - Provision for Psychoactive Medication Use…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to prevent significant medication error for five months, when one out of seven sampled residents (Resident 56) was given pantoprazole 40 mg /tab without a physician order. (pantoprazole reduces the amount of acid the stomach makes. It's used for heartburn, acid reflux.) This failure resulted in Resident 56 having been given the wrong dose of pantoprazole from 12/27/2020 to 5/26/2021, and put the resident at increased risk of potential harm. Findings: A review of Resident 56's record, indicated, she was admitted on [DATE] with diagnoses including heart, kidney and swallowing problems. She is her own health care decision maker. A review of the facility's policy and procedure titled Medication - Administration (1)(A)(ii) revised on 1/1/2012, indicated, Medications and treatments will be administered as prescribed to ensure compliance with dose guidelines. During an observation of medication administration for Resident 56 on 5/26/2021 at 8:45 am,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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's Quality Assessment and Assurance committee (QAA) failed to identify and implement plans of actions to correct deficiencies when: 1. Fall intervention strategies to reduce injuries and falls were not implemented. Refer to F 689. 2. There was not sufficient staffing to provide activities of daily living (showers) and supervision to prevent accidents and hazards. Refer to F 725. 3. Infection Control policies did not meet current standards and staff had not implemented the procedures. Refer to F 880. 4. Building maintenance for air conditioning, shower room water and room temperatures, and monitoring door closure issues was not done. Refer to F 689, F 921. These failures had the potential to put all residents at risk for injury and to be exposed to infectious disease. Findings: Record review of the facility policy, titled, Abuse - Prevention, Screening, & Training Program, revised 7/1/2018, showed its purpose was to address the health, safety, welfare, dignity and respect of residents by preventing abuse and neglect. 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 maintain an infection prevention and control program that provided a safe and sanitary environment for residents and staff when: 1. Staff did not follow facility hand hygiene and isolation policies/procedures while providing care to Resident 260 who was on contact precautions. 2. Resident 260, who was being ruled out for C.diff (Clostridioides difficile, a germ that causes severe diarrhea and inflammation of the colon) infection, was not cohorted in a manner to prevent risk of spread. 3. N95 respirator fit testing was not completed for five of six sampled staff. 4. Facility infection control plan and infection control policies/procedures were not reviewed annually as required. 5. Terminal cleaning of room previously occupied by Resident 260, was completed while occupied by Resident 260's former roommate Resident 21. 6. Staff did not follow facility policy for cleaning blood glucometer (a medical device used for determining the approximate…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a safe and sanitary environment for residents when: 1. Door closures were not maintained and closed abruptly. This failure resulted in two fractured fingers for Resident 29). 2. Air conditioning unit were not functioning in the resident dining room. This failure resulted in above normal (over 81 degrees F, Fahrenheit) room temperatures in the dining room. 3. Shower room water temperatures and shower room air temperatures were not maintained at a comfortable temperature. This failure resulted in residents refusing showers due to cold water and room air temperatures in shower rooms [ROOM NUMBERS]; 4. Shower heads were not maintained in an operable condition. This failure had the potential to contribute to residents refusing showers. 5. Maintain clean and sanitary shower rooms/stalls. This failure had the potential to result in the spread of bacteria, viruses and fungal infections among the residents and potentially contribute to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide rehabilitative care services for one resident (Resident 33). This failure had the potential to cause Resident 33 to lose strength and balance for walking, which could have led to a loss of independence and increased risk for falls. Findings: A review of Resident 33's clinical record showed admission to the facility on 4/5/2021 with diagnoses that included Alzheimer's disease (a long-term disease that caused a loss of intellectual function) and depression. Resident 33's Minimum Data Set (MDS-a standardized resident assessment) showed a Brief Interview for Mental Status (BIMS--a screening tool used in nursing homes to assess intellectual function) score of 10, which indicated moderately impaired function. Resident 33 had been living in a facility owned by the same company since 11/8/2018, and was transferred to the present facility with existing physician orders on 4/5/2021. During an interview on 5/27/2021, at 4:34 pm, the Director of Nursing…

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

Based on interview and record review, the facility failed to provide residents with personal hygiene and grooming when: 1. Three residents (Residents 15, 17, and 49) refused to shower because too cold. 2. One resident (Resident 46) had dry, scaly skin and jagged, dirty fingernails. This failure had the potential to have caused the residents to experience discomfort and anxiety from poor hygiene and fear of the cold, as well as to promote the risk of infection due to the spread of bacteria from beneath the fingernails. Findings: 1. A record review of the shower record (a document that indicated bathing occurred and how it was tolerated. Also, provided documentation that skin was observed) provided by the facility for the month of April 2021, indicated that 47 showers were refused by the residents. Most of the sheets did not indicate reason for refusal, but some did state, too cold. A record review of the shower record for Resident 15, dated 4/12/2021, indicated that the resident refused to shower three times when offerred by two different Certified Nursing Assistants (CNAs) because,…

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