Sharp Chula Vista Med Ctr SNF

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to indicate the appropriate target behavior and monitor side effects for four of thirty residents (274, 35, 58, and 51) when: 1. Resident 274 was not being monitored for appropriate behaviors and side effects for two anti-depressants (medication used for feeling of sadness) and one anti-anxiety (medication used for worry and fear) medications. 2. Residents 35 and 58 did not have monitoring for behavior and side effects for anti-depressant medications. 3. Resident 51 did not have appropriate indications for the use of anti-depressant medications. These failures had the potential for unnecessary psychotropic (mind-altering medications) medication use and side effects to decrease therapeutic effects and a decline for residents psychological and mental well-being. Findings: 1. A review of Resident 274's Medical Record indicated Resident 274 was admitted to the facility on [DATE] with diagnoses which included a history of major depressive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 safe and sanitary measures were met in the kitchen during dietary operations according to standards of practice when: 1. Food can items were dented. 2. Food items were expired. 3. Opened food items were not properly labeled and dated. 4. Grains and dust on the lids, loose and cracked lids of the clear plastic bins with food in it. 5. Food items with molds in it, and wilted produce. 6. Dirty rugs on the floor in the dry storage room, trash found in the dry food storage room and in the freezer room. 7. Ready to eat food item on top of the raw meat, and metal bin with ready to cook condensed soup on top of the food rack. 8. Food utensils such as ladles, slotted spoons and [NAME] kitchen utensil stored as clean with crusted food debris. 9. Boxes on top of the food rack past the red line/mark. 10. The following items were stored inappropriately in a food preparation area: an employee cup of coffee, a pump-up foam unit, employee drinks…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 observations, interviews, and document review, the facility failed to give one of three reviewed residents (Resident 282) the Advanced Beneficiary Notice (ABN/CMS 10055: a form which gave the choice to continue services under private pay if Medicare did not provide payment) for discontinued skilled (rehabilitation and nursing) services who remained in the facility for custodial (non-medical assistance with daily tasks, such as bathing, dressing, eating, and toileting) services. As a result, Resident 282 did not have the choice to appeal the decision or have knowledge of the costs to continue custodial care in the facility. Findings: A review of Resident 282's Medical Record indicated Resident 282 was admitted to the facility on [DATE] with diagnoses which included a history of arteriosclerotic cardiovascular disease (thickening or hardening of the arteries). On 10/9/24 at 9:26 A.M., an interview and document review was conducted with AD 1. AD 1 stated that Resident 282 last coverage day for skilled…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 clinical record review, the facility failed to ensure a significant change of status assessment (SCSA) was completed within 14 days after a significant change in the resident's physical or mental condition had been determined for one of 18 sampled residents (Resident 42). This had the potential to delay necessary health services and updated plan of care based on the Resident 42's current health status. Findings: A review of Resident 42's Medical Record indicated Resident 42 was re-admitted to the facility on [DATE] with diagnoses which included a history of stroke (when the blood flow to the brain is blocked that could lead to muscle weakness, paralysis, or death). A review of Resident 42's Minimum data set (MDS: nursing facility assessment tool) dated 8/4/24 indicated Resident 42 was able to participate with the brief interview for mental status (BIMS) interview and had a BIMS score of 9 out of 15 to indicate moderate cognitive (mental process involved in knowing, learning, 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 care plans for three of seven sampled residents (1, 45 and 51) related to Restorative Nursing Assistant (RNA) range of motion (ROM- a measure of joint functionality and flexibility) exercises. This failure had the potential for residents to not meet their functional abilities. Cross Reference to F 688. Findings: a. Resident 1 was admitted to the facility on [DATE], per the facility's Medical Record. On 10/8/24, a review of Resident 1's history and physical (H & P) dated 6/18/24, indicated Resident 1 had diagnoses which included traumatic brain injury (TBI - a disruption in the normal function of the brain that can be caused by a bump, blow, or jolt to the head) and was in vegetative state (residents may look like they are awake but have no awareness of their surroundings). The H & P also indicated Resident 1 had contractures in both upper and lower extremities. On 10/8/24, a review of Resident 1's minimum data set (MDS - 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 consistently provide Restorative Nursing Assistant (RNA) for range of motion (ROM- a measure of joint functionality and flexibility) exercises per physician's order for three of seven residents (1, 45, and 51), reviewed for limited ROM. This had the potential to worsen Resident 1's contractures (condition of shortening and hardening of muscles, tendons, or other tissue leading to deformity and rigidity of joints) and promote the development of contractures to Resident 45 and Resident 51. Cross Reference to F 656. Findings: a. Resident 1 was admitted to the facility on [DATE], per the facility's Medical Record. On 10/8/24, a review of Resident 1's history and physical (H & P) dated 6/18/24, indicated Resident 1 had diagnoses which included traumatic brain injury (TBI - a disruption in the normal function of the brain that can be caused by a bump, blow, or jolt to the head) and was in vegetative state (residents may look like they are awake…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and label house supply/stock medications with open dates. As a result, the facility could not ensure medications were safely stored to ensure their integrity. Findings: On 10/9/24 at 3:31 P.M., a concurrent observation and interview was conducted with LN 1, LN 21 and Pharm 1. During the medication storage observation, there were two boxes of insulin aspart (an injectable drug used to decrease blood sugar) stored in a tray inside a medication refrigerator. The two boxes contained one bottle each of insulin aspart. One box of insulin aspart was labeled with date open 9/21/24 and the bottle inside the box was not labeled with an open date. The other box of insulin aspart was labeled with expiration date 10/18/24 and the bottle inside the box was not labeled with an open date. The manufacturer's expiration date and lot numbers of the two insulin aspart in the tray were the same. LN 1 stated this had the potential for interchanging the bottles when returning to their boxes. On 10/10/24 at 3:26 P.M.,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, and facility document review, the facility did not identify and address concerns that was in the residents council minutes meeting regarding transportation for the outdoor activities in quality assurance and performance improvement (QAPI). This failure had the potential to effect all residents quality of life. Cross-Reference F558 Finding: On 10/10/24 at 3:49 P.M., an interview with the QAPI program members were conducted, in the conference room. The members of the QAPI team stated that they used information gathered from family, residents, pharmacy, national and state comparisons, best practices, clinical guidelines and CASPER report (a report for skilled nursing facilities used for quality improvement/assurance projects). The QAPI team further stated, these were used to track performance and to see what was not working to make changes with policies and procedures. On 10/10/24 at 3:51 P.M., an interview was conducted with the DON. The DON stated that the activities department participated in QAPI. The DON further stated, she and the AC discussed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 observations, interviews, and record reviews the facility failed to implement infection prevention and control practices with two of 18 sampled residents (Resident 52 and Resident 1) according to standards of practice and provide evidence of a tracking log of infections when: 1. A CNA did not wear appropriate personal protective equipment (PPE-use of gown, gloves, mask to prevent spread of infection) prior to entering a contact precautions (intended to prevent transmission of infectious agents) room. Cross Reference F881 2. A LN did not wear a gown for Resident 1 with enhanced barrier precautions (EBP -involves gown and glove use during high-contact resident care activities for residents [example: residents with medical devices]). This failure had the potential to spread infection or outbreaks amongst all residents, staff, and visitors entering the facility. Findings: 1. A review of Resident 52's Medical Record indicated Resident 52 was admitted to the facility on [DATE] with diagnoses which included 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 reviews, the facility failed to follow its own policy and procedure to establish an antibiotic stewardship program when the Infection Preventionist (IP) did not track and monitor appropriate use of antibiotics. This failure had the potential for lack of oversight and direction for staff. Cross reference F880 Findings. A concurrent interview and record review on 10/10/24 at 9:01 A.M., with IP was conducted. The IP stated the pharmacy helped with the antibiotics logging and tracking. The IP stated she did the urinary tract infection (UTI) tracking and the pharmacy helped with data collection and did the other infection tracking. The IP stated it was important to tracked antibiotic to make sure they are used appropriately and monitor patterns of infections and thus preventing outbreaks. An interview with the MDSC 1 on 10/10/24 at 9:12 A.M., was conducted. MDSC 1 stated a resident was coded for use of antibiotics on the MDS (a federally mandated resident assessment tool) but was not on the medication administration record (MAR) and resident was placed 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 investigate an allegation of abuse for one of three sampled residents (1). As a result, Resident 1 had an increased risk of abuse. Findings: Per the facility ' s untitled resident information sheet dated 9/26/24, Resident 1 was admitted to the facility on [DATE]. Per the facility ' s Social Work Interdisciplinary Note, dated 9/20/24 10:55 A.M., Resident 1 ' s Responsible Party (RP) notified the Social Worker (SW) of her concerns about Resident 1 ' s care, which included, .the patient stated that the CNA (Certified Nursing Assistant) pulled her arm and hurt her, and spoke to her in a hurtful way . On 9/26/24 at 10:20 A.M., an interview was conducted with the SW. The SW stated, she notified the facility ' s management of the RP ' s concerns, including the allegation of abuse. The SW further stated, that the abuse allegation was related to an incident that happened multiple months ago, but the RP did not notify the facility of the allegation of 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 a care plan was developed to ensure one of three sampled resident's safety (Resident 1). As a result, restricted persons were able to visit the resident in the facility. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses which included ill-defined liver mass concerning for malignancy per the facility's History and Physical. On 6/27/24 at 10:50 A.M., an observation of Resident 1's room was conducted. There was a sign next to the door to see the nurse prior to visiting the resident. On 6/27/24 at 11:15 A.M., an interview with Licensed Nurse (LN) 2 was conducted. LN 2 stated there was an Adult Protective Services (APS) case opened for Resident 1 because Resident 1's family member expressed concern that Resident 1's properties were transferred to the neighbors. LN 2 stated the family member informed the facility the name of the person who was not allowed to visit Resident 1. On 6/27/24 at 11:33 A.M., a 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.

Based on observations, interviews and document review, the facility failed to provide an environment that promoted dignity for 3 of 5 residents during mealtime when, all three residents were not served their meal trays the same time as the other residents, in the multi-purpose room. This failure had the potential to affect the residents' dining experience and quality of life. Findings: On 11/6/23 at 12:09 P.M., a meal observation was conducted in the facility's multi-purpose room. Five residents and a family member (FM) were in the multi-purpose room. Staff served the lunch tray of two of the five residents in the multi-purpose room. On 11/6/23 at 12:15 P.M., the following activities were observed in the multi-purpose room: - Two family members came to the multipurpose room with food and started eating. - Two of the five residents were eating, while the rest were waiting to be served their lunch tray. - Two staff brought their food in the east side of the multipurpose room that was open to the rest of the room, while the three residents were waiting to be served their lunch tray. 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 medical record review, the facility failed to accurately code the Minimum Data Set (MDS, a nursing assessment tool) for four of 21 residents (Resident 51, Resident 32, Resident 29 and Resident 12). This deficient practice had the potential to affect the residents by delaying resident care needs and provided inaccurate information to the Federal database. Findings: 1. Resident 12 was admitted to the facility on [DATE] with diagnosis which included Cerebral Vascular Attacks (CVA, is a brain attack, that interrupts in the flow of blood to cells [basic living blocks of all living things] in the brain) per progress notes on 10/31/2023 by Medical Doctor (MD). Record review of resident 12's document titled, Physician's Orders dated 05/13/21 indicated, . Admit to [Hospice Name] on Routine Level of Care Terminal . Dx (diagnosis) Cerebrovascular Disease (a group of conditions that affect blood flow and the blood vessels in the brain) . Review of resident's care plan initiated 05/13/21…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Restorative Nursing services to 45 of 45 residents with orders for restorative nursing assistant (RNA) treatments, which included two residents (Resident 29 and Resident 44) reviewed for limited range motion (ROM, amount of joint's ability to move in any direction to its limits) when: 1. Resident 29 did not receive RNA services at the frequency ordered by the physician. 2. Resident 44 did not receive RNA services at the frequency ordered by the physician. This deficient practice could place all 45 residents with orders for RNA treatment at increased risk of further decline in range of motion ROM to resident's extremities (hands, arms, legs, and feet). Cross Reference F725 and F641 Findings: 1. Resident 29 was admitted to the facility on [DATE] with diagnoses which included dementia (a gradual decline with memory, language, problem-solving and other thinking abilities) per Medical Doctor (MD) notes dated 09/12/23. Record review 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 document review, the facility failed to ensure that sufficient restorative nursing assistants (RNAs) were available to provide restorative treatments to the residents. There were a total of 45 residents in the facility receiving restorative treatment from the RNAs. This failure had the potential for residents on the RNA program to experience decline in their range of motions and affect their quality of life. Findings: On 11/7/23 at 10:04 A.M., a confidential interview was conducted with the Resident Council (an organized group of residents who meet regularly to discuss and address concerns about their rights and their care). Nine residents attended the Resident Council meeting. During the meeting, five of the nine attendees stated that they were not receiving RNA treatments in accordance to their physician's orders. One of the residents stated that the RNAs were being removed from their duties to cover the certified nursing assistants (CNAs). On 11/7/23 at 2:48 P.M., an interview with RNA…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 safety and sanitation practices were maintained in the kitchen according to standards of practice and facility policy when: 1. Three walk-in refrigerators (Ref 1, 2 & 3) had TCS (time/temperature control for food safety foods - meats, produce, etc.) foods that were stored opened, unlabeled, and available for preparation beyond the use by date. 2. Multiple food items in the dry storage room were uncovered, mislabeled, and available for meal preparation beyond the use by date. 3. Holding temperatures for TCS foods were not recorded in the temperature log book. 4. Kitchen staff was observed working in the kitchen without a beard net. 5. A bag of expired enteral nutrition (EN, liquid nutrition placed directly into the stomach by a tube) was stored in the skilled nursing satellite kitchen and available for use. 6. Fruit cups in the trayline refrigerator (Ref 4) were stored and transported to the skilled nursing facility for lunch uncovered and undated. These deficient practices exposed the facility's…

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

Based on interview and document review, the facility failed to ensure that sufficient restorative nursing assistants (RNAs) were available to provide restorative treatments to the residents, as indicated in the facility's Facility Assessment Report. There were a total of 45 residents in the facility with orders to receive restorative treatments from the RNAs. This failure had the potential for residents on the RNA program to experience decline in their range of motions and affect their quality of life. (cross reference to F-tag 688 and F-tag 725) Findings: On 11/7/23 at 10:04 A.M., a confidential interview was conducted with the Resident Council (an organized group of residents who meet regularly to discuss and address concerns about their rights and their care). Nine residents attended the Resident Council meeting. During the meeting, five of the nine attendees stated that they were not receiving RNA treatments in accordance to their physician's orders. One of the residents stated that the RNAs were being removed from their duties to cover the certified nursing assistanst (CNAs).…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 assistance for the hygiene for one (Resident 365) of five residents. This failure resulted in the resident not being provided a shower or bed bath for four days. This includes two regularly scheduled shower days and a day the resident had an offsite appointment (on day four). This failure caused Resident 365 to feel unclean and embarrassed at the offsite appointment. Findings: Resident 365 was admitted on [DATE], for antibiotic therapy due to an ongoing infection per resident facesheet. Resident 365 had a BIMS (Brief Interview for Mental Status, an assessment tool to measure mental functioning and memory) score of 15. The resident was alert, oriented, and able to make needs known. An interview was conducted on 11/07/23 at 9:34 AM. Resident 365 was seated at bedside. Family was in Resident 365's room. Resident 365 stated she was offered a shower yesterday afternoon but had not received one since 11/3/23. Resident 365 stated she was going off…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 for one of six sampled residents (Resident 29), the facility failed to document an appropriate indication for the use of Seroquel (a medication used for mental/mood conditions that help regulate mood, thoughts, and behaviors). This failure placed Resident 29 at unnecessary risk for adverse consequences related to the use of Seroquel. Findings: Review of the clinical record indicated Resident 29 was admitted to the facility on [DATE] with diagnoses which included dementia (a gradual decline with memory, language, problem-solving and other thinking abilities) per Medical Doctor (MD) notes dated 9/12/23. A record review of Resident 29's physicians orders, Antipsychotic Medication Order, dated 9/12/23, indicated the use of Seroquel 12.5 mg (milligrams) PO (by mouth) q (every) HS (bedtime) for Behavioral Disturbance secondary to dementia. Episode monitoring to include monitoring for Agitation QS (every shift) AEB (as evidenced by) a. continuous yelling, b. inability…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medications were administered correctly for 2 of 25 medication administration attempts, which resulted in an 8% medication error rate. This failure had the potential to cause harm to the residents. Findings: A review of Resident 26's medical records indicated the resident was admitted to the facility on [DATE] with diagnoses of dysphagia (difficulty swallowing), and had a gastrostomy tube (G-Tube, a tube inserted directly into the stomach to give medications, liquids and liquid food). On 11/08/23 at 9:33 A.M., a medication administration observation and interview was conducted with Licensed Nurse (LN) 21. LN 21 prepared Resident 26's medications which included: 1. Vitamin C 500 mg (milligram) 1 tablet; 2. Aspirin 81 mg (helps to prevent heart attacks) 1 tablet; 3. Calcium Carbonate 500 mg (dietary supplement) 1 tablet; 4. Vitamin D3 2000 u ([units] dietary supplement) 1 tablet; 5. Donepezil (for dementia [loss of cognitive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, and record reviews the facility failed to ensure standardized recipes were used for preparing meals for skilled nursing home residents on regular and therapeutic diets. This deficient practice had the potential to compromise the nutritional content of foods prepared for all skilled nursing facility residents. Findings: On 11/8/23 at 10:39 A.M., an observation and interview was conducted with [NAME] (CK) 1 in the main kitchen. CK 1 used a clear plastic cup to scoop a white powder from a clear plastic bin, labeled thickener, into a stainless steel food blender. CK 1 stated he was pureeing chicken soup for residents who had orders for a modified texture diet. CK 1 stated he did not follow a standardized recipe to add powdered thickener to pureed foods. CK 1 stated he just eyeballs the amount of thickener to add to a puree until it was velvety. CK 1 stated he did not use a standardized recipe to make chicken soup because he had been making chicken soup for 20 years. CK 1 stated he did not know where instructions on how to use the thickener were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility's Quality Assurance and Performance Improvement (QAPI - a systematic, interdisciplinary, comprehensive, and data-driven approach to maintaining, and improving safety and quality in nursing homes) failed to formally identify, investigate and act on staffing deficiencies in regard to the Restorative Nursing Assistant (RNA) program. (Cross reference F-tag 688 and F-tag 725) This failure placed residents who were ordered to receive RNA treatment at risk for a decline in mobility. Findings: On 11/9/23 at 1:55 P.M., a concurrent interview was conducted with the Director of Nursing (DON), the Clinical Manager (CM). The DON stated the issues the facility planned to monitor for QAPI were identified in the facility document during the quarterly QAPI meeting. The CM stated facility management was aware that insufficient RNA staffing was a problem, but it had not been identified as a formal issue to measure and monitor in QAPI meetings. On 11/9/23 at 3:31 P.M., 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.