Citrus Heights Post Acute

Based on interview and record review, the facility failed to ensure one of 5 sampled residents (Resident 1) was treated with dignity and respect, when Restorative Nursing Assistant (RNA 1) spoke inappropriately to Resident 1.This failure caused Resident 1 to feel upset, humiliated, and disrespected and had the potential to negatively impact Resident 1's psychosocial well-being.A review of the facility's 'Resident Rights' policy dated 2021, indicated, Employees shall treat all residents with kindness, respect, and dignity. A review of the admission Record indicated the facility admitted Resident 1 in the spring of 2025 with multiple diagnoses which included paraplegia (loss of movement and/or sensation, to some degree, of the legs), muscle weakness, and anxiety.A review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 5/17/25, indicated the resident had no cognitive impairment and had no behavioral symptoms including hallucinations and delusions.During a concurrent observation and interview on 7/9/25, at 9:45 a.m., Resident 1 was sitting…

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

Based on interview and record review, the facility failed to ensure required documentation for discharge was present in the medical record for one of four sampled residents (Resident 1), when there was no physician order indicating the basis of Resident 1 ' s discharge, there was no discharge summary, and there was no notice of discharge in Resident 1 ' s medical record. This failure had the potential for delay in Resident 1 ' s care after discharge. Findings: During a review of Resident 1 ' s admission records, the records indicated Resident 1 was admitted to the facility in May 2025 with diagnoses that included paraplegia (loss of movement and/or sensation, to some degree, of the legs), and local infection of the skin and subcutaneous tissue (under the skin). Resident 1 ' s Minimum Data Set (MDS, a federally mandated resident assessment tool) indicated Resident 1 had intact cognition. During a review of Resident 1 ' s case management progress notes, dated 5/29/25, the notes indicated, .[Resident 1] verbalized she is refusing care by our provider rt [related to] a self-proclaimed…

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 two out of 35 sampled residents (Resident 68 and Resident 77) received treatment and care in accordance with professional standards of practice, facility's policy and procedure (P&P), and physician's order when Resident 68 and Resident 77's wound treatment orders were not consistently done. This failure had the potential for Resident 68 and Resident 77's wounds to get worse and not achieve healing, and for the residents to not achieve their highest practicable well-being. Findings: 1a. A review of Resident 68's clinical record indicated Resident 68 was admitted July of 2020 and had diagnoses that included peripheral vascular disease (PVD- a condition where blood flow to the arms, legs, and feet are restricted due to narrowed or blocked blood vessels), venous insufficiency (a condition where the veins in the legs don't effectively return blood back to the heart, leading to blood pooling in the legs), and major depressive disorder (persistently depressed mood or loss of interest in activities, causing…

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 safe delivery of respiratory care consistent with the facility's policy and procedures (P&P) for one out of 35 sampled residents (Resident 78) Resident when, Resident 78 was provided with oxygen therapy without a physician's order. This failure had the potential to result in unsafe delivery of oxygen to Resident 78 and for Resident 78 to not achieve her highest practicable well-being. Findings: 1. A review of Resident 78's clinical record indicated Resident 78 was admitted February of 2025 and had diagnoses that included chronic obstructive pulmonary disease (COPD- a group of diseases that causes airflow blockage and breathing-related problems), congestive heart failure (CHF- a serious condition in which the heart does not pump blood as efficiently as it should), and sleep apnea (a sleep disorder that causes people to stop breathing or breathe shallowly while they sleep). A review of Resident 78's Minimum Data Set (MDS- a federally mandated resident assessment tool) Cognitive Patterns, dated 3/28/25,…

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

Based on interview and record review, the facility failed to ensure two out of 35 sampled residents (Resident 77 and Resident 141) received appropriate pain management services consistent with professional standards of practice, facility's policy and procedure (P&P), and physician's order when Resident 77 and Resident 141 pain medication orders were not consistently followed. This failure had the potential for Resident 77 and Resident 141 to develop medication dependence (the inability of the individual to function normally in the absence of the drug), overdose, not achieve pain relief, and not attain their highest practicable well-being. Findings: 1a. A review of Resident 77's clinical record indicated Resident 77 was admitted July of 2024 and had diagnoses that included vascular parkinsonism (a movement disorder caused by damage to the blood vessels in the brain, leading to impaired movement and balance), and osteoarthritis (OA- a deteriorating disease that causes pain, stiffness, and swelling where two or more bones meet). A review of Resident 77'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 provide pharmaceutical services according to policy and procedures to meet the needs of residents for a census of 158 when: 1. The facility failed to accurately document and secure emergency medications (E-kit, a sealed container of essential medications and supplies designed for immediate use in emergency situations); 2. Dispose of expired E-Kit insulin (medication used to control blood sugar) and 3. Ensure the narcotic (substance used to treat moderate to severe pain) count was correct for Resident 37. These failures had the potential for emergency medications to be unavailable when needed, the potential for not meeting the residents' therapeutic needs or worsening of their medical conditions, and potential for diversion of controlled medications. Findings: 1a. During a concurrent observation and interview on [DATE] at 11:01 a.m. with the Assistant Director of Nursing (ADON) an inspection of the Medbridge Medication Room was conducted.…

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 store, prepare, distribute, and serve food in accordance with professional standards for food service safety when: 1a. Three steam table pans were stored wet, and one had food residue in the pan, b. The food processor and blender were both stored wet with food residue in them, with the lids on, 2. The dry storage area floor had debris on it. These failures had the potential to lead to food borne illness for the 152 Residents eating facility prepared meals. Findings: 1a) During an observation and concurrent interview on 4/21/25 at 8:52 a.m., with the Dietary Supervisor (DS) during the initial kitchen tour, three steam table pans were found stored wet (wet nesting) in the ready to use area and one pan had food residue inside the pan. The DS stated she expected the steam table pans to be clean and air dried before storage. 1b) During a continued observation and interview on 4/21/25 at 8:56 a.m., with the DS during the initial kitchen tour, the food processor and food blender were both stored with a lid on top,…

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 infection control practices and procedures were followed for three of 35 sampled residents (Residents 48, 55, and 78) when: 1. Resident 48's Incentive Spirometer (a device used to exercise the lungs) was left unlabeled and not covered. 2. Resident 55's Enhanced Barrier Precautions (EBP) were not followed. 3. Resident 78's Nasal Cannula (a device used to deliver oxygen through the nose) was left uncovered. These failures had the potential to result in the spread of infection among residents. Findings: 1. A review of Resident 48's clinical record, indicated the facility admitted Resident 48 in 2017 with multiple diagnoses which included chronic respiratory failure. A review of Resident 48's Minimum Data Set (MDS - an assessment tool used to guide care) Cognitive (having full understanding) Patterns, dated 3/4/25, indicated Resident 48 had a Brief Interview for Mental Status (a tool to assess a person's cognition) score of 13 out of 15…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two out of 35 sampled Residents (Resident 110 and Resident 80) were assisted with nail care as part of their Activities of Daily Living (ADLs - normal daily functions required to meet basic needs) when; 1. Resident 110 had long toenails; and, 2. Resident 80 had long fingernails with grayish substance underneath them. These failures had the potential for Resident 110 and Resident 80 to have sustained a skin injury, and to possibly acquire an infection. Findings: 1. During a review of Resident 110's Face Sheet (front page of the chart that contains a summary of basic information about the resident). The face sheet indicated she was admitted on [DATE] with diagnoses that included metabolic encephalopathy (a condition where the brain does not receive enough nutrients or oxygen to function properly), type 2 diabetes mellitus (high blood sugar levels due to the body's inability to use insulin effectively), dermatophytosis (fungal…

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

Based on observation, interview, and record review, the facility failed to follow policy and procedure for the proper storage of drugs and biologicals for a census of 158 when: 1. Loose pills were found in a medication cart, and; 2. A bottle of Drug Buster (medication disposal system) was observed with brown substance on the outside of the bottle and on the bottle of the drawer. These failures had the potential for drug diversion and medication at risk of degradation. Findings: 1. During a concurrent observation and interview on 4/22/25 at 8:25 a.m. with Licensed Nurse (LN) 5, an inspection of the 600 Hall Medication Cart was conducted. Multiple loose pills were observed in the medication cart. LN 5 verified the loose pills in the cart. 2. During a further concurrent observation and interview on 4/22/25 at 8:25 a.m. with LN 5, an inspection of the 600 Hall Medication Cart was conducted. A white bottle of Drug Buster was observed with brown substance on the outside of the bottle and on the bottom of the drawer. LN 5 confirmed the brown substance on the outside of the Drug Buster…

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 in accordance with the physician's prescribed diet for one out of 35 sampled residents (Resident 141) when Resident 141 who was on No Added Salt diet (NAS- a dietary restriction that limits the intake of salt) received a packet of salt during the 4/21/25 lunch meal. This failure had the potential to negatively affect Resident 141's medical condition and for Resident 141 not to achieve his highest practicable well-being. Findings: A review of Resident 141's clinical record indicated Resident 141 was admitted February of 2025 and had diagnoses that included multiple fractures (break in the continuity of bone), chronic kidney disease (a long-term condition where the kidneys gradually lose their ability to filter waste products and excess fluid from the blood), and hypertension (high blood pressure). A review of Resident 141's Minimum Data Set (MDS- a federally mandated resident assessment tool) Cognitive Patterns, dated 2/9/25, indicated Resident 141 had a Brief Interview for Mental Status (BIMS- 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 observation, interview, and record review, the facility failed to ensure the call light system was accessible for two out of 35 sampled residents (Resident 120 and Resident 85) when Resident 120 and Resident 85's call light buttons were observed not within reach. This failure had the potential to result in residents' needs not being met and prevent residents' communication for assistance when needed. Findings: 1a. A review of Resident 120's clinical record indicated Resident 120 was admitted October of 2023 and had diagnoses that included dementia (a progressive state of decline in mental abilities), abnormalities of gait (manner of walking) and mobility, and muscle weakness. A review of Resident 120's Minimum Data Set (MDS- a federally mandated resident assessment tool) Cognitive Patterns, dated 2/18/25, indicated Resident 120 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 8 out of 15 which indicated Resident 120 had a moderately impaired cognition (mental process of acquiring knowledge and understanding). A review of Resident 120's MDS…

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

Based on observation, interview, and record review, the facility failed to follow proper infection control practices for one (Resident 1) of three sampled residents, when Licensed Nurse (LN) 1 did not don a gown and did not perform hand hygiene (process of cleaning ones ' hands using soap or alcohol-based hand rub) during Resident 1 ' s dressing change. These failures had the potential to increase the spread of infection. Findings: Resident 1 was admitted to the facility in November of 2024 with diagnoses that included dysphagia (difficulty swallowing) and cerebral infarction (stroke). A review of Resident 1 ' s Care Plan (CP), dated 3/18/25, indicated, Enhanced Barrier Precautions (EBP) [Precautions taken to prevent the spread of infections and include donning a gown and gloves prior to direct care activities] for G-tube [Gastrostomy Tube, a tube inserted into the stomach to deliver nutrition and medications]. Resident is not isolated to their room. Staff to gown and glove for high contact care activities. A review of the facility ' s document titled, Enhanced Barrier Precautions,…

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 store and prepare food in accordance with professional standards of food safety for a census of 154 when: 1. Four large cuts of pork loin were not thawed to standards, and 2. Foods past their expiration and use-by date were not discarded. These failures had the potential to increase the risk of foodborne illnesses. Findings: 1. During a concurrent observation and interview on 12/12/24 at 10:10 a.m., with the Kitchen Supervisor (KS), four large cuts of pork loin were thawing in a sink with no running water. The KS confirmed the meat was not thawing under running water. During an interview on 12/12/24 at 1:29 p.m., with the Registered Dietitian (RD), the RD indicated that thawing meat should be done under running cold water. The RD also indicated proper thawing was important for the safety of the residents since some foods could be considered potentially hazardous foods (PHF, foods that can support the growth of bacteria that cause food poisoning or toxins). During a review of the facility ' s policy and…

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

Based on observation, interview and record review the facility failed to ensure food safety for a census of 151 when: 1) The kitchen was not maintained under sanitary conditions; 2) The bleach concentration was out of range; and 3) Undated snacks were available for use in the nourishment room refrigerator. These failures placed the residents at risk for foodborne illnesses. Findings: 1)The initial kitchen tour was conducted on 3/3/24 starting at 8:50 a.m., with the Food Services Director (FSD) and below was noted: a) The stove top grids had thick black oily built-up residue and the ovens underneath were covered with food crusts, crumbs, and oil residue inside both ovens. In a review of the facility policy, dated November 2022, titled, Sanitization stipulated, All equipment, food contact services and utensils are cleaned and sanitized using heat or chemical sanitizing solutions. In a concurrent observation and interview, the FSD verified that the stove had dirty build up and the ovens were unclean. The FSD stated that she expected dietary staff to clean them after each use. b) The…

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

Based on observation, interview, record review, and facility policy review, the facility failed to provide respiratory care consistent with the facility policy and procedure for two of 30 sampled residents (Resident 113 and Resident 82) when: 1. Resident 113's nebulizer mask (a device used to change liquid medication into a mist form that is inhaled through a mask) was left in an opened drawer of the bedside table, uncovered and unlabeled. 2. Resident 82's nebulizer mask was hung on the wall uncovered and unlabeled. These failures placed Resident 113 and Resident 82 at risk for respiratory infections. Findings: 1. Resident 113 was admitted to the facility in 2024 with diagnoses that included, chronic respiratory failure with hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions). A review of the Medication Administration Record for Resident 113 indicated, a physician's order, dated 2/12/24 for, Ipratropium-Albuterol (a medication used to prevent wheezing and shortness of breath caused by ongoing lung disease) 3 milliliters (ml, a unit of measurement) inhale…

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

Based on observation, interview, and record review, the facility failed to label and store drugs and biologicals properly for a census of 151 when: 1. Insulin pens were not labeled with an open date, 2. Loose pills were found in medication carts, and; 3. A flush (used to keep a feeding tube from getting clogged by flushing it with warm water after each feeding and before and after giving medicines) that was ready to use was not labeled or dated. These failures had the potential for drug diversion, residents to receive expired medications, and for Resident 1 to receive an unknown fluid flush. Findings: 1. During a concurrent observation and interview on 3/5/24 at 8:45 a.m., with Licensed Nurse (LN) 1, during an inspection of the 500 Hall Medication Cart, three insulin pens were observed in the medication cart available for use with no opened date on them. LN 1 verified there were no written open dates on the insulin pens. During an interview on 3/5/24 at 9 a.m., with the Director of Nursing (DON), she confirmed insulin pens are to be labeled when opened. During 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.

Based on observation, interview, and record review, the facility failed to label and store drugs and biologicals properly for a census of 151 when: 1. Insulin pens were not labeled with an open date, 2. Loose pills were found in medication carts, and; 3. A flush (used to keep a feeding tube from getting clogged by flushing it with warm water after each feeding and before and after giving medicines) that was ready to use was not labeled or dated. These failures had the potential for drug diversion, residents to receive expired medications, and for Resident 1 to receive an unknown fluid flush. Findings: 1. During a concurrent observation and interview on 3/5/24 at 8:45 a.m., with Licensed Nurse (LN) 1, during an inspection of the 500 Hall Medication Cart, three insulin pens were observed in the medication cart available for use with no opened date on them. LN 1 verified there were no written open dates on the insulin pens. During an interview on 3/5/24 at 9 a.m., with the Director of Nursing (DON), she confirmed insulin pens are to be labeled when opened. During 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 observation, interview and record review the facility failed to follow infection control guidelines to provide a safe and sanitary environment for a census of 151 residents when, 1. two clean white linens (sheets) touched the floor as the Laundry Aide (LA) folded the sheets; and 2. clean shirt and pants placed on top of the table touched the LA's uniform as she leaned over to reach for linens, 3. the facility failed to properly label residents' personal belongings in a shared room. These deficient practices had the potential to spread infection and disease among residents and staff. Findings: 1. During a concurrent observation and interview on 3/5/24 at 12:35 p.m., with LA in the laundry department, two clean white sheets touched the floor as the LA folded the sheets. When asked, LA acknowledged that the two clean white sheets touched the floor while she folded them. She further stated, clean linens should not touch the floor for infection control reasons. 2. During a concurrent observation and…

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

Based on observation and interview, the facility failed to ensure medications were secure for a census of 149, when a medication/treatment cart was found unlocked and unattended with the key laying across the top. This failure had the potential to expose residents, staff and visitors to unauthorized access to medications, resulting in possible injury or drug diversion. Findings: During an observation on 2/22/24 at 1:45 p.m., in 500 hall, the treatment cart was up against the wall between two resident rooms, unattended and unlocked with the keys laying across the right side of the cart. During a concurrent observation and interview on 2/22/24 at 1:45 p.m., with the Registered Nurse (RN), the RN confirmed the treatment cart with prescription medications was unlocked and the cart keys were laying on top of the cart. The RN stated, The keys should be with the nurse. She should have locked the cart before leaving so no one could get into it. During an interview on 2/22/24 at 4:30 p.m., with Director of Nursing (DON), the DON stated, I would expect all medication and treatment carts with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow and maintain an effective infection prevention program for a census of 136 residents when: 1. Staff entered rooms of Coronavirus disease 2019 (COVID-19, viral respiratory illness that causes fever, coughing, and shortness of breath) patients without full personal protective equipment (PPE, equipment worn to minimize exposure to a variety of hazards); 2. Doors to COVID-19 positive residents' rooms were not closed 3. Double gloves were used without handwashing, scissors were not cleaned prior to cutting dressings, dirty scissors were placed on residents bedside table, dressings for wound care were placed on a resident bed, contaminated dressings were placed into resident wounds 4. Hand washing was not performed between glove changes, and 5. Multi-use house supply tubes of ointments were brought into a resident room. These failures increased the risk for cross-contamination (movement or transfer of harmful bacteria from one person,…

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

Based on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 1) received treatments as ordered for her pressure ulcer ( PU- injury to the skin and underlying tissue from prolonged pressure on the skin). This failure had the potential for the worsening of Resident 1's wound. Findings: Resident 1 was admitted to the facility mid 2021 with diagnoses which included dementia (memory problems), muscle weakness, and diabetes (chronic condition that affects the way the body processes blood sugar). During a review of Resident 1's Order Summary Report [OSR], Active Orders As Of: 12/28/23, the OSR indicated, Pressure injury coccyx [tailbone] area .cover with foam dressing [bandage] daily . During a review of Resident 1's Electronic Treatment Administration Record (ETAR), dated 12/1-12/31/23, the ETAR indicated a blank, uninitialed box for the date 12/26/23. During a concurrent observation and interview on 12/27/23 at 11:56 a.m., with Registered Nurse (RN 1 ) 1 , in Resident 1's bedroom. Resident had a bandage on her coccyx with…

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

Based on observation, interview, and record review, the facility failed to ensure the treatment nurse (TX 1)1 had the competencies to provide wound care for one of six sampled residents (Resident 2) when: 1. Scissors were not cleaned prior to cutting dressings; 2. Uncleaned scissors were placed on resident's bedside table; 3. Dressings for wound care were placed on resident's bed; 4. Double gloves were used without handwashing, and 5. Contaminated dressings were placed into resident's wound. These failures increased the potential for infection and/or physical harm to the resident. Findings: Resident 2 was admitted to the facility late 2023 with diagnoses which included chronic ulcer (open sore) of his right heel, diabetes (a chronic condition that affects the way the body processes blood sugar). During a review of Resident 2's, electronic treatment administration record (ETAR), dated 12/1-12/31/23, the ETAR indicated, Rt [right] heel Wound Vac [ Negative Pressure Wound Therapy, NPWT vacuum assisted wound care device, removes excess drainage] .Cleanse with NS [normal saline] .Apply…

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 safe and secured storage of prescribed medication for a census of 136 when a medication cart was left unattended and unlocked. This failure had the potential for unauthorized personnel to access the medication cart. Findings: During a concurrent observation and interview on 12/27/23 at 12:25 p.m., with Registered Nurse (RN 1), RN 1 walked by an unlocked, unattended medication cart in the 500 hallway. RN 1 confirmed the cart was unlocked and unattended. During an interview on 12/27/23 at 12:26 a.m., with Licensed Nurse (LN 1) 1, confirmed the medication cart was unlocked and unattended. LN 1 stated medication carts are supposed to be locked when not in use. When asked a potential outcome for leaving a medication cart unlocked, LN 1 stated, A patient could get into it, especially a confused patient and take medications . During an interview on 12/28/23 at 3:59 p.m., with the Director of Nursing (DON), the DON was asked the expectation of staff when leaving the medication cart. The DON stated, They…

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