Willow Creek Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to report a alleged abuse incident to the California Department of Public Health (CDPH) when two of six sampled residents (Resident 30 and Resident110) were involved in a resident-to-resident altercation without serious injury. This failure resulted in the facility not reporting the alleged violation involving resident to resident abuse within the required timeframe and had the potential for additional allegations of abuse to go unreported. Findings: During a concurrent observation and interview on 4/1/25 at 3:02 p.m. with Resident 110 in the resident ' s room, Resident 110 was sitting on the edge of her bed facing the window. Resident 110 had six 1.5-inch adhesive strips (small bandages made of breathable material used as an alternative to stitches to help close small cuts and wounds) applied to her left hand. Resident 110 was alert, oriented to person, place, date and time, understood and answered questions appropriately. Resident 110…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Minimum Data Set Assessment (MDS-assessment of physical and psychological functions and needs of residents) accurately reflected resident's health and functional status of one of four sampled residents (Resident 17) when Resident 17's use of anxiety medication and diagnoses of migraine was not accurately coded on the MDS assessment. This failure had the potential to result in Resident 17's care needs not met. Findings: During a review of Resident 17's admission Record (document with resident demographic and medical diagnosis information), dated 4/3/25, the AR indicated Resident 17 was admitted in the facility on 7/11/25 and re-admitted on [DATE] with diagnoses which included Parkinson's Disease (a progressive disease of the nervous system marked by tremor, rigidity, and slow, imprecise movements), respiratory disorder and dementia (a progressive state of decline in mental abilities). During a review of Resident 17's Minimum Data Set (MDS- 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the Level I Preadmission Screening and Resident Review (PASRR- The State is required to ensure that every person entering a Medicaid certified Nursing Facility [NF] receives a admission level screening and if necessary a level ll evaluation to ensure that their NF residence is appropriate and to identify what specialized services they may need) was completed accurately for one of four sampled residents (Resident 17) when Resident 17 was admitted for hospice care on 11/14/24 and an updated PASRR was not completed. This failure had the potential for Resident 17 not to receive the necessary and appropriate psychiatric treatment and evaluation in the facility. Findings: During a review of Resident 17's admission Record [AR], dated 4/3/25, the AR indicated, Resident 17 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included Parkinson's Disease (a progressive disease of the nervous system marked by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to develop and implement a baseline care plan for one of three sampled residents (Resident 253) when Resident 253 did not have a care plan for oxygen (O2) andmedication ciprofloxacin (antibiotic medication used to treat bacterial infections in different parts of the body). This failure resulted in no baseline care plan to address the use of ciprofloxcin and had the potential for Resident 253 to not have her oxygen needs met. Findings: During a concurrent observation and interview on 4/1/25 at 9:26 a.m. with Resident 253 in her room, Resident 253 was observed to be on oxygen (O2) at 3 liters(measurement) per minute (LPM) via nasal cannula (NC-tube used to administer via the nose). Resident 253 stated, I haven ' t always had oxygen; just since my hospitalization. During a review of Resident 253 ' s admission Record (AR) dated 4/3/25, the AR indicated, Resident 253 was admitted to the facility on [DATE] with diagnoses which included fracture…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of two sampled residents (Resident 128) was free from accidents, when Resident 128 was smoking and had ashes fall on her shirt and into her wheelchair. This failure put Resident 128 ' s safety at risk and the ashes had the potential to burn the resident. Findings: During a concurrent observation and interview on 4/2/25 at 11:40 a.m., with Resident 128, Resident 404, Activities Assistant (AA) 2 and AA 1, outside in the atrium designated smoking area of the facility, Resident 128 smoked two cigarettes and dropped ashes on her shirt and between her legs on her wheelchair. AA 2 was sitting on a bench to the right of the resident conversating with both residents and another Activities Assistant (AA 1). Resident 128 brushed the ashes off her body with her hand that had a cigarette in it. Resident 128 was not wearing a smoking apron and stated she was not offered one prior to smoking. During a review of Resident 128's admission Record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide food prepared in a form designed to meet individual needs for two of nine sampled residents (Resident 20 and Resident 8) when: 1. Resident 20 was not served pureed (food that are pudding-like texture that is smooth, blended) banana and had a physician order for a pureed diet. This failure placed residents with difficulty chewing and swallowing and, on a physician, prescribed pureed diet at risk of choking. 2. Resident 8 served minced meat for lunch on 4/1/25 instead of regular textured diet as ordered by medical doctor (MD). This failure had the potential for Resident 8 to not eat her food which could result to weight loss. Findings: 1.During a concurrent observation and record review on 4/1/25 at 12:15 p.m. with Certified Nurse Assistant (CNA) 4 and Resident 20 in the assisted dining room, Resident 20 ' s lunch meal ticket was reviewed. The meal ticket indicated Resident 20 ' s diet order: pureed, fortified, thin liquids, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of five sampled residents (Resident 102) had access to a call light when the tap button (a large square button that can be easily triggered by pressure from a hand, elbow used when residents have limited finger strength) call light was found hanging off the left handrail three inches above the floor. This failure resulted in Resident 102 not being able to directly call for help. Findings: During an observation on 4/1/25 at 8:08 a.m. with Resident 102 in the resident's room, Resident 102 laid asleep in bed. Resident 102's bed had an air mattress, and the head of the bed was elevated while enteral feeding (nutrition delivered using the gut) infused as it hung from the intravenous (IV-within the vein) pole at the right side of the bed. Resident 102 tap button call light hung from the left handrail inches above the floor. During a review of Resident 102's admission Record (AR- a document that provides resident contact details, 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 was accessible for two of three sampled residents (Resident 1 and Resident 3) when Resident 1 and Resident 3's call light was not within reach on 12/26/2024. These failures had the potential to result in Resident 1 and Resident 3 not being able to access their call light when they needed help and assistance with their activities of the daily living. Findings: During concurrent observation and interview on 12/26/2024 at 2:23 p.m. with Resident 1, in Resident 1's room, Resident 1's call light was wrapped around to the assist bar on the left side of the bed. Resident 1 was looking for his call light and was unable to find his call light. Resident 1 stated he needed his call light, and he used his call light when he needed help but was unable to reach it to call for help. During concurrent observation and interview on 12/27/2024 at 2:32 p.m. in Resident 1's room, with the Director of Staff and Development (DSD), the DSD validated that Resident 1's call light was wrapped around the assist bar…

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 and maintain infection prevention and control procedures for four of four sampled shower areas when: 1.Station 1-The women ' s shower had a pair of used gloves and washcloth in the soap bar holder, brown colored substance on the washcloth. The drains had loose hair buildup with paper debris. The men ' s shower had a brown colored substance on the grab bar near toilet seat, a uncovered toilet plunger located beside toilet had a white dried substance on it. A package of wipes used to clean a resident was open and on the floor. 2.Station 2 – The men and women ' s shower drains had dark and grey colored hair and debris in them. The tile floor in women ' s shower had dark brown colored tracks along floor. 3.Station 3- The men and women ' s shower drains had dark and grey colored hair and plastic and paper debris in them. 4. room [ROOM NUMBER] shower drain had hair and debris in the shower and the bedside commode had chipped paint 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 interview and record review, the facility failed to ensure one of five sampled residents, Resident 1, was free from abuse when Resident 1 expressly stated to Certified Nursing Assistant (CNA) 1 not to check his brief (product used to absorb urine) on 6/7/24. CNA 1 checked Resident 1's brief twice without his permission and in the process physically touched Resident 1's genitals (sexual organs located outside the body). These failures resulted in not honoring Resident 1's expressed refusal of care and could be considered physical and sexual abuse. Resident 1 felt violated, angry, humiliated, and disrespected. Findings: During a review of Resident 1's admission Record (document containing resident demographic information and medical diagnosis) undated, the admission record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnosis included Acquired Absence of Right Leg Below Knee (cutting off leg below the knee), End Stage Renal Disease (a medical condition in which a person'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 observation, interview and record review, the facility failed to report an allegation of alleged abuse to the state agency, ombudsman and local law enforcement within the required 24-hour time frame for one of five sampled residents (Resident 1) when on 6/7/24, Resident 1 reported to Licensed Vocation Nurse (LVN) 1 that Certified Nursing Assistant (CNA) 1 violated him. This failure led to the allegation of abuse on 6/7/24 to go unnoticed and unreported by the facility until 6/17/24. Findings: During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) Assessment dated 6/15/24, it indicated Resident 1's Brief Interview for Mental Status (BIMS -assessment of memory and judgment) assessment score was 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, 00-07 indicates severe impairment, 99 severely impaired). The BIMS assessment indicated Resident 1 was cognitively intact. During an interview on 6/21/24 at 11:24 a.m. with Certified Nursing Assistant (CNA) 1, CNA…

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 an effective infection control and prevention program for one of three sampled residents (Resident 2), when Certified Nursing Assistance (CNA) was observed without proper personal protective equipment (PPE-equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) and not performing hand hygiene (washing hand or using alcohol base hand rub) while providing care on 6/4/24. This failure had the potential to place Resident 2 at increased risk for an infection with multidrug resistant organisms (MRDO- bacteria (germs) that have developed resistance to multiple types of antibiotics) and had the potential transit infection throughout the facility. Findings: During a review of Resident 2 ' s admission Record (AR), dated 5/4/24, the AR indicated, Resident 2 was admitted on [DATE] with a diagnosis of Covid -19 (a highly infection respiratory disease) immunodeficiency (the decreased ability of the body…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 1 ) was assessed for the risk of entrapment (resident caught, trapped, or entangled in the space in or about the bed and side rail) from bed (side) rails (adjustable metal or rigid plastic bars in various sizes that attach to the bed, and can be placed in a guard (raised) or lowered position) prior to installation when Resident 1 had no entrapment risk assessment, physician order, and care plans prior to the use of side rails. These failures had the potential to place Resident 1 at risk for decreased freedom of movement, entrapment and/or injury. Findings: 1. During an observation on 5/14/24 at 9:28 a.m., with Resident 1, in Resident 1's room, Resident 1 was lying in bed with two bed rails up. During a concurrent observation and interview on 5/14/24 at 10:05 a.m., with Certified Nursing Assistant (CNA) 1, in Resident 1's room, Resident 1 was lying in bed with two bed rails up. CNA 1 stated…

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 services which met professional standards for one of three sampled residents (Resident 2) when Resident 2's oxygen (a colorless, odorless, tasteless gas essential to living) flow rate (the amount of oxygen being delivered to the body) was not administered according to the physician order (an order given for specific patient/resident by a health care provider). This failure resulted in Resident 2 oxygen to not be administer according to the physician order. Findings: During a review of Resident 2s admission Record (document containing resident demographic information and medical diagnosis), dated 4/29/24, the admission Record indicated, Resident 2 was admitted to the facility on [DATE]. Resident 2 ' s diagnosis included .ESSENTIAL (PRIMARY) HYPERTENSION (occurs when you have abnormally high blood pressure that's not the result of a medical condition) .CHRONIC OBSTRUCTIVE PULMONARY DISEASE (a group of diseases that cause airflow…

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 policy review, the facility failed to ensure staff washed or sanitized their hands before they put on gloves during meal preparation. This had the potential to affect all residents who received food from the kitchen. Findings included: Review of the facility policy titled, Food Preparation and Service, revised November 2022, revealed 2. Cross-contamination can occur when harmful substances, i.e. [id est, a Latin term that meant, that is] chemical or disease-causing microorganisms are transferred to food by hands (including gloved hands), food contact surfaces, sponges, cloth towels, or utensils that are not adequately cleaned. During an observation on 03/05/2024 beginning at 10:35 AM, [NAME] #2 was noted to not wash or sanitize her hands before she put on gloves to prepare a pan of lasagna. During an observation on 03/05/2024 beginning at 11:09 AM, [NAME] #3 removed her gloves, and did not wash or sanitize her hands before she put a pair of clean gloves on to finish preparation of a batch of cookies. In an interview on 03/07/2024 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 observation, interviews, and facility policy review, the facility failed to ensure 5 of 5 dumpsters were closed and the area around them was free of trash and debris to prevent the potential for vermin and pest attraction. This had the potential to affect all 155 residents who currently resided in the facility. Findings included: A review of facility policy titled, Food-Related Garbage and Refuse Disposal, revised in October 2017, revealed, 7. Outside dumpsters provided by garbage pickup services will be kept closed and free of surrounding litter. During a tour of the facility dumpsters on 03/05/2024 at 3:57 PM, the surveyor noted there were five dumpsters, all with opened lids. There was scattered trash and debris on the ground that surrounded the dumpsters to include, plastic bags, gloves, a cup, a sandwich bag labeled peanut butter and jelly and dated 03/04/2024, a pastry wrapper, a large empty tin of Mandarin oranges, and a pint size empty carton of milk. During an interview on 03/07/2024 at 11:13 AM, the Housekeeping Director stated he and the staff of the dietary…

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 review, the facility failed to ensure the accuracy of the preadmission screening and resident review (PASARR) level I screening for 1 (Resident #108) of 1 sampled resident reviewed for PASARR. Findings included: Review of the facility policy titled, admission Criteria - PASRR [preadmission screening and resident review], revised in March 2019, revealed, 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID), or related disorders per the Medicaid Pre-admission Screening and Resident Review process. a. The facility conducts a Level I PASARR screen for all potential admissions, regardless of payor source, to determine if the individual meets the criteria for a MD, ID or RD. A review of Resident #108's admission Record revealed the facility admitted the resident on 02/01/2023, with diagnoses that included post-traumatic stress disorder (PTSD). A review of Resident #108's Preadmission Screening and Resident Review Level I Screening, dated 02/02/2023, revealed the resident did…

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 document reviews, the facility failed to provide an activity program that met the needs of 1 (Resident #304) of 2 sampled residents reviewed for activities. Findings included: A review of Resident #304's admission Record revealed the facility admitted the resident on 09/25/2023. Per the admission Record, on 02/19/2024, the resident received a diagnosis of Escherichia (E) coli. A review of Resident #304's Activity Assessment, dated 09/28/2023, revealed the resident enjoyed arts and crafts, swimming, and spending time with their best friend. Per the Activity Assessment, the resident's preferred activities in the activity room and in their room. A review of Resident #304's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/042024, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. A review of Resident #304's Order Summary Report, for active orders as of 03/07/2024, revealed an order dated 02/20/2024 that indicated the resident was 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.

Based on interviews, record review, document review, and facility policy review, the facility failed to prepare enough food to ensure the planned menu was served for 1 (Resident #8) of 2 sampled residents reviewed for food. Findings included: Review of a facility policy titled, Resident Food Preferences, revised in July 2017, revealed, 10. The Food Services Department will offer a variety of foods at each scheduled meal, as well as access to nourishing snacks throughout the day and night. A review of Resident #8's admission Record revealed the facility admitted the resident on 08/19/2011, with diagnoses that included nutritional anemia, disease of the stomach and duodenum, and history of peptic ulcer disease. A review of Resident #8's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/18/2023, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. In an interview on 03/04/2024 at 10:59 AM, Resident #8 stated they did not always receive what was on the planned menu. According 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 ensure services provided met professional standard of practice for two of six sampled residents (Resident 5 and 6) when facility staff did not follow the physician's order to administer nystatin powder (a medication to treat skin infections). This failure had the potential to cause Resident 5 and 6 to experience moisture associated skin damage to the abdominal folds, armpit, breast, and groin area. Findings: During a concurrent interview and record review on 11/3/22, at 10: 35 a.m., with Licensed Vocational Nurse (LVN) 2, a document titled, Medication Administration Record, dated 11/3/23 was reviewed. The document indicated, Nystatin Powder 100,000 UNIT/GM [unit per gram - unit of measurement] Apply to groin, abdominal folds, armpits topically every shift for [Incontinence Associated Skin Damage/Moisture Associated Skin Disorder] . Start Date – 5/12/22 11/29/22 . Night . [blank, missing licensed nurse ' s initial] . LVN 2 stated, Resident 5 ' 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to notify the residents representative (RP) for one of three sampled residents (Resident 1) when licensed staff did not notify the resident representative (RP) of Resident 1 ' s altered mental status (a disruption of a person ' s normal mental function) and his transfer to an acute care hospital (a facility that provides treatment for a severe injury or illness) on 7/7/23. This failure resulted in Resident 1 ' s RP not being aware on 7/7/23 of Resident 1 ' s transfer and change in his medical condition. Findings: During a review of Resident 1 ' s admission Record (document containing resident demographic information and medical diagnosis), dated 7/24/23, the admission Record indicated, Resident 1 was admitted to the facility on [DATE]. Resident 1 ' s diagnosis included but not limited to . SCHIZOAFFECTIVE DISORDER (a disorder that includes symptoms such as delusions, hallucinations, depressed episodes, and manic periods of high energy) . CHRONIC PAIN…

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 residents (Resident 2) was treated respect and dignity, when Resident 2 ' s fingernails were long with black and brown matter under the fingernails. This failure resulted in the facility not promoting the rights of Resident 2 to a dignified and respectful existence and had the potential to compromise her health and well-being. Findings: During a concurrent observation and interview on 11/2/22, at 11:50 a.m., with Certified Nurse Assistant (CNA) 1, in Resident 2 ' s room, Resident 2 was lying in bed with both hands on top of the bedsheet cover. CNA 1 stated, Resident 2 ' s fingernails on both hands were long with black and brown matter under the fingernails. CNA 1 stated, CNAs were responsible in keeping resident ' s fingernails clean at all times. CNA 1 stated, the facility failed to keep Resident 2 ' s fingernails clean. CNA 1 stated, Resident 2 uses her hands to eat her meals, and the dirty fingernails could cause skin infection and stomach problems such as nausea, vomiting, and diarrhea.…

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 implement a system to oversee grievances in accordance with their policy and procedure (P&P) for one of six sampled residents (Resident 1) when the facility ' s Social Services Designee (SSD, designated Grievance Official) did not oversee, document, track, and investigate grievances filed by Resident 1. This failure had the potential to result in Resident 1 not being able to exercise his rights and lack of proper action to resolve his grievances. Findings: During a phone interview on 10/31/22, at 9:00 a.m., with Family Member (FM) 1, FM 1 stated, she filed a written grievance on 10/6/22 with the Social Service Designee (DSD) and was informed that her complaints would be investigated and she would be notified on the outcome of the investigation. FM 1 stated, her husband [Resident 1] received poor care from the staff that resulted in his hospitalization and eventually receiving three units of blood (a procedure in which donated blood are given through an intravenous line). FM 1 stated, she left multiple messages for the SSD…

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 effective infection control program when two of six sampled residents ' (Residents 3 and 4) oxygen concentrator (a device that concentrates the oxygen from the ambient air) filters were found covered with lint and dust. This failure placed Resident 3 and 4 at an increased risk to develop respiratory and healthcare-associated infections. Findings: During a concurrent observation and interview on 11/2/22, at 12:08 p.m., in Resident 3 ' s room, Resident 3 had an oxygen cannula (a device used to deliver supplemental oxygen) connected to an oxygen concentrator. The oxygen was operating at 3L/min (LPM-Liters Per Minute, unit of measurement). The oxygen concentrator dust filter was covered with white and gray material. Resident 3 stated, the dirty oxygen concentrator was not acceptable and he wanted the oxygen concentrator dust filter to be clean as soon as possible. During a concurrent observation and interview on 11/2/22, at 12:23…

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

Based on observation, interview and record review, the facility failed to store, prepare and serve food safely when: 1. The kitchen bread rack in dry storage area stored a loaf of garlic bread wrapped in foil, with a date which indicated best [used] by 4/30/19; a loaf of rye bread opened in a plastic bag with no written open date; four bags of hot dog buns taken out of the original packaging with no open date written. 2. A bag of chicken meat was not labeled and dated in the walk-in freezer. These failures placed residents at risk for food borne illness and growth of microorganisms (bacteria). Findings: 1. During a concurrent observation and interview with the Account Dietary Manager (DM), on 5/6/19, at 8:10 a.m., in the dry storage room, the following items were observed without an open date label or used by date: rye bread in a plastic bag, 4 packages of hot dog buns in a plastic bag. The Registered Dietician (RD) stated any open bag/packages needed to be dated. On the bread rack was a package of garlic bread which indicated best by 4/30/19. The date was verified by the DM and…

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

Based on interview and record review, the facility failed to conduct a facility-wide assessment specific to the facility needs when facility assessment did not include a water management plan. This practice failed to establish an individualized facility assessment to meet the requirement for a water management plan which had the potential for water borne bacteria exposure to the residents including Legionella (disease is a severe form of pneumonia - lung inflammation usually caused by infection, caused by a bacterium known as legionella. most people get legionnaires' disease from inhaling the bacteria in showers, water facets, water fountain) in an event of an outbreak. Findings: During a concurrent facility document review and interview with the Maintenance Director (MD), on 5/7/19, at 12:27 p.m., he stated the facility had a water management plan that he developed. The water management plan undated indicated, . Water Management Plan Committee . 1. [MD] . Maintenance . 2. [blank] .3. [blank] . 7. [blank] . Building Water System . 1. Building connects to . Vendor . Utility vendor…

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

Based on interview and record review, the facility failed to have an effective Quality Assurance and Performance Improvement (QAPI -is the specification of standards for quality of service and outcomes, a process throughout the organization for assuring that care is maintained at acceptable levels in relation to those standards, aims to improve processes involved in health care delivery and resident quality of life) program when: 1. The QAPI program did not develop and implement a water management program as part of the Infection Control Program (cross reference F 838 and F 880). This failure resulted in the facility not having a program in place to reduce the risk of water borne illnesses including Legionella (disease is a severe form of pneumonia - lung inflammation usually caused by infection, caused by a bacterium known as legionella. most people get legionnaires' disease from inhaling the bacteria in showers, water facets, water fountain). 2. The QAPI program did not develop a system of identifying and monitoring residents with weight loss and implement effective interventions…

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 infection prevention and control program when: 1. Wet kitchen towels/rags were hung on a rack on top of one another to air dry and wet towels were touching the kitchen floor. 2. The kitchen did not have a system to monitor the sanitation solution of the red sanitation water buckets used to sanitize the work surface areas used to prepare food. 3. The facility failed to have a facility-wide assessment that addressed the federal expectation to develop a water management program for the risk reduction of Legionella (a water borne bacteria which can cause life threatening pneumonia) and other water-borne pathogens (germs that cause disease) in accordance with CMS letter revision date 7/6/18. These failures placed the residents at risk for cross contamination, infection and potential for not identifying risk to water borne illnesses such as Legionella (Disease is a severe form of pneumonia - lung inflammation usually caused by infection, caused by a bacterium known as legionella. most people…

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 send a copy of the resident transfer and discharge notification to a representative of the Office of the State Long-Term Care Ombudsman (an official appointed to represent the elderly and frail's rights under public authorities) for two of five sampled residents (Resident 104 and Resident 338) when: 1. Resident 104 was transferred for hospitalization. 2. Resident 338 was transferred for hospitalization. These failures had the potential to result in inappropriate resident transfer and discharge practices for Resident 104 and Resident 338. Findings: 1. During a concurrent interview and record review of Resident 104's Electronic Medical Record with Licensed Vocational Nurse (LVN) 1, on 5/7/19, at 3:47 p.m., she stated Resident 104 had been hospitalized three times this year (2019). LVN 1 stated, The hospitalization dates are 1/8/19, 1/25/19 and 2/8/19. During a review of the clinical record for Resident 104, the admission Record dated 5/8/19, indicated he…

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 develop and implement the plan of care to reflect the care needs for three of 30 sampled residents (Residents 2, 33, and 74): 1. For Resident 33, the facility failed to develop a side rail care plan (a plan that provides direction for individualized care of the resident). 2. For Residents 2 and 74, the facility failed to implement the activities care plan when one-to-one in room visits were not followed. These failures placed the residents at risk of not receiving appropriate, consistent, and individualized care interventions to ensure their well-being. Findings: 1. During an observation on 5/6/19, at 8:21 a.m., in the resident's room, Resident 33 was lying in bed asleep. Resident 33 was observed to have three one-half side rails elevated on the bed. Resident 33's left side of the bed was observed with upper and lower side rails elevated, and the right side of the bed was observed with an upper one-half side rail elevated. During an…

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

Based on observation, interview and record review, the facility failed to ensure the food services staff had appropriate competencies or safely and effectively carry out the functions of food services when [NAME] 1 and [NAME] 3 were unable to verbalize the thermometer calibration process. This failure had the potential for untrained staff to place residents at risk of exposure to foodborne illnesses. Findings: During an interview with [NAME] 1, on 5/7/19, at 10:25 a.m., [NAME] was preparing to check food temperatures. [NAME] 1 did not calibrate the food thermometer prior to placing the thermometer in the hot meat dish. [NAME] 1 was unable to verbalize the calibration of the kitchen thermometer used to check the temperature of food. [NAME] 1 did not know the required low temperature of the thermometer in order to accurately perform the calibration. During an interview with [NAME] 3, on 5/7/19, at 10:28 a.m., she was unable to verbalize the calibration of the kitchen thermometer used to check the temperature of the food. During interview with the Account Dietary Manager (DM), on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the accuracy and completeness of medical records for five of 30 sampled residents (Residents 2, 74, 64, 84, and 109) when: 1. Resident 2's independent activities were documented as watching television in her room, when there was no television available for the resident. 2. Resident 74's physician orders indicated resident was receiving hospice (end of life treatment and care) services and the hospice services were discontinued but not reflected on the physician's order report summary. 3. Resident 84's physicians' orders dated 5/1/19 inaccurately indicated appointment scheduled with orthopedic (bone specialist) physician for splint (broken bone stabilizer) treatment and rehabilitation services when those services had been discontinued. 4. Resident 109's physicians' orders dated 5/1/19 inaccurately indicated laboratory order for TSH (thyroid stimulating hormone - help the thyroid produce hormones) and orders for Fingerstick (checking…

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 equipment in safe operating condition when: 1. Five of 24 resident beds had controls that did not work and made squeaking noises. This failure resulted in resident beds that were not safe and fully operational for Residents 14, 75, 27, 87 and 104. 2. There was ice buildup inside the walk in freezer on the plastic freezer door curtains and inside part of the door. This failure had the potential to impact the ability of dietary staff to prepare, store, and serve food in a safe and sanitary manner. Findings: During an interview with the Maintenance Director (MD), on 5/7/19, at 11:35 a.m., MD stated he was not aware of any beds that made an abnormal noise (squeak). The MD stated, I don't do regular maintenance . I just wait until somebody tells me that there is something wrong with the bed. During a concurrent observation and interview with Certified Nursing Assistant (CNA) 2, on 5/9/19, at 9:38 a.m., in Resident 14's room, CNA 2 tested Resident 14's bed. Resident 14 was in bed and gave CNA 2 permission…

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 residents right to privacy of medical records for one of 28 residents (Resident 93) when Resident 93's personal and medical information was exposed for anyone to see. This failure resulted in the violation of Resident 93's right to privacy and confidentiality of his medical information. Findings: During an observation on 5/7/19, at 8:26 a.m., in Station 3 Nurses' Station, there was a medication cart by the hallway with the computer open. Resident 93's picture and name was on the screen with his list of medications in view. There was no licensed nurse near the medication cart. During an interview with Licensed Vocational Nurse (LVN) 3, on 5/7/19, at 8:28 a.m., she stated, I am so sorry. I knew better than that to leave it [computer] open. LVN 3 stated the computer was not to be left open exposing resident personal information. LVN 3 stated, It is a confidentiality issue . You can't expose the resident's information . I took out…

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 a comfortable and homelike environment for two of 20 sampled residents (Resident 123 and Resident 14) when: 1. Resident 123's bed made loud noises whenever bed repositioning was done and the mattress had lumps which were uncomfortable for Resident 123. 2. Resident 14's bed made a loud noise whenever the bed was lowered. This failure resulted in an uncomfortable and un-homelike environment for Resident 123 and Resident 14. Findings: 1. During a concurrent observation and interview on 5/7/19, at 11:03 a.m., there was a loud creaking noise heard in the hallway in Station 3. The noise came from Resident 123's room. Resident 123 stated, It's my bed, it is the bottom [half] part of the bed. It squeaks all the time . I hate it. I have to adjust it [bed] to make me feel better. I have to keep adjusting it . Resident 123 stated she told the Maintenance Director (MD) about the squeaky noise. Resident 123 stated, The bed has lumps on it. They told me they were going to give me a new mattress. Resident 123…

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 Minimum Data Set (MDS- assessment of cognitive and functional needs) assessment accurately reflected the resident's status for one of five sampled residents (Resident 104) when Resident 104's thickened liquid diet and oxygen therapy was not coded in Sections K and O. These failures resulted in an inaccurate assessment of Resident 104's MDS assessment and had the potential to result in Resident 104's care needs not being met. Findings: During an observation on 5/6/19, at 9:08 a.m., in Resident 104's room, Resident 104 was sitting in bed eating breakfast with his oxygen cannula (a plastic tubing used for the delivery of oxygen through the nose) on his lap. The oxygen was running at 1L/min (liters per minute - flow rate of oxygen). During a review of the clinical record for Resident 104, the admission Record dated 5/8/19, indicated he was initially admitted to the facility on [DATE] with current diagnoses that included pressure…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide services which met professional standards of quality when physician's diet orders were not followed for three of five sampled residents (Resident 57, Resident 91, and Resident 104). 1. For Resident 57, the facility failed to follow physician's diet order for a regular textured diet during lunch meal service on 5/6/19 which result in Resident 57 receiving a mechanical diet instead of a regular diet. 2. For Resident 91, the facility failed to follow physician's diet order for thick liquids (thickened to nectar-thick consistency liquids) when the resident received tea without thickening. For Resident 91 this failure had the potential to result in choking and potential risk for lung infection from aspiration (food or liquid going into the windpipe). 3. For Resident 104, the facility failed to follow physician's diet order for thick liquids (thickened to nectar-thick consistency liquids) when Resident 104 received coffee without…

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 individualized and ongoing activity programs to meet the needs and interests of two of six residents (Residents 2 and 74). For Residents 2 and 74 the facility failed to provide in room one-to-one visits which had the potential for the residents to experience social isolation. Findings: 1. During a concurrent observation and interview with Resident 2, on 9/6/19, at 9:24 a.m. in the resident's room, Resident 2 was lying in bed. Resident stated she did not like group activities and preferred to do independent activities in her room. Resident 2 stated she liked to watch television, but did not have a television in the room. Resident 2's room was observed with no visible television on bed stand or bedside table. During an observation on 5/6/19, at 10:40 a.m., in the resident's room, Resident 2 was sitting up in bed asleep. No visible television was present for the resident. During a concurrent observation and interview on 5/6/19, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the policy and procedure for dialysis (procedure to remove wastes and excess fluids from the body) was followed and professional standards of quality were met when one of two sampled residents (Residents 128) did not have documentation of completed post-dialysis assessments on multiple dates. For Resident 128, this failure increased the potential for the delayed detection, reporting, and/or management of complications from the hemodialysis (dialysis done through the blood vessel) access sites. Findings: During an observation on 5/6/19, at 8:05 a.m., in resident's room, Resident 128 was seated at the edge of bed eating breakfast and declined to talk. Resident had a dressing on the left upper arm. During a review of the clinical record for Resident 128, the admission Record dated 5/8/19, indicated Resident 128 was admitted on [DATE] with a diagnosis that included End Stage Renal Disease (kidneys no longer function, needing dialysis).…

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 ensure 1 of 6 sampled residents (Resident 33) remained free from accident hazards when Resident 33's bed had three elevated side rails instead of one elevated side rail as ordered by the physician. This failure had the potential to place Resident 33 at risk for entrapment and serious injury. Findings: During an observation on 5/6/19 at 8:21 a.m. in the resident's room, Resident 33 was lying in bed asleep. Resident 33 was observed to have three one half side rails elevated on the bed. Resident 33's left side of the bed was observed with upper and lower side rails elevated, and the right side of the bed was observed with an upper one half side rail elevated. During an observation on 5/6/19, at 10:23 a.m., in the resident's room, Resident 33 had three one half side rails elevated. Resident 33's left side of the bed had one half upper and lower side rails elevated, and the right side of the bed had the upper one half side rail…

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 physician's orders were signed and dated by the attending physician in a timely manner for one of three sampled residents (Resident 45). This failure had the potential for inconsistent care coordination due to inaccurate and incomplete records. Findings: During a review of the clinical record for Resident 45, the physician's orders (PO) for the month of February, March & April, 2019 were missing the signature of the attending physician and were labeled with at least one sign here red tag in each of the month on the last page of the PO. During concurrent interview and record review with the Health Information Manager (HIM), on 5/17/19, at 6:00 p.m., she reviewed the PO for Resident 45 for the month of February, March and April, 2019, and stated the PO were not signed by the attending physician. The HIM stated she does audit and verbally reported to the Director of Nursing (DON) of the missing physician signatures for Resident 45's medication and treatment orders. During an interview with the DON, on 5/17/19, at 6:25…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure drugs stored were labeled in accordance with the facility Accessing a Multiple-Dose Vial policy and procedure for one of three sampled residents (Resident 47) when Resident 47's open insulin glargine (medication used to treat high blood sugar) pen (a device used to inject insulin) was stored in the medication cart without an open date. This failure had the potential to place Resident 47 at risk of receiving expired insulin which could lead to ineffective control of blood sugar and adverse reactions from expired medication. Findings: During a concurrent observation and interview with Licensed Vocational Nurse (LVN) 4, on [DATE], at 3:35 p.m., she obtained an insulin pen from the medication cart on Station 2. LVN 4 stated the insulin glargine pen was not labeled with an open date and it should be labeled. LVN 4 compared the undated insulin glargine pen from the unused insulin glargine pen from the medication room refrigerator and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure routine dental services were provided for one of four sampled residents (Resident 45). This failure had the potential to result in dental problem that could result in unintended weight loss and oral infection. Findings: During a concurrent observation and interview with Resident 45 and her daughter in station 1 dining room on 5/15/19, at 6:13 p.m., Resident 45 was sitting in Geri chair, holding a cup with coffee and her meal tray in front of her. The daughter was feeding her. Resident 45 meal tray consist of two cups of broth soup, plate with pureed meatloaf, pureed bread, milk shake and a small bowl of apple sauce. Resident had no teeth. Resident 45's daughter stated the Registered Nurse (RN) and Registered Dietician (RD) from the facility called and notified her about the weight loss and giving her the option of placing gastric tube (feeding thru the stomach) and she declined and told them she wants her mother to have dentures 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 prepare and serve thicken liquids in a form designed to meet individual resident needs and as ordered by the physician for two or four residents (Residents 104 and 91) when their drink (coffee and tea) were not thickened. These failures placed Residents 104 and Resident 91 at risk of choking on liquid and potential risk for lung infections from aspiration (food or liquid going into the windpipe). Findings: 1.During an observation on 5/6/19, at 9:08 a.m., Resident 104 was I his room eating his breakfast. Resident 104's breakfast consisted of partially eaten scrambled eggs, thickened milk, oatmeal and regular consistency coffee on the side table. Resident 104 stated, I can't drink it (coffee) like this. During a review of Resident 104's meal slip dated 5/6/19, indicated . Regular/Liberalized [includes individual's food preferences] - Dys Adv [Dysphagia (difficulty swallowing) Advance], Chop Mt [Meat] . Nectar [consistency] Like Liquids . During a review of the clinical record for Resident 104, the Order Summary…

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

Based on observation, interview, and record review, the facility failed to follow the physician prescribed diets for three of five sampled residents (Resident 57, Resident 91, and Resident 104). 1. For Resident 57, the facility failed to follow physician's diet order for regular textured diet during lunch meal service on 5/6/19 which result in Resident 57 receiving the wrong prescribed lunch meal. 2. For Resident 91, the facility failed to follow physician's diet order for thick liquids (thickened to nectar-thick consistency liquids) which had the potential to result in choking and potential risk for lung infection from aspiration (food or liquid going into the windpipe). 3. For Resident 104, the facility failed to follow physician's diet order for thick liquids (thickened to nectar-thick consistency liquids) which had the potential to result in choking and potential risk for lung infection from aspiration. Findings: 1. During a concurrent observation and interview with Resident 57, on 5/6/19, at 12:40 p.m., Resident 57 was served her lunch tray by Minimum Data Set Coordinator…

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.