Diablo Valley Post Acute

Based on interview and record review, the facility failed to ensure safe administration of medication for one out of six sampled residents (Resident 2) when the licensed nurse who prepared the medication handed it to another licensed nurse for administration. This resulted in the accidental ingestion of Dakin's solution (diluted solution of made of bleach and other ingredients usually used to cleanse wood to prevent infection) by Resident 2.This failure had the potential to cause harm to Resident 2's health due to the ingestion of a chemical not intended for oral consumption. During a review of the facility's admission Record, the admission record indicated Resident 2 was admitted to the facility in April 2025 with multiple diagnoses that included osteomyelitis (Inflammation of bone caused by infection, generally in the legs, arm, or spine). During an interview on 09/24/25 at 01:57 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she could recall Dakin's solution incident that happened during 04/06/24 involving Resident 1. LVN 1 stated Registered Nurse (RN) 2 was 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 ensure for one out six residents (Resident 1), Resident 1's was in a room with enhanced barrier precautions (EBP - an infection control intervention designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact resident care activities), EBP was not followed during nursing care and treatment. This failure had potential to spread infection when prevention of was not consistently practiced. Findings:During a review of facility's admission Record indicated Resident 1 was admitted to the facility in March 2025, with diagnoses that included pressure ulcer (localized skin and soft tissue injuries that develop due to prolonged pressure exerted over specific areas of the body), chronic diastolic heart (heart's main pumping chamber becomes stiff and unable to fill properly), and atrial fibrillation (irregular and often rapid heartbeat), and hypertension.During a concurrent observation and interview on 09/25/27 at 08:27 a.m., with Registered Nurse (RN) 1, RN 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.

Based on interview, record review, and facility policy review, the facility failed to resubmit a Preadmission Screening and Resident Review (PASRR) Level I evaluation for 2 (Resident #120 and Resident #124) of 5 residents reviewed for PASRR. Findings included: An undated facility policy titled, PASRR (Pre-admission Screening & Resident Review), indicated, 2. The PASRR Level I form will be maintained in the patient's medical record. The policy also indicated, 4. A positive PASRR Level I screen necessitates an in-depth evaluation of the individual, by the state-designated authority, known as Level II PASRR, which must be conducted prior to admission to the facility. 1. An admission Record revealed the facility admitted Resident #120 on 10/02/2023. According to the admission Record, the resident had a medical history that included diagnoses of bipolar disorder and major depressive disorder. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/29/2025, revealed Resident #120 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated 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 interview, record review, and facility policy review, the facility failed to ensure staff documented medication administration on the electronic Medication Administration Record (eMAR) in a timely manner for 1 (Resident #72) of 4 residents observed during medication administration. Findings included: An undated facility policy titled, Administering Medications, revealed the section titled, Policy Interpretation and Implementation, included, 19. The individual administering the medication must initial the resident's MAR on the appropriate line after giving each medication and before administering the next ones. An admission Record indicated the facility admitted Resident #72 on 05/01/2024. According to the admission Record, the resident had a medical history that included diagnoses of essential primary hypertension, type 2 diabetes mellitus, bilateral primary osteoarthritis of the knee, and adult failure to thrive. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/28/2025, revealed Resident #72 had a Brief Interview for Mental Status (BIMS)…

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, record review, facility document review, and facility policy review, the facility failed to ensure medication orders were accurately transcribed for 1 (Resident #42) of 5 sampled residents reviewed for unnecessary medications. Findings included: An undated facility policy titled, Administering Medications, indicated, Medications shall be administered in a safe and timely manner, and as prescribed. The policy revealed, 3. Medications must be administered in accordance with the orders, including any required time frame. An admission Record indicated the facility admitted Resident #42 on 07/01/2022. According to the admission Record, the resident had a medical history that included diagnoses of dementia, major depressive disorder, and unspecified mood affective disorder. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/19/2024, revealed Resident #42 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident had diagnoses of depression 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, record review, facility document review, and facility policy review, the facility failed to ensure medications were properly stored and not left at the bedside for 2 (Resident #94 and Resident #34) of 2 residents reviewed for accident hazards. Findings included: An undated policy titled, Administering Medications, indicated, Medications shall be administered in a safe and timely manner, and as prescribed. The policy revealed, 24. Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely. An undated policy titled, Self-Administration of Medications, revealed, Residents have the right to self-administer medications if the interdisciplinary team has determined that is it clinically appropriate and safe for the resident to do so. The policy revealed, 8. Self-administered medications are stored in a safe and secure place, which is not accessible by other residents. 1. An 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.

Based on observation, record review, interview, and facility policy review, the facility failed to have a medication error rate of less than 5%, with an error rate of 17.86%, affecting 2 (Resident #113 and Resident #72) of 4 residents observed during medication administration. The facility had five errors out of 28 opportunities. Findings include: An undated facility policy titled, Administering Medications, indicated, Medications shall be administered in a safe and timely manner, and as prescribed. The policy indicated, 3. Medications must be administered in accordance with the orders, including any required time frames. Further review revealed, 7. The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. 1. An admission Record, revealed the facility admitted Resident #113 on 05/19/2022. According to the admission Record, the resident had a medical history that included a diagnosis of essential hypertensin. A…

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

Based on interview, record review, and facility policy review, the facility failed to maintain an accurate medical record related to the use of pain medications for 1 (Resident #46) of 3 residents reviewed for pain management. Findings included: An undated facility policy titled, Pain - Clinical Protocol, revealed the section titled Monitoring, included, 2. The staff will evaluate and report the resident/patient's use of standing and PRN [pro re nata, as needed] analgesics. a. Depending on the characteristics of pain, the physician may start with PRN doses or supplement standing doses with PRN doses for breakthrough pain. b. If there are more than occasional analgesic requests, the physician will consider changing to regular administration of at least one analgesic with another medication for PRN use, increasing the standing dose of an existing analgesic, switching to another analgesic, and/or adding nonpharmacological measures. An admission Record indicated the facility admitted Resident #46 on 08/26/2022. According to the admission Record, the resident had a medical history that…

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 staff failed to implement their infection prevention and control program when: 1. Personal clothing and belongings were not stored in a clean and sanitary manner for one of three sampled residents (Resident 2). 2. Housekeeper (HK) 1 did not perform hand hygiene after removal of soiled gloves. 3. Certified Nursing Assistant (CNA) 1 did not properly handle and transport soiled linens. These failures have the potential to cause cross contamination and not prevent the development and spread of infections among residents, staff, and visitors. Findings: 1.During record review of Resident 2 ' s Face Sheet (FS), the FS indicated Resident 2 is an [AGE] year old female admitted to the facility in 2024. FS indicated Resident 2 had diagnoses that included Urinary Tract Infection (a condition in which bacteria [germs] enters and grow in the urinary tract, kidneys, ureters, bladder, and urethra), Irritable Bowel Syndrome (condition that leads to belly pain and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report an allegation of abuse, within required expected timeframe, to the State Survey Agency and Adult Protective Services (APS), for one of two sampled residents (Resident 1). This failure had the potential to not ensure additional protection of Resident 1 and other residents from abuse. Findings: During record review of Resident 1 ' s Face Sheet (FS), the FS indicated Resident 1 is an [AGE] year old resident admitted to the facility in 2024. FS indicated Resident 1 had a responsible party (RP 1) for emergency contact and financial decisions. FS also indicated Resident 1 ' s diagnoses included Cognitive Communication Deficit (reduced awareness and ability to initiate and effectively communicate needs), Intermittent Explosive Disorder (a mental health condition that causes sudden and impulsive episodes of anger and aggression), and Senile Degeneration of Brain (mental deterioration [loss of intellectual ability] that is associated with 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 nursing staff did not provide the resident ' s Responsible Party access to medical records within 24 hours of written request. For Resident 1, the failure to access readily available medical records resulted in delayed treatment at another facility, which had the potential for injury or harm. Findings: During review of Resident 1's Face Sheet, Face Sheet indicated Resident 1 was admitted to the facility in 2024. The Face Sheet also indicated Resident 1 had a responsible party (RP 1) for emergency contact and financial decisions. During a telephone interview on 5/30/24, at 3:44 p.m., with Representative Party (RP 1), RP 1 requested for release of medical records for Resident 1, to facility Medical Records Director (MRD 1) via telephone. MRD 1 informed RP 1 facility will need a signed Durable Power of Attorney (DPOA) from RP 1 prior to release of medical records. RP 1 stated she sent the DPOA via email to facility ' s MRD 1's work email address on 7/1124, at 3:56 p.m. RP 1 stated MRD 1 responded on 7/12/24 that he would…

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

Based on interview, and record review the facility failed to provide shower to one of three sampled residents (Resident 1) per shower schedule. This failure placed Resident 1 at risk for poor hygiene, compromised skin integrity and overall well-being. Findings: During a record review of Resident 1 ' s admission Record printed on 2/6/24, the record indicated Resident 1 was a admitted to facility on 12/27/23 and discharged on 1/28/24. During a review of Resident 1 ' s Minimum Data Set (MDS, an assessment to guide plan of care) dated 12/31/23, the assessment indicated Resident 1 was able to understand others and was able to make herself understood. The assessment indicated Resident 1 ' s Brief Interview of Mental Status (BIMS, an assessment for cognition) score was 13 out of 15, indicating intact mental status. The MDS assessment also indicated Resident 1 was dependent on staff to provide her showers/baths. During a review of Resident 1 ' s Activities of Daily Living (ADL) Care Plan dated 12/27/23, the care plan indicated Resident 1 had ADL decline due to her recent hospitalization.…

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 dignity for one of five sampled residents (Resident 165) was protected when Resident 165 was seen from the hallway, visible to other residents as well as visitors while using the bedside commode next to her bed. This failure resulted in Resident 165 feeling embarrassed. Findings: During a review of Resident 165's admission Record, dated 9/12/23, the face sheet indicated Resident 165 was admitted to the facility in July 2023. During a review of Resident 165's Minimum Data Set (MDS- an assessment tool used to guide care), dated 7/30/23, the MDS indicated, Resident 165 had a Brief Interview for Mental Status (BIMS- a tool used to assess mental function) score of 15, meaning Resident 165 was able to understand and understood others. The MDS also indicated, Resident 165 required extensive assistance with toilet use. During an observation on 9/11/23, at 10:51 a.m., Resident 165 was seen from the hallway while using bedside commode with curtain to outside window and privacy curtain was left open. During a…

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

Based on interview and record review the facility failed to ensure one (Resident 51) of six sampled residents received treatment services to address limitation in range of motion to left upper extremity when; Resident 51 had decreased functional use of left hand and resting splint was not applied to left hand as ordered by the physician. This failure had the potential to cause residents decline in range of motion and risk of decreased muscle strength. Findings: During an observation on 9/12/23 at 9:10 a.m., Resident 51 was asleep in bed with contracture (hardening of muscles and tendons) of left hand. Resident 51's left upper extremity had no splint. During a review of Annual Minimum Data Set (MDS - an assessment screening tool used to guide care), dated 8/9/22, the MDS indicated, Resident 51's Brief Interview of Mental status (BIMS) score was 05 (meaning poor cognition). Resident 51 had slurred speech, able to sometimes understood others. Resident 51 had limited range of motion and impairment on one side upper and lower extremities (shoulder, elbow, wrist, hand, hip, knee, ankle…

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 the necessary care and services related to intravenous (IV- device use to administer medications or solutions directly into the veins) therapy as ordered by the physician for one of two sampled residents Resident 92. This deficient practice had the potential for transmission of infections and bacteria to Resident 92. Findings: During a review of Resident 92's admission Record, dated 9/12/23, the admission record indicated, Resident 92 was admitted to the facility in February 2021 and was readmitted in August 2023 with multiple diagnoses that included necrotizing fasciitis (skin and soft tissue infection), resistance to antibiotics (medicines that fight bacterial infections), severe sepsis (body's extreme response to infection) and septic shock (life threatening condition when blood pressure drops to a dangerous level after an infection). During a review of Resident 92's Minimum Data Set (MDS - a standardized care-screening and assessment tool), dated 8/1/23, the MDS indicated Resident 92 had a Brief…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure two (Resident 47 and 118) of five sampled residents were free from unnecessary drug when; Resident 47 and 118 were administered antipsychotic drugs without adequate clinical indication for use: Resident 47 was administered Aripiprazole (Abilify) an antipsychotic drug for continuous purposeless yelling out. Resident 118 was administered Seroquel an antipsychotic drug for agitation and striking out at staff. Alzheimer's Dementia-is a progressive disease that destroys memory and other important mental functions. Antipsychotic medication are drugs used to treat schizophrenia and bipolar serious mental health conditions, capable of affecting the mind, emotions, and behavior. According to the manufacturer, elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Abilify and Seroquel can increase the risk of death in elderly people who have memory loss and is not approved for use in psychotic…

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 collaborate with hospice representatives and coordinate facility staff participation in the hospice care planning process for one (Resident 118) of two sampled residents receiving hospice care. This failure had the potential to result in residents to not received person centered care. Findings: Review of Significant- Minimum Data Set (MDS), Resident Assessment and care guide tool, dated 5/5/23, the MDS indicated, Resident 118's Brief Interview of Mental status (BIMS) score was 05 (meaning poor cognition). Resident 118 was not oriented to day, month or year. Resident 118 had difficulty to makes self understood and not able to understand others. Resident 118 diagnoses included Non-Alzheimer's Dementia (a group of diseases characterized by progressive deficits in behavior, executive function or language), encounter for palliative care and on hospice care ( a type of care that focuses on interdisciplinary approach to specialized nursing care for people with life limiting illnesses, available to people with a life expectancy of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to establish and implement a smoking policy that promotes safety of both smoking and non-smoking residents when: 1. Residents smoked in a non-smoking area. This failure resulted in residents smoking in a non-designated area with the potential for unsafe behaviors (no available ash trays or fire extinguishers) and exposure of non-smoking residents to smoke. 2. Resident 2 did not have a smoking assessment as indicated in the smoking care plan. This failure had the potential to result in smoking-related accidents. See also F561. Findings: During a review of Resident 1's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 6/16/23, the MDS indicated, under Section C, a Brief Interview for Mental Status (BIMS, an assessment tool for resident's orientation to time and capacity to remember) score of 15. The BIMS score range is from 0-15, a BIMS score of 13-15 is an indication of intact cognitive status. During a review of…

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

Based on observation, interview, and record review, for one of three sampled residents (Resident 2), who was dependent on staff for Activities of Daily Living (ADLs, such as transfers from bed to chair, bathing/showers, eating, personal hygiene), the facility failed to ensure showers were provided to maintain grooming and personal hygiene. This failure resulted in poor grooming and personal hygiene and delayed healing of moisture-associated skin damage. Findings: During a telephone interview on 8/28/23 at 3:20 p.m. with Certified Nursing Assistant (CNA) 2, CNA 2 stated Resident 5 was not given showers as scheduled. CNA 2 stated Resident 2 had reddened areas on skin under both breasts and on the buttocks. During a review of Resident 5's admission Record, dated 8/31/23, the admission Record indicated Resident 5 was initially admitted to the facility in March 2023 with diagnoses that included hemiplegia (paralysis of one side of the body) and hemiparesis (weakness of one side of the body), muscle weakness, need for assistance with personal care, and atopic dermatitis (itchy…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, for six of 23 sampled residents (Residents 55, 1, 103, 27, 46, and 94) the facility failed to provide personal hygiene assistance (combing hair, brushing teeth, clipping/cleaning fingernails, shaving, showering, washing/drying the face and hands) when: 1. Resident 55 had long, chipped fingernails and her facial hair was unshaved; 2. Resident 1 had long, dirty fingernails; 3. Resident 103 had long fingernails; 4. Resident 27 had long, dirty fingernails; 5. Resident 46 had long, dirty fingernails; and 6. Resident 94 was not showered as scheduled. This failure had the potential to cause infections, skin injuries, embarrassment, and low self-esteem. Findings: 1. During an observation on 8/26/19 at 9 a.m., Resident 55 was in bed, awake. Resident 55's fingernails were long and chipped, and her facial hair was overgrown and unshaved. A review of Resident 55's Minimum Data Set (MDS, an assessment tool used to guide care) dated 6/21/19 indicated Resident 55 needed…

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 record review, the facility failed to treat one of 23 sampled residents (Resident 94) with dignity when they left the resident, who was dependent on staff to dress him, in a hospital gown while he attended a group activity. This failure had the potential to humiliate Resident 94 and diminish his sense of self-worth. Findings: A review of the admission Record for Resident 94 indicated the resident was admitted to the facility with multiple diagnoses, including hemiplegia (paralysis of one side of the body) and aphasia (loss of the ability to understand or express speech, caused by brain damage). A review of Resident 94's Minimum Data Set (MDS, an assessment tool used to guide care) dated 7/16/19 indicated Resident 94 was totally dependent on staff for dressing. The MDS also indicated Resident 94's ability to make decisions regarding tasks of daily living was severely impaired. During an observation on 8/28/19 at 3:15 p.m., Resident 94 was sitting in a wheelchair wearing a hospital gown, watching a movie during the group activity.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of 23 sampled residents (Resident 207) was assessed accurately when information in two Minimum Data Sets (MDS - an assessment tool used to guide care) coded Resident 207's Hospice status inaccurately. This failure had the potential for Resident 207 to not receive appropriate interventions and treatments for end-of-life care. Findings: A review of a physician order dated 4/26/19 in Resident 207's medical record indicated hospice care (supportive care for the final phase of a terminal illness that focuses comfort and quality of life, rather than a cure) was ordered for Resident 207. A review of Resident 207's Significant Change of Condition Minimum Data Set (MDS, an assessment tool used to guide care), dated 5/6/19, and Quarterly MDS, dated [DATE], both indicated No at the question, Does the resident have a condition or chronic disease that may result in a life expectancy of less than six months? (Section J). During an interview with Minimum…

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, for one of 23 sampled residents (Resident 94) the facility failed to develop a care plan for the use of a hand mitt. There was no monitoring of the application or the skin condition for Resident 94's left hand. This failure had the potential cause Resident 94 to experience a decline in physical functioning of his left hand and in skin breakdown where the mitt was applied. Findings: A review of Resident 94's admission Record indicated the resident was admitted to the facility with multiple diagnoses, including hemiplegia (paralysis of one side of the body) and aphasia (loss of the ability to understand or express speech, caused by brain damage). A review of Resident 94's Brief Interview for Mental Status (BIMS, a tool used to assess mental function) in the Minimum Data Set (MDS, a resident assessment tool used to guide care), dated 4/15/19, indicated the resident's score was 00, meaning he was severely cognitively impaired. During an observation on 8/26/19 at 9:50 a.m., Resident 94 was lying in bed with head of the bed at 35 degree…

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, for three of three sampled residents (Residents 27, 46, and 35) the facility failed to provide the care and services to prevent an avoidable decline in range of motion and mobility when: 1. Resident 27 did not receive interventions necessary to prevent contractures (when normally stretchy tissues are replaced by non-stretchy, fiber-like tissues and prevent normal movement); 2. A physician's order to apply a splint to Resident 46's left hand was not followed; and 3. A physician's order to apply a splint to Resident 35's right lower leg was not followed. This failure had the potential for Residents 27 and 46's contractures to worsen and for Resident 35 to develop contractures. Findings: 1. A review of Resident 27's admission Record indicated Resident 27 was admitted to the facility with multiple diagnoses, including a fracture of her left hand. During an observation on 8/26/19 at 10:02 a.m., Resident 27 was sitting in her wheelchair outside her room. She was unable to move her left hand, and her fingers on that hand were folded inside…

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 medication error rate was less than five percent (%). Medication pass observations on 8/27/19 and 8/28/19 revealed two errors out of 28 opportunities, resulting in an error rate of 7.14% when: 1. For Resident 78, Licensed Vocational Nurse 5 (LVN 5) administered insulin (medication that lowers blood sugar levels in those with diabetes) using an insulin pen without first priming (removing air from the needle and insulin cartrdge) it, then removed the needle from the skin prematurely; and 2. For Resident 153, Registered Nurse 2 (RN 2) administered one tablet of Vitamin D3 instead of two tablets, per physician's orders. These failures had the potential for Residents 78 and 153 not receiving the full therapeutic effect of their prescribed medications and could result in undesired health outcomes. Findings: 1. During a medication pass observation and concurrent interview with LVN 5 on 8/27/19 at 12:15 p.m., using an insulin pen LVN 5 prepared Novolog Insulin, 12 units (units, a unit of measurement),…

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 23 sampled residents (Resident 148) were free from significant medication errors when Resident 148 was administered Renvela (a phosphate binder medication) after meals instead of with meals as per the manufacturer's instructions; This deficient practice had the potential for Resident 148 to develop hyperphosphatemia (too much phosphate), which is associated with an increased prevalence of heart and circulatory diseases and mortality rates in patients with End-Stage Renal (kidney) Disease (ESRD). Findings: A review of Patient 148's admission Record indicated Resident 148 was admitted with multiple diagnoses, including end stage renal (kidney) disease and dependence on dialysis (a mechanical treatment where excess fluid and waste are removed from the body via the blood). During an observation and concurrent interview on 8/27/19 at 8:05 a.m., Resident 148 was awake in bed, watching television, and stated the nurses usually gave him Renvela an hour after lunch. A review of Resident 148's Order Audit…

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, for one (Resident 94) of 23 sampled residents the facility failed to follow hand hygiene practices that prevent the spread of disease and infection when: Proper hand hygiene and glove changes were not performed during wound care treatment for Resident 94. This failure had the potential to spread infection. Findings: During an observation of Licensed Vocational Nurse 9 (LVN 9) on 8/26/19 at 11:35 a.m. while she was performing a wound care treatment on Resident 94, without first washing her hands LVN 9 removed multiple gloves from the glove dispensing box and placed them in a small container. LVN 9 then removed two gloves from the container and placed the gloves on her hands. She then removed the old dressing from Resident 94's left buttocks, cleaned the wound, and applied barrier cream, wearing the same pair of gloves. After finishing Resident 94's wound care treatment, LVN 9 removed the gloves she initially put on before starting the wound care treatment, and rubbed her hands with an alcohol-based hand sanitizer. During an interview…

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.