Mesa Verde Post Acute Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the failed to ensure the appropriate dialysis care was provided for one of two final sampled residents (Resident 2) reviewed for dialysis services. * The facility failed to ensure Resident 2's physician's order for 1500 ml fluid restriction was followed and carried out accordingly. In addition, the facility failed to monitor the resident's fluid intake accurately. This failure had the potential for the resident to not be provided with the appropriate care and treatment, and possibility experience medical complications related to dialysis. Findings: Review of the facility's P&P titled Fluid Restrictions revised on 4/21/22, showed the purpose of this policy is to ensure the adequate provision of care and comfort measures for the residents who are in fluid restrictions. Under the Procedures section, included the licensed nurses would do the following:- Initiate strict intake measurements per physician's order.- Record any fluids given…

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, medical record review, and facility P&P review, the facility failed to ensure one of three final sampled residents (Resident 7) remained free from an accident/hazards due to the use of the side rails/ grab bars. * The facility failed to ensure the informed consent was obtained and completed for Resident 7's bilateral U grab bars. This failure had the potential to put the resident at risk for entrapment and serious injuries. Findings: According to FDA.gov, deaths and serious injuries related to side rail entrapment have occurred with the use of side rails. The FDA issued a Safety Alert entitled Entrapment Hazards with Hospital Bed Side Rails. Residents most at risk for entrapment are those who are frail or elderly or those who have conditions such as agitation, delirium, confusion, pain, uncontrolled body movement, hypoxia, fecal impaction, acute urinary retention, etc., that may cause them to move about the bed or try to exit from the bed. Entrapment may occur when a resident is…

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, medical record review, and facility P&P review, the facility failed to provide the pharmaceutical services to meet the residents' needs for two of 19 final sampled residents (Residents 9 and 12) and one nonsampled resident (Resident 71). * The facility failed to ensure the injection sites were rotated for the subcutaneous insulin medication administration for Resident 9. * The facility failed to ensure the administration of the divalproex delayed release tablet for Resident 12 was in accordance with the best practice standards. * The facility failed to ensure the administration of the controlled medication for Resident 71 was documented on the EMAR. These failures had the potential to negatively affect the residents' health condition and well-being. Findings: Review of the facility's P&P titled Subcutaneous Medication Administration dated 12/2015 showed to administer a parenteral medication into the subcutaneous (under the skin) tissue in order to promote slow medication absorption 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, facility document review, and facility P&P review, the facility failed to ensure the facility staff and resident visitors were educated on safe food handling practices when food from the outside was brought to the facility for resident consumption. This failure had the potential for unsafe food handling which could lead to foodborne illness in the 76 residents who resided and consumed food in the facility. Findings: Review of the facility's matrix dated 9/15/25, showed 76 residents consumed an oral diet. Review of the facility's P&P titled Foods Brought in by Visitors revised 4/24/25, showed to assist the family/visitors to understand safe food handling practices (such as safe cooling/reheating processes, hot/cold holding temperatures, preventing cross contamination, hand hygiene, etc.). Review of the facility's in-service lesson plan and attendance record titled Food Brought by Visitors dated 1/17/25, showed the in-service was conducted by the DSD. The in-service included policy interpretation and implementation, which reviewed the policy specifics,…

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, facility document review, and facility P&P review, the facility failed to implement the infection control practices in the facility designed to provide a safe and sanitary environment and help prevent the development and transmission of diseases and infections. * The facility failed to maintain an accurate and complete infection control surveillance program for June, July, and August 2025. This failure posed the risk for not identifying the residents' infections and preventing the implementation of the interventions to control the potential transmission of communicable diseases to other residents in the facility. * The facility staff failed to perform hand hygiene between changing of the gloves during the medication administration. This failure posed the risk for the transmission of infection to the resident.Findings: 1. Review of the facility's P&P titled Infection Control Surveillance dated 3/1/14, showed the Infection Preventionist conducts ongoing surveillance for HAIs 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, medical record review, and facility P&P review, the facility failed to report and investigate a resident-to-resident altercation to the State Survey Agency in accordance with the state law established procedures for two of five sampled residents (Residents 1 and 4). * Resident 1 stated a male resident (Resident 4) walked into her room unsupervised, screamed and threatened her. The incident was not reported to the appropriate parties (CDPH, the Ombudsman, the residents' responsible parties, the MD and the police department) nor was an investigation initiated. This failure had the potential to negatively impact the well-being of the resident of the facility. Findings: Review of the facility's P&P titled Abuse Prevention and Management revised 5/2024 showed the facility will report all allegation of abuse, and criminal activity as required by law and regulations to the appropriate agencies. The P&P also stated to address the health, safety, welfare, dignity and respect of residents, the reports…

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 medical record review, the facility failed to ensure to coordinate the effective discharge planning process when the SSD failed to communicate to the IDT the development of the discharge plan and failed to document in the resident's medical record regarding the evaluation of the ALF waiver process. Additionally, the facility failed to notify the resident's family member about the ALF waiver was denied for one of six sampled residents (Resident 4). These failures had the potential to affect the resident's well-being after discharge. Findings: On 7/11/25 at 1702 hours, prior to the onsite investigation, a telephone interview was conducted with Family Member 2. Family Member 2 stated the facility's SSD had informed her Resident 4 will have the ALF waiver for continued care in the ALF after discharge from the SNF. However, the resident needed to pay in the ALF because the waiver was not approved. Closed medical record review for Resident 4 was initiated on 7/15/25. Resident 4 was admitted 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 observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the medications were not stored at the bedside for two of two sampled residents (Residents1 and 2) and one nonsampled resident (Resident D). * Resident 2's bubble pack of metformin (medication to treat diabetes) medication was found hidden in Resident 1's closet for 10 days. * Resident D's side table drawer had a medication cup filled with thick white cream and a tongue depressor. These failures had the potential to result in the unauthorized access to the medications and impact the residents' safety. Findings: Review of the facility's P&P review titled Medication Storage in the Facility revised 1/2025 showed the following: a. Medication and biologicals are stored safely, securely, and properly, following manufacture's guidelines or those of the supplier. The medical supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully…

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 medical record review, the facility failed to ensure one of three sampled residents (Resident 1) was properly discharged from the facility. This failure had the potential to place Resident 1 at risk for not receiving the proper care after the discharge. Findings: Closed medical record review for Resident 1 was initiated on 2/18/25. Resident 1 was admitted to the facility on [DATE], and discharged on 2/5/25. Resident 1 had a diagnosis of type two diabetes mellitus with hyperglycemia. Review of Resident 1's H&P examination dated 4/24/24, showed Resident1 had the capacity to make medical decisions. Review of Resident 1's Order Summary Report showed the following orders: - dated 1/8/24, give 15 units of Humalog insulin injection before each meal that contains carbohydrates - dated 1/9/24, Humalog Injection Solution (Insulin Lispro) inject as per sliding scale - dated 10/15/24, Trulicity Subcutaneous Solution (Dulaglutide), Inject 4.5 mg subcutaneously one time a day every Tuesday - dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to provide and document sufficient preparation to ensure the safe and orderly discharge for one of three sampled residents (Resident 1). * Resident 1 was discharged with home health services; however, there was no documentation if the home health agency referral was arrangedprior to the discharge. This failure placed Resident 1 at risk for not receiving the proper care after the discharge. Findings: Closed medical record review for Resident 1 was initiated on 2/18/25. Resident 1 was admitted to the facility on [DATE], and discharged on 2/5/25. Review of Resident 1's Order Summary Report showed an order dated 2/4/25, may discharge to home with current medications with home health PT/OT/RN to follow up with the PCP in one to two weeks. Review of Resident 1's Progress Note dated 2/3/25 at 1634 hours, showed the SSD had spoken with Resident 1 regarding the discharge and would set up for home health services as ordered. Further review for Resident 1'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 observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of four residents observed for medication administration (Resident 23) and one of 18 final sampled residents (Resident 18) were assessed to safely self-administer the medications prior to performing the self-administering medications. This had the potential for the residents to incorrectly administer the medications. Findings: Review of the facility's P&P Medication-Self Administration revised 1/1/12, showed the following: -The licensed nurse will complete the Assessment for Self-Administration of Medications. -The physician must provide an order permitting the resident to self-administer medication. -Self-administration of medications will be documented in the resident's care plan and the MAR. 1. On 6/4/24 at 0838 hours, a medication administration observation with LVN 1 was conducted for Resident 23. During the observation, LVN 1 drew up 40 units of insulin glargine KwikPen and handed the injector…

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, medical record review, facility document review, and facility P&P review, the facility failed to promote dignity and respect for two of 18 final sampled residents (Residents 18 and 23) and four nonsampled residents (Residents 4, 22, 60, and 62). * The call light was not within reach for Residents 18, 22, and 62. * The facility failed to ensure the resident's call lights were answered in a timely manner for Residents 4, 23, and 60. These failures posed the risk to negatively affect the residents' physical and emotional well-being. Findings: Review of the facility's P&P titled Communication-Call System dated 1/1/12, showed the call cords will be placed with the resident's reach in the resident's room, nursing staff will answer call bells promptly in a courteous manner. 1. Medical record review for Resident 4 was initiated on 6/4/24. Resident 4 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident 4's Quarterly MDS dated [DATE], under the toileting…

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, medical record review, and facility P&P review, the facility failed to ensure the comprehensive care plan was formulated for two of 18 final sampled residents (Residents 17 and 423). * The facility failed to develop a care plan problem to address the use of CVAD (Central Venous Access Device - a type of intravenous catheter) for Resident 423. * The facility failed to develop a care plan problem to address Resident 17's need for a cervical collar and TLSO brace (Thoracic-Lumbar-Sacral Orthosis, used to limit motion and stabilize the back). These failures posed the risk of not providing the appropriate, consistent, and individualized care of the residents. Findings: Review of the facility's P&P titled Comprehensive Person-Centered Care Planning dated 9/7/23, showed the plan of care should be based on the assessed needs of the residents. The comprehensive care plans should be reviewed and revised based on the onset of new problems, change of condition, and other time as appropriate…

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, medical record review, and facility document review, the facility failed to provide the necessary treatment and services for one of three residents who were reviewed for positioning and mobility (Resident 17). The facility failed to apply a cervical collar (c-collar) to Resident 17 as ordered by the physician. This failure had the potential to negatively affect the Resident 17's health and well-being. Findings: Review of the facility document titled Your Path to Recovery After Cervical Spine Surgery revised 11/2015 showed a cervical collar is worn at the discretion of the surgeon. Under the section titled Spine Precautions, showed a cervical collar is used to provide support and limit movement of the neck. Your doctor may or may not order a cervical collar. Typically, the collar should be worn at all times. Cervical collar is worn at the discretion of the surgeon. During an initial tour of the facility on 6/3/24 at 0845 hours, Resident 17 was observed lying in bed. A c-collar was…

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, medical record review, and facility P&P review, the facility failed to provide a safe environment free from potentially serious accident hazards for one of one residents who were reviewed for smoking (Resident 24). The facility failed to ensure the smoking materials for Resident 24 were securely stored. This posed the risk of fire and serious injuries to the residents who resided in the facility. Findings: Review of the facility's P&P titled Smoking Residents revised 7/27/23, showed the IDT will develop an individualized plan of care for safe storage, use of smoking materials, assistance, and/or required supervision, for residents who smoke. On 6/5/24 at 0415 hours, an observation and concurrent interview was conducted with Resident 24 in his room. A box of cigarettes was observed to be stored inside a bag on the ground. When asked about the cigarettes, Resident 24 stated the facility did not let him store the cigarettes in his room but kept them because the facility would forget…

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 provide the appropriate care and services to prevent UTI (urinary tract infection, a condition associated with invasion by disease causing microorganisms of some part of the urinary tract) for one of one resident (Resident 24) reviewed for urinary catheter or UTI. Resident 24 had a suprapubic catheter (a tube used to drain urine from the bladder through an incision in the abdomen) and a history of recurrent UTIs. The facility failed to ensure proper positioning of Resident 24's urinary drainage bag to prevent urine from flowing back into the bladder. This posed the risk for Resident 24 to develop a catheter-associated urinary tract infection (CAUTI). Findings: Review of the Centers for Disease Control and Prevention's (CDC) topic titled Catheter-Associated Urinary Tract Infections (CAUTI) Prevention Guideline dated 4/2024, showed urinary tract infections are the most common type of healthcare associated infection. CAUTI has been…

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, medical record review, and facility P&P review, the facility failed to ensure four of four residents reviewed for respiratory care (Residents 14, 50, 44, and 623) were provided with the appropriate respiratory care when: * The facility failed to ensure the nasal cannula was dated and labeled, and the nebulizer mask was stored properly for Residents 14 and 50. * The facility failed to ensure the CPAP mask was stored properly for Resident 623. * The facility failed to ensure the nasal cannula was stored properly for Resident 44. These failures had the potential to affect the respiratory health and well-being of the residents in the facility. Findings: Review of the facility's P&P titled Oxygen Therapy dated 11/2017 showed oxygen is administered under safe and sanitary conditions to meet resident needs. Administer oxygen per physician's order and tubing, mask, and cannulas should be changed every seven days and labeled with the date of change. 1. During the initial facility tour 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, medical record review, and facility P&P review, the facility failed to ensure the dialysis care was provided for one of one final sampled resident reviewed for dialysis services (Resident 29) as evidenced by: * The facility failed to ensure Resident 29's dialysis access site was assessed and monitored appropriately and consistently. The licensed staff failed to assess Resident 29's dialysis access site after returning from the dialysis clinic accurately. In addition, the licensed staff failed to document an assessment of Resident 29's dialysis access upon return from the dialysis clinic. These failures had the potential for Resident 29 not being provided with appropriate care and treatment and the possibility of medical complications related to the resident's dialysis access site. Findings: Review of the facility's P&P titled Dialysis Care revised 10/1/18, showed for the licensed staff caring for the residents with dialysis AV (Arteriovenous) shunt should inspect for…

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, medical record review, facility document review, and facility P&P, the facility failed to provide the pharmaceutical services to meet the residents' needs for two of two residents (Residents 17 and 23) reviewed for controlled medication administration. *The facility failed to ensure Resident 17 and 23's controlled pain medications were accurately reconciled. The controlled pain medications removed as shown on the Individual Narcotic Record were not recorded as administered on the electronic MAR. This failure had the potential for drug diversion. Findings: Review of the facility's P&P Preparation and General Guidelines - IIA5: Controlled Medications dated August 2014 showed when a controlled medication is administered, the nurse will immediately document the following in the accountability record and the MAR: -the date and time of administration, the amount administered, and the initials of the nurse administering the medication in the MAR. 1. Medical record review for Resident 17…

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, medical record review, and facility document review, the facility failed to ensure the Pharmacy Consultant's recommendations were acted upon for one of five residents reviewed for unnecessary medications(Residents 61). This failure had the potential to put Resident 61 at risk for adverse consequences related to the medication. Findings: 1. Medical review of Resident 61 was initiated on 6/3/24. Resident 61 was admitted to the facility on [DATE]. Review of Resident 61's Order Summary Report dated 5/28/24, showed a physician's order dated 1/12/24, to administer buspirone HCL (antianxiety medication) 5 mg one tablet by mouth two times a day for anxiety manifested by restlessness. Review of Resident 61's Consultant Pharmacist's Medication Regimen Review between 5/1/24 and 5/13/24, showed agitation or restlessness too subjective and should not be used as a diagnosis nor as a behavior. Please updated the order with a specific and quantifiable behavior. Further review of Resident 61's medical 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 facility P&P review, the facility failed to ensure the expired and potentially deteriorated medications were removed from the supply for two of three medication carts (Medication Carts A and B). This had the potential for expired or deteriorated medications to be administered to the residents. Findings: Review of the facility's P&P Medication Storage In The Facility effective [DATE] showed outdated or deteriorated medications will be immediately removed from stock and disposed of. 1. On [DATE] at 1219 hours, an inspection of Medication Cart B was conducted with RN 1. Two 10 ml vials of injectable sterile water with the expiration dates of [DATE] and [DATE], were observed in the cart. RN 1 verified the two vials were expired and stated the expired vials should have been removed from the cart. 2. On [DATE] at 1406 hours, an inspection of Medication Cart A was conducted with LVN 1. A box of budesonide (medication used to reduce irritation and swelling of the airways) inhalation…

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 facility document review, the facility failed to follow the menu. *Cook 1 did not follow the recipe when preparing pureed Spinach Au Gratin (creamed spinach topped with cheese and baked in the oven) *Scoop #12 was used to serve regular Spinach Au Gratin instead of scoop #8 per the spreadsheet. These failures had the potential of the menu not meeting the residents' nutritional needs which could lead to nutritional related health complications. Findings: Review of the Order Listing Report dated 6/3/24, showed eight residents were on pureed diet, and 68 residents on regular diet, with no restrictions to vegetable or spinach or cheese. 1. Review of the facility's document titled Summer Menus for Week 1 Tuesday dated 6/4, 7/2, 7/30, and 8/27/24, for lunch showed to serve Spinach Au Gratin for lunch. Review of the facility's document titled Recipe: Spinach Au Gratin, Week 1 Tuesday showed to cook spinach in enough water to cover, drain well and place in baking pan. Add margarine and cheese and mix well. On 6/4/24 at 1029 hours, an observation of the…

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

Based on observation, interview, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by: * The facility failed to ensure proper labeling and dating of foods in the kitchen. *The facility failed to ensure the food items inside the refrigerator used for residents' food brought in from outside were properly stored per the facility's P&P. * The ice machine was dirty with yellowish slimy residue in the upper inside part of the ice maker area. * The kitchen exhaust hood was observed with brownish black residue. * The facility failed to ensure the proper sanitary condition of the kitchen equipment. The oven and heated plate dispenser were observed with food debris. * The facility failed to ensure the kitchen items were air dried. * The facility failed to ensure cutting boards were kept in a sanitary condition. These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food prepared in the kitchen. Findings: Review of the facility's document titled Order Listing…

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, medical record review, and facility P&P review, the facility failed to follow the P&P for the resident's food brought by the visitors for one of 18 final sampled residents (Resident 58). * The facility failed to ensure the safe food handling guidelines were implemented to the resident's family/visitors who brought the resident food from the outside. In addition, the facility failed to provide resident and family with the P&P about the use and storage of brought in by family and visitors as part of their admission packet as per the facility's P&P. These failures had the potential for unsafe food handling and may cause foodborne illness to the residents who received food brought by the visitors. Findings: Review of the facility's P&P titled Food Brought In by Visitors revised 6/2018 showed when food is brought into a nursing home prepared by others, the nursing home is responsible for ensuring that the food container is clearly labeled with the resident's name and date received 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 facility P&P review, the facility failed to dispose of trash properly. One of three dumpsters was observed overflowing with boxes, which prevented the lid from fully closing. This had the potential to attract and harbor pests and/ or rodents. Findings: According to FDA Food Code 2013, 5-501.113, Covering Receptacles, receptacle and waste handling units for refuse, recyclables, and returnables shall be kept covered with tight-fitting lids. On 6/4/24 at 0755 hours, three dumpsters and one food waste bin were observed outside adjacent to the facility. One dumpster was observed with the lid propped open by boxes, which prevented the lid from fully closing. On 6/4/24 at 0803 hours, an observation of trash disposal and concurrent interview was conducted with the Director of Maintenance. One of three dumpsters outside adjacent to the building was observed overflowing with boxes and the lid was not fully closed. The Director of Maintenance verified the findings.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review and facility document review, the facility failed to maintain accurate and confidential resident records. * The facility failed to ensure confidential resident rosters were not included in the CDPH Survey results binder for public review. * The facility failed to ensure Resident 29's monthly weight was documented correctly. These failures had the potential for protected information to be viewed by the public and the resident's care needs not being met as the medical information was incomplete and inaccurate. Findings: 1. On 6/5/24 at 0926 hours, a binder labeled CDPH Annual Survey Binder was observed on a table in the lobby for public review. Review of the binder showed the following confidential resident rosters: - a confidential resident roster dated 8/31/21, with two residents' names and their identifiers - a confidential resident roster dated 9/1/21, with two residents' names and their identifiers - a confidential resident roster dated 9/15/21, with two…

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

Based on observation and interview, the facility failed to ensure the appropriate infection control practices were implemented to provide a safe and sanitary environment and prevent the spread of infections within the facility. * There were multiple briefs and blue chucks stacked on the top of an isolation chart located in front of room A. This failure posed the risk of transmission of infectious organisms from the floor to the residents in the facility. Findings: On 6/5/24 at 0410 hours, multiple briefs and blue chucks were observed stacked on the top of the isolation cart. On 6/5/24 at 0515 hours, CNA 3 took the briefs and chucks to be distributed to rooms A, B, and Resident 18's room. On 6/5/24 at 0520 hours, an interview was conducted with CNA 3. CNA 3 stated she put the briefs and chucks there to distribute them to different residents. CNA 3 acknowledged the briefs and chucks should not be placed on the top of isolation cart due potential contamination and spread of infection. CNA 3 verified the findings.

Based on observation, interview, facility document review, equipment instruction manual review, and facility P&P review, the facility failed to maintain the essential equipments in safe operating condition. * The facility failed to ensure the ice machine was cleaned and sanitized according to the manufacturer's specification, and per the facility's P&P. An incorrect ratio of the nickel-safe cleaner was used to descale the ice machine, a hot water instead of a sanitizing solution was used to sanitize the inside of the machine, and an unidentified and unlabeled spray bottle was used to sanitize the panels of the ice machine. These failures had the potential for the equipment to not function in the way it was intended, which could cause food-borne illnesses for the residents. * The glucometer in Medication Cart A's serial number did not match the glucometer serial number listed on the Quality Control Record. This failure post a risk for incorrect blood sugar reading resulting to incorrect blood sugar management that can negatively affect the resident's well-being. Findings: 1. Review…

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, medical record review, facility document review, and facility P&P review, the facility failed to ensure the residents' entrapment assessments were accurate, complete and the measurements were recorded during the bed inspection when identifying areas of possible entrapment with the use of bed rails for all three residents (Residents 18, 50, and 423) with side rails. These failures had the potential to negatively impact the residents resulting in possible entrapment, serious injury, and death. Findings: According to the Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, the term entrapment describes an event in which a patient/resident is caught, trapped, or entangled in the space in or about the bed rail, mattress, or hospital bed frame. Patient entrapments may result in deaths and serious injuries. These entrapment events have occurred in openings within the bed rails, between the bed rails and mattresses, under bed rails, between split rails, 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, medical record review, and facility P&P review, the facility failed to provide the necessary pharmacy services for two of two sampled residents (Residents 1 and 2) when Residents 1 and 2's controlled drug records and MARs were not maintained to ensure the accuracy reconciliation of the narcotic pain medications. * Resident 1's oxycodone HCl (narcotic pain medication) Individual Drug Record sheet did not match Resident 1's MAR. The oxycodone HCL was removed from the bubble pack for several occasions without documentation of the medication administration in the MAR. * Resident 2's hydrocodone-acetaminophen (narcotic pain medication) Individual Drug Record sheet did not match Resident 2's MAR. The hydrocodone-acetaminophen medication was removed from the bubble pack for several occasions without documentation of the medication administration in the MAR. These failures posed the for risk of diversion of the controlled medications. Findings: According to the facility's P&P titled Preparation 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 facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by the following: * The facility failed to ensure the food was stored in sanitary condition. * The facility failed to ensure proper labeling and dating of foods in the kitchen. * The facility failed to ensure the kitchen walk-in refrigerator was maintained in sanitary condition. * The facility failed to ensure the expired foods were discarded. * The facility failed to ensure the kitchen equipment was maintained in sanitary condition. * The facility failed to ensure the kitchen staff performed hand hygiene before donning and doffing gloves. * The facility failed to ensure the damaged or worn-out kitchen equipment was in good repair. * The facility failed to ensure proper sanitary condition of the hood over the stove. * The facility failed to ensure the kitchen items were air dried. * Multiple unlabled and undated food items were observed on top of the resident's clothes in Room A. These failures had the potential to cause foodborne…

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, facility document review, and facility P&P review, the facility failed to implement their infection control program in accordance with the facility's P&P. * The facility failed to implement their infection control surveillance program between the months of July 2021 and January 2022. The facility conducted surveillance of resident infections based on whether the residents were prescribed antimicrobials. The residents who were not prescribed antimicrobials (including residents diagnosed with COVID-19) were not included in the facility's infection control surveillance program. * The facility failed to ensure the monthly mapping of infections included information on the specific microorganism to identify possible outbreaks. * The facility failed to maintain the written minutes for the monthly Infection Control Committee (ICC) meetings and actions taken by the committee for the year of 2021. * The facility failed to ensure Resident 40 was placed on contact precaution due to a skin…

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, medical record review, and facility P&P review, the facility failed to ensure care was provided in a manner which promoted dignity and respect for one of 21 final sampled residents (Resident 48), * The facility failed to cover Resident 48's urinary drainage bag. This failure has the potential to negatively affect the resident's emotional well-being. Findings: Review of the facility's P&P titled Indwelling Catheter revised 9/14 showed the resident's privacy and dignity will be protected by placing a cover over the urinary drainage bag. Medical record review for Resident 48 was initiated on 2/22/22. Resident 48 was readmitted to the facility on [DATE]. Review of the MDS dated [DATE], showed Resident 48 had cognitive impairment. Resident 48 needed extensive assistance with his ADL care. On 2/22/22 at 1546 hours, and 2/23/22 at 0817 hours, Resident 48 was observed in bed Resident 48 was observed to have an uncovered urinary drainage bag hanging from the left side of his bed. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to ensure the residents' advanced directives were obtained and maintained in the medical records for three of 21 final sampled residents (Residents 7, 20, and 36). These failures had the potential for the residents' decisions regarding their health care and treatment options to not be honored. Findings: 1. Medical record review for Resident 20 was initiated on 2/22/22. Resident 20 was admitted to the facility on [DATE]. Review of Resident 20's Advance Healthcare Directive Acknowledgement Form dated 12/7/21, showed Resident 20 had formulated an advance directive. However, further review of the medical record failed to show a copy of Resident 20's advance directives. On 2/22/22 at 1439 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified Resident 20 had formulated an advance directives and a copy was not in the medical record. Cross reference to F842. 2. Medical record review for Resident 7 was initiated 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 observation and interview, the facility failed to maintain a safe environment for one of the five shower stalls used by the residents. * The facility failed to ensure one of the five shower stalls in the facility had a secured drain cover. This had to potential to result in injury as the residents could trip and get entrapped in the shower drain opening. Findings: On 2/22/22 at 1431 hours, during the Resident Council meeting, the residents complained regarding the safety of the shower rooms. On 2/25/22 at 1138 hours, an observation and concurrent interview was conducted with CNA 3. The left shower stall in Station B was observed with no shower drain cover leaving the drain hole on the floor open. The shower drain cover was observed a few inches away from the drain hole. CNA 3 stated he was afraid the residents' shower chairs would get caught in the drain hole and they would fall of the shower chairs. CNA 3 stated the shower drain cover was not securely attached and could easily be removed. On 2/25/22 at 1154 hours, an observation and concurrent interview was conducted with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to develop and implement the comprehensive person-centered care plans for four of 21 final sampled residents (Residents 35, 36, 40, and 457). * The facility failed to develop a care plan to address Resident 40's isolation precaution and skin condition. * The facility failed to develop a care plan to address Resident 457's use of side rails. * The facility failed to develop an individualized care plan to address Resident 35's needs specific to risk for falls. * The facility failed to develop a care plan to address Resident 36's violent behavior when he threw items on the floor during a verbal altercation with another resident and when he was found in possession of a BB gun ( a type of airgun) and threatened to shoot the facility's camera. These failures had the potential to negatively impact the care needed for the residents. Findings: 1. Review of the facility's P&P titled Comprehensive Person-Centered Care…

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, medical record review, and facility P&P review, the facility failed to ensure the discharge instructions provided to one of two closed record sampled residents (Resident 56) was complete and in a language that was easily understood. * Resident 56's written discharge instructions for medications was not provided in layman's terminology as evidenced by containing medical abbreviations. In addition, the discharge instructions failed to show documentation for the home health agency contact information, in which Resident 56 was to coordinate care with post discharge from the facility. This had the potential to negatively affect Resident 56's disease management and placed Resident 56 at risk to experience adverse reactions from her medications should Resident 56 not understand the instructions. Findings Review of the facility's P&P titled Transfer and discharge date d 7/2/20, showed adequate preparation and assistance is provided to residents prior to transfer or discharge from the facility. Post…

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 medical record review, the facility failed to provide the necessary care and services to maintain their highest physical well-being for one of 21 final sampled residents (Resident 48). * The facility failed to ensure Resident 48's venlafaxine (medication to treat depression) was administered as ordered by the physician. Resident 48's venlafaxine was discontinued without a physician's order. This failure had the potential to negatively affect the resident's physical and psychosocial outcomes due to complications related to the discontinuation of the medication. Findings: Medical record review for Resident 48 was initiated on 2/22/22. Resident 48 was readmitted to the facility on [DATE]. Review of Resident 48's Psychiatric Note dated 2/16/22, showed Resident 7 had a history of depression. Review of the Physician Orders for the month of March 2022 showed an active order dated 10/19/21, to administer venlafaxine 75 mg by mouth every day at bedtime for depression manifested by Resident 48'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 observation, interview, medical records review, and facility document review, the facility failed to ensure the environment remained free from accident hazards for two of 21 final sampled residents (Residents 7 and 35) * The facility failed to ensure Resident 7's bilateral floor mats were in place as ordered by the physician. * The facility failed to implement bilateral floor mats to mitigate the risk of injuries from falls for Resident 35. These failures had the potential to place the residents at risk for serious injuries. Findings: 1. Medical record review for Resident 7 was initiated on 2/22/22. Resident 7 was readmitted to the facility on [DATE]. Review of Resident 7's Physician's Telephone Order dated 2/21/22, showed to place the bilateral floor mats for fall precautions and safety. Review of Resident 7's eInteract SBAR Summary for Providers dated 2/3/22, showed Resident 7 had an unwitnessed fall and was found on the floor next to her wheelchair. Resident 7 was assessed to have a small area 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 medical record review, the facility failed to ensure the appropriate urinary catheter care was provided for one of 21 final sampled residents (Resident 48). * The facility failed to ensure Resident 48's urinary drainage tubing was off the floor. In addition, Resident 48's urinary tubing was coiled which prevented the free flow of urine into the drainage bag. These failures have the potential to cause the resident to have repeated urinary tract infections. Findings: Medical record review for Resident 48 was initiated on 2/22/22. Resident 48 was readmitted to the facility on [DATE]. Review of the Physician's Orders dated 3/22, showed an order dated 2/10/22, for Resident 48 to have an indwelling urinary catheter for a neurogenic bladder (when a person lacks bladder control due to brain or nerve problems). Review of the Physician's Telephone Order dated 2/10/22, showed to administer fluconazole (medication to treat fungal and yeasts infections) 200 mg by mouth daily for urine…

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, medical record review, and facility P&P review, the facility failed to ensure the necessary services for respiratory care needs were provided for one of 21 final sampled residents (Resident 32). This posed the risk for complications related to respiratory treatment. Findings: Review of the facility's P&P titled Oxygen Therapy revised 11/2017 showed oxygen is administered under safe and sanitary conditions to meet resident needs. Licensed Nursing staff will administer oxygen as prescribed. Oxygen tubing, mask, and cannulas will be changed no more than every seven days and as needed. The supplies will be dated each time they are changed. On 2/22/22 at 0744 hours, during the initial tour of the facility, Resident 32 was observed receiving oxygen at 1.5 L/min via nasal cannula. The oxygen tubing was not dated. On 2/23/22 at 1437 hours, an observation and concurrent interview was conducted with LVN 5. Resident 32 was observed receiving oxygen at 2.5 L/min via nasal cannula. LVN 5…

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, medical record review, and facility P&P review, the facility failed to ensure two of 21 final sampled residents (Residents 32 and 457) remained free from accident hazards due to the use of elevated grab bars and full side rails in bed. * The facility failed to ensure Resident 32's side rail assessment was accurate to show the type of bed rails recommended for use. Full length side rails were installed on both sides of Resident 32's bed. In addition, the facility failed to assess Resident 32 for the risk of entrapment The facility failed to obtain an informed consent from Resident 32 prior to the use of full length bilateral bed rails. * The facility failed to obtain an informed consent and assess Resident 457's risk for entrapment for the use of bilateral 1/2 side rails. These failures had the potential to place the residents at risk for entrapment and serious injury. Findings: According to the facility's P&P titled Bed Rails dated 12/4/20, showed prior to installation, assess…

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, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to address resident's psychosocial, emotional, mental well being for one of 21 final sampled residents (Resident 36). * Residenr 36 had manifested violent behaviors towards another resident and a visitor in the facility. Resident 36 threw things on the floow during a verbal disagreement with another resident. Resident 36 was found in possession of a BB gun and warned a family member of another resident to leave to prevent shrapnels from hitting him when he fire at the facility's camera. The facility failed to ensure the behavioral interventions were put in place to address Resident 36's behaviors and protect the other residents and visitors from his violent behaviors. This failure posed the risk for harm toward others and himself. Findings: Review of the facility's P&P titled Behavior/Psychoactive Drug Management revised 11/2018 showed it is the policy of the facility to provide…

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, medical record review, and drug information review, the facility failed to ensure the pharmaceutical services were provided to meet the needs of one of 21 final sampled residents (Resident 7) and one nonsampled resident (Resident 25). * The facility failed to ensue Resident 25's Metformin (medication to treat high blood sugar levels) ER tablet was not cut in half as per the drug information. * The facility failed to ensure Resident 7's Voltaren gel (medication for pain) ordered for pain as needed was available for use. In addition, the facility failed to ensure Resident 7's Celebrex medication for pain was administered in a timely manner as ordered by the physician. These failures had the potential to negatively affect the residents' health. Findings: 1. According to Lexicomp (pharmacological online resource), Metformin ER (extended release) tablets should be swallowed whole; do not crush, cut, or chew. Review of the Physician's Orders for Resident 25 showed an order dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to provide the necessary pharmacy services for one of 21 final sampled residents (Resident 52). * The facility failed to promptly act on the recommendation made by the Pharmacy Consultant for a lipid panel for Resident 52's use of atorvastatin (medication to treat high cholesterol level). This placed Resident 52 at risk for complications and adverse effect from the medication. Findings: According to the facility's P&P titled Drug Regimen Review revised 12/2016, showed the facility must ensure the attending physician documents in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there was to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record. During the pharmacist' monthly drug regimen review, the pharmacist will report any irregularities to the attending physician…

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 medical record review, the facility failed to ensure two of 21 final sampled residents (Residents 36 and 55) were free from unnecessary medications. * The facility failed to ensure Residents 38 and 55's midodrine medications (medication to treat low blood pressure) was administered as ordered by the physician. These failures posed the risk for the residents to experience adverse effects from the midodrine, including hypertension (high blood pressure). Findings: 1. Medical record review for Resident 38 was initiated on 2/22/22. Resident 38 was admitted to the facility on [DATE]. Review of the physician's orders showed an order dated 12/17/21, for midodrine HCL 10 mg orally every day for hypotension (low blood pressure) with SBP less than 100 mmHg. Review of Resident 38's MAR for January and February 2022 showed Midodrine 10 mg was administered on 1/10, 1/17, and 2/1/22 when Resident 38's SBP was greater than 100 mmHg. On 2/24/22 at 1013 hours, an interview and concurrent medical 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 interview, medical record review, and facility P&P review, the facility failed to ensure three of 21 final sampled residents (Residents 31, 48, and 52) were free from unnecessary psychotropic medications. * Resident 31 had the orders for Zoloft (medication for depression), Xanax (medication for anxiety) and Depakote (medication for bipolar disorder). The facility failed to ensure Resident 31's use of Xanax and Depakote had a specific behavior manifestation for the provision of psychotropic medication use. The facility also failed to ensure Resident 31 provided informed consents for the use of these medications. Furthermore, the facility failed to ensure Resident 31's behaviors were being monitored for the specific use of each psychotropic medication. This posed a risk of Resident 31 to not be informed regarding the medications she is taking and Residents 31's physician not having the necessary information to determine the effectiveness of the medication. * Resident 48 had an order for Effexor…

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

Based on observation and interview, the facility failed to ensure the medications were appropriately stored as evidenced by: *An unopened insulin bottle was stored in room temperature in Medication Cart A. This failure have the potential to alter the efficacy of the store medications. *An expired bottle of docusate sodium and personal car keys were observed stored with insulin pens in Medication Cart B. These failures have the potential for infection control issues and expose residents to expired medications with questionable potency and efficacy. Findings: 1. On 3/1/22 at 1515 hours, an observation of Medication Cart A was conducted with LVN 1. A vial of unopened Humulin R was stored at room temperature in Medication Cart A. The pharmacy label on the Humulin R vial showed to refrigerate the unopened bottle, and may store at room temperature after opening. LVN 1 verified the finding and stated the Humulin R vial should be stored in the refrigerator. 2. On 3/1/22 at 1544 hours, an observation of Medication Cart B was conducted with LVN 2 and showed the following: -a black car key was…

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 provide the assistive eating device for one of 21 final sampled residents (Resident 31). * Resident 31 was not provided built-up handle utensils (used to assist people with limited or weakened grasping strength eat more independently) during meals as ordered by the physician. This failure had the potential for the resident to not eat effectively and independently. Findings: Medical record review for Resident 31 was initiated on 3/3/22. Resident 31 was readmitted to the facility on [DATE]. Review of the Physician Orders for March 2022 showed an order to provide Resident 31 with curved utensils with built up handles to assist in improving the quality of self-feeding. On 2/22/22 at 1223 hours, an observation and concurrent interview was conducted with Resident 31. Resident 31 was observed sitting in her wheelchair at bedside with her lunch tray served over her bedside table. Resident 31's meal tray was observed with a sippy cup and a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to ensure the medial records for two of 21 final sampled residents (Residents 20 and 36) were accurately maintained. * Resident 20 had formulated an advance directive; however, Resident 20's POLST failed to show Resident 20 had formulated an advance directive. * Resident 36's treatment ordered in July 2021 for 14 days was still recapitulated in the February 2022 Physician's Orders. These failures posed the risk of the residents not receiving appropriate interventions as the medical record information was incomplete and/or inaccurate. Findings: 1. Medical record review for Resident 20 was initiated on 2/22/22. Resident 20 was admitted to the facility on [DATE]. Review of Resident 20's Advance Healthcare Directive Acknowledgement Form dated 12/7/21, showed Resident 20 had formulated an advance directive. Review of Resident 20's POLST Section D (advance directive) dated 12/7/21, failed to show documentation Resident 20 had formulated an advance…

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, medical record review, facility P&P review, and CDC guideline review the facility failed to evaluate the needs for the influenza and pneumococcal vaccinations for one of five sampled residents (Resident 457). This failure had the potential for Resident 457 acquiring, transmitting, or experiencing complications from the flu and pneumonia. Findings: Medical record review for Resident 457 was initiated on 2/22/22. Resident 457 was admitted to the facility on [DATE]. a. According to the CDC guidelines, the annual flu vaccination is recommended for everyone six months and older. For the 2021-2022 flu season, all flu vaccines will be designed to protect against the four viruses that research indicates will be the most common, which includes influenza A and influenza B. Review of the facility's P&P titled Influenza Prevention and Control revised 9/20 showed the CDC considers October 1 through March 31 as the flu season. The residents are offered influenza immunization every year during flu season,…

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 facility P&P review, the facility failed to conduct the regular inspections of all resident bed frames and mattresses as part of a regular maintenance program to identify areas of possible entrapment. This had the potential to place the residents at risk for entrapment and injury. Findings: According to the facility's P&P titled Bedrails dated 12/4/21, showed as part of the regular maintenance program was to identify areas of possible entrapment, conduct regular inspection of all bed frames, mattresses, and bedrails. On 2/22/22 at 0744 hours, during the initial tour, Resident 32 was observed in bed with bilateral full side rails (full length side [NAME]) elevated. On 2/23/22 at 1028 and 1353 hours, Resident 32 was observed in bed with bilateral full side rails elevated. On 2/23/22 at 1408 hours, an interview was conducted with CNA 6. CNA 6 stated Resident 32 used the bilateral full side rails to prevent falling from the bed. CNA 6 stated Resident 32 had a history of slipping…

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.