Newport Subacute Healthcare Center

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 treatment and services to maintain the highest practicable well-being for one of twelve sampled residents (Resident 10). * The facility failed to monitor Resident 10 who was on antibiotic treatment for UTI. In addition, the facility failed to ensure Resident 10's plan of care was updated to address Resident 10's treatment interventions and management of the UTI. This failure had the potential for the delay of the identification of the adverse effects related to the resident's use of antibiotic treatment and for the resident to not receive the appropriate and individualized care that could potentially affect the resident's health and well-being. Findings: Review of the facility's P&P titled Care Planning-Interdisciplinary Team revised 3/2022 showed a baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident. The baseline care plan includes…

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 sanitary requirements were met in the kitchen. * The facility failed to ensure the sanitary condition of the hood over the stove was maintained. * The facility failed to ensure the kitchen utensils had a smooth cleanable surface and in good condition. * The facility failed to ensure the kitchenware and kitchen utensils were clean and free of food particles or residue. * The facility failed to ensure the cutting boards were kept in a sanitary condition and with a cleanable surface. * The facility failed to ensure the heavy-duty blender used for puree preparation was air dried and free of food residue prior to storing and stacking. * The facility failed to ensure the ice machine drainpipes had an air gap and not touching the drains. * The facility failed to ensure the kitchen staff performed hand hygiene during dishwashing. These failures had the potential for cross contamination and foodborne illnesses to the residents consuming the food prepared in the facility's…

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

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 maintain the infection control program and practices to help prevent the development and transmission of diseases and infections. * The facility failed to ensure an infection control surveillance report/log and mapping were completed for the months of May and June 2025. * The facility failed to ensure Resident 24 was placed on EBP (Enhanced Barrier Precautions) per the physician's order. * The facility failed to ensure an EBP sign was placed outside of Room C for Resident 37 who had a Quinton catheter and indwelling urinary catheter, and for Resident 67 who had an AV fistula. * The facility failed to ensure the facility staff did not refill the residents' water from the bathroom sink. In addition, the facility failed to ensure the trash was emptied when filled and a used washable gown was discarded properly for Room B. * The facility failed to ensure Resident 65's water jug was not…

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 properly obtain the informed consent (permission granted in the knowledge of the possible consequences) for the use of psychotropic medications (medications affecting brain activity) and bedrails from the residents or from the responsible party (person designated to make decisions on behalf of the residents). The facility failed to obtain the informed consent for the psychotropic medications for three of five sampled residents (Residents 3, 20, and 70) reviewed for unnecessary medications and one nonsampled resident (Resident 24) reviewed for the use of the bedrails. * The facility failed to obtain renew the informed consents for the Abilify (antipsychotic medication) and Prolixin (antipsychotic medication) medications after six months for Resident 3. * The facility failed to renew the informed consents for the divalproex sodium (used to treat seizures and bipolar disorder), buspirone (antianxiety medication), Remeron…

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 copy of the resident's medical record was provided upon request within two working days for one of three residents reviewed for closed records (Resident 101). * The facility failed to provide Resident 101's requested medical record and facility documents to the legal representative until 13 days after the initial request was received. In addition, the facility's resident care policies and daily posting of the staffing record were not provided as requested to Resident 101's legal representative. This failure had the potential for violating Resident 101's and their legal representative rights to access their medical health information.Findings: On [DATE] at 1038 hours, a telephone interview was conducted with the Legal Assistant. The Legal Assistant stated Resident 101 expired on [DATE] in the facility, so the resident's representative had filed a case through the Law Firm. The Legal Assistant stated the Law…

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 written information regarding how to formulate an advanced directive for five of 16 final sampled residents (Residents 5, 6, 8, 83, and 90) reviewed for advanced directives. * The facility failed to provide the written information and assistance regarding how to formulate the advanced directive for Residents 5 and 90. * The facility failed to inform, provide, and document the written information regarding the residents' right to formulate the advanced directives for Residents 6 and 83. * The facility failed to provide the written information regarding the right to formulate the advanced directive for Resident 8. These failures had the potential for the residents to receive inaccurate and delayed treatment compatible with the residents' wishes during an emergency.Findings: Review of the facility's P&P titled Advance Directives revised on 9/2022 showed the resident has the right to formulate an advance directive,…

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 immediately notify the physician and family of a change in condition for one of four final sampled residents (Resident 9) reviewed for pressure ulcers. * The facility failed to notify Resident 9's physician and resident representative regarding Resident 9's change of condition when Resident 9 developed MASD (Moisture-Associated Skin Damage, general term for inflammation or skin erosion caused by prolonged exposure to a source of moisture such as urine, stool, sweat, wound drainage) to the coccyx (tailbone). This had the potential to negatively impact Resident 9's physical wellbeing and prevent the resident 's representative from being fully aware and understand the resident's treatments and course of actions. Findings: Review of the facility's P&P titled Change in a Resident's Condition or Status revised February 2021 showed the facility promptly notifies the resident, his or her attending physician, and the resident…

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 five unnecessary medication sampled residents (Residents 2, 20, and 24) were free from unnecessary psychotropic drugs. * The facility failed to ensure Resident 24 was monitored for the behavior manifestation per the physician's order for Risperdal (antipsychotic medication) and failed to monitor the orthostatic hypotension related to the use of antipsychotic medication. In addition, the facility failed to monitor the number of hours of sleep for Resident 24 related to the use of trazodone (antidepressant medication). * The facility failed to ensure the nonpharmacological interventions for the use of the Remeron (antidepressant medication), divalproex (bipolar medication), Nuedexta (used to treat neurological condition that causes uncontrollable episodes of laughing and/or crying), Seroquel (antipsychotic medication) and buspirone HCL (antianxiety medication) medications were provided to Resident 20. In…

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 plan of care to reflect the individual care needs for four of 21 final sampled residents (Residents 8, 68, 70, and 99), one of five residents (Resident 20) reviewed for unnecessary medications, and one of three closed record residents (Resident 10) reviewed. * The facility failed to develop a care plan to address Resident 8's use of an enteral feeding. * The facility failed to implement the care plan intervention of checking Resident 10's blood pressure every 12 hours to address Resident 10's hypotension diagnosis. * The facility failed to develop the comprehensive person-centered care plan to address Resident 20's use of divalproex sodium, Remeron, and Nuedexta medications. * The facility failed to develop a care plan to address Resident 68's use of insulin medication. * The facility failed to ensure to develop the comprehensive person-centered care plan…

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 care and services were provided to prevent the development or worsening of the pressure injuries (localized area of skin damage and underlying tissues caused by prolonged pressure or shear forces) for three of four final sampled residents (Residents 9, 62 ,and 83) reviewed for pressure injuries. * The facility failed to ensure the licensed nurses accurately documented the assessment of Resident 9's MASD to the coccyx. * The facility failed to ensure the low air loss mattress setting was consistent with Resident 62's weight and set on the alternate mode setting. * The facility failed to ensure Resident 83's low air loss mattress setting was accurate per the physician's order. In addition, the facility failed to reposition Resident 83 at least every 2 hours per Resident 83's care plan intervention. These failures placed the residents at risk of developing new pressure injuries and/or…

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 assess the appropriateness and continued use of the indwelling urinary Foley catheter (flexible tube that passes through the urethra and into the bladder to drain urine) for one of two final sampled residents (Resident 37) reviewed for urinary catheter. * The facility failed to ensure Resident 37 was assessed for the appropriateness and continued use of the indwelling urinary Foley catheter. This failure had the potential to predispose Resident 37 to catheter associated urinary tract infection.Findings: Review of the Centers for Disease Control and Prevention's article titled Clinical Safety: Preventing Catheter-Associated Urinary Tract Infection (CAUTIs) dated 6/27/25, showed a UTI is an infection that involves any of the organs or structures of urinary tract (e.g., kidneys, ureters, bladder and urethra). A CAUTI occurs when germs (usually bacteria) enter urinary tract through the urinary catheter and cause infection. Under the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to maintain the IV access for one of one final sampled residents (Resident 99) and one nonsampled resident (Resident 100) reviewed for the IV care. * The facility failed to ensure Resident 99's PICC line catheter was measured on 8/23/25, per the physician's order. * The facility failed to ensure the PICC line external catheter and arm circumference measurements were completed and documented in Resident 100's medical record. These failures had the potential to delay the identification of the IV catheter related complications for the residents.Findings: Review of the facility's P&P titled Central Venous Catheter Care and Dressing Changes revised 10/2024 showed the purpose of this procedure is to prevent complications associated with intravenous therapy, including catheter-related infections that are associated with contaminated, loosened, soiled, or wet dressings. Measure…

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 the necessary respiratory care services for four of four final sampled (Residents 3, 9, 68, and 70), and two nonsampled resident (Residents 24 and 100) reviewed for respiratory care. * The facility failed to administer the oxygen to Resident 3 per the physician's order and failed to ensure the oxygen concentrator was functioning properly. In addition, the facility failed to ensure Resident 3's nasal cannula was dated and labeled and changed weekly. * The facility failed to ensure Resident 9's oxygen tubing was changed and dated. * The facility failed to ensure Resident 24's set-up bag for the Yankauer (a rigid tonsillar suction device used for suctioning the mouth and oropharynx) suction was changed weekly. * The facility failed to ensure the suction bacterial filter was changed every month for Resident 68. * The facility failed to ensure Resident 70's oxygen and nebulizer tubing were labeled 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.

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 appropriate dialysis care was provided for four of five final sampled residents (Residents 9, 37, 68, and 99) and two nonsampled residents (Residents 67 and 100) reviewed for dialysis services. * The facility failed to ensure Resident 9's physician's order to obtain the pre and post weights on the dialysis days were followed. Resident 9's post dialysis weights were not obtained on the dialysis days. * The facility failed to ensure the emergency dialysis kit kept at bedside was complete and included clamp scissors for Residents 37 and 100. * The facility failed to ensure a dialysis e-kit was available at bedside for Residents 67 and 99. * The facility failed to ensure the emergency dialysis kit was kept at Resident 68's bedside. In addition, the facility failed to ensure the licensed staff did not monitor and document the presence of bruit and thrill for Resident 68's central venous catheter in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure three of three final sampled residents (Residents 6, 37 and 99) and one nonsampled residents (Resident 67) remained free from accident hazards due to the use of the side rails. * The facility failed to ensure the physician's order was obtained for the use of bilateral half side rails for Resident 6. In addition, the facility failed to ensure a care plan was developed to address the use of the bilateral half side rails for Resident 6. * The facility failed to ensure the less restrictive interventions were completed prior to the use of the half side rails for Residents 37 and 67. * The facility failed to ensure a physician's order and consent were obtained prior to the use of bilateral side rails for Resident 99. In addition, no care plan was developed to address the use of bilateral side rails for the resident. These failures had the potential to put the residents at risk for entrapment and serious…

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 70 and 99) were free from the unnecessary medications. * The facility failed to ensure Resident 70 who was on apixaban (medication used to prevent blood clots) was monitored for signs and symptoms of bleeding. * The facility failed to monitor Resident 99 for the signs and symptoms of bleeding related to the use of apixaban medication (medication used to prevent blood clots). These failures had the potential for the residents to receive unnecessary medications and develop significant adverse effects.Findings: According to the FDA the approved Highlights of Prescribing Information for apixaban issued on 04/2025 showed the most common adverse reaction in adult patients are related to bleeding. Review of the facility's P&P titled Anticoagulation – Clinical Protocol revised 11/2018 under the Monitoring and Follow-Up section, showed for the staff and physician 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.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 12.5%. Two of two licensed nurses (LVNs 3 and 12) were found to have made errors during the medication administration to two nonsampled residents (Residents 54 and 89). * LVN 3 failed to properly administer the potassium chloride tablet (supplement) as per the physician's order to Resident 89 when LVN 3 crushed the potassium chloride tablet and using an improper amount of water to reconstitute the medication. The physician's order specified to dissolve the potassium chloride medication with 60 ml of water, however, LVN 3 only used 10 ml. * LVN 3 failed to properly administer the crushed multivitamin with minerals (supplement) as per the physician's order to Resident 89 when LVN 3 left an excessive amount of residue in the medication cup, after administering the medication through the resident's GT. * LVN 12 failed to properly administer Resident 54's lactulose (used to treat constipation) 20 gm…

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 provide the necessary pharmacy services to ensure the proper storage, labeling, and disposal of medications. * The facility failed to remove expired medical supplies from Medication Room A. * The facility failed to ensure two prescription topical medications were labeled with the physician's order in Medication Cart A. In addition, the facility failed to ensure the facility staff's over-the-counter medications were not stored in Medication Cart A with the facility's house wound supplies. * The facility failed to ensure two prescription inhalational medications were labeled and dated in Medication Cart B. * The facility failed to ensure an opened insulin vial, and two opened insulin pens were labeled with the date opened in Medication Cart C. * The facility failed to ensure the facility staff's personal item was not stored in Dialysis Cart A. *The facility failed to ensure Resident 68's Venelex wound dressing ointment (used for wound…

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 garbage was properly stored in two of two garbage dumpsters. * The facility failed to ensure the lids for the two garbage dumpsters were fully closed. This failure had the potential to attract pest/rodents that carried diseases.Findings: Review of the facility's P&P titled Garbage and Trash dated 2023 showed all the food waste must be placed in sealed leak-proof, non-absorbent, tightly closed containers (i.e., plastic bags) and shall be disposed of as necessary to prevent a nuisance or unsightliness. Adequate, clean, vermin-proof areas must be provided for storage of garbage and rubbish. Garbage and trash cans must be inspected daily that no debris is on the ground or surrounding area, and that the lids are closed. The trash collection area is a potential feeding ground for vermin and rodents and must be kept clean. According to the USDA Food Code 2022 Section 5-501.15 Outside Receptables, the receptables and waste handing units for refuse, recyclables, and returnable used with materials…

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 document review, and facility P&P review, the facility failed to provide the necessary hospice services for one of one final sampled resident (Residents 11) reviewed for hospice services . * The facility failed to ensure Hospice A's plan of care including the physician's orders were integrated into Residents 11's care. * The facility failed to ensure the complete documentation of the hospice staff visits were available for Resident 11. * The facility failed to ensure Resident 11's IDT meeting included the hospice staff. These failures posed the risk for the delay in communication and provision of the hospice care between the hospice provider and facility.Findings: Review of the facility's P&P titled Hospice Program (undated) showed when a resident participates in the hospice program, a coordinated plan of care between the facility, Hospice agency and resident/family will be developed and shall include directives for managing pain and other uncomfortable…

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 document review, and facility P&P review, the facility failed to monitor and address the use of the antibiotics for two final sampled residents (Residents 68 and 90) and one nonsampled resident (Resident 26) reviewed for antibiotic stewardship. * The facility failed to ensure the McGeer's criteria assessment was completed in a timely manner for Resident 26 when the resident was started with antibiotics on 7/18/25. * The facility failed to ensure the McGeer's criteria were assessed for Residents 68 and 90 when the residents were prescribed with antibiotics. These failures had the potential for the antibiotics to be used when they were not indicated and the development of antibiotic-resistant bacteria.Findings: Review of the facility's P&P titled Antibiotic Stewardship - Orders for Antibiotics revised 12/2016 showed the antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Program and in…

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 administer the pneumococcal vaccine (a vaccine given to protect the resident from pneumococcal disease) to one of five final sampled residents (Resident 35) reviewed for immunizations. * Resident 35's medical record failed to show documented evidence Resident 35 was administered with the pneumococcal vaccine or had refused the pneumococcal vaccine. This failure increased the resident's risk of being infected by the pneumococcal disease and its associated complications.Findings: Review of facility's P&P titled Pneumococcal Vaccine revised 10/2019 showed all the residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or 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, medical record review, and facility P&P review, the facility failed to administer the COVID-19 (infectious disease caused by the SARS-CoV-2 virus- Severe Acute Respiratory Syndrome Corona virus 2 that causes COVID 19) vaccine to one of five sampled residents (Resident 35) reviewed for COVID-19 vaccination. * The facility failed to ensure COVID-19 vaccine was administered to Resident 35. This failure increased the resident's risk of being infected by the COVID-19 disease and its associated complications.Findings: Review of facility's P&P titled Covid Vaccine Policy and Procedure, undated, showed in part, to establish the process to comply with the Federal mandate that all staff are vaccinated against COVID-19 unless they have a medical or religious exemption to help reduce the risk residents and staff have of contracting and spreading COVID-19. COVID-19 vaccinations will be offered to all staff and residents (or their representatives if they cannot make health care decisions.) unless such…

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 resident's zone entrapment assessment was completed and the measurements were recorded upon installation during the admission when identifying areas of possible entrapment with the use of side rails for two final sampled residents (Residents 6 and 37) and one nonsampled resident (Resident 67) reviewed for the use of the side rails. * The facility failed to ensure Residents 6, 37, and 67's entrapment assessments were completed upon the installation of the residents' bilateral half 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…

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 one of five sampled residents (Resident 1) was free from physical restraints. * The Facility failed to ensure Resident 1 had a physician's order, consent, and completed assessment prior to the use of the right hand mittens. Additionally, the facility failed to initiate a care plan when the right hand mitten was provided to Resident 1. These failures posed the risk for Resident 1 and her responsible party not to be informed of her treatment and potentially compromising the resident's independence and psychosocial well-being.Findings: Review of the facility's P&P titled Use of Restraints revised 12/2007 showed the restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls. Examples of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to develop the comprehensive plan of care to reflect the individualized respiratory care needs for one of five sampled residents. * The facility failed to ensure a plan of care was developed to address Resident 1's episodes of pulling out the tracheostomy tube, putting the nasal cannula in the mouth, biting the cannula, and chewing the oxygen tubing. This failure had the potential for not providing Resident 1 the appropriate, consistent, and individualized care and negatively impact the resident's health and well-being.Findings: Review of the facility's P&P titled Care Plan (undated) showed the facility develops a comprehensive care plan for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, and psychological needs. The comprehensive care plan has been designed to:a. Incorporate identified problem areas;b. Incorporate risk factors associated with identified problems;c.…

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 necessary care and services was provided to one of five sampled residents (Resident 1) who was at risk for fall. * The facility failed to notify the physician and responsible party, and initiate a care plan when Resident 1 had an incident where her head was found hanging on the bed. This failure had the potential for the delay in providing the necessary care and services and posed a risk for Resident 1 to sustain serious injury.Findings: Review of the facility's P&P titled Accidents and Incidents - Investigating and Reporting (undated) showed all accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the administrator. The nurse supervisor/charge nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. The following data, as applicable, shall be included on the Report 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, medical record review, and facility P&P review, the facility failed to ensure the necessary care/services were performed prior to the use of the bedrails for one of five sampled resident (Resident 1). * The facility failed to ensure Resident 1 had a physician's order, consent, and assessment prior to the use of the bilateral upper bedrails. Additionally, the facility failed to initiate a care plan when the bilateral upper bedrails were provided to Resident 1. These failures had the potential to put Resident 1 at risk for serious injury.Findings: Review of the facility's P&P titled Proper Use for Bed Rails revised 8/2022 showed the use of the bed rails is prohibited unless the criteria for use of the bed rails have been met. The use of bed rails or side rails (including temporarily raising the side rails for episodic use during care) is prohibited unless the criteria for use of bed rails have been met, including attempts to use alternatives, interdisciplinary evaluation, resident…

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 to ensure the safe practices were followed for Resident 1 when the facility failed to provide the required two-person assistance as required during a resident transfer for Resident 1. As a result, Resident 1 sustained an assisted fall and an abrasion to the left upper back. This failure placed Resident 1 at risk for serious injuries. Findings: Medical record review for Resident 1 was initiated on 7/31/25. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's H&P examination dated 2/11/25, showed Resident 1 had no capacity to make decisions. Review of Resident 1's Quarterly MDS assessment dated [DATE], showed Resident 1 had severely impaired cognition and was dependent on the facility staff for ADLs care. The MDS assessment further showed Resident 1 required the assistance of two or more facility staff during chair/bed to chair transfer (ability to transfer to and from a bed to a chair) and tub/shower transfer (ability to get in 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 services to attain or maintain the highest practicable well-being for one of three sampled residents (Resident 1). * Resident 1 made an allegation of abuse on 7/5/25; however, the facility failed to initiate the change of condition assessment and monitoring of Resident 1 every shift for 72 hours. This failure had the potential for the resident to not receive the appropriate care and monitoring to prevent the development of complications and/or delayed medical treatments related to the allegation of abuse. Findings: Review of the facility's P&P titled Acute Condition Changes- Clinical Protocol dated 2001 showed the physician will help identify individuals with a significant risk for having acute changes of condition during their stay. The physician will help identify and authorize appropriate treatments. The staff will monitor and document the resident's progress and responses to treatment, and the 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, medical record review, and facility P&P review, the facility failed to ensure one of three sampled residents (Resident 2) was free from the unnecessary medications. * The facility failed to follow the physician's order to hold the midodrine (blood pressure support) medication when Residents 2's SBP was greater than 120 mmHg. This failure had the potential for Resident 2 to develop significant side effects. Findings: Review of the facility's P&P titled Administering Medications revised 4/2019 showed the medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with the prescriber's orders, including any required time frame. The following information is checked/verified for each resident prior to administering the medications: a. allergies to medications; and b. vital signs, if necessary. Medical record review for Resident 2 was initiated on 7/7/25. Resident 2 was admitted to the facility on [DATE], and readmitted on [DATE]. 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, and facility P&P review, the facility failed to provide the necessary G-tube care and services for three of six sampled residents (Residents 4, 5, and 6 ) reviewed for enteral feeding. * The facility failed to ensure Residents 4 and 5's G-tube medication ports were kept clean and patent. * The facility failed to ensure the physician's orders to flush enteral feeding with 30 ml before and after medication were followed for Resident 6. These failures posed the risk of developing complications related to enteral feeding. Findings: Review of the facility's P&P titled Maintaining Patency of a Feeding Tube (Flushing) revised 11/2018 showed the purpose of this procedure is to maintain patency of a feeding tube. The person performing this procedure should record the following information in the resident's medical record: 1. The date and time the procedure was performed. 2. Verification of tube placement. 3. Total amount used to flush tube. 4. The name and title 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, medial record review, and facility P&P review, the facility failed to ensure one of nine sampled residents (Resident 5) was provided an environment free from the physical restraints. * Resident 5 was observed multiple times with a soft mitten restraint to his right hand. There was no active physician's order, updated informed consent, and updated care plan for the soft mitten on Resident 5's right hand. * There was no appropriate assessment completed prior to placing a soft mitten restraint on Resident 5. * Resident 5 was not monitored for the use of the restraints. These failures had the potential to negatively affect Resident 5's physical mobility and psychosocial well-being. Findings: Review of the facility's P&P titled Use of Restraints revised 4/2017 showed restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives been tried. Restraints shall only be used to treat the resident's medical symptom(s) and never 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 interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the reporting of a reasonable suspicion of a crime was completed in a timely manner for one of nine sampled residents (Resident 2). * The facility failed to ensure Resident 2's allegation of neglect against RT 1 was reported timely to the CDPH L&C Program and local law enforcement agency. This failure had the potential for abuse and injury to go unreported and uninvestigated timely. Findings: Review of the facility's P&P titled Abuse Investigation and Reporting dated 1/1/24, showed the following: - All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: a. The State licensing/certification agency responsible for surveying/licensing the facility; b. The local/State Ombudsman; c. 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, medical record review, facility document review, and facility P&P review, the facility failed to provide the written information on the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which received such requests to the residents and/or their representatives; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request upon the resident transferring to an acute care hospital for three of three sampled residents (Residents 1, 2, and 3) reviewed for discharge. This failure had the potential for the residents to not receive accurate information to determine if they wanted to appeal the transfer or discharge and return to the facility. Findings: Review of the facility's P&P titled Transfer or Discharge Documentation revised December 2016 showed if a resident exercises his or her right to appeal a transfer or discharge notice he or she will not be transferred or…

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 follow their post fall protocol for two of 10 sampled residents (Residents 8 and 9). * Resident 8 experienced the falls on 4/20 and 4/22/25. The facility did not implement additional interventions for fall prevention after Resident 8's second fall on 4/22/25. Additionally, Resident 8's post fall neurological assessments were not completed as ordered for the fall on 4/20/25. * Resident 9's post fall neurological assessments were not completed as ordered for falls on 5/16 and 5/29/25. These failures had the potential for the residents to experience additional preventable falls and a potential delay in identification and interventions for post fall head injuries. Findings: 1. Review of thefacility's P&P titled Falls and Fall Risk, Management revised March 2018 showed if fall recursdespite initial interventions, staff will implement additional interventions or indicate why the current approach remains in relevant. Closed…

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 needs for one of three sampled residents (Resident 3). * The facility failed to ensure Resident 3's medication was administered as ordered. This failure had the potential for Resident 3 to experience adverse effects. Findings: Review of facility's P&P titled Medication Orders revised 1/2018 showed the medications are administered only upon the clear, complete, and signed order of a person lawfully authorized to prescribe. The prescriber is contacted by nursing for direction when delivery of a medication will be delayed, or the medication is not or will not be available. Review of facility's P&P titled Medication Administration General Guidelines revised 12/2019 showed the medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only…

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 to conduct an investigation for an abuse allegation was completed in a timely manner, report the results of the abuse investigation to the CDPH, L&C Program within five working days and inform Resident 2's family member of the results of the investigation for one of the two sampled residents (Resident 2). * Family Member 1 reported to the facility CNA 3 pinched Resident 2 on 2/13/25. The facility submitted the results of the investigation on 2/21/25, eight days after the incident had occurred. This failure posed the risk for Resident 2 to not be protected against the alleged abuse and placed other vulnerable residents at risk for abuse. Findings: Review of the facility's P&P titled Abuse Investigations revised 12/2006 showed the Administrator will inform the resident and his/ her representative of the results of investigation and corrective action taken after completion of the investigation. The Administrator…

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 protect the resident's rights to be free from the physical abuse by staff for one of four sampled residents (Resident 1). * Resident 1's hands were held down and tapped by CNA 5 while being fed by CNA 5. This failure had the potential to cause the injury and physical and/or psychosocial harm to the resident. Findings: Review of the facility's P&P titled Abuse and Neglect-Clinical Protocol revised 7/2017 showed the Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, or mental anguish, or deprivation of an individual, including a caretaker, of goods and services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. Review of the facility's SOC…

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 medical record review, the facility failed to ensure privacy was provided to one of three sampled residents (Resident 3) as evidenced by: * Resident 3's privacy curtain was not pulled while providing the ADL care and assessment. This failure posed the risk to negatively affect the dignity of Resident 3 and violate Resident 3' rights to privacy. Findings: On 8/8/24 at 1408 hours, an observation was conducted with LVN 1 and CNA 2. Resident 3's privacy curtain was observed only providing privacy to one side of the bed and around the foot of the bed. The privacy curtain was not long enough to be pulled all the way around Resident 3's bed. LVN 1 and CNA 2 were observed assessing Resident 3's body during a head-to-toe assessment. Resident 3's body was visible from the right side of his bed and from Bed A's bed. On 8/9/24 at 1017 hours, an observation and concurrent interview was conducted with CNA 2 for Resident 3. CNA 2 was observed transferring Resident 3 back to his bed after his shower with the Hoyer lift (mechanical lift to allow a person to be…

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 and interview, the facility failed to consistently provide a safe environment for the residents, staff, and visitors as evidenced by: * Two of the six facility doors were observed unlocked. This failure resulted in an unauthorized person entering a resident's room, which posed the risk of an unsafe environment for the residents, staff, and visitors. Findings: On 7/30/24 at 1350 hours, an observation and concurrent interview was conducted with the Maintenance Director. A door located on the lower level and to the side of the facility was observed open. This door led to a hallway next to the facility's laundry room and to another unlocked door with stairs that led up to Resident Room A. The Maintenance Director verified the finding. On 7/30/24 at 1403 hours, an interview was conducted with Resident 1. Resident 1 statedon 7/24/24, Resident 1 saw a transient (a person who moves from place to place/homeless person) woman looking through his window. At around 1845 hours on 7/24/24, the same…

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 assessment for the risk for entrapement, physician's order and informed consent were obtained prior to the use of side rails for five of 11 final sampled residents (Residents 20, 40, 8, 7, and 15) and two nonsampled (Residents 10 and 539) reviewed for side rails. This failure had the potential to place the residents at risk for entrapment and serious injury. Findings: Review of the facility's P&P titled Bed Safety and Bed Rails revised 08/2022 showed the following: - The use of bed rails or side rails (including temporarily raising the side rails for episodic use during care) is prohibited unless the criteria for use of bed rails have been met, including attempts to use of alternatives, interdisciplinary evaluation, resident assessment, and informed consent; and - Before using bed rails for any reason, the staff shall inform the resident or representative about the benefits and potential hazards…

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 P&P review, and facility document review, the facility failed to ensure 46 of 78 residents who received food from the kitchen received the proper diets and portion sizes when the facility's menus and recipes were not followed. * The facility failed to ensure the residents with mechanical soft diets received ground meat as shown on the Spring Cycle Menu Week 1 dated for 5/1/24. * The facility failed to ensure the finely chopped diet was on the diet manual or approved on the spread sheet and failed to ensure mechanical soft finely chopped diets were followed. * The facility failed to ensure the puree recipes for meats, vegetables, and potatoes were followed. * The facility failed to ensure 10 out of 10 residents with a CCHO diet (diet low in carbohydrates) received plain ice cream as shown on the Spring Cycle Menu Week 1 dated for 5/1/24. * The facility failed to ensure five out of five residents on renal diet (diet for residents with kidney disease, low in potassium, sodium and protein) received brown rice and did not receive fresh green…

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 P&P review, and facility document review, the facility failed to ensure the food safety and sanitary requirements were met in the kitchen when there were 46 of 78 residents receiving food from the kitchen. * The facility failed to ensure the cooling log was done for the egg salad and failed to ensure the cooling log for the roast beef was fully completed. * The facility failed to ensure the ice machine was properly cleaned. * The facility failed to ensure the temperature log for the resident refrigerator were completed. * The facility failed to ensure food preparation utensils and equipment were in good, sanitary, and cleanable working conditions: a. One blue and two green cutting boards were heavily marred b. Two rubber spatulas were chipped c. One small frying pan and one pot with black residue d. One can opener blade heavily worn and with brown residue * The facility failed to ensure staff's personal belongings were not stored on the food preparation table. * The facility failed to ensure the kitchen staff wore hair and beard restraint. *…

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, facility document review, and facility P&P review, the facility failed to implement their infection control surveillance program in accordance with the facility's P&P. * The facility failed to maintain an accurate infection control surveillance program for January through March 2024. The facility used Surveillance Data Collection Form and Infection Control Surveillance form that showed inaccurate or missing information. This failure posed the risk for not identifying residents' infections and thereby, preventing the implementation of interventions to control the potential transmission of communicable diseases to other residents in the facility. * The facility failed to follow practices on handling, storing, and processing laundry so as to prevent the spread of infection. This failure posed the risk for transmission of disease-causing microorganisms. * The facility failed to ensure the staff disinfect the blood pressure monitoring instrument before and after use in between Residents 9 and 839.…

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 P&P review, and facility document review, the facility failed to ensure the essential kitchen equipment was in the safe and operating condition as evidence by: * The facility failed to ensure one of one handwashing sink in the kitchen provided adequate water pressure and hot water. * The facility failed to ensure the walk-in Refrigerator 1 was absent of pooling water on the floor. * The facility failed to ensure the ice machine was properly cleaned as per the ice machine cleaning instruction. * The facility failed to ensure Freezer 1 door was absent of ice buildup. * The facility failed to ensure Freezer 1 door was free of caulking from peeling off with black residue and base board was not loose and free from black residue. These failures had the potential to spread infection and provide inadequate working equipments. Findings: Review of the facility census on 4/30/24 showed there were 78 residents at the facility. The facility document titled Order Listing Report with diet orders provided on 5/1/24, showed the kitchen provided the diets 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 P&P review, and facility document review, the facility failed to conduct a regular bed inspection as part of a regular maintenance program to identify areas of possible entrapment for 12 of 12 residents reviewed for side rail use; 11 final sampled residents (Residents 7, 8, 12, 15, 16, 20, 22, 40, 387, 837, and 838), and one nonsample resident (Resident 10). 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,…

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 one of five final sampled residents reviewed for unnecessary medications (Resident 4) and one of two residents reviewed for restraint use (Resident 4) were informed of the use of the psychotropic medication (medication affecting brain activities associated with mental processes and behavior) and restraint. * The facility failed to ensure the informed consents were obtained prior to administering the Seroquel (antipsychotic medication) and bilateral hand mittens for Resident 4. This failure had the potential for Resident 4 to not be informed of the potential risks and benefits of the medication and restraints. Findings: Review of the Health and Safety Code, Section 1418.8, showed the following: -(2) (A) If the physician and surgeon determine that the resident will suffer harm or severe and sustained emotional distress if the prescribed medical intervention is delayed at least five days, an interdisciplinary team…

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 offer and/or follow up on the advanced directive availability for two of 18 final sampled residents reviewed for advanced directives (Residents 6 and 12). * Resident 12 was not offered information to formulate an advanced directive. * The facility failed to ensure Resident 6 had an advance directive or a follow up was made to inquire whether or not Resident 6 had an advance directive. These failures had the potential for the residents' final wishes for medical treatment not being communicated with health care staff. Findings: Review of the facility's P&P titled Advanced Health Care Directive & POLST (Physician Orders for Life-Sustaining Treatment) reviewed 1/2022, showed the following: -The facility will make information available to residents on how to prepare an advance directive. -The SSD or designee will inquire if the resident has an advance directive and will request a copy. -If the resident is capable of making an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review and facility P&P review, the facility failed to follow their P&P for two of two final residents reviewed for the hand mitten use (Residents 4 and 22). * Resident 22's order for documentation of releasing their hand mitten did not follow facility P&P. * The facility failed to ensure Resident 4's bilateral hand mittens were monitored every two hours, and release for 15 minutes as per the physician's order. These failures resulted in inaccurate documentation of hand mitten removal, which had the potential for a delay in identifying and documenting adverse outcomes from the hand mittens use. Findings: Review of the facility's P&P Hand Control Mitten Control undated showed to release the hand mitten every two hours and exercise the resident's hand for 10 minutes, and observe for edema, and to document the date and time the hand mitten is released. 1. Medical record review for Resident 22 was initiated on 4/30/24. Resident 22 was re-admitted to the facility 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 splints (a medical device that stabilizes a part of your body and holds it in place) and orthosis (the correction of disorders of the limbs or spine by use of braces and other devices to correct alignment or provide support) were applied and the ROM exercises were provided to two of four final sampled residents reviewed for ROM functions(Residents 20 and 41). * The facility failed to ensure Resident 20 was provided with the restorative nursing services as ordered by the physician when the ROM exercises were not provided and the splint and orthosis were not applied. * The facility failed to ensure Resident 41's splint and orthosis were applied as ordered by the physician. These failures had the potential for decline in the residents' ROM and mobility. Findings: Review of the facility's P&P titled Contracture Care (undated) showed in order to provide comfort and maximum freedom, all splints and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the environment free from accident hazards. * The facility failed to ensure the fall mat was placed on the floor as ordered by the physician for one of one nonsampled resident (Resident 10). * The facility failed to ensure the doorway to Room A was free of obstruction. * The facility failed to ensure the smoking supplies were stored for safety and the quarterly smoking safety assessments for one of one final sampled resident reviewed for smoking (Resident 387) was completed timely. * The facility failed to ensure the cleaning solutions were safely stored. A bottle of Awesome Floor Cleaner was left on the floor beside Resident 837's bedside cabinet. These failures posed the risk for the unsafe environment and risk of accidents for the residents in the facility. Findings: Review of the facility's P&P titled Doorway and Resident Rool Door Policy dated 9/1/18, showed it is the policy of the facility 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, and medical record review, the facility failed to provide the necessary GT care and services for two of eight final sampled residents reviewed for GT care (Residents 4 and 6). * The facility failed to ensure Residents 4 and 6 were positioned safely at 30 to 45 degrees during the enteral feeding via GT. This failure posed the risk for developing complications related to the residents' GT. Findings: According to Taylor's Fundamentals of Nursing seventh edition, Nursing Considerations with Tube Feeding, to make sure the resident is as upright as possible during feeding. If the resident is in bed during feedings, elevate the head of the bed at least 30 degrees during feeding and for one hour afterward to prevent reflux (occurs when stomach acid repeatedly flows back into the esophagus or the tube connecting your mouth and stomach) and aspiration. 1. Medical record review for Resident 4 was initiated on 4/30/24. Resident 4 was admitted to the facility on [DATE]. Review of Resident 4'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 provide the necessary and safe respiratory care services to meet the needs of one of three final sampled residents reviewed for respiratory care (Resident 838). This failure had the potential to affect the resident's respiratory health and well-being. Findings: Review of the facility's P&P titled Oxygen Administration revised 10/2010 showed the oxygen devise (nasal cannula, mask, or nasal catheter) is changed weekly and dated with the date of change. On 4/30/24 at 0906 hours, during the initial tour of the facility, Resident 838 was observed lying in bed. Resident 838's nebulizer mask was observed in a transparent bag, unlabeled, and undated. Medical record review for Resident 838 was initiated on 4/30/24. Resident 838 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 838's Order Summary Report dated 5/1/24, showed a physician's order dated 11/28/23, for ipratropium-Albuterol…

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 the necessary pharmaceutical services to meet the needs of the residents. * The emergency kits for the facility's oral medications and intravenous medications were not replaced in a timely manner for two of seven emergency kits (Emergency Kit 1 and Emergency Kit 2) inspected in the facility. This failure had the potential to contribute to a decreased availability of medications in an emergency. Findings. Review of the facility's P&P titled Medication Ordering and Receiving from Pharmacy revised January 2018 showed the emergency needs for medication are met by using the facilities approved emergency medication supply or by special order from the provider pharmacy. The provider pharmacy supplies emergency medication including emergency drugs and antibiotics, control substances, products for infusion in limited quantities in portable sealed containers and automated dispensing system (ADS). Further 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, and medical record review, the facility failed to ensure three of five final sampled residents (Residents 6, 15, and 937) reviewed for unnecessary medications were properly monitored for their medications. * Resident 15 was administered Humulin N insulin (an intermediate acting insulin, a medication used to lower blood glucose or sugar) without monitoring Resident 15's blood sugar as per the physician's order. * Resident 937 was administered hydralazine (medication to treat high blood pressure) when Resident 937's blood pressure was below the parameter prescribed by the physician. * Resident 6 was administered metoprolol (medication to treat high blood pressure) when Resident 6's blood pressure was below the parameter prescribed by the physician. These failures had the potential for Residents 6, 15, and 937 to develop significant side effects from the medications. Findings: 1. Medical record review for Resident 15 was initiated on 4/30/24. Resident 15 was readmitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility P&P review, the facility failed to ensure the medications were safely and securely stored. * The facility failed to ensure the medication cart did not have an expired bottle of Dakins solution (wound cleanser) for one of seven medication carts (Treatment Cart 1). * The facility failed to ensure Medication Cart A was not left unlocked and unattended. * The facility failed to ensure the safe storage of a medication cup containing a white cream found at Resident 937's bedside. * The facility failed to ensure the safe storage of two opened packets of Vitamin A and D ointment found at Resident 19's bedside. * The facility failed to ensure safe storage of one bottle of Guayabron Suplemento Alimentico (nutritional supplement) found at Resident 837's bedside cabinet. These failures posed the risk of unauthorized access to the medications and had the potential for the residents to have received expired medications. Findings: Review of the facility's P&P titled Storage 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, facility P&P review, and facility document review, the facility failed to ensure the facility's P&P on Resident Food From Outside Sources was updated and followed as evidence by: * The facility failed to ensure food items in the residents' refrigerator was labeled and dated. * The facility failed to ensure the policy was updated to meet state regulations. * The facility failed to ensure the visitors and staff were educated on safe food handling of outside food. These failures had the potential to cause foodborne illnesses to the medically vulnerable resident population who consumed food brought from outside sources. Findings: 1. Review of the facility's P&P titled Bringing in Food for a Resident dated 2023 showed food or beverages should be labeled and dated to monitor for food safety. Food or beverages in the original containers marked with manufacturer expiration dates and unopened, need to be marked with resident's name. Food in unmarked or unlabeled containers will be marked…

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 P&P review, and facility document review, the facility failed to ensure the facility's garbage and refuse was properly disposed as evidence by: * The facility failed to ensure two of two waste dumpsters were properly closed. * The facility failed to ensure the organic waste and recycling barrels were used as per state mandate SB1383. * The facility failed to ensure the area behind the waste dumpsters were free from debris. These failures had the potential to cause unsafe sanitary conditions and potential to harbor pests and rodents. Findings: 1. According to the USDA Food Code 2022, Section 5-501.11 Storing Refuse, Recyclables, and Returnables showed refuse, recyclables, and returnables shall be stored in receptacles or waste handling units so that they are inaccessible to insects and rodents. According to the USDA Food Code 2022, Section 5-501.113 Covering Receptacles: Receptacles and waste handling units for refuse, recyclables, and returnables shall be kept covered. (A) Inside the food establishment if the receptacles and units: (1)…

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 document review, and facility P&P review, the facility failed to ensure Resident 387's hospice visit notes and cares provided were part of the resident's medical record. This failure resulted in Resident 387's hospice schedule and provided cares not being communicated to the facility staff, which had the potential to negatively impact the resident's well-being. Findings: Medical record review for Resident 387 was initiated on 4/30/24. Resident 387 was admitted to the facility on [DATE]. Review of Resident 387's Order Summary Report dated 5/1/24, showed the following physician's orders: - dated 10/4/23, to admit the resident to hospice services. - dated 10/4/24, for a hospice nurse to drain Resident 387's Aspira drain (a tunneled drain used to drain accumulated fluid from the peritoneal cavity) monthly or as needed. - dated 10/4/24, for the hospice nurse to provide care for the resident's Aspira drain. - dated 10/4/24 for the hospice RN to visit twice a week,…

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, facility document review, and facility P&P review, the facility failed to inform the physician of the residents with prescribed antibiotics with signs and symptoms not meeting McGeer's Criteria (criteria used by long-term care facilities to determine a true infection). This failure had the potential for antibiotics to be used when not indicated and development of antibiotic resistant bacteria. Findings: According to the Centers for Disease Control and Infection (CDC), an estimated 70% of nursing home residents receive one or more courses of antibiotics during a year. Studies have shown that 40% to 75% of the antibiotics prescribed in nursing homes may be unnecessary or inappropriate. Frail and older adults are at significant risk of harm from antibiotic overuse including increased adverse drug events, increased drug interactions and infection with antibiotic-resistant organisms. The World Health Organization (WHO) cites antibiotic resistance as one of the three biggest threats to human health. Review of the facility's P&P titled Antibiotic Stewardship Orders 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 interview, medical record review, and facility P&P review, the facility failed to ensure the pneumococcal vaccines were offered and administered to five of 11 final sampled residents reviewed for the pneumococcal vaccines (Residents 2, 6, 15, 16 and 937). This failure posed the risk for the residents to contract pneumonia. Findings: Review of the facility's P&P titled Pneumococcal Vaccine revised 3/2022 showed all the residents are offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Before receiving a pneumococcal vaccine, the resident or legal representative will receive information and education regarding the benefits and potential side effects of the pneumococcal vaccine. Provisions of such education is documented in the resident's medical record. Residents/representatives have the right to refuse vaccination. If refused, appropriate information is documented in the resident's medical record indicating the date of the refusal of the pneumococcal vaccination. Medical…

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, medical record review, and facility P&P review, the facility failed to ensure three of five final sampled residents reviewed for Covid-19 vaccines (Residents 6, 15, and 16) were offered the Covid-19 vaccine. This failure resulted in the residents not receiving the vaccine in a timely manner once they were eligible to receive it, which had the potential to negavetively impact the residents' well-being. Findings: Review of the facility's P&P titled Vaccination of Residents revised October 2019, showed all the residents will be offered vaccines that aid in preventing infectious diseases unless the vaccine is medically contraindicated or the resident has already been vaccinated. Provision of such education shall be documented in the resident's medical record. If vaccines are refused, the refusal shall be documented in the resident's medical record. If the resident receives a vaccine, at least the following information shall be documented in the resident's medical record: a. site of administration b. Date of administration; c. Lot number of the vaccine (located on 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, medical record review, and facility P&P review, the facility failed to implement their P&P for ensuring the reporting of a reasonable suspicious of a crime in accordance with section 1150B of the Act when the facility did not report the allegation of abuse to the CDPH, L&C Program, Long-Term Care Ombudsman, and local law enforcement officials in timely manner for one of six sampled residents (Resident 1). The facility did not report Resident 1's allegations of abuse against the Activities Assistant to the CDPH L&C Program, Long-Term Care Ombudsman, and local law enforcement officials within two hours as per the facility's P&P within two hours. This failure had the potential to delay the investigation of the alleged physical abuse and for the staff to not take prompt and appropriate corrective actions to prevent further abuse. Findings: Review of the facility's P&P titled Abuse Investigations and Reporting, undated, showed all alleged violation involving abuse, neglect, exploitation, or…

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 the result of the investigation to the CDPH, L&C Program, Orange District Office within five working days for one of six sampled residents (Resident 1). This failure had the potential to not protect the residents from possible abuse and/or delay in providing the necessary care. Findings: Review of the facility's P&P titled Abuse Investigation and Reporting, undated, showed all reports of residents' abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of the unknown source (abuse) shall be promptly reported to local, state, and federal agencies (as defined by current regulation) and thoroughly investigated by facility management. The P&P further showed findings of the abuse investigations will also be reported. The section for Reporting showed the administrator, or his/her designee, will provide the appropriate agencies with a written report of the findings of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure the change in condition evaluation and monitoring was completed and the physician was notified of the allegation of physical abuse for one of six sampled residents (Resident 1). This failure had the potential for Resident 1 to not receive necessary services to meet highest practicable physical, mental, and psychosocial well-being. Findings: Review of the facility's P&P titled Change in a Resident's Condition or Status revised February 2021 showed the facility promptly notified the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing payments, resident rights, etc.). The P&P further showed the nurse will notify the resident's attending physician or physician on call when there has been an accident or incident involving the resident. The nurse will record in the resident'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.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the call light system was functioning for 33 of 54 beds (Beds A, B, C, D, E, F, F, H, I, J, K, L, M, N, O, P, Q, R, S, T, U, V, W, X, Y, Z, AA, BB, CC, DD, EE, FF, andGG.) This failure had the potential of an unsafe environment by endangering the health, safety, and welfare of the affected residents who were assigned to those beds. Findings: Review of the facility's P&P titled Call System, Residents dated 9/2022 showed the residents should be provided with a way to call staff for assistance and the call system should remain functional at all times. Review of the Call Light Ledger created 9/27/23, showed 33 beds had non-functioning call lights: Beds A, B, C, D, E, F, F, H, I, J, K, L, M, N, O, P, Q, R, S, T, U, V, W, X, Y, Z, AA, BB, CC, DD, EE, FF, and GG. Review of the Unusual Occurrence Letter dated 9/28/23, showed on 9/20/23, the facility's call light system stopped working in certain rooms and the service vendor was summoned immediately for the necessary repairs. 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 two of six sampled residents (Residents 1 and 3) and one nonsampled resident (Resident A) had the functioning call light buttons available or a way to call the staff. This failure had the potential for the residents to not be able to call for assistance and receive help in a timely manner. * Resident 1 was wheelchair bound and dependent on the staff for assistance in bed mobility, toileting, and transfers. Resident 1 did not have a functional call light and was unable to get a hold of staff when needed help. * Resident 3 was wheelchair bound and needed assistance with transfers, dressing, and eating. Resident 3 did not have a working call light button and had to wheel herself out of the room to call for help. * Resident A did not have a working call button and relied on Resident 3 to get staff, or to yell if she needed assistance. Findings: Review of the facility's P&P titled Call System, Residents,…

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, record review, medical record review, and facility P&P review, the facility failed to ensure one of six sampled residents (Resident 5) who received nutrition via a gastrostomy tube was not given food by mouth. This failure had the potential for Resident 5 to choke and have poor health outcomes. Findings: Review of the facility's P&P titled Assisting the Impaired Resident with In-Room Meals revised September 2013 showed the staff are to check the meal tray before serving it to the resident to ensure it is the correct ordered diet. Medical record review was initiated for Resident 5 on 10/3/23. Resident was readmitted to the facility on [DATE]. Review Resident 5's H&P examination dated 9/8/23, showed Resident 5 could make her needs known but could not make medical decisions. Resident 5 had a diagnosis of dysphagia. Review of Resident 5's MDS dated [DATE], showed the Resident 5 had severe cognitive impairment. Review of Resident 5's physician orders dated 9/15/23, showed an order for the resident…

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 two sampled residents (Resident 1) received the appropriate care and services as ordered by the physician and as documented in the plan of care related to an indwelling urinary catheter. Resident 1 was observed to not have any urine output by CNA 1 during the night shift (2300 to 0700 hours); however,CNA 1 failed to report this finding to the licensed nurse. This failure had the potential to cause a delay in necessary care and services for Resident 1. Findings: Closed medical record review for Resident 1 was initiated on 9/7/23. Resident 1 was admitted to the facility on [DATE], and transferred to the acute care facility on 8/29/23. Review of Resident 1's Order Summary Report showed the following: - an order dated 6/6/23, for indwelling urinary catheter size FR 16/10 (with 10 ml balloon) attached to the bedside closed drainage bag system due to urinary retention. - an order dated 6/5/23, to monitor the indwelling urinary drainage…

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 safety of one of four sampled residents (Resident 1) when the facility did not place the alleged staff on leave with no resident contact during an abuse allegation as per their P&P. This failure put Resident 1 and other residents at risk for further abuse. * Resident 1 alleged CNA 1 hit him on the back of the head while unplugging his fan. Resident 1 stated he had throbbing pain to the back of his head on the pain level of five to six (on a pain scale of 0-10 with 0 = no pain and 10 =worst pain); however, the alleged CNA (CNA 1) continued to stay at the facility and was reassigned to care for other residents. This failure had the potential to result in serious injury and/or psychosocial harm and put the vulnerable residents for further abuse. Findings: Review of the facility's P&P titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigation revised September 2022 showed any employee who…

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 care plan of one of four sampled residents (Resident 1) was reviewed and revised after Resident 1 reported an abuse allegation toward CNA 1. This failure put Resident 1 at risk of not receiving resident-centered care. Review of the facility's P&P titled Care Planning - Interdisciplinary Team revised March 2022 showed assessments of residents are ongoing and care plans are revised as information about the resident and the residents' condition change. Medical record review for Resident 1 was initiated on 8/25/23. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Medical record review for Resident 1 was conducted on 9/1/23. Review of Resident 1's care plan dated 4/20/23, showed the resident had potential to demonstrate verbally abusive behaviors towards staff, and make false accusations by fabricating stories. Upon further review of Resident 1's care plans, there was no documented or…

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 presence of competent staffing to meet one of four sampled residents' (Resident 1) needs safely and in a manner to promote the resident's rights, physical, mental, and psychosocial well-being. * RN 1 failed to send CNA 1 home after the abuse allegation was made against CNA 1 as per the facility's P&P. * RN 1 failed to create or revise Resident 1's care plan after the abuse allegation. * RN 1 failed to document a Change of Condition of the abuse allegation. * The IDT meeting was not set up with Resident 1 after the abuse allegation These failures had the potential to result in serious injury and/or psychosocial harm to Resident 1 and other residents. Findings: 1. Review of the facility's P&P titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigation revised September 2022 showed any employee who has been accused of resident abuse is placed on leave with no resident contact until 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 document review, the facility failed to ensure a full-time supervisor to oversee the day-to-day operations of the food service department was employed. This failure posed a risk of lack of adequate supervision of the daily kitchen functions which could lead to food borne illness for the 28 residents who received food from the kitchen. Findings: Review of the CMS 672 Resident Census and Conditions of Residents completed by the facility dated 3/9/22, showed 28 of 65 residents received food prepared in the kitchen. Review of the facility's job description titled [NAME] showed the section titled Purpose of Your Job Position, the primary purpose of job position is to prepare food in accordance with current applicable federal, state, and local standards, guidelines and regulations Under the section titled Administrative Functions,assume authority, responsibility and accountability of Cook. Review of the facility's untitled document dated 12/6/21, showed an email from the previous DM showing her last day of employment with the facility 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 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 seasoning were stored in sanitary condition. * The facility failed to ensure the expired foods were discarded. * The facility failed to ensure the kitchen equipment and ice machine were maintained in sanitary condition. * The facility failed to ensure the kitchen staff performed hand hygiene. * The facility failed to ensure the kitchen equipment was air dried. * The facility failed to ensure the cutting boards were in sanitary condition and with cleanable surface. 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 Form CMS-672 titled Resident Census and Conditions of Residents completed by the facility dated 3/9/22, showed 22 of 65 residents residing in the facility received food…

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 manufacturer's guidelines review, the facility failed to ensure the facility equipment was maintained in safe operating condition when: * For Medication Cart 1, the glucometer's (a device that measures the amount of sugar in the blood) serial number did not match the serial number for the glucometer tested on the quality control log. The lot number for the glucometer test strips in Medication Cart 1 did not match the lot number on the quality control log for the cart. This failure had the potential risk of inaccuracy for the blood glucose test results. * The dish machine required minimum wash temperature and sanitizer concentration levels were not reached. This failure placed the 28 residents who received food from the kitchen at risk for food borne illness. Findings: 1. Review of the Assure Platinum (blood glucose monitoring system), Quality Assurance and Quality Control Reference Manual revised November 2009 showed to use Assure dose control solution to check if the meter and test strips are working correctly as a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 17 final sampled residents (Resident 50) was treated with dignity. * CNAs 1 and 3 were talking to each other in a foreign language while providing ADL care to Resident 50 whose primary language was English. This failure resulted in not ensuring resident's rights to be treated with respect and dignity. Findings: Review of the facility's P&P titled Foreign Language dated 11/1/21, showed each resident shall be cared for in a manner that promotes and enhances their quality of life, dignity, respect and individuality. Staff are to communicate with the residents in their primary language, and to speak in English at all times unless they are speaking in the resident's primary language. Medical record review for Resident 50 was initiated on 3/8/22. Resident 50 was readmitted to the facility on [DATE]. Review of Resident 50's admission Record showed the resident's primary language was English. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to provide personal privacy for one nonsampled resident (Resident 52). * LVN 2 failed to close Resident 52's privacy curtain when she administered the medications via GT. Resident 52's abdomen was exposed during the procedure. In addition, RT 1 provided tracheal suctioning without provided privacy to Resident 52. These failures had the potential to expose the residents' uncovered body parts to the public view and affect self esteem and self-worth. Findings: Medical record review for Resident 52 was initiated on 3/9/22. Resident 52 was admitted to the facility on [DATE]. Review of Resident 52's MDS assessment dated [DATE], showed Resident 52 was cognitively impaired and totally dependent on staff for ADL care. Review of Resident 52's Annual History and Physical dated 1/28/22, showed Resident 52 was alert but unable to follow commands. On 3/9/22 at 0811 hours, a medication administration observation was conducted with LVN 2. LVN 2…

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 develop the plans of care to reflect the individual care needs for two of 17 sampled residents (Residents 3 and 36 ). * The facility failed to develop a comprehensive care plan to address Resident 3's use of Ativan (antianxiety medication) and the side effects of Ativan. * The facility failed to develop a care plan to address Resident 36's preference to use his bare hands to feed himself during meals. These failures posed the risk of not providing appropriate, consistent, and individualized care to the residents. Findings: 1. Medical record review for Resident 3 was initiated on 3/8/22. Resident 3 was readmitted to the facility on [DATE]. Review of Resident 3's Order Summary Report dated 3/9/22, showed a physician's order dated 3/5/22, to administer Ativan 0.5 mg one tablet by mouth every 12 hours for anxiety disorder manifested by yelling and screaming. Review of Resident 3's Order Summary Report dated 3/9/22, showed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to provide the necessary care and services to ensure two of 17 final sampled residents (Residents 24 and 30) attained and maintained their highest practicable physical well-being. * The facility failed to ensure Resident 24 was up in a high back tilt wheelchair as tolerated on non-dialysis days as per the physician's order. This failure posed the risk for the resident to develop physical, psychosocial, emotional complication that may arise from being bed bound. *The facility failed to ensure Resident 30 had a physician's order for the use of splint on the left hand. This failure resulted in Resident 30 wearing a splint on his left hand without any indication, time frame for how long to wear the device, or monitoring. Findings: 1. On 3/08/22 at 0800, 1000, 1200, and 1430 hours, Resident 24 was observed resting in bed. On 3/10/22 at 0815 and 1315 hours, Resident 24 was observed resting in bed. Medical record review for Resident 24 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 ensure the necessary care and services were provided to prevent the development or worsening of pressure ulcers for two of 17 final sampled residents (Residents 6 and 58). * The facility failed to offload Resident 6's heels from pressure as ordered by the physician. * The facility failed to ensure Resident 58's low air loss mattress (pressure redistributing support surface) was set appropriately according to the resident's weight and physician's order. These failures had the potential of Residents 6 and 58 not receiving the appropriate care and services to promote healing or prevent the development of the pressure ulcers. Findings: 1. On 3/8/22 at 1604 hours, Resident 6 was observed lying on a low air loss mattress. Resident 6's heels were not offloaded and were observed resting directly on the mattress. Medical record review for Resident 6 was initiated on 3/8/22. Resident 6 was admitted to the facility on [DATE], and readmitted…

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 72-hour neurological assessments were conducted completely for one of 17 final sampled residents (Resident 51) at the frequency as per the physician's orders after the resident had sustained three unwitnessed falls. This posed the risk for delayed recognition of a neurological change or injury. Findings: Medical record review for Resident 51 was initiated on 3/8/22. Resident 51 was admitted to the facility on [DATE]. a. Review of Resident 51's Progress Notes dated 12/22/21 at 1430 hours, showed Resident 51 reported to staff that he had a fall around 0030 hours. Resident 51 fell on his left side and complained of mild tenderness on his left rib area. A reddish discoloration on the left cheek was observed. The physician was informed and ordered for the staff to conduct a neurocheck (or neurological assessment-a set of neurological observations to collect data on the patient's neurological status 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, and medical record review, the facility failed to provide safe respiratory care to meet the needs of one of 17 final sampled residents (Resident 6). * The facility failed to ensure Resident 6 was placed on the ventilator settings ordered by the physician. Changing the ventilator settings without the appropriate orders had the potential to result in poor health outcomes for the resident. Findings: On 3/8/22 at 0737 and 0842 hours, Resident 6 was observed in bed with a tracheostomy tube (breathing tube inserted through the neck into the airway to maintain an open airway) in place and connected to a mechanical ventilator (a machine that takes over the work of breathing when a person is not able to breathe enough on their own.). Resident 6's ventilator was observed setting for Assist Control mode (programmed to sense changes in the system pressure when a patient initiates a breath) with a rate of 18. Medical record review for Resident 6 was initiated on 3/8/22. Resident 6 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 ensure one of 17 final sampled residents (Resident 6) remained free from accident hazards related to the use of elevated side rails. Resident 6's assessments showed side rails were not appropriate or indicated; however, Resident 6 was observed with elevated side rails in place. This had the potential to place Resident 6 at risk for entrapment and serious injury. Findings: The FDA issued a Safety Alert entitled Entrapment Hazards with Hospital Bed rails. The safety alert document showed the 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, or 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 caught between the mattress and bed rail or in the bed rail itself. On 3/8/22 at 0737, 0849, and 1555…

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, observation, medical record review, and facility P&P review, the facility failed to ensure the physician's order for ferrous sulfate was complete for one nonsampled resident (Resident 52). This had the potential for the wrong dose being administered to the resident. Findings: Review of the facility's P&P titled Administering Medications revised April 2109 showed the medication label should be checked three times to verify the correct dose. According to Lexicomp (an online resource), ferrous sulfate is available in two strengths, 200 mg/5 ml and 300 mg/5 ml. Medical record review for Resident 52 was initiated on 3/9/22. Resident 52 was admitted to the facility on [DATE]. Review of Resident 52's Order Summary Report dated 3/9/22, showed a physician's order to administer ferrous sulfate (supplement) liquid 7.5 ml twice a day via gastric tube. Resident 52's physician order did not show the strength of the ferrous sulfate preparation to be administered. On 3/9/22 at 0811 hours, a medication…

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 and interview, the facility failed to ensure the medication error rate was below 5%. * The medication error rate was 22.58%. LVN 2 failed to administer the medications according to the physician's order and facility's P&P for Resident 52. This failure had the potential for drug interactions. Findings: The facility's P&P titled Administering Medications Though an Enteral Tube revised November 2018 showed if administering more than one medication, to flush with the prescribed amount of water between medications. On 3/9/22 at 0811 hours, a medication administration observation was conducted with LVN 2. LVN 2 prepared the following medications for GT administration to Resident 52. - one tablet of amlodipine (medication for hypertension) 10 mg - one tablet of sucralfate (antacid) 1 gram - one tablet of aspirin (medication to prevent clot formation) 81 mg - one tablet of hydralazine (medication for hypertension) 50 mg - one tablet of multivitamin with mineral (supplement) - one tablet of Oscal 500…

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 ensure the menu was followed as evidenced by: * [NAME] 1 failed to follow the recipe for the pureed veal patty during the puree preparation process. * Resident 29 had a physician's order for a fortified mechanical soft, finely chopped diet; however, the resident was served a mechanical soft, finely chopped diet. These failures posed the risk of the residents' nutritional needs not being met. Findings: Review of the Form CMS-672 titled Resident Census and Conditions of Residents completed by the facility dated 3/9/22, showed 22 of 65 residents residing in the facility received food prepared in the kitchen. Review of the facility's P&P titled Puree Diet (undated), showed under Procedure for entrée with meat, place cooked entrée in the blender and add broth or sauce (3:1 ratio, i.e., three ounces meat with one ounce broth/ sauce/ au just (one)/ gravy). Blend mixed contents until smooth and add thickener if…

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 food items brought to the facility for the residents by the family or visitors were stored for future consumption. This failure posed the risk for 28 residents who were on an oral diet to not have a homelike environment. Findings: Review of the facility's P&P titled Foods Brought by Family/Visitors revised October 2017 showed 7. b. Perishable foods must be stored in re-sealable containers with tightly fitting lids in a staff refrigerator. The word staff was handwritten on the policy. Review of the facility's document titled Dietary Lesson Plan dated 8/4/21, provided by the DSD, showed the facility staff were inserviced on the Outside Prepared Food- policy which read, If food is not completely consumed the same day, then must be discarded immediately and not kept in the refrigerator. On 3/8/22 at 0848 hours, an interview was conducted with the IP. The IP stated the facility did not have a refrigerator for storage of food brought to the residents by the family or visitors. The IP stated any…

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 document review, and facility P&P review, the facility failed to provide the necessary care and services for one of 17 final sampled residents (Resident 51) who received hospice services. * The facility failed to ensure Resident 51's hospice record included in the medical record. Resident 51's comprehensive plan of care, physician certification, hospice visitation calendars were not found in the medical record. This failure posed the risk for delay in the communication between the hospice provider and facility which may affect resident care. Findings: Review of the facility's contract with Hospice Provider A dated 10/5/21, showed the following: * The hospice physician would provide certification for the resident to participate in hospice services. * The hospice provider was responsible determining and scheduling services to be provided. * The hospice provider and the facility will work together to develop, review and revise the resident's plan of care. Medical…

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 one of 17 final sampled residents (Resident 58), was offered the influenza vaccine. This failure had the potential to negatively impact Resident 58's health. Findings: According to the facility's P&P titled Influenza, Prevention and control of Seasonal revised August 2014, The Infection Preventionist will promote and administer seasonal influenza vaccine .unless contraindicated, all residents and staff will be offered the vaccine . Medical record review for Resident 58 was initiated on 3/10/22. Resident 58 was admitted to the facility on [DATE]. Review of Resident 58's immunization record did not show any documentation as to whether Resident 58 was provided or had declined the influenza vaccine. In an interview with the IP on 3/10/22 at 1457 hours, the IP verified there was no record to show Resident 58 was offered or had declined the influenza vaccine. The IP stated the influenza vaccine should have been offered 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, and facility P&P review, the facility failed to provide a safe environment for one of 17 final sampled residents (Resident 33) and one nonsampled resident (Resident 1). * An exposed fluorescent light fixture was observed over Resident 33's bed. * The facility failed to ensure the electrical and antenna wall outlets with exposed wires were covered in Resident 1's room. These failures the potential for an unsafe environment for the residents. Findings: Review of the facility's P&P titled Hazardous Areas, Devices and Equipment revised July 2017 showed as a part of the facility's overall safety and accident prevention program, hazardous areas and objects in the resident's environment will be identified and addressed by the safety committee. A hazard is defined as anything in the environment that has the potential to cause injury or illness. Examples of environmental hazard include equipment and devices that are left unattended or are malfunctioning. Review of Resident 33's medical…

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.