Cupertino Healthcare & Wellness Center

Based on observation, interview and record review, the facility failed to ensure irregularities were identified during drug regimen review for the medication Lurasidone (an antipsychotic medication, works by rebalancing important natural substances in the brain called dopamine and serotonin to improve thinking, mood, and behavior) for one (Resident 17) out of 31 sampled residents when adequate monitoring for the medication was not done.This failure had the potential to compromise the physical, social, and mental well-being of Resident 17.A review of Resident 17's medical records indicated an admission date of 4/28/25. Resident 17's diagnoses included but were not limited to, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (a decline in mental ability severe enough to interfere with daily life, affecting memory, thinking, language, judgment, and behavior, often caused by nerve cells in the brain stopping working properly), and bipolar disorder (a mental health condition causing extreme mood swings,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure proper medication storage and labeling of medications when:1. Opened eyedrop medications without open and discard date labels, an eyedrop medication past discard date, and an opened Phenytoin Oral Suspension (a medication used for seizures) without open date label were found.2. Insulin pen without opened date label and an expired inhalation solution (medication used to keep airways open and to control and prevent symptoms like wheezing, shortness of breath, coughing and chest tightness) were found.3. Insulin pen without open and discard date was found.These failures had the potential for residents to receive medications with reduced efficacy.1. During a concurrent observation and interview regarding Station 5 Medication Cart on [DATE] at 10:04 a.m. with Licensed Vocational Nurse (LVN) A, the following were identified and verified by LVN A:a. A Latanoprost Eye Drop Medication indicated an open date label of [DATE] and without 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 observations, resident and staff interviews, and facility document review, the facility failed to provide food that was palatable. This failure places all residents who eats food from the facility's kitchen at risk for poor food intake which may compromise their nutritional status. Findings: 1) A review of Resident 8's medical record indicated he was initially admitted on [DATE]. Resident 8's Minimum Data Set (MDS, an assessment tool), dated 10/29/25, indicated he had a BIMS [Brief Interview for Mental Status] score of 15 - cognitively intact. Further review of the medical record indicated Resident 8 was on NAS (no added salt) regular diet. During an interview with Resident 8 on 12/16/2025 at 10:50 a.m., he stated that the facility does not know how to cook chicken. Resident 8 further described the texture of the chicken served at the facility as being [NAME] to rubber. During an observation and concurrent interview on 12/19/25 at 2:00 p.m., three surveyors, along with two Dietary Managers (DMs),…

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

Based on observation, interview and record review, the facility failed to ensure infection control practices were implemented when:1.Housekeeper J (HK J ) did not wear the proper personal protective equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) when mopping inside a the room of cohorted (joined together) residents (Resident 62 and Resident 1) who were on contact precautions (extra steps, like wearing of gloves and gown, needed to stop the spread of germs by touch) and enhanced barrier precautions (EBP, an infection control measures in nursing homes to stop the spread of multidrug-resistant organisms [MDROs]), and did not perform hand hygiene upon exit of the room. Resident 62 was on contact precautions for C. Diff [Clostridium difficile, a common, often harmful bacterium that causes severe diarrhea and inflammation of the colon]) and Resident 1 was on enhanced barrier precaution (EBP). 2.Licensed vocational nurse I (LVN I) did not perform hand hygiene (cleaning of hands with soap and water or 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 interviews, and record review, the facility failed to provide services according to professional standards for one of two sampled residents (Resident 1) when: 1. Licensed vocational nurse A (LVN A) crushed all of Resident 1's morning medications, mixed them with oatmeal, and left them at Resident 1's bedside; and 2. Certified nursing assistant B (CNA B) administered crushed medications, mixed with oatmeal to Resident 1. These failures had the potential to affect Resident 1's care, health, and well-being.Findings:1.Review of Resident 1's clinical record titled, admission Record, dated 9/25/2025, it indicated Resident 1 was admitted to the facility with diagnoses including myocardial infarction (heart attack), paroxysmal atrial fibrillation (a fast, irregular heartbeat that only lasts a few hours or days), chronic systolic heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), and hypertension (HTN - high blood pressure).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 record review, the facility failed to ensure one (Resident 1) out of three sampled residents was provided needed care and services in accordance with professional standards of practice when Resident 1 did not receive urology (a medical specialty that focuses on the diagnosis and treatment of disorders related to the urinary and reproductive systems) consultation as ordered by the physician. This failure resulted in Resident 1's prolonged use of indwelling urinary catheter [thin, flexible tube inserted into the bladder through the urethra to collect and drain urine] and placed Resident 1 at risk for urinary tract infection and delayed urology evaluation. Findings: A review of Resident 1's clinical record indicated an admission date of 1/17/25 with diagnoses including End Stage Renal Disease (kidneys no longer work as they should to meet the body's needs), Obstructive and Reflux Uropathy, unspecified (urinary tract has a blockage that prevents urine from flowing normally and…

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

Based on observation, interview and record review, the facility failed to ensure treatment and care provided were in accordance with professional standards of practice when one (Resident 1) out of three sampled residents was left with their oral medication to be taken unsupervised at bedside and was documented as given without confirmation. This failure resulted in inaccurate documentation of correct time of medication administration and had the potential for a missed dose. Findings: During a concurrent observation and interview on 12/17/24 at 11:39 a.m. with Resident 1 in her room, a medicine cup with two white capsules and a plastic cup of water were noted on her bedside table. Resident 1 stated that her nurse left it there for her to take. At 11:42 a.m., Certified Nurse Aide (CNA) B came in the room and verified the two capsules and stated she will call Resident 1's nurse. Licensed Vocational Nurse (LVN) A came in the room at 11:45 a.m. and confirmed she was Resident 1's assigned nurse and that she left the medications for Resident 1. LVN A stated It's not okay to leave…

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

Based on interview and record review, the facility failed to ensure sufficient and appropriate social services were provided for two (Resident 7 and Resident 10) out of 12 sampled residents when psychosocial and emotional assessments were not done following a resident-to-resident altercation. This failure had the potential for psychosocial decline of the residents that can affect their overall health. Findings: During an interview on 12/17/24 at 1:47 p.m. with the Social Services Director (SSD), the SSD stated it was her duty to check on residents involved in altercations. The SSD also stated she must check on the residents for three consecutive days after an alleged event except on weekends. The SSD stated, I usually ask them what happened and if they are in pain. I also ask them if they're sad. The SSD also stated the assessment must be documented on the resident's electronic chart. During a concurrent interview and record review with the SSD on 12/17/24 at 2:02 p.m. of Resident 10's and Resident 11's progress notes, the DSD verified Resident 10 had an alleged altercation with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure facility staff honored one of two residents (1) preferences when the social services assistant (SSA) did not assist Resident 1 to choose another physician. This failure had the potential to compromise resident rights. Review of Resident 1's admission Record (part of the medical record that documents patient information) indicated he was admitted to the facility on [DATE] and re-admitted on [DATE] with a diagnosis of Ankylosing Spondylitis of the Spine (an inflammatory arthritis affecting the spine and large joints). Review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 8/12/24, indicated the resident was cognitively intact (mental process used to think, learn, remember, reason, pay attention, and ultimately, comprehend information and turn it into knowledge). During an interview, on 9/11/24, at 11:30 a.m., with the SSA, SSA stated Resident 1 asked to switch physicians about two months ago. SSA stated she thought…

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

Based on observation, interview, and record review, the facility failed to provide services to obtain prescription eyeglasses for one of four sampled residents (Resident 1). This failure resulted in Resident 1's impaired vision and had the potential to result in decreased participation in activities requiring visual acuity. Findings: A review of Resident 1's Minimum Data Set (MDS, an assessment used to guide care), dated 5/25/24, indicated Resident 1 had clear speech, was able to understand and be understand by others, and had adequate vision with corrective lenses. During an interview on 7/1/24 at 1:00 p.m. with the Social Services Associate (SSA), the SSA stated referrals were sent to the eye doctor on 6/4/24, they will be in the facility to evaluate the Residents on 7/9/24. During an observation and concurrent interview on 7/1/24 at 2:09 p.m. Resident 1 was awake, lying in bed, he did not have his eyeglasses, he stated, my glasses were taken by someone here, no one will help me make an appointment. During an observation and concurrent interview on 7/22/24 at 2:05 p.m. in 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.

Based on observation, interview and record review, the facility failed to implement their elopement care plan for one of three sampled residents (Resident 1). This failure had the potential to result in another incident of Resident 1's elopement to unsafe place. Findings: Review of Resident 1's face sheet (summary page of a patient's important information) dated 8/2/2024, indicated, Resident 1 was admitted to the facility with diagnoses including Alzheimer's disease (a progressive disease that destroys memory and mental functions), dementia (a group of symptoms affecting thinking and social abilities interfering with daily functioning) with mood disturbance and history of falling. Review Resident 1's Elopement (to leave without notification or permission) Evaluation, dated 3/28/2024, indicated a score of 5 (Score value of 1 or higher indicates Risk of Elopement). Review of Resident 1's minimum data set (MDS, an assessment tool) quarterly assessment, dated 6/28/2024, indicated, Resident 1 had memory problems with short term and long-term memory. Further review indicated the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) was free from abuse when the two residents were not separated after the incident. This failure resulted in Resident 1 was feeling terrified and was not able to sleep after the incident. Findings: During a review of Resident 1's face sheet (a document that gives a resident's information at a quick glance) dated 5/24/24, it indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of aftercare following joint replacement surgery due to displaced right patella (kneecap) fracture. During an interview on 3/13/24 at 3:10 p.m. with Resident 1, Resident 1 stated on the first night after he was admitted to the facility, his roommate (Resident 2) grabbed his left leg, the facility staff did not separate the two of them after incident, he was not able to sleep and stayed up all night, because he was terrified. Resident 2 grabbed his leg again the next morning, the facility did not move Resident 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 document review, the facility failed to implement strategies to prevent the spread of coronavirus 2019 (COVID-19, a strain of virus that can cause mild to severe respiratory illness) when one of one resident (Resident 3) was not isolated after testing positive for COVID-19. This failure had the potential to result in the spread of COVID-19 in the facility. Findings: During an interview on 3/13/24 at 3:10 p.m. with Resident 1, Resident 1 stated there was a COVID positive resident who ran out of the room and went into the rehab gym over the weekend. One of the rehab staff was mad that staff let that resident came out of the room. During an interview on 3/13/24 at 3:33 p.m. with Occupational Therapist (OT) A, OT A stated Resident 3 came out of the room without a mask, went into the rehab gym, and staff had to ask her to put on a mask and she got escorted back to her room. During an interview on 3/13/24 at 3:45 p.m. with Physical Therapy Assistant (PTA) B, PTA B stated on…

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

Based on observation, interview, and facility policy review, the facility failed to date open food items and properly store dry food in sealed containers. These deficient practices affected all residents who received food from the kitchen. Findings included: A policy titled Food Storage, revised on 07/25/2019, revealed, Purpose To establish guidelines for storing, thawing, and preparing food. Policy Food items will be stored thawed, and prepared in accordance with good sanitary practice. All items will be correctly labeled and dated. Per the policy, D. Label and date all food items. The policy specified, G. Any opened products should be placed in storage containers with tight fitting lids. During an observation on 05/27/2024 at 8:39 AM, the surveyor noted in the walk-in refrigerator plastic storage container dated 05/10/2024 through 05/17/2024, of bell peppers that had a black fuzzy substance on them and a fluid seeping out of the container and two undated bags of cheese. In the walk-in freezer, there was an undated bag of diced ham that was opened to air. In the dry storage area,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure Minimum Data Set (MDS) assessments were accurate for 3 (Residents #50, #65, and #159) of 33 sampled residents. Findings included: 1. An admission Record revealed the facility admitted Resident #50 on 07/30/2016. According to the admission Record, the resident had a medical history that included diagnoses of paranoid schizophrenia, schizoaffective disorder, and major depressive disorder. An annual MDS, with an Assessment Reference Date (ARD) of 08/23/2023, revealed Resident #50 was not considered by the state level II preadmission screening and resident review process to have a serious mental illness and/or intellectual disability or a related condition. A letter from the State of California-Health and Human Services Agency Department of Health Care Services, dated 09/23/2022, revealed a level II evaluation was conducted on 08/12/2022 and specialized services were recommended. 2. An admission Record revealed the facility readmitted Resident #65…

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

Based on observation, interview, record review, facility policy review, the facility failed to develop a care plan to address the yelling behavior for 1 (Resident #17) of 1 sampled resident reviewed for behavior emotional. Findings included: A facility policy titled, Comprehensive Person-Centered Care Planning, revised in 11/2028, specified, Purpose To ensure that a comprehensive person centered care plan is developed for each resident. The policy revealed, Additional changes or updates to the resident's comprehensive care plan will be made based on the assessed needs of the resident. An admission Record revealed the facility admitted Resident #17 on 12/20/2023. According to the admission Record, the resident had a medical history that included diagnoses of mild cognitive impairment, schizophrenia, and major depressive disorder. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/28/2024, revealed Resident #17 had a Staff Assessment for Mental Status, which indicated the resident was severely impaired in cognitive skills for daily decision making. The…

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

Based on observation, interview, record review, and facility policy review, the facility failed to ensure nail care was provided for 2 (Resident #20 and Resident #93) of 5 sampled residents reviewed for activities of daily living (ADLs). Findings included: A facility policy titled, Grooming Care of the Fingernails and Toenails, revised on 10/21/2021, revealed, Purpose Nail care is given to clean the nail bed and keep the nails trimmed. Policy Fingernails are trimmed by Certified Nursing Assistants (CNAs), except for Residents with diabetes or circulatory impairments, this includes all toenails except for high-risk Residents. Note: A Licensed Nurse will trim those Residents' nails. 1. An admission Record indicated the facility admitted Resident #20 on 04/27/2015. According to the admission Record, the resident had a medical history that included diagnoses of contracture of left elbow, wrist, and hand and hemiplegia and hemiparesis following cerebral infarction. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/12/2024, revealed Resident #20 had a Brief…

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

Based on interview, record review, and facility policy review, the facility failed to ensure a root cause was determined for a fall for 1 (Resident #62) of 3 sampled residents reviewed for accidents. Findings included: A facility policy titled, Fall Management Program, revised on 03/13/2021, specified Purpose To provide residents a safe environment that minimizes complications associated with falls, The policy specified, The IDT [Interdisciplinary team] will review the circumstance surrounding the fall then summarize their conclusions on an IDT note. An admission Record revealed the facility admitted Resident #62 on 10/19/2023. According to the admission Record, the resident had a medical history that included diagnoses of adult failure to thrive, dementia, altered mental status, abnormalities of gait and mobility, and weakness. A significant change in status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/27/2024, revealed Resident #62 had a Staff Assessment for Mental Status (SAMS), which indicated the resident was severely impaired in cognitive skills 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.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure an enteral gastrostomy tube feeding was administered as ordered for 1 (Resident #113) of 1 sampled resident reviewed for tube feeding. Findings included: A facility policy titled, Enteral Feeding, revised on 01/01/2012, specified, Enteral feeding will be administered via pump as ordered by the Attending Physician. An admission Record indicated the facility admitted Resident #113 on 04/09/2024. According to the admission Record, the resident had a medical history that included diagnoses of gastrostomy status and adult failure to thrive. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/16/2024, revealed Resident #113 had a Staff Assessment for Mental Status (SAMS), which indicated the resident was severely impaired in cognitive skills for daily decision making. The MDS revealed the resident had a feeding tube and received 51% or more of their total calories by way of a tube feeding. Resident #113's care plan, initiated on 04/10/2024 and revised on…

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

Based on observation, record review, interview, and facility policy review, the facility failed to ensure a therapeutic diet were served to 1 (Resident #71) of 33 sampled residents as ordered by the physician. Findings included: A facility policy titled, Therapeutic Diets, revised on 06/01/2024, revealed, Therapeutic diets are diets that deviate from the regular diet and require a physician order. Procedure I. Therapeutic diets will not be given without a physician order. A. The nursing staff is responsible for communicating the physician's order for a therapeutic diet to the dietary department in writing. B. The therapeutic diet will be reflected on the resident's tray card. An admission Record revealed the facility admitted Resident #71 on 01/25/2024. According to the admission Record, the resident had a medical history that included diagnoses of Alzheimer's disease and dysphagia. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) 05/03/2024, revealed Resident #71 had a Staff Assessment for Mental Status (SAMS), which indicated the resident was severely…

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

Based on observation, interview, record review, document review, and facility policy review, the facility failed to ensure enhanced barrier precautions (EBP) were implemented during indwelling catheter care for 1 (Resident #12) of 1 sampled resident reviewed for urinary catheter. Findings included: The Centers for Medicare & Medicaid [CMS] Center for Clinical Standards and Quality/Quality, Safety & Oversight Group, memorandum dated 03/20/2024 with an effective date of 04/01/2024, revealed CMS is issuing new guidance for State Survey Agencies and long term care (LTC) facilities on the use of enhanced barrier precautions to align with nationally accepted standards. EBP recommendations now include use of EBP for residents with chronic wounds or indwelling medical devices during high-contact resident care activities regardless of their multidrug-resistant organism status. A facility policy titled, Enhanced Barrier Precautions, revised on 04/30/2024, revealed, 7. For residents for whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident's drug regimen was free from unnecessary medications when nursing staff did not accurately transcribe (transfer or copy information) from the physician's order to the medication administration record (MAR) for one of two sampled residents (Resident 1). For Resident 1, an order for milk of magnesia (MOM, a laxative used to treat constipation) was incorrectly transcribed onto the MAR and was administered daily instead of every third day. This failure resulted in Resident 1 receiving unnecessary doses of MOM and had the potential to compromise Resident 1's health and safety due to overuse. Review of Resident 1's Face Sheet (document that contains a summary of personal and demographic information), indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of acute respiratory failure (inability of the respiratory system to meet oxygenation requirements) and hypoxia (low levels of oxygen). Review of Resident 1's…

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

Based on observation, interview and record review, the facility failed to ensure routine medication was available for one of two sampled resident (Resident 1). This failure resulted in Resident 1 not receiving the medication which could lead to adverse effects on the health and well being of Resident 1. Findings: Review of Resident 1's face sheet (FS: a document that gives a resident's information at a quick glance) indicated Resident 1 admitted to facility on 1/28/2020. Resident 1's admission diagnoses included diabetes type 2 (high levels of sugar in blood), anxiety (excessive and persistent worry and fear about everyday situations), and nasal congestion (a stuffy or congested nose occurs when the tissue lining it becomes swollen). Review of Resident 1's physician order dated 2/16/2024, indicated, Fluticasone Propionate (medication to treat allergy symptoms like sneezing, itching and a runny or stuffy nose) Allergy Relief Nasal Suspension 1 spray (liquid medication to spray) on both nostrils (two holes in nose) one time a day for treat Nasal Congestion . During an interview with…

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

Based on interview and record review the facility failed to follow professional standards of care when a Braden Scale assessment for pressure ulcer/injury (localized damaged to the skin and/or underlying soft tissue usually over a bony prominence) was not performed until after a resident developed a pressure ulcer for one of two sampled residents (Resident 1) This failure had the potential of not thoroughly assessing the resident ' s risks and in not developing pertinent preventative measures. Findings: Review of Resident 1 ' s record indicated the resident was admitted to the facility in July 2023 and there was no Braden Scale – Predicting Pressure Ulcer Risk Evaluation until 9/28/23. Review of Resident 1 ' s Change in Condition Evaluation form, dated 9/17/23 at 10:03 p.m., indicated the resident had an open wound to his left lateral ankle. The interdisciplinary team (IDT, health care team members who meet to discuss and plan residents ' care) Progress Note, dated 9/21/23 6:14 p.m., described the wound as a Stage 3 (full-thickness loss of skin in which fat is visible in the ulcer)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their policies regarding protecting resident's personal property for two of three residents (Resident 1 and 2) when: 1. Resident 1's personal property was not stored securely when the resident was transferred to the hospital. Resident 1's missing personal property was reported and the facility did not take corrective action in a timely manner. 2. Resident 2's Inventory of Personal Effects was not signed when the resident was discharged . These failures resulted in Resident 1's missing cell phone and had the potential to result in personal belongings not accounted for. Findings: Review of Resident 1's clinical record indicated she was admitted to the facility on [DATE] with diagnoses including malignant neoplasm of rectum (cancerous tumor of the end of the colon) and sepsis (a life-threatening complication from infection which could result in organ failure). Review of Resident 1's Inventory List, dated 8/25/23 indicated an iPhone 7 plus was on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide necessary treatment for one of three residents (Resident 1) when wound dressing changes (treatments) for Resident 1 was not done for three days and wound dressing changes were not ordered by the physician. This failure had the potential to result in infection, delayed wound healing, and other health complications for the resident. Findings: Review of Resident 1's clinical record indicated she was admitted to the facility on [DATE] with diagnoses including malignant neoplasm of rectum (cancerous tumor of the end of the colon) and sepsis (a life-threatening complication from infection which could result in organ failure). It also indicated she had wounds on her right lateral breast and right chest. Review of Resident 1's Change in Condition Evaluation, dated 8/18/23 indicated Resident 1 was sent out to the hospital on 8/18/23 for shortness of breath. Review of Resident 1's Interfacility Transfer Report, dated 8/25/23 indicated Resident 1 returned…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure transportation services was provided to scheduled dialysis (a treatment to remove extra fluid and waste in the blood) appointments for one of three sampled residents (Resident 1), when Resident 1 missed two dialysis treatments for lack of transportation. This failure resulted Resident 1's transfer to emergency room (ER) for dialysis. Findings: During an interview on 8/2/23 at 1:44 p.m. with current transportation personnel, she stated she confirmed with dialysis facility nurse that Resident 1's last dialysis appointment was on 7/5/23; and that, Resident 1 missed dialysis appointments on 7/7/23 and 7/10/23 due to transportation issues. During an interview on 8/2/23 at 2:10 p.m. with the Unit Manager (UM) B, she stated if a resident missed an appointment due to transportation issues, the transportation personnel was responsible to rearrange the transportation. During an interview on 8/2/23 at 3:00 p.m. with Licensed Vocational Nurse (LVN) C, she…

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

Based on interview, record review, the facility failed to notify the responsible party (RP, person designated to make decisions on behalf of a resident) of a resident about a change in medication for one of three sampled residents (Resident 1). This failure affected the ability of Resident 1's RP to participate in Resident 1's treatment. Findings: During a phone interview on 7/5/23 at 9:24 a.m. with Resident 1's RP, she stated, the facility did not notify her of Resident 1's Lorazepam (a medication used for anxiety) order was changed. During a review of Resident 1's Physician Orders, dated 12/22/21, an order indicated, give Lorazepam 0.5mg by mouth three times a day. This order was discontinued on 6/13/23. During a review of Resident 1's Physician Orders, dated 6/13/23, the order indicated, give Lorazepam 0.5mg by mouth at bedtime. During a concurrent interview and record review with the Unit Manager (UM) A on 7/26/23 at 3:18 p.m., Resident 1's Nursing Progress Notes, dated 6/2023, was reviewed. There was no documented evidence that indicated Resident 1's RP was notified for the…

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

Based on observation, interview, and record review, the facility failed to maintain order and cleanliness in the kitchen area and to ensure that food was stored, prepared, and served under sanitary conditions when: 1. The kitchen environment was not cleaned and orderly; dry food containers and storage were dirty; 2. There were opened, undated and expired food and drinks in the freezer and walk-in refrigerator; unlabeled and undated food in the residents' refrigerator; 3. Kitchen utensils (7 water pitchers and 2 measuring cups) were not air-dried properly; 4. Proper cooling procedures were not observed for the tuna and egg salad; and 5. Med pass supplement was held in room temperature for an extended period of time. These failures had the potential to cause foodborne illness to 130 residents who received food from the kitchen. Findings: 1. During an initial kitchen observation on 7/19/21, at 8:30 a.m., the surveyors observed the following: 1) a mop head on the floor under the stove; 2) a blanket on the floor under the two door refrigerator adjacent to handwashing sink; 3) a dirty…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain residents' privacy and dignity for eight out of 26 residents (Residents 36, 39, 41, 46, 92, 109, 124, and 327) when: 1. For Resident 92, privacy curtains were not provided by the restorative nurse assistant DD (RNA DD) during care, which resulted in exposing the resident from the waist down to the public view in the hallway; 2. For Resident 46, certified nursing assistant EE (CNA EE) was standing while assisting Resident 46 with her meal and calling her mama; 3. For Resident 109, licensed vocational nurse FF (LVN FF) called Resident 109 love and Resident 109 became upset; 4. For Resident 41, CNA GG called Resident 41 mama and honey when assisting with her meal; 5. For Resident 39, LVN Q called Resident 39 mama during wound treatment; 6. For Resident 124, a privacy curtain was not provided and the resident's body was exposed to public view in the hallway; 7. For Resident 36, CNA N was standing when assisting Resident 36 with his…

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

Based on observation, interview, and record review, the facility failed to maintain a clean, safe, orderly, and sanitary homelike environment for three of five facility shower rooms. This failure had the potential to place residents at risk for injuries and prevent their rights to a comfortable environment. 1. During a concurrent observation and interview with the Maintenance Director (MD), on 7/21/21, at 3:09 p.m. in station 2, the shower room walls had irregularly shaped gray spots and open holes. The MD stated the building was old and the wall was damaged by constant splashing of water during showers. He acknowledged the wall needed to be replaced and repaired immediately. The MD confirmed the wall did not look good and it may possibly cause accidents because the open holes were located at the lower corner of the wall. 2. During a concurrent observation and interview with the MD, on 7/21/21, at 3:21 p.m. in station 3, the shower room had four wheelchairs, two walkers, two commodes (a chair or bench that has a cutout positioned over a removable pan), one large trash bin and one…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement their abuse policy and procedure for five out of seven residents (Residents 7, 57,64,78, and 118) reviewed when: 1. Corrective action to not assign male caregivers and care plan for Resident 7 were not implemented; 2. For Resident 57, social services did not conduct three daily visits following an abuse allegation as indicated in the care plan; 3. For Residents 64 and 118, social services did not do psycho-social follow-up after the incident; 4. For Resident 78, licensed nurses did not implement Resident 78's care plan following an abuse allegation These failures had the potential to affect the resident's psychosocial well-being, safety and protection from harm. Findings: 1. Review of Resident 7's clinical record indicated she was admitted to the facility on [DATE], with diagnoses including major depressive disorder (persistent loss of interest in activities) and brief psychotic disorder (sudden onset of psychotic [severe mental…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure care and services were provided in accordance with professional standards of practice for five of 26 sampled residents (Residents 22, 120, 11, 98 , and 57) when: 1. For Resident 22, facility staff failed to ensure oxygen (a colorless and odorless gas that people need to breath) was administered as specified in the physician's order; 2. For Resident 120, facility staff continued to provide restorative nursing treatment without a physician order and did not follow a physician order to monitor Resident 120's left hand swelling; 3. For Resident 11, facility staff failed to address nail care; 4. For Resident 98, facility staff failed to check the functioning of his low air loss mattress (LAL mattress, special mattress filled with air that reduces pressure) as indicated in the physician's order; and 5. For Resident 57, facility staff failed to provide treatment for his legs as indicated in the physician's order. These failures had the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents receiving dialysis (removal of waste and excess fluid from the body) treatment received care consistent with professional standards for three out of four residents (Residents 6,7 and 81) reviewed when: 1. For Resident 6, his dialysis communication records (DCR) were incomplete and his physician order, treatment administration record (TAR) did not reflect his current dialysis access site; 2. For Resident 7, her DCR's were incomplete and her care plan did not reflect the dialysis access site and necessary precautions and; 3. For Resident 81, his DCR's were incomplete. These deficient practices had the potential for the residents to be inadequately assessed and be at risk for complications. Findings: 1. Review of Resident 6's clinical record indicated he was admitted to the facility on [DATE] with diagnoses including end-stage renal disease (gradual loss of kidney function). During an interview with Resident 6 on 7/19/21, at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility had a medication error rate of 29.03% when nine medication errors occurred out of 31 opportunities during medication administration for five out of seven residents (Residents 29, 40, 57, 117, and 123). The deficient practice resulted in medications not given in accordance with the prescriber's orders and/or manufacturer's specifications, which resulted in residents not receiving the full therapeutic effect of the medications, and may cause preventable side effects for the residents. Findings: 1. During the medication pass observation on 7/19/21 at 9:21 a.m., with licensed vocational nurse (LVN) B, he administered 8 medications to Resident 57 including 3 tablets of diclofenac (a non-steroidal anti-inflammatory drug, or NSAID, for pain) 25 millligrams (mg; total 75 mg) and 1 capsule of omeprazole 20 mg (medication to prevent heartburn). Resident 57 took his medications with water. There was no food, snack, or milk offered to the resident with his…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two of 26 sampled residents (Residents 29 and 82) and one resident (Resident 123) were free of significant medication errors. Resident 123 did not receive his pain medication when needed. Resident 29 did not receive his daily sevelamer (a phosphate binder, medication to control high blood level of phosphorus, a mineral found in food, in people with kidney disease who are on dialysis) for more than two months. Resident 82 did not receive his inhalers (to treat breathing problems), Xifaxan (medication to help prevent recurrence of certain liver problems), and gabapentin (nerve pain medication) as ordered. The failures resulted in medications not available to meet the residents' therapeutic needs, and the potential for unnecessary pain and worsening of their medical conditions. Findings: 1. During the medication pass observation with licensed vocational nurse (LVN) B on 7/19/21 at 9:45 a.m., Resident 123 was in a wheelchair outside 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 and record review, the facility failed to ensure proper medication storage and labeling of medications when: 1. Temperature monitoring was not documented consistently on the temperature log sheets, in July 2021, for four out of four medication refrigerators; 2. Four inhalers were not dated after being opened; 3. Three insulin vials were identified in the active stock, being used beyond the discard (expiration) date; and 4. A non-prescription medication was not properly labeled. The deficient practices had the potential for unsafe and ineffective use of medications due to being unmonitored or used past the expiration date. Findings: 1. During an inspection of the facility's Medication room [ROOM NUMBER] on 7/19/21 at 10:31 a.m. with licensed vocational nurse (LVN) Q, it was observed the medication refrigerator temperature log for July 2021 was incomplete. The staff did not document the temperature monitoring during the 6 a.m. and 6 p.m. five days during this month. LVN Q verified…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to have sufficient staff to safely and effectively perform the meal preparation and other food and nutrition services for two of 26 sampled residents (Residents 31 and 74) and three residents (Residents 427, 327, and 27). This failure affect the residents' scheduled meal times and had the potential to affect the resident's intake. Findings: During a kitchen observation on 7/19/21 at 8:30 a.m., the dietary manager (DM) worked on the trayline. On 7/21/21 at 9:30 a.m., it was the dietary cook's regular off schedule and DM performed the dietary cooks duties. During an observation on 7/20/21 at 1:30 p.m, the test tray was plated and the tray cart was removed from the kitchen to be served to Station 2 residents. The facility staff distributed the last meal tray to the residents at 2:02 p.m. During an observation and concurrent interview with the regional registered dietitian (RRD) on 7/20/21 at 2:05 p.m., the surveyor and RRD checked the 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 interview, and record review, the facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to implement and evaluate systemic measures to ensure oversight of the following: 1. Pharmacy Services (Refer to F760 Residents Are Free of Significant Med Errors and F755 Pharmacy Services) 2 Dialysis (Refer to F698) This failure had the potential to negatively affect the improvement of the residents' quality of care, quality of life and safety in a highly susceptible population of 130 residents. Findings : During a concurrent interview and record review with the administrator (ADM), on 7/26/21 at 1:36 p.m., the ADM stated the QAPI committee included herself, the medical director (MD), director of nursing (DON), assistant director of nursing (ADON), and the facility's department heads. The ADM further stated they meet once a month. During further interview with the ADM on 7/26/21, the systemic issues identified during the survey process were discussed. The issues included medication administration practices by the nursing department, pharmacy services and…

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

Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when: 1. Staff did not properly wear N95 (a high filtering mask); 2. Rehab staff wore cloth mask as source control; 3. Licensed vocational nurse J (LVN J) wore two pairs of gloves (double gloving) and did not perform hand hygiene in between tasks; 4. Medication and treatment carts' sharps containers were full; 5. LVN BB went in and out of the room wearing a gown in the yellow zone (quarantine unit), applied wound treatment gel using her gloved index finger and did not perform hand hygiene in between tasks; 6. LVN G was wearing KN95 (a respirator that does not meet the US standard) in the yellow zone; 7. LVN Q did not perform hand hygiene in between tasks, and did not wear N95 properly; 8. Rehabilitation staff (RS CC) used hand wipes to clean medical equipment; 9. Visiting dentist was wearing a gown in the yellow zone hallway. 10.Certified nursing assistant HH (CNA HH) did not perform hand hygiene in between tasks. These failures could result in the spread of…

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

Based on observation, interview, and record review, the facility failed to maintain two clothes dryer lint traps, power generator, resident refrigerator, and kitchen equipment in safe operating condition. These failures could affect the health, safety, and comfort of all residents, staff, and visitors in the facility. Findings: 1. During a concurrent observation and interview with the housekeeping supervisor (HS), on 7/23/21 at 8:59 p.m. in laundry room, two clothes dryer lint traps (a device acts as an in line lint filter in the dryer's exhaust pipe) had thick accumulation of fibers that shed off clothing and linens. The HS stated he was expecting the lint traps to be cleaned every two hours because a clogged lint trap decreases the dryer's performance. During a concurrent interview and record review with the laundry staff (LS) on 7/23/21 at 9:10 a.m., the lint trap cleaning log indicated it was not signed off at the start of the shift. The LS stated she was not sure if the staff bypassed the lint cleaning or did not clean it at all. She acknowledged the lint trap should be cleaned…

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

Based on observation, interview, and record review, the facility failed to ensure a safe and sanitary environment when cracks and crevices where identified in the kitchen area, and a bed mattress was in the hallway for four days. These failures could affect the health and safety of the residents and staff in the facility. Findings: It is the standard of practice to ensure floors, floor coverings, walls, wall coverings, and ceilings shall be designed, constructed, and installed so they are smooth and easily cleanable. Similarly in food establishments in which cleaning methods other than water flushing are used for cleaning floors, the floor and wall junctures shall be coved and closed to no larger than one thirty-second inch (Food Code, 2019). During a kitchen area observation on 7/20/21, at 10:09 a.m., it was noted there were multiple cracks and crevices throughout the kitchen area. As an example, in front of the cook's refrigerator, adjacent to the stove, the flooring was disintegrated in multiple areas, exposing the subflooring underneath. Similarly, in the area underneath the…

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

Based on observation, interview, and record review, the facility failed to ensure the kitchen was free of pests (flies and fruit flies), and the use of an open bait mouse traps in the kitchen area. These failures has the potential to spread infectious disease to the residents in the facility. Findings: Rodent bait shall be contained in a covered, tamper-resistant bait station (Food Code, 2019). During multiple kitchen observations on 7/19/21, from 8:30 a.m. to 3:30 p.m., surveyors observed flies and fruit flies in the kitchen area. The screen was found to have a 1/2 to 1 1/2 gap, even when the door was latched. Also observed the air curtain for flies, adjacent to the coffee machine, was off on 7/19, 7/20 and 7/21. During an interview with the dietary manager (DM), on 7/20/21, at 9:53 a.m., DM said the air curtain on the back door should be on and that there is an on-off switch near the screen door.

Based on interview and record review, the facility failed to inform Family Member I (FM 1) for one of 26 sampled residents (Resident 124) when he tested positive for Coronavirus disease (COVID-19, a disease caused by a new strain of coronavirus). This deficient practice resulted in FM 1 being unaware of Resident 124's health condition and was not able to participate in his care and treatment. During a telephone interview with Resident 124's FM 1 on 7/23/21 at 9:31 a.m., she stated the facility did not inform her when Resident 124 tested positive for COVID-19 December, 2020. She only came to know the COVID-19 test result information after Resident 124 was hospitalized the following month. During a review of the clinical record for Resident 124 and concurrent interview with Infection Preventionist (IP, a person responsible for the facility's activities aimed at preventing healthcare-associated infections) on 7/26/21 at 8:26 a.m., the nursing progress notes and facility's COVID-19 Communication Log to Responsible Party indicated no communication to Resident 124's FM 1 was made. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide written notification to the Long-Term Care Ombudsman (person who routinely visits the facility and advocates for the residents) for two of four sampled residents (Residents 75 and 33) when Residents 75 and 33 were transferred to the acute care hospital. This failure had the potential to result in the residents not having an advocate who could inform them of their admission, transfer and discharge rights and options. Findings: Review of Resident 75's face sheet (document that summarizes a resident's information) indicated she was readmitted to the facility on [DATE]. During an interview and concurrent record review with the minimum data set nurse (MDSN) on 7/22/21 at 9:54 a.m., MDSN stated Resident 75 was discharged to the acute hospital on 3/26/21 and returned to the facility on 3/29/21. Review of Resident 33's face sheet indicated she was readmitted to the facility on [DATE]. During an interview and concurrent record review with the MDSN 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 interview and record review, the facility failed to provide a written notice of bed hold (written documentation specifying the duration the facility will hold a resident's bed) for two residents (117 and 125). This failure had the potential to result in residents not being able to exercise their rights. Findings: 1. During an interview with Resident 117 on 7/26/21 at 2:04 p.m., she stated she was sent to the hospital in June 2021 due to unbearable pain and the facility staff did not provide a letter or notification about the bed hold. Review of Resident 117's Minimum Data Set (MDS, an assessment tool) dated 4/21/21 indicated her cognition was intact. Review of Resident 117's situation, background, assessment, recommendation (SBAR, a tool used to communicate information to the resident's doctor) dated 6/20/21 at 2:31 p.m., indicated Resident 117 had unbearable right knee pain and did not indicate the Resident 117 was given a written form of bed hold notice. Review of Resident 117's physician order dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on an observation, interview and record review, the facility failed to complete a significant change in status assessment (SCSA) in minimum data set (MDS, an assessment tool) for two of 26 sampled residents (Residents 117 and 125). This was when Resident 125 had significant weight loss, had declined in activities of daily living (ADL, daily self-care tasks, e.g., bathing, toileting, and transferring); and Resident 117 had declined in activities of daily living and new onset of diagnosis. These failures had the potential to result in Residents 117 and 125 to be unable to achieve or maintain optimal status of health, function and quality of life. Findings: 1. Review of Resident 125's face sheet (summary page of a resident's important information) indicated she was re-admitted to the facility on [DATE] with diagnoses including dysphagia (difficulty of swallowing), major depressive disorder (mood disorder that interferes with daily life) and diabetes mellitus type 2 (chronic condition that affects the way the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and accurately assess the preadmission screening and resident review report (PASRR, an evaluation data requirement to determine whether a resident with mental illness (MI) requires specialized services such as referral to a mental health authority) for two of 26 sampled residents (Residents 71 and 125). This failure had the potential to put the residents at risk for not receiving appropriate care and services. Findings: Review of Resident 71's clinical record indicated he was admitted to the facility on [DATE] with diagnoses including bipolar disorder (mental illness which a person can experience mood swings [period of overly happy or periods of feeling sad) anxiety disorder (feelings of worry and fears) and liver cell carcinoma (a type of liver cancer). Additional review of Resident 71's clinical record indicated he was admitted to hospice (specialized care) on 6/17/21. During a concurrent interview and record review with licensed vocational…

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

Based on observation, interview and record review, the facility failed to provide an ongoing activity program to meet the needs and interests for two of 26 sampled residents (Residents 47 and 124). This deficient practice had the potential to affect the resident's psychosocial well-being and self-worth. 1. During an observation on 7/19/21 at 8:38 a.m. in station 5, Resident 47 was sitting on her wheelchair in her room in front of an overhead table. She was alert and verbally responsive and able to engage in simple conversation. She stated she had nothing to do but just to sit in her wheelchair for most of the time. On 7/19/21 at 2:45 p.m., Resident 47 was lying in bed but awake. The television was off and no radio was available. She stated she would prefer to be up and doing something rather than lying in bed. During an interview with certified nursing assistant I (CNA I) on 7/19/21 at 3:15 p.m., he stated he noticed Resident 47 received very little activities from the activity staff. The nursing staff would provide most of the interactions such as turning on the TV or offering…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide services to prevent decline in range of motion (ROM, full movement potential of a joint) for one of 26 sampled residents (Resident 34) when staff did not implement Resident 34's care plan to address contractures (shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) and the facility failed to develop restorative nursing assistant (RNA) services (a program intended to maintain or improve physical function of the body) care plan (it provides direction on the type of nursing care the individual may need) for Residents 31 and 113. These failures had the potential to result in worsening of Resident 34 contractures and had the potential to result in not meeting Residents 31 and 113's needs. Findings : 1. Review of Resident 34's face sheet indicate he was readmitted to the facility on [DATE] and has diagnoses of contracture to right hand. Review of Resident 34's activity of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the consultant pharmacist (CP) identified irregularities and make recommendations to the facility during the monthly drug regimen review (DRR); and the CP's recommendations were carried out or had the clinical rationale for not attempting the gradual dose reduction (GDR), for five of 26 sampled residents (Residents 29,31, 57, 82 and 98). This failure had the potential for medications not being optimized for best possible health outcome, and unnecessary or prolonged use of medications which could lead to medication adverse effects for the residents. Findings: 1. During the medication pass observation on 7/19/21 at 9:21 a.m., with licensed vocational nurse (LVN) B, he was administered eight medications to Resident 57 including a capsule of omeprazole 20 mg (medication to prevent heartburn). A review of the pharmacy label for omeprazole indicated, TAKE 1 CAPSULE BY MOUTH 2 TIMES A DAY BEFORE MEALS. On 7/19/21, a review of 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.

Based on interview and record review, the facility failed to ensure one of 26 sampled residents (Resident 29) was free from unnecessary medications. Resident 29 received two medications, vitamin C (a dietary supplement) and zinc sulfate (dietary supplement to treat zinc deficiency) 30 days longer than ordered by the physician. This deficient practice resulted in unnecessary medications for the resident. Findings: A review of Resident 29's clinical record indicated that he was admitted to the facility with diagnoses including end-stage renal disease (a longstanding kidney disease) and major depressive disorder (a mental disorder characterized by loss of pleasure or interest in life). His physician's orders included an order, dated 4/30/21, for vitamin C, 250 mg tablet, 1 tablet once daily x 30 days for supplement. He also had an order, dated 4/30/21, for zinc sulfate, 50 mg tablet, 1 tablet daily x 30 days for supplement. A review of the resident's June 21 Medication Administration Record indicated the nursing staff administered the vitamin C and zinc sulfate daily from 6/1 through…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of 26 sampled residents (Resident 82) was free from unnecessary psychotropic medications (drugs that affects brain activities associated with mental processes and behaviors). Resident 82 received Seroquel (an antipsychotic medication) without an adequate indication for use. The failure resulted in unnecessary medication for the resident, which had the potential for increased risks associated with psychotropic medication use that include but not limited to sedation, respiratory depression, falls, constipation, anxiety, agitation, abnormal involuntary movements, and memory loss. Findings: On 7/23/21, a review of Resident 82's clinical record indicated he was an elderly resident admitted to the facility with diagnoses including unspecified dementia (a condition characterized by memory loss) without behavioral disturbance and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of…

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

Based on observation, interview, and record review, the facility failed to follow the facility menus for three residents (Residents 60, 73, 328). This failure could affect the nutritional status of the residents. Findings: During a tray line observation and review in the kitchen on 07/19/21, at 2:26 p.m., Resident 60's meal card indicated small portion. Resident 60 received one sandwich roll on his tray. Per the menu spreadsheet, one sandwich roll was a regular or large portion. Resident should have received only 1/2 sandwich roll. During the same tray line observation and review, Resident 73's meal card indicated puree regular CHHO. Resident 73 received 1/2 cup of mashed potato. Per menu spreadsheet, 1/2 cup mashed potato was a large portion. Resident 73 should have received 1/4 cup of mashed potato for a regular portion. During the same tray line observation, Resident 328 meal card, indicated resident request large portion CCHO (Controlled Carbohydrate). Resident 328 received regular serving of french fries plus additional fries on his tray. Menu spreadsheet indicated 1/2 cup…

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

Based on observation and record review, the facility failed to ensure the dumpster lid was kept closed and the garbage was properly disposed in the trash area. This failure had the potential to attract pests in the facility. Findings: Outside receptacles must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents. Proper equipment and supplies must be made available to accomplish thorough and proper cleaning of garbage storage areas and receptacles so that unsanitary conditions can be eliminated (Food Code Annex, 2019). During an observation on 07/20/21 09:00 a.m., while in the back of the facility, surveyors observed the dumpster lid was open. The trash area was not clean and cardboard, plastics, a chair, and empty boxes were scattered around the area. Review of the facility's policy, dated 1/1/2012, titled Pest Control, indicated, Garbage and trash are not permitted to accumulate in any part of the facility.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure appropriate use of antibiotic (medication for infection) for two of three residents reviewed (Residents 25 and 123) when the surveillance data collection form was incomplete and/or not done. This failure had the potential for the resident to take unnecessary antibiotics which could lead to resistance to the antibiotic. Findings: Review of Resident 25's clinical record indicated he was admitted to the facility on [DATE] with diagnoses including calculus of the kidney with calculus of ureter (stone in the kidney). Review of Resident 25's physician's order dated 7/16/21 indicated macrobid (an antibiotic to prevent or treat urinary tract infections) 100 milligrams (mg, unit of measurement) one cap twice a day for 10 days. Review of Resident 123's physician order dated 7/23/21 indicated macrobid 100 mg twice a day for five days for UTI (urinary tract infection). Review of Resident 123's Surveillance Data Collection Form dated 7/23/21, did 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 and record review, the facility failed to ensure two of five residents (36 and 81) were offered and/or received pneumococcal vaccinations. This failure had the potential to expose residents to pneumococcal infections (caused by common bacteria [streptococcus pneumonia] that can affect different parts of the body). Findings: Review of Resident 36's clinical record indicated he was admitted to the facility on [DATE]. Review of Pneumococcal Vaccination, Informed Consent or refusal indicated the resident refused the vaccine on 12/19/19, but did not indicate the reason of the refusal. Review of Resident 81's clinical record indicated he was admitted to the facility on [DATE]. During an interview with the assistant director of nursing (ADON) on 7/26/21 at 2:35 p.m., the ADON stated the facility could not find when was the last time Residents 36 and 81 received the pneumococcal vaccine. Review of the facility's undated policy, Pneumococcal Disease Prevention indicated the facility will offer…

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.