Health Care Ctr At The Forum At Rancho San Antonio

Based on observation, interview, and record review, the facility failed to ensure food served to the residents were at acceptable temperature. This failure had the potential to impact on the residents' nutritional status and not meet the residents' desires.Findings:During an interview with Resident 61 on 1/26/26, at 11:14 a.m., she stated the hot food was not hot.During an observation and interview with the director of hospitality and nutrition (DHN) on the test tray on 1/28/26, at 12:35 p.m., the brisket, the macaroni and cheese, and the burger were at 117.9 Fahrenheit (F, a scale of temperature), 121F, and 116.9F. The DHN confirmed these hot food temperatures.During an interview with the DHN on 1/30/26, at 11:15 a.m., he stated the facility did not have the policy on food temperature served at the residents' tables.During an interview with Resident 60 on 1/30/26, at 1:04 p.m., he stated the food was cold; the hot food was not hot; the coffee in the morning was cold; the eggs, bacon, and sausages were cold when they came to his room.Review of the facility's Food and Nutrition: Test…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 infection prevention techniques were followed when:1. The Licensed Vocational Nurse (LVN) A failed to wear Personal Protective Equipment (PPE, equipment worn to minimize exposure to hazards that cause serious workplace injuries and illness) when he entered the room of a Covid-19 (highly contagious respiratory illness caused by the SARS-CoV-2 virus) positive resident (Resident 51);2. The Registered Nurse (RN) B failed to change gloves during tube feeding (liquid nutrients given through a tube inserted in the stomach) for Resident 2;3. Licensed Vocational Nurse (LVN) C used the same tissue to wipe excess liquid from both eyes during the administration of three different eye medications for Resident 4; and4. Certified Nursing Assistant F (CNA F) did not perform hand washing or hand hygiene before feeding Resident 18.These deficient practices had the potential for contamination and spread of infection.Findings: 1. Review of…

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

Based on observation, interview, and policy review, the facility failed to treat one of 14 residents (23) with respect and dignity when certified nursing assistant D (CNA D) was standing while feeding Resident 23 in his room. This failure had the potential to cause Resident 23 feeling low self-esteem.Findings:During a dining observation on 1/26/26, at 12:57 p.m., CNA D was standing while feeding lunch to Resident 23 in his room.During a concurrent interview with CNA D, she stated she was standing and feeding Resident 23 because she was short. CNA D acknowledged that she could position Resident 23's bed lower, so that she could sit on a chair and feed the resident.Review of the facility's policy, Assistance with Meals, dated 3/2022, indicated . 3. Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example: a. Not standing over residents while assisting them with meals; .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to revise and implement comprehensive care plan that included measurable objectives and interventions for one out of 14 sampled residents (Resident 33) when Resident 33's foley catheter (a device inserted into the bladder [organ that collects urine] to drain urine, made of a semi-flexible plastic tube) care plan was not revised or updated after the intervention failed. The failure had the potential for Resident 33 not attaining the highest practicable physical, mental, and psychosocial well-being.During a review of Resident 33's clinical record indicated Resident 33 was admitted to the facility on [DATE] with diagnosis including urinary retention. A review of Resident 33's physician's order dated, 1/1/26 indicated an order for Foley Catheter 16Fr (French, size is comparable to the circumference of the catheter in millimeters) due to diagnosis of urinary retention change per MD (Medical Doctor) schedule and prn (as needed) obstruction. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure necessary care and services were provided to one of three residents (41) when Resident 41's pacemaker (a small battery-operated device that helps the heart beats in a regular rhythm) information was not in his medical records. This failure had the potential for not preventing Resident 41 from experiencing serious health conditions.Findings:Review of Resident 41's admission Record indicated he was admitted to the facility on [DATE] with heart failure (a condition in which the heart muscle can't pump enough blood to meet the body's needs for blood and oxygen), atrial fibrillation (an irregular heartbeat that can lead to blood clots, heart failure, and other heart-related complications), and presence of cardiac pacemaker diagnoses.Review of Resident 41's clinical record indicated that his pacemaker information such as manufacturer, model, serial number, date implanted, name of cardiologist, etc. was not found.During an interview with the director…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 assess fall risk for one of three residents (36) when Resident 36 had not had quarterly fall risk assessment since after 5/28/25. This failure had the potential to result in Resident 36's fall risk and fall intervention were not up to date to prevent her from falling and getting injury.Findings:Review of Resident 36's admission Record indicated she was admitted to the facility on [DATE] with abnormalities of gait and mobility diagnosis.Review of Resident 36's Nursing Progress Note, dated 5/28/25, at 9:50 p.m., indicated on 5/28/25, at 4:30 p.m., Resident 36 went from her wheelchair to stand and transfer to the walker in the dining room. Resident 36 lost balance and fell onto her left side.Review of Resident 36's clinical records indicated Resident 36 was assessed for fall risk when she fell on 5/28/25. However, there were no fall risk assessments done for Resident 36 after 5/28/25.During an interview with the director of nursing (DON) on 1/30/26, at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the proper use of bed rails (side rails, adjustable rigid bars attached to the side of a bed) for one of nine residents (Resident 2) with side rails when there was no documented evidence that the bed rail entrapment risk assessment was completed.This failure had the potential to place the residents at risk of entrapment and serious injury.Findings:Review of Resident 2's admission Record indicated she was admitted on [DATE] with diagnoses including hemiplegia (loss of strength in the arm, leg, and sometimes face on one side of the body) and hemiparesis (a relatively mild loss of strength in the arm, leg, and sometimes face on one side of the body) following cerebral infarction (stroke; a result of disrupted blood flow to the brain), dysphagia (difficulty swallowing), type II diabetes mellitus (high levels of sugar in the blood).During a concurrent observation and interview with the Director of Nursing (DON), on 1/29/26 at 9:00 a.m.,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 care and services were provided in accordance with professional standards of practice for one of three sample residents (Resident 1) when: 1. The facility scheduled a change in medication administration time to start on 7/17/24 when it should have started on 7/18/24; and, 2. A medication was documented as administered when it should have been documented as refused. These failures had the potential to compromise the resident's health and well-being. Findings: 1. Review of Resident 1's medical record indicated she was admitted on [DATE] and had diagnoses including hypertension (high blood pressure). Review of Resident 1's Order Summary Report indicated she had a physician's order, dated 7/8/24, for lisinopril (medication used to lower blood pressure) 5 milligrams (mg, unit of dose measurement) three tablets (total of 15 mg) by mouth one time a day for hypertension. From 7/9/24 to 7/17/24, this medication was scheduled to be administered at 9:00…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 5 of 11 resident (Residents 3, 13, 24, 334, and 336) had: 1. documentation of reviewing advance directive status, when there was no documentation of a staff member discussing the status with four of the residents or residents' representative, or 2. the POLST (Physician Orders for Life Sustaining Treatment) for three residents, were not filled in accurately, when Section D had no check marks for the advance directive status. Findings: 1. Review of Resident 13's face sheet (FS: a document that gives a resident's information at a quick glance) indicated Resident 13 was admitted to facility on 3/4/2019. Review of Resident 13's POLST form dated 11/1/2022 indicated, section D for advance directive (AD)'s all three options were left blank, not completed. Review of Resident 13's clinical record indicated there was no document for advance directive. Further review of Resident 13's clinical record indicated there was no documented evidence for facility discussed for AD or offered help to execute AD or requested copy 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 ensure proper storage of medications in medication room when the following were found: 1. An expired over the counter (OTC: medications can buy without written by medical doctor) medications; 2. An expired suppositories (supp: solid, small, and cone shaped medications that melts upon insertion into the body). These failures had the potential for residents to receive medications with reduced efficacy (effectiveness). Findings: 1. During an observation of facility's medication room (where facility stores medications) along with director of nursing (DON) on 7/18/2024 at 7:59 a.m., observed one container of psyllium powder (fiber supplement to help with digestive health and bowel regularity) expired on 6/2024. One bottle of geri-lanta (used to treat for stomach upset) expired on 5/2024, and one bottle of milk of magnesia (used to treat for stomach upset or indigestion [stomach discomfort after eating food]) expired on 6/2024. These expired medications were stored in OTC medication supply cabinet in 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.

Based on observation, interview and record review, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food safety when: 1. Bowls used for food preparation and food service were stacked and stored wet; 2. There were undated and outdated food items in the facility's kitchen freezer; These failures had the potential to cause food contamination and food-borne illness to 38 of 39 residents who received their food from the kitchen. Findings: 1. During an observation on 7/15/24 at 8:55 a.m., there were 3 large metal bowls and one small metal bowl observed to be stacked on a metal wire rack. The bowls were stacked upside down on top of one another and were wet inside and outside of the bowl's surfaces. During a concurrent interview with the certified dietary manager (CDM), he confirmed the bowls were stacked wet and he stated they should be air dried before being stacked and stored. Review of the facility's policy titled Dishwashing Machine Use revised March 2010, indicated The following guidelines will be followed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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. Foley catheter ((F/C: a semi-flexible plastic tube, one end inserted into bladder (a body organ that stores urine] and the other end attached to a bag that collects urine)'s tubing (hard plastic tube attached between F/C and F/C's drain bag [urine collection bag] to drain urine from body) laying on floor for Resident 332; 2. Nasal Cannula (NC: a medical device to provide supplemental oxygen [O2: colorless, odorless, and tasteless gas supports life] to residents) tubes on floor and unchanged for Resident 334; 3. Licensed nurse failed to do hand hygiene after removing gloves; and 4. Phlebotomist (PHMT: person responsible to take samples of blood from residents for testing) was in the hallway with gloves on. These failures could result in the spread of infections and cross-contamination that could affect all the residents residing in the facility. Findings: 1. Review of Resident 332's face sheet (FS: a document that gives a resident's information at a…

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

Based on observation, interview and record review, the facility failed to ensure to treat with dignity and privacy for 1 of 2 sampled Resident (Resident 332) when: 1. Resident 332's foley catheter (F/C: a semi-flexible plastic tube, one end inserted into bladder [ a body organ that stores urine] and the other end attached to a bag that collects urine) drain bag (collects urine that drains through the F/C) was left uncovered. These failure had the potential for adverse effects on the psychosocial well-being and health of Resident 332. Findings: 1. Review of Resident 332's face sheet ((FS: a document that gives a resident's information at a quick glance) indicated Resident 332 was admitted to facility on 7/9/224. Review of Resident 332's admission diagnoses included fracture of superior rim of left pubis (broken bone in pelvis (basin shaped complex of bones that connects the trunk and legs of the body)]. Review of Resident 332's physician order dated 7/9/2024 indicated, Foley Catheter Fr.16 (F/C size) due to diagnosis ---change per MD (medical doctor) schedule and PRN (as needed)…

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

Based on interview and record review, the facility failed to give notice of ending of Medicare Part A stay or therapies under Part B within a timely manner to one of three randomly selected residents (Resident 26). This failure had the potential for Resident 26 not being able to appeal for continued payment by Medicare. Findings: During a review of Resident 26's SNF (Skilled Nursing Facility) Beneficiary Notification Review (SNF BNR), dated 5/23/2024, the SNF BNR indicated Resident 26's Medicare part A Skilled Services last day of coverage was 5/23/2024. The date Resident 26's SNF BNR was signed was 5/23/2024. During an interview on 7/18/24 at 10:57 a.m. with the administrator (ADM), ADM stated Resident 26's last day covered was 5/23/24, and the SNF BNR notice was given on 5/23/24. ADM stated Resident 26 should have had 48 hours between giving notice and their last day of coverage. It was not done in this situation. During a review of the facility's policy and procedure titled Health Information Record Manual: Chapter VII 7020 Medicare Notice of Medicare Non-Coverage/Advance…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS, an assessment tool) was accurate for one of 14 sampled residents (Resident 19). For Resident 19, the assessment of his alarm device was inaccurate and the MDS did not reflect the presence of a wanderguard (a device that activates an alarm when a resident attempts to leave a safe area.) Failure to accurately assess Resident 19's use of a wanderguard had the potential to compromise the facility's ability to develop and implement resident-centered care plans and interventions. Findings: Review of Resident 19's clinical record indicated he had diagnoses including dementia (decline in mental capacity affecting daily function), history of falling, and the need for assistance with personal care. Review of Resident 19's MDS, dated [DATE], indicated he had a brief interview for mental status (BIMS, an assessment to test a person's cognition level) score of 3 [a score of 0 to 7 indicates severe cognitive impairment, 8-12…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 elopement risk care plan (a written document which communicates and directs the care and services, including goals and interventions required to meet a resident's individualized need) for one of 14 sampled residents (Resident 19). This failure had the potential for Resident 19's attempts at elopement to go undetected and jeopardize Resident 19's safety. Findings: Review of Resident 19's clinical record indicated he had diagnoses including dementia (decline in mental capacity affecting daily function), history of falling, and the need for assistance with personal care. Review of Resident 19's MDS, dated [DATE], indicated he had a brief interview for mental status (BIMS) score of 3 (a score of 0 to 7 indicates severe cognitive impairment). Review of Resident 19's clinical notes, dated 8/3/23, indicated an attempted elopement (leaving unsupervised and undetected) occurred by Resident 19. The clinical notes indicated an ordered…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 follow their policy and procedure (P&P) for medication order for one of five sampled resident (Resident 340) when; 1. Resident 340 received medication pantoprazole sodium delayed release (used to reduce amount of acid in stomach to release the active ingredient (s) later after taking it) after breakfast. This failure had the potential to affect the health and well-being of Resident 340. Findings: Review of Resident 340 face sheet (a document that gives a resident's information at a quick glance) indicated Resident 340 was admitted to the facility on [DATE]. Review of Resident 340's physician orders dated 7/6/2024 indicated, pantoprazole Sodium Oral Tablet Delayed Release 40 mg (pantoprazole Sodium) Give 1 tablet by mouth in the morning for every morning before breakfast. Review of Resident 340's minimum data set (MDS: clinical assessment tool) assessment dated [DATE] indicated Resident 340 brief interview for mental status (BIMS) score 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 follow physician's orders to administer oxygen (O2: colorless, odorless, and tasteless gas supports life) for 1 of 2 sampled resident (Resident 24). This failure had the potential to compromise Resident 24's health, and well-being. Findings: Review of Resident 24's face sheet (a document that gives a resident's information at a quick glance) indicated Resident 24 was admitted to the facility on [DATE]. Review of Resident's admission diagnoses including transient ischemic attack (a condition caused by brief blockage of blood flow to the brain), thrombocytosis [blood has a higher-than-normal platelet (particles in blood that help the blood to become gel to manage bleeding) count], and atherosclerotic heart disease (a sticky substance called plaque builds up inside arteries [blood vessels carry blood from heart to body organs]). Review of Resident 24's physician orders for dated 6/23/2024 indicated, Oxygen: Administer 5 LPM (liters per…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 determine if bed rails were appropriate for two of 39 resident (Residents 17 and 81) prior to installing them. This failure had the potential of the residents being harmed from improper bed rail use. Findings: During a review of the medical record for Resident 17, a bed rail assessment was not located. Nor was the alternatives used, a physician order, or a care plan for their use, prior to installation. During a review of the medical record for Resident 81, neither a bed rail assessment, the alternatives used, a physician order, or a care plan for their use, prior to installation, were not located. During an interview on 7/19/24 at 2:28 p.m. with the director of nursing (DON), the DON stated Residents 17 and 81 do not have a physician order, assessment, alternatives attempted documented, nor a care plan. During a review of the facility's policy and procedure titled Bed Safety and Bed Rails, revised 08/2022, indicated under the sub-heading Use of Bed Rails .3. The use of bed rails or side rails .is prohibited unless 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 and interview, the facility failed to post the nurse staffing hours in a prominent place. This failure did not follow the federal regulation of posting them in a prominent place readily accessible to residents and visitors. Findings: During an observation of the nurses station during the time of the survey, the posting for the licensed and unlicensed nursing staff total number and actual hours worked was not located. During an interview on 7/19/24 at 9:29 a.m. with the administrator (ADM), the ADM stated the nursing numbers are posted in the hallway that is blocked off right now because of constriction and painting. After the surveyor brought it to the ADM's attention, the ADM stated let me get those moved.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure 1 of 2 sampled resident (Resident 339) was free from unnecessary psychotropic medication (drug that affects brain activities associated with mental processes and behaviors) when; 1. No target behavior monitoring for use of medication quetiapine (antipsychotic medication used to treat certain mental/mood disorders); 2. No non-pharmacological (any type of healthcare interventions without use of medications) approaches to minimize the need to use for medication quetiapine; 3. Pharmacy consultant (expertise in managing medications and providing clinical guidance on safe and appropriate medication use for residents)'s recommendations for quetiapine had not been followed up and; 4. MD (medical doctor)'s response for pharmacy recommendations had not been followed up. These failures resulted in inadequate monitoring and unnecessary medication for Resident 339, which potentially placed the resident at risk for experiencing harmful adverse effects from…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medications and biologicals were stored and labeled appropriately when: 1. Two unlabeled and opened bottles of Di-Dak-Sol diluted Dakin's solution (used to treat or prevent infections caused by cuts or abrasions, skin ulcers, pressure ulcers, diabetic foot ulcers, or surgery), and one unlabeled opened hydrocortisone cream 1% -topical (used to help relieve redness, itching, swelling, or other discomfort caused by skin conditions) were found in the treatment cart; 2. An expired and opened Fluocinolone acetonide Topical solution USP, 0.01% (used to reduce skin inflammation and relieve itching) and an expired opened Normal Saline solution (NSS) 100 milliliters (ml, a unit of measurement for volume) (mixture of sodium chloride in water and applied to the affected area or used to clean wounds) were inside the treatment cart; 3. One opened bottle of Doxazosin Mesylate (used in men to treat the symptoms of an enlarged prostate) 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 and record review, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food safety when: 1. A scoop was inside the dry legume container in the dry storage area; 2. There were opened, undated, unlabeled, and outdated food items in the food preparation and dry storage areas; 3. There were opened, undated, and unlabeled food items in the walk-in refrigerator; 4. There were undated, and unlabeled food items in the walk-in freezer. These failures had the potential to cause food contamination and food-borne illness to 22 of 22 residents who received their food from the kitchen. Findings: During an initial kitchen tour on 6/5/23 at 8:25 a.m., accompanied by the director of dining services (DDS), the following observations were made in the facility's kitchen: 1. Inside the kitchen's dry storage area there was a plastic bin containing dry legumes with a scoop inside the bin. The scoop was touching the legumes. 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 staff implemented proper infection control practices when: 1. The licensed nurse did not change gloves between tasks; 2. Registered Nurse D (RN D) did not perform hand hygiene in between procedures; 3. Resident 127's spirometer (an apparatus for measuring the volume of air inspired and expired by the lungs- measures ventilation, the movement of air into and out of the lungs) mouthpiece was touching the side table; 4. Trash can attached to the Medication Cart B has used facial mask and N-95; 5. Three medication containers inside the medication room refrigerator has grayish substance, and disposal container for discontinued and refused medication had red spots of liquid substance inside the medication room; 6. There was a grayish powder seen in the first drawer of the treatment cart. 7. The Medication Cart A had a bottle of Milk of Magnesia oral- MOM (a laxative to relieve occasional constipation and used as an antacid to relieve…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 services were provided to meet the professional standard of practice for one of four residents (Resident 6) who had a pacemaker (implanted device for a heart condition, a battery-powered device implanted inside the heart to restore a normal heartbeat) when: 1. The resident's medical record had no pacemaker-paced rate information, 2. The licensed nurse did not develop a care plan to manage pacemaker care. These failures had the potential to compromise Resident 6's health and safety. Findings: A review of Resident 6's clinical records indicated Resident 6 was admitted on [DATE] and had diagnoses including chronic diastolic (congestive) heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), and a pacemaker was implanted on 5/25/2022. During a concurrent interview and record review with Licensed Vocational Nurse (LVN) A on 6/8/2023, at 3:17 p.m., LVN A confirmed Resident 6's medical record had…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 12 sampled residents (Resident 17) was free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behaviors) when Resident 17 received Lorazepam (anxiolytic medication, used to reduce anxity)without a stop date. The failure had the potential to result in inadequate use of psychotropic medications. Findings: A review of Resident 17's clinical record indicated she was admitted to the facility on [DATE] with diagnoses including unspecified dementia (a term used to describe a group of symptoms affecting memory, thinking, and social abilities severely enough to interfere with the patient's daily life), anxiety, and depression. A review of Resident 17's physician's orders dated 5/19/2023 indicated administering Lorazepam 0.5 milligrams (mg, unit of measurement)1 tablet orally every 4 hours as needed (PRN) for anxiety manifested by restlessness. During a concurrent interview and 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.