Ahmc Seton Medical Center

Based on observation, interview, and record review, the facility failed to ensure one of 26 sampled residents (Resident 97) had a comprehensive care plan completed to address osteopenia (fragile bones). This facility failure had potential for Resident 97 to not receive necessary care and services.A review of the physician progress notes dated 4/24/25, indicated the diagnoses for Resident 97 included dementia (decline in memory or other thinking skills), diabetes (abnormally high blood sugar level) and hypertension (abnormally high blood pressure). A review of the facility reported incident dated 5/4/25, indicated on 4/25/25, Resident 97 fell out of bed and sustained a fracture (broken bone) through the right femur (thigh bone). A review of the facility reported incident dated 5/4/25, the result of the imaging (a procedure used to create a picture of the inside of the body) that was completed on 4/25/25, indicated Resident 97 has osteopenia (fragile bones). A review of the Minimum Data Set (MDS, a standard assessment tool, used to provide an individualized, resident centered care)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to effectively assess, evaluate, and implement interventions consistent with the nutritional status for one of three sampled residents (Resident A) when:1. The facility did not initiate a change of condition report to address Resident A's weight loss of 7.8 pounds (lbs.) within a month after it was identified on 10/7/25. 2. The facility failed to develop a care plan to address Resident A's weight loss of 7.8 pounds as identified on 10/7/25.3. Weekly weight evaluations were not implemented in accordance with the facility's policy.4. There was no documented follow up assessment, actions, or interventions by a Registered Dietitian (RD, a health professional with special training in diet and nutrition) to address Resident A's weight loss. These failures had the potential to result in continued weight loss and poor nutritional status, which could negatively impact Resident A's overall health and well-being.Review of Resident A's admission record indicated, was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure staff followed their infection control policy and procedure (P &P), when a Licensed Vocational Nurse (LVN) did not perform hand hygiene between glove changes during medication administration.This failure had the potential to expose residents to cross contamination and increase the risk of infection.During medication administration observation on 8/13/2025 at 10:04AM, room [ROOM NUMBER], LVN1 was preparing medications wearing gloves, LVN 1 was observed removing her gloves, checking the computer and donning a new pair of gloves without performing hand hygiene.During an interview on 8/13/2025 at 10:15 AM, LVN 1 acknowledged forgot to do hand hygiene before putting on a new pair of gloves, yes I know I should perform hand hygiene first.During a review of the facility's policy and procedure (P & P) titled, IC 2-I: Hand Hygiene, dated 5/2019, the P & P, indicated, To prevent the spread of infection to patients and healthcare workers by…

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 (holding or reserving a resident ' s bed while the resident is absent from the facility for therapeutic leave or hospitalization) to four of four sampled residents (Resident 1, 2, 3, and 4) or their responsible party (RP) at the time of transfer to acute care hospital. This failure could result in residents and/or their RP not being fully informed of their right to request a bed hold and to return to the facility after hospitalization, potentially leading to inappropriate discharge. Findings: 1. Resident 1 was initially admitted on [DATE] and was readmitted on [DATE], with diagnoses that include encephalopathy (a general term that describes brain disease, damage, or malfunction usually related to inflammation within the body) and urinary tract infection (an infection in any part of the urinary system). During a concurrent interview and record review on 5/8/25 at 3:37 PM, the Assistant Director of Nursing (ADON)…

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 did not thoroughly investigate a grievance regarding administration of tube feeding formula as ordered by the physician for Resident 1, one of three sample residents. The facility ' s investigation was not thorough because they failed to : 1. Consider the maximum rate their tube feeding pump could run at (295 ml/hr, mililiter per hour, milliliter= unit of fluid measurement). 2. Identify an unclear tube feeding physician order. The tube feeding order directed staff to administer each feeding (325 ml) within an hour. Given the maximum rate of the pump, it was impossible to infuse the ordered amount with the pump alone within the time frame specified. 3. During the investigation, staff failed to measure the total amount of tube feeding within an enclosed bag and staff failed to measure tube feeding formular remaining in the bag lack after the third feeding. Without this information, it would be difficult to conclude if the ordered amount of tube feeding was being administered. 4. During the investigation, staff failed to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, facility staff failed to treat three out of 24 sampled residents with dignity (Residents 6, 82, and 408) when these residents have to wait 30-45 minutes for staff to answer their request/call light for assistance. Failure to answer a resident's call light in a timely manner did not ensure these residents were treated in a dignified manner. Findings: 1. Review of Resident 6's Minimum Data Set(MDS-an assessment tool) dated 11/09/2023, indicated he was admitted to the facility on [DATE], had multiple diagnoses including: respiratory failure, obesity, kidney failure leading to dialysis, wound near the tail bone. His MDS indicated he has a urinary catheter and was incontinent of bowel. During an interview on 02/06/2024 at 10:04 AM. Resident 6's responsible party stated .my dad would have a BM and I would be on the phone with him and sometimes it could be as long as 45 minutes before they get to him. Staff would tell us that they were short staff and that they were taking care…

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

Based on interview and record review, the facility failed to inform residents about the facility's grievance process. Seven out of seven sampled residents were not aware of the grievance process (Residents 5, 19, 24, 32, 55, 57, and 72). For Resident 408, the facility failed to complete the resolution review of the grievance process. Failure to inform or follow the grievance process, did not ensure concerns from the residents or their responsible parties were addressed in an appropriate and timely manner. Findings: During the resident council meeting with residents on 01/30/2024 at 2:04 PM, Residents 5, 19, 24, 32, 55, 57, and 72 were asked about the facility's grievance process. All seven residents stated they were not aware the facility had such a process. During initial rounds on 01/30/2024 at 10:08 AM, Resident 408 stated she had eight boxes of personal items missing during her transfer to this facility. She stated the facility claimed her friend had all her missing belongings. She claimed that the facility had been lying about the whereabouts of her belongings. During an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure assessments for three of 24 sampled residents (Residents 4, 6, and 13) were accurate when; 1. The Minimum Data Set (MDS - an assessment tool) for Resident 4's dental assessment was inaccurate. 2. The MDS indicated Resident 6's hemodialysis treatment was inaccurate. 3. The MDS indicated Resident 13 had three pressure ulcers when there was only one. Failure to complete accurate assessments could potentially harm the residents by not providing needed care and services to maintain their highest level of functioning. Findings: 1. Resident 4 was admitted on [DATE] with diagnosis including hypertension (high blood pressure) and mild cognitive impairment. During an observation on 1/30/24 at 12:11 PM, Resident 4's upper denture was placed in a denture cup on top of an overbed table. Resident 4 then removed her lower denture during mealtime. During a concurrent interview, Resident 4 stated, I cannot close my mouth and chew when I use it…

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 develop a comprehensive care plan (CP) for each resident that included measurable objectives and specific interventions for seven of 24 sampled residents (Residents 4, 7, 70, 78, 38, 407, and 6) when: 1. No individualized person-centered CP was developed for Resident 4's pain due to unfit dentures. 2. No individualized person-centered CP was developed for Resident 7's use of Lovenox (a blood-thinning drug used to prevent formation of blood clots). 3. No individualized person-centered CP was developed for Resident 70's use of Zolpidem (a medication primarily used for the treatment of sleeping problems). 4. CP did not reflect the use of gloves, tab and bed alarms for Resident 78. 5. CP did not reflect management of planned weight loss for Resident 38. 6. CP for Resident 407 did not address the specific target behavior (extreme fear) for the use of Seroquel (an antipsychotic medication). 7. Dialysis CP did not reflect the accurate dialysis…

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 preventive treatment and services to maintain and improve range of motion (ROM) for four of 14 sampled residents (Residents 12, 22, 38, and 14) when the physician's order for ROM exercises was not implemented. This deficient practice had the potential to limit the residents' ROM or possible development/worsening of a contracture. According to a Medical Dictionary, retrieved from http://medical dictionary.thefreedictionary.com/range+of+motion+exercise, on 2/16/24, indicated, . Range of motion is one aspect of exercise important for increasing or maintaining joint function . Passive range of motion is movement applied to a joint solely by another person or persons or a passive motion machine. When passive range of motion is applied, the joint of an individual receiving exercise is completely relaxed while the outside force moves the body part, such as a leg or arm, throughout the available range. Injury, surgery, or immobilization of a joint may…

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, interviews, and record review, the facility failed to maintain a sanitary environment by neglecting to properly clean one of the four fixed kettles between serving porridge and soup for lunch. Additionally, kitchen prep surface drainage holes, encrusted with dried, unidentifiable food particles, were exposed and untreated. This failure had the potential to result in potential health risks to residents. Findings: During a kitchen observation on Tuesday, 01/30/24 at 10:28 AM, four large empty built-in cooking kettles were noticed, with only the last kettle functioning. At 10:36 AM, a stainless-steel prep table near the outside of dietary offices revealed a hole approximately 2 inches in diameter, uncovered, and encrusted with food residue. Another prep table on the opposite side of the room had a similar uncovered hole, also encrusted with unknown residue. In an interview on 01/30/2024 at 10:55 AM with S14 (Dietary cook), S14 explained the process of cleaning the kettle, stating, I rinse after cooking. If using 'creamier' items that leave residue on the sides, I…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, the facility failed to provide for a community dining and activity area on the 4th floor, 5th floor, and 7th floors, resulting in residents being confined to their rooms for all meals. Findings: During an observation on 01/29/2024 at 11:45 AM, there was no common area/dining room for the residents noted on the 7th floor. During an observation on 01/30/2024 at 03:50 PM on the 9th floor, there were no added chairs/tables. The room is currently being used for singing activity. Residents from 4th, 5th, and 7th floors share use of this one room. Capacity is limited, especially with all residents brought in wheelchairs accompanied by their CNAs. During an observation on 01/30/24 at 04:35 PM, there was no common area/dining room for the residents on the 5th floor. During an interview with S04 (Director of Dietary) on 2/01/2024 at 3:25 PM, stated unaware if [NAME] has any plans for installing a dining area on each floor. During an interview with S01 (Director of Admin) on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure a shower area was clean after use and two window screens were missing. Failure to clean a shower after use,and properly maintained window screens did not ensure residents were provided with a clean, comfortable, homelike environment. Lack of a window screen has the potential for flying pest to come into a resident's indoor living space. Findings: During initial tour with the Director of Nursing(DON) on 1/29/24 at 3:07 PM, the shower room across room [ROOM NUMBER] was found used and not cleaned: 1. Strands of hair on the tile floor. 2. A commode container full of empty plastic personal hygiene product bottles (lotions and shampoo containers). 3. A safety razor on the floor. 4. An opened body wash bottle labelled 211A on the grab bar. 5. Used plastic gloves in the recessed soap dish. During a concurrent interview with the DON, she stated staff should not leave the shower in this manner and staff should clean the shower after use. During initial tour…

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 pharmacy consultant's recommendation for the use of psychotropic medication was acted upon for one of eight sampled residents (Resident 86). This failure had the potential for Resident 86 to receive unnecessary psychotropic medications, be exposed to adverse health consequences from the medications, which could negatively impact the residents' mental, physical, and psychosocial well-being. Findings: Resident 86 was admitted on [DATE] with diagnoses including mood disorder (described by marked disruptions in emotions), major depressive disorder (medical illness that negatively affects how you feel, the way you think and how you act). Review of Resident 86's Physician Order Report dated 12/1/23 through 12/31/23 indicated, .Start date 11/27/23 Risperdal (Risperidone) 1 mg 1 tab oral at bedtime .for mood disorder . Review of Resident 86's Pharmacy Services: Initial Medication Regimen Review (MRR) dated 11/26/23 indicated, .D (diagnosis): Mood…

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 maintain an accurate record for 3 of 24 sample residents (Resident 25, 396, and 397). For Residents 25 and 397, staff failed to document their fluid intake accurately. For Resident 396 an anti-psychotic target behavior was documented incorrectly. Failure to accurately document fluid intake or target behavior has the potential for the care team to act or recommend treatment based on inaccurate information. Findings: 1. Review of Resident 397's record titled Minimum Data Set(MDS- an assessment form), dated 11/10/2023, indicated he was admitted to the facility on [DATE] with multiple diagnoses including: gastric reflux (stomach acid flows back towards mouth), anxiety, asthma, diabetes (blood sugar control issues), noncompliant with medical treatment, and localized fluid retention. Review of Resident 397's matrix provided by the facility 01/31/2024 indicated he had excessive unplanned weight loss. Part of managing a resident with unplanned weight loss is…

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

Based on interview and record review, the facility failed to ensure education regarding protective vaccine were documented and follow up and/or refusals were documented in two of four sampled resident's records (Residents 70 and 88). Failure to document education did not ensure residents and/or their responsible parties could make an informed decisions regarding vaccines. Failure to follow up and/or document refusals did not ensure residents healthcare choices were honored. Findings: Pneumovax vaccines help our bodies develop immunity to the bacteria that causes pneumonia. During a concurrent record and interview with RN 5 on 02/02/2024 at 11:18 AM, these items were found missing: 1. Resident 88: no pneumovax vaccine was administered, no refusal for pneumovax, and no education regarding pneumovax. 2. Resident 70: no pneumovax vaccine was administered, no refusal for pneumovax, and no education regarding pneumovax. RN 5 was asked to search these records for the missing information and RN 5 was unable to find the information.

Based on interview and record review, the facility failed to ensure education regarding protective vaccine were documented and follow up and/or refusals were documented in two of four sampled resident's records (Residents 13 and 89). Failure to document education did not ensure residents and/or their responsible parties could make an informed decisions regarding vaccines. Failure to follow up and/or document refusals did not ensure residents healthcare choices were honored. Findings: COVID-19 vaccines help our bodies develop immunity to the virus that causes COVID-19. During a concurrent record review and interview with RN 5 on 02/02/2024 at 11:18 AM, these items were found missing: 1. Resident 89, no COVID-19 vaccine was administered, no refusal for COVID-19 vaccine, and no education regarding COVID - 19 vaccine. 2. Resident 13, no COVID- 19 or pneumovax vaccine were administered, no refusals for COVID -19 or pneumovax vaccines and no education regarding COVID- 19 and pneumovax. RN 5 was asked to search these records for the missing information and RN 5 was unable to find 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, an emergency cart plastic lock tag did not match the lock tag documented on the log. Failure to follow procedure regarding logging lock tags did not ensure emergency devices and/or supplies would be available in the event of an medical emergency. Findings: During initial rounds on 01/29/2024 at 12:45 PM, a crash cart's (a cart containing essential life saving devices, medications and other supplies) red plastic lock tag (placed to ensure no one has accessed or tampered with the cart) was found not to match the information on the crash cart's log book. This observation was confirmed with RN 7. RN 7 was unable to provide an explanation of why the tag does not match the one in the log book. RN 7 explained that once the cart is accessed, the whole cart is sent to central supply to be re-stocked and new red plastic lock tag installed and the tag number is entered into the log book. Review of the facility's policy titled Pharmacy: Emergency Drugs: Crash Carts / Drug Trays / Boxes, revised on 3/21, indicated .Emergency crash carts in strategic locations…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to have a secure handrail in their corridor. Failure to maintain handrails did not ensure residents who relied on handrails for mobility and/or support would be safe from a fall. Findings: During initial tour on 01/29/2024 at 10:29 AM, a handrail outside room [ROOM NUMBER] was found not secured properly to the wall. This observation was confirmed with RN 6. RN 6 stated she would inform maintenance.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide training to all nursing staff how to perform range of motion (ROM) exercises to residents in accordance with the facility policy. (Refer to F 688) This failure could potentially delay the identification of issues and provision of care to prevent further decline of resident's functional status. Findings: Resident 98 was admitted on [DATE] with diagnosis including history of cerebral vascular attack (CVA or stroke include symptoms like trouble walking, speaking, and understanding, as well as paralysis or numbness of the face, arm, or leg). During an observation on 5/2/22, at 10:09 AM in Resident 98's room, Resident 98 was in bed alert and was waving her left arm. Resident was not able to move her right arm. Review of Resident 98's care plan, dated 4/8/22, indicated CNA (Certified Nurse Assistant) to provide ROM during adls (Activities of Daily Living) to UE (upper extremities) and LE (lower extremities). During an interview with CNA…

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 document an individualized (own) facility-wide assessment (assessment of resident care needs) to determine resources needed to care for its resident population. The lack of development and documentation of a facility-wide assessment had potential to affect the care and safety of all residents. Findings: During a review of a facility document titled Facility-Wide Self Assessment dated 7/12/21, the Facility-Wide Self Assessment indicated that the document was a template developed by the State of Missouri's [NAME] School of Nursing. The document had the State of Missouri's regulations were documented on it. During an interview with Quality Officer (QS 1), on 2/15/22, at 9:30 AM, QS 1 acknowledged that the SNF (Skilled Nursing Facility) used a template downloaded from the internet. She said that she found the template in a binder placed in her office, and did not know where the template came from. She confirmed that the SNF designated 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 observations, interviews, and record reviews, the facility failed to ensure all portions of the residents' call light system was functioning to communicate resident calls from all residents' rooms and all bathrooms to the call system's computer placed at the nursing station. This failure had a potential to delay all resident call communications between residents and staff, delaying staffs' response to residents' urgent needs, with the potential to expose all residents to adverse events (unexpected injury, harm, death or risk thereof), and compromising their health and safety. Findings: During an observation on 2/8/22, at 10:45 AM, in Resident 3's room, Resident 3's room contained three resident beds, bed A, B, and C. Resident 3 was observed sitting on her wheelchair between the footboard of bed B and the wall, facing the door. She attempted to push her wheelchair backwards to move back to her bed, bed C to use the call light to call for assistance. During an interview with Resident 3, on 2/8/22, 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.

Based on observation, interview, and record review, the facility failed to maintain resident's visual privacy for one out of 33 sampled residents (Resident 238) when the privacy curtain was not pulled and the door to the resident's room was left wide opened, exposing his diaper and legs. This deficient practice had the potential to negatively affect resident's dignity and could potentially cause feeling of being shameful. Findings: During an observation, on 2/8/22, at 1:05 PM, Resident 238 was curled up in bed asleep, turned on his right side, facing the window, with his diapers and legs exposed, visibly seen from the hallway. In an interview on 2/8/22 at 1:06 PM, the Registered Nurse (RN) 1 was called to attend to the resident and described resident as tilted on his right side with his legs and diaper exposed. RN 1 stated, the resident was inadequately covered and curtain should be pulled to provide privacy. When asked the reason for providing privacy, RN 1 stated, it's for dignity and it can be shameful. Review of the facility policy and procedure titled, Patient Rights and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review the facility failed to develop a comprehensive care plan (CCP) that included measurable objectives and timeframe for five (5) out of 33 sampled residents (Residents 135, 44, 77, 35 and 137) when: 1. For Resident 135, there was no evidence a comprehensive care plan for Dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) was developed. 2. For Resident 44, there was no evidence skin care plan was developed to address left abdominal fold abrasion and right upper buttock abrasion. 3. For Resident 77, there was no evidence skin care plan was developed to address abdominal folds rash. 4. For Resident 35, there was no evidence a CCP was developed to address the use of restraint (is any physical or chemical means or device that restricts resident's freedom). 5. For Resident 137, there was no evidence the facility and the Hospice Agency developed a CCP to address resident's Hospice care and needs. Failure to…

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

Based on observation, interview, and record review, the facility failed to ensure residents were free from a medication error rate of 5 percent or greater for six of 8 sampled residents (Resident 538, 123, 539, 540, 541, and 115) during medication pass observation when: 1. For Resident 538, Registered Nurse (RN) 3 did not give Fluticasone nasal spray (a medicine used to treat allergy or non-allergy nasal symptoms such as runny nose, and sneezing) as per the manufacturer's instructions, 2. For Resident 123, Licensed Vocational Nurse (LVN) did not rotate injection sites of Copaxone (glatiramer acetate, a medicine that is used to treat multiple sclerosis, a disease that impacts the brain and nerves) as per manufacturer's instructions (Refer to F755), 3. For Resident 539, 540, 541, and 115, RN 2 prepared medications for four Residents at the same time. These failures resulted in three medication errors out of 31 opportunities with the facility's medication error rate of 9.68 percent. Findings: 1. Review of manufacturer's instructions of Fluticasone nasal spray (a medicine used to treat…

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, interview and record review the hospital failed to ensure a Registered Dietitian (RD) provided frequent oversight of food and nutrition services and consultation to the Kitchen Supervisor which resulted in deficient practices related to the competency of foodservice staff for the following: a. Cooldown monitoring of foods capable of supporting bacterial growth associated with foodborne illness; b. Safe storage of refrigerated foods; c. Provision of timely and relevant dietary staff training related to the scope and nature of foodservice operations and d. Consistent use of standardized recipes These failures had the potential to lead to foodborne illness in a highly susceptible population for greater than 50 residents at the [NAME] and Coastside campuses who received food from the kitchen. Findings: 1. The intent of the Federal regulation as it pertains to the RD, is the RD is responsible for the functions of food and nutrition services including developing and implementing person centered…

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 food production operations the facility failed to employ sufficient and competent support personnel to implement foodservice operations as evidenced by 1) lapses in food production standards and 2) departmental position vacancies. Failure to ensure sufficient and competent dietetic services staff may result in unsafe food production practices putting residents at risk for foodborne illness and decreased meal intake further compromising medical status. Findings: 1. Recipe standardization is a key element in the efficient running of a food service institution. It plays an important role in ensuring the nutritional needs of patients are met, supporting a successful recovery. In addition, the use of standardized recipes ensures the quantity and quality of meals is consistent irrespective of who is preparing the meal. During general food production observation on 2/8/22 beginning at 11:00 AM, it was noted DS 3 was preparing zucchini for the noon meal. DS 3 was observed placing the sliced zucchini from 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 meal distribution observations the facility failed to follow the menu when the portion sizes for 6 residents (Residents 38, 72, 97, 115, 242 and 243) at the [NAME] campus with physician ordered mechanically altered diets were not correct. Failure to follow the facility approved menu may result in decreased nutritional intake further compromising medical status. Findings: During meal plating observations on 2/8/22 beginning at 11:45 AM, the portions for all items on the steam table were ½ cup except for the mechanically altered zucchini. The serving size for the zucchini was plated as a 1/3 cup serving. In an interview on 2/8/22 at 2:15 PM, Dietary Staff (DS) 5 indicated the portion sizes for all items was listed as 4 ounces. The surveyor asked how she determined the portion size for the mechanically altered zucchini. DS 5 indicated she had to use a smaller portion as there were not enough 4-ounce scoops. DS 5 further stated in the past when she needed additional items, such as scoops, she would tell 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 dietetic services operations, dietary staff interview and departmental document review the facility failed to ensure food safety standards when there was lack of 1) effective cooldown monitoring of potentially hazardous foods 2) lack of date receiving of foods capable of foodborne illness as well as shelf stable foods; 3) food storage practices that may promote cross contamination; 4) lapses in handwashing procedures; 5) lack of adequate air gaps in food production equipment at both the [NAME] and Coastside campus; and 6) retention of damaged products. Failure to provide a food production environment that is safe and sanitary may result in foodborne illness, cross contamination of food and equipment and use of expired ingredients that may affect flavor and/or texture of food. Foodborne illness and cross contamination may result in gastrointestinal distress and in severe instances may result in death. The use of expired ingredients may result in a food product that is unpalatable, resulting in decreased…

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 Quality Assurance and Performance Improvement (QAPI) identified on-going systemic issues, develop and implement appropriate plans of action to correct the identified quality deficiencies when: 1. Resident's bathrooms at [NAME] Coastside were identified to have pungent odor, peeling, cracking of vinyl flooring, and water leak were not addressed. (Refer to F 584) 2. Failed to maintain functional call light system at [NAME] Coastside since 9/30/21. (Refer to F 919) 3. The performance improvement plan did not fully reflect actions to address identification of lapses in safe food handling practices and maintenance of the dietary physical environment. (Refer to F 803, 812 and 908) 4. Evaluation of residents population and identification of the resources needed to provide the necessary care and services was not conducted. (Refer to F 838) Failure to identify and act upon systemic concerns had the potential to negatively affect the care and services…

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 3.The facility failed to follow COVID screening in accordance with their mitigation plan for all visitors and staff. During an observation on 2/7/22 at 8:30 AM, the Security Officer (SO) responsible for screening, did not screen three CDPH Surveyors, visitors, and hospital personnel. During an interview with SO on 2/8/22 at 8:40 AM, stated he was not instructed on screening for COVID. During an interview on 2/8/22 at 11:00 AM, the Infection Preventionist (IP) stated he had provided a complete packet with screening instructions to the Security Manager. He indicated the Security Manager was responsible for distributing the information to all Security Officers working at the Main Entrance to the facility. A record review of a document titled Coronavirus Disease 2019 (COVID-19) Mitigation Plan for Skilled Nursing Facilities indicated HCP (health care personnel) Screening: all those who enter the Acute and Post Acute settings are screened for COVID 19 symptoms via screening stations at entrances of [NAME] Medical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on dietetic services observations, dietary and administrative staff interview and departmental document review the facility failed to ensure essential dietetic services equipment was functional at both the [NAME] and Coastside locations when there were multiple pieces of equipment that have been non-functional from 2 months to greater than 12 months. Failure to maintain equipment in a safe and functional manner may affect the ability for the department to operate in a safe and effective manner which may result in nutritional risk to residents. This has the potential to affect the efficient delivery of meal services to 108 residents. Findings: 1a. During evaluation of warewashing procedures at the [NAME] kitchen, and concurrent interview with Dietary Staff (DS) 2 on 2/7/21 beginning at 1:30 PM, he indicted the dishwasher was currently non-functional. DS 2 stated the equipment has been broken for at least 6 months and perhaps for closer to one year. He stated there was intermittent work conducted on the…

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

Based on observation, interview, and record review, the facility failed to ensure the call light was within reach for one of 33 sampled residents (Resident 37) who was at risk for fall. This deficient practice had the potential to result in falls, injury, and harm to the resident and not meeting Resident's needs. Findings: During a concurrent observation and interview on 2/8/22, at 8:15 AM, Resident 37 was awake, banging the table with the empty water pitcher and yelling, I need water, I don't have a call light. Observed Resident 37's call light with its cord, hanging over the overhead light adjacent to Resident 37's bed. During a concurrent observation and interview on 2/8/22, at 8:35 AM, Licensed Vocational Nurse (LVN) 1 looked for Resident 37's call light, then found it hanging on the overhead light above, adjacent to Resident's bed. LVN 1 stated, the call light was supposed to be within the reach of Resident at all times and gave the call light button to the Resident. During an interview on 2/8/22, at 9:25 AM, Certified Nursing Assistant (CNA) 1 stated, Resident's call light was…

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

Based on interview and record review, the facility failed to ensure their abuse prevention policy and procedure was implemented when there was no evidence of background screening for two nursing staff (CNA 4 and LVN 8). Failure to implement abuse prevention policy had the potential to compromise the resident's health, safety, and well-being. Findings: 1. Review of the 5-DAY INVESTIGATION SUMMARY, dated 5/24/21, indicated, .On 5/20/2021 at approximately 0830, (Resident 33) reported to the charge nurse . the CNA (Certified Nursing Assistant) from the night before (5/19/2021), pushed her hard to the right side lying position even if she had just told her that she did not want to be turned . (Resident 33) mentioned to CNA that there are instructions posted that she cannot be turned to the right .after CNA pushed her, she felt pain on the right shoulder and right side of neck . During an interview on 2/11/22, at 2:35 PM, the Director of Staff Development (DSD) stated CNA 4 is the alleged staff. CNA 4 was placed on administrative leave for a week and provided with abuse prevention…

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 report an alleged abuse incident in a timely manner for one of six sampled residents (Resident 132) with abuse allegation incidents when Certified Nursing Assistant (CNA) 7 reported the alleged verbal abuse two days after the incident. The facility failure to report abuse according to the required timeframe had the potential to delay the identification and implementation of appropriate corrective action that may place the residents at risk of abuse. Findings: A review of the facility Report of Adverse Event letter dated 4/23/21 sent to the California Department of Public Health (CDPH) via fax (transmission of data) on 4/23/21 at 5:34 PM, under descrption of events indicated, It was reported today (4/23/21) at 3:40 pm that a CNA witnessed the following event on 04/20/21 at approximately 9:30 pm: .The LVN (Licensed Vocational Nurse) began suction (removal of plegm using a machine) the patient and stated I don't care if the patient is to going to die [sic]. During an interview on 2/9/22 at 3:47 PM, CNA 7 stated, on 4/20/21 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 observations, interviews, and record reviews, the facility failed to ensure the Minimum Data Set (MDS) accurately reflect the functional status of two of 13 sampled residents (Residents 66 and 65). MDS is an assessment tool that serves as the clinical basis for care planning and delivery of care and services Failure to complete accurate assessment could potentialy result in inappropriate care planning, ineffective interventions and/or delay in provision of needed care and services to maintain residents highest level of functioning. Findings: 1. Resident 66 was admitted on [DATE] with diagnoses that include ischemic stroke (occurs when a vessel supplying blood to the brain is obstructed) with left hemiplegia (paralysis on side of the body). Review of the MDS dated [DATE] and 3/15/22, indicated Resident 66 had functional limitations on one side of the upper extremities and on both lower extremities and was totally dependent on nursing staff for all his activities of daily living. During an observation 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 ensure the baseline care plan (BCP) summary was provided to one of 33 sampled residents (Residents 241) when there was no evidence a summary of there BCP was provided to the resident and/or the responsible party. This deficient practice had the potential to place the resident at risk to not receive the quality of care and the appropriate interventions and goals to maintain the resident's quality of life. Findings: Review of the Face Sheet and the Hospice Physician's Order (HPO), dated 1/28/22, the Face Sheet indicated, Resident 241 was admitted to the facility on [DATE] and the HPO indicated a terminal diagnosis of hepatic failure (liver damaged). In an interview on 2/10/22, at 10:24 AM, with the Registered Nurse (RN) 1, RN 1 explained, the facility would develop a Comprehensive Care Plan, used it as the Baseline Care plan (BCP) and would provide the BCP Summary to the resident and/or Responsible Party. During a concurrent interview and record review,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement their wound care policy for two of 33 sampled residents (Resident 44 and 77), when: 1. Staff did not develop a non-pressure skin report and the nursing weekly summary did not indicate Resident 44's new skin condition. 2. Staff did not develop a non-pressure skin report and did not complete a nursing weekly assessment to address Resident 77's abdominal folds rash. This failure could potentially result in a negative outcome for Resident 44 and 77. Findings: 1. Resident 44 was admitted on [DATE], with diagnoses that includes hemorrhagic stroke (an emergency condition in which a ruptured blood vessel causes bleeding inside the brain) with left hemiplegia (partial paralysis on one side of the body that can affect the arms, legs, and facial muscles). Review of Resident 44's progress notes, dated 1/28/21, indicated Resident 44 noted with left abdominal fold abrasion and right upper buttock abrasion. Review of Resident 44's clinical records and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the resident environment remains free of hazards when sharp objects were observed in plain sight in the room of one of 25 sampled residents (Resident 30). This failure had the potential to cause accident and harm when accessed by other residents. Findings: Resident 30 was admitted on [DATE] with diagnoses that include quadriplegia (paralysis from the neck down, including the trunk, legs, and arms). Review of Resident 30's Minimum Data Set (MDS, an assessment tool), dated 2/22/22, indicated Resident 30 is cognitively intact and has functional limitations in ROM on both upper extremities, and was totally dependent on nursing staff for all his activities of daily living. During an observation on 5/3/22 at 8:38 AM, four pairs of straight scissors and one screwdriver inside an open container were observed on the Resident 30's nightstand. In a concurrent interview, Resident 30 stated, Yesterday, I asked the staff to fix the armrest of my…

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 evaluate and implement interventions that are consistent with the nutritional status for one of four sampled residents (Resident 111) when: 1. Staff rely on the caregivers verbal report of Resident 111 meal intake percentage with no verification. 2. There was no Registered Dietitian (RD, a health professional with special training in diet and nutrition) nutritional assessment and progress notes addressing Resident 111's nutritional status for the month of February, March, and April 2022 and weight loss on March and April 2022. 3. The nursing staff did not document and communicate to the Medical Doctor (MD) and RD to address Resident 111's significant weight loss. These deficient practices resulted in a severe weight loss and had the potential to result in progressive decline in nutrition that compromised the health of Resident 111. Findings: Review of Resident 111's clinical record indicated, was admitted on [DATE] with diagnoses including hemorrhagic…

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 pharmaceutical services to meet the needs of one of eight sampled residents (Resident 123) when Licensed Vocational Nurse (LVN) did not rotate injection sites of Copaxone (glatiramer acetate, a medicine that is used to treat multiple sclerosis, a disease that impacts the brain and nerves) as per manufacturer's instructions. This failure may result to skin and fatty tissue irritation. Findings: During an observation on 2/8/22, at 9:00 AM, in Resident 123's room, LVN 3 administered (gave) Copaxone injection (a way of giving a liquid medicine by using a needle and syringe) to Resident 123's right abdomen. During review of Resident 123's Medication Administration Record (MAR), dated 1/25/22 to 2/8/22, indicated Copaxone was administered on the following dates: On 1/25/22 at 9:00 AM, given in the left arm On 1/26/22 at 9:00 AM, given in the right arm On 1/27/22 at 9:00 AM, given in the left arm On 1/28/22 at 9:00 AM, given in the right arm On 1/29/22 at 9:00 AM, given in the left arm On 1/30/22 at 9:00 AM,…

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 food at required temperature for residents. This failure had the potential to place residents at risk for poor food intake which could compromise their nutritional and health status. Findings: In an interview on 7/20/22, at 9:20 AM, Resident 91 stated, the food was served too hot, the hamburger was burned, and the food issue was brought up in the Resident Council meeting. Review of the April, May, and June 2022, Coastside Resident Council Minutes (RCM), indicated the following: On 4/28/22, it indicated, the hamburger patty was crispy and burned and the food was served too hot. On 5/26/22 indicated, the cold food is served hot and hot food is served cold. On 6/23/22 indicated, food is served too hot. In an interview, on 7/20/22, at 9:32 AM, the Dietary Staff (DS) 9 stated, the facility used a high heat disposable plates and dinex coffee mugs. In a group interview, on 7/20/22 at 12:18 PM, with the Physician 1, Chief Nursing Officer (CNO), Director of Nursing (DON), Infection Preventionist (IP) 2, 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 interviews and record reviews, the Skilled Nursing Facility (SNF) failed to ensure that staff educated and documented in residents medical records education regarding the risk and benefits of vaccinations, for one out of 33 sampled residents, Resident 35. This failure had a potential to expose Resident 35 to lack of information needed to make informed choices regarding immunization, increasing Resident 35 to the likelihood of suffering from adverse events (unanticipated injuries, harm, death or risk of infectious diseases) related to infectious diseases, and compromising her health and safety. Findings: During a review of Resident 35's record titled Inpatient Record dated 2/4/22, the Inpatient Record indicated that Resident 35 was a [AGE] years old female admitted to the SNF on 4/10/2. The SNF admitted Resident 35 with diagnoses that included hypertension, depression and anxiety. During a review of Resident 35's document titled Consultation Report dated 12/21/20, the Consultation Report indicated that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement its policy and procedure to ensure all staff were fully vaccinated for COVID-19 (a new infectious viral disease that can cause respiratory illness) when: 1. There was no evidence proof of vaccination were obtained for four (4) facility staff (Staff 1, Staff 2, Staff 3 and Staff 4). 2. Staff vaccination rate was less than 100%. Failure to track and document COVID-19 vaccination status of all staff could potentially increase risk of spreading infection in the facility. Findings: 1. Review of facility document, titled COVID-19 Staff Vaccination Status, dated 2/7/22, and concurrent interview with Infection Preventionist (IP), on 2/09/22 , at 2 PM, indicated four staff was not vaccinated without exemption/delay. IP acknowledged the findings. IP was not able to provide evidence/proof vaccination for the four staff. Review of facility policy and procedure, titled Policy Concerning Required COVID-19 Vaccinations, no date, indicated I. Policy AHMC…

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.