Golden Heights Healthcare

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure nursing staff had the knowledge and competency to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of one of three sampled residents (Resident 1) when: 1. Two Certified Nursing Assistants (CNA) failed to recognize inappropriate use of restraint after observing Resident 1's hand was tied to her bed; and 2. Two nursing staff (Licensed Vocational Nurse [LVN] and CNA) were unaware that they could report instances or allegations of abuse to the state agency (which is CDPH - California Department of Public Health) and the local Ombudsman's Office. These resulted in failure to recognize a situation that could indicate abuse and placed the residents' safety at risk. Findings: 1. Resident 1 was admitted on [DATE] and was readmitted on [DATE], with diagnoses that include dysphagia (difficulty swallowing), dementia (impairment in the ability to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from the use of physical restraint (any device, equipment or material that cannot be easily removed by the resident and limits his/her freedom of movement or normal access to his/her body) for discipline purposes and staff convenience when CNA (Certified Nursing Assistant) 1 placed a mitten on Resident 1's right hand and tied her right hand to her bed. This failure had the potential to cause physical harm, pain or mental anguish to Resident 1. Findings: Resident 1 was admitted on [DATE] and was readmitted on [DATE], with diagnoses that include dysphagia (difficulty swallowing), dementia (impairment in the ability to remember, think, or make decisions that interferes with doing everyday activities), rheumatoid arthritis (chronic swelling and tenderness of joints and other parts of the body), and osteoarthritis (degenerative joint disease, in which the tissues in the joint break…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 report an allegation of abuse to the California Department of Public Health (CDPH) and the local Ombudsman within the required two-hour period for one of three sampled residents (Resident 1) when CNA (Certified Nursing Assistant) 1 placed a mitten on Resident 1's right hand and tied her right hand to her bed. This failure had the potential to cause delay in the abuse investigation and increased risk of harm to the residents by placing Resident 1 at risk for potential repeated abuse, and other residents at risk for potential abuse. Findings: Review of the facility's Event Investigation Summary (EIS), dated 1/24/24, indicated that Resident 1 was found by staff to have her right hand bound with a mitten, surgical gloves, plastic bag and loosely secured to the side rail of her bed to prevent the resident from pulling her Nasogastric Tube (NGT - a feeding tube that goes through the nose, down the throat, and into the stomach to deliver formula or medicine)…

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

Based on observation, interview, and record review, the facility failed to implement its infection control and prevention practices during a COVID-19 (an infectious disease caused by the SARS-CoV-2 virus) outbreak when: 1. The Licensed Nurse 1 (LN1) did not wash hands before wearing gloves and before entering the room of four residents, Resident 1 (R1), Resident 2 (R2), Resident 3 (R3) and Resident 4 (R4), who were on transmission-based precautions (TBP - used in addition to standard precautions for patients who are known or suspected infections with pathogens that can be transported by airborne, droplet, or contact routes). 2. The LN1 did not remove the surgical mask and put on an N95 respirator (a respiratory protective device designed to protect against particulate matter such as dust, fumes, mists, aerosols, and smoke particulates) and face shield (to protect eyes, nose, mouth and face from flying objects and liquids) before entering the room of four residents, R1, R2, R3, and R4, who were on TBP. 3. The door of the room of four residents, R1, R2, R3, and R4 was left wide open…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 behavioral monitoring for one of three residents reviewed. (Resident 1) This failure had resulted to Resident 1 had eloped from the facility on 7/03/23 sustained mid nose abrasion and then was sent to acute hospital for evaluation. Findings: During record review of Resident 1 ' s clinical record, Resident 1 was admitted on [DATE] with diagnoses of congestive heart failure (heart cannot supply enough blood for the body), dementia (memory loss), metabolic encephalopathy (brain dysfunction due to metabolism). Review of Resident 1 ' s care plan dated 6/12/23 addressing falls indicated Monitor every two hours Review of Resident 1's treatment administration record dated 6/2023, indicated there was no evidence of documentation Resident 1 was monitored every two hours. Interview with director of nursing (DON) on 9/01/23, at 2:45 pm, DON acknowledged that there was lack of documentation that Resident 1 was monitored every two hours. During interview with…

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

Based on interview and record review, the facility failed to provide food prepared in a form designed to meet resident's individual needs for one of three residents reviewed (Resident 2). This failure had the potential to result to Resident 1's choking accident. Findings: During review of Resident 2's clinical record, indicated, Resident 2 was admitted with diagnoses included dementia (memory loss), anxiety (feeling of fear) and dysphagia (difficulty of swallowing). During an interview with registered nurse 2 (RN 2) on 8/08/2023 at 2:37 PM, RN 2 stated that there were times facility staff were not serving the appropriate meal because it was not matched to the meal ticket. Sometimes the physician changes the diet order after hours however the dietary supervisor do not update on their system. During review of the speech therapist note dated 3/24/2023, indicated discharge recommendations, Diet- Mechanical Soft textures, Thin liquids To facilitate safety and efficiency, it is recommended the patient use the following strategies and/or maneuvers during oral intake: general swallow…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 food preparation observations, dietary management staff interview and departmental document review, the facility failed to ensure correct portioning for greater than 90 residents when the dessert for the noon meal was not prepared using the proper scoop size. Consistently providing incorrect food portions may result in over or undernutrition further compromising medical status. Findings: During general food production observations on 07/17/23 at 09:17 AM, Dietary Staff 1 was portioning butterscotch pudding, the noon dessert, into individual bowls using a scoop with an ivory handle. In a follow up observation and interview, in the dish room, on 07/17/23 at 10:20 AM, with the Director of Food Services (DFS) it was noted there was a clean/sanitized ivory scoop drying on the wire rack. The DFS identified the scoop size as a #10, which equated to a serving size of 3 ounces. Review of facility document titled Daily Spreadsheet dated 07/17/23 guided staff to utilize a #8 scoop, which would have equated to 4 ounces of dessert.

Based on meal distribution observation, interview and departamental record review, the facility failed to ensure resident meals were palatable when residents complained about the taste and temperature of served meals. Findings: 1. During the Resident Council Meeting on 7/18/23 at 2:00 PM in the dining room, there were eight residents present. Observed all residents were verbal, but only six were actively participating. During interview on question number 12, (Do you receive snack at bedtime ) Resident 74 stated, today, I complained the first time. The food was cold. Did you get the pizza? Resident 51 responded, today was the worst food. Pizza? If that's what you call it Resident 4 stated, sometimes the food comes in late, especially breakfast. Lunch almost quarter to 1. Their food is very good except today. Today, I have cold scrambled egg. Resident 74 stated, they have a problem in the kitchen. The dishwasher is broken. We get plastic fork and disposable plates. My doctor ordered milk, I was told 'will get it for you, but I didn't. I'm a diabetic. I have milk for midnight snack. 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, interview, and record review, the facility interdisciplinary team failed to complete a self-administration of medications assessments for three of three sampled residents (Residents 39, 10, and 68) when: 1. A bottle of cough medicine was in plain sight on the overbed table next to the resident's bed, a bottle of vitamin D and other numerous medication bottles was at the foot of the bed of Resident 39; 2. A bottle of vitamin D, a bottle of trubiotic (supplement used for healthy stomach and bowels), was in plain sight in the open bedside cabinet, and an albuterol inhaler and 2 bottles of vitamin c was on the overbed table of Resident 10; 3. A bottle of olapatadine eye drops (used for treatment of itchy eyes), a bottle of pataday eye drops (used for relief of itchy eyes), a tube of diclofenac (used for relief of pain), a bottle of fluocinolone (used to treat skin conditions), and a tube of aspercreme (used for relief of pain) was in the open bedside drawer of Resident 68. This failure had the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure one of three (3) sampled residents (Resident 1) was provided with reasonable accommodation when the resident's request to fix the uneven arm rest of his power wheelchair was not followed through by the staff. This deficient practice had the potential to negatively impact the resident's quality of life and may place resident at risk of harm. Findings: Review of the admission Record, dated 7/20/23 indicated, Resident 1 was admitted to the facility on [DATE]. Review of the admission History and Physical, dated 6/21/23 indicated, Resident 1 was discharged form an acute care hospital to the facility, with a history of bilateral above knee amputation (AKA, removal of both legs above the knee) status post motor vehicular accident in 1987, was wheelchair bound, neurogenic bladder (lack bladder control) with suprapubic catheter (drainage tube into the urinary bladder) and sacral wound, admitted for wound care. In an observation and interview…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 complete a baseline care plan (BCP) for one of three sampled resident (Resident 92) when there was no evidence of documentation of a completed baseline care plan. A BCP includes minimum healthcare information necessary to properly care for each resident immediately upon their admission, which would address resident-specific health and safety concerns to prevent decline, injury, such as elopement or fall risk, and would identify needs for supervision, behavioral interventions, and assistance with activities of daily living, as necessary. This deficient practice had the potential to result in inadequate care and services rendered to the resident. Findings: A review of the face sheet indicated Resident 92 was admitted with diagnoses included diabetes mellitus (abnormally high blood sugar level) and gangrene (a serious condition where a loss of blood supply causes body tissue to die). During an interview on 7/21/23, at 2:25 PM, the Assistant Director of Nursing acknowledged that there was no evidence of documentation of a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to develop and to implement the Care Plans (CP, a road map for patient care) and CP interventions for five (5) of 23sampled residents (Residents 85, 20, 35, 92, and 66) when: 1. Resident 20 did not have a care plan to address the wound on the left leg; 2. Resident 85 did not have a care plan to address the contractures to both upper extremities (arms); 3. Resident 35 did not have a care plan to address the assistance required during meals; 4. Resident 92 did not have a care plan to address the left leg gangrene (tissue death caused by an infection or lack of blood flow). 5. For Resident 66, the staff did not implement the Care Plan intervention to notify the Physician and the Registered Dietitian (RD) of the significant weight loss of 8-9 % in two weeks, on 4/23. These deficient practices had the potential to place residents health and well-being at risk of harm. Findings: 1. A review of the face sheet indicated Resident 39 was admitted with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure the resident's Care Plan was updated /revised for one of three (3) sampled residents (Resident 66) when, the CP Interventions to address weight loss did not include the recommendations made by the Registered Dietitian (RD). Failure to revise/update the CP had the potential to delay the care and services, cause miscommunication among caregivers, and cause further decline in the resident's health and well-being which could further compromise her medical condition. Findings: Review of the admission Record, dated 7/20/23 indicated, Resident 66 was admitted to the facility on [DATE]. The admission History and Physical, dated 3/24/23 indicated, the diagnoses that included left femoral hip fracture (break in the thighbone [femur] of the hip joint), end stage renal disease (kidneys no longer function well enough to meet the body's needs of daily life) on Hemodialysis (HD, treatment to filter wastes and water from the blood), and anemia (too…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide supervision and assistance during meals for one of three sampled residents (Resident 35) when staff did not provide supervision and assistance to Resident 35 during lunch. This failure had resulted to Resident 35 had not adequately consumed her meal. Findings: A review of the face sheet indicated, Resident 35 was admitted with diagnoses including dementia (decline in memory and/or decision-making ability). Review of Resident 35's MDS dated [DATE], BIMS score of 3 indicated severe cognitive impairment. Functional status indicated Resident 35 required one-person physical assist with eating (how resident eats and drinks). During observation on 7/17/23, at 12:31 PM, CNA 1 placed the lunch tray on the overbed table and removed the lid off the plate and handed a fork to the resident. Resident 35 used the fork and reached for her plate twice. At 12:37 PM, Resident 35 stopped eating, put down the fork and closed her eyes. Resident 80…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide treatment and services for one of three residents reviewed, to address the contractures of both upper extremities (BUE, both arms) for Resident 85. This failure had the potential to result to reduced functional range of motion for activities of daily living. Findings: A review of the face sheet indicated Resident 85 was admitted with diagnoses included anoxic (lack of oxygen) brain damage and epilepsy. Review of Resident 85's MDS dated [DATE] BIMS score indicated severe cognitive impairment. Functional status indicated resident required two persons physical assist with bed mobility, dressing and toilet use. During observation and interview on 7/17/23, at 10:10 AM, Resident 85 was in bed, lying on her back, and had her eyes closed. She has no responses when talked to. Nurse Assistant (CNA, care giver) 1 stated, my both arms are contracted. She is on hospice. A review of the physician (Medical Doctor), MD) order for month of 7/2023,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, it was evident that the facility failed to secure the services of a licensed pharmacist who could provide comprehensive consultation on all aspects of pharmacy services. This lapse was demonstrated by the fact that the monthly medication passes consistently returned medication error rates exceeding 5%, and there was no noticeable improvement over time. Findings: During a medication pass observation conducted on 7/18/23 between the times of 7:00 AM to 9:00 AM three medication errors were observed out of twenty-five opportunities, resulting in an error rate of 12%. The three errors occurred between 3 out of 4 nurses administering medications (see F759). A review on 7/18/23 of the Pharmacy Services Agreement, which is a contract between the nursing home and the pharmacy, indicated that under Exhibit 'B', the pharmacy would provide a monthly review and observation of medication pass from the facility to a resident. A review on 7/18/23 of the Summary of Nursing Consultant Service which indicated medication pass observation for February, March, April,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 observations, interviews, and a review of records, it was found that the facility failed to maintain a medication error rate of less than 5%. During the medication pass, three medication errors were observed out of twenty-five opportunities, resulting in an error rate of 12%. Findings: 1. The manufacturer of Flonase, GlaxoSmithKline, provides the following instructions for administering the drug: *Gently blow your nose to clear your nostrils. *Place the tip of the nozzle in one nostril and close the other nostril with your finger. *Aim slightly away from the center of your nose, press the white nozzle and sniff the mist in gently. Be careful not to spray into your eyes! *Exhale through your mouth. *Repeat if your dosage calls for two sprays. *Repeat the entire process in the other nostril. *Wipe the nozzle clean with a tissue and replace the green cap. A review on 7/18/23 of Resident 44's physician's orders indicated Flonase nasal spray 2 sprays in both nares daily. Flonase is a nasal spray that contains fluticasone propionate, which is a corticosteroid that prevents 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 food production observations, dietary staff interview and departmental document review the facility failed to ensure 2 staff members (Dietary Staffs [DS] 2 and 3) were competent in position associated functions when 1) DS 2 failed to follow the standard of practice for the preparation of pureed food items. Failure to ensure proper food preparation, utilizing standardized recipes may result in compromising the nutritional status of resident; and 2) DS 3 did not take food temperatures in accordance with food safety standards. Failure to fully follow food safety standards may result in providing residents with food that is not properly cooked and/or held and may result in foodborne illness and poor meal quality. Findings: 1. During general food production observations, in the contract kitchen, and concurrent interview on 07/17/23 10:30 AM, Dietary Staff (DS) 2 was preparing pureed sugar cookies for the evening dessert. DS 2 placed multiple handfuls of 2-1/2-to-3-inch cookies in the blender. The surveyor estimated the cookie count as 20-25. DS 2 then proceeded to add…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 meal plating observations, dietary management staff interview the facility failed to ensure meals were plated in accordance with physician ordered therapeutic diets. Failure to comprehensively follow physician ordered diets may result in further compromising patient medical status. Findings: During meal plating observation on 7/17/23 beginning at 11:45 a.m., Dietary Staff (DS) 4 was designated as the starter. DS 4 was observed preparing the meal tray by placing cutlery and napkins on the tray. Additionally, the responsibility of the starter position was to verbally communicate the physician ordered diet to the cook as well as any food dislikes/preferences for the entrée plate. It was noted DS 5 did not accurately communicate the diet order. Resident 11's physician ordered diet was listed as pureed diet, double protein portion. DS 4 did not call all the full diet, eliminating the double protein portion, therefore Resident 11 received a regular pureed diet. It was also noted DS 3 was at the end of the trayline double checking meal trays, however, did not identify 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 meal distribution observations the facility failed to maintain food sanitation when staff returned soiled meal trays to the patient tray cart while unpassed meal trays remained in the cart. Findings: During dining observation, in the 100-109 hallway, on 7/17/23 beginning at 12:35 PM it was noted a nursing staff member placed two soiled patient meal tray in the same area as unpassed resident meal trays. It was noted Licensed Nurse 2 (LN 2) guided staff to place the tray in the narrow right sight of the patient meal cart. In a concurrent interview LN 2 stated his function was to check meal trays for proper texture and fluid thickness in accordance with physician's diet order. In a follow up meal distribution observation on 7/18/23 at 12:35 PM the patient meal cart was delivered to the 210 hallway. In a concurrent interview with Licensed Nurse (LN) 2 stated there was only one meal cart for clean and soiled trays and nursing staff should be holding onto soiled trays until all resident meals were passed and the cart was empty. In a phone conversation with the Administrator on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and records review, the facility failed to monitor the hospice services provided by the hospice agency for one of three residents reviewed, Resident 58, when the hospice agency did not comply with their consented number of weekly visits to Resident 58. This failure resulted in the resident looking unkempt, dry, ashy, dishelved and angry. Findings: The Minimum Data Set (MDS) dated [DATE], indicated that resident was admitted in the facility on 6/18/23 with diagnosis which includes encounter for palliative care (an interdisciplinary medical caregiving approach aimed at optimizing quality of life and mitigating suffering among people with serious complex, and often terminal illnesses), complete intestinal obstruction (significant mechanical impairment or complete arrest of the passage of contents through the intestine due to pathology that causes blockage of the bowel), chronic kidney disease stage 4 (that the kidneys are moderately or severely damaged and are not working as well as…

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

Based on observation, interview, and record review the facility failed to implement its policy and procedure on infection control and standards of practice, titled fraser health, for two of 19 sampled residents (Resident 39 and 90) when: 1. For Resident 39, 1a. The wound vac connecting tubing was in plain sight uncovered, lying on the floor. 1b. The used, dirty pair of scissors was used to cut the clean foam wound dressing. 1c. The overbed table was not cleaned and disinfected. 2. For Resident 90, the yankauer suction (an oral suction device) and its connecting tubing was undated, unlabeled and not changed (every week) as per Standard of Practice. These deficient practices had the potential to place residents at risk of exposure to healthcare acquired infections (HCAI, infections acquired while residents are receiving health care in a facility for another condition) and cross contamination (transfer of bacteria or other microorganisms from one substance or surface to another). Findings: 1a. A review of the face sheet indicated Resident 39 was admitted with diagnoses included…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 establish a system of records of receipt and disposition of all controlled drugs (is generally a drug or chemical whose manufacture, possession, or use is regulated by a government) in sufficient detail to enable an accurate reconciliation. This deficient practice had the potential for diversion of controlled medications. Findings: During an observation of medication room and concurrent interview with the Director of Nursing (DON), on 11/22/19, at 8:37 AM, DON stated that licensed nurses gave the discontinued controlled medications to her upon resident's discharge or death. DON stated she kept the controlled medications in a locked cabinet in the medication room. DON opened the locked cabinet and found 5 discontinued controlled medications. The two medications belonged to Resident 34, were as follows: - morphine 20 mg/ml (milligrams/milliliters) solution bottle - lorazepam 0.5 mg (milligrams) tablet blister pack Review of Resident 34's clinical record, titled, ANTIBIOTIC OR CONTROLLED DRUG RECORD FOR LIQUIDS…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 prepare food under sanitary conditions when one kitchen staff member (KS) did not perform hand washing after picking up a pot that had fallen on the floor and before handling clean cookware used during food preparation. This failure had the potential to contaminate food served to the residents placing them at risk for food borne illnesses. Findings: During an observation in the kitchen with the Dietary Services Supervisor (DSS) on 11/20/19 at 9:28 AM, during pureed food preparation, the KS, with gloved hands, placed a tray of cooked meat loaf patties on the kitchen countertop. On the same countertop, there were also a blender and a pot. After placing the tray of meat loaf on the countertop, the KS reached for the pot. While reaching for the pot, the pot fell on the floor. The KS picked up the pot from the floor and placed it on a rack. Without performing hand washing and changing gloves, the KS took a clean pot from another rack and placed it on the countertop with the tray of cooked meat loaf patties. The KS…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 store garbage properly when the compost dumpster was not covered. This failure had the potential for rodents and insects to access the garbage which could potentially expose the residents to serious health risks. Findings: During an observation and concurrent interview with the Dietary Services Supervisor (DSS) on 11/20/19 at 9:51 AM, the facility compost dumpster was located outside the kitchen. The compost dumpster was unattended and had one of its two lids opened and flipped upwards. The DSS acknowledged the observation and stated that the compost dumpster should be fully closed for infection control. Review of the undated facility policy titled, Food-Related Garbage and Rubbish Disposal, indicated, . Policy statement . Food-related garbage and rubbish shall be disposed of in accordance with current state laws regulating such matters . Policy Interpretation and Implementation . 2. All garbage and rubbish containers shall be provided and must be kept covered when stored or not in continuous use . 7. Outside…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 care plan for four of 19 residents when: 1. Resident 55 did not have a care plan for infection 2. Resident 72 did not have a care plan for infection 3. Resident 334 did not have a care plan for methicillin resistant staphylococcus aureus infection (MRSA infection - bacterial infection that is difficult to treat because of resistance to some antibiotics). 4. Resident 64 did not have a care plan for Divalproex (a medication used to treat manic behaviors) This deficient practice increased the risk of infection for Resident 55, Resident 72, and Resident 334. For Resident 64, this deficient practice raised the likelihood of the resident experiencing adverse effects from Divalproex. Findings: 1. During a concurrent observation and interview with Resident 55 (via translator), Certified Nursing Assistant (CNA) 2, and Licensed Vocational Nurse (LVN) 2, on 11/18/19, at 10:28 AM, in the bedroom of Resident 55, Resident 55 sat in bed next to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the medication error rate was less than 5%. For four of five residents (Resident 38, 26, 64 and 41) observed during medication passes, there were 9 errors in 29 opportunities which resulted in a medication error rate of 31.03%. 1. For Resident 38, (a.) folic acid and vitamin B 12 were not given according to physician's order and (b.) dorzolamide and brimonidine eye drops were not given according to professional standards of practice. 2. For Resident 26, the atenolol was not given according to physician's orders. 3. For Resident 64 , fluphenazine and fluticasone nasal spray were not given according to physician's orders. 4. For Resident 41, metoprolol and senna were not given according to professional standards of practice. This deficient practice had the potential for the medications to be ineffective and cause untoward effects on the residents. Findings: 1.a. Resident 38 was admitted on [DATE] with diagnoses that included vitamin…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 2 of 19 sampled residents (Resident 26 and 38) were free from any significant medication error when medications were not given according to physician's order. This deficient practice had the potential to cause Resident 26 and 38 discomfort and jeopardize their health and safety. Findings: 1. Resident 26 was admitted on [DATE], with diagnoses that included diabetes (high blood sugar), cerebral infarction (or stroke, is a brain lesion in which a cluster of brain cells die when they don't get enough blood), atrial fibrillation (an irregular and often rapid heart rate that can increase the risk of strokes, heart failure and other heart-related complications), and hypertension (high blood pressure). Review of Resident 26's clinical record titled, Minimum Data Set (MDS, a resident assessment tool), dated 8/27/19, indicated a Brief Interview for Mental Status (BIMS, a brief assessment to help detect cognitive impairment) score of 10,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 safe and secure medication storage when: 1. The facility stored medical supplies past expiration date including syringes and gloves in the medication room. 2. The facility did not ensure the medication room was accessed only by authorized staff. This deficient practice had the potential for unsafe medication administration and loss or diversion of all medication. Findings: 1. During an observation of the medication room and concurrent staff interview on [DATE] at 1:35 PM, the following expired items were found inside the medication room: - 35 pieces of 5 milliliter (ml) syringes with expiration date of 11/2018 - 22 pieces of enteral feeding flat top piston syringe with expiration date of 2/2016 - 7 pieces of latex exam gloves with expiration date of 2/2015 - 83 pieces of expired 12 powder-free nitrile exam gloves with expiration date of 10/2016 Registered Nurse (RN) 3 acknowledged the above findings. RN 3 stated that the staff…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 safe storage and consumption of food brought in by visitors when unlabeled leftover food items were found in the rooms of three of 80 residents (Resident 331, 333, and 50). This failure had the potential for the residents to consume food that was potentially expired and could cause foodborne illnesses (an infection caused by consuming food or drink contaminated with disease-causing germs). Findings: During a review of the clinical record for Resident 331, the admission Record dated 11/21/19 indicated Resident 331 was admitted on [DATE] with diagnoses including dysphagia (difficulty swallowing) and end stage renal disease (a condition in which the kidneys no longer function normally). During an observation on 11/18/19 at 10:16 AM, Resident 331 was in bed, asleep. A visitor was in Resident 331's room. There was a clear plastic box containing several pieces of white round food items and an item wrapped in aluminum foil found 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 maintain appropriate infection prevention control and practices when: 1. The medication tray and medication cart was not disinfected properly between patient use. 2. A staff's jacket was found hanging in the medication room storage. This deficient practice had the potential for spread of infection within the facility including residents and visitors. Findings: 1. During medication pass observation on 11/20/19, at 8:42 AM, and concurrent interview, Licensed Vocational Nurse (LVN) 2 put the medication tray on top of Resident's 38's overbed table. After administering Resident 38's medications, LVN 2 exited the room and placed the medication tray on top of the medication cart. Then, LVN 2 grabbed a disinfecting wipe and wiped the top of the medication tray. LVN 2 did not wipe the bottom of the medication tray and the top of the medication cart. LVN 2 proceeded in preparing Resident 15's medications using the same medication tray. LVN 2 acknowledged the above findings and stated, I should also wipe the bottom of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a Minimum Data Set (MDS - a resident assessment tool), for one of 19 sampled residents (Resident 1), was submitted in a timely manner when the MDS dated [DATE] for Resident 1 was not submitted until [DATE]. This deficient practice had the potential to misrepresent the current condition of Resident 1. Findings: During a concurrent interview and record review with MDS Coordinator and MDS Consultant, on [DATE], at 11 AM, MDS Coordinator and MDS Consultant reviewed the medical record for Resident 1 and stated Resident 1 expired in the facility, on [DATE]; however, MDS Coordinator and MDS Consultant, could not find any records of an MDS for Resident 1 in the resident's medical record. MDS Coordinator stated the MDS records for the resident would be in the previous computer software. MDS Consultant added Resident 1 resided in the facility before the facility transitioned its current electronic system in August, 2019; therefore, their MDS record was in…

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

Based on interview and record review, the facility failed to accurately document the Minimum Data Set (MDS - a resident assessment tool) for one of 19 residents (Resident 82) when the MDS for Resident 82, dated 9/21/19, indicated Resident 82 was discharged to the hospital instead of the community. This deficient practice had the potential to misrepresent the discharge location of Resident 82. Findings: A review of the medical record for Resident 82 indicated the resident received care in the facility between 9/9/19 and 9/21/19; Resident 82 was discharged to the community with home health, on 9/21/19. A review of the discharge MDS for Resident 82, dated 9/21/19, indicated the resident was discharged to the hospital. During a concurrent record review and interview with the MDS Coordinator, on 11/21/19, at 11:35 AM, MDS Coordinator reviewed the medical record of Resident 82 and stated the resident was discharged home. MDS Coordinator then reviewed the MDS of Resident 82, dated 9/21/19, and stated The discharge MDS says [Resident 82 was] discharged to hospital, but this is not the case…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 services provided by the facility met professional standards of quality when Licensed Vocational Nurse (LVN) 2 did not administer eye drops to Resident 38 according to professional standards. This deficient practice had the potential to compromise the effectiveness of the medication which could result in Resident 38 not receiving the full benefits of the medication. Findings: Resident 38 was admitted on [DATE] with diagnoses that included dementia (group of symptoms associated with a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities) and glaucoma (a condition that damages the eye's optic nerve and cause vision loss). During a medication pass observation on 11/20/19 at 9:07 AM, LVN 2 administered one drop of dorzolamide ophthalmic solution to both eyes of Resident 38, then, at 9:09 AM, LVN 2 administered one drop of brimonidine ophthalmic solution to both eyes of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, for one of 19 sampled resident (Resident 73), there was no documentation the pharmacy consultant identified significant drug-drug interactions for Resident 73's medications. This deficient practice had the potential for Resident 73 to receive unnecessary drugs which could lead to untoward effects affecting Resident 73's mental, physical, functional, and psychosocial status. Definitions: Adverse consequence is a broad term referring to unwanted, uncomfortable, or dangerous effects that a drug may have, such as impairment or decline in an individual's mental or physical condition or functional or psychosocial status. It may include various types of adverse drug reactions and interactions (e.g., medication-medication, medication-food, and medication-disease. Medication Interaction is the impact of another substance (such as another medication, herbal product, food or substances used in diagnostic studies) upon a medication. The interactions may alter absorption, distribution,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 monitor for specific target behavior/s (actual undesirable/unwanted behaviors that occur as a result of the medical condition) for the use of Divalproex (a medication used for treatment of manic behaviors) for one of two sampled residents (Resident 64). This failure placed Resident 64 at risk of continued use of medications without adequate indication for use, adequate monitoring, or performing gradual dose reductions, which can subsequently put the resident at risk for harm related to unnecessary psychotropic medication (any drug capable of affecting the mind, emotions, and behavior) use. Findings: During a review of the clinical record for Resident 64, the admission Record dated 11/21/19, indicated Resident 64 was admitted on [DATE] with diagnoses including bipolar type schizoaffective disorder (a mental disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms,…

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