Capistrano Beach Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the resident remained free from accident hazards for one of 23 final sampled resident (Resident 2). * The facility failed to ensure Resident 2 was supervised in Shower room [ROOM NUMBER]. In addition, Shower room [ROOM NUMBER] had no call system available to call the staff for assistance if needed. These failures had the potential to place the resident at risk for accidents and serious injury.Findings: Review of the facility's P&P titled Bath, Shower/Tub revised 2/2018 showed to never leave the resident unattended in the tub or shower and to use the emergency call signal for assistance, if needed. Review of the facility's P&P titled Call System, Residents dated 9/2022 showed the residents are provided with a means to call the staff for assistance from his/her bed and from toileting/bathing facilities through a communication system that directly call a staff member or a centralized workstation. 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, facility document and P&P review, the facility failed to ensure the acceptable parameters of nutritional status were maintained for one of four final sampled residents (Resident 72) ) reviewed for nutrition status. * The facility failed to ensure the nutritional assessment was completed when Resident 72 weighed 174 pounds (lbs) on 4/8/25. In addition, the facility failed to monitor Resident 72's weight and implemented interventions to address Resident 72's severe weight loss. * The facility failed to conduct a nutritional assessment in a timely manner when Resident 72 weighed 160 lbs on 8/4/25. In addition, the facility failed to closely monitor Resident 72's weight. * The facility failed to ensure the nutritional assessment was completed when Resident 72 weight 155 lbs on 10/3/25. In addition, the facility failed to monitor Resident 72's weekly weights as ordered by the physician. These failures contributed to Resident 72's severe weight loss of 45 lbs/22.50% since admission on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care and services for two of two final sampled residents (Residents 13 and 14) reviewed for oxygen therapy. * The facility failed to ensure Resident 13 received oxygen therapy as ordered by the physician's order. * The facility failed to ensure the oxygen tubing for Resident 14 was labeled with the date. These failures had the potential for the residents not to receive the appropriate respiratory care and may negatively impact the residents' medical conditions.Findings: Review of the facility's P&P titled Oxygen Administration revised 10/2010 showed under the preparation section, to verify there is a physician's order for this procedure and to review the physician's orders or facility protocol for oxygen administration. Oxygen therapy is administered by way of an oxygen mask, nasal cannula, and/or nasal catheter. The nasal cannula is a tube that is placed approximately…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to provide the pharmaceutical services to meet the resident's needs for three of three final sampled residents (Resident 2, 20, and 69) reviewed for the unnecessary medications. * The facility failed to ensure the insulin (medication to lower the blood sugar) injection administration sites were rotated for Residents 2 and 20. * The facility failed to ensure the Zosyn (antibiotic) IV medication was administered to Resident 69. These failures had the potential for the residents to not receive the necessary medications and could negatively affect the residents' well- being. Findings: Review of the facility's P&P titled Insulin Administration revised on 9/2014 showed the following: - to provide guidelines for the safe administration of insulin to residents with diabetes; - select an injection site. Insulin may be injected into the subcutaneous tissue of the upper arm and anterior or lateral areas of the thighs and abdomen. Avoid…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of three residents (nonsampled resident, Resident 40) observed for medication administration was free from the significant medication errors. * LVN 5 did not check the resident's pulse rate prior to the administration of the metoprolol (a medication to lower blood pressure) to Resident 40. This failure had the potential to negatively impact the resident's health and well-being.Findings: Review of the facility's P&P titled Administering Oral Medications revised 10/2010 showed to verify that there is a physician's medication order for this procedure and perform any pre-administration assessments. On 10/1/25 at 0828 hours, a medication administration observation for Resident 40 was conducted with LVN 5. LVN 5 was observed checking Resident 40's blood pressure prior to the medication administration, then prepared Resident 40's medications including the metoprolol 12.5 mg one tablet. The metoprolol…

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

Based on observation, interview, and facility P&P review, the facility failed to ensure the medications/supplies in the medication room and medication cart were store properly. * The facility failed to ensure the expired Covid-19 Binax Now (a test to detect Covid-19) were removed from Medication Room A. In addition, the facility failed to ensure the oral medications were stored separately from the externally used medications. * The facility failed to ensure the expired bottles of the 0.9% normal saline solutions were removed from Medication Cart A. These failures had the potential for medication errors and the use of the expired medications/supplies which could negatively impact the residents' well-being.Findings: Review of the facility's P&P titled Medication Storage in the Facility (undated) showed the outdated, contaminated or deteriorated medications and those in containers that are cracked, soiled or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy, if a current order exists,…

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

Based on observation, interview, and facility document review, the facility failed to employ a staff with the skills and abilities to effectively implement the departmental processes in accordance with standards of practice in the food services department. * The facility failed to ensure the Dietary Manager was competent in managing the day-to-day functions of the food services department. This failure had the potential to jeopardize the health and well-being of the 77 residents who received food prepared in the kitchen.Findings: Review of the facility's Matrix showed 77 residents consumed food prepared in the kitchen. Review of the facility's document titled Dietary Manager dated 6/25/24, the section for Position Summary showed the purpose of your job position is to organize, plan and supervise the dietary department functions in accordance with current applicable federal, state, and local standards that govern the facility and as directed by the Administrator and Dietitian. During the annual recertification survey from 9/29 to 10/1/25, 11/17, and 11/18/25, multiple issues were…

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

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure one of 14 kitchen staff members (Cook 2) had the appropriate skill set necessary to safely perform the manual dishwashing. * The facility failed to ensure [NAME] 2 was competent to describe or demonstrate the manual dishwashing process. This failure had the potential for the residents' dishes to not be washed correctly which could lead to sanitation concerns.Findings: Review of the facility's P&P titled 3-Compartment Procedure for Manual Dishwashing dated 2023 showed the following:- The first compartment is for washing. Fill the first compartment with detergent per manufacturer's instructions and hot water (110 to 120 degrees Fahrenheit);- The second compartment is for rinsing. Fill the second compartment with clean, clear hot water (110 to 120 degrees Fahrenheit); and- The third compartment is for sanitizing. Fill the third compartment with Sani Tech solution (a cleaning solution) from the dispenser. Test the concentration with the appropriate test strip, which 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 observation, interview, and facility document review, the facility failed to ensure the menu to meet the resident's nutritional needs was followed for one of 77 residents (Resident 23). * The facility failed to ensure Resident 23 was provided with the high caloric pudding and whole milk on her lunch tray. This failure had the potential to not meet the resident's nutritional needs.Findings: Review of the facility's Matrix showed 77 residents consumed food prepared in the kitchen. On 9/29/25 at 1238 hours, during the dining observation, Resident 23's lunch meal ticket showed Resident 23 was on a controlled carbohydrate diet with pureed texture. The meal ticket indicated for Resident 23 to have a high caloric pudding and 8 fluid ounces of nectar - mildly thick whole milk. However, Resident 23's lunch tray did not contain the high caloric pudding and whole milk. An observation, interview and concurrent meal ticket review was conducted with the MDS Coordinator in the dining room. The MDS Coordinator verified Resident 23 was not provided with the high caloric pudding and whole…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility document review, the facility failed to ensure the food served was in accordance with the prescribed diet texture to one of 23 final sampled residents (Resident 12). * The facility failed to provide Resident 12's diet was according to the physician's order. This failure posed a risk for the resident to not tolerate the food texture and choke.Findings: Medical record review of Resident 12 was initiated on 9/29/25. Resident 12 was admitted to the facility on [DATE], with diagnoses which included COPD and dysphagia. Review of Resident 12's Order Summary Report showed a physician's order dated 9/15/25, for Regular Diet, Soft and Bite-Sized Level 6 texture, vegetarian, no salad entree and may give grilled cheese, allow regular bread and toast. Review of the facility's document titled 2023/2025 Diet Manual, the IDDSI (International Dysphagia Diet Standardization Initiative) Level 6: Soft & Bite-Sized Diet showed to avoid all raw vegetables. On 9/29/25 at 1225 hours, during…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility document review, the facility failed to ensure the resident was served a substitute meal entree that was equivalent to the nutritive value of the main meal entree for one of 23 final sampled residents (Resident 12). * The facility failed to ensure Resident 12 received a substitute meal entree equivalent to the main meal entree of three ounce baked chicken. This failure had the potential for the resident to not receive a meal to meet the resident's needs.Findings: Medical record review of Resident 12 was initiated on 9/29/25. Resident 12 was admitted to the facility on [DATE]. Review of Resident 12's Order Summary Report showed a physician's order dated 9/15/25, for Regular Diet, Soft and Bite-Sized Level 6 texture, vegetarian, no salad entree and may give grilled cheese, allow regular bread and toast. On 9/30/25 at 1227 hours, an observation of the lunch meal tray line and concurrent interview was conducted with [NAME] 1. [NAME] 1 was preparing a grilled cheese…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to ensure the adaptive equipment was used properly for one nonsampled resident (Resident 23). * The facility failed to ensure the plate guard was placed on Resident 23's plate during meals. This failure posed the risk for Resident 23 to not reach her maximum level of independence.Findings: On 9/29/25 at 1216 hours, during the dining observation, Resident 23 was observed having lunch in the dining room. Resident 23's plate guard was placed under the plate. Resident 23's meal ticket showed to have the plate guard as an adaptive equipment. Medical Record Review for Resident 23 was initiated on 9/29/25. Resident 23 was admitted to the facility on [DATE]. Review of Resident 23's Order Summary Report showed a physician's order dated 6/11/25, for the resident to have a plate guard for all meals to increase independence with self-feeding. On 9/30/25 at 1300 hours, an observation and concurrent interview was conducted with the Dietary Manager…

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 facility P&P review, the facility failed to ensure safe food handling of the food brought for the residents from the outside sources. * The facility failed to ensure the visitors who brought food for the residents from outside sources and employees who handled the outside food were educated on safe food handling. This failure poses the risk of food contamination which could lead to food borne illnesses to all 77 residents who resided in the facility. Findings: Review of the facility's P&P titled Food Brought by Family and Visitors revised on 3/2022 showed the safe food handling practices are explained to family/visitors in a language and format they understand. On 9/30/25 at 0900 hours, an interview was conducted with LVN 6. LVN 6 was asked to explain the process when the visitors would bring food for the residents from the outside sources, LVN 6 stated they would check the diet order and tell the visitors the food must be labeled. When asked for how long the food brought in from the outside source could stay in the refrigerator, LVN 6 stated he was not sure…

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

Based on observation, interview, and facility P&P review, the facility failed to ensure the refuse was stored in a sanitary manner. * The facility failed to ensure the two of two garbage dumpsters' lid and one of one recycling dumpster's lid were fully closed. * The facility failed to ensure the broken items/equipment were disposed of properly. These failures had the potential for pest contamination.Findings: According to the USDA Food Code 2022, Chapter 5 Water, Plumbing, and Waste, Section 5-501.113 Covering Receptacles showed outside garbage receptacles shall be kept covered with tight-fitting lids or covers. Review of the facility's P&P titled Miscellaneous Areas dated 2023 showed the garbage and trashcans must be inspected daily, no debris is on the ground or surrounding area, and that the lids are closed. The trash collection area is a potential feeding ground for vermin and rodents and must be kept clean. 1. On 9/29/25 at 1139 hours, an observation was conducted of the facility's outside recycling dumpster and two outside garbage dumpsters. The recycling dumpster was observed…

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 facility document review, the facility failed to ensure the Facility Assessment was complete. * The facility failed to ensure the Facility Assessment addressed or included the active involvement of required individuals in developing the Facility Assessment, a plan to maximize recruitment and retention of direct care staff, and a contingency plan for staffing needs. These failures had the potential to not meet the residents' care needs if the assessed population's needs and resources were not comprehensively identified and addressed.Findings: According to the CMS QSO-24-13-NH dated 6/18/24, with an implementation date of 8/8/24, CMS had issued a revised guidance for long-term care facility assessment requirement. The Facility Assessment should address and included the active involvement of the direct care staff in developing the Facility Assessment. Also included the staffing resources necessary to care for the residents, including the weekends; a plan to maximize recruitment and retention of direct care staff member, and a contingency plan for staffing needs…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the responsible party of one of six sampled residents (Resident 1) was informed in advance of the care that was going to be furnished and of the type of provider who would be furnishing the care to Resident 1. This failure posed the risk of Resident 1's responsible party not being able to make the informed decisions about Resident 1's care. Findings: Review of the facility's P&P titled Informed Consent revised 3/25/24, showed the facility is to uphold the rights of the residents and their responsible party to participate in the planning and decision-making process concerning the resident's care and treatment. Review of the facility's P&P titled Change in Resident's Condition or Status revised 2/2021 showed a nurse or healthcare provider will inform the resident or responsible party of any changes to the resident's medical care or nursing treatments. Medical record review for Resident 1 was initiated on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the quality care and services were provided for one of three sampled residents (Resident 4). * The facility failed to ensure Resident 4's BP was monitored for hypotension. * The facility failed to ensure the results of the CBC test were promptly reported to Resident 4's physician. * The facility failed to ensure Resident 4's urine sample was collected in a timely manner. These failures had the potential for the residents to not receive the necessary care and services to maintain their highest physical well-being. Findings: Review of the facility's P&P titledProvision of Quality Care revised 12/19/22, showed based on the comprehensive assessments, the facility will ensure the residents receive the treatment and care by qualified persons in accordance with professional standards of practice, comprehensive person-centered care plans, and resident choices. The Policy Explanation and Compliance Guidelines…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable well-being for one of three sampled residents (Resident 2). * The facility failed to ensure Resident 2 was administered Tamiflu (a medication used to treat the flu or can reduce the chance of getting the flu) as ordered by the physician. This failure had the potential to negatively impact the resident's well-being. Findings: Review of the facility's P&P titled Acute Condition Changes – Clinical Protocol revised March 2018 showed the physician will help identify individuals with a significant risk for having acute changes of condition during their stay. The nurse and physician will discuss and evaluate the situation. The physician will help identify and authorize appropriate treatments. The staff member will monitor and document the resident/ patient's progress and responses to treatment, and the physician will adjust treatment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to develop and/or implement their P&P for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act when the facility failed to report an abuse allegation in a timely manner for one of two residents sampled for abuse (Resident1). * The facility failed to ensure an allegation of physical abuse was reported timely when Resident 1 stated the pillows were put on her face by Resident 2. This failure had the potential for the abuse allegation going unreported and uninvestigated. Findings: Review of the facility's P&P titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigation revised 9/2022 showed all the allegations of abuse (including injuries of unknown origin, neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly…

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

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food safety and sanitation guidelines were followed when: * The food and beverages in the walk-in refrigerator were not discarded by the use-by date. * The appropriate hair restraints were not worn by four staff in the kitchen (The DSS, Cooks 1 and 2, and the Maintenance Supervisor). * One uncovered bucket of cleaning chemical was stored next to two containers of broth base and one container of oil. * The cooking utensils, cutting boards did not have cleanable surfaces. * One rubber spatula had white residue on the spatula and handle. * 12 baking sheets had black residue. * The trash can lid was on top of the handwashing sink * One dry goods bin with white granulated powder was unlabeled. * Two dry goods scoops, with powdery white residue, were on the food preperation counter * Two oven mitts were discolored and had frayed edges. These failures had the potential to result in foodborne illnesses for the residents receiving kitchen services. Findings: Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of six final sampled residents (Resident 7) reviewed for psychotropic use was informed of the indication for the use of psychotropic medications (medication affecting brain activities associated with mental processes and behavior). * The facility failed to ensure Resident 7's informed consent was obtained when the indication for the use of risperidone (an antipsychotic medication used for mental illness that causes disturbed or unusual thinking) was changed to racing thought. This failure had the potential for Resident 7 to not be informed of the medication and potential effects of risperidone. Findings: Review of the facility's P&P titled Psychotropic Medication Use dated 7/2023 showed the residents, families, and/or representatives are involved in the medication management process. Residents (and/or representatives) have the right to decline treatment with psychotropic medications. Medical record review for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to assess one of 21 final sampled residents (Resident 74) for their self-administration of the medications. This failure had the potential to negatively impact the residents' physiological well-being and could administer the medications inaccurately. Findings: Review of the facility's P&P titled Self-Administration of Medications revised February 2021 showed the residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. The IDT assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident. Further review of the policy showed resident who are identified as being able to self-administer the medication are asked whether they wish to do so. The policy also showed any medications found at the bedside that are…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the reasonable accommodations to meet the care needs for two of 21 final sampled residents (Residents 4 and 72). * The facility failed to ensure Residents 4 and 72's call lights were kept within the residents' reach. This failure had the potential to negatively impact the residents' psychosocial well-being or result in a delay to provide care and services to the residents. Findings: Review of the facility's P&P titled Answering the Call Light revised 9/2022, showed the purpose of this procedure is to ensure timely responses to the resident's requests and needs. Ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor. 1. Medical Record review for Resident 4 was initiated on 9/19/24. Resident 4 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 4's MDS Quarterly assessment dated [DATE],…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, facility P&P review, and facility document review, the facility failed to address and follow through with the concerns brought up in the resident council meetings (a group of residents gathered to discuss interests and issues noted in facility). * The facility failed to complete the request for the OCTA Access forms for the residents. * The facility failed to thoroughly address regarding the concerns about the CNAs' mannerisms when answering the residents. These failures had the potential for the residents' identified issues to go uncorrected. Findings: Review of the facility's P&P titled Resident Council revised 2/2021 showed the facility supports the residents' rights to organize and participate in the resident council. A Resident Council Response Form will be utilized to track issues and their resolution. The facility department related to any issues will be responsible for addressing the item(s) of concern. 1. Review of the facility's Resident Council Minutes showed the resident council…

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 6. Medical record review for Resident 2 was initiated on 9/17/24. Resident 2 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 2's Physician's Orders for Life-Sustaining Treatment (POLST) dated 7/28/24, showed Resident 2 did not have an advance directive. Review of Resident 2's Advanced Healthcare Directive Acknowledgement Form, undated, showed Resident 2 did not have an advance healthcare directive; however, there was no documentation to show the resident or the resident's representative was offered information regarding the formulation of an advance directive. On 9/20/24 at 1327 hours, an interview and concurrent medical record review for Resident 2 was conducted with the SSD. The SSD verified the Advance Healthcare Directive Acknowledgement form for Resident 2 was incomplete and stated it should have been completed. The SSD verified the form did not show Resident 2 or the resident representative was offered information regarding the formulation of an advance directive. 7.…

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

Based on observation, interview, and facility P&P review, the facility failed to ensure the residents' medical records were safeguarded to protect their confidential health information for two nonsampled residents (Residents 56 and 59). This failure had the potential for the residents' personal and health information to be accessed from the unauthorized users. Findings: Review of the facility's P&P titled Confidentiality of Information and Personal Privacy revised 10/2017 showed the facility will safeguard the personal privacy and confidentiality of all resident personal and medical records. Access to the resident personal and medical records will be limited to authorized staff and business associates. On 9/17/24 at 1642 hours, Nursing Station A was observed with three computer monitors turned on. One computer monitor showed the physician's orders for Resident 59. Another computer monitor showed the care tracker/dashboard for Resident 56. Both computer monitors showing residents' information were left unattended. On 9/17/24 at 1644 hours, an observation and concurrent interview 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 interview, medical record review, and facility P&P review, the facility failed to notify the resident's representatives of the resident's transfer and reasons for the transfer to the acute care hospital in writing for one of three final sampled resident (Resident 2) reviewed for hospitalization. This failure posed the risk of the resident's representatives not being aware of their appeal rights. Findings: Review of the facility's P&P titled Transfer or Discharge, Facility Initiated dated 10/2022 showed facility-initiated transfers and discharges, when necessary, must meet specific criteria and require resident/ representative notification and orientation, and documentation as specified in this policy. Medical record review for Resident 2 was initiated on 9/20/24. Resident 2 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 2's H&P examination dated 1/5/24, showed Resident 2 had no capacity to understand and make decisions. Review of Resident 2's Orders Summary Report…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to complete a significant change MDS within 14 days after a significant change for one of two final sampled residents reviewed for hospice services (Resident 2). This failure resulted in a delay in a comprehensive reassessment of the resident's changing health status and plan of care, in the effort to attain the resident's highest level of well-being. Findings: Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual dated October 2023, showed a Significant Change in Status Assessment (SCSA) must be completed within 14 days when a resident enrolls in a hospice program. Medical record review for Resident 2 was initiated on 9/17/24. Resident 2 admitted to the facility on [DATE], and was readmitted to the facility on [DATE]. Review of Resident 2's Order Summary Report for active orders as of 7/29/24, showed a physician's order dated 7/29/24, for Resident 2 to be admitted to hospice services. Review of Resident 2's MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure the plan of care was developed for three of 21 final sampled residents (Residents 13, 43, and 72). * The facility failed to develop a comprehensive person-centered care plan to address Resident 13's fall incident on 7/27/24, and Resident 13's significant weight loss. * The facility failed to develop a plan of care to address the actual fall for Resident 43. * The facility failed to develop a comprehensive person-centered care plan to address Resident 72's fall on 5/29/24. These failures had the potential risk of not providing appropriate, consistent, and individualized care to these residents. Findings: Review of the facility's P&P titled Care Plans, Comprehensive Person-Centered revised March 2022 showed the comprehensive, person-centered care plan describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being including 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 Based on observation, interview, and medical record review, the facility failed to provide services to attain or maintain the highest practicable well-being for one of 21 final sampled residents (Resident 7). * The facility failed to follow the physician's order for Resident 7 for cervical collar at all times every shift. This failure posed the risk of adverse effects to Residents 7's well-being. Findings: Medical record review for Resident 7 was initiated on 09/18/24. Resident 7 was admitted to the facility on [DATE]. Review of the MDS comprehensive assessment dated [DATE] showed the resident's BIMS score of 12. Review of Resident 7's H&P examination dated 9/16/24, showed the resident had the capacity. The H&P examination also showed diagnoses including cervical fracture. Review of the Order Summary Report dated 9/18/24, showed a physician's order dated 6/15/24, for cervical collar at all times every shift. Review of Resident 7's Plan of Care showed a care plan problem initiated on 6/16/24, for Immobilizer- At…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to ensure the resident's low air loss mattress was set appropriately according to the resident's weight for one of two final sampled residents reviewed for pressure ulcer (Resident 13). This failure had the potential for Residents 13 not receiving the appropriate care and services to prevent the development of the pressure ulcers. Findings: On 9/18/24 at 0956 hours,and 9/19/24 at 1355 hours, Resident 13 was observed lying in bed on low air loss mattress. The low air loss mattress was observed being set to 250 pounds. Medical record review for Resident 13 was initiated on 9/18/24. Resident 13 was admitted to the facility on [DATE]. Review of Resident 13's Order Summary Report showed a physician's order dated 12/7/23, for a low air loss mattress and to monitor the low air loss mattress for setting every shift. Review of Resident 13's Braden Scale For Predicting Pressure Sore Risk dated 8/21/24, showed Resident 13 was at a high risk for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure two of 21 final sampled residents (Residents 2 and 86) received the necessary care and services to prevent accident hazards. * The facility failed to thoroughly investigate and document Resident 2's cause of skin tear on the right buttock. * The facility failed to ensure the physician's order for Resident 86 to wear WanderGuard at all times was followed. These failures had the potential to negatively impact the residents' well-being. Findings: Review of the facility's P&P titled Accidents and Incidents-Investigating and Reporting revised 7/2017 showed all accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator. The nurse supervisor/charge nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. Medical record review for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure three of six final sampled residents reviewed for weight loss (Residents 4, 13, and 35) received the appropriate services needed to maintain acceptable parameters of nutritional status. * The facility failed to implement interventions to maintain Resident 13's nutritional status when the resident experienced severe weight loss. The facility failed to notify Resident 13's physician and responsible party in timely manner and failed to ensure the IDT analyzed and implemented the necessary interventions to address Resident 13's severe weight loss. * Residents 4 and 35's weekly weights were not completed as ordered by the physicians. These failures had the potential to result in the lack of implementation, monitoring, and evaluation of the effectiveness of nutritional interventions and related outcomes and increase the potential for further weight loss and/or nutritional decline. Findings: 1. Review of the facility's P&P…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care for five of six final sampled resident (Residents 2, 4, 27, 72, and 442) and one nonsampled resident (Resident 12) reviewed for respiratory care and services. * The facility failed to ensure the physician's order for oxygen therapy was followed for Resident 442. In addition, the facility failed to clarify the physician's order when the order did not show how high the oxygen could be titrated for Resident 442. * Resident 12's oxygen concentrator was observed in the hallway, and the door was closed with compressing oxygen tubing. This failure posed the risk of Resident 12 not receiving her oxygen. * Resident 27 was not administered continuous oxygen as ordered by the physician. *The facility failed to ensure Resident 72's oxygen titration order included the parameter for the oxygen to be titrate up to. * The facility failed to ensure there was a physician's order for the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to ensure one of three final sampled residents (Resident 62) reviewed for pain management had the pain medication orders to include clear indication for use as evidenced by: * Resident 62 had the orders for acetaminophen (analgesic) and hydrocodone-acetaminophen (opioid analgesic) with the same pain levels for use. This failure posed the risk of the resident's pain not being managed appropriately. Findings: Medical record review was initiated for Resident 62 on 9/17/24. Resident 62 was admitted on [DATE]. Review of Resident 62's admission MDS dated [DATE], showed Resident 62 had severe cognitive impairment. Review of Resident 62's MAR for September 2024 showed an order dated 7/22/24, for acetaminophen for pain levels mild to severe (levels of 1-10, on a 0-10 pain scale, with 0=no pain and 10=worst pain) and order dated 6/15/24, for hydrocodone-acetaminophen for moderate to severe pain (levels of 4-10). On 9/20/24 at 1408 hours, concurrent…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and facility P&P review, the facility failed to ensure the medications were administered according to the facility's P&P for one nonsampled resident (Resident 59). This failure posed the risk of Resident 59's medications not being administered according to accepted practices. Findings: Review of the facility's P&P titled Administering Medications through an Enteral Tube revised 11/18 showed steps to administer G-tube medications included removing the plunger from the syringe prior to pouring the medications into the syringe barrel. Further steps include to flush the G-tube with water prior to administering medications and also in between administering medications. On 9/19/24 at 0820 hours, a concurrent medication administration observation for Resident 59 and interview was conducted with LVN 3. LVN 3 was observed using the syringe and plunger to push the first medication, then second medication into Resident 59's G-tube. LVN 3 failed to flush Resident 59's G-tube with 50 ml of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure two of five final sampled residents (Residents 2 and 7) reviewed for psychotropic medications (medication affecting brain activities associated with mental processes and behavior) was free from unnecessary psychotropic medications. * The facility failed to ensure Resident 7's behavior manifestation and side effects were monitored accurately for the use of risperidone (an antipsychotic medication used for mental illness that causes disturbed or unusual thinking). * The facility failed to ensure the PRN order for lorazepam (antianxiety medication)was limited to 14 days for Resident 2. These failures posed the risk of unnecessary medications for these residents and negatively affects the residents' health and well-being. Findings: Review of the facility's P&P titled Psychotropic Medication Use dated 7/2022 showed the drugs in the categories considered psychotropic medications are subject to prescribing, monitoring, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility document review, the facility failed to ensure daily nutritional and special dietary needs, and preferences were provided for one of 21 final sampled residents (Resident 62) and two nonsampled residents (Residents 592 and 593). * Resident 592's lunch tray did not include gluten free pasta. * Resident 593's lunch tray did not include double portions. * Resident 62 did not have Ensure (supplement) to his lunch tray as per the physician's orders. These failures posed the risk for the residents' foods and nutritional needs not being met. Findings: 1. Review of the facility's posted menu showed the lunch menu for 9/18/24, included chicken cacciatore with pasta, and broccoli and cauliflower with Italian green bean salad and cranberry crunch. a. Medical record review for Resident 592 was initiated on 9/18/24. Resident 592 was readmitted to the facility on [DATE]. Review of Resident 592's Order Summary Report dated 9/18/24, showed a physician's order…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and the facility document review, the facility failed to ensure one of three nonsampled residents (Resident 45) reviewed for arbitration, who had no mental capacity to understand the terms of the facility's binding arbitration agreement (an agreement that allows parties to resolve disputes and lawsuits privately rather than going to the court) did not sign the Arbitration Agreement. This failure posed the risk for the resident to not have a clear understanding of the arbitration process. Findings: Medical record review for Resident 45 was initiated on 9/20/24. Resident 45 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 45's MDS - Section C dated 6/6/24, showed the resident's BIMS score was 6 which meant he had severe cognitive impairment. Review of the Arbitration Agreement showed a notice: by signing this contract you are agreeing to have any issue of medical malpractice decided by neutral arbitration and you are giving up your…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for two of two final sampled residents reviewed for hospice services (Residents 2 and 13). * The facility failed to ensure the hospice was notified regarding significant weight loss for Residents 2 and 13. * The facility failed to ensure Resident 2 received the hospice nursing visits two times per week as per the plan of care. These failures posed the risk for delays in the communication between the hospice provider and the facility which may affect resident care. Findings: 1. Review of the facility's P&P titled Weight Assessment and Intervention dated May 2023 showed the resident weights are monitored for undesirable or unintended weight loss or gain. The P&P showed the suggested parameters: a). 1 months- 5% weight loss is significant, greater than 5% is severe; b). 3 month- 7.5% weight loss is significant; greater than 7.5% is severe; and, c). 6 months- 10% 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.

The facility failed to ensure the equipment was maintained in the safe operating condition when: * The facility's freezer compartments had ice buildup for two of two medication refrigerators. * One of one ice machines had black tape, a non-cleanable surface, and brownish-red residue inside. These failures had the potential to affect the resident's health and well-being. Findings: 1. On 9/18/24 at 1025 hours, a concurrent observation and interview was conducted with RN 1. Station 2 medication refrigerator inspection showed ice buildup. RN 1 verified the freezer compartment for the medication refrigerator in Station 2 had ice buildup. On 9/18/24 at 1110 hours, a concurrent observation and interview was conducted with RN 2. Station 1 medication refrigerator inspection showed ice buildup. RN 2 verified the freezer compartment for the medication refrigerator in Station 1 had ice buildup. 2. On 9/20/24 at 0827 hours, a concurrent observation and interview was conducted with the Maintenance Supervisor and Corporate Dietary Supervisor. During an inspection of the ice machine, the…

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

Based on observation and interview, the facility failed to ensure the facility was free of pests in one resident's room, and the kitchen. * A fly was observed in Resident 10's room and on their uncovered cup of milk and on the opening of their bedside insulated water mug. * A fly was observed in the kitchen on multiple occasions over two days, by the coffee machine, puree food preparation and tray line areas. These failures had the potential for transmission of foodborne illness to the residents. Findings: 1. On 9/17/24 at 1504 hours, during a kitchen observation, a fly was observed flying around by the coffee makers, then the stove area. On 9/18/24 at 1003 hours, during the puree food preparation observation, a fly was observed flying around the kitchen by the preparation and tray line area. On 9/18/24 at 1157 hours, a tray line observation in the kitchen was conducted. During the facility's lunch tray line, a fly was observed on a covered loaf of bread. The Corporate Dietary Supervisor verified the observation of fly. 2. On 9/17/24 at 1245 hours, Resident 10 was observed lying in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility document review, the facility failed to ensure the medications were administered as ordered for one of six sampled residents (Resident 1). * Resident 1's evening medications were not administered on the admission day because they were not delivered by the pharmacy. This failure had the potential to negatively impact the resident's well-being. Findings: Review of the facility's P&P titled Administering Medications revised 4/2019 showed the medications are to be administered in accordance with the prescriber's orders and within the required time frame. Medical record review for Resident 1 was initiated on 3/18/24. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's H&P examination dated 3/11/24, showed Resident 1 had the capacity to understand and make medical decisions. Resident 1 had active medical problems, including hypertension, hyperlipidemia, diabetes, peripheral vascular disease, and an infection in the bone of his right big toe.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure the RD and IDT evaluations and interventions related to weight loss were conducted timely for one of two sampled residents (Resident 1). This failure had the potential for a delay in providing care and interventions and continued weight loss for the resident. Findings: Review of the facility's P&P titled Weight Assessment and Intervention revised March 2022 showed any weight change of 5% or more since last weight assessment is retaken the next day for conformation, if the weight is verified, nursing will immediately notify the dietitian in writing, and the suggested parameters for evaluating significant of unplanned or undesired weight loss/gain will be based on the following criteria: a. 1 (one) month - 5% weight loss is significant; greater than 5% is severe. b. 3 (three) months - 7.5 % weight loss is significant; greater than 7.5% is severe. c. 6 (six) months - 10% weight loss is significant; greater than 10% 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to ensure one of two sampled residents (Resident 1) did not receive the unnecessary medication when the licensed nurse failed to enter or implement the physician's order correctly. This failure had the potential for the resident to experience adverse effects and negatively impact the resident's well-being. Findings: Medical record review for Resident 1 was initiated on 2/13/24. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's MAR for December 2023 showed Resident 1 received the following medications: - ethambutol HCl 100 mg 10 tablets by mouth one time a day every Monday, Wednesday, and Friday at 0900 hours for MAC infection on 12/15, 12/18, 12/20, 12/22, 12/25, 12/27, and 12/29/23. - ethambutol HCl 400 mg 2.5 tablets by mouth in the evening for MAC infection with dinner at 1800 hours on 12/23, /12/24, 12/25, 12/26, 12/27, 12/28, and 12/29/23. Review of Resident 1's MAR for January 2024 showed Resident 1 received 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.

Intakes: CA00882864 Based on observation, interview, and medical record review, the facility failed to ensure the resident's meals were served at the desired temperatures for two of two sampled residents (Residents 1 and 2). This failure had the potential for the undesirable food temperatures to result in decreased oral meal intake and undesirable weight loss for the residents. Findings: Review of the facility's document titled Resident Council Minutes dated 10/19/23, showed the residents complained of the temperatures of the hot food were not hot. On 2/13/24 at 0857 hours, an interview was conducted with Resident 1. Resident 1 stated the hot food on their meal trays were often cold, and Resident 1 often needed to ask the staff to reheat her food. On 2/13/24 at 0930 hours, an interview was conducted with Resident 2. Resident 2 stated the hot food items on their meal tray were not hot enough, and sometimes lukewarm at best. On 2/14/24 at 0945 hours, an interview was conducted with the DSS. The DSS stated the facility was aware of the residents' complaint of food not being hot enough…

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

Based on observation, interview, and facility document review, the facility failed to ensure five of six meal tray carts used for meal distribution to the residents were maintained in the proper functioning order. This failure had the potential for undesirable food temperatures and unsafe food temperatures. Findings: Review of the facility's document titled Resident Council Minutes dated 10/19/23, showed the residents complained of temperature of hot food was not hot. On 2/13/24 at 0857 hours, an interview was conducted with Resident 1. Resident 1 stated the hot food on their meal trays were often cold, and Resident 1 often needed to ask the staff to reheat her food. On 2/13/24 at 0930 hours, an interview was conducted with Resident 2. Resident 2 stated the hot food items on their meal tray were not hot enough, and sometimes lukewarm at best. On 2/14/24 at 0945 hours, an interview was conducted with the DSS. The DSS stated the facility have seven meal tray carts used to store and deliver the meal trays to the residents. The DSS stated one meal tray cart was currently out of use…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure one of two sampled residents (Resident 1) was free from sexual abuse. This failure placed Resident 1 at risk for psychological and emotional harm. * On 12/15/23, Resident 2 was observed with his hands down on Resident 1's pants and making a jerking motion. Resident 1 had severe cognitive impairment and did not have the capacity to consent. Resident 1 was not consistently monitored for 72 hours after the incident. Findings: Review of the facility's P&P titled Abuse, Neglect, Exploitation, and Misappropriation Prevention Program revised 4/2021 showed the residents have the rights to be free from abuse. Review of the facility's P&P titled Abuse and Neglect – Clinical Protocol revised 3/2018 showed sexual abuse is defined as non-consensual sexual contact of any type with a resident. The P&P also showed the staff and physician will monitor the individuals who have been abused to address any…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to provide the necessary care and services for one of two sampled residents (Resident 1) to maintain their highest physical well-being. Resident 1 was admitted from the acute care hospital with status post bilateral foot surgery. * The facility failed to provide the wound treatment to Resident 1's bilateral feet and failed to apply the wound VAC to his right first toe amputation on 8/5/23. * The facility failed to obtain Resident 1's laboratory blood test on 8/7/23, as per the physician's order. These failures had the potential to negatively affect the residents' health and well-being. Findings: Medical record review was initiated for Resident 1 on 8/16/23. Resident 1 was admitted to the facility on [DATE], from the acute care hospital. Review of Resident 1's History and Physical examination dated 8/1/23, showed Resident 1 was admitted to theacute care hospital with bilateral foot wounds, sepsis, and acute kidney injury. Resident 1 underwent…

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

Based on observation, interview, facility document and P&P review, the facility failed to ensure the CDM was competent to manage the day to day operations of the food service department as evidenced by: 1. The CDM failed to provide food in a manner that was in accordance with current food safety guidelines. 2. The CDM failed to ensure recipes were followed and correct portion sizes were served. 3. The CDM failed to ensure therapeutic diets were followed. 4. The CDM failed to ensure foods were prepared to conserve nutritive value. 5. The CDM failed to ensure mechanically altered diets were served food consistent with the prescribed texture. 6. The CDM failed to follow and document the residents' food preferences. These failures posed the risk of food borne illness for all residents who received food from the kitchen, resident's nutritional needs to not be met, aspiration risk for those residents on a mechanically altered diet, and residents' food preferences not honored. Findings: Review of the Centers for Medicare/Medicaid Services (CMS) form 672 titled Census and Conditions of…

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

Based on observation, interview, and facility P&P review, the facility failed to ensure the menu was followed. * The facility failed to ensure the recipes were followed. * The facility failed to ensure the therapeutic diets were followed. * The facility failed to ensure the correct portion sizes were followed. These failures had the potential for resident's nutritional needs not to be met which could further compromise their medical status. Findings: Review of the CMS 672 Resident Census and Conditions of Residents completed by the facility dated 12/6/21, showed 77 of 80 residents in the facility received food prepared in the kitchen. 1. Review of the facility's P&P titled Menus dated 10/2017 showed menus meet the nutritional needs of the residents in accordance with the recommended dietary allowances of the Food and Nutrition Board. a. Review of the facility's recipe titled Peanut Butter Pie showed the following ingredients for the filling: cream cheese, powdered sugar, skim milk, peanut butter, vanilla extract, and cream half & half, whipped. On 12/7/21 at 0900 hours, 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.

Based on observation, interview, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen. * The facility failed to ensure the expired foods were discarded. * The facility failed to ensure proper thawing of frozen food in the refrigerator. * The facility failed to ensure a cooling log was in place. * The facility failed to ensure proper covering, labeling, and dating of foods in the kitchen. * The facility failed to ensure the proper storage of produce. * The facility failed to ensure the proper use of the sanitizing solution in the sanitizing sink. * The facility failed to ensure proper backflow prevention of two of three air gaps. * The facility failed to ensure proper sanitary condition of the hood over the stove. * The facility failed to ensure proper sanitary condition of the drain sink under the tray line table. * The facility failed to ensure replacement of missing kitchen floor tile and grout. These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food prepared…

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 safeguard one of the 18 final sampled residents (Resident 74)'s personal belonging from loss or theft. * Resident 74's irreplaceable personal pictures were lost when he was moved to another room in the facility. This failure had the potential to negatively impact the resident's well-being. Findings: Medical record review for Resident 74 was initiated on [DATE]. Resident 74 was admitted to the facility on [DATE]. On [DATE] at 0813 hours, an interview was conducted with Resident 74. Resident 74 stated he used to have a bulletin board by his bedside with the pictures of his family and friends posted on it. Resident 74 stated one of the pictures was of his wife who had died. Resident 74 stated all of his pictures which were precious to him got lost when he was transferred to another room. Resident 74 stated he had told the facility staff about it but no one could find them. During an interview with the SSD on [DATE] at 1314 hours, the SSD stated she 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, medical record review, and facility P&P review, the facility failed to develop and implement the comprehensive person-centered care plans for three of 18 final sampled residents (Resident 29, 74, and 425). * The facility failed to develop a care plan to address Resident 425's smoking. * The facility failed to develop a care plan to address Resident 29's use of antidepressant medication. * The facility failed to develop a care plan to address Resident 74's religious food preferences. These failures had the potential to negatively impact the care needed for the residents. Findings: Review of the facility's P&P titled Care Plans, Comprehensive Person Centered revised on 12/2016 showed it is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide an environment free from accident hazards for one of 18 final sampled residents (Resident 425). * The facility failed to ensure Resident 425 was assessed for safe smoking. This failure posed the risk of fire and injury to the residents and staff in the facility. Findings: Review of the facility's P&P titled Smoking Policy - Residents revised 7/2017 showed the residents will be informed of the facility smoking policy and evaluated on admission to determine if the resident is a smoker or non-smoker. If the resident is a smoker, they will be evaluated the ability to smoke safely with or without supervision. The residents without independent smoking privileges may not keep any smoking materials except when they are under direct supervision of staff. Medical record review for Resident 425 was initiated on 12/7/21. Resident 425 was admitted to the facility on [DATE]. Review of the Order Summary Report showed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the pharmaceutical services to meet the needs of each resident when: * The facility failed to ensure Resident 6's lorazepam (anti-anxiety medication) was accurately reconciled. Five tablets for lorazepam had been removed from Resident 6's medication bubble pack after it had been discontinued on 11/24/21. The number of tablets of lorazepam removed showing on the Antibiotic or Controlled Drug Record did not match the number of tablets in the electronic MAR as administered to Resident 6. This failure had the possibility of diversion of controlled medications. * The facility failed to ensure the oral medications emergency kit was replaced in a timely manner. In addition, the coumadin tablet removed from the emergency kit was not documented in the emergency kit medication log. These failures had the potential for to contribute to a decreased availability of medications in 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.

Based on observation, interview, and facility P&P review, the facility failed to ensure the safe medication storage was observed in three of seven medication carts (Medication Cart 4, Treatment Cart 2, and IV Cart 1). * An expired bottle of vitamin E was stored in Medication Cart 4. * An expired acetic acid solution was stored in Treatment Cart 2. * Two bags of expired IV fluids were stored in IV Cart 1. These failures had the potential for the residents to be exposed to the expired medications. Findings: According to the facility's P&P titled Storage of Medications, discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. 1. On 12/08/21 at 1420 hours, during the inspection of Medication Cart 4 with LVN 5, a bottle of vitamin E with an expiration date of 9/21/21, was observed in the first drawer. LVN 5 verified the findings and stated the expired bottle of vitamin E should have been disposed. 2. On 12/08/21 at 1534 hours, during the inspection of Treatment Cart 2 with LVN 2, an opened bottle of 0.25% Acetic acid irrigation…

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

Based on observation, interview, and facility record review, the facility failed to ensure the nutritive value of minced/moist and pureed vegetables were conserved when minced/moist and pureed vegetables were prepared with additional liquid and held in a hot oven for more than an hour and a half prior to meal service. This failure placed four residents who received a minced/moist diet and seven residents who received a puree diet at risk for compromised nutritional status. Findings: The nutritional value of food, in particular vegetables, which are heated multiple times compromises both the palatability and nutritional value of food (Nutrition.gov). Review of the facility's recipe titled Capri Blend Veg undated showed for minced/moist diets, to mince regular portions, making sure all particles are no more than 4 millimeters x 4 millimeters (1/8 inch) long with no separate thin liquid prior to service. For puree diets, the recipe showed to place prepared servings into a blender or processor. Process until fine. For every five portions needed, add ¼ cup thickener, process until…

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

Based on observation, interview, and facility record review, the facility failed to ensure one sampled resident (Resident 18) and one nonsampled resident (Resident 58) received food prepared in a form to meet their individual dietary needs. This failure placed Resident 18 and Resident 58 at risk for aspiration (accidental breathing in of food or fluid into the lungs). Findings: Review of the facility document titled Week 3 Monday Cycle 4 2021 showed mechanical soft diets should have received a finely chopped salad. 1. During the lunch meal service observation on 12/6/21 at 1238 hours, Resident 58 was in the dining room for the lunch meal. Review of Resident 58's lunch meal ticket showed the diet was a regular diet with mechanical soft consistency. Resident 58's lunch meal consisted of ground meat, pasta, garlic bread and a regular tossed salad. When asked, LVN 2 verified Resident 58's salad should be finely chopped and removed the salad from the meal tray. 2. On 12/6/21 at 1330 hours, a lunch meal service observation was conducted with sampled Resident 18. Review of Resident 18's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and facility document review, the facility failed to honor religious food preferences for one sampled resident (Resident 74). This failure posed the risk of Resident 74's religious and nutritional needs not to be met. Findings: Review of the facility's P&P titled Resident Food Preferences dated July 2017 showed individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. The Food Services Department will offer a variety of foods at each scheduled meal, as well as access to nourishing snacks throughout the day and night. Medical record review for Resident 74 was initiated on 12/6/21. Resident 74 was admitted to the facility on [DATE]. Review of the facility document titled Week 3, Cycle 4 2021, Therapeutic Spreadsheets did not include a Vegetarian diet. Review of the Physician's orders dated 12/8/21, showed Resident 74's diet was a regular diet, pureed/level 4 texture, Nectar Mildly thick consistency. Review of the Dietary…

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 facility record review, the facility failed to ensure the policy regarding food brought to the facility for the residents by the family or visitors was followed. This failure posed the risk for potential unsafe food handling practices. Findings: According to the facility's P&P titled Food Brought by Family/Visitors dated October 2017 showed all personnel involved in preparing, handling, serving or assisting the resident with meals or snacks will be trained in safe food handling practices. On 12/7/21 at 1447 hours, an interview was conducted with the LVN 2. LVN 2 was familiar with the facility procedure for food brought to the facility for the residents by the family or visitors. However, LVN 2 stated she could not remember if she had received any safe food handling training. On 12/7/21 at 1459 hours, an interview was conducted with the CNA 2. CNA 2 stated she had not received training on safe food handling practices regarding food brought to the facility for the residents by the family or visitors. 12/7/21 at 1501 hours, an interview was conducted with the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to ensure the medical record for one of 18 sampled residents (Resident 7) was complete. * Resident 7's POLST (Physician Orders for Life Sustaining Treatment is a medical order that helps give people control over their care during a medical emergency) form was blank, but was signed and dated by the physician. This had the potential for the resident's emergency care needs not being met because his medical information was incomplete. Findings: Medical record review for Resident 7 was initiated on 12/6/2021. Resident 7 was admitted to the facility on [DATE]. Review of the H&P examination dated 8/26/21, showed Resident 7 was able to make his own medical decisions. Review of Resident 7's POLST dated 8/15/21, showed it was signed and dated by the physician, but the information was not filled in. On 12/6/21 at 1246 hours, RN 1 confirmed the POLST was missing the resident's wishes regarding his medical treatment in the case of an emergency. RN 1 stated 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 upon observation, interview, and facility document review, the facility failed to follow the infection control practices for three of 18 final sampled residents (Residents 52, 56, and 578): * LVN 4 failed to perform hand hygiene during the medication administration for Resident 56. * Resident 52's indwelling urinary catheter drainage tubing was observed dragging on the ground under the wheelchair. * Resident 578's wheelchair was dirty and had brown stains on the seat. These failures had the potential to cause growth and the spread of microorganisms. Findings: 1. Review of the facility's P&P titled Handwashing/Hand Hygiene revised August 2019 showed all personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infection to other personnel, residents, and visitors. Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situation - after contact with resident's intact skin, after…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to ensure one of 18 final sampled residents (Resident 7) was offered the second dose of COVID-19 vaccine. This failure had the potential for the resident not being fully vaccinated against COVID-19. Findings: Medical record review for Resident 7 was initiated on 12/9/21. Resident 7 was admitted to the facility on [DATE]. On 12/09/21 at 1355 hours, concurrent interview and medical record review was conducted with the facility's IP. Resident 7's Immunization Record showed Resident 7 received one dose of the Moderna COVID-19 vaccine on 8/14/21. When asked about Resident 7's second dose of the vaccine, the IP verified there was no documentation to show Resident 7 was offered the second dose of the Moderna COVID-19 vaccine.