Adventist Health Delano

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide oral hygiene (the practice of keeping your mouth clean and disease-free) for one of three sampled residents (Resident 1). This failure had the potential to cause sickness and disease, tooth decay, bad breath, and decrease Resident 1's feelings of self-worth.Findings: During a review of Resident 1's PHYSICIAN FACE SHEET (PFS), dated 7/5/25, the PFS indicated Resident 1 is a [AGE] year old male who was admitted to the facility on [DATE] with the following diagnosis:a. Severe sepsis (a serious condition in which the body responds improperly to an infection) with septic shock (a life-threatening condition caused by infection),b. ALS (Amyotrophic lateral sclerosis - a disease that progresses over time causing loss of muscle control),c. Ventilator (a machine that blows air in and out of lungs) dependence, and;d. Chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood) During a review of…

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

Based on interview and record review, the facility failed to implement their policy and procedure on abuse for one of three sampled residents (Resident 1) when the staff accused was not separated from providing resident care. This failure had the potential for other residents to be abused. Findings: During a review of Resident 1's CODING SUMMARY (CS), dated 4/10/25, the CS indicated Resident 1 had a diagnosis of Tracheostomy (a surgical procedure that creates an opening in the trachea [windpipe] through the front of the neck. This opening allows a tube to be inserted to maintain an airway and allow breathing) status, and cerebral infarction (loss of blood flow to a part of the brain resulting in brain tissue death).During a review of Resident 1's Minimum Data Set (MDS) Assessment (a standardized assessment to evaluate a resident's functional abilities and healthcare needs), dated 7/10/25, under the section titled, Brief Interview for Mental Status (BIMS - an assessment of cognition [how well a person thinks, remembers, and learns] with scores ranging from 0 - 15, the higher the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to follow their policy and procedure on, ADVERSE EVENT (an undesirable medical occurrence) REPORTING, for one of three sampled residents (Resident 1) when a medication error resulting in harm was not reported to the California Department of Public Health (CDPH). This failure had the potential for Resident 1 continually experience adverse health outcomes. Findings:During an interview on 7/2/25 at 9:57 a.m. with Family Member (FM) 1, FM 1 stated Resident 1 had a loss of vision to his left eye due to the facility not giving his Lumigan (prescription medicated eye drops) for intraocular pressure (the fluid pressure in the eyes. If the pressure is too high, it can cause irreversible vision loss. Normal pressure is from 10 and 21 mmHg [millimeters of mercury - a unit of measurement]) as ordered by his ophthalmologist (OPTH - medical doctor who specialize in all aspects of eye care). During a review of Resident 1's ORDER SHEET (OS), dated 2/11/25, the OS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to have a qualified full-time Director of Activities (the staff responsible for facility's resident activities program), for 45 of 45 residents. This failure had the potential for residents' activities needs to go unmet. Findings: During an interview on 4/9/25 at 3:10 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated she was taught how to fill out the Activities Evaluation in CERNER (an electronic health record charting system) and in paper chart by a unit clerk last month. CNA 1 stated the Director of Activities had been out on medical leave since February 2025. During an interview on 4/9/25 at 3:59 p.m. with Registered Nurse Manager (RNM) 1, RNM 1 stated the facility's Director of Activities had been out on medical leave since February 2025. RNM 1 stated the facility did not have an interim Director of Activities. RNM 1 stated there were CNAs who were trained to assess and complete the Activities Evaluation and to ensure…

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

Based on observation, interview, and record review, the facility failed to follow the facility's policy and procedure (P&P) titled, FACILITY PROCEDURE: STORAGE OF FOODS/PHYSICAL ENVIRONMENT, when two of six canned garbanzo beans with dents (Can 1 and Can 2) were not removed from the dry storage room. This failure had the potential to cause foodborne illness (illness caused by the ingestion of contaminated food or beverages) in all 12 of 45 residents who received food from the kitchen. Findings: During a concurrent observation and interview on 4/7/25 at 7:40 a.m. with Lead [NAME] (LC), in the Dry Food Storage Room, LC inspected the 12 ounce cans of garbanzo beans for dents. LC removed two cans from the six cans of garbanzo beans. Can 1, 12-ounce garbanzo bean can, had a dent at the seam approximately 2 inch long and ½ inch deep; Can 2 had an approximately 2 inch long and ½ deep dent. LC stated the dented garbanzo bean cans should not be in the dry food storage area with other canned foods for resident use. LC stated two out of six garbanzo bean cans had dents. LC stated the dented…

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

Based on observation, interview, and record review, the facility failed to: 1. Ensure nursing staff disinfected a glucometer (a device that measures the amount of sugar in the blood) with approved wipes for three of three sampled residents (Resident 17, and Resident 40). This failure had the potential to cause infection and spread of bacteria to residents. 2. Implement their policies and procedures titled FACILITY POLICY:ENHANCED BARREIR PRECAUTIONS IN SCU [Specialty Care Unit], and FACILITY POLICY: Infection Control in SCU for four of four sampled residents (Resident 37, Resident 32, Resident 12 and Resident 2) when: 2a.Correct Infection Control Precaution (ICP, actions taken to reduce potential of transmitting infections/germs) signage was not posted for two of four sampled residents (Resident 37, Resident 32, and Resident 12). This failure had the potential to spread disease causing organisms (germs) to other residents, staff and ultimately the community. 2b. Emergency Medical Technician Transport (EMTT) did not dispose of his personal protective equipment (PPE- disposable gown,…

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

Based on interview and record review, the facility failed to obtain and complete informed consent (a process in which residents are given important information about medical procedures and medications) for psychotropic medications (drugs that affect a person's mental state) for two of four sampled residents (Resident 21 and Resident 13). This failure had the potential for Resident 21 and Resident 13 to not be aware of the risks and benefits of taking psychotropic medications. Findings: During a concurrent interview and record review on 4/9/25 at 9:40 a.m. with Minimum Data Set Coordinator/Registered Nurse (MDSC), Resident 21's Consent for the administration of psychotropic medications (Consent), dated 2/12/25 was reviewed. The Consent indicated, Resident 21 was on Seroquel (a medication used for mental illness) 25 mg at bedtime. The Consent indicated nurses signed on 2/12/25 and physician signed on 2/20/25. MDSC stated nurses obtain consent from family/resident and physician signs the consent when they visit the resident. During a concurrent interview and record review on 4/10/25 at…

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

Based on interview and record review, the facility failed to review and accurately complete the annual Pre-admission Screening Assessment and Resident Review (PASRR - federal requirement to help ensure that individuals are not incorrectly placed in nursing homes or long-term care instead of a psychiatric setting) for one of one sampled resident (Resident 13). This failure had the potential for Resident 13 to be placed in an inappropriate setting and not receive required services. Findings: During a review of Resident 13's Preadmission Screening Resident Review (PASRR) Level 1 Screening, dated 5/6/24, the PASRR indicated, 10. Does the individual have a serious diagnosed mental disorder such as Depressive Disorder [a mental health condition characterized by persistent sadness and loss of interest], Anxiety Disorder [excessive worry, fear and other physical and behavioral symptoms that interfere with daily life], Panic Disorder [frequent and unexpected panic attacks], Schizophrenia/Schizoaffective Disorder [a chronic and severe brain disorder that disrupts a person's ability to think…

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

Based on observation, interview, and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 2 followed the facility policy and procedure (P&P) titled MEDICATION ADMINISTRATION THROUGH A FEEDING TUBE, and professional standards for one of five sampled residents (Resident 4) with a Gastrostomy Tube (GTube-a device to allow feedings and medications to be administered directly to the stomach) when LVN 2 did not flush with water between medications. This failure had the potential for medications to clog or block the GTube resulting in Resident 4 not receiving the medication. Findings: During an observation on 4/9/25 at 8:22 a.m. in Resident 4's room, LVN 2 administered Docusate Sodium (medication to manage or treat constipation) via GTube to Resident 4. LVN 2 administered the next medication. LVN 2 did not flush the GTube with water after administering Docusate Sodium and prior to administring the next medication. During an interview on 4/9/25 at 8:29 a.m. with LVN 2, LVN 2 stated she did not flush the GTube with water after administering the Docusate Sodium. LVN 2…

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

Based on interview and record review, the facility failed to ensure its Quality Assessment and Assurance (QAA) committee met at least quarterly, as required by regulation, when the QAA committee met only three times from May 2024 to April 2025. This failure had the potential for the QAA committee to not identify and correct facility quality deficits placing all 45 residents at risk for poor care. Findings: During a concurrent interview and record review on 4/10/25 at 2:03 p.m. with the facility's Registered Nurse Manager (RNM) 2, the minutes of the facility's QAA committee dated 1/20/25, 9/12/24, and 5/23/24 were reviewed. The RNM 2 stated the above minutes reflected the meetings of the facility's QAA committee during the past 12 months. The RNM 2 stated the facility's QAA committee met at least quarterly but was not able to hold quarterly meetings during the past year. During a review of the facility's policy and procedure (P&P) titled [Facility's Name] Quality Assurance and Performance Improvement Plan (QAPI) . 2025, dated 2025, the P&P did not indicate the frequency of QAA…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure four of six sampled residents (Resident 1, Resident 2, Resident 3, and Resident 4) were provided nail care. This failure had the potential for Resident 1, Resident 2, Resident 3, and Resident 4 to develop an infection and skin breakdown. Findings: During a review of Resident 1's Minimum Data Set (MDS – an assessment tool), dated 1/29/25, the MDS Section GG (functional abilities and goals) indicated Resident 1 required total assist with maintaining personal hygiene. During a review of Resident 1's Care Plan (CP), dated 10/26/24, the CP indicated, Total dependent in all ADL (Activities of Daily Living - basic personal tasks performed daily) needs due to immobility. Interventions. Provide Assistance to Support Level of Need. During a review of Resident 2's MDS, dated [DATE], the MDS Section GG indicated Resident 2 required total assist with maintaining personal hygiene. During a review of Resident 2's CP, dated 8/6/24, the CP…

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

Based on observation, interview, and record review, the facility failed to follow its policy and procedure (P&P) on restraint management for one of six sampled residents (Resident 1) when Resident 1's restraint was not monitored every two hours and the order for restraint was not renewed every three days. These failures had the potential to result in Resident 1 developing injuries and adverse health outcomes. Findings: During a review of Resident 1's Order Sheet (OS), dated 10/26/24, the OS indicated, Restraint Monitor. Right hand mitten to prevent pulling medical devices. Monitor every 2 hours and release for 15 minutes and check for circulation and skin integrity. During an observation on 1/29/25 at 1:48 p.m. in Resident 1's room. Resident 1 was wearing mittens on his right hand. During an interview on 1/29/25 at 2:56 p.m. with Licensed Vocational Nurse (LVN) 1, LVN1 stated Resident 1 was wearing mittens on his right hand because he had a behavior of pulling medical devices like GT (Gastrostomy tube – feeding tube that is surgically inserted through the abdomen and into the…

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

Based on observation, interview, and record review, the facility failed to monitor medication room temperatures for 34 out of 34 (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, Resident 9, Resident 10, Resident 11, Resident 12, Resident 13, Resident 14, Resident 15, Resident 16, Resident 17, Resident 18, Resident 19, Resident 20, Resident 21, Resident 22, Resident 23, Resident 24, Resident 25, Resident 26, Resident 27, Resident 28, Resident 29, Resident 30, Resident 31, Resident 32, Resident 33, Resident 34) sampled residents. This failure had the potential to alter medication effectiveness (the ability of a medication to produce the desired effect). Findings: During a concurrent interview and record review on 1/22/25 at 3:48 p.m. with Facility Manager (FM), the facility medication room temperature logs (MRTL), dated were reviewed. The MRTL indicated the following days had missing entries: a. January 2025, there were missing signatures for 1/2 and 1/6. b. December 2024, there were missing signatures for 12/20 and 12/30. c. November…

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

Based on observation, interview, and record review, the facility has failed to implement their policy on hazardous (dangerous and involves risk to someone's health) materials for 25 of 34 sampled residents (Resident 1, Resident 3, Resident 9, Resident 13, Resident 14, Resident 15, Resident 16, Resident 17, Resident 18, Resident 19, Resident 20, Resident 21, Resident 22, Resident 23, Resident 24, Resident 25, Resident 26, Resident 27, Resident 28, Resident 29, Resident 30, Resident 31, Resident 32, Resident 33, and Resident 34). This failure had the potential to result in physical harm to the residents. Findings: During a concurrent observation and interview on 1/22/25 at 3:24 p.m. with Quality Assurance (QA) in the activities room, the following was observed not secured and accessible by residents: a. Eight oz (ounce – unit of measurement) can of dust/lint remover (a flammable can of chemicals that removes dirt and lint). b. 18 oz bottle of foaming germicidal cleaner (a chemical cleaning product used on surfaces to kill bacteria and viruses). c. Eight cans of 8.23 oz of liquid…

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

Based on observation, interview, and record review, the facility failed to implement their policy on residents food storage for 11 of 34 sampled residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, Resident 9, Resident 10, and Resident 11). This failure had the potential for food borne illness. Findings: During a concurrent observation and interview on 1/21/25 at 3:57 p.m. with Facility Manager (FM) in the activities room, a refrigerator had a sign indicated, FOR [facility] RESIDENTS ONLY! THANK YOU! The refrigerator also had another sign that stated, NO OPEN BOTTLES LABEL ALL FOOD ITEMS WITH DATE AND TIME NO PLASTIC BAGS! In the refrigerator the following was observed: a. Approximately 24 inch (a unit of measurement) long piece of chocolate cake with a use by date of 12/20/24. b. Approximately 12 inch lemon pie with a use by date of 12/20/24. c. Liter (unit of measurement) of diet soda that was 1/4th (a unit of measurement) full, with no open date listed. d. 32 oz (ounce - a unit of measurement) bottle of cheese dip that was…

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

Based on observation, interview, and record review, the facility failed to provide home medications for one of 34 sampled residents (Resident 12). This failure resulted in Resident 12 not being dispensed his home medications upon discharge and had the potential for negative health outcomes. Findings: During an observation on 1/22/25 at 3:48 p.m. in the facility medication room (FMR), two boxes with Resident 12's name on it were observed. The boxes had a label that indicated, Albuterol Sulfate (medication used to prevent and treat breathing difficulties) 2.5mg (milligram – a unit of measurement)/3 ml (milliliter – a unit of measurement). Inhale (breathe in) 3 ml (2.5 mg) via nebulizer (a tool used to turn liquid medicine into a mist to breath in) every 6 hours. The boxes had 120 vials (a small container) of Albuterol Sulfate left. The boxes had a date indicated 12/22/24. On the boxes was a note indicating Resident 1 was discharged (no date indicated). During an interview on 1/22/25 at 3:48 p.m. with Facility Manager (FM), FM stated Resident 1 was discharged home a month ago (did not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement their policy and procedure for abuse for one of three sampled residents (Resident 1) when: 1. An allegation of abuse was not reported within twenty-four hours to the California Department of Public Health (CDPH). 2. The investigation for the allegation of abuse was not completed within five days. 3. Two Certified Nursing Assistants (CNA 1 and CNA 2) with an allegation of abuse were not removed from working in the facility immediately and/or monitored while the investigation for the allegation of abuse towards Resident 1 was still being conducted. These failures had the potential for delayed investigation and continued abuse for Resident 1. Findings: 1. During a review of Resident 1's Minimum Data Set (MDS- an assessment tool) under the section BIMS (Brief Interview for Mental Status – an assessment of cognition [mental processes including perception, memory, and thought]), dated 10/10/24, the BIMS indicated, Resident 1 had a score of 15…

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

Based on interview and record review, the facility failed to notify Family Member (FM) 1 regarding a change in condition for one of three sampled residents (Resident 1). This failure resulted in FM 1 not being aware of a change in condition for Resident 1. Findings: During an interview on 10/9/24 at 8:50 a.m. with FM 1, FM 1 stated the facility had issues with notifying the family regarding Resident 1's change in condition. FM 1 stated when Resident 1 had a podiatry appointment (specific date not given), FM 1 noticed Resident 1 right heel was black with a possible skin injury. FM 1 stated she asked facility staff (not specific) what was going on with Resident 1's right heel and they (not specific) stated the heel had been like that for a while and FM 1 should had been informed about it. During an interview on 10/9/24 at 1:16 p.m. with Registered Nurse (RN) 1, RN 1 stated Resident 1's right heel had a dry callus (a thickened area of skin that forms when the skin is repeatedly irritated, rubbed, or pressed) with a black color. RN 1 stated a wound consultant had seen it (no date given)…

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

Based on interview and record review, the facility failed to follow their grievance policy and procedure for one of three sampled residents (Resident 1). This failure resulted in grievances regarding Resident 1's provision of care to not be addressed. Findings: During a review of Resident 1's CODING SUMMARY (CS), dated 11/14/23, the CS indicated, Resident 1 diagnosis including Quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury), Chronic Obstructive Pulmonary Disease (COPD - a chronic lung disease causing difficulty in breathing), Acute (present) on chronic (persisting) respiratory failure (condition where it is difficult to breath on your own) with hypoxia (low oxygen), Tracheostomy (an incision in the windpipe made to relieve an obstruction to breathing). During a review of Resident 1's Minimum Data Set (MDS- an assessment tool) under the section BIMS (Brief Interview for Mental Status – an assessment of cognition [mental processes including perception, memory, and thought]), dated 10/10/24, the BIMS indicated, Resident 1 had a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement the Medical Doctor (MD) orders for one of six sampled residents (Resident 1). This failure had the potential for negative health outcomes. Findings: During a review of Resident 1's History and Physical (H&P), dated [DATE], the H&P indicated diagnoses including Cardiac arrest (heart stopped pumping) Anoxic brain injury (lack of oxygen to the brain causing brain death) Acute (sudden) on chronic (persistent) respiratory failure (lack of oxygen in the body). During a review of Resident 1's Minimum Data Set (MDS- an assessment tool) under the section BIMS (Brief Interview for Mental Status – an assessment of cognition [mental processes including perception, memory, and thought], dated [DATE], the BIMS indicated, Resident 1 was unable to be assessed due to persistent vegetative state (absence of responsiveness and awareness due to overwhelming dysfunction of the brain). During a review of Resident 1's MDS under the section GG (an assessment of a…

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

Based on observation, interview, and record review, the facility failed to staff appropriately to meet the needs of the residents for 12 of 13 sampled residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, Resident 9, Resident 10, Resident 11, and Resident 12). This failure resulted in diminished ability to provide effective care to the residents, had potential to have negative impacts on other residents from lack of staffing and resulted in new skin wounds for two residents (Resident 10 and Resident 12). Findings: During a review of Resident 1's CODING SUMMARY (CS), dated 11/17/23, the CS indicated, Resident 1 diagnosis including functional quadriplegia (complete immobility due to severe disability or frailty) and Guillain Barre Syndrome (a rare disorder in which your body's immune system attacks your nerves). During a review of Resident 1's Minimum Data Set (MDS – an assessment tool) under the section Brief Interview for Mental Status (BIMs – an assessment tool for cognition [the mental processes including perception, memory, and…

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

Based on interview and record review, the facility failed to follow their policy and procedure (P&P) on abuse for one of 13 sampled residents (Resident 13), when the alleged abuser Licensed Vocational Nurse (LVN) 1 was not removed from the working schedule and/or monitored until cleared from the abuse allegation. This failure had the potential to place Resident 13 at risk for further abuse and had the potential to place other residents at risk for abuse and serious harm. Findings: During a review of Resident 13's CODING SUMMARY (CS), dated 1/13/24, the CS indicated, Resident 13's diagnosis including history of chronic respiratory failure (condition when the lungs cannot get enough oxygen into the blood), dependence on respirator (means of providing oxygen to support or replace breathing), Tracheostomy (an incision into the wind pipe to provide a means for a person to breathe) and myoneural disorder (a disease that affects the nerves that control voluntary muscles). During a review of Resident 13's MDS (Minimum Data Set – an assessment tool) under the section Brief Interview for…

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

Based on interview and record review, the facility failed to complete an investigation for one of 13 sampled residents (Resident 13) allegation of abuse within five (5) working days. This failure had the potential for the abuse allegation to not be thoroughly investigated and could result in further abuse. Findings: During an interview on 5/1/24 at 10:52 a.m. with Registered Nurse (RN) 1, RN 1 stated on 4/24/24 at approximately 6:30 p.m. Resident 13's sister called and stated Resident 13 alleged Licensed Vocational Nurse (LVN) 1 had hit and aggressively pushed Resident 13's head. During an interview on 5/1/24 at 11:05 a.m. with Social Services Director (SSD), SSD stated an allegation of abuse was made on 4/24/24. SSD stated the investigation for the allegation of abuse had not been completed at this time. During an interview on 5/1/24 at 12:15 p.m. with Risk and Regulation Analyst (RRA), RRA stated the Director of Nursing (DON) had been investigating the allegation of abuse made by Resident 13, but the DON was unavailable due to being at a conference. RRA stated the Patient Care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide enough direct care staff to ensure the daily needs were met for four of four sampled residents (Resident 21, Resident 18, Resident 34, and Resident 31) when: 1. Resident 21, Resident 18, Resident 34, and Resident 31 were not turned every two hours. This failure had the potential for Resident 21, Resident 18, Resident 34, and Resident 31 to develop pressure injuries (damage that can occur as a result of being in the same position for extended periods of time). 2. Resident 21's call light was not answered timely. This failure had the potential for Resident 21 to feel devalued and helpless. 3. Resident 21 face and hands were not cleaned before meals without asking. This failure had the potential for Resident 21 to feel helpless and neglected. 4. Resident 21, Resident 34, and Resident 19's Restorative Nursing Assistant (RNA) program (provided by RNA to help maintain or improve mobility for the residents) was not performed as ordered.…

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

Based on observation, interview and record review, the facility failed to ensure 41 of 41 licensed nurses were competent to: 1. Care and manage the nephrostomy (tube placed directly into the kidney to drain urine) tube for one of one sampled resident (Resident 18). This failure had the potential for the urine to flow backwards into Resident 18's kidney and may have contributed to multiple infections. 2. Administer medications through a gastrostomy (G-tube, tube inserted into stomach for nutrition and medication) tube for two of two sampled residents (Resident 25 and Resident 17). This failure had the potential for medication reactions, blockage of the G-tube, and insufficient water provided to Resident 25 and Resident 17. Findings: 1a. During a concurrent observation and interview on 4/8/24 at 10:54 a.m. with Licensed Vocational Nurse (LVN) 2, Resident 18's nephrostomy bag was on the floor next to the bed. LVN 2 stated Resident 18 already had renal impairment (decreased kidney function). LVN 2 stated the nephrostomy bag should not be on the floor because it could cause an infection,…

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

Based on interview and record review, the facility failed to implement and maintain an effective Quality Assurance Performance Improvement Program (QAPI- a systematic, comprehensive, and data-driven approach to maintaining and improving safety and quality in nursing homes). This failure had the potential to result in facility issues not identified, recognized, addressed, and corrected appropriately. Findings: During a review of the facility's Special Care Unit (SCU) Quality Assurance Meeting Minutes (QAPI), dated 10/19/23 and 1/30/24, the QAPI indicated, the final survey findings during the onsite visit from 3/13/24 - 3/16/23.2. F658: Service provided meet professional standards. 3. F686: Treatment & services to prevent & heal pressure ulcers. 4. F688: Increase/prevention in ROM/mobility.6. F695: Respiratory/tracheostomy care and suctioning 7. F725: Sufficient nursing staff.11. F761: Label/store drugs & biologicals 12. F880: Infection prevention & control.Action column: blank. During a concurrent interview and record review on 4/11/24 at 1:59 p.m. with Quality Manager (QM), 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 interview and record review, the facility failed to: 1. Conduct infection control surveillance that included collection of data, analysis, tracking and trending, and follow up of outcomes of infections for 46 of 46 residents. 2. Ensure the Infection Preventionist (IP) and Director of Infection Prevention (DIP) performed their duties to complete infection control surveillance for 46 of 46 residents. 3. Store and label oxygen tubing to prevent contamination for one of three sampled residents (Resident 201). 4. Ensure nephrostomy (tube placed directly into the kidney to drain urine) was secured and maintained in a clean environment to prevent infections for one of one sampled resident (Resident 18). 5. Ensure hand hygiene was performed after administration of medications through a gastrostomy (G-tube, tube inserted into stomach for nutrition and medication) and before staff provided oral care and suctioning of a tracheostomy (surgical opening in the neck) for two of three sampled residents (Resident 25 and Resident 6). These failures had the potential for serious infections to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure Minimum Data Set (MDS - assessment tool) quarterly (every three months) assessments were completed for five of nine sampled residents (Resident 1, Resident 19, Resident 21, Resident 34 and Resident 13). This failure had the potential for the delay in the development and implementation of Resident 1, Resident 19, Resident 21, Resident 34 and Resident 13's individualized care plans. Findings: During a concurrent interview and record review on 4/8/24 at 9:23 a.m. with Minimum Data Set Coordinator (MDSC), MDSC stated, I'm behind with my assessments. MDSC stated quarterly MDS assessments need to be completed within 14 days of the Assessment Reference Date (ARD-the specific end point of look-back periods in the MDS assessment process). The following residents' quarterly MDS assessments were reviewed: a) Resident 1's quarterly MDS assessment dated [DATE] indicated the MDS assessment was not completed. b) Resident 19's quarterly MDS assessment dated…

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

Based on observation, interview, and record review, the facility failed to ensure professional standards of quality were followed when: 1. One of one sampled resident's (Resident 18) nephrostomy tube (tube placed directly into the kidney to drain urine) was not secured and maintained in a clean environment. This failure had the potential for Resident 18's nephrostomy tube to be displaced and urine to flow back into the kidney and the potential for infection. 2. Multiple medications were crushed and administered together through a (G-tube, inserted through the belly, directly into the stomach) for two of four sampled residents (Resident 25 and Resident 17). This failure had the potential to cause a blockage in the G-tube and violated Resident 25 and Resident 17's right to refuse a medication. 3. One of eight sampled Certified Nursing Assistants (CNA 7) performed work outside of the Certified Nursing Assistant scope of practice when CNA 7 reconnected Resident 28 to Blow By (a method used to deliver humidified air or oxygen to a resident with a tracheostomy[surgical incision 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.

Based on interview and record review, the facility failed to implement their policy and procedure (P&P) titled, Pressure Injury or Skin/Wound Conditions- Assessment, Prevention and Management when staff did not turn and reposition one of seven sampled residents (Resident 15) every two hours. This failure had the potential to result in impaired healing or worsening of a pressure injury (PI-localized damage to the skin and/or underlying tissue as a result of prolonged pressure). Findings: During a review of Resident 15's Clinical Data Flowsheet (CDF) dated 4/1/24, the CDF indicated, Resident 15 was Completely immobile (unable to make even the slightest changes in body or extremity position without assistance) with a Braden Scale Score (an assessment tool used in health care to determine a patient's risk of developing a pressure injury) of 9 (very high risk for skin breakdown). During a review of Resident 15's Physician Orders (PO) dated 3/22/24, the PO indicated, Wound Assessment.Q [every] Week, Site Coccyx [small bone at the bottom of the spine], continue to assess and measure coccyx…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: 1. Provide Restorative Nursing Assistant (RNA) program (provided by RNA to help maintain or improve mobility for the residents) for five of 35 sampled residents (Resident 31, Resident 354, Resident 19, Resident 1, and Resident 27). 2. Ensure the Director of Nursing (DON) implemented the RNA program. These failures had the potential for reduced mobility and range of motion (ROM - limit to which a part of the body can be moved around a joint) for Resident 31, Resident 354, Resident 19, Resident 1, and Resident 27. Findings: 1a. During an interview on 4/8/24 at 3:22 p.m. with Resident 31's Family Member (FM) 1, FM 1 stated Resident 31 was to get RNA care by a CNA three times a week for ROM (Range of Motion) and did not think that was happening. FM 1 stated she came in the evening to keep the Resident 31's movement (ROM) going. During an interview on 4/9/24 at 8:29 a.m. with Resident 31, Resident 31 stated no staff have done RNA care. 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.

Based on observation, interview, and record review, the facility failed to maintain safe and sanitary food handling practices for: 1. One of three sampled freezers (Freezer #6) 2. One of three sampled refrigerators (Refrigerator #5) when food items were not dated after opening. These failures had the potential to result in decreased palatability (tastiness) and foodborne illnesses for residents. Findings: 1. During a concurrent observation and interview on 4/7/24 at 10:06 a.m. with Dietary Aide (DA) 1 in the kitchen, Freezer #6 had one open four-pound bag of frozen mixed peas and carrots without an open date, one open four-pound bag of sliced carrots without an open date, and one open large half empty bag of tater tots (bite size portions of shredded potatoes) without an open date. DA 1 stated there should have been an open date on all open food items. 2. During a concurrent observation and interview on 4/7/24 at 10:08 a.m. with DA 1 in the kitchen, Refrigerator #5 had a one-gallon jar of mayonnaise that was half empty without an open date, and a one-gallon jar of dill pickle relish…

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 create a policy and procedure (P&P) to ensure safe food handling/storage guidelines were being followed for food brought to residents by family/visitors from outside of the facility. This failure had the potential to result in foodborne illness for residents. Findings: During a concurrent observation and interview on 4/10/24 at 8:28 a.m. with Activities Director (AD) in the activities room, AD stated the refrigerator was for resident use. Resident refrigerator had ice cream and orange juice, dated with patient labels. AD stated if residents want to store food in the refrigerator, she would store it for them. AD stated she was responsible for cleaning the refrigerator and checking the temperature daily. AD stated she was not sure if the facility had a P&P to ensure safe food handling/storage for food brought to residents from family/visitors. During an interview on 4/10/24 at 3:57 p.m. with Regulatory Specialist (RS), RS stated the facility did not have a P&P regarding food handling/storage of food brought to residents from…

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

Based on interview and record review, the facility failed to perform the antibiotic stewardship program (a program that promotes the appropriate use of antibiotics) for three of three sampled residents (Resident 19, Resident 20, and Resident 27) when the surveillance data collection form and infection surveillance log was not completed. This failure had the potential to result in unmonitored and unnecessary use of antibiotics for Resident 19, Resident 20, and Resident 27. Findings: During a concurrent interview and record review on 4/9/24 at 9:43 a.m. with Infection Preventionist (IP), the facility's Infection Surveillance Log (ISL), dated March 2024 was reviewed. The ISL indicated the following residents had missing information: a. For Resident 19 - Date of onset of symptoms, criteria for antibiotic use, organism, re-cultured (laboratory test used to check for bacteria or germs) date, and date resolved. b. For Resident 27 - Results of culture, start date of antibiotic treatment, onset date, organism, re-cultured date, and date resolved. c. For Resident 20 - Date of onset of…

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

Based on observation, interview and record review, the facility failed to follow their Policy and Procedure (P&P) titled Tracheostomy [surgical opening in the neck] Tube and inner Cannula [flexible tube] Changing, for one of one sampled resident (Resident 24) did not have a spare tracheostomy tube at the bedside. This failure had the potential to result in a delay in care in the event of an emergency. Findings: During an observation on 4/7/24 at 10:24 a.m., in Resident 24's room, Resident 24 had no ambu bag (manual breathing bag), no emergency blow by (method to supply oxygen) and no spare tracheostomy tube or supplies at bedside. During a concurrent observation and interview on 4/9/24 at 8:37 a.m. with Licensed Vocational Nurse (LVN) 6, in Resident 24's room, there were no emergency supplies: ambu bag, blow by or spare tracheostomy tube and supplies. LVN 6 stated the supplies are supposed to be hanging at bedside or the hook at the closet area. During an interview on 4/9/24 at 10:49 a.m. with Respiratory Therapist (RT) 2, RT 2 stated when the resident got moved, they did not move…

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

Based on interview and record review, the facility failed to ensure one of six sampled resident's (Resident 48) on a psychotropic (used to treat mental health disorders) medication, behavior was monitored consistently. This failure had the potential for staff to not be able to identify when changes occurred in Resident 48's mood/behavior. Findings: During a review of Resident 48's Physician Orders (PO), dated 1/13/24, the PO indicated, Sertraline (a psychotropic medication) daily for depression. During an interview on 4/9/24 at 9:30 p.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 stated Resident 48 expressed signs of frustrations when she could not communicate her needs. LVN 3 stated Resident 48 was also sad because she was homesick and wanted to go home. During an interview on 4/9/24 at 9:53 a.m. with Certified Nursing Assistant (CNA) 5, CNA 5 stated she did not regularly document Resident 48's behavior or mood. During a concurrent interview and record review on 4/9/24 at 11:26 a.m. with Pharmacist Supervisor (PS), Resident 48's Drug Regimen Review (DRR), dated 3/27/24 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 and record review, the facility failed to ensure one of three sampled residents (Resident 45) was provided with gradual dose reduction (GDR - reduce dose gradually over time) of an anti-depressant medication (medication used to reduce depressed mood). This failure had the potential for Resident 45 to continue taking a medication unnecessarily. Findings: During a concurrent interview and record review on 4/9/24 at 11:46 a.m. with Pharmacist Supervisor (PS), Resident 45's Medical Record (MR) was reviewed. PS stated Resident 45 was admitted on [DATE] and was prescribed Sertraline (medication for depressed mood) on 10/25/23. PS stated the start of review should have been November 2023. PS stated there was no documentation for a GDR. PS stated pharmacy review was suppose to every 3 months. PS stated it can be potentially an unnecessary medication. During a review of the facility's policy and procedure (P&P) titled, Monthly Drug Regimen Review - SCU, dated 10/19/21, the P&P indicated, 6. Gradual…

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

Based on observation, interview, and record review, the facility failed to: 1. Label and date an Intravenous (IV, in the vein) solution (fluid) and tubing (carries fluid from bag to the vein) for one of three sampled residents (Resident 13). This failure had the potential of medication being administered to the wrong resident and the potential for Resident 13 to acquire an infection due to increased time of use. 2. Date the glucose (sugar) Quality Control (QC) testing strips vial (small container) upon opening on one of four sampled medication carts (Cart 3). Findings: 1. During an observation on 4/7/24 at 10:09 a.m. in Resident 13's room, an IV solution was being administered to Resident 13. The IV solution did not have a patient identifier label or date. The IV tubing did not have a label with a date of first use. During an interview on 4/7/24 at 10:16 a.m. with Registered Nurse (RN) 1, RN 1 stated the IV bag was changed this morning, but she did not get a chance to date it or put a label on it. RN 1 stated the IV bag should have been labeled and the tubing should have been dated.…

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

Based on observation, interview, and record review, the facility failed to provide one of three sampled residents (Resident 1) with a means to call for assistance when needed. This failure had the potential for Resident 1's needs to not be met, had the potential for feelings of low self-esteem and had the potential for serious harm and other negative consequences. Findings: During a review of Resident 1's CODING SUMMARY (CS), dated 11/14/23, the CS indicated, Resident 1 had a diagnosis of Quadriplegia (life altering condition that results in loss of control of both arms and legs), Tracheostomy (a tube surgically placed into the neck/wind pipe in order to allow air to fill the lungs), chronic respiratory failure and Gastrostomy tube (a tube surgically placed into the stomach to provide nutrition and/or medication). During a review of Resident 1's MDS (Minimum Data Set – an assessment tool) under the section Functional Abilities and Goals (FG), dated 1/9/24, the FG indicated, Resident 1 was completely dependent of care from staff for: Eating, Oral hygiene, Toileting hygiene,…

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

Based on observation, interview, and record review, the facility failed to follow their Policy and Procedure (P&P) titled Procedure: Braden Scale and Prevention of Skin Breakdown and PROCEDURE: TURNING SCHEDULE for one of three sampled residents (Resident 3) when: 1. Resident 3's heel with redness and discoloration was on a flat pillow. 2. There was no documentation of repositioning for more than 4 hours for Resident 3. These failures had the potential for Resident 3 developing pressure injuries and other negative health consequences. Findings: 1. During a concurrent observation and interview on 1/16/24 at 2:45 p.m. Charge Nurse (CN) 1 in Resident 3 ' s room, Resident 3 ' s heels were directly on the middle of a flat pillow. CN 1 stated there was redness and discoloration to right heel. CN 1 stated [Resident 3] heels should had been floated (off the pillow). During an interview on 2/29/24 at 2:13 p.m. with Risk & Regulatory Analyst (RRA) 1, RRA 1 stated, Update as of 2/29/24, I received clarification that zero pressure means the area is elevated and not touching a surface like a…

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

Based on interview and record review, the facility failed to implement their policy and procedure on Team Conferences after a change of condition for seven of eight sampled residents (Resident 1, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8). This failure resulted in the reason for the change of condition to be unknown, had the potential for the skin conditions to worsen, and had the potential for lapse in continuity of care, and had the potential for harm. Findings: During a concurrent interview and record review on 1/11/24 at 2:04 p.m. with Director of Nursing (DON), the following Resident Electronic Records (RER) were reviewed: a. Resident 1 – On 10/8/23 Resident 1 was noted to have right breast redness of unknow cause. b. Resident 3 – On 10/21/23 Resident 3 was noted to have left buttock crease redness of unknown cause. On 12/18/23 Resident 3 was noted to have a left buttock sore (a wound that develops on the skin) of unknown cause. During a concurrent interview and record review on 1/12/24 at 8:22 a.m. with DON, the following Resident Electronic…

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

Based on interview and record review, the facility failed to accommodate and meet the needs of six of eight sampled residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 6, Resident 7). This failure had the potential for negative outcomes up to and including harm. Findings: During a review of Resident 1 ' s Minimum Data Set (MDS- comprehensive assessment) under Brief Interview for Mental Status (BIMS – an assessment tool for cognition), dated 12/6/23, the BIMS indicated, Resident 1 had a score of 14 out of 15 points (cognition is intact.) During an interview on 11/14/23 at 12:11 p.m. with Resident 1, Resident 1 stated there were not enough nurses in the facility. During an interview on 11/14/23 at 12:42 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated the facility sends CNAs home early toward the end of the shift. CNA 1 stated day shift works from 7 a.m. to 7:30 p.m. CNA 1 stated CNAs were sent home around 6 p.m., 6:30 p.m. or at 7 p.m. CNA stated the facility CNAs were sent home early consistently over the last few months. CNA 1 stated Residents complain…

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

Based on interview and record review, the facility failed to document resident information and follow up assessments after a change of condition for seven of eight sampled residents (Resident 1, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8). This failure had the potential for worsening skin conditions to go unnoticed, prolong healing, lack in continuity of care and other negative consequences. Findings: During a concurrent interview and record review on 1/11/24 at 2:04 p.m. with Director of Nursing (DON), the following Resident Electronic Records (RER) were reviewed: a. Resident 1 – On 10/8/23, Resident 1 was noted to have right breast redness of unknow cause. b. Resident 3 – On 10/21/23, Resident 3 was noted to have left buttock crease redness of unknown cause. On 12/18/23, Resident 3 was noted to have a left buttock sore (a wound that develops on the skin) of unknown cause. DON stated there was no documentation or follow up assessment documentation in regard to size or any other detailed information noted for Resident 1, and Resident 3 ' s identified skin…

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

Based on interview and record review, the facility failed to ensure call lights were: 1. Answered timely for three of four sampled residents (Resident 1, Resident 2, and Resident 3). 2. Within reach for one of four sampled residents (Resident 1) These failures had the potential for unmet care needs and negatively impact Resident 1, Resident 2, and Resident 3's safety and dignity. Findings: 1.During a review of Resident 2' s Minimum Data Set, (MDS - an assessment tool) dated 8/27/23, the MDS indicated, Resident 2' s BIMS (Brief Interview for Mental Status) score was 14 (a score of 13-15 suggests the resident is cognitively intact). During a concurrent observation and interview on 11/8/23, at 8:36 a.m., with Resident 2, Resident 2 stated, I look at the clock and I have a very good memory. A clock was observed on Resident 2 ' s wall. Resident 2 stated call lights were being answered late. Resident 2 stated the longest she had waited for call light to be answered was 45 minutes. Resident 2 stated, When I need to be changed it makes me frustrated and angry sometimes because I see LVNs…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure consistent sufficient staffing to meet the needs for two of four sampled residents (Resident 1 and Resident 2). This failure resulted in unmet care needs, and negatively impacted the safety, physical, mental, and psychosocial well-being for Resident 1 and Resident 2. Findings: During a review of Resident 1 ' s Minimum Data Set, (MDS - an assessment tool) dated 8/27/23, the MDS indicated, Resident 1's BIMS (Brief Interview for Mental Status) score was 14 (a score of 13-15 suggests the resident is cognitively intact). During a concurrent observation and interview on 11/8/23 at 8:36 a.m. with Resident 2, Resident 2 stated she will not get changed after 5 a.m. in morning until they come back at 10 or 11 a.m. Resident 2 stated the facility sends the staff home early and this has been going on for a while mostly in the mornings. Resident 2 stated, When we complain they always say the hospital is run like a business, so we have to cut…

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

Based on interview and record review, the facility failed to report two separate allegations of abuse, for one of four sample residents (Resident 1). These failures resulted in delayed investigation of abuse for Resident 1 and had the potential for Resident 1 to be at risk for further abuse. Findings: During an interview on 11/8/23 at 1:47 p.m. with Family Member (FM 1), FM 1 stated Resident 1 told her certified nursing assistant (CNA 5) hit him and called him a mother fucker. FM 1 stated on Wednesday FM 1 reported the abuse to Registered Nurse Manager (RNM). FM 1 stated, I told [RNM] [Resident 1] is telling me he is being abused. FM 1 stated this all started three weeks ago. FM 1 stated RNM and Registered Nurse (RN 1) went to Resident 1 ' s room and Resident 1 told RNM and RN 1 about the alleged abuse. During an interview on 11/9/23 at 9:06 a.m. with Resident 1, Resident 1 stated Certified nursing Assistant (CNA 4) called him queer. Resident 1 stated he has not reported it. Resident 1 stated CNA 5 hit him on his leg, Resident 1 believes CNA 5 hit him intentionally to hurt him.…

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

Based on interview and record review, the facility failed to implement its policy and procedure for TEAM CONFERENCES for six of six sampled residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5 and Resident 6) when: 1. Resident 5 and Resident 6 had new onset pressure ulcers (wounds caused by prolonged pressure). 2. Resident 1, Resident 2, Resident 3 and Resident 4 had fall incidents. These failures resulted in Care Plans (CP - helps nurses and other care team members organize aspects of patient care according to a timeline) not being updated and had the potential for the cause of the falls and pressure ulcers to not be identified, had the potential for increased risk of pressure injury and falls for all residents and had the potential for lack of appropriate prevention/care to be implemented resulting in negative consequences. Findings: 1. During a concurrent interview and record review on 8/23/23 at 11:32 a.m. with Quality Assurance Professional (QAP), Resident 5 and Resident 6's Electronic Medical Chart (EMC), was reviewed. The EMC indicated, Resident 5 had a left…

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.