Country Hills Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility failed to administer pain medication for two of four residents (Resident 1 and Resident 2) per the Nursing Standards of Practice, reviewed for Quality of Care when: 1. Pain medication was administered to Resident 1 without assessing the level of pain before or after administration of a narcotic (a controlled that is regulated by the government due to its potential for abuse and addiction) and, 2. The correct pain medication was not administered to Resident 2 according to the pain scale (1-10: 1 being the least amount of pain and 10 being the worst pain). These failures had the potential for Resident 1 to experience addiction and for Resident 2 to not receive adequate pain relief.Findings:1. Resident 1 was admitted to the facility on [DATE], with diagnoses which included abnormalities of gait and mobility, per the facility's admission Record.A review of Resident 1's clinical record was conducted on 7/29/25.According to Resident 1's annual Minimum Data Set, (MDS-a federally mandated resident…

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

Based on observation, interview, and record review, the facility failed to secure prescription medication when:1. A treatment cart (a cart with prescribed lotions and creams, used to treat wounds and skin conditions) was left unlocked for one of six treatment carts (Station 2 North); and,2. Medication was left on top of a medication cart, unsupervised for one of 11 medication carts (Station 3 North); and,3. Medication was left unsupervised at the bedside for one of four residents (Resident 1) when reviewed for safe medication storage.These failures had the potential for unauthorized people (resident, staff, and visitors) to have access to medications not prescribed to them.Findings: 1. An observation was conducted on 7/29/25 at 10:22 A.M. near the nursing station on 2 north. A treatment cart was unlocked, and no staff were nearby. The treatment cart contained medicated creams and lotions in the first and second drawers. Sitting across from the treatment cart were four residents. One male resident wearing a red outfit, walked past the treatment cart twice. Also observed walking past…

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 resident records were accurate and concise for one of four residents (Resident 1) when: 1. A quarterly pain assessment was not conducted for Resident 1, to determine if pain levels had increased or decreased over the past three months; and;2. Routine pain mediation was not charted for Resident 1 after administrated and was charted hours later.These failures provided inaccurate documentation in Resident 1's clinical records and could cause staff confusion.Finding: 1. Resident 1 was admitted to the facility on [DATE], with diagnoses which included abnormalities of gait and mobility, per the facility's admission Record.A review of Resident 1's clinical record was conducted on 7/29/25. According to Resident 1's annual Minimum Data Set, (MDS-a federally mandated resident assessment tool), dated 6/12/25, a cognitive score of 15 was listed, indicating cognition was intact. The Pain Assessment indicated no pain in the past five days. According to 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 ountry Hills 558-E Accommodation of Needs Based on observation, interview, and record review, the facility failed to provide residents with an alert call system for 20 of 44 Residents (1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 13, 14, 15, 17, 19, 20, 21, 22, and 23) in order for staff to respond to their needs, after their electronic call system stopped working on Station 3 North, when reviewed for Accommodation of Needs. In addition, three of the 21 residents (23, 24, and 25) with manual call bells had their call bells out of reach. This failure had the potential for 26 Residents to not have their needs met in a timely manner. Findings: On 6/10/25, an unannounced visit was conducted in response to a complaint of call lights not working on Station 3 North. An interview was conducted with the Director of Nursing (DON) on 6/10/25 at 11:58 A.M. The DON stated the call light system on Station 3 North stopped working on Wednesday 6/4/25. The DON was unaware if the call light outage was reported to the California Department…

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 correctly administer medications for one of six residents reviewed for competent nursing staff. (Resident 1) As a result of this deficient practice, the facility could not ensure medications were accurately and safely provided to residents. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses which included sequelae (after effect) of cerebral infarction (disrupted blood flow to the brain) and hypertension (high blood pressure) according to the facility's admission Record. Resident 2 was admitted to the facility on [DATE] with diagnoses which included hemiplegia (total or partial paralysis of one side of the body) and hemiparesis (muscle weakness on one side of the body) following cerebral infarction according to the facility's admission Record. On 4/7/25 at 9:05 A.M., an unannounced onsite visit to the facility was conducted related to a medication error. During an interview on 4/7/25 at 9:05 A.M. with the Assistant Director of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure medications were correctly administered according to the physician's order for one of six residents (Resident 1) reviewed for pharmacy services. As a result of this deficient practice, the facility could not ensure pharmaceutical services were safely provided to its residents. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses which included sequelae (after effect) of cerebral infarction (disrupted blood flow to the brain) and hypertension (high blood pressure) according to the facility's admission Record. Resident 2 was admitted to the facility on [DATE] with diagnoses which included hemiplegia (total or partial paralysis of one side of the body) and hemiparesis (muscle weakness on one side of the body) following cerebral infarction according to the facility's admission Record. On 4/7/25 at 9:05 A.M., an unannounced onsite visit at the facility was conducted related to a medication error. During an interview on 4/7/25…

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 correctly administer medications for one of six residents reviewed for medication errors. (Resident 1) This failure has the potential affect Resident 1's health and wellbeing. In addition, this failure has the potential to place other residents at risk for medication errors. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses which included sequelae (after effect) of cerebral infarction (disrupted blood flow to the brain) and hypertension (high blood pressure) according to the facility's admission Record. Resident 2 was admitted to the facility on [DATE] with diagnoses which included hemiplegia (total or partial paralysis of one side of the body) and hemiparesis (muscle weakness on one side of the body) following cerebral infarction according to the facility's admission Record. On 4/7/25 at 9:05 A.M., an unannounced onsite visit at the facility was conducted related to a medication error. During an interview on 4/7/25 at 9:05 A.M.…

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

Based on observation, interview, and record review, the facility failed to ensure kitchen staff maintained sanitary food practices when: 1. Drying racks and a drying cart were not clean; and 2. The hanging sprinkler system (Ansel) heads above the stove were covered in dust; and 3. A beard net was not being worn by a dishwasher; and 4. A dishwasher aide did not wash his hands after removing trash and reentering the kitchen. These failures had the potential for cross contamination and to cause food borne illness. Findings: 1. An observation and interview was conducted with Dietary Manager (DM) of the 3-compartment sink area on 3/12/25 at 8:17 A.M., Large pots and pans were upside down, air drying on 3-rack metal shelves next to the 3-compartment sink area. The 3-racks that the pots and pans were resting on appeared dirty and gritty. A finger sweep was performed on each rack, which left a clear, distinguished line on the rack. The DM stated, Yes, I see what you mean, they are dirty. The DM stated the kitchen was deep cleaned every Wednesday, but he could not provide a check list of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure five out of 13 residents reviewed for dignity were provided care in a manner that promoted dignity and respect. (Resident 50, 218,148, 5 and 51) This failure had the potential for the residents' self-esteem and self-worth to be devalued. Findings: 1. Resident 50 was admitted to the facility on [DATE] with diagnoses including dysphagia (difficulty in swallowing) and dementia (a condition characterized by loss of memory, language, problem solving and other thinking abilities) according to the facility's admission Record. A record review of Resident 50's Activities of Daily Living (ADL-basic tasks of everyday life) care plan was conducted. The ADL care plan dated 6/24/20 indicated, .has a self-care deficit related to: .cognitive loss, dementia .Assist as needed with ADLs . 2. Resident 218 was admitted to the facility on [DATE] with diagnoses which included dysphagia and dementia according to the facility's admission Record. During 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 2. According to the facility's admission Record, Resident 166 was admitted to the facility on [DATE], with diagnoses which included cirrhosis of the liver, (a type of liver damage where healthy cells are replaced by scar tissue). Resident 166's clinical record was reviewed on 3/11/25. According to the facility's Smoking Observation/Assessment form, dated 12/13/24, Resident 166 was a tobacco user and required supervision while smoking. Resident 166's clinical record was reviewed on 3/11/25. According to Resident 166's care plan, titled Potential for Injury related to smoking, revised 2/12/25, listed interventions such as, cigarettes and lighter will be stored by the smoking monitor. Resident 166's clinical record was reviewed on 3/11/25. According to the admission MDS (Minimum Data Set: a federally required assessment tool), dated 12/19/24, Section J, titled Health Condition, Resident 166 was coded as not a tobacco user. An observation of Resident 166 was conducted on 3/13/15 at 4:03 P.M., while smoking on the…

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

Based on observation, interview, and record review, the facility failed to invite and notify residents and/or their responsible parties (RP) in advance about a Resident Council meeting and care conferences for three of five residents (Resident 150, 180, and 239) reviewed. These deficient practices placed all residents at risk for not having their preferences, health needs updated. This practice did not promote a person-centered care plan. The census was 302. Cross-Reference F867 Findings: On 3/12/25 at 10:12 A.M., an observation and interview with five resident council members were conducted, on the 4th floor dining room. Three residents (Residents 239, 180,150) stated they were not informed, invited, or asked to join a care conference with the interdisciplinary team (IDT-members of the facility involved with the resident's care) to provide their input on their preferences or to receive updates about their plan of care. Interview responses of residents on 3/12/25 at 10:12 A.M.: Resident 150 stated they don't ask me to come to care conference. Resident 180 stated she was in agreement…

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 set low-air loss mattresses (LALM: a pressure relieving air mattress to alleviate pressure to boney areas of the body to help prevent skin breakdown and injury) according to manufacture weight recommendations and/or resident comfort for five of 36 sampled residents (Resident 240, 207, 51, 55, and 219) at risk for pressure ulcers. These deficient practices placed residents (Resident 240, 207, 51, 55, and 219) at risk for skin breakdown and injuries. Cross-Reference F867 Findings. 1. A review of Resident 240's admission Record indicated Resident 240 was admitted to the facility on [DATE] with diagnoses which included a history of left side hemiplegia (total paralysis of the arm, leg, and trunk on the left side of the body). A record review of Resident 240's minimal data set (MDS-nursing facility assessment tool) dated 1/16/25 indicated Resident 240 had clear speech, was able to express her ideas and understood others. Resident 240 cognitive…

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 date and later discard resident food, stored in three of six resident refrigerators, when reviewed for safe food handling practices. This failure had the potential for stored food to cause a food borne illness if consumed by the resident. Findings: An observation and interview was conducted with Licensed Nurse 41 (LN 41) of Station 4's north resident refrigerator on 3/11/25 at 1:54 P.M. Observed inside the resident refrigerator was a tray of store purchased sushi with a clear lid. The sushi tray contained a residents' name and room number, but no date of when it was placed in the refrigerator. LN 41 could not locate a best use by date on the sushi container. A large white plastic bag which contained a resident name and room number was opened. Inside the large plastic bag was a plastic store container of spinach/artichoke dip, which was half consumed. The spinach/artichoke dip container had no date of when it was opened, and LN 41 could not locate a best use by date on the container. The large plastic bag also…

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 properly explain the arbitration (a contract that says if there is a disagreement or legal issue between a resident and the facility, it will be settled by a private process instead of going to court) agreement to four of five reviewed residents (Residents 239, 229, 180, and 150) leaving them unaware that signing it meant waiving their rights to take legal actions. This deficient practice placed residents (Residents 239, 229, 180, and 150) at risk for signing an agreement without fully understanding their rights and options. Findings: On 3/12/25 at 10:12 A.M., an observation and interview with five resident council members were conducted, at the 4th floor dining room. Four out of five residents (Residents 239, 229, 180, and 150) during the resident council meeting stated they did not understand what the arbitration agreement was, were unaware they had 30 days to decline it, and were not given a copy. Residents interviewed responses 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 interview and record review the facility's Quality Assessment and Assurance Committee (QAA-facility group that monitors concerning trends in a facility) failed to identify and include in the facility's Quality Assurance Performance Improvement plan (QAPI-plan developed by QAA to help improve conditions in the facility), trends identified by surveyors during the recertification survey concerning delay of call lights, smokers, Registered Dietician (RD) recommendations, kitchen hygiene, RD kitchen audits, resident care conferences, and low air loss mattress settings. These failures had the potential for the facility to overlook trends in resident care that may have affected residents' dignity and/or health. Cross Reference: F847, F625, F550, F686, F657 Findings: On 3/14/25 at 1:59 P.M., A concurrent interview and review of the facility's QAPI/QAA program was conducted with the Administrator (ADM) and the Director of Nursing (DON). The DON stated the current QAPI programs were Falls, UTI, Hospital transfers, RNA residents, Infection reports, Pest control program, MDS assessment…

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 one of 37 sampled residents (Resident 55) with a suitable call button (button used to call for assistance). This failure prevented Resident 55 (R55) from being able to use his call button and had the potential for R55 to not have his needs met. Cross reference F919 Findings: Review of admission Record indicated R55 was admitted on [DATE] with diagnoses which included Cognitive Communication Deficit(difficulties in communication stemming from impairments in cognitive [thinking ability] functions like attention, memory, or problem-solving, rather than a primary language or speech problem), Functional Quadriplegia (the complete inability to move due to severe disability or frailty, but without physical injury or damage to the brain or spinal cord), and Metabolic Encephalopathy (a condition where the brain does not function properly). Review of Minimum Data Set (MDS-a standardized, federally mandated assessment tool used in nursing…

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 maintain a clean and sanitary living environment for one of four reviewed hospice (end of life care) residents (Resident 297) when the shared bathroom was found dirty with feces on surfaces and had a strong odor. These deficient practices placed Resident 297, other residents, staff, and visitors at risk for exposure to harmful bacteria and potential health hazard. This deficient practice also created an unsanitary living condition for residents using the bathroom. Cross-Reference F689 Findings: A review of Resident 297's admission Record indicated Resident 297 was admitted to the facility on [DATE] with diagnoses which included a history of Malignant Neoplasm of the Prostate (prostate [male organ below the bladder] cancer that is life-threatening once the cancer spreads to other parts of the body). On 3/11/25 at 2:49 P.M., an observation and interview was conducted with Resident 297 and family member's, in Resident 297's room. Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide a written notice of the bed-hold policy to residents at the time of transfer for one of 37 sampled residents (187). As a result, Resident 187 may not have been fully aware of the facility's bed-hold policy. Findings: Per the facility's admission Record, Resident 187 was admitted to the facility on [DATE] with diagnoses of paraplegia (Inability to move part of the body). On 3/13/25 at 10:10 A.M., an interview was conducted with Licensed Nurse (LN) 1. LN 1 stated, when she transferred a resident to an acute care hospital a written notice of bed-hold was not provided to the resident. On 3/13/25 at 10:18 A.M., an interview was conducted with LN 2. LN 2 stated, when she transferred Resident 187 to an acute care hospital, she did not provide a written notice of bed-hold to Resident 187. LN 2 further stated, she forgot to document offering a bed-hold to Resident 187. On 3/13/25 at 10:32 A.M., an interview was conducted with Assistant Director of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to submit the Minimum Data Set (MDS: a federally mandated resident assessment tool) timely to the federal database after the MDS was completed and signed by the LN for one of 36 residents (Resident 196) sampled. This failure resulted in the late submission of the MDS to the federal database. Findings: A review of Resident 196's admission Record indicated Resident 196 was re-admitted to the facility on [DATE] with diagnoses which included a history of Heart Failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). A record review of Resident 196's quarterly MDS dated [DATE] indicated, the MDS completion date was completed and signed on 1/27/25. On 3/13/25 at 12:26 P.M., a record review was conducted on the MDS Final Validation Report. The MDS Final Validation Report dated 2/16/25 indicated the quarterly MDS (dated 1/13/25) was submitted late. The MDS Final Validation Report indicated, .the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to create a comprehensive care plan to include special instructions for one of seven sampled residents (Resident 128). As a result Resident 128 was at risk for his dialysis to be interrupted or complications to occur by not having a staff person with him during dialysis. Findings: Per the facility's admission Record, Resident 128 was admitted on [DATE] with a diagnosis of End Stage Renal Disease (ESRD-irreversible kidney failure). Based on observations on 3/11/25 at 2:17 P.M. and 3/13/25 at 2:43 P.M. at the 2 South Nurse's Station, Resident 128 was returned to the facility via medical transport. Resident 128 was not accompanied by a facility staff member on either occasion. During a concurrent interview and record review on 3/14/25 at 10:45 A.M. with Infection Preventionist (IP)1, Resident 128's electronic medical record was accessed and reviewed. The record indicated in the Special Instructions section that Staff must accompany to Dialysis.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide routine nail care to one of one resident (Resident 190) reviewed for Activities of Daily Living (ADL, activities related to personal care) for dependent residents. As a result, Resident 190 was at risk for skin injury and infection. Findings: Resident 190 was admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (complete weakness of one side of the body and weakness on one part of the body following a stroke), dysphagia (difficulty of swallowing) following a stroke and epilepsy (seizures) per the facility admission Record. A record review of Resident 190's physician history and physical examination (H&P) on 3/6/24 indicated Resident 190 did not have the capacity to understand and make decisions. On 3/12/25 at 2:43 P.M., an interview was conducted with Certified Nursing Assistant (CNA) 21. CNA 21stated on Sunday's nail care was being…

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 maintain a safe hazard free environment for two of 34 residents (Resident 14, and Resident 15). As a result: 1. Resident 14 was placed at risk when the nursing staff placed shower blankets and/or drawsheets on Resident 14's bathroom floor for convenience, creating a slipping hazard which could have resulted in serious injury. Cross-Reference F584 2. Resident 15 was placed at risk for smoke-related injuries and burns when the facility failed to assess Resident 15's current smoking status and safety plan. Findings: A review of Resident 14's admission Record indicated Resident 14 was re-admitted to the facility on [DATE] with diagnoses which included a history of unsteadiness of feet (balance issues with walking, and/or standing). A clinical chart review was conducted on Resident 14's fall care plans that indicated the following: - Fall risk care plan initiated 9/13/23 and revised 12/10/24, indicated, .at risk for falls related to . I am…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure the nutritional status was monitored for one of seven residents reviewed for nutrition, with progressive weight loss since admission (Resident 260). This failure had the potential to result in Resident 260 to experience further functional decline and loss of lean body mass (the body weight that includes muscles, bones, and organs and excludes fat). Findings: Resident 260 was admitted to the facility on [DATE] with diagnoses which included dysphagia (difficulty in swallowing) and pressure ulcers (bedsores) according to the facility's admission Record. On 3/11/25 at 8:20 A.M., Resident 260 was observed in bed. Resident 260 had good eye contact and nodded only upon greeting. An interview on 3/12/25 at 8:50 A.M. with Certified Nurse Assistant (CNA) 35 was conducted. CNA 35 stated Resident 260 required feeding assistance with meals and one other CNA was responsible for assisting residents who required to be fed. CNA 35 stated Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to follow physician's orders for post dialysis care (Res 51) and did not follow special instructions during dialysis (Res 128) for two of nine reviewed residents (Resident 51 and 128) These deficient practices placed the residents (Resident 51 and 128) at risk for complications such as infection, clotting, discomfort and compromised safety. Findings: 1. A review of Resident 51's admission Record indicated Resident 51 was admitted to the facility on [DATE] with diagnoses which included a history of End Stage Renal Disease (ESRD: irreversible kidney failure) requiring dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed). A record review of Resident 51's MDS (Minimum data set: nursing facility assessment tool) dated 2/24/24 indicated that Resident 51 was rarely or unable to understand others or make self-understood and had severe cognitive (the mental processes…

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 properly store and label Resident 204's breathing treatment medications. As a result, the facility could not ensure medications were safely stored. Findings: On [DATE] at 10:28 A.M., an observation and interview were conducted with Resident 204. Resident 204 was in bed and connected to an oxygen concentrator machine. There was a CPAP (continuous positive airway pressure to keep airway while asleep) machine and nebulizer at bedside. Resident 204 pulled out unlabeled, undated and unpackage solution vials of Ipratropium- Albuterol medications from his bedside drawer. Resident 204 stated staff gave medications to him sometimes but he administered the solution via his nebulizer in the evenings. On [DATE] at 10:09 A.M., a concurrent observation and interview was conducted with RT 21. Resident 204 pulled out unlabeled, undated and unpackaged solution vials of Ipratropium-Albuterol medications from his bedside drawer. Resident 204 stated in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement infection control standards of practice when: 1. A facility staff did not sanitize a blood pressure cuff in between use for different residents, 2. The facility did not update their Infection Prevention and Control Program (IPCP) policy and procedure (P&P) according to federal regulations. This failure had the potential to spread infection among the residents. In addition, staff had the potential to not know current standards of practice for preventing and controlling infections. Findings: 1. An initial tour of the facility was conducted on 3/11/25 at 9:25 A.M. Certified Nurse Assistant (CNA) 31 was observed in the hall holding a portable wrist blood pressure cuff. CNA 31 stated she was taking her residents' vital signs (temperature, pulse, respirations and blood pressure). CNA 31 was observed entering room [ROOM NUMBER] and was observed from the hallway taking a resident's blood pressure with the portable wrist blood pressure…

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 two residents of 37 sampled residents (Resident 55 and Resident 268) with functional call buttons. This failure prevented residents from using their call buttons and making their needs known and having their needs met. Cross reference F558 Findings 1. Review of admission Record indicated Resident 55 (R55)was admitted on [DATE] with diagnoses which included Cognitive ( process of thinking) Communication Deficit (difficulties in communication stemming from impairments in cognitive functions like attention, memory, or problem-solving, rather than a primary language or speech problem), Functional Quadriplegia (the complete inability to move due to severe disability or frailty, but without physical injury or damage to the brain or spinal cord), and Metabolic Encephalopathy (a condition where the brain does not function properly). Review of Minimum Data Set (MDS-a standardized, federally mandated assessment tool used in nursing homes)…

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 keep one resident room (room [ROOM NUMBER]) free from cockroaches. This failure had the potential to affect the health of the three residents who reside in room [ROOM NUMBER]. Findings: A review of the admission Record for Resident 258 (R258) dated 1/22/25 indicated R258 was admitted for diagnoses which included: Infection of sacrococcygeal region (the region at the base of the spine, encompassing the sacrum (bone of the lower back) and coccyx (tailbone)), Skin Graft failure (the transplanted skin tissue fails to survive and integrate with the recipient site), Aneurysm of ascending aorta(a bulge or widening of the ascending aorta, the part of the aorta that carries blood from the heart to the head and arms). A record review of Minimum Data Set (MDS-a standardized, federally mandated assessment tool used in nursing homes) Section C dated 2/11/25 indicated Brief Interview for Mental Status (BIMS- a standardized assessment tool used to screen…

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 investigate an allegation of staff to resident abuse for one of two residents (Resident 2) when reviewed for Resident Abuse. This failure had the potential for all resident's to be at risk of staff to resident abuse. Findings: Resident 2 was admitted to the facility on [DATE], with diagnoses which included dementia (progressive memory loss), with agitation, per the facility ' s admission Record. On 2/21/25, Resident 2 ' s clinical record was reviewed: According to the Minimum Data Set, (MDS-a clinical assessment tool), Resident 2 had a cognitive score of 9, indicating cognition was moderately impaired. According to the Functional Abilities section, Resident 2 could ambulate without any assistive devices. According to the facilities SBAR (Situation-Background-Assessment-Recommendation communication tool used between staff members about a resident's change in condition), Communication Form, dated 1/31/25 at 10 A.M., Patient sustained a skin tear to right…

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 accurately assess, document, and transmit Minimum Data Set (MDS-a clinical assessment tool), information to the Center for Medicare and Medicaid Services (CMS-A federal agency that oversees health insurance) regarding the preferred language for one of two residents (Resident 1), when reviewed for MDS Assessments As a result, CMS was uninformed of Resident 3 ' s language preference. Findings: Resident 1 was readmitted to the facility on [DATE], with diagnoses which included Parkinson ' s disease, (a progressive neurological disorder that affects movement, balance, and other bodily functions), per the facility ' s admission Record. An observation was conducted of Resident 1 in her room on 2/21/25 at 10:52 A.M. Resident 1 was in bed, with the head of the bed slightly elevated. Resident 1 padded her mattress and stated No bueno, .mucho delore, no bueno (No good . much pain, no good). Resident 1 did not understand questions in English and a…

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

Based on observation, interview, and record review, the facility failed to ensure the kitchen staff competently carried out the functions of the food and nutrition services department when: 1. A Dietary Aide (DA 1) dishwasher was unable to determine the correct wash, rinse and sanitizing temperatures and process. 2. A [NAME] (CK 2) did not prepare the beef roast correctly using the cool down process for cooking hot foods. These failures had the potential to expose dishes to to unsanitary practices and contaminate the food which could result in food borne illness among all residents who consume food from the kitchen. The facility census was 294. Findings: 1. During the initial kitchen tour on 3/26/24 at 8:10 AM, a concurrent interview with the Dishwasher, Dietary Aide (DA 1), and record review of the dish machine log was conducted. The log indicated 3/25/24 Dinner: wash-200, rinse-200, and sanitizer-100 ppm (parts per million) .3/26/24 Breakfast: wash- 190, rinse- 150, and sanitizer- 100 ppm . DA 1 stated he wrote the values for 3/26/24 and initialed them. DA 1 stated he couldn't…

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

Based on observation, interviews, and record reviews the facility failed to ensure safe and sanitary conditions were maintained in the kitchen for food preparation tools and food storage methods, according to standards of practice and facility policy when: 1. Three (3) floor sink drains were full of dirt, food debris, trash, and black grime; and one floor sink drain was uncovered. 2. A Kitchen reach-in refrigerator with 7 full cases of 4-ounce Ready shake chocolate flavor milkshakes (75 milkshakes per case), and 3 cases with 10 Ready shakes of vanilla flavor, and the quart of lactaid milk with a broken thermometer. 3. Six measurement scoops, three dome lids, 1 metal egg slicer, and were found with brown and black grime and food debris on them after they were washed and stored as clean in drawers. 4. Seven cutting boards (3 green, 1 blue, 1 tan, 1 yellow, and 1 white) were found visibly worn with multiple tears and discolorations. 5. Four Resident nourishment refrigerators on nursing units had expired food items inside with visible dirt and sticky grime on the inside of the doors.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. Review of Resident 548's admission Record indicated he was admitted to the facility on [DATE]. Review of Minimum Data Set (MDS, a nursing assessment used in nursing homes) section C, Cognitive Patterns dated 3/5/24 indicated Resident 548 with a Brief Interview for Mental Status (BIMs, a test to determine cognitive levels in residents) score of 10, which indicates moderately impaired cognition. Review of MDS section GG, Functional Abilities and Goals dated 3/5/24 indicated that Resident 548 needed supervision or touch assistance for the categories of oral hygiene, toileting hygiene, shower/bath self and personal hygiene. On 3/26/24 at 10:50 A.M., during initial pooling of residents, an observation of Resident 548's room and interview with Resident 548 was conducted. Resident 548's sink was observed to have a handwritten sign that read DON'T USE. Resident 548's sink was separate from the enclosed bathroom and was the only sink in the room. Resident 548 stated that the sink had not been working since he had been…

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

Based on observation, interviews, and record reviews the facility did not ensure the kitchen was free of flies and gnats. This failure had the potential to affect residents' health through food contamination and food borne illness. The facility census was 294. Findings: During the initial kitchen tour observation on 3/26/2024 at 8:00 A.M., few flies were seen flying all over the kitchen. The kitchen appeared to be very dirty with food debris, hard crusty debris, grimy sticky black substance on the equipment. During an observation on 3/27/24 at 10:36 AM on the second floor- north nursing station, there were more than five fruit flies seen flying in the air near the resident refrigerator area. The fruit flies were verified by LN 25. During an observation and interview on 3/27/2024 at 11:02 A.M. at the third-floor resident's refrigerator with licensed nurse LN 21, LN 21 stated housekeeping cleaned the resident's refrigerator two times a week. A small dead black roach was found inside the freezer door of the refrigerator. LN 21 confirmed there was a dead roach insect inside the freezer…

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 a homelike environment for one of 35 residents (548) when the resident's bathroom sink was left nonfunctioning for at least one week. This deficient practice created an environment that was not homelike for one resident. Cross reference F880. FINDINGS: Review of Resident 548's admission Record indicated he was admitted to the facility on [DATE]. Review of Minimum Data Set (MDS, a nursing assessment used in nursing homes) section C, Cognitive Patterns dated 3/5/24 indicated Resident 548 with a Brief Interview for Mental Status (BIMs, a test to determine cognitive levels in residents) score of 10, which indicates moderately impaired cognition. Review of MDS section GG, Functional Abilities and Goals dated 3/5/24 indicated that Resident 548 needed supervision or touch assistance for the categories of oral hygiene, toileting hygiene, shower/bath self and personal hygiene. On 3/26/24 at 10:50 A.M., during initial pooling of residents, an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review the facility failed to ensure 1 of 3 residents sampled for dialysis (157) had a care plan developed for the dialysis access of an AV fistula (arteriovenous fistula is a surgical connection between an artery and a vein) to ensure the AV fistula was assessed for thrill (thrill or buzz is like a vibration caused by blood flowing through the fistula ) and bruit (Bruit is a rumbling or swooshing sound) to determine the AV fistula was functional, or to determine when the post dialysis AV fistula dressing was to be removed. As a result, and issue with the residents AV fistula would not be identified timely to receive immediate care. Findings: Resident 157 was admitted to the facility on [DATE], with diagnosis that included diabetes and renal failure requiring dialysis. On 3/27/24, Resident 157's clinical record was reviewed the only care plan related to dialysis for Resident 15's AV fistula contained only approaches related to the assessment of the signs and symptoms of infection, to be monitored…

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 did not develop patient centered care plans for 2 of 52 residents reviewed for care plans (Resident 32 and 154). These failures had the potential for the residents to not receive care and services specific to the residents' needs. Findings: 1.Resident 32 was admitted to the facility on [DATE] with diagnoses including left hand contracture (shortening of muscles and tendons, often leading to permanent deformity and stiffening of joints) according to the facility's admission Record. During an observation and interview on 3/26/24, at 9:20 A.M. with Resident 32, Resident 32 was in bed with a splint on her left hand. Resident 32 stated she could not move her left thumb. Resident 32's legs were exposed and both feet were observed to have foot drop (difficulty lifting the front part of foot). Resident 32 was able to raise both legs but were unable to bend her feet towards Resident 32's head. During an interview and concurrent record review on 3/29/24, at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure appropriate nutritional parameters were maintained for a resident, Resident 60, with a severe weight loss of 18.4% in six months. This failure had the potential to result in additional unintentional weight loss and loss of lean body mass, which could lead to further nutrition decline for Resident 60. Findings: According to an American Family Physician article titled Evaluating and Treating Unintentional Weight Loss in the Elderly, .Elderly patients with unintentional weight loss are at higher risk for infection, depression and death. [NAME], 2002; 65: pp. 640-650. According to the facility's admission Record dated 3/28/24, Resident 60 was admitted on [DATE] with diagnoses which included end stage renal disease (kidney failure), dysphagia (difficulty swallowing), type 2 diabetes mellitus (inability to manage blood sugar), and Vitamin D deficiency (low blood levels of vitamin D). During a record review of the facility's Weight…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to ensure one of one resident (Resident 154) received Trauma Informed Care (TIC- an intervention and organizational approach that focuses on how trauma may affect an individual's life and his or her response to behavioral health). This failure resulted in the facility's inability to identify possible triggers that could result in re-traumatization (the reactivation of trauma symptoms via thoughts, memories, or feelings related to the past torture experience). Findings: Resident 154 was re-admitted to the facility on [DATE] with diagnoses including post-traumatic stress disorder (PTSD- a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event) according to the facility's admission Record. During an observation on 3/27/24, at 10:14 A.M., Resident 154 was in bed with eyes closed. Resident 154's assigned certified nurse assistant (CNA 41) was interviewed on 3/27/24, at 10: 22 A.M. CNA 41 stated…

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 they provided the minimum number of sufficient staff or PPD (PPD stand for Per Patient Day, and calculations are determined by the number of residents in a skilled nursing facility and the number of clinical staff.) the PPD minimums for Skilled nursing facilities in California were ( 3.5 DHPPD staffing requirement, of which 2.4 hours per patient day must be performed by CNAs) to be able to provide services within the facility. As a result, residents may not have gotten the care they deserve. Findings: On 3/28/24, the posted and actual staffing was reviewed from 3/12/24 to 3/28/24. There was a single staffing posting made throughout the facility the posting included the entire building and was posted on the first-floor reception desk. According to the DSD the projected staffing was calculated daily and posted, the posting was not modified if the staffing numbers changed throughout the day. The posting should have been modified as needed to accurately reflect the numbers of staff providing care. The actual PPD 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 record review, the facility failed to ensure one of three licensed nurses (LN 12) was assessed for competency (a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully) to perform medication administration to residents. As a result of this deficient practice, the facility could not ensure medications were accurately and safely provided to residents. Cross reference F759. Findings: On 3/28/24 at 9:07 A.M., an observation of medication administration was conducted with LN 12. During the medication administration of a resident (Resident 122), LN 12 failed to administer three physician ordered medications. LN 12 also administered an incorrect amount of medication to Resident 122. On 3/29/24 at 8 A.M., an interview was conducted with the director of nursing (DON). The DON stated it was his expectation that residents were administered all their medications correctly and as ordered by the physician. The DON stated LN 12's medication…

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

Based on interview and record review the facility failed to ensure they posted the actual daily staffing, when they only posted the projected staffing. As a result, residetns and visitors would not know what staff were woking. Findings: On 3/28/24, the posted and actual staffing was reviewed from 3/12/24 to 3/28/24. There was a single staffing posting made throughout the facility the posting included the entire building and was posted on the first-floor reception desk. According to the DSD the projected staffing was calculated daily and posted the posting was not modified if the staffing numbers changed throughout the day. The posting should have been modified as needed to accurately reflect the numbers of staff providing care.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure medication orders for two of 35 sampled residents (Resident 60 and Resident 64) were carried out as ordered. This failure had the potential to affect Resident 60 and Resident 64's health and safety. Findings: 1. Resident 60 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease (ESRD - kidney failure) and diabetes mellitus (DM - too much sugar in the blood) according to the facesheet. A review of Resident 60's physician's orders, dated 3/25/24, indicated Resident 60 was to receive Lantus (a long-acting man-made-insulin used to control high blood sugar) 20 units subcutaneouly (under the skin) every morning. A review of Resident 60's medication administration record (MAR) for March 2024 indicated insulin glargine (lantus insulin) 20 units was not given on 3/8, 3/18, 3/20, and 3/27/24. The MAR indicated that the insulin was not given because Resident out to dialysis. A review of Resident 60's nursing progress…

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 clinical record review the facility failed to ensure that 2 of 5 residents sampled for unnecessary drugs (181, 215), had not been put on Trazodone for a non-FDA approved indication, which resulted in this medication becoming an unnecessary drug for 2 Residents, as this medication had been prescribed without an adequate (FDA approved) indication. This deficient practice resulted in this resident receiving Trazodone for a clinical indication, which had not been FDA approved, which could have caused this resident harm. Findings: a. Resident 181's clinical record was reviewed on 3/28/24. Resident 181 was admitted to the facility on [DATE], with diagnosis including cognitive impairment per the Record of Admission. A review of the physician's order for Trazodone 50mg give 1 tablet by mouth at bedtime for depression AEB (as exhibited by) inability to sleep, dated 12/1/18, and started on 5/1/19, revealed that this medication had been prescribed to treat this resident's inability to sleep, not depressive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the medication error rate was less than five percent. The facility's medication error rate was 12.5 percent. Four (4) medication errors were observed, a total of 32 opportunities, during the medication administration process for one of seven randomly observed residents (Resident 122). As a result, the facility could not ensure medications were correctly administered to all residents. Cross reference F726. Findings: A review of Resident 122's admission Record indicated the resident was admitted on [DATE] with diagnoses to include dorsalgia (back pain). On 3/28/24 at 9:07 A.M., an observation of medication administration was conducted with licensed nurse (LN) 12. LN 12 asked Resident 122 if she was having any pain or muscle spasms. Resident 122 replied, No. LN 12 then prepared and administered the following medications to Resident 122: - carvedilol 12.5 mg (heart medication) - escitalopram 10 mg (antidepressant) -multivitamin…

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

Based on observations, interviews, and record reviews the facility failed to ensure the Pureed diet menu was followed as printed. This failure had the potential to alter the nutritional value of the pureed meals, which could decrease the food intake and compromise the nutrition status of 30 residents on a pureed diet. The facility census was 294. Findings: During a review of the facility's Therapeutic Menu Spreadsheet titled Cooks Spreadsheet Spring Cycle Menus Week 4 Tuesday, 3/26/24, the regular entrée was 3 ounces roast turkey, 1/3 cup Bread dressing, ½ cup Three bean salad, 1/3 cup Seasoned peas, 1/3 cup vanilla mousse chocolate chip garnish, milk- 4 ounces. The Pureed diet indicated ½ cup of pureed Roast turkey, 1/3 cup pureed Bread dressing, ½ cup pureed Three bean salad, 1/3 cup pureed vanilla mousse and no chocolate chip garnish. During a joint observation and interview on 3/26/2024 at 12:21 P.M. in the 4th floor dining room, A Dietary Aide (DA 2) was scooping portions of the lunch meal on plates for the meal service. DA 2 served mashed potatoes to the residents on a Pureed…

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

Based on observation, interviews, and record reviews the facility did not ensure essential kitchen equipment, including the dish machine thermometer gauges, a stove range handles, and three (3) mobile tray line stations were maintained to operate at their full capacity. This failure had the potential to directly affect residents and staff's safety in the facility. Facility census was 294. Findings 1. Dish machine thermometer gauges worn and cloudy. During the initial kitchen tour on 3/26/24 at 8:15 AM, a concurrent observation and interview with the Dietary Aide (DA 1) Dishwasher was conducted. The dish machine thermometer gauges were worn and cloudy inside which made the numbers blurry and difficulty to view. DA 1 stated he had trouble estimating what the correct wash temperature was because of the blurry temperature gauges. The CDM acknowledged the cloudy temperature gauges on the dish machine and stated they needed to be repaired. During an interview on 3/29/2024 at 10:31 A.M., with the Registered Dietitian (RD), the RD sated he expected the dish machine temperature sanitizer and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure one of 35 residents (Resident 162) had a call light that was consistently working. As a result, Resident 162 was at risk of not getting her needs addressed timely which could potentially result in injury and falls. Findings: Resident 162 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction (blood supply to part of brain is blocked causing damage to brain cells) per the facesheet. A review of Resident 162's Minimum Data Sheet (MDS - an assessment tool), dated 1/20/24, indicated that Resident 162 had a Brief Interview for Mental Status (BIMS - used to screen and identify the mental condition of residents) score of 15 (cognitively intact). An observation and interview of Resident 162, while in her room, was conducted on 3/27/24 at 9:29 A.M. Resident 162 sat in her wheelchair next to the resident's bed. The call light wall plate was loose. Resident 162 stated the call light did not work. Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately access the hearing and vision deficits for one of seven residents (Resident 1), on admission for the Minimum Data Set (MDS-a clinical assessment tool) required for Centers for Medicare and Medicaid Services (CMS) coding and reviewed for Resident Assessment. As a result, the MDS submitted to CMS did not accurately portray Resident 1 ' s current health status. Findings: Resident 1 was admitted to the facility on [DATE], with diagnoses which included urinary tract infection with resistance to multiple antimicrobial drugs (commonly used drugs to treat infections), per the admission Record. On 1/11/24, Resident 1 ' s clinical record was reviewed: According to the admission Nurses Notes, dated 12/26/23 at 8:33 P.M., Resident 1 had bilateral (both eyes) blindness, was hearing impaired and used bilateral hearing aids. According to the care plan, titled Legally blind, dated 1/2/24, listed interventions of 1:1 room visits to promote socialization and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow infection control practices when: 1. A urinary catheter bag was in contact with the floor for one of two residents, (Resident 4). 2. An ice scoop was improperly stored and therefore exposed to germs. 3. One blood pressure cuff was used on patients without being properly disinfected, (Resident 5 and Resident 6). As a result, there was the potential of infections to be transmitted to residents. Findings: 1. Resident 4 was admitted to the facility on [DATE], with diagnoses which included retention of urine, (an inability to urinate), per the facility ' s admission Record. On 1/11/24 at 10:56 A.M., an observation was conducted from the hallway of Resident 4 ' s room. Resident 4 was in bed, with the bed in a low position. A urinary catheter collection bag, covered with a blue dignity bag was lying flat on the floor. On 1/11/24 at 11:01 A.M., an observation and interview were conducted with certified nurse assistant (CNA 1) outside…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide a safe discharge and transition for 1 of 2 sampled residents (1). As a result, Resident 1 was hospitalized within three days of discharge from the facility. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses which included dementia (impaired ability to remember, think, or make decisions that interfere with doing everyday activities), per the facility's Face Sheet. A review of Resident 1's clinical record was conducted. Per the History and Physical Examination, dated 6/21/23, The physician documented that Resident 1 had a grave disability (unable to provide for their basic needs for food, clothing, or shelter due to a mental disorder). Per the Progress Notes, dated 9/21/23, the Social Service Assistant (SSA) documented that Resident 1 wanted to be discharged from the facility to be homeless. The staff booked a three-night stay at a motel and discharged Resident 1 from the facility at 3:30 P.M. On 10/4/23 at 3:45 P.M., an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not provide activities to one of six units (total of 35 Residents), in the secured unit, as posted on the unit's activity schedule. This failure had the potential to decrease residents' cognitive awareness and socialization. Findings: On 4/18/22 at 10:27 A.M., during initial tour, an interview was conducted with Resident 83 in his room. Resident 83 stated there was nothing to do but smoke, and he would like to color or do something. On 4/18/22 at 2:20 P.M., a TV was opposite the nurse's station in the secured unit which was playing 50's and 60's music. Five residents were sitting in chairs and wheelchairs opposite the TV playing music. A large activity calendar was on the wall. The activities listed for the afternoon of 4/18/22 were: 2 P.M. Sing-Along, 2:30 P.M. was Chew & Chat, 3 P.M. was Balloon Ball. On 4/18/22 at 3:16 P.M., no activities were being lead and no balloons were present. The TV continued playing 50's and 60's music. On 4/18/22,…

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 label, date, and seal foods in one of two refrigerators (walk-in refrigerator) and, one of one storage rooms. These failures had the potential to cause food-borne illnesses to residents. Findings: On 4/18/22 at 8:06 A.M., an observation and interview was conducted with KA 1, during initial tour of the walk-in refrigerator. A ¼ turkey roast was in a metal tray on a shelf, wrapped in cellophane. The turkey roast was not labeled or dated to indicate when it was placed in the refrigerator. Next to the turkey roast was another metal pan with slices of turkey. The cellophane covering the metal pan was caved in and meat/gravy juices were floating on top of the cellophane cover. No label or date was found on the cellophane or on the metal pan to indicate when the sliced turkey was placed in the refrigerator. A serving tray was on a shelf which contained a total of 19 peanut butter/jelly sandwiches and cheese sandwiches. The sandwiches were cut in half and wrapped in cellophane. No labels or dates were on the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow safe infection control practices when: 1. Staff did not perform hand hygiene while passing meal trays to residents; 2. Smoking aprons were not disinfected after use; and 3. A urinary catheter bag was in contact with the floor. These failures had the potential for cross contamination of pathogens (microorganism that can cause disease). Findings: 1. On 4/19/22 at 11:37 A.M., an observation was conducted while staff were passing lunch meal trays to residents in the secured unit. All alcohol based hand rub (ABHR-a disinfectant solution) dispensers were mounted on the walls outside every third room. CNA 1 was observed exiting a resident room after delivering a lunch tray and did not use ABHR, to disinfect his hands. CNA 1 returned to the food cart and removed another lunch tray without performing hand hygiene. CNA 1 set the lunch tray on a bedside table for a male resident sitting in the hallway next to the nurse's station. CNA 1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a discharge Minimum Data Set (MDS - a comprehensive assessment and care screening tool), was developed and transmitted to the CMS system, for one of two sampled residents (Resident 2), reviewed for MDS accuracy. This failure resulted in Resident 2's discharge status not being communicated to CMS as required. Findings: Resident 2 was admitted to the facility on [DATE], per the facility's admission Record. On 4/21/22 at 2:39 P.M., a concurrent interview and record review was conducted with the MDSN 26. The MDSN 26 reviewed Resident 2's Progress Notes, dated 12/09/21, which indicated the resident left the facility Against Medical Advice (AMA) and signed the AMA form. The MDSN 26 stated the discharge MDS was not developed and transmitted to CMS. The MDSN 26 stated the facility was supposed to follow the MDS guidelines, which meant the discharge MDS should have been developed and transmitted within 14 days after leaving AMA. Per the facility's policy…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop a comprehensive person-centered care plan for: 1. One of 37 residents (Resident 5) and one of three unsampled residents (Resident 167) reviewed for wandering (a confused person who is in search of someone, or something); and 2. One of 37 residents with weight loss (Resident 122). These failures resulted in wandering behaviors and weight loss not being recognized and addressed. Findings: 1a. Resident 5 was admitted to the facility on [DATE], with diagnoses which included Alzheimer's disease (progressive mental deterioration), per the facility's admission Record. On 4/18/22 at 10:21 A.M., and at 2:48 P.M., Resident 5 was observed entering and exiting other male and female resident rooms without staff stopping or redirecting her. On 4/18/22, Resident 5's clinical record was reviewed: The MDS, a cognitive assessment, dated 3/30/22, indicated 0, (range 0-15), which meant severe cognitive impairment. The Behavior 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide consistent suprapubic catheter (tube used to drain urine from the bladder) care to one of two residents (Resident 65), sampled for urinary catheter care. As a result, there was a potential for infection and suprapubic catheter blockage. Findings: Resident 65 was admitted to the facility on [DATE], with diagnoses which included neuromuscular dysfunction of bladder (lacking bladder control), per the facility's admission Record. On 4/21/22, at 9:39 A.M., a joint interview and record review was conducted with LN 21. According to Resident 65's Order Summary Report, dated 10/28/21, .Provide suprapubic catheter care Q (every) shift, & PRN (as needed) if soiled or dislodged . According to Resident 65's Order Summary Report, dated 4/30/21, .SUPRAPUBIC CATHETER .MONITOR PLACEMENT & PATENCY (without blockage) DURING & AFTER CARE every shift . According to Resident 65's Treatment Administration Record (TAR), dated 4/2022, indicated, Provide suprapubic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the staff followed physician orders for the amount of feeding administered to two of two residents (47, 117) reviewed for tube feeding (provision of nutrition through a tube into the stomach). As a result, there was potential the residents did not receive the required nutrition. Findings: 1.Resident 47 was re-admitted to the facility on [DATE] with diagnoses which included Type 2 diabetes (a disorder with high blood sugar) per the facility's admission Record. On 4/18/22 at 8:38 A.M., an observation of Resident 47 was conducted. There was a tube feeding connected to the resident. The tube feeding bag was dated 4/17/22 and time started at 2:30 P.M. The tube feeding pump was noted to be off and approximately 900 milliliters (ml) of solution was left in the 1500 ml volume bag. A record review was conducted. The physician order dated 3/14/22 indicated for Resident 47's tube feeding to run at 45 ml/hr for 20 hours to provide 900 ml total…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide pain medication for one of one resident (Resident 246) reviewed for pain management. As a result, Resident 246's pain was not addresed or relieved. Findings: Resident 246 was admitted to the facility on [DATE], with diagnoses to include chronic pain syndrome, polyneuropathy (damage or disease of nerves causing pain), osteoarthritis (wear and tear of joints causing pain), polyosteoarthritis (inflammation of one or more joints causing pain), per the facility's admission Record. On 4/18/22 at 10:42 A.M., an interview was conducted with Resident 246. Resident 246 stated last night, he asked for pain medication and he had to wait until the licensed nurse came. Resident 246 stated when one of the licensed nurse, LN 16 finally showed up, the licensed nurse walked away without giving the pain medication and never returned with the pain medication. On 4/21/22, Resident 246's record was reviewed. According to the physician History and Physical…

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 did not assess and evaluate the need for psychotropic drugs (affects the brain and causes changes in mood, awareness, thoughts, feelings, or behavior) for one of five residents (Resident 477) reviewed for psychotropic medication. This resulted in Resident 477 having received two potentially unnecessary psychotropic medications . Findings: Per the facility's admission Record, Resident 477 was admitted on [DATE] with dementia (impaired mental capacity), depression, and history of schizophrenia (a type of mental illness). Resident 477 records were reviewed on 4/18/22. Per the physician's order listed on the MAR, dated April 2022, Resident 477 received a psychotropic drug (risperidone) for psychosis (hallucinations and disorganized thinking) as evidenced by disorganized speech, but the supporting clinical assessment was absent. Per the physician's orders, Resident 477 received a psychotropic drug (mirtazapine) for depression but the supporting clinical…

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

Based on observation, interview and record review, the facility failed to ensure the medication error rate was less than five percent. The facility's medication error rate was 24.32 percent. Nine medication errors were observed, a total of 37 opportunities, during the medication administration process for one of six randomly observed residents (Resident 47). Findings: On 4/20/22 at 9:45 A.M., an observation of medication administration was conducted with LN 6. LN 6 prepared and administered the medications to Resident 47 via the gastrostomy tube (G-tube-a surgically-placed device for direct access to the stomach). The medications included digoxin (a heart failure medicine), divalproex (anticonvulsant), docusate sodium (a stool softener), eliquis (a blood thinner), ferrous sulfate (a medication to treat iron deficiency), lansoprazole (a medication to treat high levels of stomach acid), levocarnitine (a dietary supplement), metoprolol (a blood pressure medication), and multivitamins. A review of Resident 47's records was conducted. The physician order dated 8/13/21 indicated to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the medications were administered in accordance with the physician's order for two of six randomly observed residents (Resident 47, 180) during a medication administration process when: 1. The medications were administered via the wrong route and 2. The wrong dose was administered. As a result, there was a potential the prescribed medications were ineffective. Findings: 1. Resident 47 was re-admitted to the facility on [DATE] with diagnoses which included Type 2 diabetes (a disorder with high blood sugar) per the facility's admission Record. On 4/20/22 at 9:45 A.M., an observation of medication administration was conducted with LN 6. LN 6 prepared and administered the medications to Resident 47 via the gastrostomy tube (G-tube- a surgically placed device for direct access to the stomach). The medications included digoxin (a heart failure medicine), divalproex (anticonvulsant), docusate sodium (a stool softener), Eliquis (a blood…

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.