Magnolia Post Acute Care

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility did not ensure safety with bed rails and proper use of a hoyer lift for two of 21 sampled residents (Resident 78 and Resident 23) according to the facilities policies and procedures. Findings: During a review of the facility documents, the admission Record indicated Resident 23 was admitted to the facility on [DATE] with diagnoses which included Parkinson's Disease (a movement disorder that worsens over time), and functional quadriplegia (the inability to move all four limbs). During a review of the Minimum Data Set (MDS- an assessment tool) dated 7/3/25, Resident 23 had a Brief Interview for Mental Status (BIMS- a tool to assess thinking skills) score of three, which indicated impaired cognition. The MDS indicated Resident 23 was dependent on staff to transfer to and from a bed to a wheelchair. During an observation conducted on 8/26/25 at 10:41 A.M., Resident 23 was observed inside her bedroom, laying in bed on top of a blue hoyer sling (a hammock-like device used with a hoyer lift to support a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility did not practice infection control according to facility policies and procedures and standards of practice. These failure had the potential to increase the spread of infection. Findings: On 8/26/25 at 8:02 A.M., an interview was conducted with the Infection Preventionist (IP) during a recertification survey. The IP stated a resident tested positive for Covid-19 (a contagious respiratory virus) on 8/19/25. The IP stated the facility was considered to be in an outbreak because two more residents tested positive for Covid-19, bringing the total to 3 Covid-19 positive residents. The IP stated the outbreak was reported to County Epidemiology (professionals that work to identify and evaluate diseases to protect the health of the community), but not to the state agency. The IP stated he was still new to the position but would ask the previous IP which entities to report outbreaks. On 8/27/25 at 8:39 A.M. an interview was conducted with LN 2. LN 2 stated she…

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 proper discharge planning to ensure a safe and coordinated discharge for one of three sampled residents (Resident 1) during a complaint investigation. This deficient practice placed Resident 1 at risk for an unsafe discharge and re-hospitalization. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included a history of visuospatial deficit and spatial neglect following cerebral infarction (trouble with seeing and understanding where things are in space after a brain attack also known as stroke). A record review of Resident 1's minimum data set (MDS - a federally mandated resident assessment tool) dated 5/13/25 indicated, a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of 12 points out of 15 possible points which indicated Resident 1 had moderate cognitive (pertaining to memory,…

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 their policies and procedures for investigating missing items to protect the personal property for one reviewed resident (Resident 1) during a complaint investigation. This deficient practice placed all 91 residents at risk for loss of personal belongings and potential exploitation (taking advantage of a resident for personal gain), especially those with impaired cognition (memory or thinking). Findings: A review of Resident 1's admission Record indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses which included a history of cognitive communication deficit (CCD-understanding what others say and organizing thoughts) and right ear hearing loss. A record review of Resident 1s minimum data set (MDS - a federally mandated resident assessment tool) dated 4/14/25 indicated, a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of six…

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, record review, facility document review, and facility policy review, the facility failed to ensure a significant change Minimum Data Set (MDS) was submitted timely for 1 (Resident #53) of 18 resident MDSs reviewed. Findings included: A facility policy titled, Policy/Procedure- Resident Assessment Instrument, revised 10/01/2023, specified, The Long-Term Care Facility Resident Assessment Instrument 3.0 (RAI) User's Manual Version 1.18.11 October 2023 will be the source guidance for the RAI Process. A Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.18.11 dated 10/2023, specified, An SCSA [significant change in status assessment] is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. Further review revealed, The CAAs [care area assessment] completion dated (item V0200B2) must be no later than 14 days after the ARD [assessment reference date] (ARD + 14 calendar days) and no…

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, record review, and facility policy review, the facility failed to ensure the Minimum Data Set (MDS) was accurate for 1 (Resident #41) of 18 sampled residents reviewed for MDS accuracy. Findings included: A facility policy titled, Policy/Procedure - Resident Assessment Instrument, updated on 10/01/2023, revealed, 8. Each person completing a section of the MDS attests to its accuracy by affixing his/her electronic signature to that section of the MDS. An admission Record revealed the facility admitted Resident #41 on 05/19/2024. According to the admission Record, the resident had a medical history that included cellulitis of left lower limb, local infection of the skin and subcutaneous tissue, and homelessness. An admission MDS, with an Assessment Reference Date (ARD) of 05/24/2024, revealed Resident #10 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident was cognitively intact. The MDS indicated the resident did not currently use tobacco. Resident #41's Progress Notes, revealed a note dated 05/23/2024 that indicated a nicotine…

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, record review, and facility policy review, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) Level I assessment was coded accurately for 1 (Resident #10) of 3 sampled residents reviewed for PASRR. Findings included: A facility policy titled, Policy/Procedure with a Subject titled PASRR, dated 05/01/2023, revealed, It is the policy of this facility to ensure that each resident is properly screened using the PASRR specified by the State. The policy further revealed, 2. After admission, the Interdisciplinary Team (IDT), will review follow up determinations for Level I positive, and/or if Level II is required and pending evaluation. 3. An IDT member will determine if a Resident Review (RR) is required. 4. Based upon the final determinations, the facility will ensure proper referral to state agencies for the provision of specialized services to residents with ID/RC (Intellectual disability or Related Condition) or SMI (Serious Mental Illness). 5. Social Services shall contact the appropriate State Agency for referral of specialized…

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, record review, facility document review, and facility policy review, the facility failed to ensure a care plan was completed for diuretics for 1 (Resident #53) of 5 sampled residents reviewed for unnecessary medications. Findings included: A facility policy titled, Policy/Procedure- Nursing Administrative with a Subject titled Comprehensive Assessment, revised in 03/2021, specified, All problems, goals, and interventions will be documented in the Resident's Comprehensive Care Plan. An admission Record revealed the facility admitted Resident #53 on 01/22/2024. According to the admission Record, the resident had a medical history that included diagnoses of cerebral infarction (stroke), chronic obstructive pulmonary disease, chronic kidney disease, atrial fibrillation, and hypertension. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/28/2024, revealed Resident #53 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS revealed the resident received a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their own policy regarding receipt of narcotics (controlled substance) for 1 of 2 sampled residents. This failure occurred when a licensed nurse did not check or inventory medications which included narcotics delivered by the pharmacy to the facility. As a result, the whereabouts of Resident 1's narcotic medication was not known. This deficient practice had the potential to delay pain medication administration, could affect residents ' safety and created an opportunity for drug diversion. Findings: Resident 1's record was reviewed. Per the undated facility admission document, Resident 1 was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis (partial paralysis on one side of the body) and stiffness of bilateral ankles. A record review on 5/21/24 was conducted. Per the facility's document titled: Packing Slip Proof of Delivery, dated 5/16/24, LN 3 signed for receipt of 30 tablets of Hydroco/Apap-5-325mg…

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 notify a resident ' s (4) physician regarding an altered mental status (confusion, disorientation, difficult to arouse) for one of one resident reviewed for change in condition. This failure had the potential to delay care and treatment to address the resident ' s change in condition. Resident 4 was admitted to the facility on [DATE] with diagnoses including chronic kidney disease stage three (mild to moderate loss of kidney function) and discharged to the hospital on 3/28/24 according to the facility ' s admission Record. An interview on 5/3/24 at 9:55 A.M., with licensed nurse (LN) 1 was conducted. LN 1 stated, for a change in resident ' s condition, the physician will be notified immediately. LN 1 stated vital signs will be taken, provide emergent treatment as needed, and call 911 if necessary. During an interview with LN 2 on 5/3/24, at 11:28 A.M., LN 2 stated, a change in condition was considered any deviation from a resident ' s normal status. LN…

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 The following reflects the findings of the California Department of Public Health during an abbreviated standard survey. Complaint Number: CA00334806 Category: Quality of Care/Treatment Representing the Department: Health Facilities Evaluator Nurse(s): 39111 and 49330 The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. One deficiency was issued for the complaint number: CA00884806 (Refer to F-tag 656). Based on observation, interview, and record review, the facility failed to ensure resident-specific care plans were developed for two of three residents (Resident 1 and Resident 2) when: 1. Resident 1 did not have a written care plan developed to address the presence of a cardiac pacemaker (a device used to treat an irregular heartbeat). 2. Resident 2 did not have a written care plan developed to address the presence of a cardiac pacemaker. As a result of this deficient practice, there was the potential for Resident [BN1] 1 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 interview and record review the facility failed to ensure reference checks were completed prior to hiring a certified nurse assistant (CNA). This failure had the potential to increase the possibility of abuse toward residents of the facility. Findings: A report of sexual abuse was received by the California Department of Public Health San Diego District Office on 1/10/22. An unannounced visit to the facility was conducted on 1/11/22. Resident 1 was admitted to the facility on [DATE] with diagnoses that included cognitive communication deficit (difficulty with thinking and using language) and bipolar disorder, severe, with psychotic features (episodes of mood swings with depressive lows to manic highs) according to the facility's admission Record. Resident 1 was transferred to the hospital on 1/7/22 for chest pain, and while in the Emergency Department, indicated an incident of sexual assault by a staff member at the skilled nursing facility. Resident indicated the staff member was a CNA who worked at 6…

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

Based on interview and record review, the facility failed to ensure call lights were answered in a timely manner for ten confidential residents (CR- 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10). This failure had the potential to result in residents' needs not being met, which had the potential to result in physical and emotional harm. Findings: On 7/13/21 at 10 A.M., a confidential meeting was conducted. CR 1, 2, 3, 4, 5, 6, 7, 9, and 10 stated it had taken between 20 minutes to two hours for staff to answer call lights, especially on the evening (3 P.M. - 11 P.M.) shift and night (11 P.M. - 7 A.M.) shift. CR 1, 3, 4, 5, 6, 7, 8, 9, and 10 stated the wait time for call lights to be answered was an on-going issue. CR 5 stated the wait for a call light to be answered was one hour. CR 4 stated he waited for two hours during the night shift to use the bathroom. CR 4 stated he could not walk, and two hours was too long to wait to use the bathroom. CR 4 stated he waited so long and wet his pants. CR 6 stated he used his call light and waited all night . no one came. CR 3 stated she would wait for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement their policy on abuse for one of 27 residents (435) when the facility did not follow abuse reporting after the resident reported the incident to the Director of Nursing (DON). This failure had the potential to place Resident 435 at risk for physical and/or emotional harm. Findings: Resident 435 was admitted to the facility on [DATE], with diagnoses that included anxiety and bipolar disorder (mood disorder), per the facility's admission Record. On 7/12/21 at 10:16 A.M., an observation and interview was conducted with Resident 435. Resident 435 was sitting in his room in a wheelchair. Resident 435 stated, about two or three weeks ago, a Licensed Nurse (LN) was rude to him, and smashed his cellular (cell) phone against the bedside stand. Resident 435 presented his cell phone with a cracked screen. Resident 435 stated the incident felt abusive and demeaning to him. Resident 435 stated the DON informed him to talk to the charge…

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 report an allegation of abuse to the California Department of Public Health (CDPH) in a timely manner, for one of 27 residents (435) reviewed for abuse. This failure had the potential to cause physical and/or emotional harm to Resident 435. Findings: Resident 435 was admitted to the facility on [DATE], with diagnoses that included anxiety and bipolar disorder (mood disorder), per the facility's admission Record. On 7/12/21 at 10:16 A.M., an observation and interview was conducted with Resident 435. Resident 435 was sitting in his room in a wheelchair. Resident 435 stated, about two or three weeks ago, a Licensed Nurse (LN) was rude to him, and smashed his cellular (cell) phone against the bedside stand. Resident 435 presented his cell phone with a cracked screen. Resident 435 stated he told the Director of Nursing (DON) about the incident. Resident 435 stated the incident felt abusive and demeaning to him. Resident 435 stated the DON…

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 conduct an investigation of alleged abuse for one of 27 residents (435) reviewed for abuse. As a result, the alleged licensed nurse (LN) was not suspended and reassigned to a different nurses station. This failure had the potential to result in physical and/or emotional harm for Resident 435. Findings: Resident 435 was admitted to the facility on [DATE], with diagnoses that included anxiety and bipolar disorder (mood disorder), per the facility's admission Record. On 7/12/21 at 10:16 A.M., an observation and interview was conducted with Resident 435. Resident 435 was sitting in his room in a wheelchair. Resident 435 stated, about two or three weeks ago, a Licensed Nurse (LN) was rude to him, and smashed his cellular (cell) phone against the bedside stand. Resident 435 presented his cell phone with a cracked screen. Resident 435 stated he told the Director of Nursing (DON) about the incident. Resident 435 stated the incident felt abusive…

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 baseline care plan related to the use of an indwelling catheter, in a timely manner for one of four residents (183), reviewed for urinary catheter care. This failure had the potential to affect Resident 183's coordination, treatment needs, and care. Findings: Resident 183 was admitted to the facility on [DATE], with diagnoses which included chronic kidney disease (gradual loss of kidney function), obstructive and reflux uropathy (blocked flow of urine), per the facility's admission Record. An observation was conducted on 7/12/21 at 10:14 A.M. Resident 183 was sitting up in bed. A catheter tubing was visible attached to a covered catheter bag that hung from the lower part of the bedframe. A review of Resident 183's record was conducted. A daily skilled nursing progress note dated 6/19/21, included documentation that Resident 183 .used an indwelling catheter (also referred to as Foley [brand name]) . Foley catheter used d/t (due…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop a care plan related to oxygen use for one of one resident (23) reviewed for oxygen treatment. This failure had the potential to affect Resident 23's oxygen treatment and care needs. Findings: Resident 23 was admitted to the facility on [DATE], with diagnoses that included muscle weakness, per the facility's admission Record. An observation of Resident 23 was conducted on 7/12/21 through 7/15/21. Resident 23 was receiving oxygen at 3.5 (rate of flow) liters per minute via nasal cannula (LPM/NC). An interview was conducted with Certified Nursing Assistant (CNA) 11 on 7/14/21 at 8:43 A.M. CNA 11 stated Resident 23 was on oxygen all the time during the morning (7AM - 3 PM) shift. A review of Resident 23's medical record was conducted on 7/15/21. A care plan for oxygen use could not be found. A joint interview and record review was conducted with Licensed Nurse (LN) 1 on 7/15/21 at 9:58 A.M. LN 1 stated Resident 23 had a physicians…

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 communicate food allergies to the dietary department for one of four residents (62) reviewed for food preferences. In addition, a physicians order related to oxygen use was not followed for one of one resident (23) reviewed for oxygen therapy. These failures had the potential to affect Resident 62 and 23's physical health. Findings: 1. Resident 62 was admitted to the facility on [DATE], with diagnoses which included type two diabetes (high blood sugar level), per the facility's admission Record. An interview was conducted on 7/12/21 at 10:27 A.M. with Resident 62. Resident 62 stated, They brought me eggs again this morning for breakfast, but I can't eat eggs. It makes me sick. They just seem to forget, so I just had the oatmeal or cream of wheat . A concurrent observation and interview was conducted on 7/15/21 at 7:14 A.M., with Resident 62. Resident 62 was sitting at the edge of her bed. Her breakfast tray was on the bedside table in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure low air loss mattresses (LAL [mattress designed to prevent and treat pressure ulcers; localized damage to the skin and/or underlying tissue]) were set at the correct pressure for two of eight residents (82 and 6), reviewed for pressure ulcers. These failures had the potential to cause an existing pressure ulcer to worsen for Resident 82, and for Resident 6 to develop a pressure ulcer. Findings: 1. Resident 82 was admitted to the facility on [DATE], with diagnoses that included a pressure ulcer of sacral region (base of the spine - tail bone), Stage 3 - (full thickness skin loss involving damage to the underlying tissue below the skin), per the facility's admission Record. A review of the MDS (Minimum Data Set- assessment tool) dated 6/23/21 was conducted. Resident 82 had no BIMS (Brief Interview for Mental Status) score because the resident was unable to complete the interview. Per MDS Section G (Activities of Daily Living- ADL),…

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: 1. Expired medications (meds) were discarded, 2. Expired intravenous (IV) supplies (infusion set, latex surgical gloves, silicone dressing, secondary IV tubing) were discarded, 3. The temperature for the med refrigerator was consistently monitored for one of the two refrigerators in North station's med room and, 4. A can of beer found in the med room was discarded. These failures had the potential for residents to receive expired meds and supplies, affect the efficacy of meds and the effectiveness of treatments. In addition, failure to discard a can of beer posed a risk of staff consuming alcohol while on duty. Findings: 1. On 7/15/21 at 7:29 A.M., a joint observation of the med storage room and an interview with Clinical Resource Nurse (CRN) was conducted. The med storage room was in the north station. In the second cabinet of the med storage room, one ear drop (med for ear wax removal) had an expiration date of 6/21. CRN stated the eardrops should have been discarded. On 7/15/21 at 11:49 A.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 failed to ensure a visitor (Food service delivery employee [FSD] employee) to the facility was screened for signs and symptoms of COVID-19 (highly infectious virus). In addition, the facility did not replace a contaminated shower curtain in a residents' communal bathroom and a resident's bedroom. Furthermore, a facility staff member did not consistently perform hand hygiene while providing resident care. These failures had the potential to place staff, residents, and visitors at risk of viral and/or bacterial infections. Findings: 1. On 7/12/21 at 7:45 A.M., a tour of the facility kitchen was conducted. On 7/12/21 at 7:55 A.M., a FSD employee entered the facility kitchen through a side door without being screened for COVID-19. The FSD set several boxes of food on the floor in the kitchen. Three dietary aides (DAs) were at work in the kitchen. None of the DAs stopped the FSD from entering the facility, nor did they ask if the FSD employee 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.