Somerset Post Acute Care

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure wound treatment for one of one resident (Resident 37) was completed as ordered by the physician. This failure had the potential to affect Resident 37's care and well-being. Findings: Resident 37 was admitted to the facility on [DATE] with diagnoses which included metastatic prostate cancer (prostate cancer that has spread from the prostate gland to other parts of the body) per undated admission Records. A review of Resident 37's treatment order for the left buttocks dated 1/9/25 indicated, Cleanse with NS (Normal Saline), pat dry. Apply Medihoney and Xeroform, and cover with dry dressing . A review of Resident 37's treatment order for the left buttocks dated 1/21/25 indicated, Cleanse with Dakins, pat dry. Apply Medihoney and Xeroform, and cover with dry dressing . A concurrent interview and record review of Resident 37's electronic treatment administration record (eTAR) was conducted on 3/13/25 at 2 P.M., with the Minimum Data Set (MDS)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility staff failed to consistently monitor and document urine output (UO) per the facility's policy, for three of three sampled residents (8, 37, and 40) with a urinary catheter (a tube inserted into the bladder to aid in urine flow). In addition, there was no urinary catheter order for Resident 40. This failure had the potential for Resident 8, Resident 37 and Resident 40 to have urinary retention and develop urinary tract infection (UTI). Findings: 1. Resident 8 was readmitted to the facility on [DATE], with diagnoses which included encephalopathy (a change in how the brain functions; may cause confusion, agitation) and UTI, per the facility's admission Record. Resident 8's attending physician completed Resident 8's history and physical (H & P) dated 2/10/25. The H & P indicated Resident 8 did not have the capacity to understand and make decisions. On 3/10/25 at 11:45 A.M., an observation of Resident 8 was conducted in the dining room. A urinary…

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 dialysis (the process of cleaning the blood through a machine) access site was properly cared for one of two residents investigated for dialysis (246). This failure had a potential for Resident 246's dialysis access to clot. Findings: Resident 246 was admitted to the facility on [DATE], with diagnoses that included End Stage Renal Disease (kidney failure), per the admission Record. On 3/10/25 at 9:29 A.M., Resident 246 was observed sleeping in her room, and did not respond to her name. There was a note by the wall indicating Resident 246 had a left arm dialysis access site. On 3/11/25 at 3:19 P.M., an observation of Resident 246 was conducted. Resident 246 arrived via stretcher to the facility, accompanied by transportation staff. Resident 246's left upper arm had a bandage wrapped around her dialysis access site. On 3/12/25 8 A.M, an observation of Resident 246 was conducted in her room. Resident 246 was lying in bed, with her…

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 controlled medications (CM -medications with high potential for abuse and addiction) were accurately accounted for when four out of 10 CMs were not documented on the Electronic Medication Administration Records (EMAR) and controlled drugs accountability sheet (CS-count sheet that monitors the storage and usage of controlled medications) to indicate the CMs were given to the resident. This failure had the potential for misuse or diversion of CMs. An observation of CM handoff (report that typically occurs at the end of the shift; includes necessary information to ensure safe transition of care) between Licensed Nurse (LN) 14 and LN 15 was conducted on 3/11/25 at 3:12 P.M. LN 14 counted 27 tablets of Lacosamide (medication used to treat seizures- abnormal electrical activity in the brain) 200 milligrams (mg-unit of measurement) documented as remaining on the CS. LN 15 counted 26 tablets of Lacosamide in the medication card (container card that packages medication). LN 14 counted 10 tablets of Briviact…

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 indicate the appropriate and measurable target behavior of antidepressant (medication used to treat depression, sad mood and lack of interest) for one of two sampled residents (Resident 8) reviewed for unnecessary psychotropic (mind-altering medications) medication use. This failure had the potential for unnecessary psychotropic medication use, side effects, and a decline for resident's psychological and mental well-being. Findings: Resident 8 was readmitted to the facility on [DATE], with diagnoses which included encephalopathy (a change in how the brain functions; may cause confusion, agitation) and UTI, per the facility's admission Record. Resident 8's attending physician completed Resident 8's history and physical (H & P) dated 2/10/25. The H & P indicated Resident 8 did not have the capacity to understand and make decisions. A review of Resident 8's physician order dated 3/6/25 indicated the following order: - Escitalopram Oxalate…

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 had a medication error rate of 6.45% when two medication errors occurred out of 31 opportunities during medication administration, for two out of four residents (Resident 65 and Resident 27). These failures resulted in medications not given in accordance with the physician's orders which resulted in residents not receiving the therapeutic effects of the medication. Findings: 1. During the medication pass observation on 3/12/25 at 8:15 A.M. with Licensed Nurse (LN) 11, LN 11 did not administer Lexapro (a medication to treat depression; feeling sad) to Resident 65. Resident 65's Physician Order dated, 2/27/25 indicated to give Lexapro 20 milligrams (mg -unit of measurement) 1 tablet by mouth one time a day for verbalization of feeling depressed. During an interview with the Director of Nursing (DON) on 3/13/25 at 10:40 A.M., the DON stated that Resident 65's Lexapro medication card (container card that stores medication) was inside the afternoon (labeled to store medications that were supposed to be administered in the…

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

Based on observation, interview and record review the facility failed to ensure safe and appropriate storage of medications when: 1. One out of one intravenous medication cart (IV cart - medications used through the vein) was left unlocked and unattended by a licensed nurse (LN). 2. A medication room key was left in the doorknob and left unattended by a LN. 3. Multiple medications were left unattended by a LN in the nursing station. These failures had the potential for unauthorized access of residents, visitors, and/or unlicensed staff to medications. Findings: 1. During a concurrent observation and interview with LN 1 in the facility hallway on 3/10/25 at 7:40 A.M., an IV cart was observed unlocked and unattended by a licensed staff. The drawers of the cart were able to be pulled open. The drawers contained IV medications, needles and tubing. LN 1 stated that the IV cart should have been kept locked to prevent unauthorized access to medication and supplies. During an interview with the Director of Nursing (DON) on 3/13/25 at 10:15 A.M., the DON stated that all treatment 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 provide adequate assistance to a resident (Resident 2) who required total dependence with activities of daily living (ADL-bathing or showering, dressing, getting in and out of bed or a chair, walking, toileting and eating) reviewed for accidents. This failure resulted in Resident 2 falling from bed. Findings: Resident 2 was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure with hypoxia (a condition where the lungs fail to adequately exchange oxygen, leading to low oxygen in the blood) and dependence on ventilator (breathing machine) according to the facility's admission Record. A complaint investigation was conducted on 2/5/25 at the facility. At 8:57 A.M during an interview with Licensed Nurse (LN) 1, LN 1 stated Resident 2 was still at the hospital due to a fall incident. An interview was conducted with Certified Nurse Assistant (CNA) 1 on 2/5/25 at 9:45 A.M. CNA 1 stated she was assigned to the subacute (a place…

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 readmit one of three sampled residents (Resident 1), who was transferred to a General Acute Care Hospital (GACH) for medical care, when the facility did not document a reason for refusal to readmit Resident 1 after GACH 2 had deemed Resident 1 medically and psychologically safe for discharge back to the facility according to facility policy. This deficient practice placed the resident at risk for confusion and psychosocial harm related to the inability to return to the facility and an unnecessary, extended stay at the GACH 2. Findings: Resident 1 was admitted to the facility on [DATE] with a diagnosis of suicidal ideations (thoughts about or a plan to commit suicide) and chronic respiratory failure (a condition that makes it difficult to breathe on one's own) requiring a tracheostomy (a surgical procedure that creates an opening in the neck to provide an alternative airway for breathing) and ventilator (a machine that helps patients breathe) per the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not have a written transfer agreement in place with a General Acute Care Hospital (GACH) when the facility ordered a resident (1) to transfer to GACH 2 for medical and psychological treatment. This failure could potentially place residents at risk for inadequate continuity of care and treatment. Findings: Resident 1 was admitted to the facility on [DATE] with a diagnosis of suicidal ideations (thoughts about or a plan to commit suicide) and chronic respiratory failure (a condition that makes it difficult to breath on one ' s own) requiring a tracheostomy (a surgical procedure that creates an opening in the neck to provide an alternative airway for breathing) and ventilator (a machine that helps patients breathe) per the facility's admission record. Resident 1's was transferred and admitted to GACH 2 on 11/11/24 for verbalizing a desire to die and consuming a bottle of hydrogen peroxide oral rinse (a diluted solution of hydrogen peroxide used to clean the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide RNA services for six of six residents reviewed (Residents 2, 3,12, 26, 27, 28). This failure had the potential to cause: 1. A reduction in range of motion (ability to move and use joints) for six residents. 2. An increase in contractures due to splints not being used for three residents. Findings: a. Resident 2 was re-admitted to the facility on [DATE] with diagnoses that included generalized muscle weakness and abnormalities of gait and mobility according to the facility's admission Record. A review of Resident 2's Preadmission Screening and Resident Review (PASRR) Level II, dated 12/21/22 indicated Recommended Specialized Services: Physical Therapy Consultation: Services to enhance and restore functional ability and quality of life to those with physical impairments. A review of Resident 2's medical record was conducted on 3/19/24 at 11:10 A.M. Resident 2's undated care plan, titled, has limited mobility r/t weakness indicated :…

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 document administration of a controlled medication (a medication with a high potential for abuse) on the Controlled Drug Record for three of unsampled residents (12, 20, 37). As a result, there was a potential risk for diversion (theft) of controlled medications. Findings: A random record review was conducted on 3/19/24 of a controlled medication for Residents 12, 20 and 37. On 3/20/24 at 3:25 P.M., an interview and record review were conducted with the DON, Nurse resource and LN 15: a. Resident 37 had a physician order of Tramadol 50 mg give 0.5 tablet via G- tube (gastrostomy/surgical insertion of device to the abdomen for feeding, hydration and medicine) every 6 hours as needed for moderate pain 4-6 and give one tablet via G -tube every 6 hours as needed for severe pain 7-10. Resident 37's Tramadol 50 mg was delivered by facility pharmacy in a bubble pack and dispensed as ½ tablet (25 mg) in each bubble. Resident 37's Tramadol 50 mg: On 3/2/24 at 10 A.M., Tramadol 50 mg, ½ tablet was pulled from 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 ensure: 1. Medications were stored and labeled according to the manufacturer's specifications and policy. 2. Medications were disposed appropriately. As a result, the facility could not ensure medications were safely stored to ensure their integrity. Findings: 1. The respiratory cart (RT cart/medication cart for inhalers) was inspected with RT 11 on 3/20/24 at 1:48 P.M. Resident 2's Levalbuterol 0.63 mg/3 ml solution (medication to help breathing) had a date written 2/28/24. RT 11 stated date written 2/28/24 was the date medication was opened. RT 11 stated Levalbuterol inhalation should be thrown away and order a new one. According to the manufacturer's specifications written on foil pouch, .Once the foil pouch is opened, the vials should be used within two weeks . 2. On 3/20/24 at 3:02 P.M., an inspection of medication room (med room) was conducted with LN 15 and LN 16. There were objects that look like pills, loosed particles and unidentified debris on the floor in the medication room. LN 15 picked up about…

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 document review, the facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI - a data driven and proactive approach to quality improvement) when: - The facility's pressure injury (a localized damage to the skin and underlying soft tissue usually over a bony area) data was not analyzed to identify trends. - A root cause analysis (a collective term that describes a wide range of approaches, tools, and techniques used to uncover causes of problems) was not attempted to identify cause of acquired pressure injuries in the facility. (Refer to F 686, F 725) Findings: An interview with the Administrator (ADM), Director of Nursing (DON), and facility consultant (FC) 1 and FC 2 was conducted on 3/21/24 at 6:01 P.M. to discuss the facility QAPI projects. The DON, the ADM, and FC 1 stated that pressure injury was one of the items being reviewed in the facility QAPI. The DON stated that he met with the wound physician and nurse practitioner around November or December of last year to discuss the increase of pressure injury 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 interview and record review the facility failed to promote care in a manner that maintains two of 15 sampled residents (Resident 20 and Resident 17) with dignity and respect when: 1. Resident 20 was inappropriately dressed in a hospital gown and covered with a shower blanket on a stretcher in the nursing hallway for an outside appointment and a urinary catheter bag not covered with a dignity bag (a cover that conceals the urinary catheter bag to promote dignity). 2. Resident 17 was in the shower room with doors wide open exposing Resident 2's feet while being showered by CNA 2. This failure had potential to violate the Resident 20's and Resident 17's rights for respect and dignity. Findings: 1. A review of Resident 20's admission Record indicated Resident 20 was re-admitted to the facility on [DATE] with diagnoses which included a history of functional quadraplegia (complete inability to move due to severe disability or frailty caused by another medical condition without brain or spinal cord injury). A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of 15 sampled residents (Resident 12) was assessed and provided with the appropriate call light type to call staff when needed. This failure increased the risk for Resident 12 to experience psychological and physical harm (banging on bed rails)with needs not addressed appropriately. Findings: A review of Resident 12's admission Record indicated Resident 12 was re-admitted to the facility on [DATE] with diagnoses which included a history of traumatic brain injury (happens when a sudden, external, physical assault damages the brain). A record review of Resident 12's MDS (Minimum data set: nursing facility assessment tool) dated 3/5/24 indicated that Resident 12 was rarely or never understood with severe cognitive (the mental processes that take place in the brain, including thinking, attention, language, learning, memory, and perception) deficits to understand and make decisions. On 3/18/24 at 10:46 A.M., an observation 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, record review, and document reviews, the facility failed to ensure a low air loss mattresses (LAL - an air flow mattress used to prevent skin breakdown by distributing weight over the mattress to reduce pressure to the skin) were set according to the physician's order for one of six residents (Resident 30) reviewed for pressure ulcer. These failures increased the risk for skin breakdown for all residents. Findings: 1. A review of Resident 30's admission Record indicated the resident was re-admitted to the facility on [DATE] with diagnoses that included non-traumatic acute subdural hemorrhage (develops when tiny veins that are located between the membranes covering the brain (the meninges) leak blood after an injury to the head). A record review of the Resident 30's Minimum Data Set (MDS, nursing assessment tool), dated 3/6/24, indicated Resident 30 was at risk for developing pressure ulcers and had severe impairment (diminishment or loss of function) in cognition (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 provide enough staff to meet the needs of three of six residents (Resident 26, 27, 28) reviewed for basic nursing care and RNA services. As a result, three residents did not receive RNA services as prescribed by a physician and were not positioned according to the posted facility turning schedule. Cross-Reference F688 Findings: On 3/18/24 through 3/21/24 the position of residents 26, 27 and 28 in their beds was observed as mostly on their backs without position changes every two hours. On 3/21/24 at 10:34 A.M., an interview was conducted with the WCN who stated, The acuity is too high for the number of staff. We try our best to turn and reposition the residents but due to low census the staff get [sic] cut. Full timers have been asked to work double shifts. Being a CNA here is a lot of work, they're running like headless chickens. On 3/21/24 at 1:36 P.M., an interview was conducted with the DON who stated, They (facility staff) say that they're turning their patients so why does it look like they're still in…

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

Based on 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 6.45%. Two medication errors were observed out of 31 opportunities, during the medication administration process for two of three randomly observed residents (Resident 3, 17, 39). As a result, the facility could not ensure medications were correctly administered to all residents. Findings: 1. On 03/19/2024 at 10:18 A.M., an observation of medications administration was conducted with LN 11. LN 11 prepared and administered medications to Resident 39, which included Ivermectin (drug to prevent scabies caused by mites) by mouth. LN 11 administered three (3) tablets of Ivermectin 3 mg per tablet. On 03/21/2024 a medication reconciliation for Resident 39 was conducted. Per the physician order, dated 3/5/24 listed Ivermectin oral tablet, give 15 mg by mouth in the morning starting on the 6th and ending on the 20th for prophylactically [sic] until 3/20/24. Give on March 6, 7, 10, 14 and 20, 2024. The facility had…

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 designate one or more individuals with specialized training (prior to assuming the role of the Infection Preventionist) in Infection Prevention and Control who are responsible for the facility Infection Control Program. This failure had the potential to cause a decline in Infection Control practices in the facility. Findings: An interview was conducted on 3/20/24 at 7:50 A.M. with the IP. The IP stated he was also the DSD. The IP further stated, I have taken the Center for Disease Control (CDC) on-line course but I have not taken the test and so, I don't have a credential. I was also scheduled to take the San Diego County Infection Control (IC) training this week, but had to cancel. In addition, the facility was not able to provide any proof of specialized IC training for the IP. An interview was conducted on 3/21/24 at 3:42 P.M. with the DON. The DON stated, We need a full time IP because there is a lot to do and coordinate.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to reconcile, dispose, and account for a discontinued controlled medication (medications that are regulated by the government due to the likelihood for being misused and high risk for abuse) to prevent drug diversion (the illegal distribution or abuse of prescription drugs) for one resident (Resident 1). As a result of this deficient practice, six tablets of the controlled medication went missing, and there was an inaccurate count of the controlled medication. Findings: Resident 1 was re-admitted to the facility on [DATE] with the diagnoses including chronic respiratory failure with hypoxia (a condition where there is not enough oxygen in the body) and dependence on ventilator (breathing machines that keep lungs working) according to the facility's admission Record. An abbreviated survey for a facility reported incident was conducted on 11/16/23. During an interview and concurrent observation with the Assistant Director of Nursing (ADON) on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure food was stored in a safe/sanitary manner and in accordance with acceptable standards of practice when: 1. Spoiled produce was stored among non-spoiled produce. 2. Salad dressings that required refrigeration were stored unrefrigerated. 3. Personal food items were stored in the main kitchen refrigerators and dry storage room. 4. Bread and biscuit mix were not properly labeled/dated. Failure to ensure safe food storage operations may result in exposing resident food to cross contamination and bacterial growth which may result in foodborne illness. Foodborne illness may further compromise the medical and nutritional status of the residents. Findings: 1. On 6/20/22 at 7:45 A.M., a joint observation of the facility's kitchen and interview was conducted with cook (CK) 1. Refrigerator 1 was observed to have: - a peach with the bottom half squished in and slippery - a [NAME] with the stem end covered with fuzzy gray material resembling…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of 14 residents (Resident 42) was treated with respect and dignity when the resident had his head shaved without consent. This failure had the potential for Resident 42 to experience shame and embarrassment. Findings: A review of Resident 42's admission Record indicated the resident was admitted on [DATE] and readmitted on [DATE] with diagnoses to include dependence on a respirator (machine that breathes for a person). On 1/14/22 at 10:41 A.M., a telephone interview was conducted with Resident 42's responsible party (RP). The RP stated Resident 42 was not able to communicate his needs and that she made decisions on behalf of the resident. The RP stated the facility had contacted her in October 2021 offering to provide haircut services to Resident 42. The RP stated Resident 42 had a full head of hair that was usually cut in a barber's cut (hair cut close to the sides of the head, longer on top, and usually combed over to one side). The RP…

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 two of 14 residents (Resident 392 and 37) were evaluated for the need of hand mitts (a type of physical restraint that covers a person's entire hand and limits the ability to grasp and use fingers) and had physician's orders for hand mitts prior to the use of the physical restraint. In addition, there was no documentation Resident 392 and 37 were being monitored for proper body alignment, neurocirculatory compromise, and other safety issues while the physical restraint was in use. These deficient practices had the potential to negatively impact Resident 392 and Resident 37's well-being while restrained. Findings: 1. A review of Resident 392's admission record indicated the resident was admitted to the facility on [DATE] with diagnoses to include cerebral infarction (stroke) with hemiplegia and hemiparesis (paralysis and weakness affecting one side of the body), dysphagia (unsafe/difficulty swallowing), and chronic respiratory…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of 14 residents (Resident 392) reviewed for care plans, had a written care plan that was individualized and resident specific for the use of a hand mitt (a type of physical restraint that covers a person's entire hand and limits the ability to grasp and use fingers). This failure had the potential for Resident 392's care and safety needs to not be met while being physically restrained (Cross reference F604 #1). Findings: A review of Resident 392's admission record indicated the resident was admitted to the facility on [DATE] with diagnoses to include cerebral infarction (stroke) with hemiplegia and hemiparesis (paralysis and weakness affecting one side of the body), dysphagia (unsafe/difficulty swallowing), and chronic respiratory failure with tracheostomy (artificial airway created through a person's neck to access the trachea in order to insert a breathing tube). On 6/20/22 at 9:47 A.M., an observation of Resident 392 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not assure that 1 of 14 residents received accurate daily assessments of their medical condition when Resident 1 went to the hospital for pulmonary edema (fluid in the lungs). As a result, Resident 1 potentially suffered from difficulty breathing. Findings: Per the facility admission Record, Resident 1 was admitted on [DATE] with heart failure (a weakness of the heart that leads to a buildup of fluid in the lungs and surrounding body tissue) and dementia (memory disorder with impaired reasoning). Resident 1's chart was reviewed. Per Resident 1's physician orders, dated 5/1/22 to 5/31/22, the resident received nothing by mouth due to an inability to swallow. Resident 1 received liquid nutrition, supplemental water, and medications through a tube in his stomach (enteral). Per the same physicians' orders Resident 1 had a urinary catheter (tube placed in the body to drain and collect urine from the bladder) and an order to monitor and record 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 did not ensure a physician's ordered amount of enteral (tube) feeding (liquid food provided via tube) was followed for one of seven residents (Resident 37) reviewed for tube feeding. As a result, Resident 37 had a potential to have protein-calorie malnutrition (a form of malnutrition where there is lack of dietary protein and/or calories) and unplanned weight loss while receiving nutrition via tube feeding. Findings : Resident 37 was admitted to the facility on [DATE], per the facility's admission Record. A review of Resident 37's admission History and Physical dated 5/19/22, indicated the resident was diagnosed with schizoaffective disorder (a mental disorder characterized by abnormal thought process and an unstable mood), nontraumatic intracerebral hemorrhage (stroke, disruption of blood supply in the brain) affecting right dominant side and dysphagia (difficulty swallowing). During an observation and interview with licensed nurse (LN) 17, on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review for 1 of 14 residents the facility failed to ensure that Resident 14 was sufficiently assessed for the use and side effects of her psychotropic drug treatment. This created the potential for Resident 14 to experience side effects that affected her mood and level of independence. Findings: Per the facility's admission Record, Resident 14 was admitted to the facility on [DATE] with respiratory failure (condition in which your blood doesn't have enough oxygen and it can be difficult to breathe), anxiety (feeling of worry, nervousness, or unease) and depression (illness that negatively affects how you feel, the way you think, and how you act). Resident 14's record was reviewed. Per the physician's orders for the month of June 2022, Resident 14 had orders to receive three antianxiety drugs and two antidepressant drugs. 1. Ativan for anxiety as exhibited by verbalization of distress 2. Buspar for anxiety as exhibited by excessive worry 3. Clonazepam for anxiety as…

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

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5%. The facility's medication error rate was 8.33%. Three medication errors were observed, with a total of 36 opportunities, during the administration process for one of 3 randomly observed residents ( Resident 37). As a result, the facility failed to ensure medications were administered correctly to Resident 37. Findings : On 6/22/22 at 9:50 A.M., an observation of medication administration was conducted with licensed nurse (LN) 17. LN 17 prepared and administered 8 medications to Resident 37 through a gastrostomy tube (G-tube, a surgically-placed device for direct access to the stomach), which included : Acidophilus tablet, one tablet ( used to break down food and absorb nutrients) Amlodipine tablet 10 mg, one tablet ( used to treat high blood pressure) Clonidine tablet 0.1 mg, one tablet ( used to treat high blood pressure) Carvedilol tablet 12.5 mg ( used to treat high blood pressure) Lacosamide tablet 100 mg, one tablet ( used to prevent seizures) Multivitamins…

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 licensed nurses (LN) documented insulin (injectable hormone that regulates blood sugar) administration for one of 14 residents (Resident 12), reviewed for documentation. As a result of this deficient practice, it could not be determined if Resident 12 consistently received insulin. Findings: A review of Resident 12's admission record indicated the resident was admitted to the facility on [DATE] with diagnoses to include diabetes (body's inability to regulate blood sugar levels). Resident 12's physician orders dated 4/20/22 indicated, (brand name) insulin (a short-acting insulin) given as a sliding scale dose (unit dosage was dependent on blood sugar reading) before meals and at bedtime and to hold if the blood sugar reading was below 70. The physician orders further indicated (brand name) insulin (a short-acting insulin)18 units to be given before meals routinely and to hold if blood sugar reading was below 110. Resident 12's June 2022…

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 infection control processes were followed when : 1) Hand hygiene (washing hands with soap and water or using an alcohol-based hand rub) was not performed according to CDC hand hygiene guidelines. 2) Licensed Nurse (LN) 17 entered a contact isolation room (required personal protective equipment such as gloves and gowns when entering to prevent the spread of infection) and placed a notebook from her pocket on Resident 37's side table and then placed it back into her pocket. As a result, residents were at risk for healthcare acquired infections. Findings : Resident 37 was admitted to the facility on [DATE], per the facility's admission Record. A review of Resident 37's admission History and Physical dated 5/19/22, indicated the resident was diagnosed with bacteremia ( presence of viable bacteria in the circulating blood). On 6/22/22 at 9:35 A.M., an observation of LN 17 giving medications to Resident 37 was conducted. LN 17 removed…

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.