Stillwater Post-Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based to observation, interview and record review, the facility failed to provide individualized therapeutic and/or social activities according to their plan of care for one of seven reviewed residents (Resident 67) that promotes their highest physical, mental, and psychosocial well-being. This deficient practice placed Resident 67 at risk for decreased emotional well-being, social isolation, and reduced quality of life due to the lack of meaningful engagement. Findings: A review of Resident 67's admission Record indicated Resident 67 was re-admitted to the facility on [DATE] with diagnoses which included a history of adult failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity) and dementia (a progressive state of decline in mental abilities). Observations were conducted during the following days in Resident 67's room: - 4/15/25 at 9:49 A.M., Resident 67 was in bed resting with a blanket wearing 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 37 sampled residents (Resident 141) received foot care and treatment as ordered by the physician. This failure resulted in missed appointments and treatment aimed to prevent complications from conditions such as diabetes, peripheral vascular disease, or immobility Findings: Resident 141 was admitted to the facility on [DATE] with diagnoses which included peripheral vascular disease (having to do with the blood vessels and circulation), hereditary and idiopathic neuropathy (disease or dysfunction of one or more nerves, typically causing numbness or weakness in the hands and feet), and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During an interview and observation on 4/15/25 at 8:55 A.M , Resident 141 stated he had long toenails and a fungal condition and had been on a list to see the podiatrist (healthcare provider specializing in foot care) for months. 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 observation, interview, and record review, the facility failed to evaluate the use of palm guard splints for one of four reviewed residents (Resident 163) according to professional standards of practice. These deficient practices placed Resident 163 at risk for improper care and worsening of hand contractures (a shortening of muscles). Cross-Reference F656 Findings: A review of Resident 163's admission Record indicated Resident 163 was re-admitted to the facility on [DATE] with diagnoses which included a history of hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (brain attack known as stroke when the blood flow to part of the brain is interrupted) of the left side. A record review of Resident 163's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 1/16/25 indicated, a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of 13…

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, observation, and record review, the facility failed to provide adequate supervision to prevent choking during mealtimes for one sampled resident (Resident 92). As a result of this deficient practice, the resident experienced a choking episode while eating breakfast without supervision (cross reference F656 #3). Findings: Resident 92 was readmitted to the facility on [DATE], with the diagnosis which include Parkinson's Disease (a progressive neurological disorder characterized by gradual loss of movement-related symptoms like tremors, slowness of movement, and stiffness), Dysphasia (Difficulty with swallowing), a stroke causing left non-dominant side hemiplegia and hemiparesis (weakness and paralysis of one side of the body) per facility's admission Record. On 4/17/25 at 1:23 P.M., an observation and interview with Resident 92 and Certified Nursing Assistant (CNA) 54 was conducted. The resident was eating his lunch in his bed, the meal ticket indicated chopped meat and soft fruit plate. 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 nutrition orders for two of 37 sampled residents (Resident 82, Resident 208) with tube feedings (TF: nutritional intake via tube) when: 1. Resident 82's TF was not started timely. 2. Resident 208's TF was not ran at the ordered rate. These deficient practices placed all residents on TFs at risk for malnutrition. Findings: 1. A review of Resident 82's admission Record indicated Resident 82 was re-admitted to the facility on [DATE] with diagnoses which included a history of protein calorie malnutrition (the body does not get enough calories and protein from their diet). A record review of Resident 82's MDS (Minimum data set: nursing facility assessment tool) dated 2/7/25 indicated that Resident 82 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 4/15/25 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to label and change a peripheral intravenous access (IV, location to administer medication into the blood stream) for one of 37 sampled residents (179) based on professional standards of practice. As a result, Resident 179 was placed at an increased risk of infection and medical complications. Findings: Per the facility's admission Record, Resident 179 was admitted to the facility on [DATE] with diagnoses of Amyotrophic Lateral Sclerosis (a nerve disorder causing loss of movement). On 4/15/25 at 10: 38 A.M., an observation and interview was conducted with Licensed Nurse (LN) 4 of Resident 179. The IV to Resident 179's right hand was observed to be unlabeled. Resident 179 stated that the IV had been in his right hand for one week. LN 4 stated the IV needed to be changed. On 4/17/25 a review was conducted of Resident 179's medical record. There were no orders to monitor or change the IV prior to 4/15/25. There was an order on 4/8/25 (seven…

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 medications were administered according to professional standards of practice for three of seven residents (37, 81, 92) reviewed for pharmacy services when: 1. Resident 81's pantoprazole (a prescribed medication to treat acid reflux) was dispensed and left at the resident's bedside for the resident to self-administer. 2. The manufacturer's instructions for Advair Diskus (an inhaled steroid medication) were not followed when the medication was administered to Resident 92. 3. A controlled medication (drugs with high abuse potential) prescribed to Resident 37 could not be accounted for. As a result: -Resident 81 self-administered his pantoprazole at the wrong time and not according to the physician's order. -Resident 92 was at risk of developing thrush (a fungal infection). - The facility was unable to readily identify potential loss and/or drug diversion (illegal distribution or abuse of prescription drugs). Findings: 1. A review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to complete a monthly medication reconciliation (reviewing and creating an accurate list of all medications a resident is taking if appropriate to continue, hold or stop) review (MRR) for one of 20 sampled residents (Resident 183) receiving antibiotics. This deficient practice placed residents at risk for unnecessary medication use, side effects, and harm due to lack of proper review. Cross-Reference F881 and F657. Findings: A review of Resident 183's admission Record indicated Resident 183 was admitted to the facility on [DATE] with diagnoses which included a history of metabolic encephalopathy (a brain disorder that causes problems with the body's chemistry due to lack of oxygen, blood sugar level and essential nutrients). On 4/15/25 at 2:46 P.M. a clinical chart review was conducted on Resident 183's physician's order sheet (POS). Resident 183 was taking Rifaximin (an antibiotic medication that worked by killing the bacteria 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 ensure one of 37 sampled residents (321) and one unsampled resident (59) had medications that were labeled and stored appropriately when: 1. Resident 321's intra venous antibiotic was labeled incorrectly. 2. Resident 59's prescribed medicated ointment was kept in a bowl at the resident's bedside. As a result, there was the potential for a medication errors. Findings: 1. Resident 321 was admitted to the facility on [DATE], with a diagnosis of cellulitis (bacterial infection of the skin). On admission Resident 321 had a physician's order for vancomycin (a strong antibiotic a treatment for patients with cellulitis) q (every) 12 hours, 1.5 grams intravenous to infuse at 250cc/hr (cubic centimeters per hour) over 2 hours On 4/17/25 at 8:31 A.M., an observation was made to Resident 321's bedside and there was an empty IV (intravenous) bag and tubing. The empty IV bag was not labeled correctly. The IV bag had 2 pieces of tape with handwritten…

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 Antibiotic Stewardship policy and procedures to evaluate and monitor the ongoing use of a long-term antibiotic for one of 20 sampled residents receiving antibiotics. This deficient practice placed residents at risk for antibiotic overuse, potential side effects, and the development of antibiotic-resistant infections. Cross-reference F757 and F657 Findings: A review of Resident 183's admission Record indicated Resident 183 was admitted to the facility on [DATE] with diagnoses which included a history of metabolic encephalopathy (a brain disorder that caused problems with the body's chemistry due to lack of oxygen, blood sugar level and essential nutrients). On 4/15/25 at 2:46 P.M., a clinical chart review was conducted on Resident 183's physician's order sheet (POS). Resident 183 was taking Rifaximin (an antibiotic medication that worked by killing the bacteria and preventing its growth) for encephalopathy ordered 3/4/24. 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 call lights were functioning in three residents' rooms (401, 405, 406). As a result, the residents in rooms [ROOM NUMBER] had the potential to not have their needs met in a timely manner. Findings: On 4/15/25 at 3:05 P.M., an observation and interview was conducted with a resident in room [ROOM NUMBER]. The resident stated he waited over an hour every time he used the call light to request help. On 4/15/25 at 3:35 P.M., a joint observation and interview with Certified Nursing Assistant (CNA) 56 was conducted. CNA 56 turned on the bedside call light in room [ROOM NUMBER]. CNA 56 went to the hallway to observe the call light outside the room [ROOM NUMBER]. The call light did not turn on. CNA 56 stated the call light should have been on and visible above room [ROOM NUMBER]'s door. CNA 56 then went to room [ROOM NUMBER] and turned on a bedside call light in the room. CNA 56 went into the hallway to observe the call light outside 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 Licensed Nurses (LNs) assessed a resident prior to sending the resident to the general acute care hospital (GACH), for one of three sampled residents (Resident 1). This deficient practice had the potential in a delay in the resident receiving treatment to address the onset of infection and placed Resident 1's health at risk. Findings: On 2/28/25, the Department received a complaint related to quality of care. On 3/4/25 at 10:40 A.M., an unannounced onsite visit to the facility was conducted. Resident 1 was admitted to the facility on [DATE], with diagnoses which included chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) and congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), per the facility's admission Record. A review of Resident 1's history and physical dated 10/10/24, indicated Resident 1 had 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 resident ' s (Resident 1) safety when Resident 1 eloped (leave without notice) from a facility ' s entrance/exit without their knowledge. As a result, Resident 1 had a successful elopement (leaving the facility unsafely and unescorted) on 1/28/25, and was not found as of today, 1/30/25. The facility did not know Resident 1 ' s exit point and his whereabouts. Findings: On 1/29/25 at 9:57 A.M., an unannounced onsite to the facility was conducted related to a facility reported incident on resident safety. On 1/29/25, a review of Resident 1 ' s admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included schizophrenia (serious mental illness with disorganized thinking). On 1/29/25, a review of Resident 1 ' s minimum data set (MDS - a federally mandated resident assessment tool), dated 9/11/24, Resident 1 had a Brief Interview for Mental Status (BIMS, ability to recall) score of 6/15, (a score of 13 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.

Based on observation, interview, and record review, the facility failed to ensure the floor in the hallway was safe for the residents, staff, and visitors. This failure had the potential for residents, staff and visitors passing the hallway to be at risk for stumbling and injuries. Findings: On 12/30/24, the Department received a complaint related to the facility's physical environment. On 1/2/25, an unannounced visit to the facility was conducted. On 1/2/25 at 11:10 A.M., an observation of the hallway going to station 3 was conducted. There were holes and cracks on the floor in the hallway going to station 3 from the kitchen to the nurses' station. There were two residents by the hallway ambulating with a walker, one resident wheeling himself and one in a wheelchair pushed by a staff. On 1/2/25 at 4:09 P.M., a concurrent observation of the flooring in the hallway and an interview with the Maintenance Director (MaD) was conducted. The MaD stated, We are scheduled to change the vinyl floor. I am going to order the floor so we can replace those temporarily for the residents' safety.…

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 document on a dialysis (a communication form sent to dialysis with the resident and returned to the facility with documentation from the dialysis team) communication form, a witnessed fall prior to a dialysis treatments (an off site treatment, which removes toxins from the blood because the kidneys fail to function property) for one of three resident's reviewed for Quality of Care. This failure had the potential for the dialysis staff to be unaware and not monitoring or evaluating for potential injuries related to the previous fall. Findings: Resident 1 was readmitted to the facility on [DATE] with diagnoses which included end stage renal disease, per the facility's admission Record. According to the physician's order, dated 3/5/24, dialysis every morning on Tuesday, Thursday, and Sunday. According to the facility's SBAR (Situation-Background-Assessment-Recommendation)-Fall note, dated 12/2/24 at 4:30 A.M., Resident 1 had a witnessed fall 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 Based on interview, and record review, the facility staff failed to identify, assess, and notify the attending physician for one of three sampled residents (Resident 1) when Resident 1 had no urine output (UO) for more than 24 hours and no stool output (bowel movement, BM) from her colostomy (stools moving through the intestine draining into a bag that is attached to the skin of the abdomen) bag. In addition, Resident 1 ' s output was not documented consistently in Resident 1 ' s clinical record. This failure had the potential for Resident 1 to have urinary tract infection (UTI) and went untreated. Findings: On 10/7/24 and on 10/15/24, the Department received complaints related to quality of care for Resident 1. On 10/21/24, an unannounced visit to the facility was conducted. Resident 1 was admitted to the facility on [DATE], with diagnoses which included stroke, pressure ulcer (areas of damage to the skin and the tissue underneath), and rectal cancer, per the facility's admission Record. On 10/21/24, a review…

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, interviews, and record review, the facility failed to ensure a comprehensive resident-centered care plan to provide interventions of a physician ' s order to place side rails on Resident 1 ' s bed. As a result, the facility did not follow a physician ' s order to install side rails which placed Resident 1 at an increased risk to fall related to decreased mobility. Findings: Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which include paraplegia (loss of the ability to move the lower part of the body and osteoarthritis of hip according to the facility ' s admission Record. On 6/20/24 AT 9:46 A.M., a concurrent observation and interview was conducted with Resident 1 in his bedroom. Resident 1 ' s bed was observed with half side rails to the left and right side of the bed. Resident 1 stated the side rails were installed to help him turn and/or reposition in bed. Resident 1 stated he had a fall on 6/14/24, and the side rails were provided to him after…

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

Based on observation, interview, and record review the facility failed to ensure the kitchen staff competently performed and carried out the functions of the food and nutrition services department when: 1. Two Diet Aides (DAs) did not correctly test the sanitizer in the low temperature dish machine, and 2. One Diet Aide (DA) could not properly calibrate a food thermometer. These failures had the potential for food contamination, resulting in food borne illnesses for all residents who consume food from the kitchen. Cross reference F804 Findings: 1. During an observation and interview on 4/23/24 at 9 AM with Diet Aide (DA) DA 1, DA 1 was clearing clean dishes from the clean side of the dish machine. DA 1 stated the dish machine was a low temperature machine with a minimum wash temperature of 120 degrees. DA 1 also stated 100 ppm (parts per million) was the minimum level for sanitizer testing. DA 1 then tested the dish machine sanitizer by dipping a test strip in the dish solution on the counter at the end of the machine. The test strip was dark gray, and DA 1 held it to the test strip…

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 food safety and sanitation methods in the kitchen were followed according to standards of practice and facility policy when: 1. The ice machine had dark black and dark gray debris around the chute opening and inside the ice making evaporator, and was not cleaned according to manufacturer's guidelines. 2. The ice machine did not have an air gap. 3. Two bags of hoagie rolls were found to be outdated and expired. 4. A walk-in and reach-in refrigerator did not have internal working thermometers for temperature monitoring. 5. Four food scoopers were found with brown, crusted debris and 12 scoops were found with water in them and seven sharp butcher cutting knives were found with greasy grime and food particles crusted on them. These failures had the potential to expose residents to contaminants that could cause foodborne illness. Findings: 1. During a kitchen observation and interview on 4/23/24 at 2:40 PM of the ice machine with the Maintenance Director (MDR), the MDR stated he completes the ice bin…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: 1. Ensure call lights were positioned within reach for 11 of 58 residents (3, 23, 33, 85, 87, 140, 156, 189, 197, 221, 401) , during initial tour, reviewed for call lights; and 2. A bariatric bed (a specialized bed made to accommodate larger, heavier than usual residents) was not provided as ordered by the physician for one of one resident (401) reviewed for accommodation of needs. This failure had the potential to endanger the health, safety, and recovery of the residents. Findings: 1a. Resident 3 was admitted to the facility on [DATE], with diagnoses which include anxiety disorder and schizophrenia (a mental disorder resulting in a faulty perception with withdrawal from reality), per the facility's admission Record. On 4/23/24 at 9:54 A.M., an observation was conducted in Resident 3's room. Resident 3 was asleep on her right lateral side. The call light button and attached cord was lying on the floor, near the right side of the bed,…

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 1b. Resident 164 was admitted to the facility on [DATE] with diagnoses which included PTSD according to the facility's admission Record. Findings: An observation of Resident 164 was conducted on 4/23/24 at 2:30 P.M. Resident 164 was reclining in bed, on her right side, with her hand over her face and the room dark. Resident 164 requested the surveyor to leave. A review of Resident 164's medical record was conducted on 4/24/24 at 3:57 P.M. A care plan for PTSD indicated, .resident is trigged by emotional distress . The care plan did not state what the triggers are or what to do about them. A concurrent interview and record review was conducted with the unit manager (UM) on 4/25/24 at 8:02 A.M. The UM stated, This resident is triggered by a history with family especially her father. I haven't gone into it too much because it was sexual. The Resident sees a psychologist but not any therapy that I know of. In addition, the UM stated, The care plan makes us aware that she has triggers, but we don't know what 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 ensure assistance with activities of daily living (ADL - basic and everyday skills that are essential to living independently) was provided to four of four residents (67, 86,185, 167) reviewed for ADL when: 1. Resident 67 and 86 were not provided incontinence (loss of bladder control) care in a timely manner. and, 2. Resident 86, 185 and 167 were not offered nail care. Findings: 1a A review of the admission Record indicated Resident 67 was admitted to the facility on [DATE] with diagnoses that included paraplegia (the inability to move the legs and lower body due to spinal injury), anemia (low number of red blood cells). A review of Resident 67's Minimum Data Set (MDS - an assessment tool), dated 3/13/24, was conducted. The MDS assessment indicated Resident 67 required substantial/maximal assistance with toileting hygiene and personal hygiene. Resident 67's MDS data also indicated Resident 67's cognition (the understanding of thought…

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 administer oxygen and continuous positive airway pressure (CPAP-a machine that uses mild air pressure to keep breathing airways open while you sleep) as ordered by the physician for two of four residents (Resident 89 and 401), reviewed for oxygen therapy. As a result, residents were not given the care and service prescribed, which had the potential to hinder or worsen their recovery process. Findings: 1. Resident 89 was admitted to the facility on [DATE], with diagnoses which included chronic obstructive pulmonary disease (COPD-a lung disease causing restricted airflow and breathing problems), per the facility's admission Record. On 4/23/24 at 9:10 A.M., an observation was conducted of Resident 89 in his room as he slept. Resident 89 was receiving oxygen via nasal cannula (a clear, flexible tube which delivers oxygen to the nostrils). The oxygen was supplied by a condenser (a machine that delivers concentrated oxygen), sitting 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 2. Resident 164 was admitted to the facility on [DATE] with diagnoses that included PTSD according to the facility's admission Record. An observation of Resident 164 was conducted on 4/23/24 at 2:30 P.M. Resident 164 was reclining in bed, on her right side, with her hand over her face and the room dark. Resident 164 requested the surveyor to leave. A review of Resident 164's medical record was conducted on 4/24/24 at 3:57 P.M. A care plan for PTSD indicated, .resident is trigged by emotional distress . The care plan did not state what the triggers were or what to do about them. A concurrent interview and record review was conducted with the unit manager (UM) on 4/25/24 at 8:02 P.M. The UM stated, This resident is triggered by a history with family especially her father. I haven't gone into it too much because it was sexual. The Resident sees a psychologist but not any therapy that I know of. In addition, the UM stated, The care plan makes us aware that she has triggers, but we don't know what the triggers are…

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

Based on observations, interviews and record review, the facility failed to ensure the approved menus by the Registered Dietitian (RD) were followed as printed. This failure had the potential to alter the palatability and nutritional value of the food, which could decrease food intake and compromise the resident's nutritional status. Cross reference F804 Findings: Review of the facility document titled RD Approval of Menus, signed by the facility RD on 3/1/24, indicated The Registered Dietitian for the facility has reviewed the menus and spreadsheets and has agreed that the menus meet the therapeutic needs of and reflect, based on reasonable efforts, the religious, cultural, and ethnic needs of the resident population, as well as input received from residents and resident groups . During a review of the facility's Week 4 Spring Menu April 22-28th 2024, did not have a soup listed for breakfast, lunch, or dinner. During a review of the facility's Spring Cycle Menus, Week 4 -Tuesday 4/23/24, the Lunch meal for Regular diets included Roast Turkey, Cranberry-Ginger-Citrus sauce, Bread…

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 food was served at an acceptable temperature and palatability taste to the residents, according to the facility policy and the facility's resident council. This failure had the potential to affect meal and food intake which could impair the nutrition status of the residents. Cross reference F803 Findings: During a review of the facility's Spring Cycle Menus, Week 4 -Tuesday 4/23/24, the Lunch meal for the Regular diet included Roast Turkey, Cranberry-Ginger-Citrus sauce, Bread Dressing, Seasoned peas, Three-bean salad, and Vanilla mousse chocolate chip dessert. The Pureed meal included pureed Roast Turkey, pureed Cranberry-Ginger-Citrus sauce, pureed Bread Dressing, pureed Seasoned peas, pureed vegetable, and Vanilla mousse without chocolate chips. During an observation and interview on 4/23/24 at 9:32 AM with CK 1 was conducted. CK 1 was preparing food for the lunch menu. CK 1 stated he made the pureed turkey with ground turkey that he cooked. CK 1 then stated CK 2 added salt and pepper seasoning,…

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 demonstrate infection control practices when: 1. A continuous positive airway pressure machine (CPAP- a machine worn on the face at night for the treatment of sleep apnea), mouthpiece was not stored properly for one of four residents (401) reviewed for infection control. 2. An oxygen humidifier (a clear plastic bottle which contains distilled water, that infuses oxygen with water droplets for moisture and comfort during use) was not dated when it was initiated for one of four residents (187), reviewed for oxygen therapy. 3. A urinary catheter bag (a clear flexible tube placed inside the body to drain urine into an external bag) was on the floor for one of two residents (216), reviewed for urinary catheter care. 4. A bilevel positive airway pressure (BIPAP) machine (machine used as breathing support and administered through a face mask or nasal mask) was not cleaned according to the facility's policy and procedure for one of two residents…

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, interviews, and record review, the facility failed to report an injury of unknown origin to the California Department of Public Health for one of two allegation of abuse incidents. As a result, investigation into the injury was delayed and placed Resident 220 at risk for further injury. Findings: A review of Resident 220's admission Record indicated the resident was readmitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy (an acute condition of brain dysfunction), violent behavior, dementia (a condition that effects cognitive function). A review of Resident 220's Minimum Data Set Assessment (MDS - assessment tool), dated 4/17/24, indicated the resident scored 0 on the brief interview of mental status (a score of 0-7 suggests severe cognitive impairment). On 4/23/24 at 3:29 P.M., an observation was conducted in the hallway of station 3B. Resident 220 was observed ambulating in the hallway, accompanied by a staff member. Resident 220 had greenish purple…

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 up on one of five resident's broken eyeglasses who was reviewed for visual devices, Resident 124. The deficient practice resulted in the resident using broken eyeglasses and had the potential for decreased vision, and diminished self-worth. Findings: Resident 124 was admitted to the facility on [DATE] with the diagnoses including ectropion (eyelid open in an outward direction) of unspecified eye according to the facility's admission Record. On 4/23/24, at 12:07 P.M., Resident 124 was observed having lunch in the dining room with scotch tape on the top rim of his eyeglasses. During a joint observation and interview on 4/24/24, at 4:20 P.M. with LN 11, Resident 124 was in bed coloring a book wearing eyeglasses with tape on the rim. Resident 124 stated the glass came off and nobody had checked his glasses for repair. LN 11 stated he had not reported the broken eyeglasses to social services. Certified nurse assistant (CNA) 11 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 failed to ensure residents were safe when: 1. Staff did not identify and address a potential hazard in one of two resident rooms (Resident 221), reviewed for accidents and, 2. Safe smoking assessments were not completed for one of two residents reviewed for smoking (Resident 35). As a result, there was the potential for Resident 221 and 35 to become injured from the room hazard and from not being assessed by a licensed nurse for smoking safety. Findings: 1. Resident 221 was admitted to the facility on [DATE], with diagnoses which included dementia (progressive memory loss), per the facility's admission Record. On 4/23/24 at 8:16 A.M., an observation was conducted inside Resident 221's room. Resident 221 was dressed, lying flat on his bed. The bed was pushed up against the wall on the right side, and the HOB was in contact with the adjacent wall. On the wall next to the right side of the bed, approximately 3 feet up, was peeling paint, exposed dry…

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 identify, treat or manage a resident's (155) pain prior to wound care. This failure had the potential to cause unnecessary pain for Resident 155. Findings: Resident 155 was admitted to the facility on [DATE] with diagnoses that included chronic pain syndrome (a medical condition involving pain, depression and anxiety that interfere with daily life) per the facility's admission Record. An observation was conducted on 4/24/24 at 8:44 A.M. of Resident 155. Resident 155 was reclining in bed and had bilateral bandages on her feet. Resident 155 stated she had pain in her feet and the pain medication she received was not effective. An interview was conducted on 4/24/24 at 9 A.M. with the unit manager (UM). The UM stated, Resident 155 has no other orders for pain medication. An interview was conducted on 4/25/24 at 10:23 A.M. with Resident 155. Resident 155 stated, I just had another dressing change and my feet really hurt. I did not have pain…

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 assessments were completed before a resident's dialysis (process of removing toxins from the kidneys and blood through a machine) treatment for one of three residents reviewed for dialysis. (Resident 219) This deficient practice had the potential to result in undetected complications such as infection and bleeding at the access site (part of the body where dialysis is received), and abnormal vital signs (temperature, breathing, heart rate) which can lead to a delay in necessary care. Findings: Resident 698 was admitted to the facility on [DATE] with diagnoses including end stage renal disease (ESRD-the last stage of kidney disease which the kidneys can no longer support the body's needs) according to the facility's admission Record. During an interview on 4/23/24, at 11:02 A.M., with Resident 219, Resident 219 stated she attended dialysis treatments three times per week. An interview and joint review was conducted on 4/24/24, at 4:15 P.M., with…

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 that a Vegetarian Diet (no consumption of animal meat) meal preference was honored for an unsampled resident, Resident 48. This failure had the potential for decreased food intake which could increase the risk of unintended weight loss due to the facility not meeting the resident's nutritional needs. Findings: Resident 48 was readmitted to the facility on [DATE] with diagnoses that included but not limited to diabetes (high levels of sugar in the blood) and hypertension (high blood pressure)per the facility's admission record. During an observation and interview with Resident 48 on 4/23/24 at 8:15 A.M., Resident 48 was observed in her room with a breakfast tray on the bedside table. The breakfast tray included a bowl of cottage cheese and a plate of sliced tomatoes. Resident 48 stated she did not like at the food at the facility because they do not give her foods she can eat as a vegetarian, including eggs. Resident 48 consumed…

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 clinical record was completed for one of one resident (Resident 219) reviewed for accurate medical record. This failure did not provide an accurate representation of the care provided to Resident 219 and had the potential to cause confusion amongst care providers. Findings: Resident 219 was admitted to the facility on [DATE] with diagnoses including malignant neoplasm (cancerous tumor) of prostate (a male organ below the bladder) according to the facility's admission Record. During an observation on 4/23/24, at 11:55 A.M., Resident 219 was in bed with an indwelling urinary catheter (soft, plastic or rubber tube that is inserted into the bladder to drain the urine) hanging at the side of the bed, draining tea colored urine. An interview and concurrent observation was conducted with LN 13 on 4/24/24, at 11:50 A.M. LN 13 stated Resident 219 had an indwelling urinary catheter for prostate cancer. LN 13 stated licensed nurses provided…

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

Based on observation, interview and record review, the facility failed to follow infection control practices when the facility. a. did not elevate the medical supplies above the floor. b. the storage area had water leak damaging the medical supplies. c. an employee entered an isolation room without appropriate personal protective equipment (PPE) This failure had the potential to spread germs and placed residents at risk for infections. Findings: On 3/6/24 and 3/12/24, the Department of Public Health received two complaints related to Infection Control. a.On 3/12/24 at 2:17 P.M., an observation and interview with the Infection Preventionist (IP) was conducted. The storage for medical supplies including personal protective equipment (PPE like face mask, disposable gloves, gowns) were not elevated above the floor. The IP stated the medical supplies should have been elevated to keep off the floor and prevent contamination. b. During a concurrent observation and interview on 3/12/24 at 2:34 PM. with the IP, the other storage room was outside the facility building. The outside storage 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 failed to ensure residents' skin and nails were assessed and treatment were provided to two of three sampled residents (Resident 1 and Resident 3), when; 1. staff failed to assess and provide care to Resident 1's left big toe ingrown, and, 2. staff failed to assess and provide care to Resident 3's lower lip sutures. These failures placed Resident 1 and Resident 3 for delayed healing and potential for infection. Findings: On 3/18/24, an unannounced onsite to the facility was conducted related to complaints on quality of care. 1.Resident 1 was readmitted to the facility on [DATE] with diagnoses which included diabetes (high blood sugar), per the facility's admission Record. On 3/18/24, a review of Resident 1's history and physical (H&P) dated 10/26/23 was conducted. The H&P indicated Resident 1 had the capacity to understand and make decisions. On 3/18/24, a review of Resident 1's minimum data set (MDS, an assessment tool), dated 1/31/24 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to ensure safe and sanitary measure was met when an ice scooper was left in the cart without a holder. This failure had the potential to result in harmful bacteria growth and cross contamination with the ice that could lead to pathogens to come in contact with the residents' food and drinks and may cause food borne illness to the residents. Findings: On 3/18/24, an unannounced onsite to the facility was conducted related to a complaint on quality of care. Resident 2 was readmitted to the facility on [DATE] with diagnoses which included respiratory failure and with tracheostomy (opening into the windpipe) connected to a ventilator machine (breathing apparatus), per the facility's admission Record. During an interview with a family member (FM) on 3/18/24 at 1:53 P.M., the FM stated she provided ice chips to Resident 2. FM stated the ice chips were located near the nurses' station and the ice scooper laid in the cart. FM stated she was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide adequate supervision to a resident while changing his clothing (Resident 1). This failure resulted in Resident 1 falling off of the bed and obtaining an injury. Findings: Resident 1 was re-admitted to the facility on [DATE] with diagnosis to include quadriplegia (paralysis that affects the body from the neck down), per the Resident Face Sheet. On 12/26/23, a record review was conducted. On 8/15/23, the Minimum Data Set (MDS, an comprehensive assessment tool) indicated Resident 1 required extensive assistance of two staff for dressing, for personal hygiene, and for bathing. From 12/1/23 through 12/11/23, the Point of Care History (CNA documentation regarding care needs of Resident 1) four of four entries indicated Resident 1 required a one person physical assist for support during bathing. On 10/31/23, Resident 1 ' s fall risk was assessed as 12, indicating high risk for falls. On 12/11/23, a Nursing Progress Note indicated Resident 1 had rolled…

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 nail care to one of three sampled residents (Resident 1), reviewed for Activities of Daily Living (ADL, activities related to personal care). As a result, Resident 1 ' s health and wellbeing were at risk. Findings: On 1/10/24 at 11:07 A.M., an unannounced onsite at the facility was conducted related to a complaint on infection control and quality of care. During a review of Resident 1 ' s face sheet, dated 9/15/23, the face sheet indicated Resident 1 was admitted to the facility from an acute care hospital (ACH) with diagnoses which included hemiplegia (paralysis of one side of the body), and hemiparesis (weakness or inability to move one side of the body). During a review of Resident 1 ' s History and Physical (H&P), dated 9/17/23, the H & P indicated the attending physician (AP 1) documented Resident could make needs known but could not make medical decisions. During a review of Resident 1 ' s Minimum Data Set (MDS - an assessment tool), dated 12/12/23, the MDS indicated Resident 1's brief interview…

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 clean and sanitary kitchen. As a result, the residents were at risk for food borne illness. Findings: On 6/21/22 at 7:45 A.M. during the initial tour with the Registered Dietician (RD), an unidentified food wrapped in foil was found in the refrigerator with no label to identify the food or expiration date. The RD stated, This should not be in the refrigerator. On 6/21/22 at 8 A.M., during an observation of the walk-in refrigerator with the Dietary Supervisor (DS), six individual plastic food containers containing Mixed fruit, Strawberry yogurt, Pudding, Sliced Pineapple, Prunes and Sliced turkey were not properly closed and the food in the containers were exposed. The DS stated, These lids are warped. We should not be using them. On 6/21/22 at 8:12 A.M., the ice machine was observed. The ice scoop holder had two inches of unclean water at the bottom of the ice scoop holder. On 6/21/22 at 8:15 A.M., the third sink of the three compartment sink was leaking and dripping dish water on the floor. Excess…

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 review, the facility failed to fully implement infection control standards of practice for residents on transmission-based precautions (isolation precautions to reduce the spread of infection) for the use of Personal Protective Equipment (PPE- gowns) during 4 of 8 staff interviews. This failure could expose other residents to potential infection and multi-drug resistant organisms (MDROs). Findings: On 6/21/22, the facility had multiple rooms on all units under transmission-based precautions (TBP) in yellow zones for residents with potential exposure to staff members who had tested positive for COVID-19. The red zone had 6 residents that tested positive for COVID-19. In addition, there were 26 residents in TBP due to colonization (germs living on a person's body that do not make them sick but can spread to others) with Carbapenem-resistant Acinetobacter baumanni (CRAB), a multi-drug resistant organism (MDRO). During interviews conducted with staff members between 6/21/22 and 6/28/22, 4 of 8 staff indicated when caring for residents 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 ensure the in house dialysis provider coordinated the plan of care and monthly Interdisciplinary Team (IDT) meetings with the facility and the dialysis provider, and the resident or the residents responsible party for 2 of 35 sample residents (174, 200). As a result. the residents plans of care was not completed timely and did not include the resident or their responsible party's input. Findings: 1. Resident 174 was admitted to the facility on [DATE] per the facility's face sheet. Resident 174 was to receive dialysis while staying in the facility, by the contracted home dialysis provider. A review of Resident 174's clinical record did not contain any documentation from the dialysis provider. The dialysis treatment sheets were contained in a separate binder. There were no Physicians Notes, care plans, monthly clinic visits, the dialysis Plan of Care, or any other documentation from the dialysis provider found in the resident's clinical record. 2.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to obtain an order to crush medication, and failed to administer crushed medications based on standards of practice for one sampled resident (20). Findings: Resident 20 was re-admitted to the facility on [DATE] with diagnoses which included aphasia (difficulty talking) and dysphagia (difficulty swallowing) per the facility's Resident Face Sheet. Resident 20's electronic record was reviewed on 6/23/22. Per the physician's initial history and physical dated 2/4/22, Resident 20, Does NOT have the capacity to understand and make decisions. On 6/23/22 at 8:47 A.M., LN 17 was observed giving medications to Resident 20. LN 17 poured one tablet of vitamin D3 (medication to help the body absorb calcium - a mineral) and 2 tablets of vitamin C (medication for bones, muscles and helps the body absorb iron- a mineral that helps produce blood) in one cup. LN 17 then placed the three tablets in the pill crusher and crushed all medications at the same time.…

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 1 of 2 dependent residents (39) was repositioned every two hours. As a result, Resident 39 was at risk for worsening pressure ulcers. Findings: Per Resident 39's Face Sheet, Resident 39 was admitted on [DATE] and readmitted on [DATE] with diagnosis including quadriplegia and chronic pain syndrome. According to Resident 39's History and Physical dated, 6/16/22, the resident, .Has the capacity to understand and make decisions. On 6/21/22 at 9:30 A.M., Resident 39's room was observed. Upon entering, Resident 39 could be heard yelling, Nurse!, nurse!, I want to be turned to my left side. Resident 39 was observed lying on his back with his lower extremities turned to his right side on the bed. Resident 39's call bell was out of reach on the upper left corner of his mattress. Resident 39's left and right hands were contracted (abnormal shortening and stiffness of muscles caused by lack of mobility or injuries). On 6/21/22 at 9:48 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide the prescribed amount of gastrostomy tube feeding nutrition (tube inserted in the stomach used to provide nutrition) for one of two sampled residents reviewed for tube feeding (20). Failure to provide the prescribed amount of tube feeding had the potential for residents to experience weight loss and receive inadequate nutrition. Findings: Resident 20 was re admitted to the facility on [DATE] with diagnoses which included aphasia (difficulty talking), dysphagia (difficulty swallowing), and quadriplegia (whole body was paralyzed), per the facility's Resident Face Sheet. Resident 20's clinical record was reviewed on 6/24/22. According to the physician's history and physical dated 6/10/22, Resident 20, Does NOT have the capacity to understand and make decisions. Per the physician's order dated 6/6/22 under special instructions, [Tube feeding brand] 1.5 calories at 65 ml/hour (hr) times 20 hours via pump to provide 1300 ml/1950 kcal .…

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 consistently and accurately assess the effectiveness of pain management medication for 2 unsampled residents (40, 53) and 1 sampled resident (101). As a result, there was potential the residents pain was not adequately controlled. Findings: 1. Resident 40 was admitted to the facility on [DATE] with diagnoses that included kidney disease and chronic pain disorder, per the Resident Face Sheet. The clinical record was reviewed on 6/22/22. According to the physician's orders, on 3/14/22, the resident was prescribed oxycodone (narcotic medication) 10 mg every 4 hours as needed for moderate to severe pain (scale 4-10). The resident's MAR was then reviewed. On 6/21/22 at 11:48 A.M., Resident 40 received one tablet of oxycodone 10 mg for pain 8/10. The reassessment for effectiveness was not documented until 5:25 P.M., more than five hours later and by another LN. The reassessment indicated Effective but no pain scale was used. On 6/19/22 at 6:50…

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 consistent completion of hemodialysis (dialysis-a life support treatment that replaces many of the kidney's functions) communication for 1 of 2 sampled dialysis residents (87). This failure had the potential for miscommunication between the facility and dialysis center and could affect the continuity and quality of care for Resident 87. Findings: Resident 87 was admitted to the facility on [DATE] with diagnoses that included end-stage renal disease (kidney failure), per the facility's Resident Face Sheet. According to Resident 87's care plan for dialysis, updated 6/14/22, the resident received dialysis treatments at an outpatient dialysis facility every Monday, Wednesday, and Friday. During an interview with LN 5 on 6/24/22 at 9:53 A.M., LN 5 stated each resident who received dialysis treatment had a binder that went with them to each treatment at the dialysis center. Additionally, LN 5 stated the dialysis communication record was the main form…

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 post the actual staffing hours when the facility only posted anticipated staffing for the day. As a result, the daily staffing information may not have been accurate. Findings: The facility provided daily staffing information titled, Daily Licensed Staff, from 6/7/22 to 6/21/22. The facility provided a multiple-page posting for each day. These pages included the patient census, the number of Registered Nurses (RN), the number of Licensed Nurses (LN), and the number of CNAs. These numbers were broken down to number of staff, shift hours, and total hours. The facility had a separate Daily Licensed Staff page for each of the five different units and an overall facility staffing posting for the facility. The overall facility staffing posting did not include the sub-acute unit's staffing information. On 6/24/22 at 7:35 A.M., the DON stated the postings were done the night before and was not updated when there were staffing changes. The actual staffing hours were provided several days later by payroll using the staff time cards.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure target behaviors and adverse side effects were monitored for the use of psychotropic medications, for two of 35 sampled residents (102, 171). This failure had the potential to affect the ordering physician's ability to determine the effectiveness of the medications. Findings: 1. On 6/21/22 at 9:36 A.M. Resident 102 was sitting in the hallway coloring in a book. There was a staff sitter (CNA 1) nearby observing and monitoring the resident. When interviewed, CNA 1 stated she was monitoring the resident's location and behaviors. According to CNA 1, Resident 102 had a tendency to be aggressive towards males. The clinical record was reviewed on 6/22/22. Resident 102 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder and dementia with behavioral disturbance, per the Resident Face Sheet. Resident 102's quarterly MDS (Minimum Data Set) dated 6/8/22, indicated the resident had moderately impaired…

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 that food was palatable and had an appetizing temperature. These failures can result in residents not eating the food served which could result in weight loss and further compromise their medical status. Findings: On 6/23/22, at 11:45 A.M. Tray line started. The menu consisted of glazed ham, potato medley, broccoli, corn bread and a frosty sherbet. The lead dietary aide calibrated the thermometer. Food temperatures were recorded at the start of trayline, middle of trayline and when the last tray was served on the last cart leaving the kitchen. The temperatures were as follows: Start- 11:45 A.M.: Glazed ham- 165 degrees Fahrenheit (F) Potato medley-188 degrees F Broccoli with Tarragon- 171 degrees F Frosty Sherbert- 38 degrees F Milk-38 degrees F Middle of trayline-12:25 P.M.: Glazed ham- 155 degrees F Potato medley- 160 degrees F Broccoli with Tarragon- 150 degrees F Frosty Sherbet-45 degrees F Milk- 41 degrees F Tray line production ended at 1:04 PM when the last tray was placed in the last cart going…

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

Based on observation and interview the facility failed to ensure evening snacks were available to all residents on each unit. As a result, some residents may not have been able to get an evening snack before bed. Findings: During the Resident Council meeting on 6/22/22 at 10 A.M., several residents stated evening snacks were delivered to each of the units, but delivered for specific residents only. The resident stated one has to ask for a evening snack either on admission, or earlier in the day to ensure that your snack choice would be labeled and brought to your unit for your evening snack. The residents stated there were non-labeled snacks available to all residents. On 6/23/22 at 1:12 P.M., a bin of snacks was observed on Station 2's Nurses station. Every snack in the bin including the banana, had a label with a resident's name and room number on it. There were no non-labeled snacks available to all residents.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to consistently implement its antibiotic stewardship tool for 1 of 3 sampled residents (141) colonized with multi-drug resistant organisms (MDRO). This failure could potentially increase the risk to Resident 141 for adverse side effects or the development of further MDROs. Findings: Resident 141 was admitted to the facility on [DATE] with diagnoses that included enterocolitis (inflamed colon) due to Clostridium difficile (bacteria that causes watery diarrhea), per the facility's Resident Face Sheet. During an interview with the facility's Infection Preventionist (IP) on 6/28/22 at 2:51 P.M., the IP described the facility's antibiotic stewardship program that utilized their electronic medical records (EMR) that incorporated standardized criteria for the use of antibiotics. The IP stated when antibiotics were ordered, the LN opened an event in the EMR for Infection Tracker with McGeer's Criteria (an infection surveillance checklist) 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.