El Centro Post-Acute Care

Based on interview, record review, and facility policy review, the facility failed to ensure a significant medication error did not occur for 1 (Resident #93) of 6 residents reviewed for unnecessary medications. Specifically, facility staff failed to follow a physician's order to hold losartan potassium and metoprolol tartrate (medications used to treat high blood pressure) when the resident's systolic blood pressure (SBP, the top number in a blood pressure reading) was less than 120 millimeters of mercury (mmHg). Findings included: A facility policy titled, Administering Medications, revised in 04/2019, specified, 4. Medications are administered in accordance with prescriber orders, including any required time frame. The policy also indicated, 11. The following information is checked/verified for each resident prior to administering medications: a. Allergies to medications; and b. Vital signs, if necessary. An admission Record indicated the facility admitted Resident #93 on 06/10/2024. According to the admission Record, the resident had a medical history that included diagnoses 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, record review, and facility policy review, the facility failed to have a physician's order for hospice services for 1 (Resident #221) of 2 residents reviewed for hospice services. Findings included: A facility policy titled, Hospice Program, revised 07/2017, revealed, 12. Our facility has designated [Name] (Name) RN [registered nurse] DON [Director of Nursing] (Title) to coordinate care provided to the resident by our facility staff and the hospice staff. The policy also indicated, He or she is responsible for the following: d. Obtaining the following information from the hospice: (7.) Hospice physician and attending physician (if any) orders specific to each resident. An admission Record revealed the facility admitted Resident #221 on 09/06/2024. According to the admission Record, Resident #221 had a medical history that included diagnoses of adult failure to thrive and Alzheimer's disease. Resident #221's Skilled Nursing-admission Initial Eval [Evaluation], dated 09/06/2024, revealed New…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure a resident ' s right was honored when one of 3 residents was not allowed to have a visitor after a fall incident (Resident 6). This deficient practice had the potential for the resident to have feelings of isolation, anxiety (feeling of fear, dread, and uneasiness) and/or sadness. Findings: On 8/15/24 at 11:08 A.M., an unannounced onsite visit at the facility was conducted related to a reported complaint regarding Resident 6 ' s fall incident at the facility. Resident 6 was admitted to the facility on [DATE] with diagnoses including weakness and unspecified fall according to the facility ' s admission Record. During a review of Resident 6 ' s nurse ' s notes dated 6/9/24, at 3:22 A.M., the nurse ' s note indicated Resident 6 was found on the floor lying on her back. The nurse ' s notes indicated Resident 6 was resistant, yelling in Spanish, hitting staff, refused assessment and then called her daughter on the phone. The nurse ' s note 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the tube feeding (the amount of formula) order on the Medication Administration Record (MAR) was the same as the physician's order for one of three sampled residents (1). As a result, there was a potential for Resident 1 to receive an incorrect tube feeding amount. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses that included diabetes (a disease that occurs when the blood glucose [blood sugar} is too high) and gastrostomy (artificial opening to the stomach to feed), per the admission Record. On 5/7/24 at 1 P.M., an observation was conducted. Resident 1 was with a family member. The tube feeding had a label for Glucerna 1.5 (the name of the tube feeding formula) 50 millimeters per hour (ml/hr). A record review was conducted. Per the Order Summary Report, dated 4/11/24, Resident 1 was to receive Glucerna 1.5 at 60 ml/hr for eight hours, to start at 8 P.M. until 4 A.M. or until the volume order 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 assess a resident ' s (Resident 2) wandering behavior and develop a baseline care plan (detailed plan with information about a patient's treatment, goal, and interventions) of Resident 2's wandering behavior. As a result, the lack of a resident centered care plan with specific interventions to reduce wandering behavior had the potential for Resident 2 to enter the rooms of other residents without permission. In addition, Resident 2 was found in another resident's room engaging in a sexual act. Findings: On 6/9/22 at 2:24 P.M., an unannounced onsite at the facility was conducted. 1. Resident 2 was admitted to the facility on [DATE], from a skilled nursing facility (nursing home), with diagnoses which included dementia (the loss of cognitive function like thinking, remembering, and reasoning), per the facility ' s admission Record. Resident 2 ' s history and physical (H&P), dated 2/7/22, indicated, the attending physician (AP 1) documented…

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 adequately store medications behind a locked door. This failure had the potential to result in resident harm, for approximately 20 residents in Hallway 1, through accidental ingestion of unprescribed medications without staff awareness or supervision. On 10/25/23 at 11:40 A.M. and at 12: 21 P.M. an observation was made of an unlabeled door noted to be ajar and not completely closed. Upon opening the door, the room was noted to have over the counter, non-prespricption medications stored on open shelves, as well as a locked refrigerator and three tackle boxes sealed with zip-tie closures. The door did not self-close. An interview was held with LN 1, on 10/25/23 at 12:23 P.M., regarding the unlocked door. LN 1 demonstrated opening the door and letting it close, and stated that the door did not close all the way. LN 1 stated when a person left the room the door needed to be pushed shut behind them. LN 1 stated the door should have been fixed because it would allow everyone access to the medications. The medication room should…

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, and interview, the facility failed to ensure that staff followed proper hand washing technique during a meal service for 7 residents. This failure had the potential to spread germs and cause infections among the residents. On 10/25/23 at 12:09 P.M., the following observations were made during meal service on Hallway 1. CNA 1 was seen leaving a resident room and walking to the meal delivery cart in the hallway. CNA 1 selected and held resident ' s meal tray and delivered to resident room [ROOM NUMBER]. CNA 1 then returned from resident room [ROOM NUMBER] to the meal tray cart and selected and held another tray. No hand hygiene was observed. CNA 2 was seen leaving resident room [ROOM NUMBER]. CNA 2 selected and held a tray from the meal delivery cart, and delivered to another resident room. No hand hygiene was observed. CNA 3 was seen leaving a resident room, then selected and held a tray and delivered to room [ROOM NUMBER]. CNA 3 was next seen walking from the other end of the hallway 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 develop and implement care plans related to: 1. Smoking, for one of one resident (2) reviewed for smoking, 2. Oxygen use, for three of three residents (24, 4, and 42) and 3. Indwelling catheter for one of three residents (25) reviewed for urinary catheter care. This failure had the potential to affect residents medical needs and care. Findings: 1. Resident 2 was admitted to the facility with diagnoses that included respiratory failure with hypoxia (low oxygen levels), per the facility's Record of Admission. An observation of Resident 2 was conducted on 5/3/21, at 3 P.M. Resident 2 was walking in the hallway with her walker. An interview was conducted with certified nursing assistant (CNA)12 on 5/4/21 at 8:13 A.M. CNA 12 stated, She (Resident 2) is the only smoker in the facility, and she smokes occasionally. A review of Resident 2's medical record was conducted on 5/4/21 at 8 A.M. A smoking assessment was performed for Resident 2 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 did not serve food in an appealing manner for five of five residents (23, 28, 9, 47, & 50) reviewed for food preferences. In addition, food concerns were identified during the confidential general resident council meeting for eight of 11 confidential residents. This failure had the potential for residents to suffer from a lack of daily nutritional requirements, because the food was not palatable. Findings: 1. Resident 23 was admitted to the facility on [DATE], with diagnoses which included polyneuropathy (a degeneration of the peripheral nerves of the body), per the facility's Record of Admission. A review of the MDS (Minimum Data Set - an assessment tool) was conducted on 5/4/21. Resident 23 had a BIMS (Brief Interview for Mental Status) Score of 8 (mildly impaired), and required supervision with meals (encouragement and oversight). On 5/3/21 at 5:39 P.M., an observation and interview was conducted with Resident 23. Resident 23 sat up in bed 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.

Based on observation, interview and record review, the facility failed to ensure potentially hazardous foods were clearly labeled with their use-by date. This failure had the potential to cause the food to develop pathogens that contaminate food and may cause foodborne illness if consumed. Findings: On 5/3/21 at 11:30 A.M., during the initial kitchen tour observation, several potentially hazardous foods and time control for safety foods (PHF/TCS) were not labeled with a use-by date. These foods were stored in the walk-in refrigerator, a stand up refrigerator, the dry storage area, and the freezers. In the walk-in refrigerator a carton of liquid eggs was opened with no use by date. Canned tuna was opened and stored in a stainless steel container covered with plastic wrap with an opened date of 4/26/21, but no use-by date. In the dry storage area shaved almonds in a bag, prepared garlic cloves in a jar, a packet of opened instant vanilla pudding, a box of opened raisins, an opened bag of marshmallows, a bin of saltine crackers, a box of cornbread mix, and a container of ground ginger…

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 5) Resident 10 was readmitted to the facility on [DATE], with diagnoses to include muscle wasting and atrophy (decrease in muscle mass due to extended immobility). An MDS (Minimum Data Set - an assessment tool), dated 1/27/21, indicated Resident 10 had a BIMS (Brief Interview for Mental Status; an assessment tool) score of 99 (unable to assess mental status). On 5/3/21 at 1:07 P.M., an observation of Resident 10 was conducted. Resident 10 was in bed, lying on his left side, and the head of the bed was elevated. A review of Resident 10's medical record was conducted on 5/3/21. A physician order, dated 11/5/20, indicated to Cleanse with NS (normal saline) & pat dry to SC (sacro-coccygeal; tail-bone area) stage 4 apply Santyl (a medication to treat wounds) & cover with Island (a type of dressing) drsg (dressing) daily & as needed. On 5/5/21 at 10:06 A.M., an observation of Resident 10, and an interview with certified nursing assistant (CNA) 21 was conducted. Resident 10 was turned on to his left side. CNA 21 stated…

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

Based on interview and record review, the facility failed to implement an Antibiotic Stewardship Program. This failure had the potential to increase the risk of residents developing antibiotic-resistant organisms from unnecessary or inappropriate antibiotic use. Findings: A concurrent record review (of facility residents currently taking antibiotics) and an interview was conducted on 5/5/21 at 10:52 A.M., with the Infection Practitioner (IP). The IP stated the antibiotics were prescribed by physicians based on symptoms; waiting for labs or cultures was uncommon. The IP stated, We try to discuss it with the MD (medical doctor) but they don't like being told what to do. We are not using the McGeer's criteria (a tool to review antibiotic use), but would like to implement it soon. An interview with the Director of Nursing (DON) was conducted on 5/5/21 at 3:28 P.M. The DON stated, It is sometimes difficult to approach physicians about their orders; they need to be more aware of the process and lab (laboratory) results need to be used as a criteria, not just one symptom. The Medical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement a physician's order related to: a. medication administration, and b. monitoring for side effects of a medication for one of one sampled residents (2). This failure had the potential to affect the resident's physical and emotional needs and care. Findings: Resident 2 was admitted to the facility on [DATE], with diagnoses, which included insomnia (inability to sleep) and anxiety (excessive worrying), per the physician's progress note, dated 4/29/19. a. A review of Resident 2's medical record was conducted on 5/5/21 at 11:45 A.M. A physician's order, with no date, indicated, d/c (discontinue) temazepam (medication to treat insomnia); start lorazepam (medication to treat anxiety and insomnia) 1 mg q (every) hs (bedtime) for insomnia. A concurrent record review and interview was conducted on 5/5/21 at 11:47 A.M. with the Director of Clinical Services (DCS). The DCS stated that the physician's order had no date, and had not been implemented. 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 provide podiatry services for one of one residents (25) reviewed for Activities of Daily Living (ADL). This failure had the potential to cause pain and possible infection if the overgrown toenails damaged the resident's skin. Findings: Resident 25 was admitted to the facility on [DATE], with diagnoses which included acute kidney failure (the kidneys did not function), per the facility's Record of Admission. A review of the MDS (Minimum Data Set - an assessment tool) was conducted on 5/4/21. Resident 25 had a BIMS (Brief Interview for Mental Status) Score of 7 which indicated, severe intellectual impairment, and required extensive assistance with ADL. On 5/5/21 at 8:26 A.M., an observation and interview was conducted with Resident 25. Resident 25 had long curling toenails on both feet. The last toenail of the right foot was approximately one and a half inches long. Resident 25's toenails on both feet were curling over the ends of his toes,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not provide restorative nurse's aide (RNA) services as ordered for one of one resident (10) reviewed for RNA services. This failure had the potential for Resident 10's contractures to worsen. Findings: Resident 10 was re-admitted to the facility on [DATE], with diagnoses to include muscle wasting and atrophy (decrease in muscle mass due to extended immobility). An MDS (Minimum Data Set - an assessment tool), dated 1/27/21, indicated Resident 10 had a BIMS (Brief Interview for Mental Status - an assessment tool) score of 99 (99 indicates unable to assess mental status). On 5/3/21 at 1:07 P.M., an observation of Resident 10 was conducted. Resident 10 was in bed, lying on his left side, and head of the bed was elevated. Resident 10 was fully covered by a thick blanket, with only his head exposed. On 5/4/21 at 8:58 A.M., an observation of Resident 10 was conducted. Resident 10 was lying on his left side and his eyes closed. His contractures were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Resident 4 was admitted to the facility on [DATE], with diagnoses which included chronic obstructive pulmonary disease (COPD- lung disease, too much oxygen [O2] could cause oxygen buildup, due to high carbon dioxide content in the blood that leads to drowsiness and possible death), per the facility's Record of Admission. A review of Resident 4's history and physical (H&P), dated 3/4/21, indicated Resident 4 had the capacity to understand and make decisions. On 5/3/21 at 2:41 P.M., an observation and interview of Resident 4 was conducted. Resident 4 was in bed, using oxygen (O2) via a concentrator (a device that concentrates the oxygen), running at 4 liters per minute (LPM) via nasal cannula (NC - tubing to deliver oxygen). Resident 4 stated she needed the oxygen when she was in bed, and but did not need it when she was up in the wheelchair. An additional observation of Resident 4 was conducted 5/3/21 at 6 P.M., 5/4/21 at 8:52 A.M., 11:45 A.M., 3:37 P.M., and 5/5/21 at 8:35 A.M., 1:50 P.M., and at 2:31 P.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 obtain a physician's order for one of three residents (25) reviewed for catheter care. This failure had the potential to result in a lack of treatment and services for a resident with an indwelling catheter. Findings: Resident 25 was admitted to the facility on [DATE], with diagnoses which included chronic kidney disease (as the kidneys fail, waste and excess fluid from the blood builds up in the body), per the facility's Record of Admission. A review of the Minimum Data Set (MDS - an assessment tool) was conducted on 5/4/21. Resident 25 had a BIMS (Brief Interview for Mental Status) Score of 7, which indicated, severe intellectual impairment. On 5/3/21 at 2:31 P.M., an observation was conducted. Resident 25 was lying on the bed. Catheter tubing was visible under Resident 25's left leg. The catheter tubing was attached to a covered catheter bag that hung from the lower part of the bedframe. On 5/4/21 at 9:45 A.M., a record review and…

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

Based on observation, interview, and record review, the facility failed to ensure the medication error rate was less than five percent. Fifteen medication errors out of 29 opportunities were identified during medication (med) administration, when nursing: 1. Administered seven crushed medications all at once (instead of individually) via the PEG (Percutaneous endoscopic gastrostomy tube - a tube placed directly into the stomach for the administration of food, fluids, and medications) tube to Resident 37, 2. Administered four crushed medications all at once (instead of individually) via PEG tube to Resident 18, and 3. Omitted four oral medications for Resident 304. This failure resulted in a medication error rate of 51.72% Findings: 1. On 5/5/21 at 10:11 A.M., a med pass observation for Resident 37 was conducted with licensed nurse (LN) 2. LN 2 took Resident 37's med blister packs of: -Vitamin C 500 milligram (mg) tablet (tab) one tab, - Levothyroxine [med to treat hypothyroidism] (condition where the thyroid gland does not produce enough thyroid hormone) 150 microgram (mcg) tab one…

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 (med/s) were administered correctly when: 1. Licensed nurse (LN) 2 crushed seven medications and administered all at once (instead of individually), via PEG tube (Percutaneous endoscopic gastrostomy tube - a tube placed directly into the stomach for the administration of food, fluids, and medications) to Resident 37; 2. LN 2 crushed four medications and administered all at once (instead of individually), via PEG tube to Resident 18. 3. LNs checked the medication label and expiration date of Resident 304's medications. These failures could cause harm to the residents due to unsafe administration of the medications. Findings: 1. Resident 37 was readmitted to the facility on [DATE], with diagnoses which included diabetes (high blood sugar) and with PEG tube, per the facility's Record of Admission. On 5/5/21 at 10:11 A.M., an observation of medication administration for Resident 37 was conducted with licensed nurse (LN) 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 ensure: 1. Medications (med) were labeled with an expiration date for one resident (304), and an opened bottle of normal saline was dated and labeled for one of three medication carts; 2. Expired bottles of iron supplements were co-mingled with current medications readily available for use; 3. Expired biologicals (glucose test solutions, glucose test strips, iodine swab sticks, nasal swabs, and laboratory [lab] tubes) were co-mingled with treatment supplies in two of three medication carts; and 4. The temperature was monitored for one of two medication storage rooms. These failures had the potential for residents to receive expired medications, and affect the efficacy of medications and effectiveness of treatment. Findings: 1a. Resident 304 was admitted to the facility on [DATE], with diagnoses which included Parkinson's Disease (a brain disorder that leads to shaking, stiffness and difficulty with walking, balance and coordination),…

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 an alternative weekly meal menu for four of four residents (23, 50, 9, & 47) reviewed for food preferences. This failure had the potential for residents to suffer from a lack of daily nutritional requirements because the food was not appealing and there were no alternate choices. Findings: 1. Resident 23 was admitted to the facility on [DATE], with diagnoses which included polyneuropathy (a degeneration of the peripheral nerves of the body), per the facility's Record of Admission. A review of the MDS (Minimum Data Set - an assessment tool) was conducted on 5/4/21. Resident 23 had a BIMS (Brief Interview for Mental Status) Score of 8 (mildly impaired), and required supervision with meals (encouragement and oversight). On 5/3/21 at 5:39 P.M., an observation and interview was conducted. Resident 23 sat up in bed with a tray table over her legs. Resident 23 ate two tacos from a disposable polystyrene food container. Resident 23 stated…

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

Based on interview and record review, the facility failed to ensure the Quality Assessment and Assurance (QAA- checks on standards and quality of care) Committee had the Medical Director or designee in attendance during the Quality Assurance and Performance Improvement (QAPI) meetings. The lack of participation of the medical director or designee in QAPI meetings had the potential risk to not identify care issues/services that could affect the quality of life of the residents. Findings: During an interview with the Director of Operations (DO), the Director of Clinical Services (DCS), the Administrator (ADM), and the Director of Nursing (DON) on 5/6/21 at 2:47 P.M., the DCS discussed concerns with the facility's process of the QAPI meeting. The DON stated she attended a QAA meeting on 3/6/21. The DON stated she was not aware if the Medical Director was notified. The DON acknowledged the Medical Director or designee was not present. The DO stated he found the QAA committee meeting documents in 2019 and some in 2020. The DO stated a QAA meeting was last held on 3/6/21. The DO…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the RD provided adequate oversight related to residents' (3, 83, 238) nutritional assessments reviewed for nutritional services, dietetic service operations, and staff performance in accordance with the facility contract. As a result, 1. Resident 83 was a tube feeder and weekly weights were not reviewed by the RD prior to being discontinued. 2. Following the recipe menu and updating the puree recipe. 3. Maintain sanitary kitchen equipment, storage of food, and dietary staff menu compliance. 4. Resident 238 was not accurately assessed for nutritional needs to heal his pressure ulcer. 5. Resident 3 had not been evaluated by a RD after weight loss, and abnormal lab values. These failures to ensure effective oversight of day to day dietetic service operations and nutrition services for the residents had the potential to put the residents at risk of their nutritional needs and further compromised the residents medical condition.…

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 a home like environment when resident's rooms, a hallway and the shower room were not well maintained. This failure had the potential to affect resident's comfort and quality of life. Findings: On 9/23/19 at 7:53 A.M., an observation was conducted in Resident 58's room. The wallpaper was peeling and cracked. On 9/23/19 at 8:06 A.M., an observation was conducted in Resident 19's bathroom. The wall behind the sink had a crack running along the back of the sink and the light fixture was missing a light bulb. On 9/23/19 at 8:19 A.M., an observation and interview was conducted in Resident 54's room. Resident 54 pointed to the wall behind her bed, a sheet of wallpaper had fallen off and laid behind her bed, she stated it was no good and mal (Spanish for bad) and it did not feel like home. On 9/23/19 at 8:40 A.M., an observation was conducted in Resident 3's room. The vinyl flooring under the middle bed had lifted up and was folded over under the foot of the bed. On 9/23/19 at 9:42 A.M., an observation 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, record and document review, the facility did not ensure oxygenation protocols were obtained and implemented for three of 19 sampled residents (16, 67, 238). In addition, there were no care plans developed for the interventions and monitoring of Resident 16's oxygen therapy. These failures had the potential for shortness of breath, and infection from dirty oxygen equipment. In addition, these failures subjected residents to ill-fitting nasal cannulas (NC). Findings: 1. On 9/24/19 at 9:14 AM, an observation and interview was conducted with LN 26. Resident 16 was lying in bed on his back, mouth opened, eyes closed and the NC was tight against Resident 16's cheekbones. LN 26 readjusted the resident's NC and indentations were observed on his right and left cheekbones and behind both earlobes. The oxygen tubing did not have a date to indicate when it was most recently placed. LN 26 stated the facility expected Nursing to label a date on the humidified water and tubing and to change…

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 recipe for the pureed chicken was followed for 22 residents (11, 15, 16, 17, 19, 24, 27, 28, 30, 31, 34, 40, 45, 51, 59, 66, 68, 74, 77, 78, 79, 238). In addition, the recipe had not been updated. These failures had the potential for the residents to not receive adequate consistency of food and nutritional values which could further compromise their health status. Findings: On 9/24/19 at 11:32 A.M., an observation was conducted with the DSS and [NAME] during preparation of the chicken puree diet for lunch. The [NAME] poured the cooked chicken into the big blender along with the chicken soup base, and blended. After blending, the [NAME] poured the puree chicken in a clear rectangular container, took the big measuring cup that contained 3/4 full of thickener powder, and poured the thickener powder into the pureed chicken, and mixed them with the big spoon. The [NAME] put back the remaining thickener on the table, approximately half of the thickener was left in the measuring cup. On 9/24/19 at 11:38…

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

Based on observation, interview, and record review, the facility failed to maintain sanitary kitchen equipment to prevent foodborne illnesses. This failure had the potential to put residents at risk for widespread foodborne illness. Findings: On 9/23/19 at 8:06 A.M., an initial tour of the kitchen was conducted with the DSS. 1. On 9/23/19 at 8:12 A.M., an inspection of the kitchen equipment was conducted. The microwave had a hard, thick, dark brown, and orange colored substance throughout the inside. On 9/23/19 at 8:12 A.M., a concurrent, observation, and interview was conducted with the DSS. The DSS stated the microwave should be cleaned every shift and as needed by the staff. The DSS acknowledged the microwave was dirty. A review of the facility's policy and procedure (P&P) titled Cleaning Procedures, dated 2/28/19, indicated, .all cleaning equipment and supplies should be cleaned and stored in the same sanitary manner as food equipment and utensils are cleaned as recommended 2. On 9/23/19 at 8:16 A.M., an inspection of the food storage inside the freezer number three 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.

2. On 9/24/19 at 9:14 AM, an observation and interview was conducted with LN 26. Resident 16 was lying in bed on his back, mouth opened, eyes closed NC was tight against Resident 16's cheekbones. LN 26 readjusted the Resident's NC and indentations were observed on his right and left cheekbones and behind both earlobes. On 9/25/19 at 11:25 AM, an observation of Resident 16 was conducted with Resident the Minimum Data Set Coordinator (MDS-RN who attests to the assessment of residents on an initial, quarterly, change of condition, and annual basis) Res. 16 was lying in bed, eyes closed, nasal cannula was placed in nares and held in place behind both ears. The nasal cannula had left visible lines of indentations around the cheekbones. MDS stated he had not received any report from Nursing about the Resident's nasal cannula indentations and therefore, did not do a change of condition assessment. On 9/26/19 at 10:20 AM, an interview was conducted with the RD. The RD stated the DSS conducts residents initial and quarterly nutrition assessments and faxes those assessments to the RD for…

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

Based on observation, interview, and record review, the facility failed to maintain sanitary practices to prevent cross contamination and infections. As a result, oral hygiene items and grooming items were unlabeled and left on top of the sink in a shared restroom. In addition, the facility did not follow their hand hygiene policy. Findings: 1. On 9/23/19 at 9:31 A.M., an inspection of the shared restroom was conducted. A used blue colored handle toothbrush with thin, curled bristles, a bottle of shaving cream, and small tube of toothpaste were placed on top of the hand washing sink. The oral hygiene and grooming items were all unlabeled. There were two residents who lived in the shared bedroom. On 9/23/19 at 9:42 A.M., a concurrent observation and interview was conducted with LN 5. LN 5 stated the unlabeled toothbrush, toothpaste, and shaving cream belonged to the resident in bed A. LN 5 acknowledged all oral hygiene and grooming items should have been labeled and kept inside the resident's drawer due to a potential for cross contamination. On 9/23/19 at 9:59 A.M., a concurrent…

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 ensure two of two residents reviewed for dignity (32, 48) were treated with respect and dignity when: 1. Staff did not cover urinary catheter collection bags (bag that collects urine draining from a tube inserted into the bladder) for Residents 32 and 48, and; 2. Staff did not provide Resident 48 with accessibility for the use of a call light, good oral hygiene, and activity participation with other residents. These failures had the potential to affect the emotional and psychosocial well-being of Resident 32 and Resident 48. Findings: 1a. Resident 32 was re-admitted to the facility on [DATE], with diagnoses which included urinary retention (difficulty urinating or completely emptying the bladder) and a suprapubic catheter (a tube to drain urine is inserted directly into the bladder), per the facility's Admitting Information. On 9/25/19 at 8:08 A.M., an observation was conducted of Resident 32. Resident 32's catheter collection bag 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 provide adaptive equipment to accommodate a resident's needs for one of three residents (19) sampled for nutrition. This failure inhibited Resident 19's ability to feed himself during meals and had the potential to affect his quality of life and dignity. Findings: Resident 19 was admitted to the facility on [DATE], with diagnoses which included muscle wasting (loss of muscle caused by disease or lack of use) and lack of coordination, per the facility's Record of Admission. Per the physician's order, dated 9/11/19, Resident 19 was to have a plate guard (a raised edge, attached to a plate, to prevent food from being pushed off a plate) during meals. On 9/23/19 at 12:45 P.M., an observation of Resident 19 was conducted. Resident 19 was being fed by a family member. There was no plate guard on his plate. On 9/24/19 at 8:20 A.M., an observation of Resident 19 and an interview with LN 37 was conducted. There was no plate guard on Resident 19's…

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 privacy for the use of a telephone without being overheard for one unsampled resident (50). This deficient practice violated the resident's right to privacy. Findings: Resident 50 was admitted to the facility with diagnoses that included dementia (memory problem) without behavior, per the facility's Record of Admission. On 9/25/19 at 9:10 A.M., an observation was conducted. The telephone in station 1 was heard ringing. Resident 50 was seated in the wheelchair being wheeled towards station 1 by CNA 2. CNA 2 picked up the telephone, handed it to Resident 50, and stood next to Resident 50. Another resident (18) was seated in a wheelchair next to Resident 50. Resident 50 started talking loud in a foreign language. The station 1 was busy with visitors, and residents passing by the hallway. Resident 50's telephone conversation ended at 9:16 A.M. and Resident 50 was wheeled back to her room by CNA 2. On 9/25/19 at 9:53 A.M., an interview was conducted with CNA 2. CNA 2 stated there were no phones inside 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 the form Skilled Nursing Facility Advanced Beneficiary Notice (ABN/CMS 1055-a form which gave the choice to continue services under private pay if Medicare did not provide payment), with the appeal contact information, to two of three residents (A, B) sampled for Beneficiary Protection Notification. As a result, Resident A and B did not have the information needed to appeal the decision, or to make an informed decision about their care. Findings: 1. Resident A was admitted to the facility on [DATE], for skilled services under Medicare part A, and designated a family member as the responsible party (RP), per the facility's Record of Admission. On 5/6/19, Resident A's RP signed the form CMS-R-131 Advanced Beneficiary Notice of Noncoverage (ABN). Under section D (treatment or service Medicare may not pay for) was written D/C Rehab, under section E. Reason Medicare May Not Pay was written Pt. and family request to go home and section F. Estimated…

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 a comprehensive assessment for the need of specialized rehabilitative services for one resident (76) reviewed for limited ROM (movement around the joint) exercise. This failure had the potential to cause loss of muscle strength and joint deformity for Residents 76. Findings: Resident 76 was re-admitted to the facility on [DATE] per the facility's admission Face Sheet. The Physical Therapy (PT) service notes dated, 9/27/18- 12/25/18, indicated Resident 76 was a S/P (status post) reduction of right distal femur (surgery to stabilize and heal a broken bone). On 9/23/19 at 9:52 A.M., Resident 76 was in bed in an upright position, awake, and spoke in a foreign language. On 9/24/19 at 11:12 A.M., a record review was conducted. The MDS quarterly assessment, dated 8/18/19, indicated Resident 76 required one person extensive physical assistance with mobility, and was totally dependent on staff for transfers. The PT service notes, dated…

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

Based on observation, interview, record and document review, the facility failed to consistently provide the correct measurement of nectar thickened liquids (supplement added to liquids which alters consistency of the liquid to aide with swallow difficulty) to seven residents (16, 18, 30, 38, 45, 51, 68). CNA and RNA staff provided residents nectar thickened liquids which was not in accordance with facilty policy. In addition, staff were unaware of contraindications when providing residents straws to consume their thickened liquids.The lack of providing residents with the correct measurement and delivery of nectar thickened liquids, posed a risk for ineffective swallowing precautions. Findings: On 9/23/19 at 11:24 A.M., an observation of CNA 25 was conducted. CNA 25 entered Resident 30's room and dropped off a cup which contained thickener at the bottom of the cup, onto the Resident's bedside table. In addition, CNA 25 threw a partially full cup of thickened liquid and a straw, into the trashcan. On 9/23/19 at 11:30 A.M., CNA 25 stated resident's who received thickened liquids can…

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 an effective means of communication for two residents (27, 79) reviewed for communication. As a result, Resident 27 was not provided with a communication board (board with pictures depicting ADLs, pain, hunger, etc) to communicate his needs. For Resident 79, translation services were not provided to the resident. This failure had the potential to not meet their needs and could affect the residents' psychosocial well-being and quality of life. Findings: 1. Resident 27 was admitted to the facility on [DATE], with diagnoses that included Alzheimer's disease (impaired memory) per the Record of Admission. During an initial tour of the facility on 9/23/19 at 3:25 P.M., Resident 27 was lying in bed and his eyes were closed. On 9/24/19 at 9:11 A.M., an observation was conducted in the activity room for Resident 27. The activity room was filled with residents. A group of female guests were singing and playing a violin while residents were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of four residents reviewed for pressure ulcers (238) was accurately assessed for nutritional needs. This failure placed Resident 238 at risk of not receiving adequate and appropriate nutrition to heal his pressure ulcer. Findings: Resident 238 was re-admitted to the facility on [DATE], with diagnoses which included dementia (a decline in thinking, problem solving, and memory skills), per the facility's Admitting Information. The clinical record of Resident 238 was reviewed. The Nursing admission Assessment performed on 9/10/19, indicated Resident 238 had a 1.5 cm by 0.5 cm wound on the coccyx (tailbone area). The Resident Care Plan, dated 9/10/19, indicated Resident 238 had a stage 2 pressure ulcer upon admission, with interventions that included Encourage/provide adequate nutrition/hydration. The Initial Nutrition Evaluation, dated 9/11/19, signed by the DSS, indicated Resident 238 had no pressure ulcers. The Nutritional Assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to label the enteral feeding formula (EFF-a nutritionally complete solution fed directly into the stomach) bag via tube feeding and water flush bag with frequency and volume to be infused according to the physician's order for one resident (83) reviewed for tube feeding. This failure had the potential to cause a resident to receive the wrong EFF. Findings: Resident 83 was re-admitted to the facility on [DATE], with diagnoses that included dementia (impaired memory) without behaviors, per the Record of Admission. During an initial tour and observation on 9/23/19 at 10:50 A.M. and 9/24/19 at 8:05 A.M., Resident 83 was lying in bed and his eyes were closed. The enteral feeding pump machine was turned off and a bag of 1.5 liter Glytrol, dated 9/23/19 at 12:30 A.M. and a bag of water flush dated 9/23/19 at 12:30 A.M. were both hung on the enteral feeding pump machine. There was no instructions documented on the label of the enteral feeding…

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 and interview, the facility failed to provide a sack meal for one unsampled resident (7) who received dialysis. This failure had the potential to affect the health of Resident 7 and reduce his quality of life. Findings: Resident 7 was admitted to the facility on [DATE], per the facility's Record of Admission. On 9/25/19 at 2:53 P.M., an observation and interview was conducted with LN 2. Resident 7 stated he went to dialysis in the morning, had breakfast before he left, and was sent to dialysis without food. Resident 7 stated he had only had juice and milk at the dialysis center. Resident 7 stated he was upset and hungry, because he had not been given food. Resident 7 stated the facility had never given him food to take to dialysis. LN 2 stated the facility had not allowed Resident 7 to take food to dialysis, because the food would have become contaminated. On 9/25/19 at 3:17 P.M., an interview was conducted with the DSS. The DSS stated residents would have been given a sack meal when they…

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 ensure physicians orders were recapitulation (reviewing the new MAR against the physicians orders to ensure accuracy before the start of the next month) accurately for one of one residents (67) reviewed for recapitulation of orders. This failure potentially caused confusion among staff as to whether Resident 67 needed continuous supplemental oxygen or supplemental oxygen as needed. Findings: Resident 67 was re-admitted to the facility on [DATE] with diagnoses which included pneumonia (infection of the lungs), per the facility's Record of Admission. The clinical record for Resident 67 was reviewed. Physician's Orders on admission indicated an order was written on 7/25/19 to .give O2 2 LPM PRN if O2 sat <92%. Physician's Orders recapitulated on 9/1/19 indicated the oxygen order was Oxygen at 2 liters per minute via NC (nasal cannula) continuously / SOB (shortness of breath). On 9/24/19 at 2:14 P.M., an interview was conducted with LN 3. LN 3 acknowledged…

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.