Aviara Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to manage the care related to intravenous (IV- delivery of fluids, medications, or nutrients into the body's bloodstream, usually through a needle or catheter inserted into a vein) therapy for three sampled residents (90, 124, 4) when:1. A peripherally inserted central catheter (PICC - a long, thin, flexible tube inserted into a vein in the arm and threaded into a large vein near the heart) line dressing was not assessed and changed per the facility's policy for Resident 90 and 124.2. The IV fluid intake was not documented per the facility's policy for Resident 4. This failure had the potential for medical complications related to the residents' IV therapy.1. Per the facility's admission Record, Resident 124 was admitted to the facility on [DATE] with diagnoses that included osteomyelitis (bone infection) of the vertebra (one of the individual bones that stack up to form the backbone).On 9/16/25 at 3:00 P.M., a concurrent interview and record review 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 the controlled drug records (CDR, records that are kept for drugs with high abuse potential) reconciled with the electronic medication administration record (EMAR) for four sampled residents (Resident 62, 92, 88, and 142). In addition, a controlled medication prescribed to Resident 62 could not be accounted for when it was wasted without a second nurse signature.This failure had the potential for the residents' (Resident 62, 92, 88, and 142) controlled drugs to be diverted (when a medication is taken for use by someone other than whom it is prescribed). Findings:1. A review of Resident 62's admission Record indicated the resident was admitted to the facility on [DATE] with a diagnosis of displaced comminuted fracture of shaft of right femur (break in the bone of the right leg). A review of Resident 62's physician orders indicated an order for oxycodone (a controlled pain medication) 5 milligram (mg) oral capsule on 8/6/25 for moderate to severe…

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 provider responded to the interim medication regimen review recommendations by the pharmacist for one (Resident 67) of 24 sampled residents. This failure resulted in unnecessary medications and inappropriately monitored medications for the Resident 67.A review of Resident 67's admission record initiated on 9/16/25, indicated resident was admitted on [DATE] for rehabilitation therapy, physical and occupational therapy with medical history including bipolar disorder (a chronic mental health condition characterized by extreme mood swings between mania (high energy and euphoria) and depression (low mood and lethargy), depression (a common and serious mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest in activities that were once pleasurable) & dementia (a general term for a group of brain disorders that cause a progressive decline in cognitive abilities, including: Memory, Thinking,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the medication error rate was less than five percent. The facility's medication error rate was 15.5 percent. Five (5) medication errors were observed, a total of 33 opportunities, during the medication administration process for three (3) of eleven randomly observed residents (Resident 113, 10, and 140). As a result, the facility could not ensure medications were correctly administered to all residents.Findings:1. A review of Resident 113's admission Record indicated the resident was admitted to the facility on [DATE] with a diagnosis of cerebral infarction (a condition where blood flow to the brain is interrupted, causing brain tissue to die).On 9/15/25 at 9:05 A.M., an observation of Resident 113's medication administration was conducted with LN 36. LN 36 prepared Resident 113's medication at the medication cart. LN 36 placed aspirin 81 mg (milligrams) 1 oral tablet that was enteric coated into a clear medication cup. LN 36…

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 stored according to acceptable standards of practice in four of eleven sampled medication carts when:1. A crash cart (a cart filled with supplies and medication used during a health emergency) did not contain sterile water, ky jelly, and alcohol swabs.2. A treatment cart contained an expired bottle of Derma Pak -its iodoform packing strip (medicated pieces of cloth used to pack inside of wounds to promote healing) and Clotrimazole cream (a medicated cream used to treat fungal infections of the skin) for Resident 57 without an active order.3. A medication cart contained Assure Dose glucometer drops with an open date of [DATE].This failure had the potential for medication to have reduced effectiveness and/or medication misuse. Findings:1. A review of the facility's document, undated, titled Crash Cart Checklist, indicated items that should have been included in the facility's crash cart, .Alcohol wipes, Sterile Water,…

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 pneumococcal vaccine was offered to one of five residents (Resident 124).This failure had the potential to put Resident 124 at greater risk in developing pneumococcal due to their comorbidities.Findings:A review of Resident 124's admission Record, Resident 124 was admitted on [DATE] with a diagnosis of Orthopedic aftercare following surgical amputation (cutting off a limb), other comorbidities include diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing).On 9/18/25 at 10:24 A.M., an interview and record review was conducted with the Infection Preventionist Nurse (IP). The IP stated when a new resident was admitted a review of vaccinations through the CAIRS (California vaccine registry) was done to see if the resident needed Pneumococcal vaccination. The IP stated if the resident needed a Pneumococcal vaccination, the physician would be contacted to get orders. The IP reviewed Resident 124'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure Covid-19 immunization was offered to one of five residents (Resident 124).This failure had the potential to put Resident 124 at greater risk in developing Covid-19 due to their comorbidities.Findings:A review of Resident 124's admission Record, Resident 124 was admitted on [DATE] with a diagnosis of Orthopedic aftercare following surgical amputation (cutting off a limb), other comorbidities include diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing).On 9/18/25 at 10:24 A.M., an interview and record review was conducted with the Infection Preventionist Nurse (IP). The IP stated when a new resident was admitted a review of vaccinations through the CAIRS (California vaccine registry) was done to see if the resident needed Covid-19 vaccination. The IP stated if the resident needed a Covid-19 vaccination, the physician would be contacted to get orders. The IP reviewed Resident 124's vaccination…

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, interview, and record review the facility failed to ensure infection control procedures were followed when: A. Staff did not tie plastic trash bags while transporting to the utility room, did not cover the trash bins, and trash bins were overflowing causing a foul smell in the utility room, B. a Licensed Nurse (LN) 2 did not wear a gown for Resident 6 with enhanced barrier precautions (EBP - involves gown and glove use during high-contact resident care activities for residents [example: residents with chronic wounds]) during a wound treatment observation, and, C. Newly admitted residents were not tested for tuberculosis (TB, infectious lung disease) testing upon admission. These failures had the potential for cross contamination and spread of infection between residents and staff. Findings: A. On 5/28/25 at 11:20 A.M., an observation was conducted in the utility room near nurses' station 1. A certified nursing assistant (CNA) went to the utility room with untied clear plastic bag…

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 develop and implement a comprehensive care plan related to behaviors for one of three sampled residents (Resident 1). As a result, Resident 1's needs, goals and interventions were not addressed or communicated to staff members for continuity of care. Findings: Resident 1 was admitted to the facility on [DATE], per the admission Record. An interview was conducted on 5/21/25 at 3 P.M. with Resident 1. Resident 1 reported multiple staff problems, including a Licensed Nurse (LN 1) who made a medication error, and a Dietary Services Manager (DSS), who failed to provide her food preferences. Resident 1 stated she had reported the incident with LN 1 to a charge nurse, and requested LN 1 not be assigned to her. Resident 1 stated she preferred to work with the Registered Dietitian (RD) instead of the DSS. A record review was conducted. Resident 1's Brief Interview for Mental Status (BIMS), dated 3/14/25, indicated intact cognition. A concurrent interview and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and facility documents review, the facility failed to take the resident (Resident 1) back after Resident 1 signed out for an out on pass (OOP, leave of absence) with a physician ' s order, for one of three sampled residents reviewed for residents discharged against medical advice (AMA, when a patient checks himself out against the advice of his doctor). As a result, Resident 1 was discharged against medical advice on 2/8/25. This failure was an unsafe discharge and had the potential to compromise Resident 1 ' s health, safety and well-being. Cross Reference F 655 and F 689. Findings: On 2/10/25 and 2/12/25, the Department received complaints related to admission, transfer and discharge rights. On 2/18/25, an unannounced onsite to the facility was conducted. Resident 1 was admitted to the facility on [DATE], with diagnoses which included paraplegia (loss of movement and/or sensation, to some degree, of the legs), osteomyelitis (inflammation of bone or bone marrow, usually due to infection) 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 interviews and record reviews, the facility failed to develop a baseline care plan (detailed plan with information about a resident's treatment, goal, and interventions) for one of three sampled residents related to a resident ' s (Resident 1) multiple episodes of leaving the facility and non-compliance to the ordered duration of hours while out on pass (OOP, therapeutic leave of absence). This failure had the potential for Resident 1 to not be educated on the risk and benefits of leaving the facility, and his non-compliance with the ordered duration of hours while OOP was not addressed. Cross Reference F 622 and F 689. Findings: On 2/10/25 and 2/12/25, the Department received complaints related to admission, transfer and discharge rights. On 2/18/25, an unannounced onsite to the facility was conducted. Resident 1 was admitted to the facility on [DATE], with diagnoses which included paraplegia (loss of movement and/or sensation, to some degree, of the legs), osteomyelitis (inflammation of bone or bone…

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 interviews and record reviews, the facility failed to implement their policy related to signing residents out (out on pass- OOP, leave of absence) for one of three sampled residents (Resident 1) when staff did not consistently obtain a physician ' s order for an out on pass, assessed, and documented in his clinical record the time Resident 1 returned from out on pass and, consistently signed the OOP form. This failure had the potential to compromise Resident 1 ' s health, safety and well- being. Cross Reference F 622 and F 655. Findings: On 2/10/25 and 2/12/25, the Department received complaints related to admission, transfer and discharge rights. On 2/18/25, an unannounced onsite to the facility was conducted. Resident 1 was admitted to the facility on [DATE], with diagnoses which included paraplegia (loss of movement and/or sensation, to some degree, of the legs), osteomyelitis (inflammation of bone or bone marrow, usually due to infection) and pressure ulcer (bed sores), per the facility's admission…

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 two of four licensed nurses (LN 1 and LN 4) who administered medications to residents were verified as competent (a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully) to perform medication administration/medication management. This deficient practice had the potential for medications to be administered to Resident 1 and other residents in an unsafe manner. Findings: A review of Resident 1 ' s admission Record indicated he was admitted on [DATE] with the diagnosis of low back pain. On 1/10/25 at 1:35 P.M., an interview was conducted with LN 3. LN 3 stated all LNs should be evaluated for competency to administer medications in a safe manner to residents. LN 3 stated, It ' s not like we ' re passing out candy. A review of Resident 1 ' s physician order dated 10/18/24 and medication administration record (MAR) dated 1/10/25,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) received his routine pain medication as ordered. This failure had the potential for Resident 1 to experience pain. Findings: A review of Resident 1 ' s admission Record indicated he was admitted on [DATE] with the diagnosis of low back pain. On 1/10/24 at 1:26 P.M., an interview was conducted with Resident 1 ' s family member (FM) 1. FM 1 stated there was difficulty receiving Resident 1 ' s scheduled pain medication on time. FM 1 stated Resident 1 would often text her to let her know he had not received his scheduled pain medication. FM 1 stated she would have to come to the facility to make sure Resident 1 received his pain medication. A review of Resident 1 ' s physician order dated 10/18/24 and medication administration record (MAR) dated 1/10/25, indicated the resident was to receive Norco (hydrocodone-acetaminophen) oral tablet 5-325 milligrams (a controlled pain medication [a drug…

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 develop a person-centered care plan for anticoagulant use (a medication that thins the blood, in order to prevent blood clots from forming or becoming larger) for one of three residents, (Resident 1) reviewed for comprehensive care plans. This failure had the potential for staff to provide inconsistent care, and to put Resident 1 at a higher risk of bleeding. Findings: Resident 1 was admitted to the facility on [DATE], with diagnoses which included encephalopathy (a disease that affects brain function), per the facility ' s admission Record. Resident 1 ' s clinical record was reviewed on 12/23/24: According to the physician orders, dated 12/11/24, administer enoxaparin (a medication used to prevent blood clots from forming in the blood vessels of the legs), injection, 40 milligrams/0.4 milliliters once a day for deep vein thrombosis (blood clots in the legs) prevention. According to the nurses note, dated 12/12/24 at 9:41 A.M., Resident 1 was sent to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure respect and dignity was provided to a resident (Resident 1) when Certified Nursing Assistant (CNA) 1 did not render Resident 1's request of a clean bowl for her breakfast cereals and pointed at Resident 1 to have thrown cereals into bathroom toilet bowl. As a result, Resident 1 felt disrespected and was upset with the incident. In addition, this failure had the potential for Resident 1 to feel low self-esteem. Cross Reference to F 812. Findings: On 12/17/24, the Department received a complaint related to residents' rights. On 12/17/24, an unannounced visit to the facility was conducted. A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE]. A review of Resident 1's minimum data set (MDS - a federally mandated resident assessment tool), dated 11/4/24, Resident 1 had a Brief Interview for Mental Status (BIMS, ability to recall) score of 15/15, (a score of 13 to 15 suggests the patient is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure safe and sanitary measures were met while preparing and distributing food for a resident (Resident 1), when Certified Nursing Assistant (CNA) 1 discarded cereals into the toilet bowl and did not flush the toilet bowl in Resident 1's bathroom. This finding had the potential to expose Resident 1 and her roommate to unsafe and unsanitary food practices that could lead to illness and infection. Cross Reference to F 550. Findings: On 12/17/24, the Department received a complaint related to residents' rights. On 12/17/24, an unannounced visit to the facility was conducted. A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included Sjogrens's syndrome (autoimmune disorder, in which the immune cells mistakenly attack and destroy healthy cells). A review of Resident 1's minimum data set (MDS - a federally mandated resident assessment tool), dated 11/4/24, Resident 1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, that facility failed to maintain required temperature range between 71 to 81 Fahrenheit (°F) with resident rooms in 44 of 68 random rooms inspected. Based on observation, interview, and record review, the facility failed to ensure resident room temperatures were kept at a comfortable and homelike level for 44 of 68 rooms inspected. This deficient practice had the potential for residents to feel uncomfortable. Findings: On 11/25/24 received a complaint related to the facility's physical environment, complaint of no heat in the facility and it was very cold. On 11/26/24 at 9:05 A.M., a concurrent observation and interview was conducted with Resident 2. Resident 2 was observed with three blankets in her bed. Resident 2 stated It was cold here in the middle of the night. Resident 2 stated she have thick blankets, padding under her bed and two blankets tow keep her warm On 11/26/2024 at an observation and interview was conducted with the Maintenance Assistant (MA).…

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 ensure a Peripherally Inserted Central Line catheter ( PICC- a long ,flexible tube inserted into a vein the arm use to deliver medications, fluid, blood directly to the heart) was kept flushed (pushing any residual medication or fluid through the intravenous line) for one of two sampled residents (Resident 1) for intravenous therapy. This failure had the potential for Resident 1 to have a clogged Picc line and an infection that would affect Resident 1 ' s health condition and or decline. Findings: The Department received a complaint related to quality of care and treatment on 10/7/24. An unannounced visit to the facility was conducted on 10/18/24. Resident 1 was admitted to the facility on [DATE] with diagnoses that included protein-calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to body changes in body composition and function) and functional quadriplegia (paralysis of all four limbs and the body from the neck…

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 initiate and implement care plans for two of two residents reviewed for care plans (Residents 1 and 2). This failure had the potential for staff to not be aware of the care needs for the residents. Findings: 1. Resident 1 was admitted to the facility on [DATE] with diagnoses to include an amputation (surgical removal), per the admission Record. On 10/2/24 at 1:38 P.M., an interview was conducted with Licensed Nurse (LN) 1. LN 1 stated she had provided wound care to Resident 1 and was familiar with her care. LN 1 stated Resident 1 was admitted for treatment of the stump so the surgical site could heal. Per LN 1, Resident 1 did not follow instructions to avoid pressure to the stump so it would heel. LN 1 stated she had gone into Resident 1 ' s room several times and had seen her resting the stump on the bed, with the wound in contact with the mattress and bedding. On 10/2/24, a record review was conducted. A Nurses progress note, dated 9/25/24 at 2:13…

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 and record review, the facility failed to ensure nursing staff provided and documented treatment of wounds for two of two residents reviewed for wound care (Residents 1 and 2). As a result, Residents 1 and 2 were at risk for worsening skin conditions. Findings: 1. Resident 1 was admitted to the facility on [DATE] with diagnoses to include an amputation (surgical removal), per the admission Record. On 10/2/24 at 1:38 P.M., an interview was conducted with Licensed Nurse (LN) 1. LN 1 stated she had provided wound care to Resident 1 and was familiar with her care. LN 1 stated Resident 1 was admitted for treatment of the stump so the surgical site could heal. Per LN 1, Resident 1 had fallen on the stump while in the facility, and had developed a small wound on the stump, below the surgical site. LN 1 stated the doctor had written new orders for staff to treat the known surgical site on the stump, as well as the new wound. Per LN 1, Resident 1 also had a rash on her buttocks due to moisture, which…

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 ' s Licensed Nurses (LNs) failed to complete a neurological examination (neuro check, evaluation of a patient ' s central nervous system that may include the use of lights, reflex hammers, and an example is checking the blood pressure) for Resident 1 after a Certified Nursing Assistant (CNA) 1 witnessed another resident (Resident 2) incurred physical assault to Resident 1. This failure resulted to incomplete monitoring of Resident 1 and the potential of Resident 1 ' s decline after he was physically assaulted. Findings: On 10/7/24, the Department received a facility reported incident (FRI) related to Resident-to-Resident Abuse. On 10/16/24, an unannounced visit to the facility was conducted. Resident 1 was admitted to the facility on [DATE], with diagnoses which included traumatic bleeding of the cerebrum after a fall, per the facility's admission Record. On 10/16/24, a review of Resident 1's history and physical (H&P) completed by the attending physician,…

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 was provided care and treatment in accordance with professional standards of practice for one of three sampled residents (Resident 1), identified as high fall risk when; 1. staff failed to implement fall preventions for Resident 1, 2. a Licensed Nurse (LN 1) failed to complete a neurological examination (neuro check, evaluation of a patient ' s central nervous system that may include the use of lights and reflex hammers) for Resident 1 after an unwitnessed fall, and failed to communicate to the incoming shift nurse about Resident 1 ' s fall, and 3. LN 1 failed to notify Resident 1 ' s responsible party (RP) of fall incident. These failures resulted to Resident 1 ' s fall, incomplete monitoring of Resident 1, and the resident ' s RP was not made aware of Resident 1 ' s fall. Findings: On 9/5/24, the Department received a complaint related to quality of care. On 9/16/24, an unannounced visit to the facility was conducted. Resident 1…

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

Based on interview, record review, and facility policy review, the facility failed to complete a new preadmission screening and resident review (PASARR) when a resident received a new mental illness diagnosis for 2 (Resident #11 and Resident #35) of 4 sampled residents reviewed for PASARR. Findings included: A facility policy titled, admission Criteria, revised 03/2019, revealed, 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. 1. An admission Record revealed the facility originally admitted Resident #35 on 02/03/2022. According to the admission Record, the resident received diagnoses of schizophrenia and anxiety disorder on 07/14/2022. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/05/2024, revealed Resident #35 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The MDS indicated the resident was not evaluated by the…

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

Based on observation, interview, record review, and facility policy review, the facility failed to develop a person-centered care plan for 2 (Resident #16 and Resident #38) of 4 sampled residents reviewed for accidents and respiratory care. Specifically, the facility failed to care plan the use of bed rails and supplemental oxygen use for Resident #16 and failed to care plan the use of bed rails for Resident #38. Findings included: A facility policy titled, Care Plans, Comprehensive Person-Centered, revised 03/2022, indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation 1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 1. An admission Record revealed the facility readmitted Resident #16 on 06/26/2024. According to the admission…

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 review, and facility policy review, the facility failed to have physician orders for the use of supplemental oxygen for 1 (Resident #16) of 3 sampled residents reviewed for respiratory care. Findings included: A facility policy titled, Oxygen Administration, revised 10/2010, specified, 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. An admission Record revealed the facility readmitted Resident #16 on 06/26/2024. According to the admission Record, the resident had a medical history that included diagnoses of Alzheimer's disease, Parkinson's disease, hypertensive heart and chronic kidney disease with heart failure, and atrial fibrillation. Resident #16's Order Summary Report, for active orders as of 07/03/2024, revealed no order for the use of supplemental oxygen. An observation on 07/01/2024 at 10:24 AM revealed Resident #16 lying in bed on their right side, with supplemental oxygen on by way of a nasal cannula set at one liter. During an interview 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, record review, and facility policy review, the facility failed to ensure an assessment was completed and informed consent and a physician order was obtained for the use of bed rails for 1 (Resident #16) of 3 sampled residents reviewed for accidents. Findings included: A facility policy titled, Bed Safety, revised 08/2022, indicated, The use of bed rails is prohibited unless the criteria for use of bed rails have been met. The policy indicated, 2. Prior to the installation or use of a side or bed rail, alternatives to the use of side or bed rails are attempted. Alternatives may include: a. roll guards; b. foam bumpers; c. lowering the bed; and/or d. use of concave mattresses to reduce rolling off the bed. 3. If attempted alternatives do not adequately meet the resident's needs the resident may be evaluated for the use of bed rails. This interdisciplinary evaluation includes: a. an evaluation of the alternatives to bed rails that were attempted and how these alternatives failed to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and facility policy review, the facility failed to ensure routine, scheduled pain medication was available in the facility for administration for 1 (Resident #73) of 2 sampled residents reviewed for pain management. Findings included: A facility policy titled, Pharmacy Services Overview, revised 04/2019, specified, The facility shall accurately and safely provide or obtain pharmaceutical services, including the provision of routine and emergency medications and biologicals, and the services of a licensed consultant pharmacist. The policy specified, 4. Residents have sufficient supply of their prescribed medications and receive medications (routine, emergency or as needed) in a timely manner. An admission Record revealed the facility admitted Resident #73 on 05/24/2023. According to the admission Record, the resident had a medical history that included diagnoses of spinal stenosis (space inside the spine is too small that can cause pressure on the spinal cord and nerves), acute…

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 review, manufacturer guideline review, and facility policy review, the facility failed to have a medication error rate less than 5%. The facility had 3 medication errors out of 30 opportunities, which yielded a medication error rate of 10% for 2 (Resident #30 and Resident #71) of 5 residents observed for medication administration. Findings included: A facility policy titled, Administering Medications, revised 04/2019 indicated, Medications are administered in a safe and timely manner, and as prescribed. Per the policy, 9. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dose, right time and right method (route) of administration before giving the medication. 1. The manufacturer guidelines titled, Instructions for Use for Admelog SoloStar insulin pen, revised 11/2019, specified, Step 3: Do a safety test. Always do a safety test before each injection to: * Check your pen and the needle to make sure they are working properly. * Make sure that you get the correct…

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 review, and facility policy review, the facility failed to follow infection control procedures for the storage of respiratory equipment for 1 (Resident #16) of 3 sampled residents reviewed for respiratory care. Findings included: An undated facility policy titled, Departmental (Respiratory Therapy) - Prevention of Infection, indicated, 8. Keep the oxygen cannula and tubing used PRN [pro re nata, which meant as needed] in a plastic bag when not in use. The policy indicated for Infection Control Considerations Related to Medication Nebulizers/Continuous Aerosol, 7. Store the circuit in plastic bag, marked with date and resident's name, between uses. An admission Record revealed the facility readmitted Resident #16 on 06/26/2024. According to the admission Record, the resident had a medical history that included diagnoses of Alzheimer's disease, Parkinson's disease, hypertensive heart and chronic kidney disease with heart failure, and atrial fibrillation. An observation on 07/01/2024 at 10:24 AM revealed Resident #16 lying in bed on their right…

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

Based on record review, interview, facility policy review, the facility failed to ensure the influenza vaccine was offered to 1 (Resident #69) of 5 sampled residents reviewed for immunizations. Findings included: A facility policy titled, Influenza Vaccine, revised 03/2022, specified, 1. Between October 1st and March 31st each year, the influenza vaccine shall be offered to residents and employees, unless the vaccine is medically contraindicated or the resident or employee has already been immunized. An admission Record revealed the facility admitted Resident #69 on 03/11/2022. According to the admission Record, the resident had a medical history that included diagnoses of hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (a stroke) affecting left non-dominant side, and dementia. A significant change in status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/24/2024, revealed that Resident #69 had a brief interview for mental status (BIMS) score of 2, which indicated the resident had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, inteview and record review, the facility failed to develop care plans for two residents (1,2) following a resident-resident altercation. This failure had the potential for increased risk of abuse for Resident 1 and Resident 2. Findings: A report of a resident-resident altercation was received in the district office on 6/13/24. An unannounced on-site visit to the facility was conducted on 6/20/24. Resident 1 was admitted to the facility on [DATE] with diagnoses that included Bi-Polar disorder (a disorder of wide mood swings) and dementia (a complex memory loss disorder) per the facility admission Record. A concurrent observation and interview of Resident 1 was conducted on 6/20/24. Resident 1 was sitting on her bed and had just finished lunch. Resident 1 was interviewed using a translation phone as Resident 1 spoke only Mandarin Chinese. According to the translator, Resident 1 stated she was ok, felt safe, doesn't remember much of the incident. A review of Resident 1's medical indicated no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the call light was answered in a timely manner for one of one Resident ' s (1). This failure had the potential for Resident 1 ' s needs to not be accommodated. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses that included muscle weakness,and difficulty in walking per the facility ' s admission Record. An observation was conducted on 5/28/24 at 12:15 pm of Resident 1. Resident 1 was reclining in bed, eating lunch. Resident 1 stated, Call lights can take 1, 2, 3 hours to be answered. An interview was conducted on 5/28/24 at 12:30 P.M. with Resident 2. Resident 2 stated, Call lights can take up to 3 hours (to be answered). A review of the facility ' s Resident Council Meeting Minutes from March 2024, April 2024 and May 2024 was conducted on 5/28/24 at 1:30 P.M. The April minutes indicated a council concern that call lights take too long. An interview was conducted on 5/28/24 at 1 P.M. with the Assistant…

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 review the facility failed to prevent cross contamination of the resident ice scoops stored at the water/ice stations for two of twnursing stations, when the ice scoops were not covered or contained from the environment. As a result, residents were at risk of ingesting contaminated ice, which had the potential of causing gastrointestinal infections. Findings: On 5/23/24, an unannounced visit was made to the facility. During initial tour on 5/23/24 at 11:23 A.M., of the Acadia unit, an ice chest with two covered pitchers of fresh water on a metal cart was observed next to the nursing station. A clear plastic bin was to the right of the ice chest, which contained a clear plastic ice scoop. The ice scoop was face up and the clear plastic bin was uncovered, exposing the ice scoop to the environment. During initial tour on 5/23/24 at 11:42 A.M., of the Oceana unit, an ice chest with three covered pitchers of fresh water on a metal cart was observed next to the nursing station. A clear plastic bin was to the right of the ice chest, which contained a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that Resident 1 received only medications prescribed for him. This failure had the potential for Resident 1 to have an adverse reaction to the incorrect medications administered. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses that included chronic congestive heart failure (the heart does not pump blood effectively); chronic respiratory failure (lungs can ' t exchange gases properly); and Marfan Syndrome (a disorder that affects connective tissue) per the facility ' s admission Record. There was no psychiatric diagnosis. No observational opportunity was available for Resident 1 as he had been discharged from the facility. On 1/25/24 at approximately 5 P.M., Resident 1 was administered two (2) 200 milligram (mg) tablets of Seroquel (a medication used to treat psychiatric disorders). An interview was conducted on 4/4/24 at 9:30 A.M. with the director on nursing (DON). The DON stated, The medication was given by 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 follow physicians orders related to hypertension (blood pressure) management for one of three Residents (1). This failure had the potential for Resident 1 to have elevated blood pressure. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses that included essential (primary) hypertension (high blood pressure not related to a medical condition) per the facility's admission Record. An observation and concurrent interview of Resident 1 was conducted on 10/10/23 at 3:30 P.M. Resident 1 was relaxing in bed and watching videos on her computer. Resident 1 stated,I sometimes don't get my medications and sometimes my Pressure (BP) is not checked. A review of Resident 1's medical record, including nursing care plans, was conducted on 10/10/23 at 10 A.M. A nursing care plan, dated, 4/6/22, indicated, .the resident is diagnosed with hypertension (HTN) and uses medication: Clonidine, Amlodipine, Metropolol and Lisenpril; give…

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 develop a comprehensive care plan related to cardiac pacemaker incision site for one of three residents (Resident 1). This failure had the potential to cause harm and affect the resident ' s well - being. Findings: Resident 1 was admitted to the facility on [DATE] with diagnosis which included heart failure, chronic atrial fibrillation (longstanding irregular heart rate), and presence of cardiac pacemaker per facility Face Sheet. On 8/16/23 at 10:54 A.M., a concurrent interview and record review of Resident 1 ' s care plan record was conducted with the Treatment Nurse (TN). The TN stated Resident 1 was admitted with a cardiac pacemaker incision site. The TN further stated, there should have been a care plan which would include skin integrity for Resident 1 on admission. The TN stated, there was no documented evidence that a comprehensive care plan was developed to address Resident 1 ' s cardiac pacemaker incision site. The TN acknowledged a care plan…

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 staff monitored and provide care to cardiac pacemaker (small device to regulate heart rate implanted under the skin of the chest) incision site for one of three sample residents (Resident 1). This failure had the potential to compromise Resident 1 ' s health and wellbeing. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses of heart failure, chronic atrial fibrillation (longstanding irregular heart rate), and presence of cardiac pacemaker per facility Face Sheet. A review of Resident ' 1 ' s minimum data assessment (MDS- an assessment tool), dated 5/31/23 indicated Resident 1 ' s mental status was impaired. On 8/16/23 at 10:54 A.M., a concurrent interview and record review was conducted with the treatment nurse (TN). The TN stated Resident 1 ' s treatment activity record (TAR, document where treatments are done) did not indicate Resident 1 ' s pacemaker incision site was monitored and cared for from 5/29/23 to 6/15/23.…

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 care plan was revised/updated for one of 17 sampled residents (24) who sustained multiple falls. This failure had the potential for Resident 24 to continue falling. Findings: Resident 24 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included muscle weakness (generalized), difficulty in walking, and dementia (A chronic or persistent disorder of the mental process caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) per the resident's Face Sheet. On 6/7/21 at 11:52 A.M., an observation of Resident 24 was conducted. Resident 24 was sitting in a reclining wheelchair. A wanderguard (a device worn by a resident at risk of wandering by triggering an alarm and can lock monitored doors to prevent the resident leaving unattended) was on Resident 24's right wrist. A tab alarm (A pull-string that attaches magnetically to the alarm with garment…

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 thorough fall investigations were conducted and resident-specific fall interventions were developed to prevent further incidents of fall for one of three residents (24) reviewed for accidents. These failures had the potential to increase the risk of injuries due to falls for Resident 24. Findings: Resident 24 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included muscle weakness (generalized), difficulty in walking, not elsewhere classified, Dementia (A chronic or persistent disorder of the mental process caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) per the resident's Face Sheet. On 6/7/21 at 11:52 A.M., an observation was conducted on Resident 24. The resident was sitting in a reclining wheelchair. A wanderguard (a device worn by a resident at risk of wandering by triggering an alarm and can lock monitored doors to prevent 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 answer call lights in a timely manner for four of four sampled residents (39,174,176, 280) and six of six confidential residents (CR- 1, 2, 3, 4, 5, 6). This failure had the potential for residents needs not being met. Findings: 1. Resident 39 was admitted to the facility on [DATE] with diagnoses including a fracture of the right humerus (upper arm bone) and fracture of the right shoulder per the facility's face sheet. A review of the MDS (Minimum Data Sheet- an assessment tool) was conducted on 6/9/21. Resident 39 had a BIMS (brief interview for mental status) score of 11 (mildly impaired). An interview was conducted with Resident 39 on 6/7/21 at 8:49 A.M. Resident 39 stated, Call lights are an issue as staff are not responding and I have to wait a long time for assistance to go to the bathroom; 30 minutes or more. 2. Resident 174 was admitted to the facility on [DATE] with diagnoses that included a fracture of the right pelvis per the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow their policy and procedure for storing and labeling of house supply medications for one of one treatment cart (1) and two of four medication carts (1, 2) when: 1. Resident 280's medication was not labeled in medication cart # 1; 2. Multiple wound dressing and treatment items were not labeled with an opened date in treatment cart #1; 3. House supply medications in medication cart # 2 had no opened dates and medications of discharged residents were not removed upon discharge from the facility. These failures had the potential for medication error(s) and administration of expired medication(s) to residents. Findings: 1. Resident 280 was admitted to the facility on [DATE] with diagnosis of that included a fracture of the left tibia (a fracture of the bone in the left leg) per the facility's Face Sheet. On 6/9/21, a review of Resident 280's MDS (health status screening and assessment tool), Section C dated 1/20/2020, indicated Resident…

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

Based on observation and interview, the facility failed to ensure expired medications and medical supplies were discarded from the medication storage room for one of one medication storage room reviewed. This failure had the potential for administration of expired medications and supplies to be given and used on residents. On 6/8/21, at 3:44 P.M., a joint observation of the medication storage room and interview was conducted with licensed nurse (LN) 70. LN 70 stated, only the LN's had access to the medication storage room. The following expired medications were found: 1. Five (5) unopened bottles of Strawberry Ensure (liquid supplement) with an expiration date of 5/1/21. 2. One hundred sterile starswab II culture tubes (specimen collection swab) with an expiration date of 3/13/21. 3. Fifty four sterile UniTranz - viral transport medium (specimen collection swab) with an expiration date of 12/17/20. 4. Thirty eight sterile blood tubes (collection of blood) with an expiration date of 9/30/2019. 5. One locked Emergency Injectable Kit with an expiration date of 10/20 for the following…

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 hand hygiene was performed when serving meal trays to residents. This failure had the potential to transmit infectious organisms to frail residents. Findings: On 6/7/21 at 12:46 P.M., multiple observations of lunch service were conducted in Arcadia Wing. A resident in room [ROOM NUMBER] was served lunch on a tray by a certified nursing assistant (CNA) 3. CNA 3 took the meal tray into the room. CNA 3 came out of the room, collected another meal tray from the food trolley, proceeded into room [ROOM NUMBER] and placed the meal tray on a resident's tray table. CNA 3 did not perform hand hygiene between serving each meal tray to the residents. On 6/7/21 at 12:55 P.M., a second CNA collected a meal tray from the food trolley and took it in to a resident in room [ROOM NUMBER]. The CNA came out of room [ROOM NUMBER], took another tray from the food trolley and proceeded down the hall into room [ROOM NUMBER]. The CNA did not perform hand…

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 treat one of 17 sampled residents (19) with dignity and respect when Licensed Nurse (LN 2) shoved a spoonful of crushed medication with applesauce into Resident 19's mouth. This failure had the potential to affect Resident 19's psychosocial well-being. Findings: Resident 19 was admitted on [DATE], with diagnoses which included Anxiety Disorder (A mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities) and Unspecified Atrial Fibrillation (An irregular, often rapid heart rate that commonly causes poor blood flow) per the resident's Face Sheet. A review of Resident 19's minimum data set (MDS - assessment tool), dated 3/18/21, was conducted. According to the MDS, Resident 19 had a BIMS (Brief Interview for Mental Status - use to assess a person's mental status) score of 15, which meant the resident's mental status was intact. On 6/7/21 at 3:46 P.M., an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to perform an accurate assessment to reflect a resident's status for one of four residents (42) reviewed for falls. This failure had the potential to cause Resident 42 harm when the resident's level of consciousness deteriorated after a recent fall. Findings: Resident 42 was re-admitted to the facility on [DATE] with diagnoses that included cerebral infarction (brain bleed), schizophrenia (a mental illness that interferes with the ability to think clearly, see reality from fantasy, and make decisions), and anxiety disorder (increased anxiety that interferes with daily life), per the facility's Resident Face Sheet. A review of the MDS (Minimum Data Set, an assessment tool) was conducted on 6/7/21. Resident 42 had a BIMS (Brief Interview for Mental Status) score of 9 (mildly intellectually impaired). Per the general acute care report from the hospital [name of the hospital] Emergency Department (ED) Records, dated 5/31/21, Resident 42 was sent…

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 nail trimming assistance in a timely manner for one of three residents (29) reviewed for ADL assistance. This failure had the potential to cause discomfort and injury to Resident 29. Findings: Resident 29 was admitted to the facility on [DATE] with diagnoses which included Hemiplegia (paralysis of one side of the body) and Hemiparesis (another term for hemiplegia) following Cerebral Infarction affecting right dominant side (muscle weakness or paralysis that affect one side of the body from a blockage of an artery [blood vessel] to the brain) per the resident's Face Sheet. A review of Resident 29's Minimum Data Set (MDS - assessment tool), dated 4/2/21, was conducted. The MDS indicated Resident 29 needed total assistance from staff with performing personal hygiene. On 6/7/21 at 8:39 A.M., an observation on Resident 29 was conducted. Resident 29's left foot big toenail, third and fourth toenails were each approximately 2 centimeters…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to accurately monitor and document the side effects of a medication for one of one resident (42) reviewed for anti-anxiety medications (medication used to manage anxiety disorder). This failure had the potential to cause Resident 42 harm because of inaccurate assessments of medication side effects. Findings: Resident 42 was re-admitted to the facility on [DATE] with diagnoses that included cerebral infarction (brain bleed), schizophrenia (a mental illness that interferes with the ability to think clearly, see reality from fantasy, and make decisions), and anxiety disorder (increased anxiety that interferes with daily life), per the facility's Resident Face Sheet. On 6/8/21 at 8:52 A.M., an observation of breakfast service was conducted beside the Nurses Station in Arcadia Wing. Resident 42 sat in a wheel chair with a tray table in front of her. Resident 42's eyes were closed and leaned face forward onto her tray table, and almost into her…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to consistently provide preventative skin measures for one of two residents (29) reviewed for pressure ulcer (An area of damaged skin caused by staying in one position for too long) when: - Resident 29 was not turned or repositioned every two hours - Resident 29's pressure relieving mattress was not programmed in accordance to the physician's order. These failures had the potential for Resident 29 to develop pressure ulcer. Findings: Resident 29 was admitted to the facility on [DATE] with diagnoses which included Hemiplegia (paralysis of one side of the body) and Hemiparesis (another term for hemiplegia) following Cerebral Infarction affecting right dominant side (Muscle weakness or paralysis that affect one side of the body from a blockage of an artery [blood vessel] to the brain) per the resident's Face Sheet. A review of Resident 29's care plan titled At Risk for Skin Integrity ., dated 10/20/18, was conducted. According to the care plan,…

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 licensed nurse (LN) followed the facility's policy and procedure prior to administering via gastric tube (G-tube- a gastric tube inserted through the belly directly into the stomach for administration of liquid nourishment, fluids and medications) medications for two of two residents (29, 701) observed for tube feeding. This failure had the potential for residents to further developed medical complications. Findings: 1. Resident 29 was admitted to the facility on [DATE] with diagnoses that included Viral Pneumonia (an infection of the lungs) and Dysphagia (a difficulty with swallowing) per the facility's face sheet. On 6/9/21, a review of Resident 29's MDS (minimum data set - a health status screening and assessment tool), dated 3/12/21, indicated Resident 30's BIMS Summary Score (test for cognitive function) was 0 out of 15 (severely impaired). On 6/9/21, at 9:30 A.M., an observation of medication administration with LN 73 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.