Encinitas Post-Acute

Based on observation, interview, record review, and facility policy review, the facility failed to ensure staff stored respiratory equipment in accordance with the facility policy and standard precautions. Specifically, the facility failed to store nebulizer masks and Continuous Positive Airway Pressure (CPAP) masks in a manner which limited the spread of infection for 2 (Resident #202 and Resident #298) of 2 residents reviewed for respiratory care. Findings included: 1. An undated facility policy titled, Oxygen Therapy and Devices, revealed the section titled, Oxygen Devices, included, 4) Simple Mask f. Place in a labeled bag when not in use. Further review revealed that the policy did not address the use of a nebulizer mask. During an interview on 04/30/2025 at 10:11 AM, the Director of Nursing (DON) said they were still looking for a more specific policy pertaining to the nebulizer masks and acknowledged that the provided policy covered several other types of respiratory masks, but not nebulizer masks. The DON said nebulizer masks should be stored in bags when not in use, just…

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 protect one resident (Resident 2) from physical abuse when Resident 1, who had a history of wandering, wandered into the dining hall unsupervised and hit Resident 2 on the arm. This deficient practice had the potential for Resident 2 and other residents to feel unsafe in the facility. Findings: A review of Resident 2's admission Record indicated the resident was admitted to the facility on [DATE]. A review of Resident 1's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses to include Alzheimer's Disease (a progressive irreversible brain disorder that causes memory and thinking skills to decline) and delirium (mental state characterized by confusion, disorientation, and inability to think). On 11/7/24 at 9:30 A.M., an onsite visit was conducted to investigate a facility reported allegation of abuse that occurred on 11/3/24 between Resident 1 and Resident 2. A review of Resident 1's interdisciplinary team (IDT)…

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 written care plans for one resident (Resident 1) were resident specific to include interventions that addressed the resident's need for increased supervision when up in her wheelchair and wandering the facility. As a result of this deficient practice, Resident 1 was able to wander around the facility unsupervised which caused altercations with other residents and led to an incident of physical abuse (cross reference F600). Findings: A review of Resident 1's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses to include Alzheimer's Disease (a progressive irreversible brain disorder that causes memory and thinking skills to decline) and delirium (mental state characterized by confusion, disorientation, and inability to think). On 11/7/24 at 9:30 A.M., an onsite visit was conducted to investigate a facility reported allegation of abuse that occurred on 11/3/24 between Resident 1 and Resident 2. A review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to send the results of an abuse investigation to the State agency (California Department of Public Health, CDPH-licensing and certification agency) within five working days. This deficient practice had the potential for residents to not be protected from abuse. Findings: A review of Resident 1 ' s admission Record indicated the resident was admitted on [DATE]. A review of Resident 2 ' s admission Record indicated the resident was readmitted on [DATE]. A review of Resident 1 ' s Interdisciplinary Team (IDT) note dated 10/18/24, indicated on 10/13/24 Resident 1 had hit Resident 2. On 10/24/24 at 9:25 A.M., an onsite investigation was conducted. The administrator (ADM) and director of nursing (DON) were interviewed. The ADM and DON both stated the facility ' s abuse investigation between Resident 1 and Resident 2 was completed and the results of the investigation were sent to the CDPH, but that they would verify this was done. On 10/24/24 at 11:25 A.M., an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to identify and develop a care plan for a resident at risk for abuse for one of two residents investigated. This failure meant that staff was unaware of the resident's risk for abuse and of measures to mitigate those risks. Findings: On May 9, 2024, a Health Facilities Evaluator Nurse (HFEN) entered the facility for an investigation of a Facility Reported Incident involving a physical and verbal altercation between two residents. According to the Record of Admission, undated, Resident 1 (Res 1) was admitted to the facility on [DATE], with health conditions that included: Malignant neoplasm (Cancer) of .lung; Major depressive disorder (a mood disturbance of feelings of sadness or loss of interest, that can affect how one thinks, feels, and behaves). In an interview on May 9, 2024, at 10 A.M. the Administrator (ADM) stated that Res 1 can push (mentally, psychologically, not physically) people and expects others to back down. In 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.

Based upon observation, interview and record review, the faclity failed to provide privacy for one unsampled resident (Resident 3) during bathing. As a result the facility failed to provide dignified care when bathing Resident 3. Findings: On 4/25/24 at 9:35 A.M., from the main hallway, the shower room door was observed to be held wide open with a large magnet. A curtain partially obscurred a shower stall, and a male resident, Resident 3, was observed seated in a shower chair, facing the door, and rinsing self with a hand-held shower head. The resident was without clothing. A staff member was observed next to Resident 3 and a male voice was giving verbal cues to Resident 3. On 4/25/24 at 9:37 A.M. an interview was held with LN 1, who identified CNA 1 as the staff member assisting Resident 3 in the shower, and stated that CNA 1 is not a new employee. LN 1 stated it is policy that the shower room door be closed with the sign up noting occupied when a resident is bathing. LN 1 said residents should have privacy in the shower. On 4/25/24 at 10:13 A.M., CNA 1 was interviewed. CNA 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, the facility failed to administer six out of 14 medications ordered by the physician for a total of eight days for one of three residents (Resident 1) reviewed for significant medication error. As a result, Resident 1 did not receive medications as ordered by a physician and there was no treatment provided for diagnosed health conditions. Resident 1 was at risk for worsening breathing problems, increased blood pressure, increased heart rate, and possible stroke from blood clot formation. Findings: On 3/25/24, an unannounced visit was made to the facility regarding three complaints related to medication errors which involved one resident (Resident 1). Resident 1 was admitted to the facility on [DATE], with diagnoses to include cancer in the right lung and Pneumonia in the left lung, per the facility ' s admission Record. On 3/25/24 at 10:45 A.M., an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated when Resident 1 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 develop a written care plan related to refusal of medications for one of three sampled residents (Resident 1). This failure had the potential to not meet the goals of treatment and needs of Resident 1. Findings: On 1/23/24 at 12:45 P.M., an unannounced onsite to the facility was conducted related to a complaint on Resident Rights. Resident 1 was admitted to the facility on [DATE], with diagnoses which included Parkinson ' s disease (movement disorder) and human immunodeficiency virus (HIV, virus that weakens a person ' s immune system), per the facility's admission Record. According to Resident 1's history and physical (H & P), dated 12/28/23, Resident 1 had fluctuating capacity to make his own medical decisions. On 1/23/24 at 1:07 P.M., an observation and an interview of Resident 1 was conducted in his room. Resident 1 was sitting in bed. Resident 1 stated he did not know what his goals in the facility were. Resident 1 stated his…

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 infection control practices when: 1. CNA 22 did not properly don (to put on) the required personal protective equipment (PPE) prior to entering one of 15 COVID positive (a highly contagious virus), resident rooms; 2. A urinary catheter drainage bag was in contact with the floor for one of three residents (Resident 83), reviewed for urinary catheter care; 3. A wound vac on floor was on the floor for one of one resident (Resident 55) reviewed for pressure ulcers and; 4. An oxygen tubing was not dated for one of one resident (Resident 38) reviewed for respiratory care. As a result, residents, staff and medical equipment were at risk for cross contamination. Finding: 1. On 8/14/23 at 9:08 A.M., an observation was conducted of a resident call light being on and staff (CNA 22) preparing to enter the isolated room. The door to the room was closed. Taped to the front of the door was a colored contact precaution warning, indicating all…

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 written informed consent for the use of a psychotropic (medication that affect the chemical make-up of the brain), medication prior to administration for one of three residents (Resident 77), reviewed for medication review. As a result, Resident 77 was not informed of the risk, benefits, or possible side effects when taking this medication. Findings: Resident 77 was admitted to the facility on [DATE], with diagnoses which included dementia (progressive memory loss) and depression, per the facility's admission Record. Resident 77 was listed as her own responsible party for making health care decisions on the facility's admission Record. On 8/17/23 at 7:47 A.M., an observation was conducted of Resident 77, while in the dining room. Resident 77 was in a wheelchair and a staff member was sitting beside her, assisting the resident with eating breakfast. On 8/17/23, Resident 77's clinical record was reviewed. The quarterly MDS (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 adequately train staff to perform PASRR (Preadmission Screening and Resident Review- a federally required document screening to ensure residents are appropriately placed and/or receive appropriate services) screening for one of one resident (Resident 346), reviewed for PASRR completion. This failure had the potential to place Resident 346 at risk for unmet care needs and inappropriate placement. Findings: Resident 346 was admitted to the facility on [DATE] with the diagnoses of down syndrome (a genetic disorder) according to the facility's admission Record. Resident 346 was observed sitting on a wheelchair in his room on 8/14/23 at 10:20 A.M. Resident 346 was unable to respond to questions clearly and stated, yeah as a response to simple questions. During interview and concurrent record review on 8/17/23, at 8:40 A.M., with the MDSN (a nurse who specializes in clinical assessments), the MDSN stated she completed the PASRR for Resident 346…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop a person-centered care plan for one of two residents (Resident 198), reviewed for dialysis (the process of removing excess fluid and toxins from the blood in people whose kidneys no longer function). As a result, there was the potential for Resident 198 to be at risk for fluid overload, infection, bleeding, swelling, and for the staff to not consistently assess for these risks. Findings: Resident 198 was admitted to the facility on [DATE], with diagnoses which included Acute (sudden) kidney failure and dependence on renal (kidney) dialysis, per the facility's admission Record. On 8/14/23 at 10:28 A.M., an observation and interview was conducted with Resident 198 as she returned from dialysis. Resident 198 stated she did not know if she had a shunt (a graft which connects an artery and a vein and used as an access site for dialysis) or a catheter (a device inserted under the skin to allow access to the bloodstream). Resident 198…

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 secure one of two (north/east hallway) housekeeping closets, which contained chemicals and disinfectants. As a result, there was the potential for confused residents to have access to chemicals which could be toxic if ingested. Findings: On 8/14/23 at 2:45 P.M., an observation was conducted of the housekeeping closet on the north/east hallway, outside of the rehabilitation department. The door was ajar and unlocked, with a wooden door stop on the floor between the door and the door frame, leaving the door approximately 2 inches open. Inside the closet was a large sink with chemicals on the wall above the sink. The chemicals were in clear, plastic one gallon bottles stored. Identifying the chemicals from left to right were labeled: glass cleaner (blue in color), all purpose cleaner (yellow), disinfectant (pale yellow) and bathroom cleaner (pink). On 8/14/23 at 2:47 P.M., an observation and interview was conducted with the ADM and Supervising Housekeeper (S-HSKP), at the housekeeping closet. The S-HSKP 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the oxygen level was being administered according to physician's order for one of one resident (Resident 38) reviewed for oxygen therapy. As a result, Resident 38 did not receive oxygen therapy as ordered by the physician. Findings: Resident 38 was admitted to the facility on [DATE] with the diagnoses of congestive heart failure (a condition in which the heart does not pump or fill blood as well as it should) according to the facility's admission Record. During an observation on 8/14/23, at 10:28 A.M., Resident 38 was in bed attempting to get out of bed. An oxygen concentrator (machine that provides oxygen) was next to Resident 38's bed with an oxygen tubing attached. The concentrator was observed on at 3.5 liters and the oxygen tubing was on Resident 38's chest area. LN 2 arrived in Resident 38's room and re-applied Resident 38's oxygen to the nose. LN 2 then checked the concentrator and stated the oxygen level on the concentrator…

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 pain medication was administered timely prior to wound treatment for one of three residents (Resident 55) reviewed for pain management. This failure resulted in the Resident 55 enduring pain during wound treatment. Findings: Resident 55 was re-admitted to the facility on [DATE] with the diagnosis of stage four pressure ulcer (bedsore extended to muscle, tendon or bone) of sacral region (the triangular shaped bone at the base of the back) according to the facility's admission record. An observation and interview were conducted with Resident 55 on 8/15/23, at 2:40 P.M. Resident 55 was in bed with a wound vacuum (wound vac-a device which pulls fluid from a wound over time) on the floor next to the right side of Resident 55's bed. Resident 55 further stated he was aware of a wound on his back and experienced pain during treatments. During an observation and interview on 8/16/23, at 11:20 A.M., with LN 33. LN 33 stated Resident 55 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, interview and record review, the facility did not ensure staff were knowledgeable in assessing a resident's dialysis (procedure done by a trained professional to remove wastes and excess fluids from the body) access site for one of two residents (Resident 11) reviewed for dialysis. This failure had the potential for the delayed detection, reporting, and/or management of complications from the dialysis access site for Resident 11. Findings: Resident 11 was re-admitted to the facility on [DATE] with the diagnoses of end stage renal disease (the last stage of kidney disease which the kidneys can no longer support the body's needs) according to the facility's admission record. A review of Resident 11's MDS (tool that measures health status of residents), dated 7/1/23, listed a cognitive score of 15, indicating cognition was intact. The MDS section I further indicated an active diagnosis of dependence on renal dialysis. An interview of Resident 11 was conducted on 8/14/23, at 8:19 A.M. Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility did not assure two of six residents (16, 17) were free from unnecessary use of psychotropic medication (major tranquilizer used when the resident may harm himself or others) when: 1. Resident 16 was ordered an antipsychotic medication without a clear indication for its use. 2. Resident 17 was ordered an antipsychotic medication without a clear indication for its use. As a result, Resident 16 and Resident 17 had the potential to be expose to unnecessary side effects of the medications. Findings: 1. Per the facility's admission Record, Resident 16 was admitted to the facility on [DATE] with a diagnosis of dementia. Resident 16's records were reviewed. Per the physician's History and Physical, dated 2/18/23, Resident 16 did not have the capacity to make his own decisions. Per the physician's orders, dated 9/30/22, Resident 16 was started on Seroquel (an antipsychotic medication). There was no clinical assessment and evaluation that identified the…

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

Based on observation, interview and record review, the facility failed to ensure the medication error rate was less than five percent. The facility's medication error rate was 12.9%. Four medication errors were observed out of 31 opportunities, during the medication administration process for two of three randomly observed residents (Resident 4, 27, 66). As a result, the facility could not ensure medications were correctly administered to all residents. Findings: 1. On 8/16/23 at 8:32 A.M., an observation of medications administration was conducted with LN 11. LN 11 prepared and administered 16 medications to Resident 27. One of the 16 medications was Culturelle Digestive Daily Capsule (Lactobacillus-Inulin) 15 billion cell-200 mcg (microgram). On 8/16/23 a medication reconciliation for Resident 27 was conducted. Per the physician order, dated 6/29/22, listed Culturelle Digestive Daily Capsule (Lactobacillus-Inulin) the dose of 10 billion cell-200 mcg was ordered, not 15 billion cell-200 mcg as administered. On 08/16/23 02:53 P.M., an interview and record review was conducted with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not assure that one of one resident (31) received medication ordered by the physician for her blood pressure, reviewed during significant medication error. As a result, Resident 31 was at risk to experience high blood pressure. Findings: Per the facility's admission Record, Resident 31 was admitted on [DATE] with hypertension (high blood pressure). Resident 31's records were reviewed. Per the physician's History and Physical, dated 5/23/22, Resident 31 had the capacity to make her own health care decisions. Per the physician's orders for the month of August 2023, Resident 31 was to receive Lisinopril daily in the morning to regulate her blood pressure. Resident 31's blood pressure was to be taken before she received the lisinopril. Per Resident 31's MAR, on 8/14/23, the resident did not receive her lisinopril or have her blood pressure monitored and recorded to assess her current medical need for the blood pressure medication. On 8/14/23 at…

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

Based on observation, interview and record review, the facility failed to ensure: 1. The temperature log for a medication refrigerator was complete for May 2023 and 2. The temperature for medication refrigerator was consistently monitored for one of two medication refrigerators and 3. Medications were stored and labeled according to the manufacturer's specifications and policy. As a result, the facility could not ensure medications were safely stored to ensure their integrity. Findings: 1. The medication room at the South station was inspected with the ADON on 08/16/23 at 11:18 A.M. The temperature log from April to August 2023 were requested. The temperature log for May 2023 was not available. 2. The medication room at the South station was inspected with the ADON on 08/16/23 at 11:18 A.M. The temperature log for the medication refrigerator had missed entry on 8/10/23. The ADON stated it should not be blank. On 8/17/23 at 1044 A.M., an interview was conducted with the DON. The DON acknowledged there was a missed entry on August 10, 2023 and the May 2023 could not be located. The…

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

Based on observation, interview, and record review, the facility failed to safely document used-by-date and seal food containers stored in two of four stand-alone refrigerators (Refrigerators 2 and 3), during initial kitchen inspection. As a result, residents were at risk of food-borne illness. Findings: On 8/14/23 at 7:35 A.M., an observation was conducted during initial kitchen tour of the refrigerators. During inspection of Refrigerator #3, on the right side, second shelf down from the top, was a plate of sliced red tomatoes. The plate of tomatoes was not dated, for when prepared or stored, and the clear cellophane wrap was covering ¾ of the plate, leaving the remaining ¼ plate exposed to the air within the refrigerator. On the left side of Refrigerator #3, third shelf down was a round Styrofoam container with a loose-fitting plastic lid. The Styrofoam container contained what appeared to be red salsa. The container was not dated of when placed in the refrigerator and the lid was not secured. On 8/14/23 at 7:42 A.M. ,an observation of refrigerator #2 was conducted. On the 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure prescribed treatments were implemented for one of six residents (12) reviewed for pressure ulcers. In addition, interventions to prevent the progression of pressure ulcers were not consistently implemented for one of six sampled residents (229) reviewed for pressure ulcers. These failures had the potential for pressure ulcers to worsen and affect healing. Findings: 1. Resident 12 was admitted to the facility on [DATE] with diagnoses that included an unstageable (the wound was covered in a dark scab that prevented the depth of the wound being visible) pressure ulcer (a localized area of dead tissue caused by prolonged pressure) on his right heel, per the facility's undated admission Record. On 10/22/19 at 9:30 A.M., an observation was conducted of a pressure ulcer dressing change on Resident 12's right heel. Resident 12's right heel bone was exposed and granulation tissue (formed on a wound as the wound healed) was observed around…

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 nursing staff knew the correct procedure for assessing and monitoring the AV fistula (connection between a vein and an artery) used for renal dialysis (an artificial process of removing waste products and extra fluid from the body) for 1 of 3 residents (26) reviewed for dialysis care. This failure had the potential to cause complications related to dialysis monitoring and treatment. Findings: Resident 26 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease (kidney failure) and dependence on renal dialysis, per the facility's undated admission Record. Per the MDS assessment dated [DATE], Resident 26 had a BIMS score (an assessment tool) of 15. A BIMS score of 15 meant a person was mentally intact. On 10/22/19 at 11:55 A.M., an interview was conducted with Resident 26. Resident 26 stated she attended dialysis three times a week. Resident 26 stated the only place the doctor could put in an AV…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two facility staff were able to demonstrate or verbalize the proper facility process for monitoring side effects of psychotropic medications (medicine used to treat a group of mental disorders). In addition, psychotropic medication side effect monitoring was not documented for one of three residents (6) reviewed for psychotropic medication. This failure had the potential for side effects of residents' psychotropic medication to go unnoticed. Findings: 1. Resident 35 was admitted to the facility on [DATE] with diagnoses, which included dementia (a loss of mental abilities that leads to impairments in memory, reasoning, planning, and behavior), and bipolar disorder (a mood disorder that can cause radical mood swings), per the facility's admission Record. According to a review of Resident 35's physician orders, dated 9/5/18, Psychotropic Medication Side Effect Monitoring . Refer to Care Plan or Drug Information sheet for potential…

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 un-sampled resident's (3) lunch tray provided the diet recommended by the registered dietician, as indicated on Resident 3's dietary tray ticket. This failure had the potential to contribute to Resident 3's weight loss. Findings: Resident 3 was admitted to the facility on [DATE] with diagnoses, which included dementia (a loss of mental abilities that leads to impairments in memory, reasoning, planning, and behavior) and nutritional anemia (low iron in the blood due to not consuming a balanced diet), per the facility's admission Record. On 10/23/19 at 11:43 A.M., during an observation of lunch tray line (a system of food preparation used in facilities), Resident 3's dietary tray ticket indicated the resident was to receive a magic cup (frozen dessert designed to add dietary calories and nutrients) and a health shake (milk shake to add dietary calories and nutrients) with her lunch. Resident 3's lunch tray was observed to be…

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 documentation of post dialysis nursing assessments were recorded in a readily accessible way for 1 of 3 residents (26) reviewed for dialysis care. This failure had the potential to affect the resident's care. Findings: Resident 26 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease (kidney failure) and dependence on renal dialysis (an artificial process of removing waste products and extra fluid from the body) per the facility's undated admission Record. On 10/24/19 at 10:50 A.M., an interview was conducted with LN 13. LN 13 stated the bruit and thrill assessment of a resident's dialysis access site, was supposed to be recorded on the Dialysis Care Communication/Coordination Form every time a resident returned from dialysis treatment. On 10/24/19 at 11:30 A.M., an interview was conducted with LN 22. LN 22 stated if the Dialysis Communication/Coordination Form was not completed, some nurses would document…

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 consistent implementation of their infection prevention and control program when: 1. Dirty gloves were not removed and hand hygiene was not performed at the completion of a dressing change before touching one resident (19) and her belongings. 2. After the irrigation of a wound the soiled barrier was not removed from under a resident (19) at the completion of the dressing change for one resident. 3. A laundry hand washing sink was used for cleaning paint brushes. These failures had the potential to cause cross-contamination (an unintended transfer of germs from one surface to another) of soiled items to both residents and staff. Findings: 1. Resident 19 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease (a progressive nervous system disorder that affects movement), pressure ulcer (injuries to skin and underlying tissue resulting from prolonged pressure of the skin) of the sacral region Stage…

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.