Escondido Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review, the facility failed to implement infection control practices during wound care for 1 (Resident #150) of 2 residents reviewed for pressure ulcers, and failed to ensure proper storage of oxygen and nebulizer equipment, when not in use, to prevent the spread of infection for 1 (Resident #278) of 1 resident reviewed for respiratory care. Findings included: 1. A facility policy titled, Wound Care, revised 10/2010, revealed, The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. The policy revealed the section titled, Steps in the Procedure, included, 1. Use disposable cloth (paper towel is adequate) to establish clean field on resident's overbed table. Place all items to be used during procedure on the clean field. Arrange the supplies so they can be easily reached. 2. Wash and dry your hands thoroughly. Further review revealed, 4. Put on exam glove. Loosen tape and remove dressing. 5. Pull glove…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to 1). Correctly re- position the resident with the correct orthopedic devices as ordered by the physician. 2). Provide continued care with Restorative Nursing services 3). Failed to notify the physician that physical therapy services and restorative services were not provided. 4). Failed to notify the physician the brace was not being used as ordered, for 1 of 3 residents reviewed (Resident 1) for mobility. As a result of these failures, Resident 1 was at risk for a decrease in range of motion, and experienced psychosocial distress and fear of not achieving independence with Activities of Daily Living (ADL ' s) such as dressing, grooming, and being up in her wheelchair for periods of time. Resident 1 was admitted to the facility on [DATE] with diagnoses which included multiple contractures (shortening of muscles, tendons, and skin that cause joint stiffness and limited movement. A BIMS (routine screening of memory and thinking) score of 14…

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 notify residents and their representatives of the facility bed hold policy for four of four residents reviewed for notifications regarding bed holds before or as soon as possible after transfer to hospital. This failure had the potential for psychological harm related to uncertainty if the resident could return when their condition improved. Findings: Resident 2 was admitted to the facility on [DATE] with health conditions including osteomyelitis (infection of the bone) of right tibia and fibula (lower leg bones); diabetes type 2 (a chronic disease of the body not producing insulin, causing high blood sugars), according to her admission Record. Resident 2 was transferred from the facility to an Acute Care Hospital (ACH) due to a new cough with difficulty breathing and a new need for oxygen on 11/1/24 at 4:50 P.M., according to the SBAR communication form dated 11/1/24. On 11/13/24 at 2:26 P.M. family of Resident 2 stated Resident 2's room was not held…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to treat one of seven sampled residents with dignity and respect. This failure had the potential for Resident 6 to feel ashamed and embarassed. Findings: Resident 6 was admitted to the facility on [DATE]. Resident 6's health conditions included: dementia; malignant neoplasm (spreading cancer) of the stomach according to her admission Record. On 11/22/24 at 10:56 A.M. an observation and interview were held with Resident 6 in her room. Resident 6, a small lady, was seen sitting up in bed, propped up with pillows, leaning to the left. Resident 6's breakfast tray was still in front of her. Oatmeal was seen on her lower face, and dripping from her chin onto her bedding. Resident 6 was wearing a hospital gown, unsnapped at the right collar. Her right collar bone, upper ribs and breastbone were visible. A bath blanket was sideways over her, exposing her lower legs and her right thigh. On 11/22/24 at 11:02 A.M. Licensed Vocational Nurse (LN) 1 responded to Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to exercise care in protecting 1 residents' (Resident 2) property from loss and physical damage out of 11 property loss reports reviewed. As a result, the resident's painting was reported lost. Resident 2 was admitted to the facility on [DATE] with health conditions including osteomyelitis (infection of the bone) right tibia and fibula (lower leg bones); diabetes type 2 (a chronic disease of the body not producing insulin, causing high blood sugars). Resident 2 was transferred from the facility to an Acute Care Hospital (ACH) due to a new cough, with difficulty breathing and a need for oxygen on 11/1/24 at 4:50 P.M., according to the SBAR communication form dated 11/1/24. On 11/25/24 at 4:30 P.M. the Director of Social Services (DSS) was interviewed in her office, and Resident 2's chart was reviewed, along with the past seven months of missing property reports. The DSS stated there had been 11 missing property reports filed, with 1 report…

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 implement interventions to prevent a fall for one of three residents (Resident 1) reviewed for a fall. This failure increased the risk of injury related to falls for Resident 1. Findings: Resident 1 was admitted to the facility on [DATE] with diagnosis that included: epilepsy (a brain condition of abnormal electric impulses that cause seizures, which can be staring, jerky movements, body stiffness, loss of consciousness); unsteady on feet; A BIMS (Brief Interview for Mental Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) test, completed on 7/22/24 noted Resident 1 with a score of 6, severely impaired. On 8/28/24 at 3:40 P.M. A family member was interviewed. The family member (FM) reports Resident 1 had a fall a few days ago, in addition to a fall outside the facility that happened mid-July, when Resident 1 was sent to the hospital. FM 1 stated Resident 1 hurt…

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 implement interventions to prevent a fall for one of three residents (Resident 1) reviewed for a fall. This failure increased the risk of injury related to falls for Resident 1. Findings: Resident 1 was admitted to the facility on [DATE] with diagnosis that included: epilepsy (a brain condition of abnormal electric impulses that cause seizures, which can be staring, jerky movements, body stiffness, loss of consciousness); unsteady on feet; A BIMS (Brief Interview for Mental Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) test, completed on [DATE] noted Resident 1 with a score of 6, severely impaired. On [DATE] at 3:40 P.M. A family member was interviewed. The family member (FM) reports Resident 1 had a fall a few days ago, in addition to a fall outside the facility that happened mid-July, when Resident 1 was sent to the hospital. FM 1 stated Resident 1 hurt…

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 person-centered care plans for one of five residents (Resident 1), related to: a. The potential for falls; b. Pain; c. Urinary tract infection (UTI-an infection in the urine); d. Anticoagulant (blood thinning medication) therapy; and e. The potential for skin injuries. As a result, there was the potential Resident 1's care was not being provided consistently and potential problem areas were not identified. Findings: Resident 1 was admitted to the facility on [DATE], with diagnoses which included fall, resulting in a fracture to the right hip and right wrist, requiring surgical aftercare, per the facility admission Record. On 7/18/24, Resident 1's clinical record was reviewed: a. (Falls) According to the facility's Fall Risk Assessment, dated 7/2/24, Resident 1 had a fall assessment score of 22, scores 16-42 indicate High Risk for falls. According to the 5-day Minimum Data Set (MDS-a clinical assessment tool), dated 7/8/24, Resident 1 had one…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to perform and document skin assessments prior to a discharge for one of five residents (Resident 1), reviewed for services meeting professional standards of practice. As a result, Resident 1 was discharged , and family were unaware of the bruises and skin injuries caused while at the facility. Findings: Resident 1 was admitted to the facility on [DATE], with diagnoses which included fall, resulting in a fracture to the right hip and right wrist, requiring surgical aftercare, per the facility admission Record. On 7/18/24, an unannounced visit was made to the facility in response to a complaint. The complainant provided two photographs of Resident 1's lower abdomen (lower stomach) area, showing numerous areas of black/blue/green/yellow bruising. On 7/18/24, Resident 1's clinical record was reviewed: According to the physician's order, dated 7/2/24, .Braden scale (a standardized tool used by healthcare providers to determine a resident's risk for developing…

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 routinely check and record resident room temperatures, resident bathroom water temperatures, call lights, and resident equipment. This failure had the potential for residents to be uncomfortable or at risk for accidents related to unidentified hazards. Findings: On 8/4/23 an unannounced visit was made to the facility due to a complaint of hot, uncomfortable resident room temperatures within the facility. The hallway temperature thermometers read 72 degrees Fahrenheit (F). Standing electrical fans were in the hallway of Station 3 and a portable air conditioning unit was in the north hallway of Station 3. On 8/4/23 at 2:02 P.M., an interview was conducted with Resident 4 outside of her room. Resident 4 stated her room was too cold and she had to sleep with several blankets at night. Resident 2 asked if the temperature in her room could be adjusted. On 8/4/23 at 2:15 P.M., an interview was conducted with the Interim Maintenance Director (I-MD). The I-MD stated the previous MD left on 7/6/23, and he took over the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a person-centered comprehensive care plan was developed and or implemented in regard to four sampled residents (141, 59, 81,103). These failures had the potential for an increased risk of oral infection and to negatively impact the residents' (141, 59, 81, 103) quality of life, as well as the quality of care and services received. Findings: 1. Resident 141 was admitted to the facility on [DATE] with diagnoses which included metabolic encephalopathy (problem in the brain caused by chemical imbalance in the blood), per the facility's Face Sheet. A review of Resident 141's MDS (minimum data set - an assessment tool), dated 12/16/21, was conducted. Resident 141's functional status indicated extensive assistance in all areas of his activities of daily living. On 1/31/22 at 11:14 A.M., an observation of Resident 141 was conducted in his room. Resident 141 lay on his bed with his eyes closed and mouth open. Resident 141's lips were noted…

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 implement policies and procedures for the provision of pharmaceutical services when: 1. Licensed staff failed to administer prescribed medications to Resident 39 and Resident 34. 2. Oxycodone (narcotic pain medication) 5 mg (milligram - unit of measure) tablets dated as 7/26/21 were found in the disposition locker and licensed staff were unable to determine when the medication was stored for disposition leading to inaccurate reconciliation. 3. Oxycodone 100mg(milligram)/5ml (milliliter unit of liquid measure) for Resident 1 was not accurately reconciled on the controlled drug count sheet. These failures had a potential of not effectively treating residents due to delayed or missed medications and controlled substance discrepancies leading to diversion. Findings: 1. On 1/31/22 at 9:14 A.M., at Station 3, RN 1 was observed preparing medications for administration for Resident 39. It was observed that Nevibolol (a medication for blood pressure) 10 mg and ciprofloxacin (medication to treat bacterial infections)…

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 infection control program for COVID-19 Mitigation Plan/Policies and Procedures dated 9/9/21. In addition, the facility failed to implement general infection control practices, which included: 1. The staff and visitors who entered the facility did not wear Personal Protective Equipment (PPE) which included wearing, N95 masks, gowns, gloves, and eye protection. Transmission Based Precaution's (TBP) were not followed for the entire facility (which was declared a yellow isolation zone) 2. The visitors who entered the facility did not undergo the COVID-19 screening process. 3. The licensed staff did not sanitize (to clean and make free of disease-causing elements) equipment during medication administration according to manufacturer specification. These deficient practices had the potential to result in the spread of infection placing residents, staff, and visitors at risk for infections, including COVID-19 (a highly contagious…

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 protect and treat the residents with respect and dignity for one sampled resident. (58). This failure had the potential to affect the resident's psychosocial well-being. Findings: Resident 58 was admitted to the facility on [DATE] with diagnoses which included cerebral infarction (part of the brain loses blood supply), per the facility's Face Sheet. A review of the MDS (minimum data set - an assessment tool) was conducted, dated 11/15/21, which indicated Resident 58 had a brief interview for mental status (BIMS) score of 5, which indicated Resident 58 had severe impaired cognition. On 1/31/22 at 9:40 A.M., an observation with Resident 58 was conducted in his room. Resident 58 lay on his bed with no privacy curtains pulled and faced the window with his back side to the door. The door to Resident 58's room was fully opened to the hall where visitors, and staff walked by the room. Resident 58's back, legs and his brief (underwear for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the Office of the State Long Term Care Ombudsman when one sampled resident (Resident 21) was transferred to the hospital. As a result, Resident 21 was not fully protected from an inappropriate discharge when the facility did not communicate Resident 21's transfer with an advocate from the Ombudsman office. Findings: Record review was conducted on 1/31/22 at 3:26 P.M. of Resident 21's current Facesheet. This document indicated Resident 21 was re-admitted to the skilled nursing facility on [DATE] with the added diagnosis of pneumonia. On 1/31/22 at 3:26 P.M., a review of Resident 21's Progress Notes was performed. The Progress Notes indicated Resident 21 was transferred to the hospital in October 2021. There was no documentation in the medical record of the notification to the Ombudsman's office regarding this transfer. During an interview with the Director of Nursing (DON) on 2/2/22 at 3 P.M., the DON stated there was no fax or documentation 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 consultant pharmacist (CP) failed to identify irregularities in psychotropic (a medication that affects a person's mental state) medication use for Resident 103 when: 1. Seroquel (antipsychotic medication to treat mental health issues) administered without adequate monitoring of A1c (lab value for average blood sugar in past 3 months), 2. Seroquel administered without adequate indication for use affective (mood) psychosis (a condition that affects the way your brain processes information), 3. Paxil administered without GDR (gradual dose reduction). These failures caused the resident to potentially not receive the necessary care for their needs and increased the potential for adverse reactions and death. Findings: 1. Review of Resident 103's clinical record indicated that she was [AGE] years old and admitted to the facility on [DATE]. Review of Resident 103's clinical record indicated that she had been taking Seroquel (antipsychotic medication to treat mental…

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 document review, the facility failed to ensure Resident 103 was free from unnecessary psychotropic (drugs that affects brain activities associated with mental processes and behavior) medications when: 1. Seroquel (antipsychotic medication to treat mental health issues) administered without adequate monitoring of A1c (lab value for average blood sugar in past 3 months), 2. Seroquel administered without adequate indication for use affective (mood) psychosis (a condition that affects the way your brain processes information), 3. Seroquel, trazodone (medication for mood), Paxil (a medication to treat depression) administered without behavioral interventions (non-pharmacological methods to manage behavior issues), 4. Paxil administered without GDR (gradual dose reduction) These failures caused the resident to potentially not receive the necessary care for their needs and increased the potential for adverse reactions and death. Findings: 1. Review of Resident 103's clinical record indicated she…

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 residents were free from a medication error rate of 5 percent or greater when Residents 39 and 34 were not administered three morning medications. A total of 3 medication errors were observed within a sample size of 26 opportunities for error. The facility's medication error rate was 11.54%. These failures had the potential of medications administered to residents as not treating residents effectively and exposing them to medication errors. Findings: On 1/31/2022 at 9:14 A.M., at Station 3, observed RN 1 preparing medications for administration to Resident 39. It was observed that Nevibolol (a medication for blood pressure) 10 mg (milligram - a unit of measure) and ciprofloxacin (medication to treat bacterial infections) 500mg was not available for the 9 AM administration to Resident 39. During medication administration, RN (registered nurse)1 did not inform the resident that the medication was not available. During concurrent interview and record review on 1/31/2022 at 3:20 P.M., RN 1 stated there had…

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

Based on observation, interview and record review, the facility failed to: 1. Ensure expired medications were not available for use. 2. Properly label resident medication with open dates, expiration dates and resident identification tags. These failures placed the residents at risk for receiving ineffective or expired medications and had the potential of exposing residents to infections due to cross contamination. Findings: 1. During a concurrent observation and interview on 01/31/2022 at 12:30 P.M. An observation of medication cart at Station 2 with LN 2, one opened package of Advair (medication for treating breathing issue of lungs) 100/50mcg (mcg is a unit of measure) was observed. The package had an open date of 12/18/2021 for Resident 74. LN 2 stated the medication was good for 30 days after opening and expired medications are not effective. LN 2 explained use of expired medications could cause the resident to have symptoms. Review of the medication administration record (MAR) for Resident 74 indicated resident had received the Advair 1 puff inhaled daily as ordered by…

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, interviews, and record review, the facility failed to ensure sanitary conditions were maintained during food storage when: 1. Expired sandwiches were found inside the refrigerator. 2. Two nursing unit refrigerators had expired drinks and the temperatures were out of normal range. These deficient practices had the potential to expose all residents who receive food from the kitchen to unsanitary practices and potentially unsafe foods that could lead to widespread foodborne illness. Findings: 1. On 2/1/22 at 3:20 P.M., an observation and interview with the Food & Nutrition Services Director (FNSD) was conducted. Inside the refrigerator, there were two tuna sandwiches labeled good for January 27, 2022-January 30,2022. The FNSD removed the sandwiches from the refrigerator and were thrown away. On 2/1/22 at 3:30 P.M., an interview with the FNSD was conducted. The FNSD stated, staff should have been checking the dates and removed expired items from the refrigerator to avoid foodborne illness. On 2/3/22 at 10:56 A.M., an interview with the Administrator and the FNSD…

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 The facility failed to accommodate the needs of three of nine residents (4, 76, and 399). These failure had the potential to affect the resident's dignity, and psychosocial well-being. Findings: 1. Resident 76 was admitted to the facility on [DATE], with diagnoses which included muscle weakness, per the facility's Resident Face Sheet. The MDS, dated [DATE], indicated Resident 76 had a BIMS score of 15 (a score of 12-15 indicated a resident was cognitively intact), and required the assistance of facility staff to shave. On 8/25/19 at 9 A.M., an observation and interview was conducted with Resident 76. Resident 76's hair was long, past his shoulders, and he had long facial whiskers. Resident 76 stated he had asked for a haircut and beard trim and had offered to pay for it. Resident 76 stated the facility had not assisted him with having a haircut or his beard trimmed. Resident 76 further stated being unshaven and having unkempt hair made him feel sad and depressed On 8/26/19 at 9:17 A.M., an interview 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 fully promote and facilitate resident self-determination through support of resident choice for two of 34 sampled Resident's (54, 122). There was a lack of communication amongst staff when Resident 54 requested a room change and when Resident 122 requested possession of own wheelchair for use. The lack of communication did not afford both Residents the opportunity to have their choices honored and ensure continuity of care was maintained. As a result, Resident 54 did not have access to his electric wheelchair, and Resident 122 remained in a room with an incompatible roommate. Findings: 1. Resident 54 was admitted to the facility on [DATE] with diagnoses which included dialysis (a process to filter blood) and disorders of bone density and structure per the Facility's Resident Face Sheet. On 8/25/19 at 11:20 A.M., an interview with Resident 54 was conducted. Resident 54 stated the facility took his electric wheelchair away and it had not…

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 properly store resident's medical and financial records in a secured location. This failure had the potential for resident's confidential health information, and financial information to be viewed by unauthorized staff, residents and visitors. Findings: On [DATE] at 9:10 A.M., an observation and record review was conducted on Unit 4. Behind an unlocked door, labeled Storage Room, were approximately 40 boxes. Some boxes were labeled Expired, Accounts Payable, and Activities Records. On [DATE] at 8:29 A.M., an observation and interview was conducted with the Unit Clerk (UC). The UC opened the unlocked door to the storage room, and stated it contained medical records and should have been locked. On [DATE] at 8:37 A.M., an observation and interview was conducted with M1. The M1 stated the janitors were responsible for cleaning the storage room. The M1 opened the door to the storage room and stated it contained medical records. The M 1 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 revise care plan interventions for two of 32 sampled residents (67) (138). 1. This failure had the potential to contribute to Resident 67 repeatedly falling and sustaining injuries, affecting his quality of life. 2. This failure had the potential to cause miscommunication about Resident 138's mobility limitations. Findings: 1. Resident 67's record was reviewed: Resident 67 was admitted to the facility on [DATE], with diagnoses which included dementia (memory loss), per the facility's face sheet. Per the MDS, dated [DATE], Resident 67 required the assistance of one caregiver to transfer (how a resident moves between the bed and wheelchair), and to walk. Per the MDS, Resident 67 had two or more falls without injury. On 8/25/19 at 8:15 A.M., an observation was conducted. Resident 67 was lying in bed and had a large discolored, raised area on the right side of his head, face and neck. There was a bed alarm (alarm that sounds when a 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 The facility failed to provide the necessary care and services for three of nine residents (400, 46, 101) sampled for activities of daily living when: 1. Resident 400 was not provided assistance when eating. 2. Residents 46 and 101 did not receive assistance with shaving or trimming facial hair. Findings: 1. This failure had the potential to affect Resident 400's nutritional intake. On 8/16/19 Resident 400 was admitted to the facility with diagnosois which included general weakness, and reduced mobility, per the facility's Resident Face Sheet. On 8/25/19 at 8:50 A.M., an interview with Resident 400 was conducted. Resident 400 stated, my food is always cold because I can't use my hands, others need to feed me and I have to wait. On 8/25/19 at 12:35 A.M., an observation and interview was conducted with Resident 400. Resident 400 was observed eating lunch in bed. Resident 400's right hand was shakey and most of the dark green vegetable that was in his spoon fell unto a towel that laid on his chest. Resident 400…

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 consistently document neurological examinations (an assessment for level of consciousness, pupil reaction, vital signs, sensory and motor responses related to a head injury) for one of three residents (5) reviewed for unwitnessed falls. This failure had the potential for Resident 5 to have an undetected closed head injury with a delay in treatment. Findings: Resident 5 was re-admitted to the facility on [DATE], with diagnoses which included cerebral infarction (stroke) and dementia (memory loss), per the facility's Resident Face Sheet. On 8/25/19 at 10:19 A.M., an observation was made of Resident 5 in his room. Resident 5 was lying in bed with floor mats on both sides of the bed. On 8/26/19 at 3 P.M., a review of Resident 5's clinical record was conducted. Per the facility's Event Report, dated 5/12/19, Resident 5, .had an unwitnessed fall from bed, to landing mat . Resident 5's record was reviewed. Resident 5's neurological examinations after 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.

The facility failed to provide proper shift assessments of the Arteriovenous Fistula (The AV Fistula is a blood vessel made wider and stronger by a surgeon to allow blood to flow out to and return from a dialysis machine) for two of nine (137,401) residents who received dialysis services. As a result, Resident 137 and Resident 401 did not receive proper assessment of their AV fistula's which could have hindered or caused complications with their dialysis care. Findings: 1. On 8/02/19 Resident 137 was admitted to the facility with diagnosis of end stage renal disease per the facility's Resident Face Sheet. 2. On 8/20/19 Resident 401 was admitted to the facility with diagnosis of End Stage Renal Disease per the facility's Resident Face Sheet. On 8/25/19 a t 8:08 A.M., an interview was conducted with Resident 137. Resident 137 stated she was concerned about her AV Fistula because she could not recall when the nurses at the facility had checked it. On 8/25/19 at 8:20 A.M., an interview was conducted with LN 24. LN 24 stated she had provided nursing care for Resident 137 for about three…

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 remove a discontinued narcotic (medication with a high potential for abuse) from one of six medication carts reviewed for medication storage. This deficient practice had the potential for diversion (theft) of controlled narcotic medications. Findings: On 8/28/19 at 8:28 A.M., a concurrent observation and interview was conducted with LN 3 during an inspection of Station 4's medication cart. In the narcotic drawer, behind the discard divider was a bubble pack (package of sealed pill medications on a cardboard sheet). The bubble pack was labeled with Resident 76's name, listed the medication as Ambien (a sedative used for sleep) 5 mg, and was filled on 8/2/19. There were 11 pills remaining in the bubble pack. LN 3 stated Resident 76's Ambien was discontinued on 8/11/19, and the medication was never removed from the medication cart. LN 3 stated the medication should have been given to the DON within 24 hours of being discontinued. LN 3 stated the Ambien could have been diverted, and no one would have known. 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 on observation, interview and record review, the facility failed to document daily refrigerator temperatures for one of two refrigerators used to store resident food. This deficient practice had the potential for residents food to acquire food borne illnesses when stored at improper temperatures. Findings: On 8/25/19 at 9:16 A.M., an observation was conducted of the resident refrigerator on Station 3. The temperature log taped to the outside of the refrigerator door contained no temperature entries after 8/19/19. Within the resident refrigerator was a clear plastic container of hot peppers, an unopened container of hummus, and a sealed package of orange cheese, all labeled with different resident's names. On 8/25/19 at 3:30 P.M., an interview was conducted with the RD. The RD stated food brought in from the outside for residents consumption, needed to be labeled with the resident's name, room number, and the date received. On 8/25/19 at 3:55 P.M., the RD was observed removing all food and kitchen supplied snacks from the resident refrigerator. On 8/26/19 at 8:12 A.M., a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure coordination of care with hospice (end of life care) and ensure hospice services were provided for one unsampled resident (46). As a result, there was the potential for Resident 46 to have not received appropriate and timely hospice care services. Findings: Resident 46 was admitted to the facility on [DATE], with diagnoses which included lung cancer, per the facility's Resident Face Sheet. Per the physician's order, dated 3/5/19, Resident 46 was admitted to hospice on 3/5/19. On 8/25/19, at 3:59 P.M., an observation and interview was conducted with Resident 46. Resident 46 had long whiskers on his face. Resident 46 stated the person who was supposed to shave him had not come for three days. On 8/26/19 at 2:15 P.M., an interview with Resident 46 was conducted. Resident 46 stated he was due for a shower and shave and he hoped the person who was supposed to help him was going to come that day. On 8/27/19 at 8:51 A.M., an observation…

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 staff failed to observe infection control precautions for one of 34 (38) sampled residents. This failure had the potential to transmit an infection to other residents, visitors, and staff members. Findings: On 6/19/19 Resident 38 was admitted to the facility with diagnosis which included Clostridium difficile (a serious bacteria infection) per the facility's Resident Face Sheet. On 8/25/19 at 9:05 A.M., an observation of Resident 38's room was conducted. There was a sign posted outside Resident 38's room door. Per the sign, Isolation, infection control precautions, please talk to the licensed nurse before entering room. On 8/25/19 at 4:03 P.M., an interview was conducted with HSK 21. HSK 21 stated she was not sure what type of isolation was in place for Resident 38. Hsk 1 stated she was uncertain what precautions needed to be observed before entering Resident 38's room. On 8/26/19 at 12:52 P.M., an interview and record review was conducted with MDS 1. MDS 1 stated Resident 38 was in isolation for Clostridium Difficile…

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.