Ocean View Post Acute

Based on observation, interview and record review, the facility failed to ensure kitchen staff utilized recipes when preparing foods. This failure had the potential to place residents at risk for poor intake and weight loss. Findings: A review of the 6/4/25 lunch menu was conducted. The pureed lunch menu listed pureed pesto chicken pasta, pureed breadstick and chilled steamed vegetables. An observation of food production was conducted in the kitchen with [NAME] 1 (CK 1) on 6/4/25 starting at 10:30 A.M. 1. CK 1 stated she would make pureed bread. CK 1 placed approximately eight slices of white bread into a food processor, then poured an unmeasured amount of pale yellow liquid into the food processor. CK 1 stated the pale yellow liquid was chicken broth. When asked how much chicken broth she had added to the food processor, she stated, Enough to moisten the bread. When asked where the recipe was for pureed bread, CK 1 stated she would go ask for a recipe. CK 1 returned with a recipe for pureed bread. CK 1 continued processing the bread in the food processor. CK 1 stated she 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.

Based on observation, interview and record review, the facility failed to provide alternate menu options of similar nutritional value to residents. This failure had the potential to result in meals not being equal in nutritive value, and may result in weight loss. Findings: A record review was conducted of the facility's menu and alternate items list. An Always Available Menu was posted outside of the dining room, and it included cheese quesadilla and a grilled cheese sandwich. An observation of the lunch trayline was conducted on 6/4/25, beginning at 11:45 A.M. 1. At approximately 12:20 P.M., Food Service worker (FSW) 1 stepped over to the stove and placed four small tortillas into a pan. FSW 1 added a small amount of shredded cheese to each tortilla and folded them in half. FSW 1 did not use a measuring cup or scale prior to adding the shredded cheese to the pan. FSW 1 stated two of the small quesadillas counted as a portion. 2. At approximately 12:40 P.M. FSW 1 stepped over to the stove, and placed four slices of white bread into an oiled pan. FSW 1 added two yellow, square…

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 dispose of an expired food product in a nursing unit refrigerator. This failure had the potential to place residents at risk for food borne illness. Findings: An observation of a nursing station refrigerator was conducted on 6/4/25 at 10:30 A.M. with Licensed Nurse (LN) 12. A prepackaged sandwich was in the refrigerator, with a label indicating it had been placed in the refrigerator on 5/31/25, and should be disposed of on 6/3/25. LN 12 stated a staff member should have thrown away the sandwich the previous day. Per LN 12, it was nursing staff responsibility to check all food items in the unit refrigerator to prevent food poisoning. An interview was conducted with Registered Dietitian (RD) 1 on 6/5/25 at 2 P.M. Per RD 1, nursing staff was responsible for checking the unit refrigerators for expiration dates. Per a facility policy, revised 9/13/25 and titled Food From Outside Sources, Food brought in by visitors, family, friends or other guests for residents is permitted allowing the resident the right to choose…

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 flu vaccine (a vaccine which provides immunity to a variety of influenza viruses) was provided to one of five sampled residents (Resident 69). This had the potential for putting Resident 69 at risk for acquiring, transmitting or experiencing complications from influenza (an acute contagious viral infection characterized by inflammation of the respiratory tract). Findings: A review of Resident 69's admission Record indicated Resident 69 was readmitted to the facility on [DATE] with diagnoses which included immunodeficiency (decreased ability of the body to fight infections and other diseases). A review of Resident 69's attending physician completed Resident 69's history and physical (H&P) dated 10/26/24. The H&P indicated Resident 69 did not have the capacity to understand and make decisions. On 6/4/25 at 8:57 A.M., a joint review of Resident 69's clinical record and an interview was conducted with the Infection Preventionist (IP). The IP…

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 respond to a medical records request for one of two sampled patients (1). As a result, the requester did not know if the records were made available to her. Findings: Per the facility's admission Record, Resident 1 was admitted to the facility on [DATE] with diagnoses to include dementia (a mental and physical decline). On 2/20/25 at 2:19 P.M., an interview was conducted with the Social Worker (SW). The SW stated Resident 1's Responsible Party (RP 1) emailed her a request for medical records on 2/17/25. The SW further stated, they planned on having the medical records ready by 2/21/25 per RP 1's request. On 2/28/25 at 9:28 A.M., an interview was conducted with the SW. The SW stated, the medical records were ready to be picked up on 2/21/25, but she did not respond to RP 1's record request or notify RP 1 that the medical records were ready to be picked up. The SW stated, they received an additional medical records request on 2/24/25, and delivered the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to prevent a hazardous situation when supervision was not provided for one resident (1) during an outpatient appointment and his whereabouts were unknown. This deficient practice placed Resident 1 at increased risk of injury when Resident 1 was found, sitting in the sun, outside the outpatient appointment location by a bystander and sent to the hospital. Findings: Resident 1 was admitted to the facility on [DATE] with a diagnosis of a fracture of the right femur (broken right upper leg bone) and unspecified dementia (a loss of mental functioning including, remembering and reasoning) per the facility's admission record. A review of Resident 1's physicians orders indicated, Resident 1 had an outpatient follow-up appointment with an orthopedist ( a medical specialist who focuses on injuries and diseases affecting the musculoskeletal system (bones, muscles, joints and soft tissues), on 9/5/24 at 10:45 A.M. On 9/23/24 at 2:45 P.M., an interview was conducted…

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 appropriately discharge on e of one resident (Resident 3) with elopement risk reviewed for discharge planning when; 1. There was no documentation regarding Resident 3's elopement risk and the appropriateness of a discharge to an independent living facility and, 2. A discharge care plan was not developed. As a result, Resident 3 was readmitted to the hospital. Findings: Resident 3 was admitted to the facility on [DATE] with the diagnoses including dementia (a condition characterized by loss of memory, language, problem solving and other thinking abilities) and repeated falls according to the facility's admission Record. During a review of the physician's history and physical (H&P) admission note dated 2/7/24, the H&P indicated .patient resides at Board and Care (place to live that provides food and personal care). Patient was wandering and went missing for several days. He was found by local police and brought in the hospital and placed on 5150 hold…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide a plan of care and adequate supervision to prevent one of three residents reviewed for elopements from leaving the facility (Resident 1). As a result, Resident 1 went missing from the facility without staff ' s knowledge and placed Resident 1 at risk for harm. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses including dementia (an impairment of brain function, such as memory loss and judgment) according to the facility ' admission Record. During an interview on 3/15/24, at 9:46 A.M. with Resident 1, Resident 1 stated a week ago on Monday, 3/4/24 he walked out of the facility to look for a house for sale then came back. Resident 1 stated this past Monday, 3/11/24 he left the facility again when it was still dark outside and staff from the facility found him outside during the day. An interview was conducted on 3/15/24, at 10:22 A.M. with Resident 1 ' s assigned certified nurse assistant (CNA) 1. 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 interview and record review, the facility failed to notify the responsible party when sodium valproate (a medication that effects the mind) was discontinued for one of two sampled residents (1). As a result, Resident 1 ' s responsible party was not fully aware of what medications he was taking. Findings: Per the facility ' s admission Record, Resident 1 was admitted on [DATE] with diagnoses to include dementia (a mental and physical decline), and had a designated responsible party to make his health care decisions. On 2/21/24 at 4:50 P.M., a telephone interview was conducted with the Director of Nursing (DON). The DON stated, the facility had to notify Resident 1 ' s responsible party for any changes in his medication. The DON further stated, they were not able to find any documentation that they notified Resident 1 ' s responsible party when sodium valproate was discontinued. Per the facility ' s Psychiatry Progress Note dated 12/26/23, .(Resident 1) unable to provide collateral information due 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 interview and record review, the facility failed to apply a skin protective cream as ordered for one of two sampled residents (1). As a result, Resident 1 was at increased risk of skin breakdown. Findings: Per the facility ' s admission Record, Resident 1 was admitted on [DATE] with diagnoses to include dementia (a mental and physical decline). Per the facility ' s Treatment Administration Record for Resident 1, dated 1/30/24, there was an order on 1/15/23 to, Apply barrier cream (a cream to prevent skin breakdown) .every shift for maintenance of .buttocks . In January 2024 there were 70 opportunities for staff to sign that they completed the task as ordered, and 21 opportunities were blank. On 2/20/24 at 12:23 P.M., a telephone interview was conducted with the Director of Nursing (DON). The DON stated, if there was a blank space on the Treatment Administration Record, it meant that the task was not done. The DON further stated, if the task was not done, the staff should have documented why. 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 current infection control practices were followed when a facility employee did not wear a face shield inside a resident's room (Resident 3) who was on isolation for COVID-19 (an infectious respiratory disease). Failure to follow current infection control practices had the potential to spread infectious disease to all residents, staff, and visitors. Findings: Resident 3 was admitted to the facility on [DATE] with the diagnosis including COVID-19 according to the facility's admission Record. During an observation on 11/15/23, at 9:50 A.M., Resident 3's room had a, Stop sign outside, hanging under the room number. The back of the sign indicated, Droplet (spread of germs passed through speaking, sneezing, or coughing) and Contact Precautions (prevention of infection by direct or indirect contact) .Personal Protective Equipment Needed. Gown, N-95 (a fitted filtering mask), Face shield, Gloves . During observation and 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 interview and record review, the facility failed to: 1. Perform and document neurological checks (assessing mental status, level of consciousness, eye response to light, motor strength, feeling sensation, and vital signs {blood pressure, pulse, respiratory rate} every 15 minutes for one hour, every 30 minutes for one hour, every hour for two hours, every two hours for four hours, every four hours for 16 hours, every 8 hours for 24 hours) after an unwitnessed fall per the nursing standard of practice for one of four residents (Resident 1) reviewed for falls; and 2. Accurately score (low, medium or high risk of future falls) for a fall assessment after an unwitnessed fall for one of four residents (Resident 1), reviewed for falls. As a result, Resident 1 ' s head injury could have been detected earlier and a higher fall assessment score would have implemented more interventions to prevent future falls. Findings: 1. Resident 1 was admitted to the facility on [DATE], with diagnoses which included chronic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to label the oxygen (O2) tubing and humidification water bottle for one of two residents (Resident 307). This failure had the potential to increase the risk of developing pneumonia and/or other infections, with an inadequately monitored oxygen delivery system. Findings: Resident 307 was an [AGE] year-old male, admitted on [DATE] with a diagnosis that included Acute Respiratory Failure with hypoxia (trouble breathing with blood oxygen levels below normal), pneumonia (infection in the lungs), sepsis (severe infection), hypoxia (decreased oxygen perfusion to tissues) and pleural effusion (fluid on the outside of the lungs) per the facility admission Record. During an observation on 3/20/23 at 12:54 P.M., Resident 307 was lying on his back in bed, with his eyes closed. Oxygen was observed on Resident 307 via nasal cannula (small prongs in the nose), at 2 Lpm (liters per minute), delivered via a humidified water reservoir (humidifier) that 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.

Based on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. The facility's medication error rate was 8%. Two medication errors were observed, with a total of 25 opportunities, during the administration process for one of 5 randomly observed residents ( Resident 315). As a result, the facility failed to ensure medications were administered correctly to Resident 315. Findings : On 3/23/23 at 8:10 A.M., an observation of medication administration was conducted with Licensed Nurse (LN) 1. LN 1 prepared and administered 3 medications to Resident 315 through a gastrostomy tube ( G tube, a surgically -placed device for direct access to the stomach ), which included : Amlodipine tablet 5 mg, one tablet (used to treat high blood pressure ) Gabapentin 300 mg, one tablet ( used for nerve pain) Metoprolol tablet 25 mg, one tablet (used to treat high blood pressure) LN 1 crushed each medication, and placed them into separate 30 milliliters (ml) medication cups. LN 1 added 20 ml of water to each cup and administered the crushed…

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 a copy of the Notice of Transfer or Discharge form to the Ombudsman, when residents were discharged from the facility for three of three sampled residents (13,91,95). As a result, there was a potential for residents to not have access to an advocate who could inform them of their options and rights related to transfers and discharges. Findings: 1. Resident 95 was admitted on [DATE], per the facility's admission Record. Resident 95 was transferred to a general acute care hospital (GACH) on 5/31/19, and on 7/21/19. On 8/15/19 at 10:42 A.M., a joint interview and record review was conducted with the SSD. The SSD was not able to find a copy of a Transfer/Discharge Notice form in Resident 95's record. The SSD stated, nursing was responsible for the completion of the form and should send the form to the Ombudsman. The SSD stated she did not notify the Ombudsman when a resident was transferred to a general acute care hospital. On 8/15/19 at 10:54 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 interview and record review, the facility failed to provide a written notice of bed- hold, upon transfer to the GACH, for four of four sampled residents (13, 91, 95, 98). As a result, these residents' did not have information to accept or decline a bed-hold during their absence. Findings: 1. Resident 95 was admitted on [DATE], per the facility's admission Record. Resident 95 was transferred to a GACH twice, on 5/31/19, and on 7/21/19. On 8/15/19 at 10:54 A.M., a concurrent interview and record review was conducted with the DSD. The DSD stated Resident 95's Bed Hold Informed Consent form, dated 5/16/19, was not completed when Resident 95 was transferred to a GACH on 5/31/19. The DSD stated Resident 95's Bed Hold Informed Consent form, dated 6/5/19, was not completed when Resident 95 was transferred to a GACH on 7/21/19. The DSD stated licensed nurses should have completed the bed- hold form and provided a copy of the form to Resident 95, or Resident 95's responsible party, upon transfer. On 8/15/19 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Resident 5 was admitted to the facility on [DATE], with a diagnosis of Alzheimer's Disease, unspecified (a progressive disease that destroys memory and other mental functions) per the facility's admission Record. On 8/14/19 at 9 A.M., Resident 5 was observed in the hallway, in her wheelchair, muttering to herself. On 8/15/19 at 3:30 P.M., Resident 5 was observed in the activity room, in her wheelchair, looking through a magazine. On 8/14/19 at 3:40 P.M., a review of Resident 5's medical record was conducted. No care plan for dementia was located. On 8/14/19 at 3:43 P.M., a concurrent interview and review of Resident 5's medical record was conducted with the DSD. The DSD stated there was no care plan for dementia care. Additionally, the DSD stated, We usually do one (care plan) for the behaviors associated with dementia. On 8/14/19 at 4 P.M., an interview was conducted with the DON. The DON stated, A care plan is important to identify risks for hurting herself and if current treatment is working. Based on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to revise care plans that reflected resident preferences and needs for: 1. Three of six residents (42, 59, 60) sampled for activities, and; 2. One of five residents (60) sampled for communication needs. These failures had the potential to affect the residents' care and treatment. Findings: 1. Resident 42 was admitted to the facility on [DATE], with diagnoses which included a cerebral infarction (stroke) and cognitive communication deficit (difficulty communicating), per the facility's admission Record. On 8/12/19 at 9:43 A.M., an observation of Resident 42 was conducted. Resident 42 was lying in bed with her eyes closed, calling out help, help, help, please. The lights were off in the room. On the dresser, a white and blue sock were hanging from the second drawer handle and a red and white sock was hanging from the third drawer handle. There were no activities at the bedside, no music or television was on and there were no decorations on the…

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

Based on observation, interview, and record review, the facility failed to: 1. Label and date glasses of liquids, soup bowls of liquids, remove a watermelon with fuzzy brown spots, and cover cut celery from the walk in refrigerator; 2. Remove a dented can of peaches from the storage area; 3. Remove ice cream in the walk in freezer which was soft. As a result, there was a potential for food borne illness if expired or unsafe food was served to residents. Findings: 1. During the initial observation of the kitchen on 8/12/19 at 8 A.M., there were 17 glasses and 19 soup bowls, in the walk in refrigerator, on trays. The DSS 1 stated she did not know all foods and liquids had to be marked with the contents. On 8/12/19 at 8:15 A.M., during a concurrent observation with the ADM in the walk in refrigerator, there was a watermelon which had brown indented spots. The ADM stated, This needs to be removed. On 8/12/19 at 8:20 A.M., in the walk in refrigerator, there was a large plastic bin which contained 6 stalks of celery, all of which had cut ends, and wilted leaves. The DSS 1 stated she did…

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 oberservation, interview, and record review, the facility failed to label and date resident food stored in one of two nursing station refrigerators. As a result, there was a potential for food borne illness if expired or unsafe food was served to residents. Findings: On 8/12/19 at 3:34 P.M., the pantry in Nurses' Station 3 was opened. The refrigerator contained, 7 undated health shakes. The RD 1 stated, the healthshakes were supposed to have an expiration date. They were received frozen, and once thawed, they were to be used within 7 days. The drawer of the refridgerator contained a wrapped plate of food, which the RD identified as chicken tenders. There was no date or identification label on the wrapped plate. Per the notice on the refrigerator door on Station 3, Refrigerator for residents use ONLY food needs to be dated discard after 72 hours. Per the label on the health shake container, Storage and handling Store Frozen. Thaw under refrigerations. After thawing, keep referigerated. Use within 14 days after thawing.

Based on observation, interview, and record review, the facility failed to ensure resident medical records were stored in a secured location. This failure had the potential for residents' private medical information to be viewed by non-medical staff, other residents, and visitors. Findings: On 8/14/19 at 9:24 A.M., an observation was made in the dining room. A cupboard, containing binders with resident medical information was observed, unlocked. No staff were present in the dining room. On 8/14/19 at 9:25 A.M., an observation, interview and record review was conducted with RNA 1. During the observation, Resident 66 entered the dining room and DA 39 was in the dining room setting the tables. RNA 39 stated the cupboard contained: A binder labeled RNA weekly meeting minutes -which contained weekly RNA meeting notes about residents. A binder labeled RNA Treatments Station 1- which contained a list of all residents residing on Station 1 receiving RNA, their weekly summary, their physician's order for RNA, their physical therapy referral form and their restorative treatment record. 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.

Based on interview and record review, the facility failed to implement an Antibiotic Stewardship Program (a system to monitor antibiotic use). This failure had the potential to increase the risk of adverse events from unnecessary or inappropriate antibiotic use. Findings: A concurrent interview and record review was conducted with the ICN on 8/15/19, at 2 P.M. A binder labeled Antibiotic Stewardship was reviewed and only two antibiotic surveillance sheets were present. The ICN stated this is not complete, we just introduced it. Additionally, the ICN stated, The residents get the antibiotic if the physician orders it. We don't call and discuss criteria for antibiotic usage. There is pushback from family and physicians. An interview was conducted with the ICN on 8/15/19, at 2:15 P.M. The ICN stated, It is important because residents should be treated correctly; the purpose is to reduce antibiotic use; it is not really an effective program. A joint interview was conducted with the ADM and DON on 8/15/17, at 2:30 P.M. The DON stated, We acknowledge that the program is not where it needs…

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

Based on observation, interview, and record review the facility failed to maintain a tile floor in good repair when tiles were chipped and missing, in 1 of 2 shower rooms. As a result, there was a potential for residents' feet to be cut in the shower room and there was a potential for a trip hazard. Findings: On 8/13/19 at 4:41 P.M., the tiles in the shower room at Station 3 were observed. More than eight tiles were missing or broken, some with sharp edges. On 8/13/19 at 4:45 P.M., a concurrent observation and interview was conducted with the MTD. The MTD stated, the tiles could cause cuts on residents' feet and should be replaced. On 8/13/19 at 5 P.M., an interview was conducted with the MTD. The MTD stated he did not have a work order request in the Maintenance/Housekeeping Log. Per the facility policy, Environment of Care, Keeping Resident's Room in Order, dated 8/9/19, . (1) A safe, clean, comfortable, and homelike environment .(i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes 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 interview, and record review, the facility failed to code the MDS correctly, for one of 19 sampled residents (81). As a result, there was a potential to affect the provision of care, and provided inaccurate information to the Federal database. Findings: Resident 81 was readmitted to the facility on [DATE], per the facility's admission Record. The MDS, dated [DATE], for Resident 81 was reviewed on 8/12/19. Per section N of the MDS Insulin use (injection to control blood sugar), A. Insulin Injections-Record the number of days that insulin injections were received during the last 7 days . Recorded on 7/25/19 was the number 7. On 8/12/19 at 3:30 P.M., the MDS Nurse stated Resident 81 was not diabetic (high blood sugar level), and therefore not on insulin. The MDS Nurse stated she made a mistake. Per the facility policy, Certification of accuracy of the MDS, dated [DATE], .Purpose .Legally, it is an attestation that to the best of your knowledge, the information you entered on the MDS accurately reflect 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 consistently provide a method of communication, in a residents' preferred language, for three of three residents (53, 59, 60) sampled for communication. This failure had the potential to affect the residents' ability to effectively communicate with facility staff. Findings: 1a. Resident 53 was admitted to the facility on [DATE], with diagnoses which included legal blindness (impaired ability to see), per the facility's admission Record. Per the MDS, dated [DATE], Resident 53's preferred language was [NAME], and Resident 53 required a translator to communicate with health care staff. On 8/13/19 at 3:58 P.M., an observation and interview was conducted with CNA 41. Resident 53 was lying in bed. CNA 41 stated Resident 53 spoke Korean, that there were no Korean speaking care givers in the facility, and if Resident 53 spoke to her, she would have asked the nursing supervisor to call his family and translate. On 8/13/19 at 4:18 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 did not provide person-centered, in-room activities that met the needs and preferences for three of five residents (42, 59, 60) sampled for activities. This failure had the potential to cause decreased quality of life. Findings: 1. Resident 42 was admitted to the facility on [DATE], with diagnoses which included a cerebral infarction (stroke) and cognitive communication deficit (difficulty communicating), per the facility's admission Record. On 8/12/19 at 9:43 A.M., an observation of Resident 42 was conducted. Resident 42 was lying in bed with her eyes closed, calling out help, help, help, please. The lights were off in the room. A white and blue sock hung from the second drawer handle of the dresser, and a red and white sock hung the third drawer handle. There were no activities at the bedside, there were no decorations on the wall, the television was off and there was no music. On 8/12/19 at 11:05 A.M., an observation of Resident 42 was conducted.…

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 appropriate urinary catheter (a tube placed in the bladder to drain urine) care was provided to one of three residents (53) sampled for catheter care. This failure placed Resident 53 at risk for a urinary tract infection (bacteria in the urine). Findings: Resident 53 was admitted to the facility on [DATE], with diagnoses which included neuromuscular dysfunction of the bladder (loss of bladder control due to nerve damage), per the facility's admission Record. The MDS, dated [DATE], indicated Resident 53 was totally dependent (required staff to perform all aspects of care) on facility staff for catheter care. Resident 53's catheter care plan, dated 7/15/19, was reviewed. Interventions included positioning the catheter bag (urine collection bag attached to the catheter) below the level of the bladder. On 8/13/19 at 3:58 P.M., an observation and interview was conducted with CNA 41. Resident 53 was lying in bed on his right side. 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 a CNA acted within their scope of practice when operating an enteral (through a tube inserted into the stomach) feeding pump (machine used to deliver liquid nutrition) for one unsampled resident (53). This failure had the potential to compromise Resident 53's nutritional status and well-being. Findings: Resident 53 was admitted to the facility on [DATE], with diagnoses which included dysphagia (difficulty swallowing), per the facility's admission Record. The physician's order, dated 6/30/19, indicated Resident 53 was to receive an enteral feeding. The MDS, dated [DATE], indicated Resident 53 was totally dependent (required staff to perform all aspects of care) on facility staff for nutrition. On 8/12/19 at 8:20 A.M., an observation of Resident 53 was conducted. Resident 53 was lying in bed with his eyes closed. An enteral feeding pump (EFP), turned off, was at the bedside. On 8/12/19 at 3:14 P.M., an observation of Resident 53 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 comprehensively assess the needs of one of three residents with dementia (5). This failure had the potential for Resident 5 to not achieve the highest practicable physical, mental and psychosocial well-being. Findings: Resident 5 was admitted to the facility on [DATE], with a diagnosis of Alzheimer's Disease, unspecified (a progressive disease that destroys memory and other mental functions) per the facility's admission Record. On 8/14/19 at 9 A.M., Resident 5 was observed in the hallway, in her wheelchair, muttering to herself. On 8/15/19 at 3:30 P.M. Resident 5 was observed in the activity room, in her wheelchair, looking through a magazine. On 8/14/19 at 3:40 P.M., a review of Resident 5's medical record was conducted. There was no comprehensive nursing assessment for dementia and no behavior monitoring. On 8/14/19 at 3:43 P.M., a concurrent interview and review of Resident 5's medical record was conducted with the DSD. The DSD 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 2. Resident 7 was admitted to the facility on [DATE], with diagnoses including cognitive communication deficit (difficulty communicating), per the facility's admission Record. On 8/13/19, at 9:04 AM, an observation was conducted in Resident 7's room. A plastic bag with unknown contents was on the floor of Resident 7's closet. On 8/13/19 at 4:18 P.M., an observation and interview was conducted with LN 41. LN 41 examined the contents of a plastic bag on the floor in Resident 7's closet. LN 41 stated the bag contained a cleansing enema set. LN 41 stated the cleansing enema set should not have been in Resident 7's closet because it was a medication. On 8/13/19 at 5:05 P.M., an interview was conducted with the DON. The DON stated a cleansing enema set required a physician's order, should be kept locked in a medication cart and should be administered by licensed nurses. The DON stated the cleansing enema set should not have been in Resident 7's closet. Based on observation, interview and record review, the facility…

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 ensure appropriate urinary catheter (a tube placed in the bladder to drain urine) care was provided to one of three residents (53) sampled for catheter care. This failure placed Resident 53 at risk for a urinary tract infection (bacteria in the urine). Findings: Resident 53 was admitted to the facility on [DATE], with diagnoses which included neuromuscular dysfunction of the bladder (loss of bladder control due to nerve damage), per the facility's admission Record. The MDS, dated [DATE], indicated Resident 53 was totally dependent (required staff to perform all aspects of care) on facility staff for catheter care. Resident 53's catheter care plan, dated 7/15/19, was reviewed. Interventions included positioning the catheter bag (urine collection bag attached to the catheter) below the level of the bladder. On 8/13/19 at 3:58 P.M., an observation and interview was conducted with CNA 41. Resident 53 was lying in bed on his right side. A catheter bag was hung from the side rail on the…

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