Palomar Heights Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to assist with or obtain an Advanced Directive (AD-a legal document that allows a person to specify their healthcare preferences in the event that residents become unable to make medical decisions for themselves due to illness, injury, or other circumstances) for two of 24 sampled residents (Residents 22 & 56). This deficient practice placed Residents 22 & 56 at risk for not having their medical treatment wishes known or followed during a health emergency. Findings: 1. A review of Resident 22's admission Record indicated Resident 22 was re-admitted to the facility on [DATE] with diagnoses which included a history of chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) and dementia (a progressive state of decline in mental abilities). On 5/29/25 at 3:12 P.M., an interview and record review was conducted with the Social Service Director (SSD). The SSD stated an AD was obtained upon admission and discussed with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure four of 24 residents (33, 56, 76, 27) had a safe and homelike environment when the facility did not: 1. Replace or reimburse lost belongings for Resident 33. 2. Provide a living environment that was clean and well maintained for Residents 56, 76 and 27. As a result, Resident 33 did not have the ability to have a different shirt for each day of the week. In addition, there was the potential for Residents 56, 76 and 27 to feel uncomfortable in their environment. Findings: 1. On 5/27/25 at 3:07 P.M., during initial screening, Resident 33 was interviewed. Resident 33 stated he was missing cloths, specifically the facility could not find 3 of his shirts. Resident 33 stated he notified the facility, but they had not replaced or reimbursed, the lost shirts. Resident 33 stated he was told they were waiting for corporate's decision on replacing or reimbursing the shirts. On 5/28/25 at 9:30 A.M., the Social Services Director (SSD) 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 interview and record review, the facility failed to review, a Minimum Data Set (MDS- a federally mandated resident assessment tool) to determine the Significant Change of Status Assessment (SCSA-an improvement or decline), and/or update a care plan for one of five residents sampled (Resident 9) according to the Resident Assessment Instrument (RAI-MDS manual). This deficient practice placed Resident 9 for delayed care planning and unmet care needs. Cross-Reference F640 and F657 Findings: A review of Resident 9's admission Record indicated Resident 9 was re-admitted to the facility on [DATE] with diagnoses which included a history of pulmonary fibrosis (a lung disease that occurs when lung tissue becomes damaged and scarred making it hard to breath). A review of Centers for Medicare and Medicaid Services (CMS, a federal agency) RAI Manual 3.0 October 2024, (Page 2-25) .After the IDT (Interdisclipnary Team) has determined that a resident meets the significant change in the resident's status in the clinical…

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 complete the Minimum Data Set (MDS - a federally mandated resident assessment tool) and Care Area Assessment (CAA) on time, as required by the Resident Assessment Instrument (RAI-MDS manual), for one of five sampled residents (Resident 9). This deficient practice placed Resident 9 at risk for delays in care planning and unmet care needs. Cross-Reference F637 and F657 Findings: A review of Resident 9's admission Record indicated Resident 9 was re-admitted to the facility on [DATE] with diagnoses which included a history of pulmonary fibrosis (is a lung disease that occurs when lung tissue becomes damaged and scarred making it hard to breath). A record review of Resident 9's MDS dated [DATE] Section Z indicated, a signature completion dated 5/15/25. The transmission report indicated: .Assessment Completion Late: Z0500B (assessment completion date) is more than 14 days after A2300 (assessment reference date [ARD]) . .Care Plan Completed Late: V0200B2 (CAA…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop a person-centered care plan that included activities based on resident's preferences for one of five sampled residents (Resident 9). This deficient practice placed Resident 9 at risk for not having their individual needs and interests supported, which could negatively affect their emotional well-being and quality of life. Cross-Reference F679 Findings: A review of Resident 9's admission Record indicated Resident 9 was re-admitted to the facility on [DATE] with diagnoses which included a history of major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). A record review of Resident 9's minimum data set (MDS-a federally mandated resident assessment tool) dated 4/30/25 indicated, a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of 12 points out of 15 possible points which indicated Resident 9 had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to update the care plan after a Significant Change of Status Assessment (SCSA), as required by the federal guidelines, for one of five sampled residents (Resident 9). This deficient practice placed Resident 9 at risk for receiving care that did not reflect their current condition, which could delay needed support, and negatively affecting their health and well-being. Cross-Reference F637 and F640 Findings: A review of Resident 9's admission Record indicated Resident 9 was re-admitted to the facility on [DATE] with diagnoses which included a history of pulmonary fibrosis (is a lung disease that occurs when lung tissue becomes damaged and scarred making it hard to breath). A clinical chart review of Resident 9's activities of daily living (ADL- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) care plan revised date 1/25/25 did not include SCSA updated information of Resident 9's improvement. 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 ensure three of six residents, who were unable to carry out activities of daily living (ADL-self- care activities such as grooming, bathing, and toileting), received assistance with nail care (cleaning, trimming and/or filing of nails) and shaving (Resident 5, 26 and 39). This failure resulted in residents having long and dirty fingernails which had the potential to negatively impact the residents' self-esteem and comfort. Findings: Resident 5 was admitted to the facility on [DATE] with diagnoses including hemiplegia (total or partial paralysis of one side of the body) and hemiparesis (muscle weakness on one side of the body) following cerebral infarction (disrupted blood flow to the brain) according to the facility's admission Record. A review of Resident 5's care plan initiated on 2/2/23 indicated, Resident .requires assistance related to impaired mobility .Will provide assistance with ADLs as indicated. During an observation and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide meaningful activities that matched the preferences and needs of one of five sampled residents (Resident 9) based on their comprehensive, resident-centered care plan and assessment. This deficient practice placed Resident 9 at risk for decreased mental and emotional well-being, social isolation, and reduced quality of life. Cross-References F656 Findings: A review of Resident 9's admission Record indicated Resident 9 was re-admitted to the facility on [DATE] with diagnoses which included a history of major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). A record review of Resident 9's minimum data set (MDS-a federally mandated resident assessment tool) dated 4/30/25 indicated, a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of 12 points out of 15 possible points which indicated Resident 9 had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of four residents reviewed for accidents was free of accidents during the use of a Hoyer lift (mechanical lift device used to move immobile residents). (Resident 26) This failure resulted in the Hoyer lift hitting Resident 26's left knee which caused Resident 26 pain. Findings: Resident 26 was admitted to the facility on [DATE] with diagnoses including muscle weakness and chronic venous hypertension (persistent high blood pressure in the veins, typically in the legs) with inflammation (redness and swelling) of left lower extremity according to the facility's admission Record. During an interview on 5/27/25 at 9:20 A.M. with Resident 26, Resident 26 stated a Certified Nurse Assistant (CNA) weighed him on 5/26/25. Resident 26 stated the CNA caused him pain because the sling (supports the body which connects to the lift) was not applied correctly and the metal part of the lift hit his left knee. Resident 26 stated he had arthritis…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one resident (Resident 40) with Post Traumatic Stress Disorder (PTSD) out of 24 sampled residents received trauma-informed care. This failure had the potential to re-trigger trauma for Resident 40. Findings: Review of admission Record for Resident 40 indicated she was admitted on [DATE] for diagnoses which included fractured left Radial Styloid Process (a bony projection located on the lower end of the forearm) , Seizures (a sudden, temporary disturbance in brain activity that causes changes in behavior, movement, sensation, or consciousness), Repeated Falls, Traumatic Brain Injury (a disruption of the normal function or structure of the brain caused by an external force), and Post Traumatic Stress Disorder (a mental health condition that's caused by an extremely stressful or terrifying event). Review of MDS Section C-Cognitive (thinking processes) Patterns indicated a Brief Interview of Mental Status (BIMS) score of 11 which indicated moderate…

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

Based on interview and record review the facility failed to ensure employee performance evaluations were completed annually for two of five Certified Nurse Assistants (CNA) reviewed for performance reviews. This deficient practice had the potential for CNAs to provide inadequate care to the residents. Findings: A concurrent record review and interview was conducted with the Director of Staff Development on 5/30/25 at 8:02 A.M. The DSD checked five CNA files for performance evaluations which indicated the following: CNA 8 was hired by the facility on 4/27/23 and there were no performance evaluations completed for 2024 and 2025. CNA 9 was hired by the facility on 1/25/22 and there were no performance evaluations completed for 2023 and 2025. The DSD stated it was important for employees to have evaluations to know the needs of the employees to better care for the residents. During an interview with the Director of Nursing (DON) on 5/30/25 at 10:39 A.M., the DON stated employee evaluations should be completed annually to evaluate the employee's attendance, skills, goals and the need for…

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

Based on observation and interview the facility failed to ensure the meal tray diets were verified by a licensed nurse prior to distributing to residents. As a result, the residents may have been given a diet that was incorrect. Findings: On 5/28/25 the lunch trays were brought to the floor at 12:51 P.M. Licensed Nurse 21 was observed verifying the tray cards and the food on the plate were correct. LN 21 was observed to only open the lid of a few trays, LN 21 did not open the lid on every tray to observe what was actually on the plate against the tray card. On 5/28/25 an interview was conducted with LN 21. LN 21 stated that she only lifted the lids on therapeutic diets that would prevent choking. LN 21 did not see what was on a regular tray. LN 21 did not verify for allergies or specific resident requests.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a licensed nurse (LN 37) documented a resident incident in the resident's clinical record for one of 24 sampled residents (48). As a result of this failure, it could not be determined if Resident 48 had fallen on 5/15/25. Findings: A review of Resident 48's admission Record indicated the resident was admitted on [DATE], with diagnoses that included S/P (status post) stroke, vascular dementia, (having to do with the blood vessels and circulation), and mild cognitive impairment. On 5/27/25 at 11:15 A.M., a telephone interview was conducted with Resident 48's Responsible Party (RP). The RP stated that she received a call from Resident 48 on 5/16/25 at 9:22 A.M. The RP stated that Resident 48 told her she had fallen and hit her head the night before. The RP stated two staff members helped get Resident 48 up. The RP stated she then spoke to the Assistant Director of Nursing (ADON) to report what Resident 48 had told her and the ADON stated there 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 interview and record review, the facility failed to ensure there was a process for communicating hospice services for one of two residents reviewed for hospice services (Resident 5). This failure had the potential to put Resident 5 at risk for uncoordinated medical care and treatment between the facility and the hospice agency. Findings: Resident 5 was admitted to the facility on [DATE] with diagnoses including hemiplegia (total or partial paralysis of one side of the body) and hemiparesis (muscle weakness on one side of the body) following cerebral infarction (disrupted blood flow to the brain) according to the facility's admission Record. A review of Resident 5's physician's orders (PO) in the Electronic Medical Record (EMR) was conducted on [DATE] at 10:27 A.M. The PO indicated, ADMIT TO ALL THINGS HOSPICE ON ROUTINE LEVEL OF CARE DIAGNOSIS: END STAGE STROKE . dated [DATE]. During a concurrent record review and interview on [DATE] at 9:15 A.M. with Licensed Nurse (LN) 1, LN 1 stated residents who…

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 proper infection control practices by not discarding an unlabeled intravenous (IV) hydration bag and uncapped IV tubing that was left hanging in a residents room, for one of 5 sampled residents (Resident 2). This deficient practice placed facility residents at risk for exposure to infection and the spread of harmful bacteria. Findings: According to the Centers for Disease Control and Prevention (CDC) 2024, INJECTION SAFETY GUIDELINES, indicated, .IV bags, tubing and connectors are intended for single-patient use only and should be discarded immediately after use . A review of Resident 2's admission Record indicated Resident 2 was re-admitted to the facility on [DATE] with diagnoses which included a history of human immunodeficiency virus (HIV- a virus [tiny germ] that attacks the body's immune system). A record review of Resident 2's minimum data set (MDS-a federally mandated resident assessment tool) dated 4/3/25 indicated, 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.

F883 Influenza and Pneumococcal Immunizations §483.80(d) Influenza and pneumococcal immunizations §483.80(d)(1) Influenza. The facility must develop policies and procedures to ensure that- (i) Before offering the influenza immunization, each resident or the resident ' s representative receives education regarding the benefits and potential side effects of the immunization; (ii) Each resident is offered an influenza immunization October 1 through March 31 annually, unless the immunization is medically contraindicated or the resident has already been immunized during this time period; (iii) The resident or the resident ' s representative has the opportunity to refuse immunization; and (iv)The resident ' s medical record includes documentation that indicates, at a minimum, the following: (A) That the resident or resident ' s representative was provided education regarding the benefits and potential side effects of influenza immunization; and (B) That the resident either received the influenza immunization or did not receive the influenza immunization due to medical contraindications or…

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 prevent Resident 1 from falling while transferring from bed to a wheelchair with nonfunctioning brakes. This failure had the potential to cause injury due to unnecessary falls caused by nonfunctioning brakes on Resident 1 ' s wheelchair. Cross Reference F908 Findings: Review of admission Record indicated Resident 1 was admitted on [DATE] with diagnoses which included acquired absence of left leg below the knee, difficulty in walking, and unspecified glaucoma (chronic eye disease that occurs when fluid builds up in the eye, damaging the optic nerve and causing vision loss or blindness). Review of History and Physical dated 12/11/23 indicated, .She is limited by a left BKA (Below the knee amputation-surgical removal of leg below the knee .Bed mobility: Independent, Transfer: Independent, Dressing: Independent .Orientation to time, place, and person: Patient appears moderately disoriented . Review of MDS section C-Cognitive Patterns dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a medical equipment (wheelchair) was maintained in good, proper condition on one of one resident (Resident 1) reviewed for medical equipment. As a result, Resident 1 fell due to the wheelchair's brakes not functioning. Cross Reference F689 Findings: Review of admission Record indicated Resident 1 was admitted on [DATE] with diagnoses which included: Acquired absence of left leg below the knee, difficulty in walking, and unspecified glaucoma (chronic eye disease that occurs when fluid builds up in the eye, damaging the optic nerve and causing vision loss or blindness). Review of History and Physical dated 12/11/23 indicated, .She is limited by a left BKA (Below the knee amputation-surgical removal of leg below the knee .Bed mobility: Independent, Transfer: Independent, Dressing: Independent .Orientation to time, place, and person: Patient appears moderately disoriented . Review of MDS section C-Cognitive Patterns dated 8/2/24…

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 report an allegation of abuse to the State Survey Agency for one of two sampled residents (1). As a result, the State Survey Agency ' s abuse investigation was delayed. Findings: Per the facility ' s admission Record, Resident 1 was admitted to the facility on [DATE] with diagnoses to include functional quadriplegia (inability to move most of the body including the arms and legs). Per the facility ' s admission Record, Resident 2 was admitted to the facility on [DATE] with diagnoses to include dementia (a physical and mental decline). On 2/26/24 at 11:38 A.M., an interview and review of the Abuse Log was conducted with the Director of Nursing (DON). The DON stated, Resident 1 made an allegation on 1/18/24 that Resident 2 hit her. The DON further stated, they documented the allegation in their Abuse Log, but did not notify the State Survey Agency of the allegation of abuse. On 2/26/24 at 11:43 A.M., an interview was conducted with the DON and the Social…

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 supervision for one of three residents with a fall history (Resident 2). As a result, Resident 2 had a repeat fall and sustained injuries. Resident 2 was admitted to the facility on [DATE] with 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. A review of the facility ' s document titled, Fall Risk Observation/Assessment, dated 9/29/23 indicated a score of 20. The document indicated, .A. Low risk 0-8 B. Moderate risk 9-15 C. High risk 16-42 . During a review of Resident 2 ' s progress notes (PN) dated 10/11/23, the PN indicated Resident 2 was found on the floor face down with swelling on the right eye, nosebleed, and erythema (redness) on both upper arms. During a review of the Interdisciplinary Team (IDT- team members with various areas of expertise who work together toward the goals…

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 check the blood sugar as ordered for one of two sampled residents (1). As a result, Resident 1 had an episode of low blood sugar which was not immediately identified. Findings: Per the facility ' s admission Record, Resident 1 was admitted to the facility on [DATE] with diagnoses to include diabetes (abnormal blood sugar levels). Per the facility ' s Progress Note, dated 1/26/23 at 2:52 P.M., .The change in condition/s .were .altered level of consciousness .labored or rapid breathing .chest pain/tightness .Resident presented signs of slurred speech . Per the facility ' s Progress Note, dated 1/26/23 at 9:07 P.M., .paramedics were called to have resident taken to ER (hospital emergency room). Once paramedics arrived, resident was found with a critically low blood glucose (sugar) level . Per the facility ' s Medication Administration Record (MAR), dated 11/21/23, there was an order on 11/19/22 to check Resident 1 ' s blood sugar levels before meals and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow and implement policies and procedures for an allegation of abuse when, 1. The facility did not provide results of an abuse investigation within five days of the incident for Resident 4 and, 2. The alleged perpetrator was not placed on administrative leave until completion of the abuse investigation. This failure had the potential for Resident 4 and other residents to be vulnerable and exposed to the alleged perpetrator. In addition, this failure resulted in the delay of the facility's investigation of abuse allegation, and a delay in determining the occurrence of abuse. Findings: Resident 4 was re-admitted to the facility on [DATE] with diagnoses which included traumatic brain injury (a sudden and violent blow to the head causing damage to the brain) and bipolar disorder (a mental illness causing intense mood swings from one extreme to another) according to the facility's admission Record. An observation and interview were 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 ensure Resident 1 was free from involuntary seclusion (confined to room against her will) when Certified Nursing Assistant (CNA) 1, tied a plastic bag from Resident 1's door to the hallway handrail to prevent Resident 1 from wandering outside the room while undressed. This failure had the potential to result in psychosocial trauma or unwitnessed fall for Resident 1. Findings: Resident 1 was admitted to the facility on [DATE], with the diagnoses of Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) and repeated falls. Resident 1's brief interview for mental status (BIMS - used regularly to measure and track a resident's cognitive decline) was a 3, which meant, severe cognitive impairment. During an interview on 2/4/22 at 11:15 A.M., with Assistant Director of Nursing (ADON), she stated at approximately 5:15 P.M. on 1/27/22, .the maintenance manager (MM) came to my office stating there was a plastic bag…

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

Based on interview and record review, the facility failed to conduct a quarterly (every 92 days) MDS assessment for 11 of 18 residents reviewed for Resident Assessment (3, 4, 5, 6, 7, 8, 11, 15, 17, 22, and 32). This failure had the potential for any changes to the resident's clinical status to go unrecognized and unmonitored. Findings: On 3/17/22 at 4 P.M. a record review was conducted. Per the MDS 3.0 Resident Assessments list: Resident 3 was due for a Quarterly MDS assessment on 12/22/21. Resident 3's MDS status was indicated as, Finalized. Resident 4 was due for a Quarterly MDS assessment on 1/4/22. Resident 4's MDS status was indicated as, In process. Resident 5 was due for a Quarterly MDS assessment on 12/18/21. Resident 5's MDS status was indicated as, In process. Resident 6 was due for a Quarterly MDS assessment on 12/19/21. Resident 6's MDS status was indicated as, In process. Resident 7 was due for a Quarterly MDS assessment on 12/28/21. Resident 7's MDS status was indicated as, In process. Resident 8 was due for a Quarterly MDS assessment on 1/10/22. Resident 8's MDS…

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 submit and transmit MDS assessments for 18 of 18 residents reviewed for Resident Assessment (1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 13, 14, 15, 16, 17, 22, and 32). This failure had the potential to result in delayed quality measurements from the data. Findings: On 3/17/22 at 4 P.M. a record review was conducted. Per the MDS 3.0 Resident Assessments list: Resident 1 was due for a Discharge MDS assessment on 10/22/21. Resident 1's MDS status was indicated as, In process. Resident 2 was due for a Discharge MDS assessment on 10/22/21. Resident 2's MDS status was indicated as, In process. Resident 3 was due for a Quarterly MDS assessment on 12/22/21. Resident 3's MDS status was indicated as, Finalized. Resident 4 was due for a Quarterly MDS assessment on 1/4/22. Resident 4's MDS status was indicated as, In process. Resident 5 was due for a Quarterly MDS assessment on 12/18/21. Resident 5's MDS status was indicated as, In process. Resident 6 was due for a Quarterly MDS assessment on 12/19/21. Resident 6's MDS status was indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review the facility did not ensure the Dietary Supervisor (DS) was competent to oversee the food and nutrition services at the facility when: 1. The DS did not follow the manufacturers guidelines when cleaning the kitchen's ice machine. 2. The DS did not have a kitchen cleaning schedule per the facility's policy. 3. The DS did not conduct proper oversite of the food and nutrition service staff to competently perform their job duties when: a. A Dietary employee did not wear a mask while preparing food. b. Dietary employees did not do hand hygiene after loading the dishwasher with dirty dishes. c. Dietary employees did not correctly label and date foods in the kitchen per the facility's policy. d. A cook did not prepare food in a form designed to meet the individual needs for residents on a mechanical soft and a chopped solid diet. e. A cook did not follow the approved menu and recipe. 4. The DS did not follow the facility's policy when requesting kitchen equipment…

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 document review the facility did not ensure food and nutrition service staff were able to competently carry out their job duties when: 1. A Dietary employee did not wear a mask while preparing food. 2. Dietary employees did not do hand hygiene after loading the dishwasher with dirty dishes. 3. Dietary employees did not correctly label and date foods in the kitchen per the facility's policy. As a result, residents were at risk for foodborne illnesses. 1. On 3/14/22 at 8:40 A.M., a concurrent observation and interview was conducted with [NAME] 1. [NAME] 1 was observed preparing potatoes without wearing a mask over his mouth or nose. [NAME] 1 stated it was the facility's policy he must wear a mask when in the kitchen. On 3/15/22 at 3:08 P.M. an interview was conducted with the DS. The DS stated the cook should be wearing a mask at all times while in the kitchen to prevent the spread of infection. On 3/15/22 a facility document titled Universal Source Control was reviewed. The document indicated, .All staff, regardless of vaccination status, shall…

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 document review the facility's food and nutrition services did not follow the approved menu or recipe when: 1. A cook did not follow the recipe when he prepared pureed food for lunch. 2. A cook prepared food for lunch that was not listed on the facility's approved lunch menu. 3. A cook did not use correct measuring scoops per the menu when preparing lunch trays. As a result, residents at the facility were at risk for nutritional deficits and weight loss. 1. On 3/16/22 at 10:43 A.M., a concurrent observation, document review and interview was conducted with [NAME] 1. [NAME] 1 was observed placing nine servings of cooked broccoli into the blender to prepare the lunch puree. Cook 1 was observed adding three heaping spoonfuls of chicken broth base, using a disposable plastic spoon, directly into the blender. [NAME] 1 was observed pouring water from a clear unmarked cylinder type container into the blender. [NAME] 1 stated he was not sure how much water he was using but stated it was about a half cup. [NAME] 1 was observed adding two heaping spoonfuls…

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, document review and interview, the facility's food and nutrition services did not prepare food in a form that met the individuals needs. As a result, residents on a mechanical soft and a chopped solid diet were at risk for choking. On 3/14/22 at 12:41 P.M., an observation was conducted in the facility's dining room. Resident 21 and Resident 254 were observed eating lunch. Both Resident 21 and Resident 254 had mechanical soft trays per the meal tickets located on the trays. Resident 21 and 254 were observed with a broccoli salad with large 1-1.5 inch in diameter of partially cooked whole broccoli florets with stems. Resident 51 was observed trying to eat a large raw broccoli floret which was approximately 2-2.5 inches in diameter. Resident 51's tray ticket indicated he was prescribed a chopped solid diet. When notified, the facility staff immediately removed the broccoli salads from the residents' meal trays. On 3/14/22 at 12:45 P.M., a concurrent observation and interview were conducted with the DS. The DS stated the whole pieces of broccoli in the mechanical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident was free from abuse for one of two sampled resident (154). As a result, Resident 154 was at risk for injury, pain or mental anguish. Findings: Resident 154 was admitted to the facility on [DATE], with diagnoses to include dementia (an impairment of brain function, such as memory loss and judgment) and cerebral infarction (stroke), per the Resident Face Sheet. On 3/14/22 at 1:10 P.M., Resident 154 was observed in his bed, awake and alert. Resident 154 did not respond verbally to questions, and waved both hands in the air, pointing to a feeding pump (a device used to provide liquid nutrition through a feeding tube) at the side of the bed. Resident 154 appeared unable to speak. On 3/14/22 at 3 P.M., the Admin reported an incident which occurred between Resident 154 and CNA 21. Per the Admin, CNA 21 had been suspended pending an investigation. On 3/16/22 at 2:31 P.M., an interview was conducted with the DON. Per the DON, CNA 21 had been…

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

Based on interview and record review, the facility failed to ensure the comprehensive MDS (a standardized assessment and care planning tool) was completed within the required timeframe for three of 18 residents reviewed for MDS completion (13, 14, 16). This failure had the potential for Residents 13, 14 and 16 to not receive the appropriate care. On 3/17/22 at 4 P.M., a record review was conducted. Resident 13 was due for an annual MDS assessment on 1/8/22. Per the MDS 3.0 Resident Assessments list, the annual review was, In process. Resident 14 was due for an annual MDS assessment on 1/8/22. Per the MDS 3.0 Resident Assessments list, the annual review was, In process. Resident 16 was due for an annual MDS assessment on 1/15/22. Per the MDS 3.0 Resident Assessments list, the annual review status was, In process. On 3/17/22 at 4:12 P.M., a telephone interview was conducted with the Minimum Data Set Coordinator (MDSC). The MDSC stated he was aware the MDS assessments were late, and he was doing his best to catch up while the facility attempted to hire a full-time MDSC. The MDSC 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 interview and record review, the facility failed to provide the necessary care and services for two of 14 sampled residents when: 1. Resident 11 was not provided continuity of care when a dentist appointment was not scheduled, and 2. Residents 11 and 25 were not provided wound care per physician orders. These failures resulted in delays in treatments for the residents. Findings: 1. Resident 11 was admitted to the facility on [DATE], per the Resident Face Sheet. On 3/15/22 at 10:20 A.M., an interview was conducted with Resident 11. Resident 11 stated he was seen by the dentist in the facility one week ago and was told he needed to go to the dental office for treatment. He stated that he had not heard any follow up from the staff since then. On 3/16/22 at 8 A.M., a record review was conducted. A physician's Progress Note, dated 3/2/22, indicated a dental office appointment was to be scheduled for Resident 11. On 3/16/22 at 8:33 A.M., an interview with the SSD was conducted. The SSD stated that 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 document review the facility failed to maintain kitchen equipment in a safe operating condition. As a result, the steam table had the potential for causing foodborne illnesses by not holding foods at appropriate temperatures. On 3/14/22 at 8:40 A.M., a concurrent observation and interview was conducted with the DS. Standing water and tan/white marks were observed on a shelf under the steam table. The DS stated the steam table had been leaking. On 3/16/22 at 10:29 A.M., an interview was conducted with the DS. The DS stated he was aware the steam table in the kitchen was leaking and was notified by the kitchen on Saturday 3/12/22 verbally from the DS. On 3/16/22 a facility document titled Food & Nutrition-Administrator's Monthly Inspection Checklist dated 1/29/22 was reviewed. The document indicated there was no repair done for an unidentified kitchen equipment repair. On 3/16/22 at 4:14 P.M., a concurrent interview and document review was conducted with the RD. The RD stated she conducted the monthly kitchen evaluation rounds and completes the Food…

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 observations, interviews and record review, the facility failed to ensure safe and sanitary practices were met in the facility's kitchen. 1. There was no label on the bulk cereal bin. 2. The bulk flour and thickener bins had no lids. 3. Nestle Café coffee drink dispenser was not clean with old dark black grime on it. 4. The industrial can opener was not clean as it was covered with dark black grime and dark black remnants. 5. A dented can was stored in the the ready for use storage area. 6. Containers of resident ice cream were kept in a small stand-alone refrigerator that were found below the required temperature. 7. Spoiled onions were in an open bin underneath the kitchen steamer and small nats/fruit flies were flying around the bin. 8. The food trays were being used wet and not allowed to air dry. 9. Three cutting boards were noted to be dirty with black smear stains and chips on them. 10. Dust and old food particles landed on clean dishes kept in an open bin. 11. The clean dishes used for resident food had small black spots on them. 12. The stove had dirt, old grease…

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 resident requested modifications made to the Physician's Orders for Life-Sustaining Treatment (POLST-instructions for care provided in a medical emergency) were signed by the physician for two of three residents (9, 54) sampled for advance directives (person's wishes regarding medical treatment). This failure had the potential to affect the treatment and provided to the residents in the event of a medical emergency. Findings: 1a. Resident 54 was admitted to the facility on [DATE], per the facility's Resident Face Sheet. On 11/7/19 at 8:23 A.M., a concurrent interview and record review was conducted with the SSD. The SSD stated the POLST was a physician's order, which required a signature by a physician to be valid. The SSD stated if a resident requested a change to the POLST, a new POLST form would need to be completed, and signed by the physician. The SSD reviewed Resident 54's POLST and stated it was originally dated and signed by the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the care plan for one of 18 sampled residents (8) was revised to reflect a change in condition related to contractures (shortening and hardening of muscles). The failure had the potential for miscommunication amongst care givers and decreased well-being of the resident. Findings: Resident 8 was admitted to the facility on [DATE] with diagnoses of non-traumatic (spontaneous and acute) subdural hemorrhage (clot of blood that develops between the surface of the brain that ruptures), functional quadriplegia (the complete inability to move due to severe disability), encounter for palliative care (hospice Care, end of life care) per the facility's Resident Face Sheet. On 11/04/19 at 10:13 A.M., an observation of Resident 8 was conducted. Resident 8 was lying in bed on his back, with lower extremities pulled upward under the blankets, mouth open. Resident 8 had a left arm contracture with a brace applied, and a left hand contracture with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide care that met professional standards of practice when: 1. Treatment and assessment were not done for Resident 31's left great toe wound. 2. Resident 45's emotional well being was not assessed. 3. Physician's orders were not followed for Resident 18. 4. A change of condition was not reported to the physician for Resident 18. This failure had the potential to affect the residents' physical health, and psychological well-being. Findings: 1. Per the facility's Resident Face Sheet, Resident 31 was admitted on [DATE] with diagnoses which included peripheral neuropathy (nerve damage in the legs that decreases the ability to feel pain or discomfort) and peripheral edema (swelling of the lower extremities that can inhibit blood flow to a wound). On 11/4/19, Resident 31's record was reviewed: According to a comprehensive assessment of Resident 31's functioning (MDS), dated [DATE], Resident 31 had trouble making decisions about his every day…

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 staff acted within their scope of practice when oxygen therapy was provided to one of three residents (18) sampled for oxygen use. This failure affected Resident 18's ability to breathe, which could have affected his physical health and psychological well-being. Findings: Resident 18 was admitted to the facility on [DATE], with diagnoses which included chronic obstructive pulmonary disease (COPD-difficulty breathing), per the facility's Resident Face Sheet. On 11/4/19 at 3:33 P.M., an observation and interview was conducted with Resident 18. Resident 18 was wearing a nasal cannula (tubing that delivers oxygen to the nose) and an oxygen concentrator (machine that produces oxygen) was on. The dial on the oxygen concentrator indicated Resident 18 was receiving an oxygen flow of 3 liters per minute (LPM). Resident 18 stated he required oxygen to help him breathe. On 11/5/19 at 8:18 A.M., a concurrent observation and interview was conducted. Resident 18 sat in a wheelchair in his room.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not ensure an expired hydrogen peroxide solution and a bottle of lotion with an unreadable label, had been removed. As a result, there was potential for a resident to receive care with an expired hydrogen peroxide solution and/or receive the incorrect lotion treatment. Findings: On [DATE] at 8:32 A.M., an observation of the treatment cart and an interview with the WCMN was conducted. A hydrogen peroxide bottle had expired in [DATE] and was available for use on the treatment cart. In addition, a bottle of lotion with an altered and unreadable pharmacy label was kept in the treatment cart. The WCMN stated both the hydrogen peroxide and the lotion with an unreadable pharmacy label should have been removed from the treatment cart in order to prevent use of both treatments. On [DATE] at 8:53 A.M., an interview was conducted with the DON. The DON stated the facility should have removed the hydrogen peroxide from the cart and removed the lotion with…

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

Based on a food service observation, interviews and record review the facility failed to ensure dietary staff competency when: 1. One kitchen staff member was unable to articulate or demonstrate how to correctly calibrate a thermometer used to assure proper temperature of resident food. 2. One kitchen staff member used the incorrect scoop size when preparing food trays. This failure had the potential to put residents at risk for widespread foodborne illness and receive an incorrect portion of food. Findings: 1. On 11/6/19 at 6:50 A.M., an observation and interview was conducted with the DDS/RD and [NAME] 1. [NAME] 1 stated, I never calibrate this particular thermometer, because it is provided by the supervisors, so it doesn't need to be calibrated. [NAME] 1 was unable to explain or demonstrate how to calibrate any of the thermometers available in the kitchen. On 11/6/19 at 8:15 A.M., an interview and observation was conducted with the DDS/RD and [NAME] 1. The DDS/RD asked [NAME] 1 if the thermometers had been calibrated this morning, [NAME] 1 stated, no, not this morning. The DDS/RD…

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 45 was admitted to the facility on [DATE], per the facility's Resident Face Sheet. On 11/4/19 at 1:12 P.M., an observation was conducted. CNA 1 retrieved a meal cart from the kitchen and pushed it down the hallway. CNA 1 removed a meal tray from the cart and delivered it to Resident 45, then exited the room. On 11/4/19 at 1:20 P.M., an interview with CNA 1 was conducted. CNA 1 stated he brought the meal cart down the hall and had delivered the trays to resident's in their rooms. CNA 1 stated dietary staff had been responsible for ensuring the correct diet was placed on a resident's meal tray. CNA 1 stated it was important resident's received the correct diet, because if they had been given the wrong consistency of foods, the resident could choke. On 11/4/19 at 1:30 P.M., an observation and interview is conducted with Resident 45. Resident 45's tray ticket (a paper which indicated likes, dislikes, allergies, special requests and diet) indicated he was to have received peaches or pears at lunch, and 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 accurate documentation in the Medication Administration Record (MAR), for one of 18 residents (21) sampled for nutrition. This failure had the potential to affect Resident 21's nutritional status, and cause weight loss. Findings: Resident 21 was admitted to the facility on [DATE], with diagnoses which included protein-calorie malnutrition (nutrient deficiency causing muscle wasting and weight loss), per the facility's Resident Face Sheet. On 11/5/19 at 8:05 A.M., an observation was conducted. Resident 21 was calling out Hello, come take this and pointed to her breakfast tray. On the breakfast tray was an unopened carton of health shake (nutritional supplement). CNA 5 removed the breakfast tray with the unopened carton of health shake from Resident 21's room. On 11/5/19 at 8:09 A.M., an interview was conducted with CNA 5. CNA 5 stated Resident 21 was unable to open the health shake carton without assistance. CNA 5 stated if 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 infection control practices were implemented when: 1. Proper handwashing was not implemented by an LN when caring for one of two residents (173) sampled for infections and 2. Oxygen concentrators (machines that create oxygen) had not been serviced for one of three residents (44) sampled for oxygen. These failures had the potential to spread infection to the residents, visitors and facility staff. Findings: 1. Resident 173 was admitted to the facility on [DATE] with diagnoses which included Enterocolitis (inflammation of both the small intestine and the colon). due to clostridium difficile (c -difficile, a bacterium that can cause symptoms ranging from diarrhea to life-threatening inflammation of the colon), per the facility's Resident Face Sheet. On 11/06/19 at 8:07 A.M., a joint observation and interview was conducted with LN 4. LN 4 applied gown and gloves prior to entering resident room then provided resident care. After…

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.