Fountain Valley Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to develop a comprehensive plan of care to reflect the individual care needs for one of 28 final sampled residents (Resident 20). * The facility failed to develop a care plan problem to address Resident 20's nephrostomy tubes (a thin catheter inserted through the back into the kidney to drain urine directly into a bag, bypassing a blockage or leak in the urinary tract). This failure posed the risk of not providing appropriate, consistent, and individualized care to this resident. Findings: Review of the facility's P&P titled Care Plans, Comprehensive Person-Centered, Development, Implementation & Revision revised January 2025 showed the comprehensive, person-centered care plan:a. includes measurable objectives and timeframes.b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.c. includes the resident's stated goals upon…

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, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary care and services to maintain the highest physical well-being for two of 28 final sampled residents (Residents 9 and 31). * The facility failed to initiate a change of condition, notify the physician and resident representative when Resident 9 was involved in an allegation of abuse. * The facility failed to ensure Resident 31 was continuously monitored when the resident had dysuria (painful or difficult urination) and antibiotic use. These failures had the potential for the residents not to receive the appropriate care and monitoring to prevent the development of complications and/or delayed medical treatments.Findings: 1. Review of the facility's P&P titled Abuse, Neglect, Exploitation or Misappropriation – Reporting and Investigating revised 1/2025 showed all reports of resident abuse (including injuries of unknown origin), neglect, exploitation, 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 medical record review, the facility failed to provide the necessary care and services for one of three final sampled residents (Resident 20) nephrostomy tube (a small tube inserted through the back into the kidney to drain urine when the normal urinary pathway is blocked). * The facility failed to ensure a physician's order was obtained for the care and monitoring of nephrostomy tube for Resident 20. This failure had the potential for the risk of infection and affected the well-being of the residents. Findings: On 1/5/26 at 1025 hours, during the initial tour of the facility, an observation and concurrent interview for Resident 20 was conducted. Resident 20 was sitting in bed and observed with a leg drainage bag attached to both thighs. Resident 20 stated the drainage was from his kidneys. Resident 20 further stated his drainage bag sometimes had blood. Medical record review for Resident 20 was initiated on 1/8/26. Resident 20 was admitted to the facility on [DATE]. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure appropriate GT care and services were provided for one of two final sampled residents (Resident 101) reviewed for GT. * The facility failed to ensure Resident 101's enteral formula bottle was labeled with the correct name of the resident. This failure had the potential to negatively impact the resident's well-being.Findings: Review of the facility's P&P titled Enteral Nutrition dated January 2025 showed adequate nutritional support through enteral nutrition is provided to residents as ordered. The nurses confirm the physician's order for enteral nutrition is complete before administration. During the initial tour on 1/5/26 at 1027 hours, Resident 101 was observed in bed with the GT feeding. The feeding was Glucerna 1.5 cal (enteral feeding formula) and it was infusing via GT feeding machine at 45 ml per hour. The enteral formula bottle was labeled with different name of a resident. LVN 6 was summoned 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, medical record review, facility P&P review, and facility document review, the facility failed to ensure the recommendation from Dialysis Center and fluid restriction were followed for two of three final sampled residents (Residents 10 and 113) reviewed for dialysis. * The facility failed to ensure the physician's order for 1500 ml of fluid restriction was followed and carried out accordingly for Resident 10. * The facility failed to follow up on a dialysis recommendation to check Resident 113 for C-diff (a harmful bacterium causing diarrhea and colitis often triggered by antibiotic use that disrupts gut bacteria). These failures had the potential of not identifying potential negative outcomes for the residents on dialysis.Findings: Review of the facility's P&P titled Care of Residents on Hemodialysis, Coordination of Care, Evaluation and Communication, revised 1/2025 showed the Dialysis Center, by telephone or in writing, will notify the facility of the following: - any medication given…

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, facility document review, and facility P&P review, the facility failed to ensure one of 20 kitchen staff (Dietary Aide 3) was competent in preforming the task in the food and nutrition department. * The facility failed to ensure Dietary Aide 3 was competent in the manual dishwashing procedure. This failure posed the risk for the dishes, pots, and pans used to cook the residents' food to not be cleaned and sanitized properly. Findings: Review of the facility's document titled Dietary Aide Competency Checklist signed by Dietary Aide 3 and the DSS on 10/9/25, showed Dietary Aide 3 was competent in washing and cleaning the utensils as directed and performed dishwashing/cleaning procedures. Review of the facility's document titled Dietary In-Service, Topic: Cleaning and Sanitizing Dishes, Utensils, Pots and Pans dated 11/10/25, showed Dietary Aide 3 was in attendance. Review of the facility's P&P titled 3-Compartment Procedure for Manual Dishwashing dated 2023 showed the following:Step 2: Rinse, scrape, or soak all items before washing. Use a brush,…

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 facility document review, the facility failed to ensure the menu and recipes were followed. * The facility failed to ensure 75 of 75 residents on regular diets were served the correct portion size for the entree of the lunch meal. * The facility failed to ensure the puree broccoli recipe was followed for 19 of 19 residents on the puree diet. These failures posed the risk for 75 residents on regular diets and 19 residents on puree diets to not meet their nutritional needs.Findings: 1. Review of facility's document titled Cooks Spreadsheet dated 1/5/26, showed the regular diet would serve four ounces of the Southern style patty for the regular sized portions and three ounces for small sized portions. On 1/5/26 at 0930 hours, during the initial tour of the kitchen with the DSS, a lunch preparation observation and concurrent interview was conducted with [NAME] 1. [NAME] 1 was observed portioning the ground beef for the Southern style patty. [NAME] 1 stated he was using a two-ounce scoop to form the patties. [NAME] 1 stated the portion sizes for 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 facility document review, the facility failed to ensure a vegetarian meal substitute was served for two nonsampled residents (Residents 94 and 163) who were on vegetarian preference diet. * The facility failed to ensure Residents 94 and 163 received a vegetarian meal substitute equivalent in nutritive value to the main entree served. This failure posed the risk for the residents' nutritional needs, specifically protein needs to not be met.Findings: Review of the facility's document titled Cooks Spreadsheet dated 1/6/26, showed Regular diets were to receive three ounces of pork with pear sauce. Review of the nutritional information provided by the facility for the pork during lunch on 1/6/26, showed the three ounces would provide 15.75 grams of protein. Review of the nutritional information provided by the facility for the tofu during lunch on 1/6/26, for the vegetarian lunch meal alternate, showed the three ounces would provide nine grams of protein. On 1/6/26 at 1000 hours, an interview was conducted with the DSS. The DSS stated the residents…

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.

Base on observation, interview, and facility document review, the facility failed to ensure the proper food texture was followed for 12 of 12 residents on an IDDSI Level 6 diet (Soft and Bite-Sized diet, for people who can chew but need food that's soft, tender, moist, and cut into small pieces (about 1.5cm x 1.5cm for adults) that mash easily with a fork, requiring chewing before swallowing). * The facility failed to ensure the meat, vegetables, and bread were properly prepared for the 12 residents on IDDSI Level 6 diet. This failure posed the risk for the 12 residents with swallowing and/or chewing difficulties on mechanically altered diets to not receive the diet texture as ordered by the physician.Findings: Review of the professional reference International Dysphagia Diet Standardization Initiative (IDDSI) a level 6 diet, Soft and Bite-Sized diet should have 'bite-sized' pieces no larger than 1.5 cm equivalent to half an inch. The food must be soft, tender and moist throughout but with no separate thin liquid. According to the IDDSI Audit Tool for the Soft and Bite-Sized diet,…

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, medical record review, and facility P&P review, the facility failed to ensure the necessary adaptive equipment was provided for one of 28 final sampled resident (Resident 11). * The facility failed to provide Resident 11 with a plate guard as per the physician's order. This failure had the potential for Resident 11 not being able to consume his food and drinks without the necessary assistive device.Findings: Review of the facility's P&P titled Adaptive Equipment Policy dated January 2025 showed the provision of the supplies and equipment to support self-care of the residents. Restorative and supportive care includes the assessment of self-feeding skills, providing adaptive devices, and retraining program based on resident needs and capabilities. On 1/5/26 at 1238 hours, an observation of Resident 11 and concurrent interview was conducted with LVN 5 at the bedside. Resident 11 was observed in bed eating his food from the food tray using his right hand. Resident 11's right…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and facility document review, the facility failed to ensure the Facility Assessment was complete. * The facility failed to ensure the Facility Assessment included the active involvement of the required individuals in developing the Facility Assessment, plan to maximize recruitment and retention of direct care staff, and a contingency plan for staffing needs. This failures had the potential to not meet the residents' care needs if the assessed population's needs and resources were not comprehensively identified and addressed.Findings: According to the CMS QSO-24-13-NH dated 6/18/24, with an implementation date of 8/8/24, CMS had issued a revised guidance for long-term care facility assessment requirement. The Facility Assessment should address and included the active involvement of the direct care staff in developing the Facility Assessment. Also included the staffing resources necessary to care for the residents, including the weekends; a plan to maximize recruitment and retention of direct…

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, medical record review, facility documents review, and facility P&P review, the facility failed to maintain an accurate medical record for five of 28 final sampled residents (Residents 13, 15, 87, 99, and 113). * The facility failed to ensure the section D of the POLST was completed for Resident 15, 87, and 99. * The facility failed to ensure Resident 113's blood pressure access site was accurately documented in the resident's medical record. * The facility failed to document the correct site of the blood pressure reading for Resident 13 who had an AVF in the right upper arm. These failures had the potential for the residents' care needs not being met as their medical information was inaccurateFindings: Review of facility's P&P titled Charting and Documentation review dated 1/2025 showed the documentation in the medical record will be objective (not opiniated or speculative), complete and accurate. 1. Medical record review for Resident 15 was initiated on 1/6/26. Resident 15 was admitted 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, medical record review, and facility document review, the facility failed to ensure the facility had the contract to provide the necessary care for one of two final sampled residents (Resident 2) reviewed for hospice services. * The facility failed to ensure Resident 2 had an election of hospice benefit contract between the facility and hospice provider. This failure posed a risk of delayed communication and the provision of hospice care between the hospice provider and the facility.Findings: Medical record review for Resident 2 was initiated on 1/5/26. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's Order Summary Report showed a physician's order dated 12/24/25, to admit Resident 2 to the facility under Hospice Provider A, under routine level of care. Review of the Resident 2's Election of Hospice Benefit Contract dated 12/24/25, showed the signed contract for hospice services was between Facility A and Hospice Provider A. On 1/8/26 at 1018 hours, an interview and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to maintain the infection control program and practices to help prevent the development and transmission of diseases and infections. * The two washing machines used for residents were not maintained to ensure cleanliness and free from potential contamination. * The facility failed to ensure CNA 3 donned the appropriate PPE when providing care to Resident 40 on EBP. These failures had the potential for the spread of infection in the facility.Findings: 1. Review of the facility's P&P titled Laundry Washing Machine Policy dated 1/2025, under the Policy Interpretation and Implementation sections showed for routine cleaning, washing machines shall be cleaned daily at minimum and as needed, and staff will clean and disinfect door seals, gaskets, detergent dispensers, control panels and handles. On 1/6/26 at 1528 hours, a laundry room inspection was conducted with the Maintenance Director, Maintenance Assistant, 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, medical record review, and facility P&P review, the facility failed to ensure one of three sampled residents' (Resident 3) medical record was accurate and complete. * The facility failed to ensure the documentation for monitoring Resident 3's condition for 72 hours each shift was completed after the resident's fall incident. This failure posed the risk for changes in Resident 3's health condition to go undetected and possibly delay necessary care and treatment. Findings: Review of the facility's P&P titled Change of Condition Notification dated 2001 showed the nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. Medical record review for Resident 3 was initiated on 4/10/25. Resident 3 was admitted to the facility on [DATE]. Review of Resident 3's H&P examination dated 8/24/24, showed Resident 3 had no capacity to understand and make decisions. Review of Resident 3's eINTERACT Change in Condition…

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, medical record review, and facility P&P review, the facility failed to implement their abuse P&P for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act when the facility failed to report in a timely manner an allegation of staff-to-resident abuse to the local State and Federal agencies for one of three sampled residents (Resident 1). This failure had the potential for the abuse allegation going unreported and uninvestigated. Findings: Review of the facility's P&P titled Abuse, Neglect, Exploitation or Misappropriation – Reporting and Investigating dated 2001 showed all reports of resident abuse, neglect, exploitation, or theft/misappropriation of resident property are reported to the local State, and Federal agencies (as required by current regulations) and thoroughly investigated by the facility management. The suspicion of abuse must be reported immediately to the administrator and to other officials according to state law. The abuse must…

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, medical record review, and facility P&P review, the facility failed to implement their abuse P&P related to investigation of the physical abuse for one of three sampled residents (Resident 1). This failure posed the risk for the potential abuse to remain unidentified and for the residents to go unprotected. Findings: Review of the facility's P&P titled Abuse, Neglect, Exploitation or Misappropriation – Reporting and Investigation dated 2001 showed any incident or allegation of abuse, neglect, exploitation, or theft/misappropriation of resident property are initiated and thoroughly investigated by the administrator. The staff member assigned to gather the facts will at a minimum reviews the documentation and evidence, reviews the resident's medical record to determine the resident's physical and cognitive status at the time of the incident and since the incident, interview the person(s) reporting the incident, interview any witnesses to the incident, interview staff members (on all shifts) 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, medical record review, and facility P&P review, the facility failed to provide the safe respiratory care to meet the needs for eight of eight final sampled residents (Residents 5, 43, 57, 63, 68, 110, 595, and 793) and one nonsampled resident (Resident 72) reviewed for respiratory care * The facility failed to ensure Resident 793's physician's order for the use of CPAP machine was followed up with and failed to ensure Resident 793 was utilizing the CPAP machine as ordered by the physician. In addition, the facility failed to ensure Resident 793's nasal cannula was stored in a sanitary manner. * The facility failed to ensure Resident 5's nasal cannula was changed as per the facility procedures and Resident 5's nebulizer mask storage bag was labeled per the facility policy. * The facility failed to ensure Resident 57's CPAP and nebulizer mask were stored in a sanitary manner when not in use. * The facility failed to ensure Resident 72's nebulizer mask was stored in a sanitary…

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, facility P&P review, and facility document review, the facility failed to ensure the menu was followed when: * The pureed fresh green salad with dressing was not served to 20 residents who were on pureed diets. * Resident 46's lunch tray was observed with pureed food in accordance with the menu, except the fresh green salad with dressing was missing from the lunch tray. Additionally, Resident 46's lunch tray did not contain V8 juice puree. * Resident 444's lunch tray was observed with pureed food in accordance with the menu, except the fresh green salad with dressing was missing from the lunch tray. These failures had the potential to place 20 residents on pureed diets at risk of not receiving the menu as planned. Findings: Review of the facility's documented showed 20 residents received pureed diets prepared in the facility's kitchen. 1. Review of the facility's document titled Fall Menus, Week 2, Tuesday showed a pureed diet included: pureed lemon chicken piccata, pureed…

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 facility P&P review, the facility failed to ensure the food safety and sanitation guidelines were followed when: * The facility failed to ensure the expired food items in the kitchen were discarded. A bin containing thawed packages of mechanically separated turkey had a use-by date of 11/3/24, and a bin containing thawed chicken had a use-by date of 11/3/24, were seen in the kitchen refrigerator. * The facility failed to ensure the kitchen utensils were clean, free of food particles, and not worn out. These failures posed the risk for food borne illnesses in highly susceptible resident population of 132 facility residents who received food prepared in the kitchen. Findings: Review of the facility's document showed 132 of 141 residents received food prepared in the kitchen. 1. On 11/4/24 at 0757 hours, two bins containing thawed poultry were observed on the bottom shelf of the walk-in refrigerator. One bin contained packages of mechanically separated turkey was labeled with a thaw date of 11/2/24, and a use-by date of 11/3/24. The other bin…

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, medical record review, and P&P review, the facility failed to ensure the call light was within reach for one of 30 final sampled resident (Resident 394) and one nonsampled resident (Resident 132). This failure had the potential for Residents 132 and 394 not receiving care timely. Findings: Review of the facility's P&P titled Answering the Call light dated 10/2010 showed when the resident is in bed or confine to a chair be sure the call light is within easy reach of the resident. 1. Medical record review for Resident 394 was initiated on 11/4/24. Resident 394 was admitted to the facility on [DATE], and readmitted on [DATE]. On 11/4/24 at 0815 hours, Resident 394 was awake with his call light on the floor. Resident 394 stated he could not locate his call light to call for the nurse. Resident 394 stated he needed help to change his diaper because his diaper was wet. On 11/4/24 at 0825 hour, CNA 7 was summoned to the room. CNA 7 acknowledged the call light was on the floor and 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, medical record review, and facility P&P review, the facility failed to ensure one of two final sampled residents (Resident 76) who was readmitted to the facility had a Level 1 PASARR screening. This failure had the potential of not providing the residents screened for mental illness or intellectual disabilities with additional resources if needed. Findings: Review of the facility's P&P titled PASARR revised 3/2019 showed all individuals are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. a. The facility verifies with the acute care hospital if a Level I PASARR screen for potential admissions and readmissions, regardless soft payer source, to determine if the individual meets the criteria for a MD, ID or RD. b. Before a resident can be transferred from an acute care hospital, they must undergo a PASARR Level I screening. This initial screening is designated to identify…

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, medical record review, and facility P&P review, the facility failed to ensure the comprehensive person-centered care plans were developed and implemented for five of 30 final sampled residents (Residents 34, 43, 63, 76, and 743) as evidence by the following: * The facility failed to develop and implement an EBP care plan for Resident 34. * The facility failed to develop and implement an oxygen care plan for Resident 63. * The facility failed to develop and implement a LAL mattress for Resident 76. * The facility failed to develop and implement an EBP care plan for Resident 743. * Resident 43's care plan for the use of oxygen showed to administer continuous oxygen at a rate of 2 liters per minute, however, the nursing staff failed to implement the care plan, as evidenced by having administered continuous oxygen therapy to Resident 43 at a rate of 1.5 liters per minute. These failures had the potential of not providing residents with person-centered plan of care. Findings: Review…

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 facility P&P review, the facility failed to ensure one of one final sampled resident (Resident 60) who needed a communication board (pre-printed board that has pictures, numbers, and user defined images that allows a resident to point or indicate on the board what he/she wants communicated) to communicate the needs was provided with the communication board in the resident's language to communicate care needs to the facility staff. This failure had the potential to result in a delay of care services and needs for Resident 60. Findings: Review of the facility's P&P titled Communication Barriers and Communication Boards undated showed the facility will make arrangement for interpreters and/or alternate means of communication such as communication boards with pictures, common basic words, sign language, Braille, etc., to enhance communication between the resident and staff. Medical record review for Resident 60 was initiated on 11/5/24. Resident 60 was admitted to the facility 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, medical record review, and facility P&P review, the facility failed to ensure three of three final sampled residents (Residents 43, 62, and 76) with high risk for skin breakdown were provided the necessary care and services as evidence by the following: * The facility failed to ensure Resident 76's LAL mattress setting was not appropriate to the resident's weight. * The facility failed to ensure the use of LAL mattress with specific direction for settings for Residents 43 and 62. These failures had the potential for the residents not to receive the appropriate care and services to promote skin healing. Findings: Review of the facility's P&P titled Beds, Special - Low Air Loss Therapy, undated, showed it is the policy of this facility to utilize low air loss therapy under the direction of a physician's order. Facility staff working directly with the low air loss therapy unit will have training in its use by a company representative or a trained facility staff member. Review of 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 interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the disposed narcotic count sheets were signed by two licensed nurses. This failure had the potential for medication diversion (the illegal use or distribution of a prescription medication that was not originally intended by the prescriber). Findings: Review of the facility's P&P titled Discarding and Destroying Controlled/ Non-Controlled Medications revised 5/2024 showed the following: -Medications that cannot be returned to the dispensing pharmacy (such as non-unit dose medications, medications refused by the resident, and/or medications left by residents upon discharge) are disposed of in accordance with federal, state, and local regulations governing management of non-hazardous pharmaceuticals, hazardous waste and controlled substances; and -Unless otherwise prohibited under applicable federal or state laws, individual resident medications supposed in sealed unopened containers may be returned to the issuing pharmacy for disposition provided that all such…

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, medical record review, and facility P&P review, the facility failed to ensure two of 30 final sampled residents (Residents 29 and 38) were free from the unnecessary drugs. * Resident 29 received amitriptyline (antidepressant medication) and bupropion hydrochloride (antidepressant and smoking cessation); however, the facility failed to identify what target behaviors to monitor and did not monitor the episodes of behaviors for two antidepressant medications. * The facility failed to document specific behaviors prior to prescribing Zoloft (antidepressant) and implement non-pharmacological interventions for Resident 38. These failures had the potential for Residents 29 and 38 to have adverse complications from the medication. Findings: 1. Review of the facility's P&P titled Psychotropic/Antidepressant Medication Use dated 2021 showed under the section Psychotropic Medication Management, Psychotropic medication management for the resident will involve the facility interdisciplinary…

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, medical record review, and facility P&P review, the facility failed to ensure the medication rate was less than 5%. The facility's medication error rate was 12%. * LVN 2 failed to administer Systane (eye drops, use for dry eyes) for Resident 22 as per the facility's P&P. * LVN 4 failed to check Resident 12's bowel pattern for loose stool prior to administering docusate sodium (stool softener). * LVN 1 failed to check Resident 97's bowel pattern for loose stool prior to administering docusate sodium. Findings: Review of the facility's P&P titled Administering Medications revised May 2024 showed the medications are administered in a safe and timely manner and as prescribed. 1. Review of the facility's P&P titled Eye Drops Administration Procedure undated showed ophthalmic solutions are administered into and around the eye in a safe and accurate manner. Release the eyelid and instruct the resident to close the eye for one or two minutes. On 11/6/24 at 0930 hours, a medication…

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 facility P&P review, the facility failed to ensure for the safe storage of the medications and supplies. * The Central Supply Room was observed to contain expired supplies and medications along with other supplies without a manufacturing or expiration date. * Medication Cart D was observed to contain multiple expired antifungal cream tubes. * Medication Cart C was observed to contain a bottle of aspirin 81 mg without an expiration date and medication for a discharged resident. * An antifungal cream was kept at the bedside for one final sampled resident (Resident 12). *The facility failed to ensure Medication Cart E was not left unlocked and unattended. * For Resident 82, facility failed to ensure A&D ointments (barrier cream/ointment) were not kept at Resident 82's bedside. * The facility failed to dispose the discontinue medication for Residents who had been discharged for three nonsampled resident (Residents 54, 395, and 396). * The facility failed to stored medication in…

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, medical record review, and facility P&P review, the facility failed to ensure two nonsampled residents (Residents 14 and 132) observed during the dining observation received the appropriate mechanically altered diets (the texture of the diet is altered) as ordered by the physician. * Resident 132 was not served the milk and coffee as ordered. * Resident 14 was not served the correct diet as ordered. This failure posed the risk of aspiration (inhalation of a foreign object into the airway and/or lungs) and resident's nutritional needs not being met. Findings: Review of the facility's P&P titled Food and Nutrition Services revised 10/2017 showed the food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident, the food appears palatable and attractive, and it is served at a safe and appetizing temperature. 1. On 11/4/24 at 1157 hours, a meal cart was observed to be dropped off by the kitchen staff. LVN 7 was observed to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one nonsampled residents (Resident 53) was provided with an assistive eating device during mealtimes. This failure had the potential to impact Resident 53's nutritional status. Findings: Review of the facility's P&P titled Self-Feeding Devices dated 2023 showed it is the policy of the facility that residents will receive self-feeding devices to maintain or improve their ability to eat or drink independently. Residents needing devices will receive them with each meal or snack, on their meal trays. Tray cards and diet profile will record which device is needed. On 11/4/24 at 1225 hours, a lunch observation was conducted in Resident 53's room. Resident 53 was observed feeding himself only using his right hand. Resident 53 was observed carefully scooping the food using regular utensils. There were no adaptive devices observed. Review of Resident 53's meal ticket failed to show the use of built-up utensils.…

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 facility P&P review, the facility failed to ensure the P&P regarding outside food for residents was followed. * The facility failed to ensure the facility staff responsible for handling food brought for the residents from the outside and family/visitors who brought food for residents from the outside were educated on safe food handling procedures. This failure posed the risk for food borne illness in residents who consume food from outside sources. Findings: Review of the facility's P&P titled Foods Brought by Family/Visitors revised 3/2022 showed the following: - Family/visitors are asked to prepare and transport food using safe food handling practices, including safe cooling and reheating processes, holding temperatures, preventing cross-contamination with raw and undercooked foods, and hand hygiene. - Safe food handling practices are explained to family/visitors in a language and format they understand. On 11/6/24 at 1411 hours, an interview was conducted with CNA 2. CNA 2 was asked what her role was when the residents had food brought in from…

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, medical record review, facility document review, and facility P&P review, the facility failed to ensure the infection control was maintained as evidenced by: * The facility failed to ensure Residents 34 and 743 with indwelling urinary catheters and midline IV (intravenous) catheter were placed on EBP as per the facility's P&P. * The facility failed to conduct surveillance of infections for the residents who showed signs and symptoms of infection but were not on antimicrobials. * The facility failed to identity organisms on the surveillance line listing. * Resident 38's indwelling urinary catheter drainage bag was on the floor and a urinal with scant amount of yellow urine was observed hanging from the trash can adjacent to Resident 38's bed. These failures put the residents a risk for increased risk of infection and transmissions of diseases. Findings: Review of the facility's P&P titled Enhanced Barrier Precautions revised 3/2024, showed the purpose of this policy is to ensure…

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, medical record review, and facility P&P review, the facility failed to ensure six of six final sampled residents (Residents 38, 60, 76, 443, 596, and 743) reviewed for pneumococcal vaccinations were educated and offered the pneumococcal vaccination as evidenced by: * The facility failed to offer the educational materials of the risks and benefits for the pneumococcal vaccines to Residents 60, 76, 443, 596, and 743 as per the facility's P&P. * The facility failed to offer Resident 38's responsible party the PPSV 23 (pneumococcal polysaccharide vaccine) vaccine. These failures put the residents at risk for infection and transmission of pneumococcal infections. Findings: Review of the facility's P&P titled Pneumococcal Vaccine revised on 3/2024 showed all residents are offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Prior to or upon admission, residents are assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, are offered…

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, medical record review, and facility P&P review, the facility failed to ensure six of six final sampled residents (Residents 38, 60, 76, 443, 596, and 743) reviewed for COVID-19 vaccinations were educated and offered the COVID-19 vaccination as evidenced by: * The facility failed to offer the educational materials of the risks and benefits for the COVID-19 vaccines to Residents 60, 76, 443, 596, and 743 as per the facility's P&P. * The facility failed to offer Resident 38's responsible party the seasonal COVID-19 vaccine. These failures put the residents at risk for increased risk of infection and transmission of COVID-19. Findings: Review of the facility's P&P titled Coronavirus Disease (COVID-19) - Vaccination of Residents revised on 11/2024 showed each resident is offered the COVID-19 vaccine unless the immunization is medically contraindicated or the resident is fully vaccinated. Residents who are eligible to receive the COVID-19 vaccine are strongly encouraged to do so. COVID-19 vaccine…

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, medical record review and facility P&P review, the facility failed to provide the necessary care and services to prevent the development or worsening of pressure injuries for two of two sampled residents (Residents 1 and 2). * The facility failed to assess Resident 1's skin when readmitted to the facility and failed to develop a care plan to address Resident 1's coccyx wound. * The facility failed to revise Resident 2's care plan to address Resident 2's Stage 3 pressure injury and failed to ensure Resident 2 received his wound treatment with his own wound medication supply. These failures had the potential for Residents 1 and 2 not to receive the appropriate care and services to promote healing of the pressure injury. Findings: 1. Review of the facility's P&P titled admission Notes (undated) showed should a resident be discharged from and readmitted to the facility, the new admission data must be recorded. Review of the facility's P&P titled Guidelines for Charting and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to implement their P&P to ensure the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act when the facility staff failed to immediately report an abuse allegation involving a CNA to the facility's Administrator or DON for one of two residents reviewed for abuse (Resident 1). This failure had the potential for not protecting the resident from abuse. Findings: Review of the facility's P&P titled Patient Protection Abuse, Neglect, Mistreatment and Misappropriation Prevention dated October 2021 showed the following: - Employees are educated upon hired and annually on the abuse prevention program, including the immediate reporting of any suspicious of abuse, neglect, exploitation, mistreatment, misappropriation or crime involving a resident. - Resident protection actions include immediately remove the resident from contact with the alleged abuser during the investigation. If the incident…

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 medical record review, the facility failed to ensure one of two sampled residents (Resident 1) was administered the parenteral fluids in accordance with the physician's order. * Resident 1's IV antibiotics was held without a physician's order. This posed the risk of Resident 1 receiving ineffective treatment. Findings: According to the National Institute of Health's study titled Antibiotics Non-adherence and its Associated Factors .dated 4/19/22, non-adherence to antibiotics has a considerable impact on treatment outcome. Adherent patients got three times the good treatment outcome as non-adherent patients and may result in microbial resistance, which reduces the efficacy of antimicrobials in the prevention and treatment of microbial infections . Closed medical record review for Resident 1 was initiated 12/6/23. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's Radiology Results Report dated 10/31/23, showed there was a concern for pneumonia in the clinical setting…

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, medical record review, and facility P&P review, the facility failed to thoroughly investigate an allegation of abuse for one of seven sampled residents (Resident 1). * The facility was made aware Resident 1 allegedsomeone hit him; however, they failed to conduct an investigation. This failure put Resident 1 at risk of abuse. Findings: Review of the facility ' s P&P titled Patient Protection: Abuse, Neglect, Mistreatment and Misappropriation Prevention dated 10/2021 showed any allegation of abuse requires an investigation. The facility must have evidence that all alleged violations are thoroughly investigated and must prevent further potential abuse while the investigation is in progress. On 9/13/23 at 0736 hours, CDPH, L&C Program received a complaint alleging Resident 1 was hit in the facility. Review of Resident 1 ' s medical record showed the resident was admitted to the facility on [DATE]. Review of the physician ' s note dated 7/24/23, showed the resident was admitted to the facility due…

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, medical record review, and facility P&P review, the facility failed to ensure coordination of care with Hospice A for one of seven sampled residents (Resident 1). * Resident 1 experienced a fall in the facility, and neither Family Member 1 nor Resident 1 ' s physician was notified in a timely manner. This failure had the risk of a delay in necessary care and services for Resident 1. Findings: Review of the facility ' s P&P titled Falls Practice Guide dated 12/2011 showed: - After a fall, upon the completion of the evaluation, the physician is notified and orders are documented, noted and implemented, as indicated. The family and responsible party is notified of the fall event or change in fall risk factors and the patient ' s current condition. The patient ' s condition, response to interventions and subsequent care provided is documented in the patient ' s clinical record. Medical record review for Resident 1 was initiated on 9/15/23. Resident 1 was admitted to the facility on [DATE], 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.

Based on observation, interview, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by the following: * The facility failed to ensure three of three ice machines were maintained in a sanitary condition. * The facility failed to ensure thawed meat was dated when the thawing process was started. * The facility failed to ensure safe storage of food items. * The facility failed to ensure food was covered during delivery to the residents. * The facility failed to ensure proper washing of produce. * The facility failed to ensure kitchen equipment was maintained in a sanitary condition. * The facility failed to ensure food preparation equipment was air dried. These failures had the potential to cause foodborne illness for residents who consumed food prepared in the kitchen. Findings: Review of the CMS 672 titled Resident Census and Conditions of Residents dated 6/8/22 and signed by the DON, showed 127 of the 131 residents received food prepared in the kitchen. 1. According to the USDA Food Code 2017, Section 4-601.11…

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 facility document review, the facility failed to ensure the dish machine was repaired in a timely manner to ensure the dish machine water temperature reached a minimum of 160 degrees Fahrenheit (F). This failure had the potential to cause foodborne illness for residents using dishes that were not properly sanitized. Findings: According to the USFDA Food Code 2017 Annex 3, Equipment 4-501.11 Good Repair and Proper Adjustment, proper maintenance of equipment to manufacturer specifications helps ensure that it will continue to operate as designed. Failure to properly maintain equipment could lead to violations of the associated requirements of the Code that place the health of the consumer at risk. 4-302.13 Temperature Measuring Devices, Manual Ware washing. Water temperature is critical to sanitization in ware washing operations. This is particularly true if the sanitizer being used is hot water.A temperature measuring device is essential to monitor manual ware washing and ensure sanitization. Effective mechanical hot water sanitization occurs when…

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, facility document review, facility P&P review, and prescribing highlights review, the facility failed to ensure the residents' drugs and biologicals were stored in a safe manner and labeled properly. * Eye drops, inhalers, nebulizer inhalation, and nasal spray were opened and not labeled. This failure posed to potentially expose the residents to the expired medications with questionable potency and efficacy. * The facility failed to ensure the medication storage rooms were accessible only to the licensed nursing personnel. The Maintenance Director was able to access Medication room [ROOM NUMBER]. This had the potential for unauthorized persons to access the medications. * Resident 31 had the Wixela inhaler (a bronchodilator medication, used to relax the muscles in the airways and increases air flow to the lungs) at the bedside. Resident 31 did not have a physician's order to keep medications at her bedside. This had the potential for unauthorized persons to access the medication.…

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 facility document review, the facility failed to ensure two of two RDs (RDs 1 and 2) were competent in their job duties when: * RD 1 failed to address a dish machine failure as per the facility P&P and federal food code standards. This failure caused an equipment failure to not be addressed in a timely manner which could lead to residents' dishware to not be sanitized. *RD 2 failed to address an unplanned severe weight loss of 25 pounds (lbs.), 12 % in a 28-day time frame for one of 26 sampled residents (Resident 16) with the IDT members and implement interventions. In addition, RD 2 failed to update the care plan for Resident 16 to reflect the unplanned severe weight loss. These failures posed the risk for the unplanned severe weight loss to go unaddressed which could lead to further medical complications. Findings: 1. According to the USFDA Food Code 2017 Annex 3, Equipment 4-501.11 Good Repair and Proper Adjustment, proper maintenance of equipment to manufacturer specifications helps ensure that it will continue to operate as designed. Failure…

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 medical record review, and facility P&P review, the facility failed to develop and implement a comprehensive person-centered care plan for one of 26 final sampled residents (Resident 16) whose unplanned severe weight loss of 25 pounds was not care planned. This failure had the potential for Resident 16 to have compromised nutritional status and to not receive necessary care and services. Findings: Medical record review for Resident 16 was initiated on 6/9/22. Resident 16 was admitted to the facility on [DATE]. Review of Resident 16's history and physical examination dated 2/14/22, showed Resident 16 had diagnoses which included diabetes (a chronic, metabolic disease characterized by elevated levels of blood sugar), chronic kidney disease stage III (decreased kidney function), and peripheral vascular disease (blood circulation disorder that causes the blood vessels outside of your heart and brain to narrow, block, or spasm). Review of Resident 16's Weights and Vitals Summary dated 6/9/22,…

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 medical record review, the facility failed to revise or update the plans of care for two of 26 final sampled residents (Residents 50 and 51). This failure had the potential for the residents to not receive appropriate care and interventions. * Resident 51's plan of care was not updated to reflect the current hospice provider and discontinuation of peripheral IV. * Resident 50's plan of care was not revised when the lorazepam (a medication used to treat anxiety) was discontinued. Findings: 1. Medical record review for Resident 51 was initiated on 6/7/22. Resident 51 was admitted to the facility on [DATE], and readmitted on [DATE]. a. Review of Resident 51's Medication Review Report showed an order dated 5/20/22, to admit to the facility for hospices services provided by Hospice A. However, review of Resident 51's plan of care showed the following care plan problems for care provided by Hospice B dated 5/23/22: - ADL (activities of daily living) self care deficit related to physical…

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 medical record review, the facility failed to provide the necessary care and services for one nonsampled resident (Resident 68). * LVN 6 failed to administer the correct dose of Refresh (an eye drop lubricant and moisturizes the eyes) to Resident 68 as ordered by the physician. This failure posed the risk for the resident to not receive the therapeutic benefits. Findings: The facility's P&P titled Medication and Treatment Administration Guidelines updated 03/2018 showed medications are administered in accordance with standards of practice and state specific and federal guidelines. On 6/8/22 at 0801 hours, a medication administration observation was conducted with LVN 6. LVN 6 prepared and administered Refresh lubricant eye drops one drop to both eyes for Resident 68. Review of Resident 68's medical record was initiated on 6/8/22. Resident 68 was admitted to the facility on [DATE]. Review of Resident 68's Order Summary Report showed an order dated 12/13/21, for Refresh…

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, medical record review, and facility P&P review, the facility failed to effectively assess and identify the potential source of one of 26 final sampled residents (Resident 16)'unplanned severe weight loss and implement the necessary interventions as evidenced by: * The facility failed to ensure the IDT (a group of professionals who work together to provide the greatest benefit for the resident) analyzed and implemented the necessary interventions to address Resident 16's unplanned severe weight loss of 25 lbs which was equivalent to 12% in 28 days; * The facility did not notify the physician of Resident 16's unplanned severe weight loss of 25 lbs, 12% between 10/7/21 and 11/4/21. These failures had the potential to result in the lack of implementation, monitoring, and evaluation of the effectiveness of nutritional interventions and related outcomes, and increase the potential for further weight loss and/or nutritional decline. Findings: Review of the facility's P&P titled Weight Measurement…

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 medical record review, the facility failed to provide the respiratory care in accordance with the physician's order for two of 26 final sampled residents (Residents 447 and 597). The oxygen was not administered as ordered for Residents 447 and 597. This posed the risk for complications related to respiratory treatment. Findings: On 6/8/22 at 0913 hours, Resident 447 was observed receiving oxygen at 4 LPM via nasal cannula. Review of Resident 447's medical record was initiated on 6/7/22. Resident 447 was admitted to the facility on [DATE]. Review of Resident 447's H&P examination dated 6/6/22, showed Resident 447 had a diagnosis of COPD. Review of Resident 447's Medication Review Report showed an order dated 6/8/22, to administer oxygen at 2 LPM via nasal cannula every shift for COPD. Review of Resident 447's plan of care showed a care plan problem dated 6/8/22, addressing the risk for respiratory impairment related to shortness of breath. Care plan interventions included 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, medical record review, and facility P&P review, the facility failed to provide the pharmaceutical services to one nonsampled resident (Resident 699) to assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of the resident. * The facility failed to ensure Resident 699's oxycodone tablets were administered as ordered by the physician. Resident 699 was given oxycodone 15 mg (short acting narcotic pain reliever, ordered for moderate to severe pain) instead of the routine oxycodone 15 mg ER (extended release-long-acting narcotic pain reliever) tablet. This failure had the potential of negatively impacting Resident 699's well-being. Findings: Review of the facility's P&P titled Medication and Treatment Administration Guidelines updated 3/2018 showed in part, medications are administered in accordance with the standards of practice. Medication are administered in accordance with following rights of medication administration: right…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of 25 final sampled residents (Resident 31) was free from unnecessary psychotropic drugs (any drug that affects brain activity). * The facility failed to ensure an informed consent was obtained when sertraline (antidepressant) medication for Resident 31. In addition, the facility failed to monitor the behavior related to the use of sertraline. These failures posed the potential to negatively impact the resident's well-being. Findings: Review of the facility's P&P titled Behavior Management Guidelines dated 3/2022 showed the use of psychoactive medications should be utilized only as is necessary as demonstrated by the patient's behavior. As behaviors decrease, re-evaluation of the use of the medications should occur. Patients, families/ responsible parties are educated regarding risks/ benefits of psychoactive medications prior to the first dose being administered. If required by the specific state, signed…

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, facility document review, and facility P&P review, the facility failed to ensure the kitchen staff had the appropriate skill set to safely perform the daily operations of the Food and Nutrition Services Department when: * FSW 1 was unable to provide the correct dish machine water temperatures. In addition, FSW 1 was not able to demonstrate how to test the sanitizing solution used for the dish machine. This failure had the potential for unsafe food practices which may lead to food borne illness in a highly susceptible population of 124 residents who received food from the kitchen. Findings: Review of the CMS 672 titled Resident Census and Conditions of Residents dated 6/8/22 and signed by the DON, showed 127 of the 131 residents received food prepared in the kitchen. Review of the facility's P&P titled Dishwasher Operation - Failure dated 11/2020 showed in part, whenever dishwasher temperatures .are not at the dishwasher manufacturer's recommended levels, the dishwashing process is stopped immediately and not restarted until the problem is corrected.…

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, facility document review and facility's P&P review, the facility failed to ensure the menus were followed and the residents' nutritional needs were met when: * The puree recipe for glazed ham was not followed for 11 residents who received a puree diet. * The facility failed to follow the menu for the renal CCHO diet (a diet for residents with diabetes and end stage kidney disease). * The facility failed to provide a vegetarian menu for Resident 20. These failures had the potential for residents receiving puree, renal or vegetarian diets to not have their nutritional needs met which may lead to nutritional related health complications. Findings: 1. According to the facility's P&P titled Consistency Modified Foods- level 14 pureed dated 1/2020 showed shaped pureed meats/entrees are used when available. The cook is directed to follow instruction on the product package. If not available, the regular item is pureed following the recipe. Review of the facility's document titled Maple Glazed Ham dated 10/28/20, showed to blend maple syrup, brown sugar,…

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, facility document review, and facility P&P review, the facility failed to ensure the resident's food preferences were followed for one of 26 final sampled residents (Resident 20). This failure caused the resident to receive foods she did not prefer. Findings: Review of the facility's P&P titled Food Preferences dated 11/2020 showed the residents may be visited by the food services, director, dietetics professional, registered dietitian or designee on admission, during regular meal rounds or as needed to determine food preferences. This information is entered into dietary eKardex. Dislikes and allergies/ sensitivities print on the tray card for reference during meal service. It is recommended that meal preferences be checked on a routine basis and updated. Likes and dislikes may change throughout the patient's stay. On 6/7/22 at 1222 hours, during the initial tour, an interview was conducted with Resident 20. Resident 20 stated she was a vegan (a strict vegetarian who consumes no food (such as meat, eggs, or dairy products) that comes from animals),…

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 facility P&P review, the facility failed to implement their P&P to ensure proper storage of food in the residents' room as evidenced by: * Resident 347 had the unlabled container filled with muffins at bedside. This had the potential to result in foodborne illnesses in a highly susceptible resident population. Findings: Review of the facility's P&P titled Food from Outside Sources and In room Refrigerators revised 11/2020 showed foods requiring refrigeration and non-perishable items are stored in labeled (with patient name and date of visit), closed containers supplied by the family or guest. On 6/7/22 at 1130 hours, during an inspection of Resident 347's bedside and concurrent interview with LVN 3, a clear plastic container contained seven pieces of muffins. Resident 347's plastic container was not unlabeled with the resident's name, items, and use by dates. LVN 3 verified the findings and stated the food container should have been labeled. When asked about the food, Resident 347 stated the food was brought by a familly member. When asked how…

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 facility document review, the facility failed to ensure the residents' identifiable information and medical record were maintained to ensure confidentiality and accessibility. * The facility failed to ensure the resident identifiable information was kept private when the confidential resident rosters were found in the survey binder. This failure put the residents at risk for retaliation. * The facility failed to ensure the Neurological Evaluation Flow sheets for Resident 16 for three of six falls were accessible and available. This had the potential for the residents' care needs not being met as the clinical information was not available. Findings: On 6/9/22 at 0848 hours, a concurrent observation, interview, and facility document review was conducted with the Administrator. A blue binder titled Survey Binder was observed on the wall near the bulletin board. The binder contained the most recent recertification and abbreviated survey results for the facility. Confidential…

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 medical record review, the facility failed to provide the necessary care and services for one of 26 final sampled residents (Resident 51). * Resident 51's calendar of prospective hospice provider's visit was not included in the medical record. In addition, the hospice provider failed to ensure Resident 51's hospice certification from the physician was included in the medical record. These failures had the potential for delayed or uncoordinated care between the facility healthcare team and hospice agency Findings: Review of Resident 51's medical record was initiated on 6/7/22. Resident 51 was readmitted to the facility on [DATE]. Review of the Medication Review Report showed an order dated 5/20/22, to admit Resident 51 under Hospice A. On 6/9/22 at 0954 hours, an interview and concurrent medical record review was conducted with LVN 1. LVN 1 stated Resident 51 was currently received hospice care from Hospice A. When asked how she would know when the hospice care providers would visit…

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.