California Home For The Aged

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure medical records were complete and accurately documented in accordance with accepted professional standards when: 1. One of four residents (Resident 52) medical record did not reflect when change of the humidifier bottle (medical devices filled with water that increase the humidity in the oxygen being delivered) and amount of oxygen administered was not accurately documented. This failure placed Resident 52 at risk of the humidifier bottle not being changed timely, the water becoming stagnant (stale or foul), oxygen would not be humidified leading to dry, cracked and bleeding mucosal membranes (the moist outer layer that lines various cavities in the body) and receiving the incorrect amount of oxygen. 2. Four of eight sampled residents (Residents 29, 77, 81and 83) Physician Orders for Life-Sustaining Treatment (POLST - a medical order signed by both the patient and medical provider that specifies the types of medical treatment a patient wishes…

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 implement safe infection control measures for two of three sampled residents (Resident 2 and Resident 4) when: Resident 2's urinary catheter bag (a tube that is inserted into the bladder, allowing the urine to drain freely into an attached bag), and Resident 4's urinary tubing was observed lying on the floor. This failure had the potential to spread harmful bacteria (microorganisms that can be found on surfaces and in the body), infections to both Resident 2 and Resident 4. Findings: During a review of Resident 4's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 3/27/24, the AR indicated Resident 4 was admitted on [DATE] with diagnoses of obstructive and reflux uropathy (a condition in which the flow of urine is blocked. This causes the urine to back up 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 interview and record review, the facility failed to follow the policy and procedure titled In-service Training to ensure Licensed Nurses (LNs), Certified Nursing Assistants (CNAs) and ancillary (additional) support staff received and demonstrated competency to prevent and recognize resident abuse and the necessary skills and techniques necessary to care for residents with Dementia [a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning] when: 1. 36 of 67 CNAs had not attended and completed the 2023 annual mandatory in-service training for Dementia Module 1 titled Caring for Persons with Dementia. 2. 47 of 67 CNAs had not attended and completed the 2023 annual mandatory in-service training for Dementia Module 4 titled More than Words. 3. 22 of 120 facility staff had not attended and completed the 2023 annual mandatory in-service training for Fall Prevention. 4. 50 of 120 facility staff had not attended and completed the 2023 annual mandatory in-service training for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were treated with dignity and respect for two of two sampled residents (Resident 2 and Resident 26) when Resident 2 and Resident 26's urinary catheter (tube inserted into the bladder through the urethra, to drain freely into a connected bag) bags were not placed in a dignity bag (a bag the catheter drainage bag into to shield the resident's urine from view) and were visible from the hall outside the resident's room. This failure violated Resident 2 and Resident 26's need for urinary catheterization to remain private to ensure their dignity and respect. Findings: During a review of Resident 2's admission Record (AR), dated 03/27/24, the AR indicated Resident 2 was admitted to the facility on [DATE] with diagnosis which included Dementia (impaired thinking, remembering or reasoning), Type 2 Diabetes Mellitus (high levels of sugar in the blood), Anemia (lower than normal red blood cells), Neuromuscular Dysfunction (nerve 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 ensure the Minimum Data Set assessment (MDS-assessment of physical and psychological functions and needs) accurately reflected resident's health and functional status for one of five sampled residents (Resident 65) when Resident 65's functional limitation in range of motion was inaccurately coded on the MDS assessment. This failure had the potential to result in Resident 65's care needs not met. Findings: During a review of Resident 65's admission Record (document with resident demographic and medical diagnosis information), dated 3/28/24, indicated Resident 65 was admitted in the facility on 12/20/23, with diagnosis which included hemiplegia (severe or complete loss of strength and hemiparesis (mild loss of strength), muscle weakness and atherosclerotic heart disease (thickening or hardening of the arteries caused by a buildup of plaque [small, abnormal patch of tissue] in the inner lining of an artery). During a concurrent observation…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the Level l Preadmission Screening and Resident Review (PASRR-The State is required to ensure that every person entering a Medicaid certified Nursing Facility [NF] receives a Level I screening and if necessary a Level II evaluation to ensure that their NF residence is appropriate and to identify what specialized services they may need) was completed for one of five sampled residents (Resident 27) when Resident 27 was diagnosed with major depressive disorder (persistent feeling of sadness and loss of interest), dementia (loss of of cognitive functioning-thinking, remembering and reasoning) and psychotic disorder (severe mental disorders that cause abnormal thinking and perceptions) and was started on psychotropic medications (medications used to treat mental health disorders) on 12/2/19. This failure had the potential for Resident 27 to not receive the necessary and appropriate psychiatric (relating to mental illness) level 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.

Based on interview and record review, the facility failed to provide sufficient staff with the appropriate competencies and skill sets to provide nursing services to ensure residents receive services to maintain their highest practicable physical, mental, and psychosocial well-being when one of four nursing staff (Infection Preventionist-IP) did not receive a competency skills check after being hired. This failure had the potential to place residents' at risk of being exposed to the spread of infections. Findings: During a concurrent interview and record review on 3/26/24, at 10:44 a.m., with the Director of Nursing (DON) and the Director of Staff Development (DSD), the facility document titled, Licensed Nurse Competency, undated was reviewed. The DON stated, the IP completed her employment application on 11/30/23 and was hired and started her orientation on 12/18/23. The DON stated, the IP was responsible for the facility's infection prevention and control program and reports to the DON. The DON stated, she does not recall initiating and validating the IP's nurse competency. The…

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

Based on observation, interview and record review, the facility failed to provide pharmaceutical services which ensured the administration of medications to meet residents needs for one of seven sampled residents (Resident 25) when Resident 25's metoprolol (medication used to treat high blood pressure) was not available for administration for 1 day (3/27/24). This failure had the potential for Resident 25's blood pressure to be uncontrolled and lead to serious medical condition such as a stroke (a loss of blood flow to part of the brain, which damages brain tissue). Findings: During a concurrent medication pass observation and interview on 3/27/24 at 7:15 a.m., at Station 2, Registered Nurse (RN) 1 was preparing Resident 25's medications after checking blood pressure which was 150/85 (a normal blood pressure for adults is a systolic measurement of less than 120 milimeters of mercury (mmHg unit of measurement) and a diastolic reading under 80 mmHg) and pulse of 85. RN 1 did not administer Resident 25's metoprolol medication. RN 1 stated the medication was not available to give 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.

Based on observation and interview, the facility failed to provide a safe, functional, and comfortable environment for residents, staff and the public when one of three medication rooms (Station 5) was observed with only one of four fluorescent lights was working. This failure had the potential for distribution of the wrong medications for residents and for staff to trip and fall. Findings: During a concurrent observation, interview and record review on 3/26/24, at 3:50 p.m. in Station 5 medication room with Licensed Vocational Nurse (LVN) 5, the medication room was observed to be dark when we entered the room, there were four fluorescent lights in the ceiling and only one of the four fluorescent lights was working. LVN 5 stated she did not usually worked in Station 5 and was not aware if the lights had already been reported to maintenance department. LVN 5 stated all four fluorescent lights should all be working to be better to see medication labels better. LVN 5 stated, . it could cause tripping and fall . During an interview on 3/26/24, at 5:02 p.m. with Registered Nurse (RN) 2,…

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 have an infection prevention and control program that included an antibiotic stewardship program that ensured residents who required antibiotics were prescribed the appropriate antibiotic, when the Infection Preventionist (IP) was unaware one of 21 sampled residents (Resident 67) who tested positive for extended spectrum beta-lactamase (ESBL- enzymes produced by a variety of gram negative bacteria with an increased resistance [not easily killed by] to commonly used antibiotics) and the physician was not notified of the lab results, and the resident was treated with an antibiotic her infection was resistant to. This failure had the potential for Resident 67's infection to not be treated with the appropriate medication and placed Resident 67 at risk to become septic (an infection spread throughout the body) and experience worsening of the infection. Findings: During a concurrent interview and record review, on 4/19/22, at 2:39 p.m., with the IP, the facility's antibiotic stewardship program was reviewed. The IP stated, part…

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

Based on observation, interview, and record review, the facility failed to ensure services provided met professional standards of quality when: 1. The facility's pain assessment tool for cognitively impaired (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life) residents, Pain Assessment in Advanced Dementia (impairment of at least two brain functions, such as memory loss and judgment) (PAINAD), was not used for one of 22 sampled residents (Resident 67). This failure had the potential to result in Resident 67's pain going unnoticed and untreated, which could delay healing time, disturb sleep and activity patterns, reduce function, and reduce quality of life. 2. One of four sampled licensed nurses (Registered Nurse [RN] 1) administered two medications crushed together in Resident 63's gastrostomy tube (G-tube- a tube surgically inserted through the abdominal wall that brings nutrition directly to the stomach) at the same time, against the facility's policy and procedure (P&P) titled, Medication Administration…

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

Based on observation, interview and record review, the facility failed to provide respiratory (network of organs and tissues that help you breathe) care and services in accordance with professional standards of practice for four of five sampled residents (Residents 25, 39, 52, and 55) when: 1. Resident 25 had a humidifier (a container with sterile water used to prevent dry airway when breathing oxygen) with an outdated label (3/9/22); 2. Resident 39 had a humidifier with an outdated label (4/7/22); 3. Resident 52 had a humidifier with an outdated label (4/10/22); 4. Resident 55's oxygen humidifier and tubing were not dated; and 5. A non-licensed staff member (Central Supply [CS]) routinely changed residents' oxygen humidifiers and tubing, against the facility's policy and procedure titled, Oxygen Concentrator. These failures resulted in a non-licensed staff to perform duties they were not supposed to perform and had the potential for contamination of oxygen equipment for Residents 25, 39, 52, 55 that could lead to illness, or even death. Findings: 1. During a review of Resident 25's…

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 20 of 22 licensed nursing staff (LN) possessed the competencies required to provide for residents' needs, when annual competency evaluations were not documented as completed in 2021. This failure had the potential for staff to not possess the appropriate skills and competencies to assure residents' safety and provide appropriate care. Findings: During a concurrent interview and record review on 4/21/22, at 2:25 p.m., with Accounts Payable (AP), employee files and staffing schedules were reviewed for compliance with staffing regulations. The AP validated orientation check off lists were kept in the employee files, but there were no recent annual competencies to be found in three of three sampled nursing staff files (Licensed Vocational Nurse [LVN] 7, LVN 8, and Registered Nurse [RN] 3. LVN 7's employee file indicated, LVN 7 started working at the facility on 2/10/2022. The orientation check off was completed and competencies were checked on abuse and reporting abuse. No other competency was in the file. LVN 8's…

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

Based on observation, interview, and record review, the facility failed to ensure food was stored and prepared in accordance with professional standards, when: 1. The mechanical soft (chopped to make the food soft and easy to eat) salad located on the lunch assembly line was 56 degrees Fahrenheit (F- scale used to measure temperature) (acceptable temperature is below 41 degrees F) when measured with a food thermometer. This failure had the potential to place residents at risk for complications from foodborne illness (sickness caused by bacteria, viruses, parasites, or toxins). 2. Individually wrapped cookies and crackers were stored in three easily accessible snack bins. The individually wrapped cookies and crackers and the bins were not labeled with a use-by date. This failure had the potential for residents to consume foods that may have been compromised (quality and taste) and for residents to have a decrease in their nutritional intake. Findings: 1. During a concurrent observation and interview on 4/18/22, at 11:27 a.m., with the Certified Dietary Manager (CDM), the tray line…

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

Based on observation, interviews, and record review, the facility failed to maintain an effective infection prevention and control program to prevent the development and transmission of communicable disease and infections when: 1. One of five sampled residents' (Resident 68) nasal cannula (device used to deliver oxygen that is placed in a resident's nose) was observed on the floor in Resident 68's room. This failure had the potential to result in transmission of organisms (germs) from the floor, onto the nasal cannula and to Resident 68. 2. Two of four Licensed Nurses (Licensed Vocation Nurse [LVN] 1 and LVN 3) failed to perform hand hygiene (hand washing using soap and water, and cleaning hands with waterless or alcohol-based hand sanitizer) prior to the administration of medications for three of 11 residents (Residents 69, 71 and 428). This failure had the potential to expose Residents 69, 71, and 428 to communicable diseases. Findings: 1. During an observation on 4/18/22, at 10:28 a.m., in Resident 68's room, a nasal cannula was attached to an oxygen concentrator (medical device…

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 implement and ensure their policy and procedure (P&P) titled, Mandatory COVID-19 (communicable, respiratory disease that can cause severe illness in some people) Employee Vaccination Policy was followed, when the facility did not follow their process for granting non-medical exemptions, four of 19 staff members were inaccurately documented as having a non-medical exemption, and one nursing student was marked as having a non-medical exemption, without documentation of the exemption. This failure resulted in 93.8% (percent- unit of measurement) of staff being vaccinated for COVID-19, which placed residents at risk of being exposed and contracting COVID-19 from staff. Findings: During a concurrent interview and record review, on [DATE], at 9:44 a.m., with the Infection Preventionist (IP), the facility's COVID-19 staff Vaccination Status for Providers, updated [DATE], and proof of employee granted exemptions, were reviewed. The IP stated the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop a baseline care plan for one of three sampled residents (Resident 73), when Resident 73 was admitted with hearing aids and the facility did not establish a care plan with interventions to address Resident 73's hearing needs. This failure had the potential to result in Resident 73 not having her hearing needs met. Findings: During a concurrent observation and interview on 4/18/22, at 3:19 p.m., with Resident 73, in Resident 73's room, Resident 73 was awake in her bed. Resident 73 had a hearing aid to her left ear and without a hearing aid to the right ear. Resident 73 stated her right hearing aid was missing. Resident 73 stated she kept her hearing aids in a pink box in her room. During a review of Resident 73's Minimum Data Set (MDS) assessment (an evaluation used to identify resident care needs), dated 4/6/22, the MDS assessment indicated, Resident 73 was cognitively intact with a Brief Interview for Mental Status (BIMS) (an…

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

Based on interview and record review, the facility failed to develop a comprehensive care plan with measurable objectives and timeframes for one of 19 sampled residents (Resident 52), when Resident 52 required oxygen at night and a care plan was not developed to address Resident 52's respiratory needs. This failure had the potential for Resident 52's respiratory needs to be not met, which could lead to respiratory issues and/or death. Findings: During a review of Resident 52's admission Record (AR-a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 4/20/22, the AR indicated, admission Date 7/2/21 .Chronic Obstructive Pulmonary Disease (COPD-condition involving constriction of the airways and difficulty or discomfort in breathing) . During a review of Resident 52's Order Summary Report (OS), dated 7/9/21, the OS indicated, .Oxygen at 2L/min (liters per minute- unit of measurement) via nasal cannula (device used to deliver supplemental oxygen or increased airflow to a person) at bedtime for shortness 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.

Based on observation, interview, and record review, the facility failed to ensure two out of three sampled residents (Resident 55 and Resident 44) with an indwelling urinary catheter (a soft hollow tube which is passed into the bladder to drain urine, for persons who cannot empty their bladder) received appropriate care when: 1. Resident 55's indwelling urinary catheter had sediment (substances present in urine) trapped in the tubing and the physician was not notified; and 2. Resident 44's indwelling urinary catheter bag was partially folded and placed sideways in the catheter bag (bag used to cover the urinary catheter bag for privacy), preventing the free flow of urine. These failures placed Residents 55 and 44 at risk for urinary tract infections (infection in any part of the urinary system, the kidneys, bladder, or urethra). Findings: 1. During a review of Resident 55's admission Record (AR-a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 4/20/22, the AR indicated, admission Date 3/15/22 .Diagnosis…

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 one of one sampled resident (Resident 25), that received dialysis (treatment that uses the blood stream to filter out wastes in the body for people whose kidneys are failing) treatments, received ongoing assessments, when the facility did not perform post (after) dialysis assessments (includes vital signs [clinical measurements including heart rate, temperature, respiration rate and blood pressure that indicate the state of a resident's essential body functions], access site [used for connecting to a machine that filters blood during treatment] assessment, and condition of resident) three out of five days (4/8/22, 4/11/22, 4/13/22). This failure resulted in incomplete assessments for Resident 25 and had the potential for the facility to not recognize dialysis related complications (low blood pressure, fluid overload, blood clots, muscle cramps, access site infection, and itchy skin) for Resident 25, that could lead to harm or death. Findings: During a review of Resident 25's admission Record (AR-a document that…

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 implement an annual gradual dose reduction (GDR-tapering of a medication dosage to determine if symptoms, conditions, or risks can be managed by a lower dose or it can be discontinued) of antipsychotic medication (medication for the treatment of psychosis [involves a loss of contact with reality and can feature hallucinations and delusions]) in accordance with the facility policy and procedure titled Medication Monitoring Medication Management, dated 2007, for one of five sampled residents (Resident 70) when Resident 70 was prescribed and administered an antipsychotic medication and the previous effort to conduct a GDR was 2/20/21. There were no documented clinical contraindications (specific situation in which a drug, procedure, or surgery should not be used because it may be harmful to the person) related to the antipsychotic to not conduct the GDR. This failure had the potential to result in Resident 70 receiving unnecessary antipsychotic…

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

Based on observation, interview, and record review, the facility failed to ensure the facility's medication error rate did not exceed five percent, when two of 25 medication administration opportunities observed were not administered in accordance with facility policy and procedure (P&P) and standards of practice. This failure resulted in a medication error rate of 8% (percent- unit of measurement) and placed Resident 63 at risk for drug interaction and clumping of medications, which could result in plugging of the gastrostomy tube (G-tube- a tube surgically inserted through the abdominal wall that brings nutrition directly to the stomach) and prevent Resident 63 from getting the full therapeutic effect of all administered medications and nutrition. Findings: During a review of Resident 63's admission Record (AR-a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 4/21/22, the AR indicated, admission Date 7/18/18 .Diagnosis Information . Pneumonia (lung inflammation caused by bacterial or viral infection) .…

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

Based on observation, interview, and record review, the facility failed to follow one of five sampled residents' (Resident 16) food preferences and dislikes, when Resident 16 received canned fruit instead of the preference for fresh fruit on her meal tray for lunch on 4/18/22. This failure had the potential to result in decreased food consumption for Resident 16. Findings: During a concurrent observation and interview on 4/18/22, at 11:36 a.m., with Resident 16, in Resident 16's room, Resident 16 stated she received canned fruit and not fresh fruit. Resident 16's lunch tray was observed to have a container of canned chopped peaches. Residents 16's meal tray had a tray ticket that did not indicate likes or dislikes for fruit. During an interview on 4/19/22, at 9:29 a.m., with Resident 16, Resident 16 stated she received canned fruit on her meal tray. Resident 16 stated the canned fruit was not appealing. During a concurrent observation and interview on 4/20/22, at 12:27 p.m., with Resident 16, in Resident 16's room, Resident 16 stated most of her meals came with fruit, but it was…

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

Based on interviews and record review, the facility failed to ensure each resident was offered the influenza (viral infection that attacks the respiratory system - your nose, throat and lungs) vaccine annually, when one of five sampled residents (Resident 64), was last offered the influenza vaccine in 2013, and no further education, offering, or declination (refusal) was obtained. This failure resulted in Resident 64 and/or their responsible parties (a person other than the resident, designated to make health care decisions on behalf of the resident), who had previously refused the vaccine, to not receive education and be offered the vaccine annually. Findings: During an interview on 4/19/22, at 9:03 a.m., with the Infection Preventionist (IP), the IP stated, he had worked at facility since 2017 as a nurse and had been the facility's IP since February 2020. During a review of Resident 64's Influenza Immunization Informed Consent, dated 10/21/13, the Influenza Immunization Informed Consent indicated Resident 64 had not been offered nor declined the influenza vaccination since 2013.…

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.