Fresno Postacute Care

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to meet professional standards of practice for four of eight sampled residents (Resident 8, 38, 2 and 57) when: 1. Registered Nurse (RN) 2 did not follow medication administration direction when she gave medication to Resident 8 without giving food. This failure had the potential to put Resident 8 at risk for stomach upset. 2. A small medication cup with one tablet was left on top of Resident 38's bedside table accessible to other residents. This failure had the potential for Resident 38 to not receive a prescribed medication and for other residents to have access to the medication. 3. Resident 2 and Resident 57's physician order for bed rails was not followed. This failure had the potential to put Resident 2 and Resident 57 at risk for injury which could lead to more serious health condition. Findings: 1. During a concurrent observation and interview on 8/14/24 at 7:28 a.m. in Station 1 (one)outside of room [ROOM NUMBER]. RN 2 prepared…

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 planned menus were followed for the lunch meal on August 12, 2024 when: 1. Incorrect portion sizes were used on the therapeutic diets: a. ½ cup (4 ounces) of sweet potato fries were served instead of ¼ cup (2 ounces) to 20 residents (Resident 42, 5, 16, 6, 26, 9, 23, 60, 12, 74, 34, 4, 37, 24, 77, 25, 22, 29, 78, and 13) who were on a Consistent Carbohydrate (CCHO) diet (a diet that provides a consistent amount of carbohydrates at each meal and from day to day to help keep blood sugar levels stable); and b. #16 scoop (2 ounces) of roast beef was served instead of #10 scoop (3.2 ounces) to eight residents (Resident 21, 57, 61, 54, 3, 55, 66, and 28) who were on a mechanical soft diet (a diet of soft-textured foods that are easy to chew and swallow); and c. #12 scoop (2.67 ounces) of pureed roast beef was served instead of #8 scoop (4 ounces) to seven residents (Resident 27, 1, 69, 2, 15, 49, and 44) on a puree diet (designed for residents who have difficulty chewing and/or swallowing and the texture…

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 0bservation, interview, and record review the facility failed to provide a sanitary environment to help prevent the development and transmission of communicable diseases and infections for two of seven residents (Resident 61 and Resident 238) when Certified Nursing Assistant (CNA) 1 did not perform hand hygiene (process of washing or disinfecting hands to prevent the spread of germs) after leaving the shared room of Resident 61 and Resident 238, while carrying a bag of soiled (dirty or contaminated) linen. CNA 1 then moved the linen cart without performing hand hygiene. This failure had the potential to contaminate the surface of the linen cart and cause cross contamination (when germs move from one area to another) of other surfaces. Findings: During an observation on 8/12/24 at 10:47 a.m. outside of Resident 61 and Resident 238's room, CNA 1 exited Resident 61 and Resident 238's room carrying a bag of soiled linen. CNA 1 disposed of the soiled linen bag and did not perform hand hygiene after; CNA 1 then pushed the linen cart forward without performing hand hygiene. During…

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 three of nine sampled residents (Resident 20, Resident 24 and Resident 40) when: 1. Registered Nurse (RN) 2 administered medication to Resident 20 in the hallway. 2. RN 1 administered medication to Resident 24 and did not provide privacy. 3. Licensed Vocational Nurse (LVN) 1 administered medications to Resident 40 and did not provide privacy. These failures resulted in Resident 20, Resident 24 and Resident 40 not being provided with respect and dignity while taking their medications. Findings: During a observation on 8/14/24 at 8:35 a.m. in Station one hallway during medication pass, Resident 20 was sitting up in his wheelchair. RN 2 prepared Resident 20's medications. RN 2 administered Resident 20's medications in the hallway with other residents, staff and visitors walking by. During a review of Resident 20's admission Record, dated 8/16/24, the admission Record indicated,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based observation, interview, and record review the facility failed to ensure four of fourteen residents (Residents 8, 30, 57 and 65) were provided their right to be treated with respect and dignity when: 1. Resident 30's back was not covered after being transported out of the shower room. This failure resulted in Resident 30 having his back exposed while being transported out of the shower room, down the hall, and into his room. 2. Certified Nursing Assistant (CNA) 11 stood over Resident 8 while spoon feeding him breakfast while lying in bed. This failure resulted in Resident 8 not being provided a respectful and dignified dining experience which could further enhance resident's quality of life. 3. Resident 57 was lying flat in bed eating lunch but unable to see food placed on top of the overbed table positioned in front of her. This failure placed Resident 57 at risk for aspiration and choking which could lead to more serious health condition. 4. Resident 65's urinary catheter (flexible tube inserted into…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure the Minimum Data Set assessment (MDS-assessment of physical and psychological functions and needs) accurately reflected resident's health and functional status of four of nine sampled residents (Residents' 14, 29, 34 and 38) when Resident 14, Resident 29, Resident 34 and Resident 38's smoking habits was inaccurately coded on the MDS assessment. This failure had the potential to result in Residents' 14, 29, 34 and 38's care needs not met. Findings: During a review of Resident 14'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 8/16/24, the AR indicated, Resident 14 was admitted to the facility on [DATE] with diagnoses which included pain, diabetes (high blood sugar in the blood) and abnormalities of gait and mobility. During a review of Resident 14's Smoking - Safety…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan that meets resident preferences for one of seven residents (Resident 66) when Resident 66's preference to be cared for by female staff was not care planned. This failure had the potential to cause male staff members to unknowingly enter Resident 66's room to provide care. Findings: During a review of Resident 66's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 8/15/24, the AR indicated Resident 66 was admitted on [DATE] with the following diagnoses: heart failure (condition which makes it difficult for the heart to pump blood to the rest of the body), atrial fibrillation (heart condition characterized by an irregular and often times fast heart beat) and major depressive disorder (mental condition characterized by long bouts of sadness). During an interview on 8/15/23 at 9:55 a.m. with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Findings: 2. During a concurrent observation and interview on 8/15/24 at 9:45 a.m. with Licensed Vocational Nurse (LVN) 4 in station 2 at medication cart one, two medication bottles of Perampanel (medication used to prevent seizures [rapid, rhythmic, uncontrollable shaking, with muscles contracting and relaxing repeatedly]), with no visible expiration dates. LVN 4 stated she was unable to find a visible expiration date on the label from the pharmacy and the expiration date was not marked on the bottles. LVN 4 stated every medication is to have a visible expiration date, prior to dispensing medication to residents the expiration date is to be reviewed and if the medication is expired it is to be discarded. LVN 4 stated, expired medication could have lost efficacy (desired result) and not give the desired effect or give unwanted side effects to the resident. During an interview and observation on 8/16/24 at 3:20 p.m. with Director of Nurses (DON), the DON stated the pharmacy should have written the expiration date…

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 three food service staff (DA 1, DA 2 and [NAME] 1) were competent to carry out the functions of food and nutrition services safely and effectively when they served incorrect portion sizes of food items and did not have a competency or skills check done. This failure had the potential to result in residents' diet orders and facility menus not being followed. Findings: During the lunch meal service and meal preparation on August 12, 2024, the following was observed: *Starting at 12:31 p.m., the steam table had scoops for the following: #12 scoop for the regular texture roast beef, #16 scoop for the mechanical soft roast beef, #12 scoop for the pureed roast beef, and four-ounce (oz - unit of measurement) scoop (1/2 cup) for the regular texture sweet potato fries; and *Starting At 12:32 p.m. Dietary Aide (DA) 1 was not calling out CCHO [Consistent Carbohydrate (CCHO) diet (a diet that provides a consistent amount of carbohydrates at each meal and from day to day to help keep blood sugar levels stable]; 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.

Based on observation, interview, and record review, the facility failed to ensure food was palatable and flavorful when the lunch served for residents had firm and undercooked peas, dry and bland chicken, and bland rice. This failure had the potential to result in residents to have decreased meal intake due to difficulty chewing and eating their food which can lead to resident's not meeting their nutrition needs. Findings: During an interview on 8/12/24 at 8:38 a.m. with Resident 29, Resident 29 stated food from the kitchen is dreadful. During an interview on 8/12/24 at 8:40 a.m. with Resident 12, Resident 12 stated the broccoli was too watery and felt like it was cooked for days. Resident 12 stated the rice and mashed potatoes did not taste good. Resident stated lunch and dinner from the kitchen were not appetizing at all. During an interview on 8/12/24 at 8:50 a.m. with Resident 177, Resident 177 stated the food tasted horrible and the cook did not know how to cook anything. Resident stated the food was either overcooked or undercooked. During an interview on 8/12/24 at 10:59 a.m.…

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 3. During a review of Resident 29's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 8/15/24, the AR indicated Resident 29 was admitted with the following diagnoses: diabetes mellitus (A disease which result in too much sugar in the blood), chronic kidney disease (when the kidneys have been damaged over time resulting in decreased function), vitamin D deficiency (vitamin deficiency that causes issues with your bones and muscles), and muscle weakness. During a review of Resident 29's Minimum Data Set (MDS- resident assessment tool which indicates physical and cognitive abilities), dated 5/16/24, the MDS indicated a Brief Interview for Mental Status (BIMS-an assessment of cognitive function) score of 15 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 29 had no cognitive impairment. During a concurrent observation and interview on 8/12/24 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain medical records which were complete, and accurately documented in accordance with accepted professional standards and practices for three of seven residents (Resident 51, Resident 2 and Resident 22) when: 1. Resident 51's name was spelled incorrectly on his Physician Order for Life Sustaining Treatment (POLST- a medical document which outlines a patient's preferences for end-of-life care). This failure resulted in inaccurate medical records being kept for Resident 51 and had the potential to cause confusion to staff who read his POLST form. 2. Resident 2's copy of Physician Orders for Life-Sustaining Treatment (POLST) form was not signed and readily available as part of Resident 2's current medical records. 3. Resident 22's copy of Physician Orders for Life-Sustaining Treatment (POLST) form was inaccurately dated when signed and readily available as part of Resident 22's current medical records. These failures had the potential…

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

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program when cockroaches were found in the facility kitchen and hallway. This failure had the potential to result in residents, staff, and visitors to contract diseases caused by pests. The facility census was 75. Findings: During a concurrent observation and interview on 8/12/24 at 10:31 a.m. with Dietary Aide (DA) 2 in the kitchen, there was a cockroach crawling on the wall at the dish machine area. DA 2 confirmed she saw the cockroach. DA 2 stated the kitchen had issues with cockroaches in the past. During an observation on 8/12/24 at 10:32 a.m. in the kitchen, there was a cockroach crawling on the floor by the handwashing station. During an observation on 8/12/24 at 10:34 a.m. in the kitchen, there was a cockroach crawling on the floor under the food preparation table, near the three-compartment sink. During an interview on 8/12/24 at 10:40 a.m. with the Certified Dietary Manager (CDM), the CDM stated the kitchen staff told him there has been issues with cockroaches 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 and record review, the facility failed to provide pharmaceutical services which ensured the administration of medication to meet residents needs for one of nine sampled residents (Resident 65) when Resident 65's Ergocalciferol (medication used to prevent and treat Vitamin D deficiency [nutrient the body needs for building and maintaining healthy bones]) was not available for administration for one day on 8/14/24. This failure had the potential for Resident 65 to not received the nutrient her body needs which could lead to serious health condition. Findings: During a concurrent medication administration observation and interview on 8/14/24 at 8:42 a.m. at Station one, Registered Nurse (RN) 2 was preparing Resident 65's medications. RN 2 did not administer Resident 65's Ergocalciferol medication. RN 2 stated she did not administer the medication because she had to clarify with pharmacy the medication available on hand. RN 2 stated the medication bubble pack had different 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 record review, the facility failed to ensure the facility medication error rate did not exceed five percent (10.34 percent) when: 1. Registered Nurse (RN) 2 administered metformin medication to Resident 8 without food when the medication direction indicated to administer with food. This failure had the potential for Resident 8 to develop upset stomach or gastrointestinal (GI)problems which could lead to more serious health condition. 2. RN 2 did not completely dilute Resident 65's Juven therapeutic powder (brand name [used for wound healing]) before administering to Resident 65 leaving residue of the powder in the bottom of the cup. This failure resulted in Resident 65 not receiving the complete dose which had the potential for slower wound healing and could lead to more serious health condition. 3. Registered Nurse (RN) 2 did not administer Resident 65's ergocalciferol (brand name [medication used for Vitamin D deficiency]) medication during medication pass. This failure had…

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

Based on observation, interview, and record review, the facility failed to ensure pureed meat was able to hold its shape or form for seven of 64 sampled residents (Resident 27, 1, 69, 2, 15, 49, and 44). This failure had the potential to result in residents choking or decreased meal intake. Findings: During a concurrent observation and interview on 8/13/24 at 12:15 p.m. with the Certified Dietary Manager (CDM) in Station 2 hallway, the pureed diet test tray was sampled. The pureed curry chicken was spread all over the plate and did not hold its shape or form. The CDM acknowledged that the pureed chicken did not hold its shape or form. During a review of the facility's Diet Type Report (DTR), dated 8/12/24, the DTR indicated the following residents are on pureed diet: a. Resident 27 is on CCHO, puree, nectar thick liquids diet. b. Resident 1 is on regular puree, honey thick liquids diet. c. Resident 69 is on fortified puree diet. d. Resident 2 is on regular puree, honey thick liquids diet. e. Resident 15 is on no added salt, puree, honey thick liquids diet. f. Resident 49 is on…

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

Based on observation, interview, and record review, the facility failed to ensure adaptive equipment was provided for one sampled resident (Resident 3) when Resident 3 was not provided a sippy cup on his meal tray. This failure had the potential to limit Resident 3's ability to drink independently and safely. The facility census was 75. Findings: During an observation on 8/13/24 at 12:04 p.m. in the kitchen, Resident 3's meal tray has two regular cups with no handle. During a review of Resident 3's meal ticket (MT), MT indicated, Adaptive Equip [equipment]: Sippy Cup. During an interview on 8/14/24 at 10:05 a.m. with Dietary Aide (DA) 2, DA 2 stated the kitchen does not have enough sippy cups to go on residents' meal trays. During an interview on 8/14/24 at 10:06 a.m. with DA 1, DA 1 stated the kitchen does not have enough sippy cups and regular cups so he would also use disposable cups. During a review of Resident 3's Order Summary Report (OSR), dated 8/14/24, the OSR indicated, Light up utensils and sippy cup to decrease spillage during meals. During an observation on 8/14/24 at…

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

Based on observation and interview, the facility failed to provide the minimum of at least 80 square feet per resident in 17 resident bedrooms (Rooms 4, 5, 6, 7, 8, 9, 10, 11, 12, 14, 15, 16, 17, 18, 19, 20 and 21) when there were two residents in rooms which did not meet the square footage requirement. This failure had the potential to place residents at risk for not having sufficient space to accommodate residents' needs, privacy, and comfort. Findings: During a concurrent observation and interview on 8/16/24 at 11:05 a.m. with the Maintenance Supervisor (MS), facility tour was conducted. MS stated the rooms failed to provide the minimum square footage as required by regulation. Room variations were in accordance with the particular needs of the residents. The residents had a reasonable amount of privacy. Closets and storage space were adequate. Bedside stands were available. There was sufficient room for nursing care and for residents to ambulate. Wheelchairs and toilet facilities were accessible. The waiver will not adversely affect the health and safety of residents. Room…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a sanitary, comfortable environment for four of 31 sampled residents (Resident 11, Resident 22, Resident 47 and Resident 60), when the smell of urine was noted in room [ROOM NUMBER] and hallway. This failure had the potential for Resident 11, 22, 47 and 60, to experience an uncomfortable environment. Findings: During an observation on 8/12/24 at 8:15 a.m. in the hall outside of rooms [ROOM NUMBERS], a strong urine odor was noted. During an observation in 8/12/24 at 8:20 a.m. with Resident 11 in room [ROOM NUMBER], there was a strong urine odor in the room. Resident 11 was sitting up in his bed, eating his breakfast. The privacy curtain was pulled between Resident 11's bed and Resident 60's bed. During an observation on 8/12/24 at11:55 a.m. in the hall outside of room [ROOM NUMBER] and, a strong urine odor was noted. During an observation and interview on 8/12/24 at 1:15 p.m. with Resident 11 in his room, Resident 11 stated, .I…

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 maintain an environment free from accident hazards for one of four sampled residents (Resident 2) when Resident 2 fell out of a lowered bed while she was being changed (changing of resident clothing) by Certified Nurse Assistant (CNA) 1. This failure resulted in skin tear and bruises to Resident 2. Findings: During a record review of Resident 2's admission Record (AR-a document with personal identifiable and medical information), dated October 19, 2023, the AR indicated Resident 2 was admitted to the facility on [DATE] diagnoses which included cerebral edema (swelling that occurs in the brain), traumatic brain injury (a sudden, external, physical assault that damages the brain), anxiety (a mental condition characterized by excessive apprehensiveness about real or perceived threats) and contractures (a fixed tightening of muscle, tendons, ligaments, or skin). Resident 2 required staff assistance for activities of daily living. During an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to hire a qualified Dietary Supervisor (DS) with the appropriate competencies and skill sets to carry out the functions of the food and nutrition services for 68 of 74 residents, when the dietary supervisor did not meet the minimum qualifications for the role. This failure resulted in sanitation issues in the kitchen, the menu not being followed for lunch on 8/28/2023 and had the potential to affect the nutrition and health status of medically compromised (easily gets sick) residents who received food from the kitchen. (cross-reference F-tag 812 and 803) Findings: During an interview on 8/28/23 at 3:28 p.m. with the DS, the DS stated she was awaiting to start a dietary supervisor course. The DS stated she has been the dietary supervisor for five months since March 2023. She stated she previously was the housekeeping supervisor for seven months from August 2022 through March 2023. During an interview on 8/29/23 at 4:15 p.m. with the Registered Dietitian…

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 the written menu for lunch on August 28, 2023, when: 1. Two residents who were on a small portion diet (Residents 27 and 37) did not receive the correct portion size of the entrée and side dishes. The small portion size diet was served incorrectly. This failure placed Residents 27 and 37 at a potential risk to not receive adequate nutrients. 2. Applesauce was given for dessert for seven residents on a puree diet (Residents 1,2, 5, 15, 17,48, and 58) instead of the puree raspberry parfait square. This failure had the potential for Residents 1,2, 5, 15, 17,48, and 58 to not be satisfied with the dessert and subsequently miss out on those calories provided by the dessert. 3. Seventy-one residents did not receive the zucchini, orange slice or bread roll as it was indicated on the menu on 08/28/23. These failures had the potential to affect the nutrition status of 68 of 74 medically compromised residents who received food from the kitchen. Findings: 1. During an observation on 8/28/23 at 12:12 p.m. in 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 ensure safe preparation, distribution, and storage practices were followed in the kitchen when: 1. Trash, black grime (dirt stuck to the surface of something) and a knife were found underneath the stove. 2. The can opener in the kitchen had black sticky residue and was covered in grime. 3. The shelf above the steam table was dirty. 4. A dead water bug was found in the mop closet. 5. Oven mitts had black grime. 6. Four cooking pans were crusted with black grime. These failures had the potential to attract pests, contaminate residents' food, and cause foodborne illnesses to 68 of 74 sampled residents who receive food from the kitchen. Findings: 1. During an observation on 8/28/23 at 10:46 a.m. in the kitchen, trash, food crumbs, black grime and a knife were found underneath the kitchen stove. During an interview on 8/28/23 at 3:28 p.m. with the Dietary Supervisor (DS), The DS stated the floor underneath the kitchen stove should be kept clean, sanitized, and swept; kitchen staff are responsible for cleaning the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were free from unnecessary psychotropic (drugs that affects brain activities associated with mental processes and behavior) medications for three out of three residents (Resident 62, 30, 49) when: 1. Resident 62 was administered quetiapine (an antipsychotic medication given for certain mental disorders and works by altering brain chemistry to help reduce psychotic symptoms) and the facility did not attempt or implement resident specific non-pharmacological interventions, quetiapine dose was increased without clinical justification, and facility did not monitor the use of quetiapine according to manufacturer specifications. 2. Resident 30 was administered trazodone (a psychotropic medication given for certain mental disorders including depression) and the facility did not attempt or implement resident specific non-pharmacological interventions, trazodone dose was increased without a clinical justification, facility did not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were free of medication error in excess of five percent or greater whereas the observation of 25 opportunities during the medication pass resulted in four errors (calculated medication error rate of 16%) when: 1. Licensed Vocational Nurse (LVN) 2 did not rotate the insulin (medication used to control high blood sugar) administration site when administering Resident 6's insulin. This failure placed Resident 6 at risk for elevated blood sugar levels. 2. LVN 2 administered Morphine (used to treat pain) IR (Immediate Release- morphine that acts quickly over a short period of time) instead of Morphine ER (Extended Release-morphine that acts over a long period of time). This failure placed Resident 24 at risk for ineffective pain management. 3. LVN 4 did not rinse Resident 43's mouth after administering (Budesonide/ Formoterol brand name) inhaler (a medication for lung disease that contains steroid and is administered through…

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 drugs and biologicals used in the facility were stored and/or labeled in accordance with current accepted professional principles and facility policies and procedures, for 2 of 4 medication carts and 1 of 2 medication rooms when: 1. In the Nursing Station 1 medication room, a punctured 1 milliliter (ml- unit of measure) vial of single dose (Epoetin Alfa brand name - medication which helps the body make more red blood cells) 10,000 units for Resident 73 was observed stored in the medication refrigerator. 2. In a medication cart at Station 1, Resident 21's (Budesonide/ Formoterol brand name - used to treat breathing difficulties) 160 micrograms (mcg- unit of measure) /4.5 mcg inhaler (a medication which is inhaled through the mouth to help people with damaged lungs breath better) was found not to have a beyond use date (BUD- the last date you can safely use a medication) and Resident 59's (Tiotropium bromide brand name) inhaler did not have a patient identifier or label, and did not have a BUD. 3. In a…

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

Based on observation, interview and record review, the facility failed to maintain infection prevention and control practices when: 1. Licensed Vocational Nurses (LVN 2 and 4) did not appropriately disinfect (be free of any bacteria or other microorganisms [very small creatures unable to be seen with the naked eye]) the facility's shared glucometer (a device used to measure the amount of sugar in the blood) for three sampled residents (Residents 60, 7 and 43) according to manufacturer instructions for the disinfecting wipes. 2. LVN 4 did not perform hand hygiene prior to providing care to two sampled residents (Resident 60 and 18) during medication pass (the time to hand out medications). These failures had the potential to spread infection to other residents, staff, and visitors. Findings: 1. During an observation on 8/28/23 at 11:55 a.m. in front of Resident 60's room, LVN 2 was wiping the facility's shared glucometer using a PDI Super-Sani Cloth (disinfecting) wipes, after using the glucometer to obtain a blood glucose level for Resident 60. LVN 2 covered the bottom 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 observation and interview, the facility failed to provide the minimum of at least 80 square feet per resident in 17 resident bedrooms (Rooms 4, 5, 6, 7, 8, 9, 10, 11, 12, 14, 15, 16, 17, 18, 19, 20 and 21) when there were two residents in rooms which did not meet the square footage requirement. This failure had the potential to place residents at risk for not having sufficient space to accommodate residents' needs, privacy, and comfort. Findings: During a concurrent observation and interview on 8/28/ at 1:30 p.m. with the Administrator (ADM), an facility tour was conducted. ADM stated the rooms failed to provide the minimum square footage as required by regulation. Room variations were in accordance with the particular needs of the residents. The residents had a reasonable amount of privacy. Closets and storage space were adequate. Bedside stands were available. There was sufficient room for nursing care and for residents to ambulate. Wheelchairs and toilet facilities were accessible. The waiver will not adversely affect the health and safety of residents. Room Number…

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 one of three sampled residents (Resident 31) when the family room was locked and inaccessible for resident use. This failure resulted in the violation of Resident 31's rights to use the family room. Findings: During an interview on 8/30/23 at 10:27 a.m. with Resident 31, Resident 31 stated the family room was used by family, residents, and visitors. Resident 31 stated the family room had been locked various times on weekends and in the afternoons. Resident 31 stated he used the family room to watch television, microwave food, and make phone calls. Resident 31 stated it made him upset when the family room was locked. Resident 31 stated he informed the Licensed Nurses (LNs) about the family room being locked and they did not have a key to open the door. During a review of Resident 31's Minimum Data Set (MDS- a resident assessment tool used to identify cognitive [mental processes]…

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 (MDS- a resident assessment tool that evaluates memory recall and physical functions and guides care planning decisions) assessment accurately reflected the resident's status for one of nine sampled residents (Resident 67) when Pneumonia (an infection of the lungs that may be caused by bacteria, viruses, or fungi) was listed as a current diagnosis for Resident 67. This failure resulted in an inaccurate assessment of Resident 67's and had the potential to result in Resident 67's care needs going unmet. Findings: During an observation on 8/28/23 at 10:22 a.m., Resident 67 was observed lying in their bed, body facing the open window, eyes open but did not respond when being spoken to. Resident 67 had no observable signs or symptoms of pneumonia. Resident 67 was not coughing and appeared well-hydrated. During a review of Resident 67's admission Record (AR -document with personal and demographic information),…

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

Based on observation, interview, and record review, the facility failed to ensure residents were provided an environment that promoted well-being and feeling of self-worth and self-esteem for one of 74 residents (Resident 38) when Resident 38 was eating while lying down. This failure had the potential for Resident 38 to not feel good about himself and his situation of eating while laying down which could lead to eating less of his food and choking. Findings: During a review of Resident 38's admission Record dated 08/30/20, the Admissions Record indicated . admission date 6/11/18 . Diagnosis Information . volvulus (condition where the intestine twists around itself) pain . iron deficiency anemia (condition causing decreased red blood cells) . muscle weakness . anxiety disorder . muscle spasm . difficulty walking . malignant neoplasm of prostate (uncontrolled growth of cells in the prostate [a gland surrounding the neck of the bladder in males] . During an observation on 8/28/23 at 12:40 p.m. in Resident 38's room, Resident 38 was observed laying down in bed while eating his lunch.…

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 care in accordance with professional standards of practice for one of three sampled residents (Resident 55), when Licensed Vocational Nurse (LVN) 7 failed to assess skin integrity after skin tear was reported by Certified Nursing Assistant (CNA) 2. This failure resulted in an unattended skin tear for Resident 55 which had the potential to result in further skin breakdown and infection. Findings: During an interview on 8/30/23 at 4:36 p.m. with CNA 2, CNA 2 stated she gave Resident 55 a shower on 8/28/23 and noticed a skin tear on her lower back. CNA 2 stated she documented the skin tear on the shower sheet and notified the nurse. During a concurrent interview and record review on 8/30/23 at 3:56 p.m. with LVN 7, Resident 55's Skin Monitoring: Comprehensive CNA Shower Review (CSR), dated 8/28/23 was reviewed. The CSR indicated, skin tear to sacral (lower back) area. LVN 7 stated she reviewed and signed the shower sheet on 8/28/23. LVN 7 reviewed Resident 55's clinical record and stated there was no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide an appropriate diet to maintain healthy weight for one of 74 sampled residents (Resident 38) when Resident 38 was eating a regular diet with his hands. This failure resulted in Resident 38 losing 11.6% of his body weight in three months (May to July). Findings: During a review of Resident 38's admission Record dated 08/30/20, the Admissions Record indicated . admission date 6/11/18 . Diagnosis Information . volvulus (condition where the intestine twists around itself) pain . iron deficiency anemia (condition causing decreased red blood cells) . muscle weakness . anxiety disorder . muscle spasm . difficulty walking . malignant neoplasm of prostate (uncontrolled growth of cells in the prostate [a gland surrounding the neck of the bladder in males] . During an observation on 8/28/23 at 12:34 p.m. in Resident 38's room, Resident 38 was observed eating his lunch in bed with his bare hands. Resident 38 was grabbing small pieces of his…

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.