Keystone Post-Acute

Based on observation, interview and record review the facility failed to follow professional standards for one of 11 sampled residents (Resident 216) when Resident 216 did not have his urinary catheter(a hollow tube inserted into the bladder to drain and collect urine) changed per physician order, the physician was not notified that the catheter was not changed and Resident 216 had signs that included mucus and sediment in the catheter tubing, amber-colored foul-smelling urine. This failure resulted in a missed urinary catheter change, and the lack of notification regarding Resident 216 ' s catheter tubing had the potential of delayed diagnosis and treatment of a urinary tract infection, increasing risk of worsening infection. Findings: During an observation on 5/27/25 at 10:38 a.m. in Resident 216 ' s room, Resident 216 ' s urinary catheter bag contained dark-colored urine and there was visible sediment and mucus in the catheter tubing. The room had a strong odor of urine. During a review of Resident 216 ' s admission Record (AR - a summary of information regarding a patient which…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of eleven sampled residents (Resident 38) was effectively and efficiently cared for by the administrator to maintain Resident 38's highest practicable physical, mental, and psychosocial well-being when the Administrator (ADM) was the acting decision maker for Resident 38. This failure had the potential to result in Resident 38 to not maintain his highest well-being, wishes and preferences not being upheld which had the potential to lead to decreased autonomy (ability to make own decisions and control own actions) or participation in his care planning process. Findings: During a review of Resident 38's admission Record (AR- document containing resident personal information), dated [DATE], the AR indicated, Resident 38 was admitted to the facility on [DATE], with diagnoses which included dementia (decline in cognitive functioning that interfere with daily life), major depressive disorder (mood disorder that causes persistent…

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 establish and maintain an effective infection prevention and control program for two of 26 sampled residents (Resident 57 and Resident 216) when: 1. When Resident 57 was not placed on Enhanced Barrier Precautions (EBP - an infection control intervention designed to reduce transmission of resistant organisms [bacteria that have become resistant to certain antibiotics] that requires gown and glove use during high contact resident care activities) for his central venous catheter port (a thin tube that goes into a vein in your arm or chest and ends at the right side of your heart and is attached to a device [port] under the skin) incision wound. This failure placed Resident 57 at risk for cross-contamination (the process when germs are unintentionally transferred from one substance or object to another, which causes a harmful effect) and infection (an invasion of the body by germs that cause disease). 2. When Resident 216 ' s urinary catheter…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of 11 sampled residents (Resident 46) had access to a call light when Call light cord was found strung over the head of the bed and the call light was tucked between the mattress and the bed frame. This failure resulted in Resident 46 not being able to directly call for assistance and had the potential to place Resident 46 at risk for accidents and injuries. Findings: During a review of Resident 46's admission Record (AR, a document containing resident personal information), dated 5/29/25, the AR indicated, Resident 46 was admitted to the facility on [DATE] with diagnoses which in included wedge compression lumbar fracture of the first vertebra (the first bone in the lower back has been squished or crushed in a way that makes it look like a wedge - narrower in the front than the back) dysphagia (difficulty swallowing), Alzheimer's (a disease characterized by a progressive decline in mental abilities) and Cognitive Communication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide adequate supervision and an accident-free environment for one of two sampled residents (Resident 1), when Resident 1 eloped (a resident who departs from a facility unsupervised and undetected) on 3/10/25 from the facility through the front entrance door and was found on 3/14/25 when resident returned back to her apartment. This failure resulted in Resident 1 eloping from the facility on 3/10/25, which placed Resident 1 at risk for harm, injury and/or death. Findings: During a review of Resident 1's admission Record (a summary of important information regarding a patient which include patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the admission record indicated, Resident 1 was admitted to the facility on [DATE] with a diagnosis history that includes but not limited to epilepsy (A disorder in which nerve cell activity in the brain is disturbed, causing…

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 revise and implement a comprehensive person-centered care plan for two of six sampled residents (Resident 1 and Resident 2) when Resident 1 and Resident 2 were involved in a resident to resident verbal altercation on 9/20/24, the Interdisciplinary Team (IDT-a group of health care professionals with various areas of expertise who work together to establish goals for residents) met on 9/23/24 and implemented Social Services Director (SSD) and Activities Director (AD) daily visits from 9/23/24 to 9/25/24 and Resident 1 and Resident 2's care plans were not updated to reflect these interventions. Resident 1 and Resident were not seen by the SSD and the AD on 9/24/24 and 9/25/24. This failure resulted in Resident 1 and Resident 2 at risk of not receiving appropriate, consistent, and individualized care interventions to ensure their safety and well-being. Findings: During a review of Resident 1's admission Record (AR), dated 10/3/24, the AR indicated Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain complete, accurately documented and readily accessible medical records in accordance with accepted professional standards and practices for three of six sampled residents (Resident 1, Resident 2, and Resident 4) when: 1.Resident 1 had care plan interventions for 15 Minute Checks (staff member is checking on resident every 15 minutes) documentation from 9/20/24 to 9/23/24 (72 hours) and facility staff was unable to locate 15 Minute Checks documentation for 9/20/24 to 9/21/24. 2.Resident 2 ' s care plan had goals documented for Resident 1. 3.Resident 4 had care plan intervention for 15 Minute Checks documentation from 9/15/24 to 9/18/24 (72 hours) and facility staff was unable to locate 15 Minute Checks documentation for 9/17/24 and 9/18/24. This failure resulted in incomplete medical records for Resident 1, Resident 2 and Resident 4, inaccurate medical record for Resident 1 or 2 and the facility not following their policy and procedure titled,…

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 a safe environment for six of 61 sampled residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6) when an unknown visitor entered the building on two occasions, and on the second occasion, entered three resident rooms and stole a cellular telephone from Resident 1. This failure resulted in Resident 1 and Resident 2 experiencing fear and a theft of a cellular telephone from Resident 1. Findings: During a review of the facility document titled Facility Reported Event (FRE), dated 7/27/24, the FRE indicated, Around 6:45 am on 7.27.24, a visitor entered the facility. It was unknown who the visitor was there to visit or his purpose there. The visitor followed closely behind an employee and entered the building where he was seen walking through the building and entered and exited 3 Resident rooms. [Resident 1] reported that her phone is missing and that the visitor took it from her room. The visitor has come in the building the night before and was asked to leave. The visitor was escorted out 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 safe and sanitary food preparation and storage practices in the kitchen when large pantry storage room temperatures were 96 degrees Fahrenheit (F- a unit used for measuring temperature) in the large pantry where dry goods (sugar, flour, oatmeal, cream of wheat, canned fruit, pancake mix, cornbread mix, chicken and beef flavored base, bottled lemon juice, packaged Jello, cooking oil, and packaged condiments) were stored. This failure had the potential for the dry goods to spoil and cause food-borne illness (stomach illness acquired from ingesting contaminated food) for residents that ate from the kitchen. Findings: During a concurrent observation and interview on 6/13/24 at 6:22 p.m., with the Dietary [NAME] (DC), in the kitchen, an observation was made in the large pantry (room temperature was 96 degrees F. Dietary [NAME] confirmed both the temperature from a temperature gun (a device that provides temperature measurement) in addition to the thermometer on the wall of the large pantry storage room were…

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 16 of 16 Residents (Residents 6, 8, 25, 27, 29, 32, 35, 37, 38, 41, 43 44, 45, 48, 53, 270) were assessed for the risk of entrapment (resident caught, trapped, or entangled in the space in or about the bed and side rail) from bed (side) rails (adjustable metal or rigid plastic bars in various sizes that attach to the bed, and can be placed in a guard [raised] or lowered position) and bed assist rails (a bed rail used to assist the resident with repositioning or getting in and out of bed) prior to installation, had consent (form signed by resident or family explaining the risks of bed rail use), used appropriate alternatives, and followed the manufacturers' recommendations and specifications for installing and maintaining bed rails prior to the use of the bed (side) rails when: 1. Resident 6, 8, 27, 38 had bed assist rails (U-Rail) up on one side of the bed and did not have a bed rail risk assessment, consent, physician orders, 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 ensure a registered nurse was designated as the Director of Nursing (DON) on a full time basis when the facility did not have a designated DON from 3/13/24 to 4/16/24. This failure resulted in the lack of guidance, direction and leadership to all nursing staff, and had the potential to impact the quality of care, quality of life and medical treatment and services for all facility residents. Findings: During an interview on 4/16/24 at 9:27 a.m. with the Administrator (ADM), the ADM stated the Director of Nursing (DON) was out on medical leave. The ADM stated the facility has an Interim DON (IDON) filling in full-time as the DON. During an interview on 4/23/24 at 4:16 p.m. with the IDON, the IDON stated he was hired with the facility on 1/31/24 as the Minimum Data Set (MDS) Coordinator. The IDON stated he started as on-call (available by phone) IDON on 3/18/24. The IDON stated he transferred to the full-time DON on 4/16/24. During an interview on 4/24/24 at 4:45 p.m. with the ADM, the ADM stated the DON went on leave 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, and record review the facility failed to ensure ten out of .residents (Residents 37, 17, 7, 50, 41, 34, 16, 11, 26, 2) were free from unnecessary psychotropic (drugs that affect brain activities associated with mental processes and behavior) medications when: 1. Resident 37 was administered fluoxetine (an antidepressant medication) and did not implement adequate behavior monitoring and side effect monitoring for the use of fluoxetine. 2. Resident 17 was administered buspirone and trazodone (antidepressant medications) and did not implement resident specific non-pharmacological (behavioral) interventions and adequate behavior monitoring for the use of buspirone and trazodone. 3. Resident 7 was administered duloxetine (antidepressant medication), alprazolam (antianxiety medication), and olanzapine (antipsychotic medication that alters brain chemistry to help reduce symptoms of the mind where there has been some loss of contact with reality) and did not implement resident specific…

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, record review, the facility failed to ensure food and ice were stored in accordance with professional standards for food service safety for all residents eating and drinking at the facility when: 1. The ice machine was not sanitized according to the manufacturer's directions 2. The dishes in dish machine were not sanitized according to the manufacturer's directions and the facility policy and procedure These failures had the potential to result in the growth of microorganisms and could lead to foodborne illnesses for the 63 residents eating food and drinking in the facility. Findings: 1. During an observation on 4/16/21 at 11:21 a.m., Kitchen Aid 1 (KA) as filling up a tray of cups of punch with ice from the kitchen ice machine and 35 cups water with ice. During a concurrent observation and interview on 4/16/24 at 4:16 p.m. with the Environmental Services Director (ESD) in the kitchen, MS stated he had responsibility for cleaning and sanitizing the ice machine. MS stated he…

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

Based on observation, interview and record review, the facility failed to ensure a physician obtained Informed Consents (a process in which residents are given important information of the possible risk and benefits of the use of psychoactive medications) for the use of psychotropic medications (medication capable of affecting mind, emotions, and behavior) was completed for four of ten sampled residents (Residents 2, 34, 41, and 50) when: 1. Resident 2 received Olanzapine (an antipsychotic medication that can treat several mental health conditions like schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions) and bipolar disorder (a mental health condition that affects your moods) without an informed consent. 2. Resident 34 received Quetiapine (an antipsychotic medication that treats several kinds of mental health conditions including schizophrenia and bipolar disorder) without an informed consent. 3. Resident 41 received Trazodone HCl (an antidepressant medication used to treat major…

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 homelike environment for 10 of 16 sampled residents (Residents 1, 7, 26, 29, 35, 39, 45, 48, 53, and 271) when: 1. Residents 1, 7, 26 and 271's shared bathroom had blackened floor tiles with dirt on the floor, a loose doorknob with the doorknob plate hanging on the doorknob, missing paint and chipped areas on the lower bathroom door frame, and scattered black areas measuring one-half to two inches on the bathroom ceiling and a hole on the bathroom ceiling measuring two and one-half by two inches. Residents 1,7,26 and 271 2. Resident 29 and 53's joint bathroom had a discolored bathroom ceiling with bubbling and peeling paint. 3. Resident 35's wall guard protector (devices installed into walls made to stop beds and equipment from touching walls) was found to have peeling paint, and a large hole. 4. Resident 39's room had an exposed floor with missing tiles and visible dirt. 5. Resident 45's bathroom was observed to have dirt and a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan (CP-a detailed approach to care customized to an individual resident's needs) for four of 62 sampled residents (Resident 11, Resident 41, Resident 44, and Resident 45) ) when: 1. Resident 45 did not have an individualized care plan developed and implemented for unintentional severe weight loss until 41 days after admission. This failure placed Resident 45 at risk for complications from not having care needs planned by licensed nurses to determine if nursing interventions needed to be added, changed, or completed. 2. Resident 11 did not have a person-centered CP to address his dental needs. This failure resulted in resident 11's dental and nutrition needs to go unmet. 3. Residents 41 and 44 did not have a person-centered CP to address the use of oxygen (O2) therapy. This failure resulted in Resident 41's oxygen needs to go unmet and caused Resident 44 to receive unnecessary oxygen therapy.…

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 and services in accordance with professional standards of practice for three of seven sampled residents (Residents 11, 41, and 44) when: 1. Licensed Nurses (LNs) did not have physician orders for oxygen therapy (treatment intended to relieve or heal a disorder) administration for Resident 41 and Resident 44. 2. Oxygen tubing was not labeled with date/time and stored in a protective covering (such as a bag) when not in use to prevent contamination for Residents 11, 41, and 44. These failures resulted in residents receiving unnecessary oxygen treatment and the potential for infection from contaminated oxygen tubing. Findings: 1. During a review of Resident 41's admission Record (AR-a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes) dated 4/16/2024, the AR indicated, admission Date 1/23/2020 . Diagnosis Information . Personal History of Covid-19, Personal History of Nicotine Dependence . During a review of Resident 41's Minimum…

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 and ensure residents receive services to maintain their highest practicable physical, mental, and psychosocial well-being when: 1. One of seven Licensed Vocational Nurses (LVN)s did not receive a blood glucometer (a small portable device used to check sugar levels in the blood) competency skills check off after being hired. This failure had the potential to place residents at risk of being exposed to the spread of infections. 2. Four of seven LVNs did not complete their required mandatory annual competency trainings. 3. One of five Certified Nursing Assistants (CNA)s did not receive a competency skills check off after being hired. 4. Two of five CNAs did not complete their required mandatory annual competency trainings. These failures had the potential to place residents at risk for care not provided in a safe and competent manner. Findings: 1. During an interview on 4/23/24 at 2:29 p.m. with the DSD, the DSD stated all…

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 medical records were complete and accurately documented in accordance with accepted professional standards of practice for two of eight sampled residents (Residents 23 and 31) when Resident 23 and 31's copy of 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 to receive toward the end of life) were incomplete. This failure had the potential for Resident 23 and 31's decisions regarding treatment options and end of life wishes to not be honored. Findings: During a review of Resident 23's admission Record (AR), dated [DATE], the AR indicated Resident 23 was admitted on [DATE] with diagnoses of kidney failure (a condition when the kidneys are unable to filter waste products from the blood), Type 2 Diabetes Mellitus (when the blood sugar levels in the body are too high), and major depressive disorder (a mental health…

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

Based on observation, interview, and record review, the facility failed to ensure a safe, and sanitary environment to help prevent diseases and infections when: 1. One of four residents sampled (Resident 32's) oxygen (O2) nasal cannula (NC-a tube that directs oxygen into the nose) was found on the floor and part of the tube was laying on top of a garbage can. 2. Three of four oxygen concentrators (a medical device that gives you extra oxygen) and filters sampled, were visibly soiled with dust and debris, and not cleaned according to manufacturer's recommendation. 3. One of one (central) nurses' station countertop was peeling, cracked and/or missing veneer (a thin decorative covering of fine wood applied to a coarser wood or other material) which exposed the porous, non-wipe-able countertop. 4. The facility did not have a Legionella (a microscopic organism that can cause disease) when there's an outbreak (sudden occurrence of disease) water testing protocol, nor did they perform Legionella water testing. 5. One of two medication (med) carts sampled were visibly soiled with drip marks…

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

Based on interview and record review, the facility failed to implement and maintain an effective training program for new and existing Licensed Nurses (LN's), Certified Nursing Assistants (CNAs), and ancillary (additional) support staff for demonstrated competency consistent with their expected roles in the areas of abuse, neglect and exploitation (the action of using someone or something unfairly for your own benefit) training, dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) training, communication training, resident rights training, infection control training, and falls training, for six of 13 direct care staff. This failure had the potential to place residents at risk for care not provided in a safe and competent manner. Findings: During a concurrent interview and record review on 4/23/24 at 11:16 a.m. with the Director of Staff Development (DSD), Licensed Vocational Nurse (LVN) 4's Personnel File (PF), dated (undated) was reviewed. The PF indicated LVN 4 completed dementia training on 1/27/23,…

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 a comprehensive systemic approach to ensure effective monitoring and systems to maintain acceptable parameters of nutritional status for one of five sampled Residents (Resident 45) reviewed for nutrition care when Resident 45 experienced a severe unplanned weight loss of 22 pounds (lbs-measurement of weight) or 11.2 % of admitting weight in 41 days from 3/6/24 to 4/16/24 when the Nutrition Assessment was not completed in a timely manner. As a result of these failures, Resident 45's compromised nutritional status was not addressed timely by the Registered Dietitian which could lead to further medical complications including but not limited to dehydration, loss of muscle mass with decreased mobility and negatively affect the diagnoses for Resident 45 and the reasons for admission to the facility. Findings: During an observation, on 4/16/24 10:35 a.m., Resident 45 stated food is good, but no appetite. Resident 45 stated she is…

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 five residents (Resident 16) was offered or administered the pneumonia (infection that affects one or both lung) vaccine (a substance injected into the body to protect it against diseases). This failure placed Resident 16 at risk to develop pneumonia. Findings: During a concurrent interview and record review on 04/17/24 at 5:09 p.m. with the Infection Preventionist (IP), Resident 16 Electronic Medical Record (EMR) dated April 2024 was reviewed. The IP stated, there were no records the pneumonia vaccine being given since admission. The IP stated, there were no past records of the resident receiving or refusing a pneumonia vaccine. The IP stated a declination form the refusal of the Pneumonia Vaccine should have been signed if it was offered and refused. During a review of Resident 16's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment) Section C, dated 3/24/24, the MDS Section C indicated Resident 16 had a Brief Interview…

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, record review), the facility failed to ensure physical environmental maintenance were maintained when: 1. There were multiple areas of the floor throughout the kitchen that had missing sections of epoxy (a type of synthetic resin floor system that is laid on top of concrete substrates as a form of protection and decoration). resulting in a build-up of food particles. This failure had the potential to result in the growth of pathogenic (an organism which can cause diseases in a host [person)] organisms and create an environment for pest harborage for the 62 residents eating food in the facility. 2. The heating, ventilation and air conditioning (HVAC) unit (an appliance or system used to control the humidity, ventilation, and temperature in a building) was not maintained to prevent water damage for four of eight Residents (Residents 1, 7, 26, and 271) that access the restroom. This failure had the potential for Residents 1, 7, 26, and 271's shared bathroom ceiling to develop mold…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of three hallways, handrail was firmly secured to the wall. This failure had the potential to result in injury to residents, visitors, and staff. Findings: During a concurrent observation and interview on 04/16/24 at 3:49 p.m. with Certified Nursing Assistant (CNA) 12, in the Hollywood BLVD hallway, the side handrail between rooms [ROOM NUMBERS] was loose and moved back and forth. CNA 12 stated, the handrail is lose and moved back and forth an inch. CNA 12 stated, the handrail is probably not safe for the residents to hold on to. During a concurrent observation and interview on 04/18/24 at 11:40 a.m. with the Environmental Service Director (ESD), in the hallway between rooms [ROOM NUMBERS], the ESD stated, the handrails are loose and needed to be tightened. The ESD stated, the loose handrails had the potential to cause injury if the rails come off while the residents were using it. During an interview on 04/24/24 at 11:42 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 Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a plan that provides direction for individualized care of the resident) for one of three sampled residents (Resident 1) when a fall intervention was not implemented for Resident 1. This failure resulted in an unwitnessed fall for Resident 1 on 8/23/23. Findings: During a review of Resident 1's Face Sheet (document containing resident demographic information and medical diagnosis) dated 8/10/23, the face sheet indicated, Resident 1 was admitted to the facility on [DATE] with a diagnosis which included Senile Degeneration of Brain (a progressive disease with memory loss), Encephalopathy (brain disease that alters brain function), Dementia (forgetfulness, limited social skills and thinking that interferes with daily functioning) and Bipolar Disorder (disorder associated with episodes of mood swings). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool used 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, interview, and record review, the facility failed to store and serve ice in accordance with professional standards for food safety service for 51 out of 52 sampled residents, when the ice machine was not properly cleaned and sanitized according to the manufacturer's guidelines. This failure had the potential to result in the growth of microorganisms (organisms that can only be seen through a microscope). Findings: During an observation on 8/2/22, at 9:22 a.m., in the kitchen, the Dietary Services Manager (DSM) filled cups with ice from the ice machine and placed them on a tray. During an observation on 8/2/22, at 11:03 a.m., in the kitchen, the DSM filled cups with ice from the facility's ice machine for tray line beverages. During a concurrent observation and interview on 8/2/22, at 3:04 p.m., with the Plant Manager (PM), in the kitchen, the facility's ice machine was observed. The shield and chute of the ice machine contained a yellow and brown substance. The PM stated he cleaned the ice machine every other month. The PM stated he removed the ice from 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 and record review, the facility failed to establish an infection prevention and control program that included antibiotic stewardship (program designed to reduce unnecessary use of antibiotics and to limit the spread of antibiotic resistance [happens when germs like bacteria and fungi develop the ability to defeat the drugs designed to kill them] in bacteria) when seven of seven sampled months (January 2022, February 2022, March 2022, April 2022, May 2022, June 2022 and July 2022) did not have evidence surveillance was completed to accurately monitor the use of antibiotics for residents. This failure had the potential for residents to be placed at risk for an adverse effect of antibiotics and/or develop an antibiotic-resistant (not effective to treat infection) organisms (living thing made up of one or more cells and able to carry on the activities of life) from unnecessary or inappropriate antibiotic use. Findings: During a concurrent interview and record review on 8/5/22, at 2:24 p.m., with the Infection Preventionist/MDS Coordinator (IP/MDS), the IP/MDS reviewed…

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 had a dedicated Infection Preventionist (IP- professional who ensures healthcare workers and patients are doing all the things they should to prevent infections) who was responsible for the facility's infection prevention control program when one of one staff (IP/Minimum Data Set [MDS- nurse that is responsible to provide a comprehensive assessment of each resident's functional capabilities]) worked in both roles as the MDS nurse and the facility IP. This failure resulted in the facility to have an IP responsible for two roles (Infection Preventionist and MDS Coordinator) in the facility and had the potential for the IP duties and tasks to not be completed, ultimately affecting resident care. Findings: During an interview on 8/4/22, at 2:47 p.m., with the Infection Preventionist/MDS Coordinator (IP/MDS), the IP/MDS stated, he was the IP and the MDS Coordinator. The IP/MDS stated, he does not document how his time was split between both roles. During an observation 8/5/22, at 7:59 a.m., 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.

Based on observation, interview and record review, the facility failed to ensure services provided met professional standards of quality when: 1. Licensed Vocational Nurse (LVN) 6 and LVN 7 signed the Electronic Medical Administration Record (EMAR), which indicated administration of medications, prior to administering medications to two of six sampled residents (Resident 15 and Resident 4). This failure had the potential for Resident 15 and Resident 4's EMAR to have inaccurate documentation. 2. LVN 6 administered one of one sampled residents' (Resident 24) medications via G-tube (gastrostomy tube- tube inserted through the belly to the stomach) by administering the crushed tablets prior to administering the liquid medications first, against the facility's policy and procedure (P&P). This failure had the potential for Resident 24's liquid medication to not be absorbed effectively and had the potential for blockage of the G-tube. 3. One of six sampled residents (Resident 24) had two medications with a direction order change, and the medications did not have a change of direction…

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 ongoing activities program to support residents in their choice of activities when the facility failed to provide individual activities and independent activities designed to meet the interest of four of seven sampled residents (Residents 19, 21, 28, and 248). This failure had the potential to result in Residents 19, 21, 28, and 248 to be bored, which could affect their physical, mental, and psychosocial well-being. Findings: During a review of Resident 19's clinical record titled, admission Record, (document containing resident personal information) dated 8/5/22, the admission Record indicated Resident 19 was admitted to the facility on [DATE], with diagnosis that included, .subdural hemorrhage (bleeding between the brain and the skull), Chronic Obstructive Pulmonary Disease (lung disease that block airflow and make it difficult to breathe ) and muscle weakness. During an observation on 8/1/22, at 10:14 a.m., in Resident 19'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 the menu was followed when the incorrect scoop size for the pureed (a thick liquid suspension made from cooked food ground finely) diet was used when serving the pureed green beans during the lunch meal service on August 2, 2022, for eight of eight sampled residents (Residents 5, 9, 14, 19, 21 23, 35 and 43). This failure had the potential for Residents 5, 9, 14, 19, 21 23, 35, and 43 to receive the wrong caloric intake (the number of calories consumed), which could further compromise their medical status. Findings: During a review of the facility's document titled, [Name of Vendor] Menus Lunch Daily Spreadsheet dated 8/2/22, the document indicated for the puree menu, the skillet green beans #10 (number of the scoop) scoop (2.75 ounces [units of measurement]). During an observation of the lunch meal service on 8/2/22, at 11:53 a.m., the steam table had a container of pureed green beans with a #8 scoop (4 ounces). The Dietary [NAME] (DC) served eight residents (Residents 5, 9, 14, 19, 21, 23, 35, 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 establish and maintain an infection prevention and control program to provide a safe, sanitary, and comfortable environment to help prevent infections for four of five sampled residents (Residents 4, 5, 24 and 26) when: 1. Licensed Vocational Nurse (LVN) 6 failed to sanitize (disinfect) the blood pressure cuff (device used to measure the pressure of blood in the circulatory system) in between use for Residents 4, 5, and 26; and 2. LVN 7 did not properly sanitize the glucometer (device used to measure and display the amount of sugar in the blood) according to the facility policy. These failures had the potential to result in cross contamination (bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) and transmission of infection between residents. Findings: 1. During a concurrent observation and interview on 8/3/22, at 7:04 a.m., with LVN 6 during medication pass, LVN 6…

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 pharmaceutical procedures were followed on two of two occasions (6/17/22 and 7/25/22), when unused medications were disposed of (wasted) and a witness signature was not present per the facility's policy and procedure titled, Disposal of Medications. This failure resulted in the facility to waste medications that were not in accordance with the facility's practice and had a potential for diversion (involving the transfer of any legally prescribed controlled substance from the individual for whom it was prescribed to another person for any illicit use). Findings: During a review of the facility's Method of Disposition log, dated 6/17/22 and 7/25/22, the log had one licensed staff signature. The witness signature was blank. During a concurrent interview and record review on 8/3/22, at 8:57 a.m., with the Director of Nursing (DON), the facility's Method of Disposition log dated 6/17/22 and 7/25/22 was reviewed. The DON stated, two licensed staff were required to count, record, and destroy any unused medications. The DON…

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 drugs were labeled in accordance with accepted professional principles, when one of one Tuberculin (combination of proteins that are used in the diagnosis of tuberculosis [potentially serious infectious bacterial disease that mainly affects the lungs]) vial (small container) was opened, and there was no indication of a used-by-date or when the vial was opened. This failure had the potential to yield inaccurate purified protein derivative (PPD- skin test is a test that determines if you have tuberculosis) results and or cause harm to a vulnerable population if administered beyond the manufacturer's used-by date. Findings: During a concurrent observation and interview on [DATE], at 8:57 a.m., with the Director of Nursing (DON), the facility's medication refrigerator was observed. An opened vial of Tuberculin was found in the medication refrigerator, with no opened or used-by date label. The DON stated, all opened vials of 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.