Sierra Vista Healthcare

Based on observation, interview, and record review, the facility failed to ensure pureed (food that's been blended into a smooth pudding like consistency) food was prepared in a form designed to meet individual needs for three of five sampled residents (Residents 5, 55, and 84) when Residents 5, 55, and 84's physician ordered pureed lunch meals on 1/6/26 and 1/7/26 did not hold shape or form. This failure had the potential to result in aspiration (food entering the airway or lungs), choking, and inadequate nutrition due to decreased flavor, which may result in weight loss and malnutrition.During a review of the facility's menu titled, Diet Spreadsheet dated Day: 17 - Tuesday [1/6/26], the Diet Spreadsheet indicated, . Pureed . (texture) . lunch pureed homestyle meat loaf, pureed potato gratin with thyme, and pureed steamed spinach .During an observation of the lunch meal service on 1/6/26 at 12:33 p.m. in the kitchen, Resident 5 and Resident 55's puree meat and vegetables were touching and unable to hold their shape or form when plated.During an interview on 1/6/26 at 10:36 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.

Based on interview and record review, the facility failed to ensure medical records were complete, accurate, readily accessible and systematically organized for two of thirteen sampled residents (Resident 12 and Resident 10) when:1.Resident 12's consent for the use of bedside rails, was not completed, lacking the indication for use, who the consent was discussed with, licensed nurse signature, and dates of consent, were not present in the medical record.This failure had the potential for improper use of bedside rails and potential injury of resident. 2. Resident 10's Informed Consent for the use of Bed Rails, from 8/24/20-11/3/22, could not be located for over 24 hours and had to be retrieved from an off-site location, was not complete or accurate, and was being used for Resident 10's current bed rail order.This failure had the potential to lead to miscommunication among caregivers, inconsistent care delivery, improper use of side rails, and potential injury of resident. 1.During an observation on 1/6/25 at 9:04 a.m. in Resident 12's room, Resident 12 was seen sitting up in bed…

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 prevent the elopement (when a resident leaves the facility's premises or a safe area without authorization, or necessary supervision) of one of seven residents (Resident 7) when staff did not respond promptly to a security elopement alarm when Resident 7 eloped from the facility. This failure had the potential for Resident 7 to experience injury such as falling or struck by traffic, becoming disoriented and lost due to his unsupervised time away from the facility, and also the potential for six other residents who were identified as elopement risks (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, and Resident 6) to elope. During a review of Resident 7's Progress Notes (PN), dated 11/1/25, at 8:23 p.m., the PN indicated he was admitted to the facility that evening with diagnoses that included acute encephalopathy (a rapid onset of altered brain function that can cause confusion and disorientation) and was noted to have episodes of. Severe impairment (affecting all areas of judgement). Walks frequently. During 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 interview and record review, the facility failed to administer an antibiotic (a medicine that inhibits the growth of or destroys disease causing microorganisms such as bacteria) as prescribed by a physician for one of three sampled residents (Resident 1). This failure resulted in Resident 1 not receiving antibiotics for an infected left ankle, potentially resulting in worsening infection. Findings: During a review of Resident 1's admission Record (AR) , dated 4/21/25, the AR indicated Resident 1 was admitted to the facility with diagnoses that included aftercare for a fractured left ankle. During a review of Resident 1's Progress Note (PN) , dated 3/4/25, by Surgeon 1, the PN indicated, Surgeon 1 had performed surgery on Resident 1's fractured left ankle on 1/4/25. The PN indicated Resident 1 was seen for a follow up visit by Surgeon 1 on 3/3/25. The PN indicated, concern for surgical site infection. Bactrim [an antibiotic] ordered today. The PN indicated Bactrim DS 800-160 milligrams (a unit of measurement) per tablet take one tablet by mouth two times per day for 10 days…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three residents (Resident 1) was free from injury when he attempted to self-transfer out of his bed with the bed ' s wheels unlocked, resulting in a bedside fall and fracture to his left hip. This failure had the potential to contribute to the fall with fracture when the bed ' s unlocked wheels caused the bed to move when he attempted to transfer out of bed. Findings: During a review of Resident 1 ' s admission Record (AR), dated 10/11/24, the AR indicated Resident was a [AGE] year old male admitted to the facility in 2021 with diagnosis that included neurocognitive disorder with Lewy bodies ( a type of progressive dementia that leads to a decline in thinking, reasoning and independent function); bipolar disorder (mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration, can make it difficult to carry out day-to-day tasks); and dementia (a chronic condition that causes a decline in mental…

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 post the results of the most recent survey in a place readily accessible to 91 of 91 residents, families, and their legal representatives. This failure had the potential to violate the rights of residents and their representatives to be informed of previous survey deficiencies. Findings: During an observation on 9/24/24 at 10:30 a.m., a binder labeled CDPH Survey Results was located in a holder in the hallway east of the main entrance. During a review of the facility's, CDPH Survey Results binder, undated, the binder did not contain results for the facilities last recertification survey on 9/22. During an interview on 9/24/24 at 10:35 a.m. with the Director of Nursing (DON), the DON stated the facility had their last survey 9/22. The DON stated the results of that survey were not included in the CDPH Survey Results binder. During a concurrent interview and record review on 9/24/24 at 10:42 a.m. with the Administrator (ADM), the facility's CDPH Survey Results binder, undated, was reviewed. The CDPH Survey…

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 and biologicals were stored and labeled in accordance with current accepted professional standards of practice when: 1. Two of four medication carts were found unlocked and unattended by Licensed nurses. This failure had the potential for residents, staff, and visitors to access the medication carts. 2. Polyethylene glycol 3350 was left on top of the medication cart 1 unattended in Station 1. This failure had the potential risk of other residents, staff and visitors walking by and gaining access to the medication and could lead to adverse effect when taken without a prescription. 3. An expired bottle of Lactulose ( a non-absorbable sugar used in the treatment of constipation), was observed in the medication cart. This failure had the potential for Resident to receive expired medication which could have undesired effects. Findings: 1. During a concurrent observation and interview on 9/25/24 at 8:50a.m. with Licensed Vocational…

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 an infection prevention and control program was maintained for 91 of 91 sampled residents when: 1. A room containing five full sharps containers (a bin used to store needles which have been used on residents) was unlocked and accessible to 91 of 91 residents. The sharps containers were stacked on top of each other. One of those containers was full and did not have a lid covering it. This failure had the potential to cause residents to enter the room and hurt themselves if they touched the exposed sharps. 2. Resident 58's oxygen concentrator (a medical device which provides oxygen to a resident) filter was covered in dirt, dust, and lint like materials. This failure had the potential to introduce contaminants (materials which can make something dirty) into the oxygen supply and cause Resident 59 to breathe in dirty air. 3. Resident 61 and Resident 3's oxygen concentrator filters were covered with grayish white material. This failure…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity in an environment that promotes and enhances quality of life for five of 21 sampled residents (Residents 68, 81, 245, 246, and 350,) when Residents 68, 81, 245, 246 and 350 waited up to 20 minutes for their lunch tray while watching other residents eat their meal while in the dining room. This failure violated Residents' 68, 81, 245, 246 and 350 the right to be offered a dignified dining experience. Findings: During an observation on 9/23/24 at 12:21 p.m. in the dining room, nursing staff passed out lunch trays to residents in the dining room except two residents, Resident 68 and Resident 81. Resident 68 and Resident 81 did not receive a lunch tray and watched other residents eat sitting at the same table. Resident 68 and Resident 81 were observed looking at other residents eating around them. Resident 68 and Resident 81 were served their lunch 15-20 minutes after other residents 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 develop and implement a resident centered care plan for three of 11 sampled residents (Resident 1, Resident 31, and Resident 53) when: 1. Resident 31 did not have a care plan for the use of clotrimazole (brand name-used to treat fungal infection) medication. This failure placed Resident 31 at risk for complications from not having care needs planned by licensed nurses to determine if nursing intervention needed to be added, changed, or completed. 2. The padding on Resident 1's left bedrail was not fully intact, and the metal bar was exposed This failure had the potential to result in Resident 1 sustaining an injury during a seizure (uncontrolled bursts of electrical activities that change sensations behaviors, awareness and muscle movements) episode. 3. Resident 53 did not have a care plan in place for the change in condition for diarrhea on 9/14/24. This failure had the to result in Resident 53's medical needs not to be met. Findings: 1.…

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 services which met professional standards of quality of care for one of five sampled residents (Resident 68) when Resident 68's fluid restriction order was not followed according to the physician order. This failure resulted in Resident 68 consuming more than the allowed fluid intake which could lead to fluid overload and could result in serious health condition. Findings: During a concurrent observation and interview on 9/23/24 at 7:45 a.m. during the initial tour, Resident 68 was sitting up in bed, with an over the bed table placed in front of her with a brown cup was on the bed table. Resident 68 was holding the brown cup and stated she wanted more coffee. During concurrent observation and interview on 9/23/24 at 12:55 p.m. in the dining room, Resident 68 was observed seated at a dining table with two other residents. Observed in front of Resident 68 was an eight-ounce cup (240 cc[cubic centimeter-unit of measurement]) of coffee, clear eight ounces (240 cc) cup containing reddish colored liquid,…

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 (11.54%) when: 1. Licensed Vocational Nurse (LVN) 3 administered glucophage (medication used to treat diabetes) medication and methenamine (medication used to treat urinary bladder infection suppression]) without food and did not follow instructions for medication administration with food. This failure had the potential for Resident 44 to develop gastrointestinal upset (GI-gastric upset like diarrhea) which could lead to serious health condition. 2. LVN 1 did not follow medication direction when he administered Polyethylene Glycol (medication used to treat constipation) to Resident 244. This failure had the potential for Resident 244 to develop constipation which could lead to serious health condition. Findings: 1. During a concurrent medication administration pass observation and interview on 9/25/24 at 8:40 a.m. at Station 1, LVN 3 was preparing Resident 44'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, interviews and record review, the facility failed to ensure Dietary [NAME] (DC) 1 was competent to carry out the functions of the food and nutrition services safely and effectively when DC 1 did not check the internal temperature of three pork loins prior to prepping to serve and was not able to be verbalize the cooking or process of reheating cooked food per the facility's policy. This failure had the potential to result in unsafe food being served, consumed, and could have cause food borne illness. Findings: During an observation on 9/24/24 at 10:18 a.m. in the kitchen, DC 1 was observed removing a baking tray containing three pork loins out of the oven without checking the internal temperature. DC 1 took the baking tray containing the three pork loins to the prep area for preparing to slice the pork loins for service. During an interview on 9/24/25 at 10:30 a.m. in the prep area, with DC 1, DC 1 stated he worked for the facility for three weeks. DC 1 stated he did not check the internal temperature of the pork loin. DC 1 stated he was not sure what 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, sanitary food preparation and storage practices were followed for 87 of 91 residents when: 1. A serving cart was observed with a white powdered substance spilled and scattered throughout the top surface. 2. A storage room in the kitchen was observed with dirt and debris on the floor and the base boards were peeling and missing from one side of the wall. These failures placed residents at risk for foodborne illnesses (illness caused by consuming contaminated food) and had the potential to attract pest and rodents. Findings: 1. During a concurrent observation and interview on 9/23/24 at 7:35 a.m. with the Dietary Manager Supervisor (DMS) in the kitchen, a white powdered substance was spilled and scattered on the top of the serving cart. On the serving cart was two serving tray, a box of gloves, a box of aprons, a roll of clear garbage bags and a plastic holder container for utensil. The DMS stated, The serving cart should not be like that. The DMS stated the dirty serving cart can cause…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure one of six sampled residents (Residents 351), had their code status (resident's instructions to a medical team about the type of treatment they want if their heart or breathing stops) documented upon admission on the Physician Order for Life Sustaining Treatment (POLST). Resident 365's POLST form was not completed and signed by the physician for more than eleven days after admission and not in accordance with the facility policy and procedure. This failure had the potential to result in Resident 351's wishes not being honored and unnecessary medical interventions administered. Findings: During a review of Resident 351's electronic medical records (EMR) on [DATE] at 10:10 a.m., the EMR indicated, no POLST was in the (EMR). A copy of the printed POLST form was requested on [DATE]. During a review of Resident 351's Physician Orders for Life-Sustaining Treatment (POLST) dated prepared [DATE], the POLST indicated, .Box A Cardiopulmonary Resuscitation…

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 protect the privacy of personal information for one of three sampled residents (Resident 34) when Licensed Vocational Nurse (LVN) 2 left her workstation computer open and unattended with Resident 34's information exposed to public view. This failure resulted in violation of Resident 34's right to confidentiality and the potential for unauthorized access to Resident 34's personal information. Findings: During a concurrent observation and interview on 9/25/24 at 3:40 p.m. with LVN 2, outside of Resident 34's room, LVN 2 entered Resident 34's room and left her computer screen open with Resident 34's information open. LVN 2 stated she should not have left her computer screen open. LVN 2 stated any residents, staff and visitors walking by could have seen Resident 34's private information violating her privacy. During a review of Resident 34's admission Record [AR-document which contain patient personal information], dated 9/26/24, the AR indicated Resident 34 was admitted in the facility on 11/22/23 with diagnoses…

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 a clean and homelike environment for two of six sampled residents (Resident 16 and Resident 39) when Resident 16 had the following at bedside: 1. A plastic bag of fresh onions, tomatoes and avocados on the floor. 2. On a shelf were multiple cans of soup, bananas, cookies, ramen noodle soup, bottles of spices with broken lids, individual packets of sugar, pepper, mayonnaise and loaves of bread. 3. The sink area had kitchen utensils and under the sink was a small ice chest, loaf of bread and small bottles of spices. These failures provided an unclean and un-homelike environment for Resident 16 and Resident 39 (Resident 16's roommate) and placed them at risk for cross contamination from improper storage of personal food. Findings: During a review of Resident 16's Minimum Data Set (MDS-an assessment tool used to identify cognitive [pertaining to reasoning, memory and judgement] and physical function level), assessment dated [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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Level l Preadmission Screening and Resident Review (PASRR-The State is required to ensure that every person entering a Medicaid certified Nursing Facility [NF] receives a Level I screening and if necessary a Level II evaluation to ensure that their NF residence is appropriate and to identify what specialized services they may need) was completed accurately for one of two sampled residents (Resident 68) when Resident 68 was admitted to the facility on [DATE]. This failure had the potential for Resident 68 not to receive the necessary and appropriate psychiatric level of treatment and evaluation in the facility. Findings: During a review of Resident 68's admission Record (AR), dated 9/26/24, the AR indicated, Resident 68 was admitted to the facility on [DATE] with diagnoses which included unspecified psychosis (collection of symptoms that cause a person to lose touch with reality and have difficulty distinguishing reality) and depression…

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 proper treatment and care to maintain good foot health was performed for one of six sampled residents (Resident 3) when Resident 3's toenails were long, thick, and crooked. This failure had the potential to cause Resident 3 to receive injuries from her toenails digging into her skin. Findings: During a review of Resident 3's admission Record (AR, documents containing resident demographic information and medical diagnosis), dated 9/25/24, the AR indicated Resident 3 was admitted to the facility on [DATE] with diagnoses which included diabetes mellitus (condition where the body has trouble controlling blood sugar levels), restless leg syndrome (condition which causes uncontrollable urge to move legs), and Parkinson's disease (a brain disorder which causes unintended or uncontrollable movements, such as shaking and stiffness). During a concurrent observation and interview on 9/25/24 at 11:10 a.m. with Registered Nurse (RN) 1 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 determine and document resident meal preferences for one six sampled residents (Resident 11) when Resident 11 did not have his dislikes listed on his meal ticket (a document which indicates a resident's diet, allergies, preferences, and dislikes.) This failure resulted in resident 11 not eating his lunch on 9/23/24 and caused him to not receive the nutritional benefits of his meal. Findings: During a review of Resident 11's Minimum Data Set (MDS-resident assessment tool which indicates physical and cognitive abilities), 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 11 had no cognitive impairment. During an interview on 9/23/24 at 9:00 a.m. with Resident 11, Resident 11 stated he disliked Italian food and stated it was served frequently in the facility. During a concurrent observation and interview on 9/23/24 at 12:49 p.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 Based on observation, interview and record review, the facility failed to ensure adaptive equipment was provided for one of three sampled residents (Resident 68) when Resident 68 was not provided built-up utensils on her meal tray. This failure had the potential to limit Resident 68's ability to feed herself independently and safely. Findings: During an observation on 9/23/24 at 12:45 p.m. in the dining room, Resident 68's meal tray had a regular spoon and fork. During a review of Resident 68's admission Record, dated 9/26/24, the admission Record indicated Resident 68 was admitted to the facility on [DATE] with diagnoses which included psychosis (set of symptoms that can cause someone to lose touch of reality and have difficulty distinguishing what is real and what is not), and muscle weakness. During a review of Resident 68's Order Summary Report (OSR), dated 9/26/24, the OSR indicated, . Resident to have a divided plate and built-up utensils for use during meals, and a 2-handled mug with lid for liquids .…

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 kitchen observations, interviews and facility document review, the facility failed to ensure one of two cooks (Cook 2) was competent in position related duties when [NAME] 2 was unable to demonstrate: 1. Adequate handwashing. 2. Prevention of cross contamination of food (measuring scoop use). 3. Cleaning, sanitizing and properly storing food preparation equipment (meat slicer, steam table pans & weighing scale). 4. Manual ware washing of cookware used for resident food preparation. 5. Proper testing of the kitchen sanitizing solution. 6. Preparation of puree food items for according to the recipe for Residents 44, 28, 46, 31, 27 and 17. 7. Preparation of food in a manner that maintained the nutritional value of resident meals. 8. Food prepared for the facility residents was palatable. These failures resulted in the inability to meet nutritional needs for residents receiving pureed diets, poor meal quality and decreased meal satisfaction in a medically vulnerable resident population of 76 residents who received food prepared in the kitchen and also posed a risk for food…

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

Based on observation, interview and record review, the facility failed to ensure food prepared for residents was palatable and cooked to preserve nutritive value when: 1. Residents 6, 80, and 287 complained the food lacked flavor and the vegetables were over cooked. 2. Vegetables were cooked more than two hours prior to meal service in an oven temperature above 400 degrees Fahrenheit (F). These failures could potentially affect the nutritive content of the food and the amount of food residents consume, which could result to decrease residents' food intake and lead to poor nutrition and health outcomes. Findings: 1. During a concurrent observation and interview on 8/23/22, at 1:09 p.m., on nursing unit one, residents were being served lunch in their rooms. Resident 6 stated, the food was so bland and lacked flavor. Resident 6 did not eat the turkey served with his lunch meal. Resident 287 stated, the food was not good, but he forced himself to eat because he had lost weight in the hospital. Resident 287 did not eat the broccoli served with this lunch meal. Resident 287 stated, 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 professional standards for food safety guidelines were followed when: 1. [NAME] 2 touched the trash can then failed to wash hands and sanitized kitchen counters. 2. A measuring scoop was placed on a kitchen cart then placed in a plastic bin containing a food product without being sanitized. 3. Expired food items in the walk-in refrigerator, resident refrigerator, and dry storage room were not discarded. 4. Leftover potatoes were not cooled down properly. 5. Steam table pans, three frying pans, four cutting boards and a can opener blade were not safe for use. 6. A meat slicer, mixer, can opener and a weight scale were not clean. 7. Three food items in plastic bins were not labeled and did not have open dates. 8. Milk was stored in crates on the floor of the walk-in refrigerator. 9. More than five steam table pans were stored wet and not inverted. 10. Walk-in refrigerator door, knife rack and a plastic container with clean divided plates were not clean. 11. Two kitchen brooms were stored on the floor.…

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 control and prevention program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable (contagious) diseases and infections when: 1. Family (FM) was in a contact isolation room for Clostridium difficile (C. diff- bacterial infection that causes life threatening diarrhea) without gown and gloves. This failure place residents, visitors, and staff at risk for transmission (a process on how an infectious agent can be transferred from one person to another) of C. diff infections. 2. Nurse Practitioner (NP) entered the facility without self-screening for SARS-CoV-2 (COVID-19- virus that causes a respiratory disease and is spread from person to person through sputum droplets released when an infected person coughs, sneezes, or talks). This failure placed residents, visitors and staff at increased risk for transmission 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 the proper maintenance of essential equipment when: 1. Five of five freezers (including resident refrigerator [two] and medication refrigerator[two]) had excessive ice build-up. 2. The walk-in refrigerator door in the kitchen was not flush with the door frame exposing a gap. 3. The numbers indicating the temperature of the oven located on the oven dial used to prepare resident food were worn and illegible. These failures had the potential for equipment not functioning in the way they were intended and in turn cause contamination of food and medications which could lead to illnesses for the residents. 4. The two laundry dryers' did not have heat and cool-down time control knobs. This failure placed residents at risk for exposure to mold spores due to laundry not being thoroughly dried. Findings: 1. During a review of professional reference titled, USDA Food Code 2017, Section 4-501.11, indicated, Good Repair and Proper Adjustment, Proper maintenance of equipment to manufacturer specifications helped…

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 residents were free from misappropriation of residents' property for one of three sampled residents (Resident 26) when the facility did not take action to resolve Resident 26's lost money which was not logged in his belongings inventory list. This failure resulted in the loss of Resident 26's 40 dollars. Findings: During an interview on 8/23/22, at 9:13 a.m., with Resident 26, Resident 26 stated, a month ago she had lost 40 dollars. Resident 26 stated, she informed Social Service department regarding her loss but was not reimbursed. Resident 26 stated, she asked staff to buy her drinks and snacks from the vending machine. Resident 26 stated, it was the staff who took her money. During a review of Resident 26's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) Assessment, dated 6/10/22, indicated Resident 26's Brief Interview for Mental Status (BIMS - assessment of cognitive status for memory and judgment) scored 14 out of 15 (a score of 13-15 indicates…

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 for two of six sampled residents (Resident 9 and Resident 20) when Resident 9 and Resident 20's smoking habits was inaccurately coded on the MDS assessment. This failure had the potential to result in Resident 9 and Resident 20's care needs not met. Findings: During a review of Resident 9's, Face sheet (document with resident demographic and medical diagnosis information), dated 8/25/22, indicated diagnoses which included nicotine (the substance in tobacco that people become addicted to) dependence, emphysema (damage to the air sacs in the lungs) and shortness of breath. During a review of Resident 9's, Smoking Safety Evaluation, dated 2/21/22, the Smoking Safety Evaluation indicated, Resident 9 used tobacco. During an interview on 8/25/22, at 9:33 a.m., with Resident 9, Resident 9…

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

Based on interview and record review, the facility failed to develop and implement a resident-centered comprehensive care plan for two of three sampled residents (Resident 21 and Resident 20) when: 1. Residents 21 did not have a care plan for the use of anticoagulant [blood thinner] medications. This failure placed resident 21 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 20 did not have a care plan for smoking. This failure had the potential to result in Resident 20's smoking needs going unmet. Findings: 1. During a review of Resident 21's clinical record titled admission RECORD dated 8/24/22, was reviewed. The admission Record indicated Resident 21 was admitted to the facility with the diagnosis of atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow and blood clot formation). During a concurrent interview and record review on 8/25/22, at 10:09 a.m., with Licensed Vocational Nurse (LVN) 1, Resident 21 Medication…

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

Based on interview and record review, the facility failed to ensure the resident-centered comprehensive care plan was revised for two of two non-sampled residents (Residents 80 and Resident 285) when: 1. Resident 80 was lactose intolerant and the care plan focus titled, Impaired nutritional and hydration status, did not reflect lactose intolerance. This failure placed Resident 80 at risk for complications abdominal cramps, bloating, and diarrhea) due to lactose intolerance and not having care needs planned by licensed nurses to determine if interventions needed to be added, changed or completed. 2. Resident 285 preferred her breakfast meal to be served at 7:00 a.m. and there was no documentation in Resident 285's care plan stating Resident 285 requested her breakfast at 7:00 a.m. This failure had the potential to result in Resident 285's mealtime preferences not being met. Findings: 1. During a review of Resident 80's clinical record titled, admission RECORD, dated 8/25/22, was reviewed. The admission Record indicated, Resident 80 was admitted to the facility with diagnoses 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 provided services which met professional standards of quality of care for one of four sampled residents (Resident 19) when Resident 19's supplemental (added when there is a lack or deficiency) oxygen flow rate was not administered according to the physician order. This failure resulted in Resident 19 not receiving the amount oxygen she needed which could lead to breathing problems. Findings: During a review of Resident 19's admission Record (AR- document containing resident personal information), dated 8/25/22, the ARindicated, Resident 19 was admitted in the facility on 9/10/21, with diagnoses which included . dependence on supplemental oxygen . During a review of Resident 19's Order Summary Report, dated 8/25/22, the Order Summary Report indicated, . Oxygen @ [at] 2L [liter]/min [minute] via [by way of] nasal cannula [a tubing used to deliver oxygen through the nose] continuously every shift . During observation on 8/23/22, at 8:25 a.m., in room Resident 19's room, Resident 19 was laying in bed with eyes…

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 for one of six sampled resident (Resident 61) when Resident 61 was not provided individual and independent activities designed to meet his interest. This failure resulted in Resident 61 inactivity (lack of activity) which could potentially affect his physical, mental and psychosocial well-being. Findings: During an observation on 8/23/22, at 8:07 a.m., in Resident 61's room, Resident 61 was in bed in a semi-sitting position, eating. Resident did not answer to questions asked. During an observation on 8/23/22, at 1:15 p.m., in Resident 61's room, Resident 61 was sitting in bed eating lunch. During a review of Resident 61's clinical record titled, admission Record, (document containing resident personal information) dated 8/25/22, the admission Record' indicated Resident 61 was admitted to the facility on [DATE], with diagnoses that included, .…

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 environment free from accident hazards for two of three sampled residents (Resident 21 and 43) when Resident 21 and 43's low air loss (LAL- an air mattress with fluctuating air) mattress prescribed air pressure setting was not set based on the patient' weight. This failure had the potential to cause fall with injury. Findings: During a concurrent observation and interview on 8/24/22, at 8:33 a.m., with Resident 21, in Resident 21's room, Resident 21 was laying in bed on a LAL mattress. The LAL mattress air setting was on lock position and the LAL mattress air pressure was set at 180 pounds. Resident 21 stated, her mattress felt lumpy [uncomfortable] and was not at the correct setting. During a review of Resident 21's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) Assessment, dated 5/31/22, indicated, Resident 21's Brief Interview for Mental Status (BIMS- assessment of cognitive status for memory and judgment) assessment scored was 15…

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 Licensed Nurses have the competencies necessary to meet the needs of the residents for two of three sampled residents (Resident 21 and 43) when Licensed Vocational Nurse (LVN) 1 and 5 did not have training and competencies to operate the low air loss (LAL- an air mattress with fluctuating air) mattress. This failure had the potential to cause resident falls and injury due to inaccurate LAL pressure settings. Findings: During a concurrent observation and interview on 8/24/22, at 8:33 a.m., with Resident 21, in Resident 21' s room, Resident 21 was laying in bed on a LAL mattress. The LAL mattress air setting was on lock position and the LAL mattress air pressure was set at 180 pounds. Resident 21 stated, her mattress felt lumpy [uncomfortable] and was not at the correct setting. During a review of Resident 21's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) Assessment, dated 5/31/22, indicated Resident 21's Brief Interview for Mental Status…

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 and biologicals were labeled in accordance with currently accepted professional principles when: 1. 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 for liquids) was opened with no indication of used-by date or open date. This failure had the potential to produce inaccurate PPD (purified protein derivatives) Test (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. 2. Resident 64's Levalbuterol (medication used to prevent and treat difficulty breathing, wheezing, shortness of breath) medication was opened with no indication of used-by date or when the foil pouch was opened. This failure had the potential to decrease the medication potency that could compromise 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 interview and record review, the facility failed to ensure residents were provided a diet that accommodated residents preferences for one of one resident (Resident 99) when Resident 99's food preferences and intolerances were not obtained in a timely manner (past 7 days). This failure posed the risk for Resident 99 to not receive the food he preferred and food that he could tolerate which in turn could contribute to decreased intake and meal dissatisfaction. Findings: During a review of the clinical record titled, admission Record (AR), dated 12/13/22, for Resident 99, the AR indicated Resident 99 was a [AGE] year-old male with diagnoses which included acute kidney failure, type 2 diabetes mellitus (the body's inability to produce the hormone insulin), hypertension (high blood pressure), and peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). During a review of Resident 99'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 ensure the recipes were followed for puree (a smooth creamy substance made of liquidized food) diets when an unmeasured quantity of food thickener was added to puree food items by [NAME] 2. This failure resulted in food recipes not followed which posed the risk to alter the nutritional value and taste of the food being produced which in turn could compromise the nutritional status and meal satisfaction for Residents 44, 28. 46, 31, 27 and 17. Findings: During a concurrent observation and interview on 8/24/22, at 10:19 a.m., with [NAME] 2, in the kitchen, [NAME] 2 was preparing food items for lunch. [NAME] 2 stated, she was preparing puree food for six residents (Residents 44, 28, 46, 31, 27 and 17). [NAME] 2 put an unmeasured quantity of cooked fish in the blender. [NAME] 2 stated, she was using about six pieces of fish. [NAME] 2 added an unmeasured amount of chicken broth to the fish three times. [NAME] 2 placed the blended fish into a steam table pan. The pureed fish had a liquid consistency. [NAME] 2…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure resident food preferences and intolerances were followed for one of one non-sampled resident (Resident 80) when Resident 80 was served milk with his lunch meal. This failure had the potential for Resident 80's meal intake to be inadequate which could compromise his nutritional status. Findings: During a review of Resident 80's clinical record titled admission RECORD dated 8/25/22, the admission Record indicated, Resident 80 was admitted to the facility on [DATE]. During an observation on 8/23/22, at 1:09 p.m., in the dining room. Resident 80 was served his lunch meal. Resident 80's lunch meal consisted of eight ounces whole milk, eight ounces of (nutritional shake brand), four ounces cranberry juice, roast turkey with gravy, bread stuffing, broccoli, dinner roll and a glazed apple square. During a review of Resident 80's lunch meal ticket, dated 8/23/22, the ticket indicated, Resident 80 was on a consistent carbohydrate regular…

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 medical records for residents that were complete, accurately documented and readily accessible for two of six sampled residents (Resident 9 and Resident 16) when the Physician Order for Life-Sustaining Treatment (POLST) form (a legal document that specifies the type of care a resident's treatment and services would like in an emergency life threatening medical situation) was incomplete for Resident 9 and Resident 16. This failure had the potential risk for Resident 9 and Resident 16's decisions regarding their healthcare and treatment options not being honored. Findings: During a review of Resident 9's clinical record titled, admission Record (document containing resident personal information), dated 8/25/22, indicated Resident 9 was admitted to the facility on [DATE] with diagnoses which included, . Chronic Obstructive Pulmonary Disease (COPD-group of lung diseases that block airflow and make it difficult to breathe), emphysema (damage to 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 conduct regular inspections of bed rails as part of the facility's regular maintenance program for one of three sampled residents (Resident 14) when Resident 14's right side rail appeared bent leaning away from the bed. This failure had the potential to result in an injury or accident to Resident 14. Findings: During an observation on 8/23/22, at 11:05 a.m., in Resident 14's room, Resident 14 was laying in bed with two bed rails up. The bed rail (right side) appeared bent leaning away from the bed and had a large gap between the mattress and the bed rail in comparison to the left side rail. During a review of Resident 14's Order, dated 8/19/22, was reviewed. The Order indicated, . Bilateral ½ siderails up to assist the resident when turning and repositioning in bed . During a concurrent interview and record review on 8/24/22, at 10:56 a.m., with Certified Nursing Assistant (CNA) 5, the facility Maintenance Request Log, undated, was reviewed. The Maintenance Request Log indicated, the date, location,…

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.