Gordon Lane Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, facility P&P review, and facility document review, the facility failed to ensure two final sampled residents (Residents 4 and 7) were provided with the necessary care and services when: * The facility failed to monitor Resident 4 when the resident developed a MASD (moisture-associated skin damage caused by prolonged or repeated exposure to moisture) in the sacral area, per the facility's Change of Condition protocols. The facility failed to provide documented evidence Resident 4 was monitored every shift for 72 after the identification of a MASD in the sacral area. In addition, the facility failed to initiate a care plan for Resident 4's non-compliance with the interventions to address the sacral wound. The MASD was classified as an unstageable pressure injury eight days later. * The facility failed to ensure Resident 7's alternating pressure mattress was not in static mode while the resident was in bed. This posed the risk of defeating the mattress'…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the appropriate care and services for the use of the GT for two of three final sampled residents (Residents 1 and 8) reviewed for the GT feeding. * The facility failed to ensure the HOB was elevated at a minimum 30-degree angle when the enteral feeding was infusing via GT, to reduce the risk of aspiration (entry of food, liquid or foreign material into the airway) for Residents 1 and 8. This failure posed the risk for complications related to use of GT for Residents 1 and 8. Findings: Review of the facility's P&P titled Care and Treatment of Feeding Tubes revised 12/19/22, showed it was the policy of the facility to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complication to the extent possible. Further review of the P&P showed the resident's plan of care would direct staff regarding proper positioning of the resident consistent 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, interviews, medical record reviews, and facility P&P review, the facility failed to provide the necessary care and services to maintain the IV access for four final sampled residents (Residents 4, 7, 68, and 102) reviewed for the IV care. * The facility failed to ensure Resident 2's peripheral IV was inserted with an ultrasound by an outside vascular access provider as per the physician's order. * For Resident 4, the facility failed to ensure the midline catheter dressing change, external catheter and arm circumference measurement, the injection cap of the midline lumen and securement device were change upon admission and as per the physician's order. * The facility failed to monitor Resident 68's Port-A-Cath site for the signs and symptoms of infection and bleeding every shift as per the physician's order. * The facility failed to ensure Resident 102's PIV was correctly labeled. These failures had the potential to delay the identification of catheter-related complications for these…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for suctioning for two of two final sampled residents (Residents 1 and 7) reviewed for respiratory care. * The facility failed to ensure the Yankauer suction tip was stored in a bag when not in use, and the suction canister and tubing were dated and changed weekly for Resident 1, per the facility's P&P. * The facility failed to ensure a physician's order was obtained prior to suctioning Resident 7. In addition, the facility failed to ensure the Yankauer suction tip was stored in a bag when not in use, and the suction canister and tubing were dated and changed weekly for Resident 7, per the facility's P&P. These failures posed the risk for complications related to suctioning and affect the residents' wellbeing.Findings: Review of the facility's P&P titled Changing Suction Canisters revised 7/8/24, showed the following: - To minimize the risk of infection to the 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, medical record review, and facility P&P review, the facility failed to ensure the appropriate pain management was provided to four of four final sampled residents (Residents 2, 11, 40, and 96) reviewed for pain management. * The facility failed to ensure Resident 2 was administered the oxycodone (controlled pain medication) medication according to the physician's orders. * The facility failed to ensure Resident 11 was administered with the hydrocodone-acetaminophen (a controlled pain medication) medication according to the physician's order . * The facility failed to ensure Resident 40 was administered with the tramadol (a controlled pain medication) and acetaminophen (a pain medication) medication according to the physician's order. * The facility failed to ensure the non-pharmacological intervention was provided to Resident 96 before the administration of the oxycodone pain medication. These failures had the potential to put the residents at risk for ineffective pain management and receive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the dialysis communication forms were completed for one of two sampled residents (Resident 5) reviewed for hemodialysis. * The facility failed to ensure the necessary information in Resident 5's dialysis communication forms between the facility and dialysis center were completed. This failure had the potential for not identifying the changes in resident condition and/or complications prior to, during, and after the hemodialysis.Findings: Review of the facility's P&P titled Hemodialysis revised 6/2023 showed the facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences, to meet the special medical, nursing, mental, and psychosocial needs of residents receiving hemodialysis. The P&P further showed the facility will assure that each 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 observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the pharmaceutical services to ensure the accurate administration of the medications as evidenced by: * The facility failed to ensure Resident 102's vancomycin medication was administered timely. This failure had the potential to negatively impact the resident's health outcomes. * The facility failed to ensure the Controlled Substance Shift Count Log (a form where the nurses sign when the controlled medications were reconciled before and after each shift) for Medication Carts A and B were signed by the incoming and/or outgoing nurses. This failure posed the risk for loss or diversion of the controlled medication in the facility.Findings: 1. Review of the facility's P&P titled Medication Administration dated 12/19/22, showed administer the medications within 60 minutes prior to or after scheduled time unless otherwise ordered by physician. Review of the facility's document…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure two of 21 final sampled residents (Residents 4 and 40) was free from the unnecessary medications. * The facility failed to monitor Resident 4 for the signs and symptoms of bleeding related to the use of Eliquis medication (an anticoagulant used to prevent blood clots). * The facility failed to assess, monitor, and provide the insulin medication to Resident 40 as per the physician's order. These failures had the potential for the residents to receive unnecessary medications and develop significant adverse effects. Findings: 1. According to the FDA approved Highlights of Prescribing Information for Eliquis issued on 04/2025 showed the most common adverse reaction in adult patients are related to bleeding. Review of the facility's P&P titled High Risk Medications – Anticoagulants revised on 12/19/22, showed the facility recognizes that some medications, including anticoagulants, are associated with greater…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility P&P review, facility failed to provide the necessary pharmacy services to ensure proper storage, labeling and disposal of the medications. * The facility failed to ensure the open vial of a PPD test (Purified Protein Derivative, test to diagnose tuberculosis infection) and Humulin N (insulin medication used to lower down blood sugar level) had a written date on when it was opened. This failure has the potential for the medication to lose its stability and effectiveness when the medication was administered beyond the required time. * The facility failed to ensure the expired medication was removed from the medication cart. This failure had the potential for the expired medication to be accidentally administered to the residents. Findings: Review of the facility's P&P titled Labeling of Medications and Biologicals revised on [DATE], showed that all the medications and biologicals used in the facility will be labeled in accordance with current state and federal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility P&P review, the facility failed to ensure the food brought in from the outside was safely stored for one final sample resident (Resident 96). * The facility failed to safely store the food brought in from the outside for Resident 96. Additionally, the facility failed to ensure Resident 96 was educated on the safe food handling guidelines. These failures had the potential to expose the residents who received food brought in by the family/visitors to food borne illnesses.Findings: Review of the facility's P&P titled Outside Food Brought in by Family or Visitors dated 1/25/24, showed it was the right of the resident of the facility to have food brought in by family or other visitors, however, the food must be handled in a way to ensure the safety of the resident. Further review of the P&P showed all the food items that are already prepared by the family or visitor brought in must be approved per nursing to ensure it is accordance with the diet order and eaten within two…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and facility document review, the facility failed to ensure the Facility Assessment addressed or included the following: 1. Active involvement of required individuals in developing the Facility Assessment; and2. A plan to maximize recruitment and retention of direct care staff. These failures had the potential to not meet the residents' care needs if the assessed population needs and resources were not comprehensively identified and addressed. Findings: According to the CMS QSO-24-13-NH dated 6/18/24, with an implementation date of 8/8/24, CMS had issued a revised guidance for long-term care facility assessment requirement. The Facility Assessment should address and included the active involvement of the direct care staff in developing the Facility Assessment. The guidance also included the staffing resources necessary to care for the residents, including the weekends; a plan to maximize recruitment and retention of direct care staff member, and a contingency plan for events that do not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medical record was complete and accurate for one final sampled resident (Resident 102), one nonsampled resident (Resident 18) and one closed record sampled resident (Resident 99) when: * The facility failed to ensure Resident 18's blood pressure measurement site was accurately documented in the resident's medical record. * The facility failed to ensure Resident 102's H&P was accurately documented. * The facility failed to ensure the facility staff were not documenting in a deceased resident's medical record (Resident 99). These failures had the potential for the residents' care needs not being met as their medical information was inaccurate.Findings: 1. Review of the facility's P&P titled Hemodialysis dated [DATE], showed the resident will not receive blood pressures or laboratory sticks on the arm where the dialysis access device is located. Medical Record Review for Resident 18 was initiated on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary care and services to ensure one of one final sampled resident (Resident 7) reviewed on hospice services attained and maintained their highest practicable well-being. * The facility failed to ensure the hospice physician's orders for the frequencies of the visits of the hospice staff were transcribed in Resident 7's electronic health record. In addition, the facility failed to ensure the CHHA and LVN visited Resident 7 per the hospice physician's orders. This had the potential for a delay in providing hospice care and services to Resident 7.Findings: Review of the facility's P&P titled Coordination of Hospice Services revised 9/2/22, showed the following:- When a resident/resident representative chooses to receive hospice care and services, the facility will coordinate and provide care in cooperation with hospice staff in order to promote the resident's highest practicable…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to maintain proper infection control practices. * The facility failed to ensure one laundry rolling rack with clean residents' clothing was appropriately covered when it was transported through the hallways and was left unattended. * The facility failed to ensure the local public health department was informed of Resident 63's unresolved scabies. Additionally, the facility failed to place Resident 63 on proper contact isolation for the unresolved scabies. * The facility failed to ensure CNA 7 did not use the same pair of gloves and gown when providing care to Resident 48 on EBP and then to Resident 105 who was not on EBP. This posed the risk of cross-contamination and spread of infection. * The facility failed to ensure Resident 36's indwelling urinary drainage bag was not touching the floor. This failure had the potential to put the resident at risk for urinary infection. * The facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, facility document review, and facility P&P review, the facility failed to monitor and address the use of the antibiotics when the resident's condition did not meet McGeer's criteria for two of five residents (Residents 4 and 53) reviewed for antibiotic stewardship. This failure had the potential for the antibiotics to be used when it was not indicated and the development of antibiotic-resistant bacteria.Findings: Review of the facility's P&P titled Antibiotic Stewardship Program revised 12/19/22, showed it is the policy of the facility to implement an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. The purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. The program included antibiotic use protocols as a system to monitor antibiotic use.the facility uses the (CDC's NHSN Surveillance Definition, updated McGeer's criteria, or other surveillance tool) to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the resident's zone entrapment assessment was completed and the measurements were recorded upon installation during the admission when identifying areas of possible entrapment with the use of side rails for one of two final sampled residents (Resident 4) reviewed for the use of the side rails. These failures had the potential to negatively impact the residents resulting in possible entrapment, serious injury, and death.Findings: According to the Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, the term entrapment describes an event in which a patient/resident is caught, trapped, or entangled in the space in or about the bed rail, mattress, or hospital bed frame. Patient entrapment may result in deaths and serious injuries. These entrapment events have occurred in openings within the bed rails, between the bed rails and mattresses, under bed rails,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to maintain the infection prevention and control practices to help prevent the transmission of communicable diseases and infections for one of three sampled residents (Resident 1) placed on contact precautions. * The facility failed to ensure the staff donned an isolation gown before contacting with Resident 1 and/or his environment. Additionally, the staff did not properly discard the isolation gown after wearing it in Resident 1's room. * The facility failed to handle the clean linens so as to prevent the spread of infection. These failures posed the risk for transmission of infection and the development of disease-causing microorganisms. Findings: 1. Review of the facility's P&P titled Head Lice and Scabies Exposure and Treatment dated 12/19/22,showed the staff will follow appropriate transmission-based precautions, including PPE use, when providing care to the affected resident/s. Review of Resident 1'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure the allegation of abuse was reported within the required time frame, the resident's responsible party was notified of the allegation, the investigation was initiated after the abuse allegation was identified, and the staff were provided an in-service regarding the code of conduct and sexual abuse prevention for one of five sampled residents (Resident 4). * CNA 11 witnessed CNA 10 in Resident 4's room. CNA 10's top scrub was lifted in front of Resident 4. This failure posed the risk for Resident 4 to not be protected against the alleged abuse and placed other vulnerable residents at risk for abuse. Findings: Review of the facility's P&P titled Abuse, Neglect and Exploitation dated 12/19/22, showed the facility will have written procedures that include reporting of all alleged violations to the Administrator, state agency, adult protective services, and to all other required agencies within specified time frame. 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, medical record review, and facility document review, the facility failed to ensure the medications were administered as ordered for one of five sampled residents (Resident 2). * Resident 2 did not receive the prescribed medications upon admission as ordered by the physician. This failure had the potential to negatively impact Resident 2's medical condition. Findings: Medical record review for Resident 2 was initiated on 5/28/35. Resident 2 was readmitted to the facility on [DATE]. Review of Resident 2's Order Summary Report dated 5/27/25 showed the following physician orders: - dated 5/14/25, omeprazole (medication to treat heart burn) DR (delayed release) 20 mg capsule to give one capsule by mouth one time a day - dated 5/14/25, venlafaxine HCL (antidepressant medication) ER (extended release) 150 mg capsule, two capsules by mouth one time a day - dated 5/12/25, lamotrigine (antiseizure medication) oral tablet 150 mg, one tablet by mouth two times a day - dated 5/12/25, lisinopril…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to implement their P&P for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act when the facility failed to report in a timely manner an allegation of staff-to-resident abuse to the CDPH, L&C Program for one of two sampled residents (Resident 1). This failure had the potential for the abuse allegation going unreported and uninvestigated. Findings: Review of the facility's P&P titled Compliance with Reporting Allegations of Abuse/Neglect/Exploitation revised 12/19/22, showed it is the policy of the facility to report the allegations of abuse/neglect/exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property are reported immediately to the Administrator of the facility and to other appropriate agencies in accordance with current state and federal regulations within prescribed timeframes. Closed medical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to implement their abuse P&P related to the investigation of the physical abuse for one of two sampled residents (Resident 1). * The facility failed to remove the alleged employee from resident care areas while the facility was investigating the abuse allegation. * The facility failed to send the result of the abuse investigation to the CDPH L&C Program. These failures posed the risk of Residents 1 to not be protected against the alleged abuse and placed other vulnerable residents at risk for abuse. Findings: Review of the facility's P&P titled Compliance with Reporting Allegations of Abuse/Neglect/Exploitation revised 12/19/22, showed when the suspicion of abuse/neglect/exploitation or reports of abuse/neglect/exploitation occur, the licensed nurse will remove the accused employee from resident care areas. The Administrator or designee will obtain statements from direct care staff, suspend 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, medical record review, facility document review, and facility P&P review, the facility failed to ensure one of two sampled residents (Resident 1) was free from the unnecessary psychotropic medications (any drug that affects brain activity). * The facility failed to obtain the informed consent from Resident 1 or surrogate for the use of Seroquel (brand name for quetiapine fumarate, a drug to treat bipolar disorder) * The facility failed to ensure Resident 1's behavior was monitored for the use of citalopram (to treat depression), quetiapine fumarate, divalproex sodium (to treat the manic phase of bipolar disorder) and lorazepam (to treat anxiety disorder) medications. * The facility failed to ensure Resident 1 was monitored for side effects and/or adverse effects related to the use of citalopram, quetiapine fumarate, divalproex sodium and lorazepam medications. * The facility failed to ensure Resident 1 was provided with the non-pharmacologic intervention for the use of the citalopram,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to protect the resident's rights to be free from the verbal abuse by a staff for one of 10 sampled residents (Resident 1). * Resident 1 was asking for help and CNA 3 answered Resident 1 in a foul language in Spanish. This failure had the potential to negatively impact Resident 1's well-being. Findings: Review of the facility's P&P titled Abuse, Neglect and Exploitation revised on 12/19/22, showed it is the policy of the facility to provide protections for the health, welfare and rights of each resident. Review of the facility's SOC 341 form dated 8/30/24, showed a student nurse witnessed CNA 3 using a foul language in Spanish to Resident 1. Review of the facility's conclusion letter dated 9/3/24, showed the facility substantiated the incident as verbal abuse. Medical record review for Resident 1 was initiated on 9/3/24. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's MDS dated [DATE], showed 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, medical record review, and facility P&P review, the facility failed to maintain the infection control practices designed to provide the safe and sanitary environment and help prevent the development and transmission of diseases and infections. * Resident 8 who was positive for COVID-19 and required isolation precautions, was cohorted with Resident 9 who was negative for COVID-19. This failure posed the risk of infection and transmission of COVID-19 and other disease-causing microorganisms. Findings: According to the CDC's Infection Control Guidance: SARS-CoV-2, under section 2, Recommended infection prevention and control practices when caring for a patient with suspected or confirmed SARS-CoV-2 infection, showed to place a patient with confirmed SARS-CoV-2 infection in a single person room .if cohorting, only patients with the same respiratory pathogen should be housed in the same room. Review of the facility document titled [NAME] Lane Care Center dated 8/12/24, showed the census…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of seven sampled residents (Resident 1) attended the scheduled neurology consultation appointment for * Resident 1 had a telemedicine neurology consultation for dementia. Resident 1's appointment was scheduled to take place at the facility utilizing Resident 1's telephone. However, at the time of Resident 1's appointment, no staff were present to assist Resident 1 with her appointment via telephone. As a result, Resident 1 did not attend her scheduled neurology appointment. This failure had the potential to delay Resident 1's plan of care. Findings: Review of the facility's P&P titled Accommodation of Needs dated 12/19/22, showed the facility will treat each resident with respect and dignity and will evaluate and make reasonable accommodations for the individual needs and preferences of a resident. Based on individual needs and preferences, the facility will assist the resident as much as possible in maintaining…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility P&P review, the facility failed to ensure the medications were stored and labeled properly and failed to ensure the drugs and biologicals were stored in a safe manner when: * One of two medication rooms (Medication Room A) had one opened, unsealed package of IV Statlock PICC Plus (a device to secure an IV catheter from kinking which could lead to blockage of fluids going through the vein). * The facility's Central Supply Room was observed to contain artificial tears, earwax softener drops, dry eye relief, muscle rub cream, and enema bottles stored on the same shelf next to the oral medications such as calcium, omeprazole, sodium chloride, and fish oil. * The facility's treatment cart was observed to contain the expired dressings, topical creams with labels not readable; and the treatment supplies and cart were not maintained in a sanitary condition. * Two of three medication carts (Medication Carts A and C) contained the medication bottles with sticky residue, and…

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

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food preparation, storage, and sanitary requirements were met in the kitchen. * The facility failed to ensure the proper disposal, labeling and dating of foods in the kitchen. * The facility failed to ensure the cutting board was in sanitary condition. * The facility failed to ensure the countertop can opener was free from brownish, whitish, and grayish discoloration. * The facility failed to ensure the stainless mixing bowls, knives, and water pitchers were rinsed prior to use. * The facility failed to ensure one knife and blender were air dried prior to use. * The facility failed to ensure a clean spatula was placed on top of an unsanitized preparation area. These failures had the potential to cause foodborne illnesses to a medically vulnerable resident population who consumed food prepared in the kitchen. Findings: Review of the Dietary Order Listing Report completed by the facility on 4/12/24, showed 84 of 88 residents in the facility received food prepared in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the infection control practices designed to provide a safe and sanitary environment were followed. * LVN 1 used Sanicloth disinfectant wipes with an unreadable expiration date. * LVN 1 placed the spoons directly on the bedside table and used the spoons to stir the medications prior to administering medications. * LVN 1 placed the piston syringe and plunger used for G-tube medication administration directly on the bedside table surface without a barrier. * LVN 4 failed to follow the Enhanced Barrier Precautions when she did not wear a gown during medication administration via G-tube for Resident 72. * LVN 4 did not perform hand hygiene and did not change gloves prior to administering oral, enteral, and subcutaneous medications. LVN 4 wore the same pair of gloves during the entire medication pass. In addition, LVN 4 used the bottom of the spoons to stir the medications and placed directly on the bedside…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility P&P review, the facility failed to ensure the residents' call light system was fully functional as evidenced by: * The call light system for two of two nursing stations were not audible. * Resident 67's call light was not answered promptly. These failures posed the risk of staff not responding promptly to residents in need of immediate assistance. Findings: Review of the facility's P&P titled Call Lights: Accessibility and Timely Response revised 9/2/22, showed the staff members who see or hear an activated call light were responsible for responding. If the staff member could not provide what the resident desired, the appropriate personnel should be notified. 1. On 4/9/24 at 1408 hours, Resident 61's call light was observed on but not audible. On 4/10/24 at 1041 hours, Resident 61's call light was observed on but not audible. On 4/10/24, medical record review for Resident 61 was initiated. Resident 61 was admitted to the facility on [DATE]. Resident 61 was observed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of six sampled residents (Resident 26) reviewed for psychotropic use was informed of the use of the psychotropic medication (medication affecting brain activities associated with mental processes and behavior). * The facility failed to ensure the informed consent was obtained prior to administering the Seroquel (an antipsychotic medication that treats several kinds of mental health conditions including schizophrenia) and paroxetine (a medication used to treat depression) for Resident 26. This failure had the potential for Resident 26 to not be informed of the medication and potential effects of Seroquel and paroxetine. Findings: Review of the facility's P&P titled Informed Consent revised on 12/2022 showed it is the policy of this facility to uphold the rights of residents to participate in the panning and decision-making process concerning their care and treatment. When situations arise that involve complex…

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 P&P review, the facility failed to ensure the accomodations of needs were met for one of 19 final sampled resident (Resident 67) and two of nonsampled residents (Residents 83 and 84). * The call lights were not within reach for Residents 83 and 84. * The call light was not answered promptly for Resident 67. These failures had the potential for the residents not getting their needs met timely. Findings: Review of the facility's P&P titled Call Lights: Accessibility and Timely Response revised 9/2/22, showed the purpose of this policy is to assure the facility is adequately equipped with a call light. Staff will ensure the call light is within reach of resident and secure as needed. Medical Record review for Resident 83 was initiated on 4/9/24. Resident 83 was admitted to the facility on [DATE]. Review of Resident 83's 5-day admission Assessment MDS dated [DATE], showed under Section B, the resident was able to make needs known, understood, and understand. Section C showed BIMS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to implement the comprehensive care plan to address the individual care needs for one of one sampled resident (Resident 7) reviewed for IV antibiotic use. * The facility failed to develop a plan of care addressing Resident 7's Vancomycin (antibiotic used to treat and prevent various bacterial infections) treatment given intravenously (giving medicines through a needle or tube inserted into a vein). This failure had the potential for not providing appropriate, consistent, and individualized care. Findings: According to the facility's P&P titled Comprehensive Care Plans revised 12/19/22, showed the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident comprehensive assessment. Medical record review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure the comprehensive plan of care was revised to reflect the resident's care needs for one of 19 final sampled residents (Resident 84). * The facility failed to ensure Resident 84's care plan was revised to reflect the treatment for both lower extremities for maintenance of skin integrity from the cellulitis related to venous insufficiency (a condition in which the veins fail to return blood efficiently to the heart). This failure placed Resident 84 at risk for the specific care needs not being addressed. Findings: Review of the facility's P&P titled Comprehensive Care Plan revised 12/19/22, showed it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident's rights, that includes measurable objectives and time frames to meet resident's medical, nursing, and mental and psychosocial needs that are identified in the resident'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, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the development of a wound for one of three sampled residents observed for wound care (Resident 74). * The facility failed to provide skin treatment to Resident 74's right lower leg swelling as ordered by the physician. This failure had the potential for Resident 74 to develop or worsening of skin breakdown. Findings: Review of the facility's P&P titled Clean Dressing Change revised on 12/19/22 showed to provide wound care in a manner to decrease potential for infection and or cross contamination. The physician's order will specify type of dressing and frequency of changes. The policy showed place a barrier cloth or pad next to the resident, under the wound to protect the linen and other body sites; and apply topical ointments or creams and dress the wound as ordered. Review of Resident 74's Order Summary Report dated 4/10/24, showed the following physician's orders: - for the left lower leg swelling, to clean 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.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the worsening of a pressure ulcer for one of the three sampled residents observed wound care (Resident 26). * The facility failed to provide wound treatment to Resident 26's right hip and right lateral malleolus pressure injuries as ordered by the physician. This failure had the potential for Resident 26's worsening of existing pressure ulcer. Findings: Review of the facility's P&P titled Clean Dressing Change revised on 12/19/22, showed the facility to provide wound care in a manner to decrease potential for infection and or cross contamination. Physician's order will specify type of dressing and frequency of changes. Policy explanation and compliance guidelines showed place a barrier cloth or pad next to the resident, under the wound to protect the linen and other body sites. Apply topical ointments or creams and dress the wound as ordered. Review of Resident 26's Order Summary Report dated 4/10/24, showed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to provide the necessary GT care and services for one of two sampled residents reviewed for GT care. * The facility failed to ensure Resident 53 was positioned safely at 30 to 45 degrees during the enteral feeding via GT. This failure posed the risk for developing complications related to GT. Findings: According to Taylor's Fundamentals of Nursing seventh edition, Nursing Considerations with Tube Feeding, to make sure the resident is as upright as possible during feeding. If the resident is in bed during feedings, elevate the head of the bed at least 30 degrees during feeding and for one hour afterward to prevent reflux (occurs when stomach acid repeatedly flows back into the esophagus or the tube connecting your mouth and stomach) and aspiration. Medical record review for Resident 53 was initiated on 4/9/24. Resident 53 was readmitted to the facility on [DATE]. Review of Resident 53's Order Summary Report showed a physician's order…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of one sampled resident (Resident 74) reviewed for the use of BiPAP (Bilevel positive airway pressure, a form of noninvasive ventilation that providers use to help with breathing) was provided with the appropriate respiratory care. * The facility failed to ensure the BiPAP mask was cleaned according to the facility's P&P. This failure had the potential to negatively impact Resident 74's medical condition. Findings: Review of the facility's P&P titled CPAP (continuous positive airway pressure) /BiPAP Cleaning revised on 12/19/22, showed to clean the CPAP/BiPAP equipment in accordance with the current CDC guidelines and manufacturer recommendations in order to prevent the occurrence or spread of infection. The P&P also showed clean mask frame daily after use with CPAP cleaning wipe or soap and water. Dry well. Cover with plastic bag or completely enclosed in machine storage when not in use. Weekly cleaning…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the pain management was provided to two of two sampled residents (Residents 7 and 23). * The facility failed to notify the physician of Resident 7's pain to obtain a pain medication to manage the resident's pain. * The facility failed to ensure Resident 23 was administed the pain medications as ordered. These failure had the potentitial for not providing the necessary care and services and effectively managing the residents' pain. Findings: 1. According to the facility's P&P titled Pain Management revised 12/19/22, showed the facility must ensure the pain management is provided to the residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. The P&P also showed the following: - Recognize when the resident is experiencing pain and identify circumstances when the pain can be anticipated; -…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to ensure two of two sampled residents (Residents 59 and 61) reviewed for dialysis services were monitored for fluid restriction as ordered. This failure posed the risk of the residents' not receiving appropriate care. Findings: 1. On 4/10/24, medical record review was initiated for Resident 59. Resident 59 was readmitted to the facility on [DATE], and discharged to the acute care hospital on 4/11/24. Review of Resident 59's physician's progress note dated 12/8/23, showed Resident 59's diagnoses included end stage renal disease with dialysis. Review of Resident 59's nutritional assessment dated [DATE], showed Resident 59's albumin level was trending downward. Review of Resident 59's April 2024 Order Summary Report showed an order dated 12/22/23, for Novasource 275 ml (nutritional supplement) three times daily; and an order dated 12/5/23, for a breakdown of Resident 59's daily fluid restrictions provided by nursing: a daily total of 780 ml. Review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility document review, the facility failed to ensure the nursing services were provided by the appropriate staff (four of four CNAs) as evidenced by: * Two CNAs (CNAs 9 and 10) applied the oxygen tubing and set the residents' oxygen rate. * The facility failed to ensure CNAs 1 and 2 were provided training on the implementation of the enhanced barrier precautions. CNAs 1 and 2 were observed not wearing a gown while transferring Resident 35 on enhanced barrier precautions. These failures posed the risk of the residents not receiving appropriate care. Findings: 1. On 4/9/24 at 1220 hours, CNA 9 was observed grabbing Resident 61's oxygen tubing and placing it into Resident 61's nostrils. CNA 9 was observed asking Resident 61's sitter whether Resident 61 was on two liters of oxygen. CNA 9 was then observed setting the dial on Resident 61's oxygen tank. On 4/9/24 at 1227 hours, an interview was conducted with CNA 9. When asked about setting the dial on Resident 61's oxygen tank,…

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, medical record review, and facility P&P review, the facility failed to provide the pharmaceutical services to meet the needs of the residents when: * The facility failed to ensure all controlled medications were accurately documented for one of 19 final sampled residents (Resident 61) and one nonsampled resident (Resident 46). * The facility failed to ensure the oral and IV E-Kit(s) for Nursing Station A were refilled/replaced by pharmacy within 72 hours of opening the E-Kit(s). These failures posed the risk for diversion of the controlled medications and medication administration errors; and timely replacement of medication for emergency use. Findings: Review of the facility's P&P titled Controlled Substance Administration and Accountability revised 6/5/23, showed it is the policy of this facility to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. The facility will have safeguards in place in order to prevent loss, diversion or accidental exposure. 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, medical record review, and facility P&P review, the facility failed to ensure the Pharmacy Consultant's recommendations were acted upon for one of five unnecessary medication sampled residents (Resident 23). * The facility failed to follow-up on the Pharmacy Consultant recommendation to monitor for CNS (central nervous system) and respiratory depression for Resident 23 who was taking routine gabapentin (nerve pain medication), methadone (opioid narcotic analgesic), and Dilaudid (opioid narcotic analgesic) medications. In addition, the facility failed to follow-up on the Pharmacy Consultant recommendation to place hold parameters for gabapentin medication for Resident 23. These failures had the potential to put the resident at risk for adverse consequences related to the medications. Findings: Review of the facility's P&P titled Medication Regimen Review revised date 12/19/22, showed medication regimen review (MRR) or drug regimen review, is a thorough evaluation of the mediation regimen of a…

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

Based on observation, interview, and medical record review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 24%. Two licensed nurses (LVNs 1 and 4) who were observed during the medication administration were found to have made errors. * LVN 1 failed to check Resident 53's heart rate prior to administering metoprolol (blood pressure medication) per the physician's orders. In addition, Resident 53 received partial dose for one medicaiton when residual of the medication was left in the medication cup. * Resident 72 received partial doses for three medications when residual of the medications were left in the medication cups. These failures had the potential to negatively impact the residents' health status and well-being. Findings: Review of the facility's P&P titled Medication Administration- General Guidelines dated October 2017 showed the medications are administered as prescribed in accordance with good nursing principles and practices. 1.a. On 4/10/24 at 0915 hours, a medication administration observation for 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.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of two LVNs observed for medication administration administered the medications without significant medication errors. * LVN 1 failed to check Resident 53's heart rate prior to administering metoprolol per the physician's orders. This failure placed Resident 53 at risk for medical complications. Findings: Review of the facility's P&P titled Medication Administration- General Guidelines dated October 2017 showed the medications are administered as prescribed in accordance with good nursing principles and practices. On 4/10/24 at 0915 hours, a medication administration observation for Resident 53 was conducted with LVN 1. LVN 1 prepared and administered Resident 53's medications which included the following: - one tablet of apixaban 5 mg - one tablet of aspirin 81 mg - 35 units of Basaglar insulin - one tablet of metoprolol tartate 100 mg - five ml of multivitamin with mineral - one tablet of vitamin C. LVN 1 was observed pouring water into the medication cup containing the crushed…

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

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the menus were followed as evidenced by: * The facility failed to ensure the spreadsheet was followed for the liberal house renal diet and renal diet. The facility failed to provide 10 pieces of cheese ravioli for Residents 13 and 34 as per the menu. *The facility failed to ensure the menu for the pureed breadstick and butter was followed when the wrong scoop size was used to serve the pureed bread for Residents 16 and 78. * The facility failed to provide butter or margarine, and milk to Resident 78 as per the menu. In addition, the facility failed to provide coffee to Resident 78 as per the resident's lunch tray ticket. * The facility failed to provide the appropriate dessert portion to one nonsampled resident (Resident 4). Two desserts instead of one dessert were given to Resident 4 during lunch. These failures had the potential for the residents to not receive adequate nutrition and appropriate servings to meet their individual needs. Findings: Review of the…

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

Based on observation, interview, and facility document review, the facility failed to ensure the food served was palatable. * The facility failed to ensure the roast beef served to Residents 78, 27, and 392 was not tough and not hard to cut or chew. This failure had the potential for the residents to not eat the food served and could affect their nutritional status. Findings: Review of the facility's menu titled Week at a Glance, Spring 2024 for regular diet showed the lunch menu for 4/9/24, including roast beef au jus, oven roasted potatoes, savory peas, dinner roll and butter or margarine, fudgy brownie with coconut topping, and whole milk. 1. On 4/9/24 at 1212 hours, during the dining observation, Resident 78 was observed being assisted with her meals by Resident 78's Family Member. Resident 78's Family Member stated the roast beef served to Resident 78 was very hard to cut and chew. Resident 78's Family Member was observed trying to cut the roast beef several times with a knife but could not cut the roast beef. Review of Resident 78's tray ticket dated 4/9/24, showed Resident 78…

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

Based on observation, interview, facility document review, and facility P&P, the facility failed to ensure the residents on pureed diet were provided with food prepared in a form to meet the residents' individual needs. This failure risk posed the risk for residents on pureed diet to develop complications like aspiration (accidental breathing in food or fluid into the lungs) and choking. Findings: Review of the facility's titled Texture-Modified and Thickened Liquids revised 9/27/21, showed texture-modified diets are prepared and served as prescribed by the physician or appropriate personnel at the community when a resident has difficulty chewing and/or swallowing. For pureed: designed for people who have severe chewing and/or swallowing problems. Properly pureed foods eliminate the chewing phase. Smooth with no lumps. Review of the Diet Type Report completed by the facility on 4/12/24, showed 10 residents on pureed diet texture. On 4/10/24 at 1030 hours, a pureed food preparation was observed with the Dietary Cook. The DSS and RD were present during the observation. A 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility document review, the facility failed to ensure the food preferences was honored for one nonsampled resident (Resident 543). * Resident 543's tray card showed puree regular with dislikes all dairy products; however, he was served pureed breadstick and butter with milk. This failure had the potential to negatively impact the resident's well-being. Findings: Medical record review for Resident 543 was initiated on 4/10/24. Resident 543 was admitted to the facility on [DATE]. Review of the Diet Type Report for pureed diet completed by the facility on 4/12/24, did not show any additional directions for Resident 543. Review of Resident 543's lunch tray ticket showed dislikes all dairy products. On 4/10/24 at 1030 hours, a pureed food preparation was observed with the Cook. The DSS and RD were present during the observation. During the pureed food preparation observation for the breadstick and butter, the Dietary [NAME] was observed to add milk to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to maintain the complete and accurate medical records for two of 19 final sampled residents (Residents 23 and 31). * The facility failed to ensure the complete documentation for Resident 31's ADL- Bed Mobility Intervention/Task. * The facility failed to ensure the informed consents obtained from Resident 23 were signed by the physician. These failures had the potential for the resident care needs not being met as the medical information was incomplete and inaccurate. Findings: 1. Review of the facility's P&P titled Documentation in Medical Record revised 12/19/22, showed documentation should be timely, accurate, relevant and complete, containing sufficient details about resident's care and responses to care for. Medical record review for Resident 31 was initiated on 4/10/24. Resident 31 was admitted to the facility on [DATE]. Review of Resident 31's Care Plan dated 2/3/24, showed the resident had an ADL self-care performance…

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

Based on observation, interview, and facility document review, the facility failed to ensure one glucometer (Glucometer C) from one of five medication carts (Medication Cart C) was maintained in safe operating condition. This failure had the potential for residents requiring glucose checks to have inaccurate readings. Findings: Review of the Assure Platinum Blood Glucose Monitoring System Instruction Manual, under Quality Checks, showed to use Assure Dose Control Solutions to check if the meter and test strips are working correctly as a system, and if the test is correct. A control solution test is performed when a new bottle of test strips is opened. On 4/11/24 at 1245 hours, Medication Cart C inspection was conducted with LVN 3. One glucometer (Glucometer C) was observed inside the top drawer of Medication Cart C. The bottle of Assure Platinum Blood Glucose Test Strips was observed with an open date of 4/11/24, and Lot No. 012523B. A bottle of control solution was observed with the control solution range for Level 1 was 84-105 mg/dl, and the control solution range for Level 2 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, document review, and facility P&P review, the facility failed to provide the written information regarding the rights to accept or refuse medical or surgical treatments and formulate the advance directives for two of the fivesampled resident (Residents 2 and 3). This failure had the potential for the residents ' decision regarding their healthcare and treatment options not being honored. Findings: According to the Code of Federal Regulations, Section § 483.10(g)(12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives). (i) These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident ' s option, formulate an advance directive. Review of the facility P&P titled Resident ' s Right Regarding Treatment and Advance Directives revised 12/9/22, showed it is the policy of this facility to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to assess one of the five sampled residents (Resident 4) for their risk for falls. This failure had the potential for the resident not receiving appropriate interventionsbased on the resident ' s fall risk assessment. Findings: Review of the facility ' s P&P titled Fall Prevention Program revised 12/19/22, showed each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. The section for Policy Explanation and Compliance Guidelines showed the following: - The facility utilizes a standard risk assessment for determining a resident ' s fall risk. - The nurse and/or interdisciplinary team will initiate interventions on the resident ' s care plan in accordance with the resident ' s level of risk. - Fall interventions include, but not limited to complete fall risk assessment every 90 days and as indicated when 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 medical record review, the facility failed to notify the resident and their representative of the transfer/discharge and reasons for the transfer in writing for one of six sampled residents (Resident 1). This failure had the potential for the resident and their representative not knowing about the appeal process should the resident and their representative believe the transfer or discharge was inappropriate or involuntary. Findings: On 10/10/23 at 1347 hours, a telephone interview was conducted with Family Member 1. Family Member 1 stated Resident 1 was transferred to the acute care hospital on [DATE]. Family Member 1 stated the facility did not provide Resident 1 or his responsible party with a written Notice of Transfer/Discharge. Family Member 1 stated she believed the transfer was inappropriate. Closed medical record review for Resident 1 was initiated on 10/10/2023. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's History and Physical examination dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of six sampled residents (Resident 1) and/or their representative were provided with the written information regarding the facility's bed-hold policy when the resident was transferredto the acute care hospital. This failure had the potential for Resident 1 or their representative to be unaware of their rights to request a bed hold and return to the first available bed should the resident's hospital stay exceed the seven-day bed-hold period. Findings: Review of the facility's P&P titled Bed-Hold Notice Upon Transfer revised 12/19/2022, showed at the time of the transfer or therapeutic leave, the residents or resident representatives will be informed in writing of the bed-hold and return policy. On 10/10/2023 at 1347 hours, a telephone interview was conducted with Family Member 1. Family Member 1 stated Resident 1 was transferred to the acute care hospital on [DATE]. Family Member 1 stated the facility did not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to provide the necessary care and services for one of six sampled residents (Resident 5) to ensure the resident maintained their highest physical well-being. * The facility did not notify the primary physician when Resident 5 refused her meals (breakfast and lunch) and was given sixunits of insulin as per the sliding scale as ordered by the physician. This failure had the potential for not providing necessary care and services to Resident 5. Findings: Lexicomp Online (a pharmacy resource used by healthcare professionals) showed Insulin Lispro is administered subcutaneously (injection given in the fatty tissue, just under the skin) within 15 minutes before or immediately after a meal. Identified under warning/precaution concerns related to adverse effects, the most common adverse effect of insulin is hypoglycemia (low blood sugar). Hypoglycemia may result from changes in meal patterns (e.g., timing of meals, changes in level of activity, increased…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure the controlled medications signed out of the controlled drug records were administered and documented on the MAR for four of six sampled residents (Residents 1, 2, 3, and 4). In addition, Resident 2's pain medication was signed out on the controlled drug record two hours apart on 9/12/23 at 1400 and 1600 hours, instead of every four hours as ordered by the physician. These failures had the potential to result in controlled medications abuse or diversion and poor health outcomes to the residents. Findings: Review of the facility's P&P titled Medication Administration dated 12/2022 showed the medications are administered by the licensed nurses or other staff who are legally authorized to do so in this state as ordered by the physician and in accordance with the professional standards of practice in a manner to prevent contamination or infection, and to sign the MAR after administering the medications. 1. Medical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure the family member for one of the five sampled residents (Resident 4) was notified of the resident's transfer to the acute care hospital. This failure had the potential to negatively impact the resident's well-being. Findings: Review of the facility's P&P titled Notification of Changes revised 12/19/22, showed the facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is change requiring such notification. Circumstances requiring notification included Accidents potential to require physician intervention and a transfer or discharge of resident from the facility. Under additional considerations, showed contact information of resident's legal representative or family member must be recorded and periodically updated. On 7/27/23 at 1710 hours, an interview was conducted with Resident 4's family member. Resident 4's family…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary care and services to ensure six of 21 sampled residents (Residents 4, 9, 18, 19, 20, and 21) maintained their highest practicable physical well-being. * The facility failed to notify the physician when Resident 4's pulse rate less than 60 bpm and DBP was below 60 mmHg as ordered by the physician. * The facility failed to monitor Resident 20 for signs and symptoms of pacemaker malfunction as ordered by the physician. * The facility failed to correctly apply the lidocaine patch 5% (pain reliever) to Resident 19 as ordered by the physician. * The facility failed to provide the Culturelle (probiotics) and the calcium carbonate-vitamin D and minerals (supplement) to Resident 18 as ordered by the physician. * Resident 9 was sent to the dialysis center without waiting for the resident's physician recommendations post status change in condition and the dialysis center…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to two of five sampled residents (Resident 4 and 6). * The facility failed to document the assessment of Resident 4 after the fall. This failure had the potential for resident care not met as the resident documentation of assessment and immediate intervention was incomplete. * The facility failed to complete the neurological assessment following an unwitnessed fall for Resident 6. This failure had the potential to delay the detection and response to changes in resident's neurological status post fall. Findings: Review of the facility's P&P titled Fall Prevention Program revised 12/19/22, showed the following: - fall interventions include but not limited to monitor for changes in resident's cognition, gait, ability to rise/sit, and balance and monitor vital signs in accordance with facility policy. - when any resident experiences a fall, the facility will assess the resident, complete…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to provide the pharmaceutical services to meet the needs of three of 21 sampled residents (Residents 16, 18, and 21). * The facility failed to ensure Residents 16 and 21 was administered the correct dosage of medication as prescribed by the physician. * The facility failed to administer the Culturelle (probiotic supplement) and calcium carbonate-vitamin D with minerals (supplement) to Resident 18 as ordered by the physician. These failures had the potential to negatively affect the residents' health conditions. Findings: According to the facility's P&P titled Medication Administration dated October 2017 under the section Preparation showed prior to administration, the medication and dosage schedule on the resident's MAR is compared with the medication label. If the label and MAR are different and the container is not flagged indicating a change in direction or if there is any other reason to question the dosage or directions,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure two of five sampled residents (Resident 4 and 7) were free from unnecessary drugs. * The facility failed to ensure Resident 4's midodrine HCL (medication to treat low blood pressure) was administered as per the physician's order parameter. * The facility failed to ensure Resident 7's Cardizem (medication to treat high blood pressure) and carvedilol (medication to treat high blood pressure) was administered as per the physician's order parameter. These failures had the potential for the residents to receive unnecessary medication and develop significant side effects from errors in medication administration. Findings: 1. Medical record review for Resident 4 was initiated on 7/28/23. Resident 4 was admitted to the facility on [DATE]. Review of Resident 4's Order Summary Report showed a physician's order dated 7/6/23, to administer midodrine HCL 2.5 mg one tablet by mouth three times a day hold for SBP greater than 110…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of five sampled residents (Resident 4) was free from significant medication errors. * The facility failed to ensure Resident 4's metolazone (water pill) was ordered based on Resident 4's discharge instruction from the hospital. This failure had the potential to negatively impact the resident's well-being. Findings: Review of the facility's P&P titled admission of a Resident revised 12/19/22, showed residents are admitted to the facility under orders of the attending physician. Medical record review for Resident 4 was initiated on 7/28/23. Resident 4 was admitted to the facility on [DATE]. Review of Resident 4's Order Summary Report showed a physician's order dated 7/6/23, to administer metolazone 5 mg one tablet by mouth every Wednesday and Saturday. Review of Resident 4's Skilled Nursing Facility Transfer Orders from the hospital printed on 7/6/23 at 1438 hours, showed an order for metolazone 5 mg one tablet by…

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, medical record review, and facility P&P review, the facility failed to ensure Residents 21's furosemide (a diuretic medication to help reduce the amount of excess fluid in the body by increasing the amount of urine produced) medication was removed from the medication cart and disposed of when the furosemide medication order was discontinued and changed by the physician. This failure resulted in LVN 1 administering twice the dose of furosemide, which had the potential to negatively affect Resident 21's health condition. Findings: According to the facility's Policy and Procedure titled Medication Storage revised 12/19/22, under the section Policy, showed it is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. The Policy Explanation and Compliance Guidelines section showed for unused medications, 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, medical record review, and facility P&P review, the facility failed to ensure the laboratory test for one of the five sampled residents (Resident 4) was ordered. * The facility failed to clarify the order for BMP test as per Resident 4's hospital discharge order with the admitting physician. This failure posed a risk for undetected blood test abnormality that could significantly impact the resident's well-being. Findings: Review of the facility's P&P titled Laboratory Services and Reporting revised 12/19/22, showed the facility must provide or obtain laboratory services to meet the needs of its residents. Medical record review for Resident 4 was initiated on 7/28/23. Resident 4 was admitted to the facility on [DATE]. Review of Resident 4's Skilled Nursing Facility Transfer Orders from the hospital printed 7/6/23 at 1438 hours, showed a laboratory order for BMP every other day for diagnosis of CKD (Chronic Kidney Disease). Review of Resident 4's medical record failed to show the physician'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to ensure compliance with state laws for one of 11 sampled residents (Resident 8) as evidenced by: * Resident 8's death certificate was not signed within the required time frame. This failure resulted in a delay in obtaining Resident 8's death certificate and a delay in arranging for funeral services. Findings: The Health and Safety Code Div. 102, Chapter 6, Article 1, section 102800, a death certificate shall be completed and submitted to the deceased 's funeral home within 15 hours after death. On [DATE] at 0917 hours, an interview with Resident 8's RP was conducted. The RP stated the facility delayed in providing Resident 8's death certificate to the funeral home. Resident 8's RP stated it took about one week to obtain the signed death certificate from the facility that resulted in Resident 8's burial being delayed. On [DATE], closed medical record review was initiated for Resident 8. Resident 8 had expired at the facility on [DATE]. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review the facility failed to ensure the medical record accuracy for two of 21 sampled residents (Residents 4 and 21). * The facility failed to ensure the documentation of Resident 4's pacemaker malfunction monitoring was accurate. In addition, the facility failed to ensure the documentation of Resident 4's Covid-19 rapid test results was timely and accurate. * Resident 21's MAR showed one medication was inaccurately documented as administered on 8/22/23 at 0900 hours. These failures had the potential for the residents' care needs not being met as Residents 4 and 21's medical information were inaccurate. Findings: Review of the facility's P&P titled Documentation in Medical Record revised 12/19/22, showed documentation should be accurate, relevant, and complete, containing sufficient details about the resident's care and/or responses to care. 1. Medical record review for Resident 4 was initiated on 7/28/23. Resident 4 was admitted 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 facility P&P review, the facility failed to maintain the effective infection control practices. * LVNs 1 and 2 failed to perform hand hygiene before donning and after doffing gloves during medication administration. This failure placed the residents and the staff at increased risk for infections. Findings: According to the facility's P&P titled Hand Hygiene revised 12/19/22 showed staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. Hand hygiene is indicated and will be performed under the conditions listed, but not limited to, after handling contaminated objects, before preparing or handling medications, before and after handling clean or soiled linens, before performing resident care procedures, and when in doubt. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. a. On 8/22/23 at 1619 hours, a medication administration observation was conducted with LVN 2. LVN 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 interview and medical record review, the facility failed to ensure the pharmaceutical services were provided to meet the resident needs as evidenced by: * Resident 1 had been getting his as needed pain medication four to six times a day for over a month. Resident 1 ran out of his pain medication on 7/17/23. As a result, Resident 1 did not receive pain medication for three days. * Controlled medications signed out of the Controlled Drug Records that were administered and documented on the MAR were not consistent for three of three sampled residents (Residents 1, 2, and 3). * The discontinued non-controlled medications were destroyed by two licensed nurses as specified by the facility's P&P. These failures had the potential to result in the medication diversion, medication administration errors, and poor health outcomes to the residents. Findings: 1. Medical record review for Resident 1 was initiated on 8/1/23. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of 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.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to follow the menu for 13 of 13 residents (Residents 8, 11, 16, 27, 28, 38, 41, 49, 50, 70, 86, 535, and 536) who were on the pureed textured diets. This failure posed the risk of the residents' nutritional needs not being met and/or residents' food preferences not being honored. Findings: Review of the facility's P&P titled Menu Planning showed all daily menu changes, with the reason for the change, are to be noted on the back of the kitchen spreadsheet. The Dietitian has to approve permanent changes on the menu and should sign and date spreadsheets when changes are made. Menu changes should also be noted on menus on the consumers board and any other menus which may be posted. Review of the facility's Spring Cycle Menu -Week 2 Wednesday dated 3/16/22, showed the following food items were to be served for lunch service: simmered Chinese chicken with one ounce sauce, brown rice, stir fry vegetables, parsley sprig, Mandarin Asian salad, lemon snow bar. On 3/16/22 at 0902 hours, an…

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

Based on observation, interview, facility document review, and facility P&P review, the facility failed to follow proper sanitation and food storage practices. * There were multiple expired food items in the kitchen. * The facility failed to ensure the low-temp dishwasher was checked for chlorine concentration properly and the chlorine test paper was not expired. These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food prepared in the kitchen. Findings: 1. Review of the CMS 672 completed by the DON dated 3/14/22, showed 85 of 94 residents residing in the facility received food prepared in the kitchen. On 3/14/22 at 0723 hours, an initial tour of the kitchen was conducted with the [NAME] 1. The following observations were made: - 12 cartons of Lyon's Ready Care Thickened Apple Juice labeled best if used by March 7, 2022. - multiple food seasoning with handwritten dates, use by date 2/8/22, 2/18/22, 2/23/22, 3/1/22, and 3/3/22. No manufactured date on the bottles noted. On 3/14/22 at 0750 hours, an observation and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, fundamental nursing skills review, and facility P&P review, the facility failed to meet the professional standards of care for one of the 20 final sampled residents (Resident 71). * LVN 5 failed to follow the standard nursing procedures for the administration of eye drops to Resident 71. This failure posed the risk for developing complications related to inappropriate technique in eye medication administration. Findings: According to the 7th edition of Fundamentals of Nursing by [NAME] et al, the chapter of Medications-Instilling Eyedrops showed the following steps: - clean the eyelids and eyelashes for debris, - tilt the patients head back , - remove the cap from the medication bottle , - invert the plastic medication container, - have the patient look up , - place the thumb or two fingers near the margin of the lower eyelid immediately below the eyelashes, and exert pressure downward over the body prominence of the check. The lower conjunctival sac 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 20 final sampled residents (Resident 75) was provided restorative nursing care as ordered by the physician. * Resident 75 had a physician's order to provide a rolled washcloth for the right hand contracture. The facility failed to ensure a rolled washcloth was applied to Resident 75's right hand to prevent further decline in the contracture. This failure had the potential to decrease Resident 75's optimal physical functioning. Findings: Review of the facility's P&P titled Restorative Nursing Care (undated) showed the restorative nursing care is performed as ordered and care planned for those residents who require such services. Such programs include assisting residents to adjust to their disabilities, to use their orthotic devices such as hand rolls. On 3/15/22 at approximately 0728 hours, during an initial tour of the facility, an observation was conducted for Resident 75. Resident 75 was seen…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility document review, the facility failed to provide the necessary care and services to address the nutritional needs for one of 20 final sampled residents (Resident 76). * The facility failed to ensure Resident 76's weight was monitored as ordered by the physician. Resident 76 was experiencing weight loss and had a physician's order to be weighed every 48 hours for 10 days. This failure had the potential to contribute to Resident 76's unmonitored weight loss and delayed intervention. Findings: On 3/17/22 at 0736 hours, an observation and concurrent interview was conducted with Resident 76. Resident 76 was observed in bed, independently eating her breakfast. Resident 76 stated she had lost weight but was not sure of how much she had lost. Medical record review for Resident 76 was initiated on 3/15/22. Resident 76 was readmitted to the facility on [DATE]. Review of Resident 76's History and Physician examination dated 2/24/22, showed Resident 76 had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and manufacturer's instructions, the facility failed to provide safe respiratory care for one of 20 final sampled residents (Residents 48). * The facility failed to ensure Resident 48's nebulizer mask kit was stored in accordance with the manufacturer's instructions. This had the potential for increased risks of infection. Findings: Review of the manufacturer's instructions titled Vixone Nebulizer Mask Kit (includes a tubing, bowl and mask) under cleaning instructions showed the following: - The VixOne nebulizer must be assembled and disinfected periodically in order to operate correctly. The manufacturer recommends full disassembly and disinfection of all components at the end of each treatment day, - Place all parts on a clean surface (fresh paper towel) to dry, - After parts are dry, reassemble and store kit until next use. Review of Resident 48's medical record was initiated on 3/16/22. Resident 48 was readmitted to the facility on [DATE]. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary pharmacy services for two of 20 final sampled residents (Residents 71 and 72) and one nonsampled resident (Resident 4). * The number of tablets for Resident 4's tramadol documented in the Controlled Medication Count Sheet did not match the number of tablets remaining in the medication bubble pack. * Resident 72's Controlled Medication Count Sheet for buprenorphine (narcotic medication) did not match the entry in the MAR. * Resident 72's buprenorphine was not administered as ordered by the physician. Resident 72's buprenorphine was not available. * The facility failed to ensure Resident 71's Trajenta (medication for blood glucose control) was administered as ordered by the physician. Resident 71's Trajenta was not available. * The Q Shift Controlled Drug Reconciliation had missing nurses' signatures. These failures posed the risk for diversion of controlled medications and possible…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to ensure one of five unnecessary medication sampled residents (Residents 12) was free from unnecessary drugs. * The facility failed to ensure Resident 12's midodrine hydrochloride (medication used to treat low blood pressure) was administered based on the physician's ordered parameter. This failure had the potential for Resident 12 to receive unnecessary medication and develop significant side effects arising from errors in administration. Findings: Medical record review for Resident 12 was initiated on 3/17/22. Resident 12 was admitted on [DATE], and readmitted to the facility on [DATE]. Resident 12 had a diagnosis of hypotension (abnormally low blood pressure). Review of Resident 12's Medication Review Report showed an order dated 11/5/21, to administer midodrine hydrochloride 10 mg give one tablet by mouth one time a day every Tuesday, Thursday, and Saturday for hypotension; to hold if systolic blood pressure (SBP, the top number…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review and facility P&P review, the facility failed to ensure two of 20 final sampled residents (Residents 41 and 58) were free from unnecessary psychotropic medications. * The facility failed to ensure to monitor for a specific behavior manifestation related to Resident 41's use of mirtazapine (anti-depression medication). This had the potential for inaccurate behavior monitoring and Resident 41's physician not having the necessary information to determine the effectiveness of the medication. * The facility failed to monitor the side effects and behavior manifestation for Resident 58's use of Zoloft (anti-depression medication). This had the potential for inaccurate side effects and behavior monitoring and for Resident 58's physician not having the necessary information to determine effectiveness of medication and if Resident 58 had side effects from medication. Findings: 1. Review of the facility's P&P titled General Guidelines for the Use of Psychoactive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility P&P review, the facility failed to store the drugs and biologicals in a safe manner for three of the 20 sampled residents (Residents 23, 53, and 57). * Topical, suppository, liquid and tablet forms of medications were observed to be stored together in a drawer in Medication Cart 3. The failure post the risk for contamination of medications. * Multiple expired medications and insulin pen with no open date were observed in Medication Cart 3. This failure had the potential for the administration of expired or deteriorated medications or biologicals. *A bottle nasal spray was observed on top of Resident 57's bedside table. This failure had the potential for residents, staff and visitors to have access to the medication. * The keys to the medication cabinets and medication refrigerator for Medication room [ROOM NUMBER] left in an unsecured drawer drawer in the nurse's station. This failure had the potential for unlicensed staff to have access to medications. Findings:…

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 the observation, interview, and medical record review, the facility failed to provide one of the 20 final sampled residents (Resident 58) the appropriate diet to meet individual needs. * The facility failed to ensure Resident 58 was provided the appropriate meal substitute. Resident 58 had a physician's order of puree diet and was provided a whole uncut cheese quesadilla at lunch. This failure posed the risk for the resident to develop complications like aspiration and choking. Findings: 1. On 3/14/22 at 1232 hours, during dining observation, Resident 58's puree meal was observed to be untouched. Resident 58 was observed dipping a rolled tortilla (looks like a burrito) in a cup of hot cocoa. When asked what Resident 58 was eating, RNA 1 stated Resident 58 did not like the puree food and had requested for cheese quesadilla as her lunch meal substitute. RNA 1 stated she had been requesting for the quesadilla since she was placed on puree diet. Review of the meal ticket showed Resident 58 was on…

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

Based on observation, interview, and facility P&P review, the facility failed to maintain the effective infection control practices. * LVNs 3 and 4 failed to perform hand hygiene before donning and after doffing gloves during resident care. * LVN 5 failed to perform hand hygiene when she administered the eye drops medication to Resident 71 These failures placed the residents and the staff at increased risk for infections. Findings: 1. Review of the facility's P&P titled Handwashing/Hand Hygiene revised January 2021, under the section When to Wash Hands, showed the employees must wash their hands for at least twenty seconds using soap and water under the following conditions: before and after performing any invasive procedure (for example, finger stick blood sampling) and after removing gloves or aprons. To use alcohol-based hand rub: after removing gloves. Under section When to use Alcohol-Based Hand Rub it showed in most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled, use an alcohol-based hand rub containing…

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 facility document review, the facility failed to establish the infection control program designed to provide a safe and sanitary environment. * The facility failed to ensure Resident 29 was accurately assessed for the presence of sings and symptoms of infection based other Mc Geer's criteria. Resident 29 who present with manifestations of a wound infection was erroneously classified as not a true infection even if the Mc Geer's criteria was met. This failure posed the risk for the development of complications when the resident's infection was not properly addressed and the documentation of inaccurate data within the antibiotic surveillance program. Findings: Review of the facility's P&P for Infection Control Surveillance Program revised on January 2018 showed the Infection Preventionist, .shall be responsible to implement the surveillance program. The infection Control Surveillance Process will include: - Collection of sings and symptom date, lab date and comparing to standard written definition (criteria) for infections, - Review of antibiotic orders - Mc…

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

Based on observation, interview, and facility P&P review, the facility failed to maintain a safe and homelike environment. * Rooms A, B, C, and D were observed with torn floor mats at the resident's bedside. This lack of maintenance placed the living conditions of residents in an unkempt environment. Findings: Review of the facility's P&P titled Interior Maintenace Resident Room and Equipmnet effective 3/1/16, showed the facility to maintain in good repair, all interior surfaces, fixtures, equipment, appliances, and furnishings to provide a safe, clean, comfortable environment for residents and employees. On 3/14/22 at 1115 hours, during an initial tour of the facility, a torn floor mat was observed by a resident's bed in Room D. The floor mat was torn at the left top corner and bottom right corner. On 3/14/22 at 1130 hours, a floor mat with torn corners was observed at a resident's bedside in Room C. On 3/14/22 at 1517 hours, a floor mat with torn corners was observed at a resident's bedside in Room B. On 3/14/22 at 1531 hours, a floor mat with torn corners and exposed foam was…

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