Park Vista At Morningside

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to provide the necessary wound care services to one of nine sampled residents (Resident 1). * The facility failed to provided Resident 1's wound treatment as per the physician's order. In addition, the facility failed to accurately monitor and document the wound care provided to Resident 1. This failure had the potential for the resident's wound to become worse and negatively affect the resident's well-being.Findings: Medical record review for Resident 1 was initiated on 8/27/25. Resident 1 was admitted to the facility on [DATE], and transferred to an acute care facility on 8/16/25. Review of Resident 1's SBAR Communication Form dated 7/31/25, showed Resident 1 had a skin tear to the right distal medial aspect of the right lower leg. Review of Resident 1`s Order Summary Report showed a physician's order dated 7/31/25, for full thickness skin tear to the right distal medial aspect of lower leg, to apply Steri-Strips (adhesive bandage strips used to…

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

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 necessary respiratory care services were provided for one of nine sampled residents (Resident 2). * The facility failed to ensure Resident 2 was provided with the continuous oxygen via nasal cannula and Resident 2's oxygen saturation was maintained greater than 92% as ordered by the physician. These failures had the potential for the resident to not receive the necessary respiratory services and negatively impact the resident's well-being.Findings: Review of the facility's P&P titled Physicians Orders and Telephone Orders dated 11/2017 showed the physicians orders shall be obtained prior to the administration of any medication or treatment from a personal lawfully authorized to prescribe for and treat human illness. All orders must be specific and complete and no standing orders shall be accepted. All orders shall be specific and complete with all the necessary details to carry out the prescribed order without…

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 control practices to help prevent the development and transmission of diseases and infections for three of nine sampled residents (Residents 4, 6, and 7). * Treatment Nurse 1 failed to perform hand hygiene and changed her gloves after removing the soiled wound dressing for Resident 4. In addition, Treatment Nurse 1 failed to dispose the unused gauze brought in resident's room and ensure the alcohol based sanitizer used was not expired. * CNA 4 failed to wear gloves and perform hand hygiene after touching contaminated items inside Resident 4's contact isolation room. In addition, CNA 4 then proceeded to deliver Resident 7's meal tray without performing hand hygiene. * CNA 4 failed to wear gloves and perform hand hygiene after touching contaminated items inside Resident 6's contact isolation room. In addition, CNA 4 then proceeded to feed Resident 6 without performing hand hygiene. 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.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen. * The facility failed to ensure proper labeling and dating of foods in the kitchen. * The facility failed to ensure proper labeling and dating of foods in the refrigerator used for residents' food brought in by visitors and expired foods were discarded. * The facility failed to ensure the foods were stored off the floor. * The facility failed to ensure the plate lowerator (adjustable heated plate dispenser), can opener, kitchen microwave, oven, and warmer were clean. * The facility failed to ensure the egg salad was not stored on the shelf containing raw meats. These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food prepared in the kitchen. Findings: Review of the facility's document titled Diet Count by Diet dated 12/2/24, showed 50 of 54 residents received food prepared in the kitchen. 1. Review of the facility P&P titled Food Storage revised 7/2024…

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 RD evaluations and interventions related to weight loss were conducted timely for one of one final sampled residents (Resident 18) reviewed for nutrition. This failure had the potential for further weight loss and not meeting the nutrition needs for the resident. Findings: Review of the facility's P&P titled Weight Management Guidelines revised 12/2023 showed the residents with significant weight variance should be identified and appropriate intervention implemented. Suggested parameters for evaluating significance of unplanned and undesired weight loss/gain are: a. 1 (one) week - 2-3% is significant; greater than 3% is severe. b. 1 (one) month - 5% is significant; greater than 5% is severe. c. 3 (three) months - 7.5% is significant; greater than 7.5% is severe. Further review of the P&P showed to follow best practice guidelines for interventions. Obtain residents preferences regarding interventions 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, and facility P&P review, the facility failed to ensure four of four final sampled residents (Residents 31, 32, 36, and 18) reviewed for respiratory care were provided with the appropriate respiratory care. * The facility failed to ensure Resident 36's oxygen was administered as ordered. In addition, the facility failed to change the humidifier and the oxygen nasal cannula (flexible tube to deliver oxygen into the nose) timely. * The facility failed to ensure Resident 32's oxygen nasal cannula was stored in a sanitary manner when not in use. * The facility failed to ensure Resident 31's oxygen nasal cannula was stored in a sanitary manner and changed timely. * The facility failed to ensure Resident 18's oxygen nasal cannula was stored in a sanitary manner. These failures had the potential to affect the respiratory health and well-being of the residents in the facility. Findings: 1. Medical record review for Resident 36 was initiated on 12/2/24. Resident 36…

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 necessary to ensure the accurate reconciliation and disposal of medications. * The facility failed to ensure one of 17 final sampled residents (Resident 25) medications were not left at the resident's bedside. In addition, the facility failed to ensure the pharmaceutical services were provided to meet the needs of one nonsampled resident (Resident 2). * The facility failed to ensure the count performed for all controlled medications in the Omnicell (automatic drug delivery system) was accurate as per the facility's P&P. This failure posed the risk of medication diversion. * The facility failed to ensure Resident 2's routine medication was available. This failure had the potential to result in poor health outcomes to the resident. Findings: 1. Review of the facility's P&P titled Automated Drug Delivery System (ADDS) dated 2022 showed the pharmacy 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, and facility P&P review, the facility failed to ensure one of 17 final sampled residents (Resident 25) was free of significant medication errors. * The facility failed to ensure Resident 25 was administered the piperacillin sodium tazobactam medication (antibiotic) as ordered by the physician. This failure had the potential to negatively impact the residents' well-being. Findings: Review of the facility's P&P titled Adminsitering Medications dated 2001 showed the medications are administered in a safe and timely manner, and as prescribed. Medications are administered within one hour of their prescribed time, unless, otherwise specified. Medical record review for Resident 25 was initiated on 12/2/24. Resident 25 was admitted to the facility on [DATE]. Review of Resident 25's H&P examination dated 11/5/24, showed Resident 25 had the capacity to understand and make decisions. Review of Resident 25's Order Summary Report dated active as of 12/3/24, showed a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed ensure proper storage and label of medications in one of two medication storage rooms (Medication room [ROOM NUMBER]) and two of three medication carts (Medication Carts A and C) when: * An opened tuberculin (medication used to help diagnose tuberculosis) vial was stored in the refrigerator inside Medication room [ROOM NUMBER] without an open date. An opened box of instant food thickener was stored in Medication room [ROOM NUMBER] and contained multiple expired packets of food thickener. In addition, a bag of the home medications without a resident's name was stored in Medication room [ROOM NUMBER]. * Temperature log for Medication room [ROOM NUMBER] had multiple missing entries on multiple dates. * Three packets of Non-Adhesive Pad was stored in Medication Cart A and had expired on 6/2024. * Residents 14 and 40's topical medications in Medication Cart C was not labeled with an open date…

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

Based on observation, interview, and facility document review, the facility failed to ensure the menu was followed for three of 50 residents who received food from the kitchen. * Residents 22, 40, and 43 were not provided with the garlic breadstick as per the lunch menu on 12/2/24. This failure had the potential for the residents not receiving adequate nutrition and not receiving the menu as planned. Findings: Review of the facility's document titled Diet Count by Diet dated 12/2/24, showed 50 of 54 residents received food prepared in the kitchen. Review of the facility's document titled Daily Spreadsheet - Monday dated 12/2/24, showed the following menu for lunch: - regular/NAS (no added salt) diet included a serving of a garlic breadstick and butter; - easy to chew diet included a soft and buttered garlic breadstick; and - soft and bite sized diet and pureed diet included a serving of pureed garlic breadstick and butter. a. On 12/2/24 at 1200 hours, LVN 1 was observed checking the meals in a meal cart. LVN 1 stated he checked if the diet matched the texture on the meal tray. 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 observation, interview, and medical record review, the facility failed to ensure one of 17 final sampled residents (Resident 30) had accurate and complete medical record. * The facility also failed to ensure the monitoring of behavior for the psychotropic medication on Resident 2's MAR was completed. This failure had the potential for the resident's care needs not being met as the medical record was incomplete and inaccurate. Findings: Medical record review of Resident 30 was initiated on 12/2/24. Resident 30 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 30's Order Summary Report dated 12/3/24, showed the following physician's orders: - dated 3/26/24, to monitor behavior for poor meal intake (less than 50 percent) for Remeron (antidpressant medication). - dated 8/2/23, to monitor behavior for verbalization of feeling anxious every shift for buspirone (antidepressant medication). - dated 6/25/24, to monitor behavior of anxiety manifested by biting nails 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, and facility P&P review, the facility failed to implement the safe and sanitary environment to help prevent the development and transmission of infections to two of 17 final sample residents (Residents 26 and 31) and one nonsampled resident (Resident 2) when: * The facility failed to ensure LVN 3 donned the appropriate PPE when administering medications through the GT tube for Resident 26 who was on the EBP precautions. In addition, Resident 26's isolation cart was touching the trash inside the resident's room. *The facility failed to ensure LVN 2 donned the appropriate PPE when administering medications to one nonsampled resident (Resident 2) on the EBP precautions. * A stack of incontinence briefs was observed on top of the isolation cart inside the Room A. In addition, the isolation cart was observed touching the trash bin. * Resident 31's incontinence briefs were stored on the floor at the right side of the bed. In addition, the isolation cart inside…

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 four of five final sampled residents (Residents 12, 21, 25, and 507) and one nonsampled resident (Resident 24) reviewed for immunizations were educated and offered the influenza and pneumococcal vaccinations as evidenced by: * The facility failed to offer the educational materials for the risks and benefits for the pneumococcal and influenza vaccines to Residents 12, 21, 24, 25, and 507 as per the facility's P&P. In addition, the facility failed to indicate which pneomococcal vaccine was offered for Residents 12, 21, 24, 25, and 507. These failures put the residents at risk for infection and transmission of pneumococcal and influenza infections. Findings: Review of the facility's P&P titled Pnemococcal Vaccine Guidelines dated 1/3/24, showed all the residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Before receiving a pneumococcal vaccine, the resident or legal…

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 essential kitchen equipment was maintained in safe operation condition when the ice machine manufacturer cleaning and sanitizing instructions were not followed for two of three ice machines (Ice Machines 1 and 2) in the facility. This failure had the potential to result in the equipment to not function in the way it was intended which could affect the health status of the residents. Findings: Review of the facility's P&P titled Ice Machine revised 10/2018 under the section titled Frequency: Two Times per Year -Internal Components, showed per the Food Code, the internal components must be cleaned and sanitized per manufacturer guidelines, county or state regulations and not less than two times per year. Review of the ice machine instruction manual for the Hoshizaki ice machine undated, showed the appliance must be maintained in accordance with the instruction manual and labels provided. Failure to install, operate, and maintain the equipment in accordance with this…

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 residents' entrapment assessments were accurate and complete; and the measurements were recorded during the bed inspection when identifying areas of possible entrapment with the use of bed side rails for three of three final sampled residents (Residents 507, 30, and 38) reviewed for the entrapment risk. 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 entrapments may result in deaths and serious injuries. These entrapment events have occurred in openings within the bed rails, between the bed rails and mattresses,…

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 implement the P&P for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act. Resident's 1 allegation of physical abuse was not reported to the local enforcement agency as per the facility's P&P. This failure had the potential for the abuse allegation going unreported and uninvestigated. Findings: Review of the facility's P&P titled Elder Abuse;Identification Investigation & Reporting dated January 2024 showed the Administrator in conjunction with the Director of Nursing notifies the following of a suspected abuse incident within two (2) hours if the alleged violation involves abuse or serious bodily injury; and 24 hours if the alleged violation does not involve abuse and does not result in serious bodily injury: a. state licensing/certification agency; b. local ombudsman; c. resident's legal representative of record (via telephone); d. resident's attending physician (via…

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 sanitary requirements were met in the kitchen. * The facility failed to ensure proper labeling and dating of foods in the kitchen * The facility failed to ensure proper labeling and dating of foods in the refrigerator used for residents' food brought in by visitors. In addition, the facility failed to ensure the foods stored in the refrigerator belonged to the residents and not the staff, and expired foods were discarded. * The facility failed to ensure the foods were stored off the floor. * The facility failed to ensure a proper sanitary condition of the ice machine. * The facility failed to ensure the plate lowerator (adjustable heated plate dispenser) and resident refrigerator were clean. * The facility failed to ensure the cutting boards were in sanitary condition. * The facility failed to ensure the cooking utensils were in good repair. These failures had the potential to cause foodborne illnesses in a medically…

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 16 final sampled residents (Residents 38 and 39) and one nonsampled resident (Resident 23) were provided with the respiratory care to prevent possible respiratory tract complications. * The facility failed to ensure Resident 38 received the necessary care for breathing treatments via CPAP machine. * The facility failed to provide the oxygen therapy as ordered by the physician to Resident 39. * The facility failed to ensure Resident 23's nebulizer mask was dated and stored in a sanitary manner. These posed the risk of the residents not receiving the appropriate breathing treatments and the spread of infection to the residents. Findings: 1. Review of the facility's P&P titled CPAP/BiPAP revised March 2015 showed to review the physician's order to determine the oxygen concentration and flow for the machine. Under the general guidelines for cleaning, it showed to wipe the machine with warm, soapy…

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 16 final sampled residents (Resident 31) remained free from accident hazards related to the use of elevated side rails. * The facility failed to ensure the physician's order was obtained and the care plan problem was developed prior to the use of side rails for Resident 31. This had the potential to put the resident at risk for entrapment and serious injury. Findings: The FDA issued a Safety Alert entitled Entrapment Hazards with Hospital Bed Side Rails. Residents most at risk for entrapment are those who are frail or elderly or those who have conditions such as agitation, delirium, confusion, pain, uncontrolled body movement, hypoxia, fecal impaction, acute urinary retention, etc., that may cause them to move about the bed or try to exit from the bed. Entrapment may occur when a resident is caught between the mattress and bed rail or in the bed rail itself. Inappropriate positioning or other care related activities…

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 one of 16 final sampled residents (Resident 41). * Resident 41's lorazepam (antianxiety medication) Controlled or Antibiotic Drug Record did not match Resident 41's MAR. LVN 1 did not document the lorazepam administration in the resident's MAR. This failure posed the risk for diversion of controlled medications. Findings: Review of the facility's P&P titled Controlled Substances revised April 2019 showed under the section for Administration, the nurse administering the medication is responsible for recording the time of administration. On 4/19/23 at 1501 hours, review of Resident 41's Controlled or Antibiotic Drug Record and MAR was conducted with LVN 2. Review of Resident 41's lorazepam Controlled or Antibiotic Drug Record showed Resident 41 was administered lorazepam 0.5 mg tablet on 1/13/23 at 1050 hours. Review of Resident 41's January 2023 MAR failed to show…

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. * The facility failed to discard outdated sterile dressing kit tray found in the intravenous cart (Medication Cart B). This posed the risk for this cleaning wound supplies lose their sterility making them unsafe to use. * The facility failed to ensure the oral medications were stored separately from externally used medications and failed to ensure the Sani wipes were stored separately from the medications found in Medication Cart A. This posed the risk for cross-contamination of the medications. * The facility failed to label three bottles of medications for one nonsampled resident (Resident 20) and failed to dispose of the discontinued medication for one nonsampled resident who had been discharged (Resident 459) from the facility. These failures posed the risk of medication errors. * The facility failed to disposed of the expired antibiotic ointment and glucose gel tubes found in…

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

Based on interview and record review, the facility failed to implement their Quality Assessment and Assurance (QA&A) plan of action. There was no documentation to show the facility was monitoring the effects of the corrective action plan to identify if they had achieved and sustained the improvement for the repeated deficient practice cited at F695 in accordance with their POC for an abbreviated survey completed on 2/18/20. This had the potential to affect the quality of care for all the residents in the facility. Findings: On 4/21/23 at 1400 hours, an interview and concurrent facility document review was conducted with the Administrator. Review of the POC submitted by the facility to the CDPH, L&C Program for the recertification survey completed on 2/18/20, showed a deficient practice cited at F695 related to the CPAP cleaning per the manufacturer's specifications. The POC included the a corrective action for the Health Information Director/Designee to conduct an audit on all CPAP orders to ensure proper placement on the MAR and weekly cleaning were conducted. Any findings will be…

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 essential equipment was maintained in the safe operating condition. * The facility failed to ensure two glucometers (a device which measures the amount of sugar in the blood) currently used by two nonsampled residents (Residents 158 and 458) stored in the medication carts were properly calibrated. In addiition, the facility failed to ensure the glucometer monitoring log were completed. These posed the risk for inaccurate blood glucose test results and inappropriate treatments. * The facility failed to ensure there was no ice build up in the chest freezer in the kitchen. In addition, the facility failed to ensure the microwave in the kitchen was free from corrosion, chipped paint, and rust. These failures had the potential for the equipment not functioning in the way they were intended and in turn could cause contamination of the food, leading to foodborne illnesses for the residents who received food from the…

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