St. Catherine Healthcare

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 were complete and accurately documented for four of 19 final sampled residents (Residents 5, 32, 42, and 107). * The facility failed to ensure Resident 5's BP access site was accurately documented in the medical record. * Resident 32's Advanced Directive was missing a page and failed to show who he selected as his healthcare agent. * The facility failed to ensure the Narcotic and Hypnotic Record form was properly documented for Resident 42. * Resident 107's POLST showed the resident did not have an Advanced Healthcare Directive, however the resident did have one at her home. These failures have the potential for the residents' care needs not being met as their medical information was inaccurate and incomplete.Findings: 1. Review of the facility's P&P titled Care of Residents on Renal Dialysis, Hemodialysis Access Site, Care Plan Diet/Fluid Restriction revised 6/2009 showed it is the…

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

Based on interview and facility document review, the facility failed to implement the facility's QAPI plan and the past Recertification Survey POC for F554 and F761. * The facility failed to show audits and/or monitoring tools were completed per the facility's POC for F554 and F761. This failure had the potential for ongoing non-compliance and complete data being reviewed by the QAPI committee. Findings: During the survey process, the survey team identified repeat deficient practices from the facility's prior recertification survey conducted from 9/23/24 to 9/26/24, for F554 and F671. Review of the facility's 2024 Recertification Survey POC accepted by the department on 11/27/24, included the following:- for F554, the POC showed the Medical Records will perform chart reviews upon admission and check for any new orders. The DON or designee will report findings to the QA&A Committee monthly for six months. - for F761, the RN Supervisor/Designee will randomly check medication carts weekly for eight weeks, and then monthly to ensure proper medication storage. The DON or designee will…

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 infection control practices were followed. * The facility records showed Resident 47 had a UTI, when the resident's symptoms did not meet criteria for a true infection. * The facility failed to ensure the Medication Cart A's fourth small drawer was free of medication spillage. In addition, the iron liquid bottle was observed with sticky spillage. * LVN 4 failed to perform hand hygiene and change gloves after touching Resident 87's surroundings, before checking the GT and administering the medications. These failures posed the risk for transmission of disease-causing microorganisms and infections to the residents, staff, and visitors.Findings: 1. Review of the facility's P&P titled Infection Prevention and Control Program revised October 2022 showed the facility will use McGeer's Criteria as a surveillance tool used to recognize the occurrent of infections, record 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 develop the comprehensive care plan to reflect the individual care needs for one of three sampled residents (Resident 1). * The facility failed to develop a care plan to address Resident 1's alleged abuse incident on 1/9/26. This failure had the potential risk of not providing the appropriate, consistent, and individualized care to Resident 1.Findings: Review of the facility's P&P titled Care Planning revised 2/2021 showed it is the policy of this facility that the IDT shall develop a comprehensive care plan for each resident. Medical record review for Resident 1 was initiated on 1/22/26. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's H&P examination dated 10/17/25, showed the resident did not have the capacity to understand and make decisions. Review of Resident 1's Progress Note dated 1/9/26, showed at around noon, the police came in stating the resident's wife called them and claimed 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 one of seven final sampled residents (Resident 1) was informed of the indication for the use of medications affecting brain activities associated with mental processes and behavior. * The facility failed to ensure Resident 1's informed consent was obtained when the indication for the use of Ativan (lorazepam, a benzodiazepine class of medication used to treat anxiety) was changed in frequency in administration from every six hours to every eight hours. * The facility failed to ensure Resident 1's informed consent was obtained for the use of Depakote (an anticonvulsant medication for labile mood). These failures had the potential for Resident 1 not to be informed of the medications and potential side effects of the use of Ativan and Depakote medications.Findings: Review of the facility's P&P titled Psychotropic (medication affecting brain activities associated with mental processes and behavior) Drug Use revised…

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 (Residents 1) was free from unnecessary psychotropic (medication affecting brain activities associated with mental processes and behavior) medications. * The facility failed to ensure Resident 1 was adequately monitored for the Depakote medication. This failure posed risk for Resident 1 to cause potential harm from adverse consequences and a significant decline in functioning. Findings: Review of the facility's P&P titled Psychotropic Drug Use revised 1/2023 showed it is the policy of this facility to ensure that residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record. These residents will be referred to the facility's Psychotropic Drug Review Committee and/or the Psychiatrist to ensure: a. Psychotropic medication was prescribed to treat a specific…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to ensure one of five sampled residents (Resident 5) reviewed for falls received the necessary care and services for the resident at risk for fall. * The facility failed to monitor and initiate a care plan when Resident 5 reported a fall on 9/1/25. This failure had the potential for the delay in providing the necessary care and services and posed a risk for Resident 5 to sustain serious injury.Findings: Review of the facility's P&P titled Psychotropic Drug Use not dated showed it is the policy of this facility to investigate the circumstances surrounding each resident fall and implement actions to reduce the incidence of additional falls and minimize potential for injury. If the resident sustains a fall, a Risk Management Assessment is completed to determine the cause of the fall, and an IDT meeting is also completed to identify internal and external factors that might have contributed to the fall. The care plan or an update to an existing care…

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, the facility failed to ensure the protocols were followed for oxygen administration for four of four sampled residents (Residents 1, 2, 3, and 4). * Residents 2, 3, and 4 were administered with more than the liters per minute ordered by the physician. * Resident 1's MAR failed to show documentation of the administration of the oxygen PRN. These failures had the potential for adverse respiratory outcomes and resulted in inaccurate administration records for the residents. Findings: Review of the facility's P&P titled Oxygen Administration reviewed 2/2023 showed the oxygen shall be administered as ordered by the physician. Review of the facility's P&P titled Guidelines For Medication Administration (undated) showed the medication administration shall be recorded on the appropriate documentation record. 1. Medical record review for Resident 1 was initiated on 6/6/25. Resident 2 was readmitted to the facility on [DATE]. Review of Resident 2'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 provide the necessary care and services for one of ninesampled residents (Resident 2). * The facility failed to timely provide and administer Resident 2's medications as per the physician's orders on 11/26 and 11/27/24. * The facility failed to follow up and notify the physician regarding Resident 2 of not receiving his medications due to pending delivery status of the ordered medications. These failures had the potential to negatively affect the resident's health condition and well-being. Findings: Review of the facility's P&P titled Prescriber Medication Orders dated 1/2019 showed the prescriber shall be contacted for direction when delivery of a medication will be delayed, or medication is not available. new medications except for emergency or stat medications are ordered as follows: the first dose of medication is scheduled to be given after the next regularly scheduled pharmacy delivery to the care center. If needed…

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 P&P review, the facility failed to ensure three of nine sampled residents (Residents 3, 4, and 5) remained free from accident hazards. * Resident 3's fall risk care plan showed the interventions including for the resident's bed to be in the lowest position and for the bilateral floor mats. However, the bed was not in the lowest position and the floor mat was folded up against the wall. * Resident 4's fall risk care plan addressing the resident's actual fall showed interventions including to maintain a clear pathway, free of obstacles, needs a safe environment: floor free from spills and/or clutter. However, the bedside table was placed on top of the floor mat next to the resident's bed. * Resident 5's fall risk care plan addressing the resident's actual fall showed interventions including for the resident's bed to be in the lowest position, for bilateral floor mats, and to maintain a clear pathway, free of obstacles, needs a safe environment: floor…

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

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food safety and sanitation requirements were met in the kitchen when: * The facility failed to ensure the thawing process for meats was followed as per the facility's P&P. * The facility failed to ensure the kitchen utensils and equipment were stored or kept in sanitary conditions. * The facility failed to ensure the food preparation equipment were in good condition. * The facility failed to remove a bag of ham with freezer burns. * The facility failed to ensure a food preparation sink had an air gap for back flow prevention. These failures had the potential to pose the risk for exposure to food-borne illnesses in a medical vulnerable population of 86 that received food prepared in the kitchen. Findings: Review of the facility's document titled Diet Order Tally Report- All Special Diets dated 9/3/24, showed 86 of 90 residents received food prepared in the kitchen. 1. Review of the facility's P&P titled Thawing of Meats dated 2023 showed thawing the meat could be done…

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, facility document review, and facility P&P review, the facility failed to ensure the infection control practices designed to provide a safe and sanitary environment and help prevent the development and transmission of infections were implemented as evidenced by: * The facility failed to implement their infection control surveillance program for January through August 2024. The facility conducted surveillance of resident infections based on whether the residents were prescribed antimicrobials. Residents who were not prescribed antimicrobials were not included in the facility's infection control surveillance program. * The facility failed to accurately track and monitor for the infections for February, May, and June 2024. * The facility failed to ensure the infection control practices were implemented on a resident with transmission-based precautions. * The facility failed to ensure the facility staff performed hand hygiene during the GT dressing change for one of 18 final sampled…

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 determine if it was safe for one of 18 final sampled residents (Resident 77) to self-administer medications. * Resident 77 was observed to have medications inside a medicine cup at the bedside. Resident 77 did not have an assessment, a physician's order, or a care plan problem addressing the self-administration of medications. This faiure had the potential for Resident 77 to administer medications inaccurately. Findings: Review of the facility's P&P titled Self Administration of Medications dated 2/2021 showed it is the policy of the facility to respect the wishes of alert, competent residents to self-administer prescribed as allowable under state regulations. If a resident desires to participate in self-administration, the interdisciplinary team will assess and periodically re-evaluate the resident based on change in the resident's status. If the resident is a candidate for self-administration of medications,…

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 recommendations from the Preadmission Screening and Resident Review (PASARR, a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) level II determination was followed up, as per the facility P&P and incorporated into the resident's plan of care for one of two final sampled resident (Resident 8) reviewed for PASARR. This failure had the potential for Resident 8 not receiving the adequate care that was recommended by PASARR level II determination and evaluation report assessed by an appropriate state-designated authority. Findings: Review of the facility's P&P titled PASRR revised 7/22 showed after admission IDT members will review the Level I PASRR assessment for accuracy and the need for PASRR Level II referral. Based upon the assessment, the facility would ensure proper referral to appropriate state agencies for the provision of specialized…

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 appropriate care and services were provided related to the use of a GT for one of 18 final sampled residents (Resident 65). * The facility failed to ensure Resident 65's GT was checked for placement prior to medication administration, flushed with at least 5 ml of water between each medication as per the facility's P&P, and flushed with 20 to 30 ml of water following medication administration as per the physician's order. This failure had the potential for GT blockage affecting the resident's health and well-being. Findings: Review of the facility's P&P titled Medication Administration - Enteral Tubes dated 1/2019 showed the facility assures the safe and effective administration of enteral formulas and medications. Enteral tubes are flushed before administering medications and after all medications have been administered with at least 30 ml of water. The P&P also showed to verify the tube placement…

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 care and services related to a PICC line for one of 18 final sampled residents (Resident 537). * The facility failed to obtain the measurement of the right upper arm circumference upon admission and dressing changes. In addition, the facility failed to develop a care plan problem to address the use of a PICC line catheter. These failures posed the risk for the resident to development complication such as catheter migration and dislodgement. Findings: According to the literature titled Nursing Advanced Skills dated 2023 in the National Library of Medicine's database, showed if a PICC line is in place, arm circumference is also measured each shift and results compared to previous readings. If arm circumference consistently increases, a deep vein thrombosis may be suspected. Accurate documentation of site assessment and related monitoring are essential. Medical record review for Resident 537 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 observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to attain and maintain the highest well-being for one of 18 final sampled residents (Resident 63). * The facility failed to monitor Resident 63's fluid restriction as per the physician's order. In addition, the facility failed to ensure Resident 63's dialysis access site was assessed prior and after dialysis treatments. These failures had the potential to negatively impact the resident's well-being. Findings: Review of the facility's P&P titled Dialysis (Renal), Pre and Post Care revised 1/2020 showed it is the policy of the facility to assist resident in maintaining homeostasis pre- and post-renal dialysis, assess and maintain patency of renal dialysis access, and assess resident daily for function related to renal dialysis. Dialysis access should be assessed upon return to the facility for patency, and any unusual redness or swelling. Documentation: assess care given,…

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 alternative measures prior to the use of bed rails for two of 18 final sampled residents (Residents 63 and 537). This failure created the potential to put the residents at risk for entrapment and serious injury. Findings: Review of the facility's P&P titled Bedrail Assessment revised 8/2017 showed it is the policy of the facility to attempt to use appropriate alternatives prior to installing a side or bed rail. After the facility has attempted alternatives to bed rails and determined that these alternatives failed to meet the resident's assessment needs, the facility IDT will assess the resident for risks of entrapment and possible benefits of using the bed rail. 1. On 9/23/24 at 0800 hours, Resident 63 was observed sitting on the bed with the bilateral bed rails elevated. Medical record review for Resident 63 was initiated on 9/23/24. Resident 63 was admitted to the facility on [DATE], 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 18 final sampled residents (Resident 7) was provided the medications as ordered by the physician. * The facility failed to ensure Resident 7 had a physician's order for nasal moisturizing spray. This failure had the potential of not meeting the resident's needs. Findings: Review of the facility's P&P titled Administration of Drugs revised 2/2022 showed it is the policy of the facility that medications shall be administered as prescribed by the attending physician. Medications must be administered in accordance with the written orders of the attending physician. On 9/25/24 at 0930 hours, Resident 7 was observed to have three bottles of Nasal Moisturizing Spray inside her bedside top drawer. Medical record review for Resident 7 was initiated on 9/25/24. Resident 7 was admitted to the facility on [DATE]. Review of Resident 7's Self-Administration of Medications Evaluation dated 8/23/24, 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 and interview, the facility failed to ensure for the safe storage of the medications and supplies. * The IV Cart was observed to contain the expired supplies along with other supplies without a manufacturing or expiration date. * An opened bottle of Gerilanta (a laxative medication) was observed in Medication Cart 2 with no open date. These failures had the potential to result in unsafe administration of the medications. Findings: a. On [DATE] at 0827 hours, an inspection of the IV Cart was initiated with RN 4. The following items were observed in the IV Cart: - 78 Red Plus Luer Lock Caps with no manufacturing or expiration dates, - five [NAME] Vial Mate Adapter with no manufacturing or expiration dates, - seven BD Vacutainer Luer Lock Access Device with no manufacturing or expiration dates, - two BD Blue Insyte Autoguard Winged Catheters with the expiration dates of [DATE] and [DATE]. RN 4 verified the above findings. b. On [DATE] at 1135 hours, an inspection of Medication Cart 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 observation, interview, facility document review, and facility P&P review, the facility failed to ensure the menus were followed when fortified (additional nutrients added through foods such as butter and cream) diets were not followed for one nonsampled resident (Resident 19). This failure had the potential for Resident 19 to not receive the diet as planned which may lead to compromised nutritional status. Findings: Review of the facility's P&P titled Fortification of Food: Increasing Calories and/or Protein in the Diet dated 2023 showed the enrichment of foods would be done on an individual basis for residents who cannot consume adequate amounts of calories and/or protein to sustain their weight or nutrition status. Identification of the residents in need of fortification would be done by the facility RD or the FNS Director. The physician would then order a fortified diet. Calories and/or protein would be added to selected foods. The facility RD or FNS Director would select the fortification method…

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 dietary texture guidelines were followed as per the facility's P&P, for one nonsample resident (Resident 19) who was on a pureed diet. This failure had the potential to lead to choking or aspiration (a condition in which food, liquids, saliva, or vomit is breathed into the airway) for Resident 19. Findings: Review of the facility's P&P titled Regular Pureed Diet dated 2020 showed the pureed diet is a regular diet that has been designed for residents who have difficulty chewing and/or swallowing. The texture of the food should be of a smooth and moist consistency and able to hold its shape. Medical record review for Resident 19 was initiated on 9/24/24. Resident 19 was admitted to the facility on [DATE], with a diagnosis of dysphagia (difficulty swallowing), oropharyngeal phase (from the oropharynx to the esophagus). Review of Resident 19's Order Summary Report dated 9/25/24, 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.

Based on interview, facility document review, and facility P&P review, the facility failed to ensure the education was provided to the staff and family/visitor on safe food handling of outside food as per the facility's P&P. This failure had the potential to cause foodborne illnesses to the medically vulnerable resident population who consumed food brought from outside sources. Findings: Review of CMS S&C-09-39 dated 5/29/09, showed the residents have the right to choose to accept food from visitors, family, friends, or other guests according to their rights to make choices. The CMS guideline further shows the facility has the responsibility under the food safety regulation to help the visitors to understand safe food handling practices such as not holding or transporting foods containing perishable ingredients at temperatures above 41 degrees Fahrenheit. Review of the facility's P&P titled Foods Brought by Family and Visitor revised 7/21/21, showed foods brought to a resident by family/visitors must be accepted by the resident, inspected before facility storage, and stored 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 interview, medical record review, facility document review, and facility P&P review, the facility failed to implement their antibiotic stewardship program when the facility failed to conduct an assessment for the McGeer's criteria to determine the true infection. This failure had the potential for inaccurately identifying for true infections and potentially inhibited the residents' physicians from discontinuing the unnecessary antimicrobials. Findings: Review of the facility's P&P titled Infection Prevention and Control Program: Antibiotic Stewardship dated 9/2017 showed it is the policy of the facility to implement an Antibiotic Stewardship Program that is incorporated in the overall Infection Prevention and Control Program which will promote appropriate use of antibiotics while optimizing the treatment of infections at the same time reducing the possible adverse events associated with antibiotic use. This policy has the potential to limit antibiotic resistance in the post- acute care setting, while…

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 complete the post fall neuro-checks at the specific time frames as per the facility's 72 hours Neuro-check Monitoring process for one of three sampled residents (Resident 1). This failure had the potential for Resident 1 to experience medical complications which could go unnoticed post fall. Findings: Review of the facility's 72 hours Neuro-check Monitoring showed the neuro-checks must be monitored every 30 min for two times, every hour for three times, every two hours for two times, every four hours for four times, and every eight hours for six times. Medical record review for Resident 1 was conducted on 6/4/24. Resident 1 was admitted to the facility on [DATE], with diagnoses including Parkinson's disease, OPD, lack of coordination, difficulty in walking, cognitive communication deficits, muscle weakness, and osteoarthritis. Review of Resident 1's progress note dated 5/31/24 at 0300 hours, showed Resident 1 fell…

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 safety and sanitation requirements were met in the kitchen. * The facility failed to ensure the measuring buckets used for food portioning were air dried prior to storing. * The facility failed to ensure the kitchen utensils were clean, free of food particles, and not worn out. 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 form CMS-672 Resident Census and Conditions of Residents completed by the facility dated 11/30/21, showed 69 of 77 residents residing in the facility received food prepared in the kitchen. 1. According to the USDA Food Code 2017, Section 4-901.11, Equipment and Utensils, Air-Drying Required, items must be allowed to drain and air-dry before being stacked or stored. Stacking wet items prevents them from drying and may allow an environment where microorganism can begin to grow. On 12/2/21 at 1301 hours, during a tray line observation,…

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 maintain the infection control practices to help prevent the development and transmission of diseases and infections during a COVID-19 facility outbreak. * The facility failed to follow timely reporting of a COVID-19 outbreak to local and state health agencies. * The facility failed to follow the infection control practices in the clean linen area. These failures had the potential to delay response time and containment of a COVID-19 outbreak. Findings: 1. Review of the County of Orange Health Care Agency - Public Health Services' document for Reportable Disease Conditions revised March 2020, showed to report COVID-19 immediately by telephone. The document showed the contact numbers for reporting, including a number for reporting on holidays, weekends, and after hours. Review of the facility's P&P titled Surveillance of Infections and Reporting revised September 2017 showed any resident or staff with suspected or diagnosed as having a reportable communicable/infectious disease shall be promptly…

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 accurately and timely identify and report CAI and HAI cases. This failure had the potential of not accurately identifying infections and timely notification to the health care provider resulted in inaccurate data being reviewed by the Infection Control Committee. Findings: According to the CDC, repeated and/or improper use of antibiotics was the primary cause of the proliferation of drug-resistant bacteria. Each time a person uses antibiotics, the sensitive bacteria are killed; however, resistant bacteria may result. These resistant bacteria may then grow and multiply. When the antibiotics fail to work, the consequences include longer lasting illnesses, extended hospital stays, and the need for more expensive and toxic medications. Some resistant infections can even cause death. Review of the facility's P&P titled Infection Control and Control Program revised September 2017 showed the following: * Ongoing monitoring for…

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 properly obtain the informed consent (permission granted in the knowledge of the possible consequences) from the responsible party/POA (persons designated to make decisions on behalf of the residents) for one of 18 final sampled residents (Resident 22). * A verbal consent for medical treatment and influenza (a contagious respiratory illness caused by flu viruses spread mainly by coughing, sneezing, and close contact) vaccine administration was obtained from Resident 22 who was assessed by the physician as not able to make medical decisions. The facility failed to ensure the consent for medical treatment and influenza vaccination was obtained from Resident 22's responsible party. This failure placed Resident 22 at risk for making health care decisions when she was not able to understand the benefits and reasonable risks of medications or treatment, and reasonable available alternatives based on the resident's 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 observation, interview, and medical record review, the facility failed to follow the physician's order for one of 18 final sampled residents (Resident 18). Resident 18 was administered guiafenesin instead of the dextrometorphan guiafenesin ordered by the physician. This failure had the potential for adverse outcomes to the resident. Findings: On 12/2/21 at 0752 hours, a medication administration observation was conducted with LVN 1. LVN 1 was observed administering guaifenesin (a cough medication used to thin secretions) 200 mg to Resident 18. Medical record review for Resident 18 was initiated on 12/2/21. Resident 18 was admitted to the facility on [DATE]. Review of Resident 18's physician's orders showed an order dated 11/28/21, to administer Tussin DM Syrup 10-100 mg/5ml dextromethorphan-guaifenesin (a cough suppressant and to thin secretions) 10 ml every 6 hours as needed for cough. On 12/2/21 at 1020 hours, a concurrent observation, interview, and medical record review was conducted with LVN 1. LVN…

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 the GT feeding of one of 18 final sampled residents (Residents 21). * The facility failed to ensure Resident 21 received the accurate amount of enteral feeding as ordered by the physician. This failure had the potential for not meeting the resident's nutritional needs Findings: Review of the facility's P&P titled Enteral Formulas, Administration of Closed System revised 2/2021 showed it is the policy of the facility that all residents requiring tube feedings will be set up on continuous feeding pumps, after appropriate diagnoses have been obtained for justification of pump, administering adequate tube feeding formula according to established criteria outcomes, utilizing closed system products when applicable. The policy provides a means to safely administer a complete nutritional feeding to the resident using a premixed formula in a closed container system protecting…

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 respiratory care and services to one nonsampled resident (Resident 36). * Resident 36 was administered oxygen without a physician's order. In addition, Resident 36's oxygen tubing touching the floor. These failures had the potential to put Resident 36 at risk for negative health outcomes and adverse effects of the improper care and administration of oxygen. Findings: According to the facility's P&P title Oxygen Administration revised date 1/2016 showed it is the policy of this facility that oxygen therapy is administered as ordered by the physician. On 11/30/21 at 1117 hours, and 12/1/21 at 0755 hours, Resident 36 was observed being awake in bed and receiving oxygen via nasal cannula (a small, flexible tube that contains two open prongs for oxygen delivery intended to sit just inside the nostril) at two liters per minute. Resident 36's oxygen tubing was observed touching the floor.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to ensure the appropriate pain management for one of 18 final sampled residents (Resident 280). * The facility failed to ensure Resident 280's pain was addressed when she reported a pain level of 7 (severe pain) on a pain scale of 0-10 (with 0=no pain and 10=worst pain). Resident 280 had reported severe pain with a pain level of 7 multiple times but was only provided a pain medication prescribed by the physician for moderate pain (pain level of 4-6). This failure had the potential to affect the resident's well-being and unnecessary pain. Findings: Medical record review for Resident 280 was initiated on 11/30/21. Resident 280 was admitted to the facility on [DATE]. Review of Resident 280's H&P examination dated 11/23/21, showed Resident 280 had sustained an ankle fracture with pending surgical intervention. Review of Resident 280's Order Summary Report dated 12/7/21, showed the following pain management orders: - Monitor pain level every shift…

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 assessment for entrapment, alternative for the use of side rails and the care plan was completed for one of 18 final sampled residents (Resident 59). * Resident 59 was observed with bilateral side rails. The facility failed to ensure the entrapment assessment, physician's order, and care plan problem were initiated prior to its use. Failure to establish a comprehensive approach for the use of bed rails posed a potential risk for residents including entrapment and/or injury due to lack of proper installation and preventive maintenance, and not meeting resident needs by informing them of risk and benefits. Findings: According to FDA.gov, Bed Rail Safety dated 8/30/18, deaths and serious injuries related to side rail entrapment have occurred with the use of side rails. Review of the facility's P&P titled Guidance: Bed Rails dated 1/2021 showed the facility would assess the resident for the use of bed side rails, grab bars as needed and with a change of condition that may warrant the use of bed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to ensure one of 18 final sampled residents (Resident 59's) medical record was complete. * Resident 59's medical record did not include the physician's progress notes. This failure had the potential for the physician's plan of care for the resident to not be effectively communicated to the interdisciplinary team. Findings: Medical record review for Resident 59 was initiated on 11/30/21. Resident 59 was admitted to the facility on [DATE]. Review of Resident 59's medical record failed to include Resident 59's physician's progress notes. On 12/7/21 at 1459 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated the physician documented Resident 59's progress on the paper records. The DON verified the progress notes were not found in Resident 59's medical records. On 12/7/21 at 1537 hours, an interview was conducted with the Medical Records Director. The Medical Records Director was not able to locate any…

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.