St Elizabeth Healthcare Center

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 two of 19 final sampled residents (Residents 34 and 65) reviewed with oxygen orders. * The facility failed to administer the oxygen as ordered by the physician to Resident 34. Resident 34 had an order for continuous oxygen at 2 LPM (liters per minute); however, it was not administered as ordered. * The facility failed to ensure Resident 65's oxygen tubing was dated. These failures posed the risk of developing complications as result of inadequate oxygen therapy, and had the potential to negatively impact the residents' medical condition.Findings: 1. Review of the facility's P&P titled Oxygen Therapy revised 2/2012 showed in part, it is the policy of this facility to administer oxygen in a safe manner. The resident's preliminary and comprehensive assessment should address that oxygen is needed and how often oxygen is to be administered. Medical record…

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, facility document review, and the California Code of Regulations review, the facility failed to ensure a staff member was onsite during the night shift who could provide the respiratory care and services to the residents, in accordance with the residents' plan of care. * For the night shift, the facility failed to ensure a staff member was on site at the facility who could provide the respiratory care and services to the residents with oxygen titration (the process of adjusting a resident's supplemental oxygen flow rate to main the target oxygen saturation levels) orders. This failure had the potential to result in negative health outcomes to the residents. Findings: Review of the California Code of Regulations, Title 16, section 1399.365, showed the respiratory care services LVNs may perform in the long-term care setting. Respiratory services LVNs may not perform included the initial setup, change out, or replacement of a breathing…

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 for one of 19 final sampled residents who was receiving dialysis care. * The facility failed to administer Resident 3's medications per the physician's orders when Resident 3 had scheduled dialysis appointments. The medication were as follows: ascorbic acid (dietary supplement), cholecalciferol (a fat-soluble vitamin used to treat or prevent Vitamin D deficiency and support bone health, immune function, and calcium absorption), cyanocobalamin (a synthetic form of vitamin B12 used to support red blood cell production, proper metabolism, and nerve function), furosemide (medication to treat fluid retention), and zinc sulfate (dietary supplement used to treat zinc deficiency). This failure had the potential to negatively impact the resident's health outcomes.Findings: Review of the facility's P&P titled Medication Administration revised 8/2021 showed medications shall be administered as…

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 appropriate pain medication was provided for one of five final sampled residents (Resident 63) reviewed for unnecessary medications. * Resident 63 was administered with hydrocodone-acetaminophen {combination medication used to treat severe pain by combining an opioid (hydrocodone) with a non-opioid pain reliever (acetaminophen)} as ordered for severe pain when the resident complained of moderate pain. This failure may have contributed to Resident 63's constipation and potentially affect the resident's clinical condition. Findings: Review of the facility's P&P titled Pain Recognition and Management revised 4/2025 showed it is the policy of this facility to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, comprehensive and routine assessments, person-centered care plan, and the residents' goals and preferences. 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, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure proper storage of the medications. * The facility failed to ensure the expired supplies were removed from Treatment Cart A and from the central supply room. * The facility failed to ensure the hydrophilic (water-miscible, topically applied formulations designed to absorb moisture (exudate) while maintaining a moist environment for skin healing) cream and zinc oxide (a topical skin protectant used primarily to treat and prevent diaper rash, minor burns, cuts, and skin irritations by creating a protective, moisture-resistant barrier) cream were not left unattended by the licensed nurse on top of Resident 14's nightstand. These failures had the potential to negatively impact the residents' well-being and posed the risk for the occurrence of errors in the administration of skin treatments.Findings: Review of the facility's P&P titled Medication Access and Storage revised 2/2019 showed…

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 medical record was accurately maintained for two of 19 final sampled residents (Residents 12 and 21). * The facility failed to ensure Resident 12's H&P examination was uploaded accordingly into the resident's electronic health record. Resident 12's H&P examination was uploaded in Resident 2's electronic health record. * The facility failed to ensure Resident 21's Restraint/Enabling Device/Safety Device Evaluation was accurately completed. These failures had the potential for the residents' care needs not being met as the medical records were inaccurate.Findings: 1.a. Medical record review for Resident 2 was initiated on 3/17/25. Resident 2 was admitted to the facility on [DATE], and readmitted on [DATE]. b. Medical record review for Resident 12 was initiated on 3/18/25. Resident 12 was admitted to the facility on [DATE], and readmitted on [DATE]. On 3/18/26 at 1103 hours, while the medical record review 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.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to maintain the essential equipment in a safe operating conditions. * The facility failed to ensure the ice machine was cleaned and sanitized as per the manufacturer's instructions. * The facility failed to ensure the glucometers (a device which measures the amount of sugar in the blood) in Medication Carts A and Cart B were calibrated and quality control was performed for two days in October 2025. These failures had the potential for the residents to receive ice from the kitchen not clean for consumption; and had the potential for the residents requiring blood glucose checks to have inaccurate readings.Findings: 1. Review of the facility's P&P titled Ice Machine Cleaning Procedures dated 2023 showed the internal components cleaned monthly or per manufacturer's recommendations.information about the operation, cleaning and care of the ice machine can be obtained from the owner's manual. Review of the facility's document titled Ice Machine Cleaning and Sanitizing Log dated 2025…

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 care plan interventions for two of eleven sampled residents (Residents 2 and 3). * The facility failed to ensure Residents 2 and 3's care plan interventions to monitor the signs and symptoms of hypoglycemia (low blood glucose) and hyperglycemia (high blood glucose) were implemented. These failures posed the risk of the residents not receiving services that were person-centered to meet the specific needs of each resident.Findings: Review of the facility's P&P titled Comprehensive Person-Centered Care Planning revised April 2025 showed it is the policy of this facility that the IDT shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. The IDT team will also develop and implement a baseline care plan for each…

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 one of three sampled residents (Resident 6) reviewed for falls remained free from accident hazards. * The facility failed to include a possible cause of injury in the initial investigation statement for a fall. * The facility failed to collaborate with the IDT (Interdisciplinary Team) following Resident 6's change in condition. These failures had the potential for Resident 6 not to receive adequate supervision, assistance, and sustain additional accidents and/or injuries.Findings: Review of the facility's P&P titled Change in Condition revised on 4/2025 showed it is the policy of this facility to ensure each resident receives quality of care and services to attain and maintain the highest practicable physical mental and psychosocial well-being in accordance with the interdisciplinary comprehensive assessment and plan of care. Additionally, under the procedure section, the IDT…

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 implement the pharmaceutical procedures when the nursing staff did not ensure an accurate controlled substance accountability for one of three sampled residents (Resident 6) reviewed for medications. * Resident 6's medications were signed out of the CDR (Controlled Drug Record) but not documented as administered on the MAR (Medication Administration Record). This failure had the potential for Resident 6 to be exposed to the medication errors and diversion of the controlled medications.Findings: Review of the facility's P&P titled Controlled Medication - Storage and Reconciliation revised 12/2023 showed it is the policy of this facility to safeguard access and storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse using separately locked, permanently affixed compartments, with the exception that controlled medications and those medications subject to abuse may be stored with non-controlled 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 observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to ensure two of three sampled residents (Residents 1 and 3) attained and maintained the highest practicable physical well-being. * The facility to ensure Resident 1's nystatin external cream (a medicated cream used to treat fungal or yeast infections of the skin) was administered as per the physician's order. * The facility failed to ensure Resident 3's fluid restriction was followed as per the physician's order. These failures had the potential to negatively affect the residents' health condition and well- being.Findings: 1. Review of the facility's P&P titled Skin Assessment revised 5/2007 showed wound care/ treatment provided for the residents will be according to the physician's orders and documented in the resident's treatment administration record and/or in nursing progress notes or in the medication administration record if applicable. Medical record review 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 observation, interview, medical record review, and facility P&P review, the facility failed to administer the parenteral fluids consistent with the professional standards of practice and in accordance with the physician orders when Resident 1's IV fluids was administered at 80 ml per hour, the facility failed to close the clamp and remove the IV container from the IV pole when the infusion was completed. In addition, the facility failed to ensure the IV solution was labeled with the date and time the IV solution was hung. These failures posed the risk for the resident to develop complications related to the use of the peripheral IV catheter.Findings: Review of the facility's P&P titled Administration of Intravenous (IV) Infusion Solution reviewed on July 2017 showed the intravenous medications/fluids must be administered in accordance with the written orders of the attending physician. The nurse hanging the IV solutions will label the bag with date, time, and initials. All administration sets should 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, medical record review, and facility P&P review, the facility failed to ensure the necessary respiratory care and services were provided for two of three sampled residents (Residents 1and 2). * The facility failed to ensure Resident 1's Yankauer suction tubing was stored in a bag. * The facility failed to ensure Resident 2's nebulizer administration set-up was stored in a bag. These failures had the potential for the residents to have respiratory infections and negatively affect the residents' well-being.Findings: 1. Review of the facility's P&P titled Respiratory Equipment policy reviewed 7/2012 showed it is the policy of the facility to have cleaning and replacement schedule for the respiratory equipment to ensure patient's safety. Respiratory equipment replacement indicated to replace Yankauer suction and bag weekly. Medical record review for Resident 1 was initiated on 7/9/25. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. 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 observation, interview, medical record review, and facility P&P review, the facility failed to ensure two of 16 final sampled residents (Residents 12 and 40) and one nonsampled resident (Resident 38) were free from the unnecessary restraints. * The facility failed to obtain the order and informed consent, complete the restraint assessment, and develop a care plan problem for the use of Tab alarm prior to applying a Tab alarm for Resident 40's bed and wheelchair. * The facility failed to obatain an informed consent and complete the restraint assessment for the use of pad alarm prior to applying a pad alarm for Resident 38's bed and wheelchair. * The facility failed to obatain an informed consent and complete the restraint assessment for the use of Tab alarm prior to applying a Tab alarm for Resident 12's bed and wheelchair. These failures posed the risk of compromising the residents' independence and psychosocial well-being. Findings: 1. Review of the facility's P&P titled Restraint, Physical 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 observation, interview, medical record review, and facility P&P review, the facility failed to develop and implement the comprehensive person-centered care plans for four of 16 final sampled residents (Residents 2, 22, 49, and 456). * The facility failed to develop a care plan problem to address Resident 22's refusal to shower, turn positions, change diaper, and take medications. * The facility failed to implement the intervention for 1:1 (one staff member to one resident) assistance during meals to address Resident 49's weight loss. * The facility failed to develop a care plan to address the use of oxygen and CPAP for Resident 456. * The facility failed to ensure Resident 2's care plan problem addressing diabetes mellitus included the use of insulin as ordered. These failures placed the residents at risk of not being provided appropriate, consistent, and individualized care. Findings: 1. Review of the facility's P&P titled Comprehensive Person-Centered care planning dated 8/2019 showed the resident has…

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 follow the professional standards of clinical practice accepted for the administration of GT medications for one of two residents (final sampled resident, Resident 8) observed for medication administration receiving GT medications. * LVN 4 did not flush the GT in between the administering of three of eight medications for Resident 8. This failure had the potential to disrupt the flow of medications and clog the GT affecting the patency and placement of Resident 8's GT. Findings: Review of the facility's P&P titled Medication Administration via Feeding Tube revised 12/2023 showed under Guidelines: If administering several medications, administer each one separately, the tube should be flushed with at least 5 ml of water between medications. According to the NIH's National Library of Medicine Open Resources for Nursing (Open RN) Nursing Skills 2021 page 14, under Enteral Medication Administration: 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 observation, interview, medical record review, and facility P&P review, the facility failed to ensure the appropriate services needed to maintain the acceptable parameters of nutritional status were provided for one of one final sampled resident (Resident 49) reviewed for weight loss. * The facility failed to ensure the RD's recommendations on 12/12/24, were followed up with the physician and addressed in the IDT weight variance meeting when Resident 49 had a severe weight loss of 36 lbs in 26 days. This failure had the potential for Resident 49 not to receive the necessary intervention to prevent further weight loss. Finding : Review of the facility's P&P titled Nutrition Care Management revised dated 7/2021 showed the recommendation based on the nutritional goals will be communicated via electronic system and the Licensed Nurse will confirm to document the physician prescription. The MD declination of RDN recommendation will be documented in the Progress Notes. The expectation that the RDN 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, medical record review, and facility P&P review, the facility failed to ensure one of five final sampled residents (Resident 6) reviewed for respiratory care was provided with the appropriate respiratory care when: * The facility failed to ensure the physician's order for CPAP had a schedule when to apply and remove the CPAP for Resident 6. Additionally, Resident 6's medical record did not show the CPAP was applied from 12/9 to 12/11/24. * The facility failed to ensure the physician's order for cleaning and maintenance of Resident 6's CPAP was accurate. The physician's order showed to clean the humidified container but Resident 6's CPAP had no humidified container. These failures had the potential to affect the respiratory health and well-being of Resident 6. Findings: Review of the facility's P&P titled BiPAP and CPAP (undated) showed the cleaning and maintenance: hand wash the tubing once a week with warm water and soap and allow to air dry. Review of the facility's P&P titled…

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

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 maintain the highest practicable physical, mental, and psychosocial well-being for one of 16 final sampled residents (Resident 354). * The facility failed to completely assess Resident 354 for pain prior to administering oxycodone (narcotic analgesic medication). This failure had the potential to cause increased pain and distress to the resident. Findings: Review of the facility's P&P titled Recognition and Management of Pain dated 7/2017 showed the pain will be documented in the EHR using a scale of 1-10 (with zero = no pain and 10 = worst pain). Monitoring: the interdiscplincary Care plan will reflect the location and the type of pain, pharmacologial and non pharmcological intervention, with evalution and revision as indicated. Medical record review for Resident 354 was initiated on 12/11/24. Resident 354 was admitted to the facility 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.

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 pharmaceutical services when: * The facility failed to ensure the accurate and complete documentation of the controlled medications administered for one nonsampled resident (Resident 356). * The facility failed to ensure the narcotic sheets had the nurses' initials and signatures for one of two medication carts (Medication Cart 1). * Medication Cart 1 was left unlocked in an area where the residents, other staff, or visitors could access it. These failures had the potential for the medications to be administered in error and opportunities for drug diversion or drug misuse. Findings: 1. Review of the facility's P&P titled Controlled Medications revised 12/2019 showed when a controlled medication is administered, the licensed nurse administering the medication immediately enters all of the following information on the accountability record: date of administration,…

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 final sampled residents (Residents 6 and 49) reviewed for unnecessary medications were free from the unnecessary psychotropic medications. * There were no specific resident-centered goals to monitor for increased appetite for Resident 6's use of mirtazapine (antidepressant medication). * There was no evidence of non-pharmacological interventions for Resident 49's use of escitalopram (antidepressant medication) These failures had the potential to result in unnecessary use of, ineffective and/ or lack of monitoring or interventions for psychotropic medications that could negatively affect Residents 6 and 49's highest practicable mental, physical, and psychosocial well- being. Findings: 1. Review of the facility's P&P titled Psychotropic Drug Use revised 8/2017 showed the licensed nurses shall review the classification of the drug, the appropriateness of the diagnosis, its indication/ behavior monitoring…

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 medication error rate was below 5%. The facility's medication error rate was 19.35%. One of three licensed nurses (LVN 4) observed during the medication administration was found to have made errors. * LVN 4 failed to ensure the full dosages for six of eight prescribed medications were administered to Resident 8 as per the physician's orders. This failure had the potential to negatively affect the residents' health. Findings: On 12/11/24 at 0755 hours, during a medication administration observation, LVN 4 administered the following medications to Resident 8 via GT: - aspirin (nonsteroidal anti-inflammatory drug) 81 mg - Cozaar (antihypertensive medication) 50 mg - demeclocycline hcl (antibiotic medication) 150 mg one tablet - Azithromycin (antibiotic medication) 250 mg one tablet - cyanocobalamin (vitamin B 12 supplement medication) 1000 mcg one tablet - multivitamins with minerals (supplement…

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, facility document review, and facility P&P review, the facility failed to ensure the medications were properly labeled and stored safely. * The facility failed to ensure the single use dressing was discarded after use. * The facility failed to ensure the topical medication was accurately labeled in accordance with currently accepted professional principles, including the expiration date. These failures had the potential to negatively impact the residents' well being. Findings: 1. Review of the facility's P&P titled Medication Access and Storage revised 2/2019 showed in part, the contaminated medications, or those without secure closures are immediately removed from stock .the provider pharmacy dispenses medications in containers that meet the legal requirements including requirements of good manufacturing practices where applicable. On 12/12/24 at 0757 hours, a concurrent inspection of the treatment cart and interview was conducted with LVN 2. An opened package of Puracol (used for wound management) wound dressing 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 two of 16 final sampled residents (Residents 456 and 904) had accurate and complete medical records. * The facility failed to ensure the information on Resident 456's POLST was accurate and updated. * The facility failed to ensure Resident 904's TAR documentation regarding multiple wound treatment orders were completed. These failures had the potential for the residents' health care needs to not be met as the medical record was incomplete and inaccurate. Findings: Review of the facility's P&P titled Documentation (undated) showed the resident's clinical record is a concise and accurate account of treatment, care, response to care, signs, symptoms, and progress of the resident's condition. 1. Medical record review for Resident 456 was initiated on 12/12/24. Resident 456 was admitted to the facility on [DATE]. Review of Resident 456's H&P examination dated 11/30/24, showed the resident had the capacity to understand…

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, facility document 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. * The facility failed to follow their water management program to regularly test water temperatures as per the facility's P&P. * The facility failed to ensure the staff performed hand hygiene as per the facility's P&P. * The facility failed to ensure the best practice was performed for infection prevention and control when an antibiotic vial was not disinfected prior connecting the intravenous solution to the antibiotic vial. * The facility failed to ensure the staff performed hand hygiene after removing gloves between resident care. These failures had the potential for increased risk of infections and compromising the residents' medical conditions. Findings: 1. According to the CMS QSO 17-30 titled Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaire's Disease 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, facility document review, and facility P&P review, the facility failed to protect the resident's rights to be free from the sexual abuse by a resident for one of three sampled residents (Resident 1). * On 7/28/24, Resident 2 was observed inappropriately touching Resident 1's genitals and making a shaking motion. Resident 1 had severe cognitive impairment and did not have the capacity to consent. This failure had the potential to cause Resident 1 to experience sexual abuse and placed Resident 1 at risk for psychological and emotional harm. Findings: Review of the facility's P&P titled Prevention of Sexual Abuse revised 11/2019 showed it is the policy of this facility that each resident has the rights to be free from abuse, specifically sexual abuse. The residents must not be subjected to sexual abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, resident representatives,…

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 one of two sampled residents (Resident 1) was provided with the necessary care and services to prevent the development and worsening of pressure injuries. * Resident 1 was evaluated to have a Stage 1 pressure injury to his sacral coccyx on 1/3/24. Resident 1's sacral coccyx pressure injury had advanced to a Stage 2 pressure injury on 1/11/24. On 1/17/24, Resident 1's wound was evaluated by Wound Specialist 1 as an unstageable pressure injury. The facility failed to ensure Resident 1's sacral coccyx unstageable pressure injury was continued to be treated by Wound Specialist 1. This failure posed the risk for Resident 1's pressure injury to deteriorate and develop additional pressure injuries. Findings: Review of the facility's P&P titled Skin and Wound Monitoring and Management revised 12/2023 showed it is the policy of the facility that a resident having a pressure injury receives the necessary treatment 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 P&P review, and facility pharmacy P&P, the facility failed to ensure the medications and supplies were properly stored. * LVN 1 left MiraLAX (medication for constipation) unattended on the medication cart. * Multiple expired medications and supplies were observed in the central supply room. * Oral and suppository medications were stored next to each other on the same shelf in the central supply room. * Expired wound care supplies were observed in the treatment cart. * Expired IV supplies were observed in the IV cart. * Medication labeled for a resident was opened, used, and stored in the central supply room. * The facility failed to store a bottle of acetaminophen (pain medication) securely and inaccessible by the staff, residents, and visitors. This had the potential for unauthorized access to the medication. These failures had the potential to result in unsafe medication administration and wound care treatment. Findings: Review of the Pharmacy Services' P&P titled Medication Storage in the Facility under storage of medications 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.

Based on observation, interview, facility documents review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen. * The facility failed to ensure the food items in the refrigerator and resident refrigerator were properly labeled. * The facility failed to ensure the resident refrigerator and the bin containing the scoops were clean. * The facility failed to ensure the kitchen utensils were in good repair. * The facility failed to ensure the cutting boards were in sanitary condition. These failures had the potential to expose the residents who consumed food prepared in the kitchen to foodborne illnesses. Findings: Review of the CMS 672 - Resident Census and Conditions of Residents completed by the facility dated 5/2/23, showed 43 of 46 residents in the facility received food prepared in the kitchen. 1. Review of the facility's P&P titled Labeling and Dating of Foods (undated) showed all food items in the storeroom, refrigerator, and freezer need to be labeled and dated on established procedures for either food safety or product…

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 establish and maintain the infection control program and practices designed to help prevent the development and transmission of diseases and infections. * The facility failed to ensure Resident 500's family member wore the required personal protective equipment when entering a contact precaution room (Room B). * The facility failed to ensure the infection control practices were maintained in the facility's storage room for cleaning supplies when the personal belongings of staff were stored with the cleaning supplies as per the facility's policy. * The facility failed to ensure the infection control practices were maintained in the facility's laundry room area when a dusty fan and air conditioning unit with dusted air vent were observed in the clean linen area. * The facility failed to ensure the staff wore the required personal protective equipment in an isolation precaution room (Room A) and changed personal protective equipment when assisting between residents in Room 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, and facility P&P review, the facility failed to provide the reasonable accommodations to meet the needs of three nonsampled residents (Residents 9, 14, and 399). * The facility failed to ensure Residents 14 and 399's call lights and water pitchers were within their reach. * The facility failed to ensure Resident 9's call light and bed remote control were within her reach. These failures created the potential to negatively impact the residents' psychosocial well-being or result in a delay to provide care. Findings: Review of the facility's P&P titled Call Light/ Bell revised 2/2023 showed to leave the resident comfortable, ensure the call device is within resident's reach before leaving the room. If resident is unable to reach the call light, do not leave the resident unattended. 1. On 5/2/23 at 0908 and 0921 hours, Resident 14 was observed seated in the wheelchair in his room, facing his bed. Resident 14's call light was observed on his bed, and the water…

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 clearly identify the current medical intervention status for one of 12 final sampled residents (Resident 20). In addition, a copy of Resident 20's advance directive was not available in the resident's medical record. These failures had the potential to not provide the proper care in accordance with the resident's treatment wishes. Findings: Medical record review for Resident 20 was initiated on 5/2/23. Resident 20 was initially admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 20's MDS dated [DATE], showed Resident 20 had moderate cognitive impairment. Review of Resident 20's Order Summary Report showed a physician's order dated 5/4/22, for DNR with comfort measures only. Review of the POLST dated 4/4/23, showed, Do Not Attempt Resuscitation/DNR (Allow Natural Death) and Selective Treatment were checked. Further review of the POLST, under Section D, showed the advance directive was not available. 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.

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 plan of care to reflect the individual care needs for one of 12 final sampled residents (Resident 349). * The established care plan problems did not include the individualized the non-pharmacological interventions to address Resident 349's specific behaviors. This failure posed the risk of not providing the appropriate and individualized care to the resident. Findings: Review of the facility's P&P titled Care and Treatment for Psychotropic Drug Use revised August 2017 showed upon initial comprehensive assessment the Social Services designee shall review new admissions for any psychiatric, mood or behavior disorders, mental and psychosocial difficulties, and/or physician's orders for psychotoropic medications. These residents will be referred to the facility's Psychotropic Drug Reviw Committe and/or the psychiatrist to ensure the care plan shows individualized, person-centered care approaches to manage behavior…

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 an individualized and ongoing activity program to meet the needs and interests of one of 12 final sampled residents (Resident 7). The facility failed to provide activities for Resident 7 which met her identified interests. This had the potential for Resident 7 to experience feelings of social isolation and frustration. Findings: On 5/2/23 at 0847 hours, during the initial tour of the facility, Resident 7 was observed awake and lying in bed. There was no TV, or any in-room sensory stimulation observed. On 5/3/23 at 0742, 1015, 1033, 1604, and 1623 hours, Resident 7 was observed awake and lying in bed. Resident 7 was observed starring at the ceiling and curtain and touching her face. There was no TV, or any in-room sensory stimulation observed. On 5/3/23 at 1055 hours, an observation of Resident 7 and concurrent interview was conducted with CNA 1. When asked about the resident's activities, CNA 1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to ensure the physician's order was obtained for a contact precaution for one nonsampled resident (Resident 500). This failure created the risk of not providing the appropriate and consistent care for Resident 500. Findings: On 5/2/23 at 0815 hours, during the initial tour of the facility, a sign showing respiratory, droplet, and contact precaution with instructions to perform hand washing, wear gloves, gown, N95 mask, and face shield was posted at the entry of Resident 500's room. On 5/2/23 at 0818 hours, an interview was conducted with LVN 2. LVN 2 stated Resident 500 was on contact isolation for cough. On 5/2/23 at 0920 hours, an interview was conducted with Resident 500. Resident 500 stated he was on isolation for cough and had not been out of the room. Medical record review for Resident 500 was initiated on 5/2/23. Resident 500 was admitted to the facility on [DATE]. Review of Resident 500's H&P examination dated 4/14/23, showed…

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 12 final sampled residents (Resident 398) remained free of accident hazards. * The facility failed to provide Resident 398 with the bilateral floor mats and bolster pillow, and failed to keep the bed in the lowest position as per the physician's orders and care plan. This failure had the potential for the resident to fall and sustain injuries. Findings: On 5/2/23 at 0849 hours, during the initial tour of the facility, Resident 398 was observed awake and lying in bed. A gray floor pad was on the left side of the bed, and the bed was observed not in the lowest position. Medical record review was initiated on 5/2/23. Resident 398 was admitted to the facility on [DATE]. Review of Resident 398's Order Summary Report showed the following physician's orders dated 10/21/22: - to use bilateral floor pads for safety; - to use bolster pillows to bilateral side of the bed to assist patient in repositioning while in bed; and - 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, and facility P&P review, the facility failed to provide the pharmaceutical services to meet the needs of one of 12 final sampled resident (Resident 25) and two nonsampled residents (Residents 43 and 44). * The facility failed to provide the pharmaceutical services to assure the accurate acquiring, receiving, dispensing, and administering of medications to meet the needs of Residents 43 and 44. * The facility failed to ensure Resident 25 received the medications via GT and not PO. Resident 25 was on a GT feeding, but the ferrous sulfate and acetaminophen medications were ordered to be given by mouth as per the physician's orders. This had the potential for Resident 25 for aspiration (accidental breathing in of food or fluid into the lungs). These failures had the potential to negatively impact the residents' well-being. Findings: Review of the facility's P&P titled Preparation and General Guidelines under Medication Administration-General Guidelines 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 12 final sampled residents (Resident 349) was free from an unnecessary psychotropic (any drug that affects brain activity) medications. * The facility failed to document the implementation of non-pharmacological interventions for crying and yelling episodes prior to the use of sertraline (antidepressant medication) and ziprasidone (antipsychotic medication) for Resident 349. This failure had the potential for Resident 349 to experience adverse effect or receive unnecessary medications. Findings: Review of the facility's P&P titled Care and Treatment for Psychotropic Drug Use revised August 2017 showed residents who use psychotropic drugs receive gradual dose reduction, and behavioral interventions, unless clinically contraindicated in an effort to discontinue these drugs. Medication record review for Resident 349 was initiated on 5/4/23. Resident 349 was admitted on [DATE]. Review of Resident 349's H&P…

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 medication error rate was less than 5%. * The facility's medication error rate was 32.56%. Two of two licensed nurses (LVNs 1 and 2) were found to have made errors during the medication administration for two of 12 final sampled residents (Residents 20 and 41) and two nonsampled residents (Residents 43 and 44). This failure had the potential to negatively affect the residents' well- being. Findings: Review of the facility's P&P titled Medication Administration-General Guidelines dated February 2015 showed the medications are administered in accordance with written orders of the attending physician. 1. On 5/2/23 at 0810 hours, a medication pass observation for Resident 20 and concurrent interview was conducted with LVN 1. LVN 1 was observed preparing and administering Resident 20's medications which included the following: - one tablet of Eliquis 2.5 mg (blood thinner) - one tablet of metoprolol tart 25 mg (medication for blood pressure) - one tablet of multivitamin 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 observatioon, interview, medical record review, and facility P&P, the facility failed to ensure two nonsampled residents (Residents 15 and 44) were free from the significant medication errors. * The facility failed to document Resident 15's controlled medication (medications that have some potential for abuse or dependence) administration and follow the physician's orders. * The facility failed to administer Resident 44's carvedilol (medication used to control high blood pressure) during the medication observation. These failures placed Residents 15 and 44 at risk for medical complications. Findings: Review of the facility's P&P titled Preparation and General Guidelines: Controlled Medications dated February 2015 showed when medication is administered, the license nurse administering the medication immediately enters the following information on the accountability record and the MAR: 1. Date and time of administration. 2. Amount administered. 3. Signature of the nurse administering the dose, completed…

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. * The facility failed to ensure the correct texture of fish and noodles were served. Chopped fish and whole noodles were served instead of ground fish and softly chopped noodles for the residents on the dysphagia mechanical soft diet (diet consists of foods that are moist soft-textured and easily formed into a bolus, meant for people with chewing and swallowing difficulties) as per the facility's menu. This failure had the potential for the residents not receiving the correct food texture and could potentially result to choking. Findings: Review of the CMS-672 form titled Resident Census and Conditions of Residents completed by the facility dated 5/2/23, showed 42 of 54 residents residing in the facility received food prepared in the kitchen. Review of the facility's P&P titled Menu Planning undated, showed the menus are planned to meet the nutritional needs of residents in accordance with established national guidelines, physician's orders, and…

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

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 inspect the bed frames, mattress, and side rails to identify areas of possible entrapment for three of 12 final sampled residents (Residents 33, 398, and 499). This had the potential to negatively impact the residents resulting to entrapment, serious injuries, and death. Findings: Review of the facility's P&P titled Bedrail Assessment revised 8/2017 showed it is the policy of the facility to assess the use of bedrails and the facility must ensure correct installation, use, and maintenance of bed rails. When installing and using bed rails, the facility should: a. Ensure that the bed's dimensions are appropriate for the resident. b. Confirm that the bed rails to be installed are appropriate for the size and weight of the resident using the bed. c. Install bed rails using the manufacturer's instructions to ensure a proper fit. d. Inspect and regularly check the mattress and bed rails 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.