Terrace View Care 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 ensure one of 12 final sampled residents (Resident 7) was free from accident hazards. * The facility failed to implement bilateral floor mattress as ordered by the physician as a fall risk precaution for Resident 7. This failure had the potential for serious injury to the resident.Findings: Review of the facility's P&P titled Floor Mat Safety and Use revised date 10/2025 showed the purpose is to prevent slips, trips, and falls related to improper placement, condition, or maintenance of floor mats and to ensure compliance with safety standards. All floor mats must be non-slip, lay flat, remain clean and dry, and not create hazards or obstruct mobility devices. On 2/17/26 at 0930 hours, during the initial tour of the facility, Resident 7 was observed lying in bed with bilateral floor mats in place. On 2/19/26 at 0939 hours, an observation of Resident 7 and concurrent interview was conducted with CNA 3. 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, and facility P&P review, the facility failed to ensure one of 12 final sampled residents (Resident 9) received care and services to maintain acceptable nutritional status. * The facility failed to ensure the RD's recommendations for Cholecalciferol 2,000 IU oral daily, Vitamin C 500 mg oral daily for 30 days and Prostat SF (liquid protein supplement) 30 ml oral daily was implemented. This failure had the potential to compromise Resident 9's nutritional status.Findings: Review of the facility's P&P titled Weight Loss - Clinical Protocol revised date 9/2025 showed the physician will help identify medical conditions (cancer, cardiac or renal disease, depression, dental problems, etc.) and medications that may be causing weight gain or loss or increasing risk for either gaining or losing weight. The physician (or staff, based on a discussion with the physician) will document relevant medical information regarding the nature, severity, causes, and consequences…

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 intravenous access for one of 12 final sampled residents (Resident 37). * The facility failed to ensure the PICC line external catheter and arm circumference measurements were completed and documented upon admission in the medical records for Resident 37. This failure had the potential to delay the identification of catheter related complications for the resident.Findings: Review of the facility's P&P titled PICC Line (Peripherally Inserted Central Catheter) revised date 4/2025 showed, the facility ensures safe insertion, maintenance, and removal of PICC lines using infection prevention practices to prevent bloodstream infections and ensure resident safety. The purpose is to standardize PICC care, prevent infection, promote staff competency, and ensure CMS compliance. Medical record review for Resident 37 was initiated on 2/17/26. Resident 37 was admitted…

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 for one of 12 final sampled residents (Resident 43) reviewed for oxygen therapy. * The facility failed to ensure Resident 43's oxygen tubing was labeled and dated. This failure had the potential to place the resident at risk of receiving improper respiratory care. Findings: Review of the facility's P&P titled Oxygen Administration date revised 10/2025 showed the purpose of this procedure is to provide guidelines for safe oxygen administration. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Assemble the equipment and supplies as needed. On 2/17/26 at 0941 hours, during the initial tour of the facility, Resident 43 was observed lying in bed and receiving oxygen at 3 LPM via CPAP mask which was attached to the oxygen machine concentrator. In addition, the oxygen tubing…

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 observations, interview, medical record review, and facility P&P review, the facility failed to provide adequate pain management for two of two final sampled residents (Residents 21 and 56) reviewed for pain management. * The facility failed to ensure Resident 21 was administered oxycodone (narcotic analgesic) medication as per the physician's order. In addition, the facility failed to monitor Resident 21's sedation level, BP, and apical pulse per the physician's order related to the administration of oxycodone medication. * Resident 56's ordered pain scale did not match the facility's standardized pain scale. In addition, the resident was administered PRN pain medication for a pain level of 5, which was below the ordered pain level of 6-10. These failures had the potential for Residents 21 and 56 to not receive effective treatment for pain.1. Review of the facility's P&P review titled Pain Assessment and Management dated 10/2025 showed the following: - Possible physiological signs of pain, including…

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 dialysis care was provided for one of two final sampled residents (Resident 9) reviewed for dialysis services. * The facility failed to ensure the emergency dialysis kit kept at bedside was complete and contained a scissor clamp for Resident 9. This failure posed the risk of possible medical complications for Resident 9. Findings: Review of the facility's P&P titled Dialysis Care revised dated 5/11/25, showed to keep dialysis emergency kit at bedside in case of bleeding from the shunt site/ dialysis catheter. Medical record review for Resident 9 was initiated on 2/18/26. Resident 9 was admitted to the facility on [DATE]. Review of Resident 9's H&P examination dated 1/22/26, showed Resident 9 had no capacity to understand and make decisions. In addition, Resident 9 had a diagnosis of ESRD and was on renal dialysis. Review of Resident 9's care plan date initiated 1/21/26, showed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of five final sampled resident (Resident 43) reviewed for the side rail use remained free from the accident hazards associated with the use of the elevated side rails. * The facility failed to ensure the physician's order was obtained for the use of bilateral half side rails for Resident 43. * The facility failed to ensure a care plan was developed to address the use of bilateral half side rails for Resident 43. * The facility failed to ensure the side rail assessment and the least restrictive interventions were completed prior to the use of bilateral half side rails for Resident 43. These failures had the potential risk for serious injury to the resident.Findings: Per the FDA's Safety Alert titled Entrapment Hazards with Hospital Bed Side Rails dated 1995, residents most at risk for entrapment are those who are frail or elderly or those who have conditions such as agitation, delirium, confusion,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure the Pharmacy Consultant's recommendations from drug regimen review in January 2026 were acted upon for one of five final sampled residents (Resident 7) reviewed for pharmacy services. * The facility failed to ensure the drug regimen review recommendations of trying and documenting non-pharmacological interventions for January 2026 were acted upon for Resident 7. This failure placed the resident at risk for receiving unnecessary medications, increasing their risk for side effects.Findings: Review of the facility's P&P titled Psychoactive/ Behavior Assessment (undated) showed, prior to the use of Psychoactive medication the Interdisciplinary Team (IDT) assess the medical necessity/ how use of the Psychoactive medication would treat the medical symptoms and there should be a documented trial of alternatives (non-pharmacological intervention/ NPI). Review of the facility's P&P titled Psychotropic Medication Use 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 maintain an accurate medical record for one of 12 final sampled residents (Resident 56). * The facility failed to ensure the Resident 56's pain level monitoring for each shift was accurately documented. This failure resulted in inaccurate medical records. Findings: Review of the facility's P&P titled Charting and Documentation revised July 2025 showed the medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care, documentation will be complete and accurate. Medical record review for Resident 56 was initiated on 2/17/26. Resident 56 was admitted to the facility on [DATE]. Review of Resident 56's Order Summary Report showed a physician's order dated 2/13/26, to monitor and assess the resident's pain level every shift, with zero for no pain, 1-4 for mild pain, 5-7 for moderate pain, and 8-10 for severe pain. Review of Resident 56's MAR 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, facility document review, and facility P&P review, the facility failed to monitor and address the use of the antibiotics for one final sampled resident (Resident 51) and one non-sampled resident (Resident 40) reviewed for antibiotic stewardship. * The facility failed to ensure the McGeer's criteria assessment was completed in a timely manner for Residents 40 and 51 when the residents were started with antibiotics. This failure had the potential for the antibiotics to be used when they were not indicated and the development of antibiotic-resistant bacteria.Findings: Review of the facility's P&P titled Antibiotic Stewardship revised 1/2025 showed the following under the Policy Interpretation and Implementation section:- Prior to calling a physician/prescriber to communicate a suspected infection, the nurse will obtain and have the following information available:Clinical signs and symptoms of suspected infection (based on approved definitions of infection by using the…

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

Based on observation, interview, and facility document review, the facility failed to ensure the glucometer in Medication Cart A, and the refrigerators used to store medications in Medication Rooms A and B were maintained in a safe operating condition. * The facility failed to ensure the glucometer calibration was conducted for the glucometer in Medication Cart A. Furthermore, the facility failed to ensure the glucose strips and control solutions had an expiration date of 90 days after opening, as per the manufacturer's information. * The facility failed to ensure the freezer compartment inside the refrigerator used for medications in Medication Room A was free of ice buildup. This had the potential to affect the refrigerator's functionality and the potentially affect the potency of the medications stored inside the refrigerator. These failures had the potential for the essential equipment to not function in the way it was intended and expose the residents to unsafe practices. Findings: 1. Review of the blood glucose meter manufacturer's information sheet titled Quality Assurance/…

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 three sampled residents (Resident 1) reviewed for falls was accurately assessed for the risk for falls. * Residents 1's Fall Risk assessment dated [DATE], showed multiple inaccurate entries, which resulted for the resident to have a lower score for a fall risk. This failure had the potential for the resident to experience adverse events related to falls.Findings: Review of the facility's P&P titled Falls and Fall Risk, Managing revised 10/2024 showed the staff will identify specific risks and causes to try and prevent falls. Closed medical record review for Resident 1 was initiated on 10/28/25. Resident 1 was admitted to the facility on [DATE], and was discharged to home on 6/28/25. Further review of Resident 1's closed medical record showed the resident had an unwitnessed fall on 6/2/25, at 2310 hours. Review of Resident 1's Fall Risk assessment dated [DATE] at 0441 hours, showed multiple…

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 four sampled residents (Resident 1) was free from the physical restraints. * CNA 1 wrapped a bed sheet around Resident 1's waist and tied it behind the resident's wheelchair, preventing Resident 1 from easily removing the material. This failure posed the risk of restricting the resident's freedom of movement and further compromising the resident's independence and psychosocial well-being. Findings: Review of the facility's P&P titled Use of Restraint dated 2024 showed the restraints shall only be used for the safety and well-being of the resident (s) and only after other alternatives have been tried unsuccessfully. Restraint shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls. The definition of restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same…

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 thoroughly investigate an allegation of abuse for one of four sampled residents (Resident 1). * The facility failed to interview Resident 1 (alleged victim) and CNA 1 (alleged perpetrator) when Resident Representative 1 reported Resident 1 was tied to his wheelchair with a bedsheet, and when Resident 1 alleged CNA 1 hit him in the face and kicked him in the stomach. This failure had the potential to put the resident at risk for further abuse.Findings: Review of the facility's P&P titled Elder/Dependent Adult Abuse dated 2/2023 showed under the section Investigation/Action, the facility will:- identify and interview all persons involved including alleged victim, perpetrator, witness, others who may have knowledge of alleged violation;- focus on determining if abuse, neglect, exploitation or mistreatment has occurred and the extent/cause;- document evidence that all alleged abuse violations are…

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 treatment and care in accordance with the professional standards of practice for one of four sampled residents (Resident 1). * The facility failed to ensure the physician was notified in a timely manner when Resident Representative 1 reported Resident 1 was tied to his wheelchair with a bedsheet, and when Resident 1 alleged CNA 1 hit him in the face and kicked him in the stomach * The facility failed to ensure the physician and resident representative were notified when Resident 1 was found on the floor and was observed with purplish discoloration on his left thigh. In addition, the facility failed to ensure monitoring of the neurological status was conducted when the resident had unwitnessed fall. These failures had the potential for Resident 1 not to receive appropriate care and treatment.Findings: Review of the facility's P&P titled Acute Condition Changes- Clinical Protocol dated 12/2024 showed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the quality care and services were provided for one of 14 final sampled residents (Resident 8) and two nonsampled residents (Residents 26 and 293). * The facility failed to ensure the physician's order was obtained, the assessment was completed, and the appropriate instructions were obtained to maintain the appropriate care of the resident's blood glucose monitoring device for Resident 26. * The facility failed to ensure the transfer orders and instructions from the acute care hospital were followed through and communicated to the resident's attending physician for Resident 293. * The facility failed to assess Resident 8 and notify the physician timely when Resident 8's oxygen saturation levels were 91 to 92% as per the physician's order to keep the oxygen saturation above 92%. These failures had the potential for the residents to not receive the necessary care and services to maintain their highest…

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 intravenous accesses for one of 14 final sampled residents (Resident 33), and two nonsampled residents (Residents 292 and 293). * The facility failed to ensure the PICC line external catheter baseline measurements were obtained and documented for Resident 292. * The facility failed to ensure the PICC line external catheter baseline measurements were obtained and documented for Resident 293. * The facility failed to ensure Resident 33's PIV site was labeled with the date, time, and licensed nurse's initials. These failures had the potential to delay the identification of intravenous catheter related complications for the residents. Findings: 1. Review of the facility's P&P titled Central Venous Catheter Dressing Changes dated 4/2024 showed the dressing of the central venous catheter is routinely changed at least five to seven days or as needed when the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the safe respiratory care services for two of four final sampled residents (Residents 8 and 294) reviewed for the respiratory care. * The facility failed to ensure Resident 8's non-invasive ventilator machine was cleaned as per the manufacturer's guidelines and the headgear and tubing were cleaned as per the facility's P&P. * The facility failed to ensure Resident 294's CPAP machine was cleaned as per the manufacturer's guidelines and failed to ensure the mask with straps and tubing were placed in the clear plastic bag when not in used. These failures had the risk for equipment contamination and respiratory complications, which might adversely affect the health and well-being of Residents 8 and 294. Findings: Review of the facility's P&P titled CPAP/BiPAP P&P revised 12/2024 showed to review the physician's order to determine the oxygen concentration and flow, and the PEEP…

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 ensure the accurate administration of the medications as evidenced by: * LVN 2 failed to administer Resident 542's dexamethasone (steroid, anti-inflammation medication) as per the physician's order. This failure had the potential to negatively affect Resident 542's health condition, for possible complications. Findings: Review of the facility's P&P titled Administering Medications revised 4/2024 showed the medications are administered in accordance with the prescriber orders, including any required time frame. Medications are administered within one hour of their prescribed time, unless otherwise specified. On 2/25/25 at 0906 hours, a medication administration observation for Resident 542 was conducted with LVN 2. LVN 2 prepared and administered Resident 542 the following medications: - one-half tablet of dexamethasone 1 mg; - one tablet of atorvastatin (anticholesterol)…

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 review, the facility failed to ensure three of five final sampled residents (Residents 27, 33, and 36) reviewed for the unnecessary medications were free from the unnecessary psychotropic drugs. * The facility failed to ensure Resident 33's orthostatic blood pressure was monitored as ordered by the physician related to the use of the sertraline (antidepressant) medication. * The facility failed to ensure Resident 36's orthostatic blood pressures were accurately monitored for the use of the Seroquel (antipsychotic medication), bupropion (antidepressant medication), and desvenlafaxine (antidepressant medication); the facility failed to document the implementation of the non-pharmacological interventions for Resident 36's use of the Seroquel, bupropion, desvenlafaxine, and Depakote(mood stabilizer) medications. In addition, the facility failed to accurately monitor the specific behavior manifestation for Resident 36's use of the Seroquel medication. * The…

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

Based on observation, interview, and facility P&P review, the facility failed to ensure the food safety and sanitation guidelines were followed when: * Seven cups of apple juice and one cup of yogurt were unlabeled and undated inside the walk-in refrigerator. This failure had the potential to result in foodborne illnesses for the residents receiving food prepared in the kitchen. Findings: Review of the facility's document showed 55 of 55 residents receiving food prepared in the kitchen. Review of the facility's P&P titled Labeling/Date Marking and Safe Storage of Refrigerated and Frozen Foods revised 1/1/18, showed to provide a means for the safe storage of refrigerated items that have been opened and may not be in their original container. Any foods removed from original container will be properly labeled as follows: the name of the food item being stored and the date the food was removed from its original container and stored. On 2/24/25 at 0800 hours, during the initial tour of the kitchen, an observation and concurrent interview was conducted with the DSS. Seven cups of apple…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and facility document review, the facility failed to ensure the Facility Assessment addressed or included the following: 1. Active involvement of required individuals in developing the Facility Assessment; 2. Resources necessary to care for residents including weekends; 3. A plan to maximize recruitment and retention of direct care staff; and 4. A contingency plan for staffing needs. This failure had the potential to not meet the residents' care needs if the assessed population's needs and resources were not comprehensively identified and addressed. Findings: According to the CMS QSO-24-13-NH dated 6/18/24, with an implementation date of 8/8/24, CMS had issued a revised guidance for long-term care facility assessment requirement. The Facility Assessment should address and included the active involvement of the direct care staff in developing the Facility Assessment. Also included the staffing resources necessary to care for the residents, including the weekends; a plan to maximize recruitment…

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 perform the hand hygiene and maintain the infection practices to help prevent the development and transmission of diseases and infection. * The Activity Assistant failed to performed hand hygiene after removing the PPE when coming out of Room A with Novel Respiratory Precaution sign. * CNA 7 failed to perform hand hygiene after removing the PPE and leaving Room A. * CNA 1 failed to performed hand hygiene after removing the PPE from answering the call light in Room A. * The facility failed to ensure CNA 8 followed the enhanced barrier precautions for Resident 292 when changing the resident's disposable briefs. These findings failed to prevent the development and transmission of communicable diseases and infections. Findings: Review of the facility's P&P titled Handwashing/Hand Hygiene revised 8/2022 showed this facility considers hand hygiene the primary means to prevent the spread of infection. Hand hygiene is the final step after…

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 from the verbal and physical abuses by another resident for two of six sampled residents (Residents 2 and 3). * Resident 1 was being assisted by two nursing aide students when Resident 1 angrily yelled and demanded Resident 2 to leave Room A. Resident 1 hit Resident 2's right foot as witnessed by the two nursing aide students on 11/16/24. Resident 2 was assessed with no physical injuries, monitored for emotional distress, and transferred to Room B. * CNA 3 witnessed Resident 1 yelling and cursing at Resident 3 on 12/13/24. Resident 3 stated Resident 1 also raised his walker as if going to hit him. Resident 3 stated he felt scared to go back to Room A. Resident 3 was then transferred to Room C. These failures had the potential to cause further serious injuries and/or psychosocial harm to Residents 2 and 3, and risk to other residents. Findings: Review of the facility'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, facility document review, and facility P&P review, the facility failed to implement the P&P for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act when the facility did not report the allegation of abuse timely as per the facility's P&P for two of six sampled residents (Resident 2 and 3) * Resident 1 was being assisted by two nurse aide students when Resident 1 angrily yelled and demanded Resident 2 to leave Room A. Resident 1 hit Resident 2's right foot as witnessed by the two nurse aide students, on 11/16/24. Resident 2 was assessed with no physical injuries, monitored for emotional distress, and was then transferred to Room B. The initial SOC-341 filed to CDPH on 11/16/24, was incomplete and did not show the description of the incident. Additional information to show the description of the incident was filed on 11/18/24, which was 48 hours after the incident. * CNA 3 witnessed Resident 1 yell and curse at 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, facility document review, and facility P&P review, the facility failed to investigate an allegation of abuse as per the facility's P&P and monitor the residents after the alleged abuse for three of three sampled residents (Residents 1, 2, and 3). * Resident 1 was being assisted by two nurse aide students, when Resident 1 angrily yelled and demanded Resident 2 to leave Room A. Resident 1 hit Resident 2's right foot, as witnessed by the two nurse aide students, on 11/16/24. Resident 2 was assessed with no physical injuries, monitored for emotional distress, and was then transferred to Room B. The facility failed to interview staff members on all shifts who had a contact with the resident during the period of the alleged incident asper the facility's P&P. Furthermore, the facility failed to ensure the SSD visited Residents 1 and 2 daily for 72 hours, as per the facility's investigation report. * CNA 3 witnessed Resident 1 yell and curse at Resident 3 on 12/13/24. 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, and facility P&P review, the facility failed to ensure the appropriate infection control practices designed to provide a safe and sanitary environment and help prevent the development and transmission of infections were implemented. * The facility failed to include the residents who exhibited sign and symptoms of infection who were not prescribed antibiotics on the Surveillance program from January 2023 to February 2024. * CNA 3 failed to perform hand hygiene after touching Resident 35's shoulder and prior to serving a meal tray to Resident 50. * The facility failed to clean and disinfect the blood pressure machine between Resident 24 and Resident 404's use. * The facility failed to disinfect the blood glucose monitoring device after being used and the LVN did not change gloves prior to insulin administration for Resident 37. * The facility failed to allow the alcohol to dry prior to Lovenox (Enoxaparin Sodium, a medicine used to treat or prevent a type of…

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

Based on interview, medical record 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 antibiotics. Findings: Review of the facility's P&P titled Antibiotic Stewardship revised 12/2021 showed antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program. Review of the facility's infection control binder showed McGeer's Infection Surveillance form or Surveillance Data Collection Form being used to assess for McGeer's criteria to determine the true infection. Review of the facility's monthly infection control surveillance forms from 6/2023 through 2/2024, showed the following surveillance data. However, the facility failed to show documentation the McGeer's/Surveillance Data Collection form 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.

Based on observation, interview, and facility document review, the facility failed to maintain the essential equipment in a safe operating condition. * The facility failed to ensure the ice machine located in the dining room was cleaned and sanitized as per the manufacturer's instruction manual. This failure had the potential for the ice machine not being maintained in a safe operating condition and posed the risk of equipment to function improperly. Findings: According to the USDA Food Code 4-501.11 Equipment 4-501.11 Good Repair and Proper Adjustment, (A) Equipment shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. Review of the ice machine manufacturer's instruction manual, Section B showed in part, cleaning and sanitizing instructions. The icemaker must be cleaned and sanitized at least once a year. More frequent cleaning and sanitizing may be required in some water conditions. - Step 9. In bad or severe water conditions, turn off the power supply, then remove, clean (cleaning solution = 5 oz. Hoshizaki Scale…

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 22 final sampled residents (Resident 505) was assessed to safely self-administer the medications prior to performing the self-administration of medications. This failure had the potential to negatively impact the resident's physiological well-being and could administer the medications inaccurately. Findings: Review of the facility's P&P titled Self-Administration of Medications showed the residents who wish to self-administer their medications may do so, if it is determined that they are capable of doing so. As part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities to determine whether a resident is capable of self-administering medications. If the staff determine that a resident cannot safely self-administer medications, the nursing staff will administer the resident's medication. In addition, the staff shall identify and give 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 ensure the physician was notified of the changes in conditions for one of 22 final sampled residents (Resident 305) as evidenced by: * The facility failed to notify the physician for Resident 305's multiple scattered reddish, maroon colored skin discoloration to the bilateral upper extremities. This failure had the potential for Resident 305 not to receive the appropriate treatment to address his medical needs and to have a delay in care and treatments. Findings: Review of the facility's P&P titled Change in a Resident's Condition or Status revised September 2023 showed the Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been: i. instructions to notify the physician of changes in the resident's condition. Regardless of the resident's current mental or physical condition, the Nursing Supervisor/Charge Nurse will inform the resident of any changes…

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 privacy was provided for one of 22 final sampled residents (Resident 18) and three nonsampled residents (Residents 14, 24, and 32). * The privacy curtain was not pulled while providing the ADL care to Residents 14, 18, and 32. * The facility failed to ensure the privacy was provided during the GT medication administration for Resident 24. These failures had the potential to negatively affect the dignity of the residents and violate the residents' right to privacy. Findings: Review of the facility's P&P titled Dignity revised November 2023 showed the residents are always treated with dignity and respect. Staff promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. 1. On 3/19/24 at 0822 hours, CNA 5 was observed inside Resident 18's room. Resident 18's privacy curtain was observed open and Resident 18 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 provide a summary of the baseline care plan for two of 22 final sampled residents (Residents 304 and 307). This failure had the potential for inappropriate interventions and care for these residents. Findings: Review of the facility's P&P titled Care Plans- Baseline revised March 2022 showed the resident and/or representative are provided a written summary of the baseline care plan (in a language that the resident/representative can understand) that includes, but is not limited to the following: - the stated goals and objectives of the resident; - a summary of the resident's medications and dietary instructions; - any services and treatments to be administered by the facility and personnel acting on behalf of the facility; and - any updated information based on the details of the comprehensive care plan as necessary. Provision of the summary to the resident and/or resident representative is documented in the 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, medical record review, and facility P&P review, the facility failed to develop and implement the comprehensive plans of care to reflect the individual care needs of three of 22 final sampled residents (Residents 12, 304, and 505). * The facility failed to develop a care plan with goal and interventions to address Resident 12's RNA services. * The facility failed to implement a care plan intervention to place TED hose (Thrombo-Embolic Deterrent, specially designed knee-high, thigh-high or waist high stockings that help prevent blood clots and swelling in your legs) to swollen extremities for Resident 304. * The facility failed to implement a pad alarm in bed/wheelchair for Resident 505. These failures posed the risk of not providing appropriate, consistent, and individualized care to these residents. Findings: Review of the facility's P&P titled Care Plans-Comprehensive revised September 2023 showed each resident's comprehensive care plan is designed to incorporate identified…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure the comprehensive plans of care for one of 22 final sampled residents (Resident 12) was revised to reflect the resident's current care needs and interventions. * The facility failed to ensure Resident 12's plan of care was revised to reflect Resident 12 was discharged from therapy services. This failure posed the risk of not providing Resident 12 with individualized and person-centered care. Findings: Review of the facility's P&P titled Care Plans-Comprehensive revised September 2023 showed the Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans when there had been a significant change in the resident's condition; when the desired outcomes is not met; when the resident has been readmitted to the facility from a hospital stay; and at least quarterly. Medical record review for Resident 12 was initiated on 3/21/24. Resident 12 was admitted to the facility on [DATE]. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure a non-English speaking resident's communication needs were met for one nonsampled resident (Resident 31) and failed to ensure the translation service contact information was available for staff. These failures had the potential for a delay in the facility's ability to communicate with the resident. Findings: Review of the facility's P&P titled Communication Barriers, Reduction Of, undated, showed the facility will provide methods of communication to assure adequate communication between residents and staff. Medical record review for Resident 31 was initiated on 3/21/24. Resident 31 was admitted to the facility on [DATE]. Review of Resident 31's MDS dated [DATE], showed Resident 31 spoke a non-English language and requested an interpreter to communicate with the health care staff. Review of Resident 31's SBAR Communication Form and Progress Note - V 3 dated 3/17/24, showed a change of condition for the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to attain or maintain the highest practicable well-being for one of 22 final sampled residents (Resident 305). * The facility failed to identify and assess for Resident 305's multiple scattered reddish, maroon-colored skin discoloration to his bilateral upper extremities. This failure had the potential risk of not providing appropriate care for Resident 305. Findings: Review of the facility's P&P titled Change in a Resident's Condition or Status revised September 2023 showed the Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been: i. instructions to notify the physician of changes in the resident's condition. Regardless of the resident's current mental or physical condition, the Nursing Supervisor/ Charge Nurse will inform the resident of any changes in the resident's medical/mental condition…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure one of 22 final sampled residents (Resident 505) remained free from the accident hazards. * The facility failed to monitor Resident 505 for 72 hours after her fall according to the facility's P&P. This failure had the potential to place the resident at risk for serious injury. Findings: Review of the facility's P&P titled Assessing Falls and Their Causes revised November 2023 showed after a fall observe for delayed complications of a fall for approximately forty-eight (48) hours after an observed or suspected fall and will document findings in the medical record. Review of the facility's P&P titled Neurological Assessment revised November 2023 showed neurological assessments are indicated: (a) upon physician order; (b) following an unwitnessed fall; (c) following a fall or other accident/injury involving head trauma; or (d) when indicated by resident's condition. 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 provide the necessary GT care for one nonsampled resident (Resident 24). * The facility failed to ensure the gastric residual volume (volume of fluid remaining in the stomach) was checked before flushing and administering a bolus feeding (a single dose of medication or other substance given over a short period of time) to Resident 24. This failure posed the potential risk for Resident 24 to have aspiration during the medication administration and for developing complications related to GT. Findings: Review of the facility's P&P titled Administering Medications Through an Enteral Tube revised March 2023 showed to check the gastric residual volume (GRV) to assess for tolerance of enteral feeding and when correct tube placement and acceptable GRV had been verified, flush tubing with 15-30 ml warm sterile water (or prescribed amount). On 3/19/24 at 0830 hours, a medication administration observation was conducted…

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 for three of 22 final sampled residents (Residents 9, 13, and 50) and one nonsampled resident (Resident 51) to meet the needs of each resident as evidenced by: * The facility failed to ensure the controlled drug Percocet (opioid analgesic) 5 mg-325 mg tablet signed out from the controlled drug record was documented as administered on the MAR for Resident 9; and the controlled drug, Norco (opioid analgesic) 5 mg-325 mg tablet signed out from the controlled drug record was documented as administered on the MAR for Resident 50. * The facility failed to the removed and not used controlled drug tablet was properly discard and not placed back into the bubble pack and taped for Resident 51. * Resident 13's Fleets enema (a liquid laxative administered into the rectum) was not administered as ordered by the physician. These failures posed the risk of diversion of the controlled…

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 22 final sampled residents (Resident 2) was provided the management for the use of psychotropic medications (medications that affect the mind, emotions, and behavior). * The facility failed to ensure the non-pharmacological approaches were provided to Resident 2 while receiving alprazolam (to treat anxiety disorders and panic disorders-sudden, unexpected attacks of extreme fear and worry about these attacks), bupropion (to treat depression), citalopram (to treat depression), and Quetiapine (Seroquel, medicine used to treat several kinds of mental health conditions including schizophrenia and bipolar disorder. It helped regulate the mood, behaviors, and thoughts) medications. This failure had the potential to cause harm to Resident 2. Findings: Review of the facility's P&P titled Behavioral Assessment, Intervention and Monitoring revised March 2023 showed non-pharmacological approaches would be utilized to the…

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

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 rate was 10.34%. One of two licensed nurses (LVN 2) observed administering the medications was found to have errors while administering the medications to two nonsampled residents (Residents 24 and 404). * The facility failed to ensure Resident 24 received the prescribed nasal gel and correct amount of the diclofenac sodium topical gel (to relieve pain from arthritis in certain joints such as those of the knees, ankles, feet, elbows, and hands). * LVN 2 prepared the expired vitamin D3 for Resident 404 during the medication pass observation. These failures had the potential for the residents to receive ineffective therapeutic effects of the medications and had negatively affect the residents' health. Findings: 1. Review of the facility's P&P titled Administering Medications revised date December 2021 showed the individual administering the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, facility record review, and facility P&P review, the facility failed to ensure the medications were properly stored and labeled for two of 22 sampled residents (Residents 307 and 505) and one nonsampled resident (Resident 37); and failed to ensure the medication room refrigerator temperatures were monitored in accordance with the facility's P&P. * The facility failed to dispose the insulin pen beyond the used by date for Resident 37. * The facility failed to dispose the medication and medical supplies after the expiration date. * The facility failed to dispose the opened sterile packages of Collagen dressing and disposable urinary drainage bag. * The facility failed to appropriately label the Apokyn Pen, blood glucose strips, and Miralax bottle with an open date. * The facility failed to monitor the temperatures of the medication room refrigerator. * The facility failed to ensure the medications for Resident 307 were not left unattended at the bedside. * The facility failed to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to ensure the medical record for one of 22 final sampled residents (Resident 13) was complete and accurate. This failure had the potential for the resident's accurate clinical status not being available and communicated to care team. Findings: Medical record review for Resident 13 was initiated on 3/29/24. Resident 13 was admitted to the facility on [DATE]. a. Review of Resident 13's MAR for March 2024 showed an order dated 3/13/24, for a Fleets enema (a liquid laxative administered into the rectum) to be administered in the afternoon for bowel management. The MAR showed it was signed as administered on 3/13/24 at 1300 hours. On 3/19/24 at 1038 hours, an interview was conducted with Resident 13. Resident 13 stated she did not receive an enema. On 3/21/24 at 1225 hours, a telephone interview was conducted with LVN 2. LVN 2 stated he did not administer an enema to Resident 13, and if the MAR showed a check mark for administered, it was done in an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and observation, the facility failed to ensure the call light in the resident's room was functioning for one of 22 final sampled residents (Resident 204). This failure had the potential for a delay in assisting the resident. Findings: Medical record review for Resident 204 was initiated on 3/19/24. Resident 204 was admitted to the facility on [DATE]. On 3/19/24 at 0816 hours, an interview and concurrent observation was conducted with Resident 204. Resident 204 stated they would like their television volume turned up. When asked if the resident pressed her call light button for the staff's assistance, the resident stated she just did. An observation of the call light illuminator in the hallway, above the resident's doorway, was not illuminated to show the call-light button was activated. The resident was asked to push the call light button again, and it was observed that the resident used her thumb to press the call light button. However, there was still no indicator light illuminated above 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.