Chapman Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary hospice care and services for one of two final sampled residents (Resident 30) reviewed for hospice services. * The facility failed to ensure Hospice A was notified when the medications listed in Hospice A medication list were discontinued for Resident 30. * The facility failed to ensure the complete documentation of the hospice staff visits were available for Resident 30, and if Hospice A staff visited Resident 30 as scheduled in the Hospice A calendar. These failures posed the risk for the delay in communication and provision of the hospice care between the hospice provider and facility.Findings: Review of the facility's P&P titled Hospice Services dated 1/2017 showed when a resident participates in the hospice program, a coordinated plan of care between the facility , the hospice agency and resident/responsible party should be developed and should include directive 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 implement the infection control practices designed to provide a safe and sanitary environment to help prevent the development and transmission of diseases and infections for one sampled resident (Resident 8) observed for infection control practices. * The facility failed to ensure CNA 1 donned the appropriate PPE when providing care to Resident 8 with a physician's order for EBP. This failure posed the risk of transmission of infections to the residents throughout the facility.Findings:Review of the facility's P&P titled Enhanced Standard Precautions revised on 5/2024 showed the following:- Enhanced Standard Precautions provide the Skilled Nursing Facility a framework for reducing Multi-Drug Resistant Organism (MDRO) transmission through Healthcare Professional (HCP) use of gowns and gloves while caring for residents at high risk for MDRO transmission at the point of care during specific activities with 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, facility document review, and facility P&P review, the facility failed to ensure the food safety and sanitation guidelines were followed when: * The facility failed to ensure four blenders were not stored wet. * The facility failed to ensure a red cutting board had cleanable surface. * The facility failed to ensure the ice machine was maintained in a sanitary condition. * The facility failed to ensure safe storage of the food brought in by the family. These failures had the potential to result in foodborne illnesses for residents receiving kitchen services. Findings: Review of the facility's document titled Diet Type Report dated 12/3/24, showed 69 of 87 residents were receiving food prepared from the kitchen. 1. According to the USDA Food Code 2022, Section 4-901.11, Equipment and Utensils, Air-Drying Required, items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items prevents them from drying and may allow an environment where microorganism can begin to grow. On 12/3/24 at 0850 hours, an observation and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one nonsampled resident (Resident 343) was safe to self-administer a medication. * Resident 343 had self-administered the lidocaine 5% cream (local anesthetic used to temporarily numb and relieve pain) and kept it at the bedside. Howevever, there was no physician's order for the lidocaine cream and self administration. Resident 343 was not a candidate for self-administer the medications as per the assessment. This failure had the potential for Resident 343 to administer the medication inaccurately. Findings: Review of the facility's P&P titled Medication - Self-Administration dated 1/2017 showed the following: - It is the policy of the facility that residents have the right to self-administer medications if the IDT determines that this practice is clinically appropriate; - On admission or shortly thereafter, each resident will be assessed to determine if they wanted to self-administer their 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 reasonable accommodations to meet the needs for one of 18 final sampled residents (Resident 339) and one nonsampled resident (Resident 45). * The facility failed to ensure the call light was within reach and accessible for Residents 45 and 339. This failure had the potential to negatively impact the residents' psychosocial well-being or result in a delay to receive care. Findings: Review of the facility's P&P titled Call Lights dated 1/2017 showed when the resident is in bed or in the wheelchair or chair in the room, staff should make sure that the call light is within easy reach of the resident. 1. On 12/3/24 at 1222 hours, Resident 339 was observed sitting in the wheelchair on the left side of the bed and near the foot of the bed. Resident 339 asked for her call light. The call light was observed clipped on the right side of the headboard and was not within Resident 339's reach. Resident 339…

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 18 final sampled residents (Residents 55) was referred to PASRR level II review when Resident 55's diagnosis was changed from Alzheimer's with psychosis to schizoaffective disorder. This failure had the potential for Resident 55 to not receive the specialized care and services appropriate for her condition. Findings: Review of the facility's P&P titled PASRR revised 3/2019 showed it is the policy of the facility to screen each resident, regardless of payment source, when applying for admission to, or residing in the facility, which is a Medicaid-certified facility, for mental illness and intellectual disability. Medical record review for Resident 55 was initiated on 12/4/24. Resident 55 was admitted to the facility on [DATE]. Review of Resident 55's Department of Health Care Services PASRR Level I Screening dated 7/1/24, showed Resident 55 had no diagnosis of serious mental disorder. 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 ensure one of two residents (final sampled resident, Resident 26) reviewed for nutrition received the appropriate services needed to maintain acceptable parameters of nutritional status when: * The facility failed to ensure the RD recommendations on 9/26/24, were followed-up with the physician and addressed in the IDT weight variance meeting when Resident 26 had severe weight loss of 11 lbs in 20 days. This failure had the potential for Resident 26 not to receive the necessary intervention to prevent further weight loss. Findings: Review of the facility's P&P titled Weight Variance Committee dated 4/2017 showed it is the policy of the facility to review and monitor the residents with weight variances, at an interdisciplinary team (IDT) meeting on a regular scheduled basis. Under the section for Procedure showed the following: - Screening of weights variances will be done on a regular…

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 necessary care and services related to GT feeding were provided for two of 18 final sampled residents (Residents 18 and 58) reviewed for tube feeding. * The facility failed to ensure Residents 18 and 58 had the updated tube feeding care plans following a revision of tube feeding orders. * The facility failed to ensure Residents 18 and 58's physician's orders for tube feeding had a start time and specified stop time or until dose complete. These failures posed the risk for developing complications related to a GT. Findings: 18 Review of the facility's P&P titled Gastrostomy Tube Feeding via Continuous Pump revised 1/2017 showed it is the policy of the facility to provide nourishment via continuous pump to residents who are unable to obtain adequate nourishment orally, as ordered by the resident's attending physician, verify that there is a physician's order for this procedure and review the resident's care plan and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for six of 18 final sampled residents (Residents 51, 58, 70, 76, 339, and 588) and four nonsampled residents (Residents 23, 37, 338, and 340) reviewed for respiratory care. * The facility failed to ensure the oxygen administration to Resident 70 was performed by a licensed nurse and failed to ensure Resident 70's oxygen administration was documented in the MAR. In addition, the facility failed to ensure a No Smoking/Oyxgen in Use sign was posted outside the resident's door per the facility's P&P. * The facility failed to ensure a No Smoking/ Oxygen in Use sign was posted outside the resident's door as per the facility's P&P for Resident 23, 37, 51, 76, and 339. * The facility failed to ensure Resident 340's suction was stored in a sanitary manner. * The facility failed to ensure Resident 338's nasal cannula tubing was stored in a sanitary manner. * 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 observation, interview, and medical record review, the facility failed to provide the necessary care and services to attain or maintain the highest physical well-being for one of one final sampled residents (Resident 341) reviewed for hemodialysis care. * The facility failed to ensure the physician's order for Resident 341's dialysis and plan of care addressing Resident 341's hemodialysis care showed the correct location of the permacath site on the right upper chest. This failure had the potential for the delay in Resident 341's dialysis site assessment and resident's poor health outcomes. Findings: Medical record review for Resident 341 was initiated on 12/9/24. Resident 341 was admitted to the facility on [DATE]. Review of Resident 341's Initial Nursing History and assessment dated [DATE], showed the permacath site on the right upper chest. Review of Resident 341's Order Summary Report dated 12/5/24, showed a physician's order dated 11/26/24, to monitor the permacath site on the left upper chest 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 ensure two of 18 final sampled residents (Residents 29 and 339) remained free from accident hazards associated with the use of elevated side rails. * The facility failed to obtain an informed consent and initiate a care plan for the use of the bilateral grab bars for Resident 29. * The facility failed to ensure the least restrictive alternatives were implemented prior to the installation of the grab rails for Resident 339. In addition, the facility failed to ensure the informed consent forms for the use of the grab rails showed who obtained the consent from Resident 339. These failures had the potential to place the residents at risk for an entrapment and serious injury. Findings: Review of the facility's P&P titled Siderails or Bedrails revised 8/2018 showed the informed consent for the physical restraint, including the use of bed or siderails even for episodic use is required to be obtained from the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility document review, the facility failed to ensure the Pharmacy Consultant's recommendations were acted upon for one of 18 final sampled residents (Resident 29) and one nonsampled resident (Resident 6). * The Pharmacy Consultant's recommendation for the tramadol (narcotic pain medication) label be changed to show the medication was for pain management and not for severe pain level (7-10) was not followed for Resident 6. * The Pharmacy Consultant's recommendation to have the A1C level monitoring every three months until treatment goal was met, then every six months months, was not followed for Resident 29. These failures had the potential to put Residents 6 and 29 at risk for adverse consequences. Findings: 1. On 12/3/24 at 1628 hours, a concurrent inspection of Medication Cart D, interview, and medical record review for Resident 6 was conducted with RN 1. The bubble pack of the tramadol medication for Resident 6 showed a label showing the tramadol medication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to ensure one of 18 final sampled residents (Resident 29) was free from the unnecessary psychotropic medications. * The facility failed to ensure Resident 29 was monitored for the orthostatic hypotention related to the use of Wellbutrin (a medication used to treat depression), quetiapine (medication used to treat bipolar disorder), and trazodone (a medication used to treat depression). This failure had the potential for the residents to have adverse complications from the psychotropic medications. Findings: Medical record review for Resident 29 was initiated on 12/06/24. Resident 29 was admitted to the facility on [DATE]. Review of Resident 29's H&P examination dated 4/1/24, showed Resident 29 had the capacity to understand and make decisions. Review of Resident's 29 Order Summary Report showed the following physician's orders: - date 4/5/24, to administer Wellbutrin XL (extended release) 300 mg one tablet orally one time a day for depression m/b…

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 during the medication administration observation was less than five percent (5%). The facility had a cumulative medication error rate of 7.41% when two of 27 opportunities for errors were observed on one licensed nurse (LVN 7) who administered medications to one nonsampled resident (Resident 688). The observed medication administration errors were: * LVN 7 failed to administer the Metamucil 4 in 1 Fiber oral packet (fiber supplement/laxative) medication to Resident 688 as ordered by the physician. * LVN 7 administered 100 mg of enoxaparin sodium (anticoagulant) instead of 10 mg of enoxaparin sodium as ordered by the physician to Resident 688. These failures had the potential to compromise the health and safety of Resident 688. Findings: Review of the facility's P&P titled Ordering and Receiving Medications from the Dispensing Pharmacy dated 4/2008 showed the medications and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of three residents (Resident 688) observed for medication administration was free from the significant medication errors. * Resident 688 received 100 mg of enoxaparin sodium (anticoagulant medication) instead of 10 mg of enoxaparin sodium as ordered by the physician. This failure posed the risk for adverse consequences to the resident. Findings: Review of the facility's P&P titled Medication Administration - General Guidelines dated 10/2017 showed medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. The facility has sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions. The Procedure section showed prior to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure proper storage, labeling, and disposal of medications for three of six medication carts (Medication Carts A, B, and C), one of 18 final sampled residents(Resident 339), and two nonsampled residents (Residents 6 and 338). * The facility failed to ensure Medication Cart A was not left unlocked and unattended. * The facility failed to ensure the IV medications on hold were not stored with the current IV medications in Medication Cart B. * The facility failed to ensure the medications on hold were not stored with current medications, orally administered medications were stored separate from externally used medications, and the bubble packs containing medications remained intact and free from tears in Medication Cart C. * The facility failed to ensure a bottle of Zenpep (pancrelipase) was not left at Resident 338's bedside table. * The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure one nonsampled resident (Resident 5) was provided with the prescribed therapeutic diet. * The facility failed to ensure Resident 5 was served a meal consistent with the ordered therapeutic diet of mechanical soft, finely chopped diet. Resident 5 was served large pieces of meat with a half piece of hard toast. This failure had the potential for Resident 5's nutritional needs to not be met and aspiration. Findings: Medical record review for Resident 5 was initiated on 12/3/24 at 1352 hours. Resident 5 was admitted to the facility on [DATE]. Review of Resident 5's H&P evaluation dated 9/30/24, showed Resident 5 could make needs known but could not make medical decisions. Review of Resident 5's physician's order dated 6/26/24, showed fortified diet mechanical soft texture, regular/thin liquid consistency, liberalized fortified mechanical soft diet (finely chopped meat/vegetables) with regular think liquids for finely chopped meat and vegetable. Review…

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

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the facility staff assisted the residents regarding the use and storage of food brought in by the family or visitors for the residents. * The facility failed to ensure the food items in the unlabeled and undated containers on Resident 81's nightstand, and inside a small refrigerator in the resident's room were properly stored. This failure had the potential to cause foodborne illnesses to the medically vulnerable resident population who consume food brought from outside sources. Findings: Review of the CMS S&C-09-39 Food Procurement, and Self-Determination and Participation, dated 5/29/09, showed the following: - The residents have the right to choose to accept food from visitors, family, friends, or other guests according to their rights to make choices; and - The facility has the responsibility under the food safety regulation to help visitors to understand safe food handling practices such as not holding or transporting foods containing perishable ingredients at…

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 P&P review, the facility failed to ensure the medical records were accurate for one of 18 sampled residents (Resident 29) and one nonsampled resident (Resident 64). * The facility failed to ensure the error on the H&P evaluation form was properly documented for Resident 64 as per the facility's P&P. * The facility failed to ensure the psychotropic medication consent forms for Resident 29 were properly completed by the physician. * The facility failed to ensure the route of medication for Resident 29 was correctly ordered on the MAR. These failures had the potential for the residents' needs not being met as the medical information were incomplete. Findings 1. Review of the facility's P&P titled Documentation Principles revised 2/2018 showed one line or an x should strike out a mistake, which should be initialed and dated. A signature should be entered if there is no entry after the x or line indicating a mistake. Medical record review for Resident 64 was initiated on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for one of one final sampled residents (Resident 70) reviewed for hospice services. * The facility failed to ensure the Hospice Aide did not provide oxygen to Resident 70 and notified the licensed nurse when Resident 70's oxygen saturation was 80%. In addition, the facility failed to ensure the physician's order on the frequency of the hospice staff visits were carried out, to clarify the frequency of the skilled nursing as needed visits, and to ensure there were no missing skilled nursing and hospice clinical notes. These failures posed the risk for delays in providing Resident 70 immediate care, and delays in the communication between the hospice provider and the facility which may affect the resident care. Findings: Review of the facility's P&P titled Hospice Care dated 9/2018 showed the following: - The facility retains primary responsibility for implementing care that is not…

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

Based on observation, interview, and facility P&P review , the facility failed to implement the infection control practices designed to provide a safe and sanitary environment and help prevent the development and transmission of diseases and infections. * The facility failed to ensure the clean linen cart was covered during the transportation. * The facility failed to ensure the staff performed hand hygiene in between assisting Residents 36 and 50 with meals. * The facility failed to ensure the staff performed hand hygiene before and after wearing gloves during the wound treatment observation for one final sampled resident (Resident 24). These failures had the potential for cross-contamination and spread of infectious organisms in the facility. Findings: 1. Review of the facility's P&P titled Infection Control Policy - Laundry Services dated 7/2019 showed it is the facility's responsibility to ensure that all laundry is handled, stored, processed and transported in a safe and sanitary manner. On 12/6/24 at 1354 hours, Laundry Aide 1 was transporting a clean linen cart. The linen…

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 conduct the regular bed inspection as part of a regular maintenance program to identify areas of possible entrapment for three of four final sampled residents (Residents 29, 51, and 339) investigated for the side rail use. These failures had the potential to negatively impact the residents resulting in possible entrapment, serious injury, and death. Findings: According to the FDA Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, the term entrapment describes an event in which a patient/resident is caught, trapped, or entangled in the space in or about the bed rail, mattress, or hospital bed frame. Patient entrapments may result in deaths and serious injuries. These entrapment events have occurred in openings within the bed rails, between the bed rails and mattresses, under bed rails, between split rails, and between the bed rails and head or foot boards. The population most…

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 activity staff failed to immediately report to the Charge Nurse when witnessing Family Member 1 hitting Resident 1 on his head with her hand. This failure had the potential to delay the alleged abuse investigation and mandatory reporting requirements. Findings: Review of the facility's P&P titled Abuse Reporting and Prevention revised 8/2018 showed the staff should notify the Charge Nurse as soon as possible. If the Charge Nurse is notified, the Charge Nurse will immediately notify the Administrator (Abuse Coordinator) and Director of Nursing. Social Services notified and begin the interventions as indicated. On 6/17/24, CDPH, L&C Program received a report from the facility which showed Family Member 1 was witnessed pushing Resident 1's head with a playing chip and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to prevent a fall incident for one of two sampled residents (Resident 1). * Resident 1's shower chair wheels were not locked when arriving at the shower room; therefore, when the resident removed his cover and leaned forward, the shower chair moved and tilted forward, causing the resident to fall on his left knee and sustaining a fracture. This failure had the potential to negatively impact the resident's well-being. Findings: Review of the facility's P&P titled Fall Risk and Prevention of Injury to include Pathological Fractures revised 03/2019 showed it is the policy of the facility to identify residents that are at risk for falls and to implement a plan of care in an attempt to prevent falls. This includes minimizing the risks for pathological fractures. Under the section for approaches to prevent falls and/or fractures, it includes locking the brakes on beds, gurneys, or…

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

Based on observation, interview, and facility document review, the facility failed to ensure the food safety and sanitation requirements were met in the kitchen as evidenced by the following: * The facility failed to ensure the storage containers for dry food were completely sealed without noticeable gaps. * The facility failed to ensure the cutting boards were in sanitary condition and with cleanable surface. * The facility failed to ensure the peelers were in sanitary condition and free of food particles. * The facility failed to ensure the kitchen equipment was air dried and free of food particles. * The facility failed to ensure the kitchen utensils were clean and free of food particles. * The facility failed to ensure the kitchen utensils had a smooth cleanable surface and were not worn out. * Unlabeled white powder was observed stored inside the metal storage for clean plastic containers. *A food tray with an uncovered bowl of peaches was left on top of the PPE cart and brought to a resident's room. These failures had the potential to cause foodborne illnesses in a medically…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to follow up with the regional center's correspondence to enquire if a Preadmission Screening and Resident Review (PASRR) Level II Screening were to be completed to determine specialized services available for one of 18 final sampled residents (Resident 15). This failure had the potential to delay additional services for individualized care and support to enhance their quality of life and to assist them in realizing their full potential, as well as integrating services into the plan of care. Findings: According to Medicaid.gov, Preadmission Screening and Resident Review (PASRR) is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care .PASRR requires that 1) all applicants to a Medicaid-certified nursing facility be evaluated for serious mental illness (SMI) and/or intellectual disability; 2) be offered the most appropriate setting for their needs (in the community, a nursing…

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 individualized resident-centered plans of care for two final sampled residents (Residents 15 and 41). * Residents 15 and 41's care plan interventions were not appropriate for their functional abilities. This failure had the potential for Residents 15 and 41 to not receive adequate and individualized care to support safety and well-being, and not communicate their appropriate plan of care to the interdisciplinary team. Findings: Review of the facility's P&P titled Assessment and Care Planning - Interdisciplinary Team revised 01/2018 showed the Interdisciplinary Team is responsible for the development of an individualized resident centered assessment and comprehensive care plan for each resident. 1. Medical record review for Resident 15 was initiated on 5/3/22. Resident 15 was admitted to the facility on [DATE]. Review of Resident 15's History And Physical Examination dated 2/7/22, showed Resident 15 did not have…

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 18 final sampled residents (Resident 19) received services consistent with professional standards of practice when: * Resident 19's arm with a dialysis access site was used for taking blood pressures despite a physician's order not to do so. * Resident 19's fluid restriction orders were not followed and the resident's fluid intake logs were inaccurate. These failures had the potential to negatively impact the resident's physical well-being. Findings: 1. According to the facility's P&P titled Dialysis Care dated 9/2017, blood pressure and venous punctures will not be performed on the extremity where the shunt is located. Medical record review for Resident 19 was initiated on 5/9/22. Resident 19 was admitted to the facility on [DATE], and had a diagnosis of end stage renal disease which required hemodialysis. Review of Resident 19's Physician Order Report dated 5/1/22, showed a physician's order dated 2/6/22, for AV…

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

Based on interview, medical record review, and facility P&P review, the facility failed to ensure proper accounting and safeguarding of the controlled medications to prevent loss, diversion, or accidental exposure when the incoming and outgoing licensed nurses assigned to Medication Carts A and B were inconsistent with signing the shift count log. This failure posed the risk for loss or diversion of controlled medications. Findings: Review of the facility's P&P titled Controlled Medication Storage dated 8/2014, under the section for Policy showed the medications included in the Drug Enforcement Administration classification as controlled substances are subject to special handling, storage, disposal and recordkeeping in the facility in accordance with federal, state and other applicable laws and regulations. The Procedures section showed at each shift change, a physical inventory of all controlled medications, including the emergency supply is conducted by two licensed nurses and is documented on the controlled medication accountability record. 1. Review of the Medication Cart 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 interview and medical record review, the facility failed to ensure the pharmacy consultant's recommendation was acted upon for one of 18 final sampled residents (Resident 15). This had the potential for the resident to be administered a sub-therapeutic medication. Findings: Review of the facility's Drug Regimen Review P&P revised 10/2017 showed the pharmacy consultant reviews each residents' medical records monthly and will report any irregularities. The P&P showed the physician will respond within 72 hours, or the nurse will call the physician to follow up. Medical record review for Resident 15 was initiated on 5/3/22. Resident 15 was admitted to the facility on [DATE]. Review of Resident 15's physician progress notes showed a note to the resident's physician from the consultant pharmacist printed 3/18/22. The note showed Resident 15 was on Ativan (a sedative that can be used to treat seizures) 1 mg IM (intramuscular -injected in to the muscle) every 12 hours as needed for seizures, and IM Ativan was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility P&P review, the facility failed to store the drugs and biologicals in a safe manner for one of two medications rooms (Medication Room A) and one of eight medication carts (Treatment Cart A). * Eight expired telfa dressings, expired hydrocerin lotion (a moisturizer used to treat or prevent rough, dry skin) and a bag of expired foley catheter leg bag were observed in Treatment Cart A. This failure had the potential for the residents to be exposed to the expired or deteriorated medications or biologicals. * The facility failed to ensure Residents A and B's medications were disposed of at the time of their discharges. This failure had the potential for the medications to be accidentally administered and/or diverted. Findings: According to the facility's Policy and Procedure titled Storage of Medications dated 4/2008, under the section Policy, showed the medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or…

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.