Garden Grove Post Acute

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 one sampled resident (Resident 16) reviewed for intravenous care. * The facility failed to ensure the peripheral IV line dressing for Resident 16 was labeled and dated. This failure had the potential for the use of the resident's outdated peripheral IV access and posed a risk for IV site complications. Findings: Review of the facility's P&P titled Peripheral Venous Catheter Insertion dated 3/2023 showed to obtain a physician's order for the peripheral venous catheter insertion. The peripheral IV catheter sites will be changed when clinically indicated. Under the procedures, showed to write the date, time, and initials on the dressing label. On 6/24/26 at 0949 hours, an observation was conducted with Resident 16. Resident 16 was observed lying on her back in bed with a peripheral IV line on the left hand and an IV antibiotic…

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, facility document review, and facility P&P review, the facility failed to ensure the pharmacist recommendations identified during the Drug Regimen Review were followed through in two of five residents reviewed for unnecessary medications ( Residents 8 and 31). * The facility failed to ensure Resident 8's Drug pharmacy recommendation for levothyroxine (medication to treat underactive thyroid by replacing missing hormones), and Latanoprost (prescription eye drop used to treat open-angle glaucoma and ocular hypertension by lowering intraocular pressure) and cyclosporine (used to treat chronic dry eye disease by decreasing eye inflammation and increasing your natural tear production) medications were followed through in a timely manner. In addition, Resident 8's medical record failed to show the rationale when the physician continued Resident 8's BP medication despite multiple low blood pressure readings. * The facility failed to follow through with the pharmacist's recommendation…

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, observation, medical record review, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure the proper storage, labeling, and disposal of medications to one of three medication rooms and one of four medication carts inspected for labeling and storage of drugs and biologicals. * The facility failed to ensure Resident 55's opened vial of lidocaine HCl (medication used to temporarily numb specific areas of the body to block pain) was dated when the vial was opened. * The facility failed to ensure expired COVID-19 testing kits were removed from the medication supply room. These failures posed the risk for the resident's use of outdated medication and inaccurate testing results for the residents.Findings: Review of the facility's P&P titled Medication Storage in the Facility revised 1/2025 showed the medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations. Outdated, contaminated, or deteriorated…

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 two of 22 final sampled residents (Residents 68 and 88) who received hospice services. * The facility failed to ensure the hospice skilled nurse visit notes and CHHA notes were available and included in Resident 68's medical records. Furthermore, the facility failed to ensure the staff awareness of the facility's hospice designee/coordinator. * The facility failed to ensure the hospice skilled nurse visit notes and CHHA notes were available and included in Resident 88's medical records. Furthermore, the facility failed to ensure staff awareness of the facility's hospice designee/coordinator. These failures posed the risk of delay in communication between the hospice provider and facility which may affect resident care. Findings: Review of the facility's P&P titled Hospice Services date revised 1/2017 showed a communication process, including how the communication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to ensure two of seven sampled residents (Residents 4 and 7) attained and maintained the highest practicable physical well-being. * The facility failed to ensure Resident 4's sling was positioned properly to the resident's left arm as ordered by the physician. Additionally, the facility failed to provide toileting schedule as ordered by the physician for Resident 4. * The facility failed to ensure Resident 7's left thumb had a splint as ordered by the physician. These failures had the potential to negatively impact Residents 4 and 7 physical well-being.Findings: 1. Medical record review for Resident 4 was initiated on 8/26/25. Resident 4 was admitted to the facility on [DATE]. Review of Resident 4's MDS Quarterly assessment dated [DATE], showed the resident had clear speech. Resident 4 could sometimes make themselves understood and sometimes was able to understand…

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

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 seven sampled residents (Resident 4). * The facility failed to assess and notify the resident's physician and family member when Resident 4 was found on the floor mattress. These failures had the potential to negatively impact the resident's well-being.Findings: Review of facility's P&P titled Fall Risk/ Prevention revised July 2018 showed if a resident sustains a fall, the licensed nurse is to be notified immediately prior to moving the resident. The licensed nurse will assess the resident immediately and an incident report will be completed with an investigation. Special emphasis should be placed on events leading up to the fall, the condition of the resident at the time of the fall and the environment where the resident fell. The incident report and the investigation will be reviewed by the Interdisciplinary Team with recommendations 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 the appropriate care and services related to GT were provided for two of seven sampled residents (Residents 2 and 3). * Resident 2 was provided with Glucerna (enteral feeding formula) 1.2 at 65 cc/hour via GT, when the physician's order specified it to be 50 cc/hour. * Resident 3 was provided with water flush at 30 cc/hour via GT, when the physician's order specified it to be 35 c/hour. These failures posed the risk for complications related to the use of GT for Residents 2 and 3.Findings: Review of the facility's P&P titled Gastrostomy Tube Feeding via Continuous Pump revised January 2017 showed it is the policy of the facility to provide nourishment via continuous pump to the residents who are unable to obtain adequate nourishment orally, as ordered by the resident's attending physician. 1. Medical record review for Resident 2 was initiated on 8/26/25. Resident 2 was admitted to the facility 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 ensure one of four sampled residents (Resident1) was free from the unnecessary medications. * Resident 1 was administered Ozempic (medication used to manage type 2 diabetes) one mg subcutaneously (beneath the skin) for DM. However, Resident 1 had no diagnosis of DM. In addition, the facility failed to ensure Resident 1's plan of care addressed the use of the Ozempic medication and monitored the side effects of the medication. * Resident 1 was administered oxycodone (used to relieve severe pain) 10 mg medication when Resident 1's pain level was below the parameters ordered for the medication. These failures had the potential for Resident 1 to receive unnecessary medications and experience adverse effects from the medications. Findings: Review of the facility's P&P titled Medication Administration revised 4/2025 showed it is the policy of the facility that medications for residents be administrated in a safe manner and as…

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

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food safety and sanitation requirements were met in the kitchen as evidenced by: * The facility failed to ensure the opened food items in the freezer were properly dated. * The facility failed to ensure the foods in refrigerator were properly labeled and dated, and failed to discard the items in the refrigerator that past the use-by date. * The facility failed to ensure the juice boxes and thickener were properly labeled and dated. * The facility failed to ensure the kitchen utensils and equipment were stored or kept in sanitary conditions. * The facility failed to ensure the food preparation equipment was in good condition. * The facility failed to ensure multiple bags of the English muffins did not have ice buildup inside. * The facility failed to ensure the sugar container was properly covered. * The facility failed to ensure the food brought from outside was properly labeled and stored for Resident 92. * The kitchen staff (Main Cook) had black hairy forearms…

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 implement the infection control practices designed to provide the safe and sanitary environment and help prevent the development and transmission of diseases and infections as evidenced by: * The facility failed to ensure the water management plan was available which addressed and identified where Legionella and other opportunistic waterborne pathogens could grow and spread, control measures to prevent the growth of the pathogens, and how to monitor them. * The facility failed to ensure the Administrator attended the quarterly infection control committee meetings. * The facility failed to ensure the Laundry Attendant performed proper hand hygiene prior to touching the clean linens. In addition, there were dirty items stored with the clean linens. * The facility failed to ensure the staff donned proper PPE when checking Resident 645's blood sugar level. * The facility failed to ensure…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility document review, the facility failed to provide the necessary care and services to ensure one of 19 sampled residents (Resident 745) and one nonsampled resident (Resident 31) attained and maintained their highest practicable physical well-being. * Resident 745's measurements of abdominal girth were not documented. * The licensed nurse did not check Resident 31's last bowel movement prior to administering the stool softener medication to determine if it needed to be hold as per the physician's order. These failures had the potential for delay in providing the necessary care and services to the residents. Findings: 1. Medical record review for Resident 745 was initiated on 3/5/25. Resident 745 was admitted to the facility on [DATE], with a diagnosis of perforated gastric ulcer (a condition where an ulcer in the stomach wall breaks through, creating a hole that allows stomach contents to leak into the abdominal cavity). Review of Resident 745's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the treatment was provided to prevent a decline in ROM functions for one of 19 final sampled residents (Resident 80). * The physician's order to apply an extension splint to Resident 80's left elbow was not followed. In addition, Resident 80's skin was not assessed when the splint was applied. These failures had the potential for Resident 80 to sustain a decline in ROM functions, leading to muscle atrophy and decrease in functioning. Findings: Review of the facility's P&P titled Splint Application dated 5/2017 showed the splints should be applied correctly to maintain the resident's ROM and prevent contractures and further loss of range of motion. During the initial tour of the facility on 3/5/25 at 0922 hours, Resident 80 was in bed asleep and noted to have contractures to the left arm. There was no splint applied to Resident 80's left arm contracture. Also, the splint was observed in the clear plastic…

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 care and services to prevent accidents for one of 19 final sampled residents (Resident 68). * The facility failed to ensure the floor mats were in place as per Resident 68's physician's order and care plan. This failure put Resident 68 at high risk for falls and serious injuries. Findings: Review of the facility's P&P titled Fall Risk/Prevention dated 7/2018 showed the residents who were assessed upon admission have a high risk for fall, a care plan will be developed and with approaches to prevent falls may include the provision of floor mats at the bedside. On 3/5/25 at 1037 hours, and 3/6/25 at 0813 hours, Resident 68 was observed in bed. The bed was observed to be in the lowest position. There were no floor mats on both sides of the bed. Medical record review for Resident 68 was initiated on 3/6/25. Resident 68 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 provide the necessary care and services to maintain the IV access for one of one final sampled resident (Resident 745) reviewed for IV care and failed to ensure the enteral feeding water bag was accurately labeled with the resident's name for one of 19 final sampled residents (Resident 30) reviewed for enteral feeding care. * The facility failed to ensure the baseline measurements of the PICC line external catheter length and arm circumference were confirmed and documented in the medical record prior to the administration of the IV antibiotics for Resident 745. In addition, the facility failed to ensure the PICC line external catheter length and arm circumference were measured and documented during the PICC dressing change as per the facility's P&P and Resident 745's care plan. These failures had the potential to delay the identification of catheter related complications for Resident 745. * The facility failed…

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's order for oxygen therapy was followed for one of two final sampled residents (Resident 80) and one nonsampled resident (Resident 695) reviewed for oxygen administration. * The facility failed to follow the physician's order for the administration of the oxygen for Resident 695. Additionally, there was no care plan developed for the use of oxygen. * The facility failed to ensure Resident 80's nasal cannula was not touching the floor and the nebulizer tubing was dated and placed on a clear plastic bag when not in use. These failures had the potential to negatively impact the resident's medical condition. Findings: Review of the facility's P&P Oxygen Administration revised 3/2017 showed it is the policy of the facility to provide guidelines for the administration of oxygen. 1.a. Medical Record Review for Resident 695 was initiated on 3/5/25. Resident 695 was admitted to the facility 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 two final sampled residents (Resident 34) reviewed for dialysis care. * The facility failed to ensure Resident 34 was assessed upon her return to the facility after dialysis treatment. * The facility failed to ensure the accurate documentation for the monitoring of Resident 34's fluid restriction. * The facility failed to ensure the emergency dialysis kit was kept at Resident 34's bedside. * The facility failed to ensure Resident 34's care plan was updated to include the dialysis transportation information as per the facility's P&P. These failures had the potential to negatively affect Resident 34's physical well-being. Findings: Review of the facility's P&P titled Dialysis Care revised 2/2018 showed in case of an emergency, at the bedside of a dialysis resident, there should be a clamp, tape, 4x4 (gauzes), and Kerlix. An individualized plan of care will be developed 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 pharmaceutical services. * The facility failed to ensure the active ingredients for Resident 31's artificial tears medication were the same as the Resident 31's physician's order. * The facility failed to ensure the Controlled Drug Record matched the MAR for Resident 66's oxycodone hcl (a narcotic pain medication). These failures had the potential to negatively affect the resident's well-being and posed the risk of diversion of the controlled medication. Findings: 1. Review of the facility's P&P titled Medication Administration - General Guidelines dated 10/2017 showed the 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. During a 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, medical record review, facility document review, and facility P&P review, the facility failed to ensure one of five sampled residents (final sampled resident, Resident 56) reviewed for the use of psychotropic medications. * Resident 56 who had diagnoses including dementia (a disorder which causes a progressive decline in memory and behavior that affects the ability to perform everyday activities) was prescribed Seroquel (an antipsychotic medication). There was no documented diagnosis prior to starting the Seroquel medication. * The facility failed to ensure an informed consent was obtained and least restrictive measures were implemented prior to starting Resident 56's Seroquel medication. * The facility failed to ensure a care plan for the use and monitoring of Resident 56's Seroquel medication was created at the time Resident 56 started receiving the medication. * The facility failed to ensure the side effects of postural hypotension was monitored for Resident 56's Seroquel 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.

Based on observation, interview, and facility P&P review, the facility failed to ensure the P&P regarding the outside food for the residents was updated to meet the state regulations and failed to ensure the visitors and staff were educated on safe food handling of outside food. These failures posed the risk for food borne illness to the residents who consumed food from outside sources. Finding: Review of the facility's P&P titled Foods and Liquids from Outside Sources or Other than the Dietary Department revised 9/2017 showed the visitors are discouraged from bringing in potentially hazardous foods, i.e., meats, fish, eggs, custards, milk products, etc. If such foods are brought to the residents, they should be consumed immediately and not shared with other residents within the facility. Food items brought into the facility for residents cannot be reheated or stored. They are to be consumed or discarded. On 3/6/25 at 1609 hours, an interview was conducted with the DSD. The DSD was asked about the facility's policy for food brought from the outside. The DSD stated the visitors were…

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 thoroughly investigate the allegations of abuse for one of two sampled residents (Resident 1). * Resident 1 claimed he was hit in the head by a staff member. The facility failed to ensure other residents were interviewed by the facility's Abuse Coordinator. This failure had the potential to put Resident 1 and other residents at risk of not being protected against the alleged abuse. Findings: Review of the facility's P&P titled Abuse Reporting and Prevention dated 8/2018 showed all reported incidents of abuse will be investigated by the Abuse Coordinator or designee thoroughly and report the results to the appropriate agencies and personnel, and to include for the interview of the involved residents and other parties who have knowledge of the alleged incident documenting on the interview records. On 9/23/24 at 1455 hours, CDPH, L&C Program received the SOC 341 form dated 9/23/24. Review of the SOC 341 showed the allegation…

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 services to attain or maintain the highest practicable well-being for two of 18 final sampled residents (Residents 4 and 5). * The facility failed to ensure the Xeloda (capecitabine - chemotherapy drug used to treat colorectal cancer) medication was administered as per the physician's orders for Resident 5. * The facility failed to follow up with the physician timely when Resident 4 had a change of condition involving an episode of hypertension (high blood pressure) of 180/100 mmHg. These failures had the potential to negatively affect the resident's health conditions and well-being. Findings: Review of the facility's P&P titled Significant Change in Conditionrevised 4/2017 showed all staff member shall communicate any information about resident status change to appropriate licensed personnel immediately upon observation. A licensed nurse shall assess the resident for signs and symptoms of physical…

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 protect the resident's rights to be free from the physical abuse by the staff. * Resident 3 was hit on the right of the head by CNA 1 with an open hand, which was witnessed by another staff. This failure had the potential to cause injury and physical and/or psychosocial harm to the resident. Findings: Review of the facility's P&P titled Abuse Reporting and Prevention revised January 2023 showed the Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, or mental anguish, or deprivation of an individual, including a caretaker, of goods and services that are necessary to attain or maintain physical, mental, and psychosocial wellbeing. This presumes that instances of abuse of all residents, even those in a coma, cause physical harm, or pain, or mental anguish. Physical Abuse means a willful physical action that is meant to inflict physical harm,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, facility document review, and facility P&P review, the facility failed to store the drugs and biologicals in a safe manner. * The facility failed to ensure the proper storage temperature of medications in Medication room [ROOM NUMBER]. The temperature of Medication room [ROOM NUMBER] was 81 degrees F; however, the medications stored in Medication room [ROOM NUMBER] showed to store at the controlled room temperature between 68 to 77 degrees F. This failure posed the risk for administration of deteriorated medication. * The facility failed to maintain the acceptable temperature of the medication refrigerator in Medication rooms [ROOM NUMBERS]. The temperatures of the medication refrigerators were below 36 to 46 degrees Fahrenheit. This failure posed the risk for administration of deteriorated medication. * The facility failed to dispose of the expired and discontinued medications and supplies in Medication Carts 1, 2, 3, and 4. This failure had the potential for the medications 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.

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 facility failed to ensure the kitchen staff performed hand hygiene during dishwashing. * The facility failed to ensure the heavy-duty blender used for puree preparation was air dried prior to storing. * The facility failed to ensure the microwave oven was clean and free of food particles. * The facility failed to ensure the cutting boards were in sanitary condition and with cleanable surface. These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food prepared in the kitchen. Findings: Review of the form CMS-672 Resident Census and Conditions of Residents completed by the DON dated 9/18/23, showed 82 of 97 residents residing in the facility received food prepared in the kitchen. 1. According to the USDA Food Code 2017, 2-301, when to Wash, food employees shall clean their hands and exposed portions of their arms immediately before…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to ensure the comprehensive care plan was implemented for one of 20 final sampled residents (Resident 22). * The facility failed to ensure Resident 22's bed was maintained in the lowest possible position in accordance with Resident 22's at risk for fall/injury care plan. This failure placed the resident at risk for not being provided appropriate, consistent, and individualized care. Findings: Medical record review for Resident 22 was initiated on 9/18/23. Resident 22 was admitted to the facility on [DATE]. Review of Resident 22's care plan titled At Risk for Fall/Injury dated 9/1/23, showed Resident 22 was at risk for fall/injury related to impaired vision, incontinence, and antihypertensive medications. In order to minimize Resident 22's risk for fall/injury the care plan showed the staff would provide the visual checks every two hours to assess the resident's needs and safety, instruct the resident to utilize the call light to ask…

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 ensure one of 20 final sampled residents (Resident 25) attained and maintained the highest practicable physical well-being. * The facility failed to coordinate with the contracted hospice agency to provide the services to Resident 25 regarding the plan of care. This failure created the risk of not providing the appropriate and consistent care to Resident 25. Findings: Review of the facility's P&P titled Hospice Services dated 1/2017 showed the facility should ensure the hospice services meet professional standards and principles that apply to individuals providing services at the facility, and to the timeliness of the services. Further review of the P&P 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 directives for managing pain 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 two of 20 final sampled residents (Residents 22 and 72) remained free from accident hazards. * The facility failed to ensure Resident 22's bed was maintained in the lowest possible position as per the physician's order. Resident 22 was assessed to be at risk for falls. * The facility failed to accurately document Resident 72's history of falls on the Fall Risk Evaluation form resulting in an inaccurate fall risk score status post an unwitnessed fall. These failures had the potential to place the residents at risk for serious injury. Findings: 1. Medical record review for Resident 22 was initiated on 9/18/23. Resident 22 was admitted to the facility on [DATE]. Review of Resident 22's physician's order dated 5/21/22, showed an order for Resident 22's bed to be positioned in the lowest possible position. Review of Resident 22's care plan titled At Risk for Fall/Injury dated 9/1/23, showed Resident 22 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, medical record review, and facility P&P review, the facility failed to ensure the equipment utilized to provide the residents with oxygen therapy was labeled and changed in accordance with the facility's P&P, for three of 20 final sampled residents (Residents 22, 23, and 87). * The facility failed to ensure Resident 22's nasal cannula oxygen tubing and oxygen concentrator humidification bottle were labeled with the date when they were changed. * The facility failed to ensure Resident 23's nasal cannula oxygen tubing and oxygen concentrator humidification bottle were changed weekly and labeled with the date when they were changed. * The facility failed to ensure Resident 87's nasal cannula oxygen tubing was changed every seven days and as needed. These failures had the potential to result in negative health outcomes to the residents. Findings: Review of the facility's P&P titled Oxygen Concentrators dated 6/2017 showed pre-filled humidifiers are to be dated and replaced weekly 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility document review, the facility failed to ensure the nursing staff demonstrated the competencies and skill sets needed to provide safe nursing care to the residents. * CNA 6 failed to perform within their scope of practice when CNA 6 was observed turning off Resident 24's enteral feeding pump prior to performing ADL care. * The blood glucose test strips and control solution were not accurately tested with the Assure Platinum glucometer (device used to measure blood sugar levels). These failures had the potential to result in inadequate care and risk for adverse consequences for the residents. Findings: 1. Review of the facility document titled Certified Nursing Assistant Job Description, undated, showed the general duties and responsibilities for CNAs are to perform assigned duties in accordance with state, federal, and facility policies and procedures. Furthermore, specific requirements for CNAs showed they must demonstrate the knowledge and skills necessary to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure the pharmaceutical services were provided to meet the needs of one nonsampled resident (Resident 27) when Resident 27's losartan (blood pressure medication) was not available on 9/15 and 9/16/23. This failure resulted in Resident 27 not receiving the blood pressure medication for two days, which had the potential to result in poor health outcomes to the resident. Findings: Review of the facility's P&P titled Medication Ordering and Receiving from Pharmacy dated 4/2008 showed repeat medications (refills) are written on a medication order form/ordered by peeling the bottom part of the pharmacy label and placing it in the appropriate area on the order form provided by the pharmacy for that purpose and ordered as follows: reorder medication five days in advance of need to assure an adequate supply is on hand. Medical record review for Resident 27 was initiated on 9/18/23. Resident 27 was admitted to the facility 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 ensure the side effect monitoring of blood thinner medications for two nonsampled residents (Residents 10 and 68). This failure had the potential to cause negative outcomes for Residents 10 and 68. Findings: Review of the facility's P&P titled Adverse Consequences and Medication Errors revised April 2014 showed the residents receiving any medication that has a potential for an adverse consequence will be monitored to ensure that any such consequences are promptly identified and reported. 1. Medical record review of Resident 10 was initiated on 9/19/23. Resident 10 was admitted to the facility on [DATE], from the acute care hospital. Review of Resident 10's H&P examination dated 7/9/23, showed Resident 10 had a history of medical diagnoses of carotid stenosis and CVA. Review of Resident 10's care plan titled At Risk for Bleeding dated 7/7/23, showed Resident 10 was on anticoagulant therapy of Plavix (blood thinner…

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 20 final sampled residents (Resident 43) were free from unnecessary psychotropic drugs (any drug that affects brain activity associated with mental processes and behavior). * Resident 43 who had diagnoses including dementia (a disorder which causes a progressive decline in memory and behavior that affects the ability to perform everyday activities) was prescribed quetiapine fumarate (Seroquel, an antipsychotic medication) for psychosis manifested by striking out at staff. There was no documented diagnosis of psychosis prior to starting the quetiapine fumarate medication. * The facility failed to ensure documentation of evaluation and rationale for increasing Resident 43's prescription of Seroquel from 12.5 mg once a day to 12.5 mg two times a day on 10/4/22, and from 12.5 mg two times a day to 50 mg two times a day on 1/30/23. * The facility failed to ensure the non-pharmacological…

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 medication error rate was 13.79%. * The facility failed to administer eyedrops as per the facility's P&P and aspirin (blood thinner) chewable tablets as chewable to Resident 28. * The facility failed to administer aspirin chewable tablets as chewable for Resident 27. * The facility failed to administer Metamucil (fiber supplement) in accordance with the pharmacy label to Resident 94. These failures had the potential to negatively affect the residents' health. Findings: 1. Review of the facility's P&P titled Specific Medication Administration Procedures - IIB6: Eye Drop Administration dated 4/2008 showed the procedure as follows: - Pull the lower eyelid down and away from the eyeball to form a pocket. - Hold the dropper tip directly over the eye, taking care to avoid touching the eye or eyelid. - Instruct resident to look upward, and place one drop into 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.