Memorial Hospital Of Gardena D/P SNF

Based on observation, interview and record review, the facility failed to: 1. Ensure food items were labeled with received and used dates in the dry storage area and two refrigerators. 2. Ensure expired foods were not stored in the kitchen and accessible to be used in food preparation in accordance with food service safety. These failures had the potential to place the residents at risk for developing a foodborne illness. Findings: During a concurrent observation and interview on 2/15/2024 at 11:43 a.m. at entrance of the kitchen observed shelves with plastic containers containing single serve lemon juice bags, 1 container with single serve ranch dressing bags, 1 container with single serve Italian dressing bags, 1 container with single serve grape jelly, 1 container single serve pack syrups, 1 container with single serve ketchup bags and 1 contain with single serve mayonnaise bags. Outside the plastic containers were not label with receiving or used by dated. The Kitchen Supervisor (KS) stated, I do not know the expiration date of these products. The KS stated the expiration date…

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 record review, the facility failed to observe infection control measures for four out of 27 sampled residents by failing to: 1. Sanitizing their hands between changing gloves, washing hands after cleaning the wound, and applying a clean dressing for Resident 32. 2. Sanitize hands and change gloves after cleaning the colostomy stoma (an opening in the abdomen that allows stool to pass through instead of the anus) and before putting on the new colostomy bag for Resident 38 and after cleaning the wound and before applying the treatment and dressing for Resident 38 and Resident 46. 3. Keep the urinary catheter bag off the floor for Resident 64. These failures had the potential to spread infections and illnesses amongst residents. Findings: 1. During an observation on 2/15/2025 at 3:20 p.m. in Resident's 32 room, with Treatment Nurse (TN) 2. TN 2 when inside Resident's 32 room with wound care supplies. TN 2 wash hands and applied clean gloves and removed soiled dressing from…

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 record review, the facility failed to: 1. Ensure one of 27 sampled residents (Resident 4), was properly assessed for dry and crusty (rough or thickened texture) skin on his left palm. This deficient practice resulted in lack of or delay in care for Resident 4 and potential risk for skin breakdown. Findings: During an observation on 2/15/2024 at 8:25 a.m. in Resident's 4 room. Resident 4 was laying on the bed and unable to verbally communicate. Resident 4's left hand was closed with very dry skin white in color and rough. During a review of Resident 4's admission record, the admission record indicated Resident 4 was admitted on [DATE], with diagnoses that included cerebral vascular accident (CVA-stroke, loss of blood flow to a part of the brain), tracheostomy (allows air to pass into the windpipe to help with breathing.), and coronary artery disease (a condition where the arteries that supply blood to the heart become narrowed or blocked.) During a review of Resident 4'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, and interview, the facility failed to: 1.Implement turning interventions in accordance with the facility's policies and procedures (P/P) for one of 27 sampled residents (Resident 5.) This deficient practice resulted in delayed turning for Resident 3 which resulted in a blister on left trochanter (hip joint) and two blisters on left thigh. Findings: During a review of Resident 5's admission Record, the admission Record, indicated Resident 5's was admitted to the facility on [DATE] with the diagnoses including cerebrovascular accident ([CVA] a medical emergency that occurs when blood flow to the brain is suddenly cut off) and hypertension (high blood pressure.) During a review of Resident 5's History and Physical (H&P), dated 5/18/2024, H&P indicated Resident 5's diagnoses included cerebrovascular accident ([CVA] a medical emergency that occurs when blood flow to the brain is suddenly cut off) and hypertension (high blood pressure.) During a review of Resident 5's Minimum Data Set ([MDS], a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: 1. Ensure that the facility staffed sufficient Certified Nurse Assistant (CNAs) to administer and provide nursing services in a timely manner for one out of 27 sampled residents (Resident 5) The deficient practice resulted in delayed care for Resident 5. Findings: During a review of Resident 5's admission Record, the admission Record, indicated Resident 5's was admitted to the facility on [DATE]. During a review of Resident 5's History and Physical (H&P), dated 5/18/2024, H&P indicated Resident 5's diagnoses included cerebrovascular accident ([CVA] a medical emergency that occurs when blood flow to the brain is suddenly cut off) and hypertension (high blood pressure.) During a review of Resident 5's Minimum Data Set ([MDS], a standardized assessment and care screening tool), dated 10/12/24, the MDS indicated Resident 5's was able to understand and be understood by others. The MDS indicated Resident 5's required supervision with eating,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to: 1. Provide one of 27 sampled residents (Resident 38) a special call light system to use. This failure caused Resident 38 to feel frustrated and helpless. Findings During a review of Resident 38's admission Record, dated 1/3/2025, the admission Record indicated Resident 38 was admitted to the facility on [DATE] with diagnosis of chronic respiratory failure with hypoxia (a condition when there is not enough oxygen in the tissues in the body). During a review of Resident 38's History and Physical (H&P), dated 4/24/2024, the H&P indicated Resident 38 had diagnoses of quadriplegia (a paralysis that affects all a person's limbs), multiple pressure sores present on admission (injury to skin caused by prolonged pressure to the skin), and tracheostomy (a procedure to help air and oxygen reach the lungs by creating a hole at the front of the neck). The H&P indicated Resident 38 was awake, alert, and interactive, but compromised in communication due to his…

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 b. During a review of Resident 36's admission Record (Face Sheet), the admission Record indicated Resident 36 was admitted to the facility on [DATE] with diagnoses that included respiratory failure (a condition that makes it difficult to breathe on your own), renal failure (one or both kidneys no longer function well on their own), and chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). During a review of Resident 36's Minimum Data set ([MDS] a standardized care screening and assessment tool), dated 11/12/2023, the MDS indicated, Resident 36's cognition (ability to learn reason, remember, understand, and make decisions) skills Resident 36 was oriented to year, month, year, and could recall questions that were previously asked. The MDS indicated, Resident 36's oral and dental status did not have mouth discomfort or difficulty with chewing. During an observation and interview on 2/8/2023 at 9:40 a.m. with Resident 36, in resident room, 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 and record review, the facility failed to; 1. Ensure the physician was promptly notified when one of one sampled resident (Resident 163), had a change of condition (a change in resident's normal, physical, mental, or behavioral state). Resident developed full-thickness skin loss potentially extending into the subcutaneous tissue layer (stage 3 pressure ulcer) on the right buttock. A physician notification was made on 2/8/2024 (1 day after the initial identification of the pressure ulcer). This deficient practice had the potential for a delay in care and intervention of Resident 163's Stage 3 pressure ulcer Findings: During a review of Resident 163's Face Sheet, the Face Sheet indicated, Resident 163 was admitted to the facility on [DATE], with diagnoses including chronic respiratory failure with hypoxia (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), tracheostomy (an opening created at the front 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 interview and record review, the facility failed to: 1.Ensure the comprehensive Minimum Data Set ([MDS] resident assessment and care screening tool) assessment for one of fifteen sampled residents (Resident 51) was completed within the required timeframe. This deficient practice had the potential to result in Resident 51 not receiving proper care and treatment. Findings: During a review of Resident 51's Face Sheet, the Face Sheet indicated, Resident 51 was admitted to the facility on [DATE], with diagnoses including respiratory failure (a serious condition that makes it difficult to breathe on your own), hypoxia (not enough oxygen), and hypercapnia (when you have too much carbon dioxide in your blood). During a review of Resident 51's MDS assessment, dated 8/21/2023, the MDS assessment, indicated Resident 51's had a Brief Interview for Mental Status (BIMS) score of 8 which indicated Resident 51's cognitive skills for daily decision making was moderately impaired. During a concurrent interview and record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide accurate information in the Minimum Data Set ([MDS] resident assessment and care screening tool) assessment for two of fifteen sampled residents (Resident 10 and Resident 36). This deficient practice had the potential to result inaccurate care and services for the residents due to inappropriate MDS care screening and assessment tool practices. Findings: a. During a review of Resident 10's Face Sheet, the Face Sheet indicated, Resident 10 was admitted to the facility on [DATE], with diagnoses including respiratory failure (a serious condition that makes it difficult to breathe on your own), Diabetes (a serious condition where your blood glucose level is to high), and congestive heart failure (a chronic condition in which the heart doesn't pump blood as well as it should). During a review of Resident 10's MDS entry assessment, dated 8/24/2023, the MDS assessment under A1000 (Race/Ethnicity) indicated, Resident 10 was Black or African American.…

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 record review the facility failed to: 1. Revise tube feeding (a way to give medications or liquid food through a small tube placed into the stomach) care plans for two out of five sampled Residents (Resident 40, and 18). These deficient practices had the potential for repeat occurrences for not revising residents care plans. Findings: a. During a review of Resident 40's admission Record (Face Sheet), the admission Record indicated Resident 40 was admitted to the facility on [DATE] with diagnoses that included respiratory failure (a condition that makes it difficult to breathe on your own), seizures (a sudden, uncontrolled body movements due to abnormal electrical activity in the brain), and diabetes mellitus (a problem in the way the body regulates and uses sugar as a fuel). During a review of Resident 40's History and Physical (H&P), dated 8/18/2023, the H&P indicated, Resident 40 unable to review systems due mental condition. During a review of Resident 40's Minimum Data set ([MDS] a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to: 1. Provide an ongoing activity program to meet the needs and interests for one of 5 sampled residents (Residents 40) to ensure residents maintained their highest physical, mental, and psychosocial well-being. This failure had the potential of not enhancing Resident 40's quality of life. Findings: During a review of Resident 40's admission Record (Face Sheet), the admission Record indicated Resident 40 was admitted to the facility on [DATE] with diagnoses that included respiratory failure (a condition that makes it difficult to breathe on your own), seizures (a sudden, uncontrolled body movements due to abnormal electrical activity in the brain), and diabetes mellitus (a problem in the way the body regulates and uses sugar as a fuel). During a review of Resident 40's History and Physical (H&P), dated 8/18/2023, the H&P indicated, Resident 40 unable to review systems due mental condition. During a review of Resident 40's Minimum…

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 record review, the facility failed to ensure a resident who received dialysis (process of removing waste products and excess fluids from the body) received treatment in accordance with standard of practice for one of one sampled resident (Resident 164) by failing to implement the physician's order for fluid restriction accurately. This deficient practice placed Resident 164 at risk for fluid overload, swelling, shortness of breath and discomfort. Findings: During a review of Resident 164's Face Sheet, the Face Sheet indicated, the facility originally admitted Resident 164 on 12/19/2023 and was readmitted on [DATE], with diagnoses including respiratory failure (a condition that makes it difficult to breathe on your own), tracheostomy (an opening created at the front of the neck so a tube can be inserted into the windpipe [trachea] to help you breathe), gastrostomy (a tube inserted through the wall of the abdomen directly into the stomach to provide nutrition and medication), and end stage…

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 record review, the facility failed to: 1. Ensure the treatment nurse was competent in wound site identification. This failure had the potential for a resident receiving treatment at the wrong site. Findings: During a concurrent interview and record review on 2/8/24 at 12:05 p.m. with LVN 2, Resident 38's Photographic Documentation, dated 2/1/24 was reviewed. The Photographic Documentation indicated Resident 38 had a wound in the left glutei fold. The actual picture indicated the wound was on the left buttock. LVN 2 agreed the wound was not in the left gluteal fold. LVN 2 stated he continued to write what the previous nurse wrote. LVN 2 could not verbalize what he would document the site as. LVN 2 stated he was trained in wound care by the facility over a two week orientation. LVN 2 stated he had no prior nursing experience before being hired as a treatment nurse. LVN 2 stated he became a nurse in February 2023 and was hired by the facility in June 2023. During a concurrent observation and interview on 2/9/24 at 8:20 a.m. with LVN 2, LVN2…

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 record review, the facility failed to: 1. Ensure expired medications were removed from the medication cart for 1 out of 5 sampled Residents (Resident 40). This failure resulted in Resident 40 receiving expired medications. Findings: During an observation on 2/7/24 at 4:19 p.m. at the 7th floor Team 2 medication cart, a packet of expired Atorvastatin (medication that lowers cholesterol) was noted. The packet had an expiration date of 1/31/24. Six pills were removed from the packet for 2/1/24 to 2/6/24. During a review of Resident 40's admission Record (Face Sheet), the admission Record indicated Resident 40 was admitted to the facility on [DATE] with diagnoses that included respiratory failure (a condition that makes it difficult to breathe on your own), seizures (a sudden, uncontrolled body movements due to abnormal electrical activity in the brain), and diabetes mellitus (a problem in the way the body regulates and uses sugar as a fuel). During a review of Resident 40'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.

Based on observation, interview, and record review, the facility failed to: 1. Ensure potassium levels were checked prior to administering a potassium supplements. This failure had the potential to result in the resident having a high potassium level, which can be life threatening. Findings: During an observation of medication pass on 2/8/24 at 11:06 a.m., LVN 1 failed to check the potassium level before giving Effer K (a medication that increases the potassium level). During an interview on 2/8/24 at 11:06 a.m. with LVN 1, LVN 1 stated, you need to check the potassium level before giving the dose. If the level is greater than 5 and you give the dose the patient can be hyperkalemic (condition of having a high potassium level) and you need to call the doctor. A high potassium level can make the heart go fast. It can hurt your heart. During an interview on 2/8/24 at 12:39 p.m., with LVN 2, LVN 2 stated, before giving a dose of potassium you should check the potassium level to ensure it's not above five. If you give the dose without checking the potassium level and the level is above…

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 record review, the facility failed to: 1. Ensure all medication carts were secured after a nurse left the keys on the side of the medication cart. This failure had the potential to result in an unauthorized person obtaining the keys and taking medication from the cart. Findings: During an observation on 2/7/24 at 2:55 p.m. at the Team 1 medication cart, a key with a blue wrist cord was noted on the side of the cart. During an interview on 2/7/24 at 2:55 p.m. with LVN 5, LVN 5 stated the key is for the medication cart. LVN 5 stated the key was left on the cart in an attempt to prevent losing them. LVN 5 stated if someone gets the key they can open the medication cart. That person can then take drugs from the cart and overdose. LVN 5 states she was trained to keep the keys in a secure place. LVN 5 states the location where the keys were observed is not a secure place. During an interview on 2/7/24 at 3:02 p.m. with LVN 6, LVN 6 stated the medication cart key should be kept on your body. If someone gets access to the key they can open the cart 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 b. During a review of Resident 36 admission Record (Face Sheet), the admission Record indicated Resident 36 was admitted to the facility on [DATE] with diagnoses that included respiratory failure (a condition that makes it difficult to breathe on your own), renal failure (one or both kidneys no longer function well on their own), and chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). During a review of Resident 36 Minimum Data set ([MDS] a standardized care screening and assessment tool), dated 11/12/2023, the MDS indicated, Resident 36's cognition (ability to learn reason, remember, understand, and make decisions) skills Resident 36 was oriented to year, month, year, and could recall questions that were previously asked. The MDS indicated, Resident 36's oral and dental status did not address Resident 36 had mouth discomfort or difficulty with chewing due to missing and broken teeth. During an observation and interview on 2/8/2023 at 9:40…

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 record review, the facility failed to: 1. Ensure the inside compartment of the ice machine was to be maintained in a sanitary manner for nine out of 59 residents. This deficient practice had the potential to result in an outbreak of foodborne illness that could affect all or most of the residents who reside in the facility. Findings: During a concurrent observation and interview on 2/6/2024 at 9:45 a.m. with Dietary Service Supervisor 1 (DSS 1) in the kitchen, found inside compartment of the ice machine was dirty. DSS 1 used a clean paper towel to swipe the inside compartment of the ice machine, produced black residue with hard water deposits. DSS 1 stated it was their engineering department who was responsible for the maintenance of the ice machine every month. DSS 1 stated the ice machine compartment was dirty and not safe for consumption. During a review of Ice Machine Cleaning Schedule 2024, the Ice Machine Cleaning Schedule indicated the ice machine was last cleaned on 1/12/2024. During an interview on 2/6/2024 at 11:50 a.m. with Registered…

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 record review the facility failed to: 1. Accurately document fluids (the amount of liquid going into the body) that were infused intravenously ([IV]a method of putting fluids, including drugs, into the bloodstream) into the body for one out of five sampled Residents (Resident 40). This deficient practice had the potential to result in confusion in the care and services rendered to Residents and inaccurate information could be entered into the resident's clinical record. Findings: During a review of Resident 40's admission Record (Face Sheet), the admission Record indicated Resident 40 was admitted to the facility on [DATE] with diagnoses that included respiratory failure (a condition that makes it difficult to breathe on your own), seizures (a sudden, uncontrolled body movements due to abnormal electrical activity in the brain), and diabetes mellitus (a problem in the way the body regulates and uses sugar as a fuel). During a review of Resident 40's History and Physical (H&P), dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility's Quality Assessment and Assurance ([QAA] develop and implement appropriate plans of action to correct identified quality deficiencies) and Quality Assurance Performance Improvement ([QAPI] takes a systematic, interdisciplinary, comprehensive, and data-driven approach to maintaining and improving safety and quality in nursing homes while involving residents and families, and all nursing home caregivers in practical and creative problem solving) committee failed to: 1. Identify facility dental services and care issues for one of one sampled residents (Resident 36). The failure to fulfill and fully implement an active QAPI process had the potential to result in resident harm by not having a system in place to identify significant resident safety issues, develop a plan to correct identified issues, and implement the plan or monitor the results of the facility plan. Findings: During a review of Resident 36 admission Record (Face Sheet), the admission…

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.