Gilroy Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 5. On [DATE] at 9:19 a.m., Licensed Vocation Nurse (LVN) C was observed removing a glucometer from the medication cart. On [DATE] at 9:22 a.m., at Resident 5's bedside, LVN C was observed pricking the resident's left middle finger to get a blood sample for the blood sugar reading. On [DATE] at 9:28 a.m., LVN C was observed removing a pre-saturated chlorox disinfectant wipe and wrapping it around the glucometer without wipping it down first. Then she placed it on top of the medication cart. On [DATE] at 9:38 a.m., LVN C used the same glucometer and entered Resident 106's room to obtain his blood sugar reading. She stated she could not get a reading because the battery in the glucometer died. Two minutes later, on [DATE] at 9:40 a.m., LVN C returned to the medication cart, and again, used the chlorox disinfectant wipe to wrap around the glucometer without cleaning it first with the wipe. On [DATE] at 9:42 a.m., LVN C returned to Resident 106's room with another glucometer and was able to obtain a blood sugar…

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 follow their Antibiotic Stewardship Program when six of 18 residents (Residents 89, 68, 108, 23, 47, and 373) who received antibiotics (medications that kill or inhibit the growth of bacteria) did not meet the Loeb's criteria [a set of minimum clinical guidelines used in long-term care facilities (LTCFs) to help healthcare providers decide when to initiate antibiotic treatment for suspected infections in residents]. These failures had the potential to increase the prevalence of multi-drug resistance organism (MDRO - these are microorganisms, mostly bacteria, that have become resistant to multiple types of antibiotics) or bacteria. Findings: 1. Review of Resident 89's clinical record titled, admission Record, dated on 6/12/2025, it indicated Resident 89 was admitted to the facility with diagnoses includes Alzheimer's disease (a progressive disease that destroys memory and mental functions) and urinary tract infection (UTI, an infection that can occur in any part of the urinary system, including the kidneys,…

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 ensure needs were accommodated for three of 26 sampled residents (Residents 100, 96, and 52) when: 1. Resident 100 and Resident 96's call light button (a red or white button used to call for assistance) were not within their reach for use; and 2. Resident 52 did not receive the appropriate call system (a device used to communicate a need for help) based on his needs. These failures had the potential for a delayed response and not meeting Resident 100, Resident 96 and Resident 52's needs. Findings: 1a. Review of Resident 100's clinical record titled, admission Record, dated 6/13/2025, indicated Resident 100 was admitted to the facility with diagnoses including wedge compression fracture (a type of spinal fracture where one or more vertebrae [back bones] collapse due to pressure, often resulting in a wedge shape) of first lumbar vertebrae (the five bones that make up the lower part of the spine, situated between the thoracic vertebrae and…

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

Based on observation, interview and document review, the facility failed to ensure the residents were made aware of the location of the latest facility's State inspection result (Statement of Deficiencies and Statement of Isolated Deficiencies generated by the most recent standard survey and any subsequent extended surveys, and any deficiencies resulting from any subsequent complaint investigations) and available to read for six out of seven residents (Residents 34, 7, 55, 88, 68, and 71). This failure had the potential to result in residents being uninformed. Findings: During an interview in the Resident Council (a group of people living in a shared space [like a nursing home, public housing, or assisted living facility] who organize to represent the interests of all residents) meeting on 6/10/2025 at 9:56 a.m., when asked if the State inspection results were available to read without asking, Residents 34, 7, 55, 88, 68, and 71 stated they were not aware of where to find the survey results. They further stated no one from the facility told them where to find it. During an…

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

Based on observation, interview, and facility's document review, the facility failed to maintain resident's rights to privacy and confidentiality to three of 26 sampled residents (Resident 371, Resident 372, and Resident 373) when: 1. Resident 371's Foley catheter drainage bag, (a device inserted into the bladder [organ that collects urine] to drain urine, made of a semi-flexible plastic tube, one end inserted into the bladder and the other end attached to a bag that collects urine) drain bag was left uncovered; and 2. Resident 372 and Resident 373's personal information and care instructions were posted in the room visible to roommate and visitors. These failures had the potential to compromise resident's rights and dignity. Findings: 1. During an observation on 6/9/25 at 2:08 p.m., in Resident 371's room, Resident 371 was sharing a room with another resident. Resident 371's bed was towards the entrance door and privacy curtains were open. Resident 371's foley catheter drainage bag with yellow colored urine about 150 ml (milliliter) was left uncovered with privacy bag that can be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to ensure 2 of 5 sampled residents (Residents 14 and 21) were free from unnecessary psychotropic medications (drugs that affects brain activities associated with mental processes and behavior) when: 1. Resident 21 received a high dose of quetiapine (generic: Seroquel: an antipsychotic medication, used to regulate the functioning of brain circuits that control thinking, mood, and perception) without documented necessity for its use and without demonstration of how the behavioral symptoms caused harm to the resident/others or causing significant distress to the resident; 2. Resident 14 received Seroquel and Fluoxetine (an anti-depressant) with no documented non-drug interventions for both medication; 3. Resident 83 received pro re nata (PRN: as needed or as the situation arises) psychotropic medication with no stop date. These failures resulted in inadequate indication and unnecessary medications which had the potential for increased risks…

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 accurately complete the Minimum Data Set (MDS, an assessment tool) for two residents (83 and 119) when: 1. For Resident 119, the facility failed to accurately complete the discharge status; 2. For Resident 83, the facility did not code the use of injectable medication and incorrectly coded Resident 83's falls. Failure to accurately assess the residents had the potential to result in inadequate or inappropriate care planning and interventions. Findings: 1. Review of Resident 119's physician order, dated 3/18/25, indicated Discharge to home with medications on 3/18/25. Home Health Services for PT (Physical Therapy) OT (Occupational Therapy) and nursing services. Review of Resident 119's discharge MDS, dated [DATE], indicated she was discharged to the acute hospital. During an interview and concurrent record review with the Minimum Data Set Manager (MDSM) on 6/11/25 at 9:13 a.m., the MDSM confirmed Resident 119 was discharged to her home on 3/18/25. The…

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

Based on observation, interview and record review, the facility failed to ensure to provide necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection and prevent new pressure injuries/ulcers (injury to skin from prolonged pressure on the skin) from developing for one of four sampled resident (Resident 57) when: 1. No dressing on right outer ankle pressure injury for Resident 57; 2. No prevalon (a medical device designed to prevent and treat heel pressure injury/ulcer) heel protector boot on to right foot for Resident 57. Above failures had the potential for delayed pressure ulcer healing and developing new pressure injuries for Resident 57. Findings: During a concurrent observation and interview with certified nursing assistant P (CNA P) on 6/10/2025 at 9:26 a.m., CNA P also observed Resident 57's right foot and confirmed right outer ankle open area with no dressing or prevalon boot were not on while Resident 57 was in bed with bare feet. CNA P confirmed prevalon boot was left on nightstand next to Resident 57's bed.…

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 and record review, the facility failed to ensure controlled medications (those with a high abuse potential) were fully accounted when controlled medication use audit for three out of seven sampled residents (Residents 53, 106, and 109) did not reconcile. The residents' medications were signed out of the Controlled Drugs Records (CDR, inventory record of controlled drugs) but not documented on the Medication Administration Record (MAR, record of medications administered to a resident) to indicate they were administered to the residents. The failure resulted in inaccurate accountability and had the potential for abuse and diversion (unlawful distribution or use) of controlled medications. Findings: During the survey, the CDRs for seven random residents receiving as-needed (PRN) controlled medications were selected for review. On 6/10/25 at 1:41 p.m., a concurrent interview and record review was conducted with the Director of Nursing (DON) and Assistant Director of Nursing (ADON). The ADON stated any time a PRN controlled medication was requested 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.

Based on interview and record review, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported irregularities during the medication regimen review (MRR) for one out of 26 sampled residents (Resident 373) when Resident 373 had two similar orders for Dilaudid (brand name for hydromorphone, a potent opioid medication used to treat moderate to severe pain).This deficient practice had the potential for excessive dose/adverse effects for Resident 373. Finding: Review of Resident 373's clinical record titled, admission Record, dated on 6/12/2025, it indicated Resident 373 was admitted to the facility with diagnoses including type 2 diabetes mellitus (a condition which affects the way the body processes blood sugar) without complications. During a review of Resident 373's physician order, dated 5/26/25 indicated an order for Dilaudid oral tablet 2 mg (milligram, unit of measurement) give 4 tablet by mouth every 3 hours as needed for pain. During a review of Resident 373's physician order, dated 5/26/25 indicated an order for hydromorphone [brand name for…

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

Based on interview and record review, the facility failed to notify the responsible party (RP, a person designated to make decisions on behalf of a resident) of resident's change of condition for one of three sampled residents (Resident 1). This failure had the potential to affect the ability of the RP to participate in the planning of resident's care and treatment plans. Findings: Review of Resident 1's admission record, indicated Resident 1 was readmitted to the facility with diagnoses including acute respiratory failure (a serious condition that makes it difficult to breathe), unspecified whether with hypoxia (low levels of oxygen in body tissues) or hypercapnia (when high levels of waste products such as carbon dioxide remain in the blood), pleural effusion (a buildup of fluid between the layers of tissue that line the lungs and chest cavity), disorders of diaphragm (the muscle that separates the chest cavity from the abdomen) and unspecified diastolic heart failure (a heart condition that can lead to decreased blood flow and other complications). The record also indicated…

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 interviews, record review, and policy review, the facility failed to ensure Level 1 Preadmission Screening and Resident Review (PASARR) was accurately completed upon admission for 1 (Resident #36) of 3 sampled residents reviewed for PASARRs. Findings included: Review of a facility policy titled, Resident Assessment- Coordination with PASARR Program, revised in 10/31/2023, revealed, This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. A review of Resident #36's admission Record revealed the facility admitted the resident on 03/16/2021. A review of Resident #36's hospital Discharge Referral, with a hospital admission date of 03/11/2021, revealed the resident had a diagnosis of unspecified psychosis with an onset date of 08/08/2019. A review of Resident #36's Preadmission Screening and Resident Review Level I Screening, dated…

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

Based on interview and record review, the facility failed to follow its policy and procedure for one of three sampled residents (Resident 1), when the facility failed to report an injury of unknown source with serious bodily injury (injury requiring medical intervention such as surgery) to the California Department of Public Health (CDPH) within 2 hours after the facility known about the injury of Resident 1. This failure had the potential for Resident 1's injury of unknown source to not be investigated thoroughly and be at risk for continued injury. Findings: During a review of Resident 1's Facility admission Record, undated, admission Record indicated, Resident 1 had diagnoses of Metabolic Encephalopathy (disorder that affects brain function), Unspecified Dementia (mild memory disturbance due to known physiological condition), Psychotic Disturbance (Psychotic disorders that affect brain function by altering thoughts, beliefs or perceptions), Muscle Weakness, and Personal History of Other Mental and Behavioral Disorders. During a review of Resident 1's Minimum Data Set Section C…

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.

2. During a concurrent observation and interview on 4/19/21 at 4:25 p.m., LN H was not wearing his facemask while in the nursing station with another staff. When asked if he needed to wear his facemask, he stated he could not answer the surveyor. During an interview with the director of nursing (DON) on 4/19/21 at 4:43 p.m., she stated staff were expected to wear a face mask while in the facility. According to the Centers for Disease Control and Prevention website https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html, Health care provider (HCP) should wear well-fitting source control (e.g facemasks or respirators) at all times while they are in the healthcare facility. 3. During an observation 4/20/21 at 8:54 a.m., LN F wore gloves while preparing medications. LN F went to room (rm) X to talk with a resident without taking off her gloves. At 8:57 a.m., LN F came out from rm X and removed her gloves. During an interview on 4/20/21 at 9:00 a.m., with LN F, she confirmed the above observation and stated she did change her gloves in rm X. LN F further stated she should 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.

Based on interview and record review, the facility failed to ensure the State Long Term Care Ombudsman (Ombudsman, an advocate for residents in the nursing homes) was notified in writing in a timely manner for 16 out of 16 discharged residents (Residents 133, 130, 135, 128, 175, 136, 176,138, 65, 132, 125, 127, 126 and 131). This failure had the potential of not providing the resident and/or their responsible party (RP, a person who is accountable in making decision in behalf of the resident) with an access to an advocate who could inform them of their rights. Findings: Review of the facility's discharges/transfer out form for March 2021 indicated the following: Resident 133 was discharged home on 3/20/21. Resident 130 was discharged home on 3/11/21. Resident 135 was discharged home on 3/24/21. Resident 128 was discharged home on 3/11/21. Resident 175 was discharged home on 3/4/21. Resident 136 was discharged home on 3/27/21. Resident 176 was discharged home on 3/6/21. Resident 65 was discharged home on 3/2/21. Resident 132 was discharged home on 3/19/21. Resident 125 was discharged…

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 provide routine and accurate administerstration of medications for one of 23 sampled residents (Resident 10), and accurate accountability of controlled substance (CS, drugs with high potential for abuse or addiction) medications for three of four random record reviews (Residents 80, 112, and 229), when: 1. Resident 10, who had recent eye surgery, did not routinely receive two of her eye medications as ordered on 4/19 and 4/20/21. This had the potential for delay in treatment for the resident; 2. The nursing staff did not document medication administration and did not give routine medications to Resident 10 in a timely manner for two days in April 2021; and, 3. CS medications were signed out from the Controlled Drug Record (CDR, an inventory sheet) but not documented on the Medication Administration Record (MAR) to indicate they were given to Residents 80, 112, and 229. This failure had the potential for CS drug abuse or diversion. Findings: 1. On 4/19/21, a review of Resident 10's clinical record indicated…

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's consultant pharmacist (CP) failed to identify and make recommendations to the facility regarding drug storage concerns and irregularities related to the residents' drug regimen for four of 23 sampled residents (Residents 32, 47, 80, and 117). The failures resulted in inadequately monitored medications, which could lead to unsafe and ineffective medications for residents, and unnecessary medications for the residents, which had the potential to place them at risk for harm or adverse consequences. Findings: 1. During an inspection of the Medication Room in Station 3/4 conducted with the assistant director of nursing (ADON) on 4/19/21 at 10:50 a.m., an opened Novolin NPH (long acting insulin to treat high blood sugar) vial for Resident 28 was identified. Its label indicated it was opened on 12/1/20, and to discard after 1/1/21. An inspection of Medication Cart #4 on 4/19/21 at 3:36 p.m. with licensed nurse (LN) D and LN E identified 3 of 3 Xalatan (latanoprost, to treat high pressure inside the eye due to glaucoma) eye…

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 ensure six of 23 sampled residents (Residents 9, 32, 47, 70, 80, and 117) were free from unnecessary psychotropic medications (drugs that affects brain activities associated with mental processes and behavior) when: 1. Resident 9 received five doses of as-needed lorazepam (a controlled medication to treat agitation and anxiety) when the nursing staff documented no behaviors observed, and there was no documented evidence the resident exhibited behaviors before receiving the lorazepam doses; 2. Resident 32 received Seroquel (an antipsychotic medications) with inadequate monitoring when there was no Abnormal Involuntary Movement Scale (AIMS; a rating scale designed to measure involuntary movements known as tardive dyskinesia, a disorder that sometimes develops as a side effect of long-term treatment with antipsychotic medications) assessment conducted since the start of Seroquel; 3. Resident 47 received divalproex sodium (Depakoke; a medication that can treat certain seizure disorders and mental/mood conditions)…

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 store and label medications in accordance with the manufacturer's instructions and the facility policy and procedures when: 1. One vial of insulin (medication to treat high blood sugar) and one vial of flu vaccine were found in active stock past their discard date; and 4 multi-dose vials (medication, usually in liquid, intended for more than one dose of medication), one oral inhaler, and 3 Xalatan (or lanatoprost, to treat high pressure inside the eye due to glaucoma) eye solution bottles were opened without an open date. Two of the Xalatan eye solutions for 2 residents were being used past the discard date. 2. A Lantus (long-acting insulin) vial was identified without patient-specific label; 3. The nursing staff had been monitoring the temperature in one of two medication refrigerators (Ref #1) once daily, a practice inconsistent with the facility's policy and procedures; and 4. Medication refrigerator temperature was not monitored on a daily basis for Ref #1. The deficient practices had a potential for…

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

Based on observation and interview, the facility failed to respond to residents' call lights in a timely manner for three of 23 sampled residents (Residents 49, 62, and 70), when: 1. Resident 62 waited 25 minutes in the bathroom to get transfer assistance from wheelchair to toilet to urinate. 2. Resident 70 waited ten minutes for her to be turned and repositioned in bed, and 3. Resident 49 waited ten minutes to get a drink. This failure resulted in the delayed response to residents' needs and could potentially cause resident emotional distress. Findings: 1. During an observation on 04/20/21 at 3:25 p.m., Resident 62 was in the bathroom and her call light was on. She stated she needed help to transfer from the wheelchair to toilet to urinate. The certified nursing assistant (CNA) came in the bathroom at 3:50 pm. Resident 62 waited for 25 minutes to get help. 2. During an observation on 04/20/21 at 3:40 p.m., Resident 70's call light was on and was answered at 3:50 p.m. Resident 70 waited 10 minutes for her call light to be answered. During an interview with Resident 70 on 4/20/21 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.

Based on observation, interview, and record review, the facility failed to implement their abuse policy for three of three sampled residents (Residents 16,18, and 56) when, 1. Residents 16, 18, and 56 were not protected from physical and verbal abuse by certified nursing assistant M (CNA M) and, 2. Residents' 18 and 56 allegations of abuse were not reported. These failures put the residents at risk for further abuse. Findings: 1. Resident 16 had diagnoses including dementia (memory loss) and altered mental status. Resident 16 was non-verbal and had severe cognitive impairment. During the initial tour on 4/19/21 at 12:53 p.m., Resident 94 (co-resident) stated, Resident 16's hands were slapped by CNA M. During an observation on 4/19/21 at 12:53 p.m., Resident 16's right hand was discolored (dark brown) while no discoloration on his left hand was noted. Review of Resident 16's interdisciplinary team (IDT) notes dated 4/14/21 indicated that Resident 94 (co-resident) had reported that CNA M had slapped Resident 16's hand on several occasions when Resident 16 was not cooperating with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to accurately code the Minimum Data Set (MDS, an assessment tool) for two of 23 sampled residents (Residents 27 and 230) when the MDS did not reflect the current status of the residents. This failure had the potential to affect inappropriate care planning and intervention. Findings: 1. Review of Resident 27's situation background assessment and recommendation (SBAR, a form of communication tool for healthcare providers) dated 1/7/31 indicated the resident had a fall. The SBAR did not indicate Resident 27 sustained a major injury. During a concurrent interview and record review on 4/23/21 at 08:26 a.m., with the minimum data set coordinator (MDSC), the MDSC reviewed Resident 27's SBAR dated 1/7/21 and the MDS Quarterly review dated 1/27/21 and confirmed Resident 27 did not sustain a major injury during a fall on 1/7/21. The MDSC acknowledged she coded Resident 27's fall with major injury and confirmed the MDS was coded incorrectly. Review of the Centers…

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 ensure services were provided to meet the professional standard of practice for three of 23 sampled residents when: 1. Resident 12's input and output was not measured and documented appropriately; 2. Resident 70 and Resident 117's physician orders for the use of oxygen was not followed. These failures had the potential to affect the residents' health condition and care. Findings: 1. Review of Resident 12's clinical record indicated, he had diagnoses of unspecified calorie malnutrition (an imbalances of a person's intake of nutrients) and urinary infection (UTI, an infections in any part of the urinary system). During an observation on 4/20/21 at 9:30 a.m., Resident 12 had a urinary catheter (a sterile flexible tube that collects urine in the bladder that is connected to a urine bag). Review of Resident 12's medication administration record (MAR) for March 2021 indicated, monitor intake and output every shift for signs and symptoms of dehydration (loss of too much fluid in the body)/fluid volume over load (too…

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 and record review, the facility failed to ensure one of 23 sampled residents (Resident 117) was free from unnecessary medications when the nursing staff did not monitor for signs and symptoms of adverse effects related to the use of blood thinning medications. Resident 117 was receiving Lovenox (generic name enoxaparin, an anti-coagulant, or blood thinning medication) and Plavix (anti-platelet agent to prevent heart attacks or strokes). This had the potential for side effects of these medications (such as bleeding, excessive bruising, etc.) to go undetected or recognized for timely intervention. Findings: On 4/23/21, a review of Resident 117's clinical record indicated he was an elderly resident admitted to the facility with diagnoses including the presence of a pacemaker (a medical device that sends electrical pulses to help your heart beat at a normal rate and rhythm) and deep vein thrombosis (DVT, a blood clot forms in a vein located deep inside your body). A review of the clinical record indicated two physician's orders, as follows: a. Lovenox 100 milligrams…

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 had a 7.14% error rate when two medication errors out of 28 opportunities were observed during the medication pass. Resident 10 did not receive an eye medication as scheduled; and the nursing staff administered eye medications not in accordance with the facility's medication administration guideline and accepted professional standards of practice. The failure resulted in medications not given as ordered and as per accepted professional standards of practice, which may negatively affect the resident's health. Findings: 1. During a medication pass observation on 04/19/21 at 04:20 p.m., licensed nurse A (LN A) was observed preparing and administering 7 medications, including two eye medications: prednisolone (to treat swelling and inflammation) 1% eye solution and brimonidine (for reduction of pressure in the eye) 0.2% eye solution, to Resident 10. At Resident 10's bedside, on 4/19/21 at 4:31 p.m., LN A administered 1 drop of the prednisolone eye solution to the resident's right eye. She then gave the resident's oral…

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.