South Marin Health & Wellness Center

Based on observation, interview, and record review, the facility failed to properly administer tube feeding to one of one resident sampled for tube feeding (Resident #8) when Resident #8 was found laying flat during tube feeding administration. This failure had the potential to result in aspiration (inhaling foreign substances like food, liquids, saliva, or stomach contents into the lungs, which can lead to pneumonia, a lung infection) of the tube feeding formula, difficulty breathing, aspiration pneumonia, and hospitalization. Review of Resident #8's face sheet (demographics) indicated an admission date of 5/28/24 and multiple medical diagnoses including but not limited to cerebral infarction (stroke caused by a blockage in the brain), dysphagia (difficulty swallowing), and gastrostomy (a surgically inserted tube that brings nutritional formula through the abdomen directly into the stomach).Review of Resident #8's physician orders indicated an order, dated 10/30/25, for tube feeding 20 hours per day from 2 p.m. to 10 a.m.Review of Resident #8's care plan, dated 7/23/24, indicated 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.

Based on observations, interviews and record reviews, the facility failed to ensure two out of four sampled residents' (Residents 5 and 68) pain was adequately and timely addressed. These failures left Resident 5 distressed, tearful, feeling like she was dying and experiencing 12/10 (Twelve out of Ten), severe pain for 30 minutes before receiving her narcotic (strong but addictive pain medicine) pain medication and Resident 68 feeling frustrated and enduring pain while having to wait for over an hour to receive his routine narcotic medication.Findings:A review of Resident 5's face sheet (front page of the chart that contains a summary of basic information about the resident) indicated an admission date of 6/2025, with a diagnosis of pathological fracture of left femur (broken bone in the thigh caused by disease) and malignant neoplasm (cancerous tumor) of the bone.A review of Resident 5s Brief Interview for Mental Status (BIMS, an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident), dated 8/28/25, resulted in a score…

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 observations, interviews and record reviews, the facility failed to ensure:only medications that were prescribed by the physician were administered for two out of four sampled residents (Residents 2 and 45). 2. two out of four sampled residents (Residents 2 and 45) were allowed to keep medications at bedside without safe administration assessment and physician order.These failures had the potential to put residents at high risk for masking of serious medical condition and adverse drug reactions.Findings:A review of Resident 2s face sheet (resident demographics) indicated an admission date of 7/2025 with a diagnosis of Hypertension (high blood pressure) and hyperlipidemia (high cholesterol)A review of Resident 45s face sheet indicated an admission date of 11/2025 with a diagnosis of muscle weakness and cellulitis (a skin infection that causes swelling and redness) of right and left lower limb.During a concurrent observation and interview on 12/01/2025 at 10:44 AM, Resident 45 was noted with refresh eye drops at bedside. Resident 45 stated she had the eye drops there since…

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 two of three medication carts (Medication cart for Station 2 and medication cart for Station 3), in addition to the medication room, were free of expired and outdated medications and medical supplies for residents. This failure had the potential to result in inadvertently using these products on residents, which could have caused them harm and infections. Findings: During a medication storage observation and interview on 11/18/24 at 10:55 a.m., with Licensed Nurse (LN) F, the medication Latanoprost 0.005% (A medication to treat increased pressure in the eye) was observed stored inside the medication cart for Station 2 with other active medications. This medication had an expiration date of 11/15/24 and belonged to Resident 47. LN F confirmed the finding and stated the Infection Preventionist (IP) and Director of Staff Development (DSD) were responsible for checking the medication carts every week to check for expired medications. LN F confirmed this expired medication should not be stored in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record reviews, the facility failed to follow the recipe for pureed rice. This failure could lead to potential food safety issues, inconsistent quality of meals for residents, and nutritional deficiencies. Findings: A review of [NAME] Puree Recipe Book, recipe name Pureed Potatoes, Pasta, [NAME] and Other grains, the recipe indicated an ingredients of potatoes, pasta, rice cooked and drained, broth hot or hot 2 percent milk, margarine and thickener. A review of [NAME] Puree Recipe Book, recipe name Pureed Salad-Potato, Pasta and Other Grains the recipe indicated an ingredients of salads, potato and pasta type and thickener. During an observation on 11/20/24 at 11:40 a.m., [NAME] 1 did not follow the pureed recipe for rice when she did not add margarine and thickener when she prepared the pureed rice. During an interview on 11/20/24 at 10:12 a.m., the Registered Dietician (RD) stated it was expected cooks were following the recipes to ensure consistent quality food was served…

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 reviews, the facility failed to ensure residents were served with food that was palatable, attractive and at an appetizing temperature. These failures could put the residents at risk for illness, injury, malnutrition (lack of proper nutrition, caused by not having enough to eat, not eating enough of the right things), and poor nutritional status. Findings: A review of Resident 18's face sheet (demographics) indicated he was admitted on [DATE] with a diagnosis of Essential Hypertension (HTN, high blood pressure) and Muscle weakness. Resident 18's Brief Interview for Mental Status (BIMS, used to get a quick snapshot of how well you are functioning cognitively -mental process involved in comprehension and gaining knowledge) dated 11/12/24 score was 15 indicating intact cognition. A review of Resident 22's face sheet indicated she was admitted on [DATE] with a diagnoses of Essential Hypertension and Atelectasis (partial or complete collapse of the lung). Resident 22's BIMS…

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 observations, interviews and record reviews, the facility failed to ensure: 1A. two food items in the freezer were clearly labeled to identify what it was, when it was opened and when to discard the food item. 1B. one pitcher of tea was discarded by the use by date of 11/16/24. 2. one dented can (might contain bacteria that can make you sick, or even produce a toxin that can be deadly) was not separated from intact cans. These failures could put the residents at risk for: 1A. allergic reactions, health complications and food poisoning (infection or irritation of your digestive tract that spreads through foods). 1B.consuming tea that might contain bacteria which can cause abdominal pain, vomiting, diarrhea (three or more loose stools per day), and fever. 2. consuming food that was contaminated with molds, bacteria or the toxin produced by the bacteria Clostridium botulinum (causes Botulism, a rare but serious condition caused by a toxin that attacks the body's nerves and may cause life-threatening symptoms such as paralysis-loss of the ability to move and difficulty…

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, interviews and record reviews, the facility failed to follow their policy on foods brought by family/ visitors when the food stored in resident's refrigerator by the nursing station did not have a use by date per their policy. This failure could lead to residents potentially consuming food that has gone past its safe consumption window, increasing the risk of foodborne illness due to bacteria growth, as well as potential issues with food quality and taste deterioration, which could impact resident nutrition and well-being. Findings: A review of Resident 225's face sheet (demographics) indicated an admission date of 11/6/24 with a diagnoses of Essential Hypertension (HTN, high blood pressure) and Hyperlipidemia (HLP, abnormally high concentration of fats or lipids in the blood). During an observation on 11/19/24 at 3:48 p.m., Resident 225 had 6 food containers in the resident's refrigerator by the nursing station as follows, 2 containers of chilis, 1 container of meatloaf, 1 container of cage free egg salad, and 2 container of potato salads. All these containers…

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, interviews, and record reviews, the facility failed to: 1. Process soiled linens to prevent the spread on infection. 2 A. Offer hand hygiene (HH) to eight of nine residents (Resident 59, Resident 225, Resident 61, Resident 121, Resident 40, Resident 5, Resident 49, and Resident 120) before meals. 2 B. Perform HH prior to donning new gloves by one dietary staff , [NAME] E. 3. Use enhanced barrier precautions (A set of infection control measures that reduce the spread of multidrug-resistant organisms (MDROs) in nursing homes) when two nursing assistants working with Resident 33 who had a history of Methicillin-resistant Staphylococcus aureus (MRSA-A type of bacteria resistant to a certain type of antibiotics), did not follow the precautions. 4. Air dry kitchen utensils prior to storing in the kitchen drawers. These failures had the potential to result in the transmission of infections to the residents of the facility. Findings: 1. During a concurrent observation and interview on 11/21/24, at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record reviews, the facility failed to ensure hot water was available for use to the shared bathrooms in rooms (rms) 26-28 and 27-29 when the hot water temperature in these rooms were below 105 degrees. This failure resulted in Resident 48 who was in RM [ROOM NUMBER] complaining of inconvenience and unpleasantness of using cold water to wash her hands for over a week. This failure also put the residents at risk for not washing their hand due to discomfort, residents could then get sick and spread infection (invasion and growth of germs in the body) to others. Findings: A review of Resident 48's face sheet (demographics) indicated an admission date of 2/28/2023. Resident 48's diagnoses included Essential Hypertension (HTN, high blood pressure), Muscle Weakness and Anxiety disorder (AD, a group of mental health conditions that cause fear, dread and other symptoms that are out of proportion to the situation). Resident 48's Minimum Data Set assessment (MDS, a federally mandated…

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 reviews, the facility failed to maintain an effective pets control program when flies were observed in the facility, bothering two residents, Resident 38 and Resident 21. This failure posed a health risk to residents as flies carries and spread diseases like food poisoning, salmonella (food poisoning caused by infection (invasion or growth of germs in the body) with the salmonella bacterium), Escherichia coli (E. coli, a sickness you get from the E.coli bacteria that causes a lot of diarrhea (3 or more loose stool per day) related illnesses) and staphylococcus (group of bacteria that causes skin infection). Flies could also contaminate food and could infest (present in large numbers) open wounds. Findings: A review of Resident 38's face sheet (demographics) indicated an admission date of 8/9/24. Resident 38's diagnoses included Hyperlipidemia (HLP, high concentration of fats or lipids in the blood) and Sepsis (body's extreme reaction to an infection, without prompt…

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 two of four Licensed Nurses (Licensed Nurse (LN) H and Licensed Nurse (LN) O ) followed professional standards of practice when: 1. LN H left medications by Resident 67's bedside without a physician order. 2. LN O did not follow facility policy when performing a blood glucose (Blood sugar) check for Resident 170. These failures had the potential to result in medication administration errors and inaccurate blood glucose tests which could have caused harm to the residents involved. Findings: Resident 67 Record review of Resident 67's Face Sheet (Facility demographic) indicated he was admitted to the facility on [DATE] with medical diagnoses including Encephalopathy (A general term for a group of conditions that cause brain dysfunction) and Diabetes Mellitus (A chronic disease characterized by high levels of blood sugar). During an observation and interview on 11/20/24 at 6:02 p.m., LN H was observed administering insulin (Injectable…

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 one of seventeen sampled residents (Resident 21) had intervention and supervision implemented to prevent falls. As a result, Resident 21 sustained four falls with minor injuries (Skin tears and bruises) in a period of ten months. This failure had the potential to result in further falls with injuries for Resident 21. Findings: Record review of Resident 21's Face Sheet (Facility demographic) indicated he was admitted to the facility on [DATE] with medical diagnoses including Chronic Obstructive Pulmonary Disease (A lung disease characterized by chronic obstruction of lung airflow that interferes with normal breathing and is not fully reversible) and Muscle Weakness (Loss of muscle strength). Record review of Resident 21s Brief Interview of Mental Status (BIMS-A cognition assessment) dated 10/11/24 indicated he received a score of 12, which indicated his cognition was moderately impaired (A score of 1-7 indicates the cognition is severely…

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 interviews and record reviews, the facility failed to ensure that one of two sampled residents, Resident 1, received care in accordance with his comprehensive person-centered care plan based on his comprehensive assessment and per his doctor's orders regarding Resident 1's medical diagnosis of dysphagia (difficulty swallowing), when on 5/24/24, Certified Nursing Assistant A (CNA A) offered Resident 1 ice chips (considered as Transitional Food- Food that starts at one texture (e.g. firm solid) and changes into another texture specifically when moisture (e.g. water or saliva) is applied or, when a change in temperature occurs (e.g. heating). This failure had the potential to result in aspiration pneumonia (Aspiration pneumonia occurs when food or liquid is breathed into the airways or lungs, instead of being swallowed) to Resident 1. Findings. A review of Resident 1's hospital Discharge Summary Notes, dated 5/24/24, at 3:29 p.m., indicated Resident 1 was admitted to this hospital from [DATE] to 5/24/24.…

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 report allegations of a staff to resident (Resident 1) verbal altercation, and an incident between residents (Resident 2 and Resident 3) within two hours of the incidents. This failures had the likelihood for incidents of potential abuse to not get prevented, corrected, or investigated in a timely manner, and can result to physical, mental, or psychosocial harm to residents. Findings: On 3/11/24, the Department received reports from the facility of an alleged incident of potential abuse between Resident 1 and Resident 2 and an incident between Certified Nursing Assistant (CNA F) and Resident 3. During a concurrent review of records and interview with the Administrator and Director of Nursing (DON) on 3/18/24 at 10:42 AM at the Administrator ' s office, the incident between Resident 1 and CNA F happened on 3/10/24 at 3:00 PM. The Department received the SOC 341 (Report of Suspected Dependent Adult/Elder Abuse) from the facility by fax on 3/11/24 at 0:34 AM. The incident between Resident 1 and Resident 2 happened on 3/9/24…

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 staff failed to respond to call lights timely when five of 16 sampled residents had to wait up to one hour for staff to respond when residents pressed their call lights for assistance. This failure resulted in residents sitting in soiled briefs. Findings: During an interview on 5/9/22 at 12:33 p.m., Resident 52 stated she had had sores on her bottom for one year and they (the sores) would heal if all the staff caring for her provided her wound care right. Resident 52 stated the longest she had to wait for staff to respond to call lights was 45 minutes, and she stated she has had to wait while she was wet which interfered with the wound healing. Resident 52 stated PM shift (3 p.m. to 11 p.m.) was the worst with responding to call lights. During an interview on 5/9/22 at 3:09 p.m. and 4:11 p.m., Resident 63 stated she would have to wait for someone to answer her call light, especially on the PM shift. Resident 63 stated the CNAs (Certified Nursing Assistants) were great, but overworked, and frequently had to work a double shift…

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 observations, interviews and record review, the facility failed to follow up on a Preadmission Screening and Resident Review (PASRR, a federal requirement to help ensure individuals are not inappropriately placed in nursing homes for long term care) level 2 referral (determines if mental illness needs of a the individual can be met in a nursing facility) for 1 out of 16 sampled residents (Resident 27) and five unsampled residents (Resident 64, Resident 7, Resident 16, Resident 65 and Resident 66). This failure had the potential risk of Resident 27 missing out on specialized services and obtaining additional resources. Findings: Resident 27 face sheet (demographics) indicates a diagnosis of Schizoaffective disorder, Bipolar type (a mental health condition with combined symptoms of both schizophrenia and mood disorder with dramatic highs, manic and depressive episodes.) During an observation in the dining room on 5/09/22 at 12:33 p.m. Resident 27 was verbal and interacting with visitor. Resident 27 was observed with inability to sit still (rocking motion) and involuntary…

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 provide two of three sampled residents (Resident 8 and Resident 18) scheduled weekly showers, who depended on staff to assist. This failure to provide the necessary care resulted in residents looking unkempt and had the potential for residents having body odors, dry/broken skin not being assessed, and/or an infection, further negatively impacting the resident's physical and psychosocial wellbeing. Findings: 1. A review of Resident 18's admission Record, indicated Resident 18 was admitted on [DATE] with diagnoses including degenerative disease of the nervous system (Your body's command center. Originating from your brain, it controls your movements, thoughts and automatic responses to the world around), dementia (mental processes caused by brain disease and marked by memory disorders, personality changes, and impaired reasoning), dysphagia (difficulty swallowing), fracture of the left femur (broken thighbone), aftercare following joint…

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 residents with or at risk for developing pressure ulcers (PUs - injury to skin and underlying tissue resulting from prolonged pressure on the skin caused by staying in one position too long) for two of three sampled residents (Resident 18 and Resident 267) were provided treatment consistent with professional standards to promote healing of a pressure ulcer when Resident 18 and Resident 267 were not being turned and repositioned per the facility's policy/procedure, nursing staff did not document turning and repositioning, inconsistent skin documentation and Resident 18's heels were not being floated (offloading by using pillow(s) under resident's calves) per physician order. This deficient practice had the potential for Resident 18 and Resident 267 to acquire new pressure ulcers and/or worsen current pressure ulcers. Findings: Resident 18 A review of Resident 18's admission Record, indicated Resident 18 was admitted on [DATE] 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.

Based on interview and record review, the facility's consultant licensed pharmacist failed to detect and report 62 medication errors involving the administration of insulin (a hormone which regulates the amount of glucose in the blood) at bedtime to one of 16 sampled residents (Resident 53). Over a four-month period, from January to April 2022, Resident 53 was administered the wrong dose of bedtime insulin 62 out of 118 nights. The wrong doses were documented in Resident 53's medication administration record. The facility's consultant licensed pharmacist reviewed Resident 53's medication administration record monthly during January and April 2022 but did not detect or report these drug errors. This failure prevented the facility from being alerted that Resident 53 was receiving the wrong bedtime doses of insulin which placed Resident 53 at risk of a potentially dangerous drop in blood sugar/hypoglycemia (low blood sugar). Findings: During an interview and record review on 5/12/22, at 10:50 a.m., the Director of Nursing (DON) stated the facility contracted with a consultant licensed…

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 one of 16 sampled residents (Resident 53) was free of significant medication errors when Resident 53 received the wrong dose of insulin (a hormone produced in the pancreas which regulates the amount of glucose in the blood) at bedtime 70 times over a period of 130 days from January 2 to May 11, 2022. These failures resulted in Resident 53 receiving up to four times the ordered bedtime dose of insulin during that period, placing Resident 53 at risk of a potentially dangerous drop in blood sugar/hypoglycemia (low blood sugar). Findings: A review of Resident 53's Facesheet indicated he was admitted to the facility on [DATE] with diagnoses which included diabetes mellitus type 2 (Type 2 diabetes is an impairment in the way the body regulates and uses sugar (glucose) as a fuel). A review of Resident 53's Physician Orders indicated order dated 1/2/22 for insulin four times a day (with meals: at breakfast, lunch and dinner; and at bedtime) as follows:…

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 employ sufficient dietary personnel when the facility's food and nutrition services was short of one dietary aide and one cook. This failure resulted in the facility's Director of Food Services (DFS) performing the duties of dietary support personnel, such as processing food deliveries, assembling resident lunch trays, and transporting resident food carts, which resulted in perishable foods being left unrefrigerated outdoors and prevented the DFS from managing and overseeing the facility's food and nutrition service. Findings: During an observation on 5/11/22, at 8:20 a.m., there were four dietary support personnel working in the kitchen: [NAME] A, [NAME] B, Dietary Aide C, and Dietary Aide D. During the same observation, the Director of Food Services (DFS) was unloading, labeling, and storing a large quantity of boxes containing food and kitchen supplies placed on pallets outdoors next to the entrance of the kitchen. During an interview on 5/11/22, at 8:45 a.m., the DFS stated he was processing the facility's…

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

Based on observations, interview and record review, the facility failed to ensure residents were aware of the facility's Grievance Process for seven out of 16 residents. This failure had the potential risk of unresolved grievances or concerns. Findings: During the resident council meeting on 05/10/22 at 10:58 a.m., Anonymous 1 stated the facility has no formal grievance process and would like it if there is one. Anonymous 2 stated she thought grievances are to be reported to the nurses. Anonymous 3 stated to just report to the Ombudsman. Anonymous 3 stated that when he has grievance or concerns, he talks to the administrator. Anonymous 1 stated not a lot of residents knew the Administrator. During an interview on 5/12/22 at 9:02 a.m., Resident 33 stated he does not know the facility's grievance process. During an interview on 5/12/22 at 9:07 a.m., Licensed Staff G stated she's not sure about the facility's grievance process. During an interview on 5/12/22 at 9:09 a.m., Unlicensed Staff H stated they report grievance to the nurses. During an interview on 5/13/22 at 8:30 a.m.,…

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 develop a comprehensive person-centered care plan with interventions to meet the needs of one of 16 sampled residents (Resident 267) when Resident 267 was assessed to be immobile and at high risk for pressure ulcers and the facility did not include in her care plan the intervention of turning and repositioning Resident 267 every two hours. This failure had the potential for Resident 267 to develop pressure ulcers. Findings: A review of Resident 267's Facesheet indicated she was admitted to the facility on [DATE] and had diagnosis including Alzheimer's disease, vascular dementia, history of falling and failure to thrive. A review of Resident 267's admission Braden Scale (a standardized tool that indicates the risk of a resident developing pressure ulcers), dated 4/5/22, indicated Resident 267 was bedfast: confined to bed and was completely immobile: does not make even slight changes in body or extremity position without assistance. The Braden Scale…

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

Based on observation, interview, and record review, facility staff failed to follow medication safety measures when licensed staff administered twice the ordered dose of a medication to a resident, Resident 57. This failure could potentially lead to further medication errors and cause harm to vulnerable residents. Findings: During a medication pass observation on 5/12/22 at 8:28 a.m., Licensed Staff G removed two tablets of Buspirone (anti-anxiety drug) 30 mg (milligrams, a unit of measure) from a bubble pack and administered them to Resident 57. Review of Resident 57's physician orders revealed, Buspirone HCl (hydrochloride, an additive for shelf life) Tablet 15 MG Give 2 tablets by mouth two times a day for anxiety. During an interview on 5/12/22 at 3:11 p.m., Licensed Staff G verified the bubble pack's instructions to give one tablet of Buspirone 30 mg did not match the physician's order to give two tablets of buspirone 15 mg. During an interview on 5/17/22 at 11:16 a.m., Director of Nursing (DON) stated that every Friday she went through all the medication bubble packs 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, interviews and record review, the facility failed to change the nasal cannula (NC) weekly for one out of 16 sampled residents (Resident 48 ). Staff did not change Resident 48's NC tubing (device used to deliver supplemental oxygen or increased airflow to a patient in need of respiratory help) per the facility's policy policy. This failure had the potential risk of Resident 48 acquiring an infection and or not receiving the correct amount of prescribed oxygen. Findings: During an observation on 5/09/22 at 11:56 a.m., Resident 48 was on oxygen at 2 liters per minute (lpm) via NC with a label that indicated a date of 4/18/22 (the date the NC was changed out). During an observation on 5/10/22 9:12 a.m., Resident 48's NC label was still dated 4/18/22 During an observation and interview on 5/11/22 at 11:50 a.m., Licensed Staff L verified Resident 48's nasal cannula, which was now on the floor, was dated 4/18/22. During an observation on 5/11/22 at 12:42 p.m., Resident 48 was in bed, with oxygen on at 2 lpm via NC with no date label. During an observation and…

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

Based on observation, interview and record review, the facility failed to ensure food was prepared and stored in sanitary manner when perishable food intended for residents was left unrefrigerated outdoors for over 1.5 hours and one of four dietary support personnel did not have their hair fully restrained/covered while preparing resident food. These failures created the potential for foodborne illness in a vulnerable resident population and for food to become contaminated and improper for resident consumption. Findings: During an observation on 5/11/22, at 8:20 a.m., there were four dietary support personnel working in the kitchen: [NAME] A, [NAME] B, Dietary Aide C, and Dietary Aide D. During the same observation, the Director of Food Services (DFS) was unloading, labeling, and storing a large quantity of boxes containing food and kitchen supplies placed on pallets outdoors next to the entrance of the kitchen. During an interview on 5/11/22, at 8:45 a.m., the DFS stated he was processing the facility's weekly food delivery that had been left by the vendor outside. The DFS stated…

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.