Hanford Post Acute

Based on interview and record review, the Pharmacy Consultant (PC) failed to identify and report to the facility irregularities related to: 1. Resident 16 's Hemoglobin (Hgb - protein found in red blood cells that is responsible for transporting oxygen throughout the body) levels was 8.1 to 8.3 gm/dL (grams per deciliter- unit of measure) for five months with no Hgb level goal. This failure had the potential risk for Resident 16 to experience tiredness and weakness with no intervention. 2. Resident 16, a kidney failure disease (-a long term disease that occurs when the kidneys are damaged and cannot filter blood properly) patient, was administered Ascorbic Acid (Vitamin C) 500 milligrams (mg- unit of measure) without Vitamin C blood monitoring. This failure had the potential risk for Resident 16 to result in toxicity from continued and unmonitored dose of Vitamin C administration. Findings: 1. During a record review of Resident 16's admission Record, dated 1/22/25, Resident 16' s' admission Record indicated, . Diagnosis information .Iron deficiency anemia (a condition where the body…

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 perform adequate lab monitoring, order medications without adequate indications for use for Resident 16 when: 1. Resident 16's Hemoglobin (Hgb - protein found in red blood cells that is responsible for transporting oxygen throughout the body) levels was 8.1 to 8.3 gm/dL (grams per deciliter- unit of measure) for five months with no Hgb level goal and Procrit [medication use to treat anemia- condition in which the body does not have enough healthy red blood cells or Hgb] medication was given to correct low Hgb levels without iron lab monitoring. This failure had the potential risk for Resident 16 to experience blood loss without adequate intervention. 2. Resident 16 received Ascorbic Acid (Vitamin C) without Vitamin C blood monitoring and dose. This failure had the potential risk for Resident 16 to result in toxicity from a continued and unmonitored dose of Vitamin C administration. Findings: 1. During a record review of the admission Record, dated 1/22/25, the admission Record indicated, . Diagnosis information…

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 of two residents (Resident 43 and Resident 67) were free from unnecessary psychotropic (drugs that affect brain activities with mental processes and behaviors) medications when: 1. Resident 43 was prescribed Aripiprazole (antipsychotic medication that helps treat mental health conditions) for behaviors of auditory hallucinations and delusions with no documentation of such behaviors; ineffective monitoring for behavior of sadness as evidence by no target goal for behavior care planned; ineffective monitoring for behaviors of distress; no non-pharmacological (behavioral) interventions were implemented for Bupropion (antidepressant medication). 2. Resident 67's Olanzapine (antipsychotic medication that alters brain chemistry to help reduce symptoms of the mind where there has been some loss of contact with reality) order was changed from as needed (prn) to routine on admission into the facility and no assessment was completed for a psychosis (a mental health condition characterized by a loss 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.

Based on observation, interview, and record review, the facility failed to ensure the medication error rate was less than five percent when the facility's medication error rate was 11.11 percent. There were 27 opportunities for errors and three medication errors occurred for three of nine sampled residents (Resident 72, Resident 73, and Resident 70) when: 1. Resident 72's blood glucose (simple sugar - the body's primary source of energy from food) was assessed after Resident 72 began eating lunch. 2. Resident 73 was administered Olmesartan (medication used to lower blood pressure) and Resident 73's blood pressure was below ordered parameters. 3. Resident 70 was administered a medication not ordered by the physician. These failures in medication errors for Resident 72, Resident 73, and Resident 70, resulted in placing residents at risk for experiencing adverse side effects without adequate monitoring. Findings: 1. During a medication pass observation on 1/21/25 at 12:06 p.m., with Licensed Vocational Nurse (LVN) 3, LVN 3 was observed retrieving Resident 72 from the dining room 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 reviews, the facility failed to ensure drugs and biologicals used in the facility were labeled and stored in accordance with the facility policy and procedures when: 1. The room temperature for two of two medication storage rooms was not monitored. This failure had the potential risk for medications to be exposed in extreme temperatures which could alter the medication chemical composition and reduce shelf life. 2. Resident 40 and Resident 11 discontinued medications were stored in the west wing medication cart, and Resident 16's discontinued ointment medication was stored in the east wing treatment cart. This failure had the potential risk to result in a medication error. 3. Resident 27, Resident 36, Resident 343, Resident 9, Resident 59, Resident 62, Resident 42, Resident 20, Resident 5, Resident 54, and Resident 3's inhaler medications stored in the respiratory therapy (RT) cart did not have an open date label (the date when a medication was first open). This failure had the potential risk for license nurses to administer expired…

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 prepare food in accordance with professional standards for food service safety for 90 of 91 sampled residents when: 1. A towel and a pair of rubber gloves were found on the floor behind the 3-compartment wash station. 2. The stove top had caramel colored residue under the grill and pan supporter, dark shiny residue was on the grill, pan supporter and stove elements, and yellow particles sprinkled on the inner burners. 3. Four pieces of toasted bread were on the floor behind the toaster. 4. The resident refrigerator had food residue on the door shelving and ice buildup in the freezer. 5. The four tiles in front of the ice machine were cracked and broken with missing pieces which created an uneven surface and exposed a dark colored flooring. These failure had the potential to result in cross contamination (the unintentional transfer of bacteria from one substance or object with harmful effect) which could lead to food borne illness (a condition where a person becomes sick after consuming contaminated food) for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure accurate and complete medical records in accordance with professional standards of practices for three of five sampled residents (Residents 31, 43, and 54) when the Physician Orders for Life-Sustaining Treatment (POLST- a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of life) was not accurate and complete with section D - (physician/NP (Nurse Practitioner)/PA (Physician Assistant) License Number, NP Certificate Number, Physician/NP/PA Phone Number fields were not filled in, and the physician and the Resident or Resident Responsible Party (RP - legally recognized decision maker) signature and/or date fields were missing. These failure had the potential for Resident 31, 43, and 54's decisions regarding treatment options and end-of-life wishes to not be honored. Findings: During a review of Resident 31's admission Record (AR - a summary of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to maintain an effective infection prevention and control program for four of 14 sampled residents (Residents 29, 31, 73 and 84) when: 1. Resident 29's urinary catheter (a flexible tube that drains urine from the bladder into a bag) bag was dragging on the ground while being pushed in his wheelchair. This failure placed Resident 29 at potential risk for cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect). 2. Resident 29's urinary catheter bag was laying on the floor. This failure placed Resident 29 at potential risk for cross contamination. 3. Resident 31's oxygen nasal cannula (O2 nasal cannula - a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) tubing was wrapped around the handle of his wheelchair, and his oxygen humidifier bottle (a sealed bottle of water that infuses moisture to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to send a copy of the resident's transfer or discharge notification to the state long term care Ombudsman (resident advocacy agency) office for one of 23 sampled residents (Resident 87) when Resident 87 was transferred to the General Acute Care Hospital (GACH). This failure resulted for the long-term care Ombudsman not being aware of Resident 87's transfer and discharge circumstances should appeals be filed by the residents or their representative. Findings: During a review of Resident 87's Face Sheet (a summary of important information regarding a patient which include patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 1/24/25, the face sheet indicated, Resident 87 was admitted to the facility on [DATE] with a diagnosis of muscle weakness (loss of muscle strength), end stage renal disease (the final stage of kidney disease where the kidneys can no longer…

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 provide written information to of the facility's bed hold policy for one of six sampled residents (Resident 16) when Resident 16 was not provided written information regarding the facility's bed hold policy upon his transfer to the hospital This failure violated the right of Resident 16 to be informed in writing of the facility's bed hold policy. Findings: During an interview on 1/24/25 at 9:21 a.m. with Licensed Vocational Nurse (LVN) 5, LVN 5 stated Resident 16 had not been notified in writing of the facility's bed hold policy. LVN 5 stated nurses only called him to notify him of the bed hold, no written policy was given to Resident 16. LVN 5 stated it was important to provide the bed hold policy so he could read it on his own time and ask questions. During an interview on 1/24/24 at 2:19 p.m. with the Business Office Manager, The BOM stated Resident 16 only received the bed hold policy in writing during his admission. The BOM stated since Resident 16 was a long-term resident business office staff did not feel the need to…

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

Based on observation, interview, and record review, the facility failed to ensure services provided met professional standards of practice for one of six sampled residents (Resident 342) when Resident 342's Oxygen (O2) therapy (a colorless, odorless, tasteless gas essential to living organisms) was not administered per the physician order and the O2 tubing (a thin, flexible tube with two prongs that fit into the nostrils and deliver oxygen) was not labeled when it was put into use allowing for tracking when it needs to be replaced to prevent bacterial contamination. This failure resulted in Resident 342 not receiving her oxygen therapy on 1/21/25 which could led to shortness of breath, fatigue, and the potential to developed respiratory infection from the use of contaminated O2 tubing. Findings: During a concurrent observation and interview on 1/21/25 at 10:58 a.m. in Resident 342's room, Resident 342 was lying in bed, the O2 concentrator (medical device that helps residents/patients' breath) was turned off, and the nasal cannula O2 tubing was tucked underneath Resident 342's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure call lights were within reach for two of three sampled residents (Resident 20 and 65) when call lights were observed clipped to privacy curtains and out of reach. This failure had the potential for Resident 20 and 65 not to receive help when in need or in the event of an emergency. Findings: During a review of Resident 20's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes) dated 7/13/23, the AR indicated Resident 20 was readmitted on [DATE] with the diagnosis of: generalized muscle weakness, gait, and mobility abnormalities (abnormal pattern of foot movement and muscle coordination), and history of falling. During a review of Resident 20's Minimum Data Set (MDS- resident assessment tool which indicated physical and cognitive abilities), dated 12/17/24, the MDS indicated a Brief Interview for Metal Status (BIMS- an assessment of cognitive…

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 services which met professional standards of practice for one of seven sampled residents (Resident 1) when license nurse did not administered Resident 1's physician's order for omeprazole (medication for gastroesophageal reflux disease [GERD]-a condition which causes stomach acid to flow back into the esophagus [tube between the mouth and stomach]) 20 milligrams (mg- unit of measurement) for seven consecutive days and the physician was notified of the missed doses. This failure resulted in Resident 1 not receiving the omeprazole on 5/1/24, 5/2/24, 5/4/24, 5/5/24, 5/6/24, 5/7/24, 5/8/24 and placed Resident 1 at potential risk to experience symptoms of GERD such as heartburn [burning sensation in the chest], sensation of a lump in the throat, chest pain, difficulty swallowing and nausea. Findings: During a review of Resident 1's admission Record (AR), undated, the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis…

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 record review, interviews, and facility policy review, the facility failed to ensure they periodically reassessed and documented a resident's mental capacity prior to allowing a resident to make life-sustaining treatment decisions for 1 (Resident #2) of 2 residents reviewed for advance directives. The facility also failed to identify or arrange for an appropriate representative when Resident #2 was assessed as being unable to make health care decisions. Findings included: A review of a facility policy titled Advance Directives, revised in September 2022, revealed, The resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. The policy revealed, If the resident is incapacitated and unable to receive information about his or her right to formulate an advance directive, the information may be provided to the residents [sic] legal representative. The policy revealed, The interdisciplinary team [IDT] assesses the residents [sic] decision-making capacity and identifies the primary decision-maker if 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 interviews, record review, and facility document and policy review, the facility failed to accurately assess and document a resident's status in the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, for 1 (Resident #66) of 3 residents reviewed who received dialysis. Findings included: A review of a facility policy titled Certifying Accuracy of the Resident Assessment, revised in November 2019, revealed, Any person completing a portion of the Minimum Data Set/MDS (Resident Assessment Instrument) must sign and certify the accuracy of that portion of the assessment. Further review of the section titled Policy Interpretation and Implementation revealed, 3. The information captured on the assessment reflects the status of the resident during the observation ('look-back') period for that assessment. A review of a facility policy titled Resident Assessments, revised in March 2022, revealed, All members who have completed any portion of the MDS resident assessment form must…

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 facility document and policy review, the facility failed to ensure a registered nurse (RN) worked at least eight consecutive hours a day on two (11/10/2023 and 11/11/2023) of the previous 30 days. Findings included: A review of a facility policy titled Departmental Supervision, Nursing, revised in August 2022, revealed, A registered nurse provides services at least eight (8) consecutive hours every 24 hours, seven (7) days a week. RNs may be scheduled more than eight (8) hours depending on the acuity needs of the resident. A review of a facility policy titled Staffing and Sufficient Nursing, revised in August 2022, revealed, A registered nurse provides services at least eight (8) consecutive hours every 24 hours, seven (7) days a week. RNs may be scheduled more than eight (8) hours depending on the acuity needs of the resident. A review of a document titled NHPPD [Nursing Hours Per Patient Day] Audit, for the timeframe from 11/05/2023 to 12/05/2023, revealed that RN Supervisor (RN-S) #2 clocked in at 6:52 AM on 11/10/2023 and clocked out 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 F-689 S/S D Based on interview and record review, the facility failed to provide adequate supervision for one of three sampled residents (Resident 1) who was a high risk for elopement (a patient who is incapable of adequately protecting himself, and who departs the healthcare facility unsupervised and undetected) when Resident 1 eloped from the facility on 9/6/23. This failure placed Resident 1's safety at risk for injuries when Resident 1 was found in a restaurant 8 miles away from the facility on 9/6/23. Findings: During a review of Resident 1's Face Sheet (FS-a document which contains patient medical history and contact details), dated 9/2023, the FS indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses of Dementia (progressive or persistent loss of intellectual functioning), Adult failure to thrive (a decline in older adults that manifest as a downward spiral of health and ability), muscle weakness, and hypertension (high blood pressure). During a review of Resident 1's Nursing-…

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

Based on interview and record review, the facility failed to create a facility assessment specific to the need of facility population and location as part of the required facility assessment, when the facility assessment did not include the required water management program. This practice failed to establish an individualized facility assessment to meet the requirement for a water management program. Findings: During an interview with the Maintenance Supervisor (MS), on 3/14/19, at 2 p.m., he stated the facility did not have a water management program in place. The MS stated he only checked the water temperature daily and emergency water supplies monthly for presence of minerals. MS stated he did not test for Legionella (disease is a severe, often lethal, form of pneumonia [lung inflammation caused by bacterial, in which the lung air sacs fill with pus], caused by the bacterium Legionella pneumophila found in both potable and non-potable water systems [showers, sinks and water fountains]). The MS stated, I do not have an emergency plan in placed if a water test comes out positive…

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 follow their Policy and Procedure on infectious diseases when they failed to have an infection control program that was effective in identification of infections and communicable diseases when: 1. Twenty of 51 sampled residents (Resident 6, 16, 18, 21, 26, 27, 29, 30, 31, 50, 64, 67, 74, 282, 283, 287, 288, 289, 290, 291) received Tamiflu (an antiviral medication) prophylactically (preventive use) following one resident exhibiting symptoms of influenza (a highly contagious viral infection of the respiratory passages causing fever, severe aching) (flu) without documented surveillance and tracking. This resulted in the inadequate surveillance of 20 residents for flu like symptoms. 2. Nine of 9 sampled residents (Resident 18, 26, 31, 50, 286, 287, 288, 289 and 290) required hospitalization in a ten-day period for metapneumovirus (hMPV) (a respiratory virus that caused an upper respiratory infection and affected the nose, throat, and airways);…

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 Storage of Medication and Labeling of Medication Containers policy and procedure when three of three insulin solution pens (medication used to treat high blood sugar) were found expired and one vial of tuberculin solution (a protein derivative to test for tuberculosis, a bacterial infection affecting the lungs) was found with no expiration date in the medication storage room refrigerator. These failures had the potential to place Resident 55, 74 and 30 at risk of receiving expired insulin which could lead to ineffective control of blood sugar and place residents at risk of receiving expired tuberculin solution and have adverse reactions from the expired medication. Findings: 1. During a concurrent observation and interview with Registered Nurse (RN) 1, on 3/13/19, at 2:45 p.m., the [NAME] Wing medication cart had insulin Basaglar injection flex pen (insulin with injection device) labeled with an open date of 2/9/19 and expiration date of 3/11/19. RN 1 stated the insulin had expired two days…

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 prepare, distribute, and serve food in accordance with professional standards for food service safety when: 1. Dietary staff (DS) 1 failed to have a hair net covering which completely covered all hair while in the kitchen. 2. Certified Nurse Assistant (CNA) 3 touched the inside rim of a resident's cup while distributing a food tray. These failures had the potential to contaminate residents food and spread infection. Findings: 1. During a concurrent observation and interview with DS 1, on 3/13/19, at 8:55 a.m., in the kitchen, DS 1 had on a hair net which covered her hair bun and left approximately four inches of hair showing on all sides while working in the kitchen. DS 1 stated the facility did not have hair nets large enough to cover all her hair. DS 1 stated not having a hair net that covered all of her hair could lead to hair falling into residents' food and contaminating the food. During a concurrent observation and interview with the Certified Dietary Manager (CDM), on 3/13/19, at 8:55 a.m., 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 interview and record review, the facility failed to effectively implement an antibiotic stewardship program when the Infection Preventionist (IP) failed to monitor and address the use of antibiotics when the resident's condition did not meet the facility McGeer Criteria (a program used to identify signs and symptoms with an aim to reduce unnecessary prescribing for the three infections where antibiotics are most frequently prescribed in nursing homes: urinary tract infections (UTIs), lower respiratory tract infections, and skin and soft tissue infections) and when the physician was not notified after the infection did not meet criteria for infection and use of antibiotic continued. This failure had the potential for antibiotics to be used when it was not indicated and the development of antibiotic-resistant bacteria. Findings: During a concurrent interview and record review with the Director of Staff Development (DSD), on 3/14/19, at 10 a.m., she reviewed the document titled, Infection Prevention and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure eligible residents were provided with Skilled Nursing Facility (SNF) Advance Beneficiary Notice of Non-coverage (ABN) (a notice a provider gives after receiving services based on Medicare, Federal funded program that covers skilled nursing facility) in writing for one of three sampled residents (Resident 6). This deficient practice failed to provide Resident 6 with timely notice of non-coverage and an opportunity to appeal the denial of Medicare part A benefits. Findings: During a clinical record review for Resident 6, the Facesheet (a document which includes admission dates, contact details and a brief medical history) indicated Resident 6 was admitted on [DATE]. During a clinical record review for Resident 6, the start date for her Medicare part A stay was 8/22/18. The last covered day for Medicare benefits was on 10/2/19. The Notice of Medicare Non-Coverage (NOMNC) letter was signed on 10/1/19 by Resident 6. During a concurrent interview and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement a person centered care plan for one of six sampled residents (Resident 67) when there was no care plan to address Resident 67's refusal to accept laboratory blood draws ordered by the physician. This failure placed Resident 67 at risk of not receiving appropriate, consistent, and individualized care interventions to ensure his well-being. Findings: During an observation on 3/12/19, at 8:30 a.m., in the resident's room, Resident 67 was lying in bed on his back asleep. During a review of the clinical record for Resident 67, the admission Record (document containing resident's personal information) dated 3/14/19, indicated Resident 67 was readmitted to the facility on [DATE]. During a concurrent interview and record review with Licensed Vocational Nurse (LVN) 8, on 3/13/19, at 2:32 p.m., LVN 8 reviewed Resident 67's Medication Review Report, dated 3/14/19, and stated Resident 67 physician gave orders on 11/27/18 for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, the facility failed to provide services to attain or maintain the highest practical well-being for one of six sampled residents (Resident 67) when the facility failed to notify the physician of Resident 67's refusal of laboratory blood tests. This failure had the potential risk of Resident 67 not receiving the appropriate care and possible adverse side effects to medications requiring routine laboratory monitoring. Findings: During on observation on 3/12/19, at 8:30 a.m., in the resident's room, Resident 67 was lying in bed on his back asleep. During a review of the clinical record for Resident 67, the admission Record, (document containing resident's personal information) indicated Resident 67 was readmitted to the facility on [DATE]. During a concurrent interview and record review with Licensed Vocational Nurse (LVN) 8, on 3/13/19, at 2:32 p.m., she reviewed Resident 67's Medication Review Report, dated 3/14/19, and stated Resident 67 had a physician's order…

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 accurate documentation for one of one sampled residents (Resident 74) when Licensed Vocational Nurses (LVNs) continued to document hearing aids being used after the hearing aids were reported missing. This failure had the potential to delay the replacement of Resident 74's lost hearing aids and potential risk of Resident 74 to experience isolation and depression from not being able to adequately hear. Findings: During a concurrent observation and interview with Family Member (FM) 1, on 3/12/19, at 9:06 a.m., in Resident 74's room, FM 1 stated the facility had lost Resident 74's hearing aids. Resident 74 was observed sitting in her wheel chair without her hearing aids. During a concurrent interview and record review with the Social Service Director (SSD), on 03/14/19, at 10:39 a.m., in the SSD office, she stated Resident 74's hearing aids went missing on 2/8/19. The SSD stated Resident 74 had an audiology appointment on 2/25/19 and a follow-up appointment was scheduled for 3/25/19 for new hearing aids.…

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.