Driftwood Healthcare Center - Hayward

Based on observation, interview, and record review. the facility failed to ensure cooks had education and skill to puree food properly for 11 of 11 residents receiving a pureed diet when they over processed and over mechanicalized food, which was watery, bland and without flavor. This failure resulted in residents being at risk for decreased satiety and nutrition intake which could result in weight loss. Findings: During an observation on 8/5/24, at 11:30 a.m., [NAME] 1 (C-1) used a handheld slotted strainer to place vegetables (mixed vegetables-cauliflower and broccoli) from cooking vessel into the blender. C-1 proceeded to puree the vegetables, periodically checking the consistency. Upon completion C-1 poured the remaining liquid into the blender which resulted in 6 cups of product. The end result was a pourable product, which resembled a slightly thick cream soup. C-1 was required to add 3-ounces of thickener, yielding vegetables which resembled a thin, pourable pudding texture. This resulted in the addition of excess cooking water being inadvertently added to blender, diluting…

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 record review, the facility failed to follow menu portions when serving orzo, baked apples and Boston cream pie. This failure resulted in residents receiving portion sizes in excess or below their required needs per physician order or dietician recommendation, potentially putting residents at risk for inability to maintain normal body weight and receiving acceptable nutritional values. Findings: During a concurrent observation and record review on 8/5/24, at 12:15 p.m., in the kitchen, Dietary Aide (DA-1) served ½ cup of orzo to 24/24 Controlled Carbohydrate (CCHO - a diet to keep carbohydrate consumption at a steady level) diet residents. The Spring/Summer 2024 Diet Spreadsheet, indicated CCHO diet residents should receive 1/3 cup of orzo. During a concurrent observation and record review on 8/5/24, at 12:30 p.m., in the kitchen, DA-1 used a #12 scoop (2.5-3 oz) to serve baked apples for both regular and CCHO diets. The Spring/Summer 2024 Diet Spreadsheet indicated a #10 scoop (3-4 oz) is required for serving baked apples for both regular and CCHO diets.…

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 juice machine was cleaned according to manufacturer's instructions when the machine was not flushed weekly and the bar gun was soaked in hot water. This failure resulted in improper sanitation and the risk for transmission of foodborne illness to 56 residents receiving juice. Findings: During a concurrent observation and interview on 8/5/24, at 10:00 a.m., in the kitchen, Kitchen Aide 1 (KA-1) soaked the juice bar gun from the juice machine in a large pitcher of hot water (water with steam emanating from vessel). KA-1 stated the required cleaning included submerging and soaking the bar gun (nozzle) daily to prevent blockages or clogs caused by sugar build-up. KA-1 stated the juice bag junction (connection to juice bag) is disconnected and rinsed when each juice bag is empty. KA-1 stated they do not use a log to document the cleaning or a cleaning schedule. During a review of Lyons Bag in the Box Equipment Cleaning Procedure, the procedure indicated the bar gun should be soaked daily in luke warm…

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 infection control policy and procedure was followed for 10 of 23 sampled (Residents 21, 16, 32, 60, 3, 27, 51, 273, 272 and 59) residents when: 1. staff did not use sterile gloves when performing sterile tracheostomy (artificial airway at the throat which is kept open with a tube inserted into the opening) suctioning (procedure to remove secretions from the respiratory tract by vacuum) on Resident 21, 2. staff did not perform hand hygiene when switching between three residents (Resident 16, 32, and 60) who needed tracheostomy care, 3. facility did not have equipment to change suction canisters (a plastic container connected to a vacuum which stores liquid from suctioning) for Resident 3, 32 and 60 and did not have equipment to change the ventilator circuit (plastic tubing which connects a tracheostomy to a ventilator [a machine used to help a resident breath mechanically]) for Resident 51, 4. staff allowed open system tube feeding…

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 one of 17 sampled residents (Resident 25) received good grooming and personal hygiene care when resident did not receive complete fingernail care. This failure resulted in Resident 25 to feel helpless and placed him at risk for developing infections and hurting himself with long, pointed fingernails. Findings: A review of Resident 25's Face Sheet, printed 8/7/24, indicated resident was originally admitted to the facility on [DATE] with diagnoses of quadriplegia (loss of strength on all four limbs) and cerebrovascular disease (a condition that affects flow of blood in the brain and spine). A review of Resident 25's Minimum Data Set (MDS, a resident assessment tool used to guide care) dated 6/8/24, indicated Resident 25 was understood and was able to understand others. The MDS indicated Resident 25's Brief Interview of Mental Status (BIMS, an assessment for cognition status) score was eight out of 15 which indicated moderately…

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 ensure consistent intervention and recommendation was carried out for tube feeds according to patient needs for (Resident 44) while tube feeds was the sole source of nutrition. This failure resulted in an unintended, unplanned weight gain of 21.27% in one year creating potential risks including: 1. Increased Risk of Cardiovascular Disease: Excess weight can lead to increased strain on the heart, potentially causing or worsening conditions such as hypertension, heart disease, and stroke. 2. Development or Worsening of Diabetes: Weight gain, particularly in the abdominal area, can lead to insulin resistance and increase the risk of developing type 2 diabetes or exacerbate existing diabetes. 3. Worsening of Respiratory Issues: Extra weight can compress the chest and diaphragm, making it harder for bed-bound patients to breathe and increasing the risk of respiratory problems, including sleep apnea. 4. Pressure Ulcers (Bedsores): Increased…

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 the necessary care and services to attain or maintain the highest practicable physical well-being for one of 17 sampled residents (Resident 43, receiving hemodialysis [a process of filtering the blood of a person whose kidneys are not working normally] treatment) when: 1. Licensed Nurse (LN) was not fully knowledgeable about the management of care in the event of Resident 43's arterial-venous fistula (a direct connection between the artery and a vein for dialysis access) site complications, post dialysis treatment. This failure resulted in the potential that staff may not correctly perform the proper intervention and prompt physician notification for a resident's dysfunctional access site condition after return from dialysis treatment. 2. LNs failed to ensure Resident 43 received Renagel (a phosphate binder used to lower high blood phosphorus [an essential mineral found in the blood to help form strong bones, teeth, and muscles] levels in…

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 Kitchen Manager (KM) had completed the required six hours of inservice training on the specific California dietary service requirements contained in California Code of Regulations (CCR) Title 22 prior to assuming full time duties as a dietetic services supervisor at the health facility, This failure resulted in the KM not possessing competencies and skills for California to carry out food and nutrition functions, potentially putting residents at risk for foodborne illness. Findings: During an interview on 8/5//24, at 11:00 AM, with KM, KM stated she worked full time and was certified as a dietary manager. KM stated she does not have 6 hours of inservice training on the specific California dietary service requirements. During an interview on 8/5//24, at 11:00 AM, with Registered Dietician (RD), RD stated she had not administered or developed the required six hour inservice training for the KM.

Based on observation, interview, and record review, the facility failed to ensure proper handling and delivery of respiratory care consistent with the facility's policy and procedures (P&P) and the professional standards of practice for three out of eight sampled residents (Resident 3, Resident 5, and Resident 7) when: 1. Resident 3's nasal cannula (a medical device with two prongs that is connected to an oxygen source used to deliver supplemental oxygen directly into the nostrils) was not labeled with the date it was first used; 2. Resident 5's nasal cannula and nebulizer (machine that turns liquid medicine into a mist that can be easily inhaled) simple facemask and tubing was not labeled with the date it was initially used and Resident 5's physician's orders for oxygen therapy were not followed; and, 3. Resident 7's nasal cannula was not labeled with the date it was first used and Resident 7 had no physician's order for the use of oxygen therapy. These failures had the potential to result in unsafe and unsanitary delivery of oxygen to Resident 3, Resident 5, and Resident 7.…

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 and maintain an effective infection prevention and control program for a census of 78 residents when: 1. Three facility staff entered a contact isolation precaution room (an isolation precaution implemented when a patient infected with a bacteria, virus, or other microorganism which is transmittable through direct or indirect contact with the patient or the patient ' s environment) without using all the required personal protective equipment (PPE); and, 2. Resident 3 and Resident 7's nasal cannula, and Resident 5's respiratory care tubing were not labeled with the date it was initially used. These failures resulted in an increased risk for cross-contamination (movement or transfer of harmful bacteria from one person, object, or place to another), potential exposure of Resident 3, Resident 7, and Resident 5 to germs, and may cause infection among residents, staff, and visitors. Findings: 1. During an observation on 3/11/24 at 12:58…

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 preventive care for pressure injury/ulcer (PI/PU, injury to skin and underlying tissue resulting from prolonged pressure) consistent with professional standards of practice for one of eight sampled residents (Resident 8) when Resident 8's physician's order of turning and repositioning every two hours was not consistently implemented. This failure resulted in Resident 8's sacral (lower back near the crease of the buttocks) wound to get worse and had the potential for Resident 8's skin condition to get worse, develop complications, and/or possible development of other pressure related injuries. Findings: A review of Resident 8's clinical record indicated Resident 8 was admitted July of 2023 and had diagnoses that included respiratory failure (a serious condition that develops when the lungs can't get enough oxygen into the blood and makes it difficult for a person to breathe on his own), nontraumatic subdural hemorrhage (a condition where a pool of blood is formed between the brain and the skull causing structural,…

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 ensure medications were secure for a census of 76, when 3 medication carts were found unlocked and unattended. This failure had the potential to expose residents, staff, and visitors to unauthorized access to medications, resulting in possible injury or drug diversion. Findings: During an observation on 3/7/24 at 12:49 p.m., in the sub-acute hall, 3 medication carts up against the wall, side by side were unattended and unlocked. During a concurrent observation and interview on 3/7/24 at 12:55 p.m., with the Licensed Nurse (LN) 1, LN 1 confirmed the carts with prescription medications were unlocked. LN 1 stated, We lock the carts usually before we leave them. We all have keys. Just to be safe from anyone, residents or staff, getting into the cart. During an interview on 3/7/24 at 4:05 p.m., with the Director of Nursing (DON), the DON stated, I would expect the nurses to lock the carts before leaving them, for the safety of the other residents which could get into them and take the medications. During a review of the facility…

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

Based on observation, interview, and facility document review, the facility failed to store, prepare, and distribute food in a safe and sanitary manner when: 1. Expired food items were found in the dry storage rack in kitchen; 2. Freezer 1 temperature was not reaching Zero (0) degree Fahrenheit and lower; 3. There was no air gap (a gap of air between the floor and a drainpipe to prevent backflow of sewage into the equipment) for food preparation sink; 4. There was no proper air gap in the ice machine; 5. Microwave was not cleaned and had food residue on the top inside surface; and 6. Kitchen counter under the steamer was sticky and dusty. These failures had the potential to cause food borne illnesses for 59 residents who received food from the kitchen for a facility census of 75. Findings: 1. During a concurrent observation and interview on 8/30/22, at 9:30 a.m., with Registered Dietician (RD), the dry storage rack in the kitchen had 1 X 28 oz ground cinnamon, 1 X 28 oz chili powder, 1 X 28 oz bay leaves with use by date 8/13/22. RD stated the ground cinnamon, chili powder and bay…

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 staff followed proper standard and transmission-based precautions to prevent the spread of infection when: 1. Laundry Staff (LS 1) stored personal items in the clean linen/laundry area; 2. Oxygen (O2) tubing was not labeled and dated for Residents 34, 39, and 57; 3. Licensed Vocation Nurse (LVN) 2 did not perform hand hygiene during medication administration; and 4. LVN 2 did not clean/disinfect the shared blood pressure (BP) machine and medication tray in between residents; and These failures had the potential to result in cross contamination and spread of infections for Residents 34, 39, 57 and other residents in the facility. Findings: 1. During a concurrent observation and interview on 9/01/22, at 1:33 p.m., LS 1, a [NAME]-colored sweater, grayish blue sweater, brown sweater, pink purse, a personal plant, a coffee maker, a refrigerator with one opened soda can and one unopened soda can, carrots, one Jello, strawberries, one…

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 and record reviews, the facility failed to complete 17 of 18 sampled residents' (Residents 6, 9, 32, 33, 11, 27, 16, 3, 5, 2, 10, 29, 4, 21, 37, 12 and 19) Minimum Data Set (MDS - an assessment tool to guide resident care) assessments within 92 calendar days. This failure resulted in Residents 6, 9, 32, 33, 11, 27, 16, 3, 5, 2, 10, 29, 4, 21, 37, 12 and 19 to not receive a timely assessment and had the potential to delay resident's care based on their individual physical and psychosocial needs. Findings: During a concurrent interview and record review with MDS coordinator (MDSC), on 9/1/22, at 12:07 p.m., Section Z of the MDS assessments for 18 residents were reviewed. Review of the completion dates of last two MDS assessments for 17 residents indicated: Residents 6, 9, 11, 3, 5, 2, 10, 4, and 12 did not have a completed MDS assessment between 3/2022 and 8/2022. Residents 32, 33, 27, 16, 29, 21, 19 did not have a completed MDS assessment between 4/2022 and 8/2022. Resident 37 did not have a completed MDS assessment between 1/2022 and 6/2022. MDSC stated the MDS…

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 three of five sampled residents (Resident 51, 43 and 75) received grooming and personal hygiene care when: 1. Resident 51 and 43 had long, sharp fingernails with black matter underneath on both hands; and 2. Resident 75 did not receive toenail care. These failures resulted in Residents 51, 43 and 75 to feel helpless and placed them at risk for developing infections and hurting themselves with long nails. Findings: 1. During a review of Resident 51's Face Sheet, printed 9/2/22, the face sheet indicated Resident 51 was originally admitted to the facility on [DATE] and had medical diagnoses including hemiplegia (weakness of one side of body) and hemiparesis (loss of strength on one side of the body) following cerebral infarction (Stroke) affecting unspecified side. During a record review of Resident 51's Minimum Data Set (MDS, a resident assessment tool used to guide care) dated 5/21/2022, the MDS Section G indicated, Resident 51 was…

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

Based on observation, interview, and record review, the facility failed to ensure three of seven sampled residents (Resident 15, 27 and 484) received medications without an error. The facility's medication pass observation during the survey resulted in seven errors out of 25 opportunities and indicated a medication error rate of 28 percent (%). This failure placed Residents 15, 27 and 484 at risk for not getting the full therapeutic effect of their prescribed medications and had the potential to result in undesired health care outcomes. Findings: During a record review of Resident 484's admission Record Report, dated 9/2/22, it indicated Resident 484 was admitted to the facility on 8/2022 with diagnosis of Type 2 diabetes mellitus (a chronic condition which affects the way body process blood glucose levels). During a record review of Resident 484's Physician orders, dated 9/1/22-9/30/22, the orders indicated Resident 484 had an to administer Metformin (diabetes medication) 1000 milligrams (mg) by mouth two times a day with breakfast and dinner. Further review of Resident 484'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 safe medication and biological storage when: 1. Seven expired hypodermic needles (needle used to inject a substance), one expired COVID-19 (a respiratory virus) antigen test kit were stored in the medication storage room; 2. One expired intravenous (IV) connector and Maxitrol (medication to treat swelling of the eye) eye ointment for a resident no longer in the facility (Resident 485) was found in the subacute Medication Cart 2; and 3. 10 loose pills and Resident 72's Humalog (blood sugar medication) was opened for more than 28 days were stored in the Medication Cart 2. These failures had the potential of exposing residents to drugs and biologicals with questionable potency and efficacy. Findings: 1. During a concurrent observation and interview on [DATE], at 10:30 a.m., with Registered Nurse (RN) 4, in the medication storage room, seven hypodermic needles with expiration date [DATE] and one COVID-19 antigen test with expiration…

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 pneumonia vaccination policy and procedure for three of five sampled residents (Residents 5, 6, and 70) when the pneumococcal vaccine was not provided to Residents 5, 6, and 70. This failure had the potential for Resident 5, 6 and 70 to contract and develop a pneumococcal infection. Findings: During an interview and record review on 9/2/22, at 10:10 a.m., with the Infection Preventionist (IP), Resident 5, Resident 6, and Resident 70's immunization records were reviewed. IP stated he could not find any prior history of pneumococcal vaccination for Residents 5, 6 and 70. IP stated Residents 5, 6, and 70 stayed in the facility for more than one year. IP stated the facility obtained a verbal consent for pneumococcal vaccination from Resident 5 on 8/1/22 and Resident 70 on 8/8/22. IP stated he did not obtain consent from Resident 6 for the pneumococcal vaccination. During a review of facility's policy and procedure (P&P) titled, Policy: Pneumococcal Vaccine, dated 6/22/22, the P&P indicated, prior to or upon…

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 accurately code rehabilitative services and functional status for one of 18 sampled residents (Resident 5) Minimum Data Set (MDS - an assessment tool to guide resident care) assessment. This failure resulted in an inaccurate reflection of Restorative Nursing Aide (RNA) interventions and functional status for Resident 5 and had the potential for Resident 5 to not receive care to meet their needs. Findings: During a record review of Resident 5's admission Record, the record indicated Resident 5 was admitted to the facility on 7/2002. The record indicated Resident 5 had a diagnosis of quadriplegia (condition where all four extremities have paralysis of varying degree). During a concurrent observation and interview with Resident 5, on 9/1/22, at 8:45 a.m., Resident 5 was lying in bed. Resident 5 was able to move upper extremities minimally and was not able to move lower extremities at all. Resident 5 stated he had contractures in both hands. Resident 5 stated he was dependent on staff to assist him 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 observation, interview and record review, the facility failed to follow the fall prevention care plan for one of one sampled resident (Resident 40) when Resident 40 did not receive frequent monitoring every 15 minutes after experiencing three falls within a one month period. This failure resulted in Resident 5 experiencing three falls, not receiving individualized care and placing Resident 5 at risk of further falls and avoidable injuries. Findings: During a review of Resident 40's undated admission Record, the record indicated Resident 40 was admitted to the facility in 2018, with diagnoses of muscle weakness, difficulty walking, and dementia with behavioral disturbance (a group of thinking and social symptoms that interferes with daily functioning such as memory loss and judgement). During a record review of Resident 40's Minimum Data Set (MDS- a standardized resident assessment and care screening tool), dated 7/23/22, indicated Resident 40 had moderately impaired cognitive function (mental function of acquiring knowledge and understanding through experiences 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 follow the physician's order for one of three sampled residents (Resident 26) with a risk of developing pressure sores when the physician's order to apply heel protectors for Resident 26 was not followed. This failure put Resident 26 at risk for developing pressure ulcers or injury to both heels. Findings: Review of Resident 26's undated Face Sheet indicated Resident 26 was admitted to the facility on [DATE] with diagnoses which included Hemiplegia and hemiparesis (muscle weakness on one side of the body making it hard to perform everyday activities like eating or dressing; may also cause loss of balance), disorder of muscle, and lack of coordination. Resident 26 was observed from 8/30/22 through 9/1/22 at various times. Resident 26 was observed lying on his back in bed without heel protectors at all times. During an interview with Licensed Vocational Nurse (LVN) 1, on 9/1/22, at 11:55 a.m., LVN 1 stated she was not aware Resident 26…

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 did not ensure appropriate indwelling catheter (a tube inserted into the urinary bladder which drains urine into a drainage bag outside the body) care for one of eight sampled residents (Resident 179) when Resident 179's. This deficient practice had the potential for Resident 179 to develop an infection or a urinary tract infection. Findings: A review of Resident 179's undated Face Sheet indicated Resident 179 was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure (serious condition that makes it difficult to breathe on your own). During an observation on 8/30/22, at 10:05 a.m., at Resident 179's bedside, Resident 179's indwelling catheter bag was full and there was urine in the tubing. During an interview on 8/30/22, at 10:25 a.m., with Registered Nurse (RN) 1, RN 1 stated resident 179's indwelling catheter bag was overflowed. RN 1 stated the night shift Certified Nursing Assistant (CNA) should have emptied 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, interview, and record review, the facility failed to follow the tracheostomy care policy and procedure and provide one of 23 residents (Resident 35) tracheostomy (a surgical opening on the neck for placing a breathing tube) care consistent with professional standards of practice when Resident 35's tracheostomy had thick greenish matter around the tracheostomy opening and soiled dressing around the stoma site (the opening in the neck where the tracheostomy tube is placed). This deficient practice placed Resident 35 at risk for airway obstruction, skin irritation, and infection. Findings: Review of Resident 35's undated Face Sheet indicated Resident 35 was admitted to the facility on [DATE] with diagnoses including Acute Respiratory Failure (a condition that makes it difficult to breathe on your own), and encounter for attention to tracheostomy (use of tracheostomy for breathing). During observation on 8/30/22, at 11:10 a.m., at Resident 35's bedside, Resident 35 had thick greenish matter…

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 an environment that promoted dignity while dining for one of 22 (Resident 9) sampled residents when Certified Nursing Assistant (CNA) 1 remained standing while assisting Resident 9 with his meal. For Resident 9, this deficient practice had the potential to result in Resident 9 receiving an undignified dining assistance. Findings: Review of the Resident Face Sheet, printed 8/27/19, indicated Resident 9 admitted to the facility with diagnoses that included hemiplegia (muscle weakness to one side of the body) and dysphagia (difficulty swallowing). During an observation on 8/27/19, at 7:48 a.m., Resident 9 was sitting up in bed, CNA 1 stood on the left side of Resident 9's bed and assisted Resident 9 with breakfast. Review of Resident 9's Minimum Data Set, dated [DATE], indicated Resident 9 required the extensive assistance of one staff person for eating. In an interview on 8/27/19, at 7:48 a.m., CNA 1 stated she remained standing…

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, for one (Resident 1) of 22 sampled residents, the facility failed to transmit Resident 1's admission and quarterly Minimum Data Sets (MDS - an assessment tool used to direct care) within the allowable timeframes after completing Resident 1's admission and quarterly MDS assessments. This deficient practice resulted in the delay of resident-specific information to reflect Resident 1's overall status, necessary for the provision of care. Findings: Review of the Resident Face Sheet, dated 8/28/19, indicated Resident 1 was admitted to the facility on [DATE] and re-admitted to the facility on [DATE]. Review of the facility's document titled CMS Submission Report MDS 3.0 NH Final Validation Report, not dated, indicated Resident 1's admission MDS was submitted to the Center for Medicare and Medicaid Services (CMS) on 1/29/19. Further review of this document, indicated the target date was 1/19/19. Review of a document titled CMS Submission Report MDS 3.0 NH Final Validation Report,…

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, for one of 22 sampled residents (Resident 79) the facility failed to provide the necessary care to maintain personal hygiene when Resident 79 did not receive assistance with shaving for a week. This failure resulted in Resident 79 having long facial and neck hair growth. Findings: Review of Resident 79's Minimum Data Set (MDS - a resident assessment tool used to guide care), dated 7/3/19, indicated Resident 79 required the extensive physical assistance of one staff person for personal hygiene that included combing his hair and shaving his facial hair. The MDS also indicated Resident 79 was cognitively intact (had the ability to clearly think, reason, and remember). In an observation and concurrent interview on 8/26/19, at 8:59 a.m., Resident 79 was noted with visible facial hair down to the neck. Resident 79 stated he needed a shave badly and it had been a week since he was last shaved. During concurrent interviews on 8/27/19, at 7:43 a.m., the Director of Nursing (DON) stated it was the Certified Nursing Assistants' (CNAs)…

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, for one of 22 sampled residents (Resident 17), the facility failed to ensure that drugs were stored in accordance with the manufacturer's instructions for use when Resident 17's Lantus insulin (injectable medication that treats diabetes) vial was stored in the medication cart beyond use by date. This failure had the potential to result in diminished efficacy of these medications. Findings: Review of Resident 17's Face Sheet, printed 8/29/19, indicated Resident 17 was admitted to the facility with diagnoses that included Type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar). Review of Resident 17's Physician Order Report, dated 8/1/19 - 8/29/19, indicated Resident 17 had a physician's order to receive 23 units of Lantus (a blood sugar medication) at bedtime every night. During an observation and concurrent interview with Licensed Vocational Nurse (LVN) 2 on 8/28/19, at 2:03 p.m., Medication Cart 3 had Resident 17'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 interview and record review, the facility failed to maintain accurate medical records on one ( Resident 133) of 22 sampled residents when Resident 133 did not have an entry tracking record completed upon returning to the facility. This deficient practice resulted in Resident 133 not being listed on the Center for Medicare and Medicaid Services (CMS) facility census and had the potential for Resident 133 to not receive care and services that were needed. Findings: Review of Resident 133's Face Sheet, dated 8/28/19, indicated Resident 133 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of the CMS Long Term Care Survey Process (LTCSP) census, indicated Resident 133 was not listed in the system. Review of a document titled MDS 3.0 Assessments, not dated, indicated Resident 133's entry tracking for 8/6/19 due status was late. During an interview with the Minimum Data Set Coordinator (MDSC) on 8/26/19 at 10:42 a.m., MDSC stated Resident 133 was initially admitted to the facility on…

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