Eden Healthcare Center

Based on observation, interview, record review, and facility policy review, the facility failed to: 1) complete a smoking assessment for Resident #79, 2) provide supervision for Resident #91, a resident who was assessed to require supervision while smoking, and 3) ensure a safety intervention for smoking was implemented for Resident #10. These failures affected 3 (Residents #10, #79, #91) of 5 sampled residents reviewed for smoking. The facility further failed to ensure staff did not leave medications at the bedside for 2 (Resident #58 and Resident #82) of 24 sampled residents. Findings included: A facility policy titled, Resident Smoking Assessment Policy, with an implementation date of 11/01/2023, revealed, Policy It is the policy of this facility to provide a safe and healthy smoke free environment for residents. Policy Explanation and Compliance Guidelines: 1. 1. All residents will be asked about tobacco use during the admission process. 2. Residents who smoke will be further assessed, using a smoking assessment. Residents will be assessed upon admission and as needed. 3.…

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 policy review, the facility failed to ensure medications were labeled and stored properly in medication carts located on 2 (South 2 Unit and North 1 Unit) of 4 units in the facility. Specifically, the South 2 Unit medication cart contained loose pills, and a topical medication and nebulizer solution were not stored separately from medications to be given by mouth, in accordance with the facility's policy. The North 1 Unit medication cart contained a bottle of guaifenesin oral solution (cough medicine) with an illegible expiration date. Findings included: A facility policy titled, Medication Administration, dated 03/01/2023, specified, 1. Keep medication cart clean, organized, and stocked with adequate supplies. The policy also indicated, 12. Identify expiration date. If expired, notify nurse manager. A facility policy titled, Medication Storage, dated 03/01/2023, specified, It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to manufactures…

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, record review, and facility policy review, the facility failed to ensure the physician was notified when blood sugar levels were 350 milligrams per deciliter (mg/dL) or higher in accordance with the facility's Hypoglycemia [low blood sugar levels]/Hyperglycemia [high blood sugar levels] Management policy for 1 (Resident #11) of 5 sampled residents reviewed for unnecessary medications. Findings included: A facility policy titled, Hypoglycemia/Hyperglycemia Management, implemented 06/01/2023 revealed, Policy: It is the policy of this facility to ensure effective management of a resident who experiences a hypoglycemic and hyperglycemic episodes. The policy specified, If the blood sugar reading is 350 mg/dL or higher, the nurse will contact the practitioner to receive further orders for treatment. An admission Record revealed the facility admitted Resident #11 on 10/16/2014. According to the admission Record, the resident had a medical history that included diagnoses of type two diabetes mellitus without complications and long-term (current) use of insulin. 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 observation, interview, facility document review, and facility policy review, the facility failed to ensure each resident had a safe and homelike environment by ensuring rooms were free of damage for 2 (Resident #112 and Resident #82) of 24 sampled residents. Findings included: A facility policy titled, Safe and Homelike Environment, dated 06/01/2023, revealed, In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. An undated facility policy titled, Maintenance Inspection, revealed, 1. The Director of Maintenance Services or designee will perform routine inspections of the physical plant using the maintenance checklist. The policy revealed, 3. All opportunities will be corrected immediately by maintenance personnel. 1. An admission Record revealed the facility admitted Resident #112 on 05/06/2024. According to the admission Record, the resident had a medical history that included a diagnosis of depression. An admission Minimum…

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

Based on interview, record review, facility policy review, and review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected whether 1 (Resident #12) of 3 sampled residents reviewed for Preadmission Screening and Resident Review (PASRR) requirements was considered by the state Level II process to have a serious mental illness, intellectual disability, or a related condition. Findings included: A facility policy titled, Conducting an Accurate Resident Assessment, dated 09/01/2024, revealed, The purpose of this policy is to assure that all residents receive an accurate assessment, reflective of the resident's status at the time of the assessment, by staff qualified to assess relevant care areas. The policy revealed, 6. A registered nurse will sign and certify that the assessment/correction request is completed. Each individual who completes a portion of the assessment will sign and certify the accuracy of that portion of the…

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

Based on interview, record review, and facility document and policy review, the facility failed to ensure 1 (Resident #39) of 3 residents reviewed for preadmission screening and resident review (PASARR) requirements was referred to the state-designated authority for a Level II PASARR evaluation following a positive Level I PASARR screening. Findings included: A facility policy titled Resident Assessment-Coordination with PASARR Program, implemented 09/01/2023, revealed 1. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening. a. PASARR Level I- initial pre-screening that is completed prior to admission i. Negative Level I Screen- permits admission to proceed and ends the PASARR process unless a possible serious mental disorder or intellectual disability arises later. ii. Positive Level II Screen- necessitates a PASARR Level II evaluation. B. PASRR Level II- a comprehensive evaluation by the appropriate state-designated authority (cannot be completed…

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, record review, and facility policy review, the facility failed to ensure medication orders specified the intended dosages for 1 (Resident #32) of 4 residents whose physician's orders were reconciled during the medication administration task. Additionally, the facility failed to ensure nursing staff contacted the physician to obtain order clarifications for Resident #32's incomplete orders. Findings included: A facility policy titled, Medication Administration, dated 03/01/2023, specified, 10. Review MAR [medication administration record] to identify medication to be administered. 11. Compare medication source (bubble pack, vial, etc. [et cetera, and other similar things]) with MAR to verify resident name, medication name, form, dose, route, and time. The policy also indicated, 20. Correct any discrepancies and report to nurse manager, MD [medical doctor] and/or DON [Director of Nursing]. An admission Record indicated the facility admitted Resident #32 on 03/29/2024. According to the admission Record, the resident had a medical history that included…

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, record review, and facility document and policy review, the facility failed to ensure 1 (Resident #39) of 4 residents reviewed for advance directives had a physician's order that was consistent with the resident's Physician Orders for Life Sustaining Treatment (POLST) form, which indicated the resident elected do not resuscitate (DNR)/no cardiopulmonary resuscitation (CPR). Findings included: A facility policy titled, Communication of Code Status, dated [DATE], revealed, It is the policy of this facility to adhere to residents' rights to formulate advance directives. In accordance with these rights, this facility will implement procedures to communicate a resident's code status to those individuals who need to know this information. The policy revealed, 3. Communication of code status include resident orders and POLST form as applicable. According to the policy, 6. The resident's code status will be reviewed quarterly or as needed and any changes will be documented in the medical record 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 interview, record review, and facility policy review, the facility failed to maintain a complete and accurate medical record for 1 (Resident #22) of 24 sampled residents. Specifically, the facility failed to document accurate skin assessment information for Resident #22. Findings included: A facility policy titled, Documentation in Medical Record, dated 03/01/2023, specified, Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. The policy also indicated, 2. Principles of documentation include but are not limited to: b. Documentation shall be accurate, relevant, and complete, containing sufficient detains about the resident's care and/or responses to care. An admission Record revealed the facility admitted Resident #22 on 08/29/2020. According to the admission Record, the resident had a medical history that included diagnoses of unspecified dementia, major depressive disorder, muscle…

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, observation, record review, and facility policy review, the facility failed to ensure enhanced barrier precautions (EBP) were implemented for 1 (Resident #22) of 2 residents reviewed for pressure injury/ulcer. Findings included: A facility policy titled, Enhanced Barrier Precautions Policy, implemented 04/01/2024, specified, 2. Initiation of Enhanced Barrier Precautions: b. Enhanced barrier precautions will be considered for residents with any of the following: i. Wounds (e.g. [exempli gratia, for example], chronic wounds such as pressure ulcers, diabetic foot ulcers, surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, PICC [peripherally inserted central catheter] lines, midline catheters) even if the resident is not known to be infected or colonized with an MDRO [multidrug resistant organisms]. The policy revealed, 3. Implementation of Enhanced Barrier Precautions: a. Make gown and gloves available immediately near or…

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, record review, and facility policy review, the facility failed to ensure the responsible party/conservator for 1 (Resident #113) of 5 residents reviewed for vaccinations were educated and provided the opportunity to consent for a pneumococcal vaccination. Findings included: A facility policy titled, Pneumococcal Vaccine (Series), implemented 06/14/2023, revealed, It is our policy to offer residents, staff, and volunteer workers immunization against pneumococcal disease in accordance with current CDC [Centers for Disease Control and Prevention] guidelines and recommendations. The policy revealed, 3. Prior to offering the pneumococcal immunization, each resident or the resident's representative will receive education regarding the benefits and potential side effects of the immunization. a. The individual receiving the immunization, or the resident's representative, will be provided with a copy of CDC's current vaccine information statement relative to that vaccine. The policy further revealed, 4. The resident/representative retains the right to refuse the…

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

Based on observation, interview, and record review, the facility failed to obtain medication for one of three sampled residents (Resident 1) when Fosamax (a medication used to prevent and treat osteoporosis [thinning of the bone]) was not available for administration to Resident 1. The failure to obtain and administer ordered medication had the potential to result in ineffective treatment and pain. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility in May 2021, with diagnoses of quadriplegia (paralysis of all four limbs) and osteoporosis. A review of Resident 1's Minimum Data Set (MDS, a resident assessment tool used to guide care) dated 3/1/24, indicated a score of 15 on the Brief Interview for Mental Status (BIMS, an assessment tool for a resident's orientation to time, and capacity to remember. The BIMS score ranges from 0-15, with 15 as an indication of intact skills). A review of Resident 1's Order Details indicated the following medication orders: - Dated 5/23/24, at 23:00, the order summary indicated Fosamax Oral tablet 70…

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 a safe and clean environment for two of six sampled residents (Resident 1 and Resident 6) when: 1. Resident 4 went into Resident 1's room and urinated on the curtain next to Resident 1's bed; and 2. Resident 4 went into Resident 6's room and urinated on the floor. These failures resulted in Resident 1 and Resident 6 experiencing emotional distress, feeling mad, and being upset. Findings: 1. A review of Resident 4's clinical record indicated Resident 4 was admitted October of 2023 and had diagnoses that included mood disorder (marked disruptions in emotions) and dementia (impairment of the ability to remember, think, or make decisions that interferes with everyday activities). A review of Resident 4's Minimum Data Set (MDS- an assessment tool used to guide care) Cognitive Patterns, dated 1/18/24, indicated Resident 4 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 2 out of 15 which indicated Resident 4 had severely impaired cognition. A review of Resident 4's progress notes, dated…

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

Based on observation, record review, and interview, the facility failed to promote the right of privacy for one (Resident 3) of three sampled Residents, when the facility allowed Resident 3 to remain without clothing from the waist down in the rehabilitation room (rehab room). This failure resulted in Resident 3 being exposed to other residents and staff members and made Resident 3 feel helpless, exposed, and disrespected. Findings: During a review of Resident 3's admission Record, undated, the Administration Record indicated the facility admitted Resident 3 in November 2023 with diagnoses which included muscle weakness. During a review of Resident 3's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 11/19/23, the MDS indicated Resident 3 scored 12 in the Brief Interview for Mental Status (BIMS, which is a scoring system used to determine the resident ' s cognitive status in regard to attention, orientation, and ability to register and recall information. A BIMS score of twelve…

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 and interview, the facility delayed reporting one of two abuse incidents to the California Department of Public Health for over 11 hours. This failure prevented oversight of the facility and delayed investigation of an assault of Resident 1 by Resident 2. See F-600 and F-689 Findings: During a review of Resident 1's Nursing Progress Notes, dated 12/15/23, at 3:16 a.m., Registered Nurse 1 (RN 1) documented on 12/14/23 at around 23:15 p.m. RN 1 made rounds and saw Resident 1 on the bed asleep. The notes indicated at 23:55 p.m., Certified Nursing Assistant (CNA 4) called RN 1 to go to the shared room of Resident 1 and Resident 2 as Resident 1 was on the floor bleeding from a head wound. The notes indicated RN 1 immediately called 911 and paramedics and police arrived. Resident 1 was sent to the acute care hospital by ambulance for treatment, and Resident 2 was taken to acute care hospital under an involuntary hold for assessment. During a review of the Police Report, case number 2023-00071046, dated 12/15/2023, the Police Report indicated Police Officer (PO)…

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 (Resident 2) of three sampled residents was provided one-to-one supervision as ordered for aggressive behaviors. The failure to provide Resident 2 with continual one-to-one supervision resulted in Resident 2 being unsupervised for six minutes and had the potential to result in serious injury to other residents. The Chief Nursing Officer (CNO), the Administrator (Admin), the Administrator In Training (AIT), the Quality Assurance Consultant (QAC), and the Minimum Data Set Consultant (MDSC), were notified of the Immediate Jeopardy (IJ, a situation in which a provider's noncompliance with one or more requirements of participation have caused or is likely to cause serious injury, harm, impairment, or death to a patient/resident), on 12/21/23, at 2:55 p.m., for the facility's failure to provide one-to-one supervision to protect facility residents from abuse by Resident 2, a resident known to have physically aggressive behavior. An…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to identify the potential need for one-to-one supervision of residents with mental or physical conditions requiring close supervision to prevent injury to themselves or others, and consequently failed to establish training and competency guidelines for staff members who provided one-to-one supervision of residents. This failure resulted in use of an untrained, non-nursing staff member (Hospitality Aide 1) to provide one-to-one supervision of a resident (Resident 2) at risk of harming others. Hospitality Aide 1 left Resident 2 unsupervised for six minutes, which had the potential to result in harm to the other residents in the facility. See F-600, F-609, and F-689 Findings: During a review of Resident 2's admission Record, undated, the admission Record indicated the facility admitted Resident 2 in October 2023. The admission Record indicated Resident 2 had diagnoses which included mental conditions which made it difficult to think clearly,…

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 maintain a full-time qualified social worker (SW) for the 121 bed facility when the facility ' s full time SW went out on maternity leave without a replacement SW, and had no estimated return date for the current SW. This placed residents of the facility at risk for their psychosocial needs to go unnoticed and unmet. Findings: During a review of the facility ' s Daily Census Report, dated 1/31/24, the Daily Census Report indicated there were 121 resident beds in the facility. During an interview on 1/31/24, at 7:30 a.m., with the Director of Nurses (DON), the DON stated the full-time SW had been out on maternity leave since 1/6/24, and the facility ' s Activity Director (AD) had assumed her roles and responsibilities. The DON did not know when the SW was due to return back to the facility. During an interview on 1/31/24, at 8:35 a.m., with the Activities Director (AD- acting social services designee), the AD stated she had assumed all social services needs on 1/8/24, when the full time SW went out on maternity leave. The…

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

Based on observation, record review, and interview, the facility failed to maintain an effective Pest Control Program when there were numerous fruit flies in the Rehabilitation Room (Rehab room). This failure created a nuisance for residents receiving rehabilitation services in the rehabilitation room, and had the potential to result in transfer of diseases such as salmonella, e.coli, and listeria (bacteria known to cause food-borne illness). Findings: During a concurrent observation and interview on 12/21/23, at 3:50 p.m., with Resident 3, in the Rehab room, there was a multitude of fruit flies flying around the room. Resident 3 stood in the middle of the room and swatted at the fruit flies flying around her face. The Rehab room had a countertop next to a wall. On top of the countertop was an apple-shaped object with holes in the top. Resident 3 stated the fruit flies had been a nuisance here for weeks, and the situation had not improved over time. During a concurrent observation and interview on 12/21/23, at 4:17 p.m., with the Administrator In Training (AIT), in the Rehab room,…

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 two sietters, the facility failed to develop and implement a training program for a one-to-one sitter (1:1, one sitter assigned to only one resident) prior to the sitter being assigned supervision of Resident 2, an abusive resident known for angry outbursts and assault. The failure to adequately train the sitter had the potential to result in inadequate supervision and placed residents of the facility at risk for injury and assault See also F 689. Findings: During a review of Resident 2's admission Record, undated, the admission Record indicated the facility admitted Resident 2 in October 2023. The admission Record indicated Resident 2 had diagnoses which included mental conditions which made it difficult to think clearly, have normal emotional responses, act normally in social situations, tell the difference between what was real and what was not real, to have firmly held beliefs which were contrary to reality, to have wide or extreme swings in mood…

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 complete documentation of medical records for one of two residents (Resident 1) involving: 1. nebulizer treatment on medication administration record (MAR) on 8/12/23 at 10:00 p.m. 2. bathing records for seven out of nine days in September 2023. This failure resulted in Resident 1 having incomplete and inaccurate medical records which potentially may affect Resident 1's care and well-being. Findings: A review of Resident 1's face sheet, undated, indicated Resident 1 was admitted to the facility May 2021, with diagnoses of asthma (narrowing and swelling of airways), myopathies (group of disorders affecting skeletal muscle structure), polymyositis (inflammation of the muscles), and quadriplegia (paralysis of arms and legs). 1. A review of Resident 1's facility document Order Summary Report, indicated a physician order, with start date of 7/1/23, of Albuterol Sulfate (medication to prevent and treat wheezing [whistling sound when airway is partially blocked] and difficulty breathing) nebulizer solution…

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 visitation hours were unrestricted for one of three sampled residents (Resident 1). This failure resulted to Resident 1's family members being denied entrance to the facility. Findings: During a review of Resident 1's face sheet, undated, the face sheet indicated Resident 1 was admitted to the facility May 2021, with diagnoses of myopathies (group of disorders affecting skeletal muscle structure), polymyositis (inflammation of the muscles), and quadriplegia (paralysis of arms and legs). During a record review of Resident 1's facility document, Progress Notes, dated 6/29/23, the Progress Notes indicated Licensed Vocational Nurse (LVN) 1 noted Resident 1's family members were in the facility visiting. LVN 1 stated family members were aware of visitor hour policy, and they were still able to get in the facility after 8:00 p.m. Progress Notes dated 7/6/23 indicated Licensed Vocational Nurse (LVN) 2 noted Resident 1 requested family…

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 promote the rights of one of one residents (Resident 1) to be treated with dignity and respect, allowing self-determination without reprisal when Resident 1 was threatened with an involuntary psychiatric hold (5150, a temporary, involuntary psychiatric commitment of individuals who present a danger to themselves or others due to signs of mental illness) after requesting return of a shower chair and refusing a psychiatric evaluation. The facility failed to allow Resident 1 to exercise her right for personal preference and retain use of a shower chair for toileting without resolution of the grievance according to facility policy and procedure and subsequent threat of removal from the facility by an ambulance crew with police presence which resulted in emotional distress for Resident 1. Findings: During a review of Resident 1 ' s Minimum Data Set (MDS, a comprehensive assessment tool used to develop a plan of care), dated 5/30/23, 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.

Based on observation, interview, and record review, the facility failed to accommodate the individual needs of one of 27 sampled residents (Residents 87) when Resident 87 was slumped in his bed and needed assistance and did not have his call light within reach. This failure resulted in Resident 87 being in an uncomfortable position with no access to his call light. Findings: During a review of Resident 87's's Face Sheet, the record indicated Resident 87 was admitted to the facility in 2019 as his own responsible party, with included diagnoses of weakness/paralysis of his left side. During a concurrent interview and observation on 6/28/21, at 11:43 a.m., Resident 87 was slumped down in the bed and stated he could not find the call light and needed help with positioning. Resident 87 did not have a call light visible on the bed or next to him. During an observation, on 6/28/21, at 11:56 a.m., Resident 87 was calling out for help repeatedly. Resident 87 was still in bed in the same position, and stated he was not comfortable in that position. During an observation, on 6/28/21, at 11:59…

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 one of 23 (Resident 32) sampled residents the use of his electric wheelchair once the COVID 19 restrictions of movement about the facility were lifted. The facility's failure resulted in Resident 32's restriction to his room and prohibited his mobility on the unit causing psychological and emotional distress. Findings: A review of Resident 32's Face Sheet indicated he was originally admitted to the facility in 2014 with included diagnoses of severe neck and back pain. The Face Sheet indicated Resident 32 was his own responsible party. A review of Resident 32's facility form, Inventory of Personal Effects, dated 11/12/15, the Inventory showed Resident 32 had an electric wheelchair. A review of Resident 32's Minimum Data Sets (MDS, a resident assessment tool used to guide care) dated 1/16/21, indicated Resident 32 required a wheelchair for mobility. The MDS indicated Resident 32 required assistance from at least one person for transfer between…

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

Based on observation, interview, and record review the facility failed to: 1.Ensure one of one medication storage rooms had no expired medications accessible for use. This failure had the potential to result in administration of ineffective medications. 2.Ensure two of two treatment carts were locked/supervised when not in use. This failure had the potential to result in loss or misuse of antibiotic creams (creams used to treat skin infections) in the cart. Findings: During an observation on 6/30/21 at 9:10 a.m., in the medication storage room, were the following expired medications: Medication cabinet had: One opened bottle of vitamin B6, 50 milligram/tablet (mg/tab), expired 4/2021; Two opened bottles of liquid ear wax removal drops, expired 5/2021; One opened bottle of simethicone 80 mg/tab, expired 3/2021. Medication room refrigerator had: Two vials of vancomycin 150 mg, for intravascular injection, expired on 3/6/21; Four bags of vancomycin 800 mg, for intravenous injection, expired on 3/3/21. The Emergency Kit had three vials of ampicillin, 2 grams, for intravenous injection,…

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

Based on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions when several food items in the Resident's refrigerator and freezer were not labeled, not dated and had no use by date. These failures had the potential to cause food contamination or food borne illness. Findings: During a food storage inspection on 6/28/21 at 12:15 p.m. of the resident's refrigerator and freezer located inside the Supply Room of the North Nursing Station, the following items were observed: 1. In the freezer compartment, three tubs of opened ice creams, two cups of ice cream and one box of frozen chicken dinner were stored without a label and no use by date. 2. In the refrigerator section, two brown bags of food items, two sandwiches, one plastic container of food and one plastic container of vegetables were stored without a label and no use by date. During an interview with the Nursing Supervisor (NS) on 6/28/21 at 12/15 p.m., NS confirmed the stored, opened food items in the resident's freezer and refrigerator were not labeled and had…

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 staff implemented policies and procedures designed to prevent and control spread of infection for three of 27 sampled residents (Resident 65, 86, and 32) when: 1. Certified nursing assistant 9 (CNA 9) failed to perform hand hygiene between care provision of two residents (Resident 65 and 86). 2. Resident 32 had an unlabeled urinal at his bedside. Findings- During an observation and interview, on 6/28/21, at 12:07 p.m., in Resident 65 and 86's shared room, Resident 65 and Resident 86 were in their respective beds. CNA 9 wore gloves, and held both of Resident 65's hands while she examined them. CNA 9 stated Resident 65's fingernails were long and had dirt beneath them. CNA 9 then removed Resident 65's socks and held and examined both feet. CNA 9 stated Resident 65's toenails were long. CNA 9 removed her gloves, and without performing hand hygiene, donned a new pair of gloves. CNA 9 went to Resident 86, removed the bed linen covering Resident 86's feet, and touched Resident 86's feet and toenails on both…

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 11 of 12 sampled employees (Hospitality Aid 1, Hospitality Aid 2, Hospitality Aid 3, Hospitality Aid 5, Dietary Aid 1, Dietary Aid 2, Medical Record, Certified Nurse Assistant 5, Certified Nurse Assistant 12, Certified Nurse Assistant 13, Certified Nurse Assistant 14) completed annual training for recognition of activities that constitute abuse and resident abuse prevention. This failure had the potential to place residents at risk for harm when staff were not trained in the prevention of resident abuse. Findings: A review of the facility staff personnel files indicated the following staff had not completed annual abuse training as follows: Hospitality Aid 1 (HA 1) had no training for 2021. Hospitality Aid 2 (HA 2) had no training for 2020 and 2021. Hospitality Aid 3 (HA 3) had no training for 2020 and 2021. Hospitality Aid 5 (HA 5) had no training for 2020 and 2021. Dietary Aid 1 (DA 1) had no training for 2020. Dietary Aid 2 (DA 2) had no training for 2020. Medical Record (MR) had no training for 2021. Certified…

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 necessary services for activities of daily living for one (Resident 17) of 27 sampled residents when: Resident 17 did not receive requested toileting assistance for 40 minutes. The failure to provide toileting resulted in Resident feeling uncomfortable, helpless and embarrassed, while she lay in a urine soaked bed. This also had the potential to result in skin irritation and breakdown. Findings: Review of Resident 17's Face Sheet indicated Resident 17 was admitted in 2012 with included diagnoses of total/partial paralysis of one side of her body and chronic pain. Review of Resident 17's Minimum Data Set (MDS, a resident assessment tool used to guide care) dated 6/25/21, indicated Resident 17 required extensive assistance for toilet use and required physical assistance from two or more persons. Review of Resident 17's care plan dated 6/28/18, indicated, Incontinence,,,clean and dry resident after each incontinent episode. During an observation and concurrent interview on 6/28/21 at 11:15 a.m., with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure two (Resident 70 and 87) of 27 sampled residents received proper treatment to maintain hearing and vision capabilities when: 1. Resident 70 did not receive treatment or hearing aids to maintain hearing ability. This failure resulted in Resident 70 not hearing staff during teaching and care provision. 2. Resident 87's eyeglasses were broken for one month with white adhesive tape applied around the lenses to hold the lenses inside the frame. This failure resulted in Resident 87 being unable to see things clearly, read, or watch television. Findings: 1. A review of Resident 70's Face Sheet indicated she was admitted in 2010 included diagnoses of paralysis/weakness of the right side of her body. The Face sheet indicated Resident 70 had a responsible party (RP) for decision-making. A review of the Minimum Data Set (MDS, a resident assessment tool used to guide care) dated 5/24/21, indicated, Resident 70 had minimal difficulty hearing.…

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 that residents' personal belongings were protected when one (Resident 32) of 32 sampled residents had personal items missing from the facility's locked storage shed. This deficient practice has the potential to emotionally distress residents and cause them to feel unsafe. Findings: According to Resident 32's Minimum Data Set (assessment of the patient) dated 4/29/29, she had high cognitive functioning. During an interview on 7/22/19 at 10:35 a.m. Resident 32 stated she asked staff a few weeks ago for a suitcase which was placed in locked storage and she was told that staff was still looking for the suitcase. Resident 32 stated she was extremely concerned about her missing suitcase, since it contained her birth certificate, marriage license, tax papers and clothes. Record review of Resident 32's Inventory of Personal Effects dated 10/19/17 indicated it was not signed by the resident and also indicated on 10/31/17, 1 big luggage and 1 small luggage was in storage . back storage. During an interview 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to adequately assess the need and provide supervision for three of sixteen (Residents 8, 40, and 84) resident smokers. This deficient practice had the potential to place residents at risk for fire related injury. Findings: A review of the admission record shows Resident 8 was admitted on [DATE] with multiple diagnoses including epilepsy (a neurological disorder in which brain activity becomes abnormal, causing seizures or periods of unusual behavior, sensations, and sometimes loss of awareness), hemiplegia (partial paralysis on one side of the body) and hemiparesis (weakness or partial loss of movement on one side of the body) following cerebral infarction (lack of blood supply to areas of the brain which causes brain cells to die), schizophrenia (a disorder that affects a person's ability to think, feel and behave clearly), major depressive disorder, anxiety disorder, and mood disorder. A review of the admission record shows Resident 40 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 store, distribute, and serve food under sanitary conditions when four cutting boards were well worn, knives were stored wet, spoiling onions were stored in the dry food storage area and when a resident's (83) snack was stored overnight at the resident's bedside. These deficient practices had the potential to cause foodborne illnesses to residents residing in the facility. Findings: 1. During an initial kitchen observation on 7/22/19 from 9:15 a.m. to 9:44 a.m., the following were observed: 1) There were four cutting boards with deep cuts, two of which also had stains. 2) Two chef knives and one bread knife were stored wet. 3) Three white onions with soft brown discolorations were stored in a bin with other onions in the dry food storage area. During an interview on 7/25/19 at 2:11 p.m., [NAME] 1 stated that she was trained to store utensils dry, but did not know the rationale for this practice. [NAME] 1 also stated all staff were responsible for inspecting kitchen equipment on a daily basis. Furthermore,…

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 infection control procedures for four (Resident 52, 100, 14 and 45) of 32 sampled residents when their Oxygen (O2) tubing and Nebulizer (device for producing a fine spray of liquid, used for inhaling a medicinal drug) face mask were not labeled, outdated and were exposed to air at the bedside. This failure had the potential for Resident 52, 100, 14 and 45 to develop avoidable infections. Findings: During an initial tour observation and concurrent interview with Licensed Vocational Nurse (LVN 1) on 7/22/19 between 8:54 a.m. and 9:34 a.m., the following were observed: Resident 52's O2 and nebulizer tubing was uncovered, without any barrier to keep it clean, a part of nebulizer tubing touching the floor was kept on bedside table. LVN 1 stated she was not sure if it was okay for the O2 tubing to be in touch with the floor. Review of Resident 52's physician's orders dated 12/1/17 showed Resident 52 was to be given medication via nebulizer every six hours as needed for wheezing. Resident 100's nebulizer…

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 obtain a doctor's order or determine if one of 32 sampled residents (Resident 312) was able to self-administer medications, when Resident 312 had a bottle of Nystatin (antifungal antibiotic topical treatment) powder at the bedside. This deficient practice had the potential to result in Resident 312 using the topical powder against safe dosing recommendations. It also had the potential to result in the use of the medications by other residents, who could potentially come into the room and obtain the treatment from the bedside table where it was stored. Findings: According to the Minimum Data Set (MDS, an assessment tool used to guide care) dated 7/16/19, Resident 312 was admitted to the facility in 2019. The MDS indicated Resident 312 was able to understand and understood others. During an observation and interview on 7/22/19 at 9:55 a.m., Resident 312 had a bottle of Nystatin treatment powder on his bedside table. Resident 312 stated a nurse had given him the bottle and had been applying the treatment by…

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 accommodate three of 32 sampled residents' (Residents 97, 312 and 17) needs when: 1. Residents 97 and 312 did not have a call light within reach. 2. Residents 17 was not able to sleep and rest well during night time, when the roommate (Resident 60) was yelling and cursing all night long for two days in a week. This deficient practice can lead to residents' unmet needs. Findings: 1. Review of Resident Face Sheet on 7/25/19, indicated Resident 97 was admitted to the facility in 2019. According to the Minimum Data Set (MDS, an assessment tool used to guide care) dated 5/16/19, Resident 97 was able to understand and be understood by others. Resident 97's diagnoses included Cerebrovascular Accident (Stroke). Resident 97 required extensive assistance in positioning in bed, toilet use, and personal hygiene. During an interview and observation on 7/22/19 at 10:22 a.m., Resident 97 was observed lying on his back. Resident 97 stated he was dizzy 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 did not provide written notice to the resident nor resident's responsible party of a room change for one of 32 sampled residents (Resident 84) before Resident 84's room was changed. This deficient practice was a violation of Resident 84's rights, and had the potential to lead to increased agitation and confusion for Resident 84. Findings: A review of the admission record shows Resident 84 was admitted on [DATE] with multiple diagnoses including dementia (a disorder that affects a person's thinking, behavior, and memory), Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), and nicotine dependence. During an interview with Resident 84 on 7/22/19 at 8:59 a.m., she stated she was upset that her room was changed without her consent. She stated she was told by facility staff on the morning of 7/16/19 that she would need to change rooms without being given a reason, and her room was changed at 12:30 p.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, facility did not follow its policy and procedures for change in residents' condition for one (Resident 60) of 32 sampled residents, when Resident 60 had acute changes in behavior with episodes of crying and racial slurs throughout the night. This failure had the potential for Resident 60 to not receive appropriate treatment needed for his well- being, Findings: Review of Face sheet dated 7/25/19 showed Resident 60 was admitted to the facility on [DATE] with diagnosis of Dementia (memory loss), Psychosis and Anxiety disorder. Review of Minimal Data Set (MDS- an assessment tool) dated 5/24/19 showed Resident 60 had no ability to recall and no orientation to surroundings. During an interview with Resident 60's roommate (Resident 17) on 7/22/19 at 9:26 a.m., Resident 17 stated, I am very sleepy now, I cannot sleep at night because of my roommate. Resident 17 also stated that Resident 60 yelled all night long. During a follow up interview on 7/24/19 at 7:33 a.m., Resident 17…

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 inform and give reasonable notice for two (Resident 3 and 313) of three sampled residents (or the responsible party) that their Medicare services were ending and their right to appeal. This failure resulted in Resident 3 and the responsible party (RP) and Resident 313 not being able to appeal for an extension of Medicare coverage. Findings: Review of Resident Face Sheet, indicated Resident 3 was admitted to the facility in 2019. Resident 3's Face Sheet also indicated Resident 3 had a representative who was responsible for financial matters. According to the Minimum Data Set (MDS - an assessment tool used to guide care), Resident 3 had moderately impaired cognition. A review of Resident 3's SNF (Skilled Nursing Facility) Beneficiary Protection Notification Review indicated Resident 3's Last covered day of Part A service (Part A terminated/denied or resident was discharged ) was 3/26/19. Review of Resident 3's Notice of Medicare Non-Coverage (NOMNC) indicated Resident 3's NOMNC did not have a signature of the resident'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 ensure two (Resident 78 and 106) of 32 sampled residents received a summary of the baseline care plan which was developed within 48 hours of the residents' admission. This failure had the potential for Resident 78 and Resident 106 to stay unaware of their updated plan of care. Findings: Review of Resident 78's Baseline care plan summary dated 5/23/19 showed Resident 78 was admitted to the facility on the same date. Review of Resident 106's Baseline Care Plan Summary dated 7/9/19 showed Resident 106 was admitted to the facility on [DATE]. During a concurrent interview and record review on 7/25/19 at 9:56 a.m., Registered Nurse (RN) 2 confirmed there was no documentation in Resident 78 ad Resident 106's clinical record if summary of baseline care plan was provided to them or their family representative. Review of facility policy and procedure titled Baseline Care plan dated 10/2017 showed The resident and their representative will be provided a summary…

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 revise the care plan for one of thirty-two sampled residents (Resident 40) following an altercation in the smoking area with another resident. This deficient practice had the potential for placing residents at risk for injury. Findings: A review of the admission record for Resident 40 indicated he was admitted on [DATE] with multiple diagnoses including encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition), altered mental status, anxiety disorder, and nicotine dependence. During a review of Resident 40's Observation Detail List Report-Incident/Accident Post Review dated 6/4/19 at 3:49 p.m., Resident 40 had an altercation with Resident 106 in the smoking area. During an interview with Resident 40 on 7/22/19 at 9:38 a.m., he stated there was an incident in the smoking area last month when another resident tried to take a cigarette from him and grabbed his arm. There was no staff supervision. During an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to follow its policy and procedure on medication storage and labeling, when unlabeled medications and medications without physician orders were stored in Treatment cart 1 and 2. This failure had the potential for facility's residents' to not receive accurate administration of medications and treatments. Findings: During an observation accompanied by Registered Nurse (RN 1) on [DATE] at 11:42 a.m. the following were observed in Treatment cart 1 and 2: 1. Mupirocin ointment 2% dispense dated [DATE] with Resident 9's name on it. 2. Clotrimazole cream 1% 45 milligrams (mg) (NDC-National Drug Code- 68462-181-47) and Nystatin cream 30 mg (NDC-45802-059-11) with no resident name or information on it. 3. Resident 25's Triamcinolone acetate 0.1% dispense dated [DATE]. 5. Resident 25's Fluocinomide 0.05% dispense dated [DATE]. During a concurrent interview and record review with RN 1 on [DATE] at 2:00 p.m., RN 1 confirmed Resident 9's physician orders…

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.