Emmanuel Post Acute Care - Hayward

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of eight sampled Resident's (Resident 21) Responsible Party (RP; the party responsible for making health care decisions when the principal party is unable to make said health care decisions for him or herself) choice in Resident's hair cut was considered. This failure resulted in Resident 21 receiving an unwanted haircut and feeling terrible. During record review of admission record, printed on 8/28/25, Resident 21 was admitted on [DATE].During record review of Resident 21's Minimum Data Set (MDS, an assessment used to guide care) dated 5/25/25, indicated Resident 21's Brief Interview for Mental Status (BIMS, an assessment used to assess mental status) score was 12 out of 15, indicated Resident was mildly impaired. During record review of Resident 21's MDS, dated [DATE], section 'GG-Functional Abilities' indicated, Impairment on one side to upper and lower extremity, and Substantial/maximal assistance (Helper does MORE THAN…

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 eight sampled Resident's (Resident 21) Responsible Party (the party responsible for making health care decisions when the principal party is unable to make said health care decisions for him or herself) choice in Resident's hair cut was considered. This failure resulted in Resident 21 receiving an unwanted haircut and feeling terrible. During record review of admission record, printed on 8/28/25, Resident 21 was admitted on [DATE].During record review of Resident 21's Minimum Data Set (MDS, an assessment used to guide care) dated 5/25/25, indicated Resident 21's Brief Interview for Mental Status (BIMS, an assessment used to assess mental status) score was 12 out of 15, indicated Resident was mildly impaired. During record review of Resident 21's MDS, dated [DATE], section 'GG-Functional Abilities' indicated, Impairment on one side to upper and lower extremity, and Substantial/maximal assistance (Helper does MORE THAN HALF…

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 necessary treatment and services to one of eight Residents (Resident 21) to increase and/or prevent a further decrease in range of motion (ROM; the full movement potential of a joint.). This failure resulted in Resident 21 not receiving physician ordered passive range of motion (PROM; the movement of a joint through the range of motion with no effort from the patient) exercises for two months and feeling weak.During record review of admission record, printed on 8/28/25, Resident 21 was admitted on [DATE].During record review of Resident 21's Minimum Data Set (MDS, an assessment used to guide care) dated 5/25/25, indicated Resident 21's Brief Interview for Mental Status (BIMS, an assessment used to assess mental status) score was 12 out of 15, indicated Resident was mildly impaired. During record review of Resident 21's MDS, dated [DATE], section 'GG-Functional Abilities' indicated, Impairment on one side to upper and lower…

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 care according to the facility's policy and procedures (P&P) for one of one resident (Resident 1) receiving medications via the gastrostomy tube (aka G-tube, a tube inserted through the abdomen that delivers nutrition and medications directly to the stomach). The nursing staff did not verify tube placement and check residual volume (the amount of fluid contents remaining in the stomach) prior to administering medications. In addition, the nursing staff administered the medications by pushing through the tube instead of allowing them to go down by gravity.The failures posed a risk for complications associated with enteral feeding, including aspiration (inhalation of foreign material into the lungs) due to undetected tube displacement, tube dislodgement from improper medication administration, and potential for gastrointestinal symptoms such as nausea, vomiting, and abdominal pain.During a medication pass observation on 8/26/25 at 8:55 a.m., Registered Nurse (RN) 1 was observed preparing 11 medications…

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's consultant pharmacist (CP) failed to identify and report irregularities during the monthly drug regimen review (MRR) for 3 out of 31 sampled residents (Residents 9, 51, and 57) when Resident 57 received lactulose (medication to treat constipation and liver disease) for a wrong indication; and Residents 9 and 51 did not receive glipizide (medication for diabetes) as per manufacturer's specifications.The failure resulted in inadequate monitoring for effectiveness and adverse effects for Resident 57's lactulose; and Residents 9 and 51 not receiving the optimized therapeutic effect of glipizide.1. A review of Resident 57's medical record indicated Resident 57 was admitted to the facility with diagnoses that include: alcoholic liver disease (a condition of liver damage) and portal hypertension (elevated pressure in the portal vein, commonly caused by liver disease). Resident 57's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 5/29/25,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of 31 sampled residents (Resident 57) was free from unnecessary medications. Resident 57 received lactulose (a medication commonly used for liver disease) for a wrong indication for use.This failure resulted in an inadequate treatment plan and insufficient monitoring for medication effectiveness and adverse outcomes related to liver disease.A review of Resident 57's medical record indicated Resident 57 was admitted to the facility with diagnoses that include: alcoholic liver disease (a condition of liver damage) and portal hypertension (elevated pressure in the portal vein, commonly caused by liver disease). Resident 57's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 5/29/25, indicated Resident 57 has no cognitive impairment.A review of Resident 57's medical record indicated Resident 57 had the following physician order:Lactulose 10 gram (gm, unit of measurement)/ 15 milliliters (mL, unit of volume), give 45 mL…

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

Based on observation, interview and record review, the facility failed to prepare one out of 42 (Resident 60) Resident meal tray according to resident preferences. This failure resulted in Resident 60 receiving lunch tray without double portion of protein, per Resident preferences. During record review of Resident 60's Minimum Data Set (MDS, an assessment used to guide care) dated 05/17/25, indicated Resident 60's Brief Interview for Mental Status (BIMS, an assessment used to assess mental status) score was 00 out of 15, indicated Resident 60 had severe cognitive impairment. During an observation on 08/26/2025 at 12:32 PM Resident 60 tray was prepared and placed on meal tray cart for delivery but was not given extra protein as listed on meal tray card. During an observation and interview on 08/26/2025 at 12:39 PM, the Registered Dietitian (RD) and Dietary Manager (DM) stated Resident 60 was not given double protein, per photo, as listed in Resident's preferences. DM stated it is important for Residents to receive meals they prefer because it is their right. During record review of…

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

Based on observation, interview, and record review, the facility staff failed to employ appropriate infection control practices during the medication administration for 1 out of 8 residents (Resident 1) when:1. Registered Nurse (RN) 1 did not wear a protective gown while administering medications via the resident's gastrostomy tube (aka G-tube, a tube inserted through the abdomen that delivers nutrition and medications directly to the stomach), a practice inconsistent with the facility's enhanced barrier precautions (EBP) policy.2. RN 1 did not change gloves and perform hand hygiene between care and after touching surfaces and going in and out of Resident 1's room. The failures had the potential to increase the risk of cross-contamination and infections, compromising patient safety.1. During medication pass observation on 8/26/25 at 9:20 a.m. RN 1 was observed putting Resident 1's medication in a plastic bag and individually crushing each oral medication. She prepared a total of 11 medications for Resident 1, including an eye medication called Artificial Tears (to lubricate the eye)…

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

Based on observation and interview the facility failed to store all drugs and biologicals in locked compartments when one medication cart and one treatment cart located in hallways were not locked. This finding had the potential for errors , missing medication and create an unsafe environment for residents. Findings: During an observation on 5/13/25, at 9:25 a.m., in hallways of station 2, there was one unlocked, unattended treatment cart and medication cart. The medication and treatment carts contained resident ' s medications. During an interview on 5/13/25, at 9:27 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated medication cart was left unattended because LVN 1 was called to attend to another issue. LVN 1 stated medication cart should be always locked when LVN 1 is not in attendance. During a concurrent observation and interview on 5/13/25, at 9:28 a.m., with LVN 2, one treatment cart was found unlocked and unattended in station 2 hallway. LVN 2 stated maybe the wound consultant left the cart unlocked. LVN 2 stated treatment cart should be locked when not in use…

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 have the ordered medication Levetiracetam or Keppra (used to prevent and control seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]) for one resident (Resident 1). This failure of Resident 1 not receiving Keppra on 8/14/24 resulted in Resident 1 ' s delayed treatment which had the potential to result in seizure episodes. Resident 1 subsequently had two seizure episodes in the morning of 8/15/24. Findings: During a review of Resident 1 ' s face sheet, undated, the face sheet indicated Resident 1 was admitted to the facility on [DATE] at 2:55 p.m., with a diagnosis of seizures. During a review of Resident 1 ' s Order Details, the Order Details indicated a physician order on 8/14/24 at 1531 (3:31 p.m.) for Levetiracetam Oral Tablet 500 mg, give 1 tablet by mouth two times a day for seizure precautions. During a review of Resident 1 ' s Medication…

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 schedule a registered nurse (RN) for 8 hours a day, 7 days a week. This failure had the potential to place residents at risk to receive inaccurate assessments and incorrect care. Findings: During a concurrent interview and record review on 2/28/24, at 1:38 p.m., with Payroll Director (PD), Payroll Based Staffing (PBJ) Reports for quarter 2 2023 (January 1 - March 31) were reviewed. The PBJ Report indicated there was no RN hours on 2/20/23 and on 3/4/23. PD stated there was no RN on duty on 2/20/23 and 3/4/23. During an interview on 2/28/24, at 3:36 p.m., with Director of Nursing (DON), DON stated it was important to have an RN on duty to confirm licensed vocational nurse (LVN) assessments. During a concurrent interview and record review on 2/29/24, at 12:52 p.m., with the Administrator (ADM), CMS (Centers of Medicare and Medicaid Services) Manual System Pub. 100-07 State Operations Provider Certification, dated December 13, 2013, was reviewed. ADM stated they did not have a policy for RN coverage. ADM stated they followed…

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, staff interview, and record review, the facility failed to store and prepare food in accordance with professional standards for safety when: 1. A dry food bin lid was unclean; 2. A frozen food bag was open to air; 3. A can with a large dent was available for use These failures had the potential for contamination of food resulting in food-borne illness for 88 residents who received food from the kitchen. 1. During an initial walkthrough observation of the kitchen on 2/26/24, at 10:00 a.m., there were bins stored on shelves in the dry food storage area. A bin containing flour had a fine dusting of white powder all over the top of the lid. During an interview on 2/28/24, at 12:29 p.m., with the Dietary Manager (DM), the DM stated bin lids covered with food debris can attract pests, and bin lids should always be kept clean. During a phone interview on 2/29/24, at 11:00 a.m., with the Registered Dietician (RD), the RD stated dirty bins attract vermin and pests. During a review of facility policy and procedure (P&P) titled, Storage of Food and Supplies, dated 2023,…

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 electronically submit complete and accurate direct care staffing information based on payroll data to Centers for Medicare and Medicaid (CMS). This failure had the potential to result in the facility's staffing to be unavailable for audit by CMS. Findings: During a concurrent interview and record review on 2/28/24, at 12:39 p.m., with Payroll Director (PD), Payroll Based Staffing (PBJ) Reports for quarter 4 2022 (July 1 - September 30) and quarter 1 2023 (October 1 - December 31) were reviewed. PBJ Report for quarter 4 2022 indicated it was not submitted. PBJ Report for quarter 1 2023 indicated it was not submitted. PD stated PBJ Reports for quarters 4 2022 and 1 2023 were not submitted. PD stated submitting PBJ reports were important for facility rating and so their staffing could have been auditable. During a concurrent interview and record review on 2/29/24, at 1:05 p.m., with PD, the Centers for Medicare and Medicaid Services Electronic Staffing Data Submission Payroll-Based Journal Long-Term Care Facility Policy Manual…

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 quarterly Minimum Data Sets (MDS, an assessment tool used to guide resident care) were completed within 14 days of the Assessment Reference Date (ARD, a date set to establish a uniform look-back period for all the responses to MDS coding items) for two of 4 sampled residents (Resident 61 and Resident 143). This deficient practice had the potential to result in Residents 61 and 143 not receiving the appropriate care and services needed based on their current health status. Findings: During a review of Resident 61's admission Record, dated 2/28/24, the record indicated Resident 61 was admitted 9/2023 with multiple diagnoses including an admission diagnosis of Tinea Corporis (a superficial fungal infection of the skin that can affect any part of the body, excluding the hands and feet, scalp, face and beard, groin, and nails). During a review of Resident 143's admission Record, dated 2/28/24, the record indicated Resident 143 was admitted 7/2022 with multiple diagnoses including an admission diagnosis of Alzheimer's…

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

Based on interview and record review, the facility failed to ensure the Minimum Data Sets (MDS, an assessment tool used to guide resident care) were completed and submitted to the Centers for Medicare and Medicaid Services (CMS) within the required time frames determined by the Assessment Reference Date (ARD, a date set to establish a uniform look-back period for all the responses to MDS coding items) when two out of 4 Resident's (Resident 31 and 83) Discharge MDS' were not completed and transmitted within 14 days of the ARD. This deficient practice had the potential to result in Residents 31 and 83, not receiving the appropriate care and services needed based on their current health status and to be billed incorrectly. Findings: During a review of Resident 31's admission Record, dated 2/28/24, the record indicated Resident 83 was admitted 10/2023 with multiple diagnoses including an admission diagnosis of Acute Pancreatitis with infected Necrosis, unspecified (a condition where the pancreas becomes swollen over a short period of time with tissue death). During a review of Resident…

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

Based on observation, interview and record review, the facility had a 5.71% error rate when two medication errors out of 35 opportunities were observed during the medication pass for two of 10 sampled residents (Resident 143 and Resident 144). Resident 143 did not receive Cosopt (eye drop medication used to treat Glaucoma (an eye condition that causes blindness) as ordered and Resident 144 was not given instructions to rinse mouth after administered a Wixela (Fluticasone/Salmeterol) Inhub Inhalation (medication used to treat asthma [a condition in which airways narrow and swell] and chronic obstructive pulmonary disease COPD, a lung disease that block airflow and make it difficult to breathe]). These failures resulted in medication not given in accordance with the prescriber's orders, which may negatively affect Resident 143 and Resident 144's health conditions. Findings: 1. During a concurrent medication administration observation, interview, and record review on 2/27/24, at 11:30 a.m., in Station 2A, Licensed Vocational Nurse 1 (LVN 1) was observed preparing medication for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement infection prevention and control practices when: 1. For one of 38 sampled residents (Resident 85), Licensed Vocational Nurse 1 (LVN 1) did not wear gloves prior to nasogastric tube (NGT, a tube inserted through the nose, down the throat and esophagus, and into the stomach used to administer nutrition or medication to patients who are unable to tolerate oral intake) feeding administration. 2. LVN 1 did not perform hand washing or hand hygiene after removing gloves from sanitizing used blood glucose machine. 3. One pill cutter (a medical device with stainless steel blade used to cut pills and tablets) at Nurses Station 2A medication cart and three pill cutters at Nurses Station 2B medication carts were stored unclean after use. 4. For one of four sampled residents (Resident 85) with indwelling urinary catheters (drains urine from the bladder into a bag outside the body), urinary drainage bag was laying on the floor. 5. Three…

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 the Minimum Data Set (MDS-an assessment and care screening tool used to guide care), was accurate for one of one sampled resident (Resident 9) when Resident 9's annual MDS was not coded accurately to reflect a functional impairment of the left hand. This failure resulted in the potential for Resident 9 to not receive appropriate care and treatment for identified conditions. Findings: During a review of Resident 9's admission Record, dated 2/28/24, the record indicated Resident 9 was admitted to the facility on 11/2018 with diagnoses of unspecified dementia (a group of symptoms affecting memory, thinking and social abilities), muscle weakness, and acquired absence of right and left leg below the knee. A review of the MDS section C-cognitive patterns, dated 12/9/23, indicated that Resident 9 had a Brief Interview of Mental Status (BIMS-a screening measure that evaluates memory and orientation) score of 10, indicating a moderate…

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 one of 38 sampled residents (Resident 25) received fingernail trimming as needed. This failure had the potential to result in skin scratches, wounds, and infections from the long fingernails. Findings: A review of Resident 25's admission Record indicated Resident 25 was admitted to the facility in January 2024, with diagnoses of Diabetes Mellitus (high blood sugar) and dementia (loss of thinking, remembering, and reasoning). A review of Resident 25's Minimum Data Set (MDS, an assessment tool used to guide care), dated 1/31/24, indicated Resident 25 had severely impaired cognition. The MDS also indicated Resident 25 was dependent (helper does all the effort. Resident does none of the effort to complete the activity. The assistance of two or more helpers is required for the resident to complete the activity) on functional abilities and goals (eating, oral hygiene, toileting hygiene, shower/bathe self, dressing, putting on/taking off footwear, and personal hygiene). A review of Resident 25's care plan…

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 range of motion (ROM) exercises were provided for one of two sampled residents (Resident 34) reviewed for limited ROM. This failure had the potential to result in decline in the Resident 34's ROM. Findings: During a review of Resident 34's admission record, dated 2/28/24, the admission record indicated Resident 34 was admitted to the facility in 2023. According to Resident 34's Minimum Data Set (MDS, an assessment tool used to guide care), dated 1/16/24, Resident 34 had a Brief Interview for Mental Status (BIMS) score of 15/15, meaning Resident 34 had intact cognition. The MDS also indicated, Resident 34 had multiple diagnoses which included muscle weakness, acquired absence of right leg above knee, paralytic gait (loss of muscle strength), and encounter for orthopedic aftercare following surgical amputation. During an interview on 2/26/24, at 10:57 a.m., with Resident 34, Resident 34 stated he was supposed to be receiving ROM exercises because he was no longer getting physical therapy. Resident 34…

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 pharmaceutical services for two of 10 sampled residents (Resident 143 and Resident 144) when: 1. For Resident 143, eye medication was unavailable for administration three consecutive times. 2. Resident 144 was not given instructions to rinse mouth after administered a powdered inhaler. These failures resulted in medication not given in accordance with the prescriber's orders, which may negatively affect Resident 143 and Resident 144's health conditions. Findings: 1. A review of Resident 143's admission Record, printed 2/28/24, indicated Resident 143 was admitted to the facility in 2022 with diagnoses of Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions) and Glaucoma (a group of eye conditions that causes blindness). A review of Resident 143's Minimum Data Set (MDS, an assessment tool used to guide care), dated 7/9/23, indicated Resident 143 had severely impaired cognition. A review…

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 skin integrity nursing assessment was done weekly for one of three residents (Resident 1). This failure resulted in the potential delay in prevention and treatment of a Stage 2 (shallow open sore) pressure ulcer. Findings: A review of Resident 1 ' s face sheet, undated, indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of nontraumatic subdural hemorrhage (pool of blood between the brain and outermost covering), Type 2 diabetes mellitus (elevated blood glucose), and muscle weakness. A review of Resident 1 ' s facility document Braden Scale For Predicting Pressure Risk, dated 6/9/23, Braden Scale For Predicting Pressure Risk indicated Resident 1 ' s Braden score was 15 (score of 15-18 = At Risk). During a concurrent interview and record review on 2/16/24, at 11:34 a.m., with Director of Nursing (DON), the facility document admission Record Data Collection, dated 11/30/22, was reviewed. The admission Record Data Collection…

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 a pharmacist completed a monthly Medication Regimen Review (MRR, a review of all ordered medications for administration safety and medication compatibility) for 10 of 10 sampled residents (Resident 1, 2, 3, 6, 10, 11, 16, 19, 20 and 24) during the months of December 2021 and January 2022. This failure had the potential to result in the administration of unnecessary or incompatible medications for the ten residents during December 2021 and January 2022. Findings: A review of Resident 1's admission Record, undated, indicated Resident 1 was admitted to the facility in 2015 with a diagnosis of iron deficiency anemia (inadequate amounts of blood levels of iron, resulting in low numbers of red blood cells which are needed for adequate blood circulation and all body functions). A review of Resident 2's admission Record, undated, indicated Resident 2 was admitted to the facility in 2018 with a diagnosis of hyperlipidemia (an abnormally high concentration of fats or lipids in the blood, associated with heart disease). 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 interview and record review, the facility failed to ensure the Minimum Data Set (MDS, an assessment tool used to guide care) was completed within 14 calendar days for three of three sampled residents (Residents 1, 2 and 3). This failure resulted in delayed completion and submission of Residents 1, 2, and 3's MDS assessments and had the potential to result in delayed care plan development and implementation for Residents 1, 2, and 3. Findings: During an interview and record review on 3/2/22, at 1:45 p.m., with the Director of Nursing (DON), Resident 1's Annual MDS with an assessment reference date (ARD, a date set to establish a uniform look-back period for all responses to MDS coding items) of 1/17/22 was reviewed. Resident 1's last Annual MDS was dated 1/17/21 and the next Annual MDS was due on 1/17/22. The DON confirmed Resident 1's annual assessment was still open, was not completed, and was more than 120 days overdue. During an interview and record review on 3/2/22, at 1:48 p.m., with the DON, Resident 2's Quarterly MDS with an ARD of 1/20/22 was reviewed. Resident 2's…

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

Based on observation, interview, and record review, the facility failed to ensure: 1. Expired drugs were removed from the medication cart for two of ten sampled residents (Resident 10 and Resident 5). 2. Expired antimicrobial (Silvadene gel) and antiseptic (Betadine) solutions were not accessible for stock use. 3. Pill cutters were cleaned after use. For Resident 10, Veltassa Oral Suspension (a medication used to treat increased potassium level in the blood) was one month past the expiration date. This had the potential to result in Resident 10 having increased blood potassium levels due to administration of expired and less effective medication. For Resident 5, Clearlax Oral Powder (medication used to treat occasional constipation) was one month past the expiration date. This failure had the potential for Resident 5 to be constipated after administration of expired and less effective medication. The failure to remove the expired antimicrobial and antiseptic solutions from stock supplies for five months after the expiration date had the potential to result in infection. The failure…

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 15 sampled residents (Resident 178) had implementation of national standards designed to prevent and control the spread of the contagious infection of Clostridia difficile. (C. diff, a bacterial infection which causes severe diarrhea and can lead to serious health problems. C. diff bacteria shed spores, a single cell organism capable of growing into the bacteria C. diff, in the feces of infected individuals. The spores can be transferred to the environment or the hands of healthcare personnel who have touched a contaminated surface or item.) The failure of Registered Nurse Consultant (RNC) to wear a gown and gloves during direct contact with Resident 178, a resident diagnosed with a C. diff infection, and the failure to perform handwashing and sanitizing of shared equipment (a writing pen) upon exiting from Resident 178's room had the potential to result in spread of C. diff infection to other residents. Findings: During 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to document: 1. The vaccination status of one (Resident 176) of five sampled residents at the time of admission for pneumococcal pneumonia (PNA, a respiratory infection causing difficulty breathing) and influenza (the flu, a contagious respiratory illness caused by influenza viruses). 2. The refusal of one (Resident 177) of five sampled residents to be vaccinated for PNA and the flu. The failure to verify and document the vaccination status of Resident 176 had the potential to result in unnecessary repeated vaccination or no offer of vaccination and subsequent infection. The failure to document the vaccine education and vaccine refusal of Resident 177 had the potential to result an increased risk of infection due to an uninformed choice from inadequate education. Findings: 1. During a review of Resident 176's admission Record, undated, the admission record indicated Resident 176 was admitted to the facility on [DATE] with a diagnosis of pneumonia. During…

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 document one (Resident 177) of five residents received education about Covid-19 vaccination (COVID-19, a respiratory infection which can result in breathing difficulty and other complications, including death.) and refused vaccination. This failure had the potential to result in Resident 177 not receiving adequate education to make an informed choice about Covid-19 vaccination, and increased risk of Covid-19 infection. Findings: During a review of Resident 177's admission Record, undated, the admission record indicated Resident 177 was admitted to the facility on [DATE] with a diagnosis of diabetes mellitus (the body's inadequate production of the hormone insulin results in high blood sugar levels causing excessive urination and damage to body organs). During a concurrent interview and record review, on 3/2/22, at 11:15 a.m., with the Infection Preventionist (IP). Resident 177's immunization records were reviewed. The IP stated she did not recall if…

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.