Hayward Hills Health Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to maintain complete and readily accessible medical records for one of three sampled residents (Resident 81), when Resident 81's medical record lacked required physician documentation at the time of review.This failure had the potential to result in staff not having essential information needed to understand Resident 81's overall care needs, which could delay or compromise safe and effective care.During a record review of Resident 81's Face Sheet, the Face Sheet indicated Resident 81 was admitted to the facility on [DATE] and discharged on 4/18/26.During a record review of Resident 81's medical record, Resident 81's medical record contained no physician progress notes or a History and Physical (a doctor's complete health report or assessment of the patient) for Resident 81's stay at the facility.During a concurrent interview and record review on 6/11/26 at 3:30 p.m., with facility's Regional Director of Clinical Operations (RDCO), Resident 81'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 interviews and record reviews the facility failed to ensure the Pharmacy Consultant (PC) provided the Medical Regimen Review (MRR) recommendations and Executive Summary to the facility within the timeframes established in the facility's policies and procedures for four out of four months and the facility did not act on the reports within 30 days for five of 10 sampled residents (Residents 56, 26, 2, 66, and 54). This failure had the potential to result in Residents not receiving therapeutic recommendation on drug therapies. Findings: During a telephone interview on 8/15/24 at 9:19 a.m., with PC and Regional Supervisor (RS), PC stated that PC visits the facility once a month and completes the MRR for the month and submits the report within 48 hours. During a telephone interview on 8/15/24 at 11:17 a.m., with the Medical Director (MD), MD stated the MRR reports and recommendations were being submitted late. MD also stated it is important to get the MRR reports in a timely manner so, medical and nursing staff can have informed recommendations regarding Resident'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 observation, interview, and record review, the facility failed to clean dishes in a safe and sanitary method when the dishwasher did not reach the required temperature. This failure had the potential to result in 65 residents being served food on dishes that were not sanitized, which could lead to the spread of disease. Findings: During an observation on 8/13/24 at 10:41 a.m. in the kitchen, the highest temperature reached by the dishwasher was 110 degrees (°) Fahrenheit (F, a unit to measure temperature). During a second observation on 8/13/24 at 10:44 a.m., the highest temperature reached by the dishwasher was 110°F. During a concurrent observation and interview on 8/13/24 at 11:11 a.m. with the Dietary Manager (DM), it was observed that the highest temperature reached by the dishwasher was 110°F. The Dietary Manager stated she would run the dishwasher again. During the second run of the dishwasher, the highest temperature reached was 110°F. The DM stated that the minimum safe temperature for the dishwasher is 120°F. During a concurrent interview and record review 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.

Based on observation, interview and record review, the facility failed to provide pharmaceutical services to meet the needs of residents by failing to ensure the proper storage and destruction of narcotic (a drug that relieves pain and induces drowsiness) medication and the delivery of the correct dose of medication as ordered by the physician when: 1. Narcotic medication was stored in an unlocked drawer in Director of Nursing (DON) office, with 7 missing narcotic medications. 2. Narcotic medication was missing during a random narcotic audit for two of three sampled residents (Residents 24 and 64). 3. Resident 24 was undermedicated with diazepam (medication used to treat anxiety, muscle spasms, seizures, and alcohol withdrawal). 4. Resident 29 received the incorrect dose of Lactulose (medication used to treat constipation and to lower ammonia level in the blood for patients with liver disease). These deficient practices had the potential to result in drug diversion (illegal distribution or abuse of prescription drugs or their use for unintended purposes) and inaccurate drug dosages…

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 it was free from medication error rate of 5% or greater during the medication pass observation. The facility had a cumulative medication error rate of 30% consisting of nine errors where medications were not administered in accordance with physician's orders, in a sample size of 30 opportunities for error. These deficient practices had the potential to result in adverse consequences. Findings During an observation on 8/12/24 at 4:18 p.m. with Registered Nurse (RN) 1, RN 1 prepared medication for Resident 29 to be delivered via gastrostomy tube (G-tube, a tube inserted through a surgically created hole through the abdomen to deliver food/medications/fluids directly into the stomach) during evening medication schedule. During preparation, RN 1 placed clonazepam 1.5 milligrams, Ducolax stool softener 100 milligrams, Calcium 500 milligram oyster shell, Senna tablet 8.6 milligram, multivitamin with iron and folic acid, and Vitamin B1 100 milligrams and placed in a plastic bag and pounded the 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the safe storage, labeling, open date, expiration date, and disposal of medications and vaccinations. Medications and vaccines were not stored and maintained within standards for safety when: 1. Over the counter eye drops were not labeled with resident's name. 2. Two open inhalers did not have opened dates and one open inhaler was expired and still being used. 3. One aplisol multidose TB vial opened without a documented open date with instructions to discard product after 30 days of being opened. 4. Twenty-one vaccine syringes, stored in medication refrigerator, expired 6/30/2024. 5. Intravenous (IV) heparin flushes were expired 7/20/24 in the emergency kit (E-kit is a limited supply of medication and intravenous supplies for urgent use in a sealed box.) 6. One e-kit was unsealed and had a documented open date of May 2024. 7. Medication/vaccine refrigerator temperature was not monitored twice daily and not consistently monitored…

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 and prepare food in accordance with professional standards of food service safety when: 1. Expired chocolate pudding was observed in the refrigerator. 2. Uncovered frozen soup with white crystals on top was observed in the freezer. These failures had the potential to result in food-borne illnesses or unpalatable food. Findings: During a concurrent observation and interview with the Dietary Manager (DM) on 8/12/24 at 9:39 a.m., frozen soup that was not securely covered was observed in the freezer. DM stated that the soup was open and appeared freezer burned. DM stated that a potential consequence of freezer burned food is that it might affect the taste of the food when served. During a concurrent observation and interview with the DM on 8/12/24 at 9:52 a.m., chocolate pudding was observed in the refrigerator with a preparation date of 8/4/24 and a use by date of 8/10/24. DM stated that the chocolate pudding is expired. DM stated that expired foods should not be in the refrigerator or served to residents.

Based on interview and record review, the facility failed to report alleged abuse or mistreatment for Resident 32 to the appropriate authorities. This failure had the potential to result in the event not being investigated completely, which could lead to further events of abuse or mistreatment. Findings: During an interview on 8/14/24 at 9:41 a.m. with Resident 32, Resident 32 stated approximately one year ago, a Certified Nursing Assistant (CAN) 1 touched her in a way that she felt was inappropriate. Resident 32 stated she felt very, very uncomfortable about the incident and she reported the event to facility staff a short time after it happened. Resident 32 stated after the event, she did not like having CNA 1 near her because she felt uncomfortable. During a record review of the Electronic Medical Record (EMR) for Resident 32, the Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan) was reviewed. The MDS, dated 7/21/23, indicated Resident 32 had a Brief Interview for Mental Status score 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 interview and record review, the facility failed to complete the required Preadmission Screening and Resident Review (PASARR, a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) for one of three sampled residents (Resident 63). PASARR requires that 1) all applicants to a Medicaid-certified nursing facility be evaluated for a serious mental disorder and/or intellectual disability; 2) be offered the most appropriate setting for their needs (in the community, a nursing facility, or acute care setting); and 3) receive the services they need in those settings.) This failure had the potential to result in residents not receiving appropriate care for their mental disorders or intellectual disabilities. During a review of Resident 63's admission Record, the admission Record indicated Resident 63 was initially admitted to the facility in January 2024 with multiple diagnoses, including developmental disorder of scholastic skills (a type of intellectual…

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 two sampled residents (Resident 2) was free from abuse when: There was no care planning intervention developed, implemented, and monitored for effectiveness after the first incident of physical abuse to Resident 2 by Resident 1. This failure resulted in further physical abuse to Resident 2, 21 days after the initial abuse by Resident 1. This failure also had the potential to expose other residents to an environment lacking protection and safety from abuse that may result in injuries and psychosocial distress, compromising their health and safety. During a review of face sheet for Resident 1, the face sheet indicated, Resident 1 was originally admitted [DATE], re-admitted on [DATE], with diagnoses that included stroke with R sided weakness, hypertension, and depression. During a review of the Minimum data set (MDS, a resident assessment tool) dated 11/29/23, the MDS indicated a brief interview for mental status (BIMS, a short…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop an individualized comprehensive care plan with measured objectives and specific interventions for one of two sampled residents (Resident 2) when there was no care plan to address the physical, mental, and psychosocial wellbeing of Resident 2 after two cases of abuse. This deficient practice had the potential for Resident 2 ' s needs not to be identified and negatively impact his physical, mental, and psychosocial functioning. Findings: During a review of Resident 1 ' s Face Sheet, the Face sheet indicated Resident 1 was originally admitted [DATE] and re-admitted in February 2023 with diagnoses that included stroke with right sided weakness, high blood pressure, and depression. During a review of the Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan.), dated 11/29/23, the MDS indicated a Brief Interview for Mental Status (BIMS, is a scoring system used…

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 activities of daily living (ADLS,Activities of daily living are those needed for self-care and mobility and include activities such as bathing, dressing, grooming, oral care, ambulation, toileting, eating, transferring, and communicating.) to one of three sampled residents (Resident 1), when Resident 1 did not receive schedules showers for nine weeks and fingernails were long with brown matter underneath the nail. This failure placed Resident 1 feeling not cared for and neglected. Findings: During a review of Resident 1 ' s Face Sheet, dated October 2023, the Face sheet indicated Resident 1 was admitted to the facility in October 2023 with diagnoses to include left sided weakness. During a review of Resident 1 ' s Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan.), dated 1/6/24, the MDS indicated, Resident 1 ' s Brief Interview for Mental (BIMS, is a scoring system used to determine the resident ' s cognitive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to ensure residents had a safe and comfortable environment when; 1. Resident rooms [ROOM NUMBERS]'s room temperature was above 81 degrees Fahrenheit (F). 2. Resident 59's bed was broken. 3. Closet doors for 12 of 70 residents (Residents 56, 36, 60, 41, 64, 13, 118, 119, 40, 62, 48, 10) did not close. 4. Built in dresser drawers for 12 of 70 residents (Residents 53, 36, 60, 41, 12, 18, 118, 119, 40, 62, 48, 10) were covered in thick, textured paint making them difficult to open and close and were dirty inside. 5. The automatic patio door in lobby was non-operational. These deficient practices did not ensure a homelike environment and had the potential to cause discomfort from high environmental temperatures inside the facility. Findings: 1. During an interview on 6/21/22 at 10:25 a.m., Resident 52 stated the temperature in room [ROOM NUMBER] was too hot., and the Air-conditioning (AC) system was not working properly. Resident 52 further…

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 four (Residents 2, 23, 26 and 29 ) sampled residents restorative nursing care (RNA). No RNA services were provided for Resident 2's lower extremities and contractures (hardening or shortening of a muscle) and no splint was applied for Resident 23's left hand. For Resident 26, no ambulation was provided or Resident 29's range of motion (ROM) to the upper extremities, all of which were ordered by the physician and according to the residents' plan of care. These deficient practices had the potential to cause a decrease in Residents 2, 23, 23, and 29 ROM. Findings: 1. Review of the Minimum Data Set (MDS - an assessment screening tool used to guide care) dated 3/5/22, indicated Resident 2's Basic Interview of mental status (BIMS) score was 8 (meaning moderate cognitive impairment). Resident 2 had limited ROM and impairment to the upper (shoulder, elbow, wrist, and hand) and lower extremity hip knee, ankle and foot. The diagnoses…

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 and prepare food in accordance with professional standards of food service safety when: 1. Dietary Aide (DA) 1 did not wear a hair net while inside the kitchen. 2. An opened container of syrup was stored inside the refrigerator beyond its use-by date. 3. Storage bins for rice, lentils and food thickener had dusty covers. 4. Soft and sprouted potatoes were stored. 5. A dented seven-pound can of chocolate pudding was stored together with non-dented canned food items in the dry storage area. These failures had the potential to result in food-borne illnesses. Findings: During initial kitchen tour observation and concurrent interview with the Certified Dietary Manager (CDM) on 6/20/22 at 10:25 a.m., the following were observed; 1. DA 1 did not wear a hair net while inside the kitchen. 2. There was an opened container of syrup with a use-by date of 5/6/22. CDM stated she was responsible in checking the refrigerators making sure all food items beyond their use-by dates were thrown out. CDM further stated she…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to ensure the Air-conditioning (AC) system on A side was cooling when residents' rooms [ROOM NUMBERS] air temperature was 83 degrees. {Acceptable air temperature ranges between 71 degrees to 81 degrees Fahrenheit(F)} This deficient practice had the potential to cause residents discomfort and susceptible to heat exhaustion. Findings: During an interview on 6/21/22 at 10:25 a.m., Resident 52 stated that the temperature in rooms on A side was too hot. Resident 52 stated the AC system was not working properly, reported this to the nurse and was transferred to another room. Resident 52 further stated he was concerned for other residents. During rounds on A side on 6/21/22 at 11:55 a.m., and accompanied by the Regional Maintenance Director (RMD), rooms [ROOM NUMBERS]'s air temperature was 83 degrees F. RMD stated the facility had no maintenance supervisor and will check the AC for proper functioning. During an interview on 6/21/22 at 12:47 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 observation, interview, and record review, the facility failed to implement or develop the Comprehensive Plan of Care policy and procedure for the following three (Resident 37, 56 and 57) of 22 sampled residents when; -Resident 56's care plan was not developed to ensure safe smoking interventions were implemented. For example, an apron to protect clothing and self against burns. -Resident 57 did not have a care plan to address an impairment of the lower extremities. - Resident 37 had no care plan developed for range of motion. These deficient practices had the potential for residents to not receive care and treatment services based on care assessment needs. Findings: 1. During an interview on 6/22/22 at 8:18 a.m., Resident 56 stated he was a smoker and smoked cigarettes as scheduled. Review of Resident 56's Significant change in status Minimum Data Set (MDS- an assessment and care screening tool used to guide care), dated 11/7/21, indicated Resident 56's diagnoses included seizure disorder or epilepsy…

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 licensed nursing staff routinely administered pain medication in the absence of pain for one of 22 sampled residents (Resident 7). Resident 7 was ordered Morphine (an opioid/narcotic), twice a day for moderate pain. Staff routinely administered the narcotic when the resident denied having pain. Staff also continued to administer the medication when Resident 7 had become lethargic. This failure resulted in respiratory depression, and unnecessary admission to the hospital. Findings: Record review on 6/22/2022 of the document Resident Face Sheet showed the facility admitted Resident 7 on 3/22/2021. The diagnoses included arthritis. Record review on 6/23/2022 of the document, Minimum Data Set (MDS, a resident assessment tool for planning care) dated 3/14/2022, showed Resident 7 had clear speech, was able to express her ideas and wants and understood what was said to her. During the initial rounds on 6/20/2022 at 11:30 a.m., Resident 7 was observed awake, sitting up in bed…

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

Based on observation, interview, and record review, for one of one sampled resident (Resident 29) reviewed for dialysis (process when a machine filters the blood of wastes when the kidneys are not healthy enough to do it), the facility failed to ensure that a phosphate binder (binds/attaches to some of the phosphate in food reducing one's blood phosphorus levels) was administered as ordered by the physician. This failure had the potential to result in increased blood phosphorus (mineral) levels. Findings: Review of Resident 29's Resident Face Sheet indicated Resident 29 was initially admitted with diagnoses that included end stage kidney failure, diabetes mellitus (abnormal levels of blood sugar), and dependence on hemodialysis. Review of Resident 29's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 4/19/22 indicated Resident 29 had a Brief Interview for Mental Status (BIMS, an assessment tool for resident's orientation to time and capacity to remember) score of 15, meaning cognitively intact. Furthermore, Resident 29 required staff supervision and set…

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

Based on interviews and record review, the facility failed to ensure two sampled residents (Resident 2 and 29) were free from unnecessary drugs when; -Resident 2 was administered Clonazepam (Klonopin- antianxiety) without adequate monitoring of behavior manifestations and medication side effects. -Resident 29 was administered Remeron (antidepressant) medication without appropriate indication and gradual dose reduction. These failures had the potential for residents to receive unnecessary medications and adverse medication side effects. Findings: Review of Minimum Data Set (MDS - an assessment screening tool used to guide care) dated 3/5/22 indicated Resident 2's Basic Interview of mental status (BIMS) score was 8 (meaning moderate cognitive impairment). Resident 2 had no behavioral symptoms. Resident 2 diagnoses included, anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety or fear that are strong enough to interfere with one's daily activities). During an observation on 6/20/22 at 11:42 a.m., Resident 2 was in bed awake, verbal with…

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

Based on observation, interview, and record review, for one of three sampled residents (Resident 29) reviewed for food concerns, the facility failed to provide food at a safe and appetizing temperature when Resident 29 was served a lunch tray that had been sitting at the bedside for two hours or more. This failure had the potential to result in food borne illness and resulted in Resident 29 being served cold food. Findings: Review of Resident 29's Resident Face Sheet indicated Resident 29 had been known to the facility since 7/21/17 with diagnoses that included diabetes (abnormal levels of blood sugar), major depressive disorder (persistently depressed mood), and dependence on hemodialysis (treatment to filter water and waste from a patient's blood when the kidneys are not working normally). Review of Resident 29's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 4/19/22 indicated Resident 29 had a Brief Interview for Mental Status (BIMS, an assessment tool for resident's orientation to time and capacity to remember) score of 15, meaning cognitively…

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 licensed staff did not provide the necessary rehabilitative services for one of 22 sampled residents. (Resident 25). Resident 25 had bilateral foot drop (inability to lift the front part of the foot causing the toes to drag on the ground which may be due to muscular problems or other underlying issues). Staff had not supported Resident 25's feet with a splint and there were no RNA (Restorative Nursing Assistant) visits documented in the clinical record. This failure resulted in the potential decrease in muscle strength in her feet and general range of motion. Findings: Record review on 6/22/2022 of the document, Resident Face Sheet showed diagnoses that included Joint Derangement (disturbance in the normal resting position of the joint that results in obstruction of movement). Review of the document, MDS 3.0 Nursing Home Quarterly . (resident assessment) dated 4/12/2022, showed Resident 25 was unable to walk, was bed-bound, and required extensive care from staff for dressing, toilet use and personal hygiene. The Functional…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, for one of four (Resident 49) sampled residents reviewed for advanced directives, the facility failed to ensure medical records were complete and accurate when Resident 49's Physician Order for Life -Sustaining Treatment (POLST, a form that gives seriously-ill patients control over end-of-life care decisions including medical care, prevents unwanted treatments and ensure patient's wishes are honored) was incomplete and not signed by Resident 49 or the Resident Representative. This failure had the potential to result in unwanted treatment and medical interventions and not honoring Resident 49's wishes for end-of-life care. Findings: Review of Resident 49's Resident Face Sheet indicated Resident 49 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder (a mental illness), visual loss, history of breast cancer, congestive heart failure (progressive disorder affecting pumping power of the heart muscle), and dyspnea (difficult or labored…

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.