Ramona Rehabilitation And Post Acute Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure intravenous (IV - fluids/medication given directly into the bloodstream) antibiotic medications was provided according to the physician's orders upon discharge from the General Acute Hospital (GACH), for one of five residents (Resident A). This failure resulted in Resident A not receiving the IV antibiotics as prescribed, and needed to extend the IV medication to address Resident A's infection. Findings: On March 6, 2025, at 10:30 a.m., an unannounced visit was conducted for the investigation of a complaint for quality of care. On March 6, 2025, at 11:15 a.m., a review of Resident A's medical record was conducted. Resident A's admission Record, indicated Resident A was admitted to the facility on [DATE], with diagnoses which included sepsis (a life-threatening blood infection), bacteremia (bacteria in the blood stream), and xenogenic heart valve (a type of tissue from another species - a pig or a cow). A review of Resident A's Extended Care…

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 an allegation of physical abuse was reported to California Department of Public Health (CDPH) immediately, but not later than two (2) hours after the allegation was made. The facility was made aware of the alleged physical abuse of a facility staff (Certified Nursing Assistant [CNA] 1) to a resident (Resident 1) on October 28, 2024. This failure had the potential to cause a delay in the investigation of the alleged abuse and to expose residents in the facility to further abuse. Findings: On November 18, 2024, at 10:15 a.m., an unannounced visit was conducted at the facility to investigate an abuse allegation. On November 18, 2024, Resident 1's medical record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which include pulmonary fibrosis (scar tissue in the lungs), chronic respiratory failure (difficulty breathing on your own), and anxiety (excessive and persistent worry). Resident 1's Minimum Data Set (MDS - 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 ensure an assessment was conducted, for three of six residents (Resident 20, 30, and 33) reviewed for safe self-administration of medication when: 1. One 30 ml (milliliters - unit of measurement) cup of powder medication was found on the bedside table of Resident 20; 2. One opened tube of Desitin (brand of ointment used to prevent and treat rash) 57 GM (gram-unit of measurement) ointment was found on bedside table of Resident 30; and 3. One opened bottle of 15 ml eyedrops (medication that relieves eye irritation) was found on the overbed table of Resident 33. These failures had the potential for Residents 20, 30, and 33 to receive multiple doses of medication without proper monitoring, which could lead to harmful effects. Findings: 1. On October 21, 2024, at 9:13 a.m., during a concurrent observation and interview with Resident 20 in her room, one 30 ml cup of powder medication was observed on top of her bedside table. In a concurrent…

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 expired, discontinued, and unlabeled medications and intravenous (IV- into the vein) fluids were not readily available for use. These failures have the potential for the residents to receive wrong, contaminated, expired, or ineffective medication therapy. Findings: 1a. On October 23, 2024, beginning at 3:27 p.m., an inspection of the Station 4 Medication Cart (Med Cart) was conducted with Licensed Vocational Nurse (LVN) 9. The following medications were found expired and kept stored in the second left drawer of Med Cart 4: - One tablet ondansetron (medication for nausea/vomiting) 4 mg (milligrams- unit of measurement) tab (tablet), labeled for Resident 31, with an expiration date of March 18, 2024; - Eight tablets of Clonidine (a blood pressure medication) 0.1 mg tab, labeled for Resident 12, with an expiration date of October 2, 2024; - 25 tablets of ondansetron tab 4 mg, labeled for Resident 19, with an expiration date of October 1, 2024; - Three tablets hyoscyamine (medication that reduces…

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 safe storage practices were followed in the kitchen when: - One seven-pound (lb- unit of measurement) can of cranberry jelly was found in the dry storage area undated; - Two stalks of celery in a plastic bag were found in the walk-in refrigerator with the bag open exposing the celery to air; and - Five three-lb bars of chopped spinach were found in the freezer not dated. These failures had the potential to cause food-borne illnesses in a highly susceptible resident population. Findings: On October 21, 2024, at 9:00 a.m., an initial kitchen tour was conducted with the Dietary Manager (DM). The following were observed: - One seven-lb can of cranberry jelly was found in the dry storage area undated; - Two stalks of celery in a plastic bag were found in the walk-in refrigerator with the bag open exposing the celery to air; and - Five three-lb bars of chopped spinach were found in the freezer not dated. On October 21, 2024, at 9:22 a.m., a concurrent interview was conducted with the DM. The DM stated all…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when: 1. Certified Nursing Assistant (CNA) 2 did not use personal protective equipment (PPE - equipment use to protect against infection or illness) when providing care to a resident requiring enhanced barrier precautions (EBP-an infection control intervention to reduce transmission of multidrug-resistant organisms [MDRO- bacteria that have become resistant to multiple antibiotics]); 2. The Laundry Staff (LS) failed to follow proper handling and storage of clean linens; 3. The Certified Occupational Therapy Assistant (COTA - healthcare provider who performs physical movement) did not conduct proper handwashing before and after providing therapy treatment to a resident; 4. The facility staff failed to ensure the nebulizer treatment tube (a plastic device that delivers air and medicine through a tube for breathing treatment) was changed according to the physician's order; and 5. Two direct…

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 treat resident with respect and dignity when the staff failed to cover the urinary bag, for one of one resident reviewed for dignity (Resident 53). This failure increased the potential to negatively affect Resident 53's psychosocial wellbeing. Findings: On October 21, 2024, at 3:30 p.m., Resident 53 was observed with Licensed Vocational Nurse (LVN) 1. Resident 53's urinary bag was observed attached to the resident and was filled with 300 ml (millimeter-unit of measurement) yellow liquid. The urinary bag was observed hanging below the level of Resident 53's bed. In a concurrent interview with LVN 1, she stated the staff did not cover the urinary bag with a dignity bag (used to cover urine collection bag) and was exposed. She further stated, it should have been covered, I will feel embarrassed if that bag was mine and not covered. On October 23, 2024, Resident 53's record was reviewed. Resident 53 was admitted to the facility on [DATE],…

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 facility policy review the facility failed to answer the call light within a reasonable time, for one of 95 residents (Resident 34). This failure had the potential to not meet the resident's needs. Findings: On October 21, 2024, at 10:05 a.m., an interview with Resident 34 was conducted. Resident 34 stated on the he could not get help for up to an hour usually during the morning shift. A review of Resident 34's electronic medical record indicated Resident 34 was admitted to the facility on [DATE], with diagnoses which include fusion of the spine (surgical process that joins vertebrae in the spine), wedge compression fracture (fracture when the front of a vertebrae collapses) of T7-T8 vertebrae, and ankylosing spondylitis (inflammatory arthritis) of thoracic region. A review of Resident 34's History and Physical, dated September 28, 2024, indicated Resident 34 was mentally capable of understanding. On October 24, 2024, 12:40 p.m., an interview with the Assistant Director of Nursing (ADON)…

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 medical record review, the facility failed to manage the pain, for one of three residents reviewed for pain (Resident 137), when the pain medication was not administered according to the physician's order. This failure resulted in Resident 137 not receiving the pain medication as ordered by the physician and had the potential for Resident 137 to experience pain not to be managed appropriately and affect overall health condition. Findings: On October 21, 2024, at 9:22 a.m., a concurrent observation and interview was conducted with Resident 137. Resident 137 was observed wearing a neck brace sitting at bedside and grimacing while repositioning himself. Resident 137 stated he arrived at the facility on October 16, 2024, around 5 p.m., and did not receive pain medication until the next day around 7 a.m. Resident 137 further stated he asked for pain medicine at 2 a.m., in the morning of October 17, 2024, and the nurse replied, We don't have your doctor's orders and the pain…

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, concurrent interview, and record review, the facility failed to monitor for anticoagulant (medication that treats blood clots) use, for one of two residents reviewed (Resident 138), when Resident 138 was observed to have multiple bruises on both arms. This failure resulted in Resident 138 not being monitored for potential harmful side effects of anticoagulants. Findings: On October 22, 2024, at 2:45 p.m., a concurrent observation and interview with Resident 138 was conducted. Resident 138 was observed with multiple scattered purple and red discolorations on both arms. Resident 138 stated he was on blood thinner and was not given instructions or teaching on monitoring for signs and symptoms of bleeding. On October 22, 2024, a review of Resident 138 electronic medical record indicated Resident 138 was admitted to the facility on [DATE], with diagnoses which included acute embolism and thrombosis of deep veins (condition blocking blood flow in veins and arteries) of the left lower extremity,…

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 orders for enhanced barrier precautions, (EBP - the use of gown and gloves for residents that have chronic wounds, or indwelling devices during high-contact procedures to prevent the spread of multi-drug resistant organisms in nursing homes) for one of three residents (Resident 7), during wound care. This failure had the potential for the spread of multi-drug resistant organisms. Findings: On September 5, 2024, at 10:26 a.m., an unannounced visit to the facility on a complaint investigation was initiated. On September 5, 2024, at 2:22 p.m., observed a sign on the outside of Resident 7's room indicating Enhanced Barrier Precautions. The Treatment Nurse (TN) was observed preparing for Resident 7's dressing change and wound observation. While the TN donned gloves, she was not observed wearing a gown during wound care for Resident 7. On September 5, 2024, at 2:47 p.m., an interview was conducted with the TN. The TN stated that 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, interview, and record review, the facility failed to ensure the call light was within reach for one of three sampled residents, (Resident 2). This failure had the potential to result for Resident 2's needs being unmet, and the inability to call for help. Findings: On June 25, 2024, at 10:36 a.m., an unannounced visit to the facility was conducted to investigate a complaint regarding quality of care issue On June 25, 2024, at 12:59 p.m., observed Resident 2 lying in bed on his back, with eyes closed, respirations even and unlabored. Resident 2's call light was observed on the left side of his bed on the ground, not within resident's reach. On June 25, 2024, at 1:05 p.m., a concurrent observation and interview were conducted with the Certified Nursing Assistant (CNA). The CNA observed Resident 2's call light on the floor, on the left side of the bed. The CNA picked up the call light up and placed it on the left side of Resident 2's bed. The CNA stated that call lights should be within reach…

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 Treatment Nurse (TN), followed infection control guidelines when she did not perform hand hygiene after removing contaminated gloves and prior to donning clean gloves for during wound care for one of three residents, (Resident 5). This failure had the potential to contaminate the TN's hands and the resident's wounds. Findings: On June 25, 2024, at 2:18 p.m., the Treatment Nurse, (TN) was observed providing skin care to Resident 5. The TN placed a sterile drape with Triamcinolone Acetonide External Cream 0.1% (a topical steroid that helps lessen skin rash and irritations) in a medicine cup on Resident 5's overbed table, located on the left side of Resident 5's bed. The TN donned clean gloves, removed Resident 5's socks, used a body wipe to clean under Resident 5's breasts, groin, and abdominal fold, changing gloves between each area. The TN applied the cream to these areas and to Resident 5's buttocks and sacral area after…

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, for one of three sampled residents (Resident A), the staff removed the Certified Nursing Assistant (CNA 2) after the resident made an allegation of sexual abuse against the CNA. This failure resulted in Resident A seeing CNA 2, causing the resident to become upset and angry. Findings: On May 7, 2024, at 10:20 a.m., an unannounced visit to the facility was conducted to investigate an allegation of sexual abuse. During an interview on May 7, 2024, at 1:40 p.m., with CNA 1, CNA 1 stated on May 5, 2024, around lunch time, at 12:30 p.m., she was in the dining room preparing residents for lunch. CNA 1 stated she heard Resident A yelling at CNA 2 to go away, and get him away. CNA 1 stated she intervened and removed CNA 2 from the dining room. CNA 1 stated she asked Resident A, why she was upset. CNA 1 stated the resident reported that CNA 2 licked her and looked down at her private area. CNA 1 stated CNA 2 returned to the dining room to assist another…

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 physician orders were followed for one of three sampled residents. This failure had the potential to cause further complications for Resident A's heart rates and blood pressures. Findings: On April 10, 2024, at 10:15 a.m., an unannounced visit was made to the facility to investigate quality care issues. A review of Resident A's medical record indicated Resident A was admitted to the facility on [DATE], with diagnoses which included COPD (Chronic Obstructive Pulmonary Disorder-causes airflow blockage and breathing related problems), hypertension (blood pressure higher than 130/80), diabetes mellitus (disease with too much sugar in the blood), and atrial fibrillation (irregular, often fast heart rate, causes poor blood flow). A review of Resident A's physician orders indicated the following: -Clonidine tablet 0.1mg (milligram-a unit of measurement), give 1 (one) tablet via PEG (percutaneous endoscopic gastrostomy-a feeding tube placed…

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 weigh one (Resident A) out of three residents, on admission and every week for the first four weeks, in accordance with the policy and procedure. This failure had the potential for Resident A to not receive treatment and care in accordance with professional standards of practice. Findings: On January 24, 2024, at 11:45 a.m., an unannounced visit was made to the facility for an allegation of quality of care and treatment. A review of Resident A ' s medical record indicated, Resident A was admitted to the facility on [DATE], with diagnoses which included Type II diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar), atrial fibrillation (irregular, often rapid heart rate that causes poor blood flow), and cirrhosis of the liver (liver damage leading to scarring and liver failure). Resident A has the capacity to understand and make medical decisions. A review of Resident A ' s weights, indicated the following: a. 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 interview, and record review, the facility failed to ensure that a COVID-19 outbreak was reported to California Department of Public Health (CDPH). This failure had the potential for CDPH not to be aware of the facility needs related to staffing, protective equipments, and technical assistance during the outbreak situation at the facility. Findings: On January 9, 2024, at 12:30 p.m., an unannounced visit to the facility on a complaint investigation was initiated. On January 9, 2024, at 12:56 p.m., an interview was conducted with the Infection Preventionist, (IP). The IP stated that on December 1, 2023, they had more than one resident test positive for COVID-19. The IP stated that CDPH was not notified and was unsure if they were required to notify the state survey agency. On January 9, 2024, at 1:45 p.m., an interview was conducted with the facility Administrator (Admin). The Admin stated that he did not notify CDPH of the COVID-19 outbreak that started on December 1, 2023. A record review of the facility ' s document titled COVID 19 Surveillance Information Log 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow facility policy and procedure in assessing the need for a pneumococcal vaccine within five working days of admission, for one of five residents (Resident 1). This failure had resulted for the resident not to be afforded the benefit of receiving a pneumococcal vaccine, placing the resident at risk for pneumococcal infection. Findings: On January 9, 2024, at 12:30 p.m., an unannounced visit to the facility was conducted to investigate infection control issue. A review of Resident 1 ' s medical records indicated he was admitted on [DATE], with diagnoses of atrial flutter (an irregular heartbeat), type 2 diabetes mellitus (a chronic condition that affects the way the body uses sugar. The body either resists the effects of insulin — a hormone that regulates the movement of sugar into the cells — or doesn't produce enough insulin to maintain normal sugar levels), rheumatoid arthritis (a chronic progressive disease-causing inflammation in the joints…

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 for one of three sampled residents (Resident 1): A. Resident 1's third toe discoloration on the right foot identified by staff on September 16, 2023, was addressed and referred to the physician for appropriate care and treatment. In addition, Resident 1's third toe discoloration on the right foot had an ongoing assessment and evaluation . B. Resident 1's new skin discoloration to the third and fourth toes observed by the Certified Nursing Assistant (CNA) on September 27 2023, was reported to the licensed nurse. These failures had the potential for the delay in necessary care and treatment of the right third and fourth toe and possible complication like amputation. Findings: On October 13, 2023, at 10:30 a.m., an unannounced visit was conducted at the facility for an investigation of an allegation of neglect. On October 13, 2023, a record review was conducted on Resident 1. Resident 23 was admitted to the facility on [DATE], 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 interview and record review, the facility failed to ensure residents were free from potentially dangerous drug-drug interactions and duplication of therapy when two similar medications for COPD (congestive obstructive pulmonary disease - chronic lung disease that causes obstructed airflow from the lungs) were ordered and administered to one of five residents reviewed (Resident 288). This had the potential to cause harm to the resident from the side effects after receiving more than what was recommended by drug manufacturers. Findings: Review of Resident 288's medical record indicated the resident was admitted on [DATE], with diagnoses that included COPD. There was a physician order on February 23, 2023, for Bevespi (glycopyrrolate-formoterol - combination of an anticholinergic drug and a long-acting beta2-agonist used to increase airway to help breathe better in patients with COPD) with the direction for the resident to inhale two puffs by mouth two times a day for COPD. There was a physician order 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 ensure sanitary conditions were maintained and food was stored in accordance with professional standards for food service safety when: 1. Food items were not appropriately labeled with the use by date; 2. An open plumbing fixture under the kitchen sink had aluminum foil in the vacant hole and needed to be replaced and repaired; 3. One expired plastic container of ground turmeric was found in the dry storage area and readily available for use; 4. Two air gaps (space between the water outlet and the flood level of a fixture) required cleaning and/or repair; 5. The ice machine was found to have a light brown residue around the inner rim of the door; and 6. One cook did not perform hand hygiene during the lunch tray line observation when touching the plates and plate covers after using two oven mittens. These failures had the potential for the growth of harmful bacteria and cross contamination that could lead to food borne illnesses for a medically compromised population of 88 residents who ate orally and…

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

Based on observation, interview, and record review, the facility failed to ensure the trash containers were not overfilled and the lids were kept securely closed to prevent the potential attraction of pests and vermin (nuisance animals that could spread diseases). This facility failure increased the potential for attracting insects and vermin, which could result in food-borne illnesses in a highly susceptible population of 90 residents. Findings: During the initial kitchen tour on March 6, 2023, at 10:01 a.m., an observation of the trash bin recycle container was conducted with the Food and Nutrition Service Manager (FNSM). The trash bin recycle container was observed to have two open inlets on top of the lids where the recycled trash was placed. The trash bin recycle container was observed to be overfilled and the lids were not able to be securely closed. The three regular trash containers were observed to be overfilled with their lids not securely closed. In a concurrent interview, the FNSM stated the recycle container lids and the regular trash containers should be completely…

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

Based on observation, interview, and record review, the facility failed to perform proper hand hygiene after providing care for one of three residents reviewed (Resident 51) on contact transmission-based isolation precautions. This failure had the potential to result in transmission of infectious illnesses to the vulnerable population of the facility. Findings: A record review of Resident 51 indicated, an admission to the facility, dated February 13, 2023, with a diagnoses of pneumonia (an infection in the lungs), gastritis (inflammation of the stomach, and enterocolitis due to Clostridium Difficile (inflammation of the colon caused by a bacteria). A review of Resident 51's progress notes indicated, a positive result for C.diff, dated February 24, 2023, and Resident 51 had been put on contact isolation on February 23, 2023, due to loose stools and a possible diagnosis of C.diff. On March 6, 2023, at 11:45 a.m., during an observation, Certified Nursing Assistant (CNA) 1 removed her Personal Protective Equipment (PPE) (gloves, gowns, face shields) and placed used cloth gown in 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 observation, interview, and record review, the facility failed to ensure provision of pharmacy services met the needs of the residents when: 1. One medication order was duplicated in the medical record of Resident 28. This had the potential to increase the side effects from receiving more than the prescribed dose by the physician; and, 2. Discontinued medications were left in the medication cart for resident use. This had the potential for residents to receive wrong medications. Findings: 1. Review of Resident 28's medical record indicated the resident was admitted on [DATE], with diagnoses which included pancytopenia (low levels of red blood cells, white blood cells, and platelets in blood). There was a physician order on January 26, 2023 for Procrit (epoetin alfa - injectable drug to treat low red blood cells) 40,000 units (unit of measure) to be given under the skin one time every 30 days for pancytopenia. There was a physician order on February 28, 2023 for epoetin alfa 40,000 units to be given once…

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 services provided meet the storage of medications at the bedside, for one of 24 residents (Resident 10) reviewed, when the medication Afrin (nasal spray to relieve congestion) was observed at the bedside. This failure had the potential for Resident 10 to experience side effects after receiving a medication without a physician's order. Findings: On March 6, 2023, at 3:26 p.m., Resident 10 was observed lying in bed. An unlabeled bottle of Afrin nasal spray was observed at the bedside. In a concurrent interview with Resident 10, she stated a visitor brought the medication from home. On March 6, 2023, at 3:39 p.m., a concurrent interview and record review was conducted with Licensed Vocational Nurse 1 (LVN). LVN 1 stated there was no order for Afrin found at the bedside. She stated all medications brought from home should be made known to the nursing staff and should have a physician order. On March 8, 2023, at 10:25 am., the Assistant…

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.