San Jacinto Valley Post Acute

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 two residents, Resident 1, a medication ordered by the doctor was given as prescribed. This failure had the potential for Resident 1 to have hypokalemia (low potassium level in the blood) which could cause Resident 1 to experience muscle cramps and abnormal heart rhythms. Findings: On January 22, 2024, at 9:28 a.m., at the north unit of the facility, a med pass (administration of medications) observation was conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 prepared Resident 1 ' s medications which included potassium chloride. LVN 1 placed the box of potassium chloride oral packets, which were labeled for Resident 1 and dated October 24, 2024, on top of the medication cart. LVN 1 removed one oral potassium chloride packet from the box, prepared it, and administered it to Resident 1. A review of Resident 1 ' s medical record indicated she was admitted to the facility on [DATE], with diagnoses which included stroke…

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 infection prevention protocols were implemented, for two of two residents, Residents 1 and 2, when a facility staff member did not perform hand hygiene in between residents ' care, and did not disinfect the automatic blood pressure cuff (BP cuff) before and after residents ' use. These failures had the potential for the vulnerable residents to be exposed to cross-contamination and the development of infections. Findings: On January 22, 2024, at 9:24 a.m., a medication pass was conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 carried an automatic BP cuff machine from the top of the medication cart and went to Resident 1 ' s room. LVN 1 applied the BP cuff to Resident 1 ' s left wrist. After obtaining Resident 1 ' s BP reading, LVN 1 removed the automatic BP cuff from Resident 1 ' s wrist and place it on top of the medication cart. LVN 1 did not perform hand hygiene and did not disinfect the automatic BP cuff machine after use on Resident 1. LVN 1 prepared Resident 1 ' s medications, went back to…

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 four residents reviewed for urinary catheter (tube inserted into the bladder to drain urine), the urinary catheter drainage bag was covered with a dignity bag (a bag that covers and holds a catheter drainage to keep it out of sight). This failure resulted in violation of Resident 37's rights to be treated with dignity and respect. Findings: On November 4, 2024, at 10:17 a.m., Resident 37 was observed with the urinary catheter drainage bag not covered with a dignity bag. On November 4, 2024, at 10:20 a.m., during an interview with Certified Nursing Assistant (CNA) 1, she stated there should be a dignity bag over the urinary catheter drainage bag. CNA 1 stated not covering the drainage bag could cause embarrassment to the resident. On November 4, 2024, at 10:25 a.m., during an interview with the Licensed Vocational Nurse (LVN) 1, she stated the dignity bag should be placed over the urinary catheter drainage bag. LVN 1…

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 care plan for the care of resident's surgical site and left hip dressing was initiated and developed for one of 19 residents reviewed (Resident 141). This failure had the potential for Resident 141 not to receive the necessary care and services if the surgical site developed infection and/or the resident experienced other complications. Findings: On November 4, 2024, at 12:15 p.m., Resident 141 was observed awake, alert, lying in bed. Resident 141 stated she fell at home and broke her left hip. She stated she had left hip surgery. Resident 141 stated the surgeon applied a special type of dressing and it should not be removed for seven days. On November 5, 2024, a record review was conducted for Resident 141. Resident 141 was admitted to the facility on [DATE], with diagnoses which included fracture of the left hip. The history and physical (H&P) indicated Resident 141 had the capacity to understand and make decisions. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure services provided met professional standards of practice for two (Residents 45 and 12) of 19 residents reviewed, when: 1. For Resident 45, one opened tube of Voltaren cream (medication used to treat arthritis pain) and one opened bottle of Magnesium Ashwagandha tablets (a medication that supports mental health and sleep) were observed on top of the resident's bedside table; and 2. For Resident 12, one opened bottle of Calcium Carbonate (medication used to relieve heartburn, acid indigestion, and stomach upset) was observed on top of the resident's bedside table. These failures had the potential for Residents 45 and 12 to receive medications without a physician's order. Findings: 1. On November 4, 2024, at 11:46 a.m., Resident 45 was observed lying in bed. One opened tube of Voltaren cream and one opened bottle of Magnesium Ashwagandha tablets were observed on top of Resident 45's bedside table. During a concurrent interview with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure for one of 19 residents (Resident 66) reviewed who smoked in the facility did not have a lighter in her possession. This failure had the potential to result in injury or accident related to unsupervised smoking. Findings: On November 14, 2024, at 10:54 a.m., during a concurrent observation and interview with Resident 66, Resident 66 was brought back to her room in a wheelchair by a facility staff. Resident 66 stated she smokes four times a day and just came back from the smoking patio. Resident 66 stated she was allowed to keep her smoking materials with her and pulled out a pack of cigarettes and a lighter from her pocket. An oxygen concentrator (a machine that supplies oxygen) was observed at Resident 66's bedside. Resident 66 stated she used oxygen during the night. Resident 66 stated she was aware not to smoke in her room. On November 6, 2024, at 12:15 p.m., during an interview with the Activities Director (AD), the AD stated…

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 food items were not stored in the refrigerator, readily available for use. This failure had the potential to result in foodborne illness to an already vulnerable facility population. Findings: On November 4, 2024, at 9:55 a.m., an initial tour of the kitchen was conducted with the Dietary Supervisor (DS). A one gallon size pitcher of water, that was almost full, dated 11/3/24, was observed in the refrigerator, readily available for use. In a concurrent interview, the DS stated the water was used for residents who preferred cold water and 11/3/24 was the use-by-date. The DS stated the water should have been discarded on or before the use-by-date. Additionally, a one-gallon pitcher with a thickened liquid, approximately a quarter-full, dated 10/30/24, was observed in the refrigerator, readily available for use. In a concurrent interview, the DS stated the liquid in the pitcher was used for residents who are on a diet with thick liquids and 10/30/24 was the use-by-date. The DS stated the thickener…

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 prevention and control practices were implemented for three of 19 residents reviewed (Residents 69, 86, and 140) when: 1. For Resident 69, the hand held nebulizer mouthpiece (a device that contains medication that turns into a mist) was left exposed on top of the bedside table near the resident's urinal; 2. For Resident 86, the Enhanced Barrier Precaution (EBP - infection control practices that use gowns and gloves to reduce the spread of multidrug-resistant organisms) was not followed when the resident was admitted with the colostomy (an operation in which a piece of the colon is diverted to an artificial opening in the abdomen that allows stool to pass through); and 3. For Resident 140, the Physical Therapy Assistant (PTA) was not wearing a gown when performing physical therapy exercises at the resident's bedside. Resident 140 was identified for EBP. These failures had the potential to increase the risk for cross…

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 ensure the resident's representative was informed of an incident of fall for one of six resident reviewed (Resident C). This failure has the potential to result in the resident's representative to be unaware of the resident's condition which could delay the involvement of the representative in planning the care for their family member (Resident C). Findings: On May 24, 2024, at 10:30 a.m., an unannounced visit to the facility was conducted to investigate a complaint of quality of care. On May 28, 2024, Resident C ' s medical record was reviewed. Resident C was admitted to the facility on [DATE], with diagnoses which included Myocardial Infarction (heart attack) and Type 2 Diabetes Mellitus (a group of diseases that result in too much sugar in the blood). A review of Resident C ' s SBAR (stands for Situation, Background, Assessment, Recommendation- a form used to communicate)/Summary for Providers, dated for May 15/2024, at 7:15 a.m., indicated .falls .CNA…

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 that one (Resident D) of four residents reviewed for pressure ulcers/injuries (PU/PI-localized damage to the skin and underlying soft tissue usually over a bony prominence resulting from intense or prolonged pressure), received care and services consistent with professional standards of practice, when the status of the pressure injuries, which included measurements, were not consistently documented. In addition, the facility failed to ensure provision of wound treatment was coordinated with the wound care team. These failures have the potential to result in inconsistent provision of wound treatment which could contribute to the delayed healing of the resident's pressure injuries. Findings: On May 24, 2024, at 10:30 a.m., an unannounced visit to the facility was conducted to investigate a complaint related to quality of care. On May 24, 2024, Resident D's medical record was reviewed. Resident D was admitted to the facility on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was transferred with two person assist using the Hoyer lift (a portable total patient lifting tool to assist in transferring patients in and out of bed), from his Geri-chair (a large padded chair that can recline and is used for people with limited mobility), to bed. This failure had the potential to result in an injury to Resident 1. Findings: On March 19, 2024, at 10:59 a.m., an unannounced visit to the facility was condcuted to investigate quality care issues. A review of Resident 1's medical records indicated he was admitted on [DATE], with diagnoses which included CVA (cerebral vascular accident – stroke), affecting left side non-dominate, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), diabetes mellitus type 2 (a chronic condition that affects the way the body uses sugar. The body either resists the effects of insulin — a hormone that regulates the…

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

Based on observation, interview, and record review, the facility failed to ensure food safety requirements for food storage and preparation were followed when: - Multiple food items stored in the dry storage area and refrigerator were not labeled with the opened date, or use-by date, and expired food was available for resident use; - Thawing meat in the refrigerator was not labeled with the start and end date of thawing; - The facility log for the dish machine (dish washer) temperatures were not documented for 14 out of 79 entries; and - Two of the five kitchen food carts (large carts used to transport resident food to the floor for meal service) were observed with peeling duct tape. These failures had the potential to place the residents of the facility at risk for food-borne illness in a medically vulnerable resident population who consumed food in the facility. Facility census was 95. Findings: On February 27, 2024, at 11:25 a.m., an unannounced visit was conducted at the facility for a complaint allegation. On February 27, 2024, at 11:33 a.m., a kitchen tour was conducted 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, for one of eight residents reviewed (Resident 3), professional standards of practice were followed when the facility practice for hospice services (focused care for end-of-life) evaluation was not conducted prior to the resident ' s discharge with hospice services. This failure had the potential for Resident 3 ' s family to not fully understand hospices services, and to potentially experience emotional distress. Findings: On January 30, 2024, at 10:35 a.m., an announced visit was conducted at the facility for a complaint investigation. On January 30, 2024, Resident 3 ' s medical record was reviewed. Resident 3 was admitted to the facility on [DATE], and re-admitted on [DATE], with diagnoses which included acute and chronic respiratory failure (sudden and chronic lung condition that makes it hard to breath), sepsis (severe blood infection), vascular dementia (brain damage caused by multiple strokes), cardiac arrhythmia (irregular heartbeat) and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure discharge planning activities were conducted and documented for one of two residents reviewed (Resident 4). This failure had the potential to result for a delay in achieving Resident 4 ' s discharge goal. Findings: On January 19, 2024, at 1:04 p.m., an unannounced visit to the facility was conducted for an investigation of a complaint. On January 19, 2024, at 1:44 p.m., a concurrent observation and interview was conducted with Resident 4. Resident 4 was in his room, sitting on his bed, alert and oriented. Resident 4 stated he did not receive assistance from the facility to find housing. On January 19, 2024, Resident 4 ' s record was reviewed. Resident 4 was admitted to the facility on [DATE], with diagnoses which included Diabetes Mellitus (high blood sugar levels), Hypertension (high blood pressure) and Anemia (low blood oxygen levels). The Minimum Data Set (MDS – an assessment tool) dated November 1, 2023, indicated Resident 4 ' s cognition…

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 faciity failed to provide quality of care when: 1. The facility failed to ensure a change of condition (COC) was completed, monitoring done, and the care plan updated and/or revised for two of eight residents reviewed (Resident 1 and 2), when Resident 1 and 2 appeared to be intoxicated on December 14, 2023. This failure had the potential to result in Resident 1 and 2 to not be adequately monitored for safety risks, and possible medication(s) interactions. 2. The facility failed to accommodate the need for one of one resident, Resident 5, when a bariatric chair (specialized seating) was not available for his use. This failure had the potential for Resident 5 to be at risk for further decline in mobility. Findings: On January 30, 2024, at 10:35 a.m., an unannounced visit was conducted at the facility. On January 30, 2024, at 12:23 p.m., Resident 1 was observed sitting on his bed. During a concurrent interview, Resident 1 stated he had a history of alcohol 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 ensure that the restorative nurse assistant (RNA) exercises were provided for two of three sampled residents, Resident 4 and 5 when: 1. Rehabilitation therapists ' recommendations for Resident 4 were not communicated to the nursing department and the RNA. 2. Resident 5 did not receive RNA exercises on January 15 and 31, 2024 and February 1, 2, 5 and 7, 2024. These failures had the potential for Resident 4 and 5 to have a decline of range of motion. On February 8, 2024, at 10:26 a.m., an unannounced visit was conducted to the facility for an investigation of three complaints. Findings: 1. On February 8, 2024, at 10:26 a.m., a concurrent observation and interview was conducted with Resident 4 in her room. Resident 4 was lying in bed, alert. Resident 4 stated she did not receive any exercises after her skilled therapy ended. A review of Resident 4's record was conducted and indicated that Resident 4 was admitted to the facility on [DATE], with 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide treatment for one of three sampled residents (Resident 1) when Resident 1 ' s foley catheter care was not provided every shift. This failure has the potential for an increased risk of recurrence of infection for Resident 1. Findings: On December 6, 2023, at 11:00 a.m., an unannounced visit was conducted at the facility to investigate a complaint allegation. On December 6, 2023, Resident 1 ' s record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses that include Urinary Tract Infection, Anemia (the body does not have enough red blood cells), Atrial Fibrillation (irregular and rapid heart rhythm), Heart Failure (the heart doesn ' t pump enough blood), Chronic Kidney Disease Stage 3 (kidneys are damaged), Anxiety (mental illness), Depression (mental illness), and Unstageable Pressure Injury of Sacral Region (breakdown of skin due to pressure at the bottom of the spine). The Minimum Data Assessment (MDS –…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based interview and record review the facility failed to administer three routine medications (Quetiapine Fumarate, Mirtazapine, and Lactulose) on August 9, 2023, in accordance with the policy and procedure for one of four sampled residents. This failure had the potential to result in harm to Resident 1. Findings: A review of Resident 1's admission record indicated the resident was admitted to the facility on [DATE], with diagnoses which included respiratory failure, COPD (chronic obstructive pulmonary disease- chronic respiratory distress- a condition that makes it difficult to oxygenate), diabetes mellitus (inability to regulate blood sugar) and dementia (loss of cognitive functioning- thinking, remembering, and reasoning). A review of Resident 1's physician orders for August 2023, indicated the resident had orders for the following: a. Quetiapine Fumarate (antipsychotic medication) 300 mg (milligram- a unit of measure), 1 tablet by mouth at bedtime for bipolar disorder (mental illness that causes unusual…

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 undated/unlabeled and expired food items were not stored in the refrigerator, readily available for use. This failure had the potential to result in foodborne illness to an already vulnerable facility population. Findings: On June 6, 2022, at 9:47 a.m., an initial tour of the kitchen was conducted with the Food Service Supervisor (FSS). One open bag of tofu (one piece of approximately half a pound of tofu) was observed in the refrigerator, readily available for use. The tofu bag had a date of May 31, 2022. In a concurrent interview, the FSS stated the May 31, 2022 label represented the date the tofu bag was opened. The FSS stated the facility did not have storage guidelines specific for tofu. He stated the tofu should not have been stored in the refrigerator past five days from the opening date and should have been discarded. Additionally, a container of dough was observed in the freezer, readily available for use. The dough did not have a label indicating an open date or a use by date (expiration…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide respiratory services according to professional standards of practice when: 1. The licensed nurses administered oxygen without the oxygen flow rate specified in the physician's orders for 14 shifts, from June 3, 2022, to June 8, 2022, for one of four residents reviewed for oxygen use (Resident 212). This failure had the potential for Resident 212 to receive ineffective or unnecessary oxygen therapy. 2. The facility did not change the oxygen nasal cannula (NC - a tube used to deliver oxygen through the nose) and oxygen set-up bag, for two of four residents reviewed for oxygen use (Residents 1 and 50). This failure had the potential for bacterial growth in the NC, which could cause respiratory infections in Residents 1 and 50. Findings: 1. On June 6, 2022, at 12 p.m., Resident 212 was observed awake, sitting up in bed, and conversant. Resident 212 was observed wearing a NC connected to a concentrator (a machine converting room air to…

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

Based on observation, interview, and record review, the facility failed to follow the professional principles on storing medications when: 1. One bottle of antifungal powder, dated May 11, 2022, was found on Resident 49's nightstand and there was no physician's order for use. This failure had the potential for Resident 49 to receive antifungal powder unnecessarily. 2a. One tube of Santyl ointment (medication that removes dead tissue from wounds so they can start to heal) labeled for a discharged resident was found stored in the treatment cart readily available for use; and 2b. One bottle of Narcan (medication used for the treatment of a known or suspected use of opioid [medication used mostly to relieve pain] overdose) nasal spray labeled for a discharged resident was found stored in the medication cart readily available for use. These failures had the potential for the discontinued medications for discharged residents to be available for use by other residents. Findings: 1. On June 6, 2022, at 11:40 a.m., a bottle of antifungal powder, dated May 11, 2022, was found on Resident 49's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure proper infection prevention and control was practiced when: 1. One dirty bedpan was found on the floor in Resident 49's room; and 2. Resident 49's CPAP (Continuous Positive Airway Pressure - a common treatment for obstructive sleep apnea [breathing stops temporarily]) machine was not cleaned since his admission on [DATE]. These failures had the potential to increase the risk of bacterial growth, cross-contamination, and infections. Findings: 1. On June 6, 2022, at 11:40 a.m., a dirty bed pan was observed on the floor in the corner of Resident 49's room. On June 7, 2022, at 9:27 a.m., a dirty bed pan was observed on the floor in the corner of Resident 49's room. On June 8, 2022, at 10 a.m., an interview was conducted with the Certified Nurse Assistant (CNA). The CNA stated the bed pan should not be left on the floor. The CNA stated the bed pan should be kept clean and stored in the resident's drawer or closet. On June 8, 2022, at…

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.