The Village Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure three (Resident D, E, and F) of 13 residents (Residents D, E, and F), received treatment and care in accordance with professional standards of practice to meet each resident's highest practicable physical, mental, and psychosocial well-being, when: 1. Resident D did not receive antibiotic (used to treat infection) medication as ordered by the physician. In addition, the topical treatments for Resident D's moisture associated skin damage (MASD - skin inflammation that occurs when the skin is exposed to moisture for a long time); 2. Resident E's neurocheck (a series of tests to check the brain, spinal cord, and nerve function) was not conducted according to the physician's order after the resident fell; and 3. Resident F was not administered medication to address constipation according to the physician's order. These failures have the potential to result in a delay in the care and treatment for Resident D, E, and F, and could have affect their…

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 interviews and record reviews, the facility failed to ensure accurate skin assessments and wound care treatment were provided to promote the healing and prevention of new pressure injuries from developing, for three of 13 residents (Residents A, B, and C). These failures have the potential to result in delayed wound healing. Findings: On January 27, 2025, at 9:45 a.m., an unannounced visit to the facility was conducted to investigate quality of care and treatment complaints. On January 28, 2025, at 2 p.m. an interview was conducted with the Treatment Nurse (TN). The TN stated if a resident develops a pressure ulcer/injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence), the Certified Nursing Assistants (CNA) are usually the first ones to notice and would report their findings of the wound to her. The TN stated she would conduct the following procedures when a resident was identified with a pressure ulcer/injury: - Evaluate the resident's skin; -…

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, for one of three residents (Resident G), was reported to the California Department of Public Health (CDPH - State Agency) immediately or within two hours after the facility was made aware of the alleged abuse. This failure resulted in a delayed investigation by CDPH and had the potential to expose the resident to further abuse. Findings: On January 27, 2025, at 9:45 a.m., an unannounced visit to the facility was conducted to investigate an allegation of abuse. On January 28, 2025, at 10 a.m., an interview was conducted with the Infection Preventionist (IP). The IP stated an allegation of abuse was discussed during a stand up meeting on January 24, 2025, that Resident G reported to the licensed nurse at around 9 p.m., on January 23, 2025, a Certified Nursing Assistant (CNA) pushed her. The IP stated the facility decided not to report to CDPH Resident G's allegation of abuse as it was decided as a false allegation.…

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 a thorough investigation of an allegation of physical abuse was conducted, for one of three residents (Resident G), after the facility was made aware of the allegation of abuse. This failure had the potential to result in further abuse for Resident G, which could affect the resident's emotional and psychosocial well-being. Findings: On January 27, 2025, at 9:45 a.m., an unannounced visit to the facility was conducted to investigate an allegation of abuse. On January 28, 2025, at 10 a.m., an interview was conducted with the Infection Preventionist (IP). The IP stated an allegation of abuse was discussed during a stand up meeting on January 24, 2025, that Resident G reported to the licensed nurse at around 9 p.m., on January 23, 2025, a Certified Nursing Assistant (CNA) pushed her. On January 28, 2025, at 4:15 p.m., an interview was conducted with the Director of Medical records (DOMR). The DOMR stated stand-up meetings with all department heads…

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 reviews the facility failed to ensure, for four of six residents reviewed (Residents A, B, C, and D), wound management to treat pressure ulcers (localized area of skin and tissue damage caused by prolonged pressure on the skin) was provided according to the plan of care, when: 1. For Resident A, there was no comprehensive assessment (indicating measurement, color, tissue appearance, presence of drainage, odor, appearance of surrounding tissue) of the re-opened sacral wound; 2. For Resident B, there was no comprehensive assessment of the wound on the bilateral buttocks upon admission. In addition, there was no weekly re-evaluation of the bilateral buttocks wound the week of September 18 to 20, 2024; 3. For Resident C, there was no treatment provided to the left buttock pressure ulcer. In addition, there was no comprehensive assessment of the left buttocks wound upon admission; and 4. For Resident D, there was no comprehensive assessment of the left buttocks pressure…

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 informed consent was obtained from the resident or resident representative for the use of psychotropic (medications that affect the mind, emotions, and behavior) medications, for four of five residents reviewed for unnecessary medications (Residents 12, 15, 17, and 19),when the facility's informed consent forms were not properly completed and signed by the resident or resident representative and the physician who obtained the informed consent. This failure resulted in the resident and/or resident's representative to not be informed of the risk and benefits of the proposed care and treatment regarding the use of the psychotropic medications. Findings: 1. During a review of Resident 12's admission Record, indicated Resident 12 was admitted to the facility on [DATE], with diagnoses of depression (a mental health disorder). During a review of Resident 12's Minimum Data Set (MDS - an assessment tool), dated May 3, 2024, indicated a BIMs (Brief…

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: 1. Three of five emergency kits (e-kit; a kit/box containing medications and supplies for immediate use during a medical emergency) were not replaced timely after being opened. This failure had the potential for emergency medication to be unavailable when needed. 2. Controlled substance medications (medication with a high potential for abuse and addiction) were accurately accounted for on the Medication Administration Record (MAR) and the Drug Control Receipt Record/Disposition Form (count sheet - an inventory sheet that keeps record of the usage of controlled medications), for two of four residents reviewed (Residents 17 and 19). This failure had the potential to not have an accurate accountability of controlled medications and the potential for abuse or misuse of these medications. In addition, both failures had the potential for not meeting the residents' therapeutic (related to healing of a disease) needs or worsening of their medical conditions. Findings: 1. On May 20, 2024, at 9:46 a.m., during an inspection…

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 temperature in the medication refrigerator was monitored twice daily, according to the facility's protocol. This failure had the potential for the medications stored in the medication refrigerator to not be stored in a proper temperature to maintain its efficacy and/or full therapeutic effects in which can lead to unsafe administration of medications to residents. Findings: On May 20, 2024, at 9:46 a.m., during a concurrent interview and inspection of the facility's medication room with Registered Nurse (RN) 1, the medication refrigerator was observed to have contained vaccines, insulin products, a refrigerated emergency kit (medications for use in the emergency), and other refrigerated medications. RN 1 stated the medication refrigerator temperatures were expected to be checked and documented on the Temperature Log by the licensed nurse twice daily at each shift. A review of the medication refrigerator temperature logs from September 2023 to May 2024, indicated they were incomplete and/or…

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

Based on observation, interview, and record review, the facility failed to ensure the food service employees were able to carry out the functions of food and nutrition services safely and effectively when: 1. Prep [NAME] did not document the cooling process for tuna salad made on May 20, 2024; 2. Prep [NAME] and [NAME] 2 were unable to demonstrate the cooling process for tuna salad; 3. [NAME] 2 did not know how to calibrate thermometer; 4. Dishwasher 2 did not know how long kitchenware need to immerse into sanitizer; 5. Dishwasher 1 and Dishwasher 2 did not follow manufacturer guideline instruction time length for dipping test strip in sanitizer to check the concentration of sanitizer; 6. [NAME] 1 prepared grainy broccoli for two Residents (Resident 135 and 281) who had physician prescribed pureed diet texture (the food texture should be smooth for residents who have difficulty chewing and/ or swallowing ability) during lunch on May 21, 2024. (Cross referred F 805). These failures had the potential to cause foodborne illness for 37 out of 37 sampled residents who received foods from…

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 and sanitary food preparation and storage practices were implemented when: 1. Prep [NAME] did not monitor the cooling process for tuna salad prepared on May 20, 2024; (Cross reference 802) 2. Dishwasher 1 did not cover his mustache; 3. Can opener base had residue buildup; 4. Rusted shelves were found in the kitchen; 5. Dust was found in the kitchen; 6. Trash were found on the walk-in freezer floor; 7. The ice machine's deflector (a piece of plastic cover inside ice bin to prevent harvested ice from filling up in the front of the storage bin) had residue buildup; 8. [NAME] shelves' plastic coating in refrigerator number (#) 4 was worn off; 9. The vent above the stove was covered with grease and dust; 10. Opened food items exposed to air in the walk-in freezer; 11. There was condensation on the ventilation above the dish machine; 12. Two microwaves in the dining room had residue buildup. These failures had the potential to increase the risk of cross-contamination and exposure to microorganisms that…

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 a comprehensive care plan (specific interventions to provide effective and person-centered care to meet the resident's needs) was initiated for the use of apixaban (medication that helps prevent blood clots), for two of five residents (Residents 8 and 12). This failure had the potential to result in the delay in treatment and care for Residents 8 and 12. Findings: On May 22, 2024, Resident 8's record was reviewed. Resident 8 was admitted on [DATE], with diagnosis which included atrial fibrillation (a condition which causes the heart to beat faster than normal). A review of the Resident 8's Order Summary, dated April 29, 2024, indicated, .Eliquis (another name for apixaban) Oral Tablet 5 mg (milligram- unit of measurement) Give 5 mg by mouth two times a day for AFIB (atrial fibrillation). On May 22, 2024, Resident 12's record was reviewed. Resident 12 was admitted on [DATE], with diagnosis which included acute embolism (a sudden blocking of 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 interview and record review, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported irregularities during the monthly medication regimen review (MRR), for one of five sampled residents (Resident 19), when: 1. Zoloft (another name for sertraline [a psychotropic medication for depression]) was administered without adequate behavioral and manufacturer's specified monitoring documented during use; and 2. Escitalopram (a psychotropic medication for depression) was administered without adequate behavioral monitoring documented during use. These failures had the potential for the medication to not be optimized for best possible health outcome, and had the potential for unnecessary or prolonged use of the medication which could lead to adverse effects and unidentified risks associated with the use of psychotropic medications that included but not limited to sedation, respiratory depression, constipation, anxiety, agitation, and memory loss. Findings: During a review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure two of four residents (Residents 8 and 12) who were receiving Eliquis (another name for apixaban [medication to prevent clots]) were free from unnecessary medications when the nursing staff did not monitor for signs and symptoms of side effects related to the use Eliquis. This failure had the potential for the side effects of Eliquis (such as bleeding, excessive bruising, and others) medication to be undetected or unrecognized for timely intervention. Findings: 1. During a review of Resident 8's admission Record, dated May 22, 2024, it indicated Resident 8 was admitted to the facility on [DATE] with diagnoses which included atrial fibrillation (an irregular heartbeat). A review of Resident 8's physician's orders indicated the following: - April 29, 2024 - .Eliquis Oral Tablet 5 milligram (mg, unit of measurement) Give 5 mg by mouth two times a day for AFIB (atrial fibrillation) .; and - May 12, 2024- .Eliquis .Monitor for s/sx (signs 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 for one of five sampled residents (Resident 19) was free from unnecessary psychotropic (affects brain activities associated with mental processes and behavior) medications when: 1. Resident 19 was receiving Zoloft (another name for sertraline [a psychotropic medication for depression - mood disorder]) and was administered without adequate behavioral and manufacturer specified monitoring documented; 2. Resident 19 was receiving Escitalopram (medication for depression) and was administered without adequate behavioral monitoring documented; and 3. Resident 19 was receiving PRN (as-needed) Xanax (another name for alprazolam (medication for anxiety [feeling of restlessness) and was administered without prescriber-documented rationale and specified duration for extended use beyond 14 days. These failures had the potential to result in unnecessary use of medications for Resident 19, which increased the potential for medication interactions, adverse…

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 medication error rates are below 5 percent, for two of ten residents (Residents 131 & 138), observed during medication administration. These failures resulted in medication error rate of 19.23 percent in which resulted in medications not to be given according to the physician orders. In addition, these failures had the potential for the residents to not receive the full therapeutic (relating to the healing of disease) effects of the medications. Findings: 1. On May 21, 2024, at 8:58 a.m., during a medication pass observation with Licensed Vocational Nurse (LVN) 1, LVN 1 was observed to have prepared and administered four medications to Resident 138. The medications included one aspirin (used to prevent blood clots) enteric-coated (EC [tablet designed to pass through the stomach and get absorbed into the bloodstream by the small intestine]) tablet, one sennosides (another name for Geri-Kot [used for constipation]) tablet, and one Trelegy Ellipta (used for chronic obstructive pulmonary disease [COPD], a…

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

Based on observation, interview, and record review, the facility failed to ensure the appropriate food texture was provided, for two of two residents (Resident 135 and 281) who had a physician-prescribed pureed diet (food that has been grounded, pressed and/or strained to a soft smooth consistency like pudding). This failure had the potential to place the residents at risk of aspiration (accidentally inhaling food or liquid into the lungs), choking, and decreased meal intake. Findings: (Cross referred 802) On May 21, 2024, at 11:39 a.m., a concurrent noon prep pureed meal observation and interview was conducted with [NAME] (CK) 1. CK 1 placed five scoops of broccoli in the mixer and gradually added 2.5 cups milk to make pureed broccoli. End product of pureed broccoli was observed to have some fiber. On May 21, 2024, at 1:23 p.m., a test tray (to evaluate the quality of a meal during a meal service and identify any areas for improvement) of pureed foods was conducted with the Food Service Director (CDM). One teaspoon of the pureed broccoli was tasted and the pureed broccoli had…

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

Based on observation, interview, and record review, the facility failed to ensure the diet order was followed according to the physician's order, for two out of nine sampled residents (Residents 12 and 15) when: 1. Resident 12, did not receive large portions on May 21,2024 lunch meal tray according to the diet ordered by the physician; and 2. Resident 15, did not receive fortified food items (food items enriched with high calories to help gain weight) on May 21, 2024 lunch meal tray according to the diet ordered by the physician. These failures had the potential to result in not improving Resident 12 and 15's weight, further compromising Resident 12 and 15's nutritional and medical overall condition. Findings: 1. During a review of the facility provided document titled, Diet Type Report (which consist residents' name and physician diet ordered), dated May 20, 2024, indicated, Resident 12 is on large portions. A review of the Resident 12's Physician Diet Order, dated May 9, 2024, indicated, .Large portions . A review of Resident 12's Meal Tray Ticket (menu based on the resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not implement and maintain infection control procedures when the licensed nurse did not disinfect a shared stethoscope between each resident use. This failure had the potential to spread infection that could risk the health and well - being of 2 of 37 medically compromised residents (Residents 138 and 181). Finding: On May 21, 2024, at 9:01 a.m., Licensed Vocational Nurse (LVN 1) was observed using a stethoscope and checked Resident 181's blood pressure without cleaning the stethoscope in between residents. On May 21, 2024, at 9:37 a.m. an interview was conducted with LVN 1 regarding the process for cleaning a shared stethoscope between resident. LVN 1 stated I know I didn't clean it. LVN 1 added, It (stethoscope) should be cleaned each time before and after use. A review of Resident 181's admission Record, (summary of patient information), dated May 21, 2024, indicated Resdient 181 was initially admitted to the facility on [DATE], with a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure care and treatment was provided for three of the six residents (Residents 2, 4 and 5) as evidenced by the following: 1. For Residents 4 and 5, intravenous (IV - given through the veins) medication was not administered in accordance with the physician order. This failure had the potential to result in infection not resolving and could lead to hospitalization; and 2. For Residents 2 and 4, wound treatment was not provided as ordered by the physician. This failure had the potential to result in delayed wound healing for the resident's skin condition to achieve their highest practicable level of physical and mental well-being. Findings: On March 7, 2024, at 10:04 a.m., an unannounced visit was conducted at the facility to investigate a complaint for quality-of-care issue. 1a. On March 7, 2024, a review of Resident 4's admission record, indicated Resident 4 was admitted to the facility on [DATE], with diagnoses which included osteomyelitis…

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 do a dressing change on a peripherally inserted central catheter (PICC-is a thin flexible tube that is inserted into a vein in the upper arm and used to give intravenous fluids and other drugs) as ordered by the physician, for one of six sample residents (Resident 4). This failure increased the potential for Resident 4 to acquire an infection to the area where the catheter was placed which can spread to the resident's blood and other parts of the body. Findings: On March 7, 2024, at 10:04 a.m., an unannounced visit was conducted at the facility to investigate a complaint for quality-of-care issue. On March 7, 2024, a review of Resident 4's admission record, indicated Resident 4 was admitted to the facility on [DATE]. Resident 4's diagnosis included osteomyelitis (inflammation of bone caused by infection, generally in legs, arm or spine) of right ankle and foot, Type 2 diabetes (condition in which body has trouble controlling blood sugar),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, for one (Resident 1) of three residents, the facility failed to admit Resident 1 to the facility when a bed was not made readily available for an arranged admission on [DATE]. The facility's failure to make a bed readily available for a pre-arranged admission resulted in a denial of Resident 1's entry and admission on [DATE]. Findings: On August 9, 2023, at 9:30 a.m., an unannounced visit was conducted to investigate an issue regarding Admission, Transfer and Discharge Rights. On August 9, 2023, at 9:30 a.m., the Director of Nursing (DON) and Administrator (ADM) were interviewed. The DON indicated that Resident 1was denied admission into the facility on July 20, 2023, when he showed up positive for COVID -19 infection on a spot testing conducted upon arrival to the facility. The DON indicated they do not have a bed available to quarantine (isolation precaution purposes) the resident to prevent spread of infection. DON was unable to provide for documented…

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

Based on observation, interview, and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety when: 1. The food service department had no system for ambient food (food that can be safely stored at room temperature in a sealed container, for example, canned tuna fish) cooling down process; 2. Improper labeling for thawing meat; and 3. A tray of diced chicken was found in the walk-in refrigerator, and was passed the used-by-date and not discarded. These failures had the potential to cause foodborne illnesses in a medically vulnerable population of 20 out of total census of 21 residents who received food from the kitchen. Findings: 1. During the kitchen initial tour on January 10, 2022, at 11:24 a.m., an interview was conducted with the Kitchen Supervisor/Cook (KS). The KS stated the temperature of the tuna salad was not monitored before storing it in the refrigerator. He added they did not record any temperature for the cooling down process of any ambient food that they made and there was no cooling log…

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

Based on observation and interview, the facility failed to provide a clean environment for the residents and visitors when one garbage disposal bin located outside by the kitchen was overflowing and was not securely closed with the dumpster lid. This failure had the potential for an unsafe environment for the residents and visitors due to possible pest infestation and spread of diseases in the facility. Findings: During the kitchen initial tour observation on January 10, 2022, at 10:35 a.m., one dumpster located outside nearby facility kitchen was observed not securely closed by the lid, and the bags of trash were overflowing on top of the dumpster. A concurrent interview with the Food Service Director (FSD), she confirmed the dumpster was not securely closed with lid. The FSD stated the facility only had one dumpster for the trash and the trash pick up date was every Monday. She agreed it was not acceptable and the dumpster lid should be close tightly to prevent rodent infestation. During a follow up interview with the FSD on January 11, 2022, at 3:30 p.m., she stated the food…

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 rcord review, the facility failed to ensure range of motion (ROM) exercises were provided according to the physician's orders, for three of four residents reviewed for limited ROM (Residents 2, 8, and 12). This failure had the potential to result in a decline in the residents' ROM and could affect the residents' activities of daily living for Resident 2, 8, and 12. Findings: 1. On January 10, 2022, at 11:40 a.m., a concurrent observation and interview was conducted with Resident 2. Resident 2 was observed lying in bed, alert, and conversant. In a concurrent interview with Resident 2, she stated she did not receive any restorative therapy since last week. On January 11, 2022, Resident 2's record was reviewed. Resident 2 was admitted to the facility on [DATE], with diagnoses which included generalized muscle weakness and intracerebral hemorrhage (stroke - bleeding into the brain tissue) with hemiplegia (weakness of one side of the body) and hemiparesis (paralysis of one side of…

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

Based on observation, interview, and record review, the facility failed to ensure the menu was followed during the lunch meal on January 10, 2022, when the menu item, zucchini, was substituted by the yellow squash without notifying the Food Service Director or facility Registered Dietitian (RD). This failure had potential to compromise residents' intake when the planned menu was not followed. There were 20 out of 21 residents received meals from the kitchen. Findings: During lunch meal service observation on January 11, 2022, at 11:30 a.m., a tray of cooked yellow squashes was observed on the trayline (a system of food preparation in which food trays move along an assembly line). A concurrent review of facility document, titled Menu-Daily Spreadsheet: Tuesday-Day 24, dated 2021, it indicated seasoned zucchini should be served. A concurrent interview with the [NAME] (Cook 2), he stated he used the yellow squashes to substitute the zucchinis because there were not enough zucchinis in the refrigerator. He stated he did not notify the Food Service Director (FSD) for the substitution. 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 proper infection control measures were implemented when multiple facility staff did not wear proper PPE (Personal Protective Equipment - mask, gown, gloves, face shield or goggles) when surgical mask was placed on top of the N95 mask (a mask to filter airborne particles) while providing care to the residents inside the PUI Unit (Person Under Investigation - a resident suspected of having or exposed to COVID-19 [coronavirus-an illness caused by a virus that can spread from person to person]). This failures had the potential to result in the transmission of infection to an already vulnerable population of residents in the facility. Findings: On January 10, 2022, at 12:45 p.m., a concurrent observation and interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 was observed to place a surgical mask over the N95 respirator mask before entering room [ROOM NUMBER] (PUI unit). CNA 1 was observed to assist Resident 7 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 information regarding formulating an Advance Directive (AD - written instruction related to the provision of health care when the resident is no longer able to make decisions) was provided to the resident, for one of nine residents reviewed for AD (Resident 20). This failure had the potential for Resident 20, to not be able to exercise their rights to formulate an Advance Directive. Findings: On January 11, 2022, Resident 20's record was reviewed. Resident 20 was admitted to the facility on [DATE]. The History and Physical, dated September 16, 2021, indicated Resident 20 was mentally capable of understanding. There was no documented evidence the facility provided information to Resident 20 regarding the right to formulate an advance directive since admission on [DATE]. On January 12, 2022, at 2:24 p.m., the Director of Nursing (DON) was interviewed. The DON stated the Advance Directive should be offered to Resident 20 upon admission and during…

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