Huntington Valley Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of five final sampled residents (Resident 3) reviewed for unnecessary medications was free from unnecessary psychotropic medications. * The facility failed to ensure Resident 3's orthostatic blood pressure was accurately monitored, as ordered by the physician, for the use of the quetiapine (antipsychotic) medication. This failure had the potential for adverse effects from the psychotropic medication for Resident 3.Findings: Review of the facility's P&P titled Psychoactive/Psychotropic Medication Use dated 4/2025 showed psychotropic medication management for the residents will involve the interdisciplinary [NAME] consideration of the following: indication and clinical need for medication, dose, duration, and adequate monitoring for efficacy and adverse consequences. Management will also include preventing (where possible), identifying, and responding to adverse consequences. Staff will monitor for potential…

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, medical record review, facility document review, and facility P&P review, the facility failed to follow their protocol for written notification of transfer or discharge for two of three residents (Residents 29 and 138) reviewed for hospitalizations. * The facility failed to provide written information to Resident 29 about the facility's bed-hold information and failed to ensure a copy of the transfer discharge notification was sent to the Ombudsman when Resident 29 was transferred to the acute care hospital on 4/19/26. * The facility failed to ensure a copy of the transfer discharge notification was sent to the Ombudsman when Resident 138 was transferred to the acute care hospital. These failures had the potential for Residents 29 and 138 to not receive additional protection when the residents were being inappropriately transferred or discharged from the facility. Findings: Review of the facility's P&P titled Transfer or Discharge Notices revised 3/2025 showed residents (or 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 medical record review, the facility failed to ensure the MDS assessment was accurate for two of 27 final sampled residents (Residents 15 and 50) reviewed for MDS. * Resident 15's MDS assessment dated [DATE], showed Resident 15 had a diagnosis of schizophrenia (a chronic and severe brain disorder that affects how a person interprets reality); however, Resident 15 did not have schizophrenia. * Resident 50 was administered lamotrigine (anticonvulsant/mood stabilizer) medication for bipolar (a mental health condition that causes extreme mood swings) disorder. The facility failed to code the diagnosis of bipolar disorder in Resident 50's quarterly MDS assessment dated [DATE]. These failures posed the residents at risk of not receiving an individualized plan of care based on their specific needs. Findings: 1. Medical record review for Resident 15 was initiated on 5/18/26. Resident 15 was admitted to the facility on [DATE]. Review of Resident 15's Psychiatric Initial Evaluation dated 3/9/26,…

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 medical record review, the facility failed to ensure the PASRR (Preadmission Screening and Resident Review) Level 1 screening (identifies if a resident has a suspected mental illness or intellectual/developmental disability or related condition) contained accurate information specific to mental illness, for one of one resident (Resident 11) reviewed for PASRR. * Resident 11 had a diagnosis of Bipolar (a mental health condition that causes extreme mood swings) disorder and was prescribed divalproex sodium (mood stabilizing medication); however, the level 1 PASRR showed Resident 11 had no diagnosed mental illness and was not prescribed a psychotropic medication. This failure had the potential for Resident 11 not receiving a PASRR Level II Mental Health Evaluation (determines if the resident can benefit from specialized mental health services), which posed the risk for Resident 11 not receiving recommendations for specialized services that supplement nursing facility care to address 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 observation, interview, and medical record review, the facility failed to ensure the comprehensive care plan was implemented for one of 27 final sampled residents (Resident 74). * The facility failed to implement Resident 74's care plan specific to oxygen administration. This failure placed the resident at risk for not being provided appropriate, consistent, and individualized care.Findings: Medical record review for Resident 74 was initiated on 5/18/26. Resident 74 was admitted to the facility on [DATE]. Review of Resident 74's Care Plan Report showed a care plan focus initiated on 2/10/26, titled At Risk for Ineffective Breathing Pattern related to chronic pulmonary edema (a condition defined by excess fluid in the lungs, which collects in the air sacks and impairs oxygen exchange). The care plan interventions included the administration of oxygen as ordered. Review of Resident 74's Order Summary Report showed a physician's order dated 4/9/26, to administer oxygen continuously at a rate of two LPM…

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, medical record review, and facility P&P review, the facility failed to ensure the comprehensive plan of care were revised to reflect the residents' current care needs and interventions for four of 27 final sampled residents (Residents 31, 50, 63, and 84) reviewed for care plans. * The facility failed to revise Resident 31's care plan for impaired skin integrity and coccyx (tailbone) pressure injury (localized areas of skin and tissue damage from prolonged pressure) to include the Wound Consultant's recommendations to avoid sitting for longer than two-hour periods at a time. * The facility failed to revise Resident 50's care plan for anticoagulant (blood thinners) therapy to reflect the resident's current Eliquis (anticoagulant) medication use. * The facility failed to revise Resident 63's care plan for dehydration to reflect the resident's current enteral feeding (delivers liquid nutrients directly into the stomach or small intestine for individuals unable to meet nutritional…

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, medical record review, and facility P&P review, the facility failed to ensure the quality of care and services were provided for one of 27 final sampled residents (Resident 3) reviewed for quality of care. * The facility failed to ensure the injection sites for the insulin (medication to control blood glucose levels) administration were rotated for Resident 3. This failure had the risk for lipodystrophy (buildup of fatty lumps) and decreased with insulin absorption.Findings: Review of the facility's P&P titled Insulin Administration revised 3/2025 showed insulin may be injected into the subcutaneous tissue of the upper arm and the anterior or lateral areas of the thighs and abdomen. Injection sites should be rotated, preferably within the same general area. Medical record review for Resident 3 was initiated on 5/18/26. Resident 3 was admitted to the facility on [DATE], and had the diagnosis of Type 2 diabetes mellitus with hyperglycemia (high blood sugar). Review of Resident 3'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, medical record review, and facility P&P review, the facility failed to ensure to provide the necessary care and services to maintain skin integrity for one of three sampled residents (Resident 17) reviewed for pressure injuries. * The facility failed to ensure Resident 17's LAL (low air loss mattress) setting was consistent with the resident's weight. This failure had the potential for the resident not to benefit from the therapy provided by the LAL mattress.Findings: Review of the facility's P&P titled Support Surface Guidelines revised 4/2026 showed support surfaces are used for pressure redistribution, shear reduction, and in some cases temperature or moisture control for the resident at risk of pressure injury. Select appropriate pressure redistribution support surfaces based on current recommended practices for device selection, as well as the resident's risk factors, clinical and functional needs, and preferences. Following the manufacturer's recommendation for use, ensure…

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, medical record review, and facility P&P review, the facility failed to ensure the nutritional recommendations from the RD were followed for one of three final sampled residents (Resident 29) reviewed for nutrition. * The facility failed to ensure the physician was notified of the RD/IDT team's recommendations for the liquid protein supplement and therapeutic diet change to address Resident 29's weight loss. Resident 29 did not receive the supplement as recommended by the RD. This failure had the risk of not providing the nutritional needs and poor health outcome for Resident 29.Findings: Review of the facility's P&P titled Nutritional Assessment revised 10/2017 showed the dietician, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission (within current baseline assessment timeframes) and as indicated by a change in condition that places the resident at risk for impaired nutrition. As part of the comprehensive…

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, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to maintain the intravenous access for one sampled resident (Resident 23) and two nonsampled residents (Residents 9 and 123) reviewed for intravenous fluids. * The facility failed to ensure Resident 9's IV medication was correctly labeled. * The facility failed to ensure Resident 23's PICC line external catheter and arm circumference measurements were completed and documented upon admission in the resident's medical record. * The facility failed to ensure Resident 123's IV tubing was labeled. These failures had the potential to delay the identification of catheter related complications for the residents. Findings: 1. Review of the facility's P&P titled Care of Peripheral Inserted Central Lines (PICC) – Dressing Change and Site Care (undated) showed the purpose of this procedure is to assure safety and aseptic technique in the performance of this procedure and to minimize…

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, medical record review, facility document review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 8%. Two of five licensed nurses (LVNs 2 and 4) who were observed during medication administration were found to have errors. * LVN 2 failed to administer Resident 85's metformin (medication to lower the blood sugar) as ordered by the physician. * LVN 4 failed to administer Resident 92's diltiazem (medication used to treat high blood pressure) as ordered by the physician. These failures created the risk for the residents to have potential side effects or complications related to the medications.Findings: Review of the facility's P&P titled Administering Medication revised 1/2026 showed the medications are administered in a safe and timely manner and as prescribed. Medications are administered in accordance with the prescriber's orders, including any required time frame. 1. On 5/19/26 at 1115 hours,…

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, facility document review, and facility P&P review, the facility failed to ensure the drugs and biologicals were stored, labeled, and/or disposed properly. * The facility failed to ensure discontinued or expired medications and supplies were removed from Medication room [ROOM NUMBER] and Medication Cart A. * The facility failed to ensure the orally administered medications were stored separately from the externally used medications in Medication Cart A. These failures posed the risk for the administration of potentially contaminated or deteriorated medications, and posed the risk for the medications to be used or improperly administered to the residents.Findings: Review of the facility's P&P titled Medication Labeling and Storage revised 1/2026 showed the nursing staff was responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Multi-dose vials that have been opened or accessed are dated and discarded within 28 days unless 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, facility document review, and facility P&P review, the facility failed to ensure the menu was followed for one of one nonsampled resident (Resident 120) reviewed for therapeutic diet. * The facility failed to ensure Resident 120 was served with the boiled potatoes as per the therapeutic spreadsheet for the lunch meal on 5/18/26. This failure had the potential to not meet Resident 120's nutritional needs and negatively impact the resident's nutritional health.Findings: Review of the facility's document titled Diet Type Report dated 5/18/26, showed 115 of 121 residents in the facility received food prepared in the kitchen. Review of the facility's P&P titled Menus revised 1/2026 showed menus meet the nutritional needs of residents in accordance with the recommended diet allowances of the Food and Nutrition Board. Menus for regular and therapeutic diets are written at least two weeks in advance and are dated and posted in the kitchen at least one week in advance. If a food group is…

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, facility document review, and facility P&P review, the facility failed to ensure one of 27 final sampled residents (Resident 31) received food that accommodated the resident's preferences. * Resident 31 was not served with the fresh fruit cup as per the lunch meal ticket on 5/18/26. This failure posed the risk of Resident 31 not enjoying her meal and for her food preferences not being honored.Findings: Review of the facility's document titled Diet Type Report dated 5/18/26, showed 115 of 121 residents in the facility received food prepared in the kitchen. Review of the facility's P&P titled Resident Food Preferences revised 1/2026 showed when possible, staff will interview the resident directly to determine current food preferences based on history and life patterns related to food and mealtimes. The food services department will offer a variety of foods at each scheduled meal, as well as access to nourishing snacks throughout the day and night. Medical record review for Resident…

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

Based on observation, interview, and facility P&P review, the facility failed to ensure the garbage was properly stored in two of four garbage dumpsters. * Two garbage dumpsters were observed with the lids partially propped open by the garbage bags, preventing the lids from fully closing. This failure had the potential to attract pest/rodents that carried diseases.Findings: Review of the facility's P&P titled Dumpster Management undated showed, dumpsters must be covered and secured at all times, free of visible leaks or damage, and washed and deodorized as needed (minimum quarterly). Dumpster enclosures must be maintained with lids closed to reduce odor. In addition, further review of the facility's P&P titled Miscellaneous Areas: Garbage and Trash dated 2018 showed, adequate, clean, vermin-proof areas must be provided for storage of garbage and rubbish. Furthermore, the facility's P&P titled Sanitization date revised 11/2022 showed, garbage and refuse containers are in good condition, without leaks, and waste is properly contained in dumpsters or compactors with lids (or otherwise…

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, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary care and services for one of two final sampled residents (Resident 63) reviewed for hospice services. * The facility failed to ensure the hospice staff were included in Resident 63's interdisciplinary team meetings to discuss Resident 63's plan of care; and failed to ensure the hospice plan of care was integrated into the facility's care plan to include the frequency of visits of each hospice staff and the provisions of care. These failures posed the risk for delay in communication and/or uncoordinated medical care between the facility and hospice provider which may affect Resident 63's care.Findings: Review of the facility's P&P titled Hospice Program dated 2001 showed it is the responsibility of the facility to meet the residents' personal care and nursing needs in coordination with the hospice representative, and ensure that the level of care provided is appropriately…

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, facility document review, and manufacturer's guidelines review, the facility failed to ensure the facility equipment was maintained in a safe operating condition for one of two medication carts (Medication Cart A) inspected. * The facility failed to ensure Medication Cart A's glucometer's (a device that measures the amount of sugar in the blood) serial number was documented on the quality control record and failed to ensure the lot number for the glucometer test strips in Medication Cart A matched the lot number on the quality control record for the cart. Additionally, the documented control test results were not observed on the glucometer result history. These failures had the potential risk of inaccuracy for the blood glucose test resultsFindings: Review of the Assure Platinum (Blood Glucose Monitoring System), Quality Assurance and Quality Control Reference Manual revised 8/2023 showed to check the glucometer and test strips using the Assure Dose Control Solutions to confirm the meter and test strips are working properly. To conduct a control…

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, medical record review, and facility document review, the facility failed to ensure the Office of the State LTC Ombudsman was provided with a copy of the notice of transfer/discharge for one of 11 sampled residents (Resident 1). * The facility failed to send a copy of the notice of transfer/discharge to the representative of the Office of the State LTC Ombudsman when Resident 1 was discharged from the facility. This failure posed the risk of the LTC Ombudsman not being aware of the circumstances of the resident's transfer/discharge should an appeal be filed or requested by the resident or their representatives regarding the transfer.Findings: Closed medical record review for Resident 1 was initiated on 12/23/25. Resident 1 was admitted to the facility on [DATE], and transferred to the acute care hospital on [DATE]. Further review of Resident 1's medical record failed to show documented evidence of the notification to the LTC Ombudsman regarding Resident 1's transfer to the acute care hospital.…

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 medical record review, the facility failed to implement the plan of care to reflect the individual care needs for one of five sampled residents (Resident 2). * The facility failed to ensure Resident 2's care plan was followed when the resident went out to an outpatient medical appointment without someone or was not accompanied by the resident's responsible party. This failure had the potential to negatively affect the resident's well-being and safety.Findings: Medical record review for Resident 2 was initiated on 11/26/25. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's H&P examination dated 7/5/25, showed Resident 2 had no capacity to make medical decisions. Further review of the H&P showed the resident had mild and intermittent episodes of confusion. Review of Resident 2's care plan for elopement initiated 8/6/25, showed Resident 2 was not to leave the facility without a responsible person. Review of Resident 2's Order Summary Report showed an order 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 observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary treatment and services for the provision of parenteral fluids (liquids administered to the body, most commonly via a vein (intravenous, to provide hydration, correct the electrolyte imbalances, deliver nutrients, or administer the medications when normal oral intake is not possible) for one of six sampled residents (Resident 1). * The facility failed to ensure Resident 1's intravenous fluids (IVF) was administered and documented as per the facility's P&P. This failure had the potential to negatively affect Resident 1's health and well-being. Findings: Review of the facility's P&P titled Intravenous Administration of Fluids and Electrolytes dated 2001 showed the resident should be monitored frequently, per facility policy, when continuous fluids are infusing for signs and symptoms of fluid overload, catheter patency, insertion site complications, and resident's tolerance of procedure. 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, medical record review, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure the proper storage of the medications for one of six sampled residents (Resident 2). * The facility failed to ensure Resident 2 had no medication stored at the bedside. This failure had the potential for Resident 2 to administer the medication inaccurately.Findings: Review of the facility's P&P titled Self-Administration of Medications revised 2/2021 showed any medications found at the bedside that are not authorized for self-administration are turned over to the nurse in charge for return to the family or responsible party. On [DATE] at 0941 hours, an observation was made in Resident 2's room. One tube of diclofenac sodium 1% topical gel (medication that treats arthritis/osteoarthritis) was observed on the top drawer of Resident 2's bedside drawer with a fill date of [DATE], and had expired on 11/2023. Resident 2 was observed to be in the room. Medical record…

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, medical record review, and facility P&P review, the facility failed to ensure the laboratory tests for one of six sampled residents (Resident 1) was performed as ordered. * The facility failed to ensure Resident 1's physician's order for stat CBC (Complete Blood Count) and CMP (Comprehensive Metabolic Panel) were completed as ordered. This failure posed the risk for Resident 1 not receiving the appropriate treatment, which could significantly impact the resident's well-being.Findings: Review of the facility's P&P titled Lab and Diagnostic Test Results - Clinical Protocol revised 11/2018 showed the physician will identify and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs. The staff will process test requisitions and arrange for tests. The laboratory, diagnostic radiology provider, or other testing sources will report test results to the facility. The P&P further showed a nurse will identify the urgency of communicating with the attending physician…

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 medical record review, the facility failed to ensure the medical records for three of eight sampled residents (Residents 1, 2, and 3) were accurate and complete. * Resident 1's POLST did not show the physician's phone number, license number, signature, or the resident's responsible party's signature, address, and telephone number. In addition, the responsible party's signature was written in by the nurse filling out the form and did not indicate it was a verbal consent. Additionally, the NP's name was written in the section where the NP's supervising physician's name should have been. * Resident 2's POLST did not show the NP's phone number, license number, date signed, or the name of the NP's supervising physician. In addition, the POLST did not indicate if the NP had discussed the information with Resident 2. Resident 2's POLST did not show the resident's address and telephone number, and the resident's signature was undated. Additionally, the POLST did not show the title of 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, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by: * The facility failed to ensure the sanitary condition of the hood over the stove was maintained. * The facility failed to ensure the kitchen utensils had a smooth cleanable surface and in good condition. * The facility failed to ensure the kitchenware and kitchen utensils were clean and free of food particle or residue. * The facility failed to ensure the cutting boards were kept in a sanitary condition and with cleanable surface. * The facility failed to ensure the heavy-duty blender used for puree preparation, scoops used for food portioning, and clear plastic bins were air dried and clean prior to storing and stacking. * The facility failed to ensure the countertop mounted can opener was in a sanitary condition and free of rust. * The facility failed to ensure the microwave utilized to warm up the food was in a sanitary condition and free of rust. These failures had the potential 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 observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to implement the infection control practices designed to provide a safe and sanitary environment and help prevent the development and transmission of diseases and infections. * The facility failed to ensure the facility's monthly Infection Prevention and Control Surveillance Log was accurate. * The facility failed to implement the EBP as per the facility's P&P for Residents 916 with a central line (thin, flexible tube inserted into a large vein near the heart). * OT 1 failed to perform hand hygiene in between resident care for Residents 33 and 52 during the dining observation. * LVN 6 failed to don the gown before entering Resident 3's EBP room to change and administer the resident's enteral feeding. * LVN 1 failed to perform hand hygiene and change gloves prior to the administration of insulin medication for Resident 370. * The facility failed to ensure LVN 7 practiced sanitary…

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, medical record review, and facility P&P review, the facility failed to ensure the safe self-administration of medication for one nonsampled resident (Resident 41). * Two bottles of Systane eye drops (medication to temporarily relieve dry, irritated eyes) were kept at Resident 41's bedside table. Resident 41 had self-administered the Systane eye drop medication after being assessed to not self-administer her medications. This failure had the potential for the resident to administer the medications inaccurately and negatively affect the resident's physiological well-being. Findings: Review of the facility's P&P titled Self-Administration of Medications revised on 2/2021 showed the following: - As a part of the evaluation comprehensive assessment, the IDT assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident; - If it is deemed safe and appropriate for a resident 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 interview, medical record review, and facility P&P review, the facility failed to obtain and/or maintain the copies of the advanced directives (written statement of a person's wishes regarding medical treatment) and provide the written information regarding how to formulate the advanced directives for four of 28 final sampled residents (Residents 44, 88, 97, and 106). * The facility failed to ensure a copy of the advance directive was available in Residents 44 and 106's medical record. * The facility failed to provide the written information and assistance regarding how to formulate an advance directive for Resident 88. * The facility failed to provide the written information regarding how to formulate the advance directive for Resident 97 was provided to the resident or responsible party. These failures had to the potential for residents' to receive inaccurate and delayed treatment compatible with the residents' wishes during an emergent situation. Findings: Review of the facility's P&P titled Advance…

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, medical record review, facility document review, and facility P&P review, the facility failed to meet the professional standards of care for one nonsampled resident (Resident 370) observed for medication administration. * LVN 1 failed to follow the proper procedure for the administration of insulin. This failure posed the risk for the resident to develop complications related to the inappropriate technique with the administration of insulin (used to treat high blood sugar). Findings: Review of the facility's P&P titled Insulin Administration revised 5/2024 showed the Steps in the Procedure (Insulin Injections via Syringe) section including to clean the injection site with an alcohol wipe and allow to air dry. Review of the Administration Guide from the manufacturer of the Lantus insulin (undated) showed Step 4: Choose an Injection Site included the following: - Decide on an injection area- either upper arm, thigh, or abdomen. Injection sites within an injection area must be…

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, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable well-being for one of 28 final sampled residents (Resident 21) and two nonsampled residents (Residents 57 and 101) as evidenced by: * The facility failed to ensure the follow-up assessment and documentation were completed for Resident 21's foot scab and bilateral feet dryness. * The facility failed to ensure Resident 57's post fall neurological assessment and monitoring were accurately completed after the resident had a fall on 3/16/25. * The facility failed to ensure the attending physician was made aware regarding the recommendations from the acute care hospital for Resident 101 to be assisted in drinking the thickened liquid with a spoon. CNA 8 was observed using a plastic straw to provided assistance to Resident 101 when drinking the thickened liquids. These failures posed the risk of the residents not receiving…

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, medical record review, and facility P&P review, the facility failed to ensure the treatment was provided to prevent the decline in the ROM functions for one of three final sampled residents (Resident 63) reviewed for prevention of ROM functions. * The physician's order to apply an extension splint to Resident 63's left knee was not followed. In addition, Resident 63's skin was not assessed when the splint was applied. This failure had the potential for Resident 63 to sustain a decline in ROM functions, leading to muscle atrophy (loss of muscle mass and strength) and decrease in functioning. Findings: Review of the facility's P&P titled Restorative Nursing Services dated 5/2024 showed the restorative care will be provided to help promote optimal safety and independence. During the initial tour of the facility on 4/1/25 at 1045 hours, an observation and concurrent interview with Resident 63 was conducted. Resident 63 was observed wearing the left lower leg splint. Resident 63…

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, medical record review, and facility P&P review, the facility failed to ensure one of 28 final sampled residents (Resident 73) received the appropriate care and services for an indwelling urinary catheter. This failure had the potential for the resident to develop complications associated with the use of indwelling urinary catheter. Findings: Review of the facility's P&P titled Urinary Catheter Care revised on 5/2024 showed the following: - Observed the resident for complications associated with urinary catheters; and - Report unusual findings to the physician or supervisor immediately if urine has an unusual appearance like color, blood, etc. and if signs and symptoms of urinary tract infection or urinary retention occur. Medical record review for Resident 73 was initiated on 4/4/25. Resident 73 was readmitted to the facility on [DATE]. Review of Resident 73's MDS dated [DATE], showed Resident 73's BIMS score was 12, indicating moderate cognitive impairment. 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 observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary GT care and services for two of two final sampled residents (Residents 3 and 30) reviewed for enteral feeding. * The facility failed to ensure the intake and output were monitored for Resident 30 who was receiving an enteral feeding. * The facility failed to ensure Resident 3's enteral feeding formula was changed within 24 hours and label the resident's enteral feeding water bag with the date and time the bag was prepared. These failures posed the risk for developing complications related to enteral feeding and GT. Findings: Review of the facility's P&P titled Intake, Measuring and Recording revised 5/2024 showed the following: - The purpose of this procedure is to accurately determine the amount of liquid the resident consumes in a 24 hour period; - At the end of the shift, the facility staff should total the amounts of all liquids the resident consumed; - Record all the fluid intake 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 observation, interview, medical record review, and facility P&P review, the facility failed to to provide the necessary care and services to maintain the IV site accesses for two of 28 final sampled residents (Residents 67 and 667) and two nonsampled residents (Residents 366 and 916) as evidenced by: * The facility failed to ensure the PICC line baseline external catheter length and arm circumference measurements were obtained and documented for Residents 667 and 916. * The facility failed to ensure the arm circumference and external catheter length were measured on admission and during the midline dressing change for Resident 366's midline line use. * Residents 67's PIV site was not labeled with the date, time, and licensed nurse's initials. In addition, the facility failed to ensure a physician's order was obtained for the use of the PIV. These failures had the potential to delay the identification of intravenous catheter related complications for the residents. Findings: According to the National…

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, medical record review, and facility P&P review, the facility failed to ensure two of two final sampled residents (Residents 21 and 30) and two nonsampled residents (Residents 7 and 101) reviewed for respiratory care were provided with the appropriate respiratory care and services when: * The facility failed to ensure Residents 7 and 30 were receiving the oxygen as per the physician's order and the nasal cannula tubing was stored in a sanitary manner. * The facility failed to ensure Resident 101's CPAP machine was cleaned as per the manufacturer's user guidelines. * The facility failed to ensure Resident 21's oxygen tubing was not on the floor. These failures had the potential to affect the respiratory health and well-being of these residents in the facility. Findings: Review of the facility's P&P titled Oxygen Administration revised 10/2010 showed the staff should verify there is a physician's order for oxygen administration and review the physician's orders or facility protocol…

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, medical record review, and facility P&P review, the facility failed to provide the appropriate pain management for one of two final sampled residents (Resident 111) reviewed for pain management. * The facility failed to accurately document the monitoring of pain for Resident 111 and administer the pain medication according to the physician's order. In addition, the facility failed to ensure the non-pharmacological interventions were provided to Resident 111 prior to the administration of the pain medication. These failures had the potential to put Resident 111 at risk for ineffective pain management and adverse effects related to the use of unnecessary pain medication. Findings: Review of the facility's P&P titled Pain Assessment and Management revised 5/2024 showed the pain management program is based on a facility-wide commitment to appropriate assessment and treatment of pain, based on the professional standards of practice, the comprehensive care plan, and the resident's choices related…

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, medical record review, and facility P&P review, the facility failed to ensure the appropriate dialysis care was provided for two of 28 final sampled residents (Residents 70 and 88) reviewed for dialysis services. * The facility failed to ensure the dialysis communication records were accurately completed for Resident 70. * The facility failed to ensure the emergency dialysis kit was kept at Resident 88's bedside. In addition, the facility failed to ensure the licensed nurses assessed and documented Resident 88's dialysis access, and covered Resident 88's dialysis access site with a transparent dressing. These failures had the potential for the residents to experience medical complications. Findings: 1. Review of the facility's P&P titled Care of a Resident with End-Stage Renal Disease dated 2001 showed the residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care. Medical record review for Resident 70 was initiated on 4/1/25. 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 observation, interview, medical record review, and facility P&P review, the facility failed to ensure dementia care interventions were being implemented for one of five sampled residents (Resident 105) reviewed for dementia care. This failure had the potential for Resident 105 to not receive the appropriate treatment and services needed for her dementia. Findings: Review of the facility's P&P titled Dementia - Clinical Protocol revised 11/2018 showed the following: - The staff and physician will evaluate individuals with new or worsening cognitive impairment and behavior and differentiate dementia from other causes; - The staff and physician will review current physical, functional, and psychosocial status of individuals with dementia, and will summarize the individual's condition, related complications, and functional abilities and impairments; - The IDT will identify and document the resident's condition and level of support needed during care planning and review changing needs as they arise; -…

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, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary pharmaceutical services as per the facility's P&P for one of 28 final sampled Resident (Resident 65) and one nonsampled resident (Resident 55). * The facility failed to ensure the administration of the controlled medication for Residents 55 and 65 was documented on the EMAR. This failure had the potential for the medications to be administered in error and opportunities for drug diversion or drug misuse. Findings: Review of the facility's P&P titled Controlled Substances revised 11/2022 showed the system of dispensing of controlled substances includes the following: Records of personnel access and usage; medication administration records. Review of the facility's P&P titled Medication Administration revised 5/2024 showed individual administering the medications initials the resident's MAR on the appropriate line after giving each medication. As required 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of five sampled residents (Resident 42) reviewed for unnecessary medication was free from unnecessary medications. The facility failed to adhere to Resident 42's blood pressure parameters prescribed by the physician for three medications: amlodipine (blood pressure medication), spironolactone (diuretic medication), and ethacrynic acid (diuretic medication). This failure had the potential for Resident 42 to receive unnecessary medications and to experience adverse effects. Findings: Review of the facility's P&P titled Administering Medications revised 5/2024 showed medications are administered in accordance with prescribed orders. Medical record review for Resident 42 was initiated on 4/3/25. Resident 42 was admitted to the facility on [DATE], and readmitted [DATE]. Review of Resident 42's Order Summary Report showed the following physician's orders: - dated 12/21/24, to administer one amlodipine 5 mg tablet by…

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, medical record review, and facility P&P review, the facility failed to ensure two of five sampled residents (two final sampled residents, Residents 95 and 105) reviewed for unnecessary medication were free from the unnecessary psychotropic medication. * The facility failed to obtain Resident 95's informed consent prior to administering the Depakote (mood stabilizer) medication. * The facility failed to evaluate the behavioral symptoms for the use of psychotropic medication for Resident 105. These failures had the potential for the residents to experience adverse effects from the psychotropic medication. Findings: 1. Review of the facility's P&P titled Psychoactive/Psychotropic Medication Use revised 5/2024 showed the prescribing clinician will obtain an informed consent from the resident or resident representative prior to administration of a psychotropic medication and will document the consent form in the resident's medical record. The P&P also showed monitoring of the resident receiving…

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 facility P&P review, the facility failed to provide the necessary pharmacy services to ensure the proper storage and labeling of the medications. * The facility failed to ensure the orally administered medications were stored separate from the externally used medications in Medication Carts D and E. * The facility failed to ensure Resident 111's gentamicin (used to treat skin infections) medication was labeled with the opened date. * The facility failed to ensure Resident 44's Preparation H (medication is used to temporarily relieve swelling, burning, pain, and itching caused by hemorrhoids) external cream and Lidocaine (pain reliever) cream were not stored at the bedside. These failures had the potential to negatively impact the residents' well-being, and the potential for the medications to lose the stability and effectiveness. Findings: Review of the facility's P&P titled Drug Storage and Labeling Drugs and Biologicals (undated) showed oral medications will be stored…

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, facility document review, and facility P&P review, the facility failed to ensure the food items were served in the appetizing temperatures as evidenced by: * The food temperatures were below the recommended temperature for hot meats, vegetables, and potatoes. This failure posed the risk for not providing palatable and appetizing food for the residents receiving a meal tray from the kitchen. Findings: Review of the facility's Diet Type Report dated 4/1/25, showed 116 of 123 residents consumed the foods prepared in the kitchen. Review of the facility's P&P titled Meal Service dated 2018 showed meals that meet the nutritional needs of the resident will be served in an accurate and efficient manner, and served at the appropriate temperatures. The food will be served on trayline at the recommended temperatures indicated below and recorded on the daily therapeutic menu. Hot food serving temperature must be at or above minimum holding temperature of 140 degrees Fahrenheit. The temperature of the foods should be periodically monitored throughout the meal…

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 document review, the facility failed to ensure the Facility Assessment addressed or included the following: 1. Active involvement of required individuals in developing the Facility Assessment; 2. Resources necessary to care for residents including weekends; 3. A plan to maximize recruitment and retention of direct care staff; and 4. A contingency plan for staffing needs. This failure had the potential to not meet the residents' care needs if the assessed population's needs and resources were not comprehensively identified and addressed. Findings: According to the CMS QSO-24-13-NH dated 6/18/24, with an implementation date of 8/8/24, CMS had issued a revised guidance for long-term care facility assessment requirement. The Facility Assessment should address and included the active involvement of the direct care staff in developing the Facility Assessment. Also included the staffing resources necessary to care for the residents, including the weekends; a plan to maximize recruitment…

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, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for one of one final sampled residents (Resident 100) reviewed for hospice services. * The facility failed to ensure Resident 100's HA visits schedule for two times a week was followed per the hospice provider's calendar. This failure posed the risk for delays in the communication between the hospice provider and facility, which may affect the resident care. Findings: Review of the facility's P&P titled Hospice Program revised on 7/2017 showed the Hospice providers who contract with this facility are held responsible for meeting the same professional standards and timeliness of service as any contracted individual or agency associated with the facility. Review of the facility's contract with Hospice A dated 11/1/24, showed the following: - Hospice shall designate an interdisciplinary group member who shall be responsible for coordinating with the facility the provision of hospice…

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, medical record review, and facility P&P review, the facility failed to implement their P&P for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B when the facility failed to report an allegation of resident-to-resident abuse to the CDPH, L&C Program and to the local ombudsman for one of the nine sampled residents (Resident 5). This failure had the abuse allegation going unreported and uninvestigated. Findings: Review of the facility's P&P titled Abuse, Neglect, Exploitation or Misappropriation – Reporting and Investigating revised 9/2022 showed all the reports of the resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigation are documented and reported. Closed medical record review for Resident 5 was initiated 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, medical record review, and facility P&P review, the facility failed to implement their abuse P&P related to investigation of the resident-to-resident abuse for one of nine sampled residents (Resident 5). * The facility failed to conduct a thorough investigation when Resident 5 was reported to be verbally abusive to the roommate. This failure posed a risk for the resident to not be protected against the alleged abuse and placed other vulnerable residents at risk for abuse. Findings: Review of the facility's P&P titled Abuse, Neglect, Exploitation or Misappropriation – Reporting and Investigating revised 9/2022 showed all the allegations are thoroughly investigated. The Administrator initiates the investigations. Within five business days of the incident, the Administrator will provide a follow-up investigation report. Closed medical record review for Resident 5 was initiated on 1/31/25. Resident 5 was admitted to the facility on [DATE] and discharged on 7/31/24. Review of Resident 5's H&P…

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, medical record review, facility document review, and facility P&P review, the facility failed to ensure one of nine sampled residents (Resident 1) was free from the unnecessary psychotropic medications. * The facility failed to obtain the informed consent from Resident 1 or surrogate decision maker for the use of lorazepam (a drug used to relieve anxiety) and when there was an increase in the dosage of the citalopram (a drug used to treat depression) medication. * The facility failed to ensure Resident 1 was provided with the non-pharmacologic interventions for the use of the citalopram, quetiapine fumarate (a drug that can treat schizophrenia, bipolar disorder and depression), and buspirone (a drug used to treat anxiety) medications. These failures have the potential to negatively affect Resident 1's well-being. Findings: Medical record review for Resident 1 was initiated on 1/29/25. Resident was admitted to the facility on [DATE] and readmitted on [DATE]. a. Review of Resident 1's Order…

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, medical record review, facility document review, and facility P&P review, the facility failed to ensure the resident's food preferences and allergies were considered and adhered to for one of nine sampled residents (Resident 4). * The facility failed to ensure Resident 4 was not served food containing fish as Resident 4 was allergic to fish. This failure caused an adverse reaction on Resident 4's well-being. Findings: Review of the facility's P&P titled Tray Identification revised 4/2007 showed the appropriate identification/coding shall be used to identify various diets. To assist in setting up and serving the correct food trays/diets to residents, the food services department will use appropriate identification (example color coded or computer-generated diet cards) to identify the various diets. The food services manager or supervisor will check trays for correct diets before the food carts are transported to their designated areas. The nursing staff check each food tray for the correct…

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, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary services to attain or maintain the highest practicable well-being for two of eight sampled residents (Residents 1 and 2). * The facility failed to ensure the necessary care and services were provided timely for Resident 2 who had a fall. Additionally, Resident 1's physician ordered the CBC, CMP, and UA with culture laboratory tests; however, the facility failed to perform these laboratory tests. * The facility failed to complete the neurological assessments following Resident 1's unwitnessed fall on 11/23/24. These failures had the potential for the delay of care provided and poor health outcomes for the residents. Findings: 1. Closed medical record review for Resident 2 was initiated on 1/6/25. Resident 2 was admitted to the facility on [DATE] and readmitted on [DATE]. a. Review of the facility's P&P titled Fall – Clinical Protocol revised 3/2018 under the Assessment 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 observation, interview, medical record review, and facility P&P review, the facility failed to ensure two of eight sampled residents (Residents 1 and 8) were free from unnecessary psychotropic drugs. * Resident 1, who had diagnoses including dementia, was prescribed lorazepam (antianxiety medication) PRN for anxiety manifested by restlessness. There was no documented diagnosis, or diagnosis of anxiety prior to starting the PRN lorazepam medication. Additionally, Resident 1's physician's orders for the lorazepam medication were continuously renewed PRN for 14 days and eventually extended to be given PRN for 30 days. There was no documented evidence of the evaluation for the renewal of the PRN lorazepam medication order nor rationale from the prescribing practitioner to indicate why it was appropriate for the PRN lorazepam medication order to be extended beyond 14 days. * Resident 8, who had diagnoses including dementia, was prescribed risperidone (antipsychotic medication) for psychosis manifested by…

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, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for one of two sampled residents (Resident 2) to help attain and maintain their highest practicable physical well-being. * The facility failed to ensure Resident 2's Senna (stool softener), enoxaparin (anticoagulant medication), acetaminophen (analgesic), gabapentin (anticonvulsant and nerve pain medication) and nystatin suspension (antifungal medication) were administered as per the physician's order. This failure had the potential to negatively impact the resident's well-being. Findings: Review of facility's P&P titled Administering Medications revised 4/2019 showed the medications are administered in a safe and timely manner and as prescribed. If a drug is withheld, refused, or given at a time other than scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose. The individual administering the medication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to provide the necessary care and services to ensure one of 12 sampled residents (Resident 8) attained and maintained the highest practicable physical well-being. This failure posed the risk for delayed care and intervention to Resident 8. Findings: Closed medical record review for Resident 8 was initiated on 10/10/24. Resident 8 was admitted to the facility on [DATE], and readmitted on [DATE]. Resident 8 was transferred to the acute care hospital on 9/29/24. Review of Resident's Change in Condition Evaluation dated 9/27/24 at 2116 hours, showed at 1630 hours, a family member approached LVN 7 to check on Resident 8 because Resident 8's family member observed the resident with productive cough and appeared to be slightly weak. Review of Resident 8's E-interact SBAR Summary for Providers dated 9/28/24, showed a CNA had reported the resident ate 0-25% of breakfast; and the family member reported the resident had been eating little for three days.…

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, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the development of new pressure injury (areas of damaged skin caused by staying in one position for a long time which reduces blood flow to the area and causes the skin to die and develop a sore) and promote healing of existing pressure ulcer for two of three sampled residents (Residents 8 and 11) reviewed for pressure injury. * The facility failed to ensure Resident 8 was turned and repositioned at least every two hours as per the plan of care. * The facility failed to ensure Resident 11's pressure ulcer was assessed weekly. These failures posed Residents 8 and 11 at risk for developing new pressure ulcers and worsening of the existing pressure ulcer. Findings: 1. Review of the facility's P&P titled Turning and Repositioning Schedule revised December 2023 showed it is the policy of the facility to ensure the safety and comfort of the residents…

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, medical record review, and facility P&P review, the facility failed to establish and maintain the infection control program and practices designed to help prevent the development and transmission of diseases and infections as evidenced by: * The facility failed to ensure the EBPs (Enhanced Barrier Precautions) were followed for Resident 9 when the staff did not wear a disposable gown before providing care to the resident. * The facility failed to ensure the hand hygiene was performed after using the gloves in between the dressing change. These failures had the potential for spread of infections in the facility. Findings: Review of the facility's P&P titled Enhanced Barrier Precautions (EBP) revised august 2022 showed Enhanced Barrier Precautions are utilized to utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents. EBPs employ targeted gown and glove use during high contact resident care activities. Examples of high-contact resident care activities…

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, medical record review, facility document review, and facility P&P review, the facility failed to implement their P&P for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act when the facility failed to report an allegation of staff-to-resident abuse to the law enforcement agency, CDPH L&C Program, and Ombudsman office (an advocate for long term residents) for one of three sampled residents (Resident 1). This failure had the potential to put residents at risk for further abuse. Findings: Review of the facility's P&P titled Abuse Investigation and Reporting revised November 2017 showed all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall promptly report to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Medical record review for Resident 1 was initiated on 9/17/24.…

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, medical record review, and facility P&P review, the facility failed to implement their abuse P&P related to investigation of the physical abuse for one of three sampled residents (Resident 1). * The facility failed to complete a thorough investigation including to conduct the interview of the person(s) reporting the incident, any witnesses to the incident, the resident, the staff members from different shifts and disciplines, resident's roommate if appropriate, family members, other residents to whom the accused employee provides care or services and report the result of the investigation to the CDPH L&C Program, Orange District Office within five working days. This failure posed the risk for the potential abuse to remain unidentified and for the residents to go unprotected. Findings: Review of the facility's P&P titled Abuse Investigation and Reporting revised November 2017 showed the individual conducting the investigation will, as a minimum, interview the person(s) reporting the incident,…

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, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary services related to foot care for one of three sampled residents (Resident 2). * The facility failed to ensure the skin check, accurate assessment, and monitoring of Resident 2's bilateral feet after the podiatry care for fungal infection, including debridement and nail trimming. This failure had the potential to negatively impact the resident's health and well-being. Findings: Review of the facility's P&P titled Charting and Documentation revised on 7/2017 showed all facility services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. 2. The following information is to be…

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, medical record review, facility document review, and facility P&P review, the facility failed to ensure one of three sampled residents (Resident 1) was provided non-pharmacologic intervention for the use of psychotropic medication (medication that affects the mind, emotions, and behavior). This failure had the potential for Resident 1 to have adverse complications from the medication. Findings: Review of the facility's P&P titled Psychotropic Medication Use revised July 2022 showed non-pharmacological approaches are used to minimize the need for medications, permit the lowest possible dose, and allow for discontinuation of medications when possible. Medical record review for Resident 1 was initiated on 9/17/24. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's Order Summary Report for September 2024 showed a physician's order dated 7/11/24, to administer Lexapro oral 5 mg tablet by mouth one time a day for depression as manifested by tearful episodes. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the development or worsening of pressure injuries for three of six sampled residents (Residents 2, 4, and 5). Findings: * Resident 2's pressure injuries were not measured and assessed weekly. In addition, no pictures were taken as per the facility's protocol. * Resident 2's low air loss mattress was set too high for Resident 2's weight. * Resident 4's low air loss mattress was set too high for Resident 4's weight. * Resident 5's low air loss mattress was set too high for Resident 5's weight. These failures posed the risk for the residents to develop new pressure injuries and for existing pressure injuries to get worse. Findings: 1. Review of the facility's P&P titled Prevention/Management of Pressure Ulcers/Injuries revised 12/2022 showed the following: - to ensure weekly observation is completed and all changes are documented accordingly in the medical…

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, medical record review, facility document review, and facility P&P review, the facility failed to implement and maintain their infection control program for two of six sampled residents (Residents 2 and 6) as evidenced by: * LVN 1 failed to wear a disposable gown as required for EBP prior to performing the wound care to Resident 2. * LVN 1 failed to establish a clean field to place the clean and sterile wound supplies for Resident 2. * LVN 3 failed to wear a disposable gown as indicated for EBP while performing wound care and to establish a clean field to place the wound supplies while performing wound care for Resident 2. * CNA 1 failed to wear a disposable gown as indicated for EBP during transfer and repositioning of a resident. These failures have the potential risk of transmission of disease-causing microorganisms and infections to the residents. Findings: Review of the facility's P&P titled Enhanced Barrier Precautions revised 8/2022 showed the following: - Enhanced Barrier…

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, medical record review, and facility P&P review, the facility failed to provide the adequate supervision and necessary services for one of two sampled residents (Resident 1) to prevent the elopement. * The facility failed to monitor Resident 1's whereabouts, resulting in Resident 1 leaving the facility undetected and sustaining a fall. * The facility failed to notify Resident 1's responsible party of Resident 1's episodes of elopement and fall. These failures had the potential to negatively impact the resident's well-being. Findings: Review of the facility's P&P titled Elopements revised December 2007 showed the staff shall investigate and report all cases of missing residents. If an employee discovers that a resident is missing from the facility, he/she shall notify the resident's legal representative. Review of the facility's P&P titled Change of Condition in a Resident's Condition or Status, undated, showed the facility promptly notifies the resident, his or her attending physician, and 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, medical record review, and facility document review, the facility failed to ensure Resident 1 was free from the physical abuse when Resident 2 hit Resident 1 across the face, causing Resident 1 to have a bloody nose and a skin tear to the left forearm. This failure had the potential for not protecting the resident and negatively impact the resident's well-being. Findings: Review of the facility's 5-day Investigation Summary dated 10/29/23, showed on 10/28/23 at approximately 0630 hours, Resident 2 hit Resident 1 across the face because Resident 1 was sitting in Resident 2's wheelchair and would not get out of it. Resident 1 suffered a bloody nose and a left forearm skin tear. 1. Medical record review was initiated for Resident 1 on 11/7/23. Resident 1 was admitted to the facility on [DATE], and had diagnoses including dementia. Review of Resident 1's History and Physical examination dated 8/21/23, showed Resident 1 did not have the capacity to understand or make medical…

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, medical record review, and facility document review, the facility failed to ensure one of three sampled residents' (Resident 3) medication was administered as ordered by the physician. This failure had the potential to affect Resident 3's physical well-being. Findings Review of the facility's P&P titled Administering Medications revised 4/2019 showed the medications are administered in accordance with theprescriber's orders including any required time frame. The policy also showed medication times are determined by resident need and benefit including enhancing the optimal therapeutic effect of the medication, preventing potential food interactions, and honoring resident preferences. According to the Promacta website, Promacta is used for the treatment of thrombocytopenia (a condition that occurs when the platelet count in blood is too low) and should be taken at the same time each day. Medical record review for Resident 3 was initiated on 11/7/23. Resident 3 was admitted to 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 interview and medical record review, the facility failed to ensure the medications brought by the family was accurately and safely accounted for one of three sampled resident (Resident 3). This failure had resulted in a missing dose of Resident 3's medication. Findings: Medical record review for Resident 3 was initiated on 11/7/23. Resident 3 was admitted to the facility on [DATE]. Review of Resident 3's Order Summary Report showed a physician's order dated 10/18/23, to administer Promacta 50 mg (Eltrombopag Olamine) one tablet by mouth in the morning for thrombocytopenia/anemia with a start date of 10/19/23. On 11/6/23 at 1537 hours, an interview was conducted with Resident 3's family member (Family Member 1). Family Member 1 stated she had personally delivered a 30-day supply of Promacta 50 mg to the facility and delivered it to the nursing station. However, Family Member 1 stated the facility had notified her one tablet was missing from Resident 3's supply. On 11/13/23 at 1535 hours, an interviewand…

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 medical record review, the facility failed to maintain the accurate medical record for one of three sampled residents (Resident 3) when LVN 7 inaccurately documented the administration of Resident 3's Promacta medication. This failure had the potential to cause a delay on Resident 3 receiving his medication. Findings: Medical record review for Resident 3 was initiated on 11/7/23. Resident 3 was admitted to the facility on [DATE]. Review of Resident 3's Order Summary Report showed a physician's order dated 10/18/23, to administer Promacta 50 mg (Eltrombopag Olamine) one tablet by mouth in the morning for thrombocytopenia/anemia with a start date of 10/19/23. Resident 3's MAR for October 2023, showed Promacta 50 mg was scheduled to be given at time 0600 hours daily. Further review of the MAR showed on 10/21/23, Resident 3 was administered his Promacta by LVN 7. On 11/9/23 at 1525 hours, a telephone interview was conducted with LVN 7. LVN 7 verified he took care of Resident 3 on 10/21/23. LVN…

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, facility document review, and P&P review, the facility failed to ensure the professional standards for food safety and sanitation guidelines were followed when: 1. Pasteurized eggs were not used to serve under cooked eggs. 2. Time Temperature Control for Safety Foods (TCS) (food that require time and temperature controls to limit the growth of illness causing bacteria) were not handled safely. 3. Expired food was not discarded. 4. Food was not stored properly. 5. Food was not dated. 6. Hair restraints were not worn appropriately. 7. Food contact surfaces were worn and no longer cleanable. 8. Kitchen equipment was not clean. These failures had the potential to cause food borne illnesses in a medically vulnerable population of 131 who received food prepared in the kitchen. Findings: Review of the CMS 672 Resident Census and Conditions of Residents completed by the facility on 6/5/23, showed 131 of 131 residents in the facility received food prepared in the kitchen. 1. Review of the facility's P&P titled Procedure For Refrigerated Storage dated 2018…

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 facility P&P review, the facility failed to provide the necessary pharmacy services to ensure proper storage, labeling, and disposal medications. * The facility failed to ensure two expired oral inhaler medications were removed from Medication Cart A. * The facility failed to ensure properly label an eye drop medication in Medication Carts A and B. * The facility failed to ensure three opened insulin pens in Medication Carts A and B had an open date. * The facility failed to ensure personal medications in Medication Cart A were removed and not used. * The facility failed to ensure eight expired boxes of influenza vaccine were removed from the refrigerator in Medication Room A. * The facility failed to ensure one opened insulin pen in the refrigerator in Medication Room A had an open date. * The facility failed to ensure the IV E-kit in Medication Room A was replaced. * The facility failed to ensure the orally administered medications were stored separate from externally used medications. * The facility failed to ensure the medications for…

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

Based on observation and interview, the facility failed to show their Quality Assessment and Assurance (QA&A) plan of correction. There was no evidence of documentation to show the facility had developed a plan of correction for the repeated deficient practices cited at F558, F689, F694, F758, F759, F761, F806, F812, and F880 from the last recertification survey completed on 4/21/21. This had the potential to negatively affect the quality of care for all the residents in the facility. Findings: During the recertification survey from 6/5/23-6/13/23, the following deficient practices: F558, F689, F694, F758, F759, F761, F806, F812, and F880 were identified, which were the repeated deficient practices cited from the last recertification survey completed on 4/21/21. On 6/13/23 at 1518 hours, an interview was conducted with the Administrator. The Administrator was asked to show documentation of the facility's QA&A plan of correction developed to prevent the deficient practices cited at F558, F689, F694, F758, F759, F761, F806, F812, and F880 from the last recertification survey 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 3. Review of the facility's P&P titled Isolation - Categories of Transmission-Based Precautions revised 9/2022 showed when a resident is placed on transmission-based precaution, appropriate notification is posted on the entrance door of the room and on the front of the chart so that personnel and visitors are aware of the need for and the type of precaution. The signage informs the staff of the type of CDC precautions, instructions for the use of PPE, and/or instructions to see a nurse before entering the room. The signage and notifications must comply with the resident's right to confidentiality or privacy. Review of the CDC Type and Duration of Precautions Recommended for Selected Infections and Conditions updated 9/2018 showed the following: - For herpes zoster (varicella-zoster or shingles) infection that is disseminated in any patient, or localized in immunocompromised patient until disseminated infection ruled out, the type of precautions to be followed are airborne, contact, and standard precautions, 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, facility document review, and facility P&P review, the facility failed to ensure the kitchen and patient care equipment was maintained. * The ice machine manufacturer's guidelines for cleaning and sanitizing were not followed and the ice machine did not have an air gap. * The walk-in freezer floor located in the kitchen was not leveled. * The facility failed to ensure the glucometers (a device which measures the amount of sugar in the blood) currently used and stored in the medication carts were properly calibrated. The facility failed to ensure the glucometer monitoring log was completed and the quality control showed the serial numbers of the glucometer calibrated. In addition, the facility failed to ensure the control solutions used to calibrate the glucometer machine for Station 1 were not expired. This posed the risk for inaccurate blood glucose test results and inappropriate treatments, which posed the risk of inaccurate blood glucose readings used to determine the residents' insulin doses. These failures posed the risk of equipment to not…

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 facility P&P review, the facility failed to ensure the regular inspection of all the bed frames, mattresses, and side rails was conducted as part of the regular maintenance program to identify areas of possible entrapment rails. This failure had the potential to negatively impact the residents resulting to entrapment, serious injuries, and death. Findings: According to the Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, the term entrapment describes an event in which a patient/resident is caught, trapped, or entangled in the space in or about the bed rail, mattress, or hospital bed frame. Patient entrapments may result in deaths and serious injuries. These entrapment events have occurred in openings within the bed rails, between the bed rails and mattresses, under bed rails, between split rails, and between the bed rails and head or foot boards. The population most vulnerable to entrapment are elderly patients and residents, especially those who…

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 medical record review, the facility failed to ensure the call light for one of 27 final sampled residents (Residents 81) was answered promptly. In addition, the facility failed to ensure Resident 81's call light was within the resident's reach. These failures had the potential for the residents to not get their needs met timely. Findings: On 6/8/23 at 1017 hours, Resident 81 was observed awake in bed. Resident 81's right leg was seen dangling on the right side of the bed and the resident attempted to lean forward but could not. Resident 81 stated, have you seen my shoes? I want to go outside to get some air. Resident 81's call light cord was noted tangled around the left side rail and the call light button was hanging and almost touching the floor. Resident 81 tried pulling the call light cord but could not get the call light button. On 6/8/22 at 1022 hours, a staff was called to assist Resident 81. Resident 81 was then observed pressing up and down the buttons on the bed remote control. Resident 81 used the bed's remote control to raise the head…

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, medical record review, and facility P&P review, the facility failed to notify Responsible Party 1 of a change in condition for one nonsampled resident (Resident 24). * The facility failed to notify Responsible Party 1 when Resident 24 had new medication orders, lab orders, and new appointment. This failure had the potential to negatively impact the resident's psychosocial and physical wellbeing and prevent the resident's responsible party from being fully aware of the resident's treatments, understand the course of actions, and not make appropriate decisions in the care and treatment of Resident 24. Findings: Review of the facility's P&P titled Change in a Resident's Condition or Status revised date 2/2021 showed the facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/ mental condition and/ or status (such as changes in level of care, billing/ payments, resident rights, etc.) A significant change 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to implement the restraint free periods and least restrictive measures for one of 27 final sampled residents (Resident 72) when Resident 72's bed was placed against the wall without medical necessity. This failure posed the risk of compromising Resident 72's independence and had the potential for increased risk of physical harm to the resident. Findings: Review of the facility's P&P titled Use of Restraints revised 4/2017 showed the definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which the staff applied it given that resident's physical condition (i.e., side rails are put back down, rather than climbed over), and this restricts his/her typical ability to change position or place, that device is considered a restraint. Restraints may only be used if/when the resident has a specific medical symptom 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 observation, interview, medical record review, and facility P&P review, the facility failed to develop the comprehensive plans of care to reflect the individual care needs for four of 27 final sampled residents (Residents 72, 88, 96, and 727) and one of 21 nonsampled residents (Resident 114). * The facility failed to develop an individualized a care plan problem to address Resident 114's use of ipratropium- albuterol medication (a breathing treatment that works by relaxing and opening air passage to the lungs to make breathing easier) and implementation of enhanced standard precaution related to infection in the urine. * The facility failed to develop an individualized care plan problem to address Resident 727's use of bilateral foam boots (heel boot that protects and support heel and ankle for pressure build up and friction) * The facility failed to develop a comprehensive person centered care plan to address the use of side rails for Resident 72. * The facility failed to develop a comprehensive person…

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 medical record review, interview, and facility P&P review, the facility failed to ensure the comprehensive care plans for four of 27 final sampled residents (Residents 6, 18, 92, and 86) were revised. * The facility failed to ensure Residents 6 and 86's care plans were revised to reflect the residents' severe weight losses. This failure posed the risk for Residents 6 and 86 to not receive the necessary care needed to maintain acceptable parameters of nutritional status. * The facility failed to ensure Residents 18 and 92's care plans were person-centered and comprehensive to address the use of oxygen therapy and its related medical complications from COPD. This failure posed the risk for Residents 18 and 92 to not receive the necessary care needed. Findings: Review of the facility's P&P titled Care Plan, Comprehensive Person-Centered revised 3/22 showed in part, 8. The interdisciplinary team should receive and update the care plan: a. when there has been a significant change in the resident's condition;…

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, medical record review, and facility P&P review, the facility failed to provide a safe environment free from potentially serious accident hazards for two of 27 final sampled residents (Residents 81 and 96) as evidenced by: * The facility failed to ensure the smoking materials were securely stored. In addition, Resident 96 had been assessed with a need for a smoking apron and was not provided with a smoking apron during the smoking period. This posed the risk for serious injury to Resident 96. * The facility failed to provide a floor mat as per the IDT and PT recommendations for Resident 81 following a fall on 3/18/23. In addition, the facility failed to complete the neurological assessments (neurological/neuro checks are brief, serial bedside exams performed by the nursing staff to evaluate for changes in the clinical status or neurological function) following Resident 81's fall on 9/27/22 and 3/18/23. These failures had the potential to cause injury to Resident 81 in case 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the acceptable parameters of nutritional status were maintained for two of 26 final sampled residents (Residents 6 and 86) who were administered enteral (a form of liquid nutrition that is delivered into the digestive system via tube) feeding as evidenced by: * The physician and responsible party were not notified of the severe weight losses for Residents 6 and 86. * The interventions to mitigate the severe weight loss for Residents 6 and 86 were not implemented in a timely manner. * The resident-centered plans of care for Residents 6 and 86 were not revised to address Resident 6 and 86's severe weight losses. As a result of these failures, Resident 6 and 86's compromised nutritional status was not addressed timely, which could lead to further medical complications. Findings: A professional reference review of American Academy of Family Physicians Journal titled Unintentional Weight Loss in Older Adults…

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, medical record review, and facility P&P review, the facility failed to provide the necessary treatments to six of 27 final sampled residents (Residents 18, 31, 88, 92, and 114) receiving the oxygen therapy. * The facility failed to follow the physician's order for Resident 18's oxygen therapy. * The facility failed to ensure Residents 18, 31, 88, and 92's nasal cannula tubing was dated as per the facility's P&P. In addition, the facility failed to ensure the nasal cannula tubing was stored in a set-up bag when not in use for Resident 31. * The facility failed to ensure Residents 83, 88, and 114's nebulizer tubing and mask were dated as per the facility's P&P. * The facility failed to ensure Resident 31's nebulizer mask was dated. In addition, the facility failed to ensure the nebulizer mask was stored in a set-up bag when not in use. These failures had the potential to negatively impact the residents' medical conditions. Findings: 1. Review of the facility's P&P titled Oxygen…

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, medical record review, facility P&P review, the facility failed to provide the necessary care and services to attain and maintain the highest physical well-being for two of 27 final sampled residents (Residents 16 and 75) who required dialysis. * The facility failed to ensure Resident 16's dialysis checklists were accurate and complete which included Resident 16's pre dialysis check list (for blood sugars, vital signs, access site, skin integrity, medications sent with resident, an special instructions) and post dialysis checklist (for vital signs, access site, skin integrity, and special instructions). * The facility failed to ensure Resident's 75 dialysis access site was assessed for bruit and thrill as per the physician's order. These failures had the potential risk for the residents not being provided the appropriate care and treatment, which could lead to medical complications. Findings: Review of the facility's P&P titled Renal Disease, Care of a Resident (undated) showed…

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, medical record review, and facility P&P review, the facility failed to ensure the least restrictive alternative measures were implemented prior to the use of side rails for six of 27 final sampled residents (Residents 21, 25, 65, 72, 115, and 727). These failures had the potential to put the residents at risk for serious injury. Findings: Review of the facility's P&P titled Bed Safety and Bed Rails revised August 2022 showed before using bed rails for any reason, the staff shall inform the resident or representative about the benefits and potential hazards associated with the bed rails and obtain informed consent. The following information will be included in the consent: the assessed medical needs that will be addressed with the use of bed rails; the resident's risk from the use of bed rails and how these will be mitigated; the alternatives that were attempted but failed to meet the resident's needs; and the alternatives that were considered but not attempted and the reasons. 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, facility document review, and facility P&P review, the facility failed to ensure the licensed nurses had specific competencies and standard of practice skill sets needed to provide the safe and efficient nursing care to the residents as evidenced by: * LVN 9 was unable to demonstrate competency in the administration of insulin injection subcutaneously to one of 21 nonsampled residents ( Resident 23). In addition, there was no documented evidence the annual competency skills checklist for LVN 9 was completed. * The facility failed to ensure RN 2 had the appropriate competency and skill set to assess for one of 27 final sampled residents (Resident 16)'s dialysis access site. This had the potential risk of an adverse outcome in Resident 16's care or services. These failures had the potential to put the residents at risk for care not provided in a safe and competent manner. Findings: Review of the facility's P&P titled Staffing, Sufficient, and Competency Nursing revised 8/2023,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide pharmaceutical services to ensure accurate reconciliation, administration and disposal as evidenced by: * The facility failed to ensure administration of the controlled medications for one of 27 final sampled residents (Resident 112), and two nonsampled residents (Residents 9 and 73) were accurately documented to ensure accurate reconciliation and to prevent the medication administration errors. These failures posed the risk for diversion of controlled medications and medication administration errors. * The facility failed to ensure the discontinued controlled medications for Residents 72, 99, 107, 112, 377, and 378 were removed from the current medication supply and disposed of. * The facility failed to ensure non-controlled medications were discarded by two licensed nurses. * The facility failed to ensure administration of antianxiety medication for Resident 118 was…

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, medical record review, and facility document review, the facility failed to ensure three of 27 final sampled residents (Residents 2, 72, and 118) were free from the unnecessary psychotropic drugs (any drug that affects brain activity associated with mental processes and behavior). * The facility failed to ensure Resident 72 was not prescribed quetiapine fumarate (antipsychotic medication) unless the medication was necessary to treat a specific condition or diagnosis. In addition, the facility failed to monitor Resident 72's target behavior for the use of quetiapine fumarate and failed to evaluate whether a GDR should be attempted as per the Pharmacy Consultant's recommendation. * The facility failed to ensure Resident 2's target behavior for the use of Seroquel (quetiapine fumarate) was monitored accurately. * The facility failed to ensure Resident 118's hours of sleep and response to eszopiclone (a medication to treat certain sleeping problems) were monitored as per 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 medical record review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 12.5%. Three of three licensed nurses (LVNs 1, 3, and 9) who were observed during the medication administration were found to have made errors. * LVN 3 administered the metoprolol (blood pressure medication) oral tablet without food when the pharmacy placed an alert to administer the medication with food on the medication packaging and without checking the heart rate as per the physician's order. * LVN 3 administered the budesonide nebulizer (medication to decrease inflammation in the lungs) and did not have Resident 83 rinse mouth after nebulizer was administered as per the medication label instruction. * LVN 9 administered the Lantus (long-acting insulin) injection pen (prefilled devices that combine the insulin container and syringe) via intramuscular (IM, situated or taking place within, or administered into, a muscle) instead 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility document review, the facility failed to complete a laboratory test for one of 27 final sampled residents (Resident 2) as per the physician's order. This had the potential to result in the delay in evaluating the effectiveness of the medication and adjusting the dosage of the medication to meet Resident 2's needs. Findings: Medical record review for Resident 2 was initiated on 6/5/23. Resident 2 was admitted to the facility on [DATE]. Review of the Consultant Pharmacist's Medication Regimen Review dated 2/12/23, showed the Consultant Pharmacist's recommendation to arrange for CBC (a comprehensive blood test of the cells that make up blood), lipid panel (a blood panel which detects cholesterol levels), HgA1c (hemoglobin A1c, a blood test used to measure the average blood sugar levels over the past three months), LFT (liver function testing) for long-term Seroquel (an antipsychotic medication) use. Review of the physician's order dated 3/14/23, showed an order…

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, facility document review, and P&P review, the facility failed to ensure the nutritional needs were met for two of 21 nonsampled residents (Residents 107 and 877) with a vegetarian diet preference. This failure posed the threat of the nutritional needs of Residents 107 and 877 to not be met which could lead to medical complications. In addition, the facility failed to ensure the food preference was honored for one of 21 nonsampled residents (Resident 427). Resident 427 stated she disliked scrambled eggs; however, she was served scrambled eggs on her breakfast tray. This had the potential to negatively impact the resident's well-being. Findings: 1. According to the California Health and Safety Code Section 1265.10: Effective 1/1/2019, skilled nursing facilities must make available wholesome, plant-based meals of such variety as to meet the needs of patients in accordance with their physicians' orders. Review of the facility's P&P titled Vegetarian and Vegan Diet dated 2020 showed in part, the Academy of Nutrition and Dietetics recognizes that well…

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, medical record review, and facility document review, the facility failed to accurately determine whether one of 21 nonsampled residents (Resident 13) who was prescribed the antibiotics had met the McGeer's criteria. As a result, the facility failed to inform the resident's physicians that the residents did not meet McGeer's criteria for true infection and potentially inhibited the resident's physicians from discontinuing the unnecessary antibiotics. This had the potential to result in adverse reactions associated with antibiotics and the development of antibiotic resistant bacteria. Findings: According to the Centers for Disease Control and Prevention (CDC), antibiotics are among the most frequently prescribed medications in nursing homes, with up to 70% of residents in a nursing home receiving one or more courses of systemic antibiotics over a year. Studies have shown that 40-75% of antibiotics prescribed in nursing homes may be unnecessary or inappropriate. Harms from antibiotic overuse are significant for the frail and older adults receiving care in nursing…

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.