Sea Cliff 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 the plan of care was revised for one of 33 final sampled residents (Resident 30). * Resident 30's care plan was not revised to address the specific care needs for the resident's weight loss and pressure injury prevention. This failure posed the risk for Resident 30 to not receive the person-centered care and services required to attain or maintain her highest level of physical and mental well-being.Findings: Medical record review for Resident 30 was initiated on 1/7/26. Resident 30 was admitted in the facility on 5/31/25. Review of Resident 30's MDS assessment dated [DATE], showed the resident's BIMS score was 14, indicating the resident was cognitively intact. a. Review of the facility's P&P titled Nutrition Care Management revised 1/29/25, showed the facility is to provide care and services including monitoring and evaluating the resident's response to the interventions, especially when there is no progress toward…

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 a 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 the existing pressure ulcer for two of four final sampled residents (Residents 2 and 30) reviewed for pressure injury. * RN 4 failed to follow Resident 2's physician's order to cleanse the pressure injury with normal saline during the wound care observation. * The facility failed to ensure Resident 30's heels were elevated on pillow to offload pressure as ordered by the physician. These failures posed the risks of complications and delayed wound healing for Resident 2 and potential development of pressure injury for Resident 30. Findings: 1. Review of the facility's P&P titled Physician Orders revised 1/2019 showed no drugs 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 three final sampled residents (Resident 30) reviewed for nutrition maintained acceptable parameters of nutritional status. * The facility failed to ensure Resident 30's weight was monitored monthly as indicated in the care plan. This failure had the potential to negatively impact the resident. Findings: Review of the facility's P&P titled Nutrition Care Management revised 1/9/25, showed the monthly weights are to be completed unless there is an order from the physician to discontinue. Resident declination of weight will be documented and incorporated into the plan of care. Alternative care plan goals such as monitoring anthropometrics, po intake parameters, labs or other criteria will be addressed by the Registered Dietitian/ nutritionist as appropriate. Monthly weights will be taken by within the first week of each month. Medical record review for Resident 30 was initiated on 1/7/26. Resident 30 was admitted…

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 properly maintain and assess the IV accesses for three of three final sampled residents (Residents 9, 161, and 196) reviewed for IV catheters. * The facility failed to ensure Resident 9's arm circumference was measured after the initial assessment related to the resident's PICC line catheter as per the facility's P&P. * The facility failed to ensure Resident 161's midline catheter dressing was changed in seven days as per the physician's order. In addition, there was no measurement of the arm circumference after the initial assessment. Moreover, the physician's orders for the cap changes of the midline catheter were for a PICC line instead of a midline catheter. * The facility failed to ensure Resident 196 had orders for monitoring the midline IV catheter. These failures had the potential to put the residents at an increased risk of infection and to cause a delay in identifying signs of catheter-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 provide the necessary care and services to attain or maintain the highest physical well-being for one of one final sampled resident (Resident 95) reviewed for dialysis care. * The facility failed to ensure Resident 95's fluid intake and output related to the dialysis were consistently monitored. This failure posed the risk of possible medical complications for Resident 95.Findings: Review of the facility's P&P titled Documentation revised May 2007 showed the resident's clinical record is a concise and accurate account of treatment, care, response to care, signs, symptoms, and progress of the resident's condition. Medical record review for Resident 95 was initiated on 1/6/26. Resident 95 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 95's H&P examination note dated 9/24/25, showed the resident had ESRD and on dialysis. Review of Resident 95's MDS assessment dated [DATE], showed 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 the facility staff (LVNs 4 and 8) had specific competencies and standard of practice skill sets needed to provide the safe and efficient nursing care to the residents. * LVN 4 administered expired insulin to Resident 6. * LVN 8 administered medications left at Resident 102's nightstand prepared by another licensed nurse. These failures had the potential to put the residents at risk for care not provided in a safe and competent manner.Findings: 1. On [DATE] at 0839 hours, an observation and concurrent interview was conducted with Resident 102. Resident 102 was lying in bed. There were three tablets in a medication cup placed on the resident's nightstand beside resident's bed. Resident 102 stated the medications were her levothyroxine sodium (thyroid hormone replacement used to treat an underactive thyroid or hypothyroidism), Protonix (known as pantoprazole, a prescription proton pump inhibitor 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 provide the pharmaceutical services to ensure the accurate administration of the medication. The facility's medication error rate was 4.76%. * LVN 4 administered expired insulin to Resident 6. * LVN 8 administered medications left at Resident 102's nightstand prepared by another licensed nurse. These failures had the potential to put the residents at risk for care not provided in a safe and competent manner.Findings: 1. Review of the facility's P&P titled Self-Administration of Medications (undated) showed medications to be self-administered are specifically ordered and monitored by the nursing staff. On [DATE] at 0839 hours, an observation and concurrent interview was conducted with Resident 102. Resident 102 was lying in bed. There were three tablets in a medication cup placed on the resident's nightstand beside resident's bed. Resident 102 stated the medications were her levothyroxine sodium (thyroid…

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 Pharmacist Consultant identified and reported all irregularities during the monthly medication regimen for one of five final sampled residents (Resident 6) reviewed for pharmaceutical services. * Resident 6 was diagnosed with diabetes and was on long term insulin. Resident 6 did not have a Hemoglobin A1C test completed for over a year. This failure resulted in inadequate management of Resident 6's diabetes, increasing the risk of serious health issues.Findings: Review of the facility's P&P titled medication Regimen Review last revised 5/2025 stated the Pharmacist Consultant reviews the medication regimen of each resident at least monthly. Findings and recommendations are reported to the Administrator, Director of Nursing, the responsible physician and the Medical Director where appropriate.The monthly review visit includes review of all drugs ordered, information concerning the resident related to the drug…

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 (Residents 2 and 3) reviewed for unnecessary medications were free from significant medication errors. * The facility failed to ensure Resident 2 received the appropriate dose of Risperdal (antipsychotic medication) as ordered by the physician. * The facility failed to ensure Resident 3's clonidine HCL (hydrochloride) (medication to lower blood pressure) was held as ordered by the physician. These failures had the potential to negatively impact the residents' health outcomes. Findings: Review of facility's P&P titled Guidelines for Medication Administration reviewed 5/27/25, showed to observe the five rights of administering medications which included the right resident, right drug, right dose, right time, and right route. Review of the facility's P&P titled Physician Orders - CA revised 1/2019 showed verbal orders must be recorded immediately in the resident's' chart by the 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 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 eight sampled residents (Resident 4). * The facility failed to assess and monitor Resident 4's condition after the resident had difficulty swallowing his morning medications on [DATE]. In addition, the facility failed to administer the warfarin sodium (blood thinner) to Resident 4 daily as ordered by the physician on [DATE]. These failures had the potential to negatively impact the resident's well-being.Findings: Closed medical record review for Resident 4 was initiated on [DATE]. Resident 4 was admitted to the facility on [DATE], and expired on [DATE]. Review of Resident 4's H&P dated [DATE], showed resident had capacity to understand and make decisions. Review of Resident 4's admission MDS assessment dated [DATE], showed Resident 4's BIMS score was three, indicating severe 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 interview, medical record review, and facility P&P review, the facility failed to provide the pharmaceutical services for one of eight sampled residents (Resident 4) when: * LVN 4 crushed Resident 4's iron (supplement) tablet and administered it to the resident. This failure had the potential to negatively affect the resident's health conditions and posed the risk for possible complications. Findings: Review of the facility's P&P titled Crushing Medications (undated) showed the nursing staff will crush only medications that may be crushed. The Nursing Staff will use available references and resources to determine which medications should and should not be crushed. According to National Library of Medicine Daily Med:- Iron tablets are enteric coated (coating applied to oral medications to prevent the medications from dissolving in the highly acidic stomach environment) and should not be chewed or crushed. Iron tablets are enteric coated to help protect the stomach. Iron may cause gastrointestinal…

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 maintain the infection control program and practices to help prevent the development and transmission of diseases and infections. * The laundry and clean linen rooms were not maintained to ensure a clean area, free from potential contamination. * Resident 144 (final sampled resident)'s infection was not reported on the facility's monthly infection control log. * Residents 127 and 159's infections (nonsampled residents) were incorrectly listed as meeting McGeer's Criteria on the facility's monthly infection control log. * Two of four licensed nurses did not wear appropriate personal protective equipment (PPE) during the medication administrations for two of four residents (final sampled residents, Residents 111 and 152) who were on enhanced barrier precautions (EBP). * Two of four licensed nurses did not sanitize the BP cuff and stethoscope before and after use for two of four…

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 the resident and/or their representative of the transfer and reasons for the transfer in writing and send a copy of the notice to the LTC Ombudsman when the resident was transferred to the acute care hospital for one of three final sampled residents (Resident 25) reviewed for hospitalization. This failure had the potential for the resident and their representative of not knowing about the appeal process and posed the risk of the LTC Ombudsman not being aware of the circumstances of the resident's transfer/discharge should the resident and their representative believe the transfer or discharge was inappropriate or involuntary. Findings: Medical record review for the Resident 25 was initiated on 2/11/25. Resident 25 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 25's H&P examination dated 1/4/25, showed Resident 25 had the capacity to understand and make decisions. 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 resident and/or their representative were provided with the written information regarding the facility's bed-hold policy when the resident was transferred to the acute care hospital for one of three final sampled residents (Resident 25) reviewed for hospitalization. This failure had the potential for Resident 25 and/or their representative to be unaware of their rights to request a bed hold and return to the first available bed should the resident's hospital stay exceed the seven-day bed-hold period. Findings: Review of the facility's P&P titled Bed-Holds and Returns revised 12/2023 showed it is the policy of the facility to inform the resident or resident's representative in writing of their right to exercise the bed hold provision of seven days upon admission and provide a second notice before transfer to a general acute care hospital or before the resident goes on a therapeutic leave. In the event of an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services related to the GT per the facility's P&P for three of three final sampled residents (Residents 87, 111, and 152) reviewed for enteral feeding. * Two of two licensed nurses administered the medications to Residents 111 and 152 by pushing the medications through the GT instead of gravity. * One of two licensed nurses (LVN 4) did not check the tube placement and residual volume before the GT medication administration for Resident 111. * Resident 87's GT placement and residual checks were not performed prior to starting the resident's enteral feeding. These failures had the potential for the residents to develop complications related to the GT care and management, including tube dislodgement, infection of the GT site, delayed nutritional feeding, and trauma. Findings: 1. Review of the facility's P&P titled Enteral Tube Medication Administration Procedures dated 1/28/25,…

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 the facility P&P review, the facility failed to ensure the oxygen was administered as ordered by the physician for one of two final sampled residents (Resident 152) reviewed for oxygen use. This failure had the potential to affect the respiratory health and well-being of Resident 152. Findings: Review of the facility's P&P titled Oxygen Administration revised 2/2023 showed it is the policy of this facility that oxygen therapy was administered by the licensed nurse as ordered by the physician, or as a nursing measure and an emergency measure until the order can be obtained. Medical record review for Resident 152 was initiated on 2/11/25. Resident 152 was admitted to the facility on [DATE]. Review of Resident 152's Order Summary Report showed a physician's order dated 11/13/24, to administer the oxygen at two liters per minutes via nasal cannula continuously to keep the oxygen saturation level more than 90%. Review of Resident 152's MDS dated [DATE],…

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

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the provision of pharmacy services met the needs of the residents in accordance with the facility's P&P when: * The licensed nurse left Resident 152's medications unattended on the resident's bedside table during the medication administration. This failure had the potential for misuse of the medications by the residents, facility staff and/or visitors. * An opened container of the CII E-kit was not replaced timely within 72 hours after being opened. This failure had the potential for the emergency medications to be unavailable when needed. * One tablet of Percocet (narcotic pain medication) was removed from CII E-kit and wasted due to the resident's refusal was not disposed of as per the facility's policy; instead the Percocet medication was kept inside the CII E-kit while waiting for the pharmacy to replace the opened E-kit. This failure had the potential to result in controlled medication abuse, diversion or unauthorized removal from the facility. * A staff discarded…

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 (Residents 47 and 57) reviewed for unnecessary psychotropic (drug that affects brain activities associated with mental processes and behaviors) medications were free from unnecessary psychotropic medications when: * For Resident 57, the physician did not document the rationale and specified duration for the extended use of the as needed hydroxyzine (a psychotropic medication for anxiety and tension caused by nervous and emotional conditions. also used to relieve symptoms of allergic conditions) beyond 14 days. * For Resident 47, the physician did not document the rationale for the extended use of the as needed lorazepam (a psychotropic medication for anxiety) beyond 14 days and did not have documented evidence of monitoring non-pharmacological interventions, target behaviors, and adverse side effects to assess effectiveness of psychotropic medication. These failures had the potential to…

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

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate during the medication administration observation was less than 5%. * The facility had a cumulative medication error rate of 20%. Six medication errors occurred out of 30 opportunities during the medication administration for two out of four residents (final sample residents, Residents 111 and 152). This failure resulted in medications not given in accordance with the physician's orders and the facility's P&P, which had the potential for residents not receiving the full therapeutic effects of the medications and worsening of the residents' medical conditions. Findings: 1. Review of the facility's P&P titled Administration Process dated 1/28/25, showed the medications are administered in accordance with written orders of the attending physicians. Review of the facility's P&P titled General Procedures to Follow for All Medications dated 1/28/25, showed in part, .obtain and record any vital signs, as necessary, prior to mediation administration .…

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 store and label the medications in accordance with the manufacturer's instructions and the facility's P&P when: * An amber bottle of megestrol acetate (appetite stimulant) oral suspension was not properly labeled with the specific instruction on preparation in Medication Cart 2. * A bottle of Katerzia (amlodipine, use for treatment of hypertension, to lower blood pressure) oral suspension requiring refrigerated storage condition was stored at a room temperature in Medication Cart 2. * An opened Levemir insulin vial was stored without an open date in Medication Cart 1. * Three boxes of expired Tempa-DOT (single-use, disposable clinical thermometer for oral and axillary (armpit) use that measures body temperature, designed to be sanitary and prevent the spread of infection) supplies were stored in Medication Room A. These failures had the potential for the residents to receive unsafe, ineffective medications…

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 safety and sanitation guidelines were followed as evidenced by: 1. The frozen meat was not thawed in a safe manner. 2. The food preparation equipment was not clean or in good working condition. 3. The dry bulk food was not stored properly. 4. The meal preparation equipment was not air dried. 5. Two floor drains did not have a backflow prevention. 6. The cleaning equipment was not stored in a sanitary manner. These failures posed the risk for food borne illnesses in highly susceptible resident population of 157 facility residents who received food prepared in the kitchen. Findings: Review of the facility's Matrix dated 2/11/25, showed 157 of 166 residents who resided in the facility consumed food prepared in the kitchen. 1. Review of the facility's P&P titled Thawing of Meats dated 2023 showed thawing of the meat properly can be done by labelling defrosting meat with a pull date (date food put in refrigerator) and use by date. On 2/11/25 at 1022 hours, during 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 RD completed or reviewed the MDS Nutritional Status assessment and the quarterly nutritional assessment for accuracy for one of 33 final sampled residents (Resident 87). This failure posed the risk for the residents' nutritional needs to not be met in the facility. Findings: The California Business and Professions Code (B&P Code) are a set of laws that govern businesses and licensed professions in California. The B&P Code 2586 governs the services of Registered Dietitians. These services include nutritional and dietary assessments. Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual dated October 2024 showed under Section K Nutritional Status: the assessor should collaborate with the dietitian and dietary staff to ensure that items in this section have been assessed and calculated accurately. If the resident is gaining a significant amount of weight, the facility should not wait for the 30- 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 the facility P&P review, the facility failed to ensure the medical records were complete and accurately maintained for 12 of 33 final sampled residents (Residents 16, 25, 32, 37, 46, 47, 56, 57, 65, 87, 146, and 158). * Resident 47's POLST incorrectly showed the resident had the advanced directive and health care agent (person listed in the advanced directive who can legally make health-care decisions for the resident). * Resident 87's POLST failed to show the names of facility staff who reviewed and confirmed the form with the resident's responsible party. * Resident 57's post fall eInteract Change in Condition Evaluation V4.2 showed the incorrect time for the physician and resident notification. * Resident 158's POLST failed to show the physician's signature. * Resident 146's POLST failed to show the physician's signature. * The facility failed to ensure Resident 65's TARs regarding the treatment for xerosis and pruritus were completed. * The facility failed 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 provide the necessary care and services for two of four final sampled residents (Residents 16 and 93) reviewed for hospice services * The facility failed to ensure Residents 16 and 93 received HA visits two times a week 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 residents' care. Findings: Review of the facility's P&P titled End of Life Care: Hospice and/or Palliative Care revised on 12/2023 showed the following: - Hospice services will be offered as appropriate and as ordered by the physician. These services will be integrated into the overall individualized, interdisciplinary care plan. Collaboration with Hospice will include processes for orienting staff to facility policies and procedures which may include resident's rights, documentation, and record keeping requirements; and - However, the facility will…

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, facility document review, and facility P&P review the facility failed to implement an antibiotic stewardship program to reduce the risk of unnecessary or inappropriate antibiotic use when two nonsampled residents (Residents 127 and 159) were being treated for conditions which did not meet the McGeer's criteria. This failure had the potential of not accurately identifying true infections and exposing the residents to unnecessary antibiotic use. Findings: Review of the facility's P&P titled Infection Prevention and Control Program revised 9/2017 showed improving the use of antibiotics in healthcare to protect residents and reduce the threat of antibiotics resistance is a national priority, and disease caused by resistant bacteria are increasing in long term care facilities and contributing to higher rates of morbidity and mortality. The facility will promote appropriate antibiotic use while optimizing the treatment of infections, while reducing possible adverse events associated to antibiotic use. On 2/14/25 at 0804 hours, an antibiotic…

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 maintain the essential equipment in the safe operating conditions. * The facility's ice machine was not cleaned and sanitized as per the manufacturer's instructions. This failure had the potential for the essential equipment not functioning in the way it was intended and in turn cause contamination of the food, leading to illnesses for the residents. Findings: Review of the facility's Matrix showed 157 of 166 residents consumed food prepared in the kitchen. Review of the USDA Food Code 2022, Section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, (A) Equipment Food-Contact Surfaces and utensils shall be clean to sight and touch. Review of the facility's P&P titled Ice Machine Cleaning Procedures dated 2023 showed the internal components are to be cleaned monthly per manufacturer's recommendations. Review of the facility's ice machine manufacturer guidelines titled Cleaning and Sanitizing Procedure Instructions (undated) showed the following: -…

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 protect the residents' rights to be free from the physical abuse for two of six sampled residents (Residents 1 and 2). * Resident 2 allegedly called Resident 1 a bad word and scratched Resident 1's face. In response, Resident 1 bit Resident 2's hand and was found by staff with Resident 2's hand in her mouth. Resident 1 had a scratch mark on her face and Resident 2 had a bite mark on her right hand. This failure had the potential for Residents 1 and 2 to be seriously injured or have psychosocial harm. Findings: Review of the facility's P&P titled Abuse: Prevention of and Prohibition Against revised on 1/2021 showed in part, it is the policy of this Facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The facility will provide oversight and monitoring to ensure that its staff, who are agents of the facility, deliver care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for two of seven sampled residents (Residents 2 and 5). * Resident 2 did not receive Marinol (medication to stimulate appetite) as ordered from 2/2 - 2/7/24, and the physician was not notified. Additionally, there was no follow up with the pharmacy about the medication not being delivered timely. * Resident 5 complained of numbness and feeling like having a stroke; however, the physician was not notified until six hours and 11 minutes later. These failures had the potential to negatively affect the residents'health conditions and well-being. Findings: 1. Review of the facility's P&P titled Medication Administration (undated) showed the medications are to be administered within one hour before or one hour after the prescribed time. Medical record review for Resident 2 was initiated on 5/31/24. Resident 2 was admitted to the facility on [DATE], and readmitted on [DATE]. 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 provide the necessary care and services to one of two sampled residents (Resident 1) as ordered by the physician. * The facility failed to order and administerResident 1's aspirin (a medication used to thin the blood) and atorvastatin (a medication to treat high cholesterol) according to the discharge medication orders from the hospital. This failure had the potential to negatively affect the residents' health condition and well-being. Findings: Review of the facility's P&P titled Medication Orders (undated) showed under the section for Written Transfers Orders (sent with the resident by an acute care hospital or other health care facility) the following: - implement a transfer order without further validation if it is signed and dated by the resident's current attending physician, unless the order is unclear or incomplete or the date is different from the date of admission; - if the order is unsigned, signed by another…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to promote dignity and respect for eightof 14 sampled residents (Residents 2, 3, 7, 8, 9, A, B, and C) * The facility failed to ensure the resident's call lights were answered in a timely manner for Residents 3, 7, 8, 9, A, B, and C. * The facility failed to ensure the call light was within the reach of Resident 2. These failures posed the risk to negatively affect the residents' physical and emotional well-being. Findings: Review of the facility's P&P titled Call Light/Bell revised 5/2020 showedit is the policy of the facility to provide the resident a means of communication with nursing staff. Under the procedure sectionshowed following: - Answer the call light/bell within a reasonable time; - Turn off the call light/bell; - Listen to the resident request/need; - Respond to the request. If the item is not available or unable to assist, explain to the resident and notify the charge nurse for further…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to develop the comprehensive plan of care to reflect the individual activity needs for one of 14 sampled residents (Resident 2). This failure posed the risk of not providing individualized activities to the residents. Findings: Review of the facility's P&P titled Comprehensive Resident Centered Care Plan revised 1/2021 showed it isthe policy of the facility that the IDTshall develop and implement a comprehensive person-centered care plan for each resident consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Under the procedure section showed the care plan is developed by the IDT which included but not limited to following professionals: a. Attending physician; b. Registered nurse responsible for resident; c. Dietary supervisor/dietitian; d. Social services staff…

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 one of 14 sampled residents (Resident 9). * The facility failed to ensure Resident 9 received the protein supplement as ordered by the physician two times a day. This had potential for not providing necessary care and services to meet the care needs for this resident and medical complication. Findings: Review of the facility's P&P titled Medication Administration, undated, showed if a dose of a regularly scheduled medication is held, refused, or given at a time other than the prescribed time, that particular dose on the medication sheet is to be circled, and an explanation is to be offered on the back of the medication sheet. If doses of any medication are refused for more than three (3) consecutive days, or if the refusal of one dose could cause or has caused further deterioration in the resident's clinical condition, the attending physician is to be notified.…

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 RNA services to seven of 14 sampled residents (Residents 2, 9, 10, 11, 12, 13,and 14) as ordered by the physician. This failure had the potential for the resident's decline in ROM functions and deterioration in their ability to perform ADL care. Findings. Review of the facility's P&P titled ROM (range of motion) and Contracture Prevention revised 5/2019 showed the facility is to ensure that resident receive services, care, and equipment to assure that every resident maintains, and/or improves to his/her highest level of range of motion and mobility, unless reduction is clinically unavoidable. Under the procedure section showed an interdisciplinary care plan is developed to maintain or increase joint mobility, the implementation of the program was carried out by the appropriate personnel in skilled rehab, routine therapy, restorative nursing, or CNA staff. 1. Medical record review for Resident 2 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 P&P review, the facility failed to ensure one sampled resident (Resident 1) wasassessed to determine if it was safe to self-administer their medications prior to self-administration of the medications as per the facility's P&P. * LVN 3 left Resident 1's oral medications at the Resident 1's bedside unattended for Resident 1 to self-administer medications without LVN 3's supervision. However, Resident 1 was not assessed to safely self-administer the medications. This failure put Resident 1 at risk for unsafe self-administration of the medications. Findings: Review of the facility's P&P titled Self-Administration/Bedside Medication Order, undated, showed the residents may self-administer medications when a desire is expressed and when the center's Inter-Disciplinary Team (IDT- a team of healthcare professionals from different professional disciplines who work together to manage the physical, psychological, and spiritual needs 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 and interview, the facility failed to maintain a safe, clean, comfortable, and homelike environment for one of three sampled residents (Resident 3). * The baseboards and walls by the baseboards in Resident 3's bathroom (in Room A) were observed in a state of disrepair: the walls and baseboards were unclean, stained, had exposed plaster, holes in some areas, and had peeling paint. The toilet seat was also observed with yellow stains. This failure had the potential to negatively impact the resident's safety, right to a dignified existence, and quality of life. Findings: Review of the written complaint, Family Member 2 reported several concerns with Room A. These included the room's worn-out condition, a non-functional paper towel dispenser in the adjacent bathroom, inadequate lighting, an unpainted white patch on the wall from a previously incomplete repair, the need for room painting, and the view outside the closed curtains which revealed a lack of landscaping and a view of dirt. On 9/1/23 at 1120 hours, an observation of Room A was conducted with 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 obtain radiology services for one of three sampled residents (Resident 1). * The facility failed to obtain a chest x-ray for Resident 1 as ordered. This had the potential to result in delayed diagnosis and treatment for Resident 1. Findings: On 8/29/23 at 1505 hours, a telephone interview was conducted with Family Member 1. Family Member 1 stated Resident 1 was admitted at the facility from 2/14 to 2/19/23. Family Member 1 explained Resident 1 had developed an increasingly productive cough but did not receive the scheduled chest x-ray at the facility. Subsequently, Resident 1 was transferred to the acute care hospital after a fall and diagnosed with pneumonia. Family Member 1 expressed the belief that if the facility had addressed the resident's symptoms promptly, he might not have become weak and suffered a fall. Medical record review for Resident 1 was initiated on 8/29/23. Resident 1 was admitted to the facility on [DATE]. Review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to ensure the medical record for one of three sampled residents (Resident 1) was accurate. The facility failed to ensure Resident 1's Fall Risk Evaluation was completed accurately. This had the potential for the resident's care needs not being met as their medical information was inaccurate. Findings: Medical record review for Resident 1 was initiated on 8/29/23. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's Fall Risk Evaluation dated 2/14/23 at 2017 hours, showed Resident 1 had one to two falls in the past three months. Review of Resident 1's Change in Condition Evaluation dated 2/18/23 at 1859 hours, showed Resident 1 suffered a fall on 2/18/23, resulting in a left elbow skin tear measuring 1.5 cm, left eyebrow bruising and cuts, and pain level of 8 (on a pain scale of 0 to 10, 0 is no pain and 10 is excruciating pain). Resident 1's responsible party and physician were notified at 1800 hours. However, 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 document review, the facility failed to ensure one of three sampled residents (Resident 1) was free from the physical abuse when Resident 2 hit Resident 1 with his cane. This resulted in multiple injuries to Resident 1's right arm and shoulder, which had the potential to negatively impact the resident's well-being. Findings: Review of the facility's P&P titled Abuse: Prevention of and Prohibition Against revised January 2021 showed it is the policy of this facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Review of SOC 341 Report of Suspected Dependent Adult/Elder Abuse dated 8/12/23, showed Resident 2 hit Resident 1 with his cane after getting into a verbal argument, causing a laceration to Resident 1's right hand. a. Medical record review for Resident 1 was initiated on 8/15/23. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's MDS dated [DATE], 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 interview and medical record review, the facility failed to notify one of two sampled residents' (Resident 1) representative or responsible party of Resident 1's nephrology (a specialty within the internal medicine field related to kidney care) appointment. This failure had the potential for Resident 1's representative or responsible party of not being involved in resident's plan of care. Findings: Review of the SOC 341 dated 7/18/23, showed Family Member 1 stated Resident 1 was dropped off at a nephrologist's (a medical doctor who specializes in kidney care) office, and she was not aware of the appointment until Resident 1's family member received a call from the nephrologist office. Medical record review for Resident 1 was initiated on 7/28/23. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 1's History and Physical examination dated 9/27/22, showed Resident 1 had fluctuating capacity to understand and make medical decisions. Further review 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.

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 for one of two sampled residents (Residents 1) to maintain their highest physical well-being. The facility failed to follow the physician's order for a nephrology (a specialty within the internal medicine field related to kidney care) consult for Resident 1. This failure posed the risk for delayed care and necessary interventions to Resident 1. Findings: Medical record review for Resident 1 was initiated on 7/28/23. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 1's Order Summary Report showed an order dated 12/1/22, to have a nephrology consult. Further review of Resident 1's medical record failed to show documentation Resident 1 was seen by a nephrologist as recommended by the physician. On 8/1/23 at 1528 hours, a concurrent interview and medical record review was conducted with LVN 1. LVN 1 stated any orders for consults/appointments would 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.

Based on observation, interview, facility P&P review, facility document review, the facility failed to follow the menu for 19 residents who were on a pureed diet. The facility failed to ensure the kitchen staff used the correct scoop size when serving pureed broccoli. This failure had the potential of not following the menu and not meeting the residents' nutritional needs which could lead to nutritional-related health complications. Findings: Review of the facility's P&P titled Menu Planning 2020 showed the menus are planned to meet nutritional needs of residents in accordance with established national guidelines, physician's orders, and to the extent medically possible, in accordance with the most recent recommended dietary allowances of the Food and Nutrition Board of the National Research Council National Academy of Sciences. Review of the facility's document titled Fall Menus for Week 1 Thursday for 9/8, 10/6, 11/3, and 12/1/22, showed the seasoned broccoli would be served with #12 scoop for the pureed diet. Review of the facility's document showing the scoop measurements…

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 document review, the facility failed to ensure the food safety and sanitation requirements were met. * The facility failed to air dry equipment. * The facility failed to ensure the upper plate domes and bottom plates were free from chip and cracks. * The facility failed to ensure the chlorine strips and pH sanitizer strips were not expired. * The facility failed to ensure Resident 53's food items were not served to Resident 42. These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food prepared in the kitchen. Findings: Review of CMS-672 Resident Census and Conditions of Residents completed by the facility dated 11/1/22, showed 160 of 168 residents residing in the facility received food prepared in the kitchen. 1. According to the USDA Food Code 2017, 4-901.11, Equipment and Utensils, Air- Drying Required, items must be allowed to drain and air-dry before being stacked or stored. Stacking wet items…

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, facility document review, and facility P&P review, the facility failed to implement their infection control program in accordance with the facility's P&P. * The facility failed to implement their infection control surveillance program for the months of January 2022 through September 2022. The facility conducted surveillance of the resident infections based on whether the residents were prescribed the antimicrobial medications. The facility failed to determine whether the residents who were not prescribed antimicrobial medications met the facility's criteria for infection (utilizing McGeer's Criteria) and thus, failed to include these residents in the facility's infection control surveillance program. This failure posed the risk for not identifying the resident infections and controlling the potential transmission of communicable disease to other residents throughout the facility. * The facility failed to ensure the low air loss mattress (a mattress designed to distribute the patient's body…

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 care was provided in a manner which promoted respect and dignity for two of 33 final sampled resident (Residents 39 and 526). * Resident 39 had to wait 40 minutes to an hour to have her soiled diaper changed by the facility staff. This had the potential of not maintaining or enhancing the resident's self-esteem and self-worth. * The facility failed to ensure privacy during the delivery of personal care and services by pulling the privacy curtains closed and providing clothing or a cover to prevent exposure of body parts for Resident 526. This failure posed the potential to negatively impact the resident's psychosocial well-being. Findings: 1. On 11/3/22 at 1006 hours, an interview was conducted with Resident 39. Resident 39 described an incident when CNA 8 left her waiting for hours in her soiled diaper which caused her to develop a rash. On 11/4/22 at 1555 hours, a follow-up interview was conducted with Resident 39.…

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 P&P review, the facility failed to obtain an informed consent (process in which a health care provider educates a patient about the risks, benefits, and alternatives of a given procedure or intervention to obtain agreement or permission for care, treatment, or services) for the psychotropic medications for one of 33 sampled residents (Resident 99). This failure had the potential to compromise the right of the residents or responsible parties (persons designated to make decisions on behalf of the residents) to be fully informed regarding care and treatment to make health care decisions. Findings: Review of the facility's P&P titled Informed Consent dated 4/2013 showed the physician's orders related to the use of psychotherapeutic drug should not be initiated until an informed consent is obtained. Medical record review for Resident 99 was initiated on 11/4/22. Review of the March and June 2022 MDS showed Resident 99 had a BIMS score of 4 (meaning severe impairment of mental status). Review of Resident 99's medication 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 ensure the facility's P&P addressing self administration of the medications was implemented for one nonsampled resident (Resident 5). * LVN 11 left Resident 5's oral medications at the resident's bedside unattended and Resident 5 took the oral medications without LVN 11's supervision. However, Resident 5 was not a candidate to safely self-administer the medications. This failure put Resident 5 at risk for unsafe self-administration of the medications. Findings: Review of the facility's P&P titled Preparation and General Guidelines, Medication Administration-General Guidelines dated 2/23/15, showed the residents are allowed to self-administer medications when specifically authorized by attending physician and in accordance with procedures for self-administration of medications. Review of the facility's P&P titled Preparation and General Guidelines, Self-Administration of Medications dated 2/23/15, showed 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 provide information on how to formulate an advance directive for four of 33 final sampled residents (Residents 82, 95, 121, and 471). This had the potential for the residents' decision regarding their healthcare and treatment options not being honored. Findings: 1. Medical record review for Resident 471 was initiated on 11/1/22. Resident 471 was admitted to the facility on [DATE]. Review of Resident 471's H&P examination dated 10/23/22, showed Resident 471 had the capacity to understand and make decision. Review of Resident 471's POLST dated 10/22/22, under Section D Information and Signatures, did not show advance directive was discussed with Resident 471. Review of the Social Services Assessment/Evaluation V.2 dated 10/26/22, did not show Resident 471 was provided information on how to formulate an advance directive. Further review of Resident 471's medical record did not show documentation Resident 471 was provided information on how 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 and medical record review, the facility failed to protect Resident 526's right to be free from physical abuse by Resident 60. This had the potential for physical abuse to continue for Resident 526. Findings: Medical Record Review for Resident 60 was initiated on 11/1/22. Resident 60 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of the Facility Reported Incident dated 11/1/22, showed Residents 60 and 526 share a room. At 0425 hours, the RN reported Resident 60 climbed into Resident 526's bed and grabbed and shook Resident 526's wrist while Resident 526 was lying in his bed. Review of the facility's P&P for Abuse titled Abuse: Prevention of and Prohibition Against (undated) showed each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Abuse is willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish and Willful means 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, medical record review, and facility P&P review, the facility failed to ensure accurate assessment and coding of MDS for two of 33 sampled residents (Residents 99 and 144) as evidenced by: * The facility failed to accurately assess Resident 99 when the quarterly assessment dated [DATE], showed Resident 99 did not receive any antipsychotic medication the last seven days. The MAR showed Resident 99 received antipsychotic medication from 6/15/22 through 6/21/22. * The facility failed to accurately code Resident 144's weight loss in the MDS. These failures resulted in inaccurate assessment which could delay appropriate therapy leading to poor resident outcomes. Findings: 1. Review of the facility's P&P titled Comprehensive assessment dated 12/2021 showed it is the policy of this facility to conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity which are based on the state's specific Resident Assessment instrument…

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 develop the plans of care to reflect the individual care needs for six of 33 final sampled residents (Resident 98, 99, 123, 138, 140, and 144). * The facility failed to develop a comprehensive person-centered care plan to address Resident 123's indwelling urinary catheter. * The facility failed to develop a comprehensive person-centered care plan to address Resident 140's Trazodone use. * The facility failed to develop a comprehensive person-centered care plan to address Resident 144's refusal of meals and weight loss. * The facility failed to implement bilateral floor mats for Resident 138. * The facility failed to implement bilateral floor mats for Resident 98 to prevent injury if fall occurred, and failed to develop a care plan to address Resident 98's left first toe wound. * The facility failed to have a person centered and individualized care plan developed for Resident 99's uncontrolled crying, yelling out and poor appetite.…

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 comprehensive plan of care for one of 33 final sampled residents (Resident 95) was revised to reflect the resident's current care needs and interventions. This posed the risk of not providing Resident 95 with individualized and person-centered care. Findings: Medical record review for Resident 95 was initiated on 11/1/22. Resident 95 was readmitted on [DATE]. Review of the Order Summary Report dated 11/8/22, showed the following physician's orders: - dated 9/17/22, to monitor neck area for skin integrity secondary to the use of the soft collar every shift; - dated 9/17/22, to put on the soft collar at all times and may remove during ADL care every shift; - dated 9/17/22, to administer ipratropium-albuterol solution 0.5-2.5 mg/3 ml one dose every four hours as needed for shortness of breath or wheezing; and - dated 10/10/22, to administer oxygen two liters per minute via nasal cannula continuous, may titrate to five liters to keep…

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 provided to meet care needs related to wound assessments and soft neck collar (cervical collar or neck brace, a medical device worn around the neck to help provide stability and support) application for two of 33 final sampled residents (Residents 95 and 98). * Resident 98 was observed with a wound on the tip of his left first toe; however, Resident 98's medical record failed to show documentation the facility conducted an assessment of the wound. This posed the risk for a delay in the identification of a wound and the implementation of treatments and interventions necessary to promote wound healing. * The facility failed to ensure the soft neck collar was applied to Resident 95 as per the physician's order. This posed the potential for poor health outcomes for this resident. Findings: 1. Review of the facility's P&P titled Change of Condition Reporting dated 5/2019…

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 provide floor mats for three of 33 final sampled residents (Residents 95, 98, and 138) as per the physician's orderd and the plans of care. This failure posed the risk for additional falls and injury to the residents. Findings: 1. On 11/1/22 at 0935 hours, during the initial tour of the facility, Resident 95 was observed in bed with no floor mats in place. Resident 95 stated she had a fall three weeks ago. Resident 95 stated she fell from the bed and hit her head. Resident 95 stated she was transferred to the acute care hospital. Medical record review for Resident 95 was initiated on 11/1/22. Resident 95 was readmitted to the facility on [DATE]. Review of Resident 95's Fall Risk Evaluation dated 9/17/22, showed Resident 95 was at high risk for falls. Review of Resident 95's plan of care showed a care plan problem dated 9/17/22, to address the risk for falls. The interventions included to provide floor mats at bedside. 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 observation, interview, and medical record review, the facility failed to provide the necessary services and care for the use of an indwelling urinary catheter for one of 33 final sampled residents (Resident 123) when there was no documented evidence showing an indication for the indwelling urinary catheter use for Resident 123. This posed the risk for infection related to unnecessary catheter use. Findings: On 11/3/22 at 0850 hours, Resident 123 was observed lying in bed. Resident 123 had an indwelling urinary catheter with the drainage bag hanging on the right side of the bed. Review of Resident 123's medical record was initiated on 11/3/22. Resident 123 was admitted to the facility on [DATE]. Review of the Progress Notes *NEW showed the Laboratory/Radiology Note dated 9/13/22 at 1942 hours, showing Resident 123 had an order to insert an indwelling urinary catheter; the order was noted and carried out. However, there was no documented evidence to show an indication for the use of the indwelling…

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 one of 33 final sampled residents (Resident 523) received the appropriate and necessary services for the care of a colostomy bag. * The staff failed to ensure proper care for Resident 523's colostomy bag by pricking a hole in the colostomy bag due to the initial improper application of the colostomy bag to the resident's lumbar region. This failure had the potential to result in leakage of gas and fecal matter and made the resident feel embarrassed and frustrated. Findings: Medical record review for Resident 523 was initiated on 11/1/22. Resident 523 was admitted to the facility on [DATE]. Review of Resident 523's History and Physical examination dated 11/4/22, showed the resident has the capacity to understand and make decisions. Review of Resident 523's Order Summary Report dated 10/31/22, showed an order for colostomy care in the lumbar region every shift; and colostomy appliance change or flange as needed for leakage.…

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 33 final sampled residents (Resident 144) received the appropriate services to meet their nutritional needs and maintain desirable weight. * The facility failed to notify the physician regarding Resident 144's weight loss and develop a plan to address the resident's weight loss. These failures had the potential for further weight loss and not meeting the nutrition needs for Resident 144. Findings: Review of the facility's P&P titled Nutrition revised 5/19 showed, The nurse will notify physician, family, and/or resident of weight loss/gain with interventions. Review of Resident 144's medical record was initiated on 11/3/22. Resident 144 was admitted on [DATE]. Further review of Resident 144's medical record showed the resident had a weight loss of 15.4 pounds from 5/5/22 to 6/2/22. However, there was no documented evidence the physician was notified regarding the significant weight loss. On11/4/22 at 1104…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure necessary care and services related to GT were provided for two of 33 final sampled residents (Residents 50 and 138). * The licensed nurse failed to check the GT (a flexible tube surgically inserted into the abdomen to the stomach for feeding and medication administration) placement correctly before medication administration for Resident 138. * The facility failed to ensure Resident 35's head of bed was elevated at 30-45 degrees during GT feeding administration as ordered. These failures had the potential for complication related to GT including aspiration. Findings: 1. Review of the facility's P&P titled Policy/Procedure-Nursing Clinical, Gastrostomy Tube, undated, showed under the Administering Medications through feedings tubes, to check for placement. Medical record review for Resident 138 was initiated on 11/1/22. Resident 138's admission Record showed Resident 138 was admitted to the facility on [DATE], with a diagnosis 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 and medical record review, the facility failed to ensure one of 33 final sampled residents (Resident 50) received appropriate care for peripheral IV (intravenous, infusion of substances such as an antibiotic directly into a vein). * Resident 50's IV site was on the left wrist, and Resident 50's left hand was observed swollen while IV fluid was infusing. In addition, the IV site dressing was undated. Furthermore, the IV administration was not documented and the IV monitoring was incomplete. These failures posed the risk for Resident 50 to develop complications related to the use of the peripheral IV catheter. Findings: Review of the facility's P&P titled Continuous Infusion of Medications and Solutions updated 1/2021 showed while in the facility, the nurse will monitor the access device every one to two hours for signs and symptoms of complications. The flow rate and condition of the intravenous catheter site will be documented at least every four to eight hours with consideration given to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review and facility's P&P, the facility failed to provide the necessary treatment to five of 33 final sampled residents (Residents 15, 27, 88, 95, and 521) receiving oxygen therapy and receiving medication through a nebulizer (a device which delivers medicated mist to a person via a mouth piece or a face mask). * The facility failed to change the nebulizer mask and tubing for Residents 15, 27, and 95 as per the facility's P&P. In addition, the facility failed to ensure Resident 95's humidifier bottle was dated. * The facility failed to ensure Residents 15, 95, and 521's oxygen tubing were dated. * The facility failed to change the emptied and expired oxygen humidifier bottle for Resident 88. These failures had the potential to negatively impact the residents' medical conditions. Findings: Review of the facility's P&P titled Oxygen Administration (mask, cannula, catheter) revised 5/2007, under the Instructions for Tubing and Humidifier Changes, showed oxygen tubing…

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, facility document review, and facility P&P review, the facility failed to ensure accurate reconciliation of controlled medications for one sampled resident (Resident 421) and one nonsampled resident (Resident 621). The facility failed to ensure administration of controlled medications for Residents 421 and 621 were accurately documented to ensure accurate reconciliation and to prevent medication administration errors. This posed the risk for diversion of controlled medications and medication administration errors. Findings: Review of the facility's P&P titled Medication storage in the facility dated 2/23/15, showed under the procedures, any discrepancy in controlled substance medication counts is reported to the director of nursing immediately. The director or designee investigates and makes every reasonable effort to reconcile all reported discrepancies. The director of nursing documents irreconcilable discrepancies in a report to the administrator. The medication regimen of residents using medications that have such discrepancies are…

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

Based on interview and record review, the facility failed to ensure one of 33 sampled residents (Resident 99) was free from unnecessary medication when the facility failed to ensure Resident 99's behavior manifested for pseudobulbar affect was being monitored for effectiveness of Nuedexta (medication used to treat pseudobulbar affect) and non-pharmacological approach to care was not implemented for this behavior. This failure had the potential for increased risks associated with medication use that include but are not limited to diarrhea, peripheral edema, and dizziness and may result in poor resident outcome. Findings: Review of Resident 99's medication order dated 2/11/22, showed Nuedexta 20 mg/10 mg by mouth every 12 hours for Pseudobulbar affect manifested by uncontrolled crying. Review of Resident 99's MAR from February to October 2022 showed there was no behavior monitoring for Pseudobulbar affect. During an interview on 11/3/22 at 1435 hours, LVN 7 acknowledged she had not been monitoring the uncontrolled crying and had not implemented non-pharmacological approach to care 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility's P&P review, the facility failed to ensure two of 33 final sampled residents (Residents 99 and 140) were free from unnecessary psychotropic medications when: * The facility failed to ensure Resident 99's Seroquel was used to treat a specific diagnosed and documented condition. * The facility failed to document the behaviors and implement non-pharmacological approach for yelling out behavior prior to Resident 99's Seroquel being ordered. * The facility failed to monitor the behaviors specific to Resident 99's Seroquel and mirtazapine use. * The facility failed to monitor adverse consequences for Resident 99's psychotropic medications. * The facility failed to monitor the behaviors specific to the use of trazadone and side effects of trazadone for Resident 140. These failures had the potential for the residents to receive unnecessary medications and not effectively evaluate the effectiveness of the psychotropic medications. Findings: 1. Review of the facility's P&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 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 14.29%. Three of four licensed nurses (LVNs 10, 12, and 14) had performed the medication errors during the medication administration observation. * LVN 12 failed to properly administer the medication via the GT (a flexible tube surgically inserted into the abdomen to the stomach for feeding and medication administration) to Resident 138. * LVN 14 failed to properly administer the eye drops to Resident 67. * LVN 10 failed to properly administer insulin to Resident 65. These failures had the potential to negatively affect the residents' health. Findings: 1. Review of the facility's P&P titled Policy/Procedure-Nursing Clinical, Gastrostomy Tube undated, showed under the Administering Medications through Feedings Tubes section, never mix medications. Mixing medications can cause them to interact in a way that will result in a clogged tube.…

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 store the drugs and biologicals in a safe manner. * Two expired bottles of Aspirin tablets (medication used to reduce fever and to relieve mild to moderate pain) were observed in Medication room [ROOM NUMBER]. * One open bottle of Antacid tablets extra strength (medicine that counteracts (neutralize the acid in stomach to relieve indigestion and heartburn) with no open date was found in Medication Cart 2 at Nursing Station 4. * One open tube of Medi-Honey (An ointment used to treat wounds) with no open date was observed in the Main Treatment Cart. * Multiple open medication containers with no open date were found in Nursing Station 3's medication cart. These failures had the potential for unsafe administration of medications. Findings: Review of the facility's P&P titled Medication storage in the facility dated 2/23/15, showed under the procedures section, M. outdated, contaminated, or deteriorated medications and those in…

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 record was accurate for two of 33 final sampled residents (Residents 57 and 99). * Resident 99's Weekly Nursing Summaries showed no antipsychotic medications were used; however, Resident 99 received Seroquel (antipsychotic medication) in September and October 2022. * The facility failed to ensure the wound care's MD progress notes were included in Resident 57's medical record. These failures had the potential for the residents' care needs not being met as the medical information was inaccurate, incomplete, and not readily available. Findings: 1. Medical record review for Resident 99 was initiated on 11/1/22. Resident 99 was admitted to the facility on [DATE]. Review of Resident 99's Weekly Nursing Summary dated 9/27/22 and 10/18/22, showed Resident 99 did not take antipsychotic medication. However, Review of Resident 99's Medication Administration Record for September and October 2022 showed Resident 99 received Seroquel 25…

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 ensure the freezer compartment inside the resident's refrigerator was free of ice buildup. This had the potential for the refrigerator not being maintained in safe operating condition. Findings: Review of the owner's manual for Upright Reach-Ins Bottom Mounted Condensing Unit (undated), under the Operation, showed the unit is preset to defrost every five to six hours with a duration of 45 minutes or less depending on the evaporator coil temperature. Changing the preset outside of the default range will result in cooling issues and advanced component failure. On 11/1/22 at 0800 hours, an inspection of the freezer in the kitchen was conducted with the DSS. The bottom area of the freezer compartment was observed with a build-up of ice. The DSS verified the above findings. On 11/2/22 at 1215 hours, an interview and concurrent product manual and facility document review was conducted with the Maintenance Director and DSS present. The Maintenance Director stated he cleaned the outside of freezer but did not clean the inside 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.