Regents Point - Windcrest

Based on observation, interview, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure proper medication storage.* The facility failed to ensure expired medication was removed from Medication Cart A. This failure had the potential to negatively impact the residents' well-being.Findings: Review of the facility's P&P titled Medication Administration revised 1/2023 showed Medications are administered as prescribed in accordance with manufacturers' specifications and good nursing principles and practices. Drugs dispensed in the manufacturer's original container will be labeled with manufacturer's expiration date; there will be no expired medications administered to a resident. On 6/9/26 at 0822 hours, a medication administration observation for Resident 34 was conducted with LVN 1. LVN 1 was preparing Resident 34's medications at Medication Cart A. An observation of Resident 34's opened inhaler of levalbuterol 450 mcgs per actuation had an expiration date of 2/28/26. On 6/9/26 at 0855 hours, an interview was conducted with LVN 1. LVN 1…

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

Based on observation, interview, and facility document review, the facility failed to ensure the following: * Federal regulations related to the education qualification requirements of the dietary manager were followed as outlined in the California Code, Health and Safety Code (HSC 1265.4). * The Director of Dining was competent in managing the day-to-day functions of the food and nutrition department. These failures to employ staff with the federal and state mandated qualifications to manage the food and nutrition department, the competencies to effectively and competently run the day to day operations of the food and nutrition department, and to effectively implement departmental processes in accordance with standards of practice, had the potential to jeopardize the health and well-being of the 43 residents who received food prepared in the kitchen. Findings: Review of the facility's List of Residents and Diets for Crosscheck dated 6/7/26, showed 43 of 44 residents consumed food prepared in the kitchen. 1. According to the Health and Safety Code 1265.4, (4) Is a graduate of a…

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

Based on observation, interview, and facility P&P review, the facility failed to ensure the garbage was properly stored in one of one garbage dumpster. This failure had the potential to attract pests or rodents that can carry diseases.Findings: Review of the facility's P&P titled Sanitation and Infection Prevention/ Control: Solid Waste Disposal revised date 1/2025 showed food waste and rubbish in the Food and Nutrition Services Department will be disposed of in an approved manner to prevent contamination of food, clean dishes, or clean working areas. Garbage containers are clean, lined and covered at all times. Keep lids closed on all outside trash receptacles. According to the 2022 FDA (Food and Drug Administration) Food Code, the outside garbage receptacles must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents. On 6/7/26 at 0753 hours, an observation was conducted of the facility's one of one outside garbage dumpster. The garbage dumpster was observed with one of the lids…

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 P&P review, the facility failed to ensure the medical record was complete and accurately maintained, for two of 13 final sampled residents (Residents 3 and 56).*The facility failed to ensure Resident 3's Arbitration Agreement contained the date signatures were obtained for the facility representative and Resident 3's representative.*The facility failed to ensure Resident 3's POLST contained the physician's name and phone number. *Resident 56's POLST failed to show if the resident had formulated an advance directive.These failures had the potential for the residents' care needs not being met as the medical record was incomplete. Findings: 1. a. Medical record review for Resident 3 was initiated on 6/7/26. Resident 3 was admitted to the facility on [DATE], and readmitted on [DATE]. On 6/10/26 at 1630 hours, an interview and concurrent medical record review was conducted with the Administrator. Review of Resident 3's Arbitration Agreement showed a facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary care and services for one of 13 final sampled residents (Resident 11). * The facility failed to ensure the hospice visit calendar, hospice skilled nurse visit notes, and physician's certification for hospice benefits were available and included in Resident 11's medical records. This failure posed the risk of delay in communication between the hospice provider and facility which may affect resident care. Findings: Review of the facility's P&P titled Hospice Program date revised 7/2017 showed the hospice providers who contract with this facility are held responsible for meeting the same professional standards and timeliness of service as any contracted individual or agency associated with the facility. Communicating with the hospice provider (and documenting such communication) to ensure that the needs of the resident are addressed and met 24 hours per day. Our…

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 maintain the infection prevention and control program to prevent the development and transmission of infections. * RN 1 failed to wear required personal protective equipment (PPE) while providing central line care for Resident 24, who was on enhanced barrier precautions (EBP). In addition, RN 1 failed to perform hand hygiene during the medication administration. * LVN 1 failed to perform hand hygiene during the medication administration for Residents 6 and 34. * LVN 2 failed to perform hand hygiene during the medication administration for Resident 5. * The facility failed to ensure clean linens and towels were stored in a manner that protected them from potential contamination in the laundry storage area. These failures had the potential to contribute to the spread of infection within the facility. Findings: Review of the facility's P&P titled Handwashing/Hand Hygiene revised 10/2023 showed hand hygiene is considered the primary means to prevent the spread of healthcare-associated…

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 5. On 5/12/25 at 1036 hours, during the initial tour of the facility, Resident 15 was asleep in bed with the bilateral half side rails elevated at the head of the bed. On 5/13/25 at 0923 hours, Resident 15 was observed lying in bed with the bilateral half side rails elevated. Medical record review for Resident 15 was initiated on 5/12/25. Resident 15 was admitted to the facility on [DATE]. Review of Resident 15's Order Summary Report dated 5/13/25, failed to show a physician's order for the use of bilateral half side rails in bed. Review of Resident 15's H&P examination dated 4/11/24, showed Resident 15 had a diagnosis of failure to thrive, T12 compression fracture (a break in the twelfth thoracic vertebra (T12) located in the mid-back), and osteoporosis (a disease that weakens bones, making them more likely to break). Review of Resident 15's Annual MDS assessment dated [DATE], showed a BIMS score of 9 (scores of 8 to 12 suggest moderate cognitive impairment). On 5/14/25 at 1319 hours, an interview and…

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

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food items were served in appetizing temperatures: * The temperature was not maintained at the acceptable range for cold beverages. This failure posed the risk for not providing palatable and appetizing food for the residents receiving a meal tray from the kitchen. Findings: Review of the facility's Diet Type Report dated 5/12/25, showed 45 of 45 residents consumed the food prepared in the kitchen. Review of the facility's P&P titled Cold Holding and Storage revised date 12/1/22, showed cold TCS (Time/Temperature Control for Safety) food must be held at proper temperatures to prevent harmful bacterial growth and/ or toxin production that can occur if it remains in the temperature danger zone too long. Cold TCS foods must be maintained at 41 degrees Fahrenheit or below during holding, display, service, and transport. On 5/13/25 at 1140 hours, a tray line observation and concurrent interview was conducted with the CDM. The CDM checked and verified 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.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by: * The facility failed to ensure the sanitary condition of the hood over the stove was maintained. * The facility failed to ensure the kitchen utensils had a smooth cleanable surface and in good condition. * The facility failed to ensure the kitchenware and kitchen utensils were clean and free of food particles or residue. * The facility failed to ensure the cutting boards were kept in a sanitary condition and with cleanable surface. * The facility failed to ensure the heavy-duty blenders used for puree preparation were dried and clean prior to storing. These failures had the potential for cross contamination and foodborne illnesses to the residents consuming the food prepared in the facility's kitchen. Findings: Review of the facility's Diet Type Report dated 5/12/25, showed 45 of 45 residents consumed the food prepared in the kitchen. 1. Review of the facility's P&P titled Sanitation and Infection…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the residents' entrapment assessments were accurately completed for nine of 13 final sampled residents (Residents 1, 2, 12, 15, 18, 19, 34, 40, and 397) and one nonsampled resident (Resident 16). This failure had the potential to negatively impact the residents, resulting in possible entrapment, serious injury, and death. Findings: According to the Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, the term entrapment describes an event in which a patient/resident is caught, trapped, or entangled in the space in or about the bed rail, mattress, or hospital bed frame. Patient entrapments may result in deaths and serious injuries. These entrapment events have occurred in openings within the bed rails, between the bed rails and mattresses, under bed rails, between split rails, and between the bed rails and head or foot boards. The population most…

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 written information regarding the right to formulate advance healthcare directives for one of 13 final sampled residents (Resident 19) and one nonsampled resident (Resident 298) reviewed for formulation of advance healthcare directives. This failure had the potential for the residents' decisions regarding their healthcare and treatment options not being honored. Findings: Review of the facility's P&P titled Advanced Directives revised September 2022 showed the following: - Prior to admission of a resident, the social services director or designee inquires of the resident, his/her family members and/or his or her legal representative, about the existence of any written advanced directives. - The resident or representative is provided with written information concerning the right to accept or refuse medical or surgical treatment, and to formulate an advanced directive if he or she choose to do so. - Written…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 13 final sampled residents (Resident 34) was free from accident hazards. The facility failed to implement floor mattress as ordered by the physician as a fall risk precaution for Resident 34. This failure had the potential for serious injury to the resident. Findings: Review of the facility's untitled P&P revised 11/29/22, showed bed safety, for the residents who try to get out of the bed unsafely when alone should be evaluated for a low bed and floor mat. On 5/13/25 at 0926 hours, during an observation, Resident 34 was lying in bed and no floor mattress was placed by the bed. Instead, the floor mattress was leaned against the wall. Medical record review for Resident 34 was initiated on 5/12/25. Resident 34 was admitted to the facility on [DATE]. Review of Resident 34's care plan report showed a care plan focus dated 10/11/24, to address a high risk for falls related to Alzheimer's and dementia…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to maintain the IV access for one nonsampled resident (Resident 299). * The facility failed to ensure the PICC line catheter measurements were obtained and documented. In addition, the facility failed to ensure the PICC line plan of care included the measurements of the length of the external catheter and arm circumference. These failures had the potential to delay the identification of IV catheter related complications for Resident 299. Findings: Review of the facility's P&P titled Central Venous Catheter Care and Dressing Changes dated 10/2024 showed the dressing of the central venous catheter is routinely changed at least every seven days or as needed when the dressing becomes damp, loosened or visibly soiled. The licensed nurse would measure the length of the external central vascular access device with each dressing change or if dislodgement is suspected then…

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 2. Review of the facility's P&P titled CPAP/BiPAP Support revised 3/2015 showed to review the physician's order to determine the oxygen concentration and flow, and the PEEP pressure for the machine. Review and follow manufacturer's instruction for CPAP machine setup and oxygen delivery. Under the general guidelines for cleaning showed the following: - Machine cleaning: to wipe the machine with soapy water and rinse at least once a week and as needed. - Humidifier (if used): use clean, distilled water only in the humidifier chamber; to clean the humidifier weekly and air dry; and to disinfect using vinegar-water solution (1:3) in the clean humidifier. To soak for 30 minutes and rinse thoroughly. - Filter cleaning: to rinse the washable filter under running water once a week to remove dust and debris. - Mask and nasal pillows: to wipe with isopropyl alcohol daily after use. - Tubings and headgear (strap): to wash with soapy water, rinse, and air dry weekly. Review of the ResMed AirSence 10 (CPAP machine) user…

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 2. Review of the facility's P&P titled Medication Administration Subcutaneous dated 2007 showed the licensed nurses to administer medications via the subcutaneous route in a safe, accurate and effective manner. The procedures included the following: - To check the last injection sites and select a new appropriate site for injection. - To document the injection on the MAR along with the site. Medical record review for Resident 597 was initiated on 5/13/25. Resident 597 was admitted to the facility on [DATE]. On 5/14/25 at 1410 hours, an observation and concurrent interview was conducted with Resident 597. Resident 597 was in his wheelchair awake with bluish to greenish discoloration on the posterior right upper arm. Resident 597 stated the nurse gave his injection medication for blood clot on the back of his arm. Review of Resident 597's Order Summary Report dated 5/14/25, showed a physician's order dated 4/29/25, to administer enoxaparin sodium injection 40 mg subcutaneously one time a day for DVT prophylaxis…

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 6.45%. One of two licensed nurses (LVN 1) observed during the medication administration was found to have made errors. * LVN 1 failed to ensure metformin medication (antidiabetic) was administered to Resident 26 with meal as per the physician's orders. * LVN 1 failed to ensure Resident 697 received calcium citrate (supplement) on time following admission to the facility. These failures created the risk for the residents to have potential side effects or complications related to the medications. Findings: 1. Review of the facility's P&P titled Administering Medications dated 4/2019 showed the following: - Medications are administered in accordance with prescriber orders, including any required time frame - Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and facility document review, the facility failed to ensure the Facility Assessment addressed or included the following: 1. Active involvement of required individuals in developing the Facility Assessment;and 2. A contingency plan for staffing needs. This failure had the potential not to meet the residents' care needs if the assessed population's needs and resources were not comprehensively identified and addressed. Findings: According to the CMS QSO-24-13-NH dated 6/18/24, with an implementation date of 8/8/24, the CMS issued revised guidance for long-term care facility assessment requirement. The Facility Assessment should address and included the active involvement of the direct care staff in developing the Facility Assessment. There should also be a contingency plan for staffing needs for events so as not to activate the facility's emergency plan. Review of the Facility's assessment dated [DATE], did not show the direct care staff members, direct care representatives, residents, residents'…

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

3. Review of the facility's P&P titled Bedpan/ Urinal Offering/ Removing dated 2/2018 showed store the bedpan or urinal as per facility policy. Review of the facility's P&P titled Handwashing/ Hygiene dated 8/2019 showed the use of an alcohol-based hand rub at least 62% alcohol or alternatively, soap (antimicrobial or non- antimicrobial) and water: after handling contaminated equipment. On 5/12/25 at 1242 hours, an observation in Resident 597's room and concurrent interview was conducted with CNA 5. Resident 597's urinal containing urine was observed on top of the overbed table near uncovered cups of water and cranberry juice. CNA 5 entered the room, put on gloves, removed the urinal, and discarded the urine to the toilet, rinsed the urinal, and placed the urinal back to Resident 597's overbed table near the uncovered cups of water and cranberry juice. CNA 5 used the same gloves previously used to discarding the contents of the urinal, to move the overbed table and put on socks to Resident 597's feet. CNA 5 acknowledged the urinal was on top of the over bed table and verified he…

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 record reviews, interviews, and document review, the facility failed to ensure the Minimum Data Set (MDS) assessments were accurate for 2 (Resident #3 and Resident #34) of 12 sampled residents. Specifically, the facility incorrectly coded Resident #3 as not being considered by the state level I preadmission screening and resident review (PASARR) process to have a serious mental illness and Resident #34 as not receiving hospice care. Findings included: 1. A review of the Centers for Medicare & Medicaid [NAME] Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2023, revealed Code residents identified as being in a hospice care program for terminally ill persons where an array of services is provided for the palliation and management of terminal illness and related conditions. A review of Resident #34's Profile Face Sheet revealed the facility admitted the resident on 03/10/2023, with diagnoses that included chronic obstructive pulmonary disease, atherosclerotic heart…

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 interviews, record review, and document review, the facility failed to ensure a preadmission screening and resident review (PASARR) evaluation was completed after 1 (Resident #43) of 2 sampled residents reviewed for PASARR received a newly evident possible or serious medical illness. Findings included: A review of a document provided by the facility titled, Preadmission Screening and Resident Review, with a copyright date of 2024, revealed Level I Screening The Screening is submitted online by the facility and is a tool that helps identify possible SMI [serious mental illness] and/or ID/DD/RC [intellectual disability/developmental disability/related condition]. Level II Evaluation If the Screening is positive for possible SMI and/or ID/DD/RC, then a Level II Evaluation will be performed. The Level II Evaluation helps determine placement and specialized services. A review of Resident #43's Profile Face Sheet revealed the facility admitted the resident on 03/20/2024, with diagnoses to include major depressive disorder and dementia. A review of Resident #43's quarterly Minimum…

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 record review, interviews, and facility policy review, the facility failed to ensure staff followed the physician's order to notify the physician when a resident's blood glucose level was above 300 milligrams per deciliter (mg/dL) and failed to hold a medication when the resident's systolic blood pressure (SBP) was greater than 140 milligrams of mercy (mmHg) for 1 (Resident #107) of 5 sampled residents reviewed for unnecessary medications. Findings included: A review of the facility policy titled, Non-controlled Medication Orders, dated January 2023, revealed Medications are administered only upon the receipt of a clear, complete and signed order by a person lawfully authorized to prescribe. A review of Resident #107's Profile Face Sheet revealed the facility admitted the resident on 04/24/2024, with diagnoses to include type 2 diabetes mellitus, hypotension, long term use of insulin, and need for assistance with personal care. A review of Resident #107's Interim Care Plan, initiated on 04/24/2024, revealed the resident was admitted with a diagnosis of diabetes and needed…

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 observations, interviews, record review, document review, and facility policy review, the facility failed to ensure staff changed their gloves during the provision of catheter care for 1 (Resident #33) of 2 sampled residents reviewed for urinary catheters. The facility also failed to ensure staff disinfected a glucometer after use for 2 (Resident #16 and Resident #110) of 6 residents observed for medication administration. Findings included: 1. A review of the facility policy titled, Handwashing/Hand Hygiene, revised in October 2023, revealed this facility considers hand hygiene the primary means to prevent the spread of healthcare-association infections. The policy specified, Indications for Hand Hygiene 1. Hand hygiene is indicated: a. immediately before touching a resident; b. before performing an aseptic task; c. after contact with blood, body fluids, or contaminated surfaces; d. after touching a resident; e. after touching the resident's environment; f. before moving from work on a soiled body site to a clean body site on the same resident; and g. immediately after…

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

Based on record review, interviews, and facility policy review, the facility failed to ensure a pneumococcal vaccine was administered once consent was received for 1 (Resident #25) of 5 sampled residents reviewed for immunizations. Findings included: A review of the facility policy titled, Pneumococcal Vaccine, revised in March 2022, revealed, All residents are offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Per the policy, 4. Pneumococcal vaccinations are administered to residents per our facility's physician-approved vaccination protocol. A review of Resident #25's Profile Face Sheet revealed the facility admitted the resident on 05/02/2023, with diagnoses to include pneumonitis due to inhalation of food and vomit, permanent atrial fibrillation, and rheumatoid arthritis. A review of Resident #25's Immunization Report for Residents, dated 07/18/2017 - 05/03/2024, revealed the resident received a pneumococcal vaccine on 07/18/2017. A review of Resident #25's medical record to indicate the resident received a follow-up pneumococcal vaccine after…

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

Based on observation, interview, facility P&P review, and medical record review, the facility failed to implement the infection control practices designed to provide a safe and sanitary environment and help prevent the development and transmission of diseases and infections for 16 nonsampled residents on Station 2. * The facility failed to ensure the CNA followed the contact precautions to wear not only N95 and face shield but also gown and gloves before entering the Covid-19 isolation rooms. * The facility failed to ensure the Housekeeper followed the contact precautions for Covid-19 isolation room regarding the use and disposal of a gown. * The facility failed to ensure the licensed nurse followed the contact precautions to wear not only N95, gown, and gloves, but also face shield when passing the medications to the residents who were on Covid-19 isolation in Station 2. These failures posed the risk for the transmission of disease-causing microorganisms. Findings: According to CDC, Coronavirus 2019 (COVID-19) Factsheet, to use PPE when caring for patients with confirmed 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 and medical record review, the facility failed to ensure one of two sampled residents (Resident 1) was provided the necessary care and services after a fall. * Resident 1 fell while the resident was being transferred by two staff members from the shower chair to the bed. The nursing staff did not conduct a post fall assessment and monitor the resident for any change in condition after the fall. This failure had the potential for Resident 1 not receiving appropriate care in a timely manner. Findings: On 9/7/23, medical record review for Resident 1 was initiated. Resident 1 was readmitted to the facility on [DATE]. Review of Resident 1 ' s History and Physical Examination dated 6/10/23, showed Resident 1 did not have capacity to understand or make decisions. Resident 1 had a diagnosis of osteopenia. Review of the fall risk assessment dated [DATE], showed Resident 1 was a low risk for falls. Review of the MDS Quarterly assessment dated [DATE], showed Resident 1 was totally dependent on two 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.