Bonita Hills Post Acute

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 respiratory care services for one of two final sampled residents (Resident 1) reviewed for tracheostomy services, and four of five residents (Residents 8, 22, 69, and 85) reviewed for oxygen therapy. * The facility failed to ensure only qualified staff managed the resident's oxygen delivery equipment. The SSD was observed turning Resident 1's oxygen concentrator off and on, in an attempt to troubleshoot a potential malfunction. * The facility failed to follow the physician's order for the administration of continuous oxygen for Resident 8. Resident 8 had an order to receive continuous oxygen at three LPM, however, Resident 8 received continuous oxygen at a rate of four LPM. * The facility failed to ensure Resident 22's nasal cannula tubing was dated and remained off of the floor. * The facility failed to document on the resident's MAR the administration of the oxygen to Resident 69. * 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 the appropriate pain management was provided for three of three final sampled residents (Residents 10, 59, and 85) reviewed for pain management. * The facility failed to administer the pain medication according to the physician's order and failed to ensure the non-pharmacological pain interventions were implemented prior to the administration of the PRN pain medications for Resident 59. * The facility failed to ensure the non-pharmacological pain interventions were implemented and documented prior to the administration of the PRN pain medications to Residents 10 and 85. These failures had the potential to put Residents 10, 59, and 85 at risk for ineffective pain management and adverse effects related to the use of unnecessary pain medication.Findings: Review of the facility's P&P titled Pain Management revised 3/17/25, showed based upon the pain evaluation, the facility in collaboration with the attending…

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 dialysis care was provided for one of three final sampled residents (Resident 28) reviewed for dialysis. * The facility failed to ensure a physician's order for the peritoneal dialysis was obtained including the care of the dialysis access site of Resident 28. These failures had the potential for medical complications related to not obtaining the physician's order for dialysis care.Findings: Review of the facility's P&P titled Peritoneal Dialysis dated 12/19/22, showed the physician's order for the individualized prescriptions must include at least the number of exchanges or cycles to be done during each dialysis session, the volume of fluid with each exchange, duration of fluid in the peritoneal cavity, the concentration of glucose or other osmotic agent to be used for fluid removal, and the use of automated, manual or combined techniques. Before, during and after receiving the peritoneal dialysis, the 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 interview, medical record review, and facility P&P review, the facility failed to ensure accurate controlled medication records for one nonsampled resident (Resident 87). * Resident 87's MAR for October and November 2024 failed to show the Oxycodone/APAP (a controlled pain medication) documented on the Antibiotic or Controlled Drug Record were administered to the resident when the medication was removed from the medication supply. This failure resulted in inaccurate accounting of a controlled medication and the potential for drug diversion. Findings: Closed medical record review for Resident 87 was initiated on 8/8/25. Resident 87 was readmitted to the facility on [DATE], and discharged on 11/25/24. Review of Resident 87's Antibiotic or Controlled Drug Record for Oxycodone/APAP (a controlled pain medication) 5-325 mg tablets initiated on 10/28/24 at 1853 hours, showed the following:- On 10/31/25 at 1330 hours, one tablet was removed from the medication supply.- On 11/4/24 at 1030 hours, one tablet 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 interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the consultant pharmacist performed a monthly Medication Regimen Review to identify potential medication irregularities for two of five sampled residents (final sampled residents, Residents 28 and 65) reviewed for unnecessary medications. * The facility failed to ensure the Medication Regimen Review conducted by the consultant pharmacist in June and July 2025 for Resident 65 addressed the use of two antidepressant medications (mirtazapine and trazodone) and antipsychotic medication (Risperidone). *The facility failed to ensure the Medication Regimen Review conducted by the consultant pharmacist for July 2025 for Resident 28 addressed the irregularities and inaccurate monitoring of the poor meal intake of less than 50% of his meals, as ordered by the physician. These failures placed the residents at risk for adverse outcomes related to the medications they were receiving.Findings: 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 one of 21 final sampled residents (Resident 59) was free from the unnecessary medications. * The facility failed to follow the physician's order to hold the metoprolol (blood pressure medication) medication when Resident 59's SBP (Systolic Blood Pressure) was less than 120 mmHg. This failure had the potential for Resident 59 to develop significant adverse and side effects from the medication. Findings: Review of the facility's P&P titled Medication Administration revised 12/19/22, showed the medications were administered by the licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician. Further review of the P&P showed to obtain and record the vital signs, when applicable or per the physician's orders. When applicable, hold the medication for those vital signs outside the physician's prescribed parameters. To administer the medication as ordered in accordance with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 29.63%. Two of three licensed nurses (LVNs 3 and 5) were found to have made errors during the medication administration observations. * LVN 3 failed to administer the complete dose for six of Resident 2's medications when significant residual of the medications were observed in the medication cups and nebulizer cup. In addition, LVN 3 combined two GT medications and failed to administer the two medications as per the physician's order. * LVN 5 failed to obtain Resident 33's heart rate prior to the administration of the carvedilol (blood pressure medication). These failures had the potential to negatively affect the residents' health.Findings: Review of the facility's P&P titled Medication Administration revised 12/19/22, showed the medications were administered by the licensed nurses, or other staff who are legally…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility P&P review, the facility failed to ensure proper labeling and storage of the drugs and biologicals in a safe manner for one of one medication room (Medication Room B), and for three of three medication carts (Medication Carts A, B, and C) inspected.* The facility failed to ensure the 0.9% sodium chloride flush (a sterile solution used to maintain the patency of intravenous catheters and prevent complications) was not kept in Resident 59's room.* A bottle of Multivite (liquid supplement) and a bottle of LiquaCel (liquid protein) were observed with a sticky brown residue in Medication Cart B.* The facility failed to dispose of the expired medical supplies in Medication Room B.* The facility failed to dispose of expired medical supplies in Medication Cart C.* The facility failed to ensure proper storage of unopened insulin (medication to control blood glucose levels) pen stored at room temperature inside Medication Cart A. These failures had the potential for 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, and facility document review, the facility failed to ensure one of five residents reviewed for dining (Resident 67) received food prepared in a form to meet the resident's individual dietary needs. * The facility failed to ensure Resident 67 was provided with a soft and bite-size texture diet. This failure had the potential to cause choking in a medically vulnerable resident. Findings: Review of the facility's document title Diet Count by Diet dated 8/5/25, showed there was five residents on a soft and bite sized (SB6) diet. Review of the IDDSI (International Diet Dysphagia Standardization Initiative- a global framework that standardizes the terminology and definitions used for texture-modified foods and thickened liquids for people with dysphagia) showed soft bite sized meats (SB6) should be no larger than 1.5 cm equivalent to 1/2 an inch.…

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 residents' food brought from outside sources was stored for future consumption. * The facility failed to provide refrigerated storage for the residents' food brought from outside sources. This failure had the potential to negatively impact all the residents who received an oral diet and resided in the facility. Findings: Review of the facility's matrix dated 8/5/25, showed 62 residents were on an oral diet. Review of the federal guidelines in the State Operations Manual S483.60(i)(3) showed the facility must have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption. Review of the facility's P&P titled Outside Food Brought in by Family and Visitors revised 1/25/24, showed all the food items that are prepared by the family or visitor brought in must be approved per nursing to ensure it is in accordance with the Diet Order and eaten within two hours of receiving 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 and interview, the facility failed to ensure the organic trash was disposed of properly. * The facility failed to separate the organic trash from their regular trash. This failure had the potential to increase the environmental impact of the facility, thus adversely impacting all the 71 residents' health who resided in the facility. Findings: Review of the Senate [NAME] 1383 regulation dated 1/1/22, showed every jurisdiction was to provide organic waste collection services to all residents and businesses. Jurisdiction includes city, county, city and county, or a special district that provides solid waste collection services. Organic waste includes food, green material, landscape and pruning waste, organic textiles and carpets, lumber, wood, paper products, printing and writing paper, manure, biosolids, digestate, and sludges. On 8/5/25 at 1515 hours, an observation of the outside trash dumpster area and concurrent interview was conducted with the DSS. The DSS stated the kitchen staff separated the organic food waste and discarded it in the organic trash bin. Two…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to implement the infection control practices designed to provide a safe and sanitary environment and prevent the transmission of diseases and infections for six of 21 final sampled residents (Residents 2, 3, 4, 46, 59, and 83). * The facility failed to ensure LVN 3 donned the gown during the medication administration observation for Resident 2. Resident 2 was on EBP (Enhanced Barrier Precaution) for her GT (Gastrostomy Tube). * CNA 8 failed to follow the EBP infection control practices while providing care to Resident 3. * LVN 6 failed to follow the EBP infection control practices while administering the GT enteral feeding for Resident 4. * LVN 1 failed to follow the infection control practices while performing the wound care for Resident 46. * The facility failed to implement the EBP as per the facility's P&P for Resident 59, who had a right upper arm PICC (Peripherally Inserted Central…

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 P&P review, and CDC Immunization Recommendations, the facility failed to offer the COVID-19 vaccinations to three of seven residents (Residents 7, 17, and 18) reviewed for immunizations. * Residents 7, 17, and 18 were eligible to receive the COVID-19 vaccine, in accordance with the facility's P&P and CDC recommendations. However, the facility failed to offer the COVID-19 vaccine to these residents. These failures increased the residents' risk for being inadequately vaccinated against COVID-19 infection and placed the residents at risk for negative health outcomes were they to develop the COVID-19 infection.Findings: Review of the CDC Recommended Adult Immunization Schedule dated 2025 showed the recommended routine COVID-19 vaccinations for individuals aged 65 years and older. The recommendations showed the following: For individuals previously vaccinated before 2024-25 vaccine with: * One or more doses Moderna or Pfizer-BioNTech: Administer one dose 2024-25…

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, facility document review, and facility P&P review, the failed to implement and maintain an effective training program for the existing facility staff. * The facility failed to ensure only qualified staff managed the resident oxygen delivery equipment. The SSD was observed turning Resident 1's oxygen concentrator off and on, in an attempt to troubleshoot a potential malfunction. * The facility failed to complete the annual skill performance for LVN 3. * The facility failed to ensure the facility staff scheduled for the 11-7 shift were provided with the in-services on 2/21 and 3/22/25. These failures posed the risk for untrained facility staff providing care to residents, which posed the risk for adverse events and negative health outcomes.Findings: 1. Medical record review for Resident 1 was initiated on 8/5/25. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's physician's order dated 5/25/25, showed an order for oxygen to be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the comprehensive plan of care interventions were implemented for a suspected allegation of financial abuse for one of three sampled residents (Resident 1). This failure had the potential for not providing care and services to meet the residents' needs. Findings: Review of the facility's P&P titled Care Plan Revisions Upon Status Change revised 12/2022 showed the following: 1. The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change. 2. Procedure for reviewing and revising the care plan when a resident experiences a status change: a. upon identification of a change in status, the nurse will notify the MDS coordinator, the physician, and the resident representative, if applicable. b. the MDS coordinator and the interdisciplinary team will discuss the resident condition and collaborate on intervention options. c. the team meeting…

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, and facility P&P review, the facility failed to ensure Resident 1 was provided a bed hold for up to seven days when Resident 1 returned to a different room and bed upon readmission to the facility on 1/2/25. In addition, the facility failed to provide Resident 1 and/or the resident's representative a written bed hold policy upon transfer to an acute care hospital. These failures had the potential for Resident 1 and/or the resident's representative to be not informed of their rights to return to the facility following hospitalization. Findings: Medical record review for Resident 1 was initiated on 1/17/25. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 1's MDS dated [DATE], showed Resident 1 had a BIMS score of two, indicating severe cognitive impairment. Review of Resident 1's eInteract Transfer Form dated 1/1/25, showed Resident 1 was transferred to the acute care hospital on [DATE]. 1. 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 observation, interview, medical record review, and facility P&P review, the facility failed to implement infection control practices designed to provide a safe and sanitary environment and help prevent the development and transmission of disease and infections. * Resident 2 who had salmonella was cohorted with Resident 1 who did not have salmonella. * RN 1 failed to perform hand hygiene and don the gloves and gown on while providing care for Resident 2 who was on contact isolation precautions. * The facility failed to ensure a visitor donned the gloves and gown on while sitting on Resident 2's bed. * The facility failed to ensure Caregiver 1 donned a gown on while feeding Resident 1 who was inside an isolation room for a contact precaution. Findings: 1. Review of the facility's P&P titled Transmission-Based (Isolation) Precautions revised 7/18/23, showed it is the policy to take appropriate precautions to prevent transmission of pathogens, based on pathogens' modes of transmission. Contact precautions…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary care and services for one of five sampled residents (Resident 3). * The facility failed to monitor Resident 3's wound separation for the forehead area and skin breakdown for the left and right arm area every shift as ordered. * The facility failed to notify the physician of the changes in Resident 3's wound separation for the forehead area and skin breakdown for the left and right arm area as documented on the TAR. These failures had the potential to negatively impact Resident 3's well-being. Findings: Review of the facility's P&P titled Skin Assessment revised 12/19/22,showed a full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, and weekly thereafter. The assessment may also be performed after a change of condition. Medical record review for Resident 3 was initiated on 11/14/24. Resident 3 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 interview and medical record review, the facility failed to ensure the ST had evaluated the resident with an order for thicken liquid as per the facility's P&P for one of five sampled residents (Resident 2). This failure had the potential for not providing necessary care and services to the resident. Findings: Review of the facility's P&P titled Thickened Liquids date implemented 12/2022, showed the thickened liquids are provided when ordered by a physician/practitioner or when ordered by a dietitian or speech-language pathologist who has been delegated to write diet orders, to the extent allowed by state law. The use of thickened liquids will be based on the resident's individual needs as determined by the resident's assessment and will be in accordance with the resident's goals and preferences. The reason for thickened liquids is to be documented in the medical record and/or indicated on the resident's comprehensive plan of care. Residents with swallowing difficulties or orders for thickened liquids…

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 five of five sampled residents (Residents 1, 2, 3, 4, and 5) remained free from the accident hazards. * The facility failed to assess the residents' ability to handle the containers and consume the hot beverages as per the facility's P&P for Residents 1, 2, 3, 4, and 5. Resident 1 spilled a cup of hot chocolate on her chest, causing redness and blisters to Resident 1's right side of chest. Resident 2 also spilled coffee on his lap. These failures posed the risk of injury to the residents who were consuming hot liquids in the facility. Findings: Review of the facility's P&P titled Hot Liquid Safety (undated) showed all residents are assessed for their ability to handle the containers and consume hot liquids. Residents with difficulties will receive the appropriate supervision and use of the assistive devices to drink hot liquids. Interventions will be individualized and noted on the resident's plan of 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 to ensure the food was prepared in a form to meet the resident's needs for one of five sampled residents (Resident 2). * Resident 2 did not receive thickened liquids as ordered. * The facility staff who were serving the hot beverage lacked knowledge in preparing a thickened liquid. These failures placed Resident 2 at risk for aspiration (when food or liquids are breathed into the lungs). Findings: Review of the facility's P&P titled Serving a Meal revised 12/2022 showed diets should be served in accordance with the physician's order. The P&P showed to use thickened liquids as provided by the dietary department. a. On 10/3/24 at 1140 hours, a concurrent observation and interview was conducted with Resident 2. Resident 2 was observed in his room sitting in a wheelchair and using his right leg to move the wheelchair. A maroon-colored cup was observed with regular consistency light brown colored liquid at the resident's overbed table.…

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 an allegation of staff to resident abuse was reported to the State Agency and failed to investigate an allegation of staff to resident abuse for one of five sampled residents (Resident 1). * The facility was informed by Resident 1's family that Resident 1 allegedly felt intimidated by the care a CNA provided to Resident 1. However, the facility failed to report the allegation to the State Agency, failed to investigate the allegation, and failed to report the results of the investigation to the State Agency within 5 working days of the alleged incident, in accordance with the facility's Abuse, Neglect and Exploitation P&P. This failure resulted in the State Agency not being notified of the resident's allegation of abuse, which posed the risk for inhibiting the State Agency from determining whether resident abuse occurred and thus ensuring the safety of the residents. Additionally, the facility's failure 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 ensure the resident's right to remain in the facility was permitted. The facility initiated a transfer/discharge of the resident without having first met the regulatory requirements, specific to a facility-initiated transfer/discharge for one of five sampled residents (Resident 1). * After Resident 1 exceeded her ordered out-on-pass time and missed her scheduled medications, the facility obtained a discharge against medical advice order. However, Resident 1 returned to the facility and wanted to enter the facility, at which time the facility did not allow Resident 1 to enter the facility. The facility failed to notify Resident 1's physician that Resident 1 had returned to the facility. The facility failed to conduct an assessment of Resident 1 upon her return to the facility. The facility failed to coordinate transition of care with a receiving facility. The facility failed to provide Resident 1 or her family with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to provide a notice of transfer/discharge to the resident and resident's representative, before the facility initiated a transfer/discharge for one of five sampled residents (Resident 1). This failure posed the risk for Resident 1 and Resident 1's representative not being aware of their appeal rights and potentially jeopardizing the appeal process in the event Resident 1 and/or Resident 1's representative felt the facility-initiated transfer or discharge from the facility was inappropriate and involuntary. Findings: Review of the facility's P&P titled Transfer and Discharge (including AMA) revised 12/19/22, showed the facility's transfer/discharge notice will be provided to the resident and the residents representative in a language and manner in which they can understand. The notice will include all of the following (information) at the time it is provided: the specific reason and basis for the transfer or discharge. 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 one of five sampled residents (Residents 4) received care and services to address their pain and skin condition. * Resident 4 complained of pain; however, the resident's pain was not comprehensively assessed for location, timing, frequency, duration of pain, pattern, radiation of pain. There were no nonpharmacological interventions offered before the pain medication administration. Resident 4 complained of moderate pain but was given a pain medication prescribed for severe pain. In addition, the physician was not informed of the resident's moderate pain. * Resident 4 was admitted with multiple skin issues; however, the resident's skin was not comprehensively assessed for description of size, location, drainage, pain, odor, type of tissue in wound bed, the extend of redness, and skin discoloration. These failures had the potential for not providing necessary care and services to meet the care needs for this 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 ensure one of five sampled residents (Resident 5) remained free from accident hazards. * While residing at the facility, Resident 5 sustained five falls. On 9/19/24 at 1340 hours, Resident 5 informed the CNA she needed to use the bathroom; however, the CNA failed to provide the resident with assistance; and at 1430 hours (per the medical record), Resident 5 was found lying on the floor in the bathroom and sustained a fractured right humerus after she attempted to transfer herself to the toilet. This failure resulted in the resident sustaining a fracture to the right humerus and hospitalization. Findings: Review of the facility's P&P titled Accidents and Supervision revised 12/19/22, showed the resident environment will remain as free of accident hazards as possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes identifying hazards and risks and implementing…

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 for the indwelling urinary catheter care to restore as much normal bladder function as possible for one of five sampled residents (Resident 4). * The catheter care was not provided in accordance with the facility's P&P for Resident 4. This failure posed the risk for the development of infection. Findings: Review of the facility's P&P titled Appropriate Use of Indwelling Catheters dated 12/19/22, showed each resident will be assessed at admission regarding continence status and whenever there is a change in urinary tract function (such as admitted continent of urine and subsequently becomes incontinent). Staff completing the assessment should consider the following: - patterns of fluid intake, such as amounts, time of day, alterations and potential complications, such as decreased or increased urine output, - documentation to support decision making will be included 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.

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 when: 1. The kitchen equipment were not air dried before storage. 2. The cutting boards were not kept in sanitary condition and with cleanable surfaces. 3. A thawing process was not followed for meats. 4. The ice machine ice storage bin's splash guard and outside left area of ice machine were not clean. These failures posed the risk for food borne illnesses in highly susceptible resident population of 75 facility residents who received food prepared in the kitchen. Findings: Review of the facility matrix showed 75 of 77 residents consumed food prepared in the kitchen. 1. Review of the facility's P&P titled Dish and Utensil Procedure dated 3/03/20, showed dishes, trays, and utensils shall be air dried before storage. Do not towel dry. On 7/09/24 at 0742 hours, during the initial tour of the kitchen with the Dietary Supervisor, the following items were observed stored wet: - two clear containers stored on top of each…

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 determine if it was safe for two of 18 final sampled residents (Residents 59 and 72) and one nonsampled resident (Resident 9) to self-administer the medications. * Resident 59 was observed with a bottle of Lung Cleansing Spray Fast Absorption Active Antibacterial Action (used to thin out mucus in the airways) at bedside. Resident 59 did not have the assessment, physician's order, and care plan addressing the resident's self administration of medications. * Resident 72 was observed with two packets of hydrocortisone acetate (used to treat skin swelling, itching and redness) 1% cream and a tube of Pain-A-[NAME] (used to treat muscle pain) pain relieving cream at bedside. Resident 72 did not have the assessment, physician's orders, and care plan addressing the resident's self administration of medications. * Resident 9 was observed with the medication at bedside. Resident 9 did not have the physician's order,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure two of three final sampled residents (Residents 62 and 476) reviewed for ADs were assisted in formulating the ADs. This failure had the potential for the facility to provide treatment and services against the resident's wishes. Findings: Review of the facility's P&P titled Residents' Rights Regarding Treatment and Advance Directives revised on 12/2022 showed the facility is to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an advance directive. The P&P defines an AD as a written instruction, such as a living will or durable power of attorney for health care, recognized under State law (weather statutory or as recognized by the courts of the State), relating to the provision of healthcare when the individual is incapacitated. The P&P further showed on admission, the facility will determine if the resident has executed an AD, and if not,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure the notice of transfer/discharge information and notification of Ombudsman regarding transfer/discharge were completed for one of three closed medical records (Resident 33) reviewed. * The facility failed to document Resident 33's notice of transfer/discharge information in the medical record and provide documentation the Ombudsman was notified. This failure had the potential of miscommunication of information and not providing necessary care and services for this resident. Findings: Review of the facility's P&P titled Transfer and Discharge (including AMA) revised 12/19/22, showed the facility's transfer/discharge notice will be provided to the resident and the resident' s representative in a language and manner in which they can understand. The notice will include all of the following at the time provided: a. The specific reason and basis for transfer or discharge. b. The effective date of transfer or discharge c.…

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 coordinate an assessment with the PASRR program for two of 18 final sampled residents (Residents 13 and18) reviewed for PASRR as evidenced by: * The facility failed to update Resident 13's PASRR when the resident had a new diagnosis of mental disorder, for the PASRR level II review. * Resident 18's initial Level 1 PASSR screening conducted on 4/22/22, was positive for mental illness and no Level II mental health evaluation was performed. These failures posed the risk for Residents 13 and 18 not receiving the necessary specialized services specific to treat mental illness and had the potential for inappropriate placement in a skilled nursing facility. Findings: Review of the facility's P&P titled Resident Assessment - Coordination with PASRR Program revised 12/2023 showed the facility coordinates assessments with the preadmission screening and resident review (PASRR) program under Medicaid to ensure that individuals with a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to provide the necessary care and services for one of 18 final sampled residents ( Resident 57) to ensure the resident maintained their highest physical well-being. * The facility failed to follow Resident 57's physician's order to provide the winged LALM (a special mattress designed to distribute the resident's body weight to prevent skin breakdown). This failure had the potential for Resident 57 to not receive the appropriate care and services needed. Findings: Medical record review for Resident 57 was initiated on 7/9/24. Resident 57 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 57's H&P examination dated 3/10/24, showed Resident 57 could make needs known but could not make medical decisions due to Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). Review of Resident 57's physician's order dated 6/14/24, showed to provide winged LALM, check…

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 respiratory care and services for three of five final sampled residents (Residents 57, 62, and 726) reviewed for respiratory care. * The facility failed to ensure Resident 57 was administered oxygen as ordered by the physician. * The facility failed to ensure Resident 62's continuous oxygen was administered as ordered. * The facility failed to ensure Resident 726's incentive spirometer was stored in a bag when not in use and the use of incentive spirometer addressed in the plan of care. These failures had the potential to negatively affect the respiratory health and well-being of the residents in the facility. Findings: Review of the facility's P&P titled Oxygen Administration revised 5/20/24, showed oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goal and preferences.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the ongoing assessment before, during, and after dialysis treatments for one of two final sampled residents (Resident 476) reviewed for dialysis services was accurate. This failure had the potential of not identifying negative outcomes for the dialysis resident (Resident 476). Findings: Review of the facility's P&P titled Hemodialysis revised 9/2022 showed ongoing assessment and oversight of the resident before, during and after dialysis treatments, including monitoring of the resident's condition during treatments, monitoring for complications, implementation of appropriate interventions, and using appropriate infection control practices. The P&P also showed the nurse will monitor and document the status of the resident's access site(s) upon return from the dialysis treatment to observe for bleeding or other complications. Medical record review for Resident 476 was initiated on 7/9/24. Resident 476…

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 proper storage, and disposal of medications. * The facility failed to dispose of the expired medications including three pieces of Bisacodyl (laxative) 10 mg suppositories which were stored together with Goodsense Clearlax Polyethylene Glycol 3350 Powder for Solution Osmotic Laxative (oral medication house supply). * The facility failed to dispose of the wasted narcotic medication stored in Medication Cart A. These failures had the potential for the medications to be accidentally administered and/or diverted. Findings: 1. Review of the facility's P&P titled Medication Storage revised 12/19/22, showed the facility ensures all medications on their premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation and security.…

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 facility P&P review, the facility failed to ensure the use and storage of food brought to the facility by the family members or visitors with safe food handling practices. This failure had the potential for unsafe food handling which could lead to food borne illness. Findings: Review of the facility's P&P titled Food: Safe Handling for Foods from Visitors dated (unknown) showed it is the center's policy to assist residents in properly storing and safely consuming foods brought into the center for residents by visitors. When bringing food items intended for later consumption, the responsible staff member will: - Ensure that foods are in a sealed container to prevent cross contamination. - Label foods with resident name and the current date. - Determine whether food items are shelf stable and can be stored in the resident room or properly stored under refrigeration. On 7/10/24 at 0845 hours, an observation and concurrent interview was conducted with LVN 1. LVN 1 stated the facility did not have a designated refrigerator for the residents' food brought by the…

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

Based on observation, interview, medical record review, and facility document review, the facility failed to implement their infection control program when: * CNA 2 failed to wear the proper PPE when performing the high-contact care for one nonsampled resident (Resident 579) who was on Enhanced Barrier Precautions. * A soiled cloth pad was placed on top of the toilet tank of adjoining bathroom of Rooms A and C. * CNA 4 did not sanitize her hands before and after providing care for one of 18 final sampled residents (Resident 55) and one nonsampled resident (Resident 53). These failures posed the risk for transmission of communicable diseases to other residents in the facility. Findings: 1. Review of the facility's guideline Titled Enhanced Barrier Protection in Nursing Homes (undated) showed a quiz form showing Question #2. Enhanced Barrier Precautions include the use of gowns and gloves during which high contact care activities? The provided key answers include: A. Bathing/showering; C. Providing Hygiene; D. Changing briefs or assisting with toileting; E. Device care or use: central…

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 safe operating condition when: * The 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 they were intended and in turn cause contamination of food, leading to illnesses for the residents. Findings: Review of the USDA Food Code 2022, 4-501.11, Good Repair and Proper Adjustment showed equipment shall be maintained in a state of repair and condition. Review of the facility's P&P titled Ice Machine Cleaning Procedures showed dated 2020 showed the ice machine needs to be cleaned and sanitized monthly, the internal components are cleaned monthly or per the manufacturer's recommendations; and information about the operation, cleaning and care of the ice machine can be obtained from owner's manual, the manufacturer and/or in the directional panel on the side of the ice machine. Review of the Scotsman Ice System Installation and User's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the residents' entrapment assessments were complete and the measurements were recorded during the bed inspection when identifying areas of possible entrapment with the use of side rails for two of 18 final residents (Residents 17 and 62) and one nonsampled resident (Resident 726) reviewed for the side rails use. * The facility failed to ensure Residents17, 62, and 726's entrapment assessments were completed and included the assessments for Zones 6 and 7. These failures 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…

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 three sampled residents (Resident 2). * The licensed nurse did not follow the physician's order to hold the antihypertensive medication when the resident's blood pressures were below the prescribed parameter for Resident 2. This failure had the potential for Resident 2 to experience adverse effects. Findings: Review of the facility's P&P titled Medication Administration-General Guidelines dated 10/2017 showed the medications are administered in accordance with the attending physician's written orders. Medical record review for Resident 2 was initiated on 3/5/24. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's MDS dated [DATE], showed Resident 2 had a diagnosis of hypertension (high blood pressure). Review of Resident 2's Order Summary Report for February 2024 showed a physician's order…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to one of three sampled residents (Resident 1). * The facility failed to notify Resident 1's primary care physician regarding a missed dialysis (a process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally) appointment. * The facility failed to document and notify Resident 1's primary care physician regarding significant weight changes. These failures had the potential for the primary care physician to not be aware of changes in Resident 1's care and needs. Findings: Review of the facility's P&P titled Hemodialysis dated 12/19/22, showed the facility will communicate with the dialysis facility, attending physician and/or nephrologist of any significant weight changes. In addition, thefacility will communicate with the attending physician, dialysis facility and/or nephrologist of any…

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 sanitary requirements were met in the kitchen. * The facility failed to ensure proper labeling and dating of food items in the kitchen, dry storage, and refrigerator. * The facility failed to ensure proper storage of the employees' food in the kitchen. * The facility failed to ensure the kitchen equipment and utensils were clean. * The facility failed to ensure the cutting boards were in sanitary condition. * The facility failed to ensure the resident dishware had a smooth cleanable surface. * The facility failed to air dry the dietary equipment. * The facility failed to ensure the employee personal items were not stored in the food preparation area. * The facility failed to provide a thermometer inside the dry storage area to ensure the food items were stored in adequate storage conditions between 50-70 degrees F. * The facility failed to ensure the proper use of sanitizing solution. * The facility failed to ensure the chlorine test strips were not expired * The facility failed to accurately…

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 h. Medical record review for Resident 30 was initiated on 1/14/22. Resident 30 was admitted to the facility on [DATE]. Review of the Order Summary Report dated 12/1/21, showed a physician order dated 9/10/21, to have RNA perform PROM exercise to all extremities three times per week every day shift for 3 months ending on 12/10/21 Review of Resident 30's Restorative record of November, December 2021, and January 2022 showed RNA services provided on the following entries: - 11/11 and 11/25/21 - 12/15 and 12/29/21 - 1/5 and 1/7/22. There were missing RNA services documentation for the months of November, December 2021, and January 2022 for Resident 30. i. Medical record review for Resident 25 was initiated on 1/14/22. Resident 25 was admitted to the facility on [DATE]. Review of Resident 25's Order Summary Report dated 12/1/21, showed a physician order dated 10/9/21, to have RNA provide exercises to the resident's left and right lower extremities three times per week every day shift for 3 months ending on 1/10/22;…

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 store the drugs and biologicals in a safe manner. * An expired bottle of lorazepam oral concentrate (medication for anxiety) was observed in Medication Cart 1. In addition, a bottle of lorazepam oral solution was stored in the medication drawer and not refrigerated as per the manufacturer's instruction. * Multiple expired, unlabeled medications with no open dates were observed in Treatment Cart 1. * Multiple expired medications were observed in Medication Cart 2. In addition, Medication Cart 2 was observed being unlocked and unattended on multiple occasions. * IV/Crash Cart 1 had an expired medication and was left unlocked. These failures had the potential to result in unsafe administration and diversion of medications. Findings: According to the facility's P&P titled,Storage and Expiration, Dating of Medications, Biologicals, Syringes and Needles revised on 10/29/2019, under the section Procedure, showed the facility should ensure the medications and biologicals that expired are stored separately until…

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 facility document review, the facility failed to establish and maintain the infection control practices designed to provide a safe and sanitary environment and help prevent the development and transmission of diseases and infections. * There were no contact precaution signs posted outside Rooms A, B, C, D, and E in the facility's Yellow zone. * The facility failed to ensure the staff donned the necessary PPE prior to entering the contact precaution rooms. In addition, CNA 1 failed to don a gown when providing ADL care to Resident 498 who was on contact precaution. * Maintenance Supervisor 1 entered a resident's room in the Yellow zone without donning the proper PPE. Maintenance Supervisor 1 was not wearing the N95 (a particulate-filtering Facetime respirator) properly. * LVN 1 crossed the Red zone plastic barrier to enter the Yellow zone. * LVN 1 failed to correctly don the N95 mask. These failures had the potential for the spread of infections in the facility. Findings: Review of the the facility's document titled Covid-19…

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 call light was provided for one of twelve final sampled residents (Resident 47). * Resident 47 was not provided a call light system in order to call for assistance when needed. This has the potential for the resident's needs not being met promptly. Findings: Medical record review for Resident 47 was initiated on 1/10/22. Resident 47 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], showed Resident 47 had severe cognitive impairment. Resident 47 had a history of falls prior to admission. On 1/10/22 at 0959 hours, during an initial tour in the Yellow Zone, Resident 47 was observed being asleep in bed. Resident 47 did not have a call light within her reach. There was no call light observed attaching to Resident 47's call light terminal. On 1/10/22 at 1045 hours, a concurrent observation and interview was conducted with LVN 3. LVN 3 verified Resident 47 did not have a call light. LVN 3 stated Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 12 final sampled residents (Resident 47) was free from a physical restraint. * The facility placed another bed next to Resident 47's bed to prevent the resident from falling. In addition, the facility failed to ensure the least restrictive measures were attempted, the assessment was completed, and the informed consent was obtained from the resident or resident's authorized representative prior to placing an additional bed which restricted Resident 47's movement. These failures had the potential to result in injury and compromising Resident 47's psychological well-being. Findings: According to the facility's P&P titled Physical Restraint Utilization (undated) showed the Interdisciplinary Team (IDT) will assess the need for physical restraints and make recommendations to the physician and family. The charge nurse will obtain a physician's order that includes the specific type of restraint, its…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility document review, the facility failed to ensure the necessary treatment and services were provided to maintain, improve or prevent further decline in ROM functions for two of 12 final sampled residents (Residents 5 and 17) and one nonsampled resident (Resident 33). * The facility failed to apply a left hand resting splint (a splint to treat moderate flexion contractures of wrist/hand/thumb) seven times per week as ordered for Resident 17. * The facility failed to apply the PRAFO (Pressure Relief Ankle Foot Orthosis-a device worn on the calf and foot similar to a boot often used for patients to prevent bedsores or ulcers from developing on the back of the heel) splint on BLE (bilateral lower extremities) seven times per week as ordered for Resident 33. * The facility failed to apply the Possey palm grip (a device used for patients at risk for hand contractures and/or skin breakdown on fingers and palm) as ordered for Resident 5. These had the potential 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 observation, interview, and medical record review, the facility failed to ensure one of 12 sampled residents (Resident 15) was provided a safe and accident free environment when Resident 15's bed was left unsupervised in a high waist-level position. This failure had the potential to result in Resident 15 experiencing an accident and injury. Findings: According to the facility's P&P titled Fall Management reviewed on 8/2/21, showed to promote patient safety and reduce patient falls by proactively identifying, care planning and monitoring of patient's fall indicators, implement interventions .consistent with the resident's needs, goals, care plan, and current professional standards of practice in order to eliminate or reduce the risk of an accident . Medical record review for Resident 15 was initiated on 1/10/22. Resident 15 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], showed Resident 15 had severe cognitive impairment. Resident 15 required extensive to total assistance from…

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

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 proper respiratory care for two of 12 final sampled residents (Residents 19 and 17). * The facility failed to ensure Resident 19 was administered oxygen as ordered by the physician. Resident 19's nasal cannula (a small, flexible tubing with two open prongs placed in the nostrils to deliver supplemental oxygen) was dated 11/29/21. * Resident 17's humidifier bottle (aids in preventing a patients airways from becoming dry while using an oxygen) and nasal cannula were not labeled to show when it was last changed. These failures had the potential for increased risk of infection. Findings: According to the facility's P&P titled Oxygen Administration/Safety/Storage/Maintenance revised on 8/2/2021, showed the facility will assure oxygen is administered and stored safely within the healthcare centers or in an outside storage area. Under the section Infection Control, showed to change oxygen supplies weekly…

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 residents were provided the medications as ordered by the physician for two nonsampled residents (Residents 26 and 41). * The facility to ensure Resident 41's pregabalin ( pain medication ) was administered as ordered by the physician. * Resident's 26's famotidine (medication to treat indigestion) medication was not available to be administered as ordered by the physician. These failures had the potential of not meeting the residents' needs. Findings: 1. On 1/12/22 at 0935 hours, a medication administration observation for Resident 41 was conducted with LVN 2. LVN 2 prepared and administered Resident 41's medications and withheld the resident's pregabalin 75 mg medication. When asked why she did not administer Resident 41's pregabalin, LVN 2 stated she had to clarify the medication with the physician. Medical record review for Resident 41 was initiated on 1/12/22. Resident 41 was admitted to the facility on [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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to ensure the pharmacy consultant's recommendations were acted upon for one nonsampled resident (Resident 33). * The pharmacy consultant recommended for Resident 33's PRN (as needed) orders for non-antipsychotic psychotropic (any drug that affects brain activity) drugs be limited to 14 days unless the prescriber documented the diagnosed specific condition being treated, rationale for the extended time period, and duration for the PRN (as necessary) order. The facility's failure to act upon the pharmacy consultant's recommendations had the potential to put Resident 33 at risk for adverse consequences related to the medication. Findings: Medical record review for Resident 33 was initiated on 1/10/22. Resident 33 was initially admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 33's Physician Order Report showed a physician's order dated 6/25/21, to administer alprazolam (antianxiety medication) 0.5 mg one tablet by mouth…

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 nonsampled residents (Resident 33) was free from an unnecessary psychotropic drug (any drug that affects brain activity). The facility failed to ensure Resident 33's prescription for alprazolam (antianxiety medication) PRN (as needed) had a duration when the physician extended the order beyond 14 days. This had the potential to negatively impact the resident's well-being. Findings: Medical record review for Resident 33 was initiated on 1/10/22. Resident 33 was initially admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 21's Physician Order Report showed a physician's order dated 6/25/21, to administer alprazolam (antianxiety medication) 0.5 mg one tablet by mouth every 12 hours as needed for verbalization of feeling anxious. Review of the physician's progress note dated 9/17/21, showed to continue Xanax (alprazolam) 0.5 mg every 24 hours PRN for 90 days then re-evaluate. The progress notes also 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.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the kitchen staff had the appropriate skill set to safely perform the daily operation of the Food and Nutrition Services Department. * Cooks 1 and 2 were unable to properly demonstrate the process to verify the correct thermometer calibration. * Dietary Aide 1 was unable to correctly describe how to manually wash dishes in an emergency and was unable to correctly test the chemical concentration measured in parts per million of quaternary sanitizing solution used to sanitize food contact surfaces. These unsafe food practices had the potential to lead to foodborne illnesses in a highly susceptible population of residents who received food from the kitchen. Findings: Review of the CMS 672 Resident Census and Conditions of Residents completed by the facility dated 1/13/22, showed 41 of 44 residents in the facility received food prepared in the kitchen 1. According to the USDA Food Code 2017, 4-502.11 Good repair and calibration, food temperature measuring devices shall 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 document review, and facility P&P review, the facility failed to ensure 12 of 44 residents received the proper amount of pureed food items when the incorrect portion size were used to served the residents who were on a pureed diet. This failure resulted in the residents on a pureed diet not receiving the nutrition as planned. Findings: According to the facility's P&P titled Menus revised date 1/9/19, menus are planned in advance and are followed as written in order to meet the nutritional needs of the residents in accordance with established national guidelines. According to the facility's P&P titled Food Preparation revised date 1/9/19, menu items are prepared according to the menu, production sheets, and recipes. Review of the facility's document titled 2021 FW LCC Menu #3 - SW (diet spreadsheet) showed the following under pureed diet: - pureed chicken served with #12 (1/3 cup) scoop size; - pureed beets served with #8 (1/2 cup) scoop size; - pureed bread served with #16 (1/4 cup) scoop size; and - pureed beans served with #8 (1/2 cup)…

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 special eating equipment and utensils were provided to one of 12 final sampled residents (Resident 5) during mealtime. * Resident 5 was provided with the regular utensils during meals when she was assessed to need the built up utensils ( a multi-purpose handle easily to create a larger gripping surface) and inner lip plate (a plate designed to assist children, the elderly, people with limited muscle control and individuals with the use of only one hand to keep food from sliding off the plate). This failure had the potential for the resident to not maintain or improve independence in self-feeding skills when consuming meals and snacks. Findings: Medical record review for Resident 5 was initiated on 1/10/22 . Resident 5 was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Review of the MDS dated [DATE],.showed Resident 5 had severe cognitive impairment and and needed extensive assistance from 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 implement their P&P to ensure proper storage of food in the residents' refrigerator. The facility failed to ensure proper labeling and dating of food items in the refrigerator used for the residents' food brought in by visitors. This had the potential to result in foodborne illnesses in a highly susceptible resident population. Findings: According to the facility's P&P titled Food Brought in by Visitors revised on 11/17/17, showed any potentially hazardous food not eaten within four hours should be discarded if not stored properly in the refrigerator. Food is stored, prepared, and distributed in accordance with professional standards for food safety. Review of the Staff Development Inservices Attendance Record for resident refrigerator temperature logs and logging all food items even they are sealed, dated 1/11/21, showed all food items placed in the refrigerator needs to have the date on when it was placed in the refrigerator. All items need to be labeled individually. On 1/1122 at 0820 hours, during…

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

Based on observation, interview, and facility P&P review, the facility failed to dispose and store trash in a sanitary manner. This failure posed a threat for pest contamination. Findings: According to the US Food Code 2013, 5-501.113, covering Receptacles, receptacle units for refuse shall be kept covered with tight fitting lids after they are filled. Review of the facility's P&P titled Sanitation and Maintenance revised 1/11/19, under disposal of garbage and refuse, showed garbage and refuse will be disposed of properly and per federal, state, and local requirements. All waste is properly contained in the dumpsters or compactors and are covered appropriately. 1. On 1/12/22 at 1040 hours, an observation of trash disposal and concurrent interview with the RD and CDM was conducted. A large plastic bag containing trash and a broom and dustpan with food particles were observed on the ground adjacent to the kitchen. The RD and CDM verified the findings. The CDM stated the pies were spilled on the floor in the dry storage area which had to be cleaned. The RD was observed picking up 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 interview and facility document review, the facility failed to establish an infection control program which included an antibiotic stewardship program designed to monitor antibiotic use. * The facility failed to ensure the assessment of the residents' signs and symptoms was reviewed and documented for appropriateness of antibiotic use in the Infection Control Surveillance log for the months of November and December 2021. This failure posed the risk of inappropriate antibiotic usage and inaccuracy of data. Findings: According to the CDC article titled Antibiotic Prescribing and Use dated 8/23/21, anytime antibiotics are used, they can cause side effects and contribute to antibiotic resistance. Antibiotic resistance happens when the germs no longer respond to the antibiotics designed to kill them. Unnecessary antibiotic use happens when a person is prescribed antibiotics when they're not needed. Review of the facility's P&P titled Antibiotic Stewardship revised on 9/20/21, and reviewed on 12/27/21, under the core elements of antibiotic stewardship: tracking, 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, medical record review, and facility P&P review, the facility failed to ensure the influenza and pneumococcal immunizations were provided for one of 12 final sampled residents (Residents 498). This failure had the potential for the residents acquiring, transmitting, or experiencing complications from influenza and pneumonia. Findings: According to the facility's P&P titled Influenza Vaccine and Pneumococcal Vaccine Policy for Residents revised on 10/4/21 and reviewed 12/31/21, under federal regulations, showed the following: - Each resident is offered an influenza immunization from October 1 through March 31 annually, unless the immunization is medically contraindicated, or the resident has already been immunized during this time period. - The resident's medical record includes documentation that indicates, at a minimum, the following: that the resident or resident's representative was provided education regarding the benefits and potential side effects of influenza immunization and that the…

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

Based on observation, interview, facility document review, and facility P&P review, the facility failed to maintain the essential equipment used to prepare, serve, and store food in the facility. * The facility failed to ensure no ice buildup in the freezer of the refrigerator used to store the resident's food bought from outside sources. * The facility failed to ensure the Robot Coupe was in good condition. * The facility failed to ensure the plate dispensing Lowerator was functioning. These failures had the potential for equipment not functioning in the way they were intended and in turn cause contamination of food and medication, leading to illnesses for the residents. Findings: Review of the CMS 672 Resident Census and Conditions of Residents completed by the facility dated 1/13/22, showed 41 of 44 residents in the facility received food prepared in the kitchen. Review of the USDA Food Code 2017, Section 4-501.11, Good Repair and Proper Adjustment, showed equipment shall be maintained in a state of repair and condition. Review of the facility's P&P titled Sanitation 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 interview and facility document review, the facility failed to obtain the approval for the room sizes not meeting the required square footage, creating the risk for being in compliance with the requirement. Findings: On 1/11/22 at 0755 hours, the Administrator was asked to provide a waiver for the list of rooms with less than the required square footage of 80 square feet per resident. Review of the facility's waiver for room variance dated 1/15/19, showed Rooms 1, 3, 5, 6, 7, 9, 11, 12, 14, 15, 17, 18, 19, 20, 21, and 23 with less than a minimum of 80 square feet per resident in multi-patient rooms were approved for a waiver; however, there was no approved waiver for 2020, 2021, and 2022. The Administrator verified the above findings and stated she was not aware of the room variance waiver and did not receive the endorsement from the previous administrator. On 1/14/22 at 1553 hours, a follow-up interview was conducted with the Administrator regarding the facility document dated 1/15/19, for room size waiver. The Administrator stated the only waiver they had was the one…

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 a safe environment for residents, staff, and visitors. * A linen was tied around the lock bar mechanism of the fire exit door located a the end of the hallway by the kitchen area, which prevented the door from locking automatically. This failure had the potential for not maintaining a safe environment for the residents, staff, and visitors. Findings: On 1/13/22 at 0647 hours, during rounds in the hallway by the kitchen, a white linen was observed tied around the lock bar of the fire exit door. The fire exit door was observed to be unlocked. There were five occupied resident rooms observed in the hallway. The residents were inside their rooms sleeping. There was no staff observed in the hallway. On 1/13/22 at 0700 hours, a concurrent observation and interview was conducted with RN 1. RN 1 stated she came from the night shift. RN 1 verified the linen (a pillow case) was tied around the lock bar of the fire exit door. RN 1 was able to push the door open without activating the lock bar mechanism, then closed it. RN 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.