La Jolla Post-Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to supply a physician prescribed condom catheter (an external apparatus that fits on the outside of the penis and drains urine into an external bag) for one of one resident (Resident 1). As a result, the facility placed an indwelling catheter (sterile flexible tube placed inside the penis, to drain urine from the bladder into an external bag). When the indwelling urinary catheter was removed, Resident 1 experienced pain, bleeding, and verbalized fear of possible future indwelling urinary catheter placements. Findings: An unannounced visit was made to the facility on [DATE], in response to a complaint which involved an indwelling urinary catheter. Resident 1 was admitted to the facility on [DATE], with diagnoses of quadriplegia (inability to move arms/legs with paralysis from the neck down, per the facility ' s admission Record. On [DATE] an interview was conducted with Resident 1, in his room. Resident 1 stated he no longer had anyone to…

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

Based on interview and record review, the facility failed to ensure staff were competent upon hire for Licensed Nursing (LN) skills, such as the insertion of a urinary catheter for one of one staff reviewed (LN 1) for nursing competency. As a result, an indwelling urinary catheter (a sterile flexible tube placed inside the penis, to drain urine from the bladder into an external bag), was improperly inserted into Resident 1, resulting in bleeding when the catheter was removed the following day. (Cross reference F-684 Findings: An unannounced visit was made to the facility on 3/14/24, in response to a complaint received by California Department of Public Health involving the insertion of an indwelling urinary catheter. On 3/14/24 at 12:05 P.M., an interview and record review was conducted with the Director of Staff Development (DSD). The DSD stated she started working at the facility on 3/31/22. The DSD reviewed all the past in-services and stated she could not find any documented evidence urinary catheters care training was provided to LNs, reviewing in-service documents back to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to follow infection control standards of practices when: 1. The Treatment nurse 1 (Tx LN 1) did not disinfect hands after removing gloves three out of six times while providing wound care for Resident 6. 2. Tx LN 1 did not disinfect scissors for two of two wound dressing changes for Resident 6. 3. One of three common resident shower rooms (shower between Station 1 and Station 2) was not cleaned after use. 4. Oxygen tubing was undated and was in contact with the floor for one of one resident (Resident 7). 5. A breathing treatment mouthpiece was exposed to the environment while lying on a tabletop for one of one resident (Resident 7). As a result, there was the potential for cross contamination and the spread of infection. Findings: 1. Resident 6 was admitted to the facility on [DATE] with diagnoses that included surgical aftercare following surgery on the digestive system, per the facility ' s admission Record. On 12/29/23 at 10:42 A.M., an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to consistently monitor and document a low air loss (LAL-a mattress designed to prevent and treat skin issues) mattress, for prevention of skin injuries as ordered by the physician and listed as an intervention in the care plans for three of three residents (Resident 1, 2, and 3), reviewed for plan of care in order to maintain skin integrity. As a result, Residents 1, 2, and 3 had the potential for worsening skin injuries. Findings: 1. Resident 1 was admitted to the facility on [DATE], with diagnoses which included peripheral vascular disease (a low, progressive circulation disorder), and diabetes (abnormal blood sugar levels), per the facility's admission Record. On 9/12/23 at 10:18 A.M., an observation and interview was conducted with Resident 1. Resident 1 was lying in bed on a LAL mattress with green padded-protection boots on both feet and both ankles were propped up on a pillow. Resident 1 stated she was not doing well today and had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to consistently provide wound treatments as ordered by the physician for two of three residents (Resident 1 and Resident 3) reviewed for Quality of Care. As a result, Residents 1 and 3 had the potential for delayed healing and worsening of wounds. Findings: 1. Resident 1 was admitted to the facility on [DATE], with diagnoses which included peripheral vascular disease (a low, progressive circulation disorder), and diabetes (abnormal blood sugar levels), per the facility's admission Record. On 9/12/23 at 10:18 A.M., an observation and interview was conducted with Resident 1. Resident 1 was lying in bed on a LAL mattress (low air loss-a mattress designed to prevent skin injuries), with green padded-protection boots on both feet and both ankles. Resident 1's legs were propped up on a pillow. Resident 1 stated she was not doing well today and had, necrotic feet (dying tissue in her feet). On 9/12/23, Resident 1's clinical record was reviewed.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to consistently implement their infection control program when: 1. Certified Nursing Assistant (CNA) 41 did not perform hand hygiene in between residents. 2. Certified Nursing Assistant (CNA) 41 did not clean and disinfect the Blood Pressure (BP) cuff in between resident use. 3. Laundry Staff (LS) 41 and LS 42 did not follow hand hygiene and gloving policy during collection of soiled linens. 4. Certified Nursing Assistant (CNA) 42 did not wear Personal Protective Equipment (PPE) in a Clostridium Difficile (C-Diff - a spore forming bacterium causing intestinal inflammation and infectious diarrhea. C- Diff infection can spread from person to person on a contaminated equipment and by contaminated hands of healthcare workers) isolation room and did not perform handwashing after contact with Resident # 265's environment. These failures had the potential for cross contamination and spread of infection to residents, resident family and visitors 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 record review, the facility failed to ensure policy and procedures to access resident records included verbal requests for one of twenty-three residents, Resident 15. This failure has the potential for Resident 15 to not have access to her records. Findings: During an initial tour observation on 4/5/22, Resident 15 produced a written request for a medical records release of information for herself for her belonging sheet. Resident 15 stated she had lost some clothing items and wanted them replaced. Resident 15 stated she was told by the facility staff to request her belongings sheet (her record of personal belongings) by completing a record request in writing. Resident 15 stated she should not have had to do that (request in writing). On 4/5/22 at 4:04 P.M., the Social Services Director stated the process for residents to see their own medical record involved the facility needing to have a written medical record release. On 4/6/22 at 8 A.M., the Medical Records Director (MRD) was interviewed. The MRD stated that it was company's policy that any request by a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to protect a resident's confidential medical information for one of 23 sampled residents (80). This failure had the potential for residents' confidential medical information to be visible to unauthorized people. Findings: Resident 80 was admitted to the facility on [DATE] with diagnoses which included diabetes (abnormal blood sugar in the body) per the facility's admission record. During the initial tour of the facility on 4/5/21, Resident 80's profile and list of medications were visible on the nurse station's computer to others. There were residents sitting across the nurse station and staff walking past the nurse station. On 4/5/22 at 10:46 A.M., an interview was conducted with LN 1. LN 1 stated she should have logged off the computer because of Health Insurance Portability and Accountability Act (HIPAA, a federal law that protect sensitive health information). On 4/5/22 at 11:55 A.M., an interview was conducted with LN 2. LN 2 stated the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for one of 23 sampled residents (15). This failure had the potential to not meet the goals of the treatment and the needs of Resident 15. Findings: Resident 15 was admitted to the facility on [DATE] with diagnoses that included aphasia following cerebral infarction (language disorder caused by brain damage) per facility's admission Record. Per Resident 15's Dietary profile, dated 10/8/21, indicated Resident 15's diet preference was vegetarian (plant based diet). Per Resident 15's Care plan titled, Altered nutrition and hydration risk ., revision date 11/15/21, indicated the intervention was to honor food and fluid preferences. No vegetarian preference was included in this care plan. On 4/8/22 at 12:58 P.M., an interview with the Registered Dietitian (RD) was conducted. The RD stated she would have included the vegetarian preference in Resident 15's care plan. She further…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow a physician's dialysis (a treatment for people whose kidneys are failing) order for fluid restriction for one of two sampled residents (63). This failure had the potential for Resident 63 to have fluid overload (a condition of having more fluids than what a dialysis patient can tolerate). Findings: Resident 63 was admitted to the facility on [DATE], with diagnoses that included End Stage Renal Disease (A disease that makes the kidneys unable to clean the blood of toxins and excrete excess fluids), Retention of Urine (Unable to completely empty the bladder of urine), and Dependence on Renal Dialysis per the facility's Resident Face Sheet. Per Resident 63's Order Listing Report, dated 3/10/22, the physician wrote an order for fluid restriction of 1500 ml.(milliliters)/day. (1,500 ml. = 6.34 cups). On 4/7/22 at 3:13 P.M., a concurrent interview and record review of Resident 63's medical record was conducted with the Director of Staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to communicate with hospice (end of life) services provided for two of 23 sampled residents (27,80). This failure had the potential to prevent residents from receiving coordinated hospice care. Findings: A. Resident 27 was admitted on [DATE] with diagnoses which included Chronic Pulmonary Obstructive Disease(COPD, lung disease), Asthma (a condition in which your airways narrow and swell and may produce extra mucus), Dependence on Supplemental Oxygen (dependence on extra oxygen use), Cerebral Atherscleroisis(a disease of the arteries characterized by the deposition of plaques of fatty material on their inner wall in arteries of the brain), and Malnutrition (A condition caused by not getting enough calories or the right amount of key nutrients, such as vitamins and minerals, that are needed for health). A record review conducted on 4/12/22 of Resident 27's physician's orders, dated 11/22/2020, read Admit to the hospice, dx: Cerebral…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow up on an optometrist appointment for one of one sampled resident (80). As a result, Resident 80 wore broken eyeglasses since admission to the facility. Findings: Resident 80 was admitted to the facility on [DATE] with diagnoses which included diabetes (abnormal blood sugar in the body) per the facility's admission record. During the initial tour of the facility on 4/5/22, Resident 80 was observed wearing eyeglasses with a white piece of tape in the middle holding the frames together. Resident 80's clinical record was reviewed. On 12/7/21 at 16:46 (4:46 P.M.) social services documented, Will fax referral to an eye MD (Medical Doctor). There was no other documentation found about any follow up done in Resident 80's clinical record. On 4/6/22 at 2:03 P.M., Resident 80 was observed in the dining room playing cards. Resident 80 was observed placing the card directly in front of his eyeglasses staring at the card, then placed it down on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide assistance device to 1 of 23 residents (Resident 28) when a grab bar (a safety assistive device to hold in the bathroom) was not provided in Resident 28's bathroom for safety. This failure had the potential for Resident 28 to have accident and fall that could lead to injury. FINDINGS: Resident 28 was admitted on [DATE] for diagnoses that include pain in left hip, shortness of breath, hypotension (a low or a fall in blood pressure) per undated Facesheet. On 4/7/2022 at 9:41 A.M., an observation and interview was conducted with Resident 28. Resident 28 was seated on the wheelchair and was using a nasal cannula connected to an oxygen concentrator. Resident 28 stated that he was handicapped and moved around the facility using the wheelchair. Resident 28 stated that he transferred from wheelchair to the toilet seat with assistance from staff. Resident 28 stated that his bathroom did not have a grab bar. Resident 28 stated that without a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure an oxygen nasal cannula (device used to deliver oxygen to a person) was changed per the facility's oxygen policy on seven of 23 sampled residents 5,14,27,28,41,60, 64) reviewed for oxygen use. This failure had the potential for residents to be placed at risk for infection. Findings: A. Resident 60 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (COPD - a breathing and lung disease) and hypoxemia (low oxygen in the blood) per the facility's admission Record. On 4/7/22 at 8:08 A.M., Resident 60 was observed eating breakfast in bed. Resident 60 was wearing a nasal cannula attached to an oxygen concentrator machine. The oxygen nasal cannula did not have a date or label. On 4/7/22 at 8:22 A.M., an interview was conducted with LN 5. LN 5 stated oxygen tubing were usually changed either weekly or monthly. LN 5 stated it was important to put the date it was changed so staff would…

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

Based on interview and record review, the facility failed to post their actual staffing hours when the facility only posted anticipated staffing for the day. As a result, the staffing information may not have been accurate. Findings: The facility provided daily staffing information titled, Today's Staffing, from 4/1/22 to 4/7/22. The facility provided a single sheet for each day, which included the patient census, the number of Registered Nurse (RN), the number of Licensed Nurse (LN), and the number of Assistants/Techs. These numbers were broken down to hours and full time employees (FTE). On 4/8/22 at 8:20 A.M., a concurrent interview and record review of the document titled Today's Staffing was conducted with the Administrator (ADM). The projected Per Patient Day (PPD-staffing ratio) value was 4.18 versus the actual PPD value was 3.58. The ADM said these numbers were the projected staffing for the day, and not the actual staffing for the day. The actual staffing information was not going to be available for several days and was provided by the Payroll Department. The Admin…

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

Based on interview and record review, the facility failed to ensure the monthly MRR was completed, and the pharmacist recommendations were acted upon monthly. This failure had the potential for medications to be continued unnecessarily. Findings: On 4/7/22, the DON presented the team with the MRR binder. The MRR binder contained all the MRR for a year, except it was missing November, December 2021, January, and February 2022. The DON was unable to produce any of the pharmacist recommendations for those four months. The March 2022 MRRs included a pharmacist recommendation dated 1/12/22, the recommendation was to reduce a trazadone dose with the end goal of discontinuing it. This recommendation was not acted upon by the Physician until 3/21/22. A pharmacist recommendation dated 2/9/22, recommending a gradual dose reduction was not acted upon by the physician until 3/21/22. A pharmacist recommendation dated 2/10/22, to discontinue PRN lorazepam was not acted upon by the physician until 3/21/22. The DON was interviewed on 4/7/22 at 1:30 P.M. The DON stated she had the email version of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure appropriate indication for a psychotropic medication (A drug that affects emotions, mental processes, and behavior) for one of five sampled residents (27). This failure put Resident 27 at risk for receiving unnecessary medication. Findings: Resident 27 was admitted to the facility on [DATE], with diagnoses that included Unspecified Dementia without Behavioral Disturbance (A decline in mental ability that affects daily living), per the facility's admission Record. On 4/8/22 at 9:54 A.M., a medical record review of Resident 27 was conducted. A behavior summary dated 2/27/22, indicated Resident 27 was given Risperidone (A medication for treating mental disorders) 1 mg. (milligram) at bedtime. This medication was ordered on 1/16/22. The behavior summary on January and February 2022, indicated a total number of behavior and/or mood episodes were none. On 4/8/22 at 10:32 A.M., a concurrent observation and interview was conducted 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, and record review, the facility failed to ensure; 1. The disposal of two opened vials of antibiotics (medication to treat infection) per facility policy and, 2. Medication storage room was locked. These failures had the potential for all residents to receive ineffective medications and access by unauthorized personnel to medications. Findings: A medication cart inspection was conducted on [DATE] with the DON in Station 1. In the first drawer of the intravenous (IV [medication through the vein]) medication cart were 2 vials of unsealed medications with a white powdery substance inside. One vial was labeled, Meropenem (antibiotic) 1 gm (gram)/vial and the other was Vancomycin (antibiotic) 1 gm. On [DATE] at 4 P.M., an interview was conducted with the DON. The DON stated that unsealed vials of medications should not be stored in the IV cart. The DON stated the nurse should waste the medication in the incinerator bin inside the medication room if not used. On [DATE] at 4:05 P.M., a…

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

Based on observation, interview, and record review, the facility failed to ensure the menus were followed when: 1. Consistent Carbohydrate (CCHO) diets were not followed for two of two residents (15,51). 2. Large portion diets were not followed for three of three residents (52,53, 54). These failures had the potential for 112 residents receiving food prepared in the kitchen to not meet their nutritional needs. Findings: 1. On 4/5/22 at 12:08 P.M., an observation of the noon meal in the assisted dining room was conducted. Resident 15's meal ticket read regular CCHO. The lunch meal included one cup of spaghetti noodles, half a cup of seasoned cabbage, small cup of cottage cheese. Unsampled resident 51's meal ticket read Regular CCHO fortified. The lunch meal included 3 ounces of spaghetti with meat sauce, half a cup of seasoned cabbage, and one garlic wheat roll. A review of the facility document titled Diet Spreadsheet X-format (a spreadsheet with portion sizes for all foods and diets) dated 4/5/22, showed CCHO diets should have received a full size chocolate chip cookie. On 4/5/22…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents' food preferences were followed for 3 of 23 final sampled residents (7, 11, 15). This failure caused the resident to not receive food they preferred. Findings: Resident 7 was admitted to the facility on [DATE] with diagnosis that included malnutrition (lack of proper nutrition) per the admission Record. On 4/5/22 at 12:10 P.M., Resident 7 received her lunch of spaghetti with meat sauce. Residents 7's meal ticket indicated her dislikes were ground meats. Resident 7 stated she would have preferred to have spaghetti sauce without meat in it. Resident 7 said she requested spaghetti sauce with no meat in the past, and was told by dietary they only served one type of meal for everyone, and they couldn't make meatless spaghetti sauce. Resident 7 stated she would rather not eat anything than eat the spaghetti with meat sauce. The dietitian was interviewed on 4/8/22 at P.M., the dietitian stated she was unclear if Resident 7…

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

Based on observation, interview, and record review, the facility failed to ensure the sanitary requirements were followed in the kitchen: a. The inside of the ice machine was not clean, and manufacturer's instructions were not followed for the ice machine cleaning and sanitizing b. A cutting board surface was heavily marred. c. Brooms and mop were stored on the floor. d. The inside of the dining bowls was not clean. e. The ice machine and three compartment sink drain did not have an air gap. f. Kitchen equipment were not air dried. These deficient practices had the potential to cause food borne illnesses for 112 residents. Findings: a. On 4/5/22 at 10:04 A.M., the following observations were made with the Maintenance Supervisor (MS): - A yellow discoloration with roughness was felt on the ice machine's white evaporator cover. - A white residue was observed on the metal splash guard. - Multiple black residues were observed on the corner of the water drip tray. When the water drip tray was wiped with white paper towel, the black residue came off onto the paper towel. On 4/5/22 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure that two of 23 sampled residents (7, 48) had a completed POLST in their clinical record. The failure had the potential the residents end of life wishes may not have accurately been followed in an emergency. Findings: On 4/5/22, the clinical record of Resident 7 was reviewed. Resident 7 was admitted to the facility on [DATE], per the admission Record. There was no POLST found in the residence clinical record. On 4/8/22, the DON produced a POLST for Resident 7 dated 4/7/22. This POLST was not signed by the physician. The DON had no explanation for the delay. On 4/5/22, the clinical record of resident 48 was reviewed. Resident 48 was admitted to the facility on [DATE], per the admission Record. Resident 48 had a POLST that was signed by the resident and dated 3/17/20, this POLST was never signed by the physician. On 4/8/22 at 1:30 P.M., the DON stated Resident 48's POLST had no physician's signature and had no explanation.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure dialysis (a process to remove waste from the blood for residents with kidney disease) assessments were consistently and accurately completed for four of four sampled dialysis residents (97, 32, 39, 64). These failures had the potential for miscommunication between the facility and dialysis center and to affect the continuity and quality of care of these residents. Findings: 1. Resident 97 was admitted to the facility on [DATE] with diagnoses, which included end stage renal disease (kidney failure) and dependence on renal dialysis, per the facility's admission Record. According to Resident 97's MDS, dated [DATE], the resident had a brief interview for mental status score of 15 (on a scale of 0 to 15, with 15 being the most cognitively intact). According to Resident 97's physician's orders, dated 9/7/17, the resident went to dialysis every Monday, Wednesday, and Friday. These orders also indicated the resident's dialysis access site…

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

Based on observation, interview, and record review, the facility failed to consistently implement their infection control program when the ice scoop was not stored in a sanitary manner. This failure had the potential to increase the risk of infection and illness to residents in the facility. Findings: On 8/8/19 at 12:24 P.M., RD 1 was concurrently interviewed as a brief inspection of the ice machine was observed. The scoop to dispense the ice was observed to be lying on top of the ice in the bin. RD 1 stated to avoid contamination, the ice scoop should have been stored in a sanitary manner outside the bin of the ice machine. During an interview with CNA 4 on 8/9/19 at 10:03 A.M., CNA 4 stated they filled up an ice chest for the nursing station from the ice machine using a scoop. CNA 4 stated the scoop had a storage area on the wall next to the ice machine. CNA 4 stated the scoop should not be left in the ice bin. During an interview with the ICN on 8/9/19 at 11:40 A.M., the ICN stated when getting ice from the ice machine, the staff needed to ensure the handle of the scoop did not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to assess one of 29 sampled residents (52), for safe self-administration of medication. This failure had the potential to put Resident 52 at risk for improper medication administration, and did not ensure safe storage of the self-administered medication. Findings: Resident 52 was admitted to the facility on [DATE] with diagnoses, which included chronic obstructive pulmonary disease (lung disease), generalized muscle weakness, and essential tremor (shaking), per the facility's admission Record. On 8/6/19 at 10:50 A.M., Resident 52 was observed sitting up in bed with oxygen (O2) on at three liters per minute by nasal cannula (a flexible tubing that rests in the nostrils to deliver O2), on the resident's bedside table sat a nebulizer (a machine that administers medication in a mist form to the lungs). During an interview, Resident 52 stated she did her own breathing treatments. Resident 52 picked up a plastic ampule (sealed container containing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: 1. Notify the physician of a high blood sugar reading for one of 14 sampled residents (39) receiving insulin (a medication to control high blood sugar); and, 2. Ensure three of six sampled residents (36, 49, 1) with identified nutritional concerns and weight loss were monitored with weekly weights as indicated by their care plans. As a result, Resident 39 may not have received treatment for high blood sugar, and there was the potential for Resident's 36, 49, and Resident 1 to be at risk of further weight loss. Findings: 1. Per the facility's admission Record, Resident 39 was admitted to the facility on [DATE], with diagnoses to include type 2 diabetes (unstable blood sugar). A review was conducted of Resident 39's EMR. Resident 39 had an order to check her blood sugar at bed time, and to notify the physician if the blood sugar reading was greater than 400. Resident 39's blood sugar reading was 495 on 7/28/19 and 425 on 8/4/19 . There…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a resident's care plan was revised after falls for one of 29 sampled residents (16). This failure had the potential to put Resident 16 at increased risk for further falls or injury. Findings: Resident 16 was admitted to the facility on [DATE] with diagnoses, which included dementia (a loss of mental abilities that leads to impairments in memory, reasoning, planning, and behaviors), and repeated falls, per the facility's admission Record. According to a review of Resident 16's medical record, the resident had witnessed falls on six separate occasions between 1/16 and 6/17/19. A review of Resident 16's Care Plan titled, At Risk for Falls and Injuries, indicated the last revision of the care plan was on 9/21/18. During an interview with LN 2 on 8/9/19 at 1:20 P.M., LN 2 stated resident care plans needed to be updated with new interventions after a resident had a fall. During an interview with LN 8 on 8/9/19 at 1:22 P.M., LN 8 stated the IDT reviewed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure nutritional recommendations by the registered dietician were not implemented for one of six sampled residents (1) with identified nutritional concerns and weight loss. This failure had the potential to contribute to further weight loss for the resident. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses, which included dementia (a loss of mental abilities that leads to impairments in memory, reasoning, planning, and behavior), dysphagia (difficulty in swallowing), gastrostomy (surgical placement of a tube in the stomach), and failure to thrive (a state of decline which may be caused by chronic diseases and functional impairments), per the facility's admission Record. According to Resident 1's Physician Progress Notes, dated 3/29/19, the resident has been dependent on gastrostomy tube (g-tube) for nutritional needs since 2017. Resident 1 was observed in bed, with Glucerna 1.5 infusing at 55 cubic centimeters…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of two residents (308) with a peripherally inserted central catheter (PICC line- to provide access to a large vein for administration of medication for long-term use), was monitored per the physician's order. This failure had the potential to affect Resident 308's care and delay the identification of catheter-related complications. Findings: Resident 308 was admitted to the facility on [DATE] with diagnoses, which included methicillin-resistant staphylococcus aureus infection (MRSA- bacteria not killed by some common antibiotics), and urinary tract infection (UTI), per the facility's admission Record. On 8/6/19 at 11 A.M., a PICC line was observed in Resident 308's left upper arm. A dressing was secured over the insertion site and dated 8/2/19. According to Resident 308's physician's orders, dated 7/21/19, the resident's catheter site dressing was to be changed every week and as needed for complications. In addition, 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, and record review, the facility failed to ensure the medication error rate was less than five percent. Thirteen medication errors out of 28 opportunities were identified during medication administration, when nursing: 1. Administered nine crushed medications via PEG (Percutaneous endoscopic gastrostomy tube - a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications) at the same time to Resident 87. 2. Omitted one medication for Resident 87. 3. Administered the incorrect form of a medication to Resident 87. 4. Administered the incorrect form of a medication to Resident 74. 5. Omitted one oral medication for Resident 38. 6. Omitted one topical medication for Resident 38. This failure resulted in the medication error rate of 46.43%. Findings: 1. On 8/8/19 at 7:42 A.M., an observation of medication administration was conducted with LN 18. LN 18 placed nine medications in one medicine cup, transferred to a small plastic bag, then crushed all nine medications together in a pill…

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

Based on observation, interview and record review, the facility failed to ensure; 1. Medications were stored properly. 2. Expired biological's were discarded in two of four medication carts and, 3. Medication Refrigerator temperatures were monitored for two of two medication refrigerators. This failure had the potential for unsafe storage and administration of resident medication. Findings: 1. On 8/8/19 at 3:38 P.M., a joint observation and interview was conducted with LN 20. LN 20 stated the medication cart she had was labeled as Medication cart 1. The suppositories and nebulizer (breathing medication) medications were stored in the same drawer with oral medication. LN 20 stated the suppositories and the nebulizer should have been kept in separate drawers. LN 20 stated the medications should have been placed where they belonged so they were not administered via the wrong route. In addition, one hydrocortisone cream 1 % (used to treat a variety of skin conditions), and one topical ketoprofen 10% cream (pain-killing topical) were stored in the same drawer with the oral medications.…

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

Based on observation, interview, and record review, the facility failed to ensure food production was implemented in a manner that mitigated the risk for food borne illness by the lack of an air gap in the food preparation (prep) sink. This failure had the potential to place residents at risk for food borne illnesses, which could have resulted in gastrointestinal distress and weight loss. Findings: During a general observation in the kitchen on 8/8/19 at 9:39 A.M., the two compartment food prep sink was plumbed directly to the wastewater system. On 8/8/19 at 9:40 A.M., RD 1 stated the food prep sink should have had an air gap to prevent any back flow of water into the sink where food was washed. On 8/8/19 at 11:12 A.M., kitchen staff were observed washing cucumbers in the food prep sink. On 8/8/19 at 12:30 P.M., the MS was concurrently interviewed while the pipe under the food prep sink in the kitchen was observed. The MS stated it looked like there was no device on the plumbing to prevent back flow into the food prep sink. The standard of practice in the food industry would be to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure hospice documentation and the hospice plan of care were up to date for one of three sampled residents on hospice services (12). As a result, the facility did not have a record of the current care the hospice agency was providing to the resident. Findings: Per the facility's admission Record, Resident 12 was admitted to the facility on [DATE] with diagnoses to include dementia (a progressive mental and physical decline). On 8/8/19, a review was conducted of Resident 12's hospice binder. Resident 12 was admitted to the hospice agency on 8/26/17 with diagnoses to include Alzheimer's disease (a progressive mental and physical decline). The most recent documentation of a nursing visit was on 6/22/19 (six weeks and five days prior). The most recent Plan of Care was dated 9/24/18 (10 months and 15 days prior). On 8/8/19 at 10:38 A.M., an interview was conducted with LN 8. LN 8 stated, all hospice documentation was kept in the hospice binder. On 8/8/19…

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.