La Mesa Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to indicate the appropriate and measurable target behavior of antidepressant (medication used to treat depression, sad mood and lack of interest) for one of five sampled residents reviewed for unnecessary psychotropic (mind-altering medications) medication use (Resident 11). This failure had the potential for unnecessary psychotropic medication use, its side effects, and a decline for residents psychological and mental well-being. Findings: A review of Resident 11's admission Record indicated Resident 11 was readmitted to the facility on [DATE], with diagnoses which included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Resident 11's physician order dated 9/27/24 indicated the following order: Venlafaxine (antidepressant) tablet for depression. AEB [sic, as evidenced by]: teary eyes. During an observation and an interview with Resident 11 in his room, on 3/25/25 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 observation, interview, and record review, the facility failed to ensure an inhaler was labeled after it was opened and used for one resident (300). This failure had the potential for the resident to receive an ineffective medication. Findings: Per the facility's admission record, Resident 300 was admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure (chronic lung disease). A review of Resident 300's medication orders indicated on 3/5/2025, the physician ordered, Fluticasone Furoate Vilanterol Inhalation (medication used to treat respiratory disease) - 1 puff inhale orally one time a day for shortness of breath (SOB)/wheezing . On 3/27/25 at 9:49 A.M., a joint observation and interview was conducted with LN 11 of the medication (med) cart. In the med cart, an opened box of Fluticasone furoate inhaler was found with no open date. LN 1 stated she opened the box yesterday and forgot to label it. LN 1 stated it should have been labeled with the opened date. On 3/27/25…

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, and record review, the facility failed to provide proper resident cohorting (the grouping of individuals with the same condition in the same location) for one resident (298) when Resident 298 was admitted into a room that was on isolation transmission-based precautions related to Resident 54's exposure to Influenza A (flu-respiratory infectious disease). This failure had the potential for Resident 298 to be exposed to an infectious disease. Findings: Per the facility's admission record, Resident 54 was admitted on [DATE] with diagnoses that included a left femur (the long bone located in the thigh) fracture. Per the facility's admission records, Resident 298 was admitted on [DATE] with diagnoses that included mild intermittent asthma (a respiratory disease). On 3/24/25 at 8:36 A.M., an observation was conducted of room [ROOM NUMBER] with a with a signage posted outside of the room isolation contact precautions. On 3/24/25 at 9:25 A.M., an interview and record review were…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 one of three residents ' (Resident 1) written care plan for activities of daily living (ADL, self-care activities such as moving in bed and toileting) was completed within seven days of the Minimum Data Set Assessment (a comprehensive assessment). As a result, Resident 1 ' s ADL care plan did not match the comprehensive assessment and there was the potential for the resident to receive care that was not individualized to meet her needs. Findings: A review of Resident 1 ' s admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses to include hemiparesis and hemiplegia (weakness and paralysis) affecting the left side of the body following a stroke. A review of Resident 1 ' s MDS assessment dated [DATE], indicated the resident required: -Extensive assistance (resident involved in activity, staff providing weight bearing support) provided by two or more staff for bed mobility (how resident moves from lying…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 care was provided in a safe and comfortable manner for one of three residents (Resident 1) when activities of daily living (ADL, self-care activities such as moving in bed) were preformed by one staff instead of two staff as was required on the resident ' s Minimum Data Set Assessment (MDS, a comprehensive assessment). As a result of this deficient practice, Resident 1 experienced discomfort and felt the care provided to her was rough. Findings: A review of Resident 1 ' s admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses to include hemiparesis and hemiplegia (weakness and paralysis) affecting the left side of the body following a stroke. A review of Resident 1 ' s MDS assessment dated [DATE], indicated the resident required extensive assistance (resident involved in activity, staff providing weight bearing support) provided by two or more staff for bed mobility (how resident moves 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 and record review, the facility failed to ensure infection control policies were followed when: 1. Oxygen tubing was not changed weekly for three of three residents reviewed for oxygen therapy (17, 52, and 53), 2. A Licensed Nurse (LN) did not perform hand hygiene between glove changes and did not ensure scissors were clean and sanitized before use during a dressing change for one sampled resident (21). These deficient practices had the potential for cross-contamination, and placed the residents, staff, and visitors at risk for facility acquired infections. Findings: 1a. On 11/29/21 at 10:42 A.M., an observation was conducted with Resident 53. Resident 53 was on the bed and actively receiving oxygen therapy. Resident 53 had nasal cannula placed in her nostrils and the oxygen tubing had a label dated, 11/15/21. In addition, the oxygen tubing was attached to the empty humidifier bottle. 1b. On 11/29/21 at 10:54 A.M., an observation of Resident 17 was conducted. Resident 17 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure three of three residents (14, 36, and 47) were assessed for self-administration of medication when medications were left unattended at the bedside. As a result, Residents 14, 36, and 47 were at risk for unsafe medication administration. Findings: 1. Resident 14 was re-admitted to the facility on [DATE] with diagnoses which included rheumatoid arthritis and osteoarthritis (joint inflammation), per the facility's Resident Face Sheet. On 11/29/21 at 10:07 A.M., an observation and interview was conducted with Resident 14. Resident 14 was on the bed with the bedside table in front of her. On top of the bedside table, there were two medicine cups which contained an opaque white cream. There was no staff observed in the room. Resident 14 stated the licensed nurse (LN) left the creams so she can apply it any time. Resident 14 further stated she applied the cream to her hands, elbows and knees where it hurts. A review of Resident 14'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 interview and record review, the facility failed to ensure Physician's Orders for Life Sustaining Treatment (POLST- an Advanced Directive legal document that indicated a person's wishes about end-of-life treatment) was current for one of 22 residents sampled for Advanced Directives (189). This failure had the potential to provide care contrary to the resident's preferences. Findings: On [DATE] at 1:29 P.M., Resident 189's health record was reviewed. Resident 189 was admitted to the facility on [DATE] with diagnoses to include Parkinson's Disease (a brain disorder that affects movement) according to the Resident Face Sheet. An assessment conducted on [DATE] indicated Resident 189 had the ability to communicate needs and understood others. The Brief Interview for Mental Status (BIMS-a screening test used to assess cognitive function) indicated mild cognitive impairment. Resident 189 required limited assistance from staff with most activities of daily living, and extensive assist with ambulation and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement a comprehensive care plan for two of three residents (36 and 82) reviewed for Low-Air-Loss (LAL- pressure relieving air mattress) when their air matress were not programmed based on resident's weight. As a result, Resident 36's level of comfort and positioning was negatively impacted when the mattress was hard and shortened, and Resident 82 had the potential for skin breakdown to worsen. Findings: 1. Resident 36 was admitted to the facility on [DATE] with diagnoses that included infection and inflammatory reaction due to internal fixation device of spine, per the facility's Resident Face Sheet. On 11/29/21 at 12:01 P.M., an observation and interview was conducted with Resident 36. Resident 36 was laying in bed on a LAL mattress with the head of the bed slightly elevated. Resident 36's was under a blanket with a silhouette of his heels together and knees bent outward. Resident 36 stated he was six feet and four inches tall, and…

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

Based on observation, interview, and record review, the facility failed to ensure the medication error rate was less than 5 % (percent) or greater. Two (2) medication errors out of 28 opportunities were identified during medication (med) administration for three randomly observed residents (78, 79, 139). The medication error rate was 7.14 %. As a result, the facility failed to ensure medications were administered according to the manufacturer's instructions and physician's orders. Findings: 1a. On 11/30/21 at 8:00 A.M., a medication pass observation was conducted. Licensed Nurse (LN) 6 prepared ten oral medications and inhalers for Resident 139 for administration which included: 1. Amlodepine 2.5mg (milligram), 1 tablet 2. Austedo 12mg, 1 tablet 3. Divalproex 500mg, 1 tablet 4. Metformin ER 500mg, 1 tablet 5. Naproxen 500 mg, 1 tablet 6. Quetiapine Fumarate 200 mg, 1 tablet 7. Ropinirole 2mg, 1 tablet 8. Senna plus 8.5mg/50mg 2 capsules 9. Symbicort 4.5 mcg (microgram)/puff, 2 puffs 10. Combivent Respimat 20-100 mcg/actuation, 1 puff LN 6 put the tablets and capsules on separate…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 treat six of six residents with respect and dignity (Resident 15, Confidential Resident 1, Confidential Resident 2, Confidential Resident 3, Confidential Resident 4, Confidential Resident 5). These failures had the potential to result in psychosocial harm for Resident 15 and Confidential Residents 1, 2, 3, 4, and 5. Findings: During a record review of Resident 15, the Resident Face Sheet indicated Resident 15 was admitted to the facility on [DATE] with diagnoses to include reduced mobility, and muscle weakness. Resident 15's MDS, Section C, dated 4/26/19, indicated Resident 15's BIMS Summary Score was 15 out of 15 (attention, level of orientation, and ability to recall information is intact). During an interview with Resident 15 on 5/6/19 at 9:56 A.M., Resident 15 stated CNA 35 was often assigned to her room during the night shift. Resident 15 stated CNA 35 was rude, and unprofessional. Resident 15 stated when CNA 35 entered her room, CNA 35 would 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 did not ensure 3 out of 3 residents were clinically appropriate for self-administration of medications. This deficient practice put Residents 22, 54 and 74 at risk for unsafe medication administration. Findings: 1) Per the facility's Resident Face Sheet, Resident 54 was admitted on [DATE] with diagnoses including dementia (a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities). On 5/6/19 at 9 A.M., Resident 54 was observed sitting on the side of her bed. Resident 54's bedside table was in front of her. On the bedside table, there was a medicine cup containing 5 pills, another medicine cup with applesauce, and a cup of apple juice. Resident 54 was observed scooping the applesauce with a spoon into the cup with the pills. She put the spoon of pills and applesauce in her mouth and sipped apple juice to swallow them. There were no staff observed in the room or outside of the room. 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 accommodate and support the residents right for self-determination for one of 18 residents reviewed for choices (175). The facility failed to promote Resident 175's right to choose their pain medication. Findings: Per the Resident Face Sheet, Resident 175 was admitted to the facility on [DATE] with a diagnosis which included muscle weakness and difficulty in walking. On 5/6/19 during an interview at 10:10 A.M., Resident 175 stated he was admitted to the facility for physical therapy after having undergone a hip replacement. Resident 175 stated, I'm getting better but I would like to stop taking the Oxycodone (narcotic pain medication) and just take Tylenol (acetaminophen) for pain. Resident 175 further stated, I would like to go home with just Tylenol and not the strong pain medications. On 5/7/19 at 12:55 P.M., LN 53 and Resident 175 were observed during Medication administration. LN 53 was observed entering Resident 175's room. LN 53…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 did not provide a clean, comfortable and homelike environment when a resident bathroom sink was clogged. This deficient practice created unsanitary conditions for 5 residents (17, 34, 58, 65, 68) who used the sink. Findings: On 5/6/19 at 9:30 A.M., Resident 65's family members (FM 1 and FM 2) were interviewed. FM 1 stated, My mom's sink has been clogged for a long time. It drains very slowly and sometimes the sink is filled with dirty water and we can't wash our hands or wet a wash cloth because we're afraid it will overflow. FM 2 stated, We've been having problems with the sink for about 4 months now. On 5/6/19 at 9:35 A.M., The sink in Resident 65's room was observed. The sink had about 3 inches of standing water in the bowl. Upon observation, there was no plug or any other object blocking the drain in the bowl of the sink. There was a clear glass vase which contained 2 inches of gray water positioned under the sink's drain pipe below the sink's counter. On 5/06/19 at 10 A.M., a concurrent observation and interview…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 provide a written notice of the facility's bed hold policy (a policy of reserving a resident's bed while a resident was out of the facility for hospitalization or therapeutic leave) prior to, or within 24 hours of the resident's transfer to the acute hospital for one of three residents (276) reviewed for bed hold notices. This failure resulted in the potential for Resident 276 and/or the resident's responsible party to be unaware of their right to reserve a bed in the facility during the resident's first seven days of being admitted to the acute hospital. Findings: On 5/9/19, Resident 276's medical record was reviewed. Resident 276 was admitted to the facility on [DATE] with the diagnoses of hepatic (liver) failure and diabetes (body's ability to produce or respond to the hormone insulin), per the Resident Face Sheet. A nurses note, dated 3/12/19 at 8:50 P.M., indicated Resident 276 was transferred to the acute care hospital emergency room. There 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 and record review, the facility failed to ensure the MDS assessment section for nutrition was accurately coded for one of four tube fed residents (Resident 38) reviewed for tube feeding. This failure had the potential to affect the nutritional plan of care and ultimately the overall quality of life for Resident 38. Findings: Resident 38 was readmitted to the facility on [DATE] with the diagnoses of dysphagia (difficulty swallowing) and new gastrostomy (GT a tube inserted through the abdomen that delivers liquid nutrition directly to the stomach) site per the registered nurse (RN) admission note. On 5/7/19 at 9:26 A.M., an interview was conducted with the SLT. The SLT stated when Resident 38 came back from the hospital in August of 2018, she was dependent on tube feeding for nutrition because of her dysphagia. The SLT stated Resident 38 had failed several swallowing evaluation attempts and she had provided treatments to Resident 38 off and on between August of 2018 and March 2019. On 5/7/19,…

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 record review, the facility failed to ensure written care plans were developed timely or consistently implemented for two of 18 residents (22 and 47) reviewed for care plans. These failures had the potential to put residents at risk by not providing appropriate, consistent, and individualized care. Findings: 1. Resident 22 was admitted to the facility on [DATE] with diagnoses which included gastrostomy (opening into the stomach from the abdominal wall, made surgically for the introduction of food), per the facility's Resident Face Sheet. On 5/6/19 at 10:34 A.M., an interview was conducted with Resident 22. Resident 22 stated he self-administered his own g-tube feedings (food formula administered through a tube that goes into the stomach) and medications through his g-tube. Resident 22 stated he has been self-administering for months. A record review was conducted on 5/6/19. Resident 22's physician's orders, dated 2/19/19, indicated, Able to self administer medication through…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 nursing staff completely and thoroughly assessed pressure injuries (localized damage to the skin and/or underlying tissue that occurs over a bony prominence as a result of prolonged pressure) according to professional standards for one of two residents (275) reviewed for pressure injuries. In addition, Resident 275 was not provided a low air loss mattress (LAL, uses alternating pressure to prevent and treat pressure injuries). These failures had the potential for Resident 275's pressure injuries to be misidentified and mistreated, and for wounds to deteriorate. Findings: Resident 275 was admitted to the facility on [DATE] with diagnoses to include displaced fracture of neck of left femur (hip fracture), per the facility's Resident Face Sheet. On 5/6/19 at 11:17 A.M., an interview was conducted with Resident 275 via an interpreter. Resident 275 stated she had wounds on both heels, and her heels felt sore when they touched 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 provide a medical device (hand roll) for one of three residents (Resident 5) reviewed for limited range of motion. This failure had the potential to result in Resident 5 to have further decreased range of motion (ROM) in her left contracted hand. Findings: During a record review for Resident 5, the Resident Face Sheet, indicated Resident 5 was admitted on [DATE] with diagnoses to include hemiplegia (weakness of one entire side of body) following cerebrovascular disease (condition where blood vessels of the brain are damaged affecting the supply of oxygen to the brain). During an observation in Resident 5's room on 5/6/19 at 10:12 A.M., Resident 5 was seen lying in bed. Resident 5's left hand was in a fist, and there was no hand roll. During an observation in Resident 5's room and concurrent interview with Resident 5's family member on 5/6/19 at 2:55 P.M., Resident 5 was observed sitting in a wheelchair, without a hand roll in the left…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 did not supervise a resident (47) while smoking cigarettes. This failure put all residents at risk for potential fires and burns due to Resident 47's unsupervised smoking. Findings: Resident 47 was admitted to the facility on [DATE], per the facility's Resident Face Sheet. On 5/6/19 at 4:35 P.M., an observation was conducted. Resident 47 was entered the facility by self-propelled wheelchair from the back patio which was adjacent to the resident's room. Resident 47 smelled strongly of fresh cigarette smoke. On 5/7/19 at 7:45 A.M., an interview was conducted with Resident 47 in the resident's room. Resident 47 stated he did not smoke cigarettes because smoking was not allowed at the facility. Resident 47's room smelled strongly of cigarette smoke. On 5/7/19 at 7:52 A.M., an interview was conducted with CNA 51. CNA 51 stated Resident 47 sneaks smoking, even though he is not allowed. CNA 51 stated Resident 47 kept cigarettes in his room and smoked…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and manage pain for one of three residents reviewed for pain management (Resident 56). This failure resulted in Resident 56 not receiving prescribed medication for pain. Findings: During a record review for Resident 56, the Resident Face Sheet, indicated Resident 56 was admitted to the facility on [DATE] with diagnoses to include muscle weakness. During a record review for Resident 56, the MDS assessment (an assessment tool), Section C, dated 3/29/19, indicated Resident 56's BIMS Summary Score was 13 out of 15 (attention, level of orientation, and ability to recall information was intact). During an observation and concurrent interview with Resident 56 on 5/6/19 at 9:46 A.M., Resident 56 stated he was having pain in his right knee. Resident 56 pointed to his right knee, and stated the pain is right here. During an observation on 5/6/19 at 9:47 A.M., in Resident 56's room, Resident 56 used his call light to request pain medication.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to ensure one of four carts containing medications was not left unattended or unlocked when reviewed for drug storage. In addition, medications were kept at the bedside for one resident (74). As a result, the medications were not safely stored and were easily accessible to residents, staff, and visitors. Findings: 1. On 5/8/19 at 10:05 A.M., a treatment cart on the west unit, was observed to be unlocked and unattended in the hallway outside the DSD's office. There were several residents in the area at that time. There were multiple medicated creams, powders and sprays, scissors and various treatment supplies in the cart. The cart was unlocked and unattended for seven minutes. On 5/8/19 at 10:12 A.M., an observation and interview was conducted with LN 16. LN 16 observed the unlocked treatment cart. LN 16 stated the treatment cart should have been locked. LN 16 stated there were many residents with dementia that could have gotten into it. On 5/8/19 at 10:17…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 document review, the facility failed to ensure Dietary Services department staff effectively performed kitchen tasks safely, competently, and in a sanitary manner when: 1. A staff member was unable to accurately describe the correct method for thermometer calibration. 2. A staff member incorrectly washed produce in a 3-compartment sink used for washing, rinsing and sanitizing dishware. 3. A staff member was unable to verbalize and demonstrate the correct techniques related to testing sanitizer solution in the red buckets. These practices had the potential for residents to be exposed to food borne illness due to unsanitary practices related to lack of knowledge of kitchen tasks demonstrated by staff. Findings: On 5/6/19 at 9:05 A.M., the initial facility kitchen tour was conducted with the RD/DSS. 1. On 5/6/19 at 9:15 A.M., an interview was conducted with the [NAME] (CK 1) on thermometer calibration. CK 1 was unable to verbalize what the correct reading on the thermometer should be when calibrating or how often the thermometer should be calibrated.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interviews and document review, the facility failed to ensure menus were followed to meet the needs of four of four residents on renal therapeutic diets. This failure negatively affected resident's nutritional needs and had the potential to further compromise their health status. Findings: On 5/6/19, a review of the therapeutic lunch menu spreadsheet for 5/6/19 was conducted. The lunch menu for the renal therapeutic diet indicated chicken with parmesan cheese, brown rice, seasoned broccoli and a wheat roll. On 5/6/19 at 11:30 A.M., a lunch tray line observation and interview with the [NAME] (CK 1) was conducted in the kitchen. On the steamtable, there were pans with: chicken with parmesan cheese, scalloped potatoes, spinach and wheat rolls. On the stovetop there were pots with carrots and brown rice. There were no pans with broccoli on the steam table or being prepared. CK 1 was asked if he had prepared all the food on the menu and he stated yes, he had everything prepared for the lunch menu that day. On 5/6/19 at 11:50 A.M., an observation was conducted in 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 an appropriate alternative meal option of similar nutritive value was provided to one resident (17). This failure had the potential to affect this resident's meal intake and ultimately nutritional and health status. Findings: On 5/7/19 at 3:20 P.M., an observation and interview was conducted with Resident 17 regarding food choices and her lunch meal. The lunch meal for 5/7/19 on the menu indicated: zesty lasagna, Italian green beans, garlic bread and a peanut butter cookie. Resident 17 stated she had been served a peanut butter and jelly sandwich for lunch that day because she did not like cheese. Resident 17 stated the food was horrible and mistakes were typically made with her meals. Resident 17 also stated the alternate food choices had been the same for years and were undesirable. A document review of the facility's Alternate Meal Options indicated alternative entrées such as hamburger, tuna or egg salad sandwich, grilled chicken sandwich, ham or turkey sandwich and chef salad. A peanut butter and…

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

Based on observation, interview and document review, the facility failed to ensure safe and sanitary conditions were met in the kitchen when: 1. A serving scoop for mashed potato flakes had hard, brown dried crusted substances on it. 2. A microwave, used to reheat resident food, was not maintained in a sanitary manner. 3. An ice machine, providing ice to residents, was not maintained in a sanitary manner. 4. Expired cheese sticks were found in a reach-in refrigerator. 5. Dirty and wet utensils were stored in a drawer, with a broken handle, containing crumbs and black grime. 6. Several utensils with burned and broken handles were used to prepare residents meal trays on the tray line. 7. Dirty light fixtures were above the food production and meal tray line areas. 8. A dirty floor area had trash, black and brown grime, and other particles under the dish sink area. These failures had the potential to cause food-borne illness in 78 of 81 residents who consumed food from the kitchen. Cross Reference Tags 802 and 925 Findings: On 5/6/19 at 9:05 A.M., during the initial facility kitchen…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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's QAA committee failed to identify, develop, and implement action plans related to Resident 47's unsupervised cigarette smoking and facility's staff awareness of ongoing non-compliance with the facility's non-smoking policy. (see F689) Findings: On 5/9/19 at 3:21 P.M., an interview was conducted with the ADM and DON regarding the facility's QAA committee. The ADM stated Resident 47's unsupervised smoking should have been brought to the QAA committee and addressed because it was an immediate safety concern that affected the entire facility. Per the facility's undated policy titled Quality Assurance and Performance Improvement (QAPI), . Purpose to ensure that a proactive approach is provided in the Quality Plan and Performance Improvement process is applicable to the resident's needs .

Based on observation, interview and record review, the facility failed to ensure pest control recommendations and concerns were addressed. This failure had the potential to contaminate food stored in the kitchen and dining areas which could lead to widespread foodborne illness. The facility census was 81. Findings: On 5/6/19 at 2:35 P.M., an observation and interview was conducted with the RD/DSS of the kitchen. There were two dirty food carts outside the back screen door of the kitchen. Each cart contained 16 dirty food trays. There was also a coffee cart which contained a dirty food tray and six dirty plate lids outside the back screen door of the kitchen. The RD/DSS stated the CNAs left them there but should not have. The RD/DSS acknowledged the flies and stated flies get into the kitchen because the back door was not always closed. On 5/7/19 at 10:32 A.M., a fly was observed flying around the food preparation area where [NAME] 2 prepared pureed food. [NAME] 2 acknowledged the fly flying around the food preperation area. A review of the pest company invoice records from January…

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