Laguna Hills Health And Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and closed medical record review, the facility failed to provide one of six sampled residents (Resident 1) sufficient preparation and orientation to ensure a safe discharge from the facility. * The facility failed to inform Resident 1 her insurance would not cover the cost of her physician ordered DME (a hospital bed and wheelchair), prior to her discharge from the facility. This failure had the potential to compromise Resident 1's ability to make an informed decision regarding her discharge plan of care, potentially leading to financial hardship, physical and psychosocial distress. Findings: On 9/10/25 at 0919 hours, a telephone interview was conducted with Resident 1. Resident 1 stated she was supposed to receive a hospital bed upon her discharge to home from the facility, however, she did not receive it. Resident 1 stated she was using her recliner chair, was unable to care for herself, had a lot of issues with her mobility, and only had a walker to assist with ambulation. Closed medical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility P&P review, the facility failed to ensure the environment remained free from accident hazards for one of four final sampled residents (Resident 42) and two nonsampled residents (Residents 26 and 166) reviewed for accidents. * The facility failed to post signage on Resident 42's room to indicate the oxygen was in use. * The facility failed to ensure the resident rooms contained secured closet/storage cabinets for 103 of 103 resident rooms. * A pair of long scissors was observed on Resident 166's overbed table. These failures posed the risk for injuries to the residents, staff, and visitors.Findings: 1. On 8/19/25 at 1010 hours, an observation was conducted of Resident Room E. Resident 26 resided in Room E. A closet/storage cabinet was observed adjacent to Resident 26’s wall and bed. The closet/storage cabinet was unsecured. On 8/19/25 at 1029 hours, an observation and concurrent interview was conducted with the Maintenance Director. The Maintenance Director verified…

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

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen. * The facility failed to ensure Station A ice machine drainpipe maintained an air gap (space between the water outlet and the flood level of the drain that prevents backflow of waste water from the drain) at the floor sink drain. This failure had the potential to result in waterborne illnesses in a highly susceptible resident population. * The facility failed to ensure proper storage of refrigerated food in the kitchen. * The facility failed to ensure the kitchen equipment was clean and in good condition. * The facility failed to ensure the broom and dustpan were stored in a sanitary manner. * The facility failed to ensure proper covering, labeling, and dating of foods in the refrigerator used for the residents' food brought in by visitors and failed to ensure the expired foods were discarded. * The facility failed to ensure the freezer used for the residents' food brought in by the visitors had a thermometer and 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 facility P&P review, the facility failed to ensure one of 169 residents (nonsampled Resident 17) was provided care in a manner that promoted dignity and respect. * The facility failed to provide Resident 17 with privacy during bedside toileting. This failure had the potential for the resident to experience a decline in her psychosocial well-being. Findings: Review of the facility's P&P titled Dignity revised February 2021 showed the staff will maintain and protect resident privacy during personal cares. Medical record review for Resident 17 was initiated on 8/18/25. Resident 17 was readmitted to the facility on [DATE]. Review of Resident 17's Order Summary Report showed a physician's order dated 2/4/21, for the resident to use a bedside commode. On 8/21/25 at 0928 hours, Resident 17 was observed being transferred to a bedside commode by CNA 1. Resident 17's privacy curtain was pulled closed but the basin, which was under the resident's commode and approximately six inches…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medications were safely administered to two of 33 final sampled residents (Residents 158 and 174). * Resident 158 had a bottle of Total Beets (dietary supplement) 650 mg chewable at the bedside. Resident 158 did not have a physician's order to self-administer the Total Beets 650 mg or to keep any medication at the bedside. * Resident 174 had the bottle of Instaflex Advanced (dietary supplement) at the bedside. Resident 174 had no physician's order to keep any medication at the bedside. These failures had the potential to negatively impact Resident 158 and 174's physiological well-being and the potential for the residents to administer the medications inaccurately. Findings: Review of the facility's P&P titled Administering Medications revised 4/2023 showed the medications are administered in a safe and timely manner, and as prescribed. The residents may self-administer their own medications only if…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the reasonable accommodation to meet the needs of two of two final sampled residents (Resident 8 and 49) reviewed for communication needs. * The facility failed to ensure the appropriate communication devices were used by staff to meet Residents 8 and 49's daily needs. This failure had the potential to negatively impact the resident's psychosocial well-being and result in delayed provision of care.Findings: Review of the facility's P&P titled Accommodation of Needs Communication revised 3/2021 showed the following: - In order to accommodate the individual needs and preferences, staff attitudes and behaviors are directed towards assisting the residents in maintaining independence, dignity, and well-being to the extent possible and in accordance with the residents’ wishes including interacting with the residents in ways that accommodate the physical or sensory limitations of the residents, promote…

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, facility document review, and facility P&P review, the facility failed to ensure all grievances filed during 2025 were available for review to ensure they were followed up on appropriately. * The facility did not file and kept copies of the residents' grievances. This failure resulted in the state agency being unable to verify grievances were follow-up on per policy. Findings: Review of the facility's Grievance/Complaints, Filing P&P dated 2001 showed once a grievance is filed, the SSD will review and investigate the allegations and submit a written report of findings to the administrator withing five working days. The SSD, Administrator, and facility staff will take immediate action to prevent future potential violations of residents' rights while the grievance is being investigated. The Administrator will review the findings with the SSD to determine what corrective action is needed, if any. The resident, or person filing the grievance, will be informed of the investigation findings verbally, and in writing. A copy of the written summary will also be filed in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure two of five final sampled residents reviewed for unnecessary medications (Residents 13 and 61) and one of one final sampled resident reviewed for behavioral-emotional management (Resident 133) were free from unnecessary psychotropic drugs. * Resident 13 did not have the monthly behavior summaries for the targeted behaviors for the Prozac (antidepressant) and divalproex sodium (an anticonvulsant medication also used for behaviors associated with bipolar disorder) medications. In addition, the facility failed to monitor the resident for orthostatic hypotension related to the resident's Zyprexa (antipsychotic medication) use when the resident was readmitted on [DATE]. * The facility failed to ensure the monthly behavioral summary was completed for Resident 61's Zyprexa medication. * Resident 133, who had a diagnosis of dementia, was prescribed Ativan (antianxiety medication and Seroquel (antipsychotic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to thoroughly investigate an allegation of facility staff to resident physical abuse, for one of two residents (final sampled resident, Resident 73) reviewed for abuse * Resident 73's roommate (Resident 170) alleged she witnessed a female staff member hit Resident 73 on the arm during care. The facility failed to conduct an interview with the RN assigned to care for Resident 73, during the time in which the alleged incident occurred. Additionally, the facility failed to conduct an interview with the CNA assigned to the station, which Resident 73 resided in at the time of the allegation. * The facility failed to interview other residents residing in the facility to determine if other residents were potentially the victim of physical abuse. These failures potentially inhibited the facility's ability to determine if resident abuse occurred and posed the risk for further abuse. Findings: Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to ensure the PASRR Level 1 screening contained accurate information specific to mental illness for one of two final sampled residents (Resident 13) reviewed for PASRR. * Resident 13 had a diagnosis of schizophrenia (chronic mental illness that impairs thought, perception, and behavior, making it difficult to function in daily life) however, PASRR Level 1 screening showed Resident 13 had no diagnosis of a mental illness. This failure had the potential for Resident 13 not receiving a Level II Mental Health Evaluation, which posed the risk for Resident 13 not receiving recommendations for specialized services that supplement nursing facility care to address resident mental health needs. Findings: Medical record review for Resident 13 was initiated on 8/18/25. Resident 13 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 13's MAR showed a physician's order dated 4/15/25, for Zyprexa (antipsychotic medication) 5 mg…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to develop and implement a plan of care to reflect the individual care needs for three of 33 final sampled residents (Residents 8, 158, and 174) and two nonsampled resident (Residents 52 and 166). * The facility failed to develop a comprehensive person-centered care plan addressing Resident 8's change of condition dated 8/12/25, regarding Resident 8's right posterior forearm with popped boils, and redness and tenderness on the surrounding site. * The facility failed to develop a comprehensive person-centered care plan to reflect the individualized care needs of Resident 52's abdominal fold moisture associated skin damage (MASD) and treatment. * The facility failed to ensure the interventions for Resident 158's plan of care to address the use of the Dexcom sensor (measures the glucose level at regular intervals) were implemented. * The facility failed to develop a plan of care to address the individualized care of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to provide the necessary treatment and services for one of five final sampled residents (Resident 1) reviewed for unnecessary medications. * The facility failed to ensure Resident 1's orthostatic BP (blood pressure) was accurately monitored as ordered by the physician. This failure had the potential to negatively affect Resident 1's health and well-being. Findings: Medical record review for Resident 1 was initiated on 8/18/25. Resident 1 was readmitted to the facility on [DATE]. Review of Resident 1's Order Summary Report dated 8/22/25, showed the following physician's orders: - dated 8/8/25, to monitor for orthostatic BP lying and sitting every day shift, for lying blood pressure; and - dated 8/8/25, to monitor for orthostatic BP lying and sitting every day shift, for sitting blood pressure. Review of Resident 1's plan of care showed a care plan focus addressing Resident 1's altered cardiovascular status and risk for hypertension (high blood…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the development or worsening of pressure injuries (localized area of skin damage and underlying tissues caused by prolonged pressure or shear forces) for two of three final sampled residents (Residents 7 and 37). * The facility failed to ensure Resident 7's low air loss (LAL) mattress setting was set for the resident's weight. * The facility failed to ensure Resident 37's LAL mattress unit was not on the statique mode and failed to ensure the LAL mattress setting was appropriate for Resident 37's weight. Additionally, the facility failed to ensure Resident 37's heel protectors were in place as per the resident's care plan. These failures placed the residents at risk of developing new pressure injuries and/or worsening of the existing ones.Findings: Review of the facility's P&P titled Pressure Ulcers/Skin Breakdown - Clinical Protocol dated 4/2018 showed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure the treatment was provided to prevent the decline in the ROM functions for one of two final sampled resident (Resident 61) reviewed for ROM functions. * The facility failed to ensure the RNA services were provided as ordered by the physician for Resident 61. This failure had the potential for decline in the residents' ROM functions and mobility.Findings: Review of the facility's P&P titled Restorative Nursing Services (undated) showed the residents will receive restorative nursing care as needed to help promote optimal safety and independence. Review of the facility's P&P titled Restorative Nursing Services revised on 7/2017 showed documentation in the medical record will be objective, complete, and accurate. On 8/18/25 at 0959 hours, during the initial tour, Resident 61 was observed lying in bed. Resident 61 stated she received the ROM exercises three weeks ago. Medical record review for Resident 61 was initiated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure five of five final sampled residents (Residents 16, 47, 96, 108, and 158) and one nonsampled resident (Resident 115) reviewed for respiratory care were provided the appropriate respiratory care. * The facility failed to ensure Resident 16 was administered the continuous oxygen at two liters per minute via the nasal cannula as per the physician's order. * The facility failed to ensure Resident 47 was administered with oxygen as ordered by the physician. * The facility failed to ensure Resident 96's oxygen tubing was not touching the trash bin at the bedside. In addition, the facility failed to ensure the nebulizer mask and tubing were labeled, dated, and not touching the floor. * The facility failed to ensure the oxygen tubing and humidifier were labeled and dated for Resident 108. In addition, the facility failed to ensure the administration and effectiveness of oxygen per the physician's order 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 observation, interview, medical record review, and facility P&P review, the facility failed to ensure the dialysis care was provided for two of two final sampled residents (Residents 8 and 58). * The facility failed to ensure Resident 8's physician's order for 1000 ml fluid restriction was followed and carried out accordingly. * The facility failed to ensure Resident 58's physician's order for 1500 ml fluid restriction was followed and carried out accordingly. In addition, the facility failed to monitor the resident's fluid intake accurately. These failures had the potential for the residents not being provided with the appropriate care and treatment, and the possibility of medical complications related to dialysis. Findings: Review of the facility's P&P titled Encouraging and Restricting Fluids revised on 10/2010 showed the purpose of this procedure is to provide the resident with the amount of fluids necessary to maintain optimum health. This may include encouraging or restricting fluids. Under the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure two of four final sampled residents (Residents 10 and 130) reviewed for grab bar use remained free from accident hazards associated with the use of elevated grab bars. *The facility failed to ensure the less restrictive interventions were used prior to the installation of the grab bars for Residents 10 and 130. This failure had the potential to put the residents at risk for entrapment and serious injuries.Findings: Review of the facility's P&P titled Bed Safety and Bed Rails revised on 8/2022, showed the following: - For the purpose of this policy “bed rails” include side rails, safety rails, and grab or assist bars; - The use of bed rails or side rails (including temporarily raising the side rails for episodic use during care) is prohibited unless the criteria for use of bed rails have been met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the pharmaceutical services for four of 33 final sampled residents (Residents 8, 37, 58, and 174) to ensure the accurate administration of the medications. * The facility failed to ensure the accurate documentation of the controlled medications for Resident 174. This failure posed the risk of diversion of controlled medications and medication administration errors. * The facility failed to ensure Resident 8, 37, and 58's insulin injection sites were rotated. These failures had the potential to negatively affect the residents' health conditions and posed the risk for possible complications.Findings: Review of the facility’s P&P titled Controlled Substances revised 11/2022 showed the controlled substance inventory is monitored and reconciled to identify loss or potential diversion manner that minimized the time between loss/diversion and detection/follow-up. The system of reconciling the receipt,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to ensure one of five residents (Resident 1) reviewed for unnecessary medications were properly monitored for the signs and symptoms of bleeding related to the use of anticoagulant (prevents blood clots) medication. * The facility failed to ensure Resident 1 was monitored for the signs and symptoms of bleeding for the use of heparin (anticoagulant medication) medication. This failure had the potential for the resident to develop significant side effect of bleeding and negatively affect the resident's health condition and well-being. Findings: According to DailyMed, an online reference for clinical drug information, the most common adverse reactions to heparin are hemorrhage (bleeding), thrombocytopenia (a serious antibody-mediated reaction), heparin-induced thrombocytopenia and heparin-inducted thrombocytopenia and thrombosis (blood clotting), injection site irritation, and general hypersensitivity reactions. Medical record review for Resident 1…

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

Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure the proper storage, labeling, and disposal of medications. * The facility stored the tuberculin (used in a skin test to help diagnose tuberculosis (TB) infection in persons at increased risk of developing active disease) solutions past the 30 days from the time it was opened. * The tuberculin solutions stored in the refrigerator in Medication Room A and B were not labeled with an open date. * A container of Super Sani Cloth Wipes was observed with faded expiration date inside Medication Room A * Resident 1's ice cream was stored inside the medication refrigerator in Medication Room A. * Three insulin (medication to lower blood sugar levels) pens did not have a pharmacy prescription labels for one nonsampled resident (Resident 167). One of two medication refrigerators' (Medication Room B) temperature was not kept under proper temperature controls. In addition, an ice buildup was observed along the back wall…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure one of 166 residents who received food from the kitchen during the dining observation received the appropriate diet as ordered by the physician. * The facility failed to ensure Resident 132 was served the super soup with lunch as ordered by the physician. This failure posed the risk of the resident's nutritional needs not being met. Findings: Review of the facility's P&P titled Therapeutic Diets revised 10/2017 showed a therapeutic diet is considered a diet ordered by a physician, practitioner, or dietician as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet, or to alter the texture of a diet. Review of the facility's document titled Diet Roster Rollup (undated) showed 166 of 168 residents residing in the facility received food prepared in the kitchen. Medical record review for Resident 132 was initiated on 8/18/25. Resident 132…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to maintain the infection control program and practices to help prevent the development and transmission of diseases and infections. * The line listings for May and June 2025 which documented residents who received antibiotics and were listed as not meeting McGeer's Criteria were inaccurately reported during the Infection Control Committee meeting. In addition, a resident with an MDRO (Multidrug-Resistant Organism) infection was not accurately documented in the report. In addition, the facility failed to identify, track and monitor infections in the facility from January to April 2025. * There was no documented evidence of recommendations to address the high incidence of of E. Coli and proetues miraabilis. Additionally, the Infection Control Committee Minutes failed to show documented evidence of follow up post report of MDRO infections from May to July 2025. * The facility failed to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record, facility document review, and facility P&P review, the facility failed to implement the facility's antibiotic stewardship program. * The facility failed to ensure the residents' physicians were informed when the residents who received antibiotics (Residents 190 and 191) did not meet the McGeer's Criteria, as documented for May 2025 line listing. In addition, the facility failed to follow-up on the urine laboratory results for one sampled resident (Resident 37) and one nonsampled resident (Resident 28), as documented for June 2025 line listing to determine if the antibiotic use met the McGeer's criteria. This failure had the potential for inaccurately identifying for true infections and potentially inhibiting the residents' physicians from discontinuing unnecessary antibiotic treatments.Findings: Review of the facility's P&P titled Antibiotic Stewardship dated 12/2024 showed the purpose of the antibiotic stewardship program is to monitor the use of antibiotics in our residents.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the residents' entrapment assessments were accurate and complete for three of four final sampled residents (Residents 8, 72, and 130) reviewed for the grab bar use. * The facility failed to ensure the entrapment assessments of the grab bars were accurate and complete for Residents 8, 72, and 130. In addition, the quarterly entrapment assessments were not completed for the listed residents. This failure had the potential to negatively impact the residents, resulting in possible entrapment, serious injury, and death.Findings: According to the Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment by the Food and Drug Administration issued on 3/10/06, the term entrapment describes an event in which a patient/resident is caught, trapped, or entangled in the space in or about the bed rail, mattress, or hospital bed frame. Patient entrapment may result in deaths…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure the resident received the treatments and services in accordance with the professional standards of practice when one of five sampled residents (Resident 1) did not receive the wound treatments and medications as ordered by the physician. In addition, the facility failed to notify the physician of the missed medication administrations. These failures had the potential to result in negative health outcomes to the resident.Findings: Review of the facility's P&P titled Pressure Ulcers /Skin Breakdown - Clinical Protocol revised 4/2018 showed the physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings, and application of topical agents. Review of the facility's P&P titled, Administering Medications revised 4/2019 showed the medications are administered in a safe and timely manner, and as prescribed. Medications are administered in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 10 sampled residents (Resident 5) remained free from the accident hazards. The facility failed to implement the floor mat as per the physician's orders and plan of care. This failure had the potential to place Resident 5 at risk for serious injuries. Findings: Review of the facility's P&P titled Falls and Fall Risk, Managing revised 3/2018 showed based on the previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to minimize complications from falling. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. In conjunction with the attending physician, the staff will identify and implement relevant interventions (e.g., hip…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to maintain the highest practicable physical, mental, and psychosocial well-being for one of 10 sampled residents (Resident 6). * The facility failed to conduct the complete pain assessment for Resident 6 prior to the administration of pain medication. In addition, the facility failed to follow the physician's order regarding pain management for Resident 6. These failures put the resident at risk for the resident's pain being improperly managed. Findings: Review of the facility's P&P titled Pain-Clinical Protocol dated 10/2022 showed the staff will reassess the individual's pain and related consequences at regular intervals, at least each shift for acute pain or significant changes in levels of chronic pain and at least weekly in stable chronic pain. Review should include frequency, duration and intensity of pain, ability to perform activities of daily living (ADLs), sleep pattern,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure the medical records for two of 10 sampled residents (Residents 4 and 6) were accurate. * The facility failed to ensure Resident 4's Fall Risk Assessments and Neurological Assessments were completed accurately after Resident 4 had a fall. Additionally, the facility failed to ensure Resident 4's Change in Condition evaluations were completed accurately. * The facility failed to ensure Resident 6's TAR was complete. These failures had the potential for Residents 4 and 6's care needs not being met as their medical information were inaccurate. Findings: Review of the facility's P&P titled Charting and Documentation (undated) showed all observations, medications administered, services performed, etc. must be documented in the resident's clinical records. All incidents, accidents, or changes in the resident's condition must be recorded. Documentation of procedures and treatments shall include care-specific details 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, medical record review, and facility P&P review, the facility failed to provide the pharmaceutical services to meet the need for one of nine sampled residents (Resident 3). * The facility failed to ensure Resident 3's scheduled medications for the morning shift were administered within 60 minutes of the scheduled time as per the facility's P&P. This failure had the potential to negatively impact Resident 3's health outcomes. Findings: Review of the facility's P&P titled Administering Medications revised April 2019 showed the medications are administered within one hour of their prescribed time unless otherwise specified (for example, before and after meal orders). During the initial tour of the facility on 9/18/24 at 0815 hours, an interview was conducted with Resident 3. Resident 3 stated a staff took his blood pressure reading at around 0738 hours and his blood pressure was higher than 175 mmHg. Resident 3 stated the nurse did not administer his morning medications yet. Resident…

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

Based on observation, interview, facility document review, and facility P&P review, the facility failed to maintain a clean AC unit for one sampled resident (Resident 6) and one nonsampled resident (Resident C). This failure had the potential to negatively affect the residents' health and well-being. Findings: Review of the facility's P&P titled Homelike Environment revised 2/2021 showed the residents are provided with a safe, clean, comfortable and homelike environment. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include a clean, sanitary, and orderly environment. 1. On 8/23/24 at 1110 hours, a concurrent observation and interview was conducted with the Housekeeping Supervisor. The Housekeeping Supervisor stated outside casing of the AC unit for every room in the facility was cleaned every day. The air outlet blade for Room A's AC was wiped with a white paper towel. A black ash residue was wiped from the air outlet blade. The Housekeeping Supervisor…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of six sampled residents (Resident 5) was properly discharged from the facility. This failure had the potential to place Resident 5 at risk for not receiving proper care while at home. Findings: Review of the facility's P&P titled Transfer or Discharge, Facility-Initiated dated 10/2022 showed the transfer is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility. A member of the interdisciplinary team will review the final post-discharge plan with the resident and family at least 24 hours before the discharge is to take place. Closed medical record review for Resident 5 was initiated on 8/23/24. Resident 5 was admitted to the facility on [DATE], and discharged on 8/5/24. Review of Resident 5's H&P examination dated 7/25/24, showed Resident 5 had the capacity to make medical decisions. Review of Resident 5's Order Summary Report…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of six sampled residents (Resident 5) was free from the unnecessary drugs. * Resident 5 was administered oxycodone-acetaminophen oral tablet 10-325 mg (narcotic pain medication to manage pain) when Resident's 5 pain level was below the ordered parameters to administer the medication. This failure had the potential for Resident 5 to receive unnecessary medication and experience adverse effects from the medication. Findings: According to Lexicomp, an online reference for clinical drug information, the warnings/precautions and concerns related to the adverse effects of oxycodone-acetaminophen included sedation, confusion, and constipation. According to the facility's P&P titled Specific Medication Administration Procedures effective date 4/08 showed to administer medications in a safe and effective manner. Under Procedure - to read medication label before administering. Closed medical record review for Resident 5…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary care and services to ensure the facility's four of four dryers and two of 35 final sampled residents (Residents 13 and 87) were free from accident hazards. * The facility failed to ensure the lint screen on all four dryers were brushed and cleaned after every load or every hour per the facility's P&P. In addition, the facility failed to ensure there were no exposed foam in one dryer causing the lint to stick to the foam, and the lint was not removed thoroughly. These failures had the risk for causing fire in the facility. * The facility failed to provide one to one feeding and supervision with meals for Resident 13 and failed to ensure Resident 13 was not given whole pills. In addition, the facility failed to ensure Resident 13 was transferred from wheelchair to bed with a two-person assist. These failures had the potential for aspiration/choking and fall/injury…

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

Based on observation, interview, facility document review and facility P&P review, the facility failed to ensure the food safety and sanitation guidelines were followed when: 1. Food stored in the walk-in refrigerator was not labeled or dated. Additionally, food requiring monitoring of cool down temperatures was not monitored. 2. The food contact surfaces were not clean or in a cleanable condition. 3. The hair restraints were not worn by two of 20 kitchen staff and two non-kitchen staff who entered the kitchen. 4. The water temperature of the manual ware washing sink was less than 110 degrees F. 5. The process for a two-compartment ware washing sink was not followed. 6. The mops was not stored in a sanitary condition. 7. The nonfood contact surfaces of kitchen were not clean. These failures posed the risk for food borne illnesses in highly susceptible resident population of 166 facility residents who received food prepared in the kitchen. Findings: Review of the facility matrix showed 166 of 172 residents consumed food prepared in the kitchen. 1. According to the USDA Food Code…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to maintain the infection prevention control program and practices designed to provide a safe and sanitary environment to help prevent the transmission of communicable diseases and infections. * The facility failed to maintain an accurate infection control surveillance program for July 2024. The facility conducted surveillance only on the residents who exhibited signs and symptoms of an infection and were prescribed antimicrobial medications. The facility failed to ensure the residents exhibited signs and symptoms of an infection but were not prescribed antimicrobial medications (including residents diagnosed with Candida Auris infection) were included in the facility's infection control surveillance log, and in the monthly infection surveillance report. In addition, the facility failed to correctly classify CAIs and HAIs, and failed to correctly identify the HAIs that met or 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.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the facility's ice machines were maintained in proper working condition when: - One of two ice machine was not clean. - Two of two ice machines were not sanitized according to the manufacturer's instruction guide. - Two of two ice machines did not have backflow prevention. These failures posed the risk of equipment to not function properly, which could negatively impact the residents' well-being. Findings: 1. According to the USDA Food Code 2022, Section 4-601.11 Food Contact Surfaces, Nonfood Contact Surfaces, and Utensils (A) Equipment, food contact surfaces and utensils shall be clean to sight and touch. On 8/12/24 at 0930 hours, an observation of the ice machine was conducted with the Maintenance Director. The chute of Ice Machine 1 (the interior area where ice is dropped into the ice storage bin) had a black residue. The Maintenance Director confirmed the finding and agreed there should not be any residue inside the ice machine. 2. Review of the facility's P&P…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility P&P review, the facility failed to ensure one of 35 final sampled residents (Resident 13) was provided care in the manner that promoted dignity and respect. * The facility failed to ensure an effective communication with Resident 13 in a language understood by the resident. This failure had the potential to negatively impact the resident's emotional well-being, and a risk for not providing the appropriate treatment for Resident 13. Findings: Review of the facility's P&P titled Communication Barriers, Reduction of (undated) showed the following: - It is the policy of the facility that interpreter services are provided to ensure resident communication is effective, as able, in a language they understand; - The facility will make arrangements for interpreters or alternate means of communication such as pictures, sign language, Braille, etc., to enhance communication between the resident and staff; - Bilingual employees, family members, clergy, or other outside resources…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide reasonable accommodations to meet the needs for three sampled residents (Residents 13, 22, and 166) and three nonsampled residents (Residents 50, 77, and 109). * The facility failed to ensure Residents 50 and 77 were provided with assistance in a timely manner. * The facility failed to ensure Residents 109 and 166's call lights were answered in a timely manner. * The facility failed to ensure Residents 13, 22, and 50's call lights were within the resident's reach. These failures had the potential to negatively impact the residents' psychosocial well-being or result in a delay to provide care. Findings: Review of the facility's P&P titled Call Light revised 1/2024 showed the purpose of this procedure is to ensure the timely responses to the resident's requests and needs. Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities 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 interviews, medical record review, and facility P&P review, the facility failed to ensure the physician and resident's responsible party were notified of the significant unplanned weight loss for one of 35 final sampled residents (Resident 25). This failure resulted in a delay in the communication of Resident 25's significant unplanned weight to the physician and responsible party, which had the potential to negatively impact the resident's well-being. Findings: Review of the facility's P&P titled Weight Management Standard updated May 2023 showed in part, Practice: evaluate residents with significant weight changes to ensure timely intervention by the facility interdisciplinary team to determine and achieve best possible clinical outcomes . MD and RP (responsible party) notification: Nursing: Complete SBAR/COC significant weight changes 5% in one month, 10% in six months. MD and RP notified. Medical record review for Resident 25 was initiated on 8/15/24. Resident 25 was admitted to the facility 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 interview, medical record review, facility P&P review, and facility document review, the facility failed to ensure the discharge process was properly followed for one of three sampled residents (Resident 150) reviewed for transfer and discharge. * Resident 150's medical record failed to show the physician's documentation Resident 150 was ready for discharge. This failure had the potential for an unsafe discharge from the facility for the resident. Findings: Review of the facility's P&P titled Transfer or Discharge Documentation (undated) showed the resident discharges or transfers because health of individuals in the facility would be endangered, the basis for the transfer or discharge must be documented in the resident's medical record by the attending physician. Medical record review for Resident 150 was initiated on 8/12/24. Resident 150 was admitted to the facility on [DATE]. Review of Resident 150's Notice of Proposed Transfer/discharge date d 6/4/24, showed Resident 150's discharge was appropriate…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to accurately coded the MDS assessments for four of 35 final sampled residents reviewed for the MDS assessments (Residents 52, 66, 127, and 161). * Resident 52's three MDS assessments were coded incorrectly for the resident's weight. * Resident 66's MDS was coded incorrectly regarding the resident's two falls. * Resident 127's MDS was coded incorrectly for the PASRR Level II screening. * Resident 161's MDS was not coded for the use of the CPAP machine. These failures had the potential for not providing necessary care and services to meet the care needs for these residents. Findings: 1. Review of CMS's Long Term Care Resident Assessment Instrument 3.0 User's Manual revised October 2023 showed for entering the resident's weights, use the most recent weight in the past 30 days, and if a resident cannot be weighed, use the standard no-information code (-). Medical record review for Resident 52 was initiated on 8/12/24. Resident 52 was readmitted to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure the care plans for four of 35 final sampled residents (Residents 23, 73, 87, and 161) were developed and implemented. * The facility failed to develop a care plan for Humulin R insulin (medication used to lower blood sugar levels in the body) per sliding scale for Resident 87. * The facility failed to develop a care plan problem to address Resident 23's use of blood glucose (a simple sugar which is an important energy source in living organism) monitoring device. * The facility failed to develop a care plan problem to address Resident 161's use of CPAP machine at the bedside. * The facility failed to develope a care plan problem to address Resident 73's use of the following medications: Cymbalta, Insulin Lispro, Plavix, Seroquel, and Trazodone. These failures put the residents at risk of not receiving resident-centered care. Findings: Review of the facility's P&P titled Care Plans - Baseline revised 3/2022 showed 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, medical record review and facility P&P review, the facility failed to ensure the comprehensive plan of care for one of 35 final sampled residents reviewed for care plans (Resident 46) was revised to reflect the residents' current care needs and interventions. * Resident 46's care plan for risk for aspiration and tube feeding intolerance was not revised to address the correct enteral feeding formula, free water, and infusing rate ordered. This failure posed the risk of not providing the resident with individualized and person-centered care. Findings: Review of the facility's P&P titled Care Plan's Comprehensive Person-Centered revised 3/22 showed a comprehensive, person-centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. Assessments of the residents are ongoing and care plans are revised as information about the residents and the resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility document review, the facility failed to provide an individualized and ongoing activity program to meet the needs and interests of one of 35 final sampled residents (Resident 13). * The facility failed to ensure Resident 13 was provided with his preferred activities in his primary language. This failure had the potential for Resident 13 to experience feelings of social isolation and depression. Findings: On 8/13/24 at 0806, 0815, 0824, and 1231 hours; and 8/14/24 at 0754 and 0806 hours, Resident 13 was observed awake and lying in bed. The TV was on in an English program. There was no radio observed in the room. On 8/13/24 at 0815 hours, an observation for Resident 13 and concurrent interview with CNA 12 was conducted. Resident 13 was observed awake and lying in bed. The TV was turned on in an English program. CNA 12 verified the TV was on English program. CNA 12 stated Resident 13 could speak a little bit of English. On 8/14/24 at 0813 hours, an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the quality care and services were provided for four of 35 final sampled residents (Residents 13, 23, 120, and 122). * The facility failed to ensure Resident 13's pacemaker (a small device placed in the chest to control abnormal heartbeat) was monitored for complications related to his pacemaker and failed to ensure the information regarding Resident 13's pacemaker was in his medical record as per the facility's P&P. * The facility failed to ensure a physician's order was obtained, the assessment was completed, and the appropriate instructions were obtained to maintain the appropriate care of a blood glucose monitoring device for two final sampled residents (Residents 23 and 120). * The facility failed to follow the physician's order for Resident 122 to receive a health shake (nutritional supplement) with meals. These failures had the potential for the residents to not receive the necessary care 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, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services related to pressure injuries (areas of damaged skin caused by staying in one position for a long time which reduces blood flow to the area and causes the skin to die and develop a sore) were provided for one of three final residents (Resident 13) reviewed for pressure injuries. * Resident 13's wound treatments was not performed as per the physician's orders. * The facility failed to ensure Resident 13's heels were offloaded (suspension of the heel in the air by placing pillows under the lower leg so as not to place pressure on the Achilles tendon and the heel to prevent or heal ulcers, wounds, and other conditions) as per the physician's order. These failures have the potential to delay Resident 13's wound healing. Findings: 1. Review of the facility's P&P titled Wound Care revised 2/24 showed the purpose of this procedure is to provide guidelines for the care of wounds…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and P&P review, the facility failed to ensure the nutritional status was assessed per the facility's P&P for one of 35 final sampled residents (Resident 25.) This failure posed the risk of nutritional interventions not being implemented in a timely manner. Findings: Review of the facility's P&P titled Nutrition Assessment revised 10/2017, showed in part, 1. The dietitian, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission (within current baseline assessment timeframes) and as indicated by a change in condition that places the resident at risk for impaired nutrition .3. The nutritional assessment will be conducted by the multidisciplinary team and shall identify at least the following components: d. Dietitian: 1) An estimate of calorie, protein, nutrient and fluid needs; 2) Whether the resident's current intake is adequate to meet his or her nutritional needs . Review of the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and medical record review, the facility failed to provide the necessary care and services to maintain the intravenous accesses for one of one sampled resident (Resident 161) reviewed for IV care. * The facility failed to ensure a physician's order was obtained for the peripheral intravenous access sites rotation every 72 hours and as needed. This failure had the potential to delay the identification of intravenous complication of the resident. Findings: Medical record review for Resident 161 was initiated on 8/12/24. Resident 161 was admitted to the facility on [DATE], with a diagnosis of local infection of the skin and subcutaneous tissue (deepest layer of the skin). Review of Resident 161's Internal Medicine History & Physical/Progress Note dated 7/10/24, showed Resident 161 had the mental capacity to make medical decisions. Review of Resident 161's Order Summary Report dated 8/15/24, showed a physician's order dated 8/14/24, to administer daptomycin (antibiotic) 600 mg intravenously one…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure seven of eight final sampled residents (Residents 1, 46, 53, 81, 107, 142, and 161) with respiratory orders were properly maintained and administered as ordered. * The facility failed to ensure Resident 1's oxygen tube was dated and labeled. * The facility failed to ensure Resident 81's CPAP mask had a storage bag. * The facility failed to ensure Resident 107 received oxygen as ordered, oxygen nasal cannula was properly labeled and had an oxygen storage bag. * The facility failed to ensure Resident 142's oxygen tubing was labeled, dated, and placed in a plastic bag when not in use. * The facility failed to ensure Resident 161 had a physician's order for CPAP use with a CPAP machine at the bedside. * The facility failed to ensure Resident 46 received oxygen at 2 liters per minute via nasal cannula as per the physician's order. * The facility failed to follow the physician's order for Resident 53's oxygen…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure appropriate pain management for two of three final sampled residents (Residents 13 and 824) reviewed for pain management. * The facility failed to accurately document monitoring of highest level of pain and failed to administer pain medication according to the physician's order for Resident 824. * The facility failed to administer pain medication according to the physicians' orders for Residents 13. These failures put Residents 13 and 824 at risk for ineffective pain management. Findings: Review of the facility's P&P titled Pain Assessment and Management revised 10/22 showed the pain management program is based on appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management. Pharmacological interventions (i.e. analgesics) may be prescribed to manage pain, however they do not usually address…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and medical record review, the facility failed to accurately administer the midodrine (for low blood pressure medication) medication during the dialysis (a process of removing excess water solutes and toxins from the blood in people whose kidneys can no longer perform these functions naturally) days for one of two sampled residents (Resident 128) reviewed for dialysis care. In addition, the facility failed to monitor the orthostatic hypotension (blood pressure drops when the resident was standing and sitting down) blood pressure accurately related to the hypotensive medication use. These failures posed the risk for medical complications for Resident 128 on the scheduled dialysis days. Findings: a. On 8/19/24 at 1330 hours, an interview was conducted with Resident 128. Resident 128 stated the dialysis schedule days were Tuesdays, Thursdays, and Saturdays at 0930 hours, in the morning. Resident 128 stated he took his medications before going to dialysis. Medical record review for Resident 128…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the narcotic medication count matched the narcotic count sheet, disposed narcotic count sheets were signed by two license nurses, and the blood pressure medication for Resident 32 had monitoring parameters as evidence by: * The facility failed to ensure the narcotic medication count matched the narcotic count sheet for four out of 14 final nonsampled residents (Residents 43, A, B, and C). * The facility failed to ensure the disposed narcotic count sheets were signed by two license nurses as per the facility's P&P for one of 35 final sampled residents (Resident 128) and three of 14 final nonsampled residents (Residents 76, 165, and 475). * The facility failed to ensure the metoprolol tartrate (blood pressure medication) medication for Resident 32 had parameters to hold the medication. These failures had the potential to result in medication diversion (the illegal use or distribution of a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility document review, the facility failed to act upon the Consultant Pharmacist's recommendations timely for one of five residents reviewed for unnecessary medications (Resident 25.) * Resident 25's Consultant Pharmacist's recommendations were not followed up on timely for June and July 2024. This failure had the potential for not addressing the care needs for this resident. Findings: Medical record review for Resident 25 was initiated on 8/12/24. Resident 25 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 25's H&P examination dated 2/6/26, failed to show documentation the resident had a psychiatric diagnosis. Review of Resident 25's Order Summary Report dated 8/14/24, showed a physician's order dated 6/17/24, for risperidone (an antipsychotic medication) 0.25 mg for psychotic features manifested by angry outbursts. Review of the Consultant Pharmacist's Medication Regimen Review for the period from 6/1/23 through 6/26/24,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to ensure two of 35 final sampled residents (Residents 13 and 46) were free from unnecessary drugs. * Resident 46 was administered carvedilol (blood pressure medication) when the resident's blood pressure or heart rate was below the parameters prescribed by the physician. * Resident 13 was administered carvedilol (medication to treat high blood pressure) on numerous occasions when Resident13's systolic blood pressure was below the parameter prescribed the physician. These failures had the potential for the residents to receive unnecessary medications and develop significant side effects such as bradycardia (abnormally low heart rate) and/or hypotension (abnormally low blood pressure). Findings: Review of Lexicomp, an online reference for clinical drug information showed adverse effects of carvedilol included bradycardia and hypotension. 1. Medical record review for Resident 46 was initiated on 8/12/24. Resident 46 was admitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to ensure an appropriate diagnosis for the use of the psychotropic medication for one of five residents reviewed for unnecessary medications (Resident 25). * Resident 25's order for risperidone (an anti-psychotic medication) had an unapproved/inappropriate diagnosis. This failure had the risk of inappropriate psychotropic medication use for the resident. Findings: Medical record review for Resident 25 was initiated on 8/12/24. Resident 25 was admitted to the facility on [DATE], and readmitted [DATE]. Resident 25 was [AGE] years old. Review of Resident 25's H& P examination dated 2/6/26, failed to show the resident had a psychiatric diagnosis. Resident 25's medical record failed to show an approved diagnosis for the risperidone medication use. Review of Resident 25's Order Summary Report dated 8/14/24, showed a physician's order dated 6/17/24, for risperidone (an antipsychotic medication) 0.25 mg for psychotic features manifested by angry…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and the facility P&P, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 6.06%. * The facility failed to ensure LVN 10 administered Resident 4's calcium-vitamin D3 600-12.5 mg-mcg (vitamin supplement) and sennosides 8.6 mg (stool softener medication) as ordered. This failure had the potential to cause negative outcome for Resident 4. Findings: Review of the facility's P&P titled Medication and Treatment Orders revised 7/2016 showed drugs and biologicals that are required to be refilled must be reordered form the issuing pharmacy not less than three days prior to the last dosage being administered to ensure that refills are readily available. Medical record review for Resident 4 was initiated on 8/12/24. Resident 4 was admitted to the facility on [DATE], and readmitted back to the facility on 6/21/23. Review of Resident 4's quarterly MDS dated [DATE], showed Resident 4 had a BIMS score of 8 which…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility P&P review, the facility failed to store the drugs, biologicals, and medical supplies in a safe manner as evidenced by the following: * The facility failed to ensure one of 14 medications for Resident 32 was not left unattended on top of the medication cart. * The facility failed to dispose of the expired medications inside Medication Room C. * The facility failed to ensure the oral and external medications were stored separately for Resident 159. * The facility failed to ensure the unlabeled medications were not kept in the medication cart, OTC medications were properly labeled with the date opened, and expired medications and opened medical supplies were properly disposed. * The facility failed to ensure the medication destruction container was not overfilled and properly disposed of medications and biologicals. * The facility failed to ensure the medication was not left at Resident 475's bedside. These failures had the potential to cause unsafe handling and…

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

Based on interview and facility document review, the facility failed to ensure the DSS met the educational requirements for the position. This failure to employ staff with the skills and educational requirements to effectively implement departmental processes in accordance with standards of practice, had the potential to jeopardize the health and well-being of the 166 residents who received food prepared in the kitchen. Findings: Review of the facility's job description for the Dietary Supervisor signed and dated by the DSS on 3/3/24, showed education/licensure requirements is completion of accredited course in dietetic training approved by the Academy of Nutrition and Dietetics (AND) (formerly known as the American Dietetic Association). Review of the facility matrix showed 166 of 172 residents consumed food prepared in the kitchen. On 8/12/24 at 0850 hours, an interview was conducted with the DSS. The DSS stated he was currently enrolled in an online course to obtain a Certified Dietary Manager certificate (an approved course in dietetic training). On 8/12/24 at 1653 hours, 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, facility document review, and facility P&P review, the facility failed to ensure one of 20 kitchen employee (DA 1) was competent in the position related duties when the manual ware washing procedure was not followed. This failure had the potential for food preparation equipment, dishware and utensils to not be cleaned and sanitized correctly. Findings: According to the USDA Food Code 2022 Section 4-501.19 Manual Ware washing Equipment, Wash Solution Temperature. The temperature of the wash solution in manual shall be maintained at not less than 110 degrees Fahrenheit (F). Review of the facility's P&P titled Guidelines for the Food and Nutrition Services Department revised 2/4/2020, under the Manual Washing section, showed in part, for the two compartment sink method as follows: 1. Fill sink #1 to the marked water line with clean hot water then add detergent according to the chemical vendor instructions. 2. Fill sink #2 to the mark line with clean hot water. 3. Wash service ware thoroughly in the hot detergent water, rinse in the clear water sink #2.…

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

Based on observation, interview, and facility document review, the facility failed to ensure the menus were followed for the residents who consumed food provided by the kitchen. * The puree recipe was not followed for puree chicken. * There were no recipes for the daily soup. These deficient practices had the potential to place the residents at risk of compromised nutritional status as a result of the food not meeting their nutritional needs. Findings: Review of the facility matrix showed 166 of 172 residents consumed food prepared in the kitchen. 1. Review of the facility's P&P titled Menus revised on 10/2017, showed menus are developed and prepared to meet resident choices including religious, cultural, and ethnic needs while following established national guidelines for nutritional adequacy. Review of the facility document titled Herb Baked Chicken Breast Fillet Recipe # 8218, Week three Tuesday noon meal, undated, showed herb baked chicken 19 each, thickener ¾ cup + 3 ¼ tablespoon, hot liquid, hot water or low sodium broth 3 ¼ cup. Puree: Place cooked portions needed into food…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility document review, the facility failed to ensure dietary texture guidelines were followed for one of 35 final sampled residents (Resident 13) who was on a pureed diet, and honey/ moderately thick liquid consistency. * The facility failed to ensure Resident 13 was served with a well mixed of honey/moderately-thick house shake. This failure had the potential to lead to choking or aspiration (a condition in which food, liquids, saliva, or vomit is breathed into the airway) for Resident 13. Findings: According to International Dysphagia Diet Standardization Initiative (IDDSI), moderately thick liquids are Level 3 liquids, which are also known as honey-like liquids, which can be drunk from a cup or taken with a spoon and have a smooth texture with no lumps, fiber, or seeds. Medical record review for Resident 13 was initiated on 8/12/24. Resident 13 was admitted to the facility on [DATE]. Review of the resident's Order Summary Report dated 8/13/24,…

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

Based on observation, interview and facility P&P review, the facility failed to ensure the facility staff and resident visitors were educated on safe food handling practices when food from the outside was brought to the facility for resident consumption. This failure had the potential for unsafe food handling which could lead to food borne illness in the xx residents who resided in the facility. Findings: Review of the facility's P&P titled Foods Brought by Family/Visitors revised 3/2022 showed in part, safe food handling practices are explained to family/visitors in a language and format they understand. Review of the facility in-service lesson plan and attendance record titled Food Brought by Family/Visitors dated 6/17/24, showed the in-service was conducted by the IP. The in-service included policy interpretation and implementation which reviewed the policy specifics however safe food handling was not included. On 8/12/24 at 1622 hours, an observation of the refrigerator used to store the resident food brought to the facility from the outside and concurrent interview was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility document review, the facility failed to provide the necessary care and services for one of three residents (Resident 159) reviewed for hospice services. * The facility failed to ensure Resident 159's hospice record was included in the resident's medical record. Resident 159's hospice nurse and aide visit progress notes were not found in Resident 159's the medical record. This failure posed the risk for delay in communication between the hospice provider and facility which may affect Resident 159's care. Findings: Review of the facility's contract with Hospice Provider A dated 5/17/24, showed the following: - The hospice agency and facility shall develop a process to exchange information between the interdisciplinary group and facility staff regarding development and updating of the plan of care and evaluation of care outcomes to ensure that each hospice patient receives necessary and appropriate care and services. - At each visit with a hospice patient, the…

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

Based on interview, facility document review, and facility P&P review the facility failed to monitor and address the use of antibiotics when the resident's condition did not meet McGeer's criteria (a set of specific definitions to identify true infections in long term nursing facilities) for one of 35 final sampled residents (Resident 136) and two nonsampled residents (Residents 12 and 142). This failure had the potential for antibiotics to be used when it was not indicated and the development of antibiotic-resistant bacteria. Findings: Review of the facility's P&P titled Antibiotic Stewardship-Order for Antibiotics dated December 2016 showed appropriate use of antibiotic included criteria met for clinical definition of active infection or suspected sepsis and pathogen susceptibility, based on culture and sensitivity, to antimicrobial (or therapy begun while culture is pending). Review of the facility's P&P titled Antibiotic Stewardship-Review and Surveillance of Antibiotic Use and Outcome revised December 2016 showed the IP or designee will review antibiotic utilization as a part…

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 the facility's P&P review, the facility failed to ensure the call light system was functioning for one of 172 residents in the facility (Resident 128). This failure had the potential for a delay of the resident alerting the staff for assistance. Findings: Medical record review for Resident 128 was initiated on 8/12/24. Resident 128 was admitted to the facility on [DATE]. On 8/12/24 at 0838 hours, an observation and concurrent interview was conducted with Resident 128. Resident 128 was in the bed and stated they pressed their call light button for staff assistance. The call light indicator did not show above the resident's doorway. Resident 128 pushed the call light button again, and the indicator light did not illuminate above the resident's doorway. The writer left the room to observe the call light panel located on the desk at the nurses' station, and did not see the resident's room illuminated, and there were no audible call-light indicator alerts. On 8/12/24 at 0844 hours,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to protect the resident's rights for one of nine sampled residents (Resident 1) to be free from the verbal abuse by the facility staff (CNA 5). This failure had the potential to cause serious psychosocial harm to Resident 1. Findings: Review of the facility's P&P titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program revised 4/2021 showed the residents have the right to be free from abuse. Review of the facility's P&P titled Abuse and Neglect – Clinical Protocol revised 3/2018 showed abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment that results in physical harm, pain, or mental anguish. Review of the facility's SOC 341 Report of Suspected Dependent Adult/Elder Abuse dated 5/29/24, showed CNA 1 witnessed CNA 5 calledResident 1 names and placed a sheet over Resident 1's head. Review of the facility's investigative summary…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to implement their P&P for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act when CNA 1 witnessed CNA 5 verbally abusive toward Resident 1 and failed to report it to the supervisor during her shift. This failure had the potential for delaying the assessment and provision of care for Resident 1 and not protecting the resident for further abuse. Findings: Review of the facility's P&P titled Abuse, Neglect, Exploitation, or Misappropriation – Reporting and Investigating revised 9/2022 showed if resident abuse is suspected, the suspicion must be reported to the administrator and to other officials immediately. The P&P defined immediately as within two hours of an allegation regarding abuse. Review of the facility's SOC 341 Report of Suspected Dependent Adult/Elder Abuse dated 5/29/24, showed CNA 1 witnessed CNA 5 calledResident 1 names and place 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, medical record review, and facility P&P review, the facility failed to provide the reasonable accommodations to meet the needs of one of eight sampled residents (Resident 3). * The facility failed to ensure Resident 3's call light was within the resident's reach. This failure created the potential to negatively impact the resident's psychosocial well-being or result in a delay to provide care. Findings: Review of the facility's P&P titled Answering the Call Light revised September 2022 showed the facility will ensure the call light is accessible to the resident when in bed, form the toilet, from the shower or bathing facility and from the floor. On 4/26/24 at 1022 hours, Resident 3 was observed lying in bed. Resident 3 stated she was dependent on the staff for her activities of daily living. Resident 3's call light button was observed on the left side of the bed clipped to the linen. When Resident 3 was asked if she could reach her call light button, Resident 3 was observed…

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 Intakes: CA00894957, CA00896581, CA00896799, CA00896945 Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the copy of the resident's medical record was provided upon request within two working days for one of eight sampled residents (Resident 2). * The facility provided Resident 2's medical records to the legal representative approximately 36 days after the initial request was received. This failure had the potential for violating Resident 2 and their legal representative rights to access their medical health information. Findings: Review of the facility's P&P titled Health Information Record Manual revised [DATE], showed the medical records, electronic/or manual, will be kept for each resident admitted for care. Further review of the P&P showed the medical records will be released only on written authorization of the resident, authorized representative, or legal guardian, or posthumously, the executer of the state. The protected health…

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

Based on observation, interview, and facility P&P review, the facility failed to ensure the appropriate infection control practices were implemented as evidenced by: * Two of eight linen carts were left uncovered. * Employee personal belongings were in the clean linen folding area. * Two of eight linen carts had used and dirty items on top of them. * Resident E removed the towels from the linen cart and put them back into the linen cart. These failures had the potential for spread of infection. Findings: Review of the facility's P&P titled Policies and Practices-Infection Control revised 10/2018 showed to maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public. Review of the facility's P&P titled Departmental (Environmental Services)-Laundry and Linen revised 1/2014 showed clean linen will remain hygienically clean (free of pathogens in sufficient numbers to cause human illness) through measures designed to protect it from environmental contamination, such as covering clean linen carts. 1. On 2/13/24 at 1145 hours, 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 interview, medical record review, and facility document review, the facility failed to ensure one of the two sampled residents (Resident 1) was wearing an aspen collar when discharged to the acute care hospital. This had the potential to negatively affect resident's well-being and placed the resident at risk for further injury. Findings: Closed medical record review for Resident 1 was initiated on 12/27/23. Resident 1 was admitted to the facility on [DATE], and discharged to the acute care hospital on [DATE]. Review of Resident 1's H&P evaluation dated 12/10/23, showed Resident 1 had a mechanical ground level fall resulting in the odontoid fracture. Review of Resident 1's Medicine Discharge Summary from the acute care hospital dated 12/2/23, showed Resident 1 was admitted for the mechanical fall and found to have the odontoid fracture; and the aspen collar was recommended. Resident 1's CT of C Spine without contrast dated 11/28/23, showed the fracture of the base of the odontoid process consistent with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure the call lights were answered in a timely manner forfive of 10 sampled residents (Residents 5, 6, 7, 8,and 10) * Residents 5, 6, 7, 8, and 10 expressed their concerns regarding the call lights not being answered in a timely manner. This failure had the potential for not providing the necessary care and services timely to meet the residents' care needs. Findings: Review of the facility's P&P titled Answering the Call Light revised 9/2022 showed the purpose of this procedure is to ensure timely responses to the resident's requests and needs, and to answer the call light immediately. 1. Medical record review for Resident 5 was initiated on 10/11/23. Resident 5 was admitted to the facility on [DATE]. Review of Resident 5's MDS dated [DATE], showed Resident 5 was cognitively intact and required extensive assistance for bed mobility, transfers, and toilet use. On 10/11/23 at 1025 hours, an 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.

Based on observation and interview, the facility failed to ensure the food preferences were honored for one of 10 sampled residents (Resident 7). * Resident 7 was served gravy with her meal when she disliked gravy. This had the potential to negatively impact the resident's well-being. Findings: On 10/11/23 at 1150 hours, an interview was conducted with Resident 7. Resident 7 stated she did not like gravy and received gravy a lot on her food trays. Resident 7 stated she received gravy one to two times a week and told the staff to take it away. On 10/16/23 at 1247 hours, an observation and concurrent interview was conducted with Resident 7. Resident 7 was observed sitting up in bed with her meal tray in front of her on her bedside table. The meal tray was observed with a gravy on the meat portion of the plate. Resident 7's meal ticket showed she was served Salisbury steak with gravy and showed one of her dislikes as GRAVY. Resident 7 stated it was written she did not like gravy. On 10/16/23 at 1254 hours, an observation and concurrent interview was conducted with the RD in Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of two sampled residents (Resident 5) was provided social services to coordinate Resident 5's medical appointment with an outside provider. This failure resulted in Resident 5 missing her medical appointment and feeling frustrated. Findings: Review of the facility's P&P titled Referrals, Social Services revised December 2008 showed the social services staff will help arrange the transportation for the outside agencies and clinic appointments. Medical record review for Resident 5 was initiated on 10/4/23. Resident 5 was admitted to the facility on [DATE], with the diagnosis of major depressive disorder and anemia (a condition from a lack of red blood cells) Review of Resident 5's H&P examination dated 2/2/23, showed Resident 5 was fully capable of making decisions for her care. Review of Resident 5's Progress Notes dated 9/15/23, showed the SSD was informed by Resident 5 that she missed her…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to provide written information regarding the rights to formulate the advance healthcare directives (legal document that states a person's wishes about receiving medical care if that person is no longer able to make medical decisions) for 10 of 35 final sampled residents (Residents 28, 33, 34, 47, 48, 57, 64, 66, 127 and 146). This failure had the potential for the residents' decisions regarding their healthcare and treatment options not being honored. Findings: Review of the facility's P&P titled Advanced Directives revised September 2022 showed the following: - Prior to admission of a resident, the social services director or designee inquires of the resident, his/her family members and/or his or her legal representative, about the existence of any written advanced directives. - The resident or representative is provided with written information concerning the right to accept or refuse medical or surgical treatment, and to…

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

Based on observation, interview, and facility P&P review, the facility failed to ensure the staff implemented the proper storage, labeling, and disposal of medications in a safe manner as evidenced by: * The facility failed to dispose of the expired medications in Medication Room A. * The facility failed to ensure an unopened insulin was stored properly when the unopened insulin was observed inside Medication Cart A. * The facility failed to dispose of the expired medications inside Medication Cart A. * The facility failed to ensure the medications administered orally were stored separately from the externally used medications in Medication Cart A. * The facility failed to ensure the medications administered orally were stored separately from the externally used medications in Medication Room C. * The facility failed to dispose of the insulin pens with an opened date beyond 28 days inside Medication Cart C. * The facility failed to ensure the opened insulin pens in Medication Cart C were properly labeled. * The facility failed to ensure the supplies used orally were stored…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, facility document review, facility P&P review, and manufacturer's instruction manual review, the facility failed to ensure the kitchen staff had the appropriate skill set to safely perform the daily operation of the Food and Nutrition Services Department. * [NAME] 1 was unable to demonstrate the correct procedure of the thermometer calibration. This had the potential for inaccurate food temperature readings and could lead to foodborne illnesses in a highly susceptible population of residents who received food prepared in the kitchen. Findings: Review of the CMS 672 Resident Census and Conditions of Residents completed by the facility dated 9/6/23, showed 169 of 176 residents in the facility received food prepared in the kitchen. Review of the facility's P&P titled Section D: Appendix 5 Calibration Instructions: Bimetallic Stemmed Thermometer, Ice Point Method revised date 12/14/17, showed the following procedure: - Fill a two-quart measure with ice; - Add water until 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, facility document review, and facility P&P review, the facility failed to ensure the menus were followed. * The wrong scoop size was used to serve the mechanical soft pasta and chicken tenders. * The wrong scoop size was used to serve the chocolate cake. * The meal ticket for Resident 48 was not updated. Resident 48's meal ticket showed the resident was on 1800 cc fluid restriction. Resident 48's physician's order for the fluid restriction was discontinued on 2/17/23. These failures had the potential for the residents to not receive adequate nutrition and appropriate servings to meet their individual needs. Findings: Review of the CMS 672 Resident Census and Conditions of Residents completed by the facility dated 9/6/23, showed 169 of 176 residents in the facility received food prepared in the kitchen. Review of the facility's menu spreadsheet for Cycle 2 2023 for Week 3 Thursday dated 9/7/23, for lunch meal showed to serve spaghetti with meat sauce, Caesar salad, garlic bread,…

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

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by: * The facility failed to ensure proper labeling and dating of opened food items in the freezer. * The facility failed to ensure the proper labeling and dating of the foods in refrigerator was in placed for the residents' food brought in by visitors. In addition, the facility failed to ensure the food items were discarded after 72 hours. * The facility failed to ensure the proper storage of the employees' belongings in the kitchen was being observed by the staff. * The facility failed to ensure the use of hair restraints was implemented by the dietary staff working in the kitchen. * The facility failed to ensure the plate warmer and egg slicer were clean. * The facility failed to ensure the cooking utensils were in good condition. These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumes food prepared from the kitchen. Findings: Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the residents' entrapment assessments were accurate, complete and the measurements were recorded during the bed inspection when identifying areas of possible entrapment with the use of bed rails for all 25 residents with grab rails. These failures had the potential to negatively impact the residents resulting in possible entrapment, serious injury, and death. Findings: According to the Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, the term entrapment describes an event in which a patient/resident is caught, trapped, or entangled in the space in or about the bed rail, mattress, or hospital bed frame. Patient entrapments may result in deaths and serious injuries. These entrapment events have occurred in openings within the bed rails, between the bed rails and mattresses, under bed rails, between split rails, and between the bed rails and head or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to properly obtain the informed consents (permission granted in the knowledge of the possible consequences) for the use of psychotropic medications (medications affecting brain activity) and treatments from the responsible party (person designated to make decisions on behalf of the residents) for two of 35 final sampled residents (Residents 70 and 136). This failure posed the risk for Residents 70 and 136 and their responsible parties to not be informed of their medications and the potential side effects. Findings: Review of the facility's P&P titled Health, Medical Condition and Treatment Options, Informing Residents revised February 2021 showed each resident is informed of his/her total health status and medical condition, including diagnosis, treatment recommendations and prognosis, in advance of treatment and on on-going basis. If a resident has an appointed representative, the representative is also informed. 1. Medical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 35 final sampled residents (Resident 28) and three nonsampled residents (Residents 52, 65, and 117) were assessed to determine if it was safe for them to self-administer their medications prior to self adminisering their medications. This failure had the potential for the medication interactions and inappropriate use of medications. * The medication tube labeled zinc oxide (medicated cream/ointment) and medication cup filled with white cream were observed at Resident 28's bedside table. * A bottle of calcium carbonate (antacid) was observed at Resident 52's bedside table. Resident 52's family member brought the calcium carbonate for the resident. Resident 52 was not assessed for self-administration of medications. * A bottle of Visine eye drops (medication to temporarily relieve eye redness and itching) was observed at Resident 65's bedside table. Resident 65 had self-administered the Visine eye…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the reasonable accommodations to meet the care needs for five of 35 final sampled residents (Residents 57, 66, 91, 135, and 682). * The facility failed to ensure Resident 682's bed was adjusted to a preferred height to transfer from bed to wheelchair and vice versa with assistance. * The facility failed to ensure Residents 57's call light was answered in a timely manner. * The facility failed to ensure Residents 66, 91, and 135's call lights were within the residents' reach. These failures had the potential to negatively impact the resident's psychosocial well-being or result in a delay to provide care and services to the residents. Findings: 1. Review of the facility's P&P titled Accommodation of Needs revised March 2021 showed the resident's individual needs and preferences, including the need for adaptive devices or modification to their physical environment, are evaluated upon admission 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 interview, facility P&P review, and facility document review, the facility failed to address the concerns [NAME] forth in the resident council meetings (a group of residents gathered to discuss interest and issues noted in the facility) and failed to notify the residents (Residents 16, 55, 78, 328, and 682) who filed the grievances regarding the outcomes of investigation. These failures had the potential for the residents' identified issues to go uncorrected. Findings: Review of the facility's P&P titled Grievances/Complaints, Recording and Investigating revised 4/2017 showed all grievances and complaints filed with the facility will be investigated and corrective actions will be taken to resolve the grievance(s). Further review of the P&P showed the resident, or person acting on behalf of the resident, will be informed of the findings of the investigation, as well as any corrective actions recommended within five working days of the filing of the grievance or complaint. a. Review of the facility'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.

Based on observation, interview, document review, and facility P&P review, the facility failed to ensure the residents' medical records were safeguarded to protect the confidential health information for five nonsampled residents (Residents 14, 26, 39, 119, and 125) and one closed record sampled resident (Resident 112). This failure had the potential for the residents' personal and health information to be accessed from the unauthorized users. Findings: Review of the facility's P&P titled Confidentiality of Information and Personal Privacy revised 10/2017, showed the facility will safeguard the personal privacy and confidentiality of all resident personal and medical records. On 9/5/23 at 1055 hours, during the initial tour of the facility, Room A's bathroom was observed with a green clipboard. Attached on the clipboard were the following: 1. A calendar titled July '23 listed names of several residents; 2. A form titled Outlook showing August 7, 2023 calendar of events with the names of Residents 14, 39, 112, 119, and 125; 3. A form titled Dental Office A Medical Order for Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to thoroughly investigate the allegations of abuse made by two of the 35 final sampled residents (Resident 38 and 153). * The facility failed to thoroughly investigate Resident 38's allegation of abuse. This failure put Resident 38 at risk of not being protected against the alleged abuse and and other vulnerable residents at risk for abuse. * The facility failed to ensure the allegation of abuse made by Resident 153 was thoroughly investigated. This failure had the potential to put Resident 153 and other vulnerable residents at risk for abuse. Findings: Review of the facility's P&P titled Abuse, Neglect, Exploitation or Misappropriation Reporting and Investigating revised September 2022 showed all allegations are thoroughly investigated, the individual conducting the investigation at a minimum interviews the resident's roommate, family members, and visitors and documents the investigation completely and thoroughly. 1. Medical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and the facility P&P review, the facility failed to develop the comprehensive plans of care to reflect the individual care needs for four of 35 final sampled residents (Residents 137, 478, 680, and 682). * The facility failed to develop a care plan problem for Resident 137's use of psychotropic medication and Resident 478's use of antibiotic medication. * The facility failed to develop a care plan problem to address Resident 680's infections. * The facility failed to ensure Resident 682's activities care plan problem address her impaired vision and preference of large print reading materials. These failures posed the risk of not providing appropriate, consistent, and individualized care to these residents. Findings: Review of the facility's P&P titled Care Plans, Comprehensive Person-Centered revised March 2022 showed the comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished 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 medical record review, the facility failed to ensure the comprehensive plans of care for one of 35 final sampled residents (Resident 66) was revised to reflect the residents' current care needs and interventions. The facility failed to ensure Resident 66's plan of care was revised to address Resident 66's continuous oxygen use. This posed the risk of not providing Resident 66 with individualized and person-centered care. Findings: On 9/5/23 at 1050 hours, during the initial tour of the facility, Resident 66 was observed in bed and on room air. Medical record review for Resident 66 was initiated on 9/5/23. Resident 66 was readmitted to the facility on [DATE]. Review of Resident 66' Order Summary Report showed the physician's order dated 9/1/23, to administer oxygen at three liters per minute via nasal cannula continuously. Review of Resident 66's plan of care showed a care plan problem dated 8/10/23, addressing Resident 66's oxygen therapy as needed. The plan of care was 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, medical record review, and facility P&P review, the facility failed to provide an ongoing in activity program to meet the needs and interests of four of 35 final sampled residents (Residents 47, 77, 153, and 682). This failure had the potential to affect the residents' psychosocial well-being. Findings: Review of the facility's P&P titled Activity Programs revised June 2018 showed the activities program is provided to support the well-being of residents and to encourage both independence and community interaction. Activities offered are based on the comprehensive resident-centered assessment and the preferences of each resident. Activities are considered any endeavor, other than routine ADLs, in which the resident participates, that is intended to enhance his or her sense of well-being and to promote or enhance physical, cognitive or emotional health. Activities are scheduled seven days a week. All activities are documented in the resident's medical record. 1. On 9/5/23 at 0924…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary services to attain or maintain the highest practicable well-being for five of 35 final sampled Residents (Residents 40, 66, 91, 127, and 153). * The facility failed to ensure Resident 153's physician's orders to place the neck brace at all times and keep the knee immobilizer in place were discontinued. This failure had the potential risk of not providing appropriate care for Resident 153. * The facility failed to ensure the necssary care and services were provided timely for Resident 127 who had a fall, including the post fall assessment, neurological assessments after a fall, developinig a care plan to address the actual fall, notifing the physician and resident's representative of the incident, and conducting an investigation to determine possible causes of the fall. This failure had the potential for delay of care provided and poor health outcomes for this…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary care and services to prevent accidents for two nonsampled residents (Residents 92 and 127). * Resident 127 had the right hip surgery with the immobilizer to the right knee. There was no revision of plan of care to address the use of immobilizer. There was no call, don't fall sign posted as per the care plan problem. * The facility failed to ensure Residents 92's bed was left in a low position and fall prevention mattress were in place as per the resident's care plan. These failures put the residents at high risk for falls and serious injuries. Findings: 1. Medical record review for Resident 127 was initiated on 9/5/23. Resident 127 was initially admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 127's Admission/readmission Data Tool v2 dated 5/22/23, under the Fall Risk Assessment, showed Resident 127 was at risk for falls. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to provide the indwelling urinary catheter (tube placed in the bladder to drain urine) care to one of 35 final sampled residents (Resident 70) as ordered by the physician. This failure posed the risk of infection. Findings: Medical record review for Resident 70 was initiated on 9/6/23. Resident 70 was admitted to the facility on [DATE]. Review of Resident 70's admission record dated 9/8/23, showed Resident 70 had a diagnosis of UTI. Review of Resident 70's Physician Order dated 7/14/23, showed to insert Foley catheter size 16 with 10 cc BSD (Balloon Sinus dilation); and provide urinary indwelling catheter care every shift and as needed. Review of Treatment Administration Record dated 8/1 to 8/31/23 and 9/1 to 9/30/23, showed no documented evidence indwelling urinary catheter care was provided on the following dates and shifts: - On 8/7, 8/28, and 9/5/23, during the 1500 to 2300 hours shifts. - On 8/7, 8/8, 8/9, 8/11, 8/14, 8/15, 8/21, and 8/28/23,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to maintain the intravenous accesses for two of 35 sampled residents (Residents 31 and 478). In addition, the facility failed to ensure the PICC line external catheter and arm circumference measurements were performed and documented in the medical record for Residents 31 and 478. These failures had the potential to delay the identification of catheter related complications for these residents. Findings: Review of the facility's P&P titled Peripheral and Midline IV Dressing Changes dated March 2022 showed for midline catheters, to measure the arm circumference of the resident and compare to the baseline when clinically indicated to assess for edema (build-up of fluid in the body tissue) and possible deep-vein thrombosis (formation of blood clots inside the blood vessel). a. Medical record review for Resident 31 was initiated on 9/5/23. Resident 31 was admitted to the facility 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, medical record review, and facility P&P review, the facility failed to ensure seven of 35 final sampled residents (Residents 31, 37, 49, 64, 66, 478, and 685) and one nonsampled resident (Resident 688) were provided with the appropriate respiratory care when: * The facility failed to ensure Resident 685's oxygen nasal cannula tubing was labeled and dated as per the physician's order. * The facility failed to ensure Resident 688 had a physician's order for administration of oxygen and oxygen nasal cannula tubing was labeled and dated. * The facility failed to ensure Residents 31 and 478's nasal cannula (flexible tube to deliver oxygen into the nose) tubings were dated as per the facility's P&P. *The facility failed to provide Resident 66 with continuous oxygen as per the physician's order. In addition, the facility failed to ensure the nasal cannula tubing and nebulizer tubing and mask were labeled and dated. *The facility failed to ensure Resident 64's nasal cannula tubing was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure the dialysis care was provided for three of 35 final sampled residents (Residents 34, 146, and 682). * The facility failed to ensure the physician's order for 1000 ml fluid restriction (a diet which limits the amount of daily fluid consumption) was followed and carried out accordingly for Resident 682. * The facility failed to ensure the physician's order for 1500 ml fluid restriction was followed and carried out accordingly for Residents 34 and 146. These failures had the potential for medical complications related to not following the physician's order for fluid restriction. Findings: Review of the facility's P&P titled Encouraging and Restricting Fluids revised October 2010 showed to follow specific instructions concerning fluid intake or restriction; be accurate when recording fluid intake; record the amount of fluid consumed on the intake side of the intake and output record; and record intake in milliliters.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to complete the assessments, attempt the least restrictive alternative measures, and obtain the physician's orders and informed consents prior to the use of side rails for three of 35 final sampled residents (Residents 64, 66, and 146). This failure had the potential to put the residents at risk for serious injuries. Findings: Review of the facility's P&P titled Bed Safety and Bed Rails revised August 2022 showed for the purpose of this policy bed rails include side rails, safety rails, and grab or assist bars. The used of bed rails or side rails (including temporarily raising the side rails for episode use during care) is prohibited unless the criteria for the use of bed rails have been met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent. Before using bed rails for any reasons, the staff shall inform the resident or representative about the benefit…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the pharmaceutical services to meet the resident's needs for one nonsampled resident (Resident 18). In addtion, the facility failed to ensure the emergency kit for oral medications was replaced in a timely manner, creating the risk for not having a medication available in case of emergency. * The facility failed to ensure Resident 18's hydrocodone-acetaminophen (narcotic pain medication) was accurately reconciled. The hydrocodone-acetaminophen tablets removed showing on the Antibiotic or Controlled Drug Record did not match the electronic MAR as administered to Resident 18. This failure had the possibility of diversion of controlled medications. Findings: 1. Review of the facility's P&P titled Administering Medications revised April 2019 showed the individual administering the medication initials the resident's MAR on the appropriate line after giving each medication 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 interview, medical record review, and facility P&P review, the facility failed to ensure the Pharmacy Consultant's recommendations from drug regimen review were acted upon for three of 35 final sampled residents (Residents 66, 96, and 127). * The Pharmacy Consultant's recommendation to verify the diagnosis for the prescribed Depakote (anticonvulsant medication used to treat mania associated with bipolar disorder, seizures, and migraine headache) medication for Resident 66 was not acted upon. * The Pharmacy Consultant's recommendation to change the instruction for the lactulose (laxative) medication administration for Resident 127 was not acted upon. * The facility failed to ensure the drug regimen review recommendations in July and August 2023 were acted upon for Resident 96. These failures posed the risk of the residents not receiving the necessary care and services or receiving unnecessary medications. Findings: Review of the facility's P&P titled Medication Regimen Reviews revised 5/2019 showed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to ensure one of 35 final sampled residents (Resident 53) was free from the unnecessary drugs. * Resident 53 was administered carvedilol (medication to treat high blood pressure) on numerous occasions when Resident 35's heart rate was below the parameter prescribed the physician. This failure had the potential for Resident 35 to develop significant side effects such as bradycardia (slower than normal heart rate). Findings: According to Lexicomp, an online reference for clinical drug information, the warnings/precautions and concerns related to the adverse effects of carvedilol included bradycardia. Medical record review for Resident 53 was initiated on 9/5/23. Resident 53 was readmitted to the facility on [DATE]. Review of Resident 53's Order Summary Report showed a physician's order dated 2/14/23, to administer carvedilol 3.125 mg two times a day for hypertension (high blood pressure, a blood pressure that is higher than normal.),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure five of 35 final sampled residents (Residents 64, 66, 70, 136, and 137) were free from the unnecessary psychotropic drugs (any drug that affects brain activity associated with mental processes and behavior). * Resident 136 had an order for Risperdal (antipsychotic medication). The facility failed to ensure Resident 136's physician's order for Risperdal had a proper diagnosis. In addition, the facility failed to ensure Resident 136's monthly behavior summary was completed for the use of Lexapro (medication used to treat depression) and Risperdal. * The facility failed to ensure Resident 70's monthly behavior summary was completed for the use of bupropion (medication used to treat depression) and Remeron (medication used to treat depression). In addition, the facility failed to document the implementation of non-pharmacological interventions for verbalization of sadness prior to…

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

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 30.77%. Two of two licensed nurses (LVNs 13 and 14) were found to have made errors during the medication administration to two nonsampled residents (Residents 85 and 683). * LVN 14 failed to properly administer the eye drops and potassium chloride (mineral supplement used to treat or prevent low amounts of potassium in the blood) to Resident 683. In addition, Resident 683 received partial doses for four medications when residual of the medications were left over in the medication cups. * LVN 13 failed to ensure Resident 85's senna (medication used to treat constipation) tablet was administered as ordered. These failures had the potential to negatively affect the residents' health conditions and posed the risk for possible complications or delay in interventions. Findings: Review of the facility's P&P titled Administering Medications revised April 2019 showed the medications are administered in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of 35 final sampled residents (Resident 681) was free from a significant medication error. * The facility failed to ensure Resident 681 received dorzolamide-timolol eye drop (to treat glaucoma) as ordered by the physician on multiple occasions. This failure placed Resident 681 at risk for medical complications. Findings: Review of the facility's P&P titled Administering Medications revised April 2019 showed the medications are administered in accordance with prescriber orders, including any required time frames. Medical record review for Resident 681 was initiated on 9/5/23. Resident 681 was admitted to the facility on [DATE], and readmitted on [DATE]. Resident 681 was admitted with a diagnosis of glaucoma (eye diseases that can cause vision loss and blindness). Review of Resident 681's H&P examination dated 8/9/23, showed Resident 681 had the capacity to understand and make decisions. Review of Resident 681'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.

Based on observation, interview, and facility document review, the facility failed to ensure one nonsampled resident (Resident 72) was provided with the prescribed therapeutic diet (correct liquid consistency). * Resident 72 was prescribed with pureed/level 4 with pudding extremely thick liquid consistency. Resident 72 was served with pureed with nectar mildly thick liquid consistency. This failure posed the risk of aspiration and resident's nutritional needs not being met. Findings: According to International Dysphagia Diet Standardization Initiative (IDDSI), there are different levels of liquid consistency: - Level 0, thin liquids for adults flow like water, and can flow through a straw or teat/ nipple; - Level 1, slightly thick liquids for adults are thicker than water, and can flow through a straw; - Level 2, mildly thick liquids for adults are sippable, pour quickly from a spoon but slower than thin drinks and slightly thick drinks, and needs some effort to drink this thickness using a standard straw; - Level 3, moderately thick liquids for adults can be drunk from a cup or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility P&P review, the facility failed to ensure the infection control practices were observed as evidenced by: * The facility failed to ensure the infection control practices were maintained in the facility's laundry room area when a food tray with traces of food was observed in the clean linen area. * During the medication administration observation, LVN 13 failed to properly disinfect the blood pressure equipment while obtaining the vital signs for Resident 85. In addition, LVN 13 failed to perform hand hygiene during the medication administration for Resident 85. * The facility failed to ensure Resident 141's transmission-based precaution physician's orders were accurate. * The facility failed to ensure the appropriate wipes were used by staff to clean the hands of nine nonsampled residents (Residents 62, 72, 73, 97, 105, 107, 130, 134, and 143) before and after meals. These failures posed the risk for transmission of disease-causing microorganisms and infections.…

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, facility document review, and facility P&P review the facility failed to monitor and address the use of antibiotics when the resident's condition did not meet McGeer's criteria (a set of specific definitions to identify true infections in long term nursing facilities) for one of 35 final sampled residents (Resident 136) and two nonsampled residents (Residents 12 and 142). This failure had the potential for antibiotics to be used when it was not indicated and the development of antibiotic-resistant bacteria. Findings: Review of the facility's P&P titled Antibiotic Stewardship- Order for Antibiotics dated December 2016 showed appropriate use of antibiotic included criteria met for clinical definition of active infection or suspected sepsis and pathogen susceptibility, based on culture and sensitivity, to antimicrobial (or therapy begun while culture is pending). Review of the facility's P&P titled Antibiotic Stewardship- Review and Surveillance of Antibiotic Use and Outcome revised December 2016 showed the IP or designee, will review antibiotic utilization as 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 interview, medical record review, and facility P&P review, the facility failed to ensure two of 35 final sampled Residents (Residents 96 and 101) and one nonsampled resident (Resident 2) were assessed for the COVID-19 vaccination status, or offered the COVID-19 vaccine. This failure put the residents at risk for increased risk of infection and transmission of COVID-19. Findings: Review of the facility's P&P titled Coronavirus Disease (COVID-19)- Vaccination of Residents revised May 2023 showed each resident is offered the COVID-19 vaccine unless the medically contraindicated or the resident is fully vaccinated. The P&P further showed resident has the opportunity to accept or refuse a COVID-19 vaccine, to change his/her decision and the information to be provided to the resident in a format and language that is understood by the resident or representative. 1. Medical record review for Resident 2 was initiated on 9/8/23. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's medical…

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

Based on observation, interview, facility document review, and facility P&P review, the facility failed to maintain the effective pest control program to prevent the presence of flies in the kitchen. This failure had the potential to lead to food-borne illnesses (illnesses caused by food contaminated with bacteria, viruses, parasites or toxins) in the facility residents who eat food prepared in the kitchen. Findings: According to the USDA Food Code 2022, 6-501.111, Controlling Pests, insects and other pests are capable of transmitting disease to humans by contaminating food and food-contact surfaces. Effective measures must be taken to eliminate their presence in food establishments. Review of the facility's P&P titled Pest Control revised May 2008 showed the facility maintains an ongoing pest control program to ensure that the building is kept free of insects and rodents. On 9/8/23 at 1007 hours, flies were observed flying in the food preparation area inside the kitchen. The RD verified the above findings. On 9/8/23 at 1050 hours, an observation of the trash disposal and concurrent…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to ensure two of 12 sampled residents (Residents 8 and 10) maintained their highest practicable physical, mental, and psychosocial well-being. * The facility failed to reorder Residents 8 and 10's medications before they ran out. This failure created the risk for poor health outcomes to Residents 8 and 10. Findings: Review of the facility's P&P titled Ordering and Receiving Medications from the Dispensing Pharmacy dated 4/2008 showed under the Policy section, the medications and related products are received from the dispensing pharmacy on a timely basis. The facility maintains accurate records of medication order and receipt. Under Subsection A. Ordering Medications from the Dispensary, Section 2, if not automatically refilled by the pharmacy, repeat the medications (refills) are written on a medication order form/ordered by peeling the bottom part of the pharmacy label and placing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility document review, the facility failed to provide adequate supervision for two of 12 sampled residents (Residents 4 and 7). * Resident 7 eloped from the facility undetected by staff. * A non-facility home care aide for Resident 5 was found sitting on Resident 4's bed and offered to perform care for the resident, which upset Resident 4. These failures had the potential to negatively impact the residents' well-being. Findings: 1. Medical record review for Resident 7 was initiated on 7/6/23. Resident 7 was admitted to the facility on [DATE]. Reviews of Resident 7's H&P examination dated 5/7/23, showed the resident required assistance to make decisions. Review of Resident 7's care plan initiated 5/17/23, showed a care plan problem addressing a risk of elopement related to cognitive loss, with an intervention for staff to maintain a safe environment. Review of Resident 7's telephone logs showed he called his family member on 6/20/23 at 1954 hours. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the resident's medical record had a physician's order for supplemental oxygen administration for one of 12 sampled residents (Resident 12). This failure created the risk for the resident's oxygen use not being accurately documented, including its effectiveness, and evaluating the need for continued use. Findings: Review of the facility's P&P titled Oxygen Administration revised 10/2010 showed the following: - Prior to administrating oxygen, verify there is a physician's order. - While the resident is receiving oxygen therapy, document the date and time the oxygen was administered, the rate of flow (lpm), the route and rationale for its use, the frequency and duration as well as the reason for prn administration. - Document all assessment date before, during and after administration and how the resident tolerated it. Medical record review for Resident 12 was initiated on 7/28/23. Resident 12 was admitted…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure the controlled medications were accurately accounted for one of 12 sampled residents (Resident 11). This failure had the potential to delay the identification and investigation of potential drug diversion. Findings: Review of the facility's P&P titled Controlled Substances revised 11/2022 showed the following: - Controlled substance inventory is monitored and reconciled to identify loss or potential diversion - Reconciling and dispensing controlled substances includes records of personal access and usage, medication administration records. - Wastage of controlled medications are done in the presence of the nurse and a witness who also signs the disposition sheet. Medical record review for Resident 11 was initiated on 7/25/23. Resident 11 was admitted to the facility on [DATE]. Review of Resident 11's Order Summary Report dated 7/28/23, showed an order dated 7/7/23, for oxycodone (a controlled medication for pain) 20…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P, the facility failed to ensure the complete and accurate medical record for one of 12 sampled residents (Resident 12) when the nursing staff failed to document Resident 12's urinary catheter replacement. This failure created the risk for the rationale for the device replacement as well as the resident's response to the procedure and other data not being included in the resident's medical record. Findings: Review of the facility's P&P titled Indwelling (Foley) Catheter Insertion, Female Resident revised 8/2022 showed after an indwelling urinary catheter is replaced, to document the date and time the procedure was performed and the indications for catheter use. Review of the facility's P&P titled Indwelling (Foley) Catheter Removal revised 8/2022 showed after removal of the catheter, to document the date and time the procedure was performed; assessment data including urine amount, color, clarity; and how the resident tolerated the procedure. Medical…

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.