Trabuco Hills Post Acute

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 obtain and maintain a copy of the Advanced Directive for one of six final sampled residents (Resident 107) investigated for Advanced Directives. * Resident 107's Advanced Directive was not in the medical record. This failure had the potential for the resident's wishes related to the provision of medical treatment and services to not be followed if the resident was unable to make medical decisions for themselves.Findings: Review of the facility's P&P titled Residents' Rights Regarding Treatment and Advance Directives dated 12/19/22, showed on admission, the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident, if cognitively able to, would like to formulate an advance directive. In the event the resident is unable to formulate an advanced directive due to cognitive impairment or deemed by the medical doctor that the resident is incapable of making decisions 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 resident privacy for one of four final sampled residents (Resident 68) investigated for tube feeding. * Resident 68 was not provided privacy during a GT feeding administration. This failure had the potential for the resident to experience a negative outcome and feel exposed.Findings: Review of the facility's P&P titled Promoting/Maintaining Resident Dignity dated 9/2/22, showed the staff will maintain resident privacy. Review of the facility's P&P titled Flushing A Feeding Tube dated 12/19/22, showed to provide privacy by pulling the privacy curtain. Medical record review for Resident 68 was initiated on 2/25/26. Resident 68 was readmitted to the facility on [DATE]. Review of Resident 68's Order Summary Report showed the following physician's orders:- dated 2/24/26, for Jevity 1.5 (enteral feeding formula) to be administered via GT at 65 ml/hr for 20 hours; and- dated 2/24/26, to flush the GT with water…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 three of 32 final sampled residents (Residents 3, 13, and 16) were free from the unnecessary psychotropic medications. * The facility failed to ensure the nonpharmacological interventions were provided to Resident 3 when Resident 3 had behavior episodes related to the use of quetiapine (antipsychotic medication) and lorazepam (antianxiety medication). * The facility failed to ensure the behaviors were monitored related to the use of quetiapine for Resident 13. In addition, orthostatic blood pressure was not monitored related to the use of the quetiapine medication for Resident 13. * The facility failed to ensure Resident 16's orthostatic blood pressure was accurately monitored as ordered by the physician for the use of the quetiapine medication. These failures had the potential for adverse effects from the psychotropic medications and the potential for not providing the correct data to the prescriber to adjust the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of two final sampled residents (Resident 68) investigated for hospitalization was readmitted to their prior room upon return to the facility. * Resident 68 was not readmitted to the same room after returning from the acute care hospital after two days. This failure resulted in the resident being upset having to switch his room once readmitted to the facility. Findings: Medical record review for Resident 68 was initiated on 2/25/26. Resident 68 was initially admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 68's Order Summary Report showed a physician's order dated 2/22/26, for a bed-hold for seven days. Review of Resident 68's Nurse Progress Note dated 2/22/26 at 1920 hours, showed the resident was transferred to an acute care hospital. Review of Resident 68's N ADV Clinical admission Assessment Note dated 2/24/26 at 2057 hours, showed the resident arrived back at the facility by…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 transfer/discharge services for one of two final sampled residents (Resident 68) investigated for hospitalization. * Resident 68 was not provided a bed-hold notice when he was discharged from the facility to the acute care hospital on 2/22/26. This failure resulted in the resident being upset having to switch his room once readmitted to the facility. Findings: Review of the facility's P&P titled Bed Hold Notice Upon Transfer dated 12/19/22, showed before a resident is transferred to the hospital, the facility will provide to the resident or the responsible party written information about the duration of the bed-hold policy and the reserve bed payment, if any. Medical record review for Resident 68 was initiated on 2/25/26. Resident 68 was initially admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 68's Bed Hold Notification Informed Consent form dated 2/16/26, 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 and medical record review, and facility P&P review, the facility failed to ensure the PASARR recommendations were followed up and incorporated into the resident care for one of three final sampled residents (Resident 3) reviewed for PASARR. * Resident 3's PASARR - level II determination recommendations were not followed up and incorporated into the resident's care. This failure had the potential for Resident 3 not receiving the adequate care that was recommended by PASARR level II determination and evaluation report assessed by an appropriate state-designated authority.Findings: Review of the facility P&P titled Resident Assessment-Coordination with PASARR Program dated 12/19/22, showed recommendations such as any specialized services, from a PASARR level II determination and PASARR evaluation report will be incorporated into the resident's assessment, care planning, and transitions of care. Review of the facility's P&P titled Comprehensive Care Plans dated 12/19/22, showed the comprehensive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a care plan for two of 32 final sampled residents (Residents 7 and 90). * The facility failed to develop a care plan to address Resident 7's preference to lower his head of the bed during GT feeding. Additionally, there was no care plan developed to address Resident 7's use of hearing devices. * The facility failed to develop a care plan to address Resident 90's weight loss of 11.5% in one month. These failures had the potential for the resident's needs not being communicated to the IDT and placed the resident at risk of not being provided appropriate, consistent, and individualized care. Findings: Review of the facility's P&P titled Comprehensive Care Plans revised 12/19/22, showed the care planning process will include an assessment of the resident's strength's and needs, and will incorporate the resident's personal preferences. The care plan will describe any services that would otherwise be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure the quality care and services were provided for one of three final sampled residents (Resident 174) reviewed for accidents. * The facility failed to ensure Resident 174 was accurately assessed for the neurological evaluations after a fall incident on 2/9/26. The facility documented the same vitals signs from the previous neurological evaluations. In addition, the facility failed to ensure Resident 174's blood pressure readings for the sitting, lying, and standing positions were obtained, as per the care plan intervention for Resident 174's fall. These failures had the potential for Resident 174 to not receive the necessary care and services to maintain the resident's highest physical well-being.Findings: Review of the facility's P&P titled Fall Prevention Program revised 12/28/23, showed when any resident experiences a fall, the facility will:- assess the resident.- complete a post-fall assessment.- complete an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to ensure one of one final sampled resident (Resident 7) investigated for hearing received proper assistance with devices to maintain hearing abilities. * Resident 7 had no physician's order for hearing aid use, and the facility did not charge or assist him with his devices. This failure resulted for the resident having difficulty communicating with others. Findings: Medical record review for Resident 7 was initiated on 2/25/26. Resident 7 was readmitted to the facility on [DATE]. Review of Resident 7's Resident's Clothing and Possessions form dated 10/14/25, showed the resident's left and right hearing aids and charger were brought to the facility. Review of Resident 7's N Adv - Clinical admission - V 29 assessment dated [DATE], showed the resident had right and left hearing aids, which were worn on admission. Review of Resident 7's Activity Assessment - V4 dated 1/9/26, showed the resident used hearing aids in both ears. On 2/25/26…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the necessary care and services were provided to prevent the development of new pressure ulcers (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) for one of four final sampled residents (Resident 9) reviewed for pressure ulcers. * The facility failed to ensure the LAL (Low Air Loss) mattress setting was consistent with Resident 9's weight. Resident 9's current weight was 102 lbs., whereas the LAL mattress setting was set at 150 lbs. This failure posed the risk for Resident 9 to not benefit from the therapy provided by the LAL mattress.Findings: Review of the manual titled DynaRest Airfloat 100 Air Mattress with Pump (undated), showed the DynaRest AirFloat 100 Air Mattress is designed for bed sore and wound care therapy treatment and prevention, which may occur during an extended hospital stay…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 physician's order was followed for one of three final sampled residents (Resident 107) reviewed for urinary catheter/UTI. * Resident 107 had an indwelling urinary catheter. The facility failed to conduct the voiding trial as per the physician's order for Resident 107. This failure had the potential for the resident to develop indwelling urinary catheter related infection and/or complications.Findings: On 2/25/26 at 0848 hours, an observation and concurrent interview was conducted with Resident 107. Resident 107 had an indwelling urinary catheter draining yellow colored urine. Resident 107 stated he had the indwelling urinary catheter because he was unable to urinate. Medical record review for Resident 107 was initiated on 2/25/26. Resident 107 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 107's Order Summary Report showed the following physician's orders:- dated 1/20/26, for 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 appropriate care and services for the use of a GT for one of four final sampled residents (Resident 7) and one nonsampled resident (Resident 69) reviewed for tube feedings. * The facility failed to ensure LVN 6 checked for gastric residual prior to flushing the GT. Additionally, LVN 6 failed to administered Resident 69's medications via the GT by gravity. * Resident 7's physician was not notified of the resident's preference to lower their head during GT feed infusion. In addition, the resident's medical record failed to show the facility discussed the risks of lowering their head of bed during tube feeding. These failures posed the risk of Residents 7 and 69 to experience gastric complications and/or discomfort.Findings: Review of the facility's P&P titled Appropriate Use of Feeding Tubes revised 12/19/22, showed a resident who is fed by enteral means receives the appropriate treatment and services…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 proper IV care was provided for one of one final sampled resident (Resident 66) receiving an IV fluids. * Resident 66's IV Sodium Chloride 0.45 % (is a sterile, medical-grade mixture of salt and water used primarily as an intravenous (IV) fluid. It is used to hydrate the body, replace fluid loss and electrolytes) bag, IV tubing, and IV site was not labeled and dated. This failure had the potential to place Resident 66 at risk of infection and IV therapy complications.Findings: Review of the facility P&P titled Intravenous Therapy dated 12/19/22, showed the facility will adhere to accepted standards of practice regarding infusion practices. All IV tubing is to be labeled with date, time and initials. IV sites are changed every seventy-two hours unless otherwise ordered by the physician . On 2/25/26 at 0825 hours, Resident 66 was observed lying in bed. A bag of 0.45 % Sodium Chloride solution was noted…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care services for one of 32 final sampled residents (Resident 187) and two nonsampled residents (Residents 49 and 54) reviewed for respiratory care. * The facility failed to ensure Resident 187's nasal cannula, nebulizer mask and tubing were stored in a sanitary condition when not in use. *The facility failed to ensure Resident 49's CPAP machine was cleaned and maintained per manufacturers recommendation for cleaning and maintenance. * The facility failed to ensure Resident 54 was not left unattended during administration of albuterol treatment (bronchodilator medication). These failures had the potential to affect the respiratory health and well-being of the residents in the facility.Findings: 1. On 2/25/26 at 0928 hours, during the initial tour of the facility, an observation was conducted in Resident 187's bedroom. Resident 187 was working with staff. The oxygen machine 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 provide adequate and appropriate pain management for one of one final sampled resident (Resident 68) investigated for pain. * The facility failed to provide Tramadol (a controlled opioid pain medication) as ordered by the physician for Resident 68. This failure resulted in the resident experiencing pain due to PRN controlled pain medication not being administered. Findings: Review of the facility's P&P titled Pain Management dated 12/19/22, showed the facility must ensure pain management is provided to residents. On 2/25/26 at 1119 hours, an interview was conducted with Resident 68. Resident 68 stated he was readmitted the prior on 2/24/26 at around 1830 hours. Resident 68 stated he took Tramadol for pain, but it was still being ordered from the pharmacy. Resident 68 stated the facility was giving him acetaminophen (a medication for mild pain) for now, which helped the pain a little bit. Resident 68 stated if the Tramadol…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and services were provided for one of three final sampled residents (Resident 174) reviewed for dialysis care. * The facility failed to ensure Resident 174's Hemodialysis Communication Records contained accurate documentation for the monitoring of Resident 174's hemodialysis access. * The facility failed to ensure Dialysis Center A was informed of Resident 174's change of condition for an unwitnessed fall on 2/9/26. * The facility failed to ensure the physician was informed of the dialysis center recommendation to hold Resident 174's hypertension medications on the days Resident 174 had hemodialysis treatments and failed to hold the blood pressure medications on the days Resident 174 had the hemodialysis treatments. * The facility failed to ensure Resident 174 was assessed and monitored following the placement of a new hemodialysis access in the right arm. These failures had the potential to delay…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 pharmaceutical services. * The facility failed to ensure eight lidocaine 4% patches were disposed of and destructed properly in one of two medication rooms (Medication room [ROOM NUMBER]). * The facility failed to ensure the narcotic sheets had the nurses' initials and signatures for one of five medication carts (Medication Cart A). * Resident 68's alprazolam (an anxiety medication) was not administered as ordered by the physician. * LVN 7 failed to check the CNA's documentation for Resident 200 who had loose bowel movement prior to administering a stool softener to the resident. These failures had the potential for the medications to be administered in error and opportunities for drug diversion or drug misuse.Findings: Review of the facility's P&P titled Destruction of Unused Drug revised 3/3/23, showed drugs will be destroyed in a manner that renders the drug…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 6.67%. Two of five licensed nurses (LVNs 5 and 6) were found to have made errors during the medication administration observation. * LVN 5 failed to administer the complete dose of Resident 46's medication when significant residual of the medication was observed in the medication cup after LVN 5 administered the vitamin B12 (supplement) via GT to Resident 46. * LVN 6 failed to administered the correct medication as ordered by the physician for Resident 69. LVN 6 administered the senna-plus (stimulant laxative with stool softener) medication instead of the sennosides (laxative) as per the physician's order. 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 Medication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, facility document review, and facility P&P review, the facility failed to provide the necessary pharmacy services for three of 32 final sampled residents (Residents 13, 22, and 35) and two of five medication carts (Medication Carts A and E) to ensure proper storage and labeling of the medications. * The facility failed to ensure the orally administered medications were stored separate from the externally used medications for one of five Medication Carts (Medication Cart A) inspected. * The facility failed to ensure the orally administered medications were stored separate from the externally used medications for one of five Medication Carts (Medication Cart E) inspected. The suppository Bisacodyl (stimulant laxative) was stored with the oral loperamide (antidiarrheal) and Cepacol oral lozenges. * The facility failed to ensure Resident 13's discontinued lorazepam (antianxiety, controlled medication) was removed from one of five Medication Carts (Medication Cart E) inspected. * The…

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

Based on observation, interview, facility document review, and P&P review, the facility failed to ensure one of 16 kitchen staff members (Dietary Aide 2) had the appropriate skill set necessary to safely perform automatic dishwashing. * Dietary Aide 2 was not competent in demonstrating the automatic dishwashing process. This failure had the potential for resident dishes not to be washed correctly which could lead to sanitation concerns.Findings: Review of the facility's P&P titled Dishwasher Temperature revised 12/19/2022, showed the following:1. All items cleaned in the dishwasher will be washed in water that is sufficient to sanitize any and all items.2. Manufacturer's instructions shall be followed for machine washing and sanitizing.3. Chemical solutions shall be maintained at the correct concentration, based on periodic testing, at least once per shift, and the effective contact time according to manufacturer's guidelines. Results of concentration checks shall be recorded.4. Water temperatures shall be measured and recorded at every shift and\or after the dishwasher has been…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 documents review, the facility failed to ensure one of one final sampled residents (Resident 200) reviewed for food accommodations and one nonsampled resident (Resident 164) received food that accommodated the residents' preferences. * Resident 200 did not consistently receive his fruit cup with meals. * Resident 164 was not served the alternative entree for the broccoli. These failures posed the risk of the residents not enjoying their meals and their food preferences not being honored. Findings: 1. Review of the facility's P&P titled Standardized Menus revised 12/19/22, showed the facility shall provide nourishing, palatable meals to meet the nutritional needs of the residents based on the recommended daily Allowances of the Food and Nutrition Board of the National Research Council. Menus will be planned to meet basic nutritional needs by providing meals based on individual nutritional assessment and the individualized plan of care. Alternative menus will be…

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

Based on interview and facility P&P review, the facility failed to ensure perishable food brought to the facility from outside sources for resident consumption was allowed to be stored and heated. * The facility failed to ensure the residents were able to store food brought from outside sources in the facility. This failure posed the potential for poor food intake which could lead to weight loss in the 161 residents who consumed an oral diet. Findings: Review of the facility's P&P titled Outside Food Brought in by Family or Visitors revised 1/25/24, showed all food items that are already prepared by the family or visitor must be approved per Nursing to ensure it is in accordance with the diet order and eaten within two hours of receiving and all remaining food must be discarded. Review of the facility's document titled Diet County by Modification/Portion dated 2/26/26, showed 161 residents who resided in the facility consumed an oral diet. On 2/26/26 at 1000 hours, an interview was conducted with the ADON. When asked how perishable food brought to the facility from outside sources…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 were complete and accurate medical records for three of 32 final sampled residents (Residents 7, 68, and 198). * Resident 7's admission Social Service Assessment failed to show the resident had hearing devices. * Resident 68's pain monitoring for each shift failed to show the resident's highest level of pain for the shift.* Resident 198's skilled evaluation notes showed the resident was on room air, when the MAR showed the resident was on oxygen. In addition, the resident's MAR had multiple blank entries. These failures resulted in inaccurate and incomplete medical records, and the potential for inaccurate information being communicated to the residents' IDT. Findings: Review pf the facility's P&P titled Documentation in Medical Record dated 121/9/22, showed each resident's medical record will contain a representation of the experiences of the resident and will include enough information to…

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

Based on interview and facility document review, the facility failed to implement the QAPI plan and the past Recertification Survey POC for F554, F578, F583, F693, F755, F761, F803, F812, F880, and F881. * The facility failed to ensure audits and/or observations for F578 and F803 were completed. Additionally, the facility failed to show the audits and observation findings for F554, F578, F583, F693, F755, F761, F803, F812, F880, and F881 were presented to the QA Committee for review, and continued monitoring. This failure had the potential for ongoing non-compliance and complete data being reviewed by the QAPI committee. Findings: Review of the facility's 2024 Recertification Survey POC accepted by the department on 12/11/24, included the following:- for F578, the POC showed the Medical Records staff will audit completion of the POLST and availability of the Advanced Directive in resident medical records withing 72 hours of admission. Findings will be reported to the SSD for further action;- for F803, the DSS, RD or trained dietary staff will conduct kitchen rounds five days a week…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 monitor and address the use of the antibiotics for one final sampled resident (Resident 22) and two nonsampled residents (Resident 18 and 95) reviewed for antibiotic stewardship. * The facility failed to ensure the infection screening evaluation was conducted when Resident 18 was prescribed an antibiotic for urinary tract infection. * The facility failed to ensure the infection screening evaluation was conducted when Resident 22 received an antibiotic for upper respiratory infection. * The facility failed to monitor and address the use of the antibiotics on admission when the resident's condition did not meet the McGeer's criteria (a set of specific definitions to identify true infections in long term nursing facilities) for Resident 95. These failures had the potential for the antibiotics to be used when it was not indicated and the development of antibiotic-resistant bacteria.Findings: Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to offer and provide education for the influenza and pneumococcal immunizations for two of six final sampled residents (Residents 66 and 195) reviewed for the immunizations. * The facility failed to ensure Resident 66 was offered the influenza and pneumococcal vaccinations. * The facility failed to ensure Resident 195's consent for the pneumococcal vaccination specified the type of pneumococcal vaccine. These failures had the potential for the residents and/or their representatives not being informed of the influenza and pneumococcal vaccines, and the benefits and risks of the vaccines to make an informed decision. In addition, these failures had the potential for the residents to not be aware of the exact type of pneumococcal vaccine being offered by the facility.Findings: Review of the facility's P&P titled Influenza Vaccination dated 12/19/22, showed the facility to minimize the risk of acquiring,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents were assessed for seasonal COVID-19 vaccination status or offered the COVID-19 vaccine for one of six final sampled residents (Resident 66) reviewed for the COVID-19 vaccination. * The facility failed to determine or offer the COVID-19 vaccine to Resident 66. This failure put the resident at risk for increased risk of infection and transmission of COVID-19. Findings: Review of the facility's P&P titled COVID-19 Vaccination dated12/19/22, showed it was the policy of the facility to minimize the risk of acquiring, transmitting or experiencing complications from COVID-19 by educating and offering our residents and staff the COVID-19 vaccine. Medical record review for Resident 66 was initiated on 2/25/26. Resident 66 was admitted to the facility on [DATE]. Review of Resident 66's H&P examination dated 9/5/25, showed Resident 66 had the capacity to understand. Review of Resident 66's CAIR report (undated)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure the residents' call system was working properly and call buttons were place within the residents' reach for three of 32 sampled residents (Residents 196, 199, and 201). * The facility failed to ensure when Resident 196 would use her call light, the call light was audible and would light up outside Resident 196's room and at the nurses' station panel. * The facility failed to ensure Resident 199's call light button was placed within Resident 199's reach. * The facility failed to ensure Resident 201's call light was working and the silver bell provided to call assistance was placed within Resident 201's reach. These failures posed the risk for the delay in response when the residents would summon the staff for assistance.Findings: 1. On 2/25/26 at 0825 hours, a concurrent observation and interview was conducted with Resident 196. Resident 196 stated she had to wait over 15 minutes this past weekend for the staff to respond to her call light.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the facility staff was trained on how to document the bowel movements for one of 32 final sampled resident (Resident 200). * The facility failed to ensure CNA 6 knew when to report and how to correctly document the bowel movements in the electronic health record. This failure had the potential for the delay in treatment and/or the resident not to receive the appropriate care. Findings: On 3/3/26 at 830 hours, an interview was conducted with Resident 200. Resident 200 verbalized he had a total of four loose stools on 3/2/26. Resident 200 stated the poop ran through me like sift. Per Resident 200 he was wearing diapers. On 3/3/26 at 0847 hours, an interview was conducted with CNA 6. When asked about Resident 200's bowel movements, CNA 6 stated she received report from the previous shift Resident 200 had two loose stools. Per CNA 6 she was to monitor Resident 200's bowel movements. Medical record review for Resident 200 was initiated on 3/3/26.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, closed medical record review and facility P&P review, the facility failed to ensure two of 12 sampled residents (Residents 1 and 2) were free from the unnecessary drugs. * Resident 1 was administered Ativan (antianxiety medication) as needed for inability to relax. The non-pharmacological interventions showed documentation of NA. * Resident 1's Informed Consent form for Cymbalta (antidepressant medication) was not obtained prior to medication administration. * Resident 2 was administered Tramadol (narcotic pain medication) as needed for moderate pain. There was no documentation to show the non-pharmacological interventions were implemented. These failures had the potential for the residents to receive unnecessary drugs with significant side effects.Findings: Review of facility's P&P titled Use of Psychotropic Medication use revised 3/2025 showed it is the intent of this policy to ensure that residents only receive psychotropic medications when other non-pharmacological…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, closed medical record review, and facility P&P review, the facility failed to provide the necessary treatment and services to maintain the highest practicable well-being for one of five sampled residents (Resident 3). * The facility failed to ensure Resident 3's change in condition of aggressive behavior was monitored every shift for 72 hours. In addition, the facility failed to ensure Resident 3's plan of care was revised to address Resident 3's recent behavioral episode. This failure had the potential to negatively affect Resident 3's health and well-being and the potential risk of not providing Resident 3 with appropriate and individualized care.Findings: Review of the facility's P&P titled Care Plan Revisions Upon Status Change revised 12/19/22, showed the comprehensive care plan will be reviewed and revised as necessary, when a resident experiences a status change. The care plan will be updated with the new or modified interventions. Closed medical record review for Resident 3 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, closed medical record review, and facility P&P review, the facility failed to provide the pharmaceutical services for one of five sampled resident (Resident 3). * The facility failed to ensure Resident 3's antianxiety medication was available for administration as ordered by the physician. In addition, the facility failed to ensure the May and June 2025 narcotic count sheets for Resident 3's clonazepam medication were available and kept in the resident's medical record. This failure had the potential to negatively impact the resident's health conditions and psychosocial well-being.Findings: Review of the facility's P&P titled Ordering and Receiving Controlled Medications revised 01/2025 showed Schedule II controlled medications prescribed for a specific resident are delivered to the facility only if a valid prescription has been received by the pharmacy prior to dispending. In an emergency situation, the provider pharmacy can accept a telephone order. A follow-up valid…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, closed medical record review, and facility P&P review, the facility failed to provide services to attain or maintain the highest practicable well-being for one of four sampled residents (Resident 1). * The facility failed to ensure the results of Resident 1's CBC (Complete Blood Count), BMP (Basic Metabolic Panel), and urinalysis test were promptly reported to Resident 1's physician. This failure had the potential for the resident not to receive the necessary care and services to maintain their highest physical well-being and potentially delaying necessary care and treatment. Findings: Review or the facility's P&P titled Laboratory Services and Reporting reviewed/revised 12/19/22, showed the facility must provide or obtain laboratory services when ordered by a physician, physician assistant, nurse practitioner, or clinical nurse specialist in accordance with state law. The policy explanation and compliance guidelines section showed the facility is responsible for the timeliness 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 a care plan was developed to address an incident between Janitor 1 and one of six sampled residents (Resident 6). The Maintenance Director and Janitor 1 failed to notify the charge nurse and the DON timely when Resident 6 had a verbal outburst towards Janitor 1 when she was asked to leave the laundry room for safety reasons. This failure placed the resident at risk for not having individualized interventions to address the resident's behavior. Findings: On 8/8/25 at 0913 hours, during the initial tour of the facility, an interview was conducted with Resident 6. Resident 6 stated Janitor 1 has been stalking her. Resident 6 stated she went down to the laundry room about three months ago because she ran out of clothes. Once in the laundry room, Janitor 1 told Resident 6 to leave, and she could not be down there. Resident 6 then stated Janitor 1 followed her to her room and she told him to leave her alone. Resident 6 stated the stalking…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 rehabilitation services were provided for one of four sampled residents (Resident 1). * The facility failed to ensure Resident 1 received the PT and OT services for the planned duration and frequency as documented in the initial PT and OT evaluation. This failure had the potential for Resident 1 to decline in the resident's range of motion and mobility. Findings: Review of the facility's P&P titled Purpose and Objectives of Inpatient Rehabilitation Services revised 12/2022 showed it is the objective of the rehabilitation department to provide comprehensive and integrated therapy services to restore patients to their highest level of function. The therapists will develop an individualized plan of care upon evaluation and continuous assessment during treatment plan. Review of the facility's P&P titled Physician Orders for Rehab Services revised 12/2022 showed the evaluating therapist must establish the therapy…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 19 sampled residents (Resident 7) was provided rehabilitative services as ordered by the physician. * Resident 7 was not evaluated and treated by the ST four times a week as ordered. This failure had the potential for Resident 7 to aspirate food and fluid into the lungs, which could result in pneumonia. Findings: Review of the facility's P&P titled Specialized Rehabilitation Services revised 12/2022 showed the facility shall provide specialized rehabilitative services, if required by the resident's comprehensive assessment and care plan, to assist them to attain, maintain or restore their highest practicable level of physical, mental, functional, and psychosocial well-being. Review of the facility's P&P titled Physician Orders for Rehab Services revised 12/2022 showed all the orders should be addressed within 72 hours of the receipt by the rehabilitationdepartment staff. Medical record review for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure 19 of 20 final sampled residents (Residents 1, 13, 16, 22, 26, 29, 71, 72, 83, 84, 95, 97, 100, 101, 111, 116, 728, 928, and 931) reviewed for side rail use remained free from the accident hazards associated with the use of elevated side rails. * The facility failed to ensure the accurate and complete assessments and evaluations for the side rails use for Residents 1, 13, 16, 26, 71, 83, 84, 95, 97, 100, 101, 116, 928, and 931. * The facility failed to attempt the alternatives prior to installation of the bed rails for Residents 1, 13, 16, 22, 26, 65, 71, 84, 95, 97, 111, 116, 928, and 931. * The facility failed to obtain the informed consent for the side rails prior to the installation of the grab bars for Residents 83, 101, and 928. * The facility failed to ensure the size of the side rails whether 1/4 or 1/2 side rails were not added after the informed consent for grab bars were obtained from the…

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

Based on observation, interview, and facility P&P review, the facility failed to ensure the food safety and sanitation guidelines were followed when: * A bin with multiple pan lids were stored with food crumbs and dirt. * Two blenders, five pink and two brown meal trays were stored wet. * A cutting board with blue colored handle did not have cleanable surface. * A cart with full of dessert in multiple small bowl were unlabeled. * The appropriate hair restraint was not worn by a dietary staff. * The condiments were not stored in sanitary condition. These failures had the potential to result in foodborne illnesses for 134 of 140 residents receiving kitchen services. Findings: 1. According to FDA Food Code 2022, 4-601.11, Equipment, Food-Contact Surfaces, Nonfood Contact Surfaces, and Utensils, the equipment food-contact surfaces and utensils shall be clean to sight and touch, the food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations; and the nonfood-contact surface of equipment shall be kept free of 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, facility document review, and facility P&P review, the facility failed to implement their infection control surveillance program in accordance with the facility's P&P and failed to maintain the infection practices to help prevent the development and transmission of diseases and infection. * The facility failed to maintain an accurate infection surveillance program for June, July, August, and September 2024. * Resident 47's urinal was found to be hanging by the trash bin. * LVN 3 wore two pairs of gloves and failed to perform hand hygiene when the top pair of gloves was removed prior to the administration of G-tube medication for Resident 72. * LVN 3 failed to sanitize the stethoscope and blood pressure machine with cuff after using for Resident 931. * LVN 1 failed to perform hand hygiene after removing gloves during medication administration observation for Resident 829 * LVN 4 failed to perform hand hygiene after removing gloves during medication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to show documented evidence Zone 1 (area of entrapment) measurement was completed for 18 of 20 final sampled residents (Residents 1, 13, 16, 22, 26, 29, 71, 72, 83, 84, 95, 100, 101, 111, 116, 728, 928, and 931) reviewed for side rail use. Also, the facility failed to conduct the monthly entrapment measurements as per the residents' care plans. These failures posed the risk of not ensuring all areas of possible entrapment to be identified. Findings: According to FDA.gov, Zone 1, is one of the seven areas for risk of resident entrapment on beds with bed rails. Zone 1 is identified as the open space within the perimeter of a bed rail. 1. On 10/09/24 at 1237 hours, concurrent observation and interview was conducted with CNA 13. CNA 13 verified Resident 1 had the bilateral 1/4 (quarter) bed rails elevated. On 10/9/24 medical record review for Resident 1 was initiated. Resident 1 was readmitted to the facility on [DATE]. 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 observation, interview, medical record review, and facility P&P review, the facility failed to assess two nonsampled residents (Residents 113 and 980) for their self-administration of the medications. This failure had the potential to negatively impact the residents' physiological well-being and could administer the medications inaccurately. Findings: Review of the facility's P&P titled Resident Self -Administration of Medication revised 12/19/22, showed the residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. The IDT teams should at a minimum consider the following: - The resident's physical capacity to : swallow without difficulty, open medication bottles, administer injections; - The resident's cognitive status, including their ability to correctly name their medication and know what conditions they are taken for; - The resident's capability to follow direction and tell time to know…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 four of 28 final sampled residents (Residents 1, 16, 22, and 97) and one nonsampled resident (Resident 128). * The facility failed to ensure Resident 16's request for an extension cord for the resident's phone was followed up. * The facility failed to ensure the call light was within reach and accessible for Resident 128. * The facility failed to ensure the call light and bed remote control were within the Resident 97's reach. * The facility failed to ensure the call light was within reach for Residents 1 and 22. These failures had the potential to negatively impact the resident's psychosocial well-being or result in a delay to receive care. 1. On 10/8/24 at 0910 hours, during the initial tour of the facility, Resident 16 was observed awake and lying in bed. Resident 16's landline phone was observed on the bedside table. Resident 16 stated when the staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure a copy of the advanced directive was obtained for one of 15 final sampled residents (Residents 83) reviewed for advanced directives. This failure had the potential for the resident's decisions regarding his health care and treatments to not be honored. Findings: Review of the facility's P&P titled Resident's Rights Regarding Treatment and Advance Directives revised 12/19/22, showed the following: - On admission, the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident, if cognitively able to, would like to formulate an advance directive. - Upon admission, should the resident have an advance directive, copies will be made and placed on the chart as well as communicated to the staff. Medical record review for Resident 83 was initiated on 10/8/24. Resident 83 was admitted to the facility on [DATE]. Review of Resident 83's MDS dated [DATE], 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 document review, the facility failed to ensure the residents' physician was notified when the residents refused laboratory collection of blood for two of five final sampled residents (Residents 16 and 95) reviewed for unnecessary medication. This failure had the potential for Residents 16 and 95 not to receive appropriate treatment and could negatively affect residents' well-being. Findings: 1. Medical record review for Resident 95 was initiated on 10/8/24. Resident 95 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 95's Physician Order Summary showed an order dated 7/26/24, for potassium chloride (potassium supplement) oral tablet extended release 10 meq two tablets by mouth in the evening for hypokalemia (low potassium level). Review of Resident 95's Consultant Pharmacist Medication Regimen Review from 9/1/24 to 9/16/24, showed to consider obtaining a repeat potassium level to monitor for adverse effect 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, facility document review, and facility P&P review, the facility failed to ensure the personal privacy was maintained for three of 28 final sampled residents (Residents 26, 72, and 931) and the resident's confidential health information on a computer was not protected for one nonsampled resident (Resident 6). * LVN 4 failed to completely close Resident 26's privacy curtain while the GT medications were being administered. Resident 26's abdomen was exposed during the procedure. * LVN 3 failed to completely close Resident 72's privacy curtain while the GT medications were being administered. Resident 72's abdomen was exposed during the procedure. * LVN 6 failed to log off from the electronic medical record where Resident 6's confidential medical information could be seen on the monitor by unauthorized personnel. These failures had the potential to negatively affect the dignity of the residents and violate the residents' privacy, and had the potential for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to failed to send a copy of the notice of transfer/discharge to the representative of the Office of the State Long-Term Care Ombudsman for one of four discharged residents (Resident 125) for closed record reviewed. In addition, the facility failed to provide the notice of transfer/discharge and reasons for the transfer in writing for one of 28 final sampled residents (Resident 25). These failures posed the risk for inappropriate transfers or discharges for Residents 25 and 125 and risk of not providing the residents and their representatives with access to an advocate who could inform them of their options and rights Findings: 1. Review of the facility's P&P titled Transfer and Discharge (including AMA) revised 12/19/22, showed for Non-Emergency Transfers or Discharges, the facility should provide the transfer/discharge notice to the resident/representative and Ombudsman as indicated. Closed medical record review 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 observation, interview, and medical record review, the facility failed to provide the individualized and ongoing activity program to meet the needs and interests of one of three final sampled residents (Resident 83) reviewed for activities. * The facility failed to provide the activities for Residents 83 to meet the resident's identified preference. This failure had the potential for the residents to experience feelings of social isolation. Findings: Medical record review for Resident 83 was initiated on 10/8/24. Resident 83 was admitted to the facility on [DATE]. Review of Resident 83's MDS dated [DATE], showed the resident's cognitive skills for daily decision making was severely impaired. Review of Resident 83's Plan of Care showed a care plan problem (undated) addressing Resident 83's risk for isolation. The care plan problem addressed the potential for social isolation due to disease and condition . The goal was for Resident 83 to participate in activities of choice (one to two times weekly). 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 provide the necessary care and services to ensure two of four discharged residents (Residents 731 and 828) attained and maintained their highest practicable physical well being when: * The facility failed to provide documented evidence a follow-up call was made to the physician when Resident 828 felt light-headed and had an assisted fall and sustained skin tear on the right lower leg. In addtion, the facility failed to ensure the treatment order obtained from the physician was consistent with Resident 828's injury status post fall. * The facility failed to ensure Resident 731's urine sample was collected in a timely manner and failed to ensure Resident 731's urinalysis result was promptly reported to Resident 731's physician. Findings: Review of the facility's P&P titled Notification of Changes reviewed/revised 12/19/22, showed the purpose of the policy is to ensure the facility promptly informs the resident, consults 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 provide the necessary care and services to prevent accidents for one of three final sampled residents (Resident 97) reviewed for accident hazards and in the laundry area. * The facility failed to clean and maintain the heating furnace inside the laundry closet. * The facility failed to implement the bilateral floor mats as per the physician's order and plan of care. These failures had the potential for accidents with serious injuries to occur. Findings: 1. On 10/9/24, during the laundry department inspection, an observation and concurrent interview was conducted with the Laundry Supervisor. The following was observed inside the closet in the laundry area where the heating furnace was located at: - dirty floor with a lot of lint on top of the vent tubes connected to the ceiling, - a stack of linens inside a clear plastic bag stored inside the closet, and - a black discoloration on the insulator foam located 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 document review, the facility failed to provide the necessary GT care and services for two of two sampled residents (Residents 26 and 72) reviewed for GT care. * The facility failed to ensure the licensed staff assessed for residuals from Resident 26's GT prior to the administration of medication. * The facility failed to ensure the licensed staff verified the placement of Resident 72's GT prior to the administration of medication. Findings: Review of the facility's P&P titled Preparation and General Guidelines 11A7: Enteral Tube Medication Administration dated August 2014, showed the facility assures the safe and effective administration of enteral formulas and medications via enteral tubes. Selection of enteral formulas, routes and methods of administration, and the decision to administer medications via enteral tubes are based on nursing assessment of the resident's condition in consultation with the physician and dietician. 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 physician's order for oxygen therapy was followed for one of two final sampled residents (Resident 95) reviewed for oxygen administration. This failure had the potential to negatively affect the resident's medical conditions. Findings: Review of the facility's P&P titled oxygen administration revised 5/20/24, showed oxygen is administered under orders of a physician, except in the case of an emergency. In such case, oxygen is administered and ordered for oxygen are obtained as soon as practicable when the situation is under control. On 10/8/24 at 1211 hours, and 10/10/24 at 0843 and 1044 hours, Resident 95 was observed lying in bed receiving oxygen at 2 liters per minute via nasal cannula. Medical record review for Resident 95 was initiated on 10/8/24. Resident 95 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 95's Physician Order Summary dated 9/9/24, showed 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 P&P review, the facility failed to provide the necessary care and services to attain or maintain the highest physical well-being for one of one final sampled residents (Resident 931) reviewed for dialysis care. * The facility failed to ensure the medications scheduled to be administered to Resident 931 on the days the resident had dialysis treatments had a physician's order to be held or were rescheduled. In addition, the facility failed to ensure Resident 931's fluid restriction was monitored by the nursing and dietary departments. These failures posed the risk for possible medical complications for Resident 931. Findings: Review of the facility's P&P titled Hemodialysis revised 6/5/23, showed the following: - The facility will assure that each resident receives care and services for the provision of hemodialysis and/ or peritoneal dialysis consistent with professional standards of practice. This will include ongoing assessment and oversight 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.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to provide the necessary pharmaceutical services when: * The facility failed to ensure all controlled medications were accounted for and documented. * The facility failed to ensure the licensed nurses followed the facility's process when opening and dispensing medications from the E-kit (emergency kit). These failures had the potential for drug diversion. Findings: Review of the facility's P&P titled Medication Storage in the Facility ID3: Controlled Medication Storage dated August 2014, showed medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal and recordkeeping in the facility in accordance with federal, state and other applicable laws and regulations. At each shift change, a physical inventory of all controlled medications, including the emergency supply is conducted by two licensed nurses and is documented on the controlled medication accountability record. 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, medical record review, and facility P&P review, the facility failed to ensure the Pharmacy Consultant's recommendations from the drug regimen review were followed through for one of five final sampled residents (Residents 95) reviewed for unnecessary medications. * The Pharmacy Consultant's recommendation for follow up laboratory to recheck the potassium level was not followed through for Resident 95. This failure posed the risk of the resident not receiving the necessary care and services or receiving unnecessary medications. Findings: Review of the facility's P&P tiled Medication Regimen Review dated 12/19/22, showed MRR (Medication Regimen Review) is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication. The MRR includes: - The review of the medical records in order to prevent, identify, report, and resolve medication related problems medication errors 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 ensure one of five final sampled residents (Resident 72) reviewed for unnecessary medications was free from the unnecessary psychotropic medications (medications affecting brain activity). * The facility failed to ensure Resident 72 was monitored for the side effects related to the use of bupropion (antidepressant), escitalopram (antidepressant), and trazodone (antidepressant) medications. In addition, the facility failed to ensure the documentation of the monitoring of side effects related to the use of psychotropic medications for Resident 72 in the MAR did not have two different meanings under the chart codes. These failures had the potential to not identify which medication caused the side effects and would negatively impact Resident 72's well-being. Findings: Review of the facility's P&P titled Use of Psychotropic Drugs reviewed 12/19/22, showed the following: - Residents are not given psychotropic drugs unless 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 the medication error rate was below 5%. The facility's medication error rate was 13.79%. One of three licensed nurses (LVN 1) observed during the medication administration was found to have made errors. * LVN 1 failed to prepare UTI-STAT oral liquid (supplement to reduce the risk of urinary tract infections) and polyethylene glycol 3350 powder (a stool softener to relieve occasional constipation) for one nonsampled resident (Resident 829) as ordered by the physician * LVN 1 failed to assess Resident 829 about her stools or review her medical record for any loose stools prior to the administration of Colace 100 mg (stool softener), as ordered by the physician. * LVN 1 failed to administer hydrocodone-acetaminophen (narcotic pain medication) 10-325 mg to resident 829 as ordered by the physician. These failures had the potential to negatively affect the resident's health conditions. Findings: 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, medical record review, facility document review, and facility P&P review, the facility failed to ensure the staff implemented the proper storage, labeling, and disposal of medications and treatment supplies in a safe and secure manner; and failed to ensure the medications were safely stored and accessed by authorized personnel only. * The facility failed to ensure medications were not left unattended. One nonsampled resident (Resident 18's) medications were left unattended on top of the medication cart and on top of her bedside table during a medication administration. * The facility failed to ensure that medications administered orally were stored separately from transdermal and ophthalmic (relating to the eye and it's diseases) medications, subcutaneous injections (SQ - an injection is given in the fatty tissue, just under the skin) were stored separately from ophthalmic medications, and medications given via inhalation were stored separately from nasal and transdermal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 follow the menu when preparing food for the residents. * The facility failed to ensure [NAME] 1 followed the recipe when preparing puree roast beef and puree potatoes. * The facility failed to ensure the recipe for fruit plate was followed. Resident 131 was served with a plateful of cantaloupe slices and several pieces of grape when the resident requested for a fruit plate. These failures had the potential of not meeting the residents' nutritional needs which could lead to nutritional related health complications. Findings: 1. Review of the facility document Order Listing Report for dietary dated 10/9/24, showed 15 residents received pureed food prepared from the kitchen. Review of the facility's diet spreadsheet titled Daily Spreadsheet Menus dated 10/9/24, showed the lunch menu including rosemary pot roast, roasted yukon gold mashed potatoes, and fresh brussels sprouts for pureed diet. 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, facility document, and facility P&P review, the facility failed to implement the antibiotic stewardship program. * The facility failed to ensure two nonsampled residents (Residents 73 and 110) were accurately and timely reviewed for the appropriate use of antibiotics. This failure had the potential for inappropriate use and increased risk of drug resistant organisms. Findings: According to the CDC, the antibiotics are among the most frequently prescribed medications in nursing homes, with up to 70% of residents in a nursing home receiving one or more courses of systemic antibiotics over a year. Studies have shown that 40-75% of antibiotics prescribed in nursing homes may be unnecessary or inappropriate. Harms from antibiotic overuse are significant for the frail and older adults receiving care in nursing homes. These harms include risk of serious diarrheal infections from Clostridium difficile, increased adverse drug events and drug interactions, and colonization and/or infection 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, interview and facility P&P review, the facility failed to ensure two of two glucometers (Glucometers A and B) were maintained in safe operating condition. In addition, the facility failed to ensure the three residents' refrigerator (in Stations A, B, and C) frozen storage area were free of ice buildup. These failures had the potential for residents requiring blood glucose checks to have inaccurate reading; and the failure had the potential for the food stored in the freezer area were not kept at the proper temperature. Findings: 1. On 10/11/24 at 12:40 hours, an interview and concurrent inspection of Medication Cart A was conducted with LVN 2. Review of the Daily Quality Control Record log for Medication Cart A dated October 2024 showed the daily Quality Control Record testing was completed with a glucometer with the serial number K008171N5044. However, the serial number of the glucometer stored in the medication cart showed a serial number of K008229N3093. LVN 2 verified there was no other glucometer stored inside the medication cart. Further review of the log…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 well-being for one of two sampled residents (Resident 1). * Resident 1 had the OT recommendations for the built-up utensils from January 2024 through April 2024. However, this recommendation was not addressed throughout the resident's therapy sessions. This failure had the potential to negatively affect the resident's health condition and well-being. Findings: Review of the facility's P&P titled Notification of Changes revised 12/19/22, showed the facility must inform the resident, consult with the resident's physician and/or notify the resident's family or legal representative when there is a change requiring such notification. Circumstances requiring notification include circumstances that require a need to alter treatment. Review of the facility's P&P titled Activities of Daily Living (ADL) revised 12/19/22, showed the facility will, based 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.

Based on observation, interview, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen. * The facility failed to ensure the expired foods were discarded. * The facility failed to ensure proper covering, labeling, and dating of foods in the kitchen. * The facility failed to ensure proper thawing of frozen food from the freezer. * The facility failed to ensure the sanitizing solution in dishwasher was checked before use. * The facility failed to ensure the Dietary Aide was wearing a hair net. * The facility failed to ensure the blender was cleaned and sanitized after use. These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food prepared in the kitchen. Findings: Review of the CMS 672 Resident Census and Conditions of Residents completed by the facility dated 4/5/22, showed 88 of 93 residents in the facility received food prepared in the kitchen. 1. Review of the facility's P&P titled Food Safety dated 12/17/21, showed the facility must store, prepare, distribute and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to accommodate the needs for one of 24 final sampled residents (Resident 232). * The facility failed to ensure Resident 232 was provided with bilateral bed grab bars to enable repositioning and bed mobility as ordered by the physician. This failure had led to Resident 232 feeling helpless, upset, and uncomfortable, which had the potential to negatively impact the resident's well-being. Findings: On 4/4/22 at 0740 hours, an observation and concurrent interview was conducted with Resident 232. Resident 232's bed was observed without any side rails or grab bars in place. Resident 232 stated he requested and signed a consent form for bilateral bed grab bars to be installed for safety and repositioning. Resident 232 stated he signed the consent form during the admission and added the bilateral bed grab bars were still not currently installed. Resident 232 stated he felt very frustrated with the situation. Medical record review for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to inform and provide the written information regarding the rights to formulate the advance directives for two of 20 final sampled residents (Residents 62 and 75). This had the potential for the facility to provide treatment and services against the residents' wishes. Findings: Review of the facility's P&P titled Advanced Directives and Advance Care Planning revised 4/14/20 showed the residents have the right to self-determination regarding their medical care. This includes the right of an individual to direct his or her own medical treatment, including the right to execute or refuse to execute an advance directive. 1. Review of Resident 62's medical record was initiated on 4/7/22. Resident 62 was admitted to the facility on [DATE]. Review of Resident 62's MDS dated [DATE], showed Resident 62 was cognitively intact. Review of Resident 62's Physician Orders for Life Sustaining Treatment (POLST) dated 2/26/22, showed 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, and medical record review, the facility failed to implement the plan of care to reflect the individual care needs for one of 24 final sampled residents (Resident 580). * Resident 580's plan of care included the use of floor mats by Resident 580's bedside due to frequent falls; however, the facility failed to implement a fall intervention to address Resident 580 as care planned. This failure posed the risk of not providing the appropriate, consistent, and individualized care to the resident. Findings: Medical record review for Resident 580 was initiated on 4/4/22. Resident 580 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], showed Resident 580 was cognitively impaired and needed extensive assistance from a staff for his ADL care. Resident 580 had balance problems and needed assistance during transfers. Review of Resident 580's Progress notes dated 3/27/22, showed Resident 580 was found on the floor on the right side of his bed laying down. Resident 580…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to provide the supervision during meals for one of 20 final sampled residents (Resident 3) to prevent him from choking. * The facility failed to ensure Resident 3 was provided 1:1 close supervision during meals as ordered by the physician. This failure had the potential for the resident to aspirate food particles and a potential delay in staff intervention. Findings: 1. Medical record review for Resident 3 was initiated on 4/5/22. Resident 3 was readmitted to the facility on [DATE]. Review of Resident 3's Order Summary Report dated 4/7/22, showed a physician's order dated 3/31/22, to provide a regular diet, puree texture (a texture-modified diet used for residents with difficulty eating solid foods), and honey/moderately (thickened to a honey-like consistency) consistency for oral gratification at breakfast, lunch and dinner with 1:1 feeding due to risk for aspiration. Review of Resident 3's Speech Therapy LP Evaluation and Plan of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for one of 20 final sampled residents (Resident 73) who was on oxygen therapy. * The facility failed to follow the physician's order for Resident 73's oxygen therapy. This failure posed the risk for the resident to develop complications related to oxygen use. Findings: Review of the facility's P&P titled Administration of Medications revised 7/14/21, showed all medications are administered per the physician's order. Medical record review for Resident 73 was initiated on 4/4/22. Resident 73 was admitted to the facility on [DATE]. Review of Resident 73's MDS dated [DATE], showed the Resident 73 was cognitively intact. Review of Resident 73's Order Summary Report dated 4/6/22, showed a physician's ordered dated 3/1/22, for continuous oxygen at 2 lpm via nasal cannula (a small flexible tubes in each nostril used to administer oxygen). Review of Resident 73's Medication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility document review, the facility failed to ensure the medications and biologicals were properly stored and secured. * Medication Cart 1 was left unlocked and unsecured in the hallway. This failure had to the,potential for unauthorized personnel, residents, and/or visitors having access to the medications. * Two liquid medication bottles which had medication residues on the outside were found to bestored with other clean liquid medication bottles. This had the potential for medication contamination. *IV Cart 1 had a dollar bill stored with the IV supplies. In addition, the expired IV supply and sterile products were found to be outside of the original sterile packaging were observed stored in IV Cart 1. This posed the risk for the residents to be potentially exposed to the expired and contaminated medical supplies. Findings: 1. Review of a facility policy titled Storage and Expiration Dating of Medications, Biologicals revised [DATE], 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.

Based on observation, interview, and facility P&P review, the facility failed to ensure the safe and sanitary storage of food brought from home for one nonsampled resident (Resident 231). This failure had the potential for the resident to be exposed to food borne illnesses. Findings: According to the facility's P&P titled Food from Outside Sources revised 11/18/21, showed all perishable foods should be refrigerated within two hours of receipt. Perishable foods that have been at room temperature and not consumed within four hours should be discarded. On 4/4/22 at 1031 hours, an observation and concurrent interview was conducted with Resident 231. Resident 231 was observed with two containers with food at the bedside. One container had white rice and another container had fish with curry. Both containers were undated and unlabeled. Resident 231 stated her daughter brought the food to the facility the night before. On 4/4/22 at 1036 hours, an interview was conducted with LVN 4. LVN 4 verified Resident 231 had containers with food at bedside unlabeled and undated. LVN 4 stated the…

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

Based on observation and interview, the facility failed to ensure the infection control practices were maintained in the facility's laundry room area. * Laundry Staff 1 was observed eating next to a pile of clean linen. * Trash were observed under the table used for clean linen. These failures had the potential for the contamination of linen used by medically vulnerable residents in the facility. Findings: 0n 4/7/22 1500 hours, during an observation of the laundry area with Laundry Staff 1, the following was observed: 1. Laundry Staff 1 was observed sitting on the table used for folding clean linen. Laundry Staff 1 was eating and drinking juice next to a pile of clean linen. When asked if food should be eaten next to clean linen, Laundry Staff 1 stated food should be eaten in the staff breakroom to prevent possible cross contamination of the clean linens. 2. Trash was observed under table used for folding clean linen. When asked about the trash under the table, Laundry staff 1 stated the trash can was moved and he did not want to get up and throw away trash. Laundry staff 1 stated…

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