Alamitos West Health & Rehabilitation

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 services to attain or maintain the highest practicable well-being for two of 27 final sampled residents (Residents 29 and 141). * The facility failed to ensure the right arm sling was applied as ordered by the physician for Resident 29. * The facility failed to ensure Resident 141's physician was notified timely of the UA (urine analysis) results and the resident's signs and symptoms of UTI (urinary tract infection). These failures had the potential for not providing the necessary care and services to the residents to meet their needs and delay in treatment. Findings: Review of the facility's P&P titled Sling, Arm revised 11/2007 showed it is the policy of this facility to: 1. Elevate ad support the arm. 2. Reduce edema. 3. Relieve stress on the shoulder or elbow. 4. Immobilize a strained or sprained muscle. 5. Immobilize a fracture. 6. Facilitate return circulation from the extremities. Medical record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services 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) and promote healing of existing pressure ulcer for three of six final sampled residents (Residents 8, 9, and 29) reviewed for pressure ulcers. * The facility failed to ensure the wound treatment was administered as per the physician's order for Resident 8. * The facility failed to conduct the Weekly Skin Evaluations and IDT Skin Review for Resident 9's coccyx to right buttock wound, as per the facility's P&P and care plan. * The facility failed to ensure the LAL mattress setting was appropriate for Resident 29's weight. These failures posed the potential risks for complications and delayed wound healing for Residents 8, 9, and 29. Findings: Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of two final sampled residents (Resident 3) reviewed for falls were provided the necessary services after a fall. * The facility failed to ensure Resident 3's fall risk evaluation was completed after Resident 3 had a fall on 8/9/25, and failed to ensure Resident 3's Fall Risk Evaluations were completed accurately. These failures had the potential risk of inaccurate fall risk score and the failure to implement the appropriate fall risk interventions for Resident 3. Findings: Review of the facility's P&P titled Fall Management System revised 4/2025 showed it was the policy of the facility to provide each resident with the appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurred. On admission, the Fall Risk Evaluation would be completed to determine the resident's risk for sustaining a fall. When a resident sustained a fall, a physical assessment would be completed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 necessary care and services were provided to one of one final sampled resident (Resident 4) reviewed for dialysis. * The facility failed to ensure Resident 4's dialysis communication forms were accurately completed. * The facility failed to ensure Resident 4 had a clamp scissors (a device for dialysis residents that control bleeding or secure tubing) available in the emergency kit at bedside. * The facility failed to ensure Resident 4's 1000 ml fluid restriction in a 24-hour period was maintained. These failures had the potential of not identifying possible negative outcomes related to the dialysis treatment for the resident.Findings: Review of the facility's P&P titled Dialysis (Renal), Pre- and Post-Care revised 1/2022 showed the care of the resident receiving dialysis services will reflect ongoing communication, coordination and collaboration between the nursing home and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the pharmaceutical services for two of 27 final sampled residents (Residents 29 and 85) and one nonsampled resident (Resident 18) to meet the needs of each resident. * The facility failed to verify with the physician the medication route for Resident 18's medication ordered. * The facility failed to ensure the metoprolol (medication to treat high blood pressure) was administered as ordered by the physician for Resident 29. * The facility failed to ensure the amlodipine (medication to treat high blood pressure) was administered as ordered by the physician for Resident 85. These failures posed the risk for negative health outcomes to the residents.Findings: Review of the facility's P&P titled Medication Administration revised 2/2022 showed it is the policy of this facility that medications shall be administered as prescribed by the attending physician. Medications must be administered in accordance with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, facility document review, and P&P review, the facility failed to ensure the pharmacy recommendations for one of five final sampled residents (Resident 11) reviewed for unnecessary medications were followed through. * The facility failed to ensure Resident 11's physician was notified of the pharmacy recommendations to notify the physician of the resident's risk for bleeding on allopurinol (medication to lower excess uric acid levels in the blood) and aspirin (medication to treat pain, fever, and inflammation). This failure had the potential to cause negative outcomes for Resident 11. Findings: Review of the facility's P&P titled Medication (Drug) Regimen Review (MRR) revised 4/2025 showed the drug regimen of each resident will be reviewed at least once a month by a licensed pharmacist. The MRR 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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 6.67%. * LVN 5 failed to apply pressure to the right tear duct or wipe the tear from the eye area right away after the administration of eye drop to Resident 107. * LVN 4 failed to administer metformin (medication to treat high blood sugar) to Resident 117 with food as ordered by the physician. These failures posed the risk for adverse health outcomes.Findings: 1. According to the National Eye Institute information titled How to put eye drops dated 12/5/24, squeeze the prescribed number of eye drops into the pocket. For at least one minute, close your eye and press your finger lightly on your tear duct (small hole in the inner corner of your eye) this keeps the eye drop from draining into your nose. Medical record review for Resident 107 was initiated on 9/25/25. Resident 107 was admitted to the facility on [DATE]. Review of Resident 107's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to ensure proper medication storage, timely disposal of expired medications, and accurate reconciliation of controlled substances were followed. * The facility failed to reconcile controlled substances for Resident 152. * The facility failed to ensure proper storage of the medications in one of two medication rooms (Station A) inspected. * The facility failed to discard the expired medications from two of five medication carts (Medication Carts C and D) inspected. These failures had the potential to negatively impact the residents' well-being.Findings: 1. Medical record review of Resident 152 was initiated on 9/25/25. Resident 152 was admitted to the facility on [DATE]. Review of Order Summary Report dated 9/29/25, showed a physician's order dated 9/22/25, to administer hydromorphone hydrochloride (a potent opioid analgesic used to manage moderate to severe pain when other treatments are inadequate) tablet 2 mg, Give one tablet 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.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure 17 of 17 residents who received pureed food from the kitchen received the proper diets when the facility's puree recipes and menu were not followed. * The facility failed to ensure the puree recipe for herb mash potatoes was followed. This failure had the potential for the residents on special diets to not receive the adequate nutritional and caloric intake as recommended on the recipes.Findings: Review of the facility's census on 9/23/25, and Order Listing Report dated 9/23/25, of residents on GT feeding showed 131 of 137 resident received food prepared from the kitchen. Review of the facility's P&P titled Food Preparation dated 2023 showed food shall be prepared by methods that conserve nutritive value, flavor, and appearance. Recipes are specific as to portion yield, method of preparation, quantities of ingredients, and time and temperature guidelines. Review the facility's document titled Recipe: Herb Mashed Potatoes dated 2025 showed the directions were to begin…

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

Based on observation, interview, facility P&P review, and facility document review, the facility failed to ensure the food safety and sanitary requirements were met in the kitchen. * The facility failed to ensure the two-compartment preparation sink had an air gap. * The facility failed to ensure food preparation utensils and equipment were in good, sanitary, and cleanable working conditions. * The facility failed to ensure that food items were dated and labeled. * The facility failed to ensure food items were discarded by the best by date. * The facility failed to ensure the kitchen staff wore hair restraint. * The facility failed to ensure fruits with tough rinds or peels like cantaloupes were washed with a brush. These failures had the potential to cause foodborne illnesses to the medically vulnerable resident population who consumed food prepared in the kitchen. Findings: 1. According to the USDA Food Code 2022, Section 5-402.11 Backflow Prevention showed improper plumbing installation or maintenance may result in potential health hazards such as cross connections, back…

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

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the facility's P&P about the Food Brought by Family or Visitor was implemented. * The facility failed to ensure the visitors and staff were educated on safe food handling practices of food brought from outside of the facility. This failure had the potential to cause foodborne illnesses to the 131 medically vulnerable resident population who received food prepared by the facility and may potentially receive foods prepared from the outside sources. Findings: Review of the facility's P&P titled Foods Brought by Family or Visitor revised 9/2025 showed all the food brought into the facility by the family members or visitors must be checked by a representative of the food and nutrition department or a nurse to assure that the food is not in conflict with the resident's prescribed diet plan as it relates to therapeutic and texture and/or fluid modifications as ordered. The resident and/or resident representative will be informed of the policy and provide safe food handling…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 infection control practices designed to provide a safe and sanitary environment and help prevent the development and transmission of infections were implemented. * The facility failed to ensure the staff performed proper doffing in a COVID-19 positive isolation room as per the facility's COVID-19 Mitigation Plan. * The facility failed to ensure the ice scooper attached to the ice bucket in Hallway A was not exposed. * The facility failed to ensure the staff wore the proper PPE while emptying Resident 77's indwelling urinary catheter bag. * The facility failed to ensure CNA 2 donned the gown when repositioning Resident 29. Resident 29 was on EBP due to her wound. In addition, CNA 2 failed to perform hand hygiene after the removal of the gloves and before touching the lunch tray. * The facility failed to include Resident 141 in the infection surveillance when the resident was having active…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 P&P review, and facility document review, the facility failed to ensure two sampled residents (Residents 3 and 4) was provided the necessary care and services as evidenced by: * The facility failed to continuously monitor Resident 3 after the resident had developed a right buttock pressure injury. * The facility failed to have the specific direction for the settings of the LAL mattress for Resident 4. These failures had the potential for the residents not to receive the appropriate care and services to promote skin healing.Findings: According to National Pressure Injury Advisory Panel (NPIAP) 2019 Clinical Practice Guideline, a support surface is a specialized device designed for pressure redistribution, microclimate management, and other therapeutic functions. These devices include mattresses, bed systems, overlays, and seat cushions. In low air loss mattresses, alternating air pressure mode provides pressure relief and redistribution 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 observation, interview, medical record review, and facility P&P review, the facility failed to implement the infection control practices designed to provide a safe and sanitary environment for one of one sampled resident (Resident 2) observed for wound care treatment. * LVN 1 and CNA 3 failed to don the gowns before starting the wound care treatment for Resident 2 who was on the EBP. This failure posed the risk of not preventing the transmission of infection to the other residents throughout the facility.Findings:Review of the facility's P&P titled IPCP Standard and Transmission-Based Precautions revised 4/2025 showed it is the policy of the facility to implement infection control measures to prevent the spread of communicable diseases and conditions. The Enhanced Barrier Protection (EBP) section showed the EBP is used in conjunction with the standard precautions and expand the use of PPE through the use of gown and gloves during high-contact resident care activities that provide opportunities for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to maintain the safe environment for three nonsampled residents (Residents A, B, and C). * The facility failed to ensure Residents A, B, and C's bed wheels werelocked while the residents were in bed. This failure had the potential to result to injury while care was being provided. Findings: 1. Medical record review for Resident A was initiated on 3/7/25. Resident A was admitted on [DATE]. Resident a had a diagnosis of unspecified dementia with psychotic disturbance. Review of Resident A's Care Plan Report dated 7/9/24, showed a care plan problem for self-care deficit addressing Resident A requires assistance from the staff with ADL care. The interventions included the following: - dependent with bed mobility: roll left to right; - dependent with chair/bed to chair transfer; - dependent with personal hygiene; - dependent with shower transfer; - dependent with toilet transfer; - dependent with toileting hygiene. Further review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and the facility P&P review, the facility failed to notify the physician of thechanges in the resident's status for one of four sampled residents (Resident 1). * The facility failed to notify the physician that Resident 1 had been refusing the bowel management medications from 1/1-1/3/25. This failure had the potential for the resident not to receive the necessary care and services which would negatively affect the resident's well-being. Findings: Review of the facility's P&P titled Change in Resident Condition dated 10/14/24, showed a change in the resident condition is reported as soon as practical Medical record review for Resident 1 was initiated on 1/3/25. Resident 1 was initially admitted to the facility on [DATE]. Review of Resident 1's Bowel Elimination record showed the resident had a bowel movement on 1/1/25 at 0830 hours. Further review of the bowel elimination record showed Resident 1's next bowel movement was on 1/4/25 at 2051 hours. Review of Resident 1's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and the facility P&P review, the facility failed to ensure the necessary care and services for two of two sampled residents (Resident 2 and 4) to prevent the elopement. * The facility failed to update the elopement assessment when Resident 2 had an increased on wandering behavior resulting in the use of Wander Guard. * The facility failed to ensure Resident 4's elopement risk assessments were completed quarterly as per the facility's P&P. These failures posed a risk for Residents 2 and 4 not to receive the necessary care and services to prevent elopement. Findings: Review of the facility's P&P titled Accident Prevention and Supervision revised 10/7/24, showed the resident environment remains as free of accident hazards as possible; and each resident will receive adequate supervision to prevent accidents and will include the following: - identifying hazard(s) and risk(s); - evaluating and analyzing hazard(s) and risk(s); - implementing interventions to reduce hazard(s)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of three sampled residents (Resident 1) received the appropriate treatment and services to prevent the urinary tract infections to the extent possible. * The facility failed to provide the daily indwelling urinary care to Resident 1 after his indwelling urinary catheter was inserted on 11/21/24. This failure posed the risk for Residents 1 to develop catheter-associated urinary tract infections. Findings: Review of the facility's P&P titled Urinary Catheters reviewed 10/14/24, showed documentation in the medical record should show continual assessment for use of the catheter. Staff will follow current standards of practice when handling catheters, the urine collection bag is kept below the level of the bladder and off the floor, the urinary catheter tubing is unobstructed and free of kinking, and appropriate technique is used when emptying the catheter bag. Medical record review for Resident 1 was initiated on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of three sampled residents (Resident 1) was free from the unnecessary drugs. * Resident 1 was administered the docusate sodium (stool softener) medication when Resident 1 had loose bowel movement or diarrhea. This failure had the potential for Resident 1 to receive unnecessary medication and experience adverse effects from the medication. Findings: Review of the facility's P&P titled Medication Administration reviewed 10/14/24, showed the medications are administered in accordance with the attending physician's written orders. Medical record review for Resident was initiated on 12/4/24. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 1's H&P examination dated 9/26/24, showed Resident 1 had a fluctuating capacity to understand and make decisions. Review of Resident 1's MDS Annual assessment dated [DATE], showed the BIMS score of 12 (moderate cognitive impairment).…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary care and services for two of four sampled residents (Residents 1 and 2). * The facility failed to notify the physician when Resident 1 had no bowel movements for more than three days. * The facility failed to apply the splints three times a day on Resident 2's feet as ordered by the physician. These failures had the potential to negatively impact these residents' well-being. Findings: 1. Review of the facility's P&P titled Constipation Management reviewed on 10/14/24, showed constipation problems are prevented through a bowel management program. The procedure includes secondary management consists of obtaining MD orders for the use of stool softeners, laxatives or suppositories. Document in the medical record the frequency of bowel movements and the resident's response to the effectiveness of the program. The program may consist of primary and/or secondary measures. These are…

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

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements in the kitchen were followed. * The facility failed to ensure the dietary staff and non-dietary staff inside the kitchen wore hair restraints. * The facility failed to ensure proper labeling and dating of food items in the kitchen. * The facility failed to ensure kitchen equipment and plates were clean. The facility failed to ensure the microwave utilized to warm up the residents' food was in sanitary condition and the plates used in trayline were free of food residue. * The facility failed to ensure pan and cutting boards were in sanitary condition. * The facility failed to air dry plates and insulated domes for plates. * The facility failed to ensure the scoop was stored properly. 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 facility's document titled Diet Type Report dated 9/24/24, showed 116 of 121 residents…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, facility P&P review, and facility document review, the facility failed to maintain the infection control practices to help prevent the development and transmission of diseases and infections. * The facility failed to show documentation of the Legionella (a bacteria that can cause a serious type of lung infection) facility risk assessment, control measures, and Legionella testing protocols. * CNAs 11 and 12 failed to wear proper PPE before providing care to Resident 34 in his room who was in EBP. In addition, CNAs 11 and 12 failed to perform hand hygiene before providing care to Resident 34. * The facility failed to ensure employee personal items were not stored in the clean laundry area. * The facility failed to ensure the visitors observed contact isolation precaution practices while inside Resident 109's room. * The facility failed to ensure CNA 14 changed gowns in between two residents These failures had the potential to result in the transmission 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 reasonable accommodations to meet the needs for one of 24 final sampled residents (Resident 414) and seven nonsampled residents (Residents 1, 24, 31, 36, 60, 78, and 104). * Resident 24 had waited for 30 minutes for a staff to assist her to use the toilet which resulted the resident to wet her diaper. * The facility failed to ensure the call light was within reach and accessible for Residents 1, 60, and 78. * The facility failed to ensure Resident 104's call light was within the resident's reach. * The facility failed to ensure Resident 36's bed control was within the resident's reach. * The facility failed to ensure Resident 414's head light cord was within reach. * The facility failed to ensure Resident 31's TV remote control was within reach. These failures had the potential to negatively impact the resident's psychosocial well-being or result in a delay to receive care. Findings: Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure the copy of advance directive was obtained or information on how to formulate an advance directive was provided for eight of 24 final sampled residents (Residents 34, 59, 75, 81, 89, 109, 414, and 566). * The facility failed to offer Resident 34 with written information regarding advance directives. * The facility failed to review the copy of the advance directives provided by Resident 59 and resident's representative, and ensure it was complete to show the resident's wishes and instructions for healthcare. * The facility failed to provide Resident 75 with written information regarding advance directives and ensure Resident 75's right to formulate an advance directive. * The facility failed to review the copy of POA provided by Resident 89 to ensure the POA was for healthcare authority and if it showed resident's wishes and instructions for healthcare. In addition, the facility failed to ensure a copy 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 comprehensive care plans were developed to reflect the individual care needs for three of 24 final sampled residents (Residents 20, 42, and 81). * The facility failed to develop a care plan to address Resident 20's fall on 9/15/24. * The facility failed to develop a care plan to address Resident 42's use of antidepressant medication. * The facility failed to develop a care plan to address Resident 81's Keflex medication. These failures had the potential for the residents to not be provided with appropriate, consistent, and individualized care. Findings: Review of the facility's P&P titled Baseline Care Plan revised 10/1/23, showed a written summary of a baseline care plan shall be provided to the resident and representative in a language that the resident/representative can understand. The summary shall include, at a minimum, the following: a. The initial goals of the resident. b. A summary 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 eight of 24 final sampled residents (Residents 10, 42, 75, 76, 89, 414, 564, and 814) and three nonsampled residents (Residents 87, 417, and 418) reviewed for respiratory care were provided the appropriate respiratory care when: * The facility failed to ensure Resident 814's oxygen nasal cannula tubing, humidifier, and Yankauer were dated, labeled, and the nasal cannula and Yankauer were stored in a set-up bag when not in use. The facility failed to develop a care plan to address Resident 814's oxygen use and monitoring of oxygen saturation level when the Resident 814 was using the oxygen. In addition, the facility failed to obtain a physician's order for Resident 814's oral suction at bedside and develop a care plan to monitor the suction use and effectiveness * The facility failed to ensure Resident 76's oxygen tubing, humidifier, and the set-up bags for the nebulizer and suction devices were dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 five final sampled residents (Resident 108)reviewed for hemodialysis care. * The facility failed to ensure the medications scheduled to be administered to Resident 108 on the days the resident had dialysis treatments had a physician's order to be held or were rescheduled. This failure had the potential for the resident's poor health outcomes. Findings: Review of the facility's P&P titled Medication Administration - General Guidelines revised 11/21 showed medications are administered within 60 minutes of scheduled time, except before or after meal orders, which are administered based on mealtimes. Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the facility. If a dose of a regularly scheduled medication is withheld,…

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

Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the pharmaceutical services to meet the resident's needs. * The facility failed to ensure the medications were available for one of six final sampled residents (Resident 564)observed and reviewed for medication administration. This failure had the potential to result in medication administration errors and poor health outcomes to the residents. Findings: Review or the facility's P&P titled Medication Administration - General Guidelines revised 11/2021 showed if a medication with a current, active order cannot be located in the medication cart/drawer, other areas of the medication room, and facility (e.g., other units) are searched, if possible. If the medication cannot be located after further investigation, the pharmacy is contacted. On 9/24/24 at 0924 hours, a medication administration observation for Resident 564 was conducted with LVN 2. LVN 2 was observed preparing and administering Resident 564's medication. LVN 2 stated he would not be able to give the Calcium…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 pharmacy services for one of five final sampled residents (Resident 81) reviewed for unnecessary medications. * The facility failed to ensure the pharmacy consultant's recommendation to reduce venlafaxine (antidepressant)dosage was acted upon by Resident 81's physician. * The facility failed to ensure the Consultant Pharmacist identified the duplicate therapy for the use of acetaminophen (analgesic). These failures had the potential to negatively impact the resident's well-being. Findings: Review or the facility's P&P titled Medication Regimen Review (Monthly Report) revised 8/2019 showed the consultant pharmacist performs a comprehensive medication regimen review (MRR) at least monthly. The MRR includes evaluating the resident's response to medication therapy to determine that the resident maintains the highest practicable level of functioning and prevents or minimizes adverse consequences related to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of five final sampled residents (Resident 81) reviewed for unnecessary medications was properly monitored for the medications. * The facility failed to ensure Resident 81 had no duplicate therapy for the acetaminophen medication. * The facility failed to ensure Resident 81 was monitored for side effects of Keflex (medication used to treat bacterial infections) medication. * The facility failed to ensure Resident 81 was monitored for the side effects of hydrocodone-acetaminophen (a controlled pain medication) medication. These failures had the potential to negatively impact the resident's well-being. Findings: Review of the facility's P&P titled Unnecessary Medications revised 8/2019 showed in part, each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with 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 two of five final sampled residents (Residents 75 and 566) reviewed for unnecessary medication were free from unnecessary psychotropic (medications which affect the brain and the nervous system to treat mental illness and conditions which impact behavior and emotions) drugs. * The facility failed to ensure the side effects and behaviors were monitored for Resident 566 related to the resident's use of sertraline (antidepressant medication) and quetiapine (antipsychotic medication). * The facility failed to ensure the physician's documentation of the rationale for extending the physician's order for doxepin (antidepressant medication) beyond the 14-day duration for Resident 75. In addition, the facility failed to ensure Resident 75 was monitored for behavior manifestations and side effects related to the use of doxepin medication. These failures had the potential to negatively impact the residents' well-being.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 during the medication pass observation was less than five percent (5%). The facility had a cumulative medication error rate of 18.52% when five of 27 opportunities for errors were observed between three licensed nurses (LVNs 3, 8, and 9) who administered medications to three nonsampled residents (Residents 33, 51, and 65). The observed medication administration errors were: * LVN 8 added 90 ml of water to Resident 51's ClearLax (a laxative to treat occasional constipation) polyethylene glycol 3350 powder instead of four or eight ounces of beverage as per the direction on the ClearLax container. * LVN 9 failed to give instructions to Resident 65 to rinse her mouth after using fluticasone propionate/salmetrol diskus (medication to prevent asthma) inhalation powder. * LVN 9 administered one tablet of B complex (supplement) to Resident 65 instead of B complex with biotin as…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 pharmacy services to ensure proper storage, labeling, and disposal of the medications. * The facility failed to ensure Resident 51's Artificial Tears (lubricate dry eyes and help keep moisture on the outer surface of your eyes) ophthalmic solution was not left unattended on the resident's bedside table. * Medication Room A room temperature log had multiple documentation of out-of-range room temperatures above 77 degrees Fahrenheit. * Medication Room B had no room temperature log. * Medication Cart F had two topical prescription medications that were not labeled with a specific resident name. * Medication Cart C had oral medications stored with externally used medications. * The facility failed to ensure Resident 1's Refresh (medication used to relieve dry, irritated eyes) lubricant eye solution in Medication Cart C had an open date labeled. * Medication Cart B…

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

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the pureed recipes were followed for 12 of 12 residents who received pureed food from the kitchen. * The facility failed to ensure the puree recipes for chicken ala king, steamed broccoli, and brown rice were followed. This failure had the potential for not providing nutritional meals to meet the needs of residents on pureed diet. Findings: Review of the facility's document titled Diet Type Report dated 9/24/24, showed 12 residents received pureed food prepared from the kitchen, with no restrictions to chicken, broccoli, or rice. Review of the facility's diet spreadsheet titled TGG Menu #5: SNF Master for Cycle Day: 25 showed the lunch menu including chicken ala king, brown rice, and steamed broccoli for L1 pureed diet. Review of the facility's P&P titled In-service: Pureed Foods revised 9/2022 showed the following: - The pureed diet is a regular diet that has been designed for residents who have difficulty chewing and/ or swallowing; - The Pureeing Process section…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 follow the facility's P&P regarding the use and storage of food brought to the residents by the family or visitors. In addition, the facility failed to ensure the staff were aware of the facility's P&P on safe food handling of outside food. These failures had the potential to cause foodborne illnesses to the medically vulnerable resident population who consume food brought from outside sources. Findings: Review of the CMS S&C-09-39 Food Procurement, and Self-Determination and Participation, dated 5/29/09, showed the following: - The residents have the right to choose to accept food from visitors, family, friends, or other guests according to their rights to make choices; and - The facility has the responsibility under the food safety regulation to help visitors to understand safe food handling practices such as not holding or transporting foods containing perishable ingredients at temperatures above 41 degrees Fahrenheit. Review of the facility's P&P titled Food Brought in 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 observation, interview, and medical record review, the facility failed to provide the necessary care and services to ensure one of three final sampled residents (Resident 59) reviewed for hospice services attained and maintained their highest practicable well-being. * The facility failed to communicate with the hospice agency regarding missing hospice aide visitations for Resident 59. This had the potential of a delay in hospice care for Resident 59. Findings: Review of the facility's P&P titled Hospice Services Facility Agreement reviewed date 1/11/24, showed the following: -The facility has a designated staff person to be responsible for working with hospice representatives to coordinate care to the resident provided by facility and hospice staff. This designee (a) has a clinical background, (b) functions within their state's scope of practice, and (c) has the ability to assess the resident or have someone that has a skill and capabilities to assess the resident; and -The designated member 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, facility P&P review, and facility document review, the facility failed to monitor and address the use of antibiotics 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 two of five nonsampled residents reviewed for infection prevention (Residents 40 and 64). This failure had the potential for antibiotics to be used when it was not indicated and the development of antibiotic-resistant bacteria. Findings: Review of the facility's P&P titled Antimicrobial Stewardship dated 10/25/23, under the Actions section showed the facility specific procedures to improve antibiotic use according to the best practice, assess resident timely as symptoms appear utilizing McGeer's criteria for infection, perform appropriate diagnostic testing for a specific infection if indicated, and if resident is asymptomatic contact provider to discuss stopping of antimicrobial. a. Medical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of five residents reviewed for immunization (Resident 50) received the influenza vaccine and failed to ensure the risks and benefits of the influenza vaccination were reviewed with the resident and/or resident representative when influenza vaccine was refused. These failures had the potential for the resident and/or their representative not being informed of influenza vaccine, the benefits and risks of influenza vaccination to make an informed decision. Findings: Review of the facility's P&P titled Influenza Vaccination dated 10/22/23, showed it is the facility policy to offer residents, staff member, and volunteer worker annual immunization against influenza. Annually during influenza season, residents staff members and volunteer workers will be offered an influenza vaccination unless such immunization is medically contraindicated, or the individual has already been immunized during this time period. Further…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility document review, the facility failed to maintain essential kitchen equipment in safe operating condition. * The facility failed to ensure the dish machine in kitchen was working. * The facility failed to ensure the digital thermometers used in the kitchen were calibrated. These failures had the potential for the equipment to not function in the way it was intended, which could cause food borne illnesses for the residents. Findings: Review of the facility's Diet Type Report dated 9/24/24, showed 116 of 121 residents residing in the facility received foods prepared in the kitchen. According to USDA Food Code 2022, Section 4-501.11, Good Repair and Proper Adjustment, showed the proper maintenance of equipment to manufacturer specifications helps ensure that it will continue to operate as designed. Failure to properly maintain equipment could lead to violations of the associated requirements of the Code that place the health of the consumer at risk. 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.

Based on interview, facility document review, and facility P&P review, the facility failed to implement their infection control program to include identifying, monitoring, tracking and reporting of facility infections. These failures had the potential to delay identifying trends in the facility infections. Findings: Review of the facility's P&P titled Infection Control Program dated 10/22/21, showed the following: * A system of surveillance is utilized for prevention, identifying, reporting, investigating and controlling infections. for all residents. * The Infection Preventionist serves as the leader in surveillance activities, maintains documentation of incidents, findings and any corrective actions made by the facility and report surveillance findings to the facility's Quality Assessment and Assurance Committee. Review of the facility's Infection Control Surveillance log showed the following: - The Infection Control Surveillance log for December 2021 showed 28 residents started on antibiotics for infection after being admitted to the facility. However, the log failed to show if…

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

Based on interview, facility document review, and facility P&P review, the facility failed to implement the antibiotic stewardship program. * The facility failed to ensure the residents placed on antibiotics were accurately and timely reviewed for the appropriate use of antibiotics. This failure had the potential for inappropriate antibiotic use and increased risk of drug resistant organisms. Findings: Review of the facility's P&P titled Antimicrobial Stewardship reviewed on 10/25/21, showed the antimicrobial stewardship promotes the appropriate use of antimocribials (including antibiotics), improves resident outcomes, reduces microbial resistance and decreases the spread of infections caused by drug-resistant organisms. Utilize McGeer's criteria to determine true infection and to reassess the need for antimicrobial use once culture and sensitivity laboratory data is available. The facility will review the findings and contact the prescriber to discuss recommended changes. Review of the Infection Control Surveillance log and Antibiotic Stewardship Data for December 2022 and review…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 information regarding the rights to formulate the advance directives (legal document that states a person's wishes about receiving medical care if that person is no longer able to make medical decisions) to one of 24 sampled residents (Resident 6). This failure had the potential to result in Resident 6's wishes related to the provision of medical treatment and services to not be followed if Resident 6 was unable to make decisions for herself. Findings: Review of the facility's P&P titled Advanced Directives and POLST Policy and Procedure showed the facility is to inform and provide information to all new residents upon admission regarding the right to accept or refuse medical surgical treatment, and at the resident's option, formulate an advance directive. Under the section for Procedure, the policy showed at the time of the admission, the facility shall provide written information to the residents regarding their…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 foot care was provided for one of 24 final sampled residents (Residents 13) and one nonsampled (Resident 39). * Residents 13 and 39's podiatric services were not provided in a timely manner. These failures had the potential to result in foot problems which could affect the resident's mobility and foot health. Findings: Review of the facility's P&P titled Foot Care showed the facility will ensure residents will receive proper treatment and care to maintain mobility and good foot health. Referrals to podiatrist (a doctor specializing in the treatment of feet), vascular (doctor who specialize in the vascular system) or orthopedic (doctors who specialize in the musculoskeletal system - the bones, joints, ligaments, tendons and muscles) surgeon, or wound care physician will be made when appropriate. 1. On 2/16/22 at 0829 hours, during a concurrent observation and interview with Resident 13, Resident 13's toe nails on both feet…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to provide the necessary care and services to prevent resident injuries and accidents for one of 24 final sampled residents (Resident 42). * The facility failed to ensure the floor mats were provided on both sides of Resident 42's bed when Resident 42 was assessed to be at risk for falls and had a history of falls with the intervention to use bilateral floor mats. This failure had the potential to increase the risk for injury to Resident 42. Findings: Medical record review for Resident 42 was initiated on 2/15/22. Resident 42 was admitted to the facility on [DATE]. Review of the History and Physical examination dated 9/16/21, showed Resident 42 did not have the capacity to understand and make decisions. Review of the MDS dated [DATE], showed Resident 42 needed extensive assistance with his ADL care. Review of the Fall Risk assessment dated [DATE], showed Resident 42 had at least one fall risk factor and a history of falls in the last three months.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility P&P review, the facility failed to provide the necessary care and services for the use of an indwelling urinary catheter for one of 24 final sampled residents (Resident 50). * Resident 50's urinary drainage bag and tubing were observed touching the floor. This deficient practice had the potential to increase the risk for the resident to develop urinary tract infection ( an infection involving any part of the urinary system, including urethra, bladder, ureters, and kidney). Findings: Review of the facility's P&P titled Urinary Catheters reviewed on 10/24/21, showed the staff will follow current standards of practice when handling catheters. Urine collection bag is kept below the level of the bladder and off the floor. Review of Resident 50's medical record was initiated on 2/16/22, and showed Resident 50 was admitted to the facility on [DATE]. Review of the resident's plan of care dated 6/4/21, showed a care plan problem addressing Resident 50's risk for infection…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility P&P review, the facility failed to ensure the medications were stored in accordance with currently accepted professional practices when: * Medication Cart 1 was left unlocked and unattended while parked in the hallway. * Resident 475's Tum (antacid) tablets were left at the bedside table. * Resident 471's albuterol inhaler (a medication used for wheezing and/or shortness of breath) was observed on top of the bedside table. * Resident 31's Sytane lubricant eye drops (medication for dry eyes) was observed left at the bedside. These failures had the potential to allow unauthorized access to medications. Findings: According to the facility's P&P titled Medication Storage In The Facility ID4: Bedside Medication Storage dated 2/23/15, showed the medications and biologicals are stored safely, securely and properly. The medication supply is accessible only to licensed nursing personnel, pharmacy personeel, or staff members lawfully authorized to administer medications.…

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

Based on observation, interview, and facility document review, the facility failed to ensure the sanitary and proper storage of fruit. This failure had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed affected food items in the kitchen. Findings: Review of the CMS 672 Resident Census and Conditions of Residents completed by the facility dated 2/15/22, showed 114 of 120 residents in the facility received food prepared in the kitchen. On 2/15/22 at 0724 hours, during the initial tour of the kitchen with the Dining Service Supervisor, one of three containers of strawberries was observed with a white feathery substance on a strawberry. The Dining Service Supervisor verified the finding and stated the strawberries were going bad and would be discarded.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary hospice services to one of 24 final sampled residents (Resident 68). * The facility failed to ensure the hospice plan of care was integrated in Resident 68's care. In addition, documentation such as physician certification, resident assessments, hospice services to be provided including the discipline and frequency of care, progress notes from hospice visits were in Resident 68's medical record. These failures had the potential to put the resident on at risk for uncoordinated medical care between the facility and hospice agency. Findings: Review of the facility's P&P titled Guidelines for Hospice Care reviewed on 10/21/21, showed the residents hospice plan of care is communicated to the facility and incorporated into the facility plan of care. The following hospice documents would be filed in the residents' record at the facility: Nursing Evaluation, hospice interdisciplinary…

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