Los Altos Post-Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure Notice of Medicare Non-Coverage (NOMNC, a form given by the facility to all Medicare beneficiaries before the end of a Medicare covered Part A stay or when all of Part B therapies are ending) was not given in a timely manner to one of two sample residents (Resident 1). This failure resulted in Resident 1 not being able to make an appeal. Findings: During an interview over the phone on 9/19/24 at 8:53 a.m. with Resident 1's relative (RR), it was stated that RR saw a voicemail from the facility on 9/11/24. RR also stated she wanted to make an appeal and called the facility on 9/11/24 regarding the NOMNC. RR stated that facility informed RR that they will call back with the information. RR stated that facility did not call back. A review of Resident 1's admission record indicated, Resident one was admitted on [DATE]. A review of Resident 1's Minimum Data Set (MDS, a federally mandated assessment tool) dated 8/14/24 indicated a Brief Interview 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 and record review, the facility failed to ensure that resident representative was notified prior to discharge for one (Resident 1) of two sampled residents. This failure had the potential to result in psychosocial distress for Resident 1 when Resident 1's relative (RR) was not able to communicate with Resident 1 before, during and right after Resident 1's discharge to another facility. Findings: During an interview over the phone on 9/19/24 at 8:53 a.m. with Resident 1's relative (RR), RR stated that facility did not communicate the discharge of Resident 1. RR stated she saw a voicemail on 9/10/24 from the facility regarding discharge and called the facility on 9/10/24 to make an appeal. RR stated she was told she will receive a call back with the information. RR stated that facility did not call back. RR also stated discharge date was not provided by the facility and there was no written notice of discharge given. RR also stated, she went to the facility on 9/13/24 and was informed that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interviews, and record review, the facility failed to ensure two of two residents (Resident 1 and 2) received proper care and treatment services when: 1. For Resident 1, there was no physician order and care plan regarding the use of left-hand splint; and 2. For Resident 2's treatment for the nephrostomy sites (an opening in the skin of the back where the tube is inserted to drain urine from the kidney), was not initiated until 4 days after admission and it was not documented in some days. These failures could affect the residents' health and individualized care and services provided while in the facility. Findings: 1. Review of Resident 1's admission Record indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses including sepsis (blood poisoning due to an infection), urinary tract infection (UTI, an infection caused by a bacterium (germs) that gets into the bladder or kidneys) and Alzheimer's disease (a progressive disease that destroys memory and mental functions).…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of four allegations of abuse was reported within 24 hours per Federal and State law when one resident (Resident 1) left the facility AMA (against medical advice) for his safety after he telephoned the police to report an allegation of being touched inappropriately. This failure had the potential to compromise resident's safety and result in further abuse. Findings: During a review of Resident 1's Face Sheet (document that contains a summary of personal and demographic information), the Face Sheet indicated, Resident 1 was admitted to the facility on [DATE] with a primary diagnosis of fusion of the spine (major surgery designed to stop motion to alleviate pain) in the lumbar region (series of small bones enclosing the spinal cord in the low back). Face Sheet further indicated Resident 1 was self-responsible. During a review of Resident 1's Release from Responsibility for Discharge, dated 10/14/23, the Release from Responsibility for Discharge…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 investigate one of four allegations of abuse when Resident 1 reported being touched inappropriately. This failure had the potential to compromise resident's safety and result in further abuse. Findings: During a review of Resident 1's Face Sheet (document that contains a summary of personal and demographic information), the Face Sheet indicated, Resident 1 was admitted to the facility on [DATE] with a primary diagnosis of fusion of the spine (major surgery designed to stop motion to alleviate pain) in the lumbar region (series of small bones enclosing the spinal cord in the low back). Face Sheet further indicated Resident 1 was self-responsible. During a review of Resident 1's Release from Responsibility for Discharge, dated 10/14/23, the Release from Responsibility for Discharge indicated, Resident 1 was leaving against the advice of the attending physician. During a review of Resident 1's Notice of Transfer or Discharge, dated 10/17/23, the Notice of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow professional standards for two of three residents (Resident 1 and 2) when: 1. Resident 1 ' s eye drop medication was not discontinued after the resident ' s refusals and statement it caused eye irritation; 2. Medications were not provided timely for Residents 1 and 2. These failures had the potential to result in health complications. Findings: 1. Review of Resident 1 ' s clinical record indicated he was admitted to the facility on [DATE] with diagnoses including atrial fibrillation (an irregular heart rhythm which can lead to blood clots and stroke) and glaucoma (damage to the nerve in the eye cause by fluid buildup or increased pressure). Review of Resident 1 ' s physician orders indicated he had a physician order for dorzolamide ophthalmic solution 2% (eye drops used to treat glaucoma) one drop in left eye two times a day, dated 10/29/23. Review of Resident 1 ' s MD progress notes, dated 10/30/23 indicated Resident 1 has glaucoma and was not…

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

Based on interview and record review, the facility failed to provide services according to professional standards for one of three sampled residents (Resident 1) when a licensed vocational nurses A (LVN A) did not follow the five rights of medications administration (safety check prior to medication administration: right patient, right drug, dosage, right route, right time) and administered the wrong medications to Resident 1. This resulted in Resident 1 getting administered incorrect medications. Findings: Review of Resident 1's electronic medication administration record (EMAR, electronic version of medications received by a resident), dated 9/19/23, indicated physician ordered medications for her. Review of an SBAR- Medication regimen report, dated 9/19/23, indicated Resident 1 received the following medications which were not ordered for her by a physician: Adderall xr, cellcept, escitalopram, Pepcid, Oxybutynin Chloride, Oyster shell Calcium/Vitamin D, presdniSONE Oral tablet, senna, D3. During a telephone interview with LVN A on 11/2/23 at 4:12p.m., LVN A stated she did not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow their smoking policy and procedure (P/P) for one of three sampled residents (Residents 1) when Resident 1 had cigarettes and a lighter in her possession, even though she was assessed to not be an independent smoker (her Smoking Safety Screen and smoking care plan indicated she was to be supervised and assisted during smoking); therefore, staff needed to control and manage Resident 1's smoking items. This failure allowed Resident 1 to manage her own smoking items, contrary to the safety measures indicated in the facility's smoking policy and procedure. Findings: Review of Resident 1's medical record indicated she was readmitted on [DATE] and had the diagnoses of mild cognitive impairment (minor problems with mental abilities such as memory or thinking), dementia (loss of mental functioning to the extent that it interferes with daily life and activities), ataxia (impaired balance or coordination), and major depressive disorder (low…

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

Based on interview and record review, the facility failed to ensure an inventory of personal effects form was completed upon discharge for one resident (Resident 4). This failure resulted to inaccurate record of personal effects . Findings : Review of Resident 4 ' s progress notes dated 4/16/23, indicated, hospice nurse declared time of death at 1235 pm today. During a telephone interview with the family member (FM) on 5/8/23 at 9:05 a.m., the FM stated Resident 4 ' s ring was missing . During record review and concurrent interview with the social service worker (SSW) on 5/24/23 at12:05 p.m., Resident 4 ' s inventory of personal effects form, dated 11/23/22, was reviewed and the ring was not listed on the form. The area to check items given upon discharge and certification of receipt upon discharge was left blank. The SSW stated he told the FM Resident 4 did not have a ring listed on his inventory of personal effects. The SSW stated he gave all belongings to the FM but did not bring the form for the family member to sign. The SSW stated he should have checked the form and accounted…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation , interview and record review , the facility failed to ensure call lights were properly working and accessible for three of four residents (Resident 1, 2, and 3) when: 1.Resident 1 ' s bed call light did not work . This failure resulted to delay in providing care to Resident 1. 2. Residents' 2 and 3 call lights were not within reach while in bed. These failures could potentially put resident ' s comfort and safety at risk. Findings : 1.Review of Resident 1 ' s admission record indicated she was admitted with a diagnoses of chronic respiratory failure and her minimum, data set (MDS, an assessment tool ) dated 3/29/23, indicated she had a a brief interview for mental status (BIMS) of 9, which meant she had mild cognitive impairment. Resident 1 required staff assistance during toilet use and was incontinent of bowels. During an observation and concurrent interview on 5/24/23 at 11:15 a.m., Resident 1 was heard calling for help. Resident 1 held the call light and stated, I ' ve been pressing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) received a medication as ordered. The facility also failed to notify the physician when Resident 1 did not receive this medication. These failures had the potential to compromise Resident 1's health and well-being. Findings: Review of Resident 1's clinical record indicated she was admitted to the facility on [DATE] with diagnoses including paraplegia (inability to move legs and lower body) and diabetes mellitus (DM, a condition which affects the way the body processes blood sugar). Review of Resident 1's physician orders indicated she had an order, dated 8/15/23 for Rybelsus (medication used to control high blood sugar) oral Tablet 7 milligrams (mg, unit of measurement) Give 7 mg by mouth one time a day for DM. Review of Resident 1's August 2023 Medication Administration Record (MAR, record of medications given) indicated Rybelsus was not signed as administered to Resident 1 on 8/16/23, 8/17/23,…

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

Based on observations, resident and staff interviews, and facility document review, the facility failed to provide food that was palatable. This failure placed the 114 residents eating at the facility at risk of poor food intake further compromising their nutritional status. Findings: During resident interviews on 3/7/22 starting at 8:30 a.m., multiple residents complained about the food generally being bad. Comments included the ham is salty, the zucchini is soggy and sloppy, the food is just not good. During an interview with Resident 3 on 3/8/22 at 7:42 a.m., Resident 3 stated the food is dreadful for example meals made with ground beef are greasy, the soups are watery, and the toast is dry and brittle. During an interview with Resident 78 on 3/8/22 at 8:58 a.m., Resident 78 said he orders take out about 80% of the time because most food at the facility is not good. During an interview with Resident 4 on 3/9/22 at 10:15 a.m., Resident 4 said he understands the food is made for many people, but they could make it somewhat tasty and not so bland, and all we (the Residents) have to…

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

Based on observation, interview, and facility document review, the facility failed to ensure food was stored and prepared in accordance with professional standards for food safety when: 1. Resident food refrigerators and microwaves were not properly monitored, and not maintained in a sanitary condition, and multiple expired, moldy, and/or unlabeled foods were stored in the refrigerators; 2. Time/Temperature Control for Safety (TCS) foods (food that requires time/temperature control for safety to limit the growth of pathogens (i.e., bacterial or viral organisms capable of causing a disease or toxin formation), were not properly monitored for cool down; 3. TCS foods were not properly labeled, and expired items were in the refrigerator; and 4. Multiple food service pans and equipment were stored wet. These failures had the potential to cause the growth of microorganisms which could cause foodborne illness or cross contaminate food (cross contamination occurs when unclean surfaces or utensils spread germs to food and can potentially cause foodborne illness) for the 114 residents eating…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure 8 of 24 residents (84, 98, 112, 7, 116, 384, 53, and 67) received necessary and proper care and services when: 1. Licensed nurses did not follow ordered pain level for pain medications for Resident 84 and Resident 98; 2. Licensed nurses did not initiate change of condition and treatment for Resident 112's abrasions; 3. Residents 7 and 98 did not get any assistance or supervision after delivery of nourishments by the housekeeping supervisor (HKS); 4. Licensed nurses did not follow Resident 116's physician's order for bolus feeding (a larger amount of liquid nutrition is given in a short period of time, usually less than 30 minutes); 5. Licensed nurses did not closely monitor Resident 384 during intravenous (IV, given through veins) fluid hydration; 6. Licensed nurses did not document Resident 53's skin tear; and 7. Resident 67's care plan for an anticoagulant was not developed. These failures had the potential to affect the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure safe medication administration, ensure medications were available to administer, medications were given according to the manufacturer's specifications, and ensure controlled medications (those with high potential for abuse and addiction) were fully accounted for when: 1. Licensed vocational nurse W (LVN W) left Resident 85's medications on his overbed table. This failure had the potential for misuse of residents' medications that could affect residents' health and well-being; 2. Two of six nurses failed to identify residents (Residents 22, 368, and 384) during medication pass. This failure had the potential for medication errors. 3. Two out of six nurses failed to inform the residents (Residents 22 and 109) the medications being administered during the medication pass. This failure had the potential for resident not to be aware of treatment and potential side effects; 4. Random controlled medication use audit for four of six…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 5 of 12 residents (10, 72, 20, 63, and 76) were free from unnecessary psychotropic medications (drugs that affects brain activities associated with mental processes and behaviors) when: 1. Resident 10 had received duloxetine (brand name: Cymbalta, antidepressant and nerve pain medication) 60 milligrams (mg, a metric unit of mass) every day since 8/1/21, and Resident 87 had received duloxetine 60 mg every day since 2/7/2020, without gradual dose reduction (GDR, a tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued); and there was no documented clinical rationale by the physician for why an attempted GDR was not indicated; 2. Resident 72 had received clonazepam (an anti-anxiety medication) 0.5 mg three times a day since 6/24/21 without GDR; 3. Resident 20 received Seroquel (an antipsychotic medication, to treat severe mental disorder in which thought, and…

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

Based on observation, interview and record review, the facility failed to ensure proper medication storage and labeling of medications when: 1. Four medications identified in the medication refrigerator did not have the pharmacy label; 2. Temperature monitoring was not consistently documented twice daily on the temperature log sheets for three of four medication refrigerators; and 3. An oral inhaler in active stock was being used beyond the discard (expiration) date. The deficient practices had a potential for medication errors due to medications not being labeled; inadequately monitored medications, which could lead to unsafe and ineffective medications for the residents; and residents to receive medications with unsafe and reduced potency from being used past their discard date. Findings: 1. During a medication room inspection observation on 3/7/22 at 10:43 a.m. in Station 3 with Registered Nurse (RN) CC, a medication refrigerator was observed inside the medication room. The refrigerator contained numerous refrigerated medications. Inspection of a medication refrigerator…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, staff interview, and facility document review, the facility failed to ensure the planned menu was followed for: 1. Eight of eight residents (Residents 51, 100, 47, 75, 468, 98, 77, 223) on renal diets (diets designed for people with kidney disease) when they were served pasta instead of peas; 2. Six of six residents (Residents 9, 27, 45, 469, 103, 378) on puree diets (texture modified diets for people with chewing or swallowing difficulties) when they were served the wrong portion size for bread and zucchini; 3. Five of five residents (Residents 59, 92, 383, 68, 66) on minced and moist diets (texture modified diets for people with chewing or swallowing difficulties) when they were served the wrong portion size for ham, zucchini, and bread; and 4. Eleven of eleven residents (Residents 26, 54, 67, 88, 368, 76, 105, 33, 32, 56, 15) on soft and bite sized diets (texture modified diets for people with chewing or swallowing difficulties) and eight out of ten residents (Residents 21, 50, 31, 91, 113, 369, 93, 52) on easy to chew diets (texture modified diets 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 record review, the facility failed to implement infection control practices when: 1. Certified nursing assistant V (CNA V) did not put on gown and gloves when he brought the lunch tray to Resident 61 who was isolated and on contact precautions (intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment); 2. Glucometer (blood sugar testing monitor) was not cleaned and disinfected after resident use; 3. Medication nurse did not wipe down the vial stopper before drawing up medication into the syringe; 4. The treatment nurse (TN) did not perform hand hygiene in between tasks during Resident 3's wound care; 5. Registered nurse N (RN N) did not properly store Resident 116's used nasal cannula tubing (a tubing used to deliver oxygen from the machine through the nostrils) when not in use; 6. For Resident 74, facility staff did not keep the urinary drainage bag connected to nephrostomy (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.

Based on observation, interview and record review, the facility failed to ensure a comfortable and safe temperature level for one of three sampled resident rooms when Resident 218's room temperature was not maintained in the range of 71 to 81 degrees Fahrenheit. This failure had the potential for the resident to have an uncomfortable environment. Findings: During a concurrent observation and interview on 3/7/22, at 8:32 a.m. inside Resident 218's room, the room temperature felt cold. Resident 218 stated It is cold in here. During a follow up interview on 3/8/22 at 8:22 a.m. with Resident 218, stated, It was still cold, and I had to ask for an extra blanket last night. During a review of Resident 218's clinical record, dated 3/6/22, the admission diagnosis indicated, Resident 218 had hemiplegia (paralysis of one side of the body), hypertension (condition in which the force of the blood against the artery walls is too high), stroke (damage to the brain from interruption of blood supply) dysphagia (difficulty swallowing foods or liquids). Her Minimum Data Set (MDS, an assessment tool),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to accurately complete the Minimum Data Set (MDS, an assessment tool) for one of 24 sampled residents (Resident 74). Failure to accurately assess the resident had the potential to compromise the facility's ability to provide resident-centered care planning and interventions. Findings: Review of Resident 74's clinical record indicated, Resident 74 was admitted on [DATE] and had diagnoses of sepsis (a life-threatening infection), hemiplegia (paralysis of one side of body) and hemiparesis (weakness on one side of body), dysphagia (difficulty swallowing), urinary tract infection, obstructive and reflux uropathy (a blockage in the urinary track), and neuromuscular dysfunction of bladder (lacks bladder control due to brain or nerve problems). During an observation on 3/07/22 at 8:48 a.m., Resident 74 was lying in bed in her room and the head of the bed was elevated. Resident 74 had Jevity (a tube feeding formula) 1.0 cal (calories) via tube feeding…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure care plans were developed and implemented for three of 24 sampled residents (Residents 6, 116, and 74) when: 1. Resident 6's care plan for non-compliance with use of Aspen collar (a device used to support the resident's neck) was not initiated; 2. Resident 116's care plans for dialysis (a procedure when a resident is attached to an artificial kidney that helps clean blood), tube feeding (a flexible tube inserted through nose or belly to provide nutrients), antidepressant (type of medication used to treat depression) and insulin (a hormone used to lower the blood sugar) use were not initiated; and 3. Resident 74's care plan for Nephrostomy (an artificial opening created between the kidney and the skin which allows for the urinary diversion) tube/drainage bag care was not implemented. These failures had the potential to compromise resident's health and well-being. Findings: 1. A review of Resident 6's clinical record indicated, the…

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

Based on observation, interview, and record review, the facility failed to provide services to prevent pressure ulcer for two of seven sampled residents (Resident 114 and Resident 220) when: 1. Resident 114's heels were not floated while in bed; and 2. Resident 220's heels were not offloaded and not covered with dressing while in bed. These failures had the potential to cause or worsen pressure ulcers. Findings: 1. During an observation on 3/7/22 at 9:51 a.m., Resident 114's heels were not floated while in bed. During a follow up observation on 3/8/22 at 9:12 a.m., Resident 114's heels were not floated while in bed. Heel protectors were on top of cabinet not in use. During an interview on 3/8/22 at 12:44 p.m. with certified nursing assistant S (CNA S), she confirmed she was not aware that Resident 114's heels were to be floated while in bed. During a concurrent interview and review of care plan on 3/8/22 at 12:54 p.m. with licensed vocational nurse T (LVN T), she stated she was not aware of pressure ulcer prevention care plan for Resident 114's heels to be floated while in bed. LVN…

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

Based on observation, interview and record review, the facility failed to ensure two of 24 sampled residents (Residents 88 and 117) received necessary respiratory care and services in accordance with professional standards of practice when: 1. Resident 88's oxygen tank was left empty while in use; and 2 .Facility staff did not post an Oxygen in use/No smoking sign on Resident 117's door. These failures had the potential to affect the resident's health and safety. Findings: 1. A review of Resident 88's clinical record indicated resident was admitted to the facility with diagnoses including atherosclerotic heart disease (a plague buildup [fat deposits] in the wall of the arteries that supply blood to the heart), unspecified dementia without behavioral disturbance (a condition characterized by memory loss) and diabetes mellitus with diabetic polyneuropathy (occurs when the body is unable to regulate glucose [sugar] in the blood, with nerve damage. Clinical records also indicated Resident 88 was on hospice care. During an observation on 3/10/2022 at 9:51 a.m., Resident 88 was asleep,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility had a 6.67% medication error rate when two medication errors out of 30 opportunities were observed during medication pass for one of six residents (Resident 378). Resident 378 received Trospium (a medication used to relax the bladder muscles to improve control of urination) not in accordance with the manufacturer's specifications and did not receive Isosorbide Mononitrate (a medication used to prevent chest pain in patients with a certain heart condition) as scheduled. These failures had the potential to result in compromising the health and safety of the residents. Findings: 1. During a review of Resident 378's medical record, the physician orders, dated March 2022, indicated an order for Trospium Chloride 20 mg (milligrams, a unit of measure), give one tablet by mouth once a day start date 2/26/22. During a medication pass observation on 3/8/22 at 9:10 a.m. in Resident 378's room, LVN T was observed administrating multiple medications including…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 offer, administer, and track pneumococcal vaccine (PV, immunization against bacterial that causes pneumonia, one type of lung infection) for two of 24 sampled residents (Resident 40 and 53). This failure had the potential to cause the health complications for the residents. Findings: 1. Review of Resident 53's clinical record indicated, Resident 53 was admitted on [DATE] and had diagnoses of depressive disorder (mood disorder which interferes with daily life), anxiety disorder (persistent feeling of worry and apprehension), Dementia (a condition characterized by memory loss) without behavioral disturbance, and history of venous thrombosis (a blood clot reduces the flow of blood in a blood vessel) and embolism (a blood clot blocks the flow of blood in a blood vessel). Review of Resident 53's immunization record, indicated Resident 53 had the Pneumococcal conjugate vaccine (PCV13, a vaccine to protect against 13 types of pneumococcal bacteria that causes…

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

Based on observation, interview, and record review, the facility failed to comply with national guidelines and facility policy to ensure food procurement, store, prepare and served under sanitary conditions. These failures had the potential to effect food quality and safety. Findings: Brief initial tour of the facility kitchen with the dietary manager (DM) was initiated on 11/18/19 at 7:59 a.m. The following were observed and acknowledged: 1. no air gap noted beneath the ice machine 2. kitchen prep sink leaking underneath into a big basin 3. four trays of ice cream cups and one-half head of cabbage in the refrigerator undated 4. bell pepper noted with black spots in the refrigerator 5. one box of opened sausage and four bags of hash browns in the freezer not dated 6. four containers of oatmeal, thickener, rice and flour with open lids 7. employee jacket in the dry storage room 8. one bottle of black sauce not labeled and not dated 1. During an observation with the DM on 11/18/19 at 8:05 a.m., no air gap noted beneath the ice machine in the kitchen. During an observation and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement it's infection control program to provide a safe and sanitary environment to prevent the development and transmission/spread of infection for 4 of 25 sampled residents when: 1. Failed to sanitize hands after taking a residents blood pressure and before returning to the medication cart 2. Nursing staff failed to observe aseptic (sterile) technique and perform handwashing/hygiene after when performing trache care. 3. Visitor coming from one resident isolation room was walking int he hallways wuith her isolation gown and gloves on. 4. For Resident 104, facility failed to change the suprapubic catheter as needed when bag was soiled (a hollow flexible tube that is used to drain urine from the bladder) as ordered by the physician. These failures had the potential to result in the transmission and spread of infection. Findings: 1. During a medication administration observation on 11/18/19 at 9:21 a.m., licensed vocational nurse D (LVN…

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

Based on observation, interview, and record review, the facility failed to provide an environment that maintained or promoted the dignity and respect for two of two residents (Residents 60 and 375) when the door was not closed and the privacy curtains were not drawn to prevent them from being unnecessarily exposed to public view. This deficient practice had the potential to cause psychosocial harm to the residents. Findings: 1. During an observation on 11/20/19 at 1:03 p.m., while walking in the hallway with other residents, staff and visitors, Resident 60's door was wide open and the privacy curtain was not drawn. Resident 60's legs and thighs, and an incontinent pad were exposed to the public view. Concurrent this observation was validated by the certified nursing assistant B (CNA B) who immediately closed the privacy curtain. Resident 60 stated, I feel hot, so I don't cover my legs with sheets, but I don't want people looking at my bottom too. 2. During an observation and concurrent interview on 11/18/19 at 9:41 a.m., Resident 375 was lying on her bed and the speech therapist…

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

Based on observation, interview and record review, the facility failed to ensure no medications were kept at bedside for one of one resident (Resident 373) without a physician's order, care plan, and prior self administration and interdisciplinary team (IDT, facility staff members from different departments who coordinate care provided to residents) assessments done. This failure had the potential for improper administration of medications, could possibly cause adverse drug reactions or side effects. Findings: During an observation with registered nurse A (RN A) on 11/18/19 at 12:44 p.m., RN A confirmed there was an opened blue bottle of liquid Antacid (medication that help neutralize stomach acid) and a bottle of Flonase nasal spray (used to treat nasal congestion, sneezing, runny nose, and itchy or watery eyes caused by seasonal or year-round allergies) kept at the bedside. RN A stated, there should be no medications kept at the bedside without a physician's order and prior assessments. During an interview and concurrent record review on 11/18/19 at 1:16 p.m., RN A could not find…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop and implement a baseline care plan for three of three sampled residents (Residents 12, 373 and 383) when: 1. Resident 12's care plan for dementia was not developed upon admission; 2. Resident 373's care plan for pain management was not developed upon admission; and 3. Resident 383's care plan for wound vacuum management was not developed upon admission. A care plan identifies residents' concerns, and outlines the care and services needed to meet their needs. Findings: 1. Review of Resident 12's admission Record indicated he was admitted on [DATE] with diagnosis of dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - and behavioral abilities to such an extent that it interferes with a person's daily life and activities). Review of Resident 12's clinical record indicated he did not have a care plan for his diagnoses of dementia. During an interview with the director of nursing (DON) on 11/22/19 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record interview, the facility failed to develop, implement, and revise the care plan (provide direction for individualized care) for four of 25 sampled residents (Residents 13, 88, 90, and 373) when: 1. For Resident 13, the care plan for actual impairment to skin integrity was not implemented; 2. For Resident 88, the care plan for fluoxetine (medication for depression) was not developed; 3. For Resident 90, the care plan for tube feeding was not revised; 4. For Resdient 373, the care plans for refusing daily weights and missing one scheduled dialysis were not developed. These failures had the potential resident care and services not meeting individual needs. Findings: 1. Review of Resident 13's clinical record indicated she was admitted on [DATE] with including diagnoses of Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), hearing loss, chronic pain, and dysphagia (difficulty in swallowing). Review of Resident 88's care…

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

Based on observation, interview, and record review the facility failed to follow physician orders according to professional standards of practice for one of 1 sampled residents (54). For Resident 54, physician orders were not followed when registered nurse C (RN C) did not check enteral feeding (tube feeding; nutrition taken through a tube that goes directly into the stomach) residuals (volume of fluid remaining in the stomach) prior to medication administration. These failures had the potential to compromise resident health. Findings: During a medication pass administration observation on 11/18/19 at 1:33 p.m., in Resident 54's room RN C did not check enteral feeding residuals prior to medication administration. During an interview with RN C on 11/18/19 at 1:50 p.m., she stated, I gave her meds earlier and I did not want her to wait any longer. During a concurrent review of Resident 54's physician orders and interview with the director of nurses (DON) on 11/19/19 at 8:46 a.m., she stated the physician orders indicated to check residuals before medication administration. The DON…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 appropriate treatment and services for eight of 25 sampled residents (Residents 90, 13, 78, 45, 49, 54, 58, and 76) when the restorative nursing assistance (RNA, it helps the residents to gain an improved quality of life by increasing their level of strength and mobility) program was not provided as scheduled. This failure had the potential not to meet the goal and address their needs. Findings: 1. Review of Resident 90's undated face sheet indicated he was admitted [DATE] with diagnoses of dementia (memory problem), hypertension (increase blood pressure), and dependence on wheelchair. His minimum data set (MDS, an assessment tool), dated 10/24/19, indicated he was severely impaired in decision making, functional limitation in range of motion was impaired on one side of the body on upper and lower extremities. Review of Resident 90's documentation survey report, indicated passive range of motion (PROM) on upper extremities and bilateral lower…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the necessary care and treatment was provided for one of one sampled resident (Resident 383) for the administration of parenteral (intravenous [IV] infusion of various solutions to maintain adequate hydration) fluids consistent with the facility's policy and professional standards when the: 1. The physician's orders for total parenteral nutrition (TPN, a way of supplying all the nutritional needs of the body by bypassing the digestive system and giving nutrient solution directly into a vein) was not followed. The TPN and peripherally inserted central catheter (PICC, a long, slender, flexible tube inserted into a peripheral vein, typically in the upper arm, and advanced until the catheter tip terminates in a large vein in the chest near the heart to obtain intravenous access) care plan was not developed. 2. Monitoring of the intake and output every shift was not completed, and the physician's order for fluid restriction was not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide adequate care and services for one of two dialysis-dependent residents (Resident 373) when: 1. Renal diet was not ordered as per resident's preference and needs 2. Dialysis was not done as per physician's order 3. Congestive Heart Failure (CHF, failure of the heart to pump adequate amount of blood that causes symptoms of shortness of breath, weakness, fatigue, and swelling of the legs, ankles, and feet) protocol was not done every shift per MD order. 4. Licensed nurses lack of knowledge on the resident's appropriate dialysis access care. These failures had the potential to affect Resident 383's care and health outcomes by placing Resident at risk for complications. Findings: A review or Resident 373's medical record indicated admission on [DATE] with diagnoses of type 2 diabetis mellitus (the body either doesn't produce enough insulin, or it resists insulin) with diabetic chronic kidney disease, end stage renal disease (ESRD, 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 record review, the facility failed to ensure for two of four sampled residents (Residents 88 and 427) were free from unnecessary psychotropic medications (medications capable of affecting the mind, emotions, and behavior) when: 1. For Resident 88, the facility failed to attempt a gradual dose reduction (GDR) for Prozac (medication for depression); 2. For Resident 427, the facility failed to ensure as needed medication (PRN) had a rationale for continued use for Ativan (medication for anxiety) and a non- pharmacological intervention was attempted before giving Ativan. These failures had the potential to negatively affect the residents' physical and psychosocial well-being. Findings: 1. Review of Resident 88's clinical record indicated he was admitted [DATE] with including diagnoses of depressive disorder (mood disorder which interferes with daily life), hypertension (increase blood pressure), and diabetes (increase blood sugar). Review of Resident 88's order summary sheet dated 1/31/19,…

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

Based on observation, interview, and record review, the facility failed to ensure medications and biologicals were labeled and stored appropriately when: 1. One expired medication was found in the medication storage room refrigerator 2. One vial of Novolog insulin was found on station 2 med cart. These findings had the potential to result in the accidental administration of expired medications. 3. Home medications labeled by outside pharmacy with MD order to be taken by Resident 373 were not verified by facility in house pharmacy. Findings: 1. During a medication storage room refrigerator observation on 11/18/19 at 9:50 a.m., with the director of nurses (DON), a bottle of Firvano (medication used to treat infections) was found with an expiration date of 10/31/19. The DON acknowledged the medication was expired. During a concurrent interview with the DON she stated expired medications needed to be discarded. 2. During a medication administration observation on 11/18/19 at 1:15 p.m., with registered nurse C (RN C) a vial of Novolog insulin (medication used to regulate he amount of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure laboratory tests were done as physician ordered for two of 25 sampled residents (Residents 12 and 94) when: 1. Resident 12's valproic acid level (a test measures the amount of valproic acid in a blood sample; valproic acid is a drug used to prevent seizures) was not done every three months; and 2. Resident 94's hemoglobin and hematocrit (H & H test; hemoglobin is the protein contained in red blood cells that is responsible for delivery of oxygen to the tissues; hematocrit measures the volume of red blood cells compared to the total blood volume), prealbumin (a blood test that used to see if a person is getting enough nutrition; prealbumin is a protein made by the liver, and the body uses prealbumin to make other proteins), and albumin (a blood test used to screen for and help diagnose a liver disorder or kidney disease; albumin is a protein made by the liver) was not done monthly. These failures had the potential to result in abnormal laboratory…

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

Based on interview and record review, the facility failed to ensure that the registered dietitian's (RD) recommendation was communicated and coordinated with the primary care physician for two of 25 sampled residents (Residents 58 and 84) in a timely manner. This failure had the potential in delay in meeting the residents' nutritional needs. Findings: Review of Resident 58's clinical record indicated she had diagnoses that included diabetes mellitus (abnormally high sugar level in the blood), anemia (lack of enough red blood cell component of blood the carry oxygen to the body's tissues), and depression (persistent feeling of sadness and loss of interest). Review of Resident 58's clinical record dated 9/25/19 indicated an RD's recommendation for primary care physician to consider prescribing appetite stimulant for Resident 58 due to no appetite. Further review of Resident 58's clinical record indicated there was no evidence of documentation that the RD's above recommendation was communicated to the Resident 58's primary care physician. Review of Resident 84's clinical 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.