Grand Park Convalescent Hospital

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record reviews the facility failed to implement its abuse policy and procedures when the facility failed to report to the Survey State Agency (SSA) an injury of unknown origin with 24 hours for one of three sampled residents (Resident 1). On 8/16/2024 at 12:22 pm, Resident 1 was found on the floor with discoloration to the left of his face and a 0.5-centimeter (cm-unit of measurement) scratch to the right side of the nose. On 8/20/2024, the hemodialysis (a medical procedure to remove fluid and waste products from the blood) center reported to Resident 1's physician that the resident had bruising and swelling to the left side of the face. The physician ordered for Resident to be transferred to a General Acute Care Hospital (GACH) for further evaluation and management. The facility never reported Resident's 1 injuries to the SSA. This deficient practice resulted in delayed investigation of Resident 1's injuries by the SSA. Findings: A review of Resident 1 ' s admission Record indicated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 maintain an infection prevention and control program designed to help prevent the development and transmission of Coronavirus – 19 (COVID-19, COVID, a virus that causes respiratory illness that can spread from person to person) as evidenced by: 1. Failing to ensure that two of the four sampled residents (Residents 1 and 3) were wearing a mask while interacting with other residents in the hallway and at the nurses station. 2. Failing to ensure that Registered Nurse (RN) 1 were wearing N95 respirators (is a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) they were fit tested for (RN 1). These deficient practices had the potential to place both residents and staff at a risk for infection to COVID-19. Findings: 1. A review of Resident 1 ' s admission record indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] 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 and record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of an abuse in accordance with state and federal law for one of one sampled resident (Resident 1). This resulted in a delay of an onsite inspection by the State Agency (SA) to ensure the safety of the residents and had the potential to result in unidentified abuse in the facility as well as failure to protect residents from any possible abuse. Findings: During a review of Resident 1 ' s admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses including chronic respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide), congestive heart failure (CHF-a chronic condition in which the heart does not pump blood as well as it should) and dysphagia (difficulty swallowing food or liquid). During a review of Resident 1 ' s Minimum Data Set (MDS - a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to address the resident's pain level before, during, and after Restorative Nursing Assistant application (RNA - a Certified Nursing Assistant [CNA] who helped patient's regain physical and cognitive ability after an injury or illness) for three of four sampled residents (Resident 52, Resident 92, and Resident 129). This deficient practice had the potential for residents to experience pain when not properly assessed. Findings: a. A review of Resident 52's admission Record indicated the facility initially admitted the resident on 10/31/2018 and re-admitted the resident on 4/27/2024, with diagnoses including polyarthritis (a condition that causes inflammation, pain, and stiffness in five or more joints at the same time), neuralgia (severe, sharp, and often shock-like pain that follows the path of a nerve) and need for assistance with personal care. A review of the Physician's Order dated 7/13/2023, indicated for Resident 52 to receive RNA 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.

Based on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service safety by not labeling: -one plastic container of Aji- Mirin Sweet Cooking [NAME] seasoning with open and use by dates. -one plastic bag of carrots with open and use by dates. -one plastic bag of ginger with open and use by dates. -one plastic bag of Dried [NAME] with open and use by dates. -one plastic container of Salted Shrimp with no open and used by dates. In addition, the facility failed to discard several items by the use by date. These deficient practices had the potential to cause food-borne illnesses. Findings: During a concurrent observation and interview on 6/17/2024 at 8:03 A.M., the Dietary Assistant (DA) observed one plastic container of Aji-Mirin Sweet Cooking [NAME] seasoning, one bag of carrots, one plastic container of Salted Shrimp, one plastic bag of ginger, and one plastic bag of Dried [NAME] with no open or use by dates. There was one bottle of [NAME] vinegar with an open date of 2/7/2024 and a use by date 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, and record review, the facility failed to provide care in a manner that maintained or enhanced residents' dignity and respect for two of 12 sampled residents (Resident 87 and 93), by standing over the residents while assisting them during a meal. These deficient practices had the potential to affect residents' sense of self-worth, self-esteem, and psychosocial wellbeing. Findings: a. A review of Resident 87's admission Record (Face Sheet) indicated the facility admitted the resident on 8/6/2020, and readmitted on [DATE], with diagnoses including Alzheimer's disease (a brain disorders the slowly destroys memory and thinking skills and eventually, the ability to carry out the simplest tasks), bipolar disorder (a serious mental illness that causes unusual shifts in mood, ranging from extreme high manic episodes to low depression episodes), and essential hypertension (a condition in which the blood vessels have persistently raised pressure). A review of Resident 87's History and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a copy of the resident's advance directive (a written instruction, recognized under State law, relating to the provision of health care when the individual is unable to make decisions for themselves) was in the resident's medical chart and the Advance Directive Acknowledgement form was completed thoroughly for two of seven sampled residents (Residents 92 and Resident 140). These deficient practices had the potential for the facility to not honor the residents' medical decisions regarding end-of-life treatment. Findings: A review of Resident 92's admission Record (Face Sheet) indicated the facility admitted the resident on 2/2/2024, with diagnoses including abnormalities in gait and mobility (a change to your walking pattern), osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down over time), and fibromyalgia (a disorder characterized by widespread musculoskeletal pain accompanied by fatigue, sleep, memory, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report the following incidents to the State Survey Agency (SSA, the Bureau of Health Facility Licensing) within the appropriate timeframe for two of six sampled residents (Resident 13 and Resident 195) as evidenced by: -For Resident 13, the facility failed to report an injury of unknown origin (an injury that the source was not observed by any person or could not be explained by the resident). -For Resident 195, the facility failed to report a fall with injury. These deficient practices resulted in a delay of an onsite inspection by the California Department of Public Health (CDPH) to ensure Resident 13's injury of unknown origin and Resident 195's fall with injury were investigated. Findings: a. A review of Resident 13's admission Record (face sheet) indicated the facility readmitted on [DATE], with diagnoses including dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 develop a comprehensive care plan for hospice (a specialized type of care that provides physical comfort and emotional, social, and spiritual support for people nearing the end of life) one of six sampled residents (Resident 123). This deficient practice had the potential for Resident 123 to not be provided with necessary and personalized care. Findings: A review of Resident 123's admission Record indicated the facility readmitted the resident on 5/31/2024 with diagnoses that included malignant neoplasm of the stomach (cancer [a disease in which abnormal cells divide uncontrollably and destroy body tissue] of the stomach), encounter for palliative care (specialized medical care for people living with a serious illness, such as cancer or heart failure [occurs when the heart muscle doesn't pump blood as well as it should]), severe protein-calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function), and sepsis (a serious condition in which the body…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 safety measures were assessed and implemented for one of six sampled residents (Resident 134) by failing to initiate a smoking risk assessment when the facility was aware the resident was a smoker. This deficient practice had the potential for Resident 134 to be at risk for injury or burns without a proper assessment. Findings: A review of Resident 134's admission Record indicated the facility admitted the resident on 5/16/2024, with diagnoses including abnormalities of gait and mobility (a change to your walking pattern), hypertension (high blood pressure) and diabetes mellitus (chronic metabolic disease that occurs when the body did not produce enough insulin or cannot use insulin properly). A review of Resident 134's admission Nursing Risks assessment dated [DATE], indicated the resident did not smoke, which did not prompt the document to allow safety measures to be reviewed and implemented. A review of Resident 134's History…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents were provided care and nutrition consistent with their weight loss assessment and the Registered Dietitian's (RD) recommendations for one of four sampled residents (Residents 133). This deficient practice had the potential to result in the resident's weight loss. Findings: A review of Resident 133's admission Record indicated the facility admitted the resident on 2/7/2024 and readmitted him on 4/7/2024 with diagnoses including end stage of renal disease (final, permanent stage of chronic kidney disease, where kidney function declined to the point that the kidneys can no longer function on their own), dependence on renal dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) and depression (an illness characterized by persistent sadness and a loss of interest in activities, accompanied by an inability to carry out daily activities). A review of Resident 133's…

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

Based on observation, interview, and record review, the facility failed to ensure a new tube feeding (a way to provide nutrition when you cannot eat or drink safely by mouth, delivered through a gastric tube [G-tube, a tube inserted through the abdomen that delivers nutrition directly to the stomach]) set was used when starting a new tube feeding bottle for one of six sampled residents (Resident 124). This deficient practice had the potential for Resident 124 to experience infection control issues and experience tube feeding intolerance symptoms such as nausea, vomiting, and abdominal discomfort. Findings: A review of Resident 124's admission Record indicated the facility admitted the resident on 1/17/2024 with diagnoses that included Parkinson's Disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), aftercare following surgery on the digestive system, gastrostomy (G-Tube, a tube inserted through the abdomen that delivers nutrition directly to the stomach), dysphagia (difficulty…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide sufficient staffing to accommodate resident needs for two of two sampled residents (Resident 28 and 99). This deficient practice had the potential for the residents to not receive timely and efficient care and needed services. Findings: a. A review of the Certified Nursing Assistant's (CNA) Assignments for 5/19/2024, indicated that on 5/19/2024, eight CNAs were working during the 11 PM-7 AM shift attending 147 residents. On 5/19/2024, one CNA was no call, no show and was not replaced. Her assignment was split between eight working CNAs during the 11 PM-7 AM shift, each CNA was assigned to 17-19 residents. A review of Resident 99's admission Record indicated the facility re-admitted the resident on 1/31/2024 with diagnoses that included need for assistance with personal care, severe morbid obesity (a disorder that involves having too much body fat, which increases the risk of health problems), hypertension (high blood pressure), and chronic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 include verbiage in the Arbitration Agreement (a contractual agreement to settle disputes out of court using a neutral third party called an arbitrator) that allowed residents the freedom to choose a venue to meet. This deficient practice had the potential for residents who have entered into a binding arbitration agreement to have a say in a convenient meeting place for both parties. Findings: A review of the facility's undated Arbitration Agreement form, indicated there were no residents who entered into a binding arbitration agreement for selection of a venue of choice that was convenient. During an interview on 6/20/2024 at 11:10 AM, the Admissions Coordinator (AC) stated the form did not indicate where the residents would meet. The AC stated having that verbiage would be a good thing to add so the residents who have entered into a binding arbitration agreement would have a say in where the meeting spot would be. During an interview on 6/20/2024 at 11:57 AM, the Business Office Manager (BOM) stated the form did not…

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

Based on interview and record review the facility failed to re-admit one of one sampled resident (Resident 1). Resident 1 who was ready to be discharged from the general acute hospital (GACH 2) on 1/19/24, the facility refused to re-admit Resident 1. This deficient practice resulted in Resident 1 not given his right to return to the facility. Findings: During a review of the admission Record indicated the facility admitted Resident 1 on 9/22/23 with diagnoses including morbid obesity (more than 80 to 100 pounds [lbs., unit of measurement] of their ideal body weight) and chronic obstructive respiratory disease (COPD, group of diseases that cause airflow blockage and breathing related problems). During a review of the Minimum Data Set (MDS, standardized care and screening tool) dated 9/25/23, indicated Resident 1 was cognitively intact (mental process involved in knowing, learning, and understanding). Resident 1 needed two-person physical assistance with eating, personal hygiene and three-person physical assistance with bed mobility, dressing, toilet use and bathing. During a 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.

Based on interview and record review the facility failed to ensure all employees of the facility participated in the facility yearly mandatory abuse training program which included types of abuse, neglect, and the process of reporting. This deficient practice had the potential for employees to not recognize abuse and thereby affect all residents in the facility. Findings: During a review of the facility In-Service Meeting Minutes dated 3/6/23 indicated an in-service was given with the topic of abuse, neglect, and reporting. The sign-in sheet indicated 46 employees attended the in-service. On 7/5/23, another in-service with topic that discussed resident rights and abuse. The sign-in sheet indicated 33 employees attended the in-service. During a concurrent interview and record review of the facilty ' s In-Service sign in sheet dated 7/5/2023, on 8/14/23 at 11:10 am, the director of staff development (DSD) stated mandatory abuse in-service were given every year. DSD stated the mandatory abuse in-service was given on 7/5/23 and all employees of the facility must attend. DSD stated there…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents were free from accident hazards for four of 11 sampled residents (Resident 9, Resident 10, Resident 60, and Resident 110). For Residents 9 and 110, yellow arm band and name plate were not provided to indicate fall risk. For Resident 60, physician's order was not implemented regarding floor mats and bed alarm and Resident 10 kept a smoking lighter at bedside. These deficient practices placed Resident 9, 60, and 110 at increased risk for falls and complications related to fall injuries, and placed Resident 10 at increased risk for injuries related to smoking. Findings: a. A review of Resident 9's admission Record indicated the facility admitted the resident on 1/23/2021 and readmitted on [DATE] with diagnoses including dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning), anxiety disorder (a mental disorder characterized by feelings 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 and record review, the facility failed to provide care in a manner that maintained or enhanced a resident's dignity and respect in full recognition of her individuality for four of 24 sampled residents (Resident 16, 19, 37 and 75) by failing to: -Provide independence and dignity by standing over the resident while assisting resident during dining for Resident 16. -Ensure Resident 19, 37 and 75`s urinary drainage bags (designed to collect urine drained from the bladder via a catheter) were covered with privacy bags. These deficient practices had the potential to negatively affect the residents` psychosocial wellbeing and loss of dignity. Findings: a. A review of the admission record indicated the facility admitted Resident 16 on 6/29/2021 with diagnoses including unspecified dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning), functional quadriplegia (paralysis of all four limbs), and need 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.

Based on interview and record review, the facility failed to ensure residents had specific choices and treatments communicated through an Advance Directives and copies of the Advance Directives (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) maintained in the Resident's clinical record for two of 24 sampled Residents (Residents 55 and 110). This deficient practice had the potential for Residents 55 and 110 not be given the right to accept or refuse specific medical treatments and have those options honored. Findings: a. A review of Resident 55's admission record indicated the facility admitted the resident on 1/15/2021, with dementia (decline in mental ability severe enough to interfere with daily functioning/life), hypertension (HTN - elevated blood pressure), and Type II diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]). A review of Resident 55's recent quarterly Minimum Data Set (MDS- a standardized…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 honor six of six sampled residents (Residents 6, 21, 28, 77, 97 and 111) rights by not providing them with written instructions regarding how to file a formal grievance. This deficient practice had the potential to deny the rights of residents to have complaints and concerns addressed. Findings: a. A review of Resident 6's admission record (face sheet) indicated the facility originally admitted the resident on 12/4/2019 and re-admitted on [DATE] with diagnoses including amyotrophic lateral sclerosis (ALS - a progressive nervous system disease that affects nerve cells in the brain and spinal cord, causing loss of muscle control) and ataxia (abnormal, uncoordinated movements). b. A review of Resident 21's face sheet indicated the facility admitted the resident on 2/23/2021 with diagnoses of deep vein thrombosis (a blood clot formed in one or more of the deep veins in the body), anemia (low number of red blood cells), and bipolar disorder (mental…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 label eternal feeding (a way of delivering nutrition directly to stomach via tube) flush bag with date, time, and initials for one of three sampled residents (Resident 85). This deficient practice had the potential for the resident to develop eternal feeding associated complications such as infection or diarrhea, and lead to serious illness or hospitalization. Findings: A review of Resident 85's admission Record indicated the facility initially admitted Resident 85 on 9/2/2014 and readmitted on [DATE] with diagnoses including gastrostomy (an opening in the stomach made surgically for food), Unspecified dementia without behavioral disturbance (a group of conditions characterized by impairment of at least two brain functions such as memory loss and judgment), major depressive disorder ( a mental health disorder characterized by low mood and loss of pleasure in life) and syncope (temporarily loss of consciousness caused by fall in blood…

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

Based on observation and interview, the facility failed to ensure the daily staffing schedule was posted for 11 consecutive days. This deficient practice had the potential of depriving the residents and their love ones of knowing who was providing direct patient care and services to the their loved ones and violating the resident's rights. Findings: On 12/16/2021, at 9:11 AM, during an inspection and observation of the facility, the daily staffing sheet titled, Census and Direct Care Service Hours Per Patient Day (DHPPD), dated 12/5/2021, was not posted or visible to residents and visitors. During an interview on 12/16/2021, at 9:13 AM, the Director of Staff Development (DSD) stated the current staffing form posted was dated 12/5/2021. The DSD stated DHPPD form on 12/5/2021 was posted by the DSD, then left for vacation, and the assistant was to take on this task. The DSD stated he was not sure if there was a policy and procedure covering posting of the staffing hours. During an interview on 12/17/2021, at 8:32 AM, the Director of Nursing (DON) stated staffing nursing daily staffing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 account for two doses of controlled medications [(illegal or prescription drugs regulated by the Controlled Substances Act (CSA) (Hydrocodone-Acetaminophen - medication use for pain) and (Clonazepam - medication use to treat seizures, panic disorder, and anxiety)] that were missing during inspection of the medication cart 2A. This deficient practice had the potential of resulting to Residents 38 and 313 missing a dose of medication, increase pain and anxiety and a decline in the quality of life for both residents and divergence of medications at the hands of unlicensed staff. Findings: On 12/16/2021, at 11:06 a.m., during Medication Cart 2A, inspection, a discrepancy was observed on the narcotic count form and the amount of medication remaining in the bubble pack (a medication packaging system that contains individual doses of medication per bubble) for the following residents: 1. One dose of Hydrocodone-Acetaminophen (a combination controlled medication used for pain) 5-325 milligram (mg - [unit of measure…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 food items such as three undated frozen Chocolate Cream pies were stored in the freezer without opened or used dates and had no label. This deficient practice had the potential of resulting to the growth of microorganisms that could cause food spoilage and placing the residents at risk for food borne illness. Findings: During the initial tour of the kitchen with the facility`s Dietary Service Supervisor (DSS) on 12/13/2021, at 7:50 a.m., three Chocolate Cream pies were observed in the freezer without opened or used dates and it was not labeled. During an interview with DSS on 12/13/2021, at 8 a.m., DSS stated all food stored in the freezer should be dated with the opened and used dates and labeled. The DSS stated frozen chocolate cream pies were improperly stored in the freezer which could resulted to food bone illness. During an interview on 12/16/2021, at 2:15 p.m., the Director of Nursing (DON) stated all food in the freezer needed to be labeled with dates. A review of facility`s undated policy 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 ensure space requirements of 80 square feet for each resident were met in resident bedrooms which had the potential to result in inadequate space to provide safe nursing care and privacy for one of 87 resident rooms (room [ROOM NUMBER]). Findings: On 12/13/2021, at 8 a.m., during a general inspection of the facility, room [ROOM NUMBER] was observed that measured less than the required 80 square footage per Resident in Resident bedroom. During an interview on 12/13/2021, at 8:47 a.m., the Director of Nursing (DON) stated the facility had a room waiver for the rooms that did not meet the required 80 square footage per resident. A review of the undated Client Accommodations Analysis submitted by the facility indicated the following rooms with their corresponding measurements: Room# No: of Beds Total Square feet/Total Square Ft per Resident 66 3 210.30/70.1 The square footage requirements for a three-bed capacity room is at least 240 square…

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