Mar Vista Country Villa Healthcare & Wellness

Based on observation, interview, and record review the facility failed to investigate a residents complaint allegation and make prompt efforts to resolve the resident ' s grievance for one of three sampled residents, Resident 1. This deficient practice resulted in inadequate available incontinent briefs in Resident 1 ' s size which the facility does not carry/stock. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted Resident 1 on 7/22/2024 with diagnoses including chronic obstructive pulmonary disease(COPD-a chronic/ongoing lung disease causing difficulty in breathing), palliative care (compassionate care for people who are near the end of life provided at the person ' s home or within a health care facility), chronic respiratory failure with hypoxia (the lungs cannot remove enough oxygen from the blood), Morbid Obesity (disorder that involves too much body fat), heart failure (heart does not pump properly), GOUT (severe joint swelling), major depressive disorder (long term low mood), gastro-esophageal reflux disease (heartburn), glaucoma (long…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 keep Hospice (compassionate care for people who are near the end of life provided at the person ' s home or within a health care facility) visit records for one of two sampled residents on Hospice, Resident 1. This deficient practice was not in line with the facility's policy and had the potential for nursing staff not be be informed of any changes recommended by the hospice staff for Resident 1. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted Resident 1 on 7/22/2024 with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), Palliative care (compassionate care for people who are near the end of life provided at the person ' s home or within a health care facility), chronic respiratory failure with hypoxia (the lungs cannot remove enough oxygen from the blood), Morbid Obesity (disorder that involves too much body fat), heart failure (heart does not pump properly), GOUT (severe joint swelling), major…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, for one of three sampled residents (Resident 1), facility failed to: 1. Adequately monitor and supervise Resident 1 to prevent elopement (to leave a health care or educational facility without permission or authorization) according to the facility ' s policy and procedures (P&P), titled, Wandering and Elopement, dated 2/10/2023 2. Ensure alarm system was in place on two of seven exit doors to alert staff if a resident was eloping and or exiting the facility. 3. Ensure the front desk was monitored daily from 7:30 P.M., to 8 A.M., These deficient practices resulted in Resident 1 eloping from the facility on 11/22/2024 at 3:45 A.M., placing the resident at increased risk for extreme weather, medical emergencies, accidents, injuries, hospitalization, and/or death. Findings: During a review of Resident 1's admission Record indicated the facility admitted Resident 1 on 7/5/2024 with diagnoses including metabolic encephalopathy (imbalance in the body ' s chemical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Licensed Vocational Nurse (LVN) 1 failed to replace missing Lidocaine patch (medication applied to skin for pain) for one of three sampled residents, Resident 1 Failed to replace missing Florastor (probiotic supplement for the gut) for one of three sampled residents, Resident 3. These deficient practices caused LVN 1 to borrow the Lidocaine patch from Resident 2 which placed Resident 2 at risk of not having enough Lidocaine patches available when needed and caused Resident 3 to miss a scheduled dose. Findings: A review of Resident 1's admission Record indicated the facility originally admitted this [AGE] year-old female on 9/12/2022 and most recently on 6/3/2024 with diagnoses including Cirrhosis of the liver (chronic liver disease), Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), Essential Hypertension (HTN-high blood pressure), Chronic Obstructive Pulmonary Disease (COPD-a chronic lung disease…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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: 1. Remove expired Glucose Quality Control Solution from medication cart A. 2. Place expired Glucose Quality Control Solution in the correct original package/box. These failures had the potential to cause confusion amongst staff and inaccurate blood sugar results to the residents in the facility. Findings: During a concurrent medication storage observation and interview on [DATE] at 2:13 pm, with License Vocational Nurse 5 (LVN 5), Medication Cart A was observed the Glucose Quality Control Solution box had an open date of [DATE] and a solution bottle was inside the box. The blood glucose solution bottle had a lot number was 030923A and the lot number on the box that the blood glucose solution was stored in, was 100625A. LVN 5 stated the Director of Nursing (DON) instructed staff that Glucose Quality Control Solution expires 28 days after opening the solution the blood glucose solution bottle. During a concurrent record review with LVN 5,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure: 1. Food was stored in a sanitary manner to prevent growth of microorganisms (germs) that could cause food borne illness (food poisoning: any illness resulting from the food spoilage of contaminated food, pathogenic bacteria, viruses, or parasites that contaminate food), as well as toxins for one of 14 residents (Resident 29). 2. Outside food brought in for the residents' stored in the residents' assigned refrigerator was discarded after 48 hours. 3. The residents' refrigertaor remained locked at all times. 4. Dented and expired canned food in the kitchen, are not stored in the same food storage room with and next to canned food ready to use for the residents. These deficient practices placed the residents at increased risk to suffer foodborne illness and complications including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever and unnecessary hospitalization. Findings: A. During a facility tour on 10/29/2024 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 review, the facility failed to ensure the resident's right to be treated with dignity was maintained by not providing a dignity bag cover (a bag used to maintain a person's mobility, dignity, and comfort) for one out 14 sampled residents (Resident 46) This deficient practice has the potential to affect resident's sense of self-worth and self-esteem for Resident 46. Findings: During a review of Resident 46's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included, Dementia (decline in mental ability severe enough to interfere with daily functioning/life), mild cognitive impairment (an early stage of memory loss or other cognitive ability loss), muscle wasting and atrophy (Decrease in size of a body part or tissue), benign prostate hypertrophy (A condition in which the prostate gland (A gland in the male reproductive system) is larger than normal) and obstructive and reflux uropathy (a disorder of the urinary tract 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, interview, and record review, the facility failed to ensure medications were not left with the resident who was not capable of self-administering oral medications for one of 14 sample residents (Resident 29). This deficient practice had the potential to result in unauthorized/unintended person accessing/using the medications with the potential for harm through drug interactions and/or allergic reactions resulting in unnecessary hospitalizations and even death. Findings: During a review of Resident 29's admission record indicated Resident 29 was admitted to the facility on [DATE], with diagnoses that included diabetes mellitus (high sugar in the blood), dysphagia oropharyngeal phase (swallowing problems occurring in the mouth and/or the throat), congestive heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs ), atrial fibrillation (irregular heartbeat), malignant neoplasm of right female breast (breast cancer), hearing loss, and acute…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 that the catheter drainage (a bag that collects urine that drains from a catheter) bag for two of 26 sampled residents (Resident 46 and Resident 50) were placed inside a dignity bag. This deficient practice resulted in violation of Resident 46 and Resident 50's right to have dignity. Findings: Durring a review of Residents 50's admission Record indicated Resident 50 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including Acute Kidney Failure (AKI -a condition where the kidney's suddenly stop working properly, causing waste to build up in the blood), history of falling, and personal history transient ischemic attack (TIA - a temporary blockage of blood flow to the brain). During a review of Resident 50's Minimum Data Set (MDS - a federally mandated resident assessment tool tool) dated 10/8/2024, indicated Resident 2 is cognitive impairment (when a person has trouble remembering,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, and interview, the facility failed to ensure a quiet, comfortable, and homelike environment for two of six sampled residents. Residents 48 and 210. This failure resulted in residents not being able to fall asleep or remain asleep throughout the night. In addition to residents not being able to rest peacefully throughout the day in a homelike environment. Findings: During a review of Resident 210's admission Record indicated Resident 210 was admitted to the facility on [DATE], with diagnoses that included: Hypertension (HTN- High or raised blood pressure, a condition in which the blood vessels have persistently raised pressure causing a high blood pressure reading), and muscle weakness (a lack of physical or muscle strength, throughout the body). During a review of Resident 210's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 9/29/2024, indicated Resident 210's cognition (the mental ability to make decisions of daily living) was intact. The MDs 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 ensure one of four sampled residents' (Resident 27) Preadmission Screening and Resident Review (PASRR - a screening evaluation used to determine whether placement in a long term care facility is appropriate for the resident) Level II (a person-centered evaluation that helps determine placement and specialized services) assessment was completed as required by PASRR Level I (a tool that helps identify possible serious mental illness and/or intellectual/development disability) assessment. This deficient practice placed Resident 27 at risk for not receiving the necessary care and specialized services tailored to Resident 27's needs. Findings: During a review of Resident 27's care plans (a guideline for nurses to help them create and achieve a solid plan of action in the treatment of a resident) did not indicate any individualized rehabilitative treatments and services as required by PASRR Level II for Resident 27's mental health condition.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 one of two residents (Resident 15) by failing to: 1) Identify Resident 15's indwelling catheter (a thin, hollow tube that's inserted into the bladder to drain urine) had yellow cloudy fluid with sediments. 2) Change Resident 15's indwelling catheter bag according to the physician's order and facility's policy and procedures titled Care of Catheter revised on 6/10/2021. These deficient practices placed Resident 15 at increased risk for urinary tract infection (UTI-is an infection in any part of the urinary system). Findings: During a review of Resident 15's face sheet (admission Record- a document containing demographic and diagnostic information) indicated Resident 15 was admitted on [DATE] and was re-admitted on [DATE] with diagnoses including: hypertensive chronic kidney disease (elevated blood pressure), obstructive and reflux uropathy (a urinary tract condition that occurs when urine cannot drain properly causing the urine to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure two of 16 sampled residents (Residents 7 and 2) by failing to ensure: 1. Resident 7 received the correct amouunt of prescribed (ordered) volume of oxygen (a colorless, odorless gas that is essential for life and the proper functioning of the body) as ordered by the physician. This deficient practice resulted in Resident 7 receiving no oxygen per physician order and had the potential to negatively impact the Resident 7's health and well-being. 2. Resident 2 received two liters (unit of measure) of continuous oxygen as oredered by the physician. This deficient practice had the potential to cause complications associated with oxygen therapy. Findings: 1. During a review of Resident 7's admission Record indicated Resident 7 was admitted to the facility on [DATE] with diagnoses that included, encephalopathy (a change in your brain function due to injury or disease), diabetes mellitus (A disease in which the body does not control the…

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

Based on interview and record review, the facility failed to complete performance evaluations annually for one out of five sampled staff. This deficient practice had the potential for residents to not receive the appropriate level of care needed affecting quality of care and potentially leading to resident harm. Findings: During a record review on 10/3/124 at 10:34 am., with the Director of Staff Development (DSD), the employee files of Certified Nursing Assistant 2 (CNA 2) was reviewed. CNA 2's employee file indicated CNA 2 was hired on 10/29/2001. The DSD stated there was no annual performance evaluation for the year 2023 or 2024 available for review in CNA 2's employee file. The DSD stated competencies are important to ensure staff are doing safe practices and are competent. The DSD stated, there is potential harm to residents if performance evaluations are not done. During an interview on 11/1/24 at 1:16 pm., the DON stated performance evaluations are annually and as needed. The DON stated competencies are evaluate to ensure staff have the proper skills to take care of the…

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

Based on observation, interview and record review, the facility failed to observe infection control measure for two of ten sampled residents (Resident 2 and Resident 50) by failing to ensure that:, 1. Resident 2's nasal cannula (a medical device that provides supplemental oxygen to the patient through two prongs that fit into the nostrils) tubing was not touching the floor. 2. Resident 2's oxygen (gas that is essential for life on earth) humidifier (a device that adds moisture to the air to prevent dryness) was changed after seven days per facility's policy. 3. Resident 50's supra pubic catheter (a thin tube that drains urine from the bladder through a small cut made in the lower abdomen [part of the body located between the chest and the hips]) drainage bag was not touching the floor. These deficient practices had the potential to result in infections for Resident 2 and Resident 50. Finding: During a review of Residents 2's admission Record indicated the facility admitted Resident 2 on 7/22/2024 with diagnoses including chronic obstructive respiratory disease (COPD a common lung…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the Assistant Director of Nursing (ADON) and licensed vocation nurse had the skill set to train the registered nursing staff regarding resident care and resident assessment. This deficient practice resulted in or had the potential to result in unsatisfactory training for the registered nursing staff. Findings: During an interview and concurrent record review, on 8/12/2024 at 3:28 p.m., the ADON stated, she has been the ADON since 3/2024. The ADON stated that she does not have a California registered nursing (RN) license, however, she is in the process of transferring her credentials to California. The ADON stated that at this time, she (ADON) is a licensed to practice as a License Vocational Nurse (LVN) pending her registered nursing license in California. The ADON stated that part of her duty as the acting director of nursing is to perform in-service education and training as needed to Certified Nursing Assistants (CNAs), License Vocational Nurses (LVNs), and to Registered Nurses (RNs) working in the facility. The…

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

Based on interview, and record review, the facility failed to ensure the Director of Staff and Development (DSD)had the specific competencies and skill sets necessary to plan, implement, direct, and evaluate the facility ' s educational programs for all employees by failing to acquire the continuing education course required to be a DSD. This deficient practice placed all employees in the facility at risk for not receiving educational provisions that a DSD is generally responsible for. Findings: A review of the facility ' s Director of Staff Development Application Form, indicated the DSD application was approved on 6/8/2023. During an interview with the DSD on 7/29/2024 at 1:37 p.m., the DSD stated, she started performing the DSD duties and responsibilities in 3/2023. The DSD stated, she transitioned from Infection Preventionist Nurse (IPN) to DSD without finishing the required continuing education to perform the task of a DSD. The DSD stated, she did not have any choice because the previous DSD had resigned. The DSD further stated, she had to do all the required paper works…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews, and record review the facility ' s governing body (individuals such as facility owner(s), Chief Executive Officer(s), or other individuals who are legally responsible to establish and implement policies regarding the management and operations of the facility) failed to ensure the Administrator (ADM) who was responsible for managing and overseeing the implementation of policies and procedures reported the change in Administrator as required by State and Federal regulations. This deficient practice had the potential to affect the safety and over all well-being of 56 out of 56 residents and had the potential to result in poor management of the facility. Findings: A review of the Electronic Licensing Management System (ELMS – a State Department of Public Health data system created to manage state licensing-related data which lists the services that are associated to a healthcare facilities) indicated, as of 7/29/2024, the ADM of Skilled Nursing Facility 1 (SNF 1) had a different name from the current ADM of the facility. During an interview with the Assistant…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 one of four sampled residents (Resident 1) by failing to provide a timely lunch tray as indicated on the facility ' s meal schedule. The deficient practice resulted in Resident 1 feeling irritable and uncomfortable due to hunger. Findings: A review of Resident 1 ' s admission Record indicated the resident was originally admitted to the facility on [DATE], with diagnoses that included, type two diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]), chronic kidney disease (CKD-a longstanding disease of the kidneys leading to renal failure), and major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy). 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 interview and record review, the facility failed to check/monitor for resident's safety every two hours around the clock in accordance with facility's policy and procedures, titled, Resident Safety, for one of three sampled residents (Resident 1). Resident 1 was at risk for fall. This deficient practice had the potential not to identify circumstances that pose a risk for the safety and wellbeing of Resident 1. Findings: A review of Resident 1's admission Record indicated the facility admitted initially Resident 1 on 8/4/2023 and was readmitted on [DATE] on with diagnoses including dementia (impaired ability to remember, think or make decisions that interferes with doing everyday activities), hypertension (HTN -elevated blood pressure), and cerebral vascular disease (CVA - a group of conditions that affect blood flow and the blood vessels in the brain). A review of Resident 1's Fall Risk Evaluation completed 2/1/2024, indicated Resident 1 was at risk for fall. A review of Resident 1's Minimum Data Set…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, facility failed to document an acute change of condition in one out of three residents medical Record, Resident 1. This deficient practice led to incomplete documentation of Resident 1 ' s Healthcare Record and had the potential to cause inaccuracies in communication of, and dissemination of vital medical information to Resident 1 ' s healthcare team regarding Resident1 ' s medical condition, leading delay in care and resulting in poor outcomes and even death. Findings: A review of Resident 1 ' s admission record indicated, facility admitted Resident 1 on 12/19/2023 with diagnoses which included cellulitis of left lower limb (an acute infection of the deep tissues of the skin and muscle), cognitive communication deficit (difficulty with thinking and how someone uses language), difficulty walking and unspecified protein-calorie malnutrition (a disorder caused by lack of proper nutrition or an inability to absorb nutrients from food. A review of Resident 1 ' s history and physical (H&P) dated 12/21/2023, indicated, Resident 1 had the capacity to…

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

Based on interview, and record review, the facility failed to provide a minimum of 3.5 nursing hours per patient day (NHPPD) on two (2) out of 14 sampled days and a minimum of 2.4 Certified Nursing Assistant (CNA) NHPPD on six (6) out of 14 sampled days in accordance with the facility's policy and State requirement. This deficient practice had a potential to violate residents' rights in receiving the required nursing hours, placing the residents at risk for inadequate care and safety. Findings: A review of the Census and Direct Care Services Hours Per Patient Day (DHPPD) indicated an actual DPHHD of 2.89 for 1/20/2024 and 3.23 for 1/22/2024 and an actual CNA (Certified Nursing Assistant) DHPPD of 1.89 for 1/20/2024, 2.18 for 1/21/2024, 2.29 for 1/22/2024, 2.26 for 1/24/2024, 2.35 for 1/26/2024, 2.39 for 1/28/2024. During an interview on 2/6/2024 at 1:40 pm, the Director of Staff Development (DSD) stated staffing is a concern in the facility and she confirmed the facility did not meet the requirement of a minimum of 3.5 nursing hours per patient day for a couple of sampled days in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report an allegation of abuse to the State Survey Agency within twenty-four hours for one of three sampled residents (Resident 1). This deficient practice resulted to a delay of an onsite inspection by the State Survey Agency to ensure Resident 1's allegation of abuse was investigated. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses of, but not limited to, Dementia (Impaired ability to remember, think, or make decisions that interfere with doing everyday activities) and repeated falls. A review of the Minimum Data Set (MDS, an assessment and care screening tool), dated August 15,2023, indicated Resident 1 did not have the capacity to understand and make decisions. Resident 1's cognition (thought process) was not intact, and the resident required extensive staff assistance for dressing, mobility, transfer, and toilet use. During a telephone interview on November 17, 2023, 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 interview and record review, the facility failed to provide medical records requested upon written request for one of three sampled residents (Resident 1). This deficient practice violated the rights of Resident 1's representative to obtain copy of the medical records. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included encephalopathy (damage or disease that affects the brain), dementia (loss of cognitive functioning-thinking, remembering, and reasoning) and generalized muscle weakness (lack of physical or muscle strength). A review of Resident 1's Minimum Data Set (MDS-a standardized screening tool) dated 4/22/2022, indicated Resident 1 had impaired cognition (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life) and required limited assistance with bed mobility, transfer, dressing, toilet use and personal hygiene. A review of the Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based one interview and record review, the facility failed to provide necessary care and treatment for urinary tract infection (UTI, an infection in the drainage system for removing urine) due to failure to promptly (with little or no delay) notify a physician and or a nurse practitioner (NP - a nurse with a graduate degree in advanced practice nursing) of a urinalysis (UA - urine test used to check for infection or kidney problems) test results positive for bacteria on [DATE] and failure to place an order for urine culture and sensitivity (C&S -a test to diagnose germs such as bacteria or fungus [yeast or mold] that can cause an infection and checks on the appropriate medicine, such as an antibiotic [medication to treat infection]) for one of three sampled residents (Resident 1) in accordance with the facility ' s policy and procedures (P&P) titled, Laboratory -Critical values (laboratory results that are outside the normal range to a degree that may constitute an immediate health risk to the individual or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide care in a manner that promoted or enhanced residents dignity and respect for four of four sampled residents (Residents 29, 33, 64 and 121) the facility's policy and procedures titled, Catheter-Care of dated 6/10/2021, by failing to: 1. Ensure facility staff practiced and promoted good attitude and behavior towards Residents 29 and 121 in accordance with the facility's policy and procedures titled, Resident Right dated 1/1/2012. 2. Ensure the Resident's urinary collection bag was covered with a privacy bag for Residents 33 and 64 in accordance with the facility's policy and procedures titled, Catheter-Care of dated 6/10/2021. These deficient practices had the potential to cause psychosocial harm and violated the resident's rights to be treated with dignity for Residents 29, 33, 64 and 121. Findings: 1. A review of Resident 29's admission Record indicated Resident 29 was admitted to the facility on [DATE], with diagnosis 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 ensure there was sufficient nursing staff available at all times to provide nursing and related services to meet the resident's needs for seven of 22 sampled residents (Resident 29, 33, 39, 40, 41, 121 and 122) in accordance with the facility's policy and procedures titled, Nursing Department-Staffing, Scheduling & Postings dated 7/2018. This deficient practice resulted in call lights not being answered in a timely manner, residents not receiving assistance from staff with activities of daily living (ADLs-bed mobility, walk in room/corridor, transfer, toilet use, bathing, personal hygiene, etc.) in a timely manner and had the potential to affect the quality of life, quality of care and treatment of residents. Findings: 1. A review of Resident 29's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses including muscle wasting and atrophy (the decrease in size and wasting of muscle tissue), type 2 diabetes (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 establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment for 3 of 3 sampled residents (Residents 3, 121 and 172) in accordance with the facility's policies and procedures titled, Resident Isolation-Initiating Transmission Based-Precautions dated 4/22/2016, and Cleaning & Disinfection of Resident Care Equipment dated 01/01/2012, by failing to: 1. Ensure a multi-use pill cutter was cleaned before and after use when cutting medication tablet that require a half dose for Resident 3 and a multi-use blood pressure cuff was sanitized between use for Resident 3 and Resident 172. 2. Ensure Resident 121, who tested positive for ESBL (Extended spectrum beta-lactamase bacteria that can't be killed by many of the antibiotics treat infections. ESBL infections are spread by direct contact with an infected person's bodily fluids), was placed on transmission-based precautions (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 transmit to Medicare and Medicaid Services (a Federal agency that administers the nation's major healthcare programs, including Medicare and Medicaid) within 14 days, the quarter and annual completed Minimum Data Set (MDS- standardized assessment and care screening tool) Assessments for five of five sampled residents (Residents 9, 11, 41, 48 and 51). This deficient practice resulted in more than 14 days delay of transmission to Medicare and Medicaid Services, the clinical assessment for Residents 9, 11, 41, 48 and 51. Findings: A review of Resident 41's admission Record indicated Resident 41 was admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses including muscle wasting, and atrophy (partial or complete wasting away of a part of the body), acute respiratory failure with hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions), obesity (excessive body fat), type 2 diabetes( body's inability to process…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 through with the Preadmission Screening and Resident Review (PASRR) recommendation to obtain a PASRR level II evaluation for two of three sampled residents (Resident 21 and 28) in accordance with the facility's policy and procedures titled Pre-admission Screening Level II Resident Review revised 9/2017. This deficient practice had the potential to result in inappropriate placement and unidentified specialized services for Residents 21 and 28. Findings: A review of Resident 21's admission Record indicated the facility initially admitted Resident 1 on 7/15/2022 and readmitted Resident 1 on 12/29/2022 with diagnoses including dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough) psychosis (a collection of symptoms that affect the mind, where there has been some loss of contact with reality) and altered mental status (change in mental function). A review of Resident 21's Minimum Data…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 formulate care plan with measurable objectives, timeframes, and interventions to meet the needs of four of 22 sampled residents (Residents 47, 48, 64 and 221) in accordance with the facility's policy and procedure titled, Comprehensive Person-Centered Care Planning dated 11/2018, The fcaility was aware that: a) Resident 47 did not have teeth. b) Resident 48 had diagnosis of post-traumatic stress syndrome (PTSD- a disorder in which a person has difficulty recovering after experiencing or witnessing a tarrying event). c) Resident 64 was on oxygen (O2- colorless, odorless, tasteless gas necessaru to sustain life) therapy. d) Resident 221 had bowel (gut) and bladder (balloon like organ that collects urine in the body) concerns. These deficient practices had the potential to negatively affect the delivery of necessary and required care and services to Residents 47, 48, 64 and 221. Findings: a) A review of Resident 48's admission Record indicated Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide services to maintain and/or improve resident's (Resident 121) bladder function when a urinal was not offered per the resident's request in accordance with the facility's policy and procedures titled, Bowel and Bladder Training/Toileting Program dated 8/21/2023. The deficient practice resulted in Resident 121 being unable to access the urinal and having to void in bed. Findings: A review of Resident 121's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses including sepsis ( a life threatening complication of an infection), type 2 diabetes (the body's inability to process sugar), obesity (a disorder involving excessive body fat), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), hypertension (elevated blood pressure), renal insufficiency ( a condition in which the kidneys lose the ability to remove waste and balance fluids) , septicemia (a 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 observation and interview the facility failed to maintain a sanitary condition in handling dishes to prevent food contamination and the growth of disease in accordance with facility's policy and procedures titled Dietary Department -Infection Control for Dietary Employees, revised 11/9/2016,when: 1. Dietary Supervisor (DS) handled clean dishes from the dishwasher with street clothes on without an apron. 2. Dietary Aid (DA) handled dirty dishes and then proceeded to handing clean dishes from the dishwasher without observing hand hygiene and putting on a clean apron. This deficient practice had the potential to place 69 of 69 residents, who consumed food prepared by the facility kitchen, at risk for food borne illness. Findings: During an observation on 10/5/2023 at 8:10 A.M., Dietary Supervisor (DS) was observed removing clean dishes from the dishwasher with her street clothes and without an apron. During an interview on 10/5/2023 at 8:15 A.M., the DS stated I need to have a clean apron on. The DS further stated the apron is to prevent contamination that may lead to sickness…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 pharmaceutical services to meet the needs of one of four sampled residents (Resident 3) by failing to ensure Resident 3 ' s medication was dispensed as written. This deficient practice had the potential for Resident 3 to receive a lesser dose than prescribed by the physician. Findings: A review of the admission Record (Face Sheet) indicated Resident 3 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus (a disease of inadequate control of blood levels of glucose), pulmonary embolism (a condition in which one or more arteries in the lungs become blocked by a blood clot ), morbid obesity due to excess calories (a chronic condition in which a person has a body mass index of 40 or higher), hyperlipidemia (high levels of fat particles called lipids in the blood), absence of right and left leg below knee, and long term use of anticoagulants (drugs that are commonly known as blood thinners and helps prevent blood…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow its policy on Medication Administration on 2 of 4 sampled residents (Resident 2 and 3) as evidenced by: 1. Failing to ensure Resident 2 ' s pain medication (oxycodone - a controlled narcotic analgesic medication that treats moderate to severe pain) was available for administration. 2. Failing to ensure that the administration of Resident 2 ' s oxycodone was documented in the medication administration record (MAR) 3. Failing to administer enoxaparin (an anticoagulant; a medication used to help prevent the formation of blood clots) as ordered by the physician and as indicated in the care plan for Resident 3. 4. Failing to ensure Resident 3 ' s enoxaparin was transcribed with the correct route to the MAR. This deficient practice had the potential for harm to the residents due to inadequate pain management for Resident 2, inaccurate record of medication use for Resident 2 and Resident 3 and risk for blood clots for Resident 3. Findings: 1. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the nursing staff failed to ensure call lights were within reach for eight of 40 sampled residents (Residents 10, 11, 12, 14, 18, 22, 56 and 114). These deficient practices had the potential to result in the residents not being able to summon staff for assistance for care and services as needed, which could lead to accidents such as falls with injuries. Findings: A. A review of Resident 10's admission Record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included end stage renal disease (disease where the kidney is unable to filter water and excess fluid from the blood), diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]) and hypothyroidism (a condition in which your thyroid gland does not produce enough of certain crucial hormones). A review of Resident 10's Minimum Data Set (MDS-a standardized assessment and care screening tool), dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the appropriate setting of the low air loss mattress (LAL-a mattress designed to prevent and treat pressure wounds) was properly set up for five of five sampled residents (Residents 4, 7, 21, 28, and 112) according to settings that were consistent with manufacturer's guide and individualized care plan for six of six sampled residents. These deficient practices placed Residents 4, 7, 21, 28, and 112 at risk to develop a pressure injury (bed sore-localized damage to the skin and or underlying soft tissue over bony prominence) or at risk of poor wound healing of the current pressure ulcer. Findings: A. A review of Resident 4's admission Record indicated Resident 4 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnosis including pressure ulcer on left and right buttock (an injury that breaks down the skin and underlying tissue), muscle wasting and atrophy (characterized by a significant shortening 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 there was sufficient nursing staff available at all times to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physically, mental and psychosocial well-being for six of 40 sampled residents (Residents 10, 45, 47, 59, 60 and 114). This deficient practice resulted in call lights not being answered in a timely manner; residents not receiving assistance from staff with activities of daily living (ADLs-bed mobility, walk in room/ corridor, transfer, toilet use, bathing, personal hygiene, etc.) in a timely manner and had the potential to affect the quality of life and treatment for Residents 10, 45, 47, 59, 60 and 114. Findings: A. A review of Resident 45's admission Record indicated Resident 45 was admitted to the facility on [DATE], with diagnosis including second degree burn on the right forearm, diabetes mellitus (DM-a chronic condition that affects the way 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.

Based on observation, interview and record review, the facility failed to ensure staffing information posted was correct, updated with the actual hours daily per facility policy on three of three sampled days (10/3/2022, 10/4/2022 and 10/5/2022). As a result, the accurate and final Direct Care Services Hours Per Patient Day (DHPPD) was not readily accessible to the residents and visitors per facility policy. Findings: During an observation on 10/3/2022 at 7:54 a.m., nurse staffing information posted was dated 9/30/2022, with no actual DHPPD hours and missing designee signature. During an observation on 10/3/2022 at 12:17 p.m., nurse staffing information posted was dated 10/3/2022, with no actual DHPPD hours and missing designee signature. During an observation on 10/3/2022 at 5:17 p.m., nurse staffing information posted was dated 10/3/2022, with no actual DHPPD hours and missing designee signature. During an observation on 10/4/2022 at 8:13 a.m., nurse staffing information posted was dated 10/4/2022, with no actual DHPPD hours and missing designee signature. During an observation on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the correct type of insulin (used to control the level of the sugar-glucose in the blood) was administered, according to a sliding scale (a dosing regimen that prescribes how much insulin to give for different levels of blood sugar) as ordered, to one of five sampled residents (Resident 23) This deficient practice had placed the resident at risk of inadequate blood sugar management, which could cause hypoglycemia (low blood sugar), a potential to lead to other health complications including coma and death. Findings: A review of Resident 23's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses including Type II diabetes (a chronic condition that affects the way the body processes blood sugar [glucose]), ischemic cardiomyopathy (a disease of the heart muscle that makes it harder for the heart to pump blood to the rest of the body), and sepsis (a life-threatening condition that arises when 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: A. Ensure that two unopened insulin (used to lower blood sugar) medications were stored in the refrigerator, in two of three medication carts affecting Resident 9 and 15. B. Remove five expired Jevity 1.2 Cal (used to provide complete, balanced nutrition for tube feeding residents) cartons from one of three medication carts affecting all residents receiving this nutritional supplement. C. Ensure medication cart was locked at all times per facility policy. These deficient practices resulted in unsafe storage of the medications and had the potential to result in medication errors leading to health complications including hospitalization or death. Findings: A. During a concurrent observation and interview on 10/4/2022, at 8:32 a.m. with Licensed Vocational Nurse 1 (LVN 1), the following medication was found: An unopened Insulin Lispro 100 unit (u) /milliliter (ml- unit of measure) vial stored in room temperature in Medication Cart B for Resident 15. LVN 1 stated unopened insulin medication should be stored in…

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

Based on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service when: 1. The refrigerator log was not being fully checked by kitchen staff. 2. The salt was stored in a container with the incorrect open and use-by date. These deficient practices may have the potential to cause food borne illness to residents who received food from the facility's kitchen. Findings: 1. During a concurrent observation and interview on 10/3/2022, at 8:12 a.m., with [NAME] 2 in the facility kitchen, the refrigerator temperature log for refrigerator #1 was missing an evening check on 10/2/2022. [NAME] 2 stated that refrigerator log should be done twice daily and the cook from the evening might have forgotten to do it. During an interview on 10/3/2022, at 5:02 p.m., with Regional Registered Dietician (RD), the RD was aware that the 10/2/22 evening temperature log was not checked and stated, it was an oversight and will conduct an in-service with staff about maintaining the refrigerator log in all shifts. 2. During a concurrent…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain an infection control and prevention program by failing to: 1. Ensure 1 of 1 sampled facility staff (Licensed Vocational Nurse 3-LVN 3) wore full personal protective equipment (PPE-mask, gown, eye protection, gloves) before entering Resident 26 and 32's room in yellow zone (area in the facility for residents under investigation for possible COVID-19 infection) per facility policy. 2. Ensure Resident 7's oxygen concentrator (portable medical device that provides oxygen) was maintained clean and in sanitary condition by not leaving any uncleaned towels, plastic bag and opened shampoo bottles on top. These deficient practices had the potential to result in the spread of disease and infection to residents and staff. Findings: 1. A review of Resident 26's admission Record indicated Resident 26 was originally admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses including encephalopathy (a disease in which 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 provide care in a manner that promoted or enhanced resident's dignity and respect for two of two sampled residents (Residents 1 and 119) by failing to ensure facility staff promote good attitude and behavior toward the residents per facility's policy. This deficient practice had the potential to cause psychosocial harm to the residents and can violate resident's right to be treated with dignity. Findings: a. A review of Resident 1's admission Record indicated the Resident 1 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis (MS- a disabling disease of the brain and spinal cord [ central nervous system]), asthma (respiratory condition marked by spasms in the bronchi of the lungs, causing difficulty in breathing) and osteoarthritis (inflammation of the bone). A review of Resident 1's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool), dated 7/5/2022, indicated Resident 1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents' medical records were updated to indicate that 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) were discussed and written information were provided to the residents and/or responsible parties for one of one sampled resident (Resident 26). This deficient practice violated the residents' and/or the representatives' right to be fully informed of the option to formulate advanced directives and had the potential to cause conflict with health care wishes for Resident 26. Findings: A review of Resident 26's admission Record indicated the facility originally admitted Resident 26 on 4/18/2022 and was re-admitted on [DATE] with diagnoses including encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition-such as viral infection or toxins in the blood), protein…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 protection of resident's medical record for one of one sampled resident (Resident 47). This deficient practice had the potential to violate Resident 47's right to privacy and confidentiality. Findings: A review of Resident 47's admission Record indicated the facility originally admitted Resident 47 on 2/3/2022 and was re-admitted on [DATE], with diagnoses including paraplegia (paralysis of the legs and lower body), osteomyelitis (bone infection) and DM (DM-a chronic condition that affects the way the body processes blood sugar [glucose]). A review of Resident 47's Minimum Data Set (MDS-a standardized assessment and care screening tool), dated 9/5/2022, indicated Resident 47 was cognitively (thought processes) intact for daily decision making and required limited assistance on staff for activities of daily living (ADLs- transfers, locomotion on and off the unit, dressing and toilet use). A review of Resident 47's California Standard…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 meet professional standards of quality for one of 19 sampled residents (Resident 24) by failing to ensure that Resident 24's medication was not left unattended at the bedside. This deficient practice had the potential of placing Resident 24 at risk of receiving the wrong medications and for another resident to consume the medications not met for them. Findings: A review of Resident 24's admission Record indicated Resident 24 was admitted to the facility on [DATE], with diagnoses including anemia (a condition which the blood does not have enough health red blood cells), muscle wasting and atrophy (characterized by a significant shortening of the muscle fibers and a loss of overall muscle mass) and dysphagia (difficulty swallowing food or liquid). A review of Resident 24's Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 7/21/2022, indicated Resident 24's cognitive (mental action or process of acquiring…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure resident receives appropriate treatment and services to increase, prevent, or maintain the range of motion (ROM- the extent of movement of a joint) mobility for one of 19 sampled resident (Resident 1). This deficient practice had the potential to place Resident 1 at risk for further ROM decline and contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). Findings: A review of Resident 1's admission Record indicated the Resident 1 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis (MS- a disabling disease of the brain and spinal cord [central nervous system]), asthma (respiratory condition marked by spasms in the bronchi of the lungs, causing difficulty in breathing), osteoarthritis (inflammation of the bone) and left leg contracture. A review of Resident 1's Minimum Data Set (MDS - a comprehensive 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 observation, interview and record review, the facility failed to ensure residents received adequate supervision while smoking cigarettes, and cigarettes and or medication were not left unattended at the bedside for two of 40 sampled residents (Resident 24 and 54). These deficient practices increased the risk for injuries, accidents, fires in the facility, and increased the risk for medication diversion and medication ingestion by unintended person. Findings: a. A review of Resident 24's admission Record indicated the facility admitted Resident 24 on 10/23/2021, with diagnoses including anemia (a condition which the blood does not have enough health red blood cells), muscle wasting and atrophy (characterized by a significant shortening of the muscle fibers and a loss of overall muscle mass) and dysphagia (difficulty swallowing food or liquid). A review of Resident 24's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 7/21/2022, indicated Resident 24's cognitive (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.