Olympia Convalescent Hospital

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement its Unusual Occurrence Reporting policy for one of two sampled residents (Resident 1) by failing to report Resident 1's injury of unknown cause occurrence to the State Survey Agency (SSA) within 24 hours. Resident 1, who was confused sustained multiple left rib fractures and was unable to report how the injury occurred. This deficient practice had the potential to result in a delay of an onsite inspection by the SSA to ensure the residents' injury and accidents were investigated and had the potential to place residents at further risk for injuries. Findings: A review of the admission Record indicated Resident 1 was originally admitted to the facility on [DATE], and readmitted on [DATE] with diagnosis including Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities), dementia (a progressive state of decline in mental abilities), glaucoma (an eye disease that occurs when fluid builds up in the eye, damaging…

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 protect one of three sampled residents' (Resident 1), right to be free from physical abuse by Resident 2. Resident 2, had a history of attempting to strike other residents and staff. As a result, on 11/1/2024, Resident 2 hit Resident 1 several times on the left side of his the face/chin which resulted in bleeding. Resident 1's left chin was treated by staff for 13 days. Resident 2 was transferred to a general acute care hospital (GACH) on 11/1/2024 by non-emergency transportation for evaluation and treatment. Findings: During a review of Resident 1's admission Record, the admission record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), atrial fibrillation (an irregular heartbeat that can lead to blood clots and increases the risk of stroke and other heart complications) and stroke. During 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 observation, interview and record review, the facility failed to prevent elopement (when a resident leaves the facility unsupervised and unnoticed by staff) for one of three sampled residents (Resident 1). For Resident 1, who was assessed as high risk for elopement and had a wander guard bracelet (a monitoring device that would emit an audible alarm to warn staff when a resident leaves the facility), the facility failed to: 1. Respond immediately when the wander guard alarm was triggered and emitted an audible alarm when Resident 1 walked out the front door of the facility on 5/19/24 at 11:53 a.m. and out to the community. 2. Provide Resident 1 with adequate supervision. These deficient practices resulted in Resident 1 eloping from the facility on 5/19/24 at 11:53 a.m. and placed Resident 1 at risk for injuries and harm while out in the community. Findings: A review of the admission Record indicated the facility admitted Resident 1 on 1/5/24 and re-admitted the resident on 2/28/24, with the diagnoses including dementia (loss of the ability for the brain to function 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 observation, interview, and record review, the facility failed to ensure seven sampled residents (Residents 28, 61, 3, and 7) were treated with dignity and respect, and staff did not refer to the residents as feeders. This deficient practice had the potential for Residents 28, 61, 3, and 7 to suffer humiliation, embarrassment, shame, and lowered self-esteem when referred to a feeders. Findings: A review of Resident 28's admission Record indicated the resident was admitted to the facility on [DATE], with medical diagnoses that included hemiplegia (an inability to move one side of the body), hemiparesis (an inability to move the arm, leg and sometimes face on one side of the body) following a cerebral infarction (lack of blood flow resulting in severe damage to part of the brain) affecting the left non-dominant side of the body, and Type 2 Diabetes Mellitus (A condition that happens because of a problem in the way the body regulates and uses sugar as a fuel). A review of Resident 28'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, the facility failed to: 1. Keep usage record of the emergency medication supplies. 2. Keep record of inventory discrepancies for their automated dispensing cabinet (STATSAFE, a computer-controlled system that stores and dispense medications). 3. Ensure the administration of a controlled substance was documented in the resident's electronic medication administration record for one of 32 sampled residents (Resident 70). These deficient practices had the potentials of medication errors and/or drug diversions. Findings: A review of Resident 70's physician order, dated 4/19/2024 at 4:29 PM, indicated to give Ativan 1 mg 1 tablet by mouth every 8 hours as needed (PRN) for anxiety disorder. A concurrent review of STATSAFE activity report from 4/21/24 to 4/30/24, generated by the pharmacy, indicated the discrepancy occurred on 4/23/24 at 10:51 AM. The report also indicated DON resolved the discrepancy on 4/26/2024 at 1:32 PM. During an inspection of the medication (med) room on 4/30/24 at 2:05 p.m., with the licensed vocational nurse 5 (LVN 5), 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.

Based on observation, interview, and record review, the facility failed to provide effective dietetic service oversight when the dietary manager did not meet the state and federal requirements for the position and the registered dietitian worked on a consulting basis, as evidenced by lapses in the delivery of food services associated with staff competency (cross reference F802), safe and sanitary food storage and food preparation practices (F812) and therapeutic diet texture accuracy, wrong portion sizes and not following the menu (cross reference F805 and F803). This deficient practice could result in compromising the safety and nutritional status of residents through the potential for cross contamination, decreased nutrient intake and choking or aspiration risk. Findings: During the annual recertification survey from 4/29/2024 to 5/2/2024, multiple issues surrounding the delivery of dietetic services were unmet in relation to: 1.The oversight of food safety, sanitation, and storage of food in the kitchen (cross reference F812) 2.The evaluation of dietary staff competency (cross…

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 kitchen staff were routinely trained and evaluated for competency related to their duties when: 1.Dishwasher 1 (DW1) and Dietary Aide 1 (DA1) did not know the proper sanitizer test strip to use for dish machine sanitizer. Both DW1 and DA1 were testing the dish machine sanitizer using the wrong test strip. 2.Cook 1 did not follow the menu and the standardized recipes when preparing pureed diet and was not evaluated for competency related to pureed diet preparation. 3. Dietary Manager (DM) did not have documented routine staff competency evaluation to ensure all kitchen staff were competent in their job-related duties. These deficient practices had the potential: 1. To result in unsafe and unsanitary food production that could place 88 out of 92 residents in the facility who received food at risk for food borne illness. 2. Not following the menu and recipe for the pureed diet had the potential for decreased meal satisfaction, decreased nutrient intake and risk for choking for 15 residents who receive 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 ensure the standardized recipes and portion sizes for lunch menu was followed on 4/29/24 when: 1.facility failed to ensure staff followed food production recipes for the puree diet (food that is blended to a pudding consistency, no chewing required) during lunch preparation and tray line observation. 15 Residents on puree diet did not receive the puree pork and kimchi stew and the zucchini, they received pureed tofu and pureed peas. 2.Cook used small scoop size to serve pork and kimchi for residents on regular and mechanical soft diet. 24 Residents on regular diet and 18 residents on mechanical soft diet received 3oz of pork and kimchi stew instead of 6 oz per menu and 15 residents on puree diet received 4 oz of pureed tofu instead of 6 ounces. This deficient practice had the potential to result in meal dissatisfaction, decreased nutritional intake and weight loss in residents who received food from the kitchen. Findings: According to the facility lunch menu for regular and mechanical soft diet on 4/29/2024,…

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: 1. 12 residents on finely chopped diet (modified diet with food prepared approximately 1/8-1/4-inch inches) and 14 residents on minced diet (modified diet with food prepared approximately 1/8-1/4-inch inches) received meat texture in the forms that meet their needs when cook served regular diet with inconsistent size and large size of meat instead of chopped and minced per resident diet orders. 2. 15 residents on pureed diet received the incorrect pureed diet texture (foods that do not require chewing and are easily swallowed. Food should be smooth .consistency of pudding) when the [NAME] served thin and soupy rice instead of pureed rice that was homogenous, cohesive and had a pudding like consistency. These deficient practice had the potential to result in decreased intake related to inconsistent and large size meats, meal dissatisfaction and increased choking and aspiration risk. Findings: According to the facility lunch menu for minced (finely chopped) diet on 4/29/24, the following items will be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and preparation practices when: 1.One small container of previously prepared rice and one small container of previously prepared minced meat with a use by date of 4/28/24 expired were stored in the reach in refrigerator. One gallon milk with open date 4/26/24 exceeding storage period for open container of milk was stored in the reach in refrigerator. Nutritional supplement (milk based high protein and calorie drinks) labeled store frozen with manufactures instruction to use within 14 days of thawing, were not monitored for the date they were thawed to ensure expired shakes were discarded after this time frame. One box containing 75 individual containers of strawberry flavored nutrition supplements with open delivery date of 4/16/24 and two boxes of sugar free vanilla flavored nutrition supplements with delivery dates of 3/29/24 were stored in the refrigerator thawed and no expiration date. This…

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 monitor signs (something found during a physical exam or as a result of a laboratory or imaging test that shows that a person may have a condition or disease) and symptoms (Something that a person feels or experiences that may indicate that they have a disease or condition) of urinary tract infection (UTI; an infection involving any part of the urinary system, including urethra, bladder, and kidney) and indwelling catheter (a flexible tube inserted in the bladder to drain out urine) was irrigated as per treatment administration record (TAR) for one of 6 residents (Resident 48). This deficient practice resulted in Resident 48 developing cloudy urine with sediment and a potential UTI and blocked indwelling catheter. Findings: A review of Resident 48's Face Sheet indicated the Resident 48 was admitted to the facility on [DATE], with diagnoses that included bladder neck obstruction, UTI, and Benign Prostatic Hyperplasia (BPH; non-cancerous…

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 one of one sampled resident (Resident 64), had a documented date for the Isosource bag (a form of liquid nutrition) hung for the gastronomy tube feeding (G-tube, a tube that is inserted through the belly to deliver nutrition, medication, and or hydration directly to the stomach). The failure has the potential to cause the bag to be infused past the manufacture's 48-hour guidelines resulting in potential growth of food borne illness. Findings: A review of Resident 64's Medical Data Set (MDS - a standardized assessment and care screening tool), dated 09/02/2023, indicates swallowing disorder and weight loss of 5% or more in the last month or loss of 10% or more in last six months. During an observation on 4/29/2024 at 08:01 a.m., in Resident 64's room, Resident 64's Isosource bag was not dated to indicate the open date. During an observation on 4/29/24 at 10:57 a.m., in Resident's 64's room, Resident 64's Isosource bag still not dated to indicate the open date. During a concurrent observation and…

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

Based on interview and record review, the facility failed to ensure one of one sampled resident (Resident 64), range of motion was documented. This deficient practice had the potential to negatively reflect Resident 64's range of motion treatment. Findings: A review of Resident 64's Medical Data Set (MDS - a standardized assessment and care screening tool), dated 09/02/2023, indicated the resident needed some help with self-care, indoor mobility (ambulation), and functional cognition. During a concurrent interview and record review on 5/01/24 at 08:45 AM with Director of Staff Development (DSD), Resident 64's Administrative Record Restorative Nursing, dated April 2024 was reviewed. The Administrative Restorative Nursing Assistant Log did not indicate Resident 64 received range of motion treatment on 4/2, 4/3, 4/4, 4/5, 4/11, 4/13, 4/20, 4/24, and 4/27. DSD stated she could not explain why Resident 64 did not receive range of motion treatment on those dates. During a concurrent interview and record review on 5/01/24 at 09:00 AM with Restorative Nursing Assistant (RNA) 1 and 2,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement their policy titled, Hand Hygiene, by failing to ensure: 1. Certified Nursing Assistant 1 (CNA 1) performed hand hygiene between care of Resident 25 and Resident 81. 2. Licensed Vocational Nurse 1 (LVN 1) performed hand hygiene between resident's room's 142 and 143. 3. A urinal was not found in Resident 82's room without being labeled. A review of Resident 25's admission Record indicated Resident 25 was admitted to the facility on [DATE] with medical diagnoses that includes dementia (impaired ability to remember, think or make decisions that interferes with doing everyday activities), depression (a constant feeling of sadness and loss of interest which stops you from doing normal activities), and hypertension (HTN -blood pumping with more force than normal through your arteries). A review of Resident 25's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 1/25/2024, indicated Resident 25 had…

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 the call light for one of six sampled resident's (Resident 28) was within reach. This failure had the potential to result in Resident 28's not receiving assistance when needed from the facility staff. Findings: During review of Resident 28's admission record, it indicated the resident was admitted in the facility on 12/8/23, with the diagnoses including but not limited to hemiplegia (an inability to move one side of body) and hemiparesis (an inability to move the arm, leg and sometimes face on one side of the body) following a cerebral infarction (lack of blood flow resulting in severe damage to some of the brain tissue) affecting left non-dominant side. During a review of Resident 28's Minimum Data Set (MDS - a standardized comprehensive assessment and care screening tool), dated 3/15/24, indicated Resident 28's cognition (the mental ability to make decisions of daily living) was severely impaired. Resident 28 required moderate to maximal assistance from staff for activities of daily living (ADLs -…

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 the facility's cook (COOK 1) was competent on hand hygiene in accordance with facility's policy and procedures titled Dietary General revised 10/2022. This deficient practice resulted COOK 1 to not wear gloves while preparing gravy and with the potential to lead to food borne illnesses. Findings: A review of the facility ' s Inservice Training Report sign in sheets titled Proper Hand Washing dated 5/17/2023 and 1/12/2024, did not include the signature for COOK 1. On 1/10/2024 The California Department of Public Health (CDPH) received a facility reported incident on an outbreak of an unknown possible gastrointestinal (referring collectively to the stomach and small and large intestines) virus that affected 10 residents causing nausea, vomiting and diarrhea. During an observation in the kitchen on 1/22/2024 at 11:15 a.m., COOK 1 was walking from the dry storage area holding a metal scooper full of flour. COOK 1 then walked to a pot of boiling water on top of a stove and held the scooper over the pot. COOK…

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's cook (COOK 1) failed to wear gloves while pouring flour into a pot of boiling water to make gravy. This deficient practice had the potential to lead to food borne illnesses. Findings: On 1/10/2024 The California Department of Public Health (CDPH) received a facility reported incident on an outbreak of an unknown possible gastrointestinal (referring collectively to the stomach and small and large intestines) virus that affected 10 residents causing nausea, vomiting and diarrhea. During an observation in the kitchen on 1/22/2024 at 11:15 a.m., COOK 1 was walking from the dry storage area holding a metal scooper full of flour. COOK 1 then walked to a pot of boiling water on top of a stove and held the scooper over the pot. COOK 1 grabbed a whisk with the other hand and began to pour flour into the pot of boiling water using the whisk while not wearing gloves. COOK 1 did not perform hand hygiene. During an interview on 1/22/2024 at 11:16 a.m. the dietary supervisor (DS) stated COOK 1 should wear gloves while placing/adding…

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

Based on observations, 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 appoint an administrator responsible for managing and overseeing the implementation of policies and procedures. This deficient practice had the potential to affect the safety and over all well-being of the residents and could result in poor management of the facility. Findings: During an interview with Certified Nursing Assistant 1 (CNA 1) on 10/24/2023 at 2:23 p.m., CNA 1 stated, she doesn ' t know the name of the Administrator (ADM) in the building but had seen him around in the facility. During an interview with Licensed Vocational Nurse 1 (LVN 1) on 10/24/2023 at 2:27 p.m., LVN 1 stated, there ' s an acting ADM in the facility who comes in at least three to four times a week. During an interview with Director of Nursing (DON) on 10/24/2023 at 2:15 p.m., DON stated, they do 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 observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five percent (%). Three medication errors out of 25 total opportunities contributed to an overall medication error rate of 12% affecting three of seven residents observed for medication administration (Residents 16, 23 and 79.) The deficient practices of failing to administer medications in accordance with the attending physician's orders increased the risk that Residents 16, 23, and 79 may have experienced health complications related to incorrect medication administration which could have negatively impacted their health and well-being. Findings: During an observation on 12/7/21 at 9:08 AM, the Licensed Vocational Nurse (LVN 1) was observed administering one tablet of chewable aspirin (a medication used to prevent blood clots) 81 milligrams (mg - a unit of measure for mass) to Resident 16. During a review of Resident 16's Order Summary Report (a document containing all currently active medication orders), dated 12/8/21, the report indicated Resident 16's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure education regarding the benefits and potential side effects of the immunization was provided to the residents or resident representatives before receiving the influenza vaccine (vaccine that protect against infection by influenza viruses) for three out of three sampled residents (Residents 5, 24, 42). This deficient practice had the potential of preventing the residents or resident representatives from making informed decisions regarding a medical treatment and the risk of acquiring, transmitting, or experiencing complications from influenza. Findings: A review of Resident 5's admission record, indicated the resident was admitted to the facility on [DATE] with diagnoses that included but were not limited to diabetes mellitus (high blood sugar), dementia (loss of memory). A review of Resident 5's Flu vaccination consent form dated 9/13/2021, indicated a signature by the responsible party consented for the resident to receive the flu vaccine. This…

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 thoroughly coordinate assessment with the Preadmission Screening and Resident Review (PASRR) and failed to incorporating the recommendation from the PASRR level II evaluation for one of three sampled residents (Resident 49). This deficient practice had the potential of resulting to in appropriate placement and unidentified specialized services for Resident 49. Findings: A review of Resident 49's admission record indicated the resident was re-admitted to the facility on [DATE], with diagnoses that included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), dementia (a group of thinking and social symptoms that interferes with daily functioning). A review of Resident 49's PASRR dated 9/21/2020, indicated the need for Level II PASRR evaluation. A review of Resident 49's Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 7/9/2021, indicated Resident 49's cognitive…

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 notify the physician and document a change in condition, for Resident 67 who was very weak and with oxygen (colorless air) saturation rate of 88 percent in room air for one of two sampled residents (Resident 67). This deficient practice had the potential to result in oxygen depletion confusion and agitation. Findings: A review of Resident 67s admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses that included but were not limited to dementia (loss of memory), hypertension (elevated blood pressure), polyneuropathy (malfunction of many peripheral nerves), and cerebral infarction (damage to the tissues in the brain). A review of Resident 67's Minimum Data Set (a standardized assessment and care screening tool) dated 11/10/2021, indicated the resident's cognitive skills of daily decision making were severely impaired and required extensive assistance from staff with activities of daily living. A review of 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 have floor mats (a safety feature placed on the floor along the side of the bed) and a bed alarm (devices that contain sensors that trigger an alarm or warning light when they detect a change in pressure) fin place and to implement it's own fall policy and procedures for a resident who had a fall and sustained a rib fracture (broken bone) for one of one sampled resident (Resident 84). These failures had the potential of placing Resident 84 at risk for further falls with injuries. Findings: A review of Resident 84's admission Record (Face Sheet), indicated the facility admitted the resident on 11/22/2021, with diagnoses including right wrist and hand fracture (broken bone) and history of falling. A review of Resident 84's History & Physical (H&P) exam form, completed by the attending physician on 11/22/2021, indicated the resident had a history of falls and required rehabilitation evaluation. The H&P further indicated Resident 84 had…

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 identify and monitor specific behaviors targeted using psychotropic medications (medications that affect brain activities associated with mental processes and behavior) for one of four sampled residents (Resident 74). Resident 74 was given the antianxiety medication Klonopin without a behavior to justify its use. Findings: A review of Resident 74's admission Record indicated the facility re-admitted the resident on 2/25/2019, with diagnoses including depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety (intense, excessive and persistent worry and fear about everyday situations), chronic kidney disease (gradual loss of kidney function), and dementia (a group of thinking and social symptoms that interferes with daily functioning). A review of Resident 74's Physician's Order dated 11/26/2021 indicated Klonopin (a medication used to treat anxiety) 1 milligram (mg - a unit of measure) by mouth every 24 hours as needed for anxiety manifested by calling…

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

Based on observation, interview, and record review the facility failed to ensure medications requiring refrigeration are stored in the refrigerator per the manufacturer's requirement for Resident 83 in one of two inspected medication carts (Medication Cart 3.) The deficient practice of failing to store medications per the manufacturer's requirements increased the risk that Residents 83 could have received medication that had become ineffective or toxic due to improper storage possibly leading to health complications resulting in hospitalization or death. Findings: During a concurrent observation and interview on 12/7/21 at 2:45 PM with the licensed vocational nurse (LVN 3) of Medication Cart 3, one unopened Levemir pen (a type of insulin used to control high blood sugar) was found stored at room temperature. Per the manufacturer's product labeling, unopened Levemir pens should be stored under refrigeration. LVN 3 stated that unopened insulin should be stored in the refrigerator otherwise it should be labeled with an open date. LVN 3 stated the insulin for Resident 83 was not opened…

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 indicate the open on gallons of milk as per facility's policy and procedures (P&P) titled Food Stoarage and Left Overs. This deficient parctice had the potential to result in foodborne illnesses (food poisoning: any illness resulting from the food spoilage of contaminated food, pathogenic bacteria, viruses, or parasites that contaminate food) among residents who consumed milk and food served by the facility. Findings: During an observation on 12/7/2021, at 8:30 AM, in the walk-in refrigerator, an opened gallon of milk was observed with no date on the cap. Additionally, other opened gallons of milk were also observed with open date on the milk gallon cap. During a concurrent observation and interview with Dietary Aide 1 (DA) 1 on 12/7/2021, at 8:33 AM, the walk-in refrigerator had one opened gallon of milk was observed with no date on the cap. The DA 1 stated, the gallon of milk was opened today (12/7/2021). DA 1 further stated, the opened gallon of milk should be dated with an open date. During an interview…

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 maintain complete medical records and documented weekly weights for one of two sampled residents (Resident 58). This failure had the potential to result in a lack of and or delay in communication among facility staff and care providers and, interrupt the provision of care and or interventions for Resident 58. Findings: A review of Resident 58's Facesheet (admission Record), indicated the facility admitted Resident 58 on 4/20/2021 with diagnoses that included unspecified dementia (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems) without behavioral disturbance, Type Two Diabetes Mellitus (DM-disease that impairs the way the body controls blood sugar), and dysphagia (difficulty or discomfort in swallowing). A review of Resident 58's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 11/4/2021, indicated Resident 58 had severe cognitive (ability to understand, remember, make decisions of daily living) impairment and had a poor…

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 74 indwelling catheter (a tube that allows urine to drain from the bladder into a bag that is usually attached to the thigh) drainage bag was not touching the floor for one out of 2 sampled residents (Residents 74). This deficient practice had the potential of cross contaminating the indwelling catheter tubing and infecting Resident's 74. Findings: A review of Resident 74's admission record indicated the resident was admitted to the facility on [DATE], with diagnoses that included but were not limited to diabetes mellitus (High blood sugar), chronic kidney disease (Inability of the kidney to filter waste product from the blood stream). A review of Resident 74's Minimum Data Set (MDS- a standardized assessment and care screening tool) dated 11/13/2021, indicated the resident's cognitive skills of daily decision making were severely impaired. The MDS also indicated the resident had an indwelling catheter. 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.