Vasona Creek Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain a complete medical record for one of three sampled residents (Resident 1) when: 1. The facility treated a wound to Resident 1's coccyx (tailbone) that was present upon admission, but did not document that they obtained a physician's order for wound treatment until eight days after admission; 2. The facility did not document treatments of Resident 1's coccyx wound until eight days after admission; and, 3. There was one week during which the facility did not document the assessment of Resident 1's coccyx wound. These failures had the potential to compromise the facility's ability to ensure Resident 1's wound was treated and monitored. Findings: Review of Resident 1's medical record indicated she was admitted on [DATE] and had diagnoses including overactive bladder (a condition that causes the sudden urge to urinate) and enterocolitis due to clostridium difficile (inflammation of the intestines that causes watery stools). Review of Resident 1's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to follow physician's orders for Resident 1 when Resident 1's physician's steroid tapering (process of slowly decreasing a steroid dosage over time) orders were not carried out correctly. This resulted in Resident 1 receiving a larger dosage than prescribed for six days, and Resident 1 missing one steroid dose entirely. These failures resulted in Resident 1 not receiving proper treatment, and had the potential to compromise Resident 1's health and well-being. Findings: Review of Resident 1's clinical record indicated he was admitted to the facility on [DATE] with diagnoses including atrial fibrillation (irregular heart rate), chronic obstructive pulmonary disease (chronic lung disease that makes it difficult to breathe) with acute exacerbation (sudden worsening in airway function), pulmonary hypertension (high blood pressure in the lungs), bronchiectasis (damage to tubes that carry air in/out of the lungs), and bacterial pneumonia (infection in the lungs…

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 treatment orders for respiratory [breathing] therapy (RT, treatment that helps individuals optimize their respiratory function, breathe more easily, and live more comfortably) was carried out as ordered for six out of six residents (Residents 3, 5, 6, 7, 8, and 9). The failure had the potential for the residents not attaining their highest practicable physical well-being, such as not being able to attend activities or carry out the activities of daily living (ADLs; such as eating, toileting, dressing, personal hygiene, etc.) due to reduced respiratory functions. Findings: 1a. A review of Resident 5's clinical record indicated she was admitted to the facility with diagnoses including history of COVD-19. Her Minimum Data Set (MDS, a care area assessment and screening tool), dated 11/5/24, indicated she had a BIMS score of 15 (Brief Interview for Mental Status, a test given by medical professionals that helps determine a patient's cognitive understanding that can be scored from 1 to 15), which indicated she had intact…

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 appropriate storage of medications in two of four medication rooms when: 1. The medication room that housed the facility's automated dispensing unit (ADU - where medications are stored and electronically tracked) was unlocked when not in use; 2. Two expired medications were identified in the medication refrigerators; and 3. The medication refrigerator temperature in Medication room [ROOM NUMBER] was not consistently monitored twice daily as per the U.S. Centers for Disease Control and Prevention's (CDC) guidelines. The failures had the potential for unauthorized access to dangerous medications; expired medications given to residents; and ineffective medications or loss of drug potency due to unmonitored temperatures. Findings: 1. During a visit to the second floor with Assistant Director of Nursing B (ADON B) on 11/20/24 at 9:30 a.m., an unmarked room was identified unlocked. The ADON B opened the door without using a key. The room…

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, record review, and facility policy review, the facility failed to ensure staff immediately reported an incident of suspected abuse to the Administrator for 1 (Resident #32) of 1 resident reviewed for abuse. Findings included: A facility policy titled, Reporting Abuse to Facility Management, revised in 12/2013, indicated, It is the responsibility of our employees, facility consultants, Attending Physicians, family members, visitors, etc. [et cetera] to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of unknown source, and theft or misappropriation of resident property to facility management. The policy specified, 4. Employees, facility consultants and/or Attending Physicians must immediately report any suspected abuse or incidents of abuse to the Director of Nursing Services. In the absence of the Director of Nursing Services such reports may be made to the Nurse Supervisor on duty. 5. Any individual observing an incident of resident abuse or suspecting resident abuse must immediately report such incident to 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, record review, facility document review, and facility policy review, the facility failed to resubmit a new Level I Preadmission Screening and Resident Review (PASARR) for 1 (Resident #74) of 4 residents reviewed for PASARR and failed to ensure a PASARR was accurately completed for 1 (Resident #110) of 4 residents reviewed for PASARR. Findings included: An undated facility policy titled, admission Criteria, revealed, 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. The policy also indicated, 11. The state may choose not to apply the preadmission screening requirement if: a. the individual is admitted directly to the facility from a hospital where he or she received acute inpatient care; b. the individual requires facility services for the condition for which he or she received care in the hospital, and c. the attending physician has certified (prior to admission) that the individual will likely need…

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, record review, and facility policy review, the facility failed to obtain treatment orders for a laceration for 1 (Resident #54) of 2 sampled residents reviewed for non-pressure related alteration in skin integrity. Findings included: A facility policy titled, Wound Care, dated 2001, indicated, The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. The policy indicated, 1. Verify that there is a physician's order for this procedure. The policy also indicated, The following information should be recorded in the resident's medical record: 6. All assessment data (i.e. [id est, which was Latin for, that is], wound bed color, size, drainage, etc. [et cetera, and other similar things]) obtained when inspecting the wound. An admission Record revealed the facility admitted Resident #54 on 12/17/2019. According to the admission Record, the resident had a medical history that included diagnoses of unspecified dementia, difficulty in walking, generalized muscle weakness, and unspecified macular degeneration (an eye…

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, record review, and facility policy review the facility failed to follow enhanced barrier precautions (EBP) for 1 (Resident #124) of 5 residents reviewed for wounds. Specifically, during an observation of wound care treatment for a pressure ulcer for Resident #124 staff members failed to wear a gown as part of the appropriate personal protective equipment (PPE). Findings included: The facility undated policy titled, Enhanced Barrier Precautions, indicated, Enhanced barrier precautions (EBPs) are utilized to reduce the transmission of multi-drug-resistant organisms (MDROs) to residents. The policy indicated, 2. EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply. The policy indicated, 3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: a. dressing; b. bathing/showering; c. transferring; d. providing hygiene; e. changing linens; f. changing briefs or assisting with toileting; g.…

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 document review, the facility failed to ensure 1 (room [ROOM NUMBER]) of 62 resident rooms accommodated no more than four residents per room. Findings included: A memorandum dated 11/15/2021, revealed room [ROOM NUMBER] had five beds. During the entrance conference on 10/28/2024 at 9:23 AM, Director of Nursing #16 stated there was one room in the facility, room [ROOM NUMBER], that housed more than four residents. The Maintenance Director was interviewed on 10/31/2024 at 1:18 PM. The Maintenance Director stated the facility had one room that housed more than four residents. The Administrator was interviewed on 10/31/2024 at 2:33 PM. The Administrator stated there had been discussion about the room with five beds. The Administrator stated that yearly the facility received a waiver for the room. The Administrator stated he received no concerns about the room having more than four residents.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and facility document review, the facility failed to provide the required 80 square (sq) feet (ft) of living space per resident in 16 of 62 resident rooms in the facility. Findings included: The Client Accommodations Analysis, dated 01/01/2023, indicated the following living space per resident: - In room [ROOM NUMBER], there was 74 sq ft per resident. - In room [ROOM NUMBER], there was 71 sq ft per resident. - In room [ROOM NUMBER], there was 70 sq ft per resident. - In room [ROOM NUMBER], there was 71 sq ft per resident. - In room [ROOM NUMBER], there was 73 sq ft per resident. - In room [ROOM NUMBER], there was 71 sq ft per resident. - In room [ROOM NUMBER], there was 73.5 sq ft per resident. - In room [ROOM NUMBER], there was 72 sq ft per resident. - In room [ROOM NUMBER], there was 74 sq ft per resident. - In room [ROOM NUMBER], there was 72 sq ft per resident. - In room [ROOM NUMBER], there was 73.5 sq ft per resident. - In room [ROOM NUMBER], there was 72 sq ft per resident. - In room…

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, observation, and record review, the facility failed to ensure care and services were provided in accordance with professional standards of practice for 13 of 28 sampled residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, and 13) when there were multiple days for which there was no evidence of documentation that scheduled treatments were provided. This failure had the potential to compromise the residents' health, safety, and overall well-being. Findings: 1. Review of Resident 1's physician order dated 5/15/24 indicated he had an order for, Destine external paste (topical cream used to aid in wound healing) 40 %, apply to bilateral buttocks topically every shift. Review of Resident 1's treatment administration record (TAR) indicated in the months of 8/2024, there were 15 days (total) for which there was no documentation that staff provided the treatment as ordered. During an interview and observation on 9/4/24 at 12:53 p.m. with Resident 1 in his room, he was sitting up in a wheelchair…

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 services were provided for three of three sampled residents (Residents 1, 2, and 3) when there were multiple days for which there was no documentation that chest percussion therapy (treatment that involves using cupped hands to tap the area over the resident's lungs to help clear secretions) was provided as ordered. This had the potential to compromise the residents' health and well-being. Findings: 1. Review of Resident 1's medical record indicated he was admitted on [DATE] and had diagnoses including pulmonary fibrosis (a condition in which the lungs become scarred) and emphysema (a condition in which damage to the air sacs in the lungs cause breathing difficulty). Review of Resident 1's Order Summary Report indicated he had a physician's order, dated 5/22/24, for chest percussion therapy four times a day. Review of Resident 1's Respiratory Administration Record (RAR), dated 8/2024, indicated he was scheduled to receive chest percussion…

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 responsible party (RP, person designated to make decisions on behalf of the resident) of a change of condition and new medication order for one of three sampled residents (Resident 1). This failure had the potential to compromise the RP's right to be fully informed of the resident's health condition and treatment. Findings: Review of Resident 1's clinical record indicated she was admitted on [DATE]. The clinical record further indicated Resident 1 had a designated RP. Review of Resident 1's situation, background, assessment, recommendation (SBAR, a communication tool), dated 5/29/24, indicated Resident 1's blood pressure was elevated. The SBAR further indicated Resident 1's physician gave an order for hydralazine (medication used to lower blood pressure) 10 milligrams (mg, unit of dose measurement) twice a day. Further review of Resident 1's clinical record indicated there was no documentation that the facility notified Resident 1's RP 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 accurately complete a Minimum Data Set (MDS, an assessment tool) for one of three sampled residents (Resident 1). Failure to accurately assess had the potential to compromise the facility's ability to develop and implement interventions to meet the resident's needs. Findings: Review of Resident 1's clinical record indicated she was admitted on [DATE] and had diagnoses including abnormal posture and difficulty in walking. Review of Resident 1's situation, background, assessment, recommendation (SBAR, a communication tool), dated 5/30/24, indicated Resident 1 had an unwitnessed fall in the facility. During an interview and concurrent record review with licensed nurse B (LN B) on 7/18/24, at 1:26 p.m., LN B reviewed Resident 1's clinical record and confirmed the resident fell on 5/30/24. LN B stated this fall should have been coded on Resident 1's MDS dated [DATE]. LN B reviewed Resident 1's MDS, dated [DATE], and confirmed section J1800 was coded No,…

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 accurately document in the clinical record for one of three sampled residents (Resident 1) when Resident 1's clinical record contained progress notes pertaining to a different, unknown resident. This failure had the potential to compromise the facility's ability to monitor and implement interventions for the correct resident. Findings: Review of Resident 1's clinical record indicated she was admitted on [DATE] and had diagnoses including abnormal posture and difficulty in walking. Review of Resident 1's Progress Notes, dated 5/30/24 at 7:15 a.m., indicated Resident 1 had an unwitnessed fall in the facility. The Progress Notes indicated the facility called 911 and emergency medical services (EMS) transported Resident 1 to the acute hospital five minutes after the fall. Resident 1's clinical record indicated she never returned to the facility after being transported to the acute hospital on the morning of 5/30/24. Further review of Resident 1's clinical…

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 accurately complete a Minimum Data Set (MDS, an assessment tool) for one of three sampled residents (Resident 1). Failure to accurately assess had the potential compromise the facility's ability to develop and implement interventions to meet the resident's needs. Findings: Review of Resident 1's clinical record indicated she was admitted on [DATE] and had diagnoses including sepsis (a condition in which the body responds improperly to an infection), diabetes (a disease that affects the body's ability to control blood sugar), respiratory failure (a condition in which the body does not have enough oxygen or has too much carbon dioxide), muscle weakness, and difficulty in walking. Review of Resident 1's Progress Notes, dated 3/13/23, indicated Resident 1 had an unwitnessed fall in the facility. During an interview and concurrent record review with MDS nurse A (MDSN A) on 6/18/24, at 10:10 a.m., MDSN A reviewed Resident 1's clinical record and confirmed…

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 care and services were provided in accordance with professional standards of practice for two of three sampled residents (Residents 1 and 2) when: 1. There was no documentation that the facility completed Skin & Wound Evaluations on a weekly basis for Resident 1; and 2. The facility did not consistently complete the Nursing Weekly Summary (an assessment form) for Residents 1 and 2. These failures had the potential to compromise the facility's ability to identify the residents' needs and implement interventions accordingly. Findings: 1. Review of Resident 1's clinical record indicated she was admitted on [DATE] and had diagnoses including sepsis (a condition in which the body responds improperly to an infection), diabetes (a disease that affects the body's ability to control blood sugar), respiratory failure (a condition in which the body does not have enough oxygen or has too much carbon dioxide), muscle weakness, and difficulty in walking.…

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 accurately complete the Elopement Risk Observation/Assessment for two of three sampled residents (Residents 1 and 2). This failure compromised the facility's ability to identify residents who were at risk for elopement and to implement relevant interventions. Findings: 1. Review of Resident 1's clinical record indicated he was admitted on [DATE] and had the diagnosis of subarachnoid hemorrhage (bleeding in the brain). Resident 1 had a physician's order, dated 2/20/24, for Seroquel (also known as quetiapine, a medication used to treat psychosis) 25 milligrams (mg, unit of dose measurement) one tablet by mouth in the morning. Resident 1 also had an informed consent (document that indicates the resident gave the facility permission to administer the medication), dated 2/20/24, for Seroquel 25 mg by mouth one time a day. Resident 1's Elopement Risk Observation/Assessment, dated 2/20/24, was reviewed. Section F of the assessment was designated to indicate…

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 the Ombudsman (resident advocate) office was notified of a hospital transfer for one of four sampled residents (Resident 2). This failure had the potential to result in Resident 2 not having someone to advocate for his admission, transfer, and discharge rights. Findings: Review of Resident 2's medical record indicated he was admitted to the facility on [DATE] and had the diagnosis of metabolic encephalopathy (a brain condition caused by chemical imbalances in the blood). Review of Resident 2's Progress Notes, dated 3/4/24, indicated Resident 2 refused medication and had increased confusion. According to the Progress Notes, Resident 2 was saying he was going to go home and did not know where he was. The Progress Notes further indicated the doctor ordered for Resident 2 to be sent to the hospital. Review of Resident 2's Hospital Transfer Form, dated 3/4/24, indicated Resident 2 was sent to the hospital at 6:00 p.m. There was no documentation 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 ensure one of four sample residents (Resident 1) received medication as ordered. This failure had the potential to compromise the resident's health and well-being. Findings: Review of Resident 1's medical record indicated he was admitted to the facility on [DATE] and had the diagnosis of alcohol dependence. Review of Resident 1's Order Summary Report indicated he had a physician order, dated 9/16/23, for Zenpep (medication used to treat inflammation of the pancreas, which is often caused by alcohol use) 5000-24000 units (does measurement) one capsule by mouth with meals. Review of Resident 1's medication administration record (MAR), dated 9/2023, indicated Resident 1 was scheduled to receive Zenpep every day at 7:30 a.m., 11:30 a.m., and 4:30 p.m. From 9/21/23 to 9/24/23, there were ten scheduled doses of Zenpep for which the documentation did not indicate the medication was administered to Resident 1. For these scheduled doses, licensed nurses…

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 food in accordance with Standing Orders for one of four sampled residents (Resident 1). This failure had the potential to compromise the resident's nutritional status. Findings: Review of Resident 1's medical record indicated he was admitted to the facility on [DATE] and had diagnoses including diabetes (a disease that affects the body's ability to control blood sugar), anemia (a deficiency of healthy red blood cells), and hyperlipidemia (an abnormally high level of fats in the blood). Review of Resident 1's lunch tray slip (a piece of paper that shows what food items the resident is supposed to receive for lunch), dated 4/30/24, indicated Resident 1 had Standing Orders for 6 ounces (oz, unit of measurement) of coffee, two servings of 8 oz of milk, 8 oz of water, half a cup of diet pudding, and 6 oz of soup. During an observation and concurrent interview with licensed vocational nurse E (LVN E) on 4/30/24 at 12:59 p.m., 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 observation, interview, and record review, the facility failed to implement infection prevention and control measures when: 1. Staff did not properly wear face masks in resident care areas; and 2. The facility did not ensure a family member of one of three sampled residents (Resident 1) was screened for Coronavirus Disease 2019 (a contagious respiratory illness caused by a virus) prior to entering the facility. These failures had the potential to result in the spread of infection in the facility. Findings: 1. During an observation on 3/19/24 at 10:52 a.m., a staff member was in the rehabilitation gym standing directly beside a resident who was using a piece of exercise equipment. The resident was wearing a face mask that covered her mouth, but her nose was not covered. The staff member standing directly beside the resident was also wearing a face mask that covered his mouth, but his nose was not covered. During an interview with licensed nurse A (LN A) on 3/19/24 at 12:50 p.m., he stated all staff must…

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 care and services in accordance with professional standards of practice for one of three sampled residents (Resident 1) when: 1. Licensed nurses did not administer a medication because it was not available in the facility; 2. The facility did not receive lab results (blood test results) and did not follow up with the lab regarding these results; 3. The facility did not administer Boost High Protein (a nutritional drink) as indicated in the admission orders; 4. Licensed nurses did not carry out an admission order for Pedialyte (a solution used to replace fluids and minerals in the body) until five days after admission; 5. The facility did not update wound treatments as ordered; and 6. There was no documentation that the facility completed a nutritional risk assessment upon admission. The failures had the potential to compromise Resident 1's health and well-being. Findings: 1. Review of Resident 1's medical record indicated Resident 1 was…

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 fulfill a records request made by the responsible party (RP, person designated to make decisions on behalf of a resident) for one of three sampled residents (Resident 1). This failure compromised the resident's and/or RP's right to access personal and medical records. Findings: Review of Resident 1's medical record indicated Resident 1 was admitted on [DATE] and had a RP. Further review of Resident 1's medical record indicated there was a letter from the RP to the facility, dated 9/12/23, requesting documents from the resident's record. The letter indicated, This is the third written request for ALL signed Documents-including the Admissions Documents. There was no documentation in the medical record that indicated the facility fulfilled this request. During an interview with medical records staff A (MRS A) on 2/12/24 at 1:27 p.m., MRS A stated residents or their RPs had the right to access and have copies of anything contained in their record. MRS 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 report a potential suspicion of a crime to the California Department of Public Health (CDPH) within 24 hours for one of three sampled residents (Resident 1). This failure had the potential to jeopardize the protection, health, and safety of Resident 1. Findings: Review of Resident 1's admission Record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included cognitive communication deficit, hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on side of the body) following non traumatic intracranial hemorrhage (bleeding inside the brain; complications could include impairment in language skills, problems with swallowing, and inability to move one part of the body) affecting right dominant side, Parkinson ' s disease (disease of the nervous system marked by tremor, muscle rigidity and slow, imprecise movement), and diffuse traumatic brain injury with loss of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement comprehensive person-centered care plans to address communication and visual impairment for one of three sampled residents (Resident 1). This failure had the potential to result in the resident not receiving the interventions necessary to maintain their highest level of well-being. Findings: Review of Resident 1's admission Record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included cognitive communication deficit, hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following non traumatic intracranial hemorrhage (bleeding inside the brain; complications could include impairment in language skills, problems with swallowing, and inability to move one part of the body) affecting right dominant side, Parkinson ' s disease (disease of nervous system marked by tremor, muscle rigidity and slow, imprecise…

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 infection control practice was implemented for one of three sampled residents (Resident 1) when Resident 1 ' s gastrostomy tube (GT, a device surgically inserted into the stomach through the abdomen used to supply nutrition or liquid when residents are unable to take anything by mouth) feeding syringe was undated. This failure could result in the spread of infection and cross-contamination in the facility. Findings: Review of Resident 1 ' s clinical record indicated he was admitted to the facility with diagnoses of dysphagia (difficulty swallowing), and on gastrostomy tube. During an observation on 8/21/23 at 2:39 p.m., in Resident 1 ' s room, an undated plastic bag containing GT feeding syringe was observed on top of Resident 1 ' s bedside table. During a concurrent observation and interview on 8/21/24 at 2:40 p.m., with the assistant director of nursing (ADON C) she acknowledged the above observation and stated that there was no date indicating when the GT feeding syringe was opened. She further…

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

Based on interview and record review, the facility failed to ensure care and services were provided in accordance with professional standards of practice for two of three sampled residents (Residents 1 and 2) when: 1. For Residents 1 and 2, there were multiple days for which there was no documentation that scheduled treatments were provided; 2. For Resident 1, documentation indicated licensed nurses did not administer medications in a timely manner on multiple days; 3. For Resident 1, licensed nurses did not administer certain medications because they were not available in the facility, and there was no documentation that the licensed nurses notified Resident 1 ' s physician about the missed doses; and 4. For Resident 2, there was no documentation that staff monitored the resident after a room change as ordered by the physician. These failures had the potential to compromise the residents ' health, safety, and overall well-being. Findings: 1a. Review of Resident 1 ' s Clinical Physician Orders indicated he had an order, dated 2/16/23 for, Apply wheelchair cushion as preventive…

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 document review, the facility failed to maintain temperatures in accordance with their policy for two out of three resident rooms (Rooms B and C). This failure had the potential to compromise the residents ' comfort and well-being. Findings: On 1/11/24 at 10:24 a.m., two residents in Room A were interviewed. Both residents denied having any concerns with the temperature in their room. On 1/11/24 at 10:33 a.m., one resident in Room B was interviewed. The resident stated the room was cold, and it felt cold every morning. The resident was wearing blankets during this interview. On 1/11/24 at 10:36 a.m., one resident in Room C was interviewed. The resident stated the room was often cold as [expletive]. The resident stated, I have to wear all these blankets and I don ' t like wearing blankets. The resident was wearing blankets during this interview. During an observation and concurrent interview with maintenance staff D (MS D) on 1/11/24 at 10:50 a.m., MS D stated resident room temperatures should be maintained between 72 and 75 degrees Fahrenheit (F,…

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 meet professional standards of care for one of three sampled residents who fell (Resident 1). Resident 1 ' s post fall documentation lacked an assessment to determine potential cause(s). This failure led to a missed opportunity of identifying pertinent preventative measures and placed the resident at risk for further falls. Findings: Resident 1 ' s Minimum Data Set (MDS, an assessment tool), dated 6/8/23, indicated the resident had memory problem, moderate difficulty in daily decision-making skills, and was extensively dependent on staff for activities of daily living such as transferring and toileting. Resident 1 had a care plan, dated 6/6/23 indicating she was at high risk for fall and injuries. Review of Resident 1 ' s Nurse ' s Note, dated 8/1/23 at 10:56 p.m., indicated the resident was found on the floor, was bleeding from her head and had two lacerations (cut) on the right eyebrow and right side of her head. Resident 1 reported she had pain level of eight out of ten and was transferred to a hospital by 911. 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.

Based on interview and record review the facility failed to follow standards of care for when a physician's order was not followed for one of two sampled residents (Resident 1). Resident 1's physician order to notify family member of refusing to take medications was not consistently followed. This failure resulted in missed opportunities for the family to be actively involved in the resident ' s care. Findings: Review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 6/22/23, indicated the resident had moderate difficulty in daily decision-making skill. Review of Resident 1's Interdisciplinary Team (IDT, members of health care team that meet to discuss and plan a resident's care) note, dated 7/26/23 at 3:12 p.m., indicated the IDT met with the resident ' s family members and discussed the resident's refusal of medications that led to high blood sugar level of 502 (normal fasting level is between 70 to 100). It also indicated the physician explained to the family the risks of refusing insulin (medication by injection used to treat high blood glucose) and the family…

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 develop and implement a discharge plan of care to include the resident and or family participation, preferences and needs to optimally prepare and transition him to a new home living environment for one of five sampled residents (Resident 3). This failure placed Resident 3 at risk for unsafe discharge with the potential to result in health complications. Findings: 1. Review of Resident 3's record indicated she was discharged to home on 9/13/23 at 11:37 a.m. Her MDS, dated [DATE], indicated the resident had mild impairment with daily decision-making skills. Resident 3's Social Services Note, dated 8/23/23 at 5:40 p.m., indicated there was a care conference, the resident was to be discharged to home, have home health services (wide range of health services provided in a home for an illness or injury) and in-home supportive services (services such as personal care and meal preparation), and durable medical equipment (equipment and supplies for everyday 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 interview and record review, the facility failed to ensure consistent documentation for one of three sampled residents (Resident 1) when: 1. There were two different versions of the same Post-Discharge Plan of Care; and 2. There were two different versions of the same Inventory of Personal Effects. These failures resulted in an inaccurate presentation of information. Findings: Review of Resident 1's medical record indicated he was admitted to the facility on [DATE]. Further review of the medical record indicated Resident 1 was discharged from the facility on 11/16/22. During an interview and concurrent record review with the assistant director of nursing (ADON) on 4/20/23 at 12:50 p.m., the ADON printed and provided a copy of Resident 1's Post-Discharge Plan of Care, effective date 11/16/22. The ADON reviewed the document and verified the section designated for social services was electronically signed on 3/23/23, and the remaining sections were electronically signed by a licensed nurse on 4/20/23.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure communication with the dialysis facility was properly coordinated when dialysis communication records (DCR) for one of two (Resident 2) was not completed. This failure may affect the quality of dialysis care being provided to the resident. Findings: Review of Resident 2's clinical record indicated he was readmitted to the facility on [DATE] with diagnoses including end stage renal disease (a condition in which the kidney no longer functions normally to filter waste and excess water from the blood as urine) and dependence on renal dialysis (a process of removing waste and excess water from the blood in those whose kidneys have lost normal function). He was scheduled for dialysis every Monday, Wednesday, and Friday. During concurrent interview and record review on 8/31/23 at 2:22 p.m., with the director of nursing (DON), she reviewed Resident 2's clinical record and confirmed that DCR's dated 5/31/23, 6/2/23, 6/7/23, 6/8/23, and 6/9/23 were not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to thoroughly investigate an allegation of a resident physical altercation of one of three sampled incidents (Resident 1). This failure had the potential of reaching an inaccurate conclusion of what had occurred. Findings: Review of Resident 2 ' s Interdisciplinary (IDT, members of health care team who meet to discuss and plan care for the resident) Note, dated 4/8/23 at 9:25 a.m., indicated on 4/7/23 Resident 2 reported his roommate (Resident 1) made contact with his head. Review of the Summary of Resident to Resident Reported Physical Altercation Note, dated 4/10/23, addressing the incident indicated Resident 2 alleged receiving physical contact by his roommate and the investigation concluded the incident did occur as reported by the victim. Other than Resident 2's statement there was no documentation supporting Resident 1 hit Resident 2's head. Review of Resident 1 ' s MDS, dated [DATE] indicated the resident had mild difficulty with memory and daily…

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 with limited range of motion received appropriate treatment and services to increase their range of motion and/or to prevent further decrease in range of motion for one of three sampled residents (Resident 1) when Resident 1 did not receive RNA (Restorative Nursing Assistant) treatment as ordered and as care planned. This failure had the potential to negatively affect Resident 1 ' s health and well-being. Findings: During a review of Resident 1's clinical record (CR), the CR indicated she was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including Morbid (severe) obesity due to excess calories, abnormalities of gait mobility and the pain in the left leg. During a review of Resident 1's minimum data set (MDS, an assessment tool), dated 6/23/2023, the MDS indicated Resident 1 had a brief interview for mental status (BIMS) score of 15 (a score of 13 to 15 indicates the resident is…

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 restorative nursing assistant (RNA) services as ordered for one of three residents (Resident 1). This failure had the potential to result in decreased mobility and health complications in the resident. Findings: Review of Resident 1's clinical record indicated he was admitted to the facility on [DATE] with diagnoses including dysphagia (difficulty swallowing) following other nontraumatic intracranial hemorrhage (type of stroke, a condition resulting from a lack of oxygen in the brain potentially causing a loss of sensory and motor function) and Parkinson's disease (a disease that include symptoms of slowness of movements, muscle rigidity, involuntary tremors/shaking and impaired balance, and posture). Review of Resident 1's Physical Therapy (PT) Discharge summary, dated [DATE] indicated he was seen by PT from 4/22/23 to 5/30/23. It indicated Resident 1 was transitioning to LTC [long term care] at this facility and shall benefit from RNA program…

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 care conferences (meetings held to discuss the plan of care with the resident or representative) were conducted for one of three sampled residents (Resident 1). This failure had the potential to compromise the resident's or representative's right to participate in the care planning process. Findings: Review of Resident 1's medical record indicated she was admitted to the facility on [DATE] and had the diagnoses of diabetes (disease that affects the body's ability to control blood sugar), chronic kidney disease, and Alzheimer's Disease (progressive mental deterioration). The medical record indicated Resident 1's family member (FM) was her responsible party (RP, person designated to make decisions on behalf of the resident). Resident 1's document titled Care Conference: Comprehensive Person-Centered, dated 5/24/22, was reviewed. The only part of the document that was filled out was the section designated to indicate Resident 1's diet order. All…

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 services were provided in accordance with professional standards of practice for one of three sampled residents (Resident 1) when: 1. There was no documentation that the facility regularly applied Resident 1's neck collar (device used to immobilize the neck) as recommended by a physician; 2. The facility did not develop a care plan to address an injury to Resident 1's neck; and 3. There was no documentation that the facility conducted an investigation regarding an injury to Resident 1's neck. These failures had the potential to negatively affect the resident's health and well-being. Findings: Review of Resident 1's medical record indicated she was admitted to the facility on [DATE] and had the diagnosis of wedge compression fracture of unspecified thoracic vertebra (a broken bone of the spine at torso level). There was no documentation of any injury to Resident 1's neck upon admission. Review of Resident 1's Progress Notes, dated 4/16/23 at 4:15…

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.

10. During an observation on 11/18/2021 at 9:00 a.m., treatment nurse B (TN B) performed wound treatments on Resident 118's feet. While wearing gloves, TN B cut the old bandages off Resident 118's feet with a pair of scissors. He removed his gloves and put on a new pair. TN B then cleaned the wounds on Resident 118's feet. He removed his gloves and put on a new pair. TN B then applied Betadine (topical medication) to the wounds on Resident 118's feet. He removed his gloves and put on a new pair. TN B then applied Santyl (topical medication) to the wound on Resident 118's right foot and covered the foot with dry dressings. He removed his gloves and put on a new pair. TN B then applied Santyl to the wounds on Resident 118's left foot and covered the foot with dry dressings. Each time TN B changed gloves, he did not perform hand hygiene after removing his used gloves and before putting on new ones. During an interview with TN B on 11/18/2021 at 9:22 a.m., he confirmed he did not perform hand hygiene when changing gloves during Resident 118's wound treatments. TN B acknowledged he was…

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 a functioning, habitable, comfortable and homelike environment for five of 30 sampled residents (Residents 111, 106, 11, 85 and 48) when: 1. For Resident 111, the string for the over bed light was short and the facility used a bath towel to make it longer; 2. For Resident 106, the string for the over bed light was short and the facility used a face cloth to make it longer; and 3. For Residents 11, 85 and 48, the facility did not maintain comfortable temperatures. These failures had the potential to compromise the residents' health, safety and comfort levels in the facility. Findings: 1. During an observation on 11/16/21 at 9:09 a.m., Resident 111's over bed light had a short string with a bath towel tied and attached. During a concurrent observation and interview on 11/16/21 at 9:10 a.m., with the administrator (ADM), he acknowledged the above observation. He stated that maintenance would check the over bed lights in the facility.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility had a medication error rate of 9.43% when five medication errors occurred out of fifty-three opportunities during medication administration for four out of nine residents (Residents 380, 19, 79 and 108). These deficient practices resulted in medications not given in accordance with the prescriber's orders and/or manufacturer's specifications, which resulted in residents not receiving the full therapeutic effects of the medications and may cause preventable side effects for the residents. Findings: 1. During the medication pass observation on [DATE] at 11:00 a.m., with licensed vocational nurse M (LVN M), she administered ten medications to Resident 380, including one tablet of hydralazine (medication to treat high blood pressure) 100 milligrams (mg, unit of dose measurement) and one tablet of isosorbide dinitrate (medication for heart failure) 10 mg. A review of Resident 380's Medications Administration History for [DATE] indicated: a. Hydralazine…

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

Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and served under sanitary conditions when: 1. The microwave film was peeling off and had a yellowish color; 2. The preparation table drawer was broken; 3. There was a build up of icicles in the kitchen freezer; 4. Two dented cans and one compromised tomato juice were found in the dry storage; 5. Dishwasher liquid was stored near the dry goods; 6. Two ice machines had whitish to yellowish substances; 7. Vegetable peeler had a paper label and had a greenish color; 8. The food strainer was broken; 9. Three cutting boards had a deep cut; 10. Staff did not demonstrate the proper procedure for testing the strength of sanitizer used for sanitizing food contact surfaces. These failures had the potential to cause foodborne illness (illness resulting from contaminated food) for 133 of 138 residents who received food from the kitchen. Findings: 1. During a concurrent observation and interview with the director of dietary services (DDS) in the kitchen on 11/15/21 at 9:12 a.m., 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's staff failed to ensure dignity and respect were maintained for two of 30 sampled residents (Residents 30 and 380). This deficient practice resulted in residents feeling sad, anxious and had the potential to affect Residents 30 and 380's self-esteem and self-worth. Findings: Review of Resident 30's clinical records indicated she was readmitted to the facility on [DATE] with diagnoses of muscles weakness, hypertensive heart disease (high blood pressure), dysphagia (difficulty of swallowing) and chronic kidney disease-stage three (CKD, kidneys are damaged and cannot filter blood as they should) 1. Review of Resident 30's Minimum Data Set (MDS, an assessment tool), dated 9/22/21, indicated her cognitive skills for daily decision making were intact and she required assistance from staff with activities of daily living. During an observation on 11/15/21 at 9:15 a.m., maintenance assistant T (MA T) twice entered Resident 30's room without knocking on 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 complete the admission Minimum Data Set (MDS, an assessment tool) within 14 calendar days after admission for one of 30 sampled residents (Resident 375). This deficient practice had the potential to delay care planning and delivery for Resident 375's care areas that would have been identified in the admission MDS. Findings: Review of Resident 375's clinical records indicated she was admitted to the facility on [DATE] with diagnoses including dementia (decline in mental capacity affecting thinking and social abilities interfering with daily functioning), major depressive disorder (mood disorder that interferes with daily life), cerebral infarction (necrotic tissue in the brain resulting from a blockage or narrowing in the arteries supplying blood and oxygen to the brain) and chronic obstructive pulmonary disease (COPD, a disease that affects airflow in the lungs and makes it difficult to breathe). During a concurrent record review and interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately complete the Minimum Data Set (MDS, an assessment tool) for two of 30 sampled residents (Residents 20 and 73). Failure to accurately assess the residents had the potential to compromise the facility's ability to provide resident-centered care planning and interventions. Findings: 1. Review of Resident 20's medical record indicated she was admitted on [DATE] and had the diagnoses of dementia (mental disorder caused by brain disease or injury), right femur neck fracture (broken right hip), muscle weakness and difficulty in walking. Review of Resident 20's Progress Note, dated 8/14/2021, indicated she was found lying on the floor inside the bathroom. Resident 20's MDS, dated [DATE] was reviewed. Section J1800 asked the question, Has the resident had any falls since admission/entry or reentry or the prior assessment? The answer to this question was coded 0 to indicate that Resident 20 did not have any falls during the specified time frame.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop and implement comprehensive person-centered care plans for three of 30 sampled residents (Residents 9, 59 and 118) when: 1. For Resident 9, the facility did not develop a care plan to address the presence of a pressure ulcer (injury to the skin and underlying tissue, primarily caused by prolonged pressure on the skin); 2. For Resident 59, the facility failed to develop a care plan to address the management of Resident 59's impaired vision; and 3. For Resident 118, the facility did not develop a care plan to address the use of an anticoagulant (medication that thins the blood and increases the risk for bleeding). These failures had the potential to result in the residents not receiving the interventions necessary to maintain their highest level of well-being. Findings: 1. A review Resident 9's clinical record indicated she was admitted to the facility on [DATE]. Review of Resident 9's discharge orders from the acute hospital, 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 provide care and services in accordance with professional standards of practice for two of 30 sampled residents (Residents 58 and 17) when: 1. For Resident 58, staff did not apply a foot cradle (device intended to prevent sheets and blankets from touching the feet) as ordered by the physician; 2. For Resident 17, staff administered oxygen without a physician's order. These failures had the potential to compromise the residents' health and well-being. Findings: 1. Resident 58's clinical record indicated she was admitted on [DATE] and had the diagnoses of sepsis (serious condition resulting from infection in the blood or other tissues), dementia (conditions of brain function impairment), and pressure ulcer (injury to the skin and underlying tissues caused by prolonged pressure) of sacral region stage 4. There was a physician order, dated 10/08/20, to use foot cradle while in bed to keep pressure off bilateral (both) lower feet from 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 dialysis services consistent with professional standards and to ensure staff coordinated resident care with the dialysis facility for two of 30 sampled residents (Residents 111 and 17) who received dialysis (medical procedure to remove fluid and waste products from the blood) when: 1. Dialysis communication records (DCRs) were not completed and; 2. Dialysis care plans were not resident-centered. These failures had the potential to affect the quality of dialysis care being provided to the residents. Findings: 1. Review of Resident 111's clinical record indicated he was admitted to the facility on [DATE] with diagnoses including end stage renal disease (a condition in which the kidneys no longer function normally) and dependence on renal dialysis. Resident 111 was scheduled for dialysis every Monday, Tuesday, Thursday and Saturday. Review of Resident 111's DCRs dated 8/14/21, 8/19/21, 8/24/21, 8/28/21, 8/31/21, 9/7/21, 10/11/21,…

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 pharmaceutical services were provided accurately, timely and as ordered for three residents (Residents 79 and 108) when medications ordered by the physician were not available in the medication cart for administration to Residents 79 and 108 and These deficient practices resulted in the residents not receiving their ordered medications and had the potential for misuse or diversion of controlled medication. Findings: During the medication pass observation on 11/16/21 at 9:13 a.m., with licensed vocational nurse K (LVN K), she was not able to administer rivastigmine (medication for dementia or memory loss) to Resident 79 because the medication was not available. During an interview on 11/16/21 at 1:52 p.m., with the LVN K, she verified that rivastigmine was reordered on 11/14/21 but had not been delivered yet. The last dose of the medication was given on 11/15/21. During an interview on 11/17/21 at 3:53 p.m., with assistant director of nursing A (ADON A), she verified that rivastigmine was not available.…

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 three of 30 sampled residents (Resident 60, 73 and 20) were free from unnecessary psychotropic medications (drugs that affects brain activities associated with mental processes and behavior when: 1. For Resident 60, there was no evidence of non-pharmacological interventions for a new behavior; 2. For Resident 73, no care plan was developed for the use of benztropine (an anti-tremor medication used to treat side effects of other drugs), no specific manifestation of extrapyramidal symptoms (EPS, drug-induced movement disorders, dystonia [involuntary muscle contractions], akathisia [urge to move], tardive dyskinesia [repetitive involuntary movements]) being monitored, and orthostatic hypotension was not monitored; and 3. For Resident 20, the facility failed to address the continued use of a PRN (as needed) psychotropic medication in a timely manner. The facility also failed to ensure there was a specific duration of use for a PRN…

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. Two expired medications were not properly discarded and not stored in the medication cart and, 2. Two medications were not properly labeled after being opened. These deficient practices had the potential for unsafe and ineffective use of medications being used past the expiration date and risk the misuse of medications because they were unlabeled or improperly labeled. Findings: 1. During a concurrent medication cart inspection for Station G and interview with assistant director of nursing E (ADON E) on 11/16/21 at 4:05 p.m., the surveyor observed one latanoprost ophthalmic (medication for eye disorder) 0.005% solution, expired on 7/22/21 as indicated on the yellow sticker attached to the vial. Also observed one vial of Lantus injection (long acting insulin for high blood sugar) 100 units/milliliter (ml), expired on 11/12/21 as indicated on the yellow sticker attached to the vial. ADON E confirmed and verified that these two medications were expired. Review of the facility's Storage of Medications…

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

Based on interview and record review, the facility failed to implement an antibiotic stewardship program (a coordinated program that promotes the appropriate use of drugs used to treat infections, including antibiotics [a medicine that inhibits the growth of or destroys bacteria or germs], for antibiotic use protocol (official procedure or system of rules) with a systematic approach of monitoring and evaluating for the appropriate use of antibiotics to improve resident health outcomes and reduce antibiotic resistance (bacteria not controlled or killed by antibiotics) for three of 30 sampled residents (Residents 60, 105 and 59). This failure had the potential for inappropriate antibiotic use. Findings: 1. During an interview on 11/19/21 at 2:21 p.m., with the assistant director of clinical services (ADCS), the ADCS reviewed the facility's Infection Prevention and Control Surveillance log for the month of April 2021 and confirmed Resident 60 did not have a completed Mcgeer Criteria for Infection Surveillance Checklist (MCISC). During an interview with the director of staff development…

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 residents' representatives and families of a confirmed COVID-19 (a respiratory disease caused by a virus which can result in severe illness and death) test by 5:00 p.m. the next calendar day when Resident 282 received a positive COVID-19 test result on 10/16/21 and notifications were not sent out until 10/18/21. This failure resulted in residents' representatives and families not receiving timely notification regarding the status and impact of COVID-19 in the facility. Findings: Review of Resident 282's clinical record indicated he was admitted to the facility on [DATE]. A review of Resident 282's progress note dated 10/16/21 indicated Resident 282's physician was called at 12:30 p.m. due to an elevated temperature, and orders were given to perform a nasal swab for COVID-19. A subsequent progress note in Resident 282's clinical record, dated 10/16/21 at 6:00 p.m., indicated Patient tested (+) with [NAME] COVID 19 Rapid Antigen test (a brand 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.

Based on observation, interview, and record review, the facility failed to ensure sanitary condition was maintained when there was no air gap (a gap of air between the floor and a drain pipe) in one of two facility ice machines. This failure had the potential to cause foodborne illness to residents. During an inspection and concurrent interview with the maintenance director (MD), the ice machine's water drain pipe and outlet hose were in the floor sink below the floor level rim (a type of floor drain used as an indirect waste receptor). The MD acknowledged the outlet hose and drain pipe should be above floor level to create an air gap and to avoid ice contamination in the event of an accidental back flow. He also stated the pipe and the hose could have been dislodged when the housekeeper was cleaning the floor. According to the 2013 Federal Food Code, an air gap between the water supply inlet and flood level rim of the plumbing fixture (floor sink), equipment, or non-food equipment shall be at least twice the diameter of the water supply inlet and may not be less than one inch.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility staff failed to observe residents' rights on personal privacy for two of four residents (48 and 246) when: 1. Licensed vocational nurse G (LVN G) did not provide privacy for Resident 48 during the administration of fluids via gastrostomy tube (GT, a surgical opening into the stomach for administration of liquids nutrition and medication). 2. Resident 246's private body part to be partially exposed for anyone passing by to see. These failures had the potential to affect residents' self-worth and psychosocial well-being. Findings: 1. Review of Resident 48's physician order dated 3/14/19 indicated flush GT with a minimum of 150 millimeter (ml, unit of measurement) of water every four hours. During an observation on 5/6/19 at 12:52 p.m., LVN G was administering fluids via GT tube for Resident 48. The bedroom door was open and the privacy curtain was not pulled. This allowed others from outside the room to view Resident 48's partially exposed abdomen.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement comprehensive plan of care for two of thirty residents (Resident 67 and Resident 82) when: 1. Resident 67's post fall care plan interventions were not re-evaluated. 2. Resident 82's unsafe behavior of wandering into other residents' rooms was not care planned These deficient practices placed residents at risk for potential injuries and accidents. Findings: 1. A review of admission records indicated Resident 67 was admitted [DATE] with diagnoses including muscle weakness and acquired absence of right leg above knee. A review of Resident 67's Safety Events record, indicated Resident 67 had an unwitnessed fall on 4/29/19. During an interview on 5/9/19 at 10:33 a.m., licensed vocational nurse J (LVN J) confirmed a short term post fall care plan target date of 5/2/19, but was not revised until 5/8/19. There was no documentation the care plan had been re-evaluated by the target date. A review of Resident 67's post fall…

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 provide appropriate positioning for eating for two of twenty residents (204 and 205). This failure had the potential to contribute to the risk of aspiration. Findings: During dining observation on 5/7/19 at 8:08 a.m., in Residents 204 and 205's shared resident room, certified nursing assistant D (CNA D) was observed leaving the food trays on the bedside tables uncovered and left the room. During a concurrent interview with Resident 204 on 5/7/19 at 8:08 a.m., Resident 204 stated the bed side table was too high and he had a hard time eating his food. Resident 204 stated he was too low in the bed and his feet touched the foot board. Resident 204 also stated he needed to be repositioned and stated, I hope I don't choke. During an observation of Resident 205 at 5/7/19 at 8:08 a.m., Resident 205 had his bedside table with the breakfast tray in front of him. The bedside table was positioned at above his shoulder. Resident 205 attempted to scoop food from the plate but was unable to. During an interview with CNA D on 5/7/19 at 8:12…

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 supervise one of three residents (Resident 82) when Resident 82's behavior of wandering into other resident rooms was not monitored. This deficient practice placed residents at risk for unsafe conditions. Findings: A review of Resident 82's admission record dated 3/28/19, indicated a diagnosis of delirium due to known physiological condition. During an observation and concurrent interview on 5/7/19 at 3:46 p.m., registered nurse Q (RN Q) confirmed Resident 82 was inside Resident 399's room. RN Q stated Resident 82 had a history of wandering into other resident's rooms. RN Q stated staff was aware of this behavior and provided redirection. RN Q confirmed there was no documented frequent monitoring of Resident 82. During an observation on 5/8/19 at 12:32 p.m., Resident 82 was seen exiting Resident 399's room. During an interview on 5/8/19 at 9:04 a.m. Resident 399 stated Resident 82 repeatedly entered her room without invitation and had attempted to open her closet door on multiple occasions. She further stated…

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 monitor a stage one pressure ulcer for one of six sampled residents (Resident 402) when Resident 402's weekly wound assessment was not completed. This failure had the potential to delay treatments and lead to worsening pressure ulcers. Findings: A review of the admission records indicated Resident 402 was admitted on [DATE] with diagnoses including subdural hemorrhage (bleeding in the brain) and muscle weakness. A review of Resident 402's skin care plan dated 4/15/19, indicated an intervention of weekly skin checks to reduce the risk for impaired skin integrity. During an interview and concurrent record review on 5/9/19 at 1:56 p.m., assistant director of nursing B (ADON B) confirmed Resident 402's Wound Management record dated 4/13/19, indicated a stage one pressure ulcer on the coccyx was identified upon admission, but no weekly assessment was completed. ADON B stated a re-assessment of the wound should be completed every 7 days.

Based on observation, interview and record review, the facility failed to get a physician's order and document administration and resident response for oxygen (a colorless and odorless gas that people need to breathe) therapy for one of three residents (Resident 209) when Resident 209 was administered oxygen without a physician's order. These failures had the potential to result in ineffective oxygen therapy. Findings: During an observation on 5/6/19 at 11:24 a.m., Resident 209 was observed lying in bed with eyes closed. Resident 209 was on oxygen via nasal cannula (a lightweight tube which on one end splits into two prongs used to deliver oxygen to a patient) at 2 liters per minute (Lpm, a unit of measurement for volume over time). During an interview with Resident 209 on 5/7/19 at 9:45 a.m., Resident 209 stated she had been using the oxygen for a few days. During another observation on 5/7/19 at 3:33 p.m., Resident 209 was in bed lying down. Resident 209 was on oxygen via nasal cannula at 2 Lpm. The oxygen tubing was dated 5/5/19. During a concurrent interview and record review…

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

Based on observation, interview, and record review, the facility failed to provide medication for one of five residents (Resident 22) when one routine medication was not available during the 9 a.m. medication pass. This failure had the potential to cause delay in treatment and compromise resident's health. Findings: A review of Resident 22's physician order indicated prescription eye drops (use for the temporary relief of burning, irritation, and discomfort due to dryness of the eye), to be instilled to both eyes, once a day. The medication was scheduled to be administered at 9:00 a.m During an observation on 5/6/19 at 10:13 a.m., licensed vocational nurse O (LVN O) administered scheduled medications to Resident 22. However, she did not administer the prescription eye drops. During a concurrent interview with LVN O, she acknowledged she did not administer the prescribed medication because Resident 22's eye drops was not available. She also confirmed since last month, the facility had been using a generic medication, an over the counter sterile eye drops. The eye drop bottle…

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 ensure that residents were free from unnecessary psychotropic drugs (medications that are capable of affecting the mind, emotions, and behavior) for three of 10 sampled residents (18, 20, and 31) when: 1. For Resident 18, lipid panel (level of fats in the blood) and hemoglobin A1C (level of sugar in the blood) blood levels were not done for the used of Quetiapine (drug used to help improve behaviors). 2. For Resident 31, no evidence of documentation that non-pharmacological interventions were tried/attempted first before giving PRN (as needed) Ativan tablets (medication for anxious behaviors). 3. For Resident 20, the indication for use of Seroquel (Quetiapine, an antipsychotic) did not include a specific target behavior and not following ordered monitoring for lipids (fats in the blood) and A1C (average level of blood sugar over the past two to three months). These failures put the residents at risk for experiencing adverse medication side effects and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to secure medication cart and ensure safe handling of discontinued medications in two of three medication carts when: 1. Medication cart 3A was left unlocked and unattended. 2. Medication cart 1B had discontinued prescription medications. These failures had the potential for unauthorized access and accidental administration of discontinued medications. Findings: 1. During the initial tour on [DATE] at 9:50 a.m., medication cart (3A) was unattended and unlocked at the hallway in front of room [ROOM NUMBER]. At 9:54 a.m., licensed vocational nurse L (LVN L) came out from a non-resident room (shower room) and stated she needed to step away for a few minutes to make personal phone call. She acknowledged she left her medication cart unlocked. During an interview with the director of nursing (DON) on [DATE] at 1:08 p.m., she stated medication carts must be securely locked at all times when out of the nurse's view to prevent access by unauthorized…

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 documentation was complete for two of fourteen residents (Residents 204 and 47), when: 1. Resident 204 was administered insulin (a medication for high blood sugar) and the dosage was not documented; 2. Resident 47 had no documentation regarding the application of carrot device (a device used to support, prevent, or correct deformities of the hand) on the right hand by CNA on a daily basis. These failures had the potential to negatively affect the delivery of care and services to the residents due to incomplete medical information. Findings: 1. Review of the clinical record indicated Resident 204 was admitted on [DATE] with the diagnosis of type 2 diabetes mellitus (a condition that results from insufficient production of insulin in the pancreas causing high blood sugar). Review of the physician orders indicated Resident 204 was started on Humalog (a fast-acting insulin) on 4/21/19 via sliding scale (the patient is given more or less…

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 implement an infection control measures for two of 30 sampled residents (1 and 18) when: 1. Resident 18's humidifier (a device for increasing or controlling the water vapor) tubing was undated and tracheal mask (a mask made of plastic used to protect the artificial created opening in the neck which the person breathes) was exposed. 2. Resident 1's urinary catheter (a tube inserted into a patient's bladder to allow the patient's urine to drain freely from the bladder) tubing was touching and dragging on the floor while Resident 1 was using the wheelchair. These failures had the potential for the development and the spread of infections in the facility. Findings: 1. Review of Resident 18's clinical record indicated he had diagnoses including tracheostomy (surgically created opening in the neck in order to place a tube into a person's windpipe) status. His physician order dated 1/22/19 indicated continuous trach collar with humidifier. Change humidifier tubing and tracheal mask weekly. During an initial tour 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.