Madera Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered Care Plan (CP-the process by which healthcare professionals and patients discuss, agree, and review an action plan to achieve the goals or behavior change of most importance to the patient) to prevent falls and injuries, for four (4) of fifty-four (54) sampled residents (Resident 4, Resident 28, Resident 250, and Resident 410) when: 1. Resident 4's supervision CP during meals was not implemented. This failure put Resident 4 at an increased risk of choking and aspiration of food. 2. Resident 28's toenail clipping and/or podiatry care was not done and there was no CP to address repeated refusals to bathe or shower. This failure placed Resident 28 at risk for infection and other diabetic (high blood sugar disease) complications. 3. Resident 250 fell out of bed on 9/13/23 and the fall mat (a cushion made of high-density foam and covered with a non-slip material to minimize the risk 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 the menu was followed for the dysphagia advanced (bite-sized foods that are moist) diet for five of 47 sampled residents (Residents 17, 22, 31, 35, and 36) when Residents 17, 22, 31, 35, and 36 received puree broccoli instead of chopped broccoli for lunch. This failure had the potential to result in Residents 17, 22, 31, 35, and 36 having a decrease in satisfaction with their meal because it was not the correct texture of food as prescribed by the physician. Findings: During an observation on 2/13/24 at 11:54 a.m. in the kitchen, [NAME] 1 plated the food for residents and served Resident 36 who was on a dysphagia advanced diet pureed broccoli. During a concurrent interview and record review on 2/15/24 at 10:29 a.m. with the Dietary Supervisor (DS), Resident 36's lunch meal tray ticket (document which indicates food items residents received for their meal), dated 2/13/24 was reviewed. The lunch meal tray ticket indicated, Resident 36 should receive half a cup of chopped roasted brussels sprouts…

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 needed care according to professional standards of practice for one of four sampled residents (Resident 59) when facility did not notify physician of Resident 59's change of condition (COC) of hyperglycemia (high blood sugar). This failure had the potential to result in Resident 59's development of diabetic ketoacidosis (DKA- complication of diabetes, when the body can't make enough insulin to allow blood sugar into the cells for energy and the body breaks down fat). Findings: During a review of Resident 59's admission Record (a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), indicated Resident 59 was admitted to the facility on [DATE] with diagnosis, . Influenza A with Pneumonia (lung inflammation caused by virus or bacteria) . Type 2 Diabetes Mellitus (DM-long term condition in which the body…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for two of four sampled residents (Resident 361 and Resident 17) when 1. Resident 361's toenails were not cut or trimmed for a year and 3 months. 2. Resident 17's toenails were not cut or trimmed. These failures resulted in Resident 361's and Resident 17's toenails to become long and curled which had the potential to result in Resident 361's and Resident 17's toenails to become painful, ingrown or to break off the nail bed causing infection and limit resident's mobility during activities of daily living (ADL). Findings: 1. During an observation on 2/13/24 at 3:20 p.m. in Resident 361's room, Resident 361 was observed lying in bed with both feet exposed, observed to have long, yellow, hard thick toenails (all ten toes). During a review of Resident 361's admission Record (AR), the AR indicated, Resident 361 was admitted to the facility on [DATE]. The AR…

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 drug records to account for the receipt and accurate reconciliation (comparing medication received is being delivered) for controlled medications (medications that may be abused or cause addiction) for one of three sampled residents (Resident 13) when the pharmacy manifest (form that contains information about the type and quantity of medication delivered) was not signed upon delivery of a controlled medication. This failure had the potential for drug diversion (distribution or abuse of a prescription drug or it's use for purpose) of Resident 13's controlled medication. Findings: During a concurrent observation and record review on 2/14/24 at 11:24 a.m. with licensed vocational nurse (LVN) 1, Resident 13's medication Acetaminophen-codeine (APAP/COD) #3 (controlled medication) tablet 300-30 mg (unit of measure) was observed during Medication cart 2's review of medications. During a review of Resident 13's admission Record (a summary…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure medications were properly stored and labeled in accordance with professional standards when: 1. The facility's medication emergency kit (ekit) containing controlled medications (medications that may be abused or cause addiction) was observed missing a zip tie. 2. Medication for one of three sampled residents (Resident 14) was observed with expired date in Medication Cart two. These failures had the potential for medication diversion (distribution or abuse of a prescription drug or it's use for purpose) from the ekit and the potential for adverse effects (undesired harmful effect) and medication error for Resident 14 when the expired medication was left in the medication cart. Findings: 1. During a concurrent observation and interview on 2/14/24 at 10:48 a.m. with licensed vocational nurse (LVN) 1 in the medication room, the ekit for medications taken by mouth, was observed inside a file cabinet with one red zip tie on the right-side…

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 and maintain an effective infection prevention and control program to prevent the transmission of infections when: 1. Unit Manager-Registered Nurse (UM- RN) did not perform hand hygiene during a dressing change to Resident 28; 2. Three hand sanitizer dispensers in the hallway outside resident rooms did not work; These failures placed residents at risk for cross-contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect). Findings: 1. During an observation on 2/14/24 at 3:35 p.m. in Resident 28's room, Unit Manager, RN (UM-RN) was observed performing a dressing change to Resident 28's right lower leg. UM-RN was observed removing soiled gloves after removing a soiled bandage and donning (putting on) new clean gloves without performing hand hygiene. During a review of Resident 28's admission Record (AR), dated 2/15/24, the AR…

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 maintain equipment in safe operating condition when a drawer holding clean utensils used for meal service was no longer on the drawer track (the mechanisms that allow drawers to open and close smoothly) and was difficult to open and close. This failure had the potential to result in contamination of the clean utensils because the drawer could not be completely closed and potential in bodily injury to dietary staff. Findings: During an initial kitchen tour on 2/13/24 at 10:58 a.m., an observation of a drawer holding clean utensils used for meal service was found to be difficult to open and close and it was kept ajar. The drawer was not on the track on one side and it make it difficult to open and close. During a concurrent observation and interview on 2/14/24 at 8:34 a.m. with the District Dietary Manager (DDM) in the kitchen, a drawer was difficult to open and close. The DDM stated, the DDM was not sure if the drawer could be fixed. During an interview on 2/15/24 at 10:41 a.m. with the Regional Maintenance…

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

Based on interview and record review the facility failed to provide a copy of the resident's medical record for one of one resident (Resident 1) when Resident 1 requested her medical records on 9/21/23. This failure was not the standard of practice according to the facility's policy and procedure (P&P) titled, Release of Information. Findings: During an interview on 10/6/23 at 12:23 p.m., with Resident 1, Resident 1 stated she requested her medical records on 9/21/23 and received her requested documents on 10/2/23. During a review of Resident 1's Medical Record Request form (MRR), dated 9/21/23, the MRR from indicated, Resident 1 and the Medical Records Director signed the MRR on 9/21/23. During a concurrent interview and record review on 10/6/23 at 11:55 a.m., with Medical Records Director (MRD), Resident 1's MMR and the facility's P&P titled, Release of Information, were reviewed. The MMR indicated Resident 1 requested the release of her medical records on 9/21/23. MRD stated Resident 1's medical records were delivered to Resident 1 a week later after the request. MRD stated he…

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 dietetic services observations, interviews, and record reviews, the facility failed to ensure the Registered Dietitian conducted effective oversight of the food and nutrition department in accordance with the facility's executed contract and professional standards of practice. These failures had the potential to result in ineffective and inadequate directing of the day-to-day Food and Nutrition operations to ensure the nutritional needs for 46 of 48 sampled residents were met in a safe and sanitary manner. (Cross reference: F692, F802, F803, F804, F805, F806 and F812) Findings: During the initial kitchen tour on 4/10/23, beginning at 9:32 AM, observations and concurrent interviews were conducted with the Dietary Manager (DM) regarding overall kitchen sanitation and cleanliness. There were multiple areas and equipment in the kitchen that were not clean including but not limited to: a. The prep sink (sink used to preparation of foods) did not have an air gap (a fixture that provides back-flow prevention). b. Several places in the kitchen covered with brown, grey and black…

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

Based on observations, interviews and record reviews, the facility failed to ensure that dietary staff safely and effectively carried out the functions of food and nutrition services when: 1. One of the dietary staff and the Dietary Manager did not know the right location to check dish machine sanitizer. This failure had the potential to cause foodborne illness for 46 out of 48 sampled residents who received food from the kitchen. 2. One of the dietary staff and the Dietary Manager did not know the proper steps for washing dishes in two-compartment sinks. This failure had the potential to cause foodborne illness for 48 out of 50 sampled residents who received food from the kitchen. 3. The AM [NAME] did not follow pureed bread recipe for preparing pureed bread during lunch on 4/11/23. This failure result in 12 out of 12 sampled residents who were on pureed bread received less nutritive value and unappetizing pureed bread. (Cross referred 803) 4. Dietary staff served 3-inch-long green bean salad for Residents on Dysphagia Mechanically Altered diet (a diet with food texture need to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen when: 1. There was no air gap (a fixture that provides back-flow prevention. When installed and maintained properly, the air gap works to prevents drain water from backing up into the sink and possibly contaminating the area used for washing food) under the prep sink (sink used to preparation of foods). 2. There was brown, grey and black debris observed several places in the kitchen: exit door to hallway, on the insect lamp, two ventilator's fans inside milk refrigerator, the exit door to the dining hall, in the dry storage room's storage shelves and door, the air conditioning and heating unit next to hand washing sink, the window, fans, ventilator in dishwashing area 3. There was calcium buildup on the dishwasher and ice machine's curtain. 4. There can opener and can opened based was unsanitary. 5. There was a red bucket filled with cleaning solution stored…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to provide a homelike environment for the residents in rooms 17, 3,10, and 26, and those using the dining room when: 1. Resident rooms 17, 3, 10, and 26 were in disrepair. 2. The noise level in the dining room was too loud. These failures resulted in an unhomelike atmosphere. FINDINGS: 1. During a concurrent observation and interview on 4/11/23, at 9:51 a.m., in room [ROOM NUMBER] with Resident 48, Resident 48 stated, she had been in the facility almost 7 months. Resident stated the entire building needed repair. Resident stated, there was tile coming up, sheet rock exposed, paint in bad condition over the entire building, and the dining room needed to be redone. During an observation on 4/10/23, at 10 a.m. in room [ROOM NUMBER], the bathroom was missing the paper towel dispenser from the wall and the wall had been damaged from where the paper towel dispenser had previously been. During a resident council meeting, on 4/11/23, at 3:28 p.m., the residents…

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 effective interventions to meet the needs of residents and in accordance with standards of practice for one of five sampled residents, Resident 41, when Resident was diagnosed with leg varicose veins and nursing staff did not implement every two hour repositioning and range of motion. This failure resulted in Resident 41 acquiring new venous ulcers, delay in wound healing, pain, suffering, and decreased mobility. This failure also had the potential to result in infection. Findings: During a review of Resident 41's admission Face Sheet (AFS-document containing resident demographic information and medical diagnosis), dated 4/13/23, the AFS indicated, Resident 41 was admitted to the facility on [DATE]. Resident 41's diagnoses included .Type 2 Diabetes Mellitus (high blood sugar) .Muscle weakness (lack of muscle strength) .Chronic atrial fibrillation (an irregular, often rapid heart rate) .Non-pressure chronic ulcer (wound due to lack…

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 a comprehensive systemic approach, to ensure effective monitoring systems to maintain acceptable parameters of nutritional status for one of five sampled residents (Resident 41). The facility failed to ensure a Registered Dietitian (RD) provided nutritional interventions despite documented meetings acknowledging weight loss. The facility failed to ensure RD effectively monitored nutrition interventions, after an unplanned severe and continuous weight loss of 13.6-pound (lbs.) 8 percent weight loss in five months from 12/6/22-4/2/23. There was no plan of care to address the weight loss and prevent further weight loss. Findings: 1. During a review of resident 41's medical record, titled, admission Face Sheet (AFS-document containing resident demographic information and medical diagnosis), dated 4/13/23, the AFS indicated Resident 41 was admitted to the facility on [DATE]. The AFS indicated Resident 41's diagnoses included .Type 2…

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

Based on observation, interview and record review, the facility failed to post the total number of licensed and unlicensed staff and actual hours worked per shift within two hours of the start of each shift in accordance with the facility policy and procedure when the posting did not represent actual hours worked but projected hours. This failure resulted in residents and visitors not having the benefit of viewing the actual hours and total number of staff providing care per shift and possibly not meeting the needs of the residents FINDINGS: During a concurrent observation and interview, on 4/12/23, at 12:07 p.m., the bulletin board on C hall was observed with the Administrator (ADM) and Director of Staff Development (DSD). The ADM indicated, the projected hours of licensed and unlicensed personnel was posted instead of actual hours. The DSD stated she had been posting the projected hours and was unaware she was supposed to port the actual hours. ADM stated, per policy, they were supposed to post the actual hours within 2 hours of the shift starting. During a review of the…

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

Based on dietary production observation, interviews and record reviews, the facility failed to ensure the pureed bread recipe was followed by an A.M. [NAME] for lunch on 4/11/23. This failure result in twelve out of twelve sampled residents (Residents' 3, 4, 18, 21, 22, 24, 25, 28, 34, 152, 155, 352) who on pureed bread received less nutritive value and unappetizing pureed bread. This failure had potential result in negatively impact the residents' nutritional status and further compromising residents' medical status. Finding: ( Cross reference 801, 802) During a concurrent observation and interview on 4/11/23, at 11:51 a.m., with an AM [NAME] (CK), in the kitchen, CK was observed pouring unmeasured hot water while preparing pureed bread. CK confirmed she was adding unmeasured hot water while preparing pureed bread. During a concurrent observation and interview on 4/11/23, at 1:04 p.m., with the Dietary Manager (DM) and District Dietary Manager (DDM), at dining room, a test meal was performed for food temperature and palatability (taste and/or flavor) of the regular and puree diet…

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

Based on observation, interview, and record review, the facility failed to follow its policy on Food: Quality and Palatability to provide appetizing food at appropriate temperatures according to residents' preferences for ten of 46 sampled residents (Residents' 6, 20, 23, 33, 39, 45, 48, 49,155, 353). This failure had the potential risk to decrease nutritional intake and affect the residents' nutritional status and further compromising residents' medical status. Finding: During an interview on 4/10/23, at 9:56 a.m., with Resident 48, Resident 48 stated, Food is not appealing, no taste, no options, no presentation, it is not good. That is my main concern. During an interview on 4/10/23, at 10:27 a.m., with Resident 39, Resident 39 stated, Food does not taste good. During an interview on 4/10/23, at 12:55 p.m., with Resident 49, Resident 49 stated, There is no taste of provided foods and soup is always cold. During an interview on 4/10/23, at 3:05 p.m., with Resident 155, Resident 155 stated, provided foods tasted horrible. During an interview on 4/10/23, at 3:30 p.m., with Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure the appropriate food and beverage textures were provided as evidence by: 1. Three of six sampled residents (Residents'11, 30, 42 ) received Dysphagia Mechanically Altered diet (a diet with food texture need to chop up or ground into small piece for residents who have limited chewing and swallowing ability) received 3-inch-long green bean salad for lunch on 4/10/23. 2. Resident 25 was ordered with honey thick consistency, was served unmixed regular consistency coffee with lumpy thickeners during lunch on 4/10/23. 3. Twelve of twelve sampled residents (Residents' 3, 4, 18, 21, 22, 24, 25, 28, 34, 152, 155, 352) ordered Dysphagia Puree diet (a diet with food texture need to blend until smooth into mashed potatoes consistency for residents who have severe chewing and/or swallowing ability) received chunks meatball during lunch on 4/11/23. 4. Seven out of seven sampled residents (Residents' 3, 22, 24, 25, 34, 155, 352) ordered…

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 maintain medical records in accordance with accepted professional standards and practices that are complete, accurately documented and readily accessible for three of six sampled residents (Residents' 22, 32 and 103) when: 1. Resident 22's copy of Physician Orders for Life-Sustaining Treatment (POLST) form (a legal document that specifies the type of care a resident's treatment and services would like in an emergency life threatening medical situation) was signed and dated thirteen months by the Medical Doctor (MD) after it was prepared and readily available as part of Resident 22's current medical records. 2. Resident 32's copy of POLST was incomplete and readily available as part of Resident 32's current medical record. 3. Resident 103's copy of POLST was inaccurate and readily available as part of Resident 103's current medical record. These failures had the potential risk for Residents' 22, 32 and 103's decisions regarding their healthcare and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement and maintain an effective infection control and prevention program to provide a safe, sanitary and comfortable environment to help prevent infections for seven of 50 sampled residents (Residents 6, 22, 41, 31, 33, 49, 353, ) when: 1.Bedpans were observed placed on the top of the two toilets (that are shared with three other residents). One bedpan was observed in Resident 31 restroom, and one bedpan was observed in Resident 33's restrooms. Resident 31's toilet seat contained a brown substance. 2. Resident 49 had concerns of smell and cleanliness of her restroom. 3. Facility did not follow policy to replace trash receptacle liners, when trash receptacle liners (used to keep the inside of trash receptacle clean and to easily contain and transport trash from trash receptacles) were missing from Resident 353, Resident 6 and Resident 22's room and Resident 41 restroom. These failures had the potential to result in cross contamination…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents were treated with respect and dignity and in an environment that promotes and enhances quality of life for three out of 11 sampled residents (Residents' 25, 28 and 156) when: 1. Residents' 25 and 28 were not given coffee as requested and watched other residents in the dining room drink coffee. 2. Resident 156 waited for her lunch tray while watching other residents on the same table ate. These failures violated Residents' 25, 28 and 156 the right to be offered a dignified dining experience. Findings: 1. During an observation on 4/10/23, at 11:40 a.m., in the dining room, Resident 28 was observed sitting across the table from another resident. Resident 28 observed requesting coffee from Certified Nursing Assistant (CNA) 7, and Resident sitting across Resident 28 was heard requesting coffee for Resident 28. Resident 28 was not served coffee and watched other residents in the dining room drink coffee. During a review 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 ensure a physician Informed Consent (a process in which residents are given important information of the possible risk and benefits of the use of psychoactive medications) for the use of psychotropic medications (medication capable of affecting mind, emotions, and behavior) for one of three sampled residents (Resident 20) was obtained when Resident 20 was administered three psychotropic medications without an informed consent. These failures resulted for Resident 20 to be administered with psychotropic medications and not fully informed of the risk and benefits and did not have the knowledge to make an informed decision which could place Resident 20 at risk for negative side effects as he was not informed of the side effects. Findings: During a concurrent observation and interview on 2/10/23, at 4:10 p.m., in room [ROOM NUMBER], Resident 20 was lying in bed watching TV. Resident 20 stated he had been in the facility for three weeks for…

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

Based on observation, interview, and record review, the facility failed to ensure one of eight sampled residents (Resident 13) had their adaptive equipment when Resident 13 was put in the wrong wheelchair. This failure had the potential to result in Resident 13 experiencing an avoidable accident and injury. FINDINGS: During a concurrent observation and interview on 4/12/23, at 4:30 pm, Resident 13 was in the hallway, in a wheelchair, holding a plastic urinal, and calling for help. Resident 31 put his call light on for Resident 13 and started yelling Help!. Business Office Manager (BOM) answered the calls for help. Resident 13 stated he needed help getting up in his chair and was afraid to fall since he's fallen before out of his chair. BOM retrieved a nursing assistant to help. During a record review of Resident 13's Brief Interview Mental Status (BIMS)(used to screen and identify the ability to think and remember), dated 2/24/23, the BIMS indicated Resident 13 had a score of 11 which indicated moderate cognitive impairment. During a concurrent interview and record review on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the Minimum Data Set assessment (MDS-assessment of physical and psychological functions and needs) accurately reflected resident's health and functional status for one of three sampled residents (Resident 20) when Resident 20's smoking habits was inaccurately coded on the MDS assessment. This failure had the potential to result in Resident 20's care needs not met. Findings: During a concurrent observation and interview on 4/10/23, at 4:10 p.m., with Resident 20 in his room, Resident 20 was observed laying in bed watching TV. Resident 20 stated he had been in the facility for three weeks to work with therapy. Resident stated he is a smoker and never stopped smoking since 1991, goes outside to smoke everyday. Resident 20 stated they have a schedule to go outside to smoke and he goes outside to smoke everyday. Resident 20 stated when he was admitted in the facility the nursing staff did not asked him if he smoked because the staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents who are receiving dialysis (the process of removing waste products and excess fluid from the body when the kidneys are not able to adequately filter the blood) treatment received services consistent with professional standards of practice for Resident 42 when Resident 42 had a water pitcher on the bedside table within Resident 42's reach for three consecutive days and in charge nurse did not monitor and record daily fluid intake. This failure placed Resident 42's care needs to go unmet and had the potential to result in fluid overload. Findings: During a review of Resident 42 's Face Sheet (a summary of important information regarding a patient which include patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the face sheet indicated Resident 42 was readmitted to the facility on [DATE] with a diagnosis which included End Stage Renal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure resident's food preference were honored for one of 50 sampled residents (Resident 49) when Resident 49 and her family told staff that Resident 49 disliked chopped foods. No food upgrade options were provided for Resident 49, despite informing the staff that she did not want tomatoes soup, yet she still received it on 4/12/23 during dinner. This failure resulted in Resident 49 decreased food intake with an unplanned 1.6-pound weight loss from 1/31/23 until 4/9/23 which further compromised Resident 49's nutritional and medical status. Findings: During a concurrent interview and meal tray ticket reviewed on 4/10/23, at 11:34 a.m., with Resident 49, Resident 49 stated, I told staff a lot of times, I do not like chopped foods, but they still give me chopped foods. Resident 49 stated, I do not know what kind of diet I am on. I got teeth, I can chew. Resident 49 stated, My son has told staff that I do not like chopped foods and requested…

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 dispose of garbage and refuse properly when trash was found outside on the floor surrounding the dumpster. And the lid of the dumpster was not close properly. This failure had the potential to attract pests and rodents. Findings: During an observation on 4/10/23, at 9:03 a.m., one of three dumpsters which was brown color, had trash, clear gloves and a glass bottle on the ground around the brown dumpster. During an observation on 4/11/23, at 8:10 a.m., observed one of the brown dumpster lids was not close and there was trash, blue and clear used glove on the ground around the brown dumpster. During a concurrent observation and interview on 4/11/23, at 8:26 a.m., with the Dietary Manager (DM), in front of the dumpster, the DM confirmed one of the brown dumpster lids was not close and there was trash, blue and clear used glove on the ground around the brown dumpster. The DM stated, the brown dumpster's lid should be close and there was supposed no trash around the brown dumpster. During an interview on 4/11/23 at…

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