Harvest Crossing Post Acute

Based on observation, interview, and record review, the facility failed to ensure one resident (Resident 26) in a sample of 24 was treated with dignity and respect when staff stood over Resident 26 while assisting with breakfast on 11/19/24. This failure had the potential to negatively impact Resident 26's psychosocial well-being. Findings: A review of Resident 26's admission Record, indicated Resident 26 was admitted to the facility with diagnoses which included alzheimer's disease (a gradual decline in memory, thinking, behavior, and social skills), and dementia (a decline in memory and other thinking skills severe enough to reduce a person's ability to perform daily activities). During a concurrent observation and interview on 11/19/24, at 7:45 a.m., Certified Nursing Assistant (CNA) 1 assisted Resident 26 with breakfast while standing over her at her bedside. Resident 26's breakfast tray was noted on the bedside table next to her bed. CNA 1 held a spoon with food up to Resident 26's mouth in one hand, and a carton of milk containing a straw in her other hand. Resident 26 pushed…

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 of 24 sampled residents (Resident 31) needs were accommodated when Resident 31 did not have a working call light (a device used by residents to call for assistance). This failure increased the risk for psychosocial and/or physical harm if Resident 31 was unable to contact staff for her needs. Findings: A review of Resident 31's clinical record titled, admission Record, indicated Resident 31 was admitted to the facility with diagnoses including osteoarthritis of hip (causes pain and stiffness of the hips) retention of urine (inability to empty the bladder completely), and stress incontinence (when movement or activity puts pressure on the bladder, causing urine to leak). During a concurrent observation and interview on 11/18/24, at 10:42 AM, the call light system in Resident 31's room was noted not to be working, confirmed by certified nursing assistant (CNA) 8. CNA 8 confirmed Resident 31 did not have a bell (a bell used to summon an attendant or give an alarm or notice) in her room. CNA 8 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.

Based on observation, interview, and record review, the facility failed to maintain residents' right to privacy of personal information, when resident meal tickets were discarded in the facility kitchen garbage bin for a census of 87. This failure increased the risk of unauthorized access of residents' personal and medical records. Findings: During a concurrent observation and interview on 11/20/24 at 8:50 PM with Dietary Aide (DA) 1 in the dishwashing area, DA 1 was observed throwing residents' meal tickets left on the meal trays into the garbage bin. DA 1 confirmed the observation. During an interview on 11/20/24 at 8:52 AM with the Interim Certified Dietary Manager (ICDM) in the dishwashing area, the ICDM confirmed DA 1 threw the residents' meal tickets into the garbage bin. The ICDM also confirmed that multiple residents' meal tickets were returned with their meal trays to the kitchen. The ICDM stated they used to shred the tickets but somehow, they reverted to throwing them back in the garbage bin. A review of a resident meal ticket indicated the meal ticket contained…

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 a safe, clean, and comfortable living environment for 2 of 24 sampled residents (Resident 340 and Resident 31), when Resident 340's and Resident 31's floor vents (provides cold and warm air) were full of dust and debris. This failure had the potential to negatively impact Resident 340's and Resident 31's homelike environment and their health. Findings: 1. A review of Resident 340's clinical record titled, admission RECORD, indicated Resident 340 was admitted to the facility with diagnoses including pleural effusion (fluid build up between the lungs and the chest) and other symptoms of the heart and lungs. A review of Resident 31's clinical record titled, admission RECORD, indicated Resident 31 was admitted to the facility with diagnoses including cough and a history of contracting Covid-19. During a concurrent observation and interview on 11/18/24 at 3:28 PM with the Maintenance Director (MD), the MD confirmed the floor vents were dirty in Resident 340's and Resident 31's room. The vents were…

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, and ensure the completion of, a Pre-admission Screening and Resident Review (PASRR, a required assessment for individuals with mental illness, intellectual or developmental disabilities, or related conditions, so that a determination of need, appropriate setting, and a set of recommendations for services to be included in the individual's plan of care is provided) for two of twenty-four sampled residents (Resident 60 and Resident 72), when, 1. Resident 72's level I PASRR did not reflect his diagnosis of autism (a disorder that affects how people interact with others, communicate, learn, and behave) or his use of psychotropic medications (drugs that treat symptoms of psychosis, such as hallucinations, delusions, and thought disorders) which resulted in a level II PASRR (mental health screening for additional services) never being completed; and, 2. Resident 60 had a positive level I PASRR screening and the required level II PASRR…

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

Based on interview and record review, the facility failed to ensure one resident on fluid restriction (Resident 7), out of 24 sampled residents, physician was notified when Resident 7's fluid intake exceeded the restricted amount specified by the physician. This failure had the potential to result in a decline in Resident 7's health and well-being. Findings: A review of Resident 7's admission Record indicated that Resident 7 was admitted with diagnoses which included chronic obstructive pulmonary disease (COPD, a lung disease), chronic congestive heart failure (the heart does not pump blood as well as it should), and chronic respiratory failure (difficulty breathing). During an interview with Resident 7 in her room on 11/18/24 at 11:40 a.m., Resident 7 stated she was on fluid restriction. Resident 7 stated she purchased drinks which she stored in her room and did not drink the fluids that came on her meal tray. During a review of Resident 7's Physician Order Summary, dated 11/10/24, the Physician Order Summary indicated, .monitor intake and output every shift .fluid restriction1…

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 assist one of twenty-four sampled residents (Resident 72) with a referral to receive outside dental services when: 1. Resident 72 requested new dentures during a dental exam on 4/11/24; and, 2. Resident 72 was unable to tolerate dental services provided within the facility on 7/26/24, 8/27/24, and 9/6/24. This failure had the potential to delay Resident 72 from receiving dental services and obtaining dentures and could have led to complications related to dental and nutritional needs for Resident 72. Findings: Review of Resident 72's admission RECORD, indicated, Resident 72 was admitted to the facility with diagnoses including autistic disorder (a brain and developmental disorder that affects how people interact with others, communicate, learn, and behave), anxiety disorder (intense, excessive and persistent worry and fear about everyday situations), adult failure to thrive (a state of decline to include weight loss, decreased appetite, poor nutrition, and inactivity), cognitive communication deficit…

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 education to a resident about Pneumococcal (a serious bacterial infection that can cause respiratory illness) vaccines for one of five sampled residents (Resident 23) prior to administration. This deficient practice violated Resident 23's right to make an informed choice to receive or not receive the pneumococcal vaccine. Findings: During a concurrent interview and record review on 11/19/24 at 11:41 AM, with the Infection Preventionist (IP), Resident 23's Immunization Report, dated 12/19/24 was reviewed. The IP confirmed Resident 23's Immunization Report indicated that education was not provided to Resident 23 prior to administration of Pneumovax (a vaccine that can prevent pneumococcal disease) on 11/25/2021. The IP stated that residents would not understand what vaccines they were taking if education was not provided. During an interview on 11/20/24 at 9:19 AM, with Resident 23, Resident 23 stated she did not understand the risks and benefits of the Pneumococcal vaccine. During an interview on 11/20/24 at 11:52…

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

Based on observation, interview, and record review, the facility failed to ensure a functioning call light system (system/device used by residents to call staff for assistance) was in place for two of twenty-four sampled residents (Resident 31 and Resident 45) when, Resident 31 and Resident 45's call lights were not working and an alterantive means to call for assistance was not provided to the residents. This failure had the potential to result in Resident 45 and Resident 31 being unable to call staff for help when needed and their needs not being met. Findings: 1a. During a review of Resident 31's undated clinical record titled, admission RECORD, indicated Resident 31 was admitted to the facility with diagnosis of, but not limited to, bilateral primary osteoarthritis of hip (causes pain and stiffness of the hips; can make it hard to do everyday activities like bending over to tie a shoe or rising from a chair) retention of urine, and stress incontinence (happens when movement or activity puts pressure on the bladder, causing urine to leak). During a concurrent observation and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide staff education regarding autism (a brain and developmental disorder that affects how people interact with others, communicate, learn, and behave) to ensure quality care was delivered for one of one residents (Resident 72) with a diagnosis of autism. This failure resulted in facility staff being untrained in caring for a resident with autism and Resident 72 not receiving specialized care and services which recognized the signs of autism and incorporated a system of responding to his behavioral health needs, which had the potential to result in escalating behaviors for Resident 72 and psychosocial distress. Findings: Review of Resident 72's admission RECORD, indicated, Resident 72 was admitted to the facility with diagnoses including autistic disorder, anxiety disorder (frequently have intense, excessive and persistent worry and fear about everyday situations, adult failure to thrive (describes a state of decline to include weight…

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 1 of 24 sampled residents (Resident 6) received treatment in accordance with quality care when, Resident 6 had left knee swelling, and exhibited signs of pain via facial grimacing and screaming during care provided to her by staff and, a. Nursing staff did not adequately assess Resident 6's source of pain and provide pain management based on Resident 6's level of pain; and, b. There was a delay in obtaining an x-ray result of Resident 6's left knee, ordered to provide information as to the source of Resident 6's pain. These failures had the potential for Resident 6 to experience prolonged pain and suffering and may have resulted in a delay of treatment and other complications related to her fractured femur (thigh bone) and dislocated left knee. Findings: Review of Resident 6's admission RECORD, indicated Resident 6 was admitted to the facility during the summer of 2024, with diagnoses including dementia (progressive loss of intellectual…

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 notice of a facility-initiated discharge to the appropriate parties and provide all the required information on the 30-Day Notice of Transfer or Discharge, (a document given by the facility to the resident indicating an upcoming transfer or discharge from the current facility to another facility/home) that was given to Resident 1 when: 1. The facility did not inform the Office of the State Long-Term Care (LTC) Ombudsman (a government appointed person who actively supports the rights of the residents) on the same day the facility served Resident 1 with a 30-Day Notice of Transfer or Discharge form, 2. The location that Resident 1 was transferred to was not listed on the 30-Day Notice of Transfer or Discharge form; and, 3. The appeal (an application to the courts for a decision to be reversed) rights information was not correct on the 30-Day Notice of Transfer or Discharge form. These failures could have resulted in Resident 1 not having access to an advocate (a person appointed to look out for the best interests 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 4. Review of Resident 16's admission Record indicated Resident 16 was admitted to the facility in October 2023, with multiple medical diagnoses that included benign prostatic hyperplasia (a condition in men in which the prostate gland is enlarged). During an observation on 11/7/23, at 9:56 a.m., in Resident 16's room, Resident 16 was observed to be sitting at the edge of his bed and was noted with an indwelling urinary catheter. Review of Resident 16's care plan failed to show a urinary catheter care plan was developed upon admission. During an interview on 11/8/23, at 3:23 p.m., with LN 14, LN 14 confirmed Resident 16 did not have a urinary catheter care plan. During a concurrent interview and record review on 11/9/23, at 10:51 a.m., with the DON, the DON confirmed Resident 16 did not have a urinary catheter care plan. The DON stated there should be a care plan in place. The DON further stated if there was no care plan in place, interventions could be missed and could cause a urinary tract infection. During 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.

Based on interview, and record review, the facility failed to ensure 1 of 21 sampled residents (Resident 10) received a required mental health evaluation for an identified mental disorder. This failure had the potential for Resident 10 's access to specialized treatment, care, and services for an identified mental disorder to be denied. Findings: During a record review of Resident 10's Preadmission Screening and Resident Review [PASRR- a comprehensive evaluation tool used to identify persons with mental illness, intellectual or developmental disabilities] Level 1 Screening Evaluation, dated 10/7/21, indicated Resident 10 had a diagnosed mental disorder for which Resident 10 was prescribed psychotropic medications (drugs that affect a person's mental activity, mood, and behavior.) Review of a letter from the State of California Department of Health Care Services (DHCS), dated 10/7/21, indicated a PASRR Level II Mental Health Evaluation(PASRR II- a comprehensive evaluation that was required to confirm the diagnosis noted in the Level I screening and identify the need for specialized…

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 an accurate psychiatric (mental health) diagnosis was documented in the medical records for 1 out of 21 sampled residents (Resident 13) based on standards of practice. This failure could result in inaccurate treatment, care and monitoring of Resident 13's psychotropic medication (medications that affect mood or behavior). Findings: Review of Resident 13's medical record, titled Order Summary Report, (a list of all doctor orders and medical conditions), dated 11/8/23, indicated Resident 13 was on multiple mind-altering medications including Depakote (or Divalproex, a medication used to treat seizure and regulate the mood) for bipolar disorder (a chronic mental illness that fluctuated between depression and anxiety) as follows: Depakote Oral Tablet .250 MG (MG means milligram, a unit of measure); Give 1 tablet by mouth three times a day for bipolar disorder m/b (manifested by) yelling and combative behavior . Review of Resident 13's medical record titled, History and Physical, (a summary of medical condition upon…

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 of 21 sampled residents (Resident 4) was assisted in gaining access to hearing services when Resident 4's physician order to be evaluated by an audiologist (a person with specialized training in the science and medicine of hearing and balance) was not acted upon. This failure had the potential for Resident 4 to not effectively communicate and express her needs and negatively impact Resident 4's quality of life. Findings: A review of Resident 4's admission Record indicated Resident 4 was admitted to the facility in May 2023. A review of Resident 4's MDS (minimum data set- a resident assessment tool) dated 8/14/23, indicated, a brief interview for mental status (BIMS) score of 14. A score of 13-15 indicated intact memory. During an interview on 11/6/23, at 2:38 p.m., with Resident 4, Resident 4 stated she was hard of hearing, and she had no hearing aids. During an interview on 11/6/23, at 2:47 p.m., with Certified Nursing Assistant (CNA) 5, CNA 5 confirmed Resident 4 had no hearing aids. CNA 5 also…

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 preventative care and treatment consistent with professional standards of care for one of six sampled residents with pressure injuries (Resident 63) when Resident 63's pressure injury (PI- an injury to skin and underlying tissue resulting from prolonged pressure) plan of care of the right knee PI was not followed. This failure had the potential for Resident 63's right knee pressure injury to worsen and develop complications. Findings: During a concurrent observation and interview on 11/7/23, at 9:49 a.m., in Resident 63's room, Resident 63 was observed laying on her right side in bed. Resident 63 had severe bilateral lower extremity contractures (the lack of full, passive range of motion (ROM) of limbs due to joint, muscle or soft tissue limitations). Resident 63 stated she did not get out of bed because she could not tolerate sitting up in a chair. During a concurrent observation and interview on 11/7/23, at 11:09 a.m., in Resident 63's room, Resident 63's right knee PI dressing change was observed.…

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, the facility failed to ensure 1 of 21 sampled residents (Resident 16) who was admitted to the facility with an indwelling urinary catheter (foley catheter, tube inserted into the bladder to drain urine) had a physician order for the catheter. This deficient practice had the potential for Resident 16 to have an increase in recurrent UTI's and could cause actual harm. Findings: Review of Resident 16's admission Record indicated Resident 16 was admitted to the facility in October 2023 with multiple medical diagnoses that included benign prostatic hyperplasia (a condition in men in which the prostate gland is enlarged) and urinary tract infection. Review of Minimum Data Set (MDS- an assessment tool used to guide care) dated 10/15/23, Section O of the MDS indicated, Resident 16 had an indwelling urinary catheter upon admission. During an observation on 11/7/23, at 9:56 a.m., in Resident 16's room, Resident 16 was observed to be sitting at the edge of his bed and was noted with an indwelling urinary catheter. During an interview on 11/8/23,…

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.

Based on observation, interview, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for 2 of 4 sampled residents with a peripherally inserted central catheter (PICC, a type of long catheter that is inserted through a peripheral vein, often in the arm, passed through to larger veins near the heart and used to give fluids, nutrition, drugs, or other treatments) line (Resident 79, and Resident 80) when: 1.Resident 79's PICC line dressing was not changed at least weekly; and 2. Resident 80's PICC line dressing was not changed at least weekly. These failures had the potential to increase the risk of developing an infection for Resident 79 and Resident 80. Findings: 1. A review of Resident 79's admission Record indicated, Resident 79 was admitted in 2023, with diagnoses including pneumonia (a respiratory infection that affects lungs), sepsis (body's extreme response to an infection) and diabetes mellitus (a chronic condition that affects the way the body processes blood sugar). During a concurrent observation and…

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

Based on observation, interview, and record review, the facility failed to ensure timely availability of medications for three of twenty-one sampled residents (Resident 29, Resident 40, and Resident 68) when: 1. Resident 29's zonisamide (medication used to prevent and control seizures) 50 mg (milligram, unit of measure) dose was not available for administration on 11/6/23. 2. Resident 40's neomycin/polymyxin B/hydrocortisone otic solution (medication used to treat ear infections) was not available for administration on 11/6/23. 3. Resident 68's lorazepam (medication used to treat anxiety) was not available for administration on 11/6/23. These failures had the potential to cause Resident 29 an increased risk of seizures, Resident 40's infection to worsen and Resident 68 to experience symptoms of anxiety and distress. Findings: 1. Resident 29 was admitted to the facility in the fall of 2020 with diagnoses which included epileptic seizures (disease characterized by recurrent seizures). A review of Resident 29's medication administration record (MAR), dated November 2023, indicated,…

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

Based on interview, and record review, the facility failed to ensure safe use and monitoring of blood thinner (medication with high risk of bleeding) and cardiac (heart) medications for 1 out of 21 sampled residents (Resident 49) based on standards of practice on safe use of high-risk (drugs with heightened risk of causing significant patient harm due to side effect profile) medications when: 1. Resident 49 was on four different blood thinning medications without daily side effect monitoring; and, 2. Resident 49 was on duplicate cardiac medications known as beta blockers (beta blocker medications are a class of drugs that cause the same additive effect on the heart) for the same indication with additive effect on heartbeat and blood pressure. These failures could have resulted in an additive medication side effects including bleeding or excessive lowering of Resident 49's heartbeat and blood pressure. Findings: 1. Review of Resident 49's medical record, titled Order Summary Report, (a list of all doctor orders and medical conditions), dated 11/8/23, the record indicated Resident 49…

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 medication administration error rate was less than 5 percent (%, a number or ratio indicating parts per hundred) when 7 medication errors occurred out of 33 opportunities during medication administration observation for 4 out of 17 residents (Resident 23, Resident 29, Resident 40, and Resident 68). As a result of these failures, the facility's medication administration error rate was 21% which could contribute to unsafe medication use and not following the doctor's orders. Findings: 1. During an observation on 11/6/23, at 8:07 AM, licensed nurse (LN) 5 prepared Resident 23's medications for administration. LN 5 administered Vitamin D3 (a vitamin essential for bone strength) 125 MCG (microgram, a unit of weight) to Resident 23 along with his other medications. A review of Resident 23's Medication Administration Record, (MAR) dated November 2023, indicated, .Vitamin D3 Oral Tablet 50 mcg .one time a day for supplement . During an interview on 11/7/23, at 1:52 PM, LN 5 confirmed that Resident 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 observation, interview, and record review, the facility failed to ensure safe medication storage practices for a census of 80 when: 1. Unlabeled prescription medications were stored in the East Hall treatment cart, 2. An expired bottle of vitamin B6 (vitamin supplement) was stored in a [NAME] Hall medication cart, 3. Expired normal saline (saltwater solution) syringes were stored in the East Hall emergency supply cart and expired normal saline vials were stored in the [NAME] Hall intravenous (IV, administered in the vein) emergency supply cart; and, 4. Unpackaged, unlabeled IV fluid bags and IV fluid bags labeled with the names of discharged residents were stored in the [NAME] Hall emergency IV supply cart. These failures had the potential for the use of medications that were expired and the possibility for a medication to be used for the wrong resident. Findings: 1. During a concurrent observation and interview on [DATE], at 3:12 PM, licensed nurse (LN) 11 confirmed there were two unlabeled…

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 safe food production when: 1. Multiple food items were found undated and were not labeled with an open date and/or use by date in the refrigerator, freezer, and the dry storage area (foods that do not require to be kept cold), 2. Multiple expired food products were not removed from the kitchen and were available for use, 3. Cleaned, ready to use water pitchers with lids were placed on an unsanitary wooden shelf; and, 4. A clear pitcher containing orange colored liquid was leaking onto the shelf and the liquid was dripping onto the bottom shelf that contained a tray with food ready to be served. These failures had the potential to expose 78 residents of a census of 80 to food borne illnesses (illnesses caused by the ingestion of contaminated food or beverages). Findings: 1.a. During a concurrent observation and interview on 11/6/23, at 8:46 a.m., with the Dietary Manager (DM) in the kitchen, the DM confirmed five bags of 5 lb (pound, a unit of weight) ground coffee were not labeled with a received date…

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 effectively coordinate nursing care with the hospice (specialized health care that focuses on the providing care to terminally ill residents) agency for 1 of 13 sampled residents (Resident 68) receiving hospice care when Resident 68 did not receive their scheduled anti-anxiety medicine. This failure resulted in Resident 68 not receiving five scheduled doses of Lorazepam (anti-anxiety medication) resulting in Resident 68 experiencing distress, agitation, and anxiety. Findings: During a review of the document titled, admission RECORD, (a document that contains the resident's demographic information) indicated, Resident 68 had an admitting diagnosis of Malignant Neoplasm (cancer) of the left breast, chronic pain, and palliative care (specialized medical care that focuses on providing relief from pain). A review of Resident 68's clinical record titled, [HOSPICE COMPANY NAME] Hospice Care Visit Notes, dated 3/13/23, indicated, Resident 68 was admitted to hospice with a diagnosis of breast cancer. During 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.

Based on observation, interview, and record review, the facility failed to implement infection control practices with a census of 80 when: 1. Resident 13 was on transmission based precautions (TBP, precautions implemented based upon means of transmission to prevent or control infections) and no TBP signage on the use of personal protective equipment (PPE), and an isolation cart (cart containing supplies such as gown, gloves, mask, and/or face shield) were not placed outside of Resident 13's room, 2. Facility failed to follow safe infection control practices for cleaning and disinfecting shared glucometers (a device used to measure blood sugar) in-between resident care for Resident 80 and Resident 50; and, 3. Facility failed to prevent contamination of multi-dose medication containers when oral syringes were returned to storage after resident use for Resident 41 and Resident 63. These deficient practices had the potential to result in the transmission and spread of infection in the facility, leading to negatively impact the residents' health and well-being. Findings: 1. During an…

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 appropriate use of an antibiotic medication (used to treat bacterial infections) within the antibiotic stewardship program, for one of seven residents (Resident 291) when Resident 291's antibiotic order did not have a stop date. This failure increased Resident 291's risk for an infection with bacterial organisms resistive to certain antibiotics (MDRO; multidrug-resistant organisms, germs that are resistant to many antibiotics) in the facility. Findings: Review of Resident 291's Order Summary Report, indicated Resident 291 had a physician order for Cephalexin [antibiotic medication used to treat bacterial infection] Oral Capsule 500 MG [milligram, a unit of measurement] .Give 1 capsule by mouth one time a day for UTI [urinary tract infection] prophylaxis [a treatment taken to prevent a disease] .Start Date .11/3/23 . There was no stop date listed. During a concurrent interview and record review on 11/8/23, at 3:44 p.m., with Licensed Nurse (LN) 11, Resident 291's physician orders, progress notes, and care plan were…

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 of 21 sampled residents (Resident 68) had a functioning call light (visual cue that a resident needs assistance) at the bedside. This failure had the potential for Resident 68's needs not being met in a timely manner and placed Resident 68 at risk for injury (falls) related to getting out of bed to find assistance. Findings: During a review of the document titled, admission RECORD, (a document that contains the resident's demographic information) indicated, Resident 68 had an admitting diagnosis of Malignant Neoplasm (cancer) of the left breast, chronic pain, and palliative care (specialized medical care that focuses on providing relief from pain and other symptoms of a serious illness). A review of Resident 68's clinical record titled, [HOSPICE (specialized health care that focuses on the providing care to terminally ill residents) COMPANY NAME] Hospice Care Visit Notes, dated, 3/13/23, indicated, Resident 68 was admitted to hospice with a diagnosis of breast cancer. During an observation on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to provide recent education to their staff regarding Post Traumatic Stress Disorder (PTSD - a mental health condition triggered by a terrifying event, causing flashbacks, nightmares, and severe anxiety) to ensure quality of care was delivered for one resident with a diagnosis of PTSD (Resident 18), with a census of 80 residents. This failure resulted in Resident 18 not receiving specialized nursing care that recognized the signs of trauma and incorporated a system of responding to trauma, which had the potential to result in re-traumatization for Resident 18. Findings: During a review of Resident 18's clinical record titled, admission RECORD, (a document that contains the resident's demographic information) indicated, Resident 18 was admitted with a diagnosis of schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), bipolar disorder (mental illness that causes unusual shifts in mood), and PTSD. A review of Resident 18's…

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

Based on interview and record review, the facility failed to ensure one resident (Resident 1), in a sample of 3, received quality care in accordance with professional standards of practice when the facility did not initiate and monitor essential laboratory values based on alerts of drug interactions for medications Resident 1 was receiving. This failure was a factor in Resident 1's transfer to the hospital with acute kidney failure, hyperkalemia (high blood potassium-a mineral that is needed by all tissues in the body), and dehydration, and had the potential to negatively impact Resident 1's health and well-being. Findings: A review of Resident 1's admission RECORD, indicated Resident 1 was admitted mid 2023 with diagnoses which included acute pulmonary edema (fluid on the lungs), and heart failure. A review of Resident 1's physician's order, dated 7/4/23, indicated, Furosemide Tablet [a water pill used to treat edema-excessive fluid accumulation] 40 MG Give 1 tablet by mouth every 12 hours for LOWER EXTREMITIES [legs] EDEMA for 30 days. A review of Resident 1's physicians order,…

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 facility policy review, the facility failed to properly store and handle food in accordance with professional standards for food service safety for a census of 43 residents, when: 1. The following expired items were in the refrigerator available for use: two jugs of tea, one jug of apple juice, one jug of sugar free punch, one half gallon cultured low-fat buttermilk, four loaves of sliced French Toast bread, seven loaves of sliced wheat bread, and three bags of hamburger buns with 12 buns in each bag; two spoiled heads of lettuce were in the refrigerator and available for use. Three expired cases of apple juice were in the dry emergency food supply and were available for use; 2. [NAME] 1 did not wear a facial hair cover while handling and preparing food in the kitchen; and, 3. Dietary Aide (DA 1) did not perform hand hygiene between handling dirty to clean items in the kitchen. These failures had the potential to expose residents to spoiled, expired and contaminated food products. Findings: 1. During the initial kitchen tour observations with the…

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

Based on observation, interview and record review, the facility failed to treat 3 of 43 residents (Resident 4, Resident 6 and Resident 20) with respect and dignity, when staff were speaking to each other in a language other than English while providing care to the residents. This failure had the potential to cause psychosocial harm to Resident 4, Resident 6 and Resident 20. Findings: During an interview, on 11/16/21, at 08:44 a.m., Resident 20 stated, when two staff members were in her room at the same time providing care they would speak to each other in a different language (other than English). Resident 20 stated, I don't know what they are talking about, me or not, it happens all the time. During an observation, on 11/16/21, at 9:53 a.m., CNA 2 and CNA 3 were standing on each side of Resident 4's bed, assisting him to get ready to get up to the wheelchair. While providing care, CNA 2 and CNA 3 were speaking to each other in another language (not English). During an interview, on 11/16/21, at 9:58 a.m., Resident 6 stated, staff came into his room and would speak a foreign…

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 resident needs were accommodated when: 1. Six of forty-three residents' (Resident 20, Resident 17, Resident 14, Resident 3, Resident 18, and Resident 15) call lights were not within reach; and 2. One of twelve sampled resident's (Resident 17) bedside drinking fluids were not within reach. These failures had the potential for Resident 20, Resident 17, Resident 14, Resident 3, Resident 18, and Resident 15 needs not being met promptly. Resident 17 was not able to reach and consume her bedside drinks when desired and was placed at risk for dehydration. Findings: 1a. During an interview, on 11/16/21, at 8:22 a.m., Resident 20 stated, at night, staff .put the call button somewhere where I can't find it, it happens all the time. During a concurrent observation and interview on 11/18/21, at 5:43 a.m., Certified Nurse Assistant (CNA) 4 confirmed, Resident 20's call light was clipped to the top left corner of the bed sheet, but hanging over the side of the bed, with the call light button approximately 1 foot…

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 medication storage when: 1. One out of two medication carts (a mobile cart that stored medication for administration to residents) stored expired (no longer should be used) and unlabeled (instruction on the outer container on who, how or when it should be used) medications. 2. Two out of two treatment carts (a mobile cart that stored medication used to treat skin related problems) stored expired and unlabeled medications. 3. One out of two medication rooms (a locked room in the facility used to store medications for safe keeping) stored Emergency kit (or Ekit, a sealed container that contained medications for emergency use) with expired medication. 4. Staffs' personal belongings were stored in two out of two medication rooms where prescription medications were stored. These failures could contribute to unsafe medication use and risk of drug diversion (diversion means illegal use of prescription medication). Findings: 1. During…

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 properly prevent COVID-19 for a census of 43 when: 1. Visitors were not screened for signs and symptoms of COVID-19 prior to facility entry; 2. Staff did not perform hand hygiene after removing a surgical facemask (a loose-fitting, disposable device that creates a physical barrier between the mouth and nose of the wearer) and prior to applying a N-95 respirator (a respiratory protective device designed to achieve a very close facial fit and provides efficient filtration of germs found in the air); and 3. Staff did not perform hand hygiene after the removal of gloves. These failures had the potential to put residents, staff and visitors at risk of contracting illnesses, including COVID-19. Findings: 1. During a concurrent interview and facility document review, on 11/18/21, at 11:09 a.m., the [facility name] Visitor Sign-in Log, dated 11/18/21 was reviewed with the Infection Preventionist (IP). The IP confirmed, the Covid-19 Signs & Symptoms column was blank for a total of seven visitors who entered 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 ensure resident's Physician Orders for Life-Sustaining Treatment (POLST- resident indicated preferences regarding end-of-life care such as resuscitative measures: the action or process of reviving someone from unconsciousness or apparent death, and other life-sustaining treatment) record was updated in the electronic medical record for one of twelve sampled residents (Resident 14). This failure placed Resident 14 at risk to not receive life sustaining treatment per resident or resident representative's wishes in the event of an emergency. Findings: Review of Resident 14's admission record indicated Resident 14 was admitted to the facility in 2005. Review of Resident 14's Minimum Data Set (MDS) assessment dated [DATE], indicated Resident 14 had moderately impaired cognition. Review of Resident 14's active physician orders dated [DATE], in the electronic record indicated, .CODE STATUS: DNR [Do Not attempt Resuscitation] (COMFORT MEASURES ONLY-SEE POLST…

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 foot care for one of twelve sampled residents (Resident 15) when, Resident 15 had three long overgrown toenails on the right foot and three long overgrown toenails on the left foot and staff did not follow a consistent process to provide nail care. This failure had the potential to affect Resident 15's foot health, with the possibility to contribute to injury and/or infection. Findings: During a concurrent observation and interview on 11/16/21, at 3:40 p.m., Licensed Nurse (LN) 1 confirmed Resident 15's right foot had three toenails that were long and needed to be trimmed. LN 1 confirmed Resident 15's left foot had three toenails that were long and needed to be trimmed. LN 1 stated the Certified Nurse Assistants (CNA's) were allowed to cut resident's toenails and toenail care was completed on Sunday's. LN 1 stated it did not appear as if Resident 15's toenails were trimmed on Sunday (11/14/21). LN 1 stated Resident 15 would allow toenail care to be completed. During an interview on 11/16/21, at 3:50…

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 preventative measures to reduce the risk of elopement (an act or instance when a cognitively impaired person leaves a safe area or premises unsupervised) for one sampled resident (Resident 86) when: 1. One of two exit doors in the Secured Memory Care Unit did not have a properly functioning motion sensor alarm; 2. An elopement evaluation was not completed after Resident 86 attempted to elope the facility; and, 3. A care plan was not initiated when Resident 86 attempted to elope the facility. These failures placed Resident 86 at an increased risk for elopement and physical harm due to her behavior of wandering in the facility. Findings: 1. A review of Resident 86's admission Record indicated, Resident 86 was admitted to the facility in November of 2021 with a diagnosis of dementia (a general term for loss of memory, language, problem- solving and other thinking abilities that are severe enough to interfere with daily life). During a concurrent observation and interview with Resident 86 on 11/15/21, 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.

Based on observation, interview, and record review, the facility failed to ensure dietary preferences were honored for two of fourteen sampled residents (Resident 8 and Resident 30) when; 1. A divided plate and straw were not provided during a lunch meal for Resident 8, and; 2. Carrots were served during a lunch meal for Resident 30 but were a documented dislike. These failures resulted in Resident 8 and Resident 30's personal preferences not being honored. Findings: 1. During an observation in the dining room on 11/16/21, at 12:00 p.m., Resident 8 was seated in the dining room eating her lunch of chicken, rice, and vegetables served on a standard plate. A cup of juice, and a cup of coffee were next to her meal plate. A review of Resident 8's dietary card under her meal plate indicated, Devices: Straws, Divided Plate, which was highlighted in blue. During a concurrent observation and interview in the dining room on 11/16/21, at 12:02 p.m., Licensed Nurse (LN) 2 stated Resident 8 preferred a divided plate because she did not like her food to touch. LN 2 confirmed Resident 8 was 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.