Alhambra Post Acute

Based on interview and record review, the facility failed to act promptly upon the grievances and recommendations from the residents' group meetings concerning residents care and life in the facility. This failure had the potential to cause residents' emotional distress. Findings: During a review of the facility's residents group meeting, titled, Resident Council Minutes/Resident Council Resolution Form, dated 8/5/24, indicated residents reported concerns included: Certified Nursing Assistants (CNAs) making too much noise at night whereby residents can't sleep, rooms too hot, cold food and food doesn't look good, request bigger room for activities. Further review of the residents' council minutes dated 9/26/24 indicated residents reported delays in receiving assistance, CNAs lack of courtesy and professionalism, feeling of neglect and no dignity or respect, not feeling safe because other resident going into their rooms, cold food. During a concurrent interview and record review on 11/19/24 at 9:41 a.m. with the Activities Director (AD), the facility's residents council minutes notes…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure three (Resident 27, 31 and 145) of five sampled residents were free from unnecessary drugs when; 1. Resident 27 was administered Seroquel (an antipsychotic - drugs used to treat schizophrenia and bipolar serious mental health conditions and not approved for use in psychotic conditions related to dementia.) medication for wandering; 2. Resident 31 had a new diagnosis of schizophrenia (a serious mental health conditions capable of affecting the mind, emotions, and behavior); 3. Resident 31 with diagnosis of dementia was administered Zyprexa (an antipsychotic) medication for yelling and screaming; 4. Resident 145 was administered antipsychotic medication without adequate indication for use. These failures had the potential for residents to receive unnecessary medications and had the potential for the residents to suffer adverse medication side effects. Findings: 1. During a review of Resident 27's Annual Minimum Data Set (MDS),…

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, interviews and record review, the facility failed to ensure storage of food under sanitary conditions when the following food items in the refrigerator were not dated and labeled with received, open and use-by dates : - One bag of cauliflower with brownish black discoloration - One bag of parsley moist and withered - Three cut up watermelon not labeled with date - One chest freezer had no temperature log. - Refrigerator temperature log missing entries - Trash can lid with brownish discoloration - Kitchen floor tiles with brownish stain and discoloration These failures had the potential to result in food borne illnesses. Findings: During the initial tour of the kitchen on 11/18/24 at 8:20 a.m. with Dietary Aide (DA)1, the following were observed in the refrigerator; one bag of cauliflower with brownish black discoloration, one bag of parsley moist and withered, three cuts up watermelon not labeled with use by date. DA 1 stated food items in refrigerator are labeled with use-by-date. DA 1 stated the bag of cauliflower and parsley were no longer good for use . DA…

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 garbage and refuse storage area was maintained in a sanitary condition when the dumpster was overflowed with bags of trash and not properly contained with lid. This failure had the potential of harborage and feeding of pest. Findings: During an observation on 11/19/24 at 7:12 a.m., with Dietary Services Manager (DSM) one dumpster located by the side of the facility overflowed with trash bags was not contained with lid. During an interview on 11/19/24 at 7:18 a.m. with Administrator (Admin) stated contracted company staff came and left without empty the dumpster. Admin stated house keeping staff assist with making sure dumpster was emptied. During an interview on 11/19/24 at 7:23 a.m. with Housekeeping Supervisor (HKS), HKS stated someone blocked the path to the dumpster and the dumpster was not emptied. During a review of the facility's policy and procedure (P&P) titled, Waste Disposal, revised January 2022, the P&P indicated, All infectious and regulated waste shall be handled and disposed of in a safe…

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

Based on observation and interview, the facility failed to provide a dining/activity room with adequate space for 42 residents. This failure resulted in limiting the independent functioning and task performance of the residents during mealtime and activity time. Findings: The facility census on 11/18/24 was 42 residents. On 11/21/24 at 12:04 p.m., observation of dining/activity room was conducted. The room which served as the residents' dining room and activity room had three square tables and accommodated five residents in wheelchairs and two ambulatory residents who used a walker as an assistive device. The dining room was observed to be crowded for the seven residents. The dining room staff were observed to push the tables to the side to be able to push and position some of the residents in wheelchairs in the dining tables. During an interview on 11/21/24 at 8:17 a.m., with Certified Nursing Assistant (CNA) 2 , CNA 2 stated the dining room was crowded at mealtimes and stated some of the ambulatory residents could slip and fall due to the tight space in the dining room. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete the Level I Preadmission Screening and Resident Review (PASARR, a federal requirement to ensure that residents are not inappropriately placed in nursing homes for long term care) assessment for one of one sampled resident (Resident 31). This failure had the potential for residents to not received appropriate care and services. Findings: During a review of Resident 31's admission Record, dated November 20 2024, the record indicated Resident 31 was originally admitted to the facility on [DATE]. During a concurrent interview and record review on 11/19/24 at 4:01 p.m. with Director of Nursing(DON), DON stated the facility was expected to complete a PASARR screening prior to residents' admission to the facility. DON could not provide Resident 31's Level 1 PASARR. DON stated Resident 31's Level 1 PASARR was not done. DON stated when Resident 31 was admitted to the facility she was a newly hired DON and did not know why Resident 31 did not have level…

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 adequate supervision was provided to prevent falls and implement resident-centered care interventions for one (Resident 31) of four sampled residents when, Resident 31 had repeated unwitnessed falls. This failure caused Resident 31 to continued to fall and had the potential to result in injuries. Findings: During a review of Resident 31's Annual Minimum Data Set (MDS), Resident Assessment and care guide tool, dated 7/17/24, indicated Resident 31's Basic Interview of Mental status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.). Resident 31's score was 03, meaning poor cognition. Resident 31's diagnoses included Non-Alzheimer's Disease (a group of diseases characterized by progressive deficits in behavior, executive function or language). Resident 31 was independent and once standing had the ability to walk at least…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, for one of two sampled residents (Resident 31), the facility failed to developed and implement person-centered interventions to prevent Resident 31 with dementia from wandering into the rooms and closets of other residents. Dementia is a general term to describe a group of symptoms related to loss of memory, judgment, language, complex motor skills, and other intellectual function, caused by the permanent damage or death of the brain's nerve cells, or neurons. However, dementia is not a specific disease. There are many types and causes of dementia with varying symptom and rates of progression. (Adapted from: About Dementia. Alzheimer's Foundation of America. 30). This failure had the potential to cause residents increase confusion and distress. Finding: During a review of Resident 31's admission Record (AR), the AR indicated, Resident 31's was an [AGE] year old female admitted to the facility on [DATE]. Resident 31's primary diagnoses included non traumatic…

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 label medications and properly dispose of a medication beyond the use by date for two of 14 sampled residents (Resident 36 and Resident 5), when while inspecting medication cart two (use by date is the date at which the manufacturer can still guarantee the full potency and safety of the drug): 1. Resident 36's one bottle of Latanoprost Ophthalmic Solution 0.005 % ( Latanoprost ) was not labeled with an open date. Another bottle Resident 36's Latanoprost was stored beyond the use by date in the medication cart (Latanoprost is an eyedrop used to treat a condition in which increased pressure in the eye can lead to gradual loss of vision). 2. A bottle of Atropine Sulfate Ophthalmic solution 1% was not properly labeled (Atropine Sulfate Ophthalmic solution is an eyedrop used to treat certain eye conditions). Findings: 1. Resident 36 was admitted on [DATE] with diagnoses including changes in retinal vascular appearance to the right eye (meaning…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain an effective infection control program when the lid (cover) of Resident 144's suction machine cannister was not changed for 18 days (Suction machine is a device that is used for removing secretions like mucus, phlegm, saliva from a person's airway; the suction machine cannister is where the secretions are collected). This failure placed the resident at increased risk of healthcare associated infections. Findings: During a review of Resident 144's admission record indicated the resident was admitted on [DATE] with diagnoses that included esophageal obstruction (a blockage or narrowing of the esophagus, the muscular tube that connects the mouth to your stomach). During a concurrent observation and interview on 11/18/24, at 2:22 p.m., with Licensed Vocational Nurse (LVN) 2, in Resident 144's room, the resident's suction machine cannister was observed to be filled with 100 milliliters (ml., a form of measurement) of phlegm. The lid of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a follow up call and /or assessment was done to verify durable medical equipment was provided to Resident 1 as ordered (DME, are equipment and supplies for everyday or extended use). This failure posed a risk for an unsafe transition from the facility to the home setting. Findings: During an interview on 4/4/24 at 1:47 p.m., Resident 1's family member 1, stated, when the resident was discharged from the facility on 3/5/24, the family member was told by the facility's Social Service Director (SSD), that the DME would be delivered at their house. The family member stated, they did not receive the delivery of the DME. Further stated, they had to move the resident around the house for safe transfers, and after a few days, the family had to purchase a wheelchair to safely move the resident around the house because the resident could not walk. A review of Resident 1's admission Record, indicated, Resident 1 was admitted to the facility on [DATE], with…

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 bathing assistance for one of two sampled residents (Resident 1) for two extended intervals: a five-day interval from 3/25/24 to 3/29/24 and a four-day interval from 3/31/24 to 4/3/24. This failure resulted in Resident 1 feeling emotional distress and that the facility did not support Resident 1's need for dignity. Findings: During a review of the admission Record (a document used to communicate basic information about a resident) for Resident 1, undated, the Record indicated Resident 1 was admitted to the facility in October 2023 with unspecified muscle weakness and paraplegia (the loss of muscle function in the lower part of the body including both legs). During a review of Resident 1's Minimum Data Set (MDS, an assessment tool used to plan care) dated 10/24/23, the MDS indicated Resident 1 had a score of 15 on the Brief Interview for Mental Status. (BIMS, is a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall…

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

Based on observation, interview, and record review, the facility failed to store medications appropriately when the following were noted: 1. Resident 5's Lotemax eye drops bottle was not labeled with open date. 2. Facility did not dispose or destroy medications for discharged residents and/or expired 11 of 11 sampled residents (Residents 37, 40, 33, 20, 301, 302, 303, 32, 99, 21, 304). 3. Facility did not dispose of expired over the counter (OTC) medications and stored open bottles of OTC medications mixed with ready-to-use medication in the medication storage room. 4. Facility did not monitor and maintain a temperature log for medication storage room for September, October, and November of 2023. These failures had the potential to result in unsafe medication administration and storage practices. Findings: 1. During medication administration observation on 11/28/23 at 09:05 a.m. with Licensed Vocational Nurse (LVN) 3, Resident 5's Lotemax 0.5% eye drop (steroid medication used for swelling) was without an open date on the bottle or the box. LVN 3 stated the medication label…

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, staff interview, and record review, the facility failed to follow their policy for the Use and Storage of Food & beverages Brought in for Resident and provide safe and sanitary storage, handling, and consumption of food brought to residents by family and visitors for two of 44 residents, when: 1.The staff refrigerator contained Resident 198's food that was not dated and stored with other unlabeled and undated staff food. This had the potential for cross contamination. 2. Resident 298 wanted to eat food brought for her birthday and have it for dinner and was told staff could not warm the food and ate cold lobster that was unpalatable. These failures had the potential for food contamination and food borne illness, and food not served at the preferred temperature diminished the enjoyment of the meal. This had the potential to affect other residents receiving food brought from outside sources for storage. Findings: 1. During a concurrent observation and interview on 11/29/23 at 4:22 p.m., with Administrator (Admin), the Staff designated white refrigerator in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow infection prevention and control practices when the following were noted: 1. Oxygen tubing nasal canula for four of four sampled residents (Resident 18, 298, 11 and 30) was unlabeled and undated. 2. Two Licensed Vocational Nurses (LVN 3 and LVN 1) did not perform hand hygiene during medication administration for two of the seven sampled residents (Resident 16 and 11). 3. Medication storage refrigerator in the medication storage room was dusty and sticky to touch. 4. Licensed Nurse did not label a wound dressing for a gastrostomy tube (GT, a tube inserted into the stomach to provide liquid nutrition, fluids, and medications) site with date and staff initials. Licensed Nurse did not perform hand hygiene during wound care for one of two residents (Resident 12). 5. Resident 12's Spirometer (handheld device to help practice deep breaths) was stored on top of his shoes on the floor. These failures had the potential for delayed wound…

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

Based on observation and interview, the facility failed to ensure privacy and right to send secure mail when a stack of residents' mail was left unattended on top of an unlocked mail box located outside the building. This failure had the potential to cause mail and identify theft. Findings: During a resident council (group) meeting on 11/28/23 at 10:02 a.m., Resident 3 stated the residents' mail was left outside the mail box unattended. During an observation and concurrent interview on 11/28/23 at 2:47 p.m., and accompanied by Activity Director (AD), the mail box located outside the building by the entrance door showed the mail box was not locked and a stack of residents' mail left unattended on top of the mail box. During an interview on 11/28/23 at 3:10 p.m., Administrator (Admin) stated he will make sure the mail box was locked. During an interview on 11/30/23 at 9:26 a.m., with Staffing/House Keeping Coordinator (SC), SC stated she was designated to collect the residents' mail from the mailbox. SC said she had the key to the mail box but forgot to lock the mail box. SC stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to offer and facilitate the preparation of an advance directive, including the right to accept or refuse medical-surgical treatment for seven of seven sampled residents upon admission. These failures resulted in Resident 3, 12, 24, 29, 30, 38, and 200 not being aware of their right to specify their wishes for medical-surgical care should they become incapacitated. Findings: 1.During a review of Resident 3's admission Record printed on 11/28/23, the record indicated Resident 3 was admitted to the facility on [DATE]. During a review of Resident 24's admission Record printed on 11/28/23, the record indicated Resident 24 was admitted to the facility on [DATE]. During a review of Resident 30's admission Record printed on 11/28/23, the record indicated Resident 24 was admitted to the facility on [DATE]. During a review of Resident 200's admission Record printed on 11/28/23, the record indicated Resident 24 was admitted to the facility on [DATE]. 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 make information on how to file a grievance or complaint available to six (3, 19, 22, 24, 26 and 38) of seven sampled residents. This deficient practice had the potential to cause residents fear and emotional distress. Findings: During a residents council (group) meeting on 11/28/23 at 10:02 a.m., Resident 3, 19, 22, 24, 26 and 38 stated they do not know how to file a grievances. During further interview on 11/28/23 at 10:02 a.m., Resident 19 stated she had no information on how to file a grievance. Resident 19 said If you have a grievance it is ignored. Review of admission Minimum Data Set (MDS), Resident Assessment and care guide tool, dated 5/30/23, indicated Resident 19's Basic Interview of Mental status (BIMS) score was 12 (meaning moderately impaired cognition). Resident 19 was oriented to correct year and day of the week. Resident 19 had clear speech, makes self understood and understand others. During an interview on 11/28/23 at 2:56 p.m., Activity Director (AD), AD stated she reviewed grievances…

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 safe pharmacy services when the following were noted: 1. Facility did not have morning medications readily available for administration for two of two sampled residents (Resident 22 and Resident 11). Resident 22 did not receive antidepressant medication. Resident 11 did not receive anticoagulant (used to prevent blood clots) as prescribed by the physician. (Cross reference F 759). 2. Facility did not maintain accounting records for controlled medications (medications with potential for abuse) for an active resident (Resident 19) and a discharged resident (Resident 299). These failures resulted in Resident 22 and Resident 11 to receive medications that were not accordng to physician orders and had the potential for drug diversion (the transfer of a controlled substance or other medication from a lawful to an unlawful channel of distribution or use). Findings: During a concurrent interview and record review on 11/28/23 at 8:22 a.m., with Licensed Vocational Nurse (LVN 3), Resident 22's medication orders…

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 interviews and record review, the facility failed to ensure two (Resident 19 and 38) of five sampled residents were free from unnecessary drugs when - Resident 19 was administered Zyprexa (antipsychotic) medication for yelling and verbally abusive behavior. - Resident 38 was administered an antipsychotic medication without adequate behavior and adverse medication side effect monitoring. These failures had the potential for residents to receive unnecessary drugs and to suffer adverse medication side effects. Findings: Review of admission Minimum Data Set (MDS), Resident Assessment and care guide tool, dated 5/30/23, indicated Resident 19's Basic Interview of Mental status (BIMS) score was 12 (meaning moderately impaired cognition). Resident 19 was oriented to correct year and day of the week. Resident 19 had clear speech, makes self understood and understand others. Resident 19 had no potential indicators of psychosis ( a severe mental condition in which thought and emotions are so affected that contact…

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 three of six sampled residents for medication administration observation (Residents 200, 11, and 5) received medications per the physician's orders. This failure resulted in a 13.16% medication error rate and Resident 200, 11 and 5 to not receive prescribed medications as ordered. Findings: During a medication administration observation, on 11/28/2023 at 8:07 a.m., Licensed Vocational Nurse (LVN) 3 administered Ventolin HFA (bronchodialator) 90 microgram (mcg) inhaler treatment to Resident 200. LVN 3 did not document the administration in Resident's 200's Medication Administration Record (MAR). During a concurrent interview and record review on 11/28/23 at 12:50 p.m. with LVN 3, the Electronic Health Record (EHR) for Resident 200's MAR dated 11/28/23 was reviewed. LVN 3 stated the record indicated she did not document Ventolin HFA 90 mcg inhaler administration for Resident 200 at the time of administration that day. During medication administration observation on 11/28/2023 at 8:47a.m., LVN 3…

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 implement the pneumococcal immunization (a vaccine to protect against pneumonia, an infection of the lungs caused by bacteria, fungi or viruses) policy for three of five sampled residents (Resident 12, Resident 13, and Resident 38) when they did not receive a pneumonia vaccine immunization. This failure placed Resident 12, 13 and 38 at risk for pneumonia. Findings: During a record review of the Electronic Health Record (EHR) of Resident 12, the record showed Resident 12 was admitted on [DATE], A review of Resident 13's EHR showed, Resident 13 was admitted on [DATE]. A review of Resident 38's EHR showed Resident 38 was admitted on [DATE]. During an interview and record review on 11/30/23 at 11:30 a.m., the Infection Preventionist (IP 1) immunization records for Residents 12, 13, 38 were reviewed. IP 1 stated she was unable to find the pneumonia vaccine immunization records for Residents 12, 13, and 38. Record review of the Infection…

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 perform a medication self-administration assessment prior to allowing Resident 12 to self-administer medications. This failure resulted in Resident 12 not taking ordered medication at the appropriate time, with the potential for adverse health outcomes related to incorrect medication administration. Findings: During a review of Resident 12's admission Record dated 11/28/23, which showed Resident 12 was admitted to the facility on [DATE]. Resident 12 had diagnoses that included hemiplegia and hemiparesis (severe or complete loss of strength to one side of the body) affecting the left side, dysphagia (difficulty and/or pain swallowing), and a gastrostomy (a surgical opening through the skin of the abdomen to the stomach). During a record review of the Medication Administration Record, dated 11/2023, the record showed Licensed Vocational Nurse 1 (LVN 1) administered Miralax (a medication to treat occasional constipation) powder to Resident…

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

Based on interview and record review, the facility failed to ensure that missing property for one of one sampled resident (Resident 24) was accounted for and addressed. This failure placed Resident 24 at risk for psychosocial stress and feeling vulnerable. Findings: During an interview on 11/27/23 at 9:24 a.m., Resident 24 stated she noticed her bank card was missing from her bedside tray table at 8:00 a.m., and notified the Licensed Vocational Nurse (LVN 4) and was told the card was not found in the room. Resident 24 further stated, I do not have the bank phone number or a phone. I am not sure what to do now. During an interview on 11/27/23 at 09:50 a.m., the Director of Nursing (DON) stated she was not aware of any reports of Resident 24's missing bank card. During an interview on 11/27/23 at 11:14 a.m., LVN 4 stated Resident 24 informed her of the missing bank card and a search was conducted of Resident 24's room. Resident 24 was provided a phone to call her responsible party. During a concurrent interview and record review on 11/29/23 at 11:16 a.m., with DON. The progress notes…

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 conduct a comprehensive Minimum Data Set assessment (MDS, an assessment tool used to direct resident care) for one (Resident 249) sampled resident as required within 14 calendar days after admission. This failure had the potential to result in no assessment of the residents' needs, strengths, and goals of care. Findings: Review of Resident 249's MDS assessment indicated Resident 249 was admitted on [DATE]. Resident 58's admission comprehensive assessment with the Assessment Reference Date (ARD) dated 11/1/2023 was completed on 11/15/2023. The ARD is the last day of the observation period the assessment covers for the resident. During an interview on 12/01/23 at 10:22 a.m., Registered Nurse/MDS Resource (MDS RN), MDS RN stated Resident 249's admission MDS assessment was completed late because of staffing issues. MDS RN stated the facility had no MDS coordinator. Review of the Long -Term Care Facility Resident Assessment Instrument 3.0 User's Manual…

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, record review, the facility failed to follow federal requirements to submit Quarterly Minimum Data Set (MDS, an assessment tool used to guide care) assessment for one of 14 sampled residents (Resident 28) within 14 days after its completion. The failure resulted in late submission of Resident 28's quarterly MDS assessment. Findings: During a record review of the admission Record dated 11/29/23, the record indicated Resident 28 was admitted to the facility 06/01/20. During a concurrent phone interview and record review on 11/29/23 at 03:25 p.m. with MDS Resource Registered Nurse (MDS RN), Resident 28's quarterly MDS assessment dated [DATE] was reviewed. MDS RN stated the assessment was completed on 11/03/23. The MDS RN stated she worked remotely and was dependent on input and assessments from different disciplines at the facility, including the Director of Nursing and Social Services. MDS RN further stated a quarterly MDS assessment should be submitted within 14 days of its completion,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS-Resident Assessment and Care Screening tool used to guide care), was accurate for two ( Residents 5 and 6) of two sampled residents when; -MDS section G did not reflect Resident 5's contractures (fixed tightening of muscle, tendons, ligaments, or skin. It prevents normal movement of the associated body part) to lower extremities (hip, knee, ankle, foot) and limitation in range of motion. -MDS section G did not reflect Resident's 6 contractures to upper extremities (shoulder, elbow, wrist and hand). These failure had the potential for residents to not receive appropriate care and services. Findings: Review of the admission Record indicated Resident 5 was admitted to the facility on [DATE] with diagnoses that included unspecified osteoarthritis (the wearing down of the protective tissue at the ends of bones cartilage occurs gradually and worsens over time). Review of the MDS dated [DATE], Section G indicated Resident 5…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop and implement a person-centered care plan for one of 14 sampled residents (Resident 38). Resident 38 did not have an individualized plan of care for her new diagnosis of Schizophrenia (a mental disorder usually exhibited with delusions - false beliefs, hallucinations - seeing or hearing things that don't exist), and new use of Seroquel (antipsychotic for Schizophrenia) medication. This failure placed Resident 38 at risk and not receive individualized care for her clinical condition. (Cross Reference F758) Findings: During a record review of the admission Record dated 11/29/23, which indicated Resident 38 was admitted to the facility 07/11/23. During an observation and interview on 11/27/23 at 9:43 a.m., Resident 38 was standing at the door of her room and was pleasantly confused at the time. During a record review of Resident 38's Minimum Data Set (MDS, an assessment used to guide plan of care) assessment dated [DATE], the Brief…

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 review and revise one of one sampled resident (Resident 6), the Activities of Daily Living (ADL) care plan for almost seven years. This failure placed Resident 29 at risk for impaired psychosocial and physical well-being. Findings: During a record review of Resident 6's admission Record dated 11/28/23, the record indicated that Resident 6 was admitted to the facility on [DATE]. During a concurrent observation and interview with Licensed Vocational Nurse (LVN 3), on 11/29/23 at 8:46 a.m., Resident 6 was sleeping in bed. LVN 3 stated Resident 6 has been out of bed in a chair for the past few days and is usually up in a chair on weekends. LVN 3 was not aware if Resident 6 was turned every two hours by the Certified Nursing Assistant (CNA). LVN 3 stated resident 6 requires total care for ADLs and contracted in her upper and lower extremities. During a concurrent observation and interview with Certified Nursing Assistant (CNA 3), on 11/29/23…

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 provide a shower for two of two sampled Residents (Residents 18 and 298) accoridng to the shower schedule. The failure resulted in Resident 298 not feeling important and placed Resident 18 and Resident 298 at risk for compromised hygiene and at risk for infections. Findings: 1.During a record review of Resident 18's undated face sheet,Resident 18 was admitted to the facility on [DATE]. During a record review of Resident 18's Minimum Data Sheet (MDS- an assessment used to guide plan of care) dated 10/18/23, indicated Resident 18 required one staff assistance for bathing. During a record review of Resident 18's Activities of Daily Living (ADL) Care Plan, dated 07/13/21, which indicated Resident 18 has an ADL self-care performance deficit and limited mobility. Resident 18 is totally dependent on 1 staff to provide bath/shower as necessary. During an observation on 11/27/23 at 9:31 a.m., Resident 18 was lying in bed wearing a hospital gown…

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 residents were served palatable food when, 1. The lunch for Resident 17 was not fortified as ordered by the physician. 2. The evening snack of Peanut Butter and Jelly (PB&J) sandwiches were not prepared according to the menu. This deficient practice placed the residents at risk of decreased nutrient intake and bland food, and potential weight for 2 residents who received food from the kitchen out of a census of 44. Findings: 1. During an observation on 11/28/23 at 11:10 a.m., a meal delivery cart holding Resident 17's lunch had a meal ticket (diet order) indicating, Special Diets: Fortified. During a record review of Resident 17's physician diet order, dated 3/23/23, printed on 12/1/23 indicated, Fortified Diet, Pureed texture, Thin Liquids consistency, for chocking on rice, add health shake with meals. During a concurrent observation and interview with Dietary Supervisor (Diet Sup) and Dietary [NAME] (Cook), on 11/28/23 at 12:06 p.m., Resident 17's meal tray was prepared as a puree texture meal. The…

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

Based on interview and record review, for one of one sampled resident (Resident 1), the facility failed to allow Resident 1's Representative (RR) to obtain a copy of the medical records within the required time frame. This failure resulted in violation of Resident 1's rights. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility in August 2019. The admission Record indicated RR was designated as Resident 1's Responsible Party and Care Conference Person (care conference, a meeting of the facility representative, resident, and family to discuss, identify, address, implement and review plans to meet the needs of the resident). During a concurrent interview and record review on 11/7/23 at 10:13 a.m. with Administrator (Adm), the letter requesting medical records dated 10/3/23 was reviewed. The letter indicated a request for Resident 1's full and complete copy of the medical records was sent to the facility on 9/5/23 which have not been provided by the facility. The letter was received along with…

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.