Atherton Park Post-Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to assess the resident for self -administration of medications for Resident 1, when four bottles of medications found in her purse. This failure could result in medication overdose or medication interaction, as these medications are not in MD order. Findings: Review of admission Record, dated 6/26/2024, indicated, admitted on [DATE], readmitted on [DATE], with diagnoses including: Fracture of Right Femur(a break in the right upper leg), Type 2 Diabetes( a condition with poor controlled blood sugar), Peripheral Vascular Disease(a slow progressive disorder and narrowing of blood vessels). During an observation on 6/26/24 at 12:30 PM, Resident 1 in bed, with a leg immobilizer on right leg, a bandage on right foot. Resident alert and has food on the bedside table. my friend brought me home cooked meal. Per patient, she stays most of the time in bed due to pain, taking Tylenol Arthritis for pain on my own. Resident 1 took out 4 bottles from her…

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 did not ensure the resident is informed of her rights and her rights are protected when: Resident 1 did not have a signed admission agreement and resident received opened mails and packages. This failure resulted in resident in resident feeling disrespected. FINDINGS: Review of admission Record, dated, 6/26/24, indicated, admitted on [DATE] and readmitted [DATE] with diagnoses including: Osteoarthritis Left Hip(a common disease of the hip due to wear and tear with progressive loss of cartilage), Anxiety Disorder, Post- Traumatic Stress Disorder, Unspecified, Morbid Obesity. During an interview on 6/27/24 at 11:15 AM, with resident in her room, per resident, she got the record she requested on 5/1/24, stated, I did get my records, what I ' m concerned about what they don ' t put in the record. Started February 2024, they don ' t bring me my mail, if ever they come with opened mail. Ordered from Amazon, was given notice delivered already, looking all…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not ensure that Resident 1 was provided pain management based on a comprehensive assessment after the incident, incident 1, when her right foot got caught while CNA wheeling resident in her wheelchair without foot rest inside the room, incident 2, while coming out of third floor elevator, right foot got caught again in the wheel of the wheelchair, incident 3, resident complained of pain, wanted to go back to bed, not able to do bike exercise due to pain. Resident 1 called 911 due to pain. This failure resulted in Resident 1 suffering from severe pain. Findings: Review of admission Record, dated 6/26/2024, indicated, admitted on [DATE], readmitted on [DATE], with diagnoses including: Fracture of Right Femur (a break in the right upper leg), Type 2 Diabetes( a condition with poor controlled blood sugar), Peripheral Vascular Disease(a slow progressive disorder and narrowing of blood vessels). Review of facility Summary of Investigation, undated,…

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 pre employment background check was completed for a Certified Nurse Assistant (CNA) 1 before allowing to work at the facility. The facility's failure had the potential for residents to experience abuse and psychosocial harm. Findings: Resident 1 was admitted with diagnoses including dementia (a decline in memory or other thinking skills and). A review of the Minimum Data Set (MDS, a standard Assessment tool) dated 1/23/24, Brief Interview of Mental Status (BIMS, a brief memory test to help determine cognitive functioning [includes memory, thinking, and decision making abilities]) score of 3 indicated severe cognitive impairment (rarely makes decisions). During an observation and interview on 2/9/24, at 10:12 AM, Resident 1 was in bed awake, verbally responsive, calm and pleasant. Resident 1 stated, The other night, around midnight, a black guy came into the room and started pounding on my chest and stomach. I told him to stop. I told him to leave. I reported it to the people here in the morning.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to develop and implement a baseline care plan for one of 34 sampled residents (Resident 1) that includes the instructions needed to provide effective and person-centered care when there was an intervention which was not applicable upon admission for Resident 1 who was at risk for fall. This failure had the potential to place Resident 1 at risk not to receive the appropriate intervention to prevent fall. Findings: Review of Resident 1's admission Record indicated, she was admitted to the facility on [DATE] with diagnoses including encephalopathy (a group of conditions that cause brain dysfunction), presence of left artificial hip joint, and orthostatic hypotension (a drop in blood pressure that occurs when moving from a laying down position to a standing position). Review of Resident 1's Minimum Data Set (MDS, resident assessment tool), dated 3/19/23 indicated, she was cognitively intact. The MDS also indicated, Resident 1 had hip fracture (a partial or…

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

Based on interview, and record review, the facility failed to ensure the director of dietary services is employed when there was no kitchen manager at the facility after 10/31/23. This failure had the potential for inadequate supervision of the dietary department for 153 residents who ate food from the kitchen out of a census of 153. Findings: During a concurrent observation and interview on 12/11/23 at 10:14 a.m. with Registered Dietitian (RD) and Assistant Kitchen Manager (AKM) in the kitchen, there was no kitchen manager. RD stated, We don't have a manager. Currently we don't have the manager . We are interviewing (the manager) . when asked. AKM also acknowledged, they don't have the kitchen manager. During an interview on 12/12/23 at 11:09 a.m. with Director of Nursing (DON), DON stated, they interviewed several candidates for the kitchen manager, but it was hard for them to find the right person. DON stated, she didn't know when asked how long they would not have the kitchen manager. During an interview on 12/12/23 at 12:45 p.m. with DON, DON stated, the last time the kitchen…

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 and sanitary conditions were met for food storage in the kitchen when: 1. There were no expiration dates on two chicken flavored base and cranberry flavored juice cocktails in a box in the refrigerator, and one box of the beef patty in the freezer. 2. There were no dates on the ranch dressing on a tray in the refrigerator and ice creams in a cup on a tray in the freezer. 3. There were two boxes of FRESH SHELL EGGS, not pasteurized eggs in the refrigerator. 4. There were expired items in the refrigerator such as one low fat cottage cheese, mayonnaise, and hot sauce. 5. Dish machine temperature logs were not filled completely for November and December 2023. 6. Pot and pan test strip/sanitation bucket logs were not filled completely for November and December 2023. These failures had the potential to put residents at risk for foodborne illnesses. Findings: 1. During a concurrent observation and interview on 12/11/23 at 10:40 a.m. with Registered Dietitian (RD) and Assistant Kitchen Manager (AKM) in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure Minimum Data Set (MDS, a resident assessment tool) quarterly assessment was completed at least every 92 days following the previous OBRA (Omnibus Budget Reconciliation Act of 1987) assessment type for two of 31 sampled residents (Resident 23, 73, and 63). Failure to complete quarterly resident assessment within the required timeframe could result in delayed identification of needs and significant issues that may affect the physical, mental, and psychosocial well-being of the residents. Findings: Review of the MDS Summary in the electronic health record (EHR) on 12/15/23, indicated the following: 1. Resident 23 was admitted on [DATE]. Review of Resident 23's quarterly MDS assessment dated [DATE] indicated, the Registered Nurse (RN) Assessment Coordinator signed the assessment as complete on 12/14/23, 64 days after the Assessment Reference Date (ARD, specific endpoint for the look-back periods in the MDS assessment process). 2. Resident 73 was…

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

Based on observation, interview, and record review, the facility failed to implement its infection control and prevention practices during a COVID-19 (an infectious disease caused by the SARS-CoV-2 virus) outbreak when: 1. Licensed Vocational Nurse (LVN) 3 did not remove her N95 respirator (a respiratory protective device designed to protect against particulate matter such as dust, fumes, mists, aerosols, and smoke particulates) and face shield (to protect your eyes, nose, mouth and face from flying objects and liquids) after leaving a Resident 22's room who was on transmission-based precautions (TBP - used in addition to standard precautions for patients who are known or suspected infections with pathogens that can be transported by airborne, droplet, or contact routes). 2. Certified Nursing Assistant (CNA) 7 did not remove her face shield after leaving a Resident 33's room who was on droplet precautions. 3. A used, green colored respirator mask was stored inside a linen cart on the third floor. 4. CNA 1 left the door wide open while assisting Resident 80 with lunch, who was 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.

The facility failed to appropriately administer medications when Resident 74 was self-administering medications without being appropriately assessed and approved for self-administration. This situation raises concerns about medication management and the need for proper protocols to ensure patient safety and compliance with medication administration guidelines. Findings: An observation on 12/12/23 at 1:14 PM, Resident 74 had multiple medications placed at their bedside. He had two pill cups, one containing two pills and the other containing six pills. There were no facility staff near or around Resident 74. There was no visible sign of any nurses near by to observe him take his medication. During an interview 12/12/23 at 1:14 PM, Resident 74 stated the reason for having multiple pills at bedside was because he prefer taking his medications throughout the day, keeping them nearby for convenience. However, when asked about the specific medications, Resident 74 expressed uncertainty. During the interview on 12/12/23 at 1:20 PM with the Assistant Director of Nursing (ADON), she mentioned…

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 homelike environment for residents on the third floor when a confused resident was observed screaming. Failure to maintain a comfortable sound level could potentially negatively impact residents' quality of life, sleep, and prevent residents from hearing their devices (computer, phone, radio, television) and each other during their daily activities. Findings: During observation of the third floor on 12/11/2023 at 10:30 AM, an unidentified resident was screaming at the top of his lungs. During an interview on 12/12/2023 at 8:43 AM, Resident 62 stated .There's a guy there in the middle hallway that yells a lot even at night. Observation of the bottom of Resident 62's bedroom door indicated he had rolled up a bed linen and taped it under the door. Resident 62 explained that he uses ear plugs at night and that bed linen was to help block out the noise at night. During an interview on 12/14/2023 at 9:49 AM, Responsible Party (RP 1) sated .I have seen .(resident) screaming constantly in the middle of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure Minimum Data Set (MDS, a resident assessment tool) comprehensive assessment was completed within the required timeframe of not less than once every 12 months (means 366 days) for one of 31 sampled residents (Resident 63). Failure to complete a comprehensive resident assessment within the required timeframe could result in delayed identification of needs, functional and health status, preferences, and goals of care that may affect the physical, mental, and psychosocial well-being of Resident 63. Findings: Review of Resident 63's admission Record, indicated, was admitted on [DATE]. Review of Resident 63's annual MDS assessment indicated, an Assessment Reference Date (ARD, specific endpoint for the look-back periods in the MDS assessment process) of 10/10/23. Further review of the annual MDS assessment indicated, the RN Assessment Coordinator signed the assessment as complete on 12/14/23, 65 days after the ARD. During an interview on 12/15/23, at…

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

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, a resident assessment tool) information for three of 31 sampled residents (Resident 23, Resident 73, and Resident 63) were electronically submitted to the Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) System within 14 days. This failure could result to ineffective monitoring of resident's decline and progress overtime, and delayed provision of resident specific information for payment and quality measure purposes. Findings: Review of the MDS Summary in the electronic health record (EHR) on 12/15/23, indicated the following: 1. Resident 23 was admitted on [DATE]. Review of Resident 23's quarterly MDS assessment dated [DATE] indicated, the Registered Nurse (RN) Assessment Coordinator signed the assessment as complete on 12/14/23, 64 days after the Assessment Reference Date (ARD, specific endpoint for the look-back periods in the MDS assessment process). 2. Resident 73 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, facility staff failed to accurately code Resident 62's fall with major injury within his Minimum Data Set (MDS, a standard resident assessment tool), dated 06/06/2023. Failure to accurately code a MDS had the potential to transmit inaccurate clinical information to the Federal/State data base and may negatively impact Resident 62's plan of care. Findings: Review of Resident 62's record titled Progress Notes, dated 05/29/2023, indicated .A thud like sound was heard .(at 9:46 PM) in room . Nurse immediately went to the room and found resident .(62) laying on the floor of his bathroom right next to the toilet.Resident is claiming an 8/10 pain along his .(right) rib, mid back and .(left) wrist. Resident verbalized that he wanted to be sent out to hospital. Called 911 . Review of Resident 62's hospital record, dated 05/30/2023, indicated he had a fracture of a bone in his spine due to the fall. During an interview on 12/12/23 11:16 AM, MDS nurse 1 reviewed Resident 62's progress…

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

Based on interview and record review, the facility failed to implement fall care plan for one of 33 sampled residents (Resident 141) when the neuro checks were not done every shift for 72 hours for Resident 141 after his fall on 11/11/23. This failure had the potential to delay the identification of needs, functional and health status for Resident 141. Findings: Review of Resident 141's clinical record indicated, Resident 141 was admitted to the facility with diagnoses including abscess of liver (a pocket of infected fluid (pus) that forms in the liver), alcoholic cirrhosis of liver with ascites (an advanced liver disease with the accumulation of fluid in the peritoneal cavity, causing abdominal swelling), and portal hypertension (an elevated pressure in the major vein that leads to the liver). Review of Resident 141's Minimum Data Set (MDS, resident assessment tool), dated 11/11/23 indicated, Resident 141 was cognitively severely impaired. Review of Resident 141's Nurse's Notes, dated 11/11/23 indicated, . OOOO (Resident 141's name) had an unwitnessed fall at 1910 (7:10 p.m.). Pt…

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 care and treatment provided meet professional standards for one of 31 sampled residents (Resident 63) when order for oxygen administration was not followed per physician's order. The deficient practice had the potential to compromise the health and safety of Resident 63. Findings: Review of Resident 63's admission Record indicated, was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD - lung disease that cause airflow blockage and breathing related problems), dependence on supplemental oxygen, and paroxysmal atrial fibrillation (occurs when a rapid, erratic heart rate begins suddenly and then stops on its own within 7 days). During an observation on 12/11/23 at 11:22 AM, in resident's room, Resident 63 was in bed asleep and was on a portable oxygen concentrator (a device that help you breathe) at 3.5L/min (liters/minute) via nasal cannula (a device that delivers extra oxygen through a tube 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 observations, interviews, and a review of records, it was found that the facility failed to maintain a medication error rate of less than 5%. During the medication pass, 2 medication errors were observed out of thrity opportunities, resulting in an error rate of 6.67%. Findings: A review on 12/12/13 of the manufacturer's insert for the Symbicort Inhaler (Budesonide 160 mcg and Formoterol 4.5 mcg), it's indicated that the user should first exhale fully. Then, they should breathe in deeply and slowly through their mouth while pressing down firmly and fully on the top of the counter. The user should continue to breathe in and hold their breath for about 10 seconds. After this, the Symbicort inhaler should be shaken again for 5 seconds and the previous steps should be repeated. After the administration of the Symbicort inhaler, it's important for the user to rinse their mouth with water and spit it out without swallowing. The final step involves cleaning the white mouthpiece by wiping both the inside and outside of the opening with a clean, dry cloth. 1. During an observation…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and record review, the facility failed to provide a safe and sanitary environment when the countertop and sides of the 3rd floor nursing station were found chipped and damaged, and four window screens were found damaged. Damaged countertop presented sharp hazard to residents and prevent staff from properly sanitizing the surfaces. Damaged window screens have the potential to let flying pests into resident's living spaces. Findings: During observation on 12/11/2023 at 1:25 PM, the window screen in the second-floor family room was found to be damaged and had a puncture gap to allow flying pest into the room. During observation on 12/14/2023 at 4:20 PM, rooms [ROOM NUMBER]'s window screens were damaged. Their metal frames were bent enough to allow flying pest into the room. During observation on 12/13/2023 at 11:14 AM, the third-floor nursing station countertop and side coverings had six major areas that were chipped and damaged. Some of the chipped area had sharp edges and presented a cutting…

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 supervision/assistance to Residents 62, 71, and 81, three of thirty-one sampled residents, to minimize their fall risks. Due to this failure, all three residents had multiple falls, and each sustained a fracture due to their falls. Additionally, lack of supervision resulted in an injury of unknown origin to Resident 105. Resident 105 was found with bleeding to his face. Findings: 1). Review of Resident 62's records titled, Minimum Data Set (MDS, a standardized resident assessment tool), dated 11/15/23, indicated his Brief Interview for Mental status (BIM) score was 13 out of 15. BIM is a standardized test for memory and reasoning functions. A score of 13 to 15 indicates no impairment in memory and reasoning. His MDS indicated he needed: 1. supervision or touch assistance with: toileting hygiene (removing clothing to urinate or to have a bowel movement and cleaning up self), lower body dressing, sit to stand, chair/bed transfers, and toilet…

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 policies and procedures for ensuring the reporting of alleged abuse/neglect in a timely manner for 5 (five) of 33 sampled residents for three incidents (between Resident 49 and Resident A, between Resident B and Certified Nursing Assistant (CNA) 8, between Resident 41 and Resident 95) when: 1. the facility reported 6 hours later to CDPH and Ombudsman after Resident 49 punched his roommate Resident A. 2. the facility reported 2 days later to CDPH and Ombudsman after Resident B was found with blankets wrapped around his waist with his arm caught inside restricting his mobility. 3. the facility reported 1 day later to CDPH and Ombudsman after Resident 41 hit Resident 95. These failures had the potential to delay identification and implementation of appropriate corrective action(s) and put all residents of the facility at risk for possible abuse/neglect. Findings: 1. Review of Resident A's clinical record indicated, Resident A was admitted to…

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

Based on interview, and record review, the facility failed to update the abuse care plan for one of 33 sampled residents (Resident B) when he was found with blankets wrapped around his waist, with his arm caught inside restricting his mobility. This failure had the potential to put the resident at risk of not receiving appropriate care. Findings: Review of Resident B's clinical record indicated, Resident B was admitted to the facility with diagnoses including nontraumatic subarachnoid hemorrhage (stroke caused by bleeding into the space surrounding the brain), diabetes (high blood sugar), and generalized muscle weakness. Review of Resident B's Minimum Data Set (MDS, resident assessment tool), dated 1/30/23 indicated, Resident B was cognitively intact. Review of the facility's document titled, 5 Day Follow-Up summary dated 4/7/23 indicated, . On 4/2/23 at 11pm, Staff (XXXXX: Certified Nursing Assistant (CNA) 8's name) was the assigned CNA for this Resident (Resident B). While Staff was making the rounds on his shift, resident was found with his hands in his brief. Resident had 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 provide the required supervision to one of two sampled residents (Resident 1). Per facility policy and staff interviews, all mechanical lifts should be operated by two staff. Resident 1 was transferred by one staff using a ceiling lift and this resulted in Resident 1 falling from the ceiling lift. Findings: Review of Resident 1's document titled MINIMUM DATA SET (MDS, a standardized resident assessment tool), dated 09/04/2023, indicated he was a quadriplegic (unable to move his arms or legs) and was totally dependent on the physical assist of two staff for transfers. Review of Resident 1 ' s document titled Progress Notes, dated 09/01/2023, indicated Resident 1 .just had a shower and (CNA 1, Certified Nursing Assistant ) was transferring . (Resident 1) using Hoyer lift and suddenly the sling slip from the hook of the Hoyer lift.(CNA 1 was) able to catch the lower part of the body .(Resident 1) hit his head and left side of his face and left shoulder on the floor . During an interview on 10/19/2023 at 3:10 PM, CNA 1 stated I…

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 Interdisciplinary Team failed to complete an assessment for safe self-administration of medication for Resident 1 when a bottle of clindamycin solution (used to treat infection) and a tube of antifungal cream was in Resident 1's possession. The facility failure has the potential for Resident 1 to overuse the medications which may lead to untoward effects. Findings: A review of the face sheet, Resident 1 was admitted with diagnoses including chronic obstructive pulmonary disease (COPD, lung disease) and folliculitis (inflammation of the hair follicles [where the hair grows]). A review of the Minimum Data Set (MDS, a standard assessment tool) dated [DATE] Brief Interview of Mental Status (BIMS, a brief memory test to help determine cognitive functioning) score of 15 indicated Resident 1 was cognitively intact. During an observation on [DATE], at 9:58 AM, Resident 1 was sitting up in the wheelchair, neatly dressed. She is alert and coherent, calm, 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 develop a comprehensive care plan and interventions implemented for Resident 1 when there was no care plan completed to address skin problems identified by the Dermatologist (a medical doctor that specializes on treatment of skin diseases). The facility failure has the potential for Resident 1 to not receive necessary care and treatment for the skin problems. Findings: A review of the face sheet indicated Resident 1 was admitted with chronic obstructive pulmonary disease (COPD, a lung disease). Minimum Data Set (MDS, a standard assessment tool) dated 8/19/22 Brief Interview of Mental Status (BIMS, a brief memory test to help determine cognitive function) score of 15 indicated cognitively intact. A review of the Dermatology consultations notes for Resident 1 dated 4/7/23, indicated, . Patient also reports multiple other concerns including nail fungus of fingers and toes, has not improved status post terbinafine (used to treat fungus infections [diseases caused by a fungus; yeast or mold] of the scalp, body 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 ensure a safe environment for the residents when: a. A power strip (extension cord) connected to an outlet up in a wall by the ceiling was hanging down with six connectors/cords plugged-in in Resident 1's room. b. A trash can with broken, sharp pointed edges was found in another resident's room. Findings: A review of the face sheet, Resident 1 was admitted with diagnoses including chronic obstructive pulmonary disease (COPD, lung disease) and folliculitis (inflammation of the hair follicles {when the hair grows]). Minimum Data Set (MDS, a standard assessment tool) dated 8/19/22 Brief Interview of Mental Statis (BIMS, a brief interview to help determine cognitive functioning) score of 15 indicated cognitively intact. Under functional status, Resident 1 requires assistance with mobility and transfer. Resident 1 was unable to walk. a. During an observation on 6/26/23, at 10:34 AM, a power strip connected to an outlet up in a wall by 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 implement their policy and procedure when a nebulizer mask and oxygen cannula were in plain sight uncovered on a resident's bedside table. The facility failure has the potential for contamination of the nebulizer mask and oxygen cannula which may result to the health problems. Findings: During an observation and interview on 6/26/23, at 10:32 AM, the Director of Staff Development (DSD, facility educator) acknowledged the nebulizer mask was uncovered in plain sight on top of the resident's bedside table, and an uncovered oxygen cannula was inside the open bedside table drawer and stated, the nebulizer mask and the oxygen cannula were not covered. It is infection control issues. They should be kept in a clean plastic bag when resident is not using them. It can cause respiratory (lungs, responsible for breathing) infections. A review of the Policy and Procedure, titled Administering Medications through a Small Volume (Handheld) Nebulizer dated 10/2010, indicated . store in a plastic bag with the resident ' 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 provide the required Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage, Form CMS-10055 (SNF ABN, Form Centers for Medicare & Medicaid Services-10055 - a written notice used to inform the resident/beneficiary of potential financial liability for the non-covered stay and the right to appeal to receive care and services which may not be covered by Medicare) for three of five sampled residents (Resident 59, Resident 60, and Resident 123) receiving Medicare Part A services. This failure had the potential for residents and/or resident representative of not being aware of the financial liability and the right to appeal for the denial or termination of resident's Medicare Part A services. Findings: During a review of the SNF Beneficiary Protection Notification Review for Resident 59, it indicated, . Medicare Part A Skilled Services Episode Start Date: 1/14/21 . Last covered day of Part A Service: 2/4/21 . The facility/provider initiated the discharge from Medicare Part A Services when benefit days were not…

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

Based on observation, interview and record review, for 26 of 26 sampled residents, the facility failed to ensure residents were able to voice their grievances when the facility failed to implement its grievance policy to address resident rights to file a grievance anonymously. This failure failed to support resident rights to file grievance without discrimination, reprisal or the fear of discrimination or reprisal. Findings: During an interview on 6/3/21, at 10:03 AM, in the Resident council meeting, Resident 53 stated there used to be a grievance form on each floor, but now, the residents could not find the forms anywhere on the units. Resident 53 stated residents always had to tell the staff verbally or the social worker if they had any grievances. Resident 53 stated they were not aware on how to file grievance anonymously. During an interview on 6/3/21, at 11 AM, with Social Services Designee (SSD) 1, SSD1 stated the grievance forms were removed from the nursing units (2nd floor and 3rd floor) because of the outbreak. SSD1 stated the grievance forms were now located in the first…

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 records review, the facility failed to ensure that safe food and sanitary condition were met for food storage and dishwashing equipment in the Nutrition Services Department, when expired and unlabeled food items were stored in the refrigerator, dry food storage area and brown stains were found inside the door of the dishwashing machine. These deficient practices have the potential to result in food borne illness for residents. Findings: During initial kitchen tour observation and concurrent interview on 6/02/21 at 9:35 am with the Kitchen Supervisor (KS), the following expired or undated items were noted: a) The miscellaneous refrigerator 1 had waffle dated 5/12/21 on the clear container only; the dietary aide 1 (DA1) stated, I think the waffle is expired. b) The holding fridge chamber 2 had shredded cheese packs dated 5/21/21 on the container only. The KS stated, it was mislabeled. c) The right chamber of the front fridge 1 had snack packs in two zip lock bags with no name…

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 a qualified social worker was employed on a full-time basis. This failure had the potential to result in residents not receiving sufficient and appropriate coordination of medically related social services to meet the resident's needs. (Refer to F742) Findings: During a review of the facility's license to operate, it indicated the facility had a bed capacity of 160, with an effective date of 3/1/21 and expires on 2/28/22. During an interview on 6/8/21 at 11:25 am, with Administrator (ADM), the ADM stated the facility has two social services designee (SSD). The ADM was asked about the qualifications of the SSD, he stated that the two SSD had no bachelor's degree in social work or human services field but has oversight from the Human Services Coordinator (HSC) and Social Services Consultant (SSC). The ADM acknowledged the facility with more than 120 beds requires a qualified social worker on a full-time basis. During a review of the Social Services Director job description, dated and signed on 8/1/19, 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 implement its plan of action to correct the identified deficiency regarding the social worker's qualification during the recertification survey conducted on 3/4/19 through 3/12/19. This failure resulted in a repeated noncompliance to F850 which had the potential to affect the resident's need for sufficient and appropriate coordination of medically related social services. (Refer to F850 and F742) Findings: During a review of the facility's recertification survey conducted on 3/4/19 through 3/12/19, the written Plan of Correction for F850 indicated, 1).A licensed social worker consultant shall oversee both SSD and SSA for meeting the psychosocial requirements of the residents until a qualified candidate is hired . 3). The administrator and licensed social worker consultant shall re-evaluate what psychosocial needs of the residents are not met and initiate further interventions with the social services team ongoing . 5). The plan of correction shall be completed by 5/2/19. During an interview on 6/8/21 at 11:25 AM, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not ensure that drugs were labeled in accordance with currently accepted professional principles, and include cautionary instructions, and the expiration dates. This failure had the potential to result in significant unsafe, and adverse consequences that will put the resident's health at risk. Findings: During an observation on [DATE] at 2:10 PM in the B wing, with a Licensed Vocational Nurse (LVN 1), the following were found inside the medication cart: 1. a Novalog Insulin vial had an opened date of 4/27; 2. Lantus insulin vials, Brinzolamide eye drops, and inhalers with no opened dates. During an interview with the LVN 1 on [DATE] at 2:10 PM, LVN 1 stated, that (Novalog Insulin ) was discontinued but is still inside the medication cart. LVN 1 also stated, these (Lantus insulin vials, Brinzolamide eye drops, and inhalers) are medications of the resident who was discharged yesterday. I will take these out Review of the Full Prescribing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement the facility's infection prevention and control program for two (2) of 26 sampled residents when: 1. Wound Nurse (WN) 1 did not complete hand hygiene during Resident 69's wound care treatment. 2. Resident 34's oxygen cannula was found on the floor uncovered. This deficient practice will result in potential spread of infection. Findings: 1. Resident 69 was admitted on [DATE], with diagnoses that included cerebral infarction (or stroke, refers to damage to tissues in the brain due to a loss of oxygen to the area), aphasia (loss of ability to understand or express speech, caused by brain damage), hemiplegia (paralysis of one side of the body) on right side. During a review of Resident 69's Minimum Data Set (MDS, a comprehensive assessment tool), dated 4/14/21, the MDS indicated, Resident 69 was receiving skin treatment medications. The MDS also indicated Resident 69 required extensive assist with transfers, dressing and toileting.…

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 26 sampled residents (Resident 69), the facility failed to implement its policy and procedure to prohibit neglect when multiple reports of allegation of neglect reported by Resident 69's responsible party (RP1) were not investigated. Failure to investigate allegation of neglect prevents timely protection of residents safety and well-being. Definition: Neglect - as defined §483.5, means the failure of the facility, its employees or services providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Findings: Resident 69 was admitted on [DATE], with diagnoses that included cerebral infarction (or stroke, refers to damage to tissues in the brain due to a loss of oxygen to the area), aphasia (loss of ability to understand or express speech, caused by brain damage), hemiplegia (paralysis of one side of the body) on right side. Review of Resident 69's Minimum Data Set (MDS, a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan for two of 26 sampled residents (Resident 29 and Resident 34) when: 1. There was no care plan addressing the behavioral manifestations and the use of psychotropic medication (drugs used to treat psychiatric conditions) for Resident 29. 2. There was no care plan addressing oxygen therapy use for Resident 34. This failure had the potential to result in inappropriate and inaccurate provisions of care that will impact the quality of care and services for Resident 29 and 34. Findings: 1. During a review of the admission record for Resident 29, the admission record indicated resident was admitted with diagnoses including end stage kidney disease, dementia (decline in memory and mental abilities) with behavioral disturbances, and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities). During a review of the physician's order for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop an updated discharge plan for one of one sampled residents (Resident A) when: 1. Resident was not informed about the outcome of the independent housing application and 2. Discharge care plan was not updated to reflect resident's discharge goal. This failure could lead to unnecessary delays in Resident A's discharge or transfer. Findings: Resident A was admitted on [DATE] with diagnoses that included diabetes, hemiplegia (paralysis of one side of the body) and absence of right leg above knee. 1. During an observation and concurrent interview with Resident A, on 8/25/21, at 10:50 AM, Resident A expressed concerns with social services and stated nothing was happening on her application for an independent housing, back in January 2021. During concurrent interview with Social Services Designee (SSD) 2 and review of Resident A's clinical record, dated 5/11/21, at 12:43 PM, indicated . SS [social services] met with [Resident A] 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 ensure one of 26 sampled residents (Resident 69) received treatment and care in accordance with professional standards of practice. This failure could negatively impact to Resident 69's physical, mental and psychosocial needs. Findings: Resident 69 was admitted on [DATE], with diagnoses that included cerebral infarction (or stroke, refers to damage to tissues in the brain due to a loss of oxygen to the area), aphasia (loss of ability to understand or express speech, caused by brain damage), hemiplegia (paralysis of one side of the body) on right side. During a review of Resident 69's Minimum Data Set (MDS, a comprehensive assessment tool), dated 4/14/21, indicated Resident 69 was receiving skin treatment medications. The MDS also indicated Resident 69 required extensive assist with transfers, dressing and toileting. During a review of Resident 69's clinical record, the physician orders, dated 5/26/21, indicated . Benzoyl Peroxide Wash…

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 behavioral health services and individualized care approaches addressing the emotional and psychosocial needs for one of 53 residents (Resident 29) receiving psychotropic medications (drugs used to treat psychiatric conditions) when: 1. Psychiatric evaluation was not coordinated after two missed appointments on 2/5/21 and 2/9/21. 2. There was no individualized care plan addressing the behavioral manifestations and the use of psychotropic medication. This failure resulted in Resident 29 not receiving the necessary behavioral health services; and the potential to not attain the highest practicable mental and psychosocial well-being. Findings: 1. During a review of the clinical record for Resident 29, the record indicated resident was admitted with diagnoses including end stage renal disease (advanced state of gradual loss of kidney function), dependence on renal dialysis (the process of removing excess water, solutes, toxins from the blood), dementia (decline in memory and mental abilities) with behavioral…

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 had a 10.34% error rate when three medication errors out of 29 opportunities were observed during a medication pass for Resident 115, Resident 126, and Resident 37. This deficient practice resulted in medications not given in accordance to the prescriber's orders and/or manufacturer's specifications which may result in residents not receiving the full therapeutic effect of the medications. Findings: 1. During drug administration observation on 6/3/21 at 8:35 AM in A wing, LVN 4 prepared Resident 115's seven medications and placed them in a medication cup. LVN 4 proceeded to position Resident 115 on a semi-Fowler's position, and poured the cup of medicines in the resident's open mouth. Resident 115 swallowed all the medicines without coughing. During a reconciliation of resident 115's electronic record of medication orders on 6/3/21 at around 9 AM with a Registered nurse in the nurses' station, the medication order indicated, Lamotrigine: Give 50 mg sublingually one time a day for neuralgia. During an interview with LVN…

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.