Anberry Post Acute

Based on observation, interview and record review, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety when:1. A box of zucchini was not labelled and dated in the walk-in refrigerator.2. Station 200's nourishment unit refrigerator was observed with a box of pizza brought into the facility that was not properly labeled with the resident's name, room number, date the food was brought in, opened or the use-by date.These failures had the potential for staff to have access to expired foods for residents.1. During concurrent observation and interview on 6/16/26 at 9:31 a.m. with the Kitchen [NAME] (KC) inside the walk-in refrigerator, an unlabeled and undated plastic bin containing zucchini was observed on a metal rack. KC stated all food items inside should be labeled. KC stated, once food or produce is put into another container for use, it should be labeled with received date and use by date. KC stated the kitchen staff missed the labelling of food and produce.During an interview on 6/17/26…

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 medical records of residents that are complete and accurately documented in accordance with accepted professional standards and practice for two of 10 sampled residents (Resident 11 and Resident 9) when:1.Resident 11's electronic health record (EHR) contained no documentation of completed ileostomy (a specific type of surgery where the lower part of the small intestine is brought through an opening in the belly to form a stoma [an artificial opening made by a surgeon on the abdomen-belly]) bag changes since 7/3/25.This failure had the potential to disrupt continuity of care, create gaps in the services provided, and lead to miscommunication among staff regarding Resident 11's status.2. Licensed Vocational Nurse (LVN) 1 did not document Resident 9's medications administered in his electronic Medication Administration Record (eMAR-digital medication chart or a smart medicine checklist used by nurse and caregivers) after she…

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 educate and offer Covid-19 vaccinations for three of three sampled employees (Certified Nurse Assistant [CNA] 5, CNA 7, and Licensed Vocational Nurse [LVN] 5) when CNA 5, 7, and LVN 5's employee files were reviewed and did not contain documentation that staff were provided education regarding the benefits and potential risks associated with COVID-19 vaccinations or if they were offered the COVID-19 vaccination.This failure had the potential to increase the risk to vulnerable nursing home residents by potentially exposing them to outbreaks and raising the likelihood of severe illness or death.During an interview on 6/19/26 at 9:50 a.m. with the Infection Preventionist (IP), the IP stated the facility did not offer Covid 19 vaccinations for staff because it was no longer mandated for staff to be vaccinated.During a concurrent interview and record review on 6/19/26 at 11:11 a.m. with the Director of Staff Development (DSD), three employee files (CNA 5, CNA 7, and LVN 5) were reviewed. The employee files reviewed did not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a safe, functional, and sanitary condition was maintained when four containers (five gallon each) containing chemicals in the dirty area of the laundry room were found covered with thick white foamy substance and the floor directly below the containers also contained the thick white foamy substance. This failure had the potential to affect the health condition of the 105 residents, staff and visitors of the facility, like severe skin burns, eye damage and toxic (poisonous or harmful) respiratory irritation. Findings: During a concurrent observation and interview on [DATE] at 8:22 a.m. with the Laundry Person (LP) in the dirty room area of the laundry room, nine containers were stacked in the corner of the room and four of the containers were covered with a white foamy substance. The LP stated she did not notice the thick white foamy substance covering the containers and was not sure what the white foamy substance was. The LP 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 meet professional standards of quality for one of three residents (Resident 1) when Resident 1 was admitted with a pressure ulcer (a localized area of skin damage and underlying tissue that develops when prolonged pressure is applied to the body) of the sacral region (the area of the lower back and pelvis) and Resident 1 required to be turned and repositioned every two hours. Resident 1's care plans did not indicate Resident 1 be turned and repositioned every two hours and Resident 1's medical records did not indicate Resident 1 was turned and repositioned every two hours. This failure resulted in incomplete and inaccurate documentation of when Resident 1 was turned and repositioned and had the potential to result in the worsening of Resident 1's pressure ulcer and the potential of developing new pressure ulcers resulting in the death of Resident 1 on [DATE] with a diagnosis of septic shock (a life-threatening condition that occurs when an 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.

Based on interview and record review the facility failed to inform and provide written information on how to formulate an advance directive (a legal document that outlines a person's wishes regarding their medical care in the event they become unable to make decisions for themselves due to illness or injury) for 87 of 87 residents when staff did not document information on how to obtain an advance directive in resident charts. This failure violated the rights of 87 residents to be informed on how to formulate and obtain an advance directive. Findings: During an interview on 12/11/24 at 10:28 a.m. with the Medical Records Director (MRD), the MRD stated the facility did not help residents obtain an advance directive, they refer the resident to someone else such as their primary physician to get an advance directive completed. The MRD stated the facility will only keep a resident's advance directive on file in their chart if a resident came in with one. The MRD stated if a resident did not have an existing advance directive when they came into the facility no education or information…

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 revise and implement a person-centered comprehensive care plan (CP- road map for the care of a resident and a necessary tool in following the nursing process) for one of eight sampled residents (Resident 45) when the care plan was not updated to reflect discharge from hospice (end of life) service. This failure had the potential for Resident 45's needs to not be meet. Findings: During an interview on 12/10/24 at 9:38 p.m. in Resident 45's room with Family Member (FM) 1, FM 1 stated her mother was no longer on hospice services. During a concurrent interview and record review on 12/11/24 at 11:23 a.m. with License Vocation Nurse (LVN) 5, LVN 5 stated Resident 45 had been on hospice but was discharged from hospice on 11/16/24. LVN 5 stated the care plan for hospice should have been updated on the same day Resident 45 was discharged from hospice. LVN 5 stated the business office and primary physician were notified when Resident 45 was discharged from…

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 meet professional standards of practice for four of 16 sampled residents (Resident 46, Resident 231, Resident 233, and Resident 235) when: 1. Resident 46, Resident 231 and Resident 235's oxygen tubing were not labled with the date the tubing was changed. This failure put Residents 46, 231 and 235 at risk of infection. 2. The Attending Physician (AP) was not notified when Resident 233's medication for hypertension (high blood pressure) was not given due to low blood pressure levels. This failure put resident 233 at risk of harm due to low blood pressure levels. 3. Resident 235's physician order (a set of instructions written by a doctor for clinicians to follow when caring for a resident) for oxygen flow rate was for 2 L/min (liters per minute - a unit of measurement) and it was set at 4.5 L/min. This failure resulted in Resident 235 receiving too much oxygen and had the potential to result shortness of breath and respiratory distress…

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 nursing staff information data posting contained or demonstrated the total numbers and actual hours worked by Registered nurses (RN), license vocational nurses (LVN) and Certified nurse aides, were posted daily. This failure resulted in 87 out of 87 residents and their family members not being able to identify who was responsible for their care, how many licensed and unlicensed staff were on shift, and the total number of hours staff were working. Findings: During an observation on 12/13/24 at 2:35 p.m. in the hallway, the Census and Direct Care Services Hours Per Patient Day (DHPPD) did not contain the total number of actual hours worked for RNs, LVNs and CNAs. During an interview on 12/13/24 at 3:04 p.m. with the Administrator (ADM) the ADM stated, We have only CNA hours posted and no nursing hours posted. The ADM stated, the posting sign had CNA actual hours and no licensed nurse actual hours posted. The ADM stated he was not aware the hours needed to be posted. The ADM stated there were no posted…

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 palatable and flavorful food when: 1. Broccoli was bland and without flavor for the regular diet. 79 Residents received broccoli at the facility. 2. Puree salad did not taste good. Five residents (Residents 2, 9, 63, 481, 482) were on the puree diet. These failures resulted in lack of flavor and palatability in vegetables and puree salad which can lead to residents having a decreased food intake and could result in weight loss and further compromise nutritional and medical status. There were 84 residents eating at the facility. Findings: During an interview on 12/9/24 at 1:10 p.m. with Resident 60 (R 60), R 60 stated the food was bland. During an interview on 12/10/24 at 12:32 p.m. with Resident 20 (R 20), R 20 stated the food did not taste good and he will not eat the food item if he does not like it. During a review of the facility menu titled, Winter Menus, the lunch menu on 12/10/24 indicated residents on regular, mechanical soft, dysphagia mechanical, no added salt and controlled carbohydrate…

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

Based on observation, interview, and record review, the facility failed to ensure food and ice were stored, distributed, and served safely when: 1. The ice machine was observed with black spots above the water trough (a compartment within the ice machine where water is stored before it is frozen into ice cubes) and pink residue on the ice grate (a compartment within the ice machine that determines the size of the ice cubes that are produced) and sensor (monitors ice levels) 2. Apple juice pitcher located in the nourishment room refrigerator was dated past the use by date; and 3. The nourishment room refrigerator had dry, sticky substance on bottom drawers and a door shelf. These failures resulted in a unit refrigerator and facility ice machine not being in clean safe operating condition, and juice kept past the use by date, which can lead to the growth of microorganisms and can result in foodborne illness for the 84 residents consuming food, juice, and ice at the facility. Findings: 1. During a concurrent observation and interview on 12/11/24 at 9:19 a.m. with Maintenance (MN) 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.

Based on interview and record review the facility failed to notify residents and residents' representatives (RP-person designated to make decisions for a resident) in writing of a resident's transfer to the hospital for four of eight residents (Resident 2, 16, 33, and 41) when the facility did not provide written notice to the resident or their RP when they were transferred to the hospital. This failure violated the rights of Residents 2, 16, 33, and 41 to be informed in writing of the reason for transfer to the hospital. Findings: During an interview on 12/24/24 at 2:39 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she had never sent a notification in writing to the resident or their RP whenever a transfer to the hospital occurred. LVN 1 stated if residents had an RP, nurses would call them, but no written notice was ever given to the RP regarding reason for transfer to the hospital. LVN 1 stated if residents or their RP's were not given a written notice for the reason for the hospitalization they may be unaware as to why the resident was sent to the hospital During an…

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

Based on interview and record review the facility failed to provide residents and residents' representatives (RP- a person designated to make decisions for a resident) written information regarding the bed hold policy for four of eight sampled residents (Resident 2, 16, and 41) when no written notices about the facility's bed hold policy was given to residents or their RPs upon the residents' transfer to the hospital. This failure violated the right for residents and RPs to be notified in writing of the facility's bed hold policy. Findings: During an interview on 12/12/24 at 9:01 a.m. with the Business Office Manager (BOM), the BOM stated whenever residents were transferred to the hospital the business office would call the RP to let them know of the bed hold policy, but she would not send them a notification in writing. The BOM stated a written bed hold notification was only given to residents and their RPs on admission and no written notice was given upon transfer to the hospital. The BOM stated she was not aware RPs needed written information regarding bed holds to be given to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement comprehensive person-centered care plans (CP - a detailed approach to care customized to an individual resident's needs) for two of 16 residents (Residents 231, and 235) when Resident 231 and Resident 235 did not have care plans for oxygen administration. This failure put Residents 231 and 235 at risk for harm due to improper monitoring, documentation and administration of oxygen use. Findings: During a concurrent observation and interview on 12/09/24 at 11:56 a.m. in Resident 231's room, Resident 231 was observed in a gown, sitting in a wheelchair with oxygen infusing via a nasal cannula (a tube that delivers oxygen through the nose to people who have low oxygen levels). Resident 231 stated she had been in the facility for two days. Resident 231 stated she was in the facility due to having a mini stroke (stroke -(damage to tissues in the brain due to a loss of oxygen to the area). During a review of Resident 231'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 observation, interview, and record review, the facility failed to ensure drugs and biologicals (a substance such as vaccines or drugs derived from a living organism used for treatment) were stored and labeled in accordance with currently accepted professional standards of practice when: 1. The refrigerator in section 300-Medroom contained an antibiotic with an unreadable expiration date. Carts 200-Backside and 300-B contained : one of five inhalers (medications used to treat respiratory disease with a mist or spray that the patient breathes in through the nose or mouth) had an expiration date of 11/2/24, lactulose (a medication used to decrease the amount of ammonia in the blood) had an expiration date of 12/2/24, 11 of 143 pill packets had expired dates in November, 26 of 60 ferrous gluconate (a medication to treat low iron in the blood) expired 5/24, combined with new packets of pills individually packaged with date of 1/27 one of one bottle of folic acid (a mineral) did not have a readable expiration date on the bottle, one of four bottles of insulin (a medication used…

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 menus were followed for 16 Residents (Resident 5, 7, 13, 18, 23, 28, 32, 33, 35, 36, 41, 44, 45, 52, 60, 281) when a dessert was served that was not on the planned and approved menu. This failure had the potential to result in 16 residents having a decreased intake of nutrients and lower satisfaction and interest of the meal as the resident could have been looking forward to receiving the planned and approved dessert menu item. Findings: During a review of Winter Menus for Monday 12/9/24, (undated), the Winter Menus indicated the lunch served on Monday included, .Southern Style Beef Pattie, Cream Gravy, Mashed Potatoes, Garlic Parmesan Spinach, Parsley Sprig Garnish, Wheat Roll, Margarine [butter] Ambrosia Pudding with 2 sl [slices] mandarin oranges/ 1 tsp [teaspoon] coconut . During an observation on 12/9/24 at 12:36 p.m., in the kitchen at tray line, resident trays at the end of tray line had different desserts placed on the resident trays. Sixteen Residents (Resident 5, 7, 13, 18, 23, 28, 32, 33,…

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, two of two Licensed Vocational Nurses (LVN 4 and LVN 7) failed to implement and maintain infection control practices to provide a safe and sanitary environment to help prevent the development and transmission of infections when: 1. Licensed Vocational Nurse (LVN) 4 failed to don appropriate Personal Protective Equipment (PPE) prior to entering an isolation room. 2. LVN 7 failed to perform hand hygiene (the cleansing of hands with soap and water, antiseptic hand washes, and antiseptic hand rubs such as alcohol-based hand sanitizers) before and after administering medications. 3. LVN 7 failed to sanitize a glucometer (a device used to measure the amount of sugar in the blood, typically using a small drop of blood placed on a test strip) according to manufacturer's instructions before placing it back in the medication cart. These failures put residents at risk of acquiring healthcare associated infections (infections that patients get while or soon after receiving…

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 personal hygiene for one of eight sampled residents (Resident 46) when Resident 46's fingernails were long and not cut. This failure had the potential to result in Resident 46 to develop skin infections or sustain skin injuries. Findings: During a concurrent observation and interview on 12/10/24 at 12:01p.m. in Resident 46's room, Resident 46 had long yellow fingernails. Resident 46 stated he did not like his fingernails long and wanted them cut or filed. Resident 46 stated he was a diabetic and long fingernails could have caused infections when he scratched his skin. Resident 46 stated he did not remember the last time staff cut or trimmed his fingernails. During a concurrent observation and interview on 12/13/24 at 8:17 a.m. with Certified Nursing Assistant (CNA) 6, CNA 6 stated Resident 46's fingernails were long and should have been trimmed or cut. CNA 6 stated Resident 46's long fingernails were dirty and could have contained…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure two of seventeen sampled residents (Resident 32 and 236) were free from unnecessary medications when: 1. Monitoring for behaviors and non-pharmaceutical interventions were not implemented for Resident 236 while administering anti-psychotic medications (a medication used to treat a collection of symptoms that affect your ability to tell what's real and what is not). 2. Resident 32 did not have monitoring orders for her anxiety and bipolar disorder in place upon her admission to the facility on [DATE]. These failures placed Resident 32 and Resident 236 at risk for receiving unnecessary antipsychotic medications and had the potential of preventing them from maintaining their highest practicable mental, physical, and psychosocial well-being. Findings: 1. During an observation on 12/9/24 at 12:25 p.m.in Resident 236's room, Resident 236 was observed eating his meal. Resident 236 began speaking very loud in his native language ([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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of eight sampled residents (Resident 21) food preferences were accommodated when halal (Halal food is prepared and processed in accordance with Islamic law and dietary standards outlined in the Quran) meat was not served. This failure had the potential to place Resident 21 at risk for not meeting his nutritional status and feeling worried and anxious about his health status. Finding: During an interview on 12/10/24 at 10:21 a.m. in Resident 21's room, Resident 21 stated he was not able to consume protein in the form of meat products. Resident 21 stated, he would like to have Halal meat and the facility was not able to accommodate to his food preferences. Resident 21 stated he was worried about his protein intake. Resident 21 stated he was ordering bone broth from online store so he can get some protein. Resident 21 stated, I want to consume meat and I want the facility to help me obtain my protein from halal meat. Resident 21…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide one of eight sampled residents (Resident 60) fluid consistent with resident needs and preferences when Resident 60's standing order (a written instruction from a healthcare provider that authorizes nurses, pharmacists, or other healthcare professionals to perform specific tasks or administer treatments without the need for an individual order each time) included apple juice and Resident 60's dislikes included apple juice. This failure placed Resident 60 at risk of not having sufficient fluid intake to maintain proper hydration. Findings: During a concurrent observation and interview on 12/9/24 at 1:09 p.m. in Resident 60's room, a cup of apple juice was on the lunch tray. Resident 60 stated, They don't always honor my food preferences. Resident 60 stated, I don't know why I have a standing order for apple juice. Resident 60 stated, I won't drink everyday but once in a while. During a concurrent interview and record review on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure accurate and complete medical records in accordance with professional standards of practices for one of nine sampled residents (Resident 59) when the Physician Orders for Life-Sustaining Treatment (POLST- a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of life) was not accurate and complete with section B (Medical Interventions) unmarked. This failure had the potential for Resident 59's decisions regarding treatment options and end of life wishes to not be honored. Findings: During a review of Resident 59's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 12/13/24, the AR indicated Resident 59 was admitted to the facility from the acute care hospital 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 observations, interviews, and policy review, the facility failed to ensure drugs and biologicals were stored in locked compartments and not left unlocked while they were unattended by authorized staff. This deficient practice was observed for 2 of 2 treatment carts in the facility and had the potential to affect all residents who resided on the 200 and 300 halls. Findings included: Review of a facility policy titled, Medications Storage, with a review date of 01/31/2022, revealed, It is the policy of this facility that all medications, drugs and biologicals are to be stored in a safe, secure and orderly manner, at a temperature as directed by the manufacturer, and accessible to only licensed nurses and the pharmacist in accordance with federal and state regulations. During an observation on 10/31/2023 at 7:21 AM, the treatment cart on the 300 Hall was observed unlocked and unattended. The contents of the treatment cart included tubes of lidocaine ointment (an aesthetic used to prevent and treat pain from some procedures, minor burns, scrapes, and insect bites), clotrimazole…

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, record review, and facility policy review, the facility failed to ensure a resident was assessed to determine if self-administration of medication was clinically appropriate for 1 (Resident #48) of 6 sampled residents reviewed for medication administration. Specifically, Resident #48 was found with two white pills in a small cup at bedside with no staff present without an assessment of the resident's ability to safely self-administer the medication. Findings included: A review of a facility policy titled, Medications, Self-Administration, reviewed on 01/31/2022, revealed, It is the policy of this facility that an individual resident may self-administer specific medications if the IDT [interdisciplinary team] has determined that this practice is safe, and physician orders are obtained for self-administration of the specific medication(s). The policy specified, 2. If a resident voices desire to self-administer medications, the IDT is to assess the resident's cognitive, physical and visual ability to carry out this responsibility. 3. A licensed nurse…

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 interviews, record review, facility document review, and facility policy review, the facility failed to ensure a Level II evaluation was completed after a positive Level I Preadmission Screening and Resident Review (PASARR) for 1 (Resident #65) of 1 sampled resident reviewed for PASARRs. Findings included: Review of guidance from the California Department of Health Care Services (DHCS), dated 08/09/2023, indicated, Purpose: The PASRR [Preadmission Screening and Resident Review] Information Notice (IN) clarifies the Hospitals' and SNFs' [skilled nursing facilities'] responsibilities to provide MCPs [Medi-Cal Managed Care Plans, health care for people with low or no income] confirmation that a PASRR Level I Screening was completed and to provide completed PASRR documentation for cases that advance to a Level II Evaluation with SNF referrals for prior authorization. Further review of the guidance indicated, PASRR documentation is no longer required to be sent to the MCP when a Level I Screening is negative for SMI [serious mental illness] and/or ID/DD/RC [intellectual…

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

Based on interviews, record review, and policy review, the facility failed to ensure staff monitored the skin as ordered by the physician for 1 (Resident #36) of 2 sampled residents reviewed for skin issues. Findings included: Review of a facility policy titled, Skin Assessments, dated 07/18/2023, revealed Purpose: To ensure that every resident admitted to and residing at the facility has their skin checked on a routine basis for any conditions that require medical intervention. If skin breakdown occurs, a resident is to receive the appropriate treatment per physician's order. Review of Resident #36's admission Record revealed the facility readmitted the resident on 10/06/2023 with diagnoses that included fracture of neck of the left femur (hip area) and age-related osteoporosis with a current pathological fracture. Review of Resident #36's admission Minimum Date Set (MDS), with an Assessment Reference Date (ARD) dated 10/12/2023, revealed the resident had a Brief Interview for Mental Status (BIMS) of 11, which indicated the resident had moderate cognitive impairment. The 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 observations, interviews, record review, and policy reviews, the facility failed to ensure a bi-level positive airway pressure (BiPAP) mask and an updraft nebulizer mask were stored in a bag when they were not in use for 1 (Resident #58) of 2 sampled residents reviewed for respiratory care. Findings included: Review of a facility policy titled, CPAP [continuous positive airway pressure] and BiPAP Use, revised on 01/31/2022, revealed, 11. Nursing staff is to ensure that the CPAP/BiPAP is kept clean at all times, and that the mask is cleaned according to the manufacturer's recommendations prior to each use. Review of a facility policy titled, Nebulizer Treatments, revised on 01/31/2022, revealed, 4. Remove nebulizer from plastic bag. Connect tubing to oxygen source and fill the nebulizer with prescribed medication. a. Nebulizer tubing and storage bags are to be changed weekly, on Sundays, and dated when changed. A review of Resident #58's admission Record indicated the facility readmitted the resident on 09/27/2023 with diagnoses that included acute and chronic respiratory…

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 interviews, record review, and policy review, the facility failed to ensure a resident's medication regimen was free from unnecessary medications for 1 (Resident #17) of 5 sampled residents reviewed for unnecessary medications. Specifically, Resident #17 had an order for lorazepam 0.5 milligrams (mg), one tablet by mouth every six hours as needed (PRN) for anxiety and agitation started on 06/15/2023 with no specified duration (stop date). Findings included: A review of a facility policy titled, Medications, Psychotherapeutic Drugs, reviewed on 01/31/2022, revealed, Purpose: To provide a therapeutic environment using only those medications with a therapeutic value to individual residents. The use of unnecessary drugs is to be avoided whenever possible. Policy: It is the policy of this facility that psychotherapeutic drugs will not be administered for purposes of discipline or convenience, and if required is to be used to treat the resident's medical symptoms. Each resident's drug regimen is to be free from unnecessary drugs. The section of the policy titled,…

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.