La Sierra Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to establish and maintain an effective infection prevention and control program during medication administration for three of 15 sampled residents (Resident 9, Resident 5, and Resident 35) when:1. During a blood glucose check (a process for measuring the concentration of glucose in the blood) and medication administration to a resident on Enhanced Barrier Precautions (EBP - an infection control intervention designed to reduce transmission of resistant organisms [bacteria that have become resistant to certain antibiotics] that requires gown and glove use during high contact resident care activities), Registered Nurse (RN) 2 placed a tray containing supplies for patient care on Resident 9's bedside table who was on EBP, then placed the tray in the medication cart without sanitizing it after providing care and medication administration to Resident 9.2. Personal Protective Equipment (PPE) was not worn during care for Resident 35 and Resident 5.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a baseline care plan (a personalized, written document that outlines a resident's health needs, goals, and the specific actions and services to be provided) for one of three sampled residents (Resident 1) when Resident 1 was a known elopement (a resident who leaves a nursing facility without authorization or staff knowledge) risk and did not have a care plan in place for elopement.This failure resulted in Resident 1 not having a care plan with interventions in place to prevent elopement and led to Resident 1 eloping from the facility on the evening of 11/16/25.During a review of Resident 1's admission Record (AR - a summary of important information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses which included dementia (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 interview and record review the facility failed to follow facility's policies and procedures that meet professional standards of quality when: 1.) One of three sampled Residents (Resident 1) did not have nursing documentation in the progress notes for 346 times that he was found on the floor and head-to-toe assessments were not complete. This failure result in no head-to-toe assessments completed and had the potential for delay in care of for Resident 1 and missed opportunity for updating his care plan. 2.) Two of five Certified Nursing Assistant ' s (CNA) working during the afternoon shift were not wearing any identification badges identifying themselves as staff. This failure had the potential for facility residents to not know who was providing care to them, and if they worked in the facility. Findings: 1. During a review of Resident 1's admission Record (AR) (document containing resident demographic information and medical diagnosis), dated 3/24/2025, the AR indicated Resident 1 was originally…

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 assess dietary preferences for seven of ten (Resident 1, 3, 6, 7, 8, 9, 10) sampled residents when they were not assessed for food preferences within 48 hours of admission. This failure resulted in Resident 1, 3, 6, 7, 8, 9 and 10's food preferences to not be considered when the facility provided meals. Findings: During an interview on 10/23/24 at 9:57 a.m. with Resident 1, Resident 1 stated she told staff multiple times she doesn't drink milk. Resident 1 stated even though she told multiple staff members, they keep bringing her milk. Resident 1 stated no one has asked her preference regarding any dietary foods. During a concurrent interview and record review on 10/23/24 at 11:30 a.m. with the Registered Dietitian (RD), Resident 1's, 3's, 6's, 7's, 8's, 9's, 10's Electronic Medical Record (EMR-digital version of the paper charts which contains the medical and treatment history of the patient/resident), dated 10/23/24 were reviewed. The EMR's indicated, Resident 1, 9, and 10 Dietary Profile/Preference was not…

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

During an interview on 08/20/2024 at 12:55 PM, Resident #29 stated they took one look at the lunch meal and could not eat it, so they asked for chicken noodle soup instead. During an interview on 08/20/2024 at 2:02 PM, Resident #58 stated the lunch was cold and the meat was dry but at least they got protein. According to an admission MDS, with an ARD of 06/27/2024, Resident #58 had a BIMS score of 13, which indicated the resident was cognitively intact. Based on observation, interview, and facility document and policy review, the facility failed to provide palatable meals. This failure had the potential to affect all residents who received meals from the facility's kitchen. Findings included: A facility policy titled, Food and Nutrition Services, revised in 10/2017, revealed, Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. The policy also revealed, 7. Food and nutrition services staff will inspect food trays to ensure that 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 facility document and policy review, the facility failed to ensure dietary staff did not document lunch meal service temperatures prior to placing the food items on the steam table for meal service and failed to ensure dietary staff utilized proper hand hygiene during meal service. These failures had the potential to affect all residents who received meals from the facility's kitchen. Findings included: A facility policy titled, Food Preparation and Service, revised 10/2017, revealed, Food and nutrition services employees shall prepare and serve food in a manner that complies with safe food handling practices. The policy also indicated, 5. Food preparation staff will adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness. The policy also indicated, 6. Bare hand contact with food is prohibited. Gloves must be worn when handling food directly. However, gloves can also become contaminated and/or soiled and must be changed between tasks. 1. During an initial tour of the facility's kitchen, on 08/19/2024 at 9:40 AM,…

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, document review, and facility policy review, the facility failed to ensure residents' rooms measured at least 80 square (sq) feet (ft) per resident in 19 (Rooms 1 through 7, Rooms 10 through 20, and room [ROOM NUMBER]) of 23 resident rooms in the facility. Findings included: A facility policy titled Bedrooms revised 05/2017, revealed, All residents are provided with clean, comfortable and safe bedrooms that meet federal and state requirements. The policy revealed, 2. Bedrooms measure at least 80 square feet of space per resident in double rooms, and at least 100 square feet of space in single rooms. The Client Accommodations Analysis, signed by the Maintenance Supervisor (MS) and dated 08/20/2024, revealed the following: - In room [ROOM NUMBER], there was 73.3 sq ft for each resident - In room [ROOM NUMBER], there was 73.3 sq ft for each resident - In room [ROOM NUMBER], there was 73.3 sq ft for each resident - In room [ROOM NUMBER], there was 73.3 sq ft for each resident - 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 observation, interview, record review, and facility policy review, the facility failed to ensure the medication error rate was less than 5 percent (%). Observation of medication administration revealed the facility had 3 medication errors out of 28 total opportunities, resulting in a medication error rate of 10.71%, affecting 2 (Residents #9 and Resident #32) of 9 residents observed during medication administration. Findings included: A facility policy titled, Administering Medications, revised in 04/2019, specified, 4. Medications are administered in accordance with prescriber orders, including any required time frame. The policy further specified, 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. 11. The following information is checked/verified for each resident prior to administering medications: a. Allergies to medications; and b. Vital signs, if necessary. 1. An admission Record indicated 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, record review, and facility policy review, the facility failed to ensure 3 (Residents #9, #32, and #19) of 12 residents reviewed during medication administration and for unnecessary medication were free from significant medication errors. Specifically, the facility failed to ensure physician ordered vital signs were obtained prior to administering medications for Resident #9 and Resident #32 and failed to hold Resident #19's medications when their blood pressure and/or pulse were outside of physician-ordered parameters for administration. Findings included: A facility policy titled, Administering Medications, revised in 04/2019, specified, 4. Medications are administered in accordance with prescriber orders, including any required time frame. The policy further specified, 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. 11. The following information is checked/verified 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 interview, record review, and facility policy review, the facility failed to ensure Minimum Data Set (MDS) assessments were accurate for 2 (Resident #46 and Resident #69) of 17 sampled residents. Findings included: A facility policy titled, Resident Assessments, revised October 2023, revealed, 12. Information in the MDS assessments will consistently reflect information in the progress notes, plans of care and resident observations/interviews. 1. An admission Record revealed the facility Resident #46 on 08/12/2022. According to the admission Record, the resident had a medical history that included diagnoses of hypertensive heart disease and heart failure. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/08/2024, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. The MDS revealed the resident used a hearing aid. A quarterly MDS assessment, with an ARD of 08/08/2024, revealed that the…

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

Based on interview, record review, and facility policy review, the facility failed to ensure an accurate Preadmission Screening and Resident Review (PASRR) was submitted for 1 (Resident #35) of 3 residents reviewed for PASRR. Findings included: During an interview on 08/22/2024 at 4:44 PM, Clinical Resource stated the facility did not have a policy for PASRR, but they followed the letter received from the State Department of Health Care Services dated 08/09/2023. The letter from the State Department of Health Care Services dated 08/09/2023, specified, Per Title 42 of the Code of Federal Regulations (C.F.R.) sections 483.100 through 483.138, individuals identified with a SMI [serious mental illness] and/or ID/DD/RC [intellectual disability/developmental disability/related conditions] must be screened and evaluated to determine whether SNF [skilled nursing facility] level of care and specialized services in the least restrictive setting that best meets their needs are required (PASRR Determination). All individuals, regardless of payer source, seeking admission to a Medicaid-certified…

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, record review, and facility policy review, the facility failed to revise 1 (Resident #15) of 17 sampled residents' comprehensive care plan. Findings included: A facility policy titled, Care Plans, Comprehensive Person-Centered, revised in March 2022, revealed, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. An admission Record revealed the facility admitted Resident #15 on 03/09/2018. According to the admission Record, the resident had a medical history that included diagnoses of hemiplegia and hemiparesis following a nontraumatic subarachnoid hemorrhage affecting the left nondominant side, flaccid hemiplegia affecting the left nondominant side, and contracted left hand. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/29/2024, revealed Resident #15 had a Brief Interview for Mental Status…

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 record review, interview, and facility policy review, the facility failed to provide fortified food intended for nutritional supplement for 1 (Resident #19) of 4 residents reviewed for nutrition. Findings included: A facility policy titled, Food and Nutrition Services, revised 10/2017, revealed, 1. The multidisciplinary staff, including nursing staff, the attending physician and the dietitian will assess each resident's nutritional needs, food likes, dislikes and eating habits, as well as physical, functional, and psychosocial factors that affect eating and nutritional intake and utilization. 2. A resident-centered diet and nutrition plan will be based on this assessment. An admission Record revealed the facility admitted Resident #19 on 11/10/2022. According to the admission Record, the resident had a medical history that included a diagnosis of protein-calorie malnutrition. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/07/2024, revealed Resident #19 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident…

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

Based on observation, interview, record review, and facility policy review, the facility failed to provide proper monitoring during the administration of a nebulizer treatment for 1 (Resident #35) of 2 residents reviewed for respiratory care. Findings included: A facility policy titled, Administering Medications through a Small Volume (Handheld) Nebulizer, revised 10/2010, indicated, The purpose of this procedure is to safely and aseptically administer aerosolized particles of medication into the resident's airway. The section titled Steps in the Procedure included 8. Dispense medication into nebulizer cup. 12. Turn on the nebulizer and check the outflow port for visible mist. 13. Ask the resident to hold the mouthpiece gently between his/her lips (or apply face mask). 14. Instruct the resident to take a deep breath, pause briefly and then exhale normally. 15. Encourage the resident to repeat the above breathing patter until the medication is completely nebulized, or until the designated time of treatment has been reached. 16. Remain with the resident for the treatment. 17. Monitor…

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

Based on observation, interview, record review, and facility policy review, the facility failed to ensure prescribed medications were available for 2 (Resident #2 and Resident #29) of 5 residents reviewed for pharmacy services. Findings included: A facility policy titled, Medication Ordering and Receiving From Pharmacy, effective 04/2008, specified, Policy Medications and related products are received from the dispensing pharmacy on a timely basis. The section of the policy titled, A. Ordering Medications from the Dispensing Pharmacy specified, 2) If not automatically refilled by the pharmacy, repeat medications (refills) are written on a medication order form/ordered by peeling the bottom part of the pharmacy label and placing it in the appropriate area on the order form provided by the pharmacy for that purpose and ordered as follows: a. Reorder medication five days in advance of need to assure an adequate supply is on hand. The policy also indicated, c. The refill order is called in, faxed, or otherwise transmitted to the pharmacy. 3) New medications, except for emergency or stat…

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 physician orders for vital signs were transcribed to medication administration records for 2 (Resident #9 and Resident #32) of 9 residents observed during medication administration. Findings included: 1. An admission Record indicated the facility admitted Resident #9 on 10/13/2017. According to the admission Record, the resident had a medical history that included a diagnosis of primary hypertension. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/22/2024, revealed Resident #9 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. Resident #9's care plan included a focus area revised 01/30/2018 that indicated the resident had hypertension. Interventions directed staff to administer atenolol, an antihypertensive medication, as ordered by the physician to monitor for side effects such as orthostatic hypotension and increased heart rate (revised 06/10/2020), and to hold the atenolol if the resident's systolic blood…

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 a comprehensive person-centered care plan for one of four sampled residents (Resident 1) when Resident 1's safety care plan intervention to not have Certified Nursing Assistant (CNA) 1 [staff accused of providing rough care] was assigned to care for Resident 1 on 12/27/22. This failure had the potential for Resident 1 ' s safety to be compromised and potentially increase his emotional distress manifested by restlessness. Findings: During an interview on 12/27/22, at 1:05 p.m., with CNA 1, CNA 1 stated, [Resident 1] accused me of providing rough care early this month. I did not do it. After the reported incident, I was assigned to care for [Resident 1] several times, including today. I was not told by the Staffing Coordinator, the Charge Nurse or Director of Nursing that I can ' t be assign to care for [Resident 1]. During a concurrent interview and record review on 12/27/22, at 1:10 p.m., with Licensed Vocational Nurse (LVN) 1, Resident 1's Care Plan, (CP), dated 12/10/22 was reviewed. The CP indicated, .…

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

Based on interview and record review, the facility failed to ensure the Quality Assurance Committee performed annual review of the infection control manual . This failure has the potential for caregivers to lack access to current standards of practice for infection prevention and control needed to provide optimal care to residents. Findings: During an interview and concurrent record review on 4/28/21, at 9:00 a.m., the infection preventionist (IP) was unable to provide evidence the infection control manual had an annual review in the past 12 months. There was no evidence of a signature page indicating review or approval of the manual within the last 12 months in any form. During review of the facility Infection Control Committee Meeting Minutes, no evidence of the infection control manual as being reviewed or approved during any of the following meetings occurring in 2020 and 2021: 7/8/20, 8/14/20, 10/9/20, 1/31/21, 2/28/21, and 3/31/21. The IP confirmed these were all the meetings that have taken place in 2020 and 2021. During an interview and concurrent record review on 04/29/21,…

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.

Based on interview and record review, the facility failed to ensure grievances identified during Resident Council (a group of residents that meet on a monthly basis to discuss issues/concerns within the facility) were addressed. This failure has the potential for no action and resolution of residents grievances which might affect their overall care. Findings: During the Resident Council meeting on 4/27/21, at 3:05 p.m., a resident (Resident 6) was asked how the facility addresses resident council concerns and grievances. Resident 6 stated, I don't know if the staff is receptive or not, they don't follow through and they pass the buck. During an interview on 4/28/21, at 3:20 p.m., with Activities Supervisor (AS 1), AS 1 indicated the resident council uses the Resident/Family Council Response form to document concerns and or grievances. When asked if the facility keeps a log of the Resident/Family Council Response forms, AS 1 was silent and unable to provide documentation. During an interview on 4/29/21, at 10:36 a.m., with Social Worker (SW 1), SW 1 was asked if the facility keeps 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 ensure a music activity designed to encourage resident participation and interests was provided for two of three sampled residents (Resident 24 and Resident 34). This facility failure had the potential to result in decreased psychosocial well-being. Findings: During a review of the facility's policy and procedure (P&P) titled, Activity Programs, dated 2018, the P&P indicated, Activity programs are designed to meet the interests of and support the physical, mental and psychosocial well-being of each resident . Our activity programs are designed to encourage maximum individual participation and are geared to the individual resident's needs . Adequate space and equipment are provided to ensure that needed services identified in the resident's plan of care are met. During an observation on 04/26/21, at 10:09 a.m., in Resident 24's room, Resident 24 was observed lying in bed, in fetal position. The activity calendar posted on the wall, dated…

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: 1. Hot water temperatures in the resident's environment was safely monitored and maintained. 2 . Accident hazards in a resident accessible area for four of four sampled residents (Resident 7, 22, 24, and 34) and three unsampled residents (Resident 5, 36, and 39) were identified. These failures had the potential to cause accidents and injuries. Findings: During an observation on 4/26/21, starting at 10:32 a.m., in Resident rooms [ROOM NUMBER], the bathroom hot water was noted to feel too hot to touch. During a concurrent interview and record review on 4/28/21, at 2:45 p.m., in the maintenance room, with a maintenance supervisor (MS 1), MS 1 stated the water temperature is kept at 118-120 Fahrenheit (F). MS 1 further stated he monitors the water temperature weekly at about five different locations. The temperatures are recorded on the, Facility Water Temperature, (FWT) log. During a review of the facility's policy and procedure…

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 19 of 23 resident bedrooms (room [ROOM NUMBER], 2, 3, 4, 5, 6, 7, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20 and 23) provided and maintained the required square footage of 80 square feet (Sq. Ft.) per resident. This failure had the potential for residents to not have reasonable privacy or adequate space. Findings: During an interview on 4/26/21 at 9:38 a.m., the director of nursing (DON) indicated there was no renovation done on the residents room since the last survey. During the initial tour observation on 4/26/21 at 10:00 a.m., the following rooms did not provide minimum square footage as required by regulation. The facility has maintained resident privacy, there was sufficient space for staff and residents to walk around the room. Closets and bathroom was adequate. Room # Sq. Ft. Number of Residents 1 220 3 2 220 3 3 220 3 4 220 3 5 210 3 6 220 3 7 220 3 10 232 3 11 216 3 12 220 3 13 220 3 14 228 3 15 225 3 16 234 3 17 217 3 18 224…

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 call lights were within residents reach for one sampled resident ( Resident 21) and two un-sampled residents (Resident 33 and 11). This failure had the potential for the residents' calls for assistance to be not timely met. Findings: According to Fundamentals of Nursing - 9th Edition ([NAME] et al; Elsevier: 2017, p. 391) indicated, call lights are additional safety features found in health care settings. During an observation on 4/26/2021, at 9:36 a,m., inside the rooms of Residents 33, 11, and 21, the call lights were draped over the overhead lights and not within the reach. During another observation and concurrent interview on 4/26/2021, at 10:33 a.m.,inside the rooms of Resident 33, 11 and 21, the call lights were draped over the overhead lights and not within reach. Resident 21 stated, I have to yell all the time but would like to use the call light they hang it and I can't reach it. During an observation and concurrent…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure acceptable standards of clinical documentation was implemented for one of 14 sampled residents ( Resident 29) when symptoms of depression were not accurately monitored as ordered . This failure has the potential for continued medication administration with no justification. Findings: According to Nursing Fundamentals by [NAME], [NAME] and [NAME], Second Edition, 2010, page 322, Documentation is the professional responsibility of all health care practitioners. It provides written evidence of the practitioner's accountability to the client, the institution, the profession and society. During a review of the clinical record for Resident 29, the Medication Administration Record (MAR) for April 2021 indicated a physician order dated 3/22/21 for Remeron (Mirtazapine medication used to treat symptoms of depression), 15 milligram (mg) 1 tablet by mouth at bedtime for eating less than 50% r/t (related to) major depressive disorder. During a record…

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

Based on observation, interviews, and record review, the facility failed to ensure unsealed, open medication bottle with the open date/time and expiration date was labeled. This failure has the potential for staff to continue using the medication beyond its' expiration date. Findings: During an observation and concurrent interview on 4/27/21 at 11:23 a.m.,with licensed vocational nurse (LVN 4) inside the medication storage room at nurse station 1, an unsealed, open bottle of Rolaids, (an over-the-counter medication used to treat symptoms of too much stomach acid), was noted stored on one of the shelves for stored medication . The bottle had a name written on it but there was no label indicating the expiration date, date/time the bottle was unsealed and opened . LVN 4 was asked about the medication and stated the medication is for a resident. LVN 4 acknowledged that there was no open date/time and expiration date on the bottle. LVN 4 proceeded on discarding the bottle of medication. During a review of the facility policy and procedure, titled Labeling of Medication Containers,…

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

Based on observation, interview, and record review, the facility failed to ensure the refrigerator designated for food had documented temperatures with in the acceptable range per policy and procedures. This failure had the potential to lead to growth of micro-organisms, which could lead to foodborne illnesses in the vulnerable population residing in this facility. Findings: The facility policy and procedure, titled Refrigerators and Freezers, dated December 2014, indicates Acceptable temperature ranges are 35 to 40 degrees Fahrenheit for refrigerators . During an observation and record review on 4/26/21, at 11:48 a.m., the food refrigerator located on Nursing Station One contained juices. The refrigerator temperature log (RTL) had several recorded temperatures above 35 to 40 degrees Fahrenheit range noted in the facility policy and procedure. The following temperatures were logged: 4/18/21 PM Shift: 42 4/19/21 NOC Shift: 42 4/20/21 NOC Shift: 42 4/22/21 NOC Shift: 44 4/23/21 NOC Shift: 46 The RTL header indicated documented reference range for food refrigerators as 36-46, which 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 ensure the dining area used during meal times for one sampled residents (Resident 21) and one un-sampled residents (Resident 36) was well lit. This failure had the potential for Residents 21 and 36 to have decreased enjoyment of dining experience with risk to affect the residents' nutritional intake and well-being. Findings: During an observation and concurrent interviews on 4/26/2021, at 12:32 p.m., in the dining room no lights were on and Resident 36 stated it was better to eat with the lights on. Certified nursing assistant (CNA3) stated it depends on resident but that it is dark in the room . CNA3 confirmed Resident 36 liked the lights on. Resident 21 stated they would like the light on when they eat. CNA4 confirmed Resident 21 would like lights on while eating. During an interview on 4/29/2021, at 11:22 a.m., with the director of nursing (DON), the DON confirmed the expectation is for the dining room to be well lit for resident comfort and well-being. During a review of the facility 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.