Millbrae Care Center

Based on interview and record review, the facility failed to complete a Significant Change in Status Assessment (SCSA, is a comprehensive assessment for a resident that must be completed when the IDT (interdisciplinary team, a collaborative group of professionals from diverse fields who work together interdependently to achieve shared goals) has determined that a resident meets the significant change guidelines for either major improvement or decline) for one of 19 sampled residents (Resident 73) who was admitted to hospice care on 11/5/25.This failure could potentially delay the provision of appropriate treatment and services for Resident 73.Review of Resident 73's admission record indicated, was admitted to hospice on 11/5/25 with diagnoses including heart failure, high blood pressure, and dementia (a group of symptoms affecting memory, thinking and social abilities).Review of Resident 73's Minimum Data Set (MDS, a resident assessment tool) with an Assessment Reference Date (ARD, specific endpoint for the look-back periods in the MDS assessment process) 11/12/25, indicated, a SCSA…

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, interviews and record reviews, the facility did not collaborate with Hospice the plan of care for two out of five residents (Residents 27and 16)This failure could result to residents not receiving care as planned.During a review of Resident 27's admission Record, dated 5/6/26, the admission record indicated, admitted on [DATE] with diagnoses including: Alzheimer's Disease( a progressive, irreversible brain disorder that destroys memory and thinking), Osteoarthritis of Knees(a common form of arthritis). During an observation on 5/5/26 at 11 AM, observed resident up on wheelchair, smiling, not responding to questions. During an interview on 5/5/26 at 11 AM with Certified Nursing Assistant (CNA) 4, stated, she has been her permanent CNA for many years. Since after her fall, she is now in wheelchair, can still walk to the bathroom with assistance. She is now under Hospice Care since last month. She had no changes, eats with good appetite, 100 % of meals, no skin breaks. She has family but only…

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 their smoking policy and procedures (P&P) when it allowed two of eight residents (Resident 4 and Resident 81) who smoked in the facility to keep possession of their own lighters and cigarettes inside the resident care area.This failure posed an increased risk for combustion and/or fire, resulting in the potential for serious injury and/or death to residents, staff, and visitors.During an interview on 05/06/2026, at 12:20 PM, at Resident 4's room with Licensed Vocational Nurse (LVN) 2, LVN 2 stated, the orange plastic tube with liquid inside found on the overbed table beside the resident's bed is a disposable cigarette lighter used by Resident 4 for smoking. LVN 2 further stated, there is a smoking schedule, but Resident 4 does not follow it. LVN 2 stated, Resident 4 keeps his cigarette in his room. LVN 2 is not sure about the facility's policy regarding safekeeping of cigarettes and lighters and if Resident 4 was educated about…

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 that respiratory care and services were provided as required for two of six sampled residents (Resident 130 and Resident 4). The facility did not provide appropriate supervision during the residents' nebulizer treatments (A nebulizer treatment is a process in which a machine turns liquid medication into a mist that the resident breathes in through a mask or mouthpiece to help improve breathing).This failure resulted in the residents not receiving respiratory treatment in accordance with the facility's policy, procedure, and individualized care plans, placing the residents at risk for unmet respiratory needs. During an observation on 5/4/2026 at 2:30 PM at Resident 130 room, Resident 130 was found sleeping with the nebulizer tubing on the resident's chest. The nebulizer machine was on the bed beside the resident, and the machine was still on. During a concurrent interview and observation on 5/4/2026 at 2:32PM in front of room [ROOM…

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 program when:Certified Nursing Assistant (CNA) 4 did not perform hand hygiene when handling soiled linens and entering resident rooms.Residents and staff personal items such as pouch, jewelry, hearing aid, dentures, cellphones, phone charger, eyeglasses, and iPad were stored in the controlled medication compartment of the medication cart.Foreign currency was kept in the top drawer of the Medication Cart #4, alongside opened bottles of over the counter oral medications, epinephrine injections (the primary emergency treatment for severe allergic reactions), and suppositories (medications administered through the rectum, vagina, or urethra).These failures had the potential for cross contamination of infection that can compromise the health and safety of residents and staff.1. During an observation on 5/4/26 at 2:54 PM in the hallway, CNA 4 was seen exiting a resident's room that had an Enhanced Barrier Precaution (are an infection control intervention designed to reduce…

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 person-centered care plan for two of two sampled residents (Resident 1, and Resident 2) when:Smoking and going out on pass (when a resident leaves the facility temporarily) was not addressed for Resident 1.Going out on pass was not addressed for Resident 2. The facility failure had the potential for the residents not to receive necessary care and services. A review of the face sheet indicated Resident 1 was admitted with diagnoses including heart failure (when the heart muscles do not pump as strong as it should) and diabetes (abnormally high blood sugar level).A review of the Minimum Data Set (MDS, a standard assessment tool) dated 1/15/26, indicated Resident 1 was cognitively intact. The MDS further indicated Resident 1 was independent with all aspects of activities of daily living (ADL).During a concurrent interview and record review on 1/28/26, at 1:47 PM, with Registered Nurse (RN) 1, the physician order for 1/2026, 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 observation, interview, and record review, the facility failed to update the care plan for one of one sampled resident (Resident 3) after Resident 3 had two fall incidents.The failures had the potential to put the resident at risk of not receiving appropriate care. A review of the face sheet indicated Resident 3 was admitted with diagnoses including dementia (decline in memory or decision-making ability), muscle weakness, and abnormalities in gait (how a person walks) and mobility.A review of the Interdisciplinary Team notes dated 1/20/26, indicated Resident 3 had two fall incidents on 1/14/26.During a concurrent observation and interview on 1/28/26, at 12:49 PM, with Resident 3, Resident 3 was sitting up in a wheelchair in the hallway, alert, verbally responsive, calm and pleasant. Resident 3 was able to state his name. Resident 3 did not know his current location and the reason for residing in the facility. When asked about the fall incidents, Resident 3 stated he was feeling sleepy, had tried to walk, and needed to use the bathroom. During an interview on 1/28/26, at…

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

Based on interview and record review, facility staff failed to provide social service-related services to 14 of 14 sample residents (Residents: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14) when there was only one social worker (SW 1) in the building and quarterly care conference meetings for at least 14 residents were not completed during the period of March 2025 to June 2025. This failure had the potential to result in residents not receiving appropriate and personalized care. Findings: The census on 06/04/2025 was 128 residents. During an interview on 06/04/2025 at 12:10 PM, SW 1 stated she was the only social worker in the building for approximately three months (March to June 2025). SW 1 stated with the facility workload, she was unable to coordinate and conduct IDT (interdisciplinary team) /care conference meetings. SW 1 explained that IDT meetings were attended by a variety of healthcare professionals, like nurses, therapists, social workers, and others, to discuss and manage resident care. During these meetings family members and/or responsible parties were invited 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 observation, interviews and record reviews, the facility failed to manage residents ' belongings for Resident 1, 2, and 3, three of 6 sampled residents. Facility staff did not: 1. Follow facility policy in identifying/marking residents ' belongings. 2. Have a facility policy to periodically update resident inventory. These failures resulted in Resident 1 and 3 with missing belongings. Findings: Review of Resident 3 ' s medical records titled INVENTORY OF PERSONAL EFFECTS, dated 02/10/2023, indicated he was admitted with two shirts, two sweaters, and a pair of white mitt/glove. During a concurrent observation and interview with the Certified Nursing Assistant 1 (CNA) caring for Resident 3, on 05/19/2025 at 2:00 PM, CNA 1 looked through Resident 3 ' s belongings and stated he had 14 white tee shirts, and four dark tee shirts. None of the clothing were marked to identify these clothing belonged to Resident 3. CNA stated all of Resident 3 ' s clothing were donated, and he has no idea what happened to Resident 3 ' s clothing/personal belongings identified during admission.…

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 a system for preventing infection for 3 (Resident #81, #21, and #116) of 24 sampled residents. Specifically, the facility failed to disinfect Resident #81's mattress after staff stepped on the mattress and disinfect a blood pressure cuff after resident use and prior to use for Resident #21 and Resident #116. Findings included: 1. A facility policy titled, Enhanced Barrier Precaution, dated 06/2022, revealed, Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP may be indicated (when Contact Precautions do not otherwise apply) for residents with any of the following: - Wounds or indwelling medical devices, regardless of MDRO colonization status. - Infection or colonization with an MDRO. The policy indicated, Use EBP for high-contact resident care activities by using…

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 document and policy review, the facility failed to ensure residents did not smoke in non-designated areas not equipped with needed safety equipment and devices. In addition, the facility failed to enforce their smoking policy regarding the storage of lighters for 2 (Resident #39 and Resident #106) of 3 sampled residents reviewed for smoking. This deficient practice had the potential to affect all 7 residents identified by the facility as smokers. Findings included: A facility policy titled, Smoking Policy - Residents, released 06/2022, indicated, 1. Prior to, or upon admission, residents shall be informed about any limitations on smoking, including designated smoking areas, and the extent to which the facility can accommodate their smoking or non-smoking preferences; for example, in making room assignments. The policy revealed, 5. Metal containers, with self-closing cover devices, shall be available in smoking areas. The policy further revealed, 12. Smoking articles for residents with independent smoking privileges: 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, record review, facility policy review, and review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument [RAI] 3.0 User's Manual, the facility failed to complete a discharge Minimum Data Set (MDS) for 1 (Resident #108) of 3 residents reviewed for closed records. Specifically, the facility failed to complete a discharge MDS assessment for Resident #108, after the resident was discharged to a hospital on [DATE]. Findings included: A facility policy titled, Minimum Data Set (MDS) Assessment Schedule, dated 10/2023, indicated, 1. The facility conducts a comprehensive assessment to identify patient's needs per the guidelines set by the RAI Manual. The policy specified MDS assessments, including g. Discharge Assessments, would be completed based on the guidelines set by the RAI Manual. The policy revealed, 5. The MDS nurse or RN [Registered Nurse] MDS Coordinator will be responsible for ensuring timely completion of all MDS assessments. 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, facility policy review, and review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument [RAI] 3.0 User's Manual, the facility failed to ensure a Minimum Data Set (MDS) assessment was accurately coded to reflect the presence of behaviors for 1 (Resident #93) of 2 residents reviewed for behaviors. Specifically, the facility failed to ensure behavioral symptoms exhibited during the seven-day look-back period were coded on Resident #93's 08/23/2024 quarterly MDS. Findings included: A facility policy titled, Minimum Data Set (MDS) Accuracy, dated 10/2023, revealed, The facility shall establish a system in which MDS accuracy is checked to assure that each patient receives an accurate assessment by staff that are qualified to assess relevant care areas and are knowledgeable of the resident's status, needs, strength and areas of potential or actual decline. The policy revealed, 6. The IDT [interdisciplinary team] will verify coding accuracy of residents that triggered in the Resident Level Quality…

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 resubmit a Level I Preadmission Screening and Resident Review (PASRR) for 1 (Resident #71) of 3 residents reviewed for PASRR requirements after receiving a letter that indicated a Level II Mental Health Examination was not scheduled and to reopen the case, a new Level I Screening would need to be submitted. Findings included: A facility policy titled, Pre-admission Screening and Resident Review, dated 12/2017, revealed, PURPOSE To ensure that all facility applicants are screened for mental illness and/or intellectual disability prior to admission and to ensure this assessment effort is coordinated with the appropriate state agencies if indicated. Preadmission Screening and Resident Review [PASRR] is a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing home for long term care. The policy further specified, h. A positive Level I screen necessitates an in-depth evaluation of the individual 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, record review, and facility policy review, the facility failed to ensure medications were not left at the bedside for 1 (Resident #21) of 5 residents observed during medication administration. Specifically, facility staff left medications at the bedside of a resident who had impaired eyesight and had not been assessed as safe to self-administer medications. Findings included: A facility policy titled, Medication Administration, dated 09/2028, revealed the section titled, Medication Administration specified, 4. Medications are to be administered at the time they are prepared. 5. The person who prepares the dose for administration is the person who administers the dose. The policy further specified, 15. Residents are allowed to self-administer medications when specifically authorized by the prescriber, the nursing care center's Interdisciplinary Team (IDT), and in accordance with procedures for self-administration of medication and state regulations, and 19. For residents not in their rooms or otherwise unavailable to receive medication on the pass,…

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 obtain laboratory services in a timely manner for 1 (Resident #15) of 5 residents reviewed for unnecessary medications. Specifically, Resident #15 had an order to check their Keppra (an anticonvulsant) level every six months. The facility failed to obtain the resident's Keppra level in September 2024, six months after the previous level was obtained. Findings included: The facility policy titled, Physician Orders, dated December 2016, indicated, Physician orders are obtained to provide a clear direction in the care of the resident. During an interview on 10/16/2024 at 1:02 PM, the Administrator stated the facility did not have a policy regarding laboratory services. An admission Record revealed the facility initially admitted Resident #15 on 11/04/2022 and most recently admitted the resident on 02/18/2024. According to the admission Record, the resident had a medical history that included diagnoses of convulsions and epilepsy. A significant change Minimum Data Set (MDS), with an Assessment…

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

Based on interview and record review, the facility failed to ensure that a Registered Nurse (RN) completed the assessments to seven of nine sampled residents (Resident 1, 2, 3, 4, 5, 6, and 7) when the residents had a change in condition. The facility deficient practice has the potential harm on the resident safety and well-being. Findings: A review of the facility fall incidents on 8/5/24, indicated Residents 1,2,3,4,5,6, and 7 had fall incidents. During an interview on 8/5/24 at 1:02 PM, the Director of Nursing (DON) reviewed the post fall assessments and stated, the assessments for Residents 1,2,3,4,5,6, and 7 were completed by Licensed Vocational Nurse (LVN) 1,2,3,4, and 5. During an interview on 8/6/24, at 4:30 PM, the Administrator stated, If an LVN is assigned to the resident, the LVN performs the post fall assessment and evaluate the resident for injury. The Registered Nurse is not necessarily present. During a review of the job description for LVN dated 5/2017, indicated, .Under the direct supervision of a registered nurse, implement and established plan of care for each…

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 medically-related social services to one of 3 sampled residents (Resident 1) when there was no social worker available from 4/22/24 to 5/10/24. This failure had the potential not to maintain the highest practicable physical, mental, and psychosocial well-being of Resident 1. Findings: Review of Resident 1's clinical record indicated, Resident 1 was originally admitted on [DATE] with diagnoses including peripheral vascular disease (a slow and progressive disorder of the blood vessels), heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs), and diabetes mellitus (high blood sugar). He was transferred to a hospital on 5/3/24, then readmitted to the facility on [DATE], then discharged to the hospital on 5/20/24. Review of Resident 1's Minimum Data Set (MDS, resident assessment tool), dated 5/13/24 indicated, Resident 1 was cognitively intact. During an interview on 6/6/24 at 4:24 PM with Ombudsman…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure the allegation of resident to resident abuse was promptly reported to the State Agency (SA, which is the California Department of Public Health) in accordance with the facility policy and procedure for one of four sampled residents Resident 1. Failure to promptly report allegation of abuse has potential for further abuse to happen thereby increasing the harm to the resident. Findings: Record review of Resident 1's admission Record, dated 4/10/24, indicated, admitted to facility on 9/21/23 with diagnoses including: Seizures ( Involuntary body twitching), Alcohol dependence with Withdrawal, Major Depression. Resident 1 went Against Medical Advice (AMA) on 9/25/23. During a review of facility document, Investigative Report, dated 9/30/23, indicated, Resident 1 is alert and oriented, self-responsible, ambulatory with Brief Interview of Mental Status (BIMS) score of 14. On 9/25/23 at 3PM, Resident 1 discharged from the facility against medical…

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 supervision to ensure safety for one of one sampled resident (Resident 3) when Resident 3 was found outside the facility unaccompanied. The facility's failure had the potential for resident harm. Resident 3 was admitted with diagnoses including dementia (a decline in memory or other thinking abilities). A review of Minimum Data Set (MDS, a standard assessment tool) dated 2/23/24, Brief Interview of Mental Status (BIMS, a brief memory test to help determine cognitive function (includes learning, thinking, and decision-making abilities) score of 5 indicated severe cognitive impairment (rarely makes decision). MDS also indicated Resident 3 has wandering behavior. During observation on 4/11/24, at 11:45 AM, Resident 3 was alert, smiling. Resident 3 got out of bed and ambulated to the bathroom. Resident 3 speaks a non-English language. A review of the Interdisciplinary Team (IDT) notes dated 1/8/24, indicated, Resident 3 walked out of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide preventive treatment and services to maintain and improve range of motion (ROM, the extent or limit to which a part of the body can be moved) for 18 of 18 sampled residents (Resident 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18,) when physician order for Restorative Nursing Assistant Program (RNA, nursing interventions that promote the residents ability to adjust to living as independently and safely as possible) was not implemented. The facility failure had the potential for the residents to limit the ROM and a possible development of a contracture (shortening of muscles and joints which limit and interfere with daily functioning). FINDINGS: 1. A review of the face sheet indicated Resident 1 was admitted with diagnoses including rheumatoid arthritis (painful swelling of the joints) and muscle weakness. Minimum Data Set (MDS, a standard assessment tool) dated 10/6/23, indicated Brief Interview of Mental Status (BIMS, a brief…

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

Based on observation, interview, and record review the facility failed to implement its plan of action to correct the identified deficiency regarding the Restorative Nursing Assistant (RNA, nursing interventions that promote the resident's ability to perform activities of daily living as independently and safely as possible) Program. The facility failure resulted in non-compliance to F688 which had the potential for the residents to limit range of motion (ROM, how far a person can move or stretch a part of the body) and a possible development of contracture (shortening of muscles and joints which limits and interfere with daily functioning). (Refer to F688) Findings: During an interview on 1/11/24, at 1:58 PM, Administrator acknowledged there were no Restorative Nurse Assistants (RNA's) from 10/2023, and the facility's failure to implement their RNA Program, was not addressed during the QAPI meetings. The Administrator stated, Obviously we didn't. No one wanted to step up. The Director of Nursing was off work and was not available for interview. A review of the facility Policy 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 interview, observation, and record review, the facility failed to respond to a residents call for staff assistance in a timely manner when Resident 38, one of 43 sampled residents, waited half an hour to receive peri-care (hygienic care) due to soiled undergarments. This failure had the potential to cause skin injury and emotional distress to the resident. Findings: Resident 38 was admitted to facility 12/6/23 with diagnoses including diabetes, congestive heart failure, brain disease, open lower leg wound, and liver disease. The resident's Minimum Data Set, (MDS) an assessment tool, dated 12/13/23, indicated Resident 38 had a cognition score (thinking ability) of 10. (Highest score is 15). Resident 38 required an interpreter for language communication. Had impairment of both lower limbs, unable to walk, or reposition in bed or turn from side to side, and required toileting hygiene assistance. During an observation and interview on 12/19/23 at 4:40 PM, with wife present, resident stated he had to wait…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide a safe and sanitary environment when shower room [ROOM NUMBER]was found uncleaned and unhygienic. The facility failure has the potential for residents to cause uncomfortable experience during bathing and use of the shower room. Findings: During an observation in shower room one on 12/21/23, at 10:56 AM, on all four shower stalls, there were black gray substance on the grout in the walls, red substance splattered on the walls, brownish clay substance smeared all over the floor, and exposed rusty sharp pices of metal on all four shower stalls. The fabric curtains of the four shower stalls has holes sorrounded by black substance and brown substance smeared the lower bottom parts of the curtains. Six large containers were inside the shower rooom 1. During an interview on 12/21/24, at 11:23 AM, Certified Nurse Assistant (CNA, caregiver) 3 stated that the shower room [ROOM NUMBER] was currently used to give showers to all residents 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 interview, observation, and record review, the facility failed to treat residents with dignity when Resident 38, one of 43 sampled residents, waited half an hour to receive peri-care (hygienic care) for soiled undergarments. This failure had the potential to cause injury and emotional distress to the resident. Findings: Resident 38 was admitted to facility 12/6/23 with diagnoses including diabetes, congestive heart failure, brain disease, open lower leg wound, and liver disease. The resident's Minimum Data Set, (MDS) an assessment tool, dated 12/13/23, indicated Resident 38 had a cognition score (thinking ability) of 10 (Highest score is 15). Had impairment of both lower limbs, unable to walk, needs repositioning in bed and turning from side to side, required toileting hygiene assistance. Required an interpreter for language communication. During an observation and interview on 12/19/23 at 4:40 PM, with wife present, resident stated he had to wait for a caregiver for half an hour today to provide peri-care. Resident stated call light response time has always been slow 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 interview and record review, the facility failed to accommodate the residents needs for tissue paper for Resident 37, one of one sampled resident, (a disposable piece of absorbent paper used as a handkerchief), who did not speak English, when tissue paper was unavailable to the resident for two days. This failure did not create an infection-controlled, individualized, respectful, and home-like environment. Findings: Resident 37 was admitted to the facility on [DATE] with diagnoses including hemiplegia, left side, (one-sided muscle paralysis), bed confinement, stroke (loss of blood flow to brain, damaging brain tissue), diabetes, (disease of too much sugar in blood), Depressive disorder, and high blood pressure. During an interview on 12/13/23 at 11 AM, Resident 37 had been asking for facial tissues for two days and staff said there were no tissues available (over the weekend). During an interview on 12/14/23 at 2:30 PM, the Supply Supervisor stated he was available to retrieve supplies if he had been…

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 the allegation of accidents, was promptly reported to the State Agency (SA, which is the California Department of Public Health, CDPH) in accordance with facility's policy and procedure for one of two sampled residents (Resident A). This failure to report fall with injury has potential for further accidents to happen not being reported. Findings: During a review on 1/11/24 at 11AM, of facility document, admission Record, dated 12/20/23, indicated, admitted on [DATE] with diagnoses including: Lymphoma (cancer of the lymphatic system), Unspecified Cord Compression( Pressure in the spinal cord), Diabetes Mellitus( high sugar levels), Anemia (low blood count). Review of facility document, Nursing admission Assessment, dated 12/20/23 indicated, for mobility, full ROM (range of motion) all extremities, moderate ability to roll from side to side. Summary: indicates, resident able to perform transfers. Review of facility document, progress notes…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to identify and document changes in Resident's A condition when: weight loss started on 1/12/23, IDT (Interdisciplinary Team) meeting done on 8/14/23, The care plan had no updates on intervention since 2019. These failures had the potential for Resident 1's condition not assessed and needs not addressed, could result in Resident A not getting the care that she needs. Findings: During a review of facility document, admission Record, dated, 1/11/24, indicated, admitted on [DATE] with diagnoses including: Cerebral Infarction (stroke), Dysphagia (problem with swallowing), Dementia(loss of memory), Epilepsy (Involuntary jerking movement of the body), Sepsis ( generalized Infection). Patient discharged to acute on 12/30/23. Review of Hospital H&P, dated 11/16/23, indicated, Full code, patient designated conservator as surrogate decision maker. Chief complaint: Hypoxia (lack of oxygen), female with history of Stroke, dementia who is bedbound and aphasic 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 interview and record review, the facility failed to provide Occupational therapy ( OT, used to improve abilities that are needed to live life as independently as possible) services to one of one sampled resident (Resident 20) when OT services was ordered by the physician. The facility failure had the potential for further physical decline during Resident 20's stay in the facility. Findings: A review of the admission notes dated 8/31/22, indicated, Resident 20 had diagnoses including atrial fibrillation (abnormal heartbeat), diabetes (abnormally high sugar level in the blood) and diastolic heart failure (when the heart does not pump as strong as it should). The physician order dated 8/31/22, indicated Occupational therapy evaluation and treatment for Resident 20. A review of the OT evaluation notes dated 9/1/22, indicated, Resident 20 was referred to OT due to new onset of reduced Activity of Daily Living (ADL, includes eating, mobility, transfer, and walking) participation, reduce dynamic balance (ability to stay standing and stable while doing movements), decrease 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, and record review, the facility failed to accommodate no more than four residents per room when one resident room contained a total of six residents. This failure had the potential for residents to receive less privacy, care and attention, more noise and distraction. Findings: During an observation on 12/13/24 at 11 AM, one resident in the room was the last person at the end of the room with five other residents on either side of her. She did not speak English. Her room had visitors visiting two residents. The visitors were spread out around the two residents and standing outside of the residents privacy curtains. The room appeared dark, crowded, noisy, and less private for all of the residents. One resident angrily did not want visitors of other residents to be talking and visiting with others in the room and wanted the visitors to remain behind the privacy curtains of the resident they were visiting. Review of the number of residents in the room showed more residents in the room, (6), than the acceptable (4) residents per room. During an interview…

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 from interviews and record review, the facility failed to ensure the allegation of resident to resident abuse was promptly reported to the State Agency (SA, which is the California Department of Public Health, CDPH) in accordance with the facility's policy and procedure for four of eight sampled residents Resident 1 and Resident 2, Resident 3 and Resident 4). Failure to promptly report allegation of abuse had the potential for further abuse to happen and thereby increasing the chances of harm to the residents. Findings: During a record review for Resident 1, admission Record, dated, 1/3/24, indicated, admitted to facility on 10/16/19 with diagnoses including: Convulsions (an involuntary muscle contraction causing shaking), Diabetes Mellitus (uncontrolled blood sugar), Dementia (memory loss). Resident 1 has a BIMS (Brief Interview for Mental Status) a mental test, score of 7, severe cognitive impairment. Unable to interview. During a record review for Resident 2, admission Record, dated, 1/3/24, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete elopement risk assessment for 2 residents, and provide supervision for (Resident 1 and Resident 2) when they left the building unsupervised. Resident 1 was found on the street in the next town, in shirt and slippers on 11/11/23 at around 5 PM. Resident 2 went missing on 7/20/21, at 9PM. Was found 7/21/21 in her San Francisco apartment. This failure has potential to result in harm or danger to these cognitively impaired residents. Findings: Review of admission record, dated 12/22/23, indicated, admitted with diagnoses including: Cellulitis Right lower leg (infection), type 2 Diabetes Mellitus (a disease which increases the sugar level in the blood and urine) Dementia ( problem with memory), major Depressive Disorder( a mental condition with feeling of inadequacy and guilt.) Review of MDS (Minimum Data Set), section C, Cognitive Pattern, dated 9/19/23, indicated, BIMS Score of 5. Indicates severe cognitive impairment. Interview on 12/19/23 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 observation interview and record review the facility failed to implement its Policy and Procedure on Abuse for one sampled resident (Resident 1) when, there was no documented evidence the Physician was notified of the allegation of financial abuse by a Family Member (FM). Failure to notify physician had the potential to negatively impact the care and services the resident needed in order to attain her highest physical mental and psychosocial well-being. Findings: Review of the admission Record dated 8/22/23 indicated, Resident 1 was admitted to the facility on [DATE]. The diagnosis included, Osteomyelitis (inflammation or swelling that occurs in the bone), dementia (loss of thinking ability, memory, attention, logical reasoning) and atrial fibrillation (irregular heartbeats). In an interview on 8/22/23, at 9:39 AM, with the Social Worker Assistant (SWA 1), SWA 1 stated, on 6/16/23 at 10:00 am, the Deputy Officer from the Millbrae Police Department came and told the facility staff that 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.

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 (CP, is a process that involves an ongoing regular assessments of the resident's condition to provide the appropriate interventions) to address the financial allegation of abuse for one resident (Resident 1) when a Family Member (FM) 1 changed the password on the resident's bank account. This deficient practice had the potential for the resident not to receive the care and service needed to maintain her highest practicable physical mental and psychosocial well-l being. Findings: Review of the admission Record dated 8/22/23 indicated, Resident 1 was admitted to the facility on [DATE]. The diagnosis included Osteomyelitis (inflammation or swelling that occurs in the bone), dementia (loss of thinking ability, memory, attention, logical reasoning) and atrial fibrillation (irregular heartbeats). In an interview on 8/22/23, at 9:39 AM, with the Social Worker Assistant (SWA 1), SWA 1 stated, on 6/16/23 at 10:00 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.

Based on interview and record review, the facility failed to ensure written policies and procedures on abuse were implemented when: 1.There was no documented evidence employment reference check/s was conducted to determine employment eligibility, for the Certified Nursing Assistant (CNA) 1 who was involved in an abuse allegation, reported by Resident 1 (R1). 2.CNA 1 was not immediately removed from duty, on 3/9/23, pending completion of the facility ' s abuse investigation. 3.Resident 1 was not monitored for 72 hours, for any psychological, behavioral, or psychosocial outcomes, after the abuse allegation incident was reported. These failures had the potential to not ensure safety, well-being, and protection of Resident 1 and other residents from abuse and/or harm. Findings: 1.During a concurrent interview and record review on 7/26/23 at 12:29 PM, with the Administrator (ADM) and Director of Nursing (DON) present, CNA 1 ' s employment records were reviewed. When asked, DON stated the facility could not find employment reference checks conducted on CNA 1. DON explained that CNA 1 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 observation, interview, and record review, the facility failed to provide resident centered care for two of two sampled residents (Resident 43 and Resident 114) when: a. Effective interventions were not developed to prevent urinary tract infection (UTI, urine infection, bladder infection) for Resident 43; b. Intervention were not reevaluated for effectiveness to address weight loss for Resident 114. This facility failure resulted to a. Recurrent UTI for Resident 43 and; b. Weight loss for Resident 114. Findings: a. Resident 43 was admitted with diagnoses including cerebral infarction (stroke) and diabetes (abnormally high sugar level in the blood). Minimum Data Set (MDS, a standardized tool) dated 10/22/21 Brief Interview of Mental Status (BIMS, a brief memory test to help determine cognitive function) score of 12 indicates moderate cognitive impairment. Under functional status, resident was totally dependent, requiring extensive assistance from a staff in performance of activities of daily living such…

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 observation, interview, and record review, the facility failed to provide a safe, hazard free environment to two of two sampled residents (Resident 64 and Resident 113) when: a. a knife was found at the bedside of Resident 64; b. A movable, unsecured TV was found placed on the bedside table at the foot area of the bed for Resident 113. This facility failure has the potential for Resident 64, other residents, and staff to sustain an injury; and the Television Set (TV) to fall on to Resident 113. Findings: a. Resident 64 was admitted with diagnoses including pulmonary embolism (presence of a blood clot in the lung) and fibrosis (when the lung is damaged and scarred). Minimum Data Set (MDS, a standard assessment tool), dated 9/27/21 Brief Interview of Mental Status (BIMS, brief memory test to help determine cognitive function) score of 15 indicates resident is cognitively intact. During an observation on 11/29/21, at 11:14 AM, a knife was found at the bedside. During a concurrent interview, Resident 64…

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 had 18.9% medication error rate when seven medication errors out of 37 opportunities were observed during a medication pass for Resident 61, Resident 68, and Resident 98. These deficient practice resulted in medications not given in accordance to the prescriber's order and/or manufacturer's specification which may result in residents not receiving the full therapeutic effect of the medications. Findings: 1. During a Medication Pass (Med Pass is the process through which medication is administered to the resident) observation on 11/30/21, at 9:01 a.m., after Resident 98 had her breakfast at 8:30 a.m., Licensed Vocational Nurse (LVN) 3, prepared and administered to Resident 98 Sevelamer (Renleva) Carbonate (a medication indicated for altered kidney function) .08 gm 1 packet mixed with 30 milliliter (ml) of water. During an interview on 11/30/21, at 12:00 p.m., with LVN3, LVN3 stated, I forgot it's to be given before meals. During a review of 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, and record review, the facility failed to ensure safe storage of medication for one of 24 sampled residents (Resident 64) when unprescribed medications were found at the bedside. This failure has the potential for duplication of treatment which can lead to untoward effects for Resident 64. Findings: Resident 64 was admitted with diagnoses including pulmonary embolism (presence of a blood clot in the lung) and pulmonary fibrosis (when lung tissue becomes damaged and scarred). Minimum Data Set (MDS, a standardized assessment tool) dated 9/27/21, Brief interview of Mental Status (BIMS, a brief memory test to help determine cognitive function) score of 15 indicates cognitively intact. During observation on 11/29/21, at 11:14 AM, combivent inhaler (used to prevent shortness of breath in a lung disease), fluticasone nasal spray (used to alleviate symptoms of allergies), a bottle of Vitamin B 12 (a dietary supplement), and silver sulfadiazine cream (used to prevent and treat wound infections) at the bedside. During a concurrent interview, Resident 64…

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 competencies of sanitizing (to make clean and hygienic; to disinfect) testing process and sanitizing process were completed according to manufactures' instructions when: 1. Kitchen Aide 1 did not follow the instruction of manufacture's sanitizing testing process. She did not check Quaternary Ammonium (quat: a kind of sanitizing water) solution temperature and dipped the test strip to the quat solution for 3 seconds rather than manufacturer's recommendation of 10 seconds. 2. Maintenance Supervisor (Env) did not follow the manufacture's instruction of sanitizing process for ice machine. This failure has the potential to increase spread of infection in the facility. Findings: 1. During a concurrent observation, interview and record review on 11/30/21, at 10:53 AM, with Kitchen Aide 1, in the kitchen, sanitizing testing process was conducted. Kitchen Aide 1, proceeded to test the sanitizer strength by placing a test strip into the quat solution for no greater than 3 seconds. Kitchen Aide 1 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.

Based on observation, interview, and record review, the facility failed to ensure menus were followed during lunch trayline observation. Parsley garnish was not served as menus for six of 18 residents. There was a total of 44 residents with physician ordered mechanical soft diets per tray tickets of 12/2/21. This failure had the potential to cause aspiration problem to residents who have swallowing difficulties, and to affect the residents' appetite. Findings: During an observation on 11/29/21, at 12:21 PM, in the kitchen, parsley garnish leaves instead of flakes as written on the menu were observed in the trays for six of 18 residents. Tray tickets indicated mechanical soft diets. During an interview on 12/03/21, at 1:57 PM, with Registered Dietitian (RD), RD stated, their educations were focused more to the infection control, not menu. RD stated, she will add more training for staff about menus. During a review of the facility's diet manual titled, Therapeutic diets, dated October 2017, the diet manual indicated, Therapeutic diets are prescribed . to support 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement and maintain its infection control program when: 1. The blood pressure (BP) monitor (an equipment used to measure blood pressure) and medication tray were not disinfected between resident use. 2. The Licensed Nurse did not wear the required personal protective equipment (PPE) inside the isolation room (room [ROOM NUMBER]) during medication administration. 3. For Resident A, the Continuous Positive Airway Pressure (CPAP) machine (an equipment that uses a hose connected to a mask or nosepiece to deliver constant and steady pressure to help the breathing during sleep) was placed on the floor and the nosepiece connected to a hose was left uncovered inside the bedside drawer. Failure to implement infection prevention practices may result in cross contamination of infection that may jeopardize the health and safety of the residents and staff. Findings: 1. During medication pass observation on 1/27/22, at 8:37 AM, Registered Nurse (RN)…

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 pharmaceutical services in a timely manner for one of five residents (Resident A) when the Sevelamer Hydrochloride (a phosphate binder medication used to control high blood level of phosphorous, a mineral found in food, in people with kidney disease who are on dialysis) was not available on 1/27/22. This failure resulted to Resident A not receiving the scheduled medication and had the potential for Resident A to suffer from high phosphate concentration in the blood. Findings: Review of the clinical record for Resident A indicated, was readmitted to facility on 1/14/22 with diagnoses including end-stage renal disease (ESRD, a longstanding kidney failure) and dependent on renal dialysis (the process of removing excess fluids and waste products from the blood when the kidneys stop working properly). Resident A had been receiving dialysis three times a week (Tuesday, Thursday, and Saturday) since admission. Review of the Physician Order Sheet dated 1/18/22, indicated, . 2. Start Sevelamer HCl 800 mg tab.…

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 five residents (Resident A) was free of significant medication error when, Resident A did not receive two doses of Sevelamer Hydrochloride (a phosphate binder medication used to control high blood level of phosphorous, a mineral found in food, in people with kidney disease who are on dialysis) on 1/27/22. This failure resulted to Resident A not receiving the scheduled medication and had the potential for Resident A to suffer from high phosphate concentration in the blood. Findings: Resident A was readmitted to the facility on [DATE] with diagnoses including end-stage renal disease (ESRD, a longstanding kidney failure) and dependent on renal dialysis (the process of removing excess fluids and waste products from the blood when the kidneys stop working properly). Resident A had been receiving dialysis three times a week (Tuesday, Thursday, and Saturday) since admission. Review of the Physician Order Sheet dated 1/18/22,…

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 hot food was served that is palatable temperature and appetizing texture when test tray temperature was not in range per policy and texture was not smooth enough softer than whipped topping per standardized recipe. This deficient practice had the potential to negatively impact the residents' dining experience which may result in poor dietary intake that could potentially compromise their health and nutritional status. Definition: 1. Food palatability - refers to the taste and/or flavor of the food, acceptable to the taste. 2. Proper (safe and appetizing) temperature - both appetizing to the resident and minimizing the risk for scalding and burns. Findings: The Guidance of Appendix PP dated 11/22/17, from Centers for Medicaid/Medicare (CMS) indicated, food should be palatable, attractive, and at an appetizing temperature as determined by the type of food to ensure resident's satisfaction. Appendix PP also indicated, providing…

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

Based on observation, interview, and record review, the facility failed to store food in accordance with accepted professional standards of practice when a Japanese bread crumbs bag was not stored properly in a clean container. This failure had the potential to put residents at risk for foodborne illness. Findings: During an observation on 11/29/21, at 10:30 AM, in the Dry Storage room of the kitchen, a Japanese bread crumbs bag was observed. The Japanese bread crumbs were in the original bag with the received date of 9/16/21, and 10/26/21 as the date opened. During an interview on 12/01/21, at 11:59 AM, with Kitchen Director, Kitchen Director stated, the reason why the opened Japanese bread crumbs were still in the original bag is the vendor sent a big bulky bag instead of a small bag. During a review of the facility's document titled, Dry Goods Storage Guidelines, dated 2018, the Guideline indicated, 6 months for bread crumbs when unopened on shelf, and 6 months when opened on shelf, but there was no mention for putting in a clean container after opening. The Guidance of Appendix…

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 essential equipment, including a sanitizer faucet, biofilm chemical for the floor drains, and splashguard, were maintained in a safe operating condition. This failure had the potential to cause contamination in the kitchen, which could affect overall food service operations and safety to residents and staff. Findings: 1. During a concurrent observation, interview and record review on 11/30/21, at 10:53 AM, with Kitchen Aide 1, in the kitchen, sanitizing (to make clean and hygienic; to disinfect) testing process was conducted. The quaternary ammonium solution (quat: a kind of sanitizing water) came from the faucet connected to kitchen plumbing (pipes for the water supply). Kitchen Aide 1 proceeded to test the sanitizer strength by placing a test strip into the solution for no greater than 3 seconds. Kitchen Aide 1 did not check the temperature of the sanitizing water in accordance with the manufacturer's testing instructions. It was noted testing solution should be between 65 and 75 degrees Fahrenheit (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.