Milpitas Care Center

Based on interview and record review, the facility failed to conduct performance review at least once every 12 months for one of 4 certified nursing assistants (CNA F) and one of two licensed vocational nurses (LVN G). This failure resulted in unidentified training needed for the CNA and the LVN to improve their skills in resident care every year. Findings: Review of CNA F's personal file indicated she was hired on 9/26/22, and she did not have a performance review done in 2023. Review of LVN G's personal file indicated she was hired on 8/18/22, and she did not have any performance review done. During an interview with the director of staff development (DSD) on 6/26/25, at 3:05 p.m., she reviewed CNA F's and LVN G's personal files and confirmed that CNA F did not have a performance review done in 2023, and LVN G did not have any performance review done since 8/18/22 when she was hired. The DSD acknowledged that staff performance review should be done every year. Review of the facility's policy, Performance Evaluations, dated 9/2020, indicated The job performance of each employee…

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 an accurate record of medication disposition when number of counted Lorazepam (medication that helps calm the brain and nervous system) tablets for destruction was not correctly documented. This failure had the potential for misuse or diversion of controlled medications. Findings: During a concurrent observation, interview, and record review on 6/24/25 at 10:20 a.m. with the Interim Director of Nursing (IDON), and the Administrator (ADM), a random audit of medications for destruction was done. The IDON verified a bottle of lorazepam 0.5 mg (milligram, a unit of measurement) tablets for destruction contained 24.5 tablets. The IDON and ADM verified the record sheet indicated 14.5 tablets were to be destructed. The IDON stated it should have been recorded as 24 tablets. The IDON also stated she counted the medications with Licensed Vocational Nurse (LVN) B prior to documentation. During a concurrent observation, interview, and record review on 6/24/25 at 10:28 a.m. with LVN B, LVN B verified there were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure two of 6 residents (25 and 79) were free from unnecessary medications when Resident 25 and Resident 79 received apixaban (a blood thinner to prevent blood clots) but were not monitored for the side effects and not care-planned on the use of the medication. This failure had the potential for the residents to experience unrecognized adverse effects. Findings: 1. Review of Resident 25's admission Record indicated she was admitted to the facility on [DATE]. Review of Resident 25's physician order, dated 6/4/25, indicated she had an order for apixaban 2.5 milligrams (mg, a metric unit of mass) two times a day. However, review of Resident 25's clinical record did not indicate that Resident 25 was monitored for the side effects and care-planned on the use of the medication. During an interview with the interim director of nursing (IDON) on 6/27/25, at 2:44 p.m., she reviewed Resident 25's clinical record and confirmed that Resident 25 was not monitored…

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

Based on observation, interview, and record review, the facility had a medication error rate of 8% when two medication errors occurred out of 25 opportunities during medication administration for 1 out of seven residents (Residents 129) when Resident 129's medications, Metformin (medication primarily used to a condition where the body doesn't use insulin properly to control blood sugar levels) and Insulin Lispro (a rapid-acting form of insulin used for the treatment of high blood sugar) were not given according to the Physician's Orders. The deficient practice resulted in medications not given in accordance with the prescriber's orders and/or manufacturer's specifications, which may result in residents not receiving the full therapeutic effect of the medications. Findings: During a medication pass observation on 6/24/25 at 4:25 p.m. with Licensed Vocational Nurse (LVN) C, LVN C administered the medications Metformin 1000 mg (milligram, a unit of measurement) tablet orally and insulin lispro 4 units injected subcutaneously (into the tissue layer between the skin and the muscle) 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, interview, and record review, the facility failed to ensure proper medication storage and labeling of medications when an opened lorazepam oral concentrate (medication that helps calm the brain and nervous system) was found inside the refrigerator without an open-date label. The deficient practice had a potential for residents to receive medications with unsafe and reduced potency which could lead to unsafe and ineffective medications for the residents. Findings: During a concurrent observation and interview on 6/23/25 at 9:01 a.m. with the Interim Director of Nursing (IDON) in the Medication Room, the IDON verified an opened box of used lorazepam oral concentrate inside the refrigerator. The IDON also verified there was no label for its open-date. The IDON stated it should have been labeled when it was opened. A review of facility's policy and procedure (P&P) entitled Medication Labeling and Storage dated 2001, the P&P indicated, .6. Medications requiring refrigeration are stored in a refrigerator located in the medication room at the nurses' station or other…

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 obtain consent (permission or agreement from someone having authority or power) for Coronavirus Disease (COVID-19, a mild to severe respiratory illness that is airborne and is spread from person to person or by contact with infectious material such as respiratory droplets in the air and to a lesser degree on high touch surfaces in the environment) vaccination for one of 5 residents (4). This failure had the potential to result in Resident 4's responsible party (RP, the party responsible to making health care decisions when the principal party is unable to make) not being aware of the risks and benefits of COVID-19 vaccine, and therefore unable to make an informed healthcare decision regarding the vaccine. Findings: Review of Resident 4's admission Record indicated he was admitted to the facility on [DATE], and he had one of his sons as his RP. Review of Resident 4's COVID-19 Immunization Record indicated on 10/30/24, Resident 4's family refused for him…

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 follow it's Policy and Procedure titled Isolation-Initiating Transmission- Based Precautions, when the facility failed to implement the transmission-based precautions for isolation precaution (process of creating barriers between people and germs to help prevent the spread of infectious microbes) when residents develop signs and symptoms of productive cough and suspected of respiratory illness during the outbreak for five of five sampled residents (Resident 1, Resident 2, Resident 3, Resident 4, and Resident 5). This failure had the potential to spread infectious disease to other residents and staff at the facility. Findings: During an interview on 12/10/24 at 10:08 a.m., with the Infection Prevention Nurse (IP), the IP stated in March 2024 about eight to nine residents with symptoms of runny nose and cough were reported. The IP stated they notified the doctor to get an order for cough and an order for isolation precaution related to respiratory illness outbreak then placed residents on isolation. During a review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide supervision to prevent one of two residents (Resident 1) who were at risk for elopement from leaving the facility without staffs' knowledge and permission when Resident 1's wander guard (device used to keep track of residents), was not checked for functionality and staff did not provide Resident 1 with supervision or assistance. These failures compromised Resident 1's safety, as she was found outside of the facility. Findings: Review of Resident 1's admission record indicated, Resident 1 was readmitted to the facility on [DATE] with diagnoses including unspecified dementia (loss of memory), unspecified severity, with other behavioral disturbance, essential primary hypertension (occurs when the abnormally high blood pressure was not a result of a medical condition), mixed hyperlipidemia (high levels of fat particles in the blood), and history of falling. Review of Resident 1's interdisciplinary team (IDT, brings together knowledge from different…

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 review the risks and benefits of bed rails (adjustable metal or rigid plastic bars that attach to the bed) with the resident, or resident representative, document the use of alternatives prior to installation of bed rails for three of 23 residents (Resident 23, Resident 25, and Resident 131), and obtain informed consent prior to the use of bed rails for three of 23 residents (Resident 4, Resident 6, and Resident 18). These failures had the potential to put the residents at risk for entrapment and serious injury due to not being aware of the risks and benefits of bed rails. Findings: During an observation on 02/26/24, at 09:05 a.m., Residents 4, 6, 18, 23, 25, and 131 had side rails up and installed on their beds. During an interview on 2/27/24, at 1:45 p.m., with Certified Nursing Assistant (CNA) C, CNA C stated, Residents 4, 6, 18, 23, 25, and 131 have side rails up on their beds. During a record review of Residents 4, 6, and 18's Medical Records (undated), it was indicated there was no signed informed…

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

Based on observation, interview, and record review the facility failed to ensure safe and sanitary food service operations were carried out according to standards of practice when: 1. A wet rice cooker pot was stored in the rice cooker without being air dried; and 2. The dry storage room bottom shelf was under six inches (a unit of length) off the floor. These failures had the potential to expose 27of 28 residents to harmful contaminants that could cause foodborne illness. Findings: 1. During a concurrent observation and interview on 2/26/24 at 8:42 a.m. with the Certified Dietary Manager (CDM) in the kitchen, there was a wet rice cooker pot stored inside of the rice cooker. The CDM took out the pot and stated they would wash the pot again, and it should have been air dried before storing in the rice cooker. During a review of the facility's policy and procedure (P&P) titled Dishwashing undated. The P&P indicated, 5. Dishes are to be air dried in racks before stacking and storing. 2. During a concurrent observation and interview on 2/27/24 at 10:20 a.m. with the CDM in the dry…

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 properly dispose the garbage and did not follow the facility's policy and procedures (P&P) for Covering receptacles when one of two dumpsters did not have lids closed properly. This failure had the potential to attract pests and rodents which could lead to unsanitary conditions and spread of disease. Findings: During an observation on 2/26/24 at 12:20 p.m. at the facility's outside dumpsters area, there was one dumpster with the lid left open. During an observation on 2/27/24 at 11:15 a.m., the same dumpster had overflowing garbage, and the lid was not closed tightly. During an interview on 2/28/24 at 3:33 p.m. with the Maintenance Supervisor (MS), the MS stated dumpsters should have been closed to prevent rodents and pests, and dumpsters were emptied every Monday, Wednesday, and Friday. During a review of the facility's policy and procedure (P&P) titled Miscellaneous Areas undated. The P&P indicated, Trash procedure: 2. Garbage and trashcans must be inspected daily that no debris is on the ground or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure pneumococcal vaccine (vaccine to prevent bacterial pneumonia [infection of the lungs]) up to date for 10 of 15 sampled residents (Resident 3, 4, 9, 11, 12, 13, 16, 17, 19, and 27) per the Centers for Disease Control and Prevention (CDC)'s pneumococcal vaccine schedule guidelines. This failure had the potential to place residents at a high risk of acquiring and transmitting pneumonia in the facility. Findings: Review of Resident 3, 4, 9, 11, 12, 13, 16, 17, 19, and 27 medical records, indicated all 10 residents were over [AGE] years old and their admission dates and pneumococcal vaccination statuses as follows: - Resident 3 was admitted on [DATE], the resident received Prevnar 13 (PCV13, a type of pneumococcal vaccine) on 6/17/15. - Resident 4 was admitted on [DATE], the resident received Pneumovax 23 (PPV23, a type of pneumococcal vaccine) on 5/27/11. - Resident 9 was admitted on [DATE], the resident received PCV13 on 3/3/22. - Resident 11 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 respect and dignity for two of 12 sampled residents (Resident 17 & Resident 19) during mealtime. These failures had the potential to negatively affect Resident 17 & Resident 19's emotional health. Findings: During an observation on 2/26/24, at 12:00 p.m., Certified Nursing Assistant (CNA) D assisted Resident 17 while eating lunch. CNA E was standing over Resident 17, who was sitting in bed in an upright position. During an observation on 2/26/24, at 12:00 p.m., CNA C assisted Resident 19 while eating lunch. CNA C was standing over Resident 19 and Resident 19 who was sitting on bed in an upright position. During an interview on 2/26/24, at 12:11 p.m., with CNA D, CNA D stated, she assisted Resident 17 while eating lunch. CNA D stated she was standing and she was supposed to sit down while assisting Resident 17. During an interview on 2/26/24, at 12:15 p.m., with CNA C, CNA C stated she assisted Resident 19 while eating lunch and she was standing over him. CNA C stated she was supposed to sit down while…

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 the Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN, a financial liability notice) for one of three sampled residents (Resident 27). This failure could lead the resident unknowingly assume financial liability for receiving services that were not covered by Medicare (federal health insurance for anyone age [AGE] and older, and some people under 65 with certain disabilities) . Findings: During a review of Resident 27's face sheet (a document that contains a summary of a resident's personal and demographic information), it was indicated Resident 27 was admitted to the facility on [DATE] and her stay was paid by Medicare until 9/29/23. Resident 27 was currently resided at the facility. During a concurrent interview and record review on 2/28/24 at 11:51 a.m. with the Social Services (SS), Resident 27's Notice of Medicare Non-Coverage (NOMNC, a notice that indicates when a resident's stay at a SNF is no longer covered by Medicare) 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 interview and record review, the facility failed complete annual performance reviews for 2 of 4 sampled staff (Certified Nursing Assistant [CNA] E and CNA C). These failures had the potential to negatively affect patient care. Findings: During a review of CNA E's employee record (undated), the employee record indicated, CNA E was hired on 11/8/22. During a review of CNA C's employee record (undated), the employee record indicated, CNA C was hired on 2/6/23. During a concurrent interview and record review on 2/28/24, at 1:48 p.m., with Director of Staff Development (DSD), CNA E's employee record was reviewed. The employee record indicated, no performance reviews since start date. DSD stated, CNA E had no performance review since she started working in 2022. CNAs are supposed to have a performance review annually. During a concurrent interview and record review on 2/28/24, at 1:50 p.m., with DSD, CNA C's employee record was reviewed. The employee record indicated, no performance reviews since start date. DSD stated, CNA C had no performance review for February 2024. During a…

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

Based on observation, interview and record review, the facility failed to store temperature sensitive medications appropriately. This failure had the potential for residents to receive medications with limited effectiveness. Findings: During a concurrent observation and interview on 2/26/24, at 11:47 a.m., with Licensed Vocational Nurse (LVN) F, in Medication Storage Room, the medication refrigerator's internal temperature read 52 degrees Fahrenheit. The internal temperature probe had a Safe Range of 10 degrees Fahrenheit to 40 degrees Fahrenheit. Two medications were noted on first shelf to be Basaglar Kwikpen 10 unit/1mL Insulin Pen [medication used to control blood sugar] both medications were unopened, packaging on medication read, Refrigerate until opened. LVN F stated, the internal temperature of the medication refrigerator is higher than 50 degrees Fahrenheit, it is too warm, we store our unopened insulin in there. During a concurrent observation and interview on 2/27/24, at 2:03p.m., with LVN F, in Medication Storage Room, a new medication refrigerator was placed in spot…

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 document repositioning for one out of 12 sampled residents (Resident 3) while in bed. This failure had the potential to result in inaccurate provision of care. Findings: During an observation on 02/29/24 at 9:32 a.m., Resident 3 was in bed lying on his back. During an interview on 2/29/24 at 9:42 a.m. with Certified Nursing Assistant (CNA) A, CNA A stated, Resident 3 was turned every hour. CNA A stated there was no evidence documentation when turning was completed. CNA A stated, there should have been a documentation for the turning. During an observation on 02/29/24 at 11:13 a.m., Resident 3 was lying in bed and was facing the right side. During a concurrent interview and record review on 2/29/24 at 11:14 a.m. with Licensed Vocational Nurse (LVN) B, Treatment Administration Record (TAR) dated 2/1/24- 2/29/24 was reviewed. The TAR indicated, Turn and reposition q1h (every one hour) every shift. Start date 2/16/24 1500 (3:00 p.m.). The TAR indicated check marks with initials three times daily for the rows…

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 proper infection control measures when: 1. The Infection Preventionist (IP) did not put on a pair of disposable gloves prior to handling a urine bag. 2. Licensed Vocational Nurse (LVN) G did not perform hand hygiene during medication administration. These failures had the potential to result in spread of infection and compromise the health and safety of the residents in the facility. Findings: 1. During a concurrent observation and interview on 2/28/24 at 10:48 a.m., with Infection Preventionist (IP), in Resident 3's room, IP handled Resident 3's urine bag and tubing with bare hands. Resident 3's urine bag and tubing both visibly contained urine. Upon leaving Resident 3's room, IP touched and pressed the top of the hand sanitizer by the door to dispense product. IP stated, I should have worn gloves prior to touching the urine bag. 2. During a concurrent observation and interview on 2/28/24, at 3:36 p.m., with LVN G, in hallway by Resident 19's room, LVN G began preparing Resident 19's medication…

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 nurse aides (Certified Nursing Assistants: CNAs) received 12 hours of annual in-service which included dementia management and abuse prevention training for a census of 28 when documentation of the nurse aide in-services could not be provided for 2 of 4 sampled staff. This failure had the potential to affect the quality of care and services provided to the residents. Findings: During a review of CNA E's employee record (undated), the employee record indicated, CNA E was hired on 11/8/22. During a review of CNA C's employee record (undated), the employee record indicated, CNA C was hired on 2/6/23. During a concurrent interview and record review on 2/28/24, at 1:48 p.m., with Director of Staff Development (DSD), CNA E's employee record was reviewed. The employee record indicated, no competencies or in-services since start date. DSD stated, CNA E has not had any competencies or in-services since she started working in 2022. They should have competencies and in-services annually and as needed. During a 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.

Based on interview and record review the facility failed to exercise the resident's right as a resident of the facility for one out of three resident (Resident 1) when Resident 1 was not allowed to leave out on pass to get her Covid-19 (Covid-19: a sickness caused by virus called severe acute respiratory syndrome coronavirus 2) booster vaccine (lessens the severity of Covid-19 by teaching the person's immune system to recognize and fight the virus that causes the disease) outside the facility. This failure had the potential to effect on health and well-being to Resident 1 Findings: During record review of Resident 1's face sheet (a document that gives a resident's information at a quick glance) indicated, Resident 1 admitted to facility on 11/8/2021 and discharged home on 1/3/2022. Resident 1's admission diagnoses including compression fracture of T11-T12 vertebra (broken bones of the spine[Spine: column of bones running from head down to the lower back]), osteoporosis (a bone disease that develops when bone mineral density and bone mass decreases, or when quality or structure 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.

Based on interview and record review, the facility failed to ensure a Registered Nurse (RN) was on duty for 8 consecutive hours, for seven days (7/15/23, 7/16/23, 7/22/23, 7/30/23, 8/13/23, 8/19/23, and 8/20/23) out of 62 sampled days. This failure had the potential to negatively affect all 27 residents at the facility. Findings: During an interview on 9/5/23 at 10:15 a.m. with Director of Nursing (DON), DON stated she works Monday through Friday for 8 hours each day, and the facility schedules an RN for Saturday and Sunday. DON stated, she serves as the RN on duty for Monday through Friday as the census is always below 60 residents at the facility. During a review of [Facility] Licensed Nurse Schedule, dated July 2023, the Schedule indicated, no RN was scheduled on 7/15/23, 7/16/23, 7/22/23, or 7/30/23. During a review of [Facility] Licensed Nurse Schedule, dated August 2023, the Schedule indicated, no RN was scheduled on 8/13/23, 8/19/23, or 8/20/23. During an interview on 9/5/23 at 11:30 a.m. with DON, DON stated no RN was on duty at the facility on 8/13/23, 8/19/23, or 8/20/23.…

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

Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, distributed and served in accordance with professional standards for food safety when: 1. Time Temperature Control for Safety Foods (TCS=food requires time/temperature control for safety to limit the growth of pathogens (i.e., bacterial or viral organisms capable of causing a disease or toxin formation) were above 41°F (°F, a temperature scale) in the Residents' refrigerator, and refrigerator and freezer temperatures were not monitored, 2. Residents' food items were not monitored for expiration dates, 3. Staff did not perform proper hand hygiene while dishwashing, 4. A can opener was not kept in sanitary condition, 5. Freezer gaskets had blackish substance in the crevices, 6. Supply closet had staff's personal belongings with the cleaning equipment, and food equipment; and 7. Food preparation sink had no air gap. These failures had the potential to cause cross contamination of food (cross contamination occurs when unclean surfaces or utensils spread germs to food and can…

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 care and services for effective communication when the facility did not provide language assistance or other communication aid for four of five sampled residents (Residents 6, 24, 127 and 128) with language barrier (speaking in foreign language). This failure had the potential to affect the psychosocial well-being of the resident and a decline in the activities of daily living. Findings: 1) A review of Resident 6's Quarterly, minimum data set (MDS, an assessment tool), dated 4/26/2022, indicated Resident 6 needed an interpreter because the Preferred Language was a foreign language. During an observation on 7/18/2022 at 12:21 p.m., Resident 6 was observed sitting on a chair eating lunch. Resident 6 was observed trying to communicate speaking her language. There was no communication aid observed near the bed or on the overbed table. During a concurrent observation and interview with certified nurse assistant E (CNA E) on 7/19/2022 at 8:54 a.m., the CNA E confirmed there was no communication aid 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.

Based on observation, interview, and record review, the facility failed to ensure three of 12 sampled residents (Resident 11, 2, and 128) received the appropriate care and services when: 1. For Resident 11, licensed vocational nurse A (LVN A) did not administer Metformin (a drug that helps to control the amount of glucose (sugar) in your blood) as ordered; 2. For Resident 2, facility staff did not follow physician's order of administering resident's tube feeding (giving medicines and liquids through a small tube placed through the nose or mouth into the stomach or small intestine) and did not monitor signs and symptoms while on anticoagulant (medicines that help prevent blood clots) medication; and 3. For Resident 128, facility staff did not properly monitor resident's intravenous (IV, into or within a vein) therapy. These failures have the potential to affect resident's health and medical condition. Findings: 1. Review of Resident 11's clinical record indicated, resident had diagnoses including Type 2 diabetes mellitus (characterized by high levels of sugar in the blood), chronic…

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 staff failed to ensure drugs and biologicals were safely stored and discarded per facility's policy and manufacturer's recommendations when; 1. a multi-dose vial of Tuberculin solution (injected under the skin to aid diagnosis of tuberculosis (infectious disease that usually affects the lungs) had no opened date; 2. one eyedrop and one insulin (medication to treat high blood sugar) vial for Resident 24 and an insulin pen for Resident 11 was being used past the discard date; and controlled medications (controlled by the government because it may be abused or cause addiction) for 5 discharged residents were not removed from the medication cart in a timely manner. These failures had the potential for residents to receive medications with reduced potency and unsafe access to controlled medications in the facility. Findings: 1. During a concurrent observation and interview with licensed vocational nurse B (LVN B) on 7/18/2022, at 9:42 a.m., while in the medication storage room, there was one opened multi-dose vial…

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 review, the facility failed to ensure the planned menu was followed when 1. Three of three residents (Residents 126, 20, and 76) on renal diets, (diets that are designed for people with kidney function that slowly gets worse with time) were served potatoes and chocolate mousse. 2. Four of four residents (Residents 128,13, 3, and 12) on puree diets (texture modified diets for people with chewing or swallowing difficulties) when they were served pureed foods different from regular foods. 3. Ketchup was not served according to the menu. These failures had the potential to result in not meeting the nutritional needs thus further compromising the nutritional status of these residents. Findings: 1. Review of the facility menu titled Cooks Spreadsheet for week 3 Monday Lunch (7/18/22) indicated French fries and Chocolate Mousse for all types of diet except Renal which was to get Pineapple Ring and Sugar Cookies. During an observation of the lunch meal service on 7/18/22 at 11:27 a.m., French fries and chocolate mousse were on 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure Escitalopram Oxalate (a psychotropic medication used to treat depression and certain anxiety disorders) was administered with consent of Resident 25. This failure had the potential of not honoring resident's rights to be informed about his treatment. Review of the clinical record indicated Resident 25 was admitted to the facility on [DATE] with diagnosis of multiple sclerosis (chronic disease affecting the central nervous system, depression (a mental health problem that involves a low mood and a loss of interest in activities). Review of Resident 25's Order Summary Report, indicated the physician order dated on 6/13/2022 to give Escitalopram Oxalate 20 milligrams (mg, unit of measurement) one tablet by mouth once a day for major depression. During a concurrent interview and record review with Registered Nurse I (RN I) on 7/20/2022 at 4:00 p.m., RN I confirmed that there was no record of informed consent for Escitalopram Oxalate 20mg for 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 staff failed to provide to one of 12 sampled residents (Resident 25) his preferred foreign television channel. This failure had the potential to affect the physical and mental well-being of Resident 25. Findings: Review of Resident 25's clinical record indicated, resident had diagnoses including Multiple Sclerosis (disabling disease of the brain and spinal cord), sepsis (life-threatening condition that occurs when the body's response to an infection damages its own tissues), hydroneprosis with uteropelvic junction obstruction (condition where blockage occurs at the junction where the ureter attaches to the kidney), depression (a mental health problem that involves a low mood and a loss of interest in activities). Review of Resident 25's Care Plan, dated 6/16/2022, indicated the resident was dependent on staff for meeting emotional, intellectual, physical, social needs related to cognitive deficits, disease process, immobility, and physical limitations. Resident 25's care plan prefers to watch television with a foreign…

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 nephrostomy tube (a catheter that's inserted through your skin and into your kidney. The tube helps to drain urine from your body) care to one of 12 sampled residents (Resident 25). This failure had the potential to affect the health and well-being of Resident 25. Findings: Review of Resident 25's clinical record indicated, resident had diagnoses including Multiple Sclerosis (disabling disease of the brain and spinal cord), sepsis (life-threatening condition that occurs when the body's response to an infection damages its own tissues), urinary tract infection (UTI, bladder infection), hydroneprosis with uteropelvic junction obstruction (condition where blockage occurs at the junction where the ureter attaches to the kidney). During a concurrent observation and interview on 7/18/2022 at 9:10 a.m., while inside Resident 25's room. Resident was lying in bed, awake and alert. Observed a catheter bag (urine drainage bag) positioned at the left side of the bed. Review of Resident 25's Plan of Care,…

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

Based on observations, interview, and record reviews, the facility failed to provide foods at an appetizing temperature for three of 24 residents (Resident 21, 11, 15) receiving food from the kitchen. This failure had the potential to result in decreased intake thus further compromising the nutritional status of these residents. Findings: During an interview on 7/18/22 at 9:31 am, Resident 21 stated the food was sometimes not warm and it was cold. Further interview at lunch meal service on 7/19/22 at 11:55 am, Resident 21 stated the food was never hot. During an interview on 7/18/22 at 10:30 am, Resident 15 stated the food was cold and that he mentioned it to the staff and the food was cold. Further interview at the lunch meal service on 7/19/22 at 11:40 am, Resident 15 stated the food was cold again. During an interview on 7/19/22 at 9:45 AM, Resident 11 stated the food was cold. Review of facility menu titled Summer Menus Week 3 Wednesday indicated for lunch on 7/20/22 Taco Casserole, Seasoned Fresh Zucchini, Fiesta Salad, and Tangy Glazed Fresh Fruit. As a result of 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 and facility document review, the facility failed to provide a therapeutic diet as prescribed by a physician for one resident (Resident 17) out of 24 residents when Resident 17 received regular texture meat instead of Mechanical soft (a modified diet that restricts foods that are difficult to chew or swallow). This failure had the potential to result in the resident not being able to chew the food possibly leading to choking. Findings: Review of the facility's Cooking Spreadsheet Week 3 Lunch 7/18/22 under Mechanical soft indicated French Dip Roast beef Grd (ground) #10 (3/8 cup) moisten with broth. During a concurrent observation and interview of the lunch meal service with Food Service Worker D (FSW D) on 7/18/22 at 11:38 a.m., Resident 17's tray had French dip Roast beef with regular sliced roast beef on a soft sandwich roll, French fries, corn coleslaw, Cappuccino mousse and milk ready for distribution. A review of Resident 17's tray ticket indicated Mechanical soft, NCS (No concentrated Sweets), NAS (No Added Salt), low fat, low cholesterol diet.…

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's document review, the facility failed to implement infection control measures when: 1. The certified nurse assistant H (CNA H) did not perform hand hygiene after touching dirty carts and placed a clean bag of towels and gowns on top of Resident 126's four wheeled walker; 2. The Infection Preventionist (IP) did not perform hand hygiene prior to donning (putting on) a pair of gloves to flush a peripheral intravenous catheter (a thin, flexible tube inserted into a vein); 3. The licensed vocational nurse A (LVN A) did not perform hand hygiene in between tasks during Resident 126's wound care; and 4. The licensed vocational nurse A (LVN A) did not perform hand hygiene in between tasks and pulled out a handful of gloves for use during Resident 24's wound care. These failures had the potential to result in the spread of infection and compromise the health and safety of the residents in the facility. Findings: 1. During an observation on 7/18/2022 at 9:43 a.m., the certified nurse assistant H (CNA H) was observed coming out from room AA (RM AA),…

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

Based on interview and record review, the facility failed to implement its policy and procedure to ensure all staff were fully vaccinated for COVID-19 (a new infectious viral disease that can cause respiratory illness) when there were no evidence of proof of vaccination or medical waiver for one of 43 staff (BOM-business office manager). As a result, the facility's COVID-19 staff vaccination rate was 97.67% on 7/22/2022. This failure had the potential to spread COVID-19 infection to staff, residents, and visitors. Findings: During an interview with the facility's infection preventionist (IP) on 7/22/2022 at 9:31 a.m., the IP stated the BOM declined to have the COVID-19 vaccine. The IP confirmed the BOM did not have any medical waiver. During an interview with the BOM on 7/22/2022 at 9:58 a.m., the BOM confirmed the declination of the COVID-19 vaccine due to having vascular problems. The BOM stated her personal physician did not sign the medical waiver because the physician required the BOM to get vaccinated. The BOM further stated, I am looking for a doctor to sign my 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.

Based on observation, interview, and record review, the facility failed to provide a safe and functional environment for staff when a kitchen cabinet door was broken at the hinge. This failure could result an injury to the staff when working in the kitchen. Findings: During the initial tour of the kitchen on 07/18/22 starting at 8:49 a.m., the cabinet door below the food preparation sink was broken at the hinge and was difficult to open and close. During a concurrent interview with the Food Service Worker D (FSW D) she stated the broken door was reported to maintenance. During an interview on 07/19/22 at 8:26 a.m., Maintenance Supervisor (MS) stated there were no issues in the kitchen reported to him yesterday. He further stated the maintenance issues was reported to him verbally. There was no maintence log to track regarding the issues and repairs if he was able to fix the problem. During an observation and concurrent interview on 7/19/22 at 8:53 a.m. in the kitchen while looking at the broken cabinet door, MS confirmed it was broken and needs fixing for safety reasons. During an…

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

Based on observation, interview and record review, the facility failed to ensure the environment was free of pests as evidenced by flying insects seen in the kitchen, and conference room. This failure had the potential to cause a health hazard to the residents and staff. Findings: During an observation on 7/18/22 at 2:57 p.m., a black insect was flying inside the conference room. During a follow up observation and interview with Maintenance Supervisor (MS) on 7/20/22 at 9:43 a.m., a black insect was flying inside the kitchen during the food preparation. MS confirmed the observation and stated an insect should have never been inside the kitchen and the insect would land on the food. During an interview with Registered Dietitian (RD) on 7/20/22 at 10:09 a.m., RD stated insects in the kitchen may cause potential contamination of food. During a review of the facility's policy and procedure (P&P) titled, Pest Control, dated 2007, the P&P indicated Pest Control is important in preventing the spread of disease.