Golden Modesto Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure residents were free of significant medication error for one of four sampled residents (Resident 1), when Resident 1 was administered the Insulin (a hormone that helps regulate blood sugar level) without a physician order and diagnosis. This failure had the potential to result in Resident 1 experiencing a hypoglycemic event (occurs when the body ' s sugar levels drop too low) causing trembling or shaking, weakness, sweating or chills, dizziness or lightheadedness, confusion or trouble concentrating, irritability, tingling or numbness of the lips, tongue or cheeks and had the potential to result in death. Findings: During a review of Resident 1's admission Record (AR- a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis…

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 residents were free from abuse and neglect for one of three sampled residents (Resident 2) when Resident 2 did not receive assistance to go to the restroom and was told by CNA 1 to soil herself while in bed. This failure resulted in Resident 2 feeling humiliated and neglected by CNA 1 when Resident 2 held her urine until her stomach was in pain and urinated on herself. Findings: During a concurrent observation and interview on 10/25/24 at 11:00 a.m. with Resident 1, in Resident 1 ' s room, Resident 1 was observed communicating using a notepad. Resident 1 stated that on the night of 10/14/24, Resident 2 asked certified nursing assistant (CNA) 1 for assistance to the restroom. Resident 1 stated CNA 1 told Resident 2, to wet her brief in bed because CNA 1 did not have time to take her to the restroom. Resident 1 stated Resident 2 was a nice person and heard Resident 2 tell CNA 1 that she was sorry, she would try harder and be a better…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to follow facility's policies and procedures and meet professional standards of quality for one of three sampled Residents (Resident 1), when staff did not document Resident 1's change of condition and post fall assessment for unwitnessed fall with injury on 9/26/24. This failure had the potential to result in the inaccurate assessment of Resident 1 and had the potential for falls and delay in care. Findings: During a review of Resident 1's admission Record (a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses for acute gastroenteropathy (Inflammation of the lining of the stomach and the intestines), abnormalities of gait (walking) and mobility (movement), muscle weakness, encephalopathy (damage or disease that affects the brain),…

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.

2. An admission Record indicated the facility admitted Resident #22 on 04/28/2021. According to the admission Record, the resident had a medical history that included a diagnosis of type 2 diabetes mellitus. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/20/2024, revealed Resident #22 had severe impairment in cognitive skills for daily decision making and had short-term and long-term memory problems per a staff assessment of mental status (SAMS). Resident #22's care plan included a focus area revised on 08/01/2024 that indicated the resident had the potential for impairment in skin integrity. Resident #22's Order Summary Report, with active orders as of 09/18/2024, contained an order dated 08/24/2024 for betadine-soaked gauze and dry gauze over the left big toe daily until resolved. During an observation on 09/18/2024 at 9:58 AM, Licensed Practical Nurse (LPN) #1 provided wound care for Resident #22. A small open area was noted to the resident's left hallux. LPN #1 did not implement enhanced barrier precautions and wore only gloves during the…

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

Based on interview, record review, and facility policy review, the facility failed to submit a status change to a Level I Pre-admission Screening and Resident Review (PASARR) following a new mental health diagnosis for 1 (Resident #62) of 3 residents reviewed for PASARR. Specifically, Resident #62 had a positive Level I PASARR and was later diagnosed with a new mental health disorder and the facility failed to submit a status change to the resident's Level 1 PASARR evaluation. Findings included: A facility policy titled, admission Criteria, revised in March 2019, indicated, 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. a. The facility conducts a Level I PASARR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for a MD, ID, or RD. An admission Record revealed the facility admitted Resident #62 on 06/12/2020. According to the admission Record, 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, record review, and facility policy review, the facility failed to ensure a Level I Pre-admission Screening and Resident Review (PASARR) was complete and accurate for 2 (Resident #62 and Resident #12) of 3 residents reviewed for PASARR. Specifically, Resident #62 and Resident #12 had a Level I PASARR completed that did not capture all their mental health diagnoses. Findings included: A facility policy titled, admission Criteria, revised in March 2019, indicated, 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. a. The facility conducts a Level I PASARR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for a MD, ID, or RD. 1. An admission Record revealed the facility admitted Resident #62 on 06/12/2020. According to the admission Record, the resident had a 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 interview, record review, and facility policy review, the facility failed to follow pharmacy recommendations for 1 (Resident #19) of 5 residents reviewed for unnecessary medications. Specifically, the facility failed to respond to May and June 2024 pharmacy recommendations for an AIMS (abnormal involuntary movement scale) assessment for Resident #19. Findings included: A facility policy titled, Antipsychotic Medication Use, revised 12/2016, indicated, 17. Nursing staff shall monitor for and report any of the following side effects and adverse consequences of antipsychotic medications to the attending physician: a. General/anticholinergic: constipation, blurred vision, dry mouth, urinary retention, sedation; b. Cardiovascular: orthostatic hypotension, arrhythmias; c. Metabolic: increase in total cholesterol/triglycerides, unstable or poorly controlled blood sugar, weight gain; or d. Neurologic: akathisia, dystonia, extrapyramidal effects, akinesia, or tardive dyskinesia, stroke or TIA [transient ischemic attack]. A facility policy titled, Medication Regimen Reviews, revised…

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 a medication error rate less than 5 percent (%). There were 2 errors out of 32 opportunities, which resulted in a 6.25% medication error rate for 2 (Resident #5 and Resident #86) of 4 residents observed for medication administration. Findings included: A facility policy titled, Administering Medications, revised 04/2019, specified, 4. Medications are administered in accordance with prescriber orders, including any required time frame. 1. An admission Record revealed the facility admitted Resident #5 on 10/17/2022. According to the admission Record, the resident had a medical history that included diagnoses of constipation and rectal prolapse. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/18/2024, revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Resident #5's Order Summary Report, with active orders as of 09/18/2024, revealed an order dated 10/26/2021 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, record review, facility document review, and facility policy review, the facility failed to ensure 1 (Resident #86) of 4 residents observed for medication administration was free from a significant medication error and failed to follow vital sign parameters when administering medications for 1 (Resident #62) of 5 residents reviewed for unnecessary medications. Findings included: 1. A facility policy titled, Administering Medications, revised 04/2019, specified, 4. Medications are administered in accordance with prescriber orders, including any required time frame. An Instructions for Use for a Humalog (insulin lispro) KwikPen revised by the manufacturer on 07/2023, specified, Prime before each injection. Priming your Pen means removing the air from the Needle and Cartridge that may collect during normal use and ensure that the Pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. Step 6: To prime your Pen, turn the Dose Knob to select 2 units. Step 7: Hold your Pen with the Needle pointing…

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 a baseline care plan was written and implemented within 48 hours for 1 of 3 sampled residents (Resident 9) when Resident 9 was admitted to the facility with a broken left hip on 12/16/23 with no documented care plan for Resident 9 ' s broken left hip. This failure had the potential for Resident 9 to have unmet care needs for her broken left hip. Findings: During a review of the facility document titled, admission Record, for Resident 9, dated 12/22/23, it did not indicate a diagnosis of a fractured hip. The .admission Record indicated Resident 9 had diagnoses that included altered mental status, history of stroke resulting in inability for Resident 9 to move parts of her body . During a review of document titled, Progress Notes, dated 12/16/23, at 10:58 a.m., for Resident 9, the Progress Notes indicated, .patient arrived [admitted back into the facility] via gurney accompanied by 2 emts [emergency medical technicians] and husband .hospice…

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 services which meet professional standards of quality for one of three sampled residents (Resident 1) when the facility did not provide Resident 1 ' s Metformin (medication used to control blood sugar) for 17 days. This failure placed Resident 1 at risk for a hyperglycemic (too much sugar in the blood) event which could lead to serious medical conditions including kidney damage, vision loss, nerve problems, loss of limbs, coma, and possibly death. Findings: During a review of Resident 1 ' s clinical record dated 5/10/2022, the admission record (AR), indicated Resident 1 was transferred to the facility from a general acute care hospital (GACH), on 5/10/2022 with a diagnosis of encephalopathy (inflammation of the active tissues of the brain), transient cerebral ischemic attack (TIA- blood supply is briefly interrupted), Alzheimer ' s Disease (brain disease that slowly destroys memories and thinking skills), and (Diabetes Mellitus,…

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 personal privacy and confidentiality rights was honored for one of three sampled resident (Resident 2) when CNA 1 used her personal phone on video, while providing bathing care and turned her phone to show Resident 1 ' s face during a bed bath. This failure resulted in the violation of the Resident 1 ' s right to privacy and confidentiality. Findings: During a review of Resident 2 ' s, admission Record (document containing resident demographic information and medical diagnosis), dated 3/9/23, the admission record indicated Resident 2 was admitted to the facility on [DATE]. Resident ' s diagnoses included .Covid-19 (A respiratory disease caused by a virus) .Cerebral Infarction unspecified (lack of blood supply to the brain) .Type 2 Diabetes Mellitus with Hyperglycemia (High blood sugar levels) . During a review of Resident 2 ' s Minimum Data Set (MDS-tool for implementing standardized assessment), dated 2/23/23, the MDS 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 observations, interviews, and record reviews, the facility failed to ensure safe and orderly discharge from the facility for one of five sampled residents (Resident 1) when Resident 1 was discharged home with no discharge orders, no discharge summary, no home health referral set up, no Durable Medical Equipment (DME) and no medications were sent home with Resident 1. This failure had the potential to cause health complications for Resident 1 from the lack of equipment, follow up care and experience difficulties in managing their condition. Findings: During a concurrent interview and record review on 11/8/23 at 2:00 p.m. with the Social Services Assistant (SSA), Resident 1 ' s Order Summary Report (OSR), dated 10/30/23, was reviewed. The OSR indicated, there were no records of a discharge order and was validated by the SSD. The SSD stated, Resident 1 did not sign an AMA (against medical advice-a document that is signed by a resident if they want to leave without a doctor ' s orders) paperwork. During a concurrent interview and record review on 11/8/23 at 2:15 p.m. with the…

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

Based on observation, interview, and record review, the facility failed to meet professional standards of quality for one of five sampled residents (Resident 2) when One of the medication for Resident 2 was left un-attended on top of a medication cart. This failure had the potential for Resident 2's medication being stolen or taken by another resident who may take it accidentally leading to harm. Findings: During an observation on 11/8/23 at 11:30 a.m., on North C Hallway, a bottle of Gabapentin (a medication to treat seizures and nerve pain) belong to Resident 2 was observed on top of a medication cart unattended. During an interview on 11/8/23 at 11:3 a.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated, medications should not be left alone. LVN 2 stated, as soon as we give it, we should put it away. During an interview on 11/8/23 at 2:20 p.m. with the Assistant Director of Nurses (ADON), the ADON stated, when nurses walked away from the medication cart, there should not be any medications left on top of medication cart. The ADON stated, after preparing the medications, 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 and record review, the facility failed to ensure four of four residents (Resident 1, 2, 3, and 4) received therapeutic diets when Resident 1, 2, 3, and 4's diets were altered without consulting with the prescribing physician or registered dietitian (RD). This failure was not the standard of practice according to the facility's policy and procedure (P&P), titled Therapeutic Diets and had the potential to negatively affect the nutritional health of Resident 1, 2, 3, and 4. Findings: During an interview on 10/10/23 2:53 p.m. with Registered Dietitian (RD), RD stated he assessed, developed, evaluated, and monitored the nutritional health needs of residents at the facility. RD stated residents with CHF (congestive heart failure: a long-term condition in which your heart can't pump blood well enough to meet your body's needs), MI (myocardial infarction; heart attack), and Renal (kidney) Disease were on strict diets to regulate phosphorus (a mineral that naturally occurs in many foods and is also available as a supplement), potassium (a mineral that your body needs to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide services inside and outside the facility for one of three sampled residents (Resident 2) when multiple physician ' s orders for Resident 2 were not completed. This failure caused Resident 2 to feel frustrated and helpless and not receive services per physician ' s orders. Findings: During a concurrent observation and interview on 8/4/23, at 10:56 a.m., Resident 2 was seen exiting his bathroom grabbing onto the door, wall, then his wheelchair, and stepping towards his bed which he dropped himself into and then put his legs up and covered them with a blanket. Resident 2 stated he was admitted on [DATE], stating he needed help, I kept falling and spent 22 days in the hospital before [he came here]. Resident 2 stated he was supposed to be here for short term rehab and the facility did do physical and occupational therapy in the beginning, but it did not feel like very much. Resident 2 stated he was supposed to have a Neurology (a branch…

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 keep residents safe from verbal abuse for one of three sampled residents (Resident 1), when Resident 1 was placed in a room with Resident 3 who was a known verbal abuser of staff and residents. This failure placed Resident 1 and any other residents that would be placed with Resident 3 in the future at risk of verbal abuse. Findings: During a concurrent observation and interview on 8/4/23, at 11:59 a.m., Resident 1 was seen in his room lying in Bed 2 closest to the window and Resident 3 was heard behind his privacy curtain in bed 1 closest to the door. Resident 1 stated he could not walk and spent 100% of his time in bed. Resident 1 stated he had been in this room for about two months with his current roommate. Resident 1 stated Resident 3 touched his leg and he felt it was inappropriate but when he asked him to remove it, he did. Resident 1 stated Resident 3 had verbal outbursts and said inappropriate things to him about wanting to see his…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow Policy and Procedure and provide adequate training for Misappropriation of Resident Property for one of three sampled residents (Resident 1), when Certified Nursing Assistant (CNA) 1 did not report suspected misappropriation of resident property and agreed to be a witness in the signing of legal documents while Resident 1 was sedated and unable to consent to changes to her financial assets on [DATE]. This failure had potential for Resident 1's financial assets to go unprotected. Findings: During an interview on [DATE], at 11:00 a.m., with Director of Nursing (DON), the DON stated she was notified that CNA 1 had been a witness to Resident 1's change in trustee legal documents. DON stated CNA 1 should not have been a witness for legal documents. DON stated CNA 1 should have reported the issue to the Licensed Vocational Nurse (LVN) or social services as soon as possible. DON stated staff should have been educated on being a witness to signing 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 observation, interview, and record review, the facility failed to ensure a comprehensive, person-centered care plan (a plan that provides direction for individualized care of resident) was developed and implemented to meet the identified needs for one of three sampled residents (Resident 2), when Resident 2 did not have a resident-centered care plan developed with interventions that would monitor for psychosocial effects from the alleged abuse incident. The deficient practice had the potential to result in resident 2 ' s identified care needs, to go unmet. Findings: During an interview on 7/13/23 at 11:20 a.m. with Resident 2. Resident 2 stated the alleged abuse incident occurred on 5/20/2023. Resident 2 stated while he was asleep, he was rudely interrupted by a Certified Nursing Assistant (CNA), when he awoke, the CNA had her hands down Resident 2 ' s pants. Resident 2 stated the CNA exited the room when Resident 2 awakened. Resident 2 stated a few nights later another CNA entered his room and wanted…

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 an effective QAPI program (Quality Assurance and Performance Improvement-is a data driven and proactive approach to quality improvement. It is a process used to ensure services are meeting quality standards and assuring care reaches a certain level) when the facility did not implement performance improvement activities in accordance with facility QAPI policies and procedures related to resident safety and reducing the risk of falls after four of 10 residents (Resident 2, 3, 7, and 8) had avoidable falls from 2/25/23 to 4/28/23. Reference F689. This failure had the potential to result in nursing staff not implementing effective fall risk prevention interventions (nursing actions taken to reduce the risk of a resident falling while in their own environment) to all residents with fall risk potential and could result in additional residents experiencing harm and serious injuries from avoidable falls. Findings: During a concurrent interview and record review on 8/17/23, at 12 p.m., with the Regional Director 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 interview and record review, the facility failed to communicate and provide mandatory Quality Assurance and Performance Improvement (QAPI) training to 71 of 152 staff when they were not informed of the facility goal to implement a Falling Star Program to reduce the risk of falls. This failure led to nursing staff being unable to verbalize an understanding of the facility's active performance improvement goals aimed at successfully implementing a program to reduce the risk of falls and improve resident safety. Findings: During an interview and record review on 8/17/2023 at 11:45 a.m. with the Director of Nursing (DON) and the Regional Director of Clinical Operations (RDCO), the RDCO stated her expectation is that the facility Administrator (ADM), who is responsible for ensuring that the QAPI program is executed, would communicate the facility plan and progress of the facility improvement projects to staff. The RDCO stated that when it became evident that expectations for QAPI Program activities had not been met, the ADM was dismissed. The RDCO stated that she believes that the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to send a copy of the resident transfer and discharge notification to a representative of the Office of the State Long-Term Care Ombudsman (an official appointed to represent the elderly and frail's rights under public authorities) for 10 of 10 sampled residents (Residents 463, 53, 357, 72, 16, 8, 62, 87, 34, and 506). These failures had the potential to result in inappropriate resident transfer and discharge practices for Residents 463, 53, 357, 72, 16, 8, 62, 87, 34, and 506. Findings: During an interview with the Director of Nursing (DON), on 8/07/19, at 11:56 a.m., the DON stated the ombudsman was not notified for all the residents that were discharged to the hospital. During a concurrent interview and record review with the Social Services Director (SSD), on 8/07/19, at 2:12 p.m., she reviewed the list of residents who were discharged to the hospital for the last three months. SSD stated I did not notify the Ombudsman on all the residents who got…

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

Based on interview and record review, the facility failed to ensure the food services staff had appropriate competencies for food safety and to effectively carry out the functions of food services when [NAME] 1, [NAME] 2, and dietary aide (DA)1 were unable to verbalize the cool down food process (a safe way to cool down food safely). This failure had the potential for untrained staff to place residents at risk for exposure to foodborne illness (food poisoning). Findings: During an interview with DA 1 and the Certified Dietary Manager (CDM), on 8/7/19, at 10:27 a.m., in the kitchen regarding cool down food process, the DA 1 stated the way she would perform the cool down process would be as follows: she had four hours to cool down the food to 70 degrees Fahrenheit (F). The CDM stated DA 1 did not know the cool down food process and needed additional training to ensure the DA 1 performed the cool down process safely. During an interview with [NAME] 2, on 8/7/19, at 10:37 a.m., [NAME] 2 verbalized the cool down food process, [NAME] 2 stated food at 135 degrees F temperature should be…

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 have an effective Quality Assessment and Performance Improvement (QAPI- a program that enables the facility to evaluate and improve the quality of Resident care and services through data collection, staff input, and other information) program when care planning issues were not identified with appropriate plans of actions developed to correct the identified deficient practice (cross reference F 656). This failure resulted in an ineffective QAPI program necessary to improve implementation of individualized resident centered care plans. Findings: During an interview with the ADM and DON, on 8/9/19, at 11:17 a.m., the ADM stated the quality assurance committee meets monthly to review past and current issues in the facility. The ADM stated the current QAPI projects in the facility were falls, restructuring the facility's infection control program, activities department resident assessments and activity care plans, and preventing drug diversion. The ADM stated the current QAPI projects were reviewed each quarter to evaluate the…

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

Based on observation, interview, and record review, the facility failed to ensure kitchen equipment was safely maintained when excess ice build-up was found inside the walk-in freezer. This failure had the potential to impact the ability of dietary staff to prepare, store, and serve food in a safe and sanitary manner for all resident, staff and visitors who were served meals from the kitchen. Findings: During a concurrent observation and interview with the Dietary Manager in training (DMIT), on 8/6/19, at 8:35 a.m. in the walk-in freezer, there was multiple small icicles around the evaporator fans and on the evaporator unit. The DMIT stated she would notify the Director of Maintenance (DM) to check on it. The DMIT stated if the freezer continued building up ice, freezer burn could potentially lead to bad taste on the food and the quality of food could be compromised. During an interview with the DM, on 8/7/19, at 8:22 a.m., he stated the dietary staff notified him about the build-up icicles on the fans and evaporator of the walk-in freezer. The DM stated he checked the walk-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 and interview, the facility failed to provide a safe, functional, and sanitary environment in the kitchen when staff left the floor near the dishwasher area saturated with water. This failure had potential to create an unsanitary, and unsafe environment for, residents who receive meals from the kitchen, dietary staff and interfere with food services to residents. Findings: During concurrent observation in the kitchen and interview with the Certified Dietary Manager (CDM), on 8/9/19, at 9 a.m., the floor near the dishwasher area was found saturated with water without a wet floor sign. The CDM stated the dietary staff had sprayed the dishwasher floor with water to clean. The CDM stated the dishwasher floor was saturated with water without placing a wet floor sign and leaving the water stagnant on the floor could cause an unsanitary environment. The CDM stated the staff should squeegee (a flat smooth rubber blade used to remove the flow of liquid on a flat surface) the dishwasher floor area before leaving and not leave the floor saturated with water. The CDM stated…

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

Based on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS- evaluation of memory recall, mood and functional abilities) assessment accurately reflected the resident's current hearing status for one of five sampled residents (Resident 26) when Resident 26's hearing loss was not accurately documented on the MDS assessment. This failure resulted in Resident 26's hearing needs going unmet. Findings: During a concurrent observation and interview with Resident 26, on 8/6/19, at 8:04 a.m., in Resident 26's room, Resident 26 sat on her bed while having breakfast. When Resident 26 was asked questions, she stated, What? I can't hear you. Resident 26 stated she had been in the facility for a year and she was hard of hearing. Resident 26 stated, I am very hard of hearing. I used to have a hearing aid. My hearing aid has been in the office for eight months. I want my hearing aid so I can hear better. I have never been to a hearing doctor. I have not seen a doctor. I want to go to a doctor for my hearing [consult]. During a review of Resident 26's…

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

Based on interview and record review, the facility failed to ensure residents receiving hemodialysis (medical procedure of removing waste products and excess fluid from the blood through an artificial kidney) treatment received care consistent with professional standards for one of two sampled residents (Resident 53) when licensed nurses did not monitor Resident 53's arteriovenous fistula (AV- is a catheter inserted into the artery and vein to provide dialysis treatment) site in the left upper arm for bruit (a sound heard through a stethoscope generated by turbulent flow of blood in an artery indicating patency) and thrill (vascular thrill) every shift. This failure had the potential to result in Resident 53's AV fistula to clog and malfunction and placed Resident 53 at risk of delay in his dialysis treatment in the event his AV fistula could not be accessed for patency. Findings: During a concurrent interview and record review with Licensed Vocational Nurse (LVN) 1, on 8/8/19, at 9:41 a.m., she reviewed Resident 53's face sheet (a document containing personal and 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 interview and record review, the facility failed to ensure dietary staff followed their food thermometer (instrument for measuring and indicating temperature) calibration (check or standardize a measuring instrument) policy and procedure when the kitchen staff did not document the food thermometer temperature calibrations. This failure had the potential to result in inaccurate food temperature and potentially result in food borne illness (food poisoning) for all residents, staff and visitors who were served meals from the kitchen. Findings: During an interview with the Dietary Aide (DA) 1, on 8/7/19, at 10:27 a.m., DA 1 stated the process for food thermometer calibration was as followed: she would get a glass of water with ice, dip the thermometer until the temperature indicator stopped moving and read 32 degrees Fahrenheit (F). The DA 1 stated the kitchen did not have a process that required the staff to document the calibration results. The DA 1 stated she had never documented thermometer calibrations. DA 1 stated since the thermometer calibrations were not documented the…

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

Based on observation, interview, and record review, the facility failed to ensure the Registered Dietitian (RD) provided frequently scheduled consultations to the Dietary Supervisor when a lapse in the delivery of food services associated with diet provision (Cross Reference F800), following of menus (Cross Reference F803), meal temperatures (Cross Reference F804), accommodating resident allergies (Cross reference F806) and food safety (Cross Reference F812 and F925)occurred. This failure to ensure food and nutrition services systems are accurately and effectively delivered have the potential to result in compromising the nutritional status of residents through the potential transmission of foodborne illness, incorrect plating of physician ordered diets, and/or decreased nutritional intake due to residents' poor acceptance of meals. Findings: On 5/15/18 at 10:13 a.m., during an interview regarding consultations with the Dietary Supervisor (DS), the Registered Dietitian (RD) stated, I leave my recommendations for the DS. I get consults (resident consults) and I address them on my…

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

Based on observation, interview and record review, the facility failed to implement their policy regarding food brought by family and visitors when: 1. Residents, family, and visitors were not provided a copy of the facility policy on food brought by Family/Visitors. 2. Staff was not aware that there was a policy and was not trained in safe food handling practices. This failure resulted in the residents, family, and visitors not being aware of the facility's policy and staff not aware of the process of handling resident's food from home safely which had the potential to result in foodborne illness. Findings: 1. On 5/17/18 at 9:26 a.m., during an interview, the Dietary [NAME] (DC) 1 stated food from home does not come to the kitchen. The DC 1 stated it goes to the nursing station. On 5/17/18 at 2:31 p.m., during an observation of the refrigerator in the North station medication room (med room) and concurrent interview, there were 2 yogurt cups labeled 35B, 8 Ensure cartons labeled 44A and 2 Ensure bottles labeled [Resident 11's last name]. Licensed Nurse (LN) 11 stated, We verbally…

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 residents were treated with dignity and respect consistent with enhancing each resident's quality of life for two of 31 sampled residents (Residents 20 and 417) and four random residents (Residents 122, 11, 85 and 53) when: 1. On 5/16/18 staff dressed a cognitively impaired resident, Resident 20, in mismatched colored shoelaces on her shoes against the facility policy to care for vulnerable and cognitively impaired residents with dignity and respect. 2. Staff did not respond in a timely manner to Resident 417's request for assistance to the bathroom and as a consequence urinated in the bed. Resident 417 expressed extreme frustration and felt disrespected because of this occurrence. 3. Staff did not address Resident 122's need for assistance with her breakfast tray and did not remove the plastic wrapping. Resident 122 was physically incapable to remove the plastic wrap, did not eat her breakfast and felt disrespected and helpless. 4. On 5/15/18 staff seated Residents 53, 85 and 11 at the same table in…

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

Based on interview, and record review, the facility failed to make prompt efforts to resolve the residents grievances and to keep the residents informed of progress towards a resolution through the facility designated Grievance Officer for six of 15 random residents(Resident 14, Resident 31, Resident 55, Resident 79, Resident 81 and Resident 86) and two of 31 sampled residents (Resident 29 and Resident 77) when resident Council members complained regarding the facility food, soup was cold, food coming out cold to the social dining room, and hot food not being served hot enough. For Resident 14, Resident 29, Resident 31, Resident 55, Resident 77, Resident 79, Resident 81 and Resident 86, these failures placed the residents at risk of not having their grievances resolved that could of improved the residents' quality of life and services received from the facility. Findings: On 5/16/18 at 10:09 a.m., The Resident Council Meeting was held at the Pinion Vineyard Room in the presence of 8 council members. On 5/16/18 at 10:20 a.m., during an interview, the Resident Council Minutes dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain an orderly environment for four of 52 bedrooms (Rooms 42, 43, 44 and 45) when: 1. room [ROOM NUMBER]'s bedroom trash can was without a liner. 2. Peri Wipes laid on top of the bedside table and the residents bed in Rooms 42, 43, 44 and 45. These failures resulted in a disorderly and un-homelike environment for the residents. Findings: 1. On 5/15/18 at 8:09 a.m., during an observation in room [ROOM NUMBER], a trash can did not have a liner and had trash inside. On 5/15/18 at 8:11 a.m., during a concurrent observation and interview in room [ROOM NUMBER], Certified Nursing Assistant (CNA) 14 stated, There should be a liner in every trash container. On 5/15/18 at 11:32 a.m., during an interview, the Director of Staff Development (DSD) stated, The liners in the trash is housekeeping responsibility. On 5/18/18 at 11:57 a.m., during an interview, the License Nurse Unit Manager stated, when housekeeping leaves, it is the CNA's [Certified…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure four of 31 sampled residents (Resident 29, Resident 89, Resident 42 and Resident 71) and one of 15 random residents (Resident 4) were free from physical restraints when: 1. Resident 29, Resident 89, Resident 42, Resident 71, and Resident 4 had a position change alarm (wheelchair alarm) (alerting devices intended to monitor a resident's movement that emits an audible loud sound when the resident moves) in place without a physician's order, no medical justification, no consent was obtained from the resident or resident's responsible party and no assessment or evaluation was done to determine the need for the wheelchair alarm. These failures resulted in: 1. Resident 29 felt angry when the position change alarm [wheelchair alarm] emitted a loud audible sound every time she moved which restricted her movement. 2. Resident 89 felt irritated when the position change alarm [wheelchair alarm] emitted a loud audible sound every time he moved.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person centered care plan for two of 31 sampled residents (Resident 33 and Resident 89) when: 1. Resident 33 did not have an individualized activities care plan to identify listening to music as his activity preference. 2. Resident 89's wheelchair alarm was not identified in the care plan. These failures placed Resident 33 at risk of inappropriate activities resulting in possible decreased psychosocial well being and Resident 89's care needs to not be met. Findings: 1. Resident 33's face sheet (a document containing resident profile information) indicated Resident 33 was admitted to the facility on [DATE] with diagnoses of major depressive disorder (a mental health disorder characterized by depressed mood or loss of interest in activities), single episode, unspecified and schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), unspecified. On 5/16/18 at 8:20 a.m.,…

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 timely revise and implement a person centered comprehensive care plan for two of 31 sampled residents (Resident 71 and Resident 72) when: 1. Resident 72's enteral nutrition (nutrition provided through a feeding tube into the stomach) care plan interventions indicating the feeding times did not match the physician's order. 2. Resident 71 sustained a fall and no new interventions were documented in the care plan. These failures had the potential to result in Resident 72 to receive inaccurate doses of his enteral nutrition and for Resident 71 to sustain reoccurring falls and at risk for not having her care needs met. Findings: 1. On 5/17/18 at 2:27 p.m., during a concurrent interview and record review, Licensed Nurse (LN) 3 stated the enteral nutrition order for Resident 72 was for Fibersource HN 1.2 at 90 cc (cubic centimeter)/hr (hour) x 20 hours. LN 3 stated the enteral feeding is turned off at 8 a.m. and turned on at 12 p.m. LN 3 stated the timing is on her nursing notes she uses during report. LN 3 stated…

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

Based on observation, interview and record review, the facility failed to provide services which met professional standards of quality when Licensed Nurse (LN) 13 did not follow the facility's Administering Medications policy and procedure, when LN 13 stored the medication inside the medication cart after Resident 77 refused the medications and documented in the medication administration record that Resident 77 took the medications. This failure had the potential to result in medications being administered to the wrong resident and the medications not being administered in a timely manner. Findings: On 5/15/18 at 11:11 a.m., during a concurrent observation, interview and record review at the facility's south medication cart, Licensed Nurse (LN) 1 opened the medication cart and several pills were in a plastic medication cup with resident's name (Resident 77) written. LN 13 stated, It's for the Resident [Resident 77]. She refused her meds [medications] this morning. She usually takes it [medications]. She only took the Zofran [a medication to prevent nausea and vomiting] and Buspar [a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain proper hydration for two of 31 sampled residents (Resident 16 and Resident 29) when: 1. Resident 29 did not have a water pitcher at her bedside table. 2. Resident 16's water pitcher was not within reach. Resident 29 did not have a water pitcher at her bedside table. These failures placed residents at risk of not having sufficient fluid intake to maintain proper hydration and placed Resident 29 and Resident 16 at risk of dehydration. Findings: 1. On 5/16/18 at 8:30 a.m., during a concurrent observation in Resident 29's room and interview, Resident 29 was sitting in a wheelchair facing the window. Resident 29 was eating cheetos chips. Resident 29 stated, I am thirsty. I don't have water until they bring me one. It has always been like that. That means I don't get to drink. I don't even know where my light is. Resident 29's call light lay on top of her stripped bed and Resident 29 was unable to see or reach it from where she sat. On…

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

Based on observation, interview and record review, the facility failed to ensure the menus were followed when the pork loin was cooked for four hours instead of the indicated [NAME] Time of - 1-1 ½ Hrs (hours) and incorrect portion size was served. These failures had the potential for residents to receive inadequate protein and nutrients in their meals. Findings: On 5/16/18 at 12:00 p.m., during an observation in the kitchen of the lunch meal service, a tray of pork loin contained a row of bigger slices and a row of smaller slices of pork loin. On 5/16/18 at 12:08 p.m., during an observation and concurrent interview with the Dietary Supervisor (DS) and the Dietary [NAME] (DC) 1, the DS weighed a piece of pork loin served for 3 oz. meal - weighing 2.5 oz. (ounces). The Dietary [NAME] stated, That is a small portion. The DS weighed another piece of pork loin weighing 2.8 oz. When asked about the Pork Loin weight, DS stated, It is really not 3 oz. DC 1 stated, It shrank in the oven. The Facility document titled, hcsgwest 2018 Diet Guide Sheet indicated . Lunch Day 4 (Week:1 -…

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 that food is palatable and served at an appetizing temperature when residents complained of food being bland and being served cold. This failure had the potential to result in residents not eating their food which could compromise their nutritional status and result in weight loss. Findings: On 5/15/18 at 8:20 a.m., during an observation in Resident 109's room and concurrent interview, Resident 109's plate was still full of breakfast food. Only half of the slice of coffee cake was eaten. Resident 109 stated, The food is very bland. I like food with taste . Everyday is the same thing. On 5/15/18 at 11:36 a.m., during an observation in the kitchen, the Dietary Aide (DA) was warming up 2 plate bases (base to keep plate warm) on a base warmer. At 11:40 a.m. tray line (meal service) started staffed with one Dietary [NAME] (DC) assembling the food on plate and one DA to arrange the food on trays and put them (trays) into the carts. The DC assembled three plates with food and waited for the dietary aide 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 accommodate the food allergies for one of 31 sampled residents (Resident 417) when Resident 417 was allergic to tangerines and was served tangerines on her meal tray. This failure had the potential to result in an allergic reaction and negative outcome to Resident 417. Findings: On 5/16/18 at 12:31 p.m., during an observation in Resident 417's room and concurrent interview, Resident 417's husband stated, My wife is allergic to oranges, orange juice and tangerines . Look at her lunch tray it has a cup of tangerines and I told them she's allergic to them. Resident 417's lunch tray was on the bedside table with a cup of tangerines. There was no allergies noted on the meal ticket. Resident 417's husband stated, I told the dietary manager Monday the 14th, and they are still getting it wrong. The facility document titled, Dietary Profile dated 5/14/18, indicated . E. Food Allergies/Intolerances - nkfa [No known Food Allergy] . K. Likes/ Dislikes - oranges . The facility document titled, Activity Log Report dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to store, prepare and serve food safely when: 1. Half a tray of bread got contaminated by a drain fly. 2. There was a 15 day old opened bag of spinach in the walk-in refrigerator. 3. One (8 pounds) and a half of turkey breast was found submerged in a basin of water. 4. Unlabeled sandwiches were laying on two food prep (preparation) tables. 5. Three frozen boxes of dough had the wrong dates (date received) on them. These failures had the potential to result in unsafe food storage and handling practices that could lead to negative outcomes to the residents. Findings: 1. On 5/15/18 at 12:22 p.m., during an observation in the kitchen, there were four flying insects by the steam table. A flying insect landed and roamed on the tray of bread that was half full and was continuously being served in the tray line (meal service). On 5/16/18 at 9:30 a.m., during an interview regarding the flying insects, the Registered Dietitian (RD) stated it 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 observation, interview and record review, the facility failed to ensure facility infection control practices were followed and implemented when: 1. Licensed Nurse (LN)1 did not perform handwashing after resident direct contact. 2. Certified Nursing Assistant (CNA) 5 did not perform proper hand hygiene before, in between, and after resident care and failed to follow transmission-based precaution when handling a resident with a diagnosis of MRSA (Methicillin-resistant staphylococcus aureus) and after disposal of soiled linens for sampled residents (Resident 16 and 56), and one of 15 random residents (Resident 87). 3. Two of 31 sampled residents (Resident 34 and Resident 45) oxygen tubing was not properly stored after use. 4. Resident 121's oxygen tubing was laying on the floor. 5. CNA 9 did not perform hand hygiene after handling and pushing soiled linen carts and before providing resident care. 6. Restorative Nursing Assistant (RNA) did not perfom hand hygiene for one of 15 random residents (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 observation, interview and record review, the facility failed to ensure call lights were within reach for three of 31 sampled residents (Resident 76, Resident 29 and Resident 420) when: 1. Resident 420's call light lay on the floor and was out of reach. 2. Resident 76's call light lay on top of the bed while resident was sitting on her wheelchair and was out of reach. 3. Resident 29's call light lay on top of the bed while resident was sitting on her wheelchair and was out of reach. These failures resulted in the potential harm of Resident 122, Resident 76 and Resident 29 to not be able to call for assistance by using the call light in the event of need or in an emergency. Findings: 1. On 5/17/18 at 8:10 a.m., during a concurrent observation and interview in Resident 420's room, Resident 420 stated Certified Nursing Assistant (CNA) 5 brought her breakfast tray in her room. The lids of the food dishes were wrapped in plastic and she requested CNA 5 to peel off the plastic wrap because she would not be…

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

Based on observation, interview, and record review, the facility failed to maintain an environment free of pest when drain flies were seen flying in the kitchen and landed on a tray of bread. This failure had the potential to result in foodborne illness to the residents from drain flies contaminating the food. Findings: On 5/15/18 at 7:54 a.m., during an observation in the kitchen, an insect was flying by the metal food preparation table. On 5/15/18 at 8:08 a.m., during an observation in the kitchen and concurrent interview, there were seven flying insects that landed on newly washed bowls. When asked what the insects were, The Dietary Aide (DA) 1 stated did not know what kind of insect. The DA stated, We just sprayed last week, Friday. On 5/15/18 at 12:22 p.m., during an observation in the kitchen, there were four flying insect by the steam table. A flying insect landed and roamed on the tray of bread that was half full and was continuously being served in the tray line during meal service. On 5/16/18 at 9:30 a.m., during an interview regarding the flying insects, the Registered…

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 resident's change of condition (COC), transfer to the hospital and death was immediately informed to the attending physician for 1 of 31 sampled resident (Resident 115). When Resident 115 was seen at 2 a.m. in his wheelchair, unresponsive, no palpable pulse and not breathing. This failure resulted in Resident 115's physician not being fully informed of his resident's medication condition. Findings: Resident 115's clinical record indicated , the resident was admitted to the facility on [DATE] with an admitting diagnosis of Hypoxemia (an abnormally low concentration of oxygen in the blood), Congestive Heart Failure (a heart condition that causes symptoms of shortness of breath, weakness, fatigue, and swelling of the legs, ankles, and feet) . Resident 115's progress notes dated [DATE] at 2:50 a.m., indicated the Resident 115 had no SOB ( Shortness of breath) and verbalized he would take his duoneb (inhalation solution used to prevent bronchospasm…

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, staff interview and record review, the facility failed to ensure the facility did not violate the right of the resident to personal privacy of his physical body and during the provision of his personal care for 1 of 10 random sampled residents (Resident 64) when: 1. Certified Nurse Assistant ( CNA) 5 exposed Resident 64's uncovered body in the hallway after his shower and dressing resident in front of the staff, residents passing by and a visitor watching. For Resident 64 , the facility failed to respect the resident's right to privacy during the provision of care and services which had resulted in the violation of the resident's right to be cared for in a manner and in an environment that honors the resident's privacy. Findings: On 5/15/18 at 9:02 a.m.,during an observation at the facility south hallway, Certified Nurse Assistant ( CNA) 5 wheeled Resident 64's wheelchair in the hallway and into his room with the resident's gown loosely tied up, exposing approximately 6-8 inches of the resident's back. On 5/15/18 at 9:32 a.m., during an interview, CNA 5 stated,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the Minimum Data Set (MDS) (a resident assessment tool used to identify resident care needs) assessment accurately reflected the resident's status for one of 31 sampled residents (Resident 89) when the use of a wheelchair alarm was not coded in Section P (section for alarms and restraint use) of Resident 89's admission and quarterly assessment. This failure resulted in an inaccurate assessment of Resident 89's MDS assessment and had the potential to result in Resident 89's care needs to not be met. Findings: Resident 89's face sheet (a document containing resident profile information) indicated Resident 89 was admitted to the facility on [DATE] with diagnoses of muscle weakness and difficulty in walking. Review of Resident 89's admission MDS assessment dated [DATE], indicated Resident 89's Brief Interview for Mental Status (BIMS) (assessment of cognitive status) score of 15 out of 15, which indicated no cognitive impairment. 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 staff interview and record review, the facility failed to ensure that the resident's Discharge Summary was documented by the attending physician and included in the resident's clinical record after the resident's death for one of 15 sampled residents (Resident 115). The facility failed to provide a recapitulation of Resident 115's stay at the facility and a final summary of Resident 115's status at the time of the discharge in the closed record which had the potential to result in the inavailability of the Discharge Summary information. Findings: Resident 115's clinical record indicated, Resident 115 was admitted to the facility on [DATE] with an admitting diagnosis of Hypoxemia (an abnormally low concentration of oxygen in the blood), Congestive Heart Failure (a heart condition that causes symptoms of shortness of breath, weakness, fatigue, and swelling of the legs, ankles, and feet). Resident 115's progress note dated [DATE] at 2:50 a.m., indicated the resident was then seen at 1 a.m. in his bed 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 observation, interview and record review, the facility failed to provide care and assistance to maintain continency of urine to one of 31 sampled residents (Resident 417) when there was no staff available timely to assist Resident 417 to use the restroom. This failure resulted to Resident 417 urinating in bed two times in one day. Findngs: On 5/15/18 at 11:32 a.m., during an interview, Resident 417 stated, I came in on Friday . and I think it was Sunday night . I kept pushing my buzzer [call light] and no one came to my room . I had to pee in my bed, it is very upsetting . I am an independent person, I got so frustrated I wanted to scream. Resident 417's husband stated, I came in Monday the 14th and she told me she had to pee in bed because no one can answer the call light to take her to the bathroom and it all happened in the same night . On 5/17/18 at 8:10 a.m., during an interview regarding Resident 417, Licensed Nurse (LN) 6 stated Resident 417 was continent of urine and used the bedpan with assistance. On 5/17/18 at 8:18 a.m., during an interview regarding 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 facility staff supported the nutritional well-being for one of 31 sampled residents (Resident 417) when the admitting staff did not fill out and submit a Diet Requisition (meal ticket) for Resident 417. This failure resulted in (Resident 417) not receiving meal trays for five (5) meals which had the potential to compromise her nutritional status and result in weight loss. Findings: On 5/14/17 at 11:32 a.m., during an interview, Resident 417 stated, When I came in on Friday afternoon, I was served no dinner and my husband had to go to the nurses' station and request one. Saturday morning - no breakfast, Saturday - no lunch, Saturday night - yes, received dinner. Sunday morning - no breakfast, Sunday - no lunch, Sunday night - yes, received dinner. Resident 417's husband stated, We met with Food Services and told them about what had happened over the weekend. On 5/16/18 at 8:57 a.m., during an interview, the Registered Dietitian (RD) stated when…

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 accurately document the physician order for life-sustaining treatment (POLST, a medical order for the specific medical treatments for a resident during a medical emergency form) in the medical records for one of 31 sampled residents (Resident 56). This failure had the potential risk for Resident 56's life-sustaining orders not being followed. Findings: On [DATE] at 4:02 p.m., during an interview and concurrent record review with Licensed Nurse (LN) 6. Resident 56's POLST, dated [DATE], indicated Do Not Resuscitate (DNR) status. LN 6 stated the doctor signed the form on [DATE]. LN 6 stated there is a binder with the POLST forms at the nurses' station. LN 6 stated the binder was labeled Master POLST binder. The original POLST form was observed in the binder. LN 6 stated there was an MD (medical doctor) order for the code status. LN 6 located the physician's order in the computer. The physician order indicated a full code status. She stated she was unsure…

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.