Carmel Hills Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure food was served at an appetizing temperature when 11 out of 92 residents (Resident 34, 68, 9, 54, 123, 36, 59, 16, 85, 46, 74) complained hot food was served cold to them. This failure had the potential to affect the amount of food residents consume, which could decrease their food intake and lead to poor nutrition and health outcomes.Findings: During an initial room rounds and interview with Resident 34 on 4/13/2026 at 10:43 a.m., Resident 34 stated hot foods always served cold for all three meals. During an initial room rounds and interview with Resident 68 on 4/13/2026 at 11:19 a.m., Resident 68 stated hot foods always served cold, not even warm to eat. Resident 68 also stated likes to drink hot coffee, facility serving coffee not hot. During room rounds and interview with Resident 9 on 4/13/2026 at 1:55 p.m., Resident 9 stated hot foods always served cold. During room visit and interview with Resident 54 on 4/13/2026 at 2:23…

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 interview and record review, the facility failed to ensure an informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) was obtained prior to the administration of a psychotropic medication (drug that affect brain activities associated with mental processes and behavior) for 1 out of 7 residents (Resident 4). The failure had the potential for the resident/resident representative not being informed in advance of the risks and benefits of the medication, the treatment alternatives, or other options before making the decision for treatment.A review of Resident 4's clinical record indicated she was admitted to the facility with diagnoses including dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and anxiety disorder.Review of Resident 4's physician orders indicated an order, dated 3/17/26, for lorazepam (medication for agitation and anxiety) 0.5 milligram, give 1 tablet by mouth every 1 hour as-needed for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure an even floor surface in facility's hallways. This failure presented a potential tripping hazard for residents who were using these hallways. Findings:During an observation on 4/13/2026 at 12:55 p.m., there was an uneven floor surface where carpeted flooring transitioned to wooden flooring in a hallway near Resident's room [ROOM NUMBER] (RR 1). Further observation indicated residents were passing by often, using walkers (a mobility aid designed with four legs with wheels and light weight to provide support while walking), wheel chairs (W/C, a mobility device designed for residents with mobility impairments to move around, propelled manually by user or by staff or powered electrically), and walking without a mobility device.During an observation on 4/14/2026 at 1:30 p.m., there was an uneven floor surface with missing and broken tile pieces in hallway near RR 2. This area was frequently used by residents that used walkers, W/C, and walked…

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 fluid restrictions were followed for one of five sampled residents (Resident 3) and failed to initiate a care plan (an individualized, collaborative document that focuses on a resident specific needs, goals, preferences and values) for restricted fluids for one of three sampled resident (Resident 54). These failures had the potential to negatively affect Resident 3 and Resident 54's fluid balance.Findings:During a concurrent observation of Resident 3's room and interview with Resident 3 on 4/13/2026 at 11:35 a.m., a plastic re-usable cup with built-in straw was full of water atop a tray table next to Resident 3's bed and within reach of Resident 3. A posted fluid restriction with breakdown between dietary and nursing for total of 1800 ml ((milliliters, unit of volume equal to one thousandth of a liter) was on a wall within this room. Resident 3 stated nursing staff replaced water in the cup for him to drink throughout 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 document review, the facility failed to conduct the Certified Nursing Assistant's (CNA) Annual Performance Evaluation (a formal, documented review of an employee's work over the past year, assessing their performance against established goals and expectations) for one (CNA M) of three sampled employees.This failure did not ensure CNA M had the necessary knowledge to provide safe resident care.Findings:Review of the facility's randomly selected three employee files indicated, CNA M was hired at the facility on 7/9/2013. There was no current annual performance evaluation found in CNA M's file.During an interview with the director of staff development (DSD) on 4/17/2026 at 10:22 a.m., DSD stated according to the business office records, CNA M had her last annual performance evaluation on 8/27/2023. DSD further stated they could not find the hard copy of the evaluation and the only reason they knew the date of her last evaluation was CNA M got a raise on that date. DSD confirmed all employees would get a raise every time they had their annual performance…

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 6.06% when 2 medication errors occurred out of 33 opportunities during the medication administration for 2 out of 7 residents (Residents 18 and 61). For Resident 61, metformin (medication to manage diabetes) was not administered with a meal as per manufacturer's specifications. Resident 18's olanzapine (an antipsychotic medication) ODT (oral disintegrating tablet - a solid dosage form that dissolves rapidly on the tongue) was crushed, a practice contrary to the accepted standards of practice.The deficient practice had the potential for adverse effects (such as stomach irritation) and ineffective use of medications for the residents.1. During the medication administration observation on 4/13/26 at 4:42 p.m., Licensed Vocational Nurse (LVN) C was observed preparing 2 medications for Resident 61 including a tablet of metformin 500 milligrams (mg, unit of measurement). On 4/13/26 at 4:43 p.m., LVN C brought the 2 medications with a small cup, about 3-4 ounces, of applesauce into Resident 61's…

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

Based on observation, interview, and record review, the facility failed to ensure 3 inhalers and 3 insulin pens (pre-filled pen containing insulin - medication to lower blood sugar) were given the expiration date in accordance with the manufacturer's specifications, and an expired and discontinued insulin pen was removed, in 1 out of 2 inspected medication carts. The failure had the potential for medication errors or residents being administered expired medications or given beyond the effective period.During an inspection of the Station 2 Pebble Beach Medication Cart with Licensed Vocational Nurse (LVN) A and LVN B on 4/13/26 at 2:40 p.m., the following was identified and verified with both staff:a. The Incruse Ellipta inhaler (medication to treat chronic breathing problems) for Resident 24 was labeled with open date of 3/26/26 and the expiration date of 5/26/26 (2 months from open date). A review of the manufacturer's instructions on the inhaler box indicated, Discard the inhaler 6 weeks after opening the moisture-protective foil tray or when the counter reads '0' (after all…

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 follow standard infection control practices when the following were observed:1. Undated nasal cannula (NC, light weight, flexible, medical device tube used to deliver oxygen [O2, a colorless, odorless and tasteless gas that is essential for life on earth, supplements for residents with breathing problem] for residents) for Resident 31,1, 44, 3, and 84;2. Undated nebulizer face mask (a medical device that fits over the nose and mouth to deliver liquid medication directly into the lungs [pair of organs, responsible to take O2 from air and transfer to blood] as a fine mist) for Resident 25 when not in use;3. Uncovered C-Pap (continuous positive airway pressure by delivering a steady, gentle stream of pressurized air through a mask to keep airway [the anatomical pathway from air to travel from nose and mouth to the lungs] open during sleep) face mask (designed to fit different breathing styles and sleeping positions) for Resident 34 and 118…

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 a safe and functional environment for kitchen staff when there was broken and buckled concrete flooring and condensed ice accumulation on the ceiling and on the floor in the walk-in freezer of the kitchen. These failures had the potential to create an unsafe environment for 23 staff in the kitchen.Findings:During a concurrent observation and interview on 4/13/2026 at 11:15 a.m. with the Head [NAME] (HC) in the walk-in freezer in the kitchen, the concrete floor was observed to be buckled and broken with multiple lines. The HC stated the floor had been in this condition for about three years, and the facility had a plan to fix it. In addition, some condensed ice accumulations were observed to be on the floor and on the ceiling. The HC stated it was slippery and not safe for the staff.During an interview on 4/14/2026 at 2:44 p.m. with the administrator (ADM), the ADM was aware of the damaged floor in the walk-in freezer in the kitchen. He stated it was found during the last recertification survey 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility policy review, the facility failed to ensure food was thawed per the facility policy, there was not a crack in the kitchen floor, utensils were stored per the facility policy, the food drains were cleaned daily, there was not a build-up around the ice machine dispenser, and expired food items were discarded after their expiration date. These deficient practices had the potential to affect all residents who received food from the kitchen. Findings included: A facility policy titled, Handling Clean Equipment and Utensils, with a copyright date of 2017, revealed 4. Stored utensils should be covered or inverted whenever possible. A facility policy titled, General Food Preparation and Handling, with a copyright date of 2017, revealed, 3. Food Preparation a. Meats, fish and poultry will be defrosted using safe thawing practices: In the refrigerator in a drip proof container, and in a manner that prevents cross contamination. In the microwave if foods are cooked and served…

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, document review, and facility policy review, the facility failed to develop a water management program that specified a detailed description and diagram of the water system in the facility. This deficient practice had the potential to affect all 91 residents who currently reside in the facility. Findings included: A facility policy titled, Legionella Water Management Program, revised 07/2017, revealed 3. The purposes of the water management program are to identify areas in the water system where Legionella bacteria could grow and spread, and to reduce the risk of Legionnaires' disease. The policy specified, 5. The water management program includes the following elements: a. An interdisciplinary water management team; b. A detailed description and diagram of the water system in the facility, including the following: (1) Receiving; (2) Cold water distribution; (3) Heating; (4) Hot water distribution; and (5) Waste. c. The identification of areas in the water system that could encourage the growth and spread of Legionella or other waterborne bacteria, including: (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 facility policy review, the facility failed to ensure licensed staff locked 1 of 4 medication carts when the cart was not within the sight of the nurse during medication administration. Findings included: A facility policy titled, Administering Medications, revised 04/2019, revealed, 19. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. During medication administration observation on 12/17/2024 at 8:24 AM, a medication cart was found unlocked, and Licensed Vocational Nurse (LVN) #1 was in a resident room, behind a privacy curtain and the medication cart was out of her line of sight. Three minutes later, LVN #1 returned to the medication cart. At 8:38 AM, 8:42 AM, and 8:56 AM, LVN #1 left the medication unlocked and out of her sight when she administered medication to Residents #9, #10, and #61. During an interview on 12/17/2024 at 9:13 AM, LVN #1 stated she should have locked the medication cart when she walked away from the medication cart. LVN #1 acknowledged…

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 facility document review, the facility failed to ensure the Registered Dietitian comprehensively carried out the functions and evaluated the effectiveness of Food and Nutrition Services as evidenced by: Lapses in the delivery of services associated with: staff competency (cross-reference F802), following the menu (cross-reference F803), providing physician prescribed diet orders (cross-reference 808), food safety and sanitation (cross-reference F812), providing physician prescribed nutrition supplements (cross-reference F692), physical environment of the kitchen (cross-reference 908). Failure to ensure dietetic services systems are accurately and effectively delivered may result in compromising the nutritional status of the residents by not assessing their nutritional needs, the potential transmission of foodborne illness, and/or a decreased nutritional intake due to not receiving the correct foods. Findings: During the annual recertification survey conducted from 3/21/22 to 3/28/22 there were multiple issues identified with respect to 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 observation, interview, and facility document record review, the facility failed to ensure staff competency when: 1. The staff members were unable to properly test the dish machine's sanitizer and were not routinely testing the concentration of the dish machine's sanitizer and wash and rinse temperature. 2. Two of three staff members were unable to test the red bucket's sanitizer correctly and two red buckets' sanitizer concentration was not consistently tested for the month of March. 3. The FSW M did not follow the pureed preparation for vegetables. 4. The FSW M did not follow the recipes for the honey glazed pork and the fresh baked sweet potatoes served for lunch on 3/21/22. These failures had the potential to result in compromising the health and safety of the 71 residents in the facility. Finding: 1. During a concurrent observation and interview with food service worker O (FSW O) on 3/22/22 at 9:30 a.m., inside the dish room, FSW O was unable to verbalize the process on how to check if the dish…

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 facility document review, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food safety when: 1. An ice machine was not kept in a sanitary condition; 2. Thawed meat was kept in the refrigerator for an extended period of time; 3. A red bucket with sanitizer was left on a food production surface; 4. A food contact surface sanitizer had inconsistent strength; 5. A protein based nutritional supplement was held above 41 degrees Fahrenheit (F, a temperature scale) for an extended period of time; 6. Food containers were stacked wet; 7. Kitchen floors had some black build up to corners of each storage area leading to the back door; 8. Spills of rice were found at the cart beside the rice container; 9. The lid of a flour container had a crack; 10. Storage rack had some brownish and blackish build up; and 11. Personal belongings were found hanging inside the dry storage area. These failures had the potential…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement infection control measures when: 1. The facility's screening process for Coronavirus disease (COVID-19, a disease caused by a contagious virus) was not in accordance with Centers for Disease Control and Prevention (CDC) guidelines; 2. The receptionist did not follow the facility's Screening Checklist when screening a visitor for COVID-19; 3. One dietary staff member was not screened for COVID-19 prior to entering the facility; 4. There were no receptacles (containers) inside the residents' rooms to dispose of used gowns in the yellow zone (area designated for resident with known or possible exposure to COVID-19); 5. One CNA did not use and dispose of personal protective equipment (PPE, mask, gown, gloves, eye protection) appropriately when providing care to Resident 3; 6. A receptacle designated for soiled adult diapers was left uncovered in the hallway; 7. The infection preventionist (IP) did not change her gown when performing…

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

Based on interview and record review, the facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN, a notice that transfers potential financial liability) to two of three residents (Residents 27 and 60). This failure had the potential to compromise the residents' right to appeal (apply for reversal of) the facility's decision to discontinue Medicare Part A services (skilled treatments paid for by Medicare). This failure also had the potential to result in the residents or residents' representatives not being informed of their payment responsibilities to the facility after Medicare Part A services ended. Findings: Review of Resident 27's medical record indicated she was admitted to the facility under Medicare Part A on 6/30/2021. The medical record further indicated Resident 27 came off Medicare Part A on 7/8/2021 and continued living in the facility. Review of Resident 27's SNF Beneficiary Protection Notification Review, filled out by the facility on 3/24/2022, indicated the facility initiated Resident 27's discharge from Medicare…

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 perform re-evaluation restraint assessments in a timely manner for three of five residents (Residents 62, 63, and 27), when restraint assessments were not performed on at least a quarterly basis. This failure had the potential of residents being physically restrained when not medically indicated. Findings: 1. During an observation on 3/21/22 at 12:37 p.m. in Resident 62's room, Resident 62 was observed sitting in her wheelchair with a seatbelt around her waist. During a review of Resident 62's electronic records, no quarterly restraint assessments were found. Resident 62 had cognitive impairment. During an interview on 3/25/22 at 9:54 a.m., with the director of nursing (DON), DON stated she did not see any quarterly restraint assessments for Resident 62. 2. During an observation on 3/21/22 at 12:08 p.m., Resident 63 was wheeling herself in the hallway seated in a wheelchair with a seatbelt around her waist. During a review of Resident…

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

Based on observation, interview and record review, the facility failed to ensure licensed nurses (incoming shift nurse and outgoing shift nurse) consistently signed off the Correct Count Verification sheet/form for controlled medications that indicated they acknowledged accuracy and accountability of controlled drugs for two of four medication carts. This failure had the potential for inaccurate recording and accounting of controlled medications. Findings: During an inspection of Nursing Station 1's Carmel and Monterey medication carts on 3/21/22 at 3:40 p.m., with licensed vocational nurse A (LVN A), LVN A confirmed there were multiple missing signatures found in the Correct Count Verification sheet for February and March 2022 for both carts. During the concurrent interview with LVN A, she stated both nurses who were coming in for the shift and going off shift should sign the form every shift. During an interview with the pharmacy consultant (PC) on 03/24/22 at 9:50 a.m., the PC concurred two nurses (incoming and outgoing shift nurses) should have signed the correct count sheet…

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 store medications in four of four medication carts and in one of two medication refrigerators when: 1. Multi-dose vials and liquid medications were not dated when opened and discarded when expired (beyond due date). 2. Expired medications were not disposed accordingly. 3. Multiple eyedrops/ointment opened and not dated, expired eyedrops not discarded and disposed. 4. Internal medications (oral medications) were mixed with external medications. These failures had the potential for administration of wrong and expired medications which could placed residents at risk for adverse drug reactions and possible complications. Findings: During an inspection of Station 2 medication refrigerator on 3/21/222 at 9:50 a.m., with licensed vocational nurse D (LVN D), there was a multidose tuberculin vial opened not dated. LVN D stated the vial should have been dated when opened. During an inspection of Station 1 Monterey medication cart on 3/21/22 at 3:40 p.m., with licensed vocational nurse A (LVN A), there were two…

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 facility document review, the facility failed to ensure the planned menu was followed and the nutrient needs were met when: 1. Milk was not served according to the menu for a random sample of 16 residents (Residents 61, 274, 275, 54, 19, 3, 53, 27, 276, 9, 10, 7, 42, 51, 22, 2); 2. Fourteen of 14 residents (Residents 22, 10, 17, 5, 61, 64, 38, 73, 40, 48, 25, 54, 34, 41) on CCHO regular texture diet (carbohydrate controlled diets, diets designed for people with diabetes that evenly spread carbohydrates throughout the meals) when they were served the wrong portion size for sweet potatoes; 3. Seven of seven residents (Residents 33, 45, 29, 27, 71, 63, 15) on puree diets (texture modified diets for people with chewing or swallowing difficulties) when they were served the wrong portion size for pork chop and zucchini, 4. Two residents (Residents 72 and 18) with a preference for no meat did not receive a good source of protein for lunch. These failures had the potential to result in not meeting the nutritional needs thus further compromising 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, staff interview, and facility document review, the facility failed to assure residents consistently received a fortified diet as prescribed by a physician when two out of 33 residents on a fortified diet did not receive any fortified foods, and six out of 33 residents on fortified diets received minimal extra calories at one meal. These failures had the potential to result in not meeting the nutritional needs and further compromising the nutritional status of the 33 residents on fortified diets. Findings: Review of facility document titled Fortified Diet from the facility's diet manual, dated 2012, indicated The fortified diet is designed for residents who cannot consume adequate amounts of calories and/or protein to maintain their weight or nutritional status. It further indicated The amount of calorie and protein increase will vary depending on the facilities current Fortification of Food policy and the individual residents needs and preferences. No other fortified diet policy was provided when requested. During an interview on 3/21/22 at 12:05 p.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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Track, offer and administer pneumococcal vaccines (vaccines intended to prevent lung infection) according to Centers for Disease Control and Prevention (CDC) guidelines for three of five sampled residents (Residents 20, 26 and 27); and 2. Perform screening prior to administering the influenza (respiratory infection) vaccine for one of five sampled residents (Resident 43). These failures had the potential to negatively affect the residents' health and well-being. Findings: 1. Review of the CDC's guidance titled Vaccines and Preventable Diseases (https://www.cdc.gov/vaccines/vpd/pneumo/hcp/who-when-to-vaccinate.html), last reviewed 1/24/2022, indicated there are two types of pneumococcal vaccines available in the United States; pneumococcal conjugate vaccines (PCV13, PCV15, and PCV20) and pneumococcal polysaccharide vaccine (PPSV23). For adults ages 19 to 64 who have risk factors, such as chronic renal failure (a kidney disease), the guidance…

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 ensure the kitchen's physical environment was free from accident hazards and equipment was in good working condition when: 1. The magnetic mesh screen at the kitchen's back door was not fully closed, the kitchen floor had a tear, and the floor coving was completely detached from the bottom part of the wall; 2. The floor drains were not emptied and cleaned; and, 3. Residents' food trays were broken exposing the metal parts at the edge. These failures had the potential to affect the health and safety of staff and 71 residents at the facility by possible exposure to disease carrying pests, hazards and injuries. Findings: 1a. During an observation on 3/21/22 at 11:31 a.m., the magnetic mesh screen located at the back of the kitchen was halfway opened. During an observation on 3/22/22 at 11:25 a.m., the magnetic mesh screen had some holes, and the bottom part was not sealed. According to Food and Drug Administration [FDA]-Food Code 2017 Section 6-202.15, it is the standard of practice to ensure the outer opening of a food…

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 interdisciplinary team (IDT, facility staff members from different departments including nursing who coordinate care provided to residents) assessed whether it was safe for one of 19 sampled residents (Resident 36) to keep her medications at the bedside and had a physician's order to administer the medication. These failures had the potential for incorrect self-medication administration and wrong medication. Findings: During the initial tour on 3/21/22 at 10:39 a.m., there was a Bengay cream (a topical cream used to treat minor aches and pains of the muscles/jointspain cream) found on top of Resident 36's tray table. During a concurrent interview with Resident 36 she stated, I have been using that for my right shoulder pain. During the record review with licensed vocational nurse C (LVN C) on 3/21/22 at 10:43 a.m., she could not find physician's order for the Bengay medication, and no documented evidence that a self-administration assessment and care plan was completed. During a concurrent interview…

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

Based on observation, interview and record review, the facility failed to provide physician ordered nutrition supplements (products that are used to complement a resident's dietary needs, a high calorie drink in this case) to one resident (Resident 71) with a history of weight loss and pressure injury. This failure had the potential to cause further weight loss and decline in health status. Findings: A review of Resident 71's clinical record, indicated Resident 71 was admitted with diagnoses including cerebral infarction (a stroke caused by narrowing of the blood vessel in the brain), and right sided weakness caused by the stroke, dysphagia (difficulty swallowing caused by stroke), and Alzheimer's disease, unspecified (a progressive disease that destroys memory and other important mental functions). A review of Resident 71's Admission's Minimum Data Set (MDS, an overall assessment of resident's status) assessment, dated 7/12/21, indicated the Brief Interview for Mental Status (BIMS) score was 99 (with severe cognitive impact), requiring extensive assistance with eating and weight…

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 a licensed nurse and student nursing assistant (SNA) had the specific competencies necessary to care for two of 19 sampled residents (Residents 11 and 60) when licensed vocational nurse A (LVN A) did not correctly demonstrate the proper use of insulin syringe, and when SNA turned off Resident 60's oxygen without informing the charge nurse. These failures had the potential for Resident 11 and 60 to not attain or maintain their highest practicable physical, mental, and psychosocial well-being. Findings: 1. During an observation on 3/22/22 at 12:08 p.m., Resident 60 was up in her wheelchair with her oxygen on via nasal cannula. She was heard requesting SNA to turn off her oxygen. The SNA turned if off herself without informing her charge nurse. During the concurrent interview with the DSD and licensed vocational nurse A (LVN A), charge nurse and infection preventionist (IP), the DSD stated SNA was doing her clinical hours in the facility as a student nursing assistant and should not have turned off 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 follow its antibiotic stewardship program (program intended to prevent the overuse of antibiotics) when antibiotics were prescribed for one of one sampled residents (Resident 8) without the use of the protocols outlining clinical symptoms to confirm the presence of an infection. This failure had the potential to increase the prevalence of multi-drug resistant organisms in the facility. Findings: Review of Resident 8's medical record indicated she was admitted on [DATE] and did not have an indwelling catheter (flexible tube inserted and left in the bladder to drain urine). Review of Resident 8's medication administration record (MAR) indicated she received the following antibiotics: 1. Ceftriaxone 1 gram (gm, unit of dose measurement) intramuscularly (IM, injected into a muscle) for urinary tract infection (UTI) from 6/23/2021 to 6/25/2021; and 2. Augmentin 500-125 milligrams (mg, unit of dose measurement) by mouth every 12 hours for UTI from 12/26/2021…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement policies and procedures that were in accordance with the Centers for Disease Control and Prevention (CDC) recommendations when it allowed medical exemptions and deferments from Coronavirus disease (COVID-19, a disease caused by a contagious virus) vaccinations for two of two staff members who were pregnant. Both staff members worked in the facility under this exemption. As a result, the facility's staff vaccination rate was 98.2% on [DATE]. In addition, the facility failed to ensure staff who were not fully vaccinated adhered to appropriate precautions to mitigate risk for COVID-19 spread. These failures increased the risk for COVID-19 exposure and infection to residents and staff. Findings: Review of the facility's Appendix B, Physician's Verification of Request for Medical Exemption or Pregnancy Deferral from COVID-19 Vaccination, dated [DATE], indicated staff member R (SM R) requested a pregnancy deferral from COVID-19…

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.