Monterey Post Acute

Based on observation, interview, and record review, the facility failed to ensure the controlled medications (drugs with high potential for abuse or addiction) were fully accounted for on the medication administration record (MAR) to indicate they were given for three out of six residents (Residents 4, 58, and 67) for these medications that were signed out of the Control Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications). This failure had the potential for access to medications and supplies by unauthorized persons such as residents and visitors. Findings: 1. The Controlled Drug Records (CDRs) for six (6) random residents receiving PRN (meaning as needed) controlled medications were requested for review during the survey. a. A review of Resident 4's MAR indicated to give Hydromorphone (used to treat moderate to severe pain) Oral tablet 2 MG (milligram, unit of dose of measurement) by mouth every 8 hours as needed for pain with start date of 1/29/25. During a concurrent interview and record review with the ADON on 2/13/25 at 8:42 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to monitor for side effects and target behaviors (behaviors intended to be changed or eliminated by medications) for one of five residents (Resident 69) who received psychotropic medications (medications that cause changes in mood, feelings or behavior). This failure had the potential to compromise the facility's ability to determine if the psychotropic medications were effective. This failure also put Resident 69 at risk for experiencing harmful effects from the medications. Findings: Review of Resident 69's clinical record indicated she was admitted to the facility on [DATE] with diagnoses that included Dementia (a decline in mental capacity affecting daily function) with behavior disturbance, Alzheimer's disease (a progressive mental deterioration due to generalized degeneration of the brain) and Schizophrenia (disorder that affects a person's ability to think, feel, and behave clearly). Review of Resident 69's medical record indicated she had a…

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

Based on observation, interview, and record review, the facility had a medication error rate of 11.9% when five medication errors occurred out of 42 opportunities during the medication administration observation for three of six residents (Residents 7, 63, and 75) when: 1. Resident 7 did not receive three medications, Amlodipine Besylate tablet, Acidophilus Xtra Oral Tablet, and Methenamine Hippurate Oral tablet as prescribed; 2. Resident 63 did not receive the medication Ferrous Gluconate as scheduled; 3. Resident 75 did not receive the medication ferrous sulfate as scheduled.; and 4. The nursing staff did not flush the resident's gastrostomy tube (G-tube; a tube surgically inserted through the abdomen into the stomach to administer nutrition and medications) as ordered by the physician during medication administration for Resident 67. The failures had the potential for the residents not receiving the full therapeutic effect of medications, and compromising the health of residents. Findings: 1. During a medication administration observation on 2/10/25 at 10: 47a.m., Licensed…

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 proper labeling and storage of medications according to the facility's policy and procedures (P&P) and/or manufacturer's specifications when: 1. One insulin vial with no vial flip -off cap (type of closure used for packing and sealing pharmaceutical products) was found with no open date in the medication refrigerator; 2. One insulin pen expired in the medication cart; 3. Medications were not properly labeled and stored in two of three inspected medication carts; a. Seven insulin pens had no open dates; b. Five Artificial Tears eye drop were unlabeled; c. One bottle of Brimonidine 0.2% Eye drops had no open date; d. One Albuterol Sulfate HFA Inhalation Aerosol had no label and identifier; 4. No temperature monitoring for two days in [DATE] for the medication refrigerator; 5. Medication Cart C was left unlocked; 6. One open bottle of mucus relief DM tablet had no open date in the medication storage room. These deficient practices had…

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 follow their infection prevention and control policy and procedures when an uncovered nebulizer (a machine that turns liquid medicine into mist that is inhaled into the lungs) mouthpiece was found on Resident 30's bedside table. This failure had the potential for the resident to acquire an infection. Findings: During an observation on 2/9/25 at 9:34 a.m., an exposed nebulizer mouthpiece was found on Resident 30's bedside table. During a concurrent observation and interview with Licensed Vocational Nurse (LVN) D on 2/9/25 at 9: 41 a.m., LVN D confirmed the mouthpiece was exposed. LVN D stated it should be cleaned, washed, dried, and then placed inside the plastic bag because of infection control. During an interview with Infection Preventionist on 2/12/25 at 4:22 p.m., IP stated the nebulizer mouthpiece should be placed in a plastic bag and not left exposed. A review of the facility's policy and procedure (P&P) titled, Infection Prevention and Control Program, dated 09/18/2023, the P&P indicated An infection…

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' environment was maintained safe and sanitary when Resident 17's bedside table was damaged. This failure had the potential for injury, decreased self-esteem and the potential to affect Resident 17's psychosocial well-being. Findings: Review of Resident 17's clinical record indicated he was admitted to the facility on [DATE] with diagnoses that included Parkinsonism (a group of symptoms that affect movement, including slowness, stiffness, and shakiness), contracture left hand (shortening and hardening of muscles, tendons, and other tissue, often leading to deformity and rigidity of joints), epilepsy (nerve cell activity is disturbed in the brain causing seizures), major depressive disorder (mental health condition showing persistent low mood and loss of interest that significantly interfere with daily life), hemiplegia and hemiparesis of left side (partial or total paralysis), anxiety disorder (feeling of worry, anxiety or…

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

Based on observation, interview, and record review, the facility failed to ensure food was palatable when brown rice was served undercooked for 18 Residents. This failure had the potential to harm the digestive tract (pathway for food to travel to the body) of residents and cause further health issues. Findings: During an interview with Resident 1 on 10/4/24 at 11:05 a.m., Resident 1 stated I don ' t like the food here. It ' s horrible. A lunch test tray conducted on 10/4/24 at 12:42 p.m. with Certified Dietary Manager (CDM). A regular diet tray was tested for temperature and palatability. The test tray plate included fish, brown rice, and beans. CDM agreed the brown rice was undercooked, and the texture was rough. CDM stated she usually tasted food prior to serving but today, she did not. During a concurrent observation and interview with Resident 2 on 10/4/24 at 12:53 p.m., Resident 2 was sitting on the bed with her lunch tray on the bedside table. Resident 2 ' s lunch tray consisted of string beans, brown rice and chicken with white sauce on top. Resident 2 stated the chicken was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide care and services in accordance with professional standards of practice for one of four sampled residents (Resident 1) when: 1. There were multiple days for which there was no documentation of treatment to Resident 1's right heel wound; and 2. There were multiple Weekly Summary Documentations (resident assessments done on a weekly basis) that were not accurately completed. Failure to provide treatments had the potential to result in worsening of Resident 1's right heel wound. Failure to accurately assess had the potential to compromise the facility's ability to plan care and provide interventions. Findings: 1. Review of Resident 1's medical record indicated he was admitted on [DATE] and had diagnoses including diabetes (disorder characterized by difficulty in blood sugar control and poor wound healing). Review of Resident 1's Change in Condition Evaluation, dated 5/7/24, indicated he had a deep tissue injury (DTI, pressure-related injury 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 interview and record review, the facility failed to ensure one of four sampled residents (Resident 2) received a medication as ordered. This failure had the potential to compromise the resident's health and well-being. Findings: Review of Resident 2's medical record indicated she was admitted on [DATE] and had diagnoses including dislocation of the left hip and fractures of the neck, forearm, spine, pelvis, and tibia (large bone in the lower leg). Review of Resident 2's Order Summary Report indicated she had a physician's order, dated 12/7/23, for Enoxaparin Sodium Injection Solution Prefilled Syringe (medication used to prevent blood clots) 40 milligrams per 0.4 milliliters (mg/ml, unit of dose measurement) inject 1 syringe subcutaneously (beneath the skin) every 12 hours to prevent deep vein thrombosis (DVT, a blood clot in a deep vein, usually in the legs). Review of Resident 2's medication administration record (MAR), dated 12/2023 and 1/2024, indicated she was scheduled to receive the above…

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 safety of one of two residents (Resident 1) when the Certified Nursing Assistant A (CNA A) did not provide appropriate physical assistance/support in accordance with Resident 1's needs and did not make sure the shower chair was close enough to Resident 1 during transfer from bed to shower chair. This failure put Resident 1's safety at risk. Findings: Review of Resident 1's medical record indicated diagnoses that included hemiplegia (paralysis of one side of the body) and hemiparesis (weakness of one side of the body), abnormal gait and mobility, and muscle weakness. Review of Resident 1's Fall Risk Assessment (FRA, an assessment to determine the likelihood of falling) dated 9/26/23 indicated he was unable to independently come to a standing position and had a score of 20 (a score of 20 means high risk for fall). Review of Resident 1's Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 6/20/24 indicated he had impairment on one side of upper and lower extremities. He needed…

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

Based on interview and record review the facility failed to ensure a physician's decision to administer an antibiotic eye drop was ordered and carried out for one of two sampled residents (Resident 1). This failure had the potential to cause health complications to Resident 1. Findings: Review of Resident 1's Physician A's progress notes, dated 7/21/24 at 12 noon, indicated the patient complains of right upper lid swelling, and in the morning he has discharge. Impressions/plans: Right eye Blepharitis (inflammation, scaling, reddening and crusting of the eyelid). Order Cipro Opthalmic Gtt (drops). Review of Resident 1's record lacked documentation indicating the antibiotic was ordered and given. During an interview on 8/14/24 at 3:55 p.m., Physician A stated Resident 1's eye lid was inflamed and because the resident reported eye discharge he would have ordered an antibiotic. During an intervew on 8/14/24 at 4:25 p.m., the assistant director of nurses (ADON) who reviewed the record stated she did not find a physician's order for the eye antibiotic. Based on interview and record review…

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 one allegation of abuse was reported to the California Department of Public Health (CDPH) within 24 hours for one sampled resident (Resident 1) when Resident 1 filed a grievance of an allegation of abuse on 1/27/24 but the facility did not report to CDPH until 2/2/24. This failure resulted in the delay of the abuse allegation investigation and had the potential to result in further abuse. Review of Resident 1's Face Sheet (document that contains a summary of personal and demographic information), indicated Resident 1 was admitted to the facility on [DATE] with a primary diagnosis of fracture (break in bone) of neck, unspecified, subsequent encounter. Face Sheet further indicated Resident 1 was self-responsible. Review of Resident 1's Discharge Summary from an acute care hospital, dated 1/26/24, indicated Resident 1 suffered a head on collision in a motor vehicle accident (MVA), she had chronic pain and required high doses of opiates (a substance…

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 appropriate social services support following an abuse allegation for one of one resident (Resident 1). This failure had the potential to place Resident 1 at risk for psychosocial distress. Findings: An employee-to-resident abuse allegation investigation was conducted on 11/15/23. A record review of Resident 1's medical record, indicated there was no documented evidence indicating a social services assessment focused on Resident 1's psychosocial well-being was done after the abuse allegation. During an interview on 5/3/24 at 2:19 p.m. with the Director of Nursing (DON), the DON stated there should be 72 hours nursing monitoring every shift after an incident, and social services psychosocial follow up for 72 hours after the abuse allegation. The DON was not able to find any social services follow up notes for the incident. During a review of the facility's job description titled Social Services Director updated 10/2021, the job description indicated, DUTIES AND RESPONSIBILITIES 6. Assess residents upon admission,…

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

Based on observation, interview, and record review, the facility failed to: 1. Ensure the kitchen's two-compartment sink had an air gap (physical space or separation between the drain pipe and the floor); and 2. Properly label residents' food that was brought in from outside the facility and stored in the resident refrigerator/freezer. These failures had the potential to result in food borne illness for 67 out of 68 residents. Findings: 1. During an observation and subsequent interview with the dietary manager (DM) and cook 1 (CK G) on 6/26/23 at 7:47 a.m., an air gap under the two-compartment sink was not visible. A metal mesh band was wrapped around the drain pipe at floor level. The DM and CK G stated they were not sure where the drain pipe ended. During an interview with the DM on 6/26/23 at 9:31 a.m., she stated the maintenance director told her there was no air gap for the two compartment sink. A review of the facility's policy and procedure (P&P) titled Air Gap, revised 11/2012, indicated indirect waste piping shall discharge into the building drainage system through an air…

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 equipment was maintained in good repair when the water heater for the kitchen dishwasher had been broken for over one month. This failure had the potential to result in food borne illness for 67 out of 68 residents. Findings: During a kitchen observation and concurrent interview with the Dietary Manager (DM) on 6/26/23 at 9:31 a.m., the DM stated the dishwasher was not reaching the proper water temperature. The DM further stated the dishwasher had not been in use since she started two weeks ago. Review of the Kitchen's Dishwasher Temperature/Sanitizer Record for the month of May 2023, revealed there were no entries for temperature and sanitizer. During an interview with the [NAME] President of Operations (VPO) on 6/26/23 at 3:17 p.m., he stated the water heater for the kitchen dishwasher broke. During an interview with the DM on 6/26/23 at 3:21 p.m., the DM confirmed the kitchen dishwasher had not been in use during the month of May 2023. 2022 Food Code Section 4-501.11 states that equipment must 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 ensure: 1. The call button (device used by a resident to signal his or her need for assistance from professional staff) was within reach for two of 17 sampled residents (Residents 4 and 14) and one non-sampled resident (Resident 29); and 2. The call light (visual signal indicating a resident needs assistance) was answered in a timely manner for one of 17 sampled residents (Resident 7). These failures had the potential to negatively affect the residents' health, safety, and overall well-being. Findings: 1. During an observation on 6/26/23 at 8:43 a.m., Resident 29's call button was on the floor under the head of the bed, while Resident 29 was asleep in bed. During an observation and subsequent interview with the activities director (ACD) on 6/27/23 at 8:20 a.m., Resident 4 was lying in bed with the call button was tied to the side rail and hanging out of reach. The ACD confirmed the call button was not accessible to Resident 4. The ACD then untied the call button from the side rail and placed it where 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 develop and/or update the comprehensive person-centered care plan (a written plan that is a means of communicating and organizing the actions of a constantly changing nursing staff to provide direction for consistent care of the resident) for six of 17 sampled residents (Residents 7, 11, 50, 55, 57, and 68) when: 1. For Resident 7, the facility failed to create and implement a care plan for Enoxaparin Sodium injections (medication-a blood thinner) and a wound vac device (vacuum-assisted closure of a wound is a type of therapy to help wounds heal); 2. For Resident 11, the facility failed to create a baseline fall care plan and failed to update interventions on the fall care plan; 3. For Resident 50, the facility did not develop a care plan to address the use of side rails (device attached to the sides of the bed to act as a barrier or to help with movement in bed); 4. For Resident 55, the facility did not develop a care plan to address…

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 controlled medications (those with high potential for abuse and addiction) were fully accounted when controlled medication use audit for 4 out of 4 sampled residents (Residents 8, 28, 48, and 328) did not reconcile. The medications were signed out of the Narcotic Record (an inventory sheet that keeps record of the usage of controlled medications) but not documented on the Medication Administration Records (MAR) to indicate they were given to the residents. The failure resulted in inaccurate accountability and had the potential for misuse or diversion (illegal distribution or abuse of prescription drugs or their use for purposes not intended by the prescriber) of controlled medications. Findings: The Narcotic Records for four random residents receiving PRN (as needed) controlled medications were requested for review during the survey. During an interview on 6/27/23 at 2:14 p.m., with Nurse Supervisor B (NS B), she stated whenever a resident requested a PRN controlled medication, the nurse needs to conduct an…

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

Based on observation, interview, and record review, the facility failed to ensure one of 17 sampled residents (Resident 11) was free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behaviors) when: 1. Resident 11 received paliperidone (an antipsychotic medication) at the daily dose of 6 milligrams (mg, unit of measurement), twice the ordered dose of 3 mg, for about three months; and 2. Resident 11 also received bupropion (medication for depression) without adequate indication. The failures resulted in excessive and unnecessary medications for the resident, which had the potential for increased risks associated with psychotropic medication use that include but not limited to sedation, falls, constipation, anxiety, agitation, abnormal involuntary movements, and memory loss. Findings: 1. A review of Resident 11's electronic clinical record indicated he was an elderly resident admitted to the facility with diagnoses including depression and schizophrenia (chronic, severe mental disorder that affects the way a person…

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 one of 17 sampled residents (Resident 11) was free of a significant medication error when Resident 11 received daily dose of paliperidone (an antipsychotic medication) 6 milligrams (mg, unit of measurement), instead of 3 mg as ordered, for about three months. The failure posed a risk for adverse consequences related to the medication (such as sedation, falls, constipation, anxiety, agitation, abnormal involuntary movements, and memory loss) to the resident. Findings: A review of Resident 11's clinical record indicated he was an elderly resident admitted to the facility with diagnoses including depression and schizophrenia (chronic, severe mental disorder that affects the way a person thinks, acts, expresses emotions, perceives reality, and relates to others). A review of the 3/30/23 Minimum Data Set (MDS, a care area assessment and screening tool) indicated he had a BIMS score of 15 (Brief Interview for Mental Status, a test given by medical professionals that helps determine a patient's cognitive…

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 dignity of one of 68 residents (Resident 18) when a staff member was standing over the resident while helping her eat, instead of sitting down. This failure had the potential to have a negative effect on the resident's psychosocial well-being. Findings: Review of Resident 18's medical record indicated she was admitted with diagnoses which included chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems), heart failure (a condition in which the heart is not able to pump blood as well as it should), Alzheimer's Disease (a brain disorder that gets worse over time), dementia (mental disorder caused by brain disease or injury), and dysphagia (difficulty swallowing foods or liquids). During an observation and subsequent interview with certified nursing assistant E (CNA E) on 6/30/23 at 12:57 p.m., CNA E was observed standing next to Resident 18's bed, which was raised to a high position, helping Resident 18 eat. When asked why she was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the local long-term care Ombudsman (LTC Ombudsman, organization that routinely visits the facility and advocates on behalf of the residents) about hospital transfers for two of three residents (Residents 230 and 14). This failure had the potential to compromise the residents' admission, transfer, and discharge rights. Findings: 1. Review of Resident 230's medical record indicated she was admitted on [DATE] and had the diagnoses of fracture of shaft of right tibia (broken right leg), fracture of right patella (broken right knee cap), muscle weakness, and abnormalities of gait (manner of walking) and mobility. Review of Resident 230's Progress Notes, dated 10/22/22, indicated a right ankle x-ray showed that Resident 230 had an acute distal fibular fracture (broken ankle). The notes further indicated Resident 230 was transferred to the hospital. Further review of Resident 230's medical record indicated there was no documentation that the facility…

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 notify one of three residents (Resident 14), or the resident representative, of the facility's bed hold policy duration when the resident was transferred to the hospital. This failure had the potential to result in Resident 14 not being able to return to the facility after a hospital stay. Findings: During a review of Resident 14's electronic medical record (record), it indicated Resident 14 was transferred to the general acute care hospital (GACH) on 5/7/23 for a fall; on 4/13/23 per resident request; on 3/28/23 for twitching and blood in his urine; and on 3/13/23 for increased temperature. During the review of Resident 14's record, there was no documentation of Resident 14 or his representative receiving, in writing, the duration of the facility's bed hold policy. During an interview with the health information director (HID) on 6/29/23 at 2:44 p.m., she stated she did not have any notices to the Ombudsman nor any documentation of bed-hold information being given for Resident 14's transfers on 5/7/23, 4/13/23, 3/28/23,…

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

Based on observation, interview, and record review, the facility failed to ensure: 1. One of five sampled residents (Resident 4) had and was wearing his hearing aids (small devices placed in the ear to amplify sound); and 2. An ophthalmologist (eye doctor) order for eye drops and reading glasses was carried out in a timely manner for one of five residents (Resident 11). These failures had the potential to compromise the residents' health, ability to relate to others, and psychosocial well-being. Findings: 1. Resident 4 was admitted to the facility with diagnoses which included cognitive communication deficit. During an observation on 6/27/23 at 8:31 a.m., Resident 4 was very hard of hearing. She kept asking the surveyor to repeat questions. During an interview with registered nurse C (RN C) on 6/27/23 at 8:42 a.m., she stated she did not know if Resident 4 had hearing aids. During a review of Resident 4's electronic record (record) on 6/28/23 at 9:05 a.m., there was a new physician order, dated 6/28/23 @ 0800 (8:00 a.m.), for hearing aids to both ears. During an interview 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 ensure the wound vac (vacuum-assisted closure of a wound is a type of therapy to help wounds heal) was set up according to the physician orders for one of 17 sampled resident (Resident 7). This failure had the potential to result in delayed wound healing and worsening of Resident 7's stage 4 pressure ulcer (a deep wound reaching the muscles, ligaments, or bones). Findings: During a review of Resident 7's medical record dated 5/18/23, the medical record indicated multiple diagnoses including endocarditis (infection of the inner lining of the heart), pressure ulcer of the sacral region (skin injury near the lower back and spine) stage 4, absence of left leg below the knee, and anxiety disorder (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness). During a concurrent observation and interview with the assistant director of nursing (ADON) on 6/28/23 at 8:36 a.m., in Resident 7's room, the wound vac was turned off, and the ADON was observed turning the wound vac on. 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 record review, the facility failed to follow physician's orders for three of six sampled residents (Residents 8, 30, and 52) when: 1. For Resident 8, the facility did not provide restorative nursing assistant (RNA, an exercise program) treatments as ordered; 2. For Resident 30, the facility did not apply splints (device used to maintain the position of a body part) as ordered; and 3. For Resident 52, the facility did not provide RNA treatments as ordered. These failures had the potential to cause declines in the residents' functional abilities. Findings: 1. Review of Resident 8's medical record indicated she was admitted on [DATE] and had the diagnosis of quadriplegia (inability to move both arms and both legs). Review of Resident 8's Minimum Data Set (MDS, an assessment tool), dated 4/19/23, indicated she had a brief interview for mental status (BIMS) score of 14 (a score of 13 to 15 indicates the resident is cognitively intact). Review of Resident 8's Order Summary Report…

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 use a Hoyer lift (a mechanical device used for resident transfers) when transferring one of 11 residents (Resident 230). This failure resulted in Resident 230's second fall in the facility. Findings: Review of Resident 230's medical record indicated she was admitted on [DATE] and had the diagnoses of fracture of shaft of right tibia (broken right leg), fracture of right patella (broken right knee cap), muscle weakness, and abnormalities of gait (manner of walking) and mobility. Review of Resident 230's Fall Scene Investigation Report, dated 10/9/22, indicated two certified nursing assistants (CNAs) were transferring Resident 230 from bed to wheelchair. The CNAs lost their grip and they assisted the resident to the ground. Item number 25 on the Fall Scene Investigation Report indicated, Describe initial interventions to prevent future falls. The person who filled out the report typed Hoyer in response to this. Review of Resident 230's Fall Scene…

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 administer oxygen in accordance with their policy for one of 17 sampled residents (Resident 55) when: 1. Resident 55's nasal cannula (NC, flexible tubing inserted into the nostrils and attached to an oxygen source) was outdated; and 2. There was no Oxygen in Use sign displayed at the entrance of Resident 55's room. These failures had the potential to compromise the resident's health and safety. Findings: Review of Resident 55's medical record indicated she was admitted on [DATE] and had the diagnosis of shortness of breath. Review of Resident 55's Order Summary Report indicated she had a physician's order, dated 6/5/23, to administer oxygen at two to four liters (oxygen flow rate) via NC for shortness of breath. During an observation on 6/26/23 at 10:00 a.m., Resident 55 was in her room receiving oxygen via NC. The NC was dated 6/16/23 (10 days prior to this observation). There was no Oxygen in Use sign displayed at the entrance 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 the assessments related to the use of side rails (device attached to the sides of the bed to act as a barrier or to help with movement in bed) were completed and accurate for two of 17 sampled residents (Resident 11 and Resident 50). This failure had the potential to increase the risk for injury to the residents. Findings: 1. Review of Resident 11's medical record indicated he was originally admitted on [DATE] with multiple diagnoses including heart failure (heart does not pump enough blood for the body's needs), diabetes (elevated blood sugar), and schizophrenia (a serious mental disorder in which people interpret reality abnormally). During an observation 6/27/23 at 11:45 a.m., in Resident 11's room, there were two side rails on the top half of the bed. Resident 11 was sitting in his wheelchair next to the bed. During an interview and record review on 6/27/23 at 11:56 a.m. with the Minimum Data Set Coordinator (MDSC), 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 one of six sampled residents (Resident 55) was seen by a mental health professional when requested. This failure had the potential to compromise the resident's mental, emotional, and psychosocial well-being. Findings: Review of Resident 55's medical record indicated she was admitted on [DATE] and had the diagnosis of major depressive disorder (a mood disorder that causes persistent feelings of sadness and loss of interest). Review of Resident 55's Minimum Data Set (MDS, an assessment tool), dated 5/10/23, indicated she had a brief interview for mental status (BIMS) score of 15 (a score of 13 to 15 indicates the resident is cognitively intact). Review of Resident 55's Order Summary Report indicated she had a physician's order, dated 5/10/23, to Refer to [mental health professional] prn [as needed]. During an interview with Resident 55 on 6/26/23 at 10:00 a.m., she stated she asked the social services director (SSD) if she could see someone for a…

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

Based on observation, interview, and record review, the Consultant Pharmacist (CP) failed to identify and report irregularities to the facility related to medication regimen review (MRR); and the facility failed to carry out the CP's recommendation, for two of 17 sampled residents (Residents 11 and 50) and for Resident 27. These failures resulted in medication interactions, inadequate indication for use, and inadequate monitoring for the residents which had the potential to compromise their health. Findings: 1. During the medication administration observation with Registered Nurse C (RN C) on 6/26/23 at 10:03 a.m., she was observed administering 11 medications to Resident 27. The medications included a tablet of iron (ferrous) sulfate (to treat iron deficiency anemia) 325 milligrams (mg, unit of measurement) and a tablet of calcium carbonate plus vitamin D 600 mg- 400 mg (a supplement). A review of Resident 27's physician's orders indicated the following: - Ferrous sulfate 325 mg, give 1 tablet by mouth one time a day for supplement, dated 1/16/19. It was scheduled to 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility had a medication error rate of 8.11% when three medication errors occurred out of 37 opportunities during the medication administration observation for two out of nine residents (Resident 27 and 34). Resident 34 received the wrong strength of an eye drop medication; and Resident 27 received two medications not in accordance with the physician's order and/or accepted professional standards of practice. These failures had the potential for the residents not receiving the full therapeutic effect of medications, or adverse affects, compromising the residents' health. Findings: 1. During a medication administration observation with Licensed Vocational Nurse A (LVN A) on 6/26/23 at 8:40 a.m., she was observed preparing an eye medication, brimonidine ophthalmic solution (medication for glaucoma - group of eye conditions that damage the optic nerve) 0.15% for Resident 34. On 6/26/23 at 8:48 a.m., at Resident 34's bedside, LVN A was observed instilling 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 insulin pens and other medications were properly labeled as in accordance with the facility policy and procedures (P&P) and/or accepted professional standards; expired medications were removed from active stock; and the medication refrigerator temperature was monitored every day. The failure had the potential for mix-up errors; or for residents given expired medications. Also, unmonitored temperature could lead to loss of stability and efficacy of medications, which could lead to ineffective medications for the residents. Findings: 1. During a visit to the medication room with the Assistant Director of Nursing (ADON) on 6/26/23 at 10:51 a.m., the medication refrigerator was identified. It contained a bottle of lorazepam (a controlled medication to treat anxiety or agitation) oral concentrate, numerous insulin (medication to lower blood sugar) vials and pre-filled pens, several bags of intravenous antibiotics (to treat infections), several types of eye drops, several Aplisol solution (used in 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 and interview, the facility failed to ensure proper pest control in the kitchen, when two flying insects were observed near freezer #2 and the coffee maker. This failure had the potential to result in the spread of food borne illness to 67 out of 68 residents. Findings: During an observation and subsequent interview with the Dietary Manager (DM) in the food preparation area of the kitchen on 6/29/23 at 1:58 p.m., two small insects were observed flying around near freezer #2 and the coffee machine. The DM acknowledged the two flying insects. During an interview and subsequent observation with the DM on 6/30/23 at 8:59 a.m., the DM stated the facility would be replacing bulbs in the bug lights. One bug light in the food preparation area of the kitchen was observed not working. The DM stated she would ask maintenance to put a second bug light in the food preparation area of kitchen. During an interview with the Maintenance Director (MNT) on 6/30/23 at 9:28 a.m., he stated he was going to get more bulbs today, and that he would add another bug light in the 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 sanitary conditions were maintained in food services when: 1. there was ice build-up in one of two freezers 2. two bananas with brown spots were found inside the refrigerator 3. two plate warmers had dark brown and black substances 4. there was no air gap in the two compartment sink 5. there was no air gap in the dishwasher 6. there was an undated bag of cookies 7. there was a dented can of pineapple and a dented can of tuna These failures had the potential to result in cross contamination and cause food borne illness (illness caused by food or water contaminated bacteria, viruses, parasite, or toxins). Findings: 1. During a kitchen observation and concurrent interview with the dietary manager (DM) on 5/1/19 at 7:50 a.m., there was an ice build-up in the freezer. The DM stated the freezer gasket should have been fixed and there should not be ice build-up in the freezer. 2. During an observation and concurrent interview with the DM on 5/1/19 at 7:53 a.m., there were two bananas with brown spots. The DM…

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 need was accommodated for one of three sampled residents (Resident 66) when the certified nursing assistant (CNA) did not provide her shower as scheduled. This failure had the potential to negatively affect the resident's physical and psychosocial well-being. Findings: Review of Resident 66's clinical record indicated she had diagnoses including diabetes (increase in blood sugar), hypertension (increase in blood pressure), abnormal gait and mobility, and muscle weakness. Her Minimum Data Set (MDS, an assessment tool) dated 3/26/2019, indicated the resident could make decisions, required assistance with bed mobility, transfer, dressing, toileting, personal hygiene, and bathing, During an interview with Resident 66 on 5/1/19 at 10:10 a.m., she stated she did not get her shower as scheduled. Resident 66 also stated she did not feel good and preferred to have a shower. During a record review and concurrent interview with certified nursing assistant I (CNA I) on 5/3/19 at 9:28 a.m., she stated she was the assigned CNA…

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 re-evaluate the PASRR (pre-admission screening and resident review, a federal requirement to help ensure individuals are not inappropriately placed in nursing homes for long term care) for one of four residents (Resident 2) when Resident 2 had a qualifying diagnosis of dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment). This failure had the potential to put the resident at risk for not receiving appropriate care and services. Findings: Review of Resident 2's clinical record indicated she had diagnoses including epilepsy (a disorder in which nerve cell activity in the brain is disturbed causing seizures), bipolar disorder (a mental condition), and dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning). During an interview with the social services director (SSD) on 5/2/19 at 9:08 a.m., she stated she is responsible for completing…

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/or implement care plans for four of 17 sampled residents (Residents 35, 39, 66, and 271) when: 1. For Resident 35, the facility did not develop care plans to address the use of Duloxetine (medication used to treat depression), Zolpidem (medication used to treat sleeping difficulty) and Heparin (blood thinner); 2. For Resident 39, the facility did not develop a care plan to address the use of Buspar (medication used to treat depression); 3. For Resident 66, the facility did not develop a care plan to address the use of Trazodone Hydrochloride (medication used to treat depression); and 4. For Resident 271, the facility did not develop a care plan when the resident acquired a blister (a pocket of body fluid [serum, blood, or pus] within the upper layers of the skin) on his left heel. These failures had the potential to result in the residents not receiving the care and services necessary to maintain their health, safety and well-being.…

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 assistance for one of 17 residents (Resident 26) with activities of daily living (ADLs, activities such as grooming, hand washing, bathing, eating) when nursing staff did not clean Resident 26's hands and fingernails. This failure had the potential to spread infection to the resident. Findings: Review of Resident 26's clinical record indicated Resident 26 was readmitted to the facility on [DATE] with diagnoses including hemiplegia (paralysis [the loss of the ability to move or sometimes feel parts or most of the body] on one side of the body) hemiparesis (muscle weakness or partial paralysis on one side of the body), muscle weakness, and aphasia (a language disorder that affects a person's ability to communicate) following a cerebrovascular accident (CVA or stroke, damage to the brain from interruption of its blood supply). During an observation on 5/1/19 at 8:07 a.m., Resident 26 was sitting up on his bed and eating his breakfast…

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 according to professional standards of practice for four residents (Residents 15, 48, 67, and 72) when: 1. For Resident 15, the licensed nurse did not wait at least five minutes between eye drop administrations; 2. For Resident 48, the facility did not obtain a physician's order to transfer her to the acute hospital; 3. For Resident 67, the facility did not list all of his allergies in the clinical record; also for Resident 67, the facility administered oxygen without a physician's orde and 4. For Resident 72, the facility did not notify the physician when Resident 72 was transferred to the acute hospital. These failures had the potential to negatively affect the residents' health, safety, and well-being. Findings: 1. During a medication pass observation on 5/1/19 at 4:00 p.m., licensed vocational nurse B (LVN B) prepared two eye drops for Resident 15. LVN B administered dorzolamide (eye drops to reduce eye pressure)…

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 2. Review of Resident 32's clinical record indicated she was admitted on [DATE] with diagnoses including peripheral neuropathy (weakness, numbness and pain in the hands and feet caused by nerve damage), encephalopathy (disease that affects brain function), and difficulty in walking. Review of Resident 32's physician's order, dated 1/11/19, indicated she was to receive RNA treatments consisting of omnicycle, shoulder and elbow exercises, sitting on the edge of the bed and on the wheelchair, and standing with a walker. Review of Resident 32's document Rehabilitation and Restorative Nursing Program, dated 1/8/19, indicated she was to receive the above RNA treatments five times a week, Monday through Friday. Resident 32's RNA treatment record was reviewed on 5/3/19. Review of the record indicated from 1/11/19 to 5/2/19, the RNA documentation was left blank 20 times. During an interview with the MDS RN on 5/3/19 at 8:05 a.m., she stated a blank RNA documentation meant the treatments were not done. During an interview…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide adequate supervision for one of four sampled residents (Resident 61) when the facility failed to develop and implement care plan interventions to prevent falls. These failures had the potential to result to an injury to Resident 61 from falls. Findings: Review of Resident 61's clinical record indicated he had diagnoses including history of falling, Parkinson's disease (disease affects your brain and body movement), muscle weakness, dementia (memory problems), and cognitive communication deficit (problem in communication). Review of Resident 61's Minimum Data Set (MDS, an assessment tool) dated 4/11/2018, indicated Resident 61 was cognitively impaired (memory problem). He required staff assistance for bed mobility, transfer, dressing, eating, toileting, personal hygiene, and bathing. He was also impaired in both lower extremities. Review of Resident 61's Fall Risk assessment dated [DATE], indicated he had a score of 26 which…

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 implement a bowel and bladder training program for two of five sampled residents (Residents 66 and 5) who were assessed to be a candidate for bowel and bladder training (programs to train the bowels and bladder to control incontinence). This failure had the potential to cause the resident to decline in bowel and bladder control. Findings: 1. Review of Resident 66's clinical record indicated she was admitted [DATE] with diagnoses including diabetes (increase in blood sugar), hypertension (increase in blood pressure), abnormal gait and mobility, and muscle weakness. Her Minimum Data Set (MDS, an assessment tool) dated 3/26/2019, indicated the resident could make decisions, required assistance with bed mobility, transfer, dressing, toileting, personal hygiene, and bathing. MDS also indicated Resident 66 was frequently incontinent of her bowel and bladder. Review of Resident 66's bowel and bladder program screening dated 3/19/19, indicated Resident 66 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure three of 17 sampled residents (Residents 35, 2, and 66) were free from unnecessary psychotropic medications (medications capable of affecting the mind, emotions and behavior) when: 1. For Resident 35, gradual dose reduction (GDR, stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the medication can be discontinued) was not attempted by the facility for zolpidem (hypnotic medication); 2. For Resident 2, the side effects of anti-depressant medication (trazodone) were not accurately assessed and monitored; and 3. For Resident 66, the indication for use of trazodone did not include a specific target behavior. These failures put the residents at risk for experiencing adverse medication side effects and receiving psychotropic medication without the appropriate indication. Findings: 1. Review of Resident 35's clinical record indicated she was admitted on [DATE] and with diagnoses including…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure two of three sampled residents (Residents 9 and 52) were provided with appropriate care and/or services under hospice care (provides medical services, emotional support, and spiritual resources for people who are in the last stages of a terminal illness) and ensuring coordination of care between the facility and the hospice agency when: 1. For Resident 9, the facility did not have hospice nursing visit notes readily available in the resident's medical record. Also, the facility did not involve the hospice nurse during their multidisciplinary care conference . 2. For Resident 52, the facility did not complete an individualized hospice care plan and the hospice nurse was not included in the multidisciplinary care conference. Findings: 1. Review of Resident 9's clinical record indicated she was admitted to hospice care on 10/12/18. Review of the Visit Note Report indicated a visit date on 4/18/19 and 4/19/19. Both of these reports were received by…

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.