Rancho Bellagio Post Acute

Based on observation, interview, and record review, the facility failed to ensure proper disposal of garbage when three dumpsters were overflowing, the lids could not be closed, and the surrounding area was littered with debris. This failure had the potential to attract pests and cause infection control issues. Findings: On December 8, 2024, at 8:15 a.m., during an observation of the dumpster storage area outside of the facility near the corner entrance, three out of three dumpsters were overflowing with garbage and cardboard boxes. The dumpster lids were not closed, and debris was scattered around the dumpsters. On December 8, 2024, at 10:17 a.m., during a concurrent observation and interview with the Dietary Supervisor (DSS), in front of the dumpsters, the DSS stated the dumpsters should be closed and not overflowing with garbage or boxes. The DSS further stated there should not be any debris surroundnig the dumpster area to prevent pest infestations, which could lead to infection control issues. On December 8, 2024, at 10:22 a.m., during a concurrent observation and 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 interview and record review, the facility failed to provide Advance Directive (AD-a written instruction related to the provision of health care when the resident is no longer able to make decisions) education, materials, and follow-up for three of five residents reviewed for AD (Residents 19, 35, and 69) and/or their resident representatives (RP). This failure had the potential for Residents 19, 35, and 69's medical preferences not being honored during critical healthcare decisions. Findings: 1. Resident 35's record was reviewed. Resident 35 was admitted to the facility on [DATE], with a diagnoses which included cerebral infarction (lack of oxygen to the brain). A review of Resident 35's history and physical dated November 4, 2024, indicated Resident 35 had the capacity to understand and make decisions. Resident 35 is self-responsible. A review of Resident 35's, Advance Directive Acknowledgement, dated November 3, 2024, indicated, Resident 35 was not screened or provided AD education. A review 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 lunch menu on December 9, 2024, met residents' needs when: 1. Dietary Aide (DA 1) served pudding instead of mandarin oranges for five of five residents (Residents 19, 41, 134, 190 and 332) on a renal diet (a restricted diet that can help slow kidney damage). 2. [NAME] (CK 1) served pureed spinach instead of green beans for one of one resident (Resident 332) on a renal pureed diet (smooth, lump-free foods that require no chewing). 3. DA 1 used a #8 scoop size to serve dessert for regular diets. 4. CK 1 did not follow the recipe when preparing garlic parmesan spinach. These failures had the potential for residents to miss out on therapeutic and nutritional benefits, correct serving portion, and/or palatability (acceptable taste). Findings: 1. A review of the facility's Winter menu for Week 2, dated December 9, 2024, indicated: -Southern beef patties with cream gravy, Mashed Potatoes (renal diet: wheat pasta) Garlic Parmesan…

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 its policy on Meal Service to provide appetizing food at appropriate temperatures and appetizing taste according to residents' preferences for 14 of 96 sampled residents (Residents 14, 15, 19, 29, 36, 41, 43, 51, 65, 69, 73, 77, 182, and 282). This failure placed residents at potential risk to decrease nutritional intake and affect the resident's nutrition status. Findings: On December 8, 2024, at 8:47 a.m., during an interview with Resident 73, she stated, the served food does not taste very good, not good quality. On December 8, 2024, at 9:30 a.m., during an interview with Resident 282, he stated, food tasted bad and is cold for breakfast, lunch and dinner every day. On December 8, 2024, at 9:55 a.m., during an interview with Resident 182, he stated, food tasted bland. On December 8, 2024, at 9:55 a.m., during an interview with Resident 14, she stated, the served food taste bad. On December 8, 2024, at 10:12 a.m., during an interview with Resident 41, she stated, the served food not appetizing,…

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

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen when: 1. Food and Nutrition Service employees did not follow the facility cleaning procedure to clean food preparation surfaces and stationary equipment. 2. Four out of four green storage shelves in the walk-in refrigerator had buildup; 3. Dust was hanging on walk-in refrigerator's fan covers; and 4. One wet plastic container was stacked with other dried plastic containers. These failures had the potential to cause foodborne illness (stomach illness acquired from ingesting contaminated food) in a medically vulnerable population of 95 out of 95 residents who received food prepared in the kitchen. 1. During a review of the facility provided procedure title, SHELVES, COUNTERS, AND OTHER SURFACES INCLUDING SINKS (HANDWASHING, FOOD PREPARATION, ETC.), the procedure indicated, CLEANING PROCEDURE: 1. Remove any large debris and wash surface with a warm detergent solution . 2. Rinse with clear water using a clean sponge or cloth. Wipe dry…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the medication Nexium (esomeprazole-is used to treat conditions where there is too much acid in the stomach) was administered according to the physician's order for one of one resident reviewed (Resident 56). This failure had the potential to result in the worsening of gastroesophageal reflux disease (GERD-overaccumulation of stomach acid) for Resident 56. Findings: On December 11, 2024, at 2:48 p.m., during an interview with Resident 56, she stated she had been experiencing a little bit of nausea. Resident 56 stated she takes Nexium before breakfast for GERD but further stated she had not taken her Nexium medication for two days. A review of Resident 56's admission Record, indicated Resident 56 was admitted to the facility on [DATE], with diagnoses which included gastroparesis (a condition in which the muscles in the stomach does not move food for digestion) and GERD. A review of Resident 56's Physician's Order, dated October 10, 2024,…

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 replace the oxygen humidifier bottle in accordance with the facility policy and procedure for one of one resident reviewed for respiratory (Resident 66). This failure had the potential to result in ineffective oxygen therapy, respiratory distress, cross-contamination, and infection, which would lead to a decline in Resident 66's health condition. Findings: On December 9, 2024, at 10:27 a.m., a concurrent observation and interview were conducted in Resident 66's room with LVN 3. Resident 66 was receiving oxygen via nasal cannuala (NC-plastic tube that allows oxygen to be delivered to the nose from a machine). The nasal cannula was observed to be labeled with a date of 12/7. A humidifier bottle (plastic cannister filled with water to humidify air flow) was less than half filled and labeled with the date 11/24. LVN 3 stated, the nasal cannula and humidifier bottle should be changed every seven days. LVN 3 stated the cannula and humidifier…

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 medication error rates were not five percent or greater when: 1. Resident 21's lidocaine (local anesthetic to relieve pain) patch was applied to the wrong body location; and 2. Resident 137's Metformin (medication to treat high blood sugar) and Carvedilol (heart medicine) were administered without food. These failures had the potential for Residents 21 and 137 to not adequately received the therapeutic effect of the medications. Findings: 1. On December 10, 2024, at 8:39 a.m., during medication administration observation inside Resident 21's room with Licensed Vocational Nurse (LVN) 3, LVN 3 applied Lidocaine Patch 5% (percent - unit of measurement) on Resident 21's back near the right shoulder blade. A review of Resident 21's Physician's Orders, dated August 18, 2024. indicated, .Lidocaine Patch 5% apply to each knee topically one time a day for pain management . On December 10, 2024, at 12:27 p.m., during a concurrent interview and review of Resident 21's Physician's Orders, with LVN 3, he stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement proper infection control measures when Certified Nurse Assistant (CNA) 1 did not perform hand hygiene and wear personal protective equipment (PPE - equipment use to protect against infection or illness) upon entering the room and while providing care to Resident 283, who was positive for Clostridium Difficile infection (C. diff - a bacteria that cause diarrhea and is spread through contact with contaminated surfaces or people). This failures had the potential to increase the spread of pathogens (germs) and infections from staff to residents, potentially leading to illness. Findings: On December 10, 2024, at 8:25 a.m., during a concurrent observation and interview in the hallway outside Resident 283's room, a contact precaution (a set of precautions to prevent the spread of germs that are transmitted through direct or indirect contact) sign was observed on the wall. CNA 1 entered and exited the room, provided care to 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 maintain the dish machine's temperature within the manurfacturer's guidelines. Failure to ensure adequate water temperature in the dish machine may result in ineffective cleaning of dishes, putting 95 residents at risk for food-borne illness (stomach illness acquired from ingesting contaminated food). Findings: According to the United States FDA (Food and Drug Administration) Food Code 2022, Section 4-204.115 Warewashing Machines, Temperature Measuring Devices, the Food Code indicated, The requirement for the presence of a temperature measuring device in each tank of the warewashing machine is based on the importance of temperature in the sanitization step. In hot water machines, it is critical that minimum temperatures be met at the various cycles so that the cumulative effect of successively rising temperatures causes the surface of the item being washed to reach the required temperature for sanitization. When chemical sanitizers are used, specific minimum temperatures must be met because the effectiveness…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of seven residents' (Resident 7) call light was answered timely. This failure had the potential to not meet the resident's needs. Findings: On October 31, 2024, at 8:44 a.m., an unannounced visit was conducted to the facility for a quality of care issue. On October 31, 2024, at 12:02 p.m., during a concurrent observation and interview with Certified Nursing Assistant (CNA) 2, CNA 2 was observed to not answer Resident 7's call light after walking past the resident's room twice. CNA 2 stated he had just finished taking his morning break and did not have any residents to assist at the time. CNA 2 stated he saw the call light on and thought the nurse assigned to that room would answer it. CNA 2 stated he should have answered the call right away, even if the room was not on his assignment list. CNA 2 further stated he should have checked on the resident and communicated the resident's needs to the other CNA or licensed nurse. CNA 2…

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 correct size bed rails were installed on one resident's bed as indicated on the resident's bed rails admission assessment, for one of seven sampled residents (Resident 2). This failure had the potential to result in negative outcomes including accident, physical restraint, decline in mobility and function, and psychosocial outcome. Findings: On October 31, 2024, at 12:02 p.m., a concurrent observation and interview were conducted with Resident 2. Resident 2 stated her bed was comfortable, but she did not like her side rails. Resident 2 stated she initially had short side rails but after she returned from the hospital, they changed her bed to one with longer side rails. She further stated that she felt closed in and she could not transfer easily to her wheelchair. A review of Resident 2's medical records indicated she was originally admitted on [DATE], with diagnoses of left knee and hip effusion (when fluids collect around a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when a Certified Nurse Assistant (CNA) did not perform handwashing after leaving the room of a resident on Enhanced Barrier Precautions (EBP - infection prevention and control practices that can help reduce the spread of infection). This failure had the potential to increase the spread of pathogens (germs) from staff to residents which could lead to infections and illness. Findings: On October 31, 2024, at 9:29 a.m., a Certified Nursing Assistant (CNA) 1 was observed providing care to a resident on EBP. CNA 1 removed her gown and gloves and did not perform hand hygiene after exiting the resident's room. CNA 1 was observed grabbing a meal tray cart from outside and pushing the cart down the hallway. On October 31, 2024, at 9:31 a.m., CNA 1 was interviewed. CNA 1 stated she had forgotten to wash her hands and that she should have used the gel sanitizer outside in the hallway after leaving…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of three residents (Resident 1) ' s family was notified of a change in condition within 24 hours, on August 9, 2024. This failure had the potential for Resident 1's family to not know the medical condition of Resident 1, and not be able to advocate and assist with making medical decisions based on the change of condition. Findings: On September 16, 2024, at 2:30 p.m., an unannounced visit to the facility on two complaints investigation was initiated. A review of Resident 1's medical records indicated she was originally admitted on [DATE], with diagnoses of aphasia, (affects the ability to express and understand written and spoken language), after a stroke, urinary tract infection, (infection in the bladder), hydronephrosis, (caused by a blockage in the tube that connects the kidney to the bladder), with renal and ureteral calculi, (hard deposits made of minerals and salts that form inside the kidneys), Pressure ulcer injury,…

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 report an allegation of sexual abuse within two hours to the California Department of Public Health (CDPH) after the allegation was made for two of three sampled residents (Residents A and C). This failure had the potential to result in further abuse. Findings: On May 29, 2024, at 9:40 a.m., an unannounced visit to the facility was conducted to investigate an allegation of abuse. a. During an interview on May 29, 2024, at 1:17 p.m., with Resident A, she stated she was touched inappropriately three weeks ago by Resident B. Resident A further stated she felt dirty. During a review of Resident A's admission RECORD, indicated Resident A was admitted on [DATE], with diagnoses which included depression (feelings of sadness) and schizoaffective disorder (a mental health disorder). During a review of Resident A's MDS (minimum data set- an assessment tool) dated April 30, 2024, indicated Brief Interview of Mental Status (a tool used to screen and identify 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, for one of three residents reviewed, (Resident 1), a follow up call and/or assessment was done to verify durable medical equipment (DME) was provided to Resident 1 upon discharge as ordered. This failure had the potential to complicate Resident 1's recovery and had the potential for Resident 1 to suffer undue financial expenses for needed medical equipment. Findings: On November 20, 2023, at 8 a.m., a telephone interview was conducted with Resident 1. Resident 1 stated when he was discharged from the facility, the facility did not provide him with the ordered DME, and he had to purchase the equipment himself. On November 21, 2023, at 10:40 a.m., an unannounced visit was conducted at the facility. On November 21, 2023, Resident 1's medical record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which included rhabdomyolysis (a breakdown of muscle tissue that releases a damaging protein into the blood), acute…

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 representative for one of three sampled residents (Resident 1) when the facility applied a knee immobilizer to Resident 1. This failure had the potential to violate the rights Resident 1's representatives. Findings: A review of Resident 1's admission record indicated the resident was admitted to the facility on [DATE], with diagnoses which included cerebral infarction (impaired oxygen delivery to the brain), diabetes mellitus (inability to regulate blood sugar), and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). The record further indicated the resident, and her daughter-in-law were the resident's responsible parties. A review of Resident 1's Brief Interview for Mental Status (BIMS) dated June 9, 2023, indicated a score of 3 (severe cognitive impairment). A review of Resident 1's History and Physical dated June 9, 2023, indicated the resident was alert and oriented times one.…

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 pain medication was offered or provided for one of four residents reviewed (Resident 1). This failure had the potential for Resident 1 to have increased pain which could impair mobility and function. Findings: On September 9, 2023, at 11:28 a.m., an unannounced visit was conducted at the facility for a complaint investigation. On September 9, 2023, at 12:10 p.m., Resident 1 was observed sitting on the edge of her bed. During a concurrent interview, Resident 1 stated she had been at the facility for about two months. Resident 1 stated she took routine pain medication for chronic pain. Resident 1 stated sometimes the medication was not available at the facility. Resident 1 stated her only concern was that the pain medication was not available consistently for her use and there was a delay in her receiving it. On September 9, 2023, Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses…

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 pharmaceutical services were provided to meet the needs of a resident when the physician ordered medications were not acquired by the facility timely and available for use, for one of four residents reviewed (Resident 1). This failure had the potential to result in the delay of treatment and care for Resident 1. Findings: On September 9, 2023, at 11:28 a.m., an unannounced visit was conducted at the facility for a complaint investigation. On September 9, 2023, at 12:10 p.m., Resident 1 was observed sitting on the edge of her bed. During a concurrent interview, Resident 1 stated she had been at the facility for about two months. Resident 1 stated she took routine pain medication for chronic pain. Resident 1 stated sometimes the medication was not available at the facility. Resident 1 stated she was told the medication could not be given because the facility needed authorization, and they were not able to contact the physician.…

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, for one of four residents reviewed (Resident 1), to maintain accurate medical records in accordance with accepted professional standards and practice when the staff failed to accurately document medication given to Resident 1 on the medication administration record (eMAR). This failure could increase the potential for confusion to occur in the provision of care for Resident 1 and for Resident 1 to receive unnecessary duplicated medication. Findings: On September 9, 2023, at 11:28 a.m., an unannounced visit was conducted at the facility for a complaint investigation. On September 9, 2023, at 12:10 p.m., Resident 1 was observed sitting on the edge of her bed. During a concurrent interview, Resident 1 stated she had been at the facility for about two months. Resident 1 stated she took routine pain medication for chronic pain. Resident 1 stated sometimes the medication was not available at the facility. Resident 1 stated her only concern was that the pain…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) received colostomy care as ordered by the physician. This deficient practice had the potential for Resident 1 to suffer from infection, skin breakdown, and pain. Findings: On October 11, 2023, at 9:00 a.m., an unannounced visit was conducted at the facility. A review of Resident 1's admission record dated October 11, 2023, indicated he was admitted to the facility on [DATE], with diagnoses that included colostomy (an opening in the belly that's made during surgery with the end of the colon brought through this opening to form a stoma), abdominal abscess (pocket of infected fluid and pus located inside the belly), encephalopathy (disease, damage, or malfunction of the brain) and type 2 diabetes (a disease in which your blood sugar levels are too high). During an observation on October 11, 2023, at 9:15 a.m., of Resident 1's colostomy, the colostomy bag was full of fecal matter, bloated and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that one of three sampled residents, Resident 1, bedframe was properly maintained in safe operating condition. The brake on Resident 1's bed was malfunctioning, causing the bed to move from left to right while in the locked position. This failure had the potential to place the resident at risk for entrapment, accident, and injury. Findings: On October 11, 2023, at 9:00 a.m., an unannounced visit was conducted at the facility. A review of Resident 1's admission record dated October 11, 2023, indicated he was admitted to the facility on [DATE], with diagnoses that included colostomy (an opening in the belly that's made during surgery with the end of the colon brought through this opening to form a stoma), abdominal abscess (pocket of infected fluid and pus located inside the belly), encephalopathy (disease, damage, or malfunction of the brain) and type 2 diabetes (a disease in which your blood sugar levels are too high). During an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a call light (a device to alert nursing staff when a resident is in need) was within reach of one resident (Resident 1) out of a sample of three residents. This failure prevented Resident 1 from communicating his care needs and had the potential to increase his anxiety (a feeling of fear, and uneasiness). Findings: On October 11, 2023, at 9:00 a.m., an unannounced visit was conducted at the facility. A review of Resident 1's admission record dated October 11, 2023, indicated he was admitted to the facility on [DATE], with diagnoses that included colostomy (an opening in the belly that's made during surgery with the end of the colon brought through this opening to form a stoma), abdominal abscess (pocket of infected fluid and pus located inside the belly), encephalopathy (disease, damage, or malfunction of the brain) and type 2 diabetes (a disease in which your blood sugar levels are too high). During a concurrent observation and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to administer pain medication in accordance with the facility policy and procedure for one of three sampled residents (Resident 1). This failure had the potential to jeopardize the health and safety of Resident 1. Findings: A review of Resident 1's admission record indicated the resident was admitted to the facility on [DATE], with diagnoses which included malignant neoplasm of unspecified site (cancer) and pressure ulcer of sacral region (tail bone). A review of Resident 1's Brief Interview for Mental Status (BIMS) dated June 19, 2023, indicated the resident had a score of 10 (moderate cognitive impairment). A review of Resident 1's physician orders indicated the following: a. Morphine sulfate solution 20 mg/ml, give 0.25 ml by mouth every 2 hours as needed for mild breakthrough pain and give 0.5 ml by mouth every 2 hours as needed for moderate breakthrough pain AND give 1 ml by mouth every 2 hours as needed for severe breakthrough pain dated June 30,…

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 infection control measures were implemented when: 1. One facility staff did not perform hand hygiene during, donning (putting on gloves and gown) and doffing (removing gloves and gown) of PPE (Personal Protective Equipment - mask, gown, gloves, face shield or goggles) inside the PUI Unit (Person Under Investigation - a resident suspected of having or exposed to COVID-19 [coronavirus-an illness caused by a virus that can spread from person to person]) upon meal pass; 2. A resident's urinal was placed on a bedside table beside a lunch tray; 3. A licensed nurse did not disinfect a medication tray during med pass; 4. One facility staff touched resident's meal with dirty gloves; 5. During multiple observations one facility staff was observed not wearing a face shield according to facility policy in a PUI room; 6. One facility staff during med pass did not perform hand hygiene between glove use; 7. Multiple staff were observed…

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 one of four residents (Resident 15) dignity when the resident was observed with long, dirty fingernails and with an unshaven face. This failure had the potential to affect resident's self-esteem and psychosocial well-being. Findings: During an observation on March 4, 2022, at 10:23 a.m., Resident 15 was observed with an unshaven beard. Resident 15 was observed with long and dirty fingernails. In a concurrent interview, Resident 15 stated he wanted to be shaved. He stated he has not been shaved in over a week. Resident 15 stated, he made a request for his nails to be trimmed. During an observation and interview on March 4, 2022, at 10:46 a.m., with the Certified Nursing Assistant (CNA 1), she stated nails and beards should be assessed when giving a bath. CNA 1 stated, Resident 15's beard and fingernails were long and should have been taken care of during a shower. Resident 15's record was reviewed. Resident 15 was admitted 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 keep Resident 11 free from verbal abuse when the staff, while exiting the room used foul language which was perceived by Resident 11 as being directed to her. This failure had the potential for Resident 11 to experience psychological harm. Findings: During an interview conducted on March 1, 2022, at 9:05 a.m., Resident 11 stated she had a verbal altercation with CNA 2 on February 20, 2022, and she and her roommate overheard Certified Nursing Assistant (CNA 2) say an expletive phrase, (curse words in spanish) as he walked out of the resident's room. She stated that she cried and felt horrible. Resident 11 stated CNA 2 came into her room and stated, I will lose my license and have to go back to flipping burgers.She stated that she felt bad and did not want to, ruin this kids' life, but he shouldn't have said that to her. She reported that she cried and felt horrible. Resident 11 stated that she notified the Licensed Vocational Nurse (LVN 1) the day of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report an allegation of verbal abuse involving a Certified Nurse Assistant (CNA) and a resident, no later than 2 hours to the State Survey Agency, after the allegation was made. This failure had the potential to result in a delay of investigation which placed resident at risk for further abuse. Findings: During an interview conducted on March 1, 2022, at 9:05 a.m., Resident 11 stated she had a verbal altercation with CNA2 on February 20, 2022 and she and her roommate overheard Certified Nursing Assistant (CNA 2) say an expletive phrase, (curse words in spanish) as he walked out of the resident's room. She stated that she cried and felt horrible. Resident 11 stated CNA 2 came into her room and stated, I will lose my license and have to go back to flipping burgers.She stated that she felt bad and did not want to, ruin this kids' life, but he shouldn't have said that to her. She reported that she cried and felt horrible. Resident 11 stated that she…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a comprehensive care plan was developed to address resident's dental problem, for one of 19 residents reviewed (Resident 37). This failure had the potential for staff not to be aware of the resident's dental needs and provide the necessary care. Findings: On March 1, 2022, at 8:39 a.m., Resident 37 was observed with a full upper denture and missing teeth on the lower portion of mouth. In a concurrent interview with Resident 37, he stated difficulty chewing food and required lower dentures. He stated a dental consultation was completed and no follow-up from staff. Resident 37's record was reviewed. Resident 37 was admitted to the facility on [DATE], with diagnoses which included cerebrovascular accident (interruption in the blood to cells in the brain) and mild protein calorie malnutrition (a medical condition when not consuming enough protein and calories-leads to muscle loss). A document titled, Nursing Admission/readmission…

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 meet professional standards during medication administration for one of three residents (Resident 54), when the Diclofenac Gel (medication used to treat pain) was not administered in accordance with the physician's order. This failure had the potential to result in not having the effective amount of medication at all times and prolonging the amount of time for the resident to feel relief. Findings: On March 1, 2022, at 4:29 p.m., during the medication administration observation, Licensed Vocational Nurse (LVN 2) did not administer Diclofenac gel to Resident 54. Resident 54's record was reviewed. Resident 54 was admitted to the facility on [DATE], with diagnoses which included asthma (a respiratory condition causing difficulty in breathing) and necrotizing fasciitis (infection that destroys tissue under skin). The Order Summary Report, for the month of March, 2022, indicated, .Diclofenac Sodium Gel 1% Apply topically four times a day 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, interview, and record review, the facility failed to provide activities that met the interest for one of one residents reviewed (Resident 44). This failure had the potential to result in a decline in the physical, and emotional well-being of Resident 44. Findings: Resident 44 was observed on his iPad on multiple occasions: a. On February 28, 2022, at 4:27 p.m., playing game; b. On March 1, 2022, at 12:50 p.m., watching movie; c. On March 2, 2022, at 3:50 p.m., watching movie; and d. On March 3, 2022, at 9:50 a.m., playing game. A review of Resident 44's record indicated, he was admitted to the facility on [DATE], with diagnoses which included rheumatoid arthritis (inflammatory disorder affecting many joints, including those in the hands and feet.), scoliosis (abnormal shape of the spine), muscle wasting atrophy (weak muscles), and dysphagia (difficulty speaking). Resident 44's history and physical examination, dated December 23, 2021, indicated resident has the capacity to understand and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident received treatment and care for one of 19 residents reviewed (Resident 25), when he was not re-evaluated for persistent swelling (edema) of bilateral lower extremities. This failure had the potential to result in the delay in treatment and further decline in resident's medical condition, affecting, psychosocial, mental, and physical well-being of Resident 25 Findings: On February 28, 2022, at 3:45 p.m., Resident 25 was observed with swelling to both lower extremities. In a concurrent interview with Resident 25, he stated he had swelling for a while. Resident 25's record was reviewed. Resident 25 was admitted to the facility on [DATE], with diagnoses which included coronary artery disease (narrowing or blockage of coronary arteries). The document titled, Interact Change in Condition Evaluation, dated January 31, 2022, indicated, .resident bilateral legs and feet swollen and redness .bilateral leg edema +3 (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 Based on observation, interview, and record review, the facility failed to ensure the medication error rate was less than 5% when: 1. For Resident 54, the medications Q-var inhaler (used to treat lung problem) and Diclofenac Sodium topical Gel 1% (used to treat pain) were not administered in accordance with the physician order. 2. For Resident 52, the medication [NAME] C tablet (B complex) was not available for administration. This failure resulted in a medication error rate of 6.12% which had the potential to which cause complications to an already compromised residents. Findings: 1. On March 1, 2022, at 4:29 p.m., during the medication administration observation, Licensed Vocational Nurse (LVN 2) administered the following medications to Resident 54: - Sulfamethoxazole- Trimethoprim 800-160 mg (milligrams-unit of measurement) 1 tablet (used to treat infection); - Famotidine 20 mg 1 tablet (used to treat indigestion); - Metoprolol 50 mg 1 tablet (used to treat high blood pressure); - Methocarbamol 500 mg 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the appropriate diet texture was provided for one of one resident (Resident 37), when Resident 37 was having difficulty chewing food due to dental problem. This failure had the potential to negatively affect the resident's food intake which could cause a decline in nutritional health status of Resident 37. Findings: On March 1, 2022, at 8:39 a.m., Resident 37 was interviewed. Resident 37 stated he had difficulty chewing food especially if the meat served was tough. Resident 37 stated he was using his old full upper dentures and had only four teeth on the bottom. Resident 37 stated he did not have partial lower dentures. He stated he followed-up with the staff but he did not get any response. Resident 37's record was reviewed. Resident 37 was admitted to the facility on [DATE], with diagnoses that included cerebrovascular disease (interruption in the blood to cells in the brain) and mild protein calorie malnutrition (a medical condition when not…

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