Morgan Hill Healthcare Center

Based on observation, interview, and record review, the facility failed to ensure adequate safety monitoring for four of 14 sampled residents (Resident 16, 31, 37, and 38) when the wanderguard device was not checked for proper functioning. This failure had the potential for the alarm system to not work and increase the risk for elopement (leave a facility without staff knowledge). Findings: During an observation on 12/4/23 at 10:07 a.m., Resident 31 was dressed in street clothes and lying on top of his bed sleeping. There was a Wanderguard (a device that activates an alarm when a resident attempts to leave a safe area) on his right wrist. Review of Resident 31's physician order dated 1/2/22 indicated: Wanderguard on at all times, check placement to right wrist every shift. Review of Resident 31's quarterly Elopement Risk Assessment, dated 11/30/23, indicated a score of 8 (A score of 6 or more indicates that the resident should be considered High Risk for elopement.) During an observation on 12/4/23 at 10:40 a.m., Resident 38 was sitting on the edge of his bed dressed in street…

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

Based on observation, interview and record review, the facility failed to provide respiratory care in accordance with professional standards of practice for one of six residents (Resident 101) on respiratory treatment when: 1. The licensed nurse failed to ensure oxygen was administered as specified in the physician's order; 2. The facility staff failed to monitor Resident 101's shortness of breath as specified in the physician's order for more than two months. These failures had the potential to compromise Resident 101's health and safety. Findings: 1. Review of Resident 101's clinical record indicated he had diagnoses including chronic respiratory failure with hypoxia (inability to keep oxygen and carbon dioxide at normal levels), congestive heart failure (heart works less efficiently and can lead to buildup of fluid in the lungs and shortness of breath), hypertensive heart disease with heart failure (type of high blood pressure that affects the blood vessels of the heart). During an observation on 12/4/23 at 10:08 a.m., Resident 101 was lying in bed receiving oxygen at 4 liters…

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 daily staffing information posted was the current date. This failure had the potential to result in nurse staffing misinformation to the residents, family and visitors. Findings: During an initial facility rounds on 12/4/2023 at 10:30 a.m., the Census and Direct Care Service Hours Per Patient Day (DHPPD - contains daily staffing information) form was posted in front of the nurse station, dated 11/30/23. During another facility rounds on 12/5/2023 at 10:00 a.m., the DHPPD form was still posted with the same date, 11/30/23 ( 5 days past). During a concurrent observation and interview with director of nursing (DON) on 12/7/2023 at 1:14 p.m., DON reviewed the DHPPD posting. The DON confirmed the date in the DHPPD form was 12/6/2023. DON stated the posting was always the day before the current date. DON was informed of the date observed on 12/4 and 12/5/2023. The DON stated nobody updated the staffing information on a weekend. During a concurrent observation and interview with the administrator in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement infection control practices when: 1. Certified nursing assistant D (CNA D) did not perform hand hygiene when assisting two residents (Residents 16 and 24) with meals; 2. Licensed vocational nurse A (LVN A) did not perform hand hygiene in between glove changes during Resident 47's wound treatment; 3. Certified nursing assistant G (CNA G) practiced double gloving (wearing of inner and outer gloves) during Resident 47's incontinent care; and 4. Resident 10's urinary drainage bag was found lying on the floor. These failures had the potential to compromise resident's health and safety in the facility. Findings: 1. During dining observation on 12/4/2023 at 12:39 p.m., inside the dining room, Resident 24 was eating lunch using her fork. CNA D held Resident 24's fork and knife to help slice the meat on her plate. After assisting Resident 24, CNA continued feeding Resident 16 using his spoon. CNA D did not perform hand hygiene after…

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 treat two of 14 sampled residents (Resident 16 and 10) with respect and dignity when: 1. Certified nurse assistant D (CNA D) was standing while feeding Resident 16 in the social dining area; and 2. Resident 10's urinary drainage bag was not covered with a privacy bag. These failures had the potential to negatively affect resident's emotional and psychosocial well-being. Findings: Review of Resident 16's clinical record titled, admission Record, indicated resident was admitted to the facility with diagnoses including hemiplegia (paralysis of one side of the body/a severe or complete loss of strength in the arm, leg, and sometimes face on one side of the body) and hemiparesis (a relatively mild loss of strength in the arm, leg, and sometimes face on one side of the body) following cerebral infarction (also called stroke) affecting left non-dominant side, dysarthria (difficulty speaking) following cerebral infarction and vascular dementia (a…

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

Based on observation, interview, and record review the facility failed to ensure resident's care needs were accommodated for two of 14 sampled residents (Resident 47 and 40) when Resident 47 and Resident 40's call light buttons were not within reach to use. These failures had the potential to affect residents' physical and psychosocial well-being. Findings: 1) Review of Resident 47's clinical record titled, admission Record, indicated Resident 47 was admitted to the facility with diagnoses including paraplegia (a paralysis that occurs in the lower half of the body. It can be a result of an accident or a chronic condition), osteomyelitis (infection of the bone) and pressure ulcer (PU-damage to the skin caused by prolonged pressure) of sacral region (part of the body located in between the bilateral buttocks), stage 4 (PU stage with full-thickness skin loss and possible involvement of the muscle, bone, tendon or joint). During an observation and concurrent interview on 12/4/2023 at 9:30 a.m., Resident 47 was lying in bed with head of bed (HOB) elevated. Resident 47's call light button…

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 protect a resident's rights to confidentiality of protected health information (PHI, any information in the medical record that can be used to identify an individual and that was created, used, or disclosed in the course of providing a health care service such as diagnosis or treatment) when licensed nurse left the computer screen open and unattended on top of the medication cart. This failure had the potential to compromise the resident's privacy and confidentiality. Findings: During an observation on 12/5/23 at 10:05 a.m., a computer with a resident's medical record information was left opened and unattended on a medication cart in the hallway with two residents nearby potentially seeing the information. During an observation and concurrent interview with the Director of Staff Development (DSD) on 12/5/23 at 10:08 a.m., the DSD walked by the nurses' station and noticed the computer screen on top of the medication cart open. The DSD stated the Medication Administration Record (MAR, a record of medications…

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 written notification to the Office of the State Long-Term Care Ombudsman (LTCO - person who routinely visits the facility and advocates for the residents in the nursing homes) for 28 out of 31 discharged residents reviewed when: 1. Resident 49 went for dialysis and was transferred to the hospital; 2. Resident 50 was transferred to the hospital; and 3. Social service director (SSD) failed to notify the State LTCO for 26 more resident discharges in a period of 3 months (September-[DATE]). This failure had the potential to compromise the resident's admission, transfer, and discharge rights. Findings: 1. Review of Resident 49's clinical record indicated she was admitted to the facility on [DATE] with a diagnoses of hypertensive heart disease with heart failure (heart problems that occur because of high blood pressure that is present over a long time), unspecified sequelae of cerebral infarction (a result of disrupted blood flow to the brain),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to encode and transmit in a timely manner the Minimum Data Set (MDS- a tool used for resident assessment) for two of 14 sampled residents (Resident 29 and 14) when: 1. The MDS nurse (MDSN) used a wrong assessment reference date (ARD - date of the MDS assessment) for Resident 29's Skilled Nursing Facility Part A Prospective Payment System Discharge Assessment (SNF Part A PPS DC - a required assessment to determine resident's last day of skilled services and resident's current status); and 2. Resident 14's two MDS Entry Tracking's were transmitted to the Center for Medicare and Medicaid System (CMS) late. These failures resulted in wrong ARD MDS assessment submitted to CMS and Entry Tracking's not received by CMS within the time requirement. Findings: 1. Review of Resident 29's clinical record titled admission Record, indicated, Resident 29 was readmitted to the facility on [DATE] with diagnoses including ataxia (no coordination due to lose muscle control…

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

Based on observation, interview and record review, the facility failed to ensure residents at risk for pressure injuries (an area of skin that breaks down when something keeps rubbing or pressing against the skin) received care, consistent with professional standards of practice to prevent pressure injuries for one of three residents (Resident 40) at risk for pressure injuries when licensed nurses did not follow Resident 40's doctor's order to prevent pressure injuries and did not update Resident 40's care plan. These failures had the potential to result in Resident 40's development of pressure injuries. Findings: Review of Resident 40's clinical record titled, admission Record indicated Resident 40 was admitted to the facility with diagnoses including disorder of the autonomic nervous system (a dysfunction of the nerves that regulate nonvoluntary functions, such as heart rate, blood pressure, and sweating), chronic (persisting for a long time or constantly recurring) atrial fibrillation (an irregular and often very rapid heart rhythm), anxiety disorder (a mental illness that causes…

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 adequate communication with the dialysis center for one of two residents on dialysis (Resident 21), when the communication form sections which are to be filled out by the facility and dialysis center was not completed. This failure had the potential to result in Resident 21's negative health outcome. Findings: Review of Resident 21's clinical record titled, admission Record, indicated Resident 21 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus (a condition which affects the way the body processes blood sugar) due to underlying condition with foot ulcer (open sores or lesions that will not heal or that return over a long period of time), metabolic encephalopathy (an alteration in consciousness caused due to brain dysfunction) , multiple sclerosis (a disease affecting the brain and spinal cord that disrupts the communication of the brain and the rest of the body) and chronic kidney disease with heart failure (A…

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

Based on observation, interview, and record review, the facility failed to ensure controlled substance medications (those with high potential for abuse and addiction) were accurately accounted for on the Medication Administration Record (MAR) and the Controlled Drug Record (CDR) for one of three randomly selected residents (Resident 44). This failure resulted in the facility not having accurate accountability of controlled medications and potential for abuse or misuse of this medication. Findings: A review of Resident 44's clinical record indicated she had a physician's order, dated 11/8/23, for Norco (hydrocodone-acetaminophen, a controlled medication for pain) 5-325 milligrams (mg, a unit of measurement), one tablet by mouth every four hours as needed for pain. During a concurrent interview and record review on 12/7/23 at 9:29 a.m., with the Director of Nursing (DON), a review of Resident 44's CDR for Norco and the 10/2023 MAR reflected the nursing staff removed one tablet of Norco on 10/20/23 at 6 p.m., and on 10/24/23 at 9 p.m., without documenting in the MAR that they were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure the pharmacist's medication regime review (MMR) recommendations for one of 14 sampled residents (Resident 16) were acted upon. This failure had the potential to negatively affect the residents' health and well-being. Findings: 1. Review of Resident 16's medical record indicated he was admitted on [DATE] with diagnoses including major depressive disorder (a mood disorder that causes persistent feelings of sadness or loss of interest) and vascular dementia (decline in thinking skills caused by blocked or reduced blood flow to the brain). Review of Resident 16's document titled Note To Attending Physician/Prescriber, written by the consultant pharmacist (CP) and dated 4/19/23, indicated: This resident has been taking the antidepressant Zoloft 150 mg. (milligrams, unitof measurement) for depression since 12/21, please evaluate the current dose and consider a dose reduction. Review of a physician telephone order, dated 4/26/23, indicated Resident 16's…

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

Based on observation, interview and document review, the facility failed to comply with Federal and State laws, and regulations when the approval letter for staffing waiver was not posted where visitors, family and residents could easily read. This failure had the potential to result in nurse staffing misinformation about residents' care. Findings: During an observation on 12/4/2023 at 1:30 p.m., the facility's postings in a locked glass frame located at the hallway entrance included the facility's license posted but no staffing waiver letter of approval posted. During another observation of the facility's postings in a locked glass frame on 12/5/2023 at 4:05 p.m., the staffing waiver letter of approval was not posted. During a concurrent observation and interview with the facility's administrator in training (AIT) on 12/7/20023 at 2:03 p.m., the AIT reviewed all the postings in a locked glass frame located at the hallway entrance. The AIT confirmed she couldn't find the staffing waiver letter of approval. AIT stated the staffing waiver letter of approval should have been posted.…

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 that part of a handrail in the hallway was firmly affixed and secured to the wall. This failure had the potential to cause injuries to residents, staff, and visitors. Findings: During a concurrent observation and interview on 12/6/23 at 9:23 a.m., with Certified Nursing Assistant (CNA) F and CNA G, CNA F confirmed that the handrail in the hallway going to the dining area was loose and wiggly. CNA F stated the residents used the handrail to grab on for support. CNA G stated, it's loose and it should be fixed. During a concurrent observation and interview on 12/7/23 at 9:17 a.m., with the Maintenance Director (MD), the MD confirmed that the handrail was loose and stated it was missing a screw. MD stated he was not aware of the issue. During a concurrent observation and interview on 12/7/23 at 9:29 a.m., with the Director of Nursing (DON), DON confirmed that the handrail was loose. During a review of the facility's Handrails policy, dated 3/1/23, indicated The facility will equip corridors with a handrail on each side of…

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

Based on observation, interview, and record review the facility did not ensure the proper sanitization levels of the dishwasher and 2-compartment sink, when kitchen staff did not properly check the sanitizer strength in the dishwasher nor in the 2-compartment sink. This failure had the potential of causing a facility-wide food borne illness. Findings: During an observation and concurrent interview on 6/28/22 at 8:39 a.m., with a cook (Cook I), [NAME] I stated, the cook in the morning needs to checks washer sanitizer. Water temp should be 140F degrees , it is 119F degrees. [NAME] I ran the dishwasher twice, the temperature was at 120F degrees. [NAME] I tested the dishwasher sanitizer by holding test paper in the sanitizer water for 10 seconds, which she confirmed, then read the results. During an observation and concurrent interview on 6/28/22 at 10:53 a.m. with [NAME] I, [NAME] I stated, we don't check the sanitizer for the compartment sink. The sanitizer is added one Tbs of sanitizer per gallon of water, which she pointed to a cup, indicated a small amount. [NAME] I was not sure…

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

Based on observation, interview and record review, the facility failed to implement their infection control practices and precautions when: 1. Facility staff did not ensure visitors were thoroughly screened for signs and symptoms of Covid-19 (an acute respiratory illness in humans caused by a coronavirus, capable of producing severe symptoms and in some cases death, especially in older people and those with underlying health conditions) and did not give directions on screening; 2. Facility staff did not clean and disinfect the thermometer in the screening area after each use; and 3. One facility staff did not perform hand hygiene before glove use. These failures have the potential to spread infection and to compromise the health and well-being of the residents in the facility. Findings: 1. During an observation on 6/27/2022 at 8:37 a.m., surveyors were in the main entrance lobby. Licensed vocational nurse F (LVN F) asked for surveyors' vaccination status but did not screen surveyors for signs and symptoms of Covid-19, no instructions on screening and did not take surveyor's…

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

Based on observation, interview and record review, the facility failed to ensure four controlled medications ( medications included in the Drug Enforcement Administration) which are subject to special handling, storage, disposal and record keeping in the facility) had been accurately accounted for in the two of two medication carts checked when the amount of medications counted from the blister cards (a pharmacy-prepared paperboard with medications in individual doses that can be punched out of the card when administered) were not consistent with the narcotic count sheet for three controlled medications, and one controlled medications was signed out before dispensing and administering the medication to resident. These failures had the potential to create problems related to accounting of controlled medications. Findings: During an inspection of medication cart # 1 (Men's side) with licensed vocational nurse C (LVN C) on 6/27/22 at 9:18 a.m., LVN C stated at the start of each shift, two nurses (incoming and outgoing nurses) should count the controlled drugs and affix their signatures…

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 12 sampled residents (Residents 20, 25 and 29) were free from unnecessary psychotropic medications (drugs that affects brain activities associated with mental processes and behaviors, example is antipsychotics) when: 1. Resident 20 had no informed consent signed prior to the administration of Duloxetine (Cymbalta, antidepressant). 2. Resident 25 did not have a documented clinical rationale or justification for the continued use of Olanzapine (antipsychotic- medication used to manage psychosis including delusion or hallucinations)when the recommended GDR was declined by her primary care physician (PCP). 3. Resident 29, did not have an informed consent signed for the dose increase of Seroquel (used to treat certain mental/mood disorders) from 50mg. ( milligrams, unit of measurement) to 75mg. per day. These failures resulted in the unnecessary use of psychotropic medications. Findings: 1. A review of Resident 20's clinical record indicated…

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

Based on observation, interview, and record review, the facility failed to prepare the puree meals to meet the nutritive value needed for 9 of 9 residents who receive a puree diet, when: 1. the cook added water and thickener to the pureed vegetables, 2. the bread and cake, which were on the menu, were not pureed nor served to the residents who are on a puree diet. These failures had the potential of the residents who received a puree diet to not receive the appropriate nutrients/calories. Findings: During an observation on 6/28/22 at 11 a.m. of kitchen cook (Cook H), after cooking the Italian blend vegetables, [NAME] H drained the vegetables using a colander. He then added less than one cup of water to five scoops of the vegetables and blended it. [NAME] H then placed five scoops of vegetables into robot coupe, added 2 cups water, and blended it. It was runny. He then added 4 scoops of vegetables to robot coupe, blended them, did not added any water. This came out thick thick, used spatula to scoop into container with other pureed veggies, whisked to blend, added thickener, about…

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 1. properly label the arrival and/or open date of foods in the kitchen and 2. to keep MedPass formula at proper temperature, when - onions were in a clear bin unlabeled, - three clear containers of pastas were unlabeled, - four open boxes of breakfast cereal were unlabeled, - packets of hot chocolate mix and low calorie instant lemon drink were unlabeled, and - containers of MedPass formula were on medication carts for extended periods without proper refrigeration. These failures had the potential of causing food-borne illness. Findings: 1. During an observation and subsequent interview on 6/28/22 at 8:31 a.m., with the dietary supervisor (DS). It was observed that a clear plastic container containing onions did not have a delivery date on it. DS stated, the clear container of onions needed a date on the outside. During an observation and subsequent interview on 6/28/22 at 9:03 a.m., with DS, there were three containers with pastas without any date on them, four opened boxes of cereal without a date on them, a container…

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 Resident 20's personal request to have a darker window cover/blinds/shades to prevent eye glare, and to have a over bed light cord string were accommodated; and facilty failed to honor Resident 20's food preferences. These failures resulted in Resident 20's discomfort, and feeling stressed and irritated; and had the potential to result in patient not being able to maintain or achieve independent functioning, dignity, and well being to the extent possible in accordance with the resident's own needs and preferences. Findings: A review of Resident 20's facesheet included diagnoses of sleep disorder, seizures, glaucoma (eye disease that can cause vision loss and blindness) and macular degeneration (an eye disease that can blur the person's central vision). Her care plan on Impaired visaul function, dated 1/8/22 included intervention to provide lighting that avoid glare. 1. During an observation and concurrent interview with Resident 20 on 6/27/22 at 1:48 p.m., Resident 20 was awake, lying in bed. 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.

Based on interview and record review, the facility failed to follow their policy and procedure to notify the Office of the State Long-Term Care Ombudsman of Resident 29 being transferred twice to the hospital. This failure had the potential of Resident 29 being incorrectly transferred. Findings: During a review of Resident 29's electronic record (eRecord), Resident 29 had been transferred to the hospital on 7/29/2020 and again on 11/12/21. During an interview on 6/30/22 at 11:52 a.m. with social services staff (SS), SS stated Ombudsman is supposed to be notified of residents being transferred to the hospital. During an interview on 6/30/22 at 1:25 p.m. SS stated she could not find either notice from Resident 29's transfers to the hospital, which should have been sent to Ombudsman. During a review of the facility's policy and procedure titled, Transfer or Discharge Notice, revised 03/21, the policy and procedure indicated, Residents and/or representatives are notified in writing, and in a language and format they understand . a. Transfer refers to the movement of a resident from 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 interview and record review, the facility failed to develop and update the care plans for three of 12 sampled residents (Residents 14, 20 and 28). For Resident 14, there was no care plan developed for scattered skin rashes on her several body parts. For Resident 20, there was no care plan developed for Cymbalta (antidepressant); and the care plan was not revised/updated or implemented for depression to reflect the change of medications, and ambulation. For Resident 28, there was no care plan developed regarding the presence of left eye conjuntivitis; the care plan for impaired visual function was not implemented. A personalized care plan identifies residents' individualized concerns/needs that outlines the care and services needed to meet their needs. Findings: Resident 14 was in bed with During an observation on 6/27/22 at 11:01 a.m., certified nursing assistant H (CNA H) was present in the room with Resident 14 and observed the resident rubbing her back against the sheets and mattress. CNA H noticed…

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 care and services according to professional standards of practice for two of 12 sampled residents (Residents 19 and 40). When Resident 19's Depakote (medication to treat certain seizures, mania caused by bipolar disorder) level every 6 months and Resident 40's EKG (electrocardiogram, measures the heart's electrical activity) every 6 months while on Nuplazid (indicated for the treatment of hallucinations and delusions associated with Parkinson's disease psychosis) were not done as ordered. These failures could negatively affect the resident's health, safety, and well-being in the facility. Findings: Review of Resident 19's, clinical record, indicated she was admitted with Schizoaffective disorder (a condition that can make you feel detached from reality and can affect your mood), psychotic disorder with hallucinations (mental disorders in which a person's personality is severely confused and that person loses touch with reality), paranoid personality disorder (mental health condition marked by a pattern of distrust…

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 A review of Resident 28's facesheet indicated admission on [DATE]. Her MDS dated [DATE] and 5/5/22 indicated impaired vision and difficulty hearing. During an observation on 6/27/22 at 10:09 a.m., Resident 28 was in bed awake, watching TV without any sounds. Resident 28 claimed she had no hearing aid and had difficulty with hearing but could not turn the TV loud enough to hear because the facility would not allow it. Resident claimed she could not reach for her headphones which were hung near the TV set and staff did not offer it to her. Resident 28 also indicated she loved reading books, and she stated, I can't read because of the problem in my eyesight. Resident 28 stated she and her daughter were concerned about her eye and wanted to see the eye specialist. During the concurrent interview with certified nursing assistant G (CNA G) who was at bedside, CNA G validated Resident 28 was not wearing her hearing aid and offered the headphones but she could not make it work. During a record review and concurrent…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to consistently provide a restorative nurse assistant (RNA) program (nursing intervention to assist or promote resident's ability to attain their maximum functional potential) for two residents (20, 28). These failures had the potential to compromise the residents' ability to attain their maximum functional potential and result in a decline of resident's health. Findings: Review of Resident 20's clinical record indicated she was admitted with diagnoses including hemiplegia (paralysis of one side of the body) and hemiparesis (weakness of one side of the body), and muscle weakness. Her admission minimum data set (MDS, an assessment tool) dated 1/6/22 indicated she had functional limitation in range of motion with impairment on both sides of upper and lower extremities, and resident and direct care staff believed she was capable of increased independence in at least some ADLs (activities of daily living, i.e bed mobility, transfer, dressing,…

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 proper functioning of a wander guard (a device worn on a resident or their mobility equipment to warn staff of resident possibly leaving the facility) for one resident (Resident 32). This failure has the potential of a resident eloping (leaving the facility without staff's knowledge), and potentially being harmed or killed. Findings: During a review of Resident 32's electronic record (eRecord) on 6/27/22 4:15 p.m., Resident 32's eRecord indicated that he had eloped on 4/26/22, and was found by sign board by staff. Resident 32 was at high risk for elopement. During an interview on 6/29/22 at 4:01 p.m. with the director of nursing (DON), DON stated, Resident 32 eloped. Afterward, he started using a wander guard. The wander guard should be checked weekly. DON stated, she did not see a schedule for checking the wander guard in the physicians orders. During an interview on 6/30/22 at 11:35 a.m., DON stated, physicians orders were started after you pointed them out to me. DON stated, checks for wanderguard,…

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 licensed pharmacist performed a monthly Medication Regimen Review (MRR) for one of four residents (Resident 29) when Resident 29 was missing some monthly MRRs. This failure had the potential of residents being administered incorrect medications. Findings: During an interview on 6/30/22 at 2:36 p.m., with the director of nursing (DON), DON stated, in 12/2020 we were in a full COVID outbreak, so no, the pharmacist did not do a MRR. DON stated, the facility had a temporary pharmacist, but we were not introduced to them. During a review of Resident 29's eRecord and the binder for the facility's MRR, both records indicated, Resident 29 did not have a MRR for: 12/2020, 5/2021, 10/2021, 11/2021, 4/12/22, 5/13/22. The facility was not able to provide a copy of a MRR for those months. During an interview on 7/01/22 at 11:17 a.m., with the consultant pharmacist, (CP), CP stated, she performed a MRR on 12/2020, 4/2022, and 5/2022.

Based on observation, interview, and record review, the facility had a 7.14% (percent) error rate when two medication errors out of 28 opportunities were observed during a medication pass. These failures resulted in the medications not being administered according to the physician orders and the manufacturer's specifications. Findings: A review of Resident 8's physician order dated 4/25/22 indicated Insulin Aspart Solution 100 units/ml. (milliliter, units of measurement), inject 8 units subcutaneously (under the skin) before meals for type 2 diabetis mellitus( a disorder in which the body does not produce enough or respond normally to insulin, causing blood sugar levels to be abnormally high). During the medication pass observation on 6/28/22, at 4:54 p.m., licensed vocational nurse A (LVN A) prepared Resident 8's medication of Aspart insulin (medication to lower blood sugar) and was about to administer to Resident 8. When LVN A rechecked the insulin syringe, LVN A verified the syringe contained 7 units and she had to add one more unit to complete the correct dose of 8 units. During…

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 licensed nurses stored, disposed/discard medications per manufacturer's recommendations when: 1. One multi-dose vial of tuberculin solution (drug use to help diagnose tuberculosis)was dated when opened. 2. One pack of Tylenol (analgesic and antipyretic-for fever) suppository (inserted via rectum) was not stored together with Refresh eye drops (drug used to lubricate dry eyes). 3. One bottle of Fluticasone nasal spray (drug used to relieve symptoms of rhinitis such as sneezing and a runny, stuffy nose) opened on 5/18/22 was disposed/discarded from the medication cart. 4. One container of Breo Ellipta (drug used for asthma) 100-25 mcg. (micrograms, unit of measurement) inhaler opened on 4/10/22 , marked by pharmacy discard after 42 days from opened date was disposed beyond the discard date. 5. The medication refrigerator's temperature was not checked and recorded twice per day per facility's guidelines when storing testing solution (i.e. tuberculin solution). These failures had the potential of…

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

Based on observation, interviews and record review, the facility failed to ensure the Resident' 20s food allergy was considered, and dislikes were followed. This failure could compromise and affect Resident 20's clinical condition and could potentially result in complications. Findings: A review of Resident 20's Order Summary Report included allergies such as fish, bean, pineapple .etc. Her dietary indicated she was allergic to beans and dislikes carrots. During a lunch observation on 6/28/22 at 12:50 p.m., certified nursing assistant G (CNA G) provided Resident 20's lunch tray with some beans mixed in the food served. It also included cooked vegetables and carrots. This observation was validated by CNA G. During the concurrent interview, Resident 20 stated she was allergic to beans and would not eat carrots at all. Resident 20 claimed staff continued to provide her with food that included beans and carrots and she would just set them aside. Resident also claimed the staff were aware she does not want carrots. During the interview and concurrent record review with the registered…

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