Camino Ridge Post-Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the proper care and treatment services for oxygen (O2, a colorless, odorless gas) use was provided for four of seven sampled residents (Residents 42, 155, 303, and 40) when: 1. Resident 42's O2 concentrator's (a device which concentrates the oxygen from ambient air) filter had a grayish substance build-up and there was no Oxygen in Use/No Smoking sign posted at the entrance or door of Resident 42's room; 2. Resident 155's oxygen concentrator's filters were dusty; 3. Resident 303's door or entance there was no sign posted for Oxygen in Use/No Smoking; and 4. Resident 40's door or entance there was no sign posted for Oxygen in Use/No Smoking. These deficient practices had the potential for the residents to have complication related to improper treatment while receiving O2 therapy. Findings: 1. Review of Resident 42's clinical record titled, admission Record, dated 3/28/2025, indicated Resident 42 was admitted to the facility with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of two residents (Resident 91) who received dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) treatment received care in accordance with professional standards of practice when: 1. Staff did not follow Resident 91's fluid restriction (limiting liquids) order; 2. There was no documentation of Resident 91's fluid intake each shift for staff to determine if Resident 91 have met the fluid restriction order; and 3. There was no record of Resident 91's intake and output (I&O - the measurement of the fluids and food that enter [intake] and leave [output] the body) monitoring. This deficient practice had the potential to result in Resident 91's fluid overload (a condition where there is an excessive amount of fluid in the body) or dehydration (a condition that occurs when the body loses more fluids than it takes in, resulting in a lack of water in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and document review, the facility failed to ensure the licensed nursing staff employed at the facility had appropriate competencies, and skill sets related to intravenous (IV, to deliver a medication into a vein) therapy to ensure the residents with peripherally inserted central catheter (PICC, a long, thin tube that's inserted through a vein in the arm and passed through to the larger veins near the heart, used for long term IV medication administration) lines received safe and appropriate medical care to attain or maintain the highest practicable physical, mental, and psychosocial well-being. There were 2 residents with PICC lines admitted to the facility at the time of the survey. This failure could compromise the safety and quality of care for the two residents. Findings: During an interview on 3/28/25 at 9:07 a.m., the DON stated he had been working at the facility for five weeks. The DON stated he was responsible for competency evaluations and the ongoing education program through…

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 accurate accountability of controlled drugs (medications that can be easily abused and are under strict government control) and document medication administration in accordance with the facility policy and procedures (P&P) for three out of four residents (Resident 38, Resident 56, and Resident 59). This failure had the potential for medication errors and controlled drug abuse or diversion (when healthcare providers obtain or use prescription medicines illegally). Findings: 1. During a review of Resident 38's clinical record, it indicated Resident 38 was admitted to the facility with diagnoses including bipolar disorder (mental disorder characterized by periods of elevated mood and depression, often with poor decision-making). During a review of Resident 38's physician's order, dated 2/18/25, it inlcuded order for morphine sulfate (controlled medication for pain) tablet 15 mg (milligram, unit of measurement), 1 tablet by mouth every 12 hours as needed for severe pain. During a concurrent interview and record review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to act upon the facility's Consultant Pharmacist's (CP) recommendations during the Medication Regimen Review (MRR, a monthly thorough evaluation by the consulting pharmacist of a resident's medication regimen, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) to address the recommendation/ irregularities for the month of December 1, 2024 to January 31, 2025's MRR for 2 of 4 sampled residents (Resident 2 and 32). This deficient practice had the potential to result in adverse medication outcomes and for potential unnecessary medications for Resident 2 and Resident 32. Findings: 1. During a review of Resident 2's medical record, it indicated Resident 2 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including bipolar disorder (mental disorder characterized by periods of elevated mood and depression, often with poor decision-making), gout…

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, interviews, and record review, the facility failed to ensure two out of 18 sampled residents (Resident 68 and Resident 38) were free from unnecessary psychotropic (drugs that affects brain activities associated with mental processes and behavior) medications when: 1. Resident 68 continued to receive Quetiapine (a type of drug [antipsychotic] used to treat symptoms of psychosis) without an updated abnormal involuntary movement scale (AIMS - a clinical rating scale used to assess the severity and frequency of involuntary movements, such as those that can occur as a side effect of certain medications, such as antipsychotics) completed, and there were no non-pharmacological interventions (treatments or strategies that aim to improve health or manage conditions without using medications, focusing instead on physical, psychological, or behavioral approaches) implemented for Resident 68's Quetiapine use; and 2. Resident 38 received Quetiapine without target behavior monitoring. These failures had…

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

Based on observation, interview and record review, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food safety when: 1. Insulated food covers used for food service were stacked and stored wet; 2. There were unlabeled and undated food items in the reach-in refrigerator. These failures had the potential to cause food contamination and food-borne illness to 89 of 90 residents who received their food from the kitchen. Findings: 1. During an initial tour of the kitchen on 3/24/25 at 9:15 a.m., accompanied by the dietary manager (DM), there were 36 insulated plate covers observed to be stacked on a metal wire rack. The insulated plate covers were stacked inside of one another and were wet inside and outside of the plate covers' surfaces. The DM confirmed the insulated plate covers were wet and she stated they should have been air dried before being stacked and stored. According to the 2022 Food and Drug Administration (FDA) Food Code, Section 4-901.11 Equipment and Utensils, Air-Drying Required, After cleaning…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and facility's document review, the facility failed to implement infection control measures when: 1. Resident 73's nebulizer equipment was left uncovered and undated; 2. Certified nursing assistant L (CNA L) was wearing gloves in the hallway after resident care; 3. Certified nursing assistant N (CNA N) was wearing gloves in the hallway after resident care; 4. Resident's used basins were unlabeled and stored on top of bathroom toilet's tank; 5. There was no enhance barrier precautions (EBP - an infection control strategy, focusing on the targeted use of gown and gloves during high-contact resident care activities [such as dressing, bathing, transferring, changing linens, etc.] to reduce the spread of multidrug-resistant organisms [MDROs] in nursing homes) signage by the door and no isolation cart right outside Resident 11's door entrance; 6. Resident 15's urine bag (also called urine drainage bag, is a bag connected to a catheter or sheath that collects urine drained from the…

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

Based on observation, interview, and record review, the facility failed to promote and maintain resident dignity during mealtime for one out of two residents (Resident 49) when Certified Nursing Assistant B (CNA B) was standing while providing feeding assistance to Resident 49 during meal. This failure had the potential for violation of the resident's dignity. During an observation in Resident 49's room on 3/24/25 at 12:33 p.m., with Certified Nursing Assistant B (CNA B), during lunch, CNA B was observed standing while providing feeding assistance to Resident 49. Resident 49 was lying on his bed, the head of the bed was elevated, the meal tray was on top of bedside table across the bed, Resident 49 was not at eye level with CNA B. CNA B was standing, holding the spoon with food and bringing to Resident 49's mouth. During an interview on 3/24/25 at 1:03 p.m., with CNA B, she confirmed the observation. CNA B stated she was standing because there was no chair inside Resident 49's room. During a review of Resident 49's clinical record indicated Resident 49 was admitted to the facility…

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

Based on observation, interview, and record review, the facility failed to ensure a significant change in status assessment (SCSA) was completed within 14 days after a significant change in the resident's physical or mental condition had been determined for one of 18 sampled residents (Resident 11). This failure had the potential of not providing the appropriate care and services to Resident 11. Findings: Review of Resident 11's clinical record titled, admission Record, dated 3/27/2025, indicated Resident 11 was admitted to the facility with diagnoses of nondisplaced supracondylar fracture without intracondylar extension of lower end of left femur (broken thigh bone [femur] just above the knee, where the bone is broken but remains in its normal alignment, and the fracture doesn't extend into the knee joint), type 2 diabetes mellitus (a condition which affects the way the body processes blood sugar), dementia(a group of symptoms affecting thinking and social abilities interfering with daily functioning), other chronic (something that continues over an extended period of time) 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 interview and record review, the facility failed to ensure a baseline care plan was completed within 48 hours of admission for one of two residents (Resident 50). This failure had the potential for the resident and/or responsible party (RP) to be unaware of the plan of care. Findings: During a review of Resident 50's clinical record, it indicated Resident 50 was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease (a disease that include symptoms of slowness of movements, muscle rigidity, involuntary tremors/shaking and impaired balance and posture) and history of falling. During a review of Resident 50's care plan admission Baseline it was initiated on 3/25/25. The admission baseline care plan was developed six days after Resident 50 was admitted to the facility on [DATE]. During a review of Resident 50's interdisciplinary team (IDT- a group of health care professionals from diverse fields who work toward a common goal for residents) admission assessment dated , 3/20/25 was…

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

Based on observation, interview, and record review, the facility failed to ensure care plans were reviewed and updated by the interdisciplinary team (IDT, a group of health care professionals from diverse fields who work in a coordinated fashion toward the common goal for the resident for two of 18 sampled residents (Residents 11 and 68) when: 1. Resident 11's fall, activity and pain care plans were not updated after a significant change in status; and 2. Resident 68's care plan for antipsychotic (a type of drug used to treat symptoms of psychosis) use was not updated. This deficient practice had the potential to compromise resident's health, safety and psychosocial well-being. Findings: 1. Review of Resident 11's clinical record titled, admission Record, dated 3/27/2025, indicated Resident 11 was admitted to the facility with diagnoses of nondisplaced supracondylar fracture without intracondylar extension of lower end of left femur (broken thigh bone [femur] just above the knee, where the bone is broken but remains in its normal alignment, and the fracture doesn't extend into the…

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

Based on observation, interview, and record review, the facility had a medication error rate of 6.67% when two medication errors occurred out of 30 opportunities during the medication administration for two out of nine residents (Resident 26 and Resident 155). The failures resulted in the nursing staff not following physician's orders and the facility's policy and procedures (P&P), which had the potential for the residents not receiving the medications full therapeutic effects, and could also result to complications of the medications. Findings: 1. During the medication administration observation on 3/24/25 at 4:42 p.m., Registered Nurse H (RN H) was observed preparing and administering 2 medications, tablet and one liquid supplement to Resident 26. Included in the medications was carvedilol (class of medications called beta-blockers. It works by relaxing blood vessels and slowing heart rate to improve blood flow and decrease blood pressure) 3.125 mg (milligram, unit of measurement). RN H checked the blood pressure (BP) on Resident 26's right arm using manual BP apparatus (a machine…

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 medication storage and labeling of medications when one expired insulin vial was not removed from active stock and opened multi-dose vials/inhalers had no open date. These failures had the potential for residents to receive medications with reduced efficacy. Findings: 1. On [DATE] at 11:39 a.m., an inspection of the medication cart 1 with Licensed Vocational Nurse C (LVN C) identified one opened multi dose vial of insulin dated [DATE]. LVN C confirmed this finding and stated the insulin vial opened date [DATE] should be discarded after 28 days. A review of the manufacturer's label for the insulin Novolin N vial indicated Storage conditions and expiration dates, in-use (opened) room temperature 42 days. During an interview on [DATE] at 4:03 p.m., with the Director of Nursing (DON), the DON stated, the insulin opened, date [DATE] should not be used and should be discarded because of the effectiveness. During a review of the…

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

Based on observation, interview, and record review, the facility failed to follow their Antibiotic Stewardship Program for two of 18 sampled residents (Residents 68 and 301) when: 1.Resident 68 received two different antibiotics (medications that kill or inhibit the growth of bacteria) to treat pneumonia (an infection/inflammation in the lungs) and urinary tract infection (UTI- an infection in the bladder/urinary tract) without provider's full assessment and the diagnostic test performed indicated Resident 68 was negative for the mentioned infections; and 2. Resident 301 was prescribed with topical (medication or treatment applied directly to the skin or body surfaces) antibiotics without a stop date. These failures had the potential to increase the prevalence of multi-drug resistance organism or bacteria. Findings: 1.Review of Resident 68's clinical record titled, admission Record, dated 3/26/2025, indicated Resident 68 was readmitted to the facility with diagnoses including dementia, severe, with other behavioral disturbance (unusual, disruptive, or problematic behaviors that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 91) received pneumococcal (common bacteria that can affect different parts of the body) vaccination. This failure resulted in Resident 91's positive chest x-ray (a diagnostic test used to generate images of tissues and structures inside the body) result of pneumonia (an infection/inflammation in the lungs) during the facility stay. Findings: Review of Resident 91's clinical record titled, admission Record, dated 3/27/2025, indicated Resident 91 was admitted to the facility on [DATE] with diagnoses including end stage renal disease (ESRD - irreversible kidney failure), type 2 DM with diabetic neuropathy (with nerve damage), congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), and dependence on dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly). Review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure updated Coronavirus Disease 2019 (COVID-19, a highly contagious respiratory illness in humans capable of producing severe symptoms) 2024-2025 vaccination (a way to create immunity to [protection from] diseases) was offered to two of five sampled residents (Residents 15 and 35). This deficient practice placed Resident 15 and Resident 35 at risk for COVID-19 infection and had the potential to result in the spread of infection placing residents, staff, and visitors at risk to be infected with COVID-19. Findings: 1.Review of Resident 15's clinical record titled, admission Record, dated 3/26/2025, indicated Resident 15 was re-admitted to the facility on [DATE] with diagnoses including paraplegia (the inability to voluntarily move the lower parts of the body), type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) with other diabetic kidney complication, essential hypertension (HTN-high blood…

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 abuse policy for five of seven allegations of abuse: 1. Resident 1 had altercations with three residents (Residents 2, 3, and 4) over a four-month period. After Resident 1 and Resident 2 had an altercation on 11/16/23, the residents' care plans were not revised and there were no documented interventions to prevent future occurrences. After Resident 1 and Resident 4 had a verbal altercation on 2/15/24, the residents' care plans were not revised and there were no documented interventions to prevent recurrence between the two residents. On 2/17/24, Resident 1 and Resident 4 had a physical altercation, which caused injury to Resident 4's leg. 2. After Resident 5 allegedly hit Resident 6's hand, Resident 5's care plan was not revised and there was no documentation that indicated the interventions implemented to prevent possible future altercations. 3. The facility's investigative report regarding Resident 7's allegation of abuse was not sent to the California Department of Public Health (CDPH) within five working…

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 services were provided to meet professional standard of practice for one of three residents (Resident 1) when: 1. Licensed nurse A (LN A) did not check the vital signs and document the characteristics of the pain for Resident 1's during pain assessment, 2. LN A did not follow-up with Resident 1's physician regarding request for the order for pain medication, 3. Facility LNs did clarify with physician regarding Resident 1's pain management plan, and 4. Resident 1's nursing weekly summaries were not done consistently. These failures had the potential to compromise Resident 1's health and safety. Findings: 1. Review of Resident 1's medical record indicated diagnoses that included compression fracture of fourth lumbar vertebrae (one or more bones weaken and crumple in the spine), radiculopathy lumbar region (inflammation of the nerve root in the lower back), sciatica (compression of a spinal nerve root in the lower back), low back pain, calculus 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 promote care in a manner that maintain resident dignity and respect for one of two residents (Resident 1) when certified nursing assistant C (CNA C) told Resident 1 to urinate in diaper instead of assisting her to the bathroom. This failure had the potential to affect Resident 1's self-esteem and feel less self-worth that may lead to emotional distress. Findings: Review of Resident 1's medical record indicated diagnoses that included compression fracture of fourth lumbar vertebrae, radiculopathy (lumbar region), sciatica, low back pain, calculus of gall bladder with chronic cholecystitis, diaphragmatic hernia, diabetes mellitus, neuralgia, neuritis, and depression. Review of Resident 1's minimum data set (MDS, a resident comprehensive assessment and care screening tool) dated 9/28/23 indicated her brief interview for mantal status' (BIMS) score was 8 (a score of 8-12, means resident cognition is moderately impaired). She can understand others and make…

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 responsible party (RP, a person who makes healthcare decisions on patient's behalf) as soon as practicable of the hospital transfers due to fall for one of three residents (Resident 1). This failure resulted in Resident 1's RP not being informed and had the potential for Resident 1's RP's non-involvement in the urgent healthcare decision that may compromise Resident 1's health and safety. Findings: Review of Resident 1's medical record indicated, Resident 1 had an incident of witnessed fall on her room on 12/21/23 at 5:00 p.m. Resident 1 claimed she hit her head on the floor. Resident 1's physician was notified on 12/21/23 at 7:00 p.m. Resident 1 was transferred to the hospital for further evaluation and treatment as ordered by the physician. Resident 1 came back to the facility same day on 12/21/23. Further review of the Resident 1's medical record on 1/24/24 at 10:32 a.m. indicated, Resident 1's RP was notified the next day on 12/22/23 at…

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 resident's minimum data set (MDS, a resident comprehensive assessment and care screening tool) accurately reflected the actual resident's condition status for one of two residents (Resident 1) on two MDS assessments completed. This failure had the potential to affect the care provided for Resident 1. Findings: Review of Resident 1's medical record indicated diagnoses that included legal blindness (a level of visual impairment that limits the activities performed by individuals without assistance). Review of the MDS on 1/24/24 indicated Resident 1's vision status was coded adequate on 6/28/23 and 9/28/23. During an interview with the certified nursing assistant D (CNA D) on 2/20/24 at 2:23 a.m., she stated Resident 1 cannot see well and sometimes needed verbal cueing during activities of daily living (ADLs). During an interview with licensed nurse E (LN E) on 2/21/24 at 2:10 p.m., he stated Resident 1's vision was impaired. 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 interview and record review, the facility failed to promote appropriate services to achieve or maintain as much as normal bladder function as possible when certified nursing assistant C (CNA C) encouraged one of two sampled residents (Resident 1) to urinate in diaper. This failure had the potential to result in losing and declining the current bladder function for Resident 1 that may lead to skin breakdown and urinary infection. (Cross reference to tag F550) Review of Resident 1's medical record indicated diagnoses that included diabetes mellitus (a group of diseases that result in too much sugar in the blood), compression fracture of fourth vertebrae (one or more bones weaken and crumple in the spine), and radiculopathy of lumbar region (inflammation of the nerve root in the lower back). Review of the Resident 1's minimum data set (MDS, a resident comprehensive assessment and care screening tool) dated 6/28/23 and 9/28/28 indicated Resident 1 is frequently incontinent of bladder function. 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 interview and record review, the facility failed to ensure a request for documents was fulfilled in a timely manner when the facility did not provide the requested documents to Resident 1's responsible party (RP, the individual that make medical and healthcare decision on behalf of the client) within the timeframes specified in their policies. This failure had the potential to cause undue concern and anxiety on behalf of the Resident 1 ' RP. Findings: Review of Resident 1 ' s medical record indicated he was originally admitted to the facility on [DATE] and was discharged on 5/11/23. Review of the Resident 1 ' s interdisciplinary team (IDT, professional disciplines, as appropriate, will work together to provide the greatest benefit for the resident) meetings dated 9/20/20, 12/27/21, 3/29/22 and 6/29/22 indicated Resident 1 ' s daughter is the RP. During an interview with the facility ' s business office personnel (BOP) on 11/21/23 at 9:42 a.m., the BOP confirmed receiving an e-mail message around first…

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 care and services in accordance with the facility's policy and procedures (P&Ps) for four of 20 sampled residents (Residents 20, 34, 67, and 311) and four non-sampled residents (Residents 298, 305, 310, and 350) when: 1. Nursing staff failed to inform the physician when medications were not available for Resident 20 and Resident 298; 2. The nursing staff documented they administered the calcium acetate (medication to prevent high blood phosphate levels in patients who are on dialysis due to severe kidney disease) to Resident 20 when they did not have the medication available to administer; 3. For Resident 350, the nursing staff held the medication seven times while there was no physician's order to hold, and did not inform the physician of the held medication; 4. A nursing staff prepared Residents 305 and 310's medications for administration at the same time; 5. Resident 67 received oxygen administration without a physician'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure routine medications were available for administration for two of 20 sampled residents (Residents 20 and 34) and one non-sampled resident (Resident 298); and failed to ensure accurate accountability of controlled medications (those with high potential for abuse and addiction) for three of four random sampled residents (Residents 39, 74, and 80), when: 1. Resident 298 did not receive three of her routine medications, as prescribed, for six days; 2. Resident 20 did not receive Creon (a pancreatic enzyme replacement therapy for patients with pancreatic problems) for 12 days, and calcium acetate (medication to prevent high blood phosphate levels in patients who are on dialysis due to severe kidney disease), as prescribed, for almost two months; 3. Random controlled medication audit for Residents 39, 74, and 80 did not reconcile. The medications were signed out of the Count Sheet (a controlled drug record, an inventory sheet that keeps…

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 interviews and record review, the facility failed to ensure three of 20 sampled residents (Residents 20, 22, and 67) were free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behaviors). Resident 67 received an antipsychotic medication and medication to treat high cholesterol without monitoring for lipid panel; Resident 22 received clozapine (an antipsychotic medication) which requires monthly blood count monitoring but did not get one for almost two months; and Resident 20 received medications for bipolar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs) and depression without monitoring for specific target behaviors for these conditions. The failure resulted inadequate monitoring for potential adverse consequences (such as side effects) and effectiveness of the medications for the residents. Findings: 1. A review of Resident 67's clinical record indicated he 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.

Based on observation, interview, and record review, the facility had a medication error rate of 15.22% when seven medication errors occurred out of 46 opportunities during the medication administration observation for three of seven residents (Residents 71, 298, and 350). Resident 298 did not receive three routine medications as prescribed, and a wrong dose of docusate sodium (DSS, medication to regulate bowel movement). Resident 350's spironolactone (a diuretic to remove fluid from the body) was held (not given) without a prescribed hold parameter, and received levothyroxine (a thyroid medication) not in accordance with the manufacturer's guidelines. Resident 71 received iron sulfate (to treat iron deficiency anemia) not in accordance with the doctor's order and accepted professional standards of practice. The failure had the potential for the residents not receiving the full therapeutic effect of medications or adverse affects, compromising the residents' health. Findings: 1. During a medication administration observation with Registered Nurse (RN) F on 10/23/23 at 8:21 a.m., 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 observation, interview, and record review the facility failed to ensure safe and sanitary food service operations were carried out according to standards of practice when: 1. Expired foods were found in one of the kitchen refrigerators and the dry storage room; 2. The food preparation sink and the dishwashing sink drains did not have air gaps (an unobstructed vertical space between the water outlet and the flood level of a fixture), and food preparation sink drain was leaking; and 3. Multiple cutting boards with dust and stains stored under the food preparation sink. These failures had the potential to expose 96 of 97 residents to harmful contaminants that could cause foodborne illness. Findings: 1. During a concurrent observation and interview on 10/23/23 at 8:09 a.m. with the Dietary Consultant (DC) in the kitchen, there was a pitcher of iced tea with use by date of 10/22/23 in the refrigerator that stored milk and juice. The DC confirmed the use by date, and stated the iced tea should have been removed from the refrigerator. 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 observation, interview, and record review, the facility failed to ensure infection control practices were implemented when: 1. A Certified Nursing Assistant failed to perform hand hygiene when entering different residents' rooms to place and set up lunch trays, 2. A licensed nurse used unclean gloves to inject insulin for Resident 20, 3. A licensed nurses did not perform hand hygiene between glove changes during medication administration for Resident 34, These failures could result in the spread of infection and cross-contamination that could affect the 97 residents in the facility. Findings: 1. During an observation and concurrent interview with Certified Nursing Assistant (CNA) L in Station 2 on 10/23/2023 at 12:12 p.m., CNA L was observed entering five different residents' rooms to place and set up lunch trays without performing hand hygiene between rooms and residents. CNA L confirmed the above observation and acknowledged that she should have sanitized her hands to prevent infections. 2. A review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement their policy on self-administration of medication (resident takes medication without staff assistance) and bedside medication storage for two of 20 sampled residents (Resident 7 and 297) when: 1. For Resident 7, the facility did not ensure self-administered medications were stored in a safe and secure place; 2. For Resident 297 the facility did not determine that the resident was clinically appropriate and safe to self-administer medications; did not obtain a physician's order to self-administer medications; and did not develop care plans to address self-administration of medications or bedside storage of medications. These failures had the potential for unsafe and improper administration of medications. Findings : 1. Review of Resident 7's clinical record indicated, he was admitted to the facility with diagnoses including kidney failure and dependance on renal dialysis (removal of waste products from the blood when the kidneys…

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 safe and comfortable temperature of 71 to 81 degrees Fahrenheit for two of three common residents' area (Room A and B), one hallway and dining area. The failure resulted in the residents exposed to cold and uncomfortable environment. Findings: During an observation and interview on 10/23/23 at 11:27 a.m. with Resident 22, Resident 22 was in her bed with fleece blanket over him. Resident 22 stated the room gets cold in the morning. During an interview on 10/24/23 at 8:56 a.m. with Resident 39, Resident 39 stated that the room gets cold in the morning. During a concurrent environmental tour and interview on 10/25/23 at 12:58 p.m. with Assistant Maintenance (AM), AM measured the temperatures of three resident rooms (Room A: 69.6, Room B: 68, and Room C: 72.5 degrees Fahrenheit), 3 hallways (71.6, 69-, and 73.3-degrees Fahrenheit) and dining area (68.5 degrees Fahrenheit). AM stated that room temperatures should have been between 75 to 80 degrees Fahrenheit. During an interview on 10/26/23 at 10:40 a.m.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their policy and procedure to notify the Office of the State Long-Term Care Ombudsman (organization that advocates for the residents) when two of 20 sampled residents (Residents 6 and 67) were transferred to the acute care hospital from the facility without notifying the Ombudsman. This failure had the potential to compromise the residents' admission, transfer, and discharge rights. Findings: Review of Resident 6's clinical record indicated she was admitted to the facility on [DATE]. Resident 6 was transferred to the acute hospital from the facility on 10/10/23. Resident 6's family was concerned about Resident 6 not eating and wanted further evaluation and requested the hospital transfer. Resident 6 was admitted to the hospital and did not return to the facility. Review of Resident 67's clinical record indicated he was admitted to the facility on [DATE]. Resident 67 was transferred to the acute care hospital on 7/22/23 due to difficulty…

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 environment remains as free of accident hazards for one of 20 sampled residents (Resident 66) when Resident 66 was using an electric hot water kettle unsupervised inside his room. This failure had the potential to increase the risk for accident to occur. Findings: During a review of Resident 66's care plan dated 10/17/23, the care plan indicated Resident 66 required partial/moderate assistance with ADLs (activities of daily living) related to reduced mobility and muscle weakness. During a concurrent observation and interview on 10/24/23 at 9:52 a.m. with Resident 66 in the resident's room, Resident 66 had an electric hot water kettle was boiling hot water on the nightstand. Resident 66 stated he did not like cold water and he preferred hot water. He had been using the kettle since he was admitted to the facility, and he had been using it on his own. During an interview on 10/25/23 at 12:36 p.m. with the Dietary Consultant (DC), the DC stated there was hot water dispenser in the front lobby, the…

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

Based on observation, interview, and record review, the facility failed to ensure the correct enteral formula (liquid food products that are specially formulated to increase the amount of nutrients that will maintain proper function of the body) as prescribed by the physician for one of one sampled resident (Resident 2). This failure could result to resident's discomfort and further complications. Findings: Review of Resident 2's clinical record indicated Resident 2 have dementia (condition affecting memory, thinking and social abilities), dysphagia (difficulty swallowing) and receiving tube feeding via gastrostomy tube (tube inserted through the stomach for feeding and hydration). The physician on 7/17/23 ordered Jevity 1.5 (high calorie therapeutic nutrition formula) at 40 milliliter per hour. During an observation on 10/23/23 at 2:55 p.m. with Registered Nurse (RN) J, RN J was starting a new tube feeding (liquid nutrients given through a tube inserted in the stomach) formula to Resident 2. During a concurrent observation and interview on 10/23/23 at 3:36 p.m. with RN J, RN J…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to administer parenteral fluids (the delivery of fluid or medication through an intravenous, subcutaneous, intramuscular, or mucosal route) consistent with professional standards of practice and in accordance with physician orders to one of one sampled resident (Resident 37) when: 1. The facility failed to clarify the physician order; 2. The facility failed to ensure Resident 37 received the Total Parenteral Nutrition (TPN) as ordered by the physician; 3. The facility failed to perform an aseptic technique during maintenance of the peripherally inserted central catheter line (PICC line, a long, thin tube that's inserted through a vein in your arm and passed through to the larger veins near your heart) during therapy. These deficient practices placed Resident 37 at risk for malnutrition, dehydration, and PICC line infection. Findings: 1. A review of Resident 37's clinical record indicated she was readmitted to the facility on [DATE] with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 20) received care and services for provision of hemodialysis (HD, the process of removing excess water, substances, and waste products from the blood in people whose kidneys could no longer perform these functions) consistent with the professional standards of practice, physician orders, and the facility's policies and procedures when 1.The facility failed to implement the physician order for fluid restriction; 2.The facility failed to monitor intake and output (I &O) measurements when Resident 20 was on fluid restriction. These failures had the potential for Resident 20 to have fluid overload and the possibility of medical complications. Findings: 1. A review of Resident 20's clinical record indicated he was admitted to the facility with diagnoses including hyperparathyroidism (excess of the hormone made by four small glands in the neck [parathyroid glands]), end-stage kidney disease, kidney dialysis (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 interview and record review, the facility failed to provide medically-related social services (services provided by the facility's staff to assist residents in attaining or maintaining their mental and psychosocial health) when 72 hour monitoring was not done after an abuse allegation incident for two of three residents (Resident 7 and Resident 397). The failure had the potential to affect the mental and psychosocial well-being of the residents. Findings: During a concurrent interview and record review on 10/26/23 at 11:16 a.m. with Assistant Director of Nursing (ADON), Resident 7's Progress Notes (part of a medical record where healthcare professionals' documents details of a patient's clinical status), dated 12/25/22 was reviewed. ADON confirmed there was no documentation on the Social Services progress notes and Social Services should have monitored Resident 7 for any change in mood, behavior, and socialization. During a concurrent interview and record review on 10/27/23 at 8:57 a.m., with Director of Nursing (DON), Resident 7 and Resident 397's Progress Notes and SBAR…

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

Based on observation, interview, and record review, the facility failed to ensure a non-sampled resident (Resident 350) was free from unnecessary medications when she received three medications with incorrect indications for use. As a result, one of the three medications, the spironolactone (a diuretic, medication to remove fluid from the body and also for high blood pressure [BP]), was held seven times in a 12-day period from 10/12 to 10/23/23. The failure had the potential for worsening of the resident's medical conditions such as excessive fluid retention, high blood pressure, and electrolyte imbalance in the blood due to fluid retention. Findings: During a medication administration observation on 10/23/23 at 9:17 a.m., Licensed Vocational Nurse (LVN) G was observed administering six medications to Resident 350. The medications included a tablet of furosemide (a diuretic) 40 milligrams (mg, unit of measurement) and 5 tablets of midodrine (medication to treat low BP) 2.5 mg. She stated she will hold the BP medications even though there's no hold parameters. She stated the…

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

Based on observation, interviews, and record review, the facility failed to ensure one non-sampled resident (Resident 298) was free from a significant medication error when Resident 298 did not receive her digoxin (medication to treat some heart problems, such as irregular heartbeats), as prescribed, for six days. The failure had the potential to cause complications, such as too fast heartbeats or worsening of heart failure, for the resident. Findings: During a medication administration observation with Registered Nurse (RN) F on 10/23/23 at 8:21 a.m., she was observed preparing seven medications for Resident 298. She stated she did not have two of the medications and needed to check to see if they were in the emergency kit (e-kit, a kit containing medications and supplies for emergency use). On 10/23/23 at 8:29 a.m., RN F returned to the medication cart and stated they were not available in the e-kit. On 10/23/23 at 8:34 a.m., RN F stated she was missing another medication for Resident 298. On 10/23/23 at 8:40 a.m., at Resident 298's bedside, RN F informed the resident she did 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two insulin pens (pre-filled, multi-dose pens containing medication to lower blood sugar) and six (6) oral inhalers (medications to treat breathing problems) were dated with an open date in two of two medication carts inspected. The failure had the potential for these medications to be given beyond its expiration date, which would be ineffective for the residents. Findings: 1. During an inspection of the Station 4 Medication Cart with Registered Nurse (RN) D on 10/24/23 at 12:01 p.m., a fluticasone/vilanterol ellipta Inhaler (a hand-held inhaler for breathing conditions) was identified inside an opened foil tray. There was no written open date anywhere on the inhaler, tray, or the medication box. A review of the manufacturer's labeling on the medication box with RN D indicated, Discard the inhaler 6 weeks after opening the moisture-protective foil tray or when the counter reads 0 (after all blisters have been used), whichever comes…

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, interviews and facility document review, the facility failed to ensure the diet spreadsheet was followed for one of 44 residents (Resident 18) who received a controlled carbohydrate diet (CCHO, the focus of the diet is eating the same amount of carbohydrates every day. This helps keep the blood sugar, or glucose levels stable). This failure had the potential to result in the resident to not be able to maintain her blood sugar in the therapeutic range. Findings: During a review of Resident 18's admission Record dated 10/26/23, the record indicated Resident 18 was admitted to the facility on [DATE], with diagnosis of type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar). During a review of Resident 18's physician order dated 9/19/18, Resident 18 was on CCHO diet. During the tray line (a system of food preparation, used in healthcare setting, in which trays move along an assembly line) observation on 10/25/23 at 12:10 p.m., Dietary Aide (DA) K…

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

Based on observation, interview, and record review, the facility failed to properly dispose the garbage and did not follow the facility's policy and procedures (P&P) for Covering receptacles when two of five dumpsters did not have lids closed properly. This failure had the potential to attract pests and rodents which could lead to unsanitary conditions and spread of disease. Findings: During an observation on 10/23/23 at 8:00 a.m. at the facility's outside dumpsters area, there was one dumpster with the lid open, and two other dumpsters with overflowing garbage which caused dumpster lids were not fully closed. During a concurrent observation and interview on 10/24/23 at 2:41 p.m. with the Director of Maintenance (DOM), there were two dumpsters with lids open, one of the open dumpsters had overflowing garbage. The DM stated dumpsters were supposed to be always closed to prevent rodents and wild animals. The garbage pickup company came every Tuesday but had not showed up today. During a review of the facility's P&P titled, Garbage and Rubbish Disposal, dated 2/2009, the P&P 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three residents (1) received necessary treatments for pressure ulcers (injuries to skin and underlying tissue resulting from prolonged pressure on the skin) when Resident 1 was admitted to the facility with pressure ulcers on his left, right heel, and coccyx (the bony structure at the bottom of the spine), but there were no treatment orders for his pressure injuries until two weeks later. This failure had the potential to delay the wound healing and to cause the wounds getting worse or infected. Findings: Review of Resident 1's admission Record indicated he was admitted to the facility on [DATE] with diagnoses including dementia (the loss of cognitive functioning such as thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities), pressure ulcer of right heel, pressure ulcer of left heel, mixed incontinence, and reduced mobility. Review of Resident 1's Interagency Discharge Summary…

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 responsible party (RP, an individual authorized by the resident to act for him as an official delegate or agent) about change of condition for one of three residents when Resident 1 fell, and his RP was not notified. This failure resulted in Resident 1's RP being uninformed and unaware of his condition. Findings: Review of Resident 1's admission Record indicated he was admitted to the facility on [DATE] with dementia (the impaired ability to remember, think, or make decisions that interferes with doing everyday activities) diagnosis, and he had a RP. Review of Resident 1's Fall Report of Incidents, dated 5/13/22 and 10/15/22, indicated Resident 1 fell, and 'self-responsible' was indicated for Responsible Party Notified. During an interview with the director of nursing (DON) on 8/7/23 at 10:40 a.m., the DON reviewed Resident 1's 5/13/22 and 10/15/22 Fall Report of Incidents and confirmed that the licensed nurse did not notify Resident 1's RP…

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 13. During an observation on 1/4/22 at 1:49 p.m., in Resident 82's room, the oxygen tubing currently in use was not dated or timed. During an interview on 1/7/22 at 1:49 p.m. with the assistant director of nursing (ADON), the ADON confirmed the oxygen tubing should be labeled, stating, if it is not labeled then we do not know when to change it. It is only to be used for 3 days. During a review of facility's policy and procedure titled, Oxygen Administration dated August 2014, it indicated .g. label humidifier with date and time opened. Change humidifier and tubing per facility procedure. 9. During an observation in the dining room on 1/4/22 at 11:53 a.m., the activities assistant (AA) assisted Resident 44 with her meals. At 11:56 a.m., the AA assisted Resident 3 with her meals without performing hand hygiene in between tasks. During an interview with the AA on 1/4/22 at 12:02 p.m., the AA confirmed the above observation and stated hand hygiene should be performed in between tasks. Review of the CDC website…

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 an advance directive (AD, a written instruction, such as a living will or durable power of attorney for health care when the individual is incapacitated) or Physician Orders for Life-Sustaining Treatment (POLST, a form designed to improve patient care by creating a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency) was available, completed, and accurate for 5 of 18 residents (18, 41,194, 52, and 54) reviewed under the advance directive care area. These failures had the potential to result with the inability to make medical decisions when residents cannot make decisions for themselves and could lead to the delivery of unnecessary or inappropriate medical services, which are against the resident's goals and wishes. Findings: 1.Review of Resident 18's admission record indicated he was readmitted on [DATE] with a diagnosis…

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

Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and served under sanitary conditions when: 1. Two refrigerators and one ice cream freezer had wire shelves with yellowish to orange color and; 2. the freezer and chest freezer had ice build-up. These failures had the potential to cause foodborne illness (illness resulting from contaminated food) for 82 of 85 residents who received food from the kitchen. Findings: 1. During a kitchen observation with the dietary manager (DM) on 1/4/22 at 8:55 a.m., the refrigerator (#1) containing pasteurized eggs, tomatoes, vegetables, and milk had six wire shelves that were chipping and had orange to yellowish color. The right side of the refrigerator had yellowish to orange color. During a concurrent interview with the DM, the DM acknowledged the above observation and stated the wire shelves needed to be changed and the right side of the refrigerator needed to be cleaned. During a kitchen observation on 1/4/22 at 9:00 a.m. with the DM, the refrigerator (#2) containing milk, juice, thickened…

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 garbage was disposed properly when four of 5 facility dumpster lids were left opened. This failure had the potential to result in the spread of disease from vermin infestation and unsanitary environment for the residents. Findings: During an observation on 1/4/22 at 11:05 a.m., two of the facility's garbage dumpster lids were open. There was a plastic garbage bag hanging in one of the dumpster. During a concurrent observation and interview with the infection preventionist (IP) on 1/4/22 at 11:12 a.m., the IP confirmed the above observation and closed the lids of the dumpster. During an interview with the environmental services manager (ESM) on 1/4/22 at 11:14 a.m., the ESM stated the garbage dumpster lids should be closed. During an observation on 1/6/22 at 8:00 a.m., one of the garbage dumpsters for cardboard was full and the lid was opened. Another garbage dumpster for cardboard had its lid propped open. During an interview with the ESM on 1/6/22 at 10:05 a.m., the ESM stated it was okay for 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 test three out of 4 unvaccinated staff (LN D, LN E, and CNA F) twice per week and when scheduled to work for Coronavirus disease-2019 (COVID-19, a highly contagious viral infection that can trigger respiratory tract infection) during the sampled period of 11/01/2021 to 12/30/2021. This deficient practice had the potential for unvaccinated staff, who are at higher risk for contracting COVID-19, to spread infection within the facility. Findings: During an interview with the administrator (ADM) on 1/7/22 at 9:59 a.m., he stated the facility provided twice a week testing for unvaccinated staff. During an interview with the assistant director of nursing (ADON) on 1/7/22 at 11:20 a.m., she confirmed four staff were unvaccinated. Review of licensed nurse D (LN D) Individual Employee Time Cards indicated she worked on 11/11/21 and 11/25/21 to 11/27/21. Review of LN D's Testing Dates indicated LN D was not tested on [DATE]. On the week of 11/25/21, LN D was…

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

Based on observation, interview, and record review, the facility failed to treat four of 18 sampled residents (Residents 44, 31, 196, and 63) with respect and dignity when: 1. The activities assistant (AA) stood beside the residents to assist with their meals; 2. Resident 31's urine bag (bag that is attached to a tube that is connected to the bladder) was not covered. 3. A certified nursing assistant (CNA) stood while feeding Resident 196, and 4. Resident 63's indwelling catheter was not covered. These failures resulted in not ensuring residents' rights to be treated with respect and dignity and could potentially affect the residents' self-worth. Findings: 1. During a dining observation on 1/4/22 at 11:53 a.m., the AA assisted Resident 44 with her meal. The AA was standing while trying to feed Resident 44. At 11:56 a.m., the AA assisted Resident 3 with her meal. The AA was standing while feeding Resident 3. During an interview with the AA on 1/4/22 at 12:02 p.m., the AA confirmed the above observations and stated she should sit down when providing assistance to residents 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to implement their abuse policy for one of 18 sampled residents (Resident 52) when the facility did not report a suspected financial abuse to the state agency. This failure had the potential to put the resident at risk for possible abuse. Findings: Review of Resident 52's clinical record indicated she was readmitted to the facility on [DATE] with diagnoses including sepsis (a life-threatening complication of an infection). Review of Resident 52's social services notes dated 11/10/21 indicated a suspicion of financial abuse by the DPOA (durable power of attorney, an authorization to a person to act on behalf). During a telephone interview with the social services director (SSD) on 1/10/22 at 2:41 p.m., the SSD stated the suspicion of abuse was not reported to the state agency. The SSD further stated it should be reported to the state agency. Review of the facility's policy, Abuse Prevention, Intervention, Investigation & Crime Reporting Policy dated 11/2016…

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 care and services were provided in accordance with professional standards of practice for five of 18 sampled residents (194, 84, 52, 54, and 344) when: 1. For Resident 194, facility staff failed to obtain an order for a peripherally inserted central catheter (PICC line, a long, thin tube inserted through a vein in the arm and passed through to the larger veins near the heart) management, there was no assessment of the PICC line upon admission, and the care plan was not implemented. 2. For Resident 84, facility staff failed to ensure oxygen (02, a colorless and odorless gas that people need to breathe) order was administered as specified in the physician's order and the order was not verified with the physician when Resident 84 had two active oxygen orders. 3. For Resident 52, there was no physician order and care plan for midline (thin, soft plastic tube that is put into a small blood vessel, used to administer intaravenous [IV]…

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 each resident received adequate supervision and assistance to maintain an environment free of accident hazards for two of 18 sampled residents (Residents 68 and 56). 1. For Resident 68, the nursing staff allowed the resident to smoke outside the patio unsupervised, and without a smoking assessment. 2. For Resident 56, the sitter (person assigned to stay with the resident at all times to keep her safe) left the resident unattended and unsupervised. These failures had the potential to result in harm to residents and staff. Findings: 1. A review of Resident 68's clinical record indicated he was admitted with multiple diagnoses including weakness, abnormalities in gait and mobility, lack of coordination and falling. During an interview on 1/4/22 at 11:05 a.m. with certified nursing assistant G (CNA), CNA G stated, [Resident 68] is on the patio smoking. During a concurrent observation and interview on 1/4/22 at 11:20 a.m. with Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure three of 18 sampled residents (31, 54 and 72) with indwelling catheters (a small, flexible tube that can inserted through the bladder to drain into a urine bag) had an appropriate urinary management when: 1. For Resident 31, there was no documented foley catheter care; 2. For Resident 54, there was no care plan regarding the use of foley catheter and; 3.For Resident 72's suprapubic urinary catheter (a hollow flexible tube inserted through a cut in the abdomen that is used to drain urine from the bladder into a bag) had dark brown urine with sediments in his catheter and the physician was not notified of the resident's dark brown urine with sediments. These deficient practices had the potential to put residents not receiving the interventions necessary to maintain their highest level of well-being and had the potential to put resident at risk of urinary infection. Findings: 1. Review of Resident 31's clinical record indicated he was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide dialysis services consistent with professional standards and to ensure staff had coordinated residents' care with the dialysis facilities for two of five sampled residents (Residents 83 and 68) receiving hemodialysis (medical procedure to remove fluid and waste products from the blood and to correct electrolyte i.e., salts and mineral imbalances by using a machine and an artificial kidney) when: 1. Communication with the dialysis clinics were not properly coordinated when dialysis communication records (DCR) were not completed; 2. Staff were not trained on emergency care for residents with renal diseases, dialysis care and there was no emergency dialysis kit available; and, 3. The dialysis care plan was not resident-centered. These failures may affect the quality of dialysis care being provided to the residents. Findings: 1a. Review of Resident 83's clinical record indicated he was readmitted to the facility on [DATE] with…

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

Based on observation, interview, and record review, the facility failed to provide sufficient social services for one of the eighteen sampled residents (83) needing dental service. This failure had the potential to result in unmet care needs. During a concurrent observation and interview with Resident 83, on 1/4/22, at 12:24 p.m., Resident 83 stated that he told social services when he lost his upper and lower dentures sometime in October 2021. He further stated that his food has been chopped up because he has no teeth and no dentures. Review of Resident 83's Minimum Data Set (MDS, a clinical assessment tool) dated 12/21/21, indicated his BIMS score is 15 and is cognitively intact. During a concurrent interview and record review on 01/06/22 at 09:49 a.m., with the social service director (SSD) she reviewed Resident 83's clinical record and her social services documentation and was not able to find documentation of a referral to the dental company and no grievance documentation about missing dentures on 10/1/21. The SSD also reviewed the Dental Services documentation and found…

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 reorder one of three emergency medication kits (E-kits) after medications were used. The facility also failed to ensure controlled medications (medications regulated by the government because they may be abused or cause addiction) for two of three residents (Residents 32 and 60) were accounted for. These failures had the potential to result in residents not receiving medications needed to maintain their health and well-being. Failure to account for controlled medications had the potential to result in diversion (transfer for illicit use) of the medications. Findings: 1. During an interview with the assistant director of nursing (ADON) on 1/4/2022 at 9:34 a.m., she explained that when staff use medication from the E-kit, they should order a new E-kit right away. During an observation and concurrent interview with the ADON on 1/4/2022 at 10:00 a.m., an E-kit containing insulin (medication used to lower blood sugar) was inspected. There was a document on the outside of the container that indicated the E-kit should have the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure two of 18 sampled residents (33 and 63) were free from unnecessary psychotropic medications (drugs that affects brain activities associated with mental processes and behavior when: 1. For Resident 33, the facility failed to ensure there was a specific duration of use for a PRN (PRN as needed) psychotropic medication that exceeded 14 days and there was no specific target behavior for the use of Ativan (a medication for anxiety [feelings of worry and fears) and, 2. For Resident 63, the facility failed to obtain informed consent for the use of psychotropic medication. These failures could result in lack of adequate monitoring and had the potential for the residents to receive unnecessary medications Findings: 1. Review of Resident 33's clinical record indicated he was admitted to the facility on [DATE] with diagnoses including schizophreniform disorder (a psychotic disorder that affects how a person think, emotions and how a person…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure medications were stored in a safe manner when: 1. The temperatures in two of two medication refrigerators were not within acceptable parameters; and 2. There was expired insulin (medication used to lower blood sugar) in one of three emergency medication kits (E-kits). These failures had the potential to result in residents receiving medications with reduced potency or efficacy. Findings: 1. During an observation on [DATE] at 9:34 a.m., medication refrigerator 1 was inspected. The internal thermometer indicated the temperature inside the medication refrigerator was 30 degrees Fahrenheit (F, unit of temperature measurement). There were various types of medication stored in the refrigerator including insulin. During a concurrent interview with the assistant director of nursing (ADON), she confirmed the above observation and confirmed the temperature was too low. The ADON stated the temperature in the medication refrigerator should be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to prepare food that conserved nutritive value and flavor when pureed, mechanical soft, and ground foods were prepared hours before serving. This failure had the potential for two residents who received a pureed diet out of 85 residents to receive food with reduced nutrients or flavor. Findings: During a food preparation observation in the kitchen on 1/6/22 at 9:33 a.m., the dietary cook (DC) pureed (puree, a cooking technique that mashes or liquefies food) cooked chicken fajitas and stored the puree in the oven. During an interview with the dietary manager (DM) on 1/6/22 at 9:44 a.m., the DM stated the puree will be stored in the oven until 11 a.m. During an interview with the registered dietitian (RD) on 1/6/22 at 9:47 a.m., the RD was asked if it was okay for the puree to be stored in the oven hours before the tray line. The RD stated the puree can be stored in the oven but will double check with [name]. The tray line started at 11:25…

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.