Napa Valley Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of 30 sampled residents (Resident 39) remained free from significant medication error when rapid acting insulin (medication used to decrease blood sugar) was administered at the wrong time.This failure had the potential to result in Resident 39 experiencing adverse complications from hypoglycemia (condition in which blood sugar level drops below normal) including dizziness, sleepiness, passing out or death. Findings:During a review of Resident 39's Face Sheet (Resident Demographics), the Face Sheet indicated Resident 39 was admitted to the facility on [DATE] with diagnoses which included Type 2 Diabetes Mellitus (disease that causes blood sugar levels to be high).During an observation on 7/23/2025 at 3:35 p.m. with Licensed Vocational Nurse (LVN 2), in Resident 39's room, LVN 2 administered Insulin Aspart (rapid acting medication used to decrease blood sugar) 2 units (unit of measurement) via flex pen (injection device).…

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 medication cart (a cart that contains medications for residents) was locked while not in use and unattended. This failure had the potential to allow residents, staff and visitors to gain access to the medication cart.Findings:During a concurrent observation and interview on 7/21/2025 at 1:50 p.m. with the Infection Preventionist (IP) on Unit 1A, the medication cart was observed unlocked and unattended. IP stated the medication cart should be locked when not in use.During an interview on 7/22/2025 at 8:47 a.m. with the Director of Nursing (DON), the DON stated the medication carts should be locked at all times when not in use.During a review of the facility's policy and procedure (P&P) titled, Storage of Medications, revised April 2007, the P&P indicated, Compartments .containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others.

Based on observation, interview and record review, the facility failed to ensure the garbage was disposed of properly, when a garbage can lid and a garbage compactor (a machine that reduces the volume of trash by compacting it), were not closed and the surrounding area had piles of trash bags on the ground.This failure resulted in pest attraction and odor in the garbage disposal area.Findings:During a concurrent observation and interview on 7/23/2025 at 11:50 a.m., with the Housekeeping Supervisor (HS), in the garbage disposal area, the garbage compactor was not closed, the surrounding area had piles of trash bags on the ground with flies and a foul odor. The HS stated the compactor should be covered when not in use to prevent odor and to prevent attracting pests.During a concurrent observation and interview on 7/24/2025 at 7:50 a.m., with Housekeeping (HK), in the garbage disposal area, one of the garbage can lids was opened with birds flying in and out of the garbage can. Housekeeping (HK) stated the garbage can lid needed to be closed to prevent harborage of rodents or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a speech therapy evaluation for one of 30 sampled residents (Resident 60) was performed when ordered by the physician.This failure had the potential to result in Resident 60 receiving an inappropriate diet, choking or weight loss.Findings:During a review of Resident 60's Face Sheet (Resident Demographics), the Face Sheet indicated Resident 60 was admitted to the facility on [DATE] with diagnoses which included Myasthenia Gravis (chronic autoimmune disease that causes muscle weakness) and Parkinson's Disease (brain disorder that causes uncontrollable body movements).During a review of Resident 60's Physician Orders, dated 6/11/2025, the physician orders indicated, a speech therapy evaluation was ordered for Resident 60 on 6/11/2025 at 11:13 a.m. There was no documentation in Resident 60's record which indicated the speech therapy consult had been performed (43 days later).During an interview on 7/24/2025 at 2:44 p.m. with the Speech Therapist…

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 a sanitary and comfortable environment when the Stop sign banners in Hallway 3A had hair and lint on the velcro areas of the banners. This failure had the potential to negatively affect the residents' homelike environment. Findings:During a concurrent observation and interview on 7/21/2025 at 2:45 p.m., with the Director of Staff Development (DSD), three Stop sign banners were hanging on Hallway 3A rails next to rooms [ROOM NUMBER]. The Stop sign banners had hair and lint on the velcro areas. The DSD stated the Stop sign banners are put on the door to prevent wandering residents from going into residents room. The DSD confirmed the hair and lint on the velcro areas on the three Stop sign banners.During a concurrent observation and interview on 7/21/2025 at 3:25 p.m., with Housekeeping (HK), HK confirmed the hair and lint on the velcro areas on the three Stop sign banners hanging on Hallway 3A rails next to rooms [ROOM NUMBER]. HK…

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 report an injury of unknown origin when one of two sampled residents (Resident 1) was found to have extensive bruising and pain to his left leg, that ultimately was found to be a fractured femur (broken thighbone, the longest and strongest bone in the human body) in the emergency department (ED), and facility staff were unable to explain how Resident 1 got the bruise. This failure prevented outside agencies from investigating the injury of a vulnerable resident who was nonverbal and unable to advocate for himself or explain how he was injured. Findings: During a record review on 5/8/25 at 11:06 a.m., Resident 1's face sheet indicated an admission date of 11/10/21 and multiple medical diagnoses including Lewy Body dementia (a progressive brain disorder causing problems with thinking, movement, mood, and behavior). Review of Resident 1's nurse progress note dated 5/3/25 at 2:15 p.m. indicated, This nurse was called to room [approximately] 11am by CNA's [certified nursing assistants] to show me the residents [left] leg. Upon…

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 infection control policy when disposable razors were found either on top or partially inserted into sharps containers (containers specifically designed for items that are both contaminated and pose a puncture risk) in three communal (used or shared by multiple residents) shower/tub rooms. This failure had the potential risk of subjecting staff and residents to injury and blood-borne pathogen (infectious bacteria, virus, or fungus that can cause disease when transmitted through blood or other body fluids) transmission. Findings: During an observation on 4/8/25 at 11:00 a.m., the station three tub room was observed. There was a blue disposable razor partially inserted through the lid mechanism. There was no protective cover observed on the razor, leaving the sharp portion exposed. During an observation on 4/8/25 at 11:17 a.m. in the station three shower room, two blue disposable razors were found atop the sharps container lid. The sharps container was full of used disposable razors. During an observation…

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 maintain the safety one of two sampled residents when a staff member solely operated a mechanical lift to transfer Resident 1 from the bed to a recliner. This failure resulted in Resident 1 to fall and sustain a hematoma (a closed wound where blood collects and fills a space) on her head. Findings: A review of Intake Information dated 2/10/25 indicated a complaint alleging Resident 1 sustaining a fall as she was transferred from bed to a chair on 2/9/25. A review of Resident 1's Face Sheet indicated she was admitted to the facility with diagnoses including multiple sclerosis (a disease resulting in the damage to the nerves in the brain, spinal cord, and nerves) and dementia (a general term for loss of memory and other mental abilities severe enough to interfere with daily life). Resident 1's Progress Notes , dated 2/9/25 , indicated, Resident had a witnessed fall while transferring to chair. Aide reported that while she was transferring via [product brand] lift to chair, the chair tipped over and resident fell backwards…

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

Based on interview and record review, the facility failed to provide a written notification of the hospital transfer for one of two sampled residents (Resident 1) to her Responsible Party (RP). Failure to notify the Responsible Party (RP) of Resident 1's whereabouts had the potential for an inability for her to advocate for Resident 1's needs and preferences during the transfer process, and coordinate care with the receiving hospital. Findings: A review of Intake Information dated 12/13/24 indicated RP was not notified of Resident 1's transfer to acute care, nor of any bed hold policy. A review of Resident 1's Face Sheet indicated she was admitted to the facility with diagnoses including schizophrenia and left femur (thigh bone) fracture. Resident 1's Face Sheet indicated RP's name, call phone number and mailing address were listed under her Contacts . Further review of Resident 1's records indicated she was transferred to acute care for chest pain and fainting on 11/27/24. During an interview on 1/9/25 at 12:15 p.m., Licensed Staff B stated residents' families and responsible…

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 oxygen therapy (A medical treatment that provides supplemental or extra oxygen for breathing) was provided as ordered by the physician for two of two sampled residents on continuous supplemental oxygen (Resident 5 & Resident 6) when the nasal cannulas (A device consisting of a lightweight tube used to deliver supplemental oxygen) were not observed to be in their noses in the early morning hours of 10/08/24, and the oxygen settings were incorrect. In addition, the facility failed to ensure the administration of oxygen therapy was documented for one of three sampled residents (Resident 4). These findings had the potential to result in harm, suffering and death to the residents on oxygen therapy. Findings: Record review of Resident 4's Face Sheet (Facility demographic) indicated he was admitted to the facility on [DATE] with medical diagnoses including Parkinson's Disease (A chronic, progressive brain disorder that causes movement…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide enough nursing staff to deliver the nursing and related care and services required by the residents. Three of three unlicensed staff interviewed (Anonymous Staff D, Anonymous Staff E, and Anonymous Staff F) indicated the facility was extremely short-staffed for certified nursing assistants (CNAs), and this affected the quality of care the residents were receiving. This finding had the potential to result in inability for the residents to reach their full potential, neglect, and feelings of abandonment and frustration. Findings: Record review of Resident 4's Face Sheet (Facility demographic) indicated he was admitted to the facility on [DATE] with medical diagnoses including Parkinson's Disease (A chronic, progressive brain disorder that causes movement problems, stiffness, and other symptoms) and Acute Respiratory Failure (Acute respiratory failure is defined as the inability of the respiratory system to meet the oxygenation, ventilation, or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was treated with dignity and respect when two certified nursing assistants (Unlicensed Staff A and Unlicensed Staff B) attempted to provide incontinence care (Cleaning the private areas and changing the undergarments of a patient with loss of bowel or bladder control) to Resident 1 against her wishes. This finding had the potential to result in injuries to Resident 1, frustration, sadness, and trauma. Findings: Record review of the facility Face Sheet (Facility demographic) indicated Resident 1 was admitted to the facility on [DATE] with medical diagnoses including Hemiplegia (Severe or complete loss of strength on one side of the body) and Hemiparesis (Weakness or inability to move one side of the body). Record review of Resident 1's MDS (Minimum Data Sheet-An assessment tool) dated 8/28/24 indicated her BIMS (Brief Interview of Mental Status-A cognition [the mental action or process of acquiring…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report an allegation of abuse within two hours to the DEPARTMENT for one of three sampled residents (Resident 1). This finding had the potential to result in inability for the DEPARTMENT to investigate and advocate for Resident 1's rights, and possible continuous abuse to Resident 1 and other residents of the facility. Findings: Record review of the facility Face Sheet (Facility demographic) indicated Resident 1 was admitted to the facility on [DATE] with medical diagnoses including Hemiplegia (Severe or complete loss of strength on one side of the body) and Hemiparesis (Weakness or inability to move one side of the body). Record review of a nursing note dated 8/08/24 at 10:53 a.m., indicated, Resident [Resident 1] was complaining NOC (night) shift CAN (Certified Nursing Assistant). this nurse and DSD (Director of Staff Development) went her (Sic) room asked her what happened last night. resident stated when CNA cleaned her they held her hand and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three sampled residents at risk for elopement (Resident 3) eloped from the facility, when several steps to prevent it, such as completing the elopement risk assessment, creating a care plan to prevent elopement, and initiating interventions to keep her safe, were omitted. Resident 3 eloped form the facility on 8/20/24 while being COVID-19 positive and was found a block away from the facility on a high traffic street, by police. This failure had the potential to result in serious harm, including death, to Resident 3. This failure placed other residents of the facility and residents of the community at risk for becoming infected with COVID-19, a contagious and potentially deadly illness. Findings: Record review of Resident 3's Face Sheet (Resident demographics) indicated Resident 3 was admitted to the facility on [DATE] with medical diagnoses including Parkinson's Disease (A chronic, progressive brain disorder that causes movement problems,…

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 reviews, the facility failed to ensure there were adequate staff to care for three out of three sampled residents (Residents 2,3 and 4) needs when: 1. Residents 2, 3 and 4 complained of staffs late response to call lights and late provision of care due to short staffing. 2. Unlicensed staff statements the facility was short staffed, stating they have difficulty meeting their residents needs timely, or completing their task timely. These failures resulted in: 1a Resident 2 feeling frustrated, anxious, and afraid staff would not be available to assist her in case of a medical emergency. 1b Resident 3 feeling frustrated and upset waiting for a long time before staff responds to call light and 1c Resident 4 feeling unsafe and in fear something might happen to her and there would be no staff to assist her when she needed medical attention. These failures could also put the residents at risk for falls, injuries, accidents, late provision of care or care not being rendered at all.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to: 1.ensure six out of nine licensed staff (Licensed Staff A,B, C, E, F and G) were aware of the facility ' s Antibiotic Stewardship Program (ASP, a coordinated program that promotes the appropriate use of antimicrobials, including antibiotics- a group of agents that share the common aim of reducing the possibility of infection and sepsis (body's extreme reaction to an infection). 2.promote the appropriate use of antibiotics when the antibiotic was prescribed without proper indication and no attempts were made by the facility to reassess the need for continued antibiotic use for one out of two sampled residents (Resident 1) when Resident 1 received the antibiotic Augmentin ES-600 oral suspension 5 milliliters (ml, a unit of measurement) by mouth two times a day for Aspiration Pneumonia (infection of the lungs that occurs when food or liquid is breathed into the lungs instead of being swallowed) from 6/18/24 up to 6/25/24 for a total of 8 days and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility did not ensure residents receive treatment and care in accordance with professional standards of practice when Licensed Staff C allowed family members to administer medication to one out of two sampled residents (Resident 1). This failure was a safety risk and could potentially lead to incorrect dose administration and lack of patient education. Findings: A review of Resident 1 ' s face sheet (demographics) indicated Resident 1 was admitted on [DATE]. Her diagnoses included chronic kidney disease stage 3A (CKD, mild to moderate loss of kidney function), Cachexia (significant loss of muscle and adipose tissue- body fat) and Hyperlipidemia (HLP, high levels of fats (lipids) in your blood). A review of Resident 1 ' s Data Sheet Assessment (MDS, a standardized assessment tool that measures health status in nursing home residents) dated 5/29/24, indicated Resident 1 needed maximal assistance up to dependent on staff for provision of personal care. During an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that staff wore face masks appropriately in patient care areas during a covid outbreak in the facility. This failure had the potential to spread infections among residents in the facility. Findings: During an observation and concurrent interview on 2/2/24 at 11:45 a.m., a nurse was standing at a medication cart with her mask pulled down below her chin while talking on her cell phone in the hallway outside a resident room. Continuing the observation, a nurse at the Station 3 nurses ' station was sitting at a computer with her mask pulled down under her chin. When queried, Licensed Nurse A stated she needed a break from her mask. When asked the reason N95 masks were required in the facility, Licensed Nurse A stated it was because of the current COVID outbreak in the building. Licensed Nurse A stated she should go to the break room if she needed to take off her mask. During an interview on 2/2/24 at 2:20 p.m., Anonymous Resident stated…

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

Based on observation, interview, and record review, the facility failed to serve food at a palatable temperature when a test tray of beef stroganoff with noodles was not at a palatable temperature. This failure resulted in two anonymous residents complaining that hot foods were served cold. Findings: On 1/17/24, the Department received an anonymous complaint that indicated, food is cold/inedible. During an interview on 2/2/24 at 11:10 a.m., an anonymous resident, who had been living at the facility for over a year, verified hot foods were served cold, especially hamburgers. During an observation on 2/16/24 at 12:38 p.m. with Registered Dietitian, a test tray of beef stroganoff with noodles, revealed the beef was warm, not hot, and the noodles were cold. The beef was 116 degrees Fahrenheit, and the noodles were 92 degrees Fahrenheit. Both surveyors testing the tray agreed the temperature of the food was not palatable and needed to be warmer. Review of facility policy Food and Nutrition Services, revised 10/2017, indicated, Each resident is provided a nourishing, palatable,…

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 ice machine in the kitchen was sanitized and maintained to prevent buildup of water deposits on outer surface. This had the potential for cross contamination and the spread of water borne pathogens to the residents that use ice in the facility. Findings: During an observation on 2/2/2024 at 10:07 a.m., The ice machine in the facility ' s kitchen had a visible white crust like substance, dust, and water stain marks on the exterior surface of the top front panel. Also, there was a panel on the left side of the ice maker that was not completely secured. During a concurrent observation and interview on 2/2/2024 at 10:15 a.m., with the Registered Dietitian (RD), after showing her the surfaces on the ice machine, the RD acknowledged there was build-up on the front surface. The RD stated the maintenance director (MD) was responsible for cleaning and sanitizing the ice machine. Also, The RD confirmed ice machine was last cleaned on 1/30/2024 as indicated on the maintenance log posted on the front 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain a homelike environment for the residents when the walls of the residents ' communal areas and showers had crumbling dry wall, a loose tile, and a brownish black substance on the grout. This had the potential to result in residents feeling that the facility is not being maintained. Findings: On 1/17/24, the Department received an anonymous complaint that indicated, Black mold in showers. During an observation on 2/2/24 at 9:54 a.m., the resident shower next to resident room [ROOM NUMBER] had a brownish black substance on the grout between the tiles and the wall at the entrance to the shower had crumbling drywall that exposed the metal supports underneath it. During an observation on 2/2/24 at 10:29 a.m., the cabinet under the sink in the activity room/dining room had a brownish black substance in the corner on the caulking between the wall and the cabinet. The corner of the wall adjacent to the sink was cracked and crumbling where…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide care, consistent with professional standards of practice, to prevent pressure injuries (bedsores) to one of two residents (Resident 1), when the facility did not frequently and regularly turn and reposition Resident 1, who could not turn and reposition herself independently, and was at risk for developing pressure injuries. This failure resulted in Resident 1 developing two unstageable (unable to determine the exact extent of the wounds) pressure injuries, one on her sacrum (the tailbone area) and one on her buttocks area. Findings: A review of Resident 1 ' s Facesheet indicated she was admitted to the facility on [DATE] with a primary diagnosis of hip fracture. A review of Resident 1 ' s admission Assessment, which included a Skin Assessment, dated 6/7/22, indicated Resident 1 ' s skin was intact and had no pressure injuries. A review of Resident 1 ' s Braden Scale assessment (a standardized assessment that indicates the resident ' s risk of…

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

Based on observation and interview, the facility failed to provide a safe, clean, comfortable, and homelike environment to one of three residents (Resident 1) when the reading light above Resident 1's bed and the outlet in Resident 1's bathroom did not work. This failure resulted in Resident 1's not being able to read while in bed and not being able to charge her cell phone in the bathroom. Findings: During an interview on 11/8/23, at 10:20 a.m., Resident 1 stated her bed light and the outlet in the bathroom did not work. Resident 1 stated she used the bed light to read while in bed and the outlet in the bathroom to charge her cell phone. During a concurrent observation, the Maintenance Director tested the operation of the bed light and the bathroom outlet and confirmed both were non-operational. A review of facility policy and procedure titled Maintenance Service , revised December 2009, indicated: The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to issue the notice of discharge as soon as practicable to two of three residents (Residents 2 and 3); failed to timely provide a copy of the notice of discharge to the Ombudsman for three of three residents (Residents 1, 2 and 3); and failed to indicate a valid reason for discharge and to list the name of address of the Office of the State Long-Term Care Ombudsman and location to which the resident would be discharged on the notice of discharge to one of three residents (Resident 1). These failures could have resulted in Residents 2 and 3 not having enough time to prepare for discharge from the facility; the Office of the State Long-Term Care Ombudsman not assisting Residents 1, 2 and 3 during the discharge process; and Resident 3 not knowing where she would be discharge to. Findings: A review of Resident 1's admission Record indicated she was admitted to the facility on [DATE]. During an interview and record review on 10/17/23, at 1 p.m., Resident 1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure resident discharges in accordance with federal regulations for one of three residents (Resident 1) when the facility initiated the discharge of Resident 1 for the reasons of lack of insurance coverage and non-payment before Resident 1's insurance coverage lapsed and before non-payment by Resident 1's for charges related to her stay at the facility. This failure resulted in Resident 1 being subject to an invalid discharge process. Findings: A review of Resident 1's admission Record indicated she was admitted to the facility on [DATE]. During an interview and record review on 10/17/23, at 1 p.m., Resident 1 stated on 10/11/23 the facility provided her a letter indicating she had to leave the facility within 30 days. A review of the letter indicate it was dated 10/11/23, addressed to Resident 1, signed by the Administrator, titled 30 Day Notice to Vacate [Facility] , and indicated that Resident 1 will be discharged from the facility on 11/10/23 due…

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 records review, the facility failed to ensure one of four sampled residents (Resident 1) was free from significant medication errors, when Resident 1 had a physician ' s order for 1) Dilaudid (an opioid [class of drugs that derive from, or mimic, natural substances found in the opium poppy plant] - used to relieve moderate to severe pain) 4 mg (milligram-a unit of mass) to give one tablet three times a day for pain management; and 2) Roxycodone (also an opioid) 5 mg to give 2 tablets every 4 hours as needed for pain management; however, the facility did not administer the medication according to the physician ' s order. This failure had the potential to result in ineffective pain management, over sedation, or possible dependence or addiction to the medication. Findings: Review of the Face sheet (A one-page summary of important information about a resident) indicated Resident 1 was admitted on [DATE] with diagnoses including but not limited to Fracture (break in a bone) of the Sacrum (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 interviews and records review, the facility failed to implement a physician ' s order for pain management for two of four sampled residents (Resident 1 and Resident 2) when: 1. Resident 1 had a physician ' s order for Dilaudid (an opioid [class of drugs that derive from, or mimic, natural substances found in the opium poppy plant] used to relieve moderate to severe pain) 4 mg (milligram-a unit of mass) to be given three times a day for pain management; however, the facility did not administer the medication according to the physician ' s order. This failure had caused Resident 1 to experience moderate to severe pain which prevented him to sleep during the night and prevented him to participate with occupational therapy (a form of therapy for those recuperating from physical or mental illness that encourages rehabilitation through the performance of activities required in daily life). 2. Resident 2 had a physician ' s order for Hydrocodone-Acetaminophen (a combination of opioid pain medication -…

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 did not have sufficient staff to meet the care needs of three of three sampled residents (Resident 1, Resident 2 & Resident 3) when they were not provided with activities of daily living (ADLs-Activities related to personal care such as bathing and toileting) as required, and call lights were not answered promptly. The night of 8/11/23 one Certified Nursing Assistant (CNA) was assigned to provide services to 43 residents. In addition, staffing shortages occurred in all shifts. These findings had the potential to result in harm to the residents involved, inability for staff to respond to medical emergencies, and lack of health services provided to the residents of the facility. Findings: Record review of a report sent to the DEPARTMENT on 8/14/23 indicated the facility was, tremendously, understaffed, and on the night of 8/11/23 one CNA has been ensigned the entire section 3 of the facility (Which based on the facility census on 8/11/23, housed 43 residents).…

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

Based on observation, interview and record review, the facility failed to ensure residents' meals were palatable, appetizing and safe for ingestion. Three of four sampled residents (Resident 3, Resident 4 and Resident 5) complained about the food quality and taste. These findings could have resulted in decreased caloric intake, malnutrition, frustration, and decreased quality of life for the residents of the facility. Findings: Record review of a report sent to the DEPARTMENT on 8/14/23 indicated the food was not edible, and the facility was out of several essential food items such as milk and butter. During an interview on 8/23/23 at 10:20 a.m., with Resident 3, she stated the food needed to be improved as it was often not appetizing. Resident 3 stated the meat was hard and difficult to cut, and the flavor was fair. Resident 3 stated she lost a lot of weight when she was first admitted to the facility as a result of the food not being appetizing, but she had since adjusted. During an interview with Dietary Staff F on 9/13/23 at 6:53 a.m., she confirmed the facility did run out of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 2) was treated with dignity and respect when he was noted to be resting in bed in the early morning hours, with no blanket, no bed linens, and no clothing except for his disposable attends (A form of undergarment designed to be used / worn once and then thrown away), and a thin top sheet. Resident 2 voiced being terribly cold on multiple occasions, and when the call light was pressed to alert staff he needed a blanket, it took 10 minutes for a staff member to respond to it. These findings had the potential to result in suffering, frustration and feelings of distress for Resident 2. Findings: Record review indicated Resident 2 was admitted to the facility on [DATE] with medical diagnoses including Diabetes Mellitus (A chronic disease characterized by high levels of blood sugar) and Cognitive Disorder with Lewy bodies (A condition that affects brain regions involved in thinking, memory and…

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

Based on interview and record review, the facility failed to document in the facility assessment, the resources necessary to care for its residents competently during day-to-day operations. The staffing section on the facility assessment made it impossible to determine how many Certified Nursing Assistants (CNAs) were needed based on the census, condition of residents, or any other category that would provide specific information on the number of required CNAs per shift to meet the residents' needs. As a result, there were days and nights when the facility was extremely short staffed, including the night shift of 8/11/23, when one CNA (Unlicensed Staff E) was assigned 43 residents requiring assistance with ADLs (Activities related to personal care such as dressing, bathing and toileting). These findings had the potential to result in lack of nursing services, decreased quality of life and neglect to the residents of the facility. Findings: Record review of the staffing timesheets for August, 2023, indicated Unlicensed Staff E was assigned to care for 43 residents the night shift of…

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

Based on observation, interview and record review, the facility failed to store and prepare foods in a safe and sanitary environment when: 1. Cool down process for prepared food was not monitored 2. No air gap in the food production sink 3. Food storage were dirty 4. Food items were not labeled and dated 5. Dented cans of tomato sauce were in the dry storage area These failures could have resulted in foodborne illness and allergies to all residents in the facility. Findings: 1. During an interview on 9/14/21, at 9:45 a.m., Dietary Staff U was asked about tuna salad preparation. Dietary Staff U stated, she got the tuna from the dry storage and mixed all the ingredients together. Dietary Staff U was asked if she ever took the temperature of the tuna salad and she stated, she took temperature of the tuna salad after making it but there was no log to show that temperature was taken and monitored. During an interview on 9/14/21, at 9:55 a.m., Dietary Staff V was asked about Turkey salad preparation. Dietary Staff V stated, Turkey was pre-cooked and was in the fridge and they just mixed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to monitor residents for potential COVID-19 infection when six of seven residents sampled for COVID-19 screening review (Residents 6, 46, 54, 60, 66, 91) were not monitored for symptoms of COVID-19, even after identifying a resident positive for COVID-19 in the facility. This failure could potentially lead to undetected COVID-19 infections in residents, spread of COVID-19 amongst staff and residents, hospitalizations, or death. Findings: During an interview on 9/13/21, at 9:57 a.m., Administrator stated there were no Covid Positive residents in the facility. During an observation and interview on 9/13/21, at 10:55 a.m., a staff wearing a face mask and a face shield was observed entering Resident room [ROOM NUMBER], after using alcohol hand sanitizer and donning gown, gloves. During an observation on 9/13/21, in the main corridor that led into hallway one, a sign indicated YELLOW ZONE. During an interview, on Nursing Station #1, on 9/13/21, at 12:25 p.m.,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement person-centered care plans for 2 of 20 sampled residents (Resident 60 & Resident 53) when: 1 a. Resident 60 was found to have three broken/ decayed teeth after a dental exam and the facility did not develop a dental care plan to address prevention of potential complications from broken/ decayed teeth. This failure resulted in staff not assessing Resident 60 for dental problem. b. Resident 60 had verbalized she needed new eyeglass because could not see well and the facility did not implement their interventions as listed in Resident 60's vision care plan. This failure resulted in Resident 60 refusing to participate with activities of interest, feeling uncomfortable and sad.(Reference F 685). 2) Resident 53 was receiving food through a gastric tube (a tube inserted through the wall of the abdomen directly into the stomach) to meet his nutritional needs and the facility did not develop an individualized care plan. This failure…

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 implement timely revision of comprehensive care plan for 2 of 20 sampled residents (Resident 60 and Resident 7) when: 1) Resident 60 had two incidents of accidental fall in a 43-day period which caused Resident 60 to experience physical discomfort; 2) Resident 7 had a care plan for assessment of medication side affects, for medications she was not prescribed for six years. This caused a pattern of yelling, screaming and anxiety for Resident 7 and other residents. This failure puts Resident 60 at risk for more incidents of falling that could potentially result to serious injuries or death, and Resident 7 at risk for not receiving medications that would reduce her non compliance and disruptive behavior. Findings: During a clinical record review for Resident 60, the Progress Notes dated 05/18/2021 at 11:39 p.m., indicated Resident 60 had a fall at 07:30 p.m. that day. During a clinical record review for Resident 60, the Progress Notes dated 05/19/21 at 02:00 p.m., indicated Resident 60 was noted with redness at the corner of…

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

Based on observation, interview and record review, the facility failed to ensure person centered care when pharmacological interventions for behaviors were not considered after non-pharmacological interventions were ineffective, for one sampled resident (Resident #7). This failure to review and consider medication therapy for behaviors related to a primary diagnosis of Schizoaffective disorder (Schizoaffective disorder is a chronic mental health condition characterized primarily by symptoms of schizophrenia, such as hallucinations or delusions, and symptoms of a mood disorder, such as mania and depression.), and depression had the potential to result in increased anxiety, non-compliant behavior and contribute to increased agitation and behaviors. Findings: During an observation on 9/13/21, at 10:30 a.m., Resident #7's door was open, and she was yelling at anyone passing her room to remove a trash can located at the foot of her bed. Multiple staff were observed explaining to her the trash can was necessary for disposal of gowns and gloves. Resident #7's agitation increased as…

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 have sufficient number of dietary staff to provide food and nutrition services needed by the residents and to maintain cleanliness of the food storage units. This failure resulted in: 1. Freezers and refrigerators were not cleaned 2. Residents' food preferences were not updated 3. Not enough time to train dietary staff Findings: 1. During an observation in the initial tour of the kitchen on 9/13/21, at 9:56 a.m., freezer one was observed with dried brownish dirt on the freezer floor and freezer three had corn bits and dried yellowish-brownish dirt on the freezer floor. During an interview on 9/16/21, at 9:59 a.m., Registered Dietician (RD) was asked about kitchen and food storage cleaning. RD stated, they usually do it as a team but, with staffing issue she did not have enough staff, they cannot do it. RD stated, there was a professional cleaning company for food services that deep clean the entire kitchen on 9/3/21. RD was asked if the refrigerator and freezers were included in the deep clean and RD stated,…

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

Based on observation, interview and record review, the facility failed to follow menus for: 1. five residents on renal diet and 17 residents on heart healthy diet 2. seven residents on pureed diet 3. 12 residents on fortified diet 4. 28 residents on mechanical soft/ground diet These failure resulted in residents not receiving their physician ordered diets and could result in residents not getting their nutritional needs to maintain normal body weight. Findings: 1. A review of facility's menu spreadsheet for 9/13/21 indicated, residents on renal and heart healthy diet, should receive diet salad dressing for the green salad. During an observation on 9/13/21, at 11:36 a.m., lunch tray line was observed. All residents that were served green salad had either regular Italian or regular Balsamic Vinegar dressing. During an interview on 9/16/21, at 9:59 a.m., Registered Dietician (RD) was asked about the salad dressing served on 9/13/21 for renal and heart healthy diet residents. RD stated they served standard dressing to renal and heart healthy diet residents because they did not 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: 1. Provide food preferences to three sampled residents (Resident 36, 86 and 72). 2. Offer food substitute to five sampled residents (Resident 36, 86, 113, 157 and 158). These failures could result to residents losing appetite and potential weight loss. Findings: During an interview on 9/13/21 at 12:05 p.m., Resident 72 stated she was always given eggs, but she did not eat eggs. Resident 72 stated she had told the staff she did not like eggs, but they brought it to her anyway. During an interview on 9/13/21, at 11:10 a.m., Resident #157 stated the food was industrial, and not good. He stated he had asked for substitutions, but not received them. Resident #157 stated he asked for a meal substitution because he was hungry. He stated they always brought a peanut butter and jelly sandwich, and that gets old. During an observation on 9/13/21, at 1:35 p.m., Resident #113, was observed to refuse his lunch tray. Staff did not offer something else…

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 therapeutic diets to two residents on Renal diet (Resident 23 and 36). This failure could result to residents not receiving proper nutrition needed. Findings: During a concurrent observation and record review on 9/13/21, at 11:36 a.m., Resident 23's lunch tray was observed with one whole banana. Tray ticket was reviewed and indicated, 80 GM Renal BANANA 1-each. During an interview on 9/15/21, at 4:51 p.m., RD was asked about the banana served for the renal diet resident. RD stated, it was a lapse in judgement. RD stated staff knew not to serve banana to renal diet residents. RD further stated, she did not have enough time to train Dietary Staff Y who prepared the trays for lunch. During an observation and interview on 9/14/21, at 12:48 p.m., Resident #36's lunch observation indicated One roll, mashed potatoes covered in gravy, meat covered in gravy, mixed vegetables, and peaches with what appeared to be grease spots hardened around…

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 Policy and Procedure (P&P) for the Quality Assurance and Performance Improvement (QAPI) Program, when they did not communicate QAPI initiatives, or seek input from staff, residents, and family members. This failure had the potential for the QAPI Committee to miss valuable feedback from the residents, family members and staff who provide direct resident care. Findings: During an observation on 9/13/21, at 11 a.m., a communication board behind glass indicated Quality Advancement and Performance Improvement (QAPI) Committee Components. No current projects were listed. A copy of the QAPI plan dated 2019 was observed. During an interview on 9/14/21, at 11:45 a.m., Licensed Staff E and Unlicensed Staff X stated they had not been asked for feedback or input about resident care issues and did not know what QAPI was. During an interview on 9/16/21, at 3:44 p.m., the Medical Director stated he attended the monthly QAPI. He indicated the committee reviewed Policy and Procedures (P&P), Infection Prevention and COVID data every…

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

Based on interview and record review, the facility failed to notify responsible party and the physician for one resident (Resident 53) of a significant weight loss. This failure resulted in significant weight loss not monitored and addressed. Findings: A review of Resident 53's weights record dated 7/8/21 to 9/13/21 indicated, recorded weight of 175 lbs (pounds) on 7/11/21 and weight of 165 lbs on 8/22/21. Resident 53 had a significant weight loss of 5.71% in 30 days. A review of Resident 53's progress notes dated 8/22/21 to 9/14/21, did not indicate notification of significant weight loss to responsible party and the physician. Progress notes did not indicate Registered Dietician's (RD) documentation about the significant weight loss. Progress notes indicated Resident 53 had four IDT (Interdisciplinary Team) meetings from 8/23/21 to 8/30/21. During a concurrent interview and record review on 9/15/21, at 1:18 p.m., Resident 53's progress notes from 8/22/21 to 9/14/21 were reviewed with Licensed Staff E. Licensed Staff E was asked about the process if resident had weight loss.…

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 complete a comprehensive assessment for 1 of 20 sampled residents (Resident 60) when a Minimum Data Set (MDS - an assessment tool completed by clinical staff to assess a resident's cognitive, psychological, physical, and functional capabilities) was not completed within 14 days of Resident 60's admission to hospice care. This failure resulted in an inaccurate representation of Resident 60's current clinical status and had the potential to cause inadequate care based on a delinquent comprehensive assessment and care planning. Findings: During a clinical record review for Resident 60, the Physician's Order dated 03/09/21 indicated an order for hospice referral due to Cerebral Infarction (stroke). During a clinical record review for Resident 60, the Progress Note dated 03/12/21 indicated, Resident 60 was admitted to Hospice Services. During a concurrent interview and record review of Resident 60's MDS with the Assistant Director of Nursing (ADON) on 09/17/21 at 11:25 a.m., the MDS indicated a Significant Change in Status…

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 accurately document an MDS assessments for 1 of 20 sampled residents (Resident 60). This failure resulted to inaccurate reflection of resident status and incomplete comprehensive care plans to meet Resident 60's needs. Findings: 1. Significant Change in Status Assessment (2/11/21) During a clinical record review for Resident 60, the Dental Progress Note dated 1/21/2021, indicated Resident 60 had three broken/ decayed teeth and had Periodontal Disease (a gum infection that is ongoing). During a clinical record review for Resident 60's MDS Significant Change in Status assessment dated [DATE], Section L0200 (Dental and Oral Status) indicated Resident 60 had no obvious or likely cavity or broken natural teeth. 2. Quarterly Assessment (5/5/21) a. During a clinical record review for Resident 60, the Progress Note dated 3/12/21 indicated Resident 60 was admitted to Hospice Services. During a clinical record review for Resident 60's MDS Quarterly assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow the facility's policy and procedure to ensure a PASARR (Medicaid Pre-admission Screening and Resident Review) was completed for one of 10 sampled residents (Resident 66). This failure had the potential to put residents at risk for not receiving the appropriate mental health care to meet their needs. Findings: During a record review of Resident 66's chart on 9/13/21 at 2:00 p.m., no PASARR form was found in the medical record. During an interview with Medical Records Manager on 9/14/21 at 10:30 a.m., when asked where PASARR forms were kept, he stated they were kept in the Matrix (Electronic Medical Record). During a record review on 9/14/21 at 11:00 a.m., there was no PASARR form found for Resident 66 in the Matrix. During an interview with Licensed Staff A on 9/15/21 at 2:21 p.m., when asked for Resident 66's PASARR, Licensed Staff A looked into the medical record and stated there was no PASARR found for Resident 66. Licensed Staff…

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 communicate the recommendations of the restorative nursing assistants (RNA, provide rehabilitation care to help people regain or improve their physical, mental and emotional health) to the rehabilitation (rehab) department for one of six residents (Resident 91) sampled for ADL (activities of daily living) decline. This failure could potentially result in a decline in mobility, loss of independence, depression, and could cause Resident 91 to give up. Findings: During an observation and interview on 9/13/21 at 4:21 p.m., Resident 91 stated the staff were not trained in rehabilitation. Resident 91 stated staff did not seem to understand that she was numb on her left side, which was paralyzed. Resident 91 stated that during transfers (such as from bed to chair) she did most of the work herself. She stated that a few weeks ago, she pulled a muscle in her shoulder when a staff member helped her during a transfer. Resident 91 stated that she lost her balance due to a miscommunication with the staff member, and when…

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 care and services to meet the nutritional needs of one resident (Resident 53) with feeding tube (medical device used to provide liquid nourishment, fluids and medications by bypassing oral intake). This failure resulted in Resident 53 having significant weight loss in 30 days. Findings: A review of Resident 53's weights record dated 7/8/21 to 9/13/21 indicated, recorded weight of 175 lbs (pounds) on 7/11/21 and weight of 165 lbs on 8/22/21. Resident 53 had a significant weight loss of 5.71% in 30 days. A review of Resident 53's Physician Order Report dated 7/19/21, it indicated, Monitor Intake and Output (I & O) every shift; NOC (night), AM, PM. During an interview on 9/16/21, at 2:06 p.m., Licensed Staff L was asked if they were monitoring and documenting Resident 53's tube feeding. Licensed Staff L stated she got the total amount of feeding formula consumed during her shift and the total of fluids provided and documented it at the end of her shift. During an interview on 9/16/21, at 3:17 p.m.,…

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

Based on observation, interview and record review, the facility failed to provide care and services according to resident needs and professional standard of practice to one resident (Resident 53) with a feeding tube (medical device used to provide liquid nourishment, fluids and medications by bypassing oral intake). This failure resulted in: 1. Water flushing order not followed 2. Possible aspiration pneumonia Findings: 1. During an observation on 9/15/21, at 2:46 p.m., Resident 53 was observed with feeding tube Diabetisource (formula) running at a rate of 85 ml (milliliters) per hour with 100 ml flushing every eight hours. Review of Resident 53's Physician Order Report dated 9/1/21 to 9/16/21, it indicated, Diabetisource @ 85 ml/hr x 20 hours via PEG-Tube (Percutaneous Endoscopic Gastrostomy-tube placed directly into the stomach for administration of food, fluids and medications) Special Instruction: ON at 2:00 PM; OFF at 10:00 AM. Physician order report with start date 9/14/21 indicated, Enteral-Free Water Flush 150 ml TID Three Times a Day. During an observation on 9/16/21, 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.

Based on record review and Administrator interview the facility failed to ensure an effective Quality Assurance and Performance Improvement (QAPI) Plan. Failure to assess areas of patient care priorities resulted in the facility's inability to self-identify areas for improvement. Findings: The concept of developing QAPI plans is for facility self-identification and correction of quality deficiencies. In addition to identification and correcting quality deficiencies it provides opportunities for improvement, which will lead to improvement in the lives of nursing home residents, through continuous attention to quality of care, quality of life, and resident safety (Centers for Medicare/Medicaid Services, State Operations Manual Transmittal 169). The annual recertification survey from 9/20/21 - 9/21/21 revealed deficient practices related to the safe and effective implementation of food services (Cross Reference F801, F802, F803, F 806, F 808, F812, F692), Covid Monitoring (Cross Reference F880), PASARR Screening (Cross Reference F645), Activities of Daily Living Decline (Cross…

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 interview and record review, the facility failed to re-check blood sugars and notify the physician/nurse practitioner, as ordered, of blood sugar levels greater than 450 for one of two sampled residents (Resident (R) 58), who were reviewed for insulin concerns. The facility identified 24 residents with physician orders for finger stick blood sugar level checks and 12 residents with physician orders for sliding scale insulin. Findings Include: The facility's policy titled, Change in a Resident's Condition or Status, dated 05/2017, indicated, . Our facility shall notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status . The nurse will notify the resident's Attending Physician or physician on call when there has been a(an) . specific instruction to notify the Physician of changes in the resident's condition . The nurse will record in the resident's medical record information relative to changes in the resident's…

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

Based on record review, staff interview, and facility policy review, the facility failed to ensure the Consultant Pharmacist identified, and acted upon, irregularities for the use of an antipsychotic medication (Haldol decanoate) for one resident (Resident (R) 51), out of a survey sample of five residents and one expanded resident sample reviewed. Findings Include: Review of R51's, Resident Face Sheet, indicated the facility admitted Resident 51 on 03/19/13. Review of, Note to Attending Physician/Prescriber, dated 12/06/18, with a hand-written noted that a telephone order was obtained to have R51 seen by psych services to address her current use of Haldol. This note came from the Consultant Pharmacist. Review of a nursing, Resident Progress Note, dated 12/06/18, indicated a referral was obtained to have R51 evaluated by behavioral health services for medication management and treatment of early onset Alzheimer's disease. Review of a document titled, .Behavioral. dated 12/10/18, indicated R51 was seen by an Advance Practice Registered Nurse (APRN), and the APRN recommended Resident…

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

Based on observation, interviews, record review, and review of facility policy, the facility failed to ensure one of five sampled residents, (Resident (R) 51), had appropriate clinical indications for the continued use of an antipsychotic medication (Haldol decanoate), out of a survey sample of five and one expanded resident sample for unnecessary medications. (Cross Reference F756) Findings include: Review of R51's, Resident Face Sheet, indicated the facility admitted Resident 51 on 03/19/13, with a diagnosis of early onset Alzheimer's disease. Review of, Consents-Facility Verification of Informed Consent-Psychotropic Drug, dated 03/09/16, indicated Resident 51's representative was informed R51 was administered Haldol decanoate 25 milligrams (mg) intramuscular (IM), scheduled one time a month for behavioral or psychological symptoms of dementia. Review of, Consents-Facility Verification of Informed Consent-Psychotropic Drug, dated 08/29/18, indicated R51's resident representative was informed the use of Haldol decanoate 12.5 mg IM was for the treatment of random outbursts and…

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