San Luis Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to complete a new Preadmission screening and Resident Review (PASARR- a federal requirement to ensure resident with mental disorder or intellectual disorder or intellectual disabilities are not inappropriately placed in a nursing home) level 1 screening for one of six sampled residents (Resident 6) when Resident 6's PASARR level 1 dated 9/9/24 completed prior to admission to the facility did not include diagnosis of psychosis (a severe mental condition in which thought, emotions are so affected that contact is lost with reality) and depression (a serious, persistent mood disorder) and use of psychotropic medication (drugs that affect the mind, emotions, and behavior).This failure had the potential for Resident 6 to not receive the appropriate services related to her diagnoses and medication used. Findings: During a concurrent observation, and interview, on 3/3/26 at 12:05 p.m. in the dining room with Resident 6, Resident 6 was observed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a comprehensive, person-centered care plan (a plan that provides direction for individualized care of the resident) was developed and implemented to meet the identified needs for one of eight sampled residents (Resident 41), when Resident 41 did not have a care plan for their arm sling (a supportive device-usually a fabric pouch with a strap-used to hold an injured arm, wrist, or shoulder still against the body). This failure placed Resident 41 at risk for delayed healing by not identifying and monitoring for compliance with the arm sling. Findings: During a review of Resident 41's admission Record (AR-a document containing pertinent resident profile information), dated 3/6/26, the AR indicated Resident 41 was admitted to the facility on [DATE] with diagnoses which included fracture (define) of the right femur (long bone of the leg), fracture of the right patella (knee cap), fracture of the humerus (long bone of the arm), and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide care and services in accordance with professional standards of quality of care for three out of six sampled residents (Residents' 11, 48, and 65) when:1.Licensed Vocational Nurse (LVN) 3 signed the electronic Medication Administration Record (eMAR- legal record of drug administration to a patient at a facility by a health care professional) prior to administering Resident 11 and Resident 65's received their medications. These failures resulted in inaccurate charting and placed Resident 11 and Resident 65 at risk to not receive the medications ordered.2.Registered Nurse (RN) 1 did not shake the inhaler (handheld, pressurized device that delivers a specific, measured dose of medication) before he gave it to Resident 48 to self administer.This failure had the potential to result in Resident 48 not receiving the accurate dose of medication which could lead to Resident 48 not experiencing relief of his condition.Findings: 1. During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide pharmaceutical services which ensured the administration of medications to meet residents needs were met for one of 10 sampled residents (Resident 31), when Resident 31's buspirone (medication used to treat anxiety (feeling of fear, dread, and uneasiness, often accompanied by physical symptoms)) medication was not available during medication pass on 3/5/26.This failure had the potential for Resident 31's anxiety behavior to increase which could result in serious medical conditions such as worsening of anxiety, panic episodes, insomnia, irritability, dizziness, headache, and nausea. Findings: During a concurrent observation and interview on 3/3/26 at 11:23 a.m. during initial tour in Resident 31's room, Resident 31 was lying in bed, watching television and talking with another resident in bed next to Resident 31's bed. Resident 31 was appropriately dressed and stated his only concern was the food. Resident 31 stated he felt safe in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and review of facility documents, the facility failed to ensure the Dietary Manager (DM) received frequently scheduled consultation from the Registered Dietitian (RD). Failure to have the RD provide frequent oversight and consultation with the DM of food and nutrition services can result in a lack of the RD identifying system issues regarding menus and recipes not being followed, food not in the proper form, and lack of competent staff and ensuring development of a prompt action plan to resolve the issues for the health and safety of the 66 residents admitted to the facility. Cross Reference F802, F803, F804, F805.Findings:During a series of observations and interviews that identified multiple failures to deliver food and nutrition services safely and effectively on 3/3/26 through 3/5/26 indicated the facility RD lacked familiarity with the food and nutrition service operation in relation to:a. During an observation on 3/3/26 at 12:01 p.m.of the lunch meal service, in the meal…

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 review of facility documents, the facility failed to ensure menus were followed for a renal diet for one sampled resident (Resident 15) during the lunch meal service on Tuesday, March 3, 2026. This failure had the potential to result in the resident exceeding the micronutrients in the physician's prescribed therapeutic diet order which may compromise the nutritional and medical status of the resident.During an observation of the lunch meal service on 3/3/26 at 12:01 p.m., in the meal cart, a concurrent review of Resident 15's lunch meal ticket showed a renal, consistent carbohydrate diet, regular texture and thin liquids with a scoop plate as the adaptive equipment. During a further review of Resident 15's meal ticket at the same time, indicated three ounces of pot roast, 1/2 cup white rice, 1/2 cup mixed vegetables. It was observed on Resident 15's lunch tray there was a scoop plate with three ounces of pot roast, 1/2 cup of mashed potatoes, and 1/2 cup mixed vegetables. During an observation with concurrent interview with the Food Service…

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, record review, and facility policy review, the facility failed to provide two of three residents (Resident (R)47 and R62) or their responsible party, reviewed for hospital transfers out of a total sample of 36 residents a written bed hold when R47 and R62 was transferred to the hospital. This failure had the potential to cause confusion or distress regarding return to the same room after hospitalization. Findings include: Review of facility's policy titled Admission, Transfer and Discharge Notice of Bed Hold Policy Before/Upon Transfer revision date 11/2018 indicated, .The facility will provide written information to the resident or resident representative specifying the duration of the state bed-hold policy, if any, during which time the resident is permitted to return and resume residence in the facility.This information will be provided to the resident and the resident representative before a transfer or therapeutic leave and at the time of transfer of a resident for hospitalization 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, record review, and facility policy review, the facility failed to provide three of three residents (Resident (R)41, R47 and R62) reviewed for hospital transfers out of a total sample of 36 residents' notification to the ombudsman when R41, R47 and R62 transferred to the hospital. This failure placed the resident and their representative at risk of having incomplete information, misunderstanding the reason of transfer/discharge, and the discharge appeal process. Findings include: Review of the facility's policy titled Admission, Transfer and Discharge Notice Requirements Before Transfer/Discharge dated 07/2018, read in part .10. Notifications to the Office of the State LTC [Long Term Care] Ombudsman will occur before or as close as possible to the actual time of a facility-initiated transfer/discharge. 1.Review of R41's undated Face sheet located in the resident's electronic medical record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE]. Review of R41's…

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

Based on observation, interview, and record review, the facility failed to revise the care plan to include refusals for weekly weights for one resident (Resident (R)41) out of a sample of 36 residents. Refer to F692. Findings include: Review of R41's admission Record from the electronic medical record (EMR) Profile tab showed a facility admission date of 10/11/21 with medical diagnoses that included Hydronephrosis with Renal and Ureteral Calculous Obstruction, Dysphagia, Anemia and Muscle Weakness. Review of R41's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/18/24, located in the resident's EMR under the MDS tab indicated the facility assessed R41 to have a Brief Interview for Mental Status (BIMS) score was 12 out of 15, indicating R41 was cognitively alert. Review of R41's Care Plan, located in the resident's EMR section titled Care Plans, revealed the resident had a care plan with revision date of 08/01/24. The care plan identified the resident had focus for R41 was at risk for altered nutrition/hydration status and/or weight fluctuations.…

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, observations, and a review of the facility policies, the facility failed to ensure one resident (Resident (R)25) in a total sample of 30, received a range of motion care and treatment. Specifically, the facility failed to provide restorative aide care per R25's care planned intervention to prevent further contractures of her right hand. Findings included: Review of the facility's policy titled, Restorative Nursing Program, undated revealed, .The Restorative Nursing Program (RNP) is designed to assist the facility team help residents to achieve and maintain their highest functional level . the RNP has two general purposes (a). the program may be used to help residents restore function . (b). to assist residents to maintain function or prevent, to the extent possible, or minimize functional declines .RNPs do not require a physician order .RNP activities may be provided by designated RNAs (Restorative Nursing Assistants, Certified Nursing Assistants (CNAs) .If the resident or representative…

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, medical record review, and policy review, the facility failed to ensure one of five residents (Resident (R) 41) reviewed for nutrition had weekly weights obtained after a significant weight loss. This failure had the potential for residents to lose a significant amount of weight without interventions which could have adverse health effects. Findings include: Review of R41's admission Record from the electronic medical record (EMR) Profile tab showed a facility admission date of 10/11/21 with medical diagnoses that included Hydronephrosis with Renal and Ureteral Calculous Obstruction, Dysphagia, Anemia and Muscle Weakness. Review of the NSG Skin and Nutrition Review, located under the Evaluations tab of the EMR, dated 05/31/24stated the reason for the review was significant/grad weight loss/gain. Comments section stated R41 weight history: 05/22/24: 136 lbs (-5#/-3.7% x 1 week, not sig), 5/10/24:145 lbs and 4/27/24: 148 lbs (-17#/-11.5% x 1 mon, sig) Significant weight loss noted in the past 1 month likely related to poor intake secondary to food consistency. PO…

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 record review, observation, interview, and review of the facility policies., the facility failed to ensure staff followed enhanced barrier precautions and standard nursing precautions while providing wound care for one of one resident (Resident (R)19) out of a sample size of 30. Specifically, facility staff failed to follow personal protective equipment (PPE) guidelines properly and did not use a clean barrier surface for wound care supplies when providing bilateral wound care to R19. This facility failure had the potential to cause further infection to the resident's wounds. Findings include: Review of the facility's policy titled, Infection Control Enhanced Barrier Precautions, not dated, revealed, Enhanced Barrier Precautions (EBP) are an infection control intervention used to reduce transmission of multi drug-resistant organisms . EBP is an extension of standard precautions utilized for resident . Review of the facility undated policy titled, Infection Prevention and Control Program, revealed,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents were treated with respect and dignity for four of six sampled residents (Resident 1, 2, 3 and 5) when Certified Nursing Assistant (CNA) 1 disrespectfully responded to Resident 1, 2, 3 and 5. This failure resulted in Resident 1, 2, 3 and 5 feeling disrespected. Findings: During a concurrent interview and record review on 5/24/24 at 2:48 p.m. with the Social Services (SS), Resident 1's Grievance Form (GF) dated 4/11/24 was reviewed. The GF indicated, .[Resident 1] complain that CNA [1] is rude, calls me girlie and not with respect. Resident request to go to bed right after dinner and CNA stated I have to care for other people you are not the only one . The SS stated CNA 1 was re-educated on customer service. During a concurrent interview and record review on 5/24/24 at 2:50 p.m. with the SS, Resident 2's Grievance Form (GF) dated 5/15/24 was reviewed. The GF indicated, .[Resident reported that CNA [1] made a comment 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 observation, interview and record review, the facility failed to meet professional standards of quality, for one of four sampled residents (Resident 4), when Resident 4 had a fractured (break or crack) left fifth finger (pinky) on 5/19/24 and a splint (immobilizer) was not placed until 5/20/24. This failure placed Resident 4 at risk for further damage to his fractured left fifth finger. Findings: During a concurrent interview and record review on 5/24/24 at 2:35 p.m. with Licensed Vocational Nurse (LVN) 2, Resident 4's Interdisciplinary Notes (IDT) dated 5/21/24 was reviewed. The IDT indicated, .On 5/19/2024, during routine nail care, the C N A [Certified Nursing Assistant] noted that resident's left 5th digit [finger] is swollen with blackish discoloration. Charge Nurse assessed the affected site right away . Notified MD and ordered X-ray [picture of bone] to be done on the left fingers. Result came with findings . Fracture .left fifth middle NP [Nurse Practitioner] on call was notified on 5/19/2024…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement a resident-centered comprehensive care plan for one of three sampled residents (Resident 1), when Resident 1 with known behavior of physical aggression was left unsupervised on 4/23/24. This failure resulted in Resident 1 punching Resident 2. Findings: During a review of Resident 1's admission Record (document containing resident demographic information and medical diagnosis) undated, the admission record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnosis included Alzheimer ' s (affects memory, thinking and behavior), major depression and anxiety. During a concurrent observation and interview on 5/6/24 at 10:00 a.m. with Resident 1, in Resident 1's room, Resident 1 was lying on his bed. Resident 1 did not recall the altercation on 4/23/24. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) Assessment dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to meet professional standards of quality, for one of three sampled residents (Resident 1) when Resident 1 did not have duloxetine (medication for depression) available for three days and licensed nurses did not follow up with pharmacy to check the order status. This failure placed Resident 1 at risk to experience anxiety, irritability, difficulty in sleeping, and possibly nightmares. Findings: During on observation on [DATE] at 5:33 p.m. in Resident 1 ' s room, Resident 1 was seated in her wheelchair. Resident 1 stated she has not received duloxetine for three days because the facility ran out of her medication. Resident 1 stated the medication was working well and since she stopped taking the medication, she experienced nightmares. During a review of Resident 1's Face Sheet (FS, a document with demographic, personal and medical information) undated, the FS indicated Resident 1 had diagnoses which included anxiety and major depression.…

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 grooming needs were met for one of three sampled residents (Resident 1) when Certified Nursing Assistants (CNAs) and Licensed Nurses (LNs) failed to provide Resident 1 with fingernail care to keep nails groomed as indicated in the facility's policy titled, Quality of Life Activities of Daily Living. This failure resulted in Resident 1's care needs unmet and placed Resident 1 at risk for developing injury and/or infections. Findings: During a concurrent observation and interview on 8/24/23, at 9:49 a.m., with Certified Nursing Assistant (CNA) 1, in Resident 1's room, Resident 1's fingernails on her left hand were long and untrimmed. CNA 1 stated Resident 1's fingernails should be trimmed and filed. CNA 1 stated Resident 1 was unable to trim her nails independently and it was the CNA's and Licensed Vocational Nurse (LVN's) responsibility to trim Resident 1's nails. CNA 1 stated Resident 1's nails should have been trimmed to prevent…

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 distribute food in accordance with professional standards for food service safety when: 1. An undated opened whole milk 2 percent (% - a unit of measurement) gallon was placed in a plastic container containing ice and ready for use in the food preparation counter. 2. An undated with no use by date bag of hamburger patties were stored and ready for use in freezer 2 of the kitchen. 3. Two undated and open plastic bags of white bread, one bottle of ground spice pimiento, and one bottle of salt were stored and ready for use in the condiments shelves in the kitchen. These failures to ensure effective dietetic service operations placed residents that received meals from the kitchen at risk for food borne illness and the growth of microorganisms. Findings: 1. During a concurrent observation and interview with the Dietary Manager (DM) on 5/22/19, at 8:15 a.m., in the kitchen, an undated gallon of opened whole milk 2 percent was placed in a plastic container with ice and ready for use on the food preparation…

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 have an effective Quality Assessment and Performance Improvement (QAPI- a program that enables the facility to evaluate and improve the quality of resident care and services through data collection, staff input, and other information) program when: 1. Four out of five staff which included: Licensed Vocational Nurse (LVN) 6, Certified Nursing Assistant (CNA) 5, CNA 6 and LVN 2 were unable to identify the purpose of the QAPI program or the current facility QAPI projects. These failures resulted in an ineffective QAPI program necessary to improve quality of care provided to residents and ensure adequate staff knowledge of the facility QAPI program and QAPI project improvements plans. Findings: 1. During an interview with Licensed Vocational Nurse (LVN) 6 on 5/28/19, at 5:23 p.m., LVN 6 stated she did not know what QAPI was and could not state what QAPI project the facility was currently working on. During an interview with Certified Nursing Assistant…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents were treated with respect and dignity and in an environment that prootes and enhances the quality of life for two of three sampled residents (Resident 17 and Resident 15) when: 1.Certified Nursing Assistant (CNA) 1 stopped assisting Resident 17 during lunch and Resident 17 waited to be fed while watching other residents to be fed. This failure violated Resident 17's right to a dignified existence and had the potential to result in Resident 17 to experienced weight loss. 2. Resident 15's upper body parts and brief were exposed while resting in bed. This failure violated Resident 15 right to be treated with respect and dignity. Findings: 1. During an observation on 5/22/19 at 12:26 p.m in the dining room, Resident 17 sat in her wheelchair and there were two other residents in the dining table who was getting assistance with their meals. CNA 1 stopped assisting Resident 17 and CNA 1 stood up and left Resident 17 in the dining…

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 reasonable accommodations for one of 51 sampled residents (Resident 353) when Resident 353's call light was not within reach and hung on the wall outlet. This failure had the potential to result in Resident 51's needs to go unmet. Findings: During a concurrent observation and interview with Resident 353, on 5/22/19, at 10:30 a.m., in Resident's 353 room., Resident 353 laid in bed with her call light clipped on the wall outlet and was not within her reach. Resident 353 stated she did not know where her call light was and could not find the call light from her position in bed. Resident 353 stated she would have to yell for help if she needed help from staff. During a concurrent observation and interview with Certified Nursing Assistant (CNA) 1, on 5/22/19, at 10:35 a.m., CNA 1 stated Resident 353's call light hung on the wall outlet and was not within Resident 353's reach. CNA 1 stated, [Residents'] call light should always be within reach to prevent accidents or falls and to meet [residents'] needs.…

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

Based on observation, interview, and record review the facility failed to protect the privacy of personal information for one of three sampled residents (Resident 51) when Licensed Vocational Nurse (LVN) 1 left the protected health information (PHI) exposed to public view. This failure resulted in the potential for unauthorized access to personal information and violated Resident 51's rights to confidentiality. Findings: During an observation on 5/22/19 at 8:14 a.m. in the facility's west wing hallway, the computer on the medication cart was left open and unattended by LVN 1. The computer screen displayed Resident 51's name, photo, date of birth , vital signs (reflect essential body functions, including your heart rate, breathing rate, temperature, and blood pressure), room number, allergies, physician orders and medications visible to everyone who passed by the medication cart. During an interview with LVN 1 on 5/22/19 at 2:40 p.m., LVN 1 stated the computer screen displayed Resident 51's name, photo, date of birth , vital signs, room number, allergies, physician orders 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 observation, interview, and record review the facility failed to ensure medications were administered in accordance with professional standard of practice for one of three sampled residents (Resident 39) when Licensed Vocational Nurse (LVN) 5 did not follow the facility's medication administration policy and procedures and administered an incorrect dosage of ascorbic acid (vitamin c) to Resident 39. This failure resulted in Resident 39 not receiving the appropriate dosage of ascorbic acid as prescribed by the Medical Director (MD). Findings: During a medication administration observation on 5/22/19, at 8:50 a.m., in the facility's east wing hallway, LVN 5 administered one tablet of 250 milligrams (mg- a unit of dry measurement) ascorbic acid to Resident 39. During a concurrent interview and record review with LVN 5, on 5/22/19, at 2:30 p.m., LVN 5 reviewed Resident 39's physician's order dated 5/15/18 which indicated, .Ascorbic Acid tablet Give 500 mg by mouth two times a day related to Nutritional Deficiency . LVN checked the ascorbic acid bottle which indicated, .ascorbic…

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 three sampled residents (Resident 30 and Resident 51) received treatment and care in accordance with professional standards of practice, comprehensive person centered care and the residents' choices to enable residents to maintain their highest practicable level when: 1. For Resident 30, the facility failed to assess, document and inform the Medical Doctor (MD) when Resident 30's Carvedilol (tablet 3.125 mg [milligrams - unit of measurement] a medication to treat high blood pressure) medication was not given 13 times in January 2019, 14 times in February 2019, 16 times in March 2019, 11 times in April 2019 and seven times in May 2019 for low blood pressure. 2. For Resident 51, the facility failed to assess, document and inform the MD when Resident 51's Carvedilol 6.25 mg and Lotensin (a medication to treat high blood pressure) 5 mg was not given four times in April 2019 and 16 times in May 2019 for low blood pressure. These…

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 Licensed Vocational Nurse (LVN) 7 followed the facility policy and procedure titled, Medication Administration for two of two sampled residents (Residents 26 and 21) when LVN 7 administered physician ordered medications two hours before medications were due for administration for Resident 26 and Resident 21. These failures resulted in Resident 26 and Resident 21's sleep interruption and caused Resident 26 and Resident 21 to feel tired and frustrated. Findings: During an interview with LVN 7, on 12/7/18, at 1p.m., LVN 7 stated she began her 6 a.m. medication administration pass at 3 a.m., LVN 7 stated the facility policy and procedure titled, Medication Administration, dated, 8/20/18 indicated medications may be administered one hour before or one hour after the scheduled medication administration time. LVN 7 stated she was aware of the standard of practice of administering medications one hour before or one hour after the scheduled administration time. LVN 7 stated passing medications two hours earlier than 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 policy and procedure titled, Medication Storage Guidance when the medication refrigerator temperature which stored drugs and biologicals was not monitored and documented on 5/21/19 on the morning shift temperature log. This failure had the potential for drugs and biologicals stored inside the medication refrigerator to decreased its effectiveness. Findings: During an observation on 5/22/19, at 9:49 a.m., in the medication room, the medication room refrigerator temperature was not documented for 5/21/19 morning shift. The medication refrigerator contained three vials of pneumovax vaccine (fights bacteria against pneumonia, blood infections, and bacterial meningitis-infection in the brain) one Engerix vaccine (immunization against infection caused by Hepatitis B-liver infection), three Tuberculin test (a tool for screening tuberculosis), three insulin aspart vials (a rapid acting insulin used to lower blood sugar level), two vials of regular insulin (a short acting insulin used to lower blood sugar…

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 medical records were accurately documented in accordance with the facility policy and procedure and accepted professional standards of practice for one of one sampled residents (Resident 30) when Licensed Vocational Nurse (LVN) 4 did not document the accurate diagnosis for Resident 30's laboratory (lab) orders. This failure resulted in an inaccurate medical record for Resident 30. Findings: During a review of the clinical record for Resident 30, the face sheet (a document containing resident profile information) undated, indicated, Resident 30 was re-admitted to the facility on [DATE] with diagnoses which included hypothyroidism (a disorder where the thyroid gland does not produce sufficient thyroid hormone and can cause sensitivity to cold and hot temperatures) and polyneuropathy (damage to multiple nerves outside of the brain and central nervous system. During a concurrent interview and record review with the Facility Nurse Consultant (FNC) on…

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

Based on observation, interview, and record review, the facility failed to implement and maintain an effective infection control program for 1of 2 sampled residents (Resident 47) when Resident 47's urinal was unlabeled, undated, had yellow, sticky substance on the handle and hung on the side of the garbage can. These failures had the potential to place the Residents 47 at risk for cross contamination and exposure to infectious organisms. Findings: During an observation on 5/22/19, at 10:30 a.m., in Resident 47's room, Resident 47 sat on the seat of his wheelchair. Resident 47's urinal was unlabeled, undated, had a yellow, sticky substance on the handle and hung at the side of the garbage can. Resident 47's urinal contained 50 milliliters (ml- a unit of measurement) of yellow liquid. During a concurrent observation and interview with Licensed Vocational Nurse (LVN) 1, on 5/22/19, at 10:45 a.m. in Resident 47's room, LVN 1 stated Resident 47's urinal was unlabeled, undated, had urine on the handle of the urinal and should not be hanging at the side of the garbage can. LVN 1 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.