Crystal Cove Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review and facility P&P review, the facility failed to provide the necessary respiratory care and services for three of three final sampled residents (Residents 67, 336, and 686) reviewed for the respiratory care. * The facility failed to obtain a physician's order prior to the oxygen administration for Resident 686. * The facility failed to obtain a physician's order prior to the oxygen administration for Resident 336. The facility failed to place an Oxygen In Use sign outside the door of Resident 336's room as per the facility's P&P. In addition, the facility failed to develop a care plan problem to address Resident 336's oxygen use. Furthermore, the facility failed to administer oxygen as per the physician's order to Resident 336. * The facility failed to ensure Resident 67's nebulizer tubing was labeled with Resident 67's name and the date. These failures had the potential to negatively impact the residents' well-being. Findings: Review of the facility's P&P…

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, medical record review, and facility P&P review, the facility failed to ensure the dialysis care was provided for one of two final sampled residents (Resident 70) reviewed for dialysis as evidenced by: * The facility failed to ensure the dialysis emergency kit was maintained at the bedside for Resident 70. In addition, the facility failed to ensure Resident 70's dialysis access site was assessed and monitored appropriately and consistently. The licensed staff failed to consistently assess Resident 70's dialysis access site prior to the resident being transported to the dialysis treatment center and upon returning from the dialysis center. In addition, the licensed staff documented Resident 70's dialysis access type as either catheter or left blank, instead of permacath. These failures had the potential for Resident 70 not being provided with the appropriate care and treatment, which could lead to medical complications related to the resident's dialysis access site. Findings:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility document review, the facility failed to ensure the competency of two of two licensed nurses (LVN 12 and the ADON) interviewed regarding bladder training and failed to ensure the annual performance evaluation was conducted for one of three licensed nurses (LVN 5) reviewed for the annual performance evaluation. * The facility failed to ensure LVN 12 and the ADON were able to demonstrate their competency on the bladder training for a resident with an indwelling urinary catheter. * The facility failed to provide the training materials used for the in-service trainings provided to the facility staff. * The facility failed to ensure the annual performance evaluation was completed for LVN 5. These failures had the potential to put the residents at risk for care not being provided in a safe and competent manner. 1. According to [NAME] and Wilkins' article titled Reducing CAUTIs with a Bladder Retraining Program dated 2013 showed the bladder retraining with a catheter…

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 medical record review, the facility failed to ensure one of five final sampled residents (Resident 67) reviewed for unnecessary drugs were free from unnessary drugs. * Resident 67 had duplicate medication orders with different dosages. This failure posed the risk of medication errors. Findings: Medical record review for Resident 67 was conducted on 2/19/25. Resident 67 was admitted to the facility on [DATE]. Review of Resident 67's H&P examination dated 3/28/24, showed Resident 67 had the capacity to understand and make decisions. Review of Resident 67's Order Summary Report showed the following physician's orders: - dated 8/16/24, to administer guaifenesin oral tablet 400 mg PO every six hours as needed for cough and congestion. - dated 1/2/25, to administer geri-tussin (a brand of cough and cold medicine that contains guaifenesin, an expectorant and helps relieve cough, chest congestion, and stuffy nose) oral liquid 100 mg/5 ml 10 ml PO every six hours as needed for cough…

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 medical record review, the facility failed to ensure two of five final sampled residents (Residents 1 and 336) reviewed for unnecessary medications was free from the unnecessary psychotropic medication. * The facility failed to ensure the informed consent for zolpidem (hypnotic medication) was signed by the physician. In addition, the facility failed to ensure the monitoring for hours of sleep related to the use of zolpidem matched the documentation of the episode when Resident 336 was unable to sleep. * The facility failed to ensure the informed consent for Resident 1's clonazepam (antianxiety medication) medication was renewed and the consent was obtained from the responsible party and signed by the physician. These failures had to potential to result in unnecessary use and ineffective monitoring for the use of psychotropic medication that could negatively affect Resident 336's well-being. Findings: 1. Medical record review for Resident 336 was initiated on 2/18/25. Resident 336 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the medications were stored safely, securely and properly labeled. * The facility failed to ensure the single use dressings and discontinued topical medication were removed and discarded from the treatment cart. Furthermore, the facility failed to ensure the treatment cart was clean. * The facility failed to ensure the expired Covid testing kits were discarded. * The facility failed to ensure a medication with white pasty cream and a bottle of Adapt stoma powder (powder used to absorb moisture from broken skin around the stoma, which allows for better barrier adhesion to help protect the skin) were not kept at Resident 54's bedside. These failures had the potential to negatively impact the residents' wellbeing. Findings: Review of the facility's P&P titled Medication, Labeling and Storage (undated) showed the facility stores all the drugs and biologicals in a safe, secure, and orderly manner. 1. 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, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by: * The facility failed to ensure the kitchen utensils were clean and free of food particle or residue. * The facility failed to ensure the kitchen utensil was in good condition. These failures had the potential for cross contamination and foodborne illnesses to the residents consuming the foods prepared in the facility's kitchen. Findings: Review of the facility's Diet Type Report dated 2/18/25, showed 80 of 86 residents consumed the foods prepared in the kitchen. 1. Review of the facility's P&P titled Dishwashing dated 2023 showed all the dishes will be properly sanitized through the dishwasher. The dishwasher will be kept clean and in good working order. Gross food particles shall be removed by careful scraping and pre-rinsing in running water. According to the USDA Food Code 2022, 4-601.11 Equipment, Food - Contact Surfaces, Nonfood Contact Surface, and Utensils, the equipment food-contact surfaces 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 7. Medical record review for Resident 336 was initiated on 2/18/25. Resident 336 was admitted to the facility on [DATE]. Review of Resident 336's POLST dated 2/14/25, showed a different resident name and the wrong birthdate. Review of Resident 336's Informed Consent - Immunization (Updated) - V2 dated 2/14/25, for influenza vaccine, showed a different resident name. Review of Resident 336's Informed Consent - Immunization (Updated) - V2 dated 2/14/25, for pneumonia vaccine, showed a different resident name. Review of Resident 336's Informed Consent - Immunization (Updated) - V2 dated 2/14/25, for Covid-19 vaccine, showed a different resident name. Review of Resident 336's Consent to Treat dated 2/14/25 showed a different resident name. On 2/21/25 at 1338 hours, an interview and concurrent medical record review for Resident 336 was conducted with RN 4. RN 4 verified the above findings. 10. Medical record review for Resident 26 was initiated on 2/19/25. Resident 26 was admitted to the facility on [DATE], 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, medical record review, facility document review, and facility P&P review, the facility failed to maintain the infection control program designed to help prevent the development and transmission of diseases and infections. * The facility failed to implement their infection control surveillance program for November 2024, December 2024, and January 2025. The facility failed to correctly identify the HAIs and CAIs. The facility failed to conduct an accurate infection surveillance as per the McGeer criteria. The facility failed to ensure the residents infections were mapped and tracked. In addtion, the facility failed to ensure the infection control data presented to the infection control meeting was accurate and complete. * The facility failed to ensure the clean personal clothing and linen cart were covered during transportation. * The facility failed to ensure LVN 10 had performed hand hygiene while providing a wound care treatment to Resident 336. * The facility failed to ensure…

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 medical record review, the facility failed to provide the appropriate care and services to prevent UTIs for one of three final sampled residents (Resident 336) reviewed for the use of indwelling urinary catheter. * The facility failed to ensure the indwelling urinary catheter care was provided to Resident 336. In addition, the facility failed to monitor Resident 336's urinary output as per the resident's plan of care and provide the bladder training for Resident 336. These failures posed the risk for Resident 336 to develop CAUTI and negatively impact Resident 336's well-being. Findings: Review of the Centers for Disease Control and Prevention's article (undated) titled Catheter-Associated Urinary Tract Infection showed a UTI is an infection in the urinary tract system (including the bladder and the kidneys). Germs can travel along the catheter, and if they enter the urinary tract, may cause an infection in the bladder or kidneys. Prevention of the CAUTIs include proper…

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, medical record review, and facility P&P review, the facility failed to ensure the comprehensive care plan was developed and implemented for one of two sampled residents (Resident 1). * The facility failed to implement Resident 1's care plan for the use of dental appliances (dentures) during meals and for the coordination of a dental consult, to assist Resident 1 with obtaining lower dentures, after his readmission to the facility. * The facility failed to develop a comprehensive care plan to address Resident 1's hard of hearing status. These failures placed the resident at risk of not being provided appropriate, consistent, and individualized care. Findings: Review of the facility's P&P titled Care Plans Comprehensive Person Center (undated) showed a comprehensive, person-centered care plan for the resident should be developed by the interdisciplinary team with the input from the resident and his family or legal representative. The comprehensive, person-centered care plan should…

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, medical record review, and facility P&P review, the facility failed to provide dental services to meet the needs of one of two sampled residents (Resident 1). * The facility failed to assist Resident 1 with obtaining the lower dentures since his readmission to the facility. * The facility had failed to conduct a loss or theft investigation specific to Resident 1's lower dentures and failed to coordinate a dental consult for Resident 1. These failures had the potential to negatively affect Resident 1's well-being. Findings: Review of the facility's P&P titled Dental Services (undated) showed the routine and emergency dental services are available to meet the resident's oral health needs in accordance with the resident's assessment and plan of care. The social services representatives will assist the residents with the appointments, transportation arrangements, and reimbursement of the dental services under the State plan if eligible. The dentures will be protected from loss 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 observation, interview, and medical record review, the facility failed to provide the necessary care and treatment related to oxygen administration for one of three final sampled residents (Resident 2). * The facility failed to administer the oxygen to Resident 2 as ordered by the physician. This failure posed the risk of the resident developing complications due to inadequate oxygen therapy. Findings: Medical record review for Resident 2 was initiated on 12/5/23. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's History and Physical examination dated 12/4/23, showed Resident 2 had the capacity to understand and make decisions. Resident 2 had the left and right upper lungs embolism (a condition in which one or more arteries in the lungs become blocked by a blood clot). Review of Resident 2's admission diagnosis list dated 12/1/23, showed COPD, obstructive sleep apnea (noncontinuous airflow blockage during sleep), and acute and chronic respiratory failure. Review of the Order…

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, medical record review, and facility P&P review, the facility failed to ensure the home health services were in place before the resident was discharged home from the facility for one of two sampled residents (Resident 2). * Resident 2 was discharged home with an order for home health services, which included registered nursing and physical therapy. However, the facility failed to ensure home health services were in place, prior to Resident 2 being discharged home. This failure posed the risk for an unsafe transition from the facility to the home setting. Findings: Review of the facility's P&P titled Discharge Summary and Plan revised 10/2022 showed when a resident's discharge is anticipated, a discharge summary and post-discharge plan is developed to assist the resident with discharge. The post-discharge plan is developed by the care planning/interdisciplinary team, with the assistance of the resident and his or her family and includes: where the individual plans to reside and arrangements…

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, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for one of two sampled residents (Resident 2). * The facility failed to obtain a physician's order for the use of an intermittent urinary catheter (in an attempt to obtain a urine specimen) for Resident 2. This failure posed the risk for the unnecessary use of a urinary catheter which had the potential for negative health outcomes. * The facility failed to ensure Resident 2's abductor pillow was utilized properly. Resident 2 recently had undergone hip surgery. Resident 2's plan of care included the use of an abductor pillow, status post-surgery, while in bed. Resident 2 was observed lying in bed without the abductor pillow straps attached to Resident 2's legs. This had the potential for Resident 2's surgically repaired hip to move out of position and posed the risk for injury. Findings: 1. Review of the facility's P&P titled Catheterization Intermittent Female Resident Revised…

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, medical record review, and facility P&P review, the facility failed to ensure the pain assessment was conducted in accordance with the facility's P&P, after a resident complained of pain for one of two sampled residents (Resident 1). * Resident 1 refused to undergo dialysis and claimed he was in pain. The facility failed to conduct a pain assessment specific to Resident 1's complaint of pain. This failure posed the risk to not identify, address, and treat Resident 1's underlying cause of pain, which posed the risk for negative health outcomes. Findings: Review of the facility's P&P titled Pain Assessment and Management revised 10/2022 showed identifying the causes of pain (included) review of the resident's clinical record to identify conditions or situations that may predispose the resident to pain. During the pain assessment gather the following information: location of pain, characteristics of pain, intensity of pain, pattern of pain, and frequency of pain. Upon completion of the pain…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of two sampled residents (Resident 1) was free from significant medication errors. * Resident 1's written order for clonidine was incorrectly entered into Resident 1's electronic medical record. As a result, Resident 1 did not receive 34 doses of clonidine as ordered. This failure posed the risk for negative health outcomes for Resident 1. Findings: Review of the facility's P&P titled Administering Medications revised 4/2019, showed medications are to be administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescribed orders. Closed medical record review for Resident 1 was initiated on 10/24/23. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's physician's orders, showed an order dated 7/26/22, for clonidine (antihypertensive medication) 0.3 mg 3 tablets orally twice a day (0900 & 1700 hours) routinely. Review of Resident 1's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to ensure a laboratory test was performed as ordered by the physician, for one of two sampled residents (Resident 1). * Resident 1's physician ordered a lipase (enzyme secreted by the pancreas) level; however, the facility failed to perform the laboratory test. This failure had the potential for a delay in necessary treatment and services for Resident 1. Findings: Closed medical record review for Resident 1 was initiated on 10/24/23. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's SBAR Summary for Providers dated 10/9/22 0830 hours, showed Resident 1 had a change in condition. Resident 1 was noted with complaints of nausea and vomiting, with an episode of a small amount of emesis. Resident 1's physician was notified and ordered laboratory tests (which included a lipase level). Review of Resident 1's physician's order dated 10/9/22, showed an order to obtain a lipase level. Review of Resident 1's medical record failed to…

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 medical record review, the facility failed to ensure the medical record was accurate for one of two sampled residents (Resident 1). * Resident 1 had an abdominal ultrasound performed on 10/9/22;however, the licensed nurse documented Resident 1 had a KUB performed on 10/9/22. This failure had the potential for the resident's care needs not being met as the medical information was inaccurate. Findings: Closed medical record review for Resident 1 was initiated on 10/24/23. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's Order Summary Report showed an order dated 10/9/22, for an abdominal ultrasound to be performed. Review of Resident 1's Alert Charting dated 10/9/22 1432 hours, showed LVN 2 documented Resident 1 had a KUB done at this time with results pending. On 11/6/23 at 1125 hours, an interview and concurrent medical record review was conducted with the DON. The DON was asked if Resident 1 had an abdominal ultrasound or a KUB performed on 10/9/22. The DON…

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, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by: * The facility failed to ensure proper labeling and dating of opened food items in the refrigerator. * The facility failed to ensure the bin containing kitchen utensils was clean. * The facility failed to ensure the handles of the ladles were not melted. * The facility failed to ensure turkey baster was clean. * The facility failed to ensure plate warmer was clean. * The facility failed to ensure the glaze on the handles of the adaptive utensils (specialized forks, spoons with built-up handles to help people with disabilities to dine independently) was not worn off. These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumes food prepared from the kitchen. Findings: Review of the CMS 672 Resident Census and Conditions of Residents completed by the facility on 8/15/23, showed 76 of 87 residents in the facility received food prepared in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to implement their infection control surveillance program in accordance with the facility's P&P and failed to maintain the infection practices to help prevent the development and transmission of diseases and infection. * The facility failed to maintain an accurate infection surveillance program for April, May, and July 2023 when: - the facility failed to ensure an Infection Prevention and Surveillance Log was completed for April 2023. - the facility failed to ensure a summarized Monthly Infection Control Surveillance was completed for May 2023. - the facility failed to ensure all McGeer's Criteria were completed for July 2023. - the facility failed to ensure McGeer's Criteria had accurate information regarding infection surveillance for two of 20 final sampled residents (Residents 14 and 488). * The facility failed to ensure the infection control practices were implemented in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, facility document, and facility P&P review, the facility failed to implement the antibiotic stewardship program. The facility failed to ensure two of 20 final sampled residents (Residents 14 and 488) were accurately and timely reviewed for the appropriate use of antibiotics. This failure had the potential for inappropriate use and increased risk of drug resistant organisms. Findings: Review of the facility's P&P titled Infection Prevention and Control Program revised 10/2018, under Section Antibiotic Stewardship Program, showed the following: a. Culture reports, sensitivity data, and antibiotic usage reviews are included in surveillance activity. b. Medical criteria and standardized definitions of infections are used to recognize and manage infections. c. Antibiotics usage is evaluated, and practitioners are provided feedback on reviews. 1. Review of the Infection Prevention and Control Surveillance Log for July 2023 showed Resident 14 was on an Bactrim 800 mg (an antibiotic medication) for…

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

Based on observation, interview, facility document review, and facility P&P review, the facility failed to maintain the essential equipment used to prepare, serve, and store food in the facility. * The facility failed to ensure Freezer #1 was functioning properly to maintain the required temperature of 0 degrees F or lower. * The facility failed to ensure the ice machine was not leaking. * The facility failed to ensure the microwave used to warm the residents' foods was free from rust. These failures had the potential for equipment not functioning in the way they were intended and in turn cause contamination of food, leading to food-borne illnesses for the residents who received food from the kitchen. Findings: Review of the CMS 672 Resident Census and Conditions of Residents completed by the facility on 8/15/23, showed 76 of 87 residents in the facility received food prepared in the kitchen. Review of the USDA Food Code 2022, Section 4-501.11, Good Repair and Proper Adjustment showed equipment shall be maintained in a state of repair and condition. 1. During the initial 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, medical record, facility P&P review, and facility document review, the facility failed to ensure the staff provided care and promoted dignity and respect for one nonsampled resident (Resident 3). * CNA 1 was observed standing over Resident 3 while assisting the resident with meals. This failure had the potential to negatively impact the resident's well-being. Findings: Review of the facility's P&P titled Dignity revised 2/2021 showed when assisting with care, residents are supported in exercising their rights. For example, residents are provided with a dignified dining experience. On 8/15/23 at 1206 hours, during the initial dining observation in the dining room, CNA 1 was observed standing over Resident 3 while assisting the resident to eat. Several chairs were observed in the dining room. On 8/15/23 at 1300 hours, an interview was conducted with CNA 1. CNA 1 stated he was only cuing Resident 3 to eat, however, CNA 1 was informed he was observed standing over to feed Resident 3. CNA 1 acknowledged he was feeding Resident 3. CNA 1 stated he was supposed to get a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of 20 final sampled residents (Resident 13) was given the opportunity to participate in the care plan conferences. This had the potential for Resident 13 to not be able to choose treatments options and make decisions in care planning. Findings: Review of the facility's P&P titled Care Plans, Comprehensive Person-Centered revised March 2022 showed each resident has the right, individually or through a responsible party, to participate in the development and implantation of his or her comprehensive person-centered care plan including the right to participate in the planning process, suggests some possible individual goals and approaches, request meetings, and participate in suggesting the type, amount, frequency, and duration of care. The resident should be informed of the date of his or her care planning conference(s) and given the opportunity to participate. During the interview on 8/15/23 at 0919 hours,…

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, medical record review, and facility P&P review, the facility failed to ensure the personal belongings were returned timely during and after discharge for one of 20 final sampled residents (Resident 441). * Resident 441's personal medications (a bottle of multivitamins and a bottle of vitamin D) were not returned timely by the facility during discharge and after discharge. This had the potential for Resident 441's personal belongings being lost. Findings: Review of the facility's P&P titled Medications Brought to the Facility by the Resident/Family revised April 2017 showed the medications brought into the facility that are not approved for the resident's use shall be returned to the family. If the family does not pick up those medications within the 30 days, the facility may destroy them in accordance with established policies. On 8/10/23 at 0948 hours, a telephone interview was conducted with Resident 441. Resident 441 stated she was discharge from the facility on 7/27/23.…

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, medical record review, and facility P&P review, the facility failed to obtain and maintain the copies of advance directives (legal document that states a person's wishes about receiving medical care if that person is no longer able to make medical decisions) and failed to provide the information regarding the rights to formulate the advance directives for three of 12 final sampled residents (Residents 48, 72, and 539). These failures had the potential for the residents' decisions regarding their healthcare and treatment options not being honored. Findings: Review of the facility's P&P titled Advance Directives (undated) showed the following: - Prior to or upon admission of a resident, the SSD or designee inquire of the resident, his/ her family members and/ or his or her legal representative, about the existence of any written advance directives - If the resident or the resident's representative has executed one or more advance directive(s), or executes one upon admission, copies of 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the information on how to file a grievance was provided to one of 12 final sampled residents (Resident 72) and four nonsampled residents (Resident 7, 11, 41, and 60) participated in the Resident Council and failed to ensure the residents' grievances were resolved by the facility. These failures had the potential to cause the residents feeling hopeless and may negatively affect their emotional well-being. Findings: Review of the facility's P&P titled Grievances/Complaints, Filing (undated) showed the residents have the right to file a grievances either orally or in writing to the facility staff or the agency designated to hear the grievances. Upon admission, the residents are provided with written information on how to file a grievance or complaint. A copy of the grievance/complaint procedure will be posted on the residents bulletin board. Review of the facility's monthly Resident Council…

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, medical record review, facility document review, and facility P&P review, the facility failed to report an allegation of resident-to-resident altercation between one of 20 final sampled residents (Resident 13) and one nonsampled resident (Resident 50) to the CDPH L&C and LTC Ombudsman Programs as per the facility's P&P. This failure had the potential for the residents to be vulnerable for further abuse. Findings: Review of the facility's P&P titled Resident-to-Resident Altercations revised September 2022 showed the facility staff will monitor residents for aggressive/inappropriate behavior towards other residents, family members, visitors, or to the staff. Occurrences of such incidents are promptly reported to the nurse supervisor, DON, and Administrator. The Administrator will report the incident in accordance with the criteria established under Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating. If two residents are involved in an altercation, the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure the physician and resident's representative were notified, changes in the care plan approaches were completed, and continued monitoring was performed for one of 20 final sampled residents (Resident 13) and one nonsampled resident (Resident 50) for an allegation of resident-to-resident altercation as per the facility's P&P. * Resident 13 claimed he was allegedly punched in the face seven times by Resident 50. This failure had the potential for further resident abuse to occur and put other residents at risk for abuse. Findings: Review of the facility's P&P titled Resident-to-Resident Altercations revised September 2022 showed the facility staff monitor the residents for aggressive/inappropriate behavior towards other residents, family members, visitors, or to the staff. Occurrences of such incidents are promptly reported to the nurse supervisor, director of nursing services, and to the administrator. The Administrator…

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 medical record review, the facility failed to ensure two of 20 final sampled residents (Residents 8 and 13) received the accurate MDS assessments. * Resident 13 stated he was legally blind, unable to read fine prints, and was not on a physician's prescribed weight gain regimen. However, the MDS dated [DATE], showed Resident 13 had adequate vision and was on physician prescribed weight gain. * Resident 8's Annual MDS failed to accurately reflect the resident's fall with major injury. These failures had the potential of not meeting the residents' care needs. Findings: According to the Long-Term Care Facility Assessment Instrument 3.0 User's Manual Version 1.17.1, October 2019, Chapter One, it is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT completing the assessment. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to ensure the comprehensive plan of care for one of 20 final sampled residents (Resident 8) was revised to reflect the resident's current care needs and interventions. * Resident 8's plan of care showed a care plan problem dated 4/22/22, addressing Resident 8's at risk for falls and use of the bilateral floor mats as one of the interventions. The physician ordered to discontinue the bilateral floor mats on 7/15/22. Resident 8's care plan was not revised to reflect the physician's order dated 7/15/22, to discontinue the bilateral floor mats. This failure posed the risk of not providing Resident 8 with an individualized and person-centered care. Findings: On 8/15/23 at 0853 hours, 8/16/23 at 1446 hours, and 8/18/23 at 0809, 0836, and 1011 hours, Resident 8 was observed in bed, without the bilateral floor mats. Medical record review for Resident 8 was initiated on 8/15/23. Resident 8 was admitted to the facility on [DATE]. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to provide the necessary care and services to ensure two of 20 final sampled residents (Residents 34 and 48) attained and maintained their highest practicable well-being. * The facility failed to coordinate the care of Resident 48 with the contracted hospice. The hospice calendar and the sign-in/out forms did not show skilled nursing and CHHA visits provided as per the physician's orders. In addition, the medication profile list, nursing clinical notes, and hospice aide notes were not updated. Furthermore, a hospice packet containing the Continuous Care Note, Continuous Care Documentation, Continuous Care Initiation Sheet, Hospice Aide Care Plan/Note, Plan of Care, Pain Inventory Scale, and Medication List were blank. These failures had the potential for Resident 48 to not receive appropriate care and treatment for hospice services. * The facility failed to ensure the injection sites for insulin administration were rotated for Resident 34. This…

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, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary care and services to prevent accidents for one of 20 final sampled residents (Resident 8). * The CNA improperly turned Resident 8 to her left side while in bed during incontinence care, and Resident 8 fell off the bed. As a result, Resident 8 sustained a fracture to the right humerus. * The facility failed to ensure the recommendation to apply the ice pack to the right shoulder area from Resident 8's orthopedic appointment was verified and followed. Findings: Medical record review for Resident 8 was initiated on 8/15/23. Resident 8 was admitted to the facility on [DATE], with a diagnosis of cerebral infarction (area of necrotic tissue in the brain) affecting left non-dominant side. a. Review of Resident 8's MDS dated [DATE], showed Resident 8 had a moderate cognitive impairment and required extensive assist from one person for bed mobility. Review of the eInteract Change 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, medical record review, and facility P&P review, the facility failed to provide the safe respiratory care for one of 20 sampled residents (Resident 17). * The facility failed to ensure Resident 17's C-PAP (continuous positive airway pressure) machine was cleaned as per the manufacturer's user cleaning guidelines. This failure had the potential to adversely affect the health and well-being Resident 17 and posed the risk for equipment contamination and respiratory complications. Findings: Review of the facility's P&P titled CPAP/BiPAP Support dated 3/2015 showed specific cleaning instruction guidelines are obtained from the manufacturer of the PAP device. The components of the machine such as the masks, nasal pillows, tubing and headgear should be cleaned with a mild detergent daily and allow to airdry. On 8/18/23 at 0843 hours, an observation and concurrent interview was conducted with Resident 17. Resident 17 was observed in bed, had an oxygen tubing via nasal cannula with 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, medical record review, and facility P&P review, the facility failed to ensure the dialysis care was provided for one of 20 final sampled residents (Resident 34) as evidenced by: * The facility failed to ensure Resident 34's dialysis access site was assessed and monitored appropriately and consistently. The licensed staff failed to consistently assess Resident 34's dialysis access site prior to the resident being transported to the dialysis and upon return from the dialysis clinic. In addition, the licensed staff documented Resident 34's dialysis access type as AV fistula (arteriovenous fistula, created by connecting an artery and a vein directly), instead of AV Graft (arteriovenous graft shunt, created by inserting a synthetic tube between an artery and a vein). Furthermore, the licensed staff documented the presence of warmth/ color and edema of Resident 34's left AV Graft but did not notify the physician. These failures had the potential for Resident 34 not being provided with…

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

Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the pharmaceutical services to ensure accurate reconciliation, administration, and disposal of medications as evidenced by: * The facility failed to ensure non-controlled medications were discarded by two licensed nurses. * The facility failed to ensure administration of the controlled medications for one of nonsampled (Resident 539) was accurately documented to ensure accurate reconciliation and to prevent the medication administration errors. These failures had the potential for medication administration error, inaccurate reconciliation, and drug diversion (illegal distribution or abuse of prescription drugs or their use for unintended purposes) of controlled medications. Findings: Review of the facility's P &P titled Disposal of Medications, Syringes and Needles, Hygeia LTC Pharmacy Policy and Procedures dated 2020 showed controlled substances shall be disposed of by the care center in the presence of appropriately titled professionals,…

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, medical record review, and facility P&P review, the facility failed to ensure two of 20 final sampled residents (Residents 28 and 66) were free from the unnecessary medications. * The facility failed to accurately document the monitoring for signs and symptoms of bleeding related to Resident 28's use of apixaban (anticoagulant medication used to prevent blood clots). * The facility failed to monitor Resident 28's orthostatic blood pressure (a form of low blood pressure that happens when standing after sitting or lying down) * The facility failed to ensure accurately documenting the monitoring of the side effects related to Resident 66's use of apixaban (anticoagulant medication used to prevent blood clots). These failures had the potential for residents to receive unnecessary medications and develop significant adverse effects, and risk for adverse effects from prolonged used of medication. Findings: 1. According to Lexicomp, apixaban is an anticoagulant and may increase the risk…

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, medical record review, and facility P&P review, the facility failed to ensure three of 20 final sampled residents (Residents 8 and 34) were free from unnecessary psychotropic medications (any drug which affects brain activities associated with mental processes and behavior). * The facility failed to ensure the number of behavioral episodes related to the use of alprazolam was monitored per shift as per the physician's order. Furthermore, the facility failed to ensure the monthly behavior summary related to the use of zolpidem was completed for July 2023 for Resident 34. * The facility failed to consistently monitor the behavior manifestation, and accurately document the monthly behavioral episodes related to the use of Trazodone for Resident 8. These failures had the potential for the residents to develop significant adverse effects from the psychotropic medications and had the potential to negatively impact the residents' well-being. Findings: Review of the facility's P&P titled Psychotropic…

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, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. * The facility's medication error rate was 6.67%. Two of three licensed nurses observed (LVNs 3 and 4) were found to have made errors during the medication administration observation. * LVN 3 failed to administer the correct medication as ordered by the physician for Resident 17. * LVN 4 failed to administer one medication as ordered by the physician for Resident 640. These failures had the potential to negatively affect the residents' health. Findings: 1. Review of the facility's P&P titled Administering Medications revised 4/19 showed the individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. On 8/17/23 at 0830 hours, a medication administration observation for Resident 17 was conducted with LVN 3. LVN 3 prepared and administered the following medications to Resident 17: -…

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, medical records, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure proper storage, labeling, and disposal medications. * The facility failed to ensure an opened Aplisol Injection tuberculin purified protein derivative (aids in the diagnosis of tuberculosis) vial was labeled with opened date. * The facility failed to ensure the opened insulin vials from the insulin emergency kit was labeled with opened date and the insulin emergency kit was replaced. * The facility failed to ensure proper disposal of the expired Covid swab test supplies. * The facility failed to ensure an unopened pen of Insulin Lispro (fast acting insulin) was refrigerated. These failures had the potential to negatively impact the residents' well-being and had the potential for the medications to loss the stability and effectiveness. Findings: Review of the facility's P & P titled Medication Labeling and Storage revised February 2023 showed the following: - Medication vials that have been opened or accessed (needle punctured) are 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, facility document review, facility P&P review, and manufacturer's instruction manual review, the facility failed to ensure the kitchen staff had the appropriate skill set to safely perform the daily operation of the Food and Nutrition Services Department as evidenced by: * The Dietary Director/RD was unable to demonstrate the correct procedure of the thermometer calibration. This had the potential to lead to foodborne illnesses in a highly susceptible population of residents who received food prepared in the kitchen. Findings: Review of the facility's P&P titled Thermometer Use and Calibration dated 2018 showed food thermometers are to be used properly and calibrated to ensure accurate temperature reading. Review of the facility's document titled Inservice: Checking Accuracy and Calibrating a Thermometer (undated) showed the following: - Food thermometers are to be checked for accuracy and calibrated, if needed, on a regular basis (a) each week, (b) when one is dropped, or (c)…

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, facility document review, and facility P&P review, the facility failed to ensure the menus were followed. * A chicken broth was used instead of water during the pureed bread preparation. This failure placed the residents receiving pureed diet at risk for not receiving the menu as planned. Findings: Review of the facility's Menu Planning dated 2018 showed the seasonal menus are provided with corresponding recipes. Menus are planned to meet the nutritional needs of residents in accordance with established national guidelines, physician's orders and, to the extent medically possible, in accordance with the most recent recommended dietary allowances of the Food and Nutrition Board of the National Research Council National Academy of Sciences. Review of the facility's diet spreadsheet for Wednesday Cycle 3 2023 for 8/16/23, for lunch showed to serve garlic bread for pureed diet. Review of the Diet Type Report showed there were seven residents on pureed diet, with no restrictions to bread. Review of the recipe for Pureed Bread/Margarine showed to use white…

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 facility document review, the facility failed to ensure the food served was palatable. * The pureed bread was sticky in texture. * The garlic bread was chewy in texture. These failures had the potential to impact the residents' nutritional status. Findings: Review of the CMS 672 Resident Census and Conditions of Residents completed by the facility on 8/15/23, showed 76 of 87 residents in the facility received food prepared in the kitchen. Review of the Diet Type Report showed there were 63 residents on regular diet, with no restrictions to bread. Review of the Diet Type Report showed there were seven residents on pureed diet, with no restrictions to bread. Review of the facility's diet spreadsheet for Wednesday Cycle 3 2023 for 8/16/23, for lunch showed to serve garlic bread for regular diet, and pureed garlic bread for puree-level 4 diet. According to the International Dysphagia Diet Standardization Initiative (IDDSI) showed level 4 - pureed foods are not sticky. It is important that pureed foods are not too sticky because this can cause 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 and interview, the facility failed to ensure the food preference was honored for one nonsampled resident (Resident 12). * Resident 12 disliked wheat bread but was served a ham sandwich with wheat bread on his lunch tray. This had the potential to negatively affect the resident's food intake and nutritional status. Findings: On 8/15/2023 at 1226 hours, Resident 12 was observed on his bed with a lunch tray in front of him. The plate consisted of pork chop with gravy, herbed rice, green beans and a ham sandwich with wheat bread. Resident 12 was observed not eating his lunch. When asked about his lunch, Resident 12 stated it tasted like garbage and he did not like wheat bread. Review of Resident 12's meal ticket (used to identify the resident's diet, allergies, and food preferences) showed Resident 12 disliked wheat bread. On 8/15/2023 at 1250 hours, an interview and concurrent review of Resident 12's lunch tray and tray ticket was conducted with CNA 3. CNA 3 verified Resident 12 was served a sandwich with wheat bread even though the meal ticket showed Resident 12…

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 facility P&P review, the facility failed to ensure food safety and sanitation requirements were met in the kitchen as evidenced by: * The facility failed to ensure meat was properly thawed using the sink thawing method. * The facility failed to ensure a proper sanitary condition of the ice machine. * The facility failed to ensure food preparation equipment was clean. * The facility failed to ensure that a wooden table used in the kitchen for food preparation was cleanable. * The facility failed to ensure a food blender was allowed to air dry. * The facility failed to ensure that kitchen equipment was clean. * The facility failed to replace a worn can opener blade with exposed metal. * The facility failed to replace cutting boards that were marred and did not have cleanable surfaces. * The facility failed to ensure food contact surfaces were smooth and cleanable. These failures had the potential to cause foodborne illnesses in the 68 medically vulnerable residents who consumed food prepared in the kitchen. Findings: Review of the CMS 672 Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide safe respiratory care for two of 18 final sampled residents (Residents 9 and 368). * The facility failed to ensure Resident 9's oxygen nasal cannula tubing was clean and the nasal cannula and oxygen humidifier bottle were both labeled with the date they were last changed as per the facility's P&P to ensure they were changed weekly. The facility also failed to ensure Resident 9 had a physician's order for supplemental oxygen therapy. * The facility failed to provide Resident 368 the incentive spirometry therapy as ordered. These failures had the potential to adversely affect the health and well-being of the residents and posed the risk for equipment contamination and respiratory complications. Findings: Review of the facility's P&P titled Oxygen Administration revised June 2018 showed the purpose of this procedure is to provide guidelines for safe oxygen administration. Under the section for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to attain or maintain the highest physical well-being for one of 18 final sampled residents (Resident 51) who required dialysis. * The facility failed to ensure Resident 51's Facility Dialysis Communication Records (a form used to communicate the resident's health information such as vital signs, status of dialysis access site, presence and/or absence of bleeding before and after dialysis treatment, new physician's orders, and special instructions from the dialysis center) were completed for eight out of 16 dialysis days. This failure had the potential for Resident 51 not being provided with the appropriate care and treatment and the possibility of medical complications. Findings: Review of the facility's P&P titled Dialysis Services revised November 2017 showed the facility will provide ongoing communication and collaboration with the dialysis facility regarding dialysis care 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, medical record review, and facility P&P review, the facility failed to implement their policies to provide pharmaceutical services to meet the needs of the residents. * The licensed nurses failed to document in the Medication Administration Record after administering the controlled medications for one of 18 final sampled residents (Resident 9) and one nonsampled resident (Resident 27). This posed the risk of Residents 9 and 27 receiving additional medications which could negatively impact their health. * The facility failed to ensure the Station 2 Unit 2 glucometer was labeled and calibrated correctly. This failure had the potential to cause inaccurate blood sugar level readings and lead to inappropriate administration of insulin. Findings: 1. According to the facility's P&P titled Administering Medication revised April 2019, the individual administering the medications should initial the resident's Medication Administration Record on the appropriate line after giving 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, medical record review, and facility P&P review, the facility failed to ensure one of 18 final sampled residents (Resident 42) was free from unnecessary psychotropic medications (any drug that affects brain activities associated with mental processes and behavior). * Resident 42 was receiving sertraline (antidepressant medication) for depression manifested by tearfulness. The physician increased the dose of the sertraline to 75 mg. However, the facility failed to ensure the documented rationale from the physician for increasing the dose of sertraline was based on Resident 42's assessed condition. In addition, the facility failed to provide documentation showing nonpharmacological interventions were attempted prior to increasing the dose of the medication. In addtion, the physician failed to obtain an informed consent from the resident or resident representative for the increased dose of sertraline. These failures had the potential for Residents 42 to experience adverse effects or receive…

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 medical record review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 7.14%. Two of three licensed nurses (LVNs 1 and 2) observed administering the medications were found to have made errors while administering the medications to one of 18 final sampled residents (Resident 368) and one nonsampled resident (Resident 59). * LVN 2 failed obtain Resident 368's heart rate and blood pressure level before administering metoprolol (medication used to lower the blood pressure) to Resident 368. * LVN 1 failed to administer the medications per the physician's orders for Resident 59. These created the risk of complications and ineffective therapeutic effects of the medications. Findings: 1. On 6/2/21 at 0944 hours, a medication administration observation for Resident 368 was conducted with LVN 2. LVN 2 was observed preparing and administering seventeen medications to Resident 368. The medications included metoprolol 25 mg,…

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, facility document review, and facility P&P review, the facility failed to ensure the medications were stored and labeled properly as evidenced by: * The facility failed to ensure opened vials of Tubersol (used to test for tuberculosis) were labeled with the opened date to ensure they were discarded after 30 days as per the manufacturer's instructions. This posed the risk of accurate test results for residents testing for tuberculosis. * The facility failed to ensure the medication bottle for Xalatan (medication used to reduce pressure in the eyes) was labeled with the opened date to ensure it was discarded after six weeks. This had the potential for the medication's effectiveness to be affected. * RN 2 failed to label the IV antibiotic when administered to Resident 218. * The facility failed to ensure an expired medication was removed from the Station 2 medication cart. These posed the risk of medication administration errors. Findings: 1. According to the facility's P&P titled…

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, facility P&P, and facility document review, the facility failed to ensure the kitchen staff had the appropriate skill set to safely perform the daily operations of the Food and Nutrition Services Department when: * Dietary Aide 3 was unable to state the appropriate water temperature necessary for the manual dishwashing procedure, verbalize the correct cool down procedure used to safely cool down ambient foods, and state the correct water temperature required to safely thaw foods using the sink thawing method. * Dietary Aides 1 and 2 were unable to correctly test the dish machine sanitizer. These failures had the potential for unsafe food practices which may lead to food borne illness in a highly susceptible population of 68 residents who received food from the kitchen. Findings: Review of the CMS 672 completed by the facility dated 6/1/21, showed 68 of 76 residents residing in the facility received food prepared in the kitchen. 1a. Review of the facility's P&P titled 3 Compartment Procedure for Manual Dish Washing dated 2018 showed the first…

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

Based on observation, interview, and facility document review, the facility failed to ensure the food preference was honored for one of 18 final sampled residents (Resident 38). Resident 38 disliked vegetables, but was served green beans for lunch. This had the potential to negatively impact the resident's food intake and well-being. Findings: On 6/3/21 at 1305 hours, a lunch observation and concurrent interview was conducted with Resident 38 in his room. Resident 38 ate the pasta on his plate, but the green beans and the meat was not touched. Review of Resident 38's dietary tray card (a card that displays resident information, diet type, and food preferences and allergies) showed the resident disliked vegetables. Resident 38 stated he did not like the vegetables, but they kept on serving it to him and he felt terrible about it. On 6/3/21 at 1305 hours, an interview and concurrent review of Resident 38's lunch tray and dietary tray card was conducted with CNA 4. CNA 4 verified Resident 38 was served with green beans even though the dietary tray card showed Resident 38 disliked…

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, facility document review, and facility P&P review, the facility failed to ensure the infection control practices were implemented to help prevent the development and transmission of infections. * The facility failed to ensure Phlebotomist 1 donned the proper PPE when performing a blood draw in the Yellow Zone (a designated area in the facility to cohort residents under investigation [PUI] or newly admitted residents for observation). * The facility failed to ensure Occupational Therapist 1 carried the resident's soiled clothing and isolation gown away from his body and without touching his uniform. * The facility failed to ensure CNA 8 was informed of her positive COVID-19 test result in a timely manner and failed to properly screen her for symptoms of COVID-19 when she reported to work. These failures posed the risk for transmission of disease-causing microorganisms and infections. Findings: According to the facility's P&P titled Isolation - Categories of Transmission-Based Precaution revised 1/2012, standard precaution shall be used when caring for…

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