Majestic Mountain Care Center

Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and served in a safe and sanitary environment when: 1. The dish machine was used without reaching 120 Fahrenheit (F-Unit of measurement) and without sanitizer. 2. The ice machine was not clean and was not cleaned according to the manufacturer's instructions. 3. The three-compartment sink (piece of equipment used in professional kitchens for manual dishwashing and consists of three compartments: the first for washing, the second for rinsing, the third for sanitizing) was used for food preparation and was not clean. 4. Kitchen floors, ceiling panels, walls, doors, and screens were not maintained in good condition. 5. The area underneath the three-compartment sink was not clean. 6. A can-opener and serving trays were not clean. 7. Pastrami deli meat and canned mushrooms were not discarded by the used by date (indicating the last day the product is recommended for use). These failures had the potential to contaminate resident food sources that can cause foodborne illness in a…

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

Based on interview and record review the facility failed to ensure arbitration agreements were explained to residents in a manner they could understand for 57 of 57 residents when the Admissions Coordinator (AC) did not explain arbitration to newly admitted residents.This failure violated the rights of 57 of 57 residents residing in the facility to be properly informed of the arbitration process and agreement. During an interview on 7/23/25 at 10:54 a.m., with the AC, The AC stated she gave residents the arbitration agreement upon their admission to the facility. The AC stated she did not explain what arbitration was to any resident who were newly admitted . The AC stated she had residents review the agreement with the rest of the admission packet on their own time. The AC stated she did not know what arbitration was and therefore had never explained it to any resident.During an interview on 7/24/25 at 2:44 p.m. with the Administrator in Training (AIT), the AIT stated the AC needed to be familiar with what arbitration was and the facility's arbitration agreement. The AIT stated…

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

Based on interviews and record reviews, the facility failed to implement adequate measures and a comprehensive water management plan to minimize the risk of Legionella (a harmful bacterium that lives in water systems and areas that are continuously wet) and other pathogens in the building's water system.This failure had the potential to expose 57 of 57 residents to Legionnaires' disease (a disease caused by legionella which affects the lungs) or other opportunistic infections. Findings:During a concurrent interview and record review on 7/23/25 at 2:21 p.m., with the Maintenance Supervisor (MS) the Facilities, Water Management plan, undated, was reviewed. The Water Management plan's sections titled, Description of the Building Water System, Identification of Potential Growth Areas, and Control Measures and Monitoring, were all empty and incomplete. The MS stated no legionella testing was done in 2024, and the facility currently did not have its Water Management plan complete. The MS stated it was important to have a complete water management plan because proper measures and plans 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, and record review, the facility failed to ensure essential kitchen equipment was in safe operating condition when: 1. The three-compartment sink (piece of equipment used in professional kitchens for manual dishwashing and consists of three compartments: the first for washing, the second for rinsing, the third for sanitizing) was used for food preparation, did not drain, causing water and debris to back up into the sink. 2. The three-compartment sink was used as a food preparation sink and did not have an air gap (a space between the drain spout and the in-floor drain inlet that prevents contaminated water from flowing back into a clean water supply). 3. The facility did not have drain plugs in order to plug the sinks of the three-compartment sink, so the sink could be used in the way it was intended for ware washing. These failures had the potential to contaminate food sources for 55 residents who received food from the kitchen, causing foodborne illness in a vulnerable population and resulting in severe patient harm or death; this failure also had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide a safe, comfortable, homelike environment for four of 19 sampled residents (Resident 12 , 16. 31 and 38) when:1. Resident 12 was not provided with a mattress that was comfortable for him.This failure caused Resident 12 to be uncomfortable and not receive restful sleep.2. Resident 31 and Resident 38's room had two white painted patches approximately the size of 3.5 x 1.5 and 9 x 3 feet on the wall next to the door leading to the corridor.This failure had the potential for Resident 31 and Resident 38 to feel depressed and was not homelike environment.3. Resident 31 and Resident 38 shared restroom that had brown like substance on the seat of the toilet, personal items on the floor and top of the toilet. This failure had the potential for Resident 31 and Resident 38 to have cross-contamination (the physical movement or transfer of harmful bacteria from one person, object or place to another) and a not homelike environment.4. Resident…

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

Based on interview and record review the facility failed to ensure licensed nurses have the specific competencies and skill sets necessary to care for residents' needs for one of five sample staff Licensed Vocational Nurse (LVN 2), when LVN 2 did not had the annual nursing skills training competency completed according to facility's policy and procedure (P&P) Nursing Skills Training and Competency Policy. This failure had the potential for areas of improvement to be identified for LVN 2 which placed all residents at risk for their health and safety.Findings:During an interview and record review on 7/24/2025 at 10:28 a.m. with the Director of Staff Development (DSD), the DSD stated LVN 2 did not have her annual nursing skills training competency check-off list in her personal file. The DSD stated it should have been done annually. The DSD stated it should have been done in 5/2025 and was not sure why it was not done. The DSD stated the annual nursing training skills training competency check-off list was needed to make sure the nurses were competent to care for the residents. The DSD…

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 fortified (foods that have essential nutrients added to them, typically to improve their nutritional value or address nutrient deficiencies) diets were prepared according to facility fortified menu for 6 of 6 residents (Resident 2, 3, 18, 24, 26, and 56). This failure had the potential to result in weight loss and/or further complicate medical status for Resident 2, 3, 18, 24, 26, and 56 who received a prescribed fortified diet out of a of 56 residents. Findings: During a concurrent observation and interview on 7/21/25 at 12:08 p.m. with [NAME] 1 in the kitchen, the tray line food service (a food service model where trays are assembled in a linear fashion on a conveyor or table) was observed. [NAME] 1 plated food on resident plates, including a scoop of cooked cauliflower. [NAME] 1 reviewed Resident 1's meal ticket (a printed card or document that specifies a resident's diet order. It includes details such as the resident's name, room number, diet type, allergies, and specific food and beverage…

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, the rights of residents' individual needs and preferences were provided for one of 19 sampled residents (Resident 22), when the call light in Resident 22's room was not fixed and she was not able to return to her room since 6/6/25. This failure resulted in Resident 22 feeling nervous and had the potential for her to be depressed. Findings: During a concurrent observation and interview on 07/22/25 at 1:01 p.m., with Resident 22 in Resident 22's room, Resident 22 was in bed with curtains drawn to separate her from the room. Resident 22 had a television on the dresser with two bags of items on the chair next to the bed. Resident 22 stated she did not like her current room and did not like her roommate. Resident 22 stated her roommate was nice and was evil in certain time. Resident 22 stated her roommate went through her items and she did not like it. Resident 22 stated she had been in the current room for two months. Resident 22 stated…

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

Based on observation, interview and record review the facility failed to complete a performance review (a formal assessment of a nurse aide's job performance, covering areas like clinical competence, communication, teamwork, and professionalism, to identify strengths and areas for improvement) of every nurse aide at least once every 12 months for one of two sampled Certified Nursing Assistant (CNA 2) when CNA 2 did not receive nurse aide performance review every 12 months.This failure resulted in CNA 1 not getting their performance evaluated and had the potential for weak areas not to be identified and improved which could affect resident care. Findings: During a concurrent interview and record review on 7/24/25 at 10:02 a.m., with the Director of Staff Development (DSD), CNA2's personal file was reviewed. The DSD stated she was not able to find CNA 2's annual evaluation in her file. The DSD stated CNA 2 was hired on 5/1/24 and her annual evaluation should have been done 5/2025. The DSD stated she was the interim (temporary) DSD and was in a position to perform CNA 2's annual…

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' preferences were honored for one of 19 sampled residents (Resident 20) when, Resident 20's meal card (printed ticket or document associated with each resident that details their specific dietary needs, preferences, allergies, adaptive equipment requirements, and even dislikes, ensuring personalized meal delivery and safety) did not have anything listed on his dislikes and the meal card was not updated to include his dislikes for fishes.This failure resulted in Resident 20 feeling unheard when served disliked food and had the potential for weight loss from not eating.Findings:During a concurrent observation and interview on 7/21/25 at 12:20 p.m., in the dining room, Resident 20 's meal card did not have anything listed on his dislikes. Resident 20 stated he did not like fish and was served fish in the facility. Resident 20 stated he had been in the facility for one year and his meal card was not updated to reflect his…

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 medications were administered according to professional standards of practice for one of six sampled residents (Resident 1), when Resident 1 was not administered medication metformin (medication used for the treatment of diabetes a condition in which there is too much sugar in the blood), enoxaparin (medication used as a blood thinner to prevent blood clots), and nystatin powder (medication used to treat a fungal infection) according to physician orders due to medication unavailability in the facility. This failure had the potential to result in medication ineffectiveness resulting in blood clots that could have led to stroke (interruption in blood supply to the brain) or death, high blood sugar or uncontrolled blood sugar, and worsening of active fungal infection for Resident 1. Findings: During a review of Resident 1's admission Record (AR- a summary of information regarding a resident which includes patient identification, past medical…

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 at risk for elopement received adequate supervision and monitoring to prevent accidents for one of six sampled residents (Resident 2), when on 6/1/25 Resident 2 left the facility through the front door and walked half a mile to a grocery store. This failure had the potential for Resident 2 to result in injury caused by falls due to areas of uneven terrain (land that is not flat, varies in height, may have bumps or holes making it difficult to walk)), motor vehicle accident due to a busy highway located next to the facility, and heat exhaustion due to rise in temperature of over 90 degrees Fahrenheit (unit of measurment) for Resident 2. Findings: During a review of Resident 2's admission Record (AR- a summary of information regarding a resident which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to report allegations of abuse according to the facility's policy and procedure (P&P) titled, Abuse, Neglect and Exploitation, for one of three sampled Residents (Resident 1), when Resident 1 reported a resident-to-resident verbal altercation to licensed vocational nurse (LVN) 1 on 2/9/25 and LVN 1 failed to report the incident . This failure resulted in the incident of abuse being reported three days later causing Resident 1 distress when Resident 1 continued to encounter Resident 2 during smoking breaks and was not monitored or separated by the facility staff. This failure exposed Resident 1 to further verbal altercations and emotional distress. Findings: During a review of Resident 1's admission Record (AR- a summary of information regarding a resident which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 1 was admitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow the policy and procedure, titled Abuse, Neglect and Exploitation to ensure residents were free from abuse for one of three sampled residents (Resident 1), when certified nursing assistant (CNA) 1 deliberately cut Resident 1's hair without permission and disregarding Resident 1's personal preference to grow and donate her hair to charity. This failure resulted in emotional distress causing unnecessary mental trauma evidence by Resident 1 feeling angry, sad, betrayed and expressing feelings of being cautious, scared and vigilant in the facility following the incident. Findings: During a review of Resident 1's admission Record (AR a summary of information regarding a resident which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses of dysphagia (difficulty…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation interview and record review the facility failed to develop and implement a comprehensive person-centered care plan that included measurable objectives and timeframes to meet psychosocial needs according to the policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, for one of four sampled Residents (Resident 1), when Resident 1 ' s preference to grow her hair to donate to charity was not documented as part of the plan of care in the care plan. This failure resulted in psychosocial and emotional harm for Resident 1, when her hair was deliberately cut by certified nursing assistant (CNA) 1 and stated she was feeling betrayed, angry and sad. Findings: During a review of Resident 1's admission Record (AR- a summary of information regarding a resident which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 1 was admitted to the facility on [DATE]…

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 five sampled residents (Resident 1), when Resident 1 had an unwitnessed fall on 8/6/24 and the facility staff did not complete a change of condition assessment, skin assessment and post fall assessment. This failure resulted in incomplete documentation for Resident 1 and put Resident 1 at risk for falls and potential delay in care. Findings: During an observation on 8/16/24 at 9:58 a.m., Resident 1 was observed lying in bed with eyes closed. Resident was dressed, clean and groomed. During a review of Resident 1's admission Record (AR-a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease (disorder of the brain that slowly destroys memory and…

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

Based on interview, record review, and facility policy review, the facility failed to provide a response and resolution for resident grievances in a timely manner. This deficiency had the potential to affect all residents that resided in the facility. Findings included: An undated facility policy titled, Theft/Loss/Complaint/Grievance Policy, indicated, Policy Statement: [Facility name] will promptly resolve all grievances and will provide a copy of this policy to the resident upon request. The policy indicated, A resident or representative will be notified of: A reasonable expected time frame for completing the review of the grievance and The right to obtain a written decision regarding his or her grievance. The policy indicated, A Grievance Official will: Notify resident or representative's RP [responsible party] of results of investigation and corrective action within 7 days of the completion of the investigation. The policy indicated, Written grievance decisions will include: Date the grievance was received; A summary statement of the resident's grievance; A summary of the…

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

Based on interview, record review, and facility policy review, the facility failed to provide a means for residents to file an anonymous grievance. This deficiency had the potential to affect all residents that resided in the facility. Findings included: An undated facility policy titled, Theft/Loss/Complaint/Grievance Policy indicated, A resident or representative will be notified of: The right to file grievances orally (meaning spoken) or in writing; The right to file grievances anonymously; The contact information of the grievance official with whom a grievance can be filed. The policy also indicated, Anonymous grievances will have written decisions completed as related to a resident and if needed. 1. An admission Record revealed the facility admitted Resident #5 on 12/20/2018. According to the admission Record, the resident had a medical history that included diagnoses of multiple sclerosis, epilepsy, atrial flutter, and major depressive disorder. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/09/2024, revealed Resident #5 had a Brief Interview…

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

Based on interview, record review, and facility policy review, the facility failed to ensure pharmacy recommendations were implemented for 3 (Residents #29, #42, and #50) of 5 sampled residents reviewed for unnecessary medications. Findings included: An undated facility policy titled, Consultant Pharmacist Services Provider Requirements, indicated, 1) Reviewing the medication regimen (medication regimen review) of each resident at least monthly, or more frequently under certain conditions, incorporating federally mandated standards of care in addition to other applicable professional standards as outlined in the procedure for medication regimen review (see IIIA1: MEDICATION REGIMEN REVIEW(MONTHLY REPORT)), and documenting the review and findings in the resident's medication record. The policy revealed 10. A written or electronic report of findings and recommendations resulting from the activities as described above is given to the administrator and/or director of nursing (at least monthly). 11. Resident-specific recommendations are documented in the resident's (active record). 1. An…

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

Based on observation, interview, record review, and facility policy review, the facility failed to have a medication error rate less than 5 percent (%). The facility had 4 errors out of 28 total opportunities, resulting in a medication error rate of 14.28%, affecting 2 (Resident #61 and Resident #43) of 5 residents observed during medication administration. Findings included: A facility policy titled, Administering Medications, revised in 04/2019, specified, 4. Medications are administered in accordance with prescriber orders, including any required time frame. 5. Medication administration times are determined by resident need and benefit, no staff convenience. Factors that are considered include: a. enhancing optimal therapeutic effect of the medication; b. preventing potential medication or food interactions; and c. honoring resident choices and preferences, consistent with his or her care plan. The policy further specified, 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time, and…

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

Based on interview, record review, and facility policy review, the facility failed to notify the physician when new pressure ulcers were identified and when nursing staff noted increased wound measurements or a decline in the condition of pressure ulcers for 2 (Resident #15 and Resident #46) of 4 sampled residents reviewed for pressure ulcers. Findings included: A facility policy titled, Change in a Resident's Condition or Status, revised in 02/2021, indicated, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g. [for example], changes in level of care, billing/payments, resident rights, etc. [et cetera]). The policy also indicated the nurse was to notify the resident's attending physician or physician on call when there was a, d. significant change in the resident's physical/emotional/mental condition. e. need to alter the resident's medical treatment significantly. 1. An admission Record indicated the facility admitted Resident #15 on 07/28/2022.…

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, record review, and review of the Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to complete Minimum Data Set (MDS) assessments timely for 1 (Resident #21) of 20 sampled residents' whose electronic medical records were reviewed. Findings included: On 08/06/2024 at 12:32 PM, the Director of Clinical Operations (DCO) stated the facility used the RAI manual as their policy for MDS assessments. The CMS Long-Term Care Facility RAI 3.0 User's Manual, dated 10/2023, revealed, The Quarterly assessment is an OBRA [Omnibus Budget Reconciliation Act] non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA assessment of any type. Per the manual The ARD (A2300) must be not more than 92 days after the ARD of the most recent OBRA assessment of any type. The manual specified, -The ARD must be within 92 days after the ARD of the previous OBRA assessment (Quarterly, Admission, SCSA [Significant Change in Status…

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

Based on interview, record review, and review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to ensure a Minimum Data Set (MDS) assessment accurately reflected the presence of a serious mental illness per the state Level II Preadmission Screening and Resident Review (PASRR) process for 1 (Resident #15) of 4 residents reviewed for PASRR requirements. Findings included: On 08/06/2024 at 12:32 PM, the Director of Clinical Operations (DCO) stated the facility used the RAI manual as their policy for MDS assessments. The CMS Long-Term Care Facility RAI 3.0 User's Manual, dated 10/2023, indicated A1500: Preadmission Screening and Resident Review (PASRR) included Coding Instructions that specified, -Code 1, yes: if PASRR Level II screening determined that the resident has a serious mental illness and/or ID/DD [intellectual disability/developmental disability] or related condition, and continue to A1510, Level II Preadmission Screening and Resident Review (PASRR) Conditions. An…

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

Based on interview, record review, and facility document review, the facility failed to complete a Level I Preadmission Screening and Resident Review (PASRR) assessment for 1 (Resident #40) of 2 residents reviewed for PASRR. Findings included: A California Department of Health Care Services PASRR Information Notice titled, When to initiate a Preadmission Screening and Resident Review (PASRR) Reconsideration Request or Resident Review, dated 04/02/2024, indicated, If the Level I Screening indicates suspected SMI [Serious Mental Illness] and/or ID [Intellectual Disabilities]/DD [Developmental Disabilities]/RC [Related Conditions], the individual must be referred for further evaluation (Level II Evaluation). The goal of the Level II Evaluation and subsequent Determination process is to ensure appropriate placement of individuals in the least restrictive setting that best meets their needs and identify the need for specialized services (PASRR Determination). The notice also indicated, SNFs [skilled nursing facilities] must initiate a Resident Review by completing a Level I Screening…

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, record review, facility document review, and review of a memorandum from the California Department of Health Care Services, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) Level I screening was resubmitted for 1 (Resident #39) of 4 residents reviewed for PASRR. Specifically, the facility failed to resubmit a Level I screening to re-open their case when a Level II evaluation could not be completed due to the resident being hospitalized . Findings included: A memorandum from the California Department of Health Care Services, dated 04/02/2024, revealed, Subject: When to initiate a Preadmission Screening and Resident Review (PASRR) Reconsideration Request or Resident Review. The memorandum specified, PASRR cases closed as 'Attempt' or 'Unavailable' due to the SNF [skilled nursing facility] not providing the required documentation to the Level II Contractor timely (within 24 hours of a positive Level I Screening) or the unavailability of an individual during the scheduled Level II Evaluation are not considered completed. 'Attempt'…

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, record review, and facility policy review, the facility failed to ensure the care plan was updated with fall interventions for 1 (Resident #39) of 4 residents reviewed for accidents. Findings included: A facility policy titled, Care Plans, Comprehensive Person-Centered, revised in 03/2022, indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The policy indicated, 9. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. 10. When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers. 11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 12. The interdisciplinary team reviews and updates 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, record review and facility policy review, the facility failed to ensure an environment free of accidents and hazards for 1 (Resident #39) of 4 residents reviewed for accidents. Specifically, the facility failed to prevent repeat falls for Resident #39. Findings included: A facility policy titled, Falls and Fall Risk, Managing, revised 03/2018, specified, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The policy revealed the section titled Resident-Centered Approaches to Managing Falls and Fall Risk included 1. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls and 5. If falling recurs despite initial interventions, staff will implement additional 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 record review the facility failed to ensure resident rights were implemented according to the facility's policy and procedure (P&P) for call lights and Resident rights for three of four sampled residents (Resident 1, Resident 2, and Resident 3) when Resident 1, Resident 2, and Resident 3's call lights were ignored while CNAs were observed by staff and residents to be using personal cellphones and not providing requested assistance. This failure resulted in Resident 1, Resident 2 and Resident 3 to have feelings of being ignored, loss of dignity and respect from the facility staff and had the potential to cause skin breakdown and falls when requested assistance to use the restroom or changing of soiled briefs was not honored. Findings: During a concurrent observation and interview on 5/15/24 at 10:52 a.m. with Resident 1, Resident 1 was observed crying while recalling events that transpired in the facility. Resident 1 stated the facility staff were not answering her call lights…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report a sexual abuse allegation in accordance with the facility's policy and procedure and state regulations, for one of three sampled residents (Resident 1), when Resident 1 reported alleged sexual abuse to Licensed Vocational Nurse (LVN) 1 and the allegation was not reported immediately to the State Licensing Agency and Adult Protective Services as required by law. This failure resulted in a delayed investigation of the alleged sexual abuse and placed Resident 1 at risk for physical, emotional, and psychological harm. Findings: During a review of Resident 1's admission Record (a document containing resident ' s information), indicated, Resident 1 was admitted to the facility on [DATE]. During a review of Resident 1's Diagnosis Report (a document listing resident's diagnoses) dated 04/17/24, indicated Resident 1 was admitted to the skilled nursing facility with diagnoses which included, Dementia (progressive or persistent loss of intellectual…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility failed to provide necessary care and services to ensure that residents ' abilities in activities of daily living did not diminish for two of three sampled residents (Resident 1 and Resident 2) when Resident 1 and Resident 2 did not receive showers as scheduled. These failures resulted in Resident 1 and Resident 2 not having their needs met and feeling like staff did not care. Findings: During a review of Resident 2 ' s admission Record (AR), dated 9/30/22, the AR indicated, Resident 2 was admitted on [DATE], with diagnosis of Cerebral Infarction (stroke resulting from a blockage in the blood vessels supplying blood to the brain), Muscle weakness, Hemiplegia (complete paralysis (loss of the ability to move and sometimes to feel anything in part or most of the body)) and hemiparesis (weakness of one entire side of the body) affecting left side. During a review of Resident 2 ' s Brief Interview for Mental Status (BIMS- a mandatory tool used to screen and identify…

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 establish and maintain an infection prevention and control program designed to provide a safe, sanitary environment and to help prevent the development and transmission of communicable diseases and infections for one of four sampled staff members (Licensed Vocational Nurse (LVN) 1) when the facility did not follow its policy and procedure (P&P) UNIFORM AND DRESS CODE ACKNOWLEDGEMENT and LVN 1 was observed to have long black acrylic (fake) nails on. This failure had the potential to spread germs/infection between residents/staff and placed residents at risk of injury from the nails. Findings: During a concurrent observation and Interview on 9/30/22, at 11 a.m., with LVN 1, LVN 1 was seen with approximately 1-inch-long black nails. LVN 1 stated her nails were acrylic, were at least an inch long and that she knew she should not have them on. LVN 1 stated the nails are an infection issue and no one at the facility has told her anything about removing them. During an interview on 9/30/22, at 11:20 a.m., with the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for one of six sampled residents (Resident 4) when Resident 4 was assessed with a pressure injury (PI -localized damage to the skin as well as underlying soft tissue) on 11/14/22 and a care plan was not developed and implemented to address the PI. Resident 4 was admitted to the Acute Care Hospital (ACH) on 11/24/23 and returned to the facility on [DATE] with an unstageable PI (when the PI depth cannot be determine because the base of the wound is covered by a layer of dead tissue that may be yellow, grey, green, brown, or black) and a care plan identifying effective interventions was not developed and implemented. This failure resulted in not addressing the skin integrity of Resident 4, led to avoidable worsening of the PI and Resident 4 experienced decreased mobility, pain, and suffering. Findings: During a record review Resident 4 ' s admission Record (AR- a document also…

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

Based on observation, interview, and record review, the facility failed to ensure residents were treated with dignity and respect in an environment that promoted and enhanced their self-esteem for one of three sampled residents (Residents 1) when the urinary catheter (a flexible tube inserted into the bladder to drain urine) bag for Resident 1 was uncovered. This failure resulted in Resident 1 feeling embarrassed. Findings: During an observation on 10/12/23, at 9:01 a.m., in Resident 1's room, her urinary catheter bag was filled with urine and was visible to anyone who walked by the room. During an interview on 10/12/23, at 9:04 a.m., with Resident 1, Resident 1 stated she felt embarrassed knowing that her urinary catheter bag was visible to everyone. During a review of Resident 1's Minimum Data Set (MDS-is a standarized assessment tool that measures health stats in nursing home residents) assessment, dated 9/4/23, the MDS assessment indicated, Resident 1 had no cognitive impairment with a Brief Interview for Mental Status (BIMS- 0-7 severe cognitive impairment, 8-12 moderate…

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 develop and implement a resident-centered comprehensive care plan for one of three sampled residents (Resident 1) when Residents 1 did not have a care plan for urinary catheter (a tube placed in the body to drain and collect urine from the bladder). This failure placed resident 1 at risk for complications from not having care needs planned by licensed nurses to determine if nursing interventions needed to be added, changed, or completed. Findings: During an observation on 10/12/23 at 9:04 a.m., in Resident 1's room, Resident 1 was lying in bed with the catheter bag attached to the bed frame. During a review of Resident 1's Order Summary Report (OSR) , dated 9/18/23, the OSR indicated, .[brand name urinary catheter] .for wound management . During a concurrent interview and record review on 10/12/23 at 9:48 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 1's care plans were reviewed. LVN 1 stated there was no care plan developed for the urinary catheter. LVN 1 stated the care plan should have been developed when 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 maintain an effective infection control program when: 1. One of three sampled residents restrooms (Resident 1's) portable raised toilet seat (equipment goes on top of a toilet bowl to increase its height) had a brown colored smear. 2. One of three sampled residents (Resident 1's) urinary catheter (a tube placed in the body to drain and collect urine from the bladder) bag was touching the ground. This failure had the potential for cross contamination. Findings: 1. During a concurrent observation and interview on 10/12/23 at 9:15 a.m. with Certified Nursing Assistant (CNA) 1 in Resident 1's restroom, a portable raised toilet seat was on the ground and had a brown colored smear inside the seat. CNA 1 stated there was a dirty brown smear on the raised toilet seat. CNA 1 stated the raised toilet seat should been cleaned after each use for infection control. During a concurrent interview and photo review on 10/12/23 at 12:06 a.m., with the Director of Nursing (DON), a photo of the portable raised toilet seat in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure Services Provided Meet Professional Standard of Quality for two of 11 Residents, (Resident 9, and Resident 11) when Certified Nursing Assistants (CNA) 2 and 6 provided wound care to Residents 9 and 11 without the skills, experience, and knowledge. This failure resulted in CNA 2 and 6 providing wound care to Residents 9 and 11 which had the potential for infection, deterioration, and inaccurate assessment of wounds. Findings: During a review of Resident 9's Minimum Data Set [(MDS- a resident assessment tool used to identify cognitive (mental processes)] and physical functional level assessment dated [DATE], the MDS indicated, Resident 3's Brief Interview for Mental Status (BIMS - screening tool used to assess resident cognitive level) score was 15 out of 15 which indicated Resident was cognitively intact. (Score level: 0-7 indicated severe cognitive impairment - [memory loss, poor decision making-skills] 8-12 moderate cognitive…

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 appropriate care and services were provided for one of 11 sampled residents (Resident 3) when staff failed to provide scheduled showers for 23 days. This failure resulted in Resident 3 not receiving her scheduled showers and placed her at risk for skin breakdown, infections, discomfort, and did not promote cleanliness. Findings: During a concurrent observation and interview on 6/23/23, at 12:35 p.m. with Resident 3, in Resident 3's room, Resident 3 was lying in bed with messy and matted hair. Resident 3 stated, she wanted to take a shower last night because she had not showered in over a week and a half. Resident 3 stated, she felt dirty without showering for so long. During a review of Resident 3's Minimum Data Set (MDS- a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment dated [DATE], the MDS indicated Resident 3's Brief Interview for Mental Status (BIMS - screening…

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 post the results of the most recent abbreviated survey document titled, Statement of Deficiencies in a place readily accessible to residents and their representatives. This failure resulted in depriving residents and visitors the opportunity and of their right to view abbreviated survey findings and plans of correction (POC) for the facility. Findings: During a concurrent observation and interview with the Administrator (ADM), on 8/26/19, at 10:20 a.m., the Survey Inspection binder was located in a holder on the wall in front of the lobby piano. The binder did not contain any abbreviated survey and any subsequent POCs statement of deficiencies for the facility. The Administrator stated she did not know the abbreviated surveys results and POC were supposed to be made available for review by residents and visitors. She stated abbreviated survey results and POCs were not in the binder and were not made available for review.

Based on observation, interview and record review the facility failed to provide a safe and sanitary environment in the kitchen for 62 of 64 sampled residents' when: 1. Brownish liquid was observed leaking from a garbage disposal. 2. Two broken dusty meal carts were stored in the kitchen. 3. Vent screen on the ice machine was covered with dust. 4. Ice machine had an orange substance on the ice machine water distributor. These failures resulted in an unsanitary environment and had the potential to cause food contamination for the 62 Residents that received meals from the kitchen. Findings: 1. During an observation in the dining room on 8/26/19, at 8:35 a.m., a brownish liquid was observed leaking from a garbage disposal into a basin placed on the floor. The basin was full with brownish water in the dish washing area. The Dietary Supervisor (DS) stated the leak had begun approximately two weeks ago. The DS stated the dietary staff had forgotten to discard the brownish water and empty the basin. During a concurrent observation and interview with the Maintenance Supervisor (MS), 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 maintain an effective infection prevention and control program when: 1. Six of eight sampled residents (Resident's 415, 48, 16, 414, 42, and 3's) oxygen tubing were not dated and appropriately stored to prevent cross contamination. 2. Spoiled tomatoes were stored in the refrigerator, a tub of ice cream was dripping in the freezer, one bag of noodles in the pantry were expired. 3. One of three sampled residents (Resident 49's) urinary catheter (a tube placed in the body to drain and collect urine from the bladder) bag was touching the ground. These failures had the potential for cross contamination (transfer of germs) and spread of infection. Findings: 1. During the initial tour of the facility on 8/26/19 at 10:30 a.m., Resident 415's a Nebulizer (a portable medical device used to deliver medication) sat on the top of the bed side stand with a used Nebulizer mask (oxygen tubing that allows the patient to breathe the aerosol mist [medication] in through the nose and mouth to treat the passageways and the lungs…

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 and confidentiality of residents personal and medical information for two of seven sampled residents (Resident 51 and Resident 28), when Registered Nurse (RN) 1 left the Medication Administration Record (MAR) open and easily visible in the hallway with Resident 51 and Resident 28's personal and medical information exposed and visible to other residents, staff and visitors passing by. This failure had the potential to result in the unauthorized access to Resident 51 and Resident 28's personal and medical information and violated Resident 51 and Resident 28's rights to confidentiality. Findings: During a medication pass observation on 8/26/19, at 11:40 a.m., in the west hallway, the medication cart faced the hallway unattended with Resident 51's MAR visible to staff, residents and visitors passing by. The MAR displayed Resident 51's name, room number, date of birth , admission date, gender, height, weight, medical record number, allergies, medical diagnoses, and prescribed medications.…

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

Based on observation, interview and record review the facility failed to provide a safe, clean, comfortable homelike environment for one of 31 sampled residents (Resident 27) when Resident 27's dresser had visible dust. This failure resulted in an unclean and uncomfortable environment for Resident 27. Finding: During a concurrent observation and interview with Resident 27 on 8/26/19, at 10:30 a.m., during an initial environmental tour in Resident 27's room, Resident 27's dresser had visible dust on top of the dresser. Resident 27 stated, It's dusty on top . It needs to be cleaned. During an interview with House Keeping Supervisor (HKS) 1, on 8/26/19, at 10:35 a.m., HKS 1 stated dusting was supposed to be done every day. HKS 1 stated Resident 27's dresser should have been dusted. HKS 1 stated, I guess we missed cleaning it [dresser]. During a review of the facility's policy and procedure titled Housekeeping- Resident Rooms dated 9/2016 indicated, . Purpose. To promote the quality of life by providing clean and sanitary living spaces. Policy. The housekeeping Department coordinates…

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 an interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for one of three sampled residents (Resident 47) when a care plan for Resident 47's anti-coagulant (blood thinner) medication was not developed. This failure placed Resident 47 at risk of not receiving appropriate, consistent, and individualized care and monitoring interventions to ensure adverse affects of the blood thinner such as excessive bleeding were identified. Findings: During a concurrent interview and record review with the Assistant Director of Nursing (ADON), on 8/28/19, at 8:26 a.m., she reviewed Resident 47's physician's ordersThe ADON stated Resident 47 had a physician order for apixaban (medication used to prevent blood clots) with a start date 12/9/14 for a diagnosis of deep vein thrombosis (DVT - a blood clot in a deep vein). The ADON reviewed Resident 47's care plans and stated Resident 47 did not have a care plan for the use of the blood thinner. The ADON stated Resident 47 should have had a care plan developed for the use of apixaban 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 meet professional standards of quality for two of five sampled residents (Resident 33 and Resident 3) when: 1. Registered Nurse (RN 1) used an inappropriate medication administration technique while using an insulin pen (a device used to inject insulin [hormone- regulatory substance made by the body to control blood sugar production]) during a medication pass observation for Resident 33. This failure placed resident 33 at risk for dosing errors and had the potential for adverse effects such as hyperglycemia (high blood sugar). 2. Licensed Vocational Nurse (LVN 1) pulled Resident 3's controlled medication (medications that can cause physical and mental dependence) before its scheduled time and stored the controlled medication in a clear pill crusher pouch (a pouch which safely contains pills during crushing process). This failure had the potential for resident 3 to receive the wrong medication which could have led to harmful side effects. Findings: 1. During a medication pass observation on 8/27/19, at 11:26…

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

Based on interview and record review, the facility failed to ensure a performance review of every nurse aide at least once every 12 months was completed for two of 15 Certified Nursing Assistants (CNAs) CNA 2 and CNA 3. These failures had the potential for residents' needs to go unmet by CNAs' whose competence had not been determined through annual performance reviews. Findings: During a concurrent interview and employee record review with the Director of Staff Development (DSD), on 8/28/19, at 8:02 a.m., the DSD reviewed annual competency evaluations completed for the year of 2019. The DSD stated CNA 2, and CNA 3 did not have annual performance reviews. The DSD stated the performance evaluations should have been done within 90 days after hire, then once a year, and then yearly. The DSD stated she did not know how she missed completing the evaluation for CNA 2 and CNA 3. The DSD stated, I guess, I just missed them.

Based on interview, and record review the facility failed to ensure as needed (PRN) Psychotropic drugs (any drug that affects brain activities associated with mental processes and behavior) were time limited to 14 days for two of four sampled residents (Resident 14 and Resident 15) when: 1. PRN Lorazepam (medication to treat anxiety) was prescribed Resident 14 since 3/19/19 without a 14 day time limited date and without the attending physicians' document rationale to extend the PRN Lorazepam prescription beyond the 14-day time limit. 2. PRN Lorazepam was prescribed for Resident 15 since 5/3/19, without a 14 day time limited date and without the attending physicians' document rationale to extend the PRN Lorazepam prescription beyond the 14-day time limit. This failure placed Resident 14 and Resident 15's health and safety at risk due to the continuous administration of the unnecessary psychotropic medications. Findings: 1. During a review of the clinical record for Resident 14, the Physicians Orders, indicated, Lorazepam 2MG/ML [milligrams/milliliter - unit of dose] may give 0.25ml…

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 the maintain garbage disposal and ice machine equipment in safe operating condition when: 1. Brownish liquid was observed leaking from a garbage disposal onto a pan on the kitchen floor. 2. The Vent screen on the ice machine was covered with dust. 3. The Ice machine had an orange substance on the ice machine water distributor. These failures resulted in an unsanitary environment and had the potential to cause food contamination for the 62 Residents that received meals and ice from the kitchen. Findings: 1. During an observation in the dining room on 8/26/19, at 8:35 a.m., a brownish liquid was observed leaking from a garbage disposal into a basin placed on the floor. The basin was full with brownish water in the dish washing area. The Dietary Supervisor (DS) stated the leak had begun approximately two weeks ago. The DS stated the dietary staff had forgotten to discard the brownish water and empty the basin. During a concurrent observation and interview with the Maintenance Supervisor (MS), on 8/27/19, at 2:31…

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.