Lake Merritt Healthcare Center LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow it's smoking policy and procedure to prevent accidents hazards, complete smoking/safety evaluation, develop and implement care plan that promote smoking safety for three (Resident 19, 37 and 41) of three sampled residents when: 1. Resident 19 with amputated fingers, bilateral hands and non-compliance with smoking policy and procedure kept cigarettes and lighter in her possession. 2.Facility did not assess and complete a care plan for Resident 41 for safe smoking practices. Resident 41's charge nurses were unaware if Resident 41 smoked cigarettes, when direct care staff including Certified Nursing Assistants (CNA 1 and CNA 3) were aware that Resident 41 had always smoked at the facility. 3. Resident 37 did not receive smoking aprons, and cigarette holder per plan of care during smoking. 4. Facility staff (Janitor 1) smoked in the smoking patio when door to all rooms adjacent to smoking patio were left open with residents 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.

Based on observation, interview, and record review, the facility failed to complete performance review and maintain competency/skills records for three of three sampled licensed nurses (LVN 1, RN 2, and RN 4). A Licensed Nurse is a healthcare professional who has met requirements by state board of nursing to practice nursing skills within defined scope. This failure placed facility to be unaware and address training needs for LVN 1, RN 2 and RN 4 and placed all residents receiving care from LVN 1, RN 2 and RN 4 for receiving care from incompetent licensed nurses. Findings: During an interview and record review with Director of Staff Development (DSD) and Licensed Vocational Nurse 1 (LVN 1) on 10/24/24 at 9:36 a.m., personnel file for LVN 1 was reviewed. The DSD stated LVN 1 was hired on 6/17/24 and she was only able to find background information, hiring application etc. in LVN 1's file. LVN 1 stated she never received an orientation/ training and/or a competency evaluation upon hire and/or after hire. During an interview and record review with the DSD on 10/23/24 at 2:40 p.m. 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 facility failed to complete an annual performance review, commonly known as competency/skills checks for one of three sampled Certified Nursing Assistants (CNA 7). Facility did not complete and maintain records for competency/skills checks completed upon hire/orientation for two of three sampled CNAs (CNA 4 and CNA 6). CNA is an unlicensed health professional providing nursing or nursing-related services to residents in the facility. This failure placed facility's residents residing at the facility at risk for not receiving need-based care, compromised safety, and receiving care from incompetent CNAs. Findings: During a review of facility's undated and untitled Staff list, the list indicated CNA 4 was an active, on-call CNA since 5/3/24; CNA 6 was an active, full-time CNA since 1/26/24 ; and CNA 7 was facility's active and full-time employee as a CNA since 11/1/20. During an interview and record review on 10/23/24 at 3:27 p.m. with Director of Staff Development (DSD), in DSD's office, an electronic Excel spreadsheet with facility's staff names…

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

Based on observation, interview, and record review the facility failed to store and prepare foods in a sanitary manner that prevented foodborne illness when: - One bag of sliced ham unlabeled and undated was stored in the refrigerator. - Kitchen vents, fans and window screens with dusty areas. These failures had the potential for residents to be exposed to food borne illness. Findings: During the initial tour of the kitchen on 10/21/24 at 9:22 a.m. accompanied by Dietary Aide (DA) and Dietary Manager (DM) one opened bag of sliced ham not labeled with use-by date was observed in the refrigerator. During a concurrent observation and interview on 10/22/24 at 8:47 a.m. with Maintenance Supervisor (MS) and DM in the Kitchen, vents, fans and window screens were dusty. MS stated he cleaned monthly. MS stated he did not have a record or documentation of the cleaning. During an interview on 10/22/24 at 9:02 a.m. with DA, DA stated she received training on labeling and dating food items. DA stated it was important to label with use-by date food items stored in the refrigerators. During a…

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

Based on observation, interview, and record review, the facility failed to maintain and observe infection control practices when: 1. Registered Nurse (RN) 2 did not perform hand hygiene during medication administration. 2. Nutritional feeding pole in Resident 33's had multiple dried light brown stains. These failures had the potential for cross contamination and spread of infections among residents at the facility. Findings: 1. During medication preparation observation on 10/22/24 at 8:21 a.m. with RN 2, RN 2 was preparing Resident 17's nine medications, poured the tablets and capsule in a medication cup and mixed the laxative powder with 4 ounces (oz) of orange juice in a plastic cup. During medication administration observation on 10/22/24 at 8:28 a.m. with RN 2 in Resident 17's room, RN 2 handed Resident 17 the medication cup and the 4 oz of orange juice placed on the medication tray, Resident 17 poured the tablets and capsules into his mouth and drank the 4 oz of orange juice. RN 2 took the empty medication cup and 4 oz plastic cup from Resident 17's hands and discarded the cups…

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 staff attempted to use appropriate measures to communicate with one of three sampled non-English speaking residents (Resident 43) when; Resident 43's communication tool/binder was not used. This failure placed Resident 43 at risk for not feeling understood, unmet needs and decline in health. Findings: During a review of Resident 43's Admission-Minimum Data Set (MDS - Resident assessment and care guide tool), dated 7/10/24, the MDS indicated Resident 43's preferred language was Chinese. MDS indicated Resident 43 needed and wanted an interpreter to communicate with doctor or health care staff. Resident 43's diagnoses included Depression (a mental health condition that causes a persitent low mood and loss of interest in activities). During a concurrent observation and interview on 10/23/24 at 8:36 a.m. with CNA 5, Resident 43's laid in bed in her room, Resident 43 spoke in her native language. A communication binder laid on Resident 43's bedside table. CNA 5 stated she could only communicate with Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide an ongoing and effective activity program to meet resident activity preferences, physical and psychosocial goals for one of 15 sampled residents (Resident 37). This failure placed Resident 37 at risk for mental and psychosocial decline. Findings: During a record review of Resident 37's admission Record printed on 10/22/24, the record indicated Resident 37 was admitted to the facility on [DATE] A review of Resident 37's admission Minimum Data Set (MDS, an assessment used to plan care) dated 3/10/24 indicated, it was very important for Resident 37 to do his favorite activities. During a record review of Resident 37's discharge planning review completed on 9/16/24, the assessment indicated Resident 37 enjoys activities including drawing and painting. During a record review of Resident 37's activity care plan dated 03/2024, the care plan indicated to, allow resident choices and provide resident with outdoor activities. During an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to assess and provide an appropriate wheelchair to one of 15 sampled residents (Resident 37), for seven months, since admission to the facility. This deficiency placed Resident 37 at risk for physical decline and resulted in Resident 37 feeling worthless, and hopeless about his personal goals of discharge from the facility. Findings: During a record review of Resident 37's admission Record printed on 10/22/24, the record indicated Resident 37 was admitted to the facility on [DATE] with left hip contracture (a medical condition with hardening of muscles leading to deformity and rigidity in joints). During a record review of Resident 37's contracture care plan, initiated on 3/4/24, the care plan indicated to, use assistive device as/if ordered. During a record review of Resident 37's discharge planning review dated 6/25/24 and 9/16/24, the assessments indicated Resident 37's goal was to go back to the community with home health services. During…

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

Based on observation, interview and record review, the facility failed to administer medication as ordered by the physician for one of five sampled residents (Resident 20) when Registered Nurse (RN) 2 thought Resident 20's eye drop medication was not available. This failure had the potential for Resident 20 to experience adverse effect from missed eye drop dose. Findings: During a concurrent medication administration and interview on 10/22/24 at 8:31 a.m. with RN 2, RN 2 took out Resident 20's one eye drop bottle labeled Simbrinza (a combination eye drop containing two medications: brinzolamide and brimonidine, a medication used to treat glaucoma and high pressure in the eye) and one eye drop bottle labeled Artificial Tears (eye drops used to lubricate dry eyes and help keep moisture on the outer surface of your eyes) from the first left medication drawer of the medication cart. RN 2 stated Resident 20 had an order for Brinzolamide (medication used to treat glaucoma and high pressure in the eye) eye drop but the eye drop bottle was not inside the medication cart after looking. RN 2…

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 proper medication storage for one of one sampled medication room and one of one sampled resident (Resident 31) when: 1. An unauthorized staff had access to the medication room. 2. Unlabeled, undated medication cup filled with white creamy substance was left unattended on top of Resident 31's overhead light fixture for over 24 hours. This failure had the potential for loss or diversion of medications and residents' accidental access to unknown substance. Findings: 1. During a concurrent observation and interview on 10/23/24 at 8:36 a.m. with the CSS, the CSS unlocked the medication room door with a key from a set of keys he was holding. The CSS stated the key to the medication room was given when he started working at the facility. The CSS stated he ordered over the counter medication for the facility and stored in the medication room. During an interview on 10/23/24 at 10:16 a.m. with the DON, the DON stated, the CSS can open the medication room to access over the counter medication even without 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 that when it did not hire a full-time registered dietitian, the person designated to serve as the director of food and nutrition services met both the federal and/or state educational qualifications for the position. The lack of full-time, competent oversight of food and nutrition staff placed residents who received food from the kitchen at risk for food borne illness (illness caused by food contaminated with bacteria, viruses, parasites, or toxins) and/or decreased nutrient intake which had the potential to result in death and/or nutritional related medical complications Finding: During an interview on 10/21/24 at 1:45 p.m. with Dietary Manager (DM), DM stated she worked full time. DM stated she was not a certified director of food and nutrition. DM stated she was still in school. DM said facility has a Registered Dietician (RD) that visit weekly to complete new admission assessment of residents. During an interview on 10/21/24 at 1:17 p.m. with Registered Dietician (RD), RD stated she visited weekly to support…

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 accurately complete functional status in discharge planning assessment (an evaluation of residents' clinical and functional condition to arrange resources to help them prepare for a smooth discharge from the facility) for one of 15 sampled residents (Resident 37). This failure resulted in an inaccurate reflection of Resident 37's clinical condition, and placed him at risk for receiving inappropriate care upon discharge from the facility. Findings: During a record review of Resident 37's admission Record printed on 10/22/24, the record indicated Resident 37 was admitted to the facility on [DATE]. During a review of Resident 37's Minimum Data Set (MDS, an assessment used to plan care) dated 9/9/24, the assessment indicated Resident 37 was able to understand others and was able to make his needs known. The assessment indicated Resident 37 was dependent on staff for toilet hygiene, shower/bathing, lower body dressing, personal hygiene, and…

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

Based on interview and record review, the facility failed to follow a written hospice agreement that included joint responsibilities to develop and implement a coordinated plan of care (POC) for one sampled resident (Resident 3) admitted into hospice program, when Resident 3's hospice POC did not reflect the participation of facility staff, Resident 3 and Resident 3's representative (FM 1). {POC means a written plan of care established, maintained, reviewed, and modified as necessary, for an individual that reflects the participation of hospice, facility, the patient and patient's family, as appropriate and complies applicable to federal and state laws and regulations}. {Hospice- a program that gives special care to people who are near the end of life and have stopped treatment to cure or control their disease}. Findings: During a review of Resident 3's Significant change in status-Minimum Data Set (MDS - an assessment screening tool used to guide care), dated 10/1/24, MDS indicated Resident 3 was on hospice care. Resident 3's diagnoses included Non-Alzheimer's Dementia (a group of…

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

Based on observation, interview and record review, the facility failed to ensure medication error rate was below five percent (%). When: 1. Registered Nurse (RN) 1 administered medication late to (Residents 255, 26, 13 and 44). 2. Losartan (medication to treat high blood pressure) was not given to Resident 44. 3. RN 1 did not wait five minutes in between administration of eye drop treatment as ordered by the physician. These deficient practices placed Residents 255, 26, 13 and 44 at risk of developing complications related to error in medication administration. Findings: 1. During concurrent medication administration observation and interview on 11/13/23, at 10:26 a.m., with RN 1, RN 1 was doing morning medication pass. RN 1 stated, she was delayed passing medications for Residents 255, 26, 13 and 44. When asked regarding the standards of practice. RN 1 stated, 10:00 a.m. was supposed to be the latest she can administer morning medications. RN 1 also stated, any time after 10:00 a.m. was considered late because it would be too close to next dose if Residents had same medications. RN…

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 store food and maintain the ice machine and ice scooper in a sanitary manner when: 1. Unlabeled, and outdated food were available for use in the kitchen freezer and dry storage. 2. Unlabeled, and expired food were available for use in the resident refrigerator. 3. Ice machine and ice scooper were not sanitized after the ice scooper was left in the ice machine. These failures had the potential to put residents at risk for infection and food borne illnesses. Findings: 1. During a concurrent observation and interview on 11/13/23, at 9:35 a.m., with Dietary Manager (DM), freezer 3 was observed. DM verified an opened package of sliced ham and 12 pie crusts out of its original package, were not labeled with received, opened, or used by dates, were in freezer 3. DM verified an opened plastic bag with 3 waffles had a use by date of 11/6/23 and an opened plastic bag with 5 French toasts had a use by date of 11/7/23, were found in freezer 3. DM removed the food items and stated they shouldn't be there, and they needed 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.

Based on observation, interview and record review, the facility failed to provide restorative nursing services (RNS, exercises or activities designed to maintain or improve residents' abilities to the highest practicable level such as: range of motion exercises, splint or brace assistance, etc.) for two of 13 residents (Resident 24 and Resident 40) when physician's orders were not followed consistently. These failures had the potential for residents to decline or not maintain their highest practicable physical, mental, and psychosocial well-being. Findings: 1. Resident 24 was admitted to the facility with diagnoses that included paraplegia (inability to voluntarily move the lower parts of the body), muscle wasting and atrophy (decrease in size and wasting of muscle tissue), and mild cognitive impairment (decline in memory and thinking). During an observation on 11/13/23, at 10:06 a.m., Resident 24 was in bed, awake and verbal. Resident 24 was observed moving his right arm and using the bed remote control with his right hand. When asked how his left arm was, Resident 24 stated that…

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

Based on observation, interview, and record review, the facility failed to provide care according to professional standards of practice for one of one sampled residents (Resident 40), when Licensed Vocational Nurse (LVN) 2 did not check the placement of Resident 40's enteral feeding tube (a tube placed through the skin of the abdomen directly into the stomach to deliver medication) and did not check the amount of residual (undigested stomach contents) in the stomach before medications were administered through the feeding tube. This failure placed Resident 40 at risk of aspiration (the intake of foreign matter into the lungs) and medications not being administered into the stomach. Findings: During medication pass observation and concurrent interview on 11/14/2023, at 12:20 p.m,. with LVN 2, LVN 2 administered medication through Resident 40's feeding tube. LVN 2 confirmed, she did not check placement and did not check residual content remaining in Resident 40's stomach. LVN 2 further added, she should have checked the placement using stethoscope (a medical instrument for listening…

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 two of five sampled nursing staffs (Registered Nurse (RN) 1 and Certified Nursing Assistant (CNA) 2 were provided with competencies and skills necessary to perform their work roles safely and successfully. This failure had the potential to not provide appropriate nursing services to meet the needs of residents and promote the residents' physical, mental and psychosocial well-being. Findings: 1. During an interview on 11/15/23, at 7:36 a.m, with RN 1, RN 1 stated she worked the night shift on 11/14/23 beginning at 11 PM to 11/15/23 ending at 7:30 AM. RN 1 stated she was hired as a full-time nurse recently and had completed a two-week training with two nurses on different work shifts. During a concurrent interview and record review on 11/15/23, at 7:38 a.m, with RN 1, Resident 48's medical records were reviewed. When asked, RN 1 stated she was not aware Resident 48 had an indwelling urinary catheter (a device that is inserted into the bladder to drain the urine). RN 1 confirmed she had not checked Resident 48's…

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

Based on interview and record review, the facility failed to ensure an employee performance review was conducted at least every 12 months for one of five sampled nursing staffs (Certified Nursing Assistant (CNA) 2). This failure had the potential to affect the quality of nursing services rendered to residents in the facility when staff performance reviews remain unchecked. Finding: During a concurrent interview and record review on 11/16/23, at 12:27 p.m., with the Director of Nursing (DON) and the Acting Director of Staff Development (DSD) present, CNA 2's personnel records were reviewed. CNA 2's personnel records indicated a hire date of 5/9/16. CNA 2's Employee Performance Review, record was last completed on 6/3/22. DSD confirmed CNA 2's performance review was not completed within the past 12 months. Review of the facility's Policy and Procedures (P&P), titled, Performance Evaluations, revision dated 6/2020, the P&P indicated, Policy Statement - The job performance of each employee shall be reviewed and evaluated at least annually. Policy Interpretation and Implementation - 1. 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 observation, interview and record review, the facility failed to post the daily nurse staffing information on 11/13/23. This failure resulted in nurse staffing information and posting requirements that were not readily available to residents and visitors. Findings: During a concurrent observation and interview on 11/13/23, at 12:12 p.m., with the Director of Nursing (DON) present, the DON confirmed the required nurse staffing data information for 11/13/23, was not posted on the clear poster board by the nursing station. The Daily Nurse Staffing Information sheet posted on 11/13/23 was for 11/9/23. It was also noted that several sheets filed on the clear poster board included Nurse Staffing Information for 11/8/23, 11/7/23, 11/6/23, 11/2/23, 11/1/23 and 10/27/23. When asked, the DON stated there was no nurse staffing information sheets for the past three days. The DON stated nurse staffing information should be posted daily. Review of the facility's Policy and Procedures (P&P), titled, Staff Posting Requirements, dated 2/2017, the P&P indicated, Policy - It is the policy of…

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

Based on observation, interview, and record review, the facility failed to ensure one resident of 26 sampled residents observed during medication administration pass (Resident 44) was free from significant medication error when: Losartan (medication to treat high blood pressure) was not administered as prescribed by the physician. This deficient practice had the potential for increased blood pressure and possible for stroke. Findings: During a review of Resident 44's face sheet, dated 11/14/23, it indicated, Resident 44 was admitted to the facility in November 2023 with multiple diagnoses that included Essential Primary Hypertension (high blood pressure). During a concurrent interview and medication administration observation on 11/13/23, at 11:33 a. m., with RN 1, RN 1 did not give Losartan 50 milligrams (mg) to Resident 44. RN 1 stated, there was no available medicine to give. RN 1 also stated, she will contact the pharmacy for order. During a review of Resident 44's Administration Record, dated 11/15/23, it indicated, Losartan 50mg tablet: .scheduled for 11/13/23 9:00 a.m., was…

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

Based on observation, interview, and record review, the facility failed to properly secure medications when two of two Licensed Staff did not keep medication cart 2 locked or under direct observation of authorized staff. This failure had the potential for residents, unauthorized staff, and visitors to have access to medications. Findings: During medication administration observation, on 11/13/23, at 10:26 a.m., with Registered Nurse (RN) 1, RN 1 left medication cart two unlocked and unattended, with medication drawers facing the hallway. RN 1 entered resident room, and the left unlocked medication cart out of her view. An unauthorized staff was observed walking by the medication cart twice. During a concurrent observation and interview on 11/13/23, at 11:28 a.m., Licensed Vocational Nurse (LVN) 1, LVN 1 left medication cart two drawer unlocked and unattended in the hallway outside a resident room and across from activity room. LVN 1 entered the activity room leaving medication cart out of her view. One resident walked pass the unlocked medication cart two. LVN 1 acknowledged, she…

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

Based on observation, interview, and record review, the facility failed to implement their infection prevention and control program when: 1. Licensed staff did not sanitize portable blood pressure machine before and after each resident use. 2. Two licensed staff did not sanitize tray used to deliver medications to residents during medication administration. 3. Two licensed staff touched a resident's medication with bare hands. 4. Licensed staff touched inside resident's right eye twice with dropper tip during medication administration. 5. Licensed staff did not wash hands before administration of medication via gastronomy tube (G-tube, a tube inserted through the belly that brings nutrition or medications directly to the stomach). 6. Nasal cannulas (a device used to deliver supplemental oxygen) worn by 2 residents (Resident 2 and Resident 12) were not labeled with dates when it was initially used or with date of replacement. 7. There was no appropriate water management program and control measures to prevent the growth of Legionella (a type of bacteria), and other opportunistic…

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 offer pneumococcal immunization for one of five sampled residents (Resident 31). This failure had the potential to not help protect Resident 31 against serious illnesses like pneumonia (lung infection). Findings: During a concurrent interview and record review on 11/15/23 at 4:31 p.m., with the Infection Preventionist (IP), Resident 31's medical records were reviewed. Resident 31's Facesheet indicated an admission date of 9/10/23. IP confirmed Resident 31's Informed Consent for Pneumococcal Polysaccharide Vaccine, was not filled out. IP was unable to provide the status of Resident 31's pneumococcal immunization. IP stated informed consent for pneumococcal vaccinations should be done on admission of the resident into the facility. Review of the facility's Policy and Procedures (P&P), titled, Pneumococcal Vaccine, revision dated 10/2019, the P&P indicated, Policy Statement - All residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Policy Interpretation and Implementation -…

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 one of two washing machines in the laundry room was in operable condition. This failure had the potential to disrupt laundry services provided to residents and staff in the facility. Findings: During an observation on 11/15/23, at 10:49 a.m., with the Housekeeping Manager (HMR) present, inside facility's laundry room, a washing machine had a white paper attached indicating OUT OF SERVICE. During an interview on 11/15/23, at 11:03 a.m., with the HMR, HMR stated the Maintenance Director (MD) was informed about a year ago, that the washing machine was not working. HMR stated she had not received an update about the washing machine from the Maintenance Department. During an interview on 11/15/23, at 11:28 a.m., with the MD, MD confirmed he was aware that one of the washing machines in the laundry room was out of service. MD stated he had called a vendor for a price quote but had not placed an order. Review of the facility's Daily Maintenance Reporting Log, dated 11/23/22, indicated a work request was made…

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 one of 13 sampled residents (Resident 23), had a call light that was easily accessible. This failure had the potential to neglect Resident 23's call for help in an emergency. Findings: During a review of Resident 23's admission Record, dated 11/14/23, the record indicated Resident 23 was admitted 06/2023 with a diagnosis of Quadriplegia (partial or complete paralysis of both the arms and legs), unspecified. During a review of Resident 23's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan.), dated 8/14/23, the MDS indicated Resident 23's Brief Interview for Mental Status (BIMS, is a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) score was 15. During a concurrent observation and interview on 11/13/23, at 2:35 p.m., with Resident…

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

Based on observation, interview, and record review, the facility failed to label and store food and maintain sanitary conditions in the kitchen when: 1. The following outdated food was available for use: A. Gallon of milk B. Beef Base C. Five gallon of dill pickles D Sauerkraut 2. Cleaning procedures were not followed . These failures had the potential to cause food contamination and food borne illness in residents. Findings: 1. On 07/12/21, at 10:30 a.m., during the initial tour and interview of the kitchen, with the Dietary Manager (DM) , DM verified a gallon of milk had expired on 7/10/21, beef base had expired on 5/21/21, and a five gallon container of dill pickles and gallon of sauerkraut were expired on 3/21/21, in refrigerator one. The DM stated the expired items should have been removed from the refrigerator. Review of the facility's undated P&P titled General Receiving of Delivery of Food indicated all items should be labeled with the delivery date or a use by date. 2. During an observation and concurrent interview on 7/12/21, at 12:30 a.m with DM in the kitchen, a metal…

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

Based on observation, interview and record review, the facility failed to follow it's policy and procedure for infection contol for one (Resident 23) of six sampled residents when: 1. Licensed Vocational Nurse (LVN 1) did not perform hand hygiene and don (to put on) a new pair of gloves before administering eye drops to Resident 23. 2. LVN 1 personal belongings were found in the medication storage room. 3. [NAME] (Cook)1 was observed not wearing a face mask while preparing the lunch trays. These failures had the potential to result in the spread of infectious organisms not only to Resident 23, but to other residents, staff, and visitors at the facility. Findings: 1. During an observation on 7/13/21, at 8:53 a.m., in Resident 23's room, LVN 1 was observed wearing gloves while administering oral medications to Resident 23. LVN 1 was observed adjusting Resident 23's head of the bed with the bed remote control. LVN 1 was observed wearing the same pair of gloves while administering eye drops to Resident 23's left eye. LVN 1 after administering the eye drops proceeded to place their…

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 record review, the facility had eighteen residents (Rt) rooms (Rooms 8, 9, 10, 11, 12, 14, and 15) with multiple beds that provide less than 80 square feet (sq. ft.) per resident who occupy these rooms. The deficient practice had the potential to result in inadequate space for the delivery of care to each of the residents in each room, or for storage of the residents' belongings. Findings: During observations between 7/12/21 through 7/15/21, the following rooms and corresponding square footage per bed were identified. Room Activity Room size Floor Area 8 Rt 209.84 69.9 8 Rt 209.84 69.9 8 Rt 209.84 69.9 9 Rt 206.4 68.8 9 Rt 206.4 68.8 9 Rt 206.4 68.8 10 Rt 159.46 79.3 10 Rt 159.46 79.3 11 Rt 148.74 74.4 11 Rt 148.74 74.4 12 Rt 211.06 69.8 12 Rt 211.06 69.8 12 Rt 211.06 69.8 14 Rt 209.33 69.8 14 Rt 209.33 69.8 14 Rt 209.33 69.8 15 Rt 208.12 69.4 15 Rt 208.12 68.4 During observations of care and services from 7/12/21 through 7/15/21 there was sufficient space for the provision of care for the residents in all rooms. There was no heavy equipment kept in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide assessment of dialysis (artificial means of filtering the blood when the kidneys fail) access site on the arm of one (Resident 10) in a sample of 16 residents who received dialysis when, the facility did not have a complete and accurate monitoring of Resident 10's dialysis access site. This failure had the potential for Resident 10 to have a clogged access site which would prevent Resident 10 from receiving dialysis without surgical intervention to replace the access site. Findings: During a review of Resident 10's Face Sheet, dated 7/14/21, the face sheet indicated Resident 10 was admitted to the facility on [DATE] with diagnoses that included end-stage renal disease (ESRD, a condition in which the kidneys no longer function normally) and was dependent on hemodialysis (artificial means of filtering the blood when the kidneys fail) treatment. During a review of Resident 10's Physician Orders (PO), dated July 2021, the PO indicated an order 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to keep two (Resident 7 and 15) of 44 sampled resident's beds in working condition when: 1. The remote bed control for Resident 7's bed was not functional, to raise or lower the head of the bed. 2 The remote bed control for Resident 15's bed was not functional to raise or lower the head and foot of the bed. The failure to maintain the bed controls in working condition resulted in increased back pain for Resident 7 and placed Resident 15 at risk for discomfort and back pain. Findings 1 During a record review of Resident 7's Facesheet dated 7/14/21, the Facesheet indicated Resident 7 was admitted to the facility on [DATE] with diagnosis of Spina bifida ( A medical condition which can cause back pain and loss of sensation in lower extremities). During a record review of Resident 7's Minimum Data Set (MDS- An assessment used to plan and guide care) dated 7/7/21, the MDS assessment showed Resident 7's Brief Interview for Mental Status (BIMS) score…

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.