The Rehabilitation Center Of Oakland

Based on interview and record review the facility failed to ensure 4 Certified Nursing Assistants (CNAs) and 1 Licensed Vocational Nurse (LVN) had the appropriate competencies to care for residents when the facility did not complete Orientation Evaluation Checklists for LVN 1 and CNA 3, and Annual Performance Evaluations for CNAs 1, 2 and 4. This failure had the potential for resident care to be provided in an unsafe and incompetent manner. Findings: During a concurrent interview and record review on 9/12/24, at 11:59 a.m., with Director of Staffing Development (DSD), CNAs 1, 2, and 3 and LVN 1's personnel folders were reviewed. DSD stated CNA 1's personnel folder indicated CNA 1 was hired on 8/17/23 and did not have an Annual Performance Evaluation. DSD stated CNA 2's personnel folder indicated CNA 2 was hired on 5/17/23 and did not have an Annual Performance Evaluation. DSD stated Annual Performance Evaluations had to be done annually and were important to evaluate CNA's competency. DSD stated CNA 3's personnel folder indicated CNA 3 was hired on 5/23/24 and did not have 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, and record review the facility failed to ensure proper storage and labeling of medication and biologicals (made from a variety of natural sources human, animal, or microorganisms and are used to treat, prevent, or diagnose diseases and medical conditions) for one of one sample medication room and two of two medication carts when: 1. Three opened vials of Tuberculin Purified Protein Derivative (PPD- indicated to aid diagnosis of tuberculosis infection (TB) in persons at increased risk of developing active disease) was unlabeled and undated with an open date. 2. Two activase (a clot-busting medication. It helps the body to produce a substance that dissolves unwanted blood clots.) vials for a discharged resident (Resident 222) were stored in the refrigerator. 3. Thirteen expired Influenza (common respiratory illness. Symptoms often include fever, head, and body aches, coughing and a stuffy or runny nose.) vaccine vials were stored in the refrigerator. 4. Expired medications for Resident 13, 14 and 52 was stored in the medication cart. 5. Two opened…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain and observe infection control practices when: 1. Certified Nursing Assistant (CNA) 6 picked up a soiled linen on the floor of Resident 37 and Resident 58's room and disposed the soiled linen in the cart across Resident 37 and Resident 58's room. 2. Licensed Vocational Nurse (LVN) 3 did not perform hand hygiene and did not put on a new pair of gloves prior to administering eye drops to Resident 51. 3. LVN 3 did not remove gloves after applying topical medication (a medication that is applied to a particular place on or in the body.) to Resident 20. 4. Resident 17, 22 and 44's nasal cannula tubing was undated, unlabeled and was touching the floor. These failures had the potential for cross contamination and spread of infections among residents at the facility. Findings: 1. During an observation on 9/9/24 at 12:32 p.m. in Resident 37 and Resident 58's room, CNA 6 picked up a white linen on the floor with a gloved hand and proceeded…

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 one sampled resident (Resident 30) was treated with dignity and respect when Resident 30 attended activity wearing facility gown and disposable undergarment was soaking wet with urine. This failure had the potential to negatively impact Resident 30's sense of self-worth and self-esteem. Findings: During an observation on 9/9/24 at 12:38 p.m. in the activity room, Resident 30 was sitting on the wheelchair wearing facility gown and liquid was dripping from the wheelchair onto the floor. Other residents in the room were wearing personal clothes. During a concurrent observation and interview on 9/9/24 at 12:40 p.m. with the Activity Director (AD) in the activity room, the AD pulled up Resident 30's gown to check the disposable undergarment. The AD stated Resident 30's diaper was soaking wet with urine. The AD stated Resident 30 wearing gown and soaking wet affected their dignity. During a review of the facility's policy and procedure titled, Resident Rights, dated 1/1/12, indicated, Employees are 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 ensure one of 4 sampled residents (Resident 11), had a Doctor's Order for supplemental oxygen before they received the supplemental oxygen. This failure had the potential for Resident 11 to receive supplemental oxygen inappropriately and in an unsafe manner. Findings: A review of Resident 11's admission Record printed 9/12/24, indicated Resident 11 was admitted to the facility in 2024 with multiple diagnoses including a primary admitting diagnosis of Acute and Chronic Respiratory Failure (a condition that occurs when the lungs are unable to get enough oxygen into the blood or remove enough carbon dioxide from the blood) with Hypoxia (a condition that occurs when the body's tissues, blood, or cells don't have enough oxygen to function normally). During a concurrent observation and interview on 9/09/24, at 10:48 a.m., Resident 11 was observed as they used an oxygen concentrator (a medical device that gives you extra oxygen) via nasal canula (a thin, flexible tube with two prongs that sit inside the nostrils and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the call light (a device used by a patient to signal his or her need for assistance) was within reach for one of three sampled Residents (Resident 56). This deficient practice resulted in the delay of care and services. Findings: During a review of Resident 56's face sheet dated, 9/10/24, indicated Resident 56 was admitted to the facility on [DATE]. During a review of Resident 56 Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan) dated 8/13/24, the MDS indicated, Resident 56 had multiple diagnoses that included, muscle weakness, polyneuropathy (nerve damage causing problems with sensation, coordination, or other body functions). The MDS also indicated Resident 56 had a 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…

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 sampled Residents (Resident 1) had staff identify themselves with name badges while they received care. This failure had the potential to cause Resident 1 emotional distress and anxiety. Findings: During a review of Resident 1's face sheet, dated 4/12/24, face sheet revealed Resident 1 was admitted to the facility in 1/2024. During a review of Resident 1's Minimum Data Set (MDS- an assessment tool used to guide care) dated 2/1/24, the MDS indicated Resident 1 had multiple diagnoses that included arthritis (swelling and tenderness of one or more joints) and anxiety disorder. The MDS also revealed Resident 1 had a Brief Interview for Mental Status (BIMS -a screening tool used to assess cognition) score of 15/15. Meaning, Resident 15 was able to understand and understood others. During a telephone interview on 4/12/24, at 8:26 a.m. with the Responsible Party (RP), RP stated there were multiple issues with staff members that included leaving Resident 1 in bloody bed sheets. RP further 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 implement their Policy and Procedure (P&P) for one of four sampled residents when Resident 1's social security card, a watch, and other personal items reported missing were not investigated thoroughly and documented. This failure placed resident 1 at risk for emotional distress, potential financial hardship and affected Resident 1's sense of security and well-being. Findings: During a review of Resident 1's admission Record , printed on 9/29/23, the admission Record indicated Resident 1 was originally admitted to the facility on admitted to the facility in December 2019. The admission records also indicated that Resident 1 had a medical diagnosis including unspecified dementia (a loss of brain function that occurs with certain diseases, affecting one or more brain functions such as memory, thinking, language, judgment, or behavior). During a record review of Resident 1's Minimum Data Set (MDS, a resident assessment tool used to guide care) dated 7/10/23, the MDS assessment section C indicated Resident 1's…

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

Based of observation, interview, and facility document review, the facility failed to ensure: 1. There was adequate supervisory oversight for the Food and Nutrition Department; 2. Food was ordered in the right quantity for the planned menu; and 3. The RD inspected the resident food refrigerator located in the nursing station. These failures had the potential to result in unsafe and unsanitary practices in regard to food storage, food preparation, and food service, as well as result in an inadequate supply of food for the planned menu to meet the nutritional needs of the residents all of which could in turn affect the safety and wellbeing of 52 residents who ate food by mouth out of a facility census of 54. Findings: Review of the undated job description titled Director of Nutrition Services (DNS), indicated this position was responsible overseeing the day-to-day operation of the Food and Nutrition Services department. An example of areas the DNS was responsible for according to the job description included ensuring nutritious meals to all residents, maintaining a safe and sanitary…

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

Based on observation, interview, and facility record, the facility failed to ensure kitchen staff were competent for job duties performed when Certified Nursing Assistant/Diet Aide 1 (CNA 1) washed dishes in the kitchen and did not know the appropriate sanitizer strength and did not ensure appropriate wash water temperature for the dish machine (Cross-reference F812). This failure had the potential to result in contamination of dishware, utensils, and food leading to illness for 52 residents who received food from the kitchen out of a facility census of 54. Findings: Review of the job description titled, Dietary Aide, published March 2012, indicated the Dietary Aide position was responsible for maintaining daily care of the dishwasher and washing dishes. In an interview with CNA 1 and a concurrent observation of the dish machine on 7/26/22 at 9:10 a.m., indicated CNA 1 washed dishes using the dish machine. CNA 1 stated she was usually a CNA but washed dishes today because the diet aide went home, so she helped out. CNA 1 stated she was responsible for testing the sanitizer of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility document review, the facility failed to store, prepare, and distribute food in a safe and sanitary manner when: 1. The dish washing machine not reaching the required minimum temperature for the wash cycle and leaking. (Cross reference F908) 2. Hand Hygiene protocol was not followed. 3. Expired food items were found in the dry storage room. 4. Multiple dry food items did not have a use by date or open date on them. 5. Sanitizer strength for food contact surface using red bucket was not an appropriate strength. 6. There was no air gap (a gap of air between the floor and a drainpipe to prevent backflow of sewage into the equipment) for food preparation sink. 7. Toaster was not cleaned regularly and had buildup of black and brown residue. 8. Microwave was not cleaned and had food residue on the top inside surface. 9. Industrial Can opener was not clean with sticky yellow and black residue build up and the blade coating was peeled off. 10. Kitchen vents and surrounding…

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 its policy and procedure to ensure safe and sanitary storage and consumption of food brought in for residents from outside the facility when outside food belonging to 52 residents were not labeled upon storage or discarded after two days. This failed practice had the potential for consumption of unsafe food and cause foodborne illness to 52 residents who ate food by mouth out of a census of 54 residents. Findings: During an interview on 7/25/22 at 12:45 p.m., with Licensed Vocational Nurse (LVN) 3, LVN 3 stated the resident refrigerator in the facility was used for storing resident food only and expired food was cleaned out every week by the Housekeeping Department. During a review of facilities document titled, Attention all Staff:, affixed to the resident refrigerator, the document indicated, All perishable food placed in this refrigerator MUST have a room number and date marked on it and can ONLY be held for TWO days (48 hrs.). Any expired Dates will be thrown out. During a concurrent observation…

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

Based on interview and document review, the facility failed to ensure registry staff were vaccinated for COVID-19 (a serious respiratory disease) when 8 of 23 registry staff did not receive the COVID-19 booster immunization and one vaccine exempt registry staff did not meet the religious exemption criteria. This failure had the potential for unvaccinated staff to increase the spread of COVID-19 and its complications of severe illness, hospitalization and/or death to residents they cared for and other staff that worked in the facility. Findings: During an interview and concurrent document review on 7/28/22 at 9:25 a.m., the logs for staff vaccination logs were examined. The Registry staff log indicated, 8 of 23 did not have COVID-19 booster vaccinations. One of two exempt registry staff identified on the log did not meet the religious justification criteria. The IP stated registry staff were from out-of-state where they were not required to have COVID boosters. During an interview on 7/29/22 at 10:30 a.m., the [NAME] President of Operations (VPO) stated all staff, including registry…

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 essential equipment when there were issues with dish washing machine not reaching the required minimum temperature for the wash cycle and leaking. (Cross reference 812) This failure had the potential for equipment not functioning as per manufacturers guidance resulting in ineffective ware washing processes and in turn could cause contamination of food, leading to foodborne illness for 52 residents who received food from the kitchen and negatively affect residents ' well-being out of a census of 54 Findings: An observation during the initial tour of the kitchen on 07/25/22 at 10:12 a.m., showed the dish machine was dripping water from the catch tray onto to floor. During a concurrent observation and interview on 7/26/22 at 9 :18 a.m., the dishwashing procedure were reviewed with Certified nursing Assistant/ Dietary aide (CNA 1). CNA 1 explained the operation of the machine. The dishwashing process, water was pouring from dish machine catch tray onto the Kitchen floor. CNA 1 also stated that it was 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 provide personal care and grooming for four of 24 residents (Residents 165, 265, 6, and 12) who were unable to perform activities of daily living when: 1. Resident 165's fingernails and toenails were long, jagged, with brown substances underneath them; 2. Resident 265's fingernails were long with dark brown substances underneath them, and Resident 265 had dried food crumbs around his mouth and clothes; 3. Resident 6's fingernails were very long, with dark brown substance underneath his nails; and 4. Resident 12's fingernails were long with thick black matter underneath and Resident 12's legs were dry, cracked, and scaly. These deficient practices had the potential for unmet personal care needs for Residents 165, 265, 6, and 12. Findings: 1. A review of Resident 165's admission Record indicated Resident 165's diagnoses included need for assistance with personal care. During a concurrent interview and observation on 7/25/22, at 10:15 a.m., at Resident 165's bedside, Resident 165's fingernails were long, jagged…

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 conduct a timely performance review and in-service training program for two of three sampled Certified Nursing Assistants (CNA 1 and 4) when CNA 1 and 4 did not complete their CNA skills observation checklist and 12-hour mandatory in-services within the past 12 months. This failure had the potential for residents to receive incompetent care from CNA 1 and 4. Findings: During a record review of CNA 1's employee file, CNA 1 did not have a completed CNA skills observation checklist and the 12-hour mandatory in-services within the past 12 months. CNA 1's file indicated CNA 1 was hired on 12/2/05. During a review of CNA 4's employee file, CNA 4 did not have a completed CNA skills observation checklist and the 12-hour mandatory in-services within the past 12 months. CNA 4's file indicated CNA 4 was hired 4/21/20. During an interview on 7/27/22, at 1:05 p.m., with Quality Regional Management Consultant (QRMC) 2, QRMC 2 confirmed there were no CNA skills observation checklists completed within the past 12 months for CNA 1 and CNA…

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

Based on interview and record review, the facility failed to provide dementia (chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes and impaired reasoning) training to three of three sampled certified nursing assistants (CNA 1, 4 and 5) when mandatory dementia training was not completed by CNA 1, 4, and 5 in the last 12 months. This failure had the potential for unmet care needs of residents with dementia by CNA 1, 4 and 5. Findings: During a record review of the employee files CNA 1, 4, and 5, on 7/27/22, at 9:05 a.m., all three employee files did not have in-service records of the mandatory dementia training completed in the last 12 months. During an interview with the Director of Staff Development (DSD) on 7/27/22, at 10:30 a.m., DSD stated she was new and did not know where the training records were in the facility. The facility's policy and procedure titled, In-Service Training and Record Keeping, dated 2/20/20, indicated, The purpose of the policy and procedure was to establish guidelines…

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 refrigerated medications, in accordance to facility policy which requires storage of medications between 36-46 degrees Fahrenheit (F). The medications were stored at temperatures that were too cold. This failure exposed patients to compromised medications. Findings: A review on 07/26/22 of the facility policy titled, STORAGE OF MEDICATIONS, dated April 2008, indicated, Medications requiring refrigeration or temperatures between 2 C (36F) and 8 C(46 F) are kept in a refrigerator. During an observation on 07/26/22 at 1:15 PM in the nursing station, two-medication room refrigerator was 30 F. There were multiple medication storage within the refrigerator. The manufacturer required all these medications (Tuberculin test, Humalog, Flu vaccine, etc.) were to be stored between 36-46 F. A review on 7/26/22 of the Medication Refrigerator Log, a log that had documented daily refrigerator temperatures, indicated for 7/26/22 that the refrigerator was at 30 F. During an interview on 7/26/22 at 2:15 PM, with Licensed…

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 the Pharmacy Consultant (PC)'s monthly recommendations were acted upon for five of 24 sampled residents (Resident 12, 13, 19, 22 and 37) when the PC's recommendations were not reviewed for Resident 12, 13, 19, 22 and 37 who were prescribed psychotropic drugs (medications used to stabilize or improve mood, mental status or behavior) for five consecutive months, from March through July 2022. This failure had the potential for unnecessary medications to be given to Resident 12, 13, 19, 22, and 37. Findings: During a review of the Consultant Pharmacist's Medication Regimen Review, dated 6/14/22, for Resident 12, it indicated, to monitor appropriate behavior and side effects of the medication sertraline (medication for depression) for depression on the Medication Administration Record (MAR). Resident 12's MAR indicated the monitoring of Resident 12's behaviors and medication side effects started 42 days later, on July 26, 2022. During a review of the Consultant Pharmacist's Medication Regimen Review, dated 6/14/22, 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 observations, interviews, and document reviews the facility failed to be free of medication error rates of five percent or greater when two medication errors were observed out of 32 opportunities. The medication error rate was calculated as followed: two divided by 32 then multiplied by 100, which was equal to 6.2 percent. This failure resulted in multiple medication errors. Findings: 1. A review on 07/26/22 of the facility policy dated October 2017 entitled Medication Administration-General Guidelines indicated Prior to administration, the medication and dosage schedule on the resident's medication administration record (MAR) is compared with the medication label. If the label and MAR are different and the container is not flagged indicated a change in directions or if there is any other reason to question the dosage or directions, the physician's orders are checked for the correct dosage schedule. During an observation on 07/26/22 at 9:20 AM LVN 1 was preparing Resident 43's Metoprolol for oral administration. LVN 1 did not compare the MAR with the medication label. LVN 1…

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

Based on interview and medical record review, the facility failed to ensure 37 of 74 sampled residents received or were offered the pneumococcal vaccine when 37 of 74 residents did not have a record of the pneumococcal vaccine in their records. This failure had the potential risks of spreading bacterial infection and causing respiratory complications to residents. Findings: During a review of the facility's undated pneumonia vaccination log, the log indicated 37 of 74 residents did not have a record of pneumonia vaccine administration. During an interview on 7/28/22, at 9:25 a.m., with Infection Preventionist (IP), IP stated he has been the IP for a month. IP stated he picked up where the previous IP last recorded pneumonia vaccines. IP state he was still reviewing patient charts to verify if residents had their pneumonia vaccine and was working to update the incomplete pneumonia vaccine list. Review of the facility's policy and procedure (P&P), titled, Policy for Pneumonia Vaccine (New), dated 10/2014, indicated, on admission, all residents will be evaluated for pneumococcal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: 1. Remove expired stock from treatment cart three (two expired skin staple removal kits, and one bottle of povidone iodine (disinfecting) solution). This failure had the potential for use of expired, and potentially less effective items. 2. Label two opened bottles of liquid nutritional supplements with either a date opened or expiration date. This failure had the potential for use of expired nutritional supplements which could lead to gastrointestinal distress. 3. Label a white colored cream in a medication cup in treatment cart three with type of cream, resident name, or date. This failure had the potential to result in use of expired cream on the wrong resident and/or for the wrong reason. Findings: 1. During an observation of treatment cart three, with Registered Nurse (RN 1) on [DATE] at 11:35 p.m., the bottom drawer contained a 16-ounce bottle of povidone iodine solution dated 12/2017. RN 1 stated the solution was expired 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 store, prepare, and served food under sanitary conditions when: 1. Multiple food items were outdated, unlabeled, and undated; 2. Staff belongings were stored on a 3 step ladder next to refrigerator 3 and 4; 3. Freezer 1 had brown sticky residue on the bottom shelves, and unlabeled ice cream bowls. These failures had the potential to cause food contamination or food borne illness. Findings: 1. During observation and concurrent interview on 6/9/19 at 8:05 a.m., the following were observed: a. In the kitchen refrigerator number three: three glasses of nectar thick liquid did not have preparation date or use by date; four tuna half-sandwiches had a prepared date of 6/7/19, and no use by date; seventeen half-sandwiches had no label and no use by date; three bowls of cottage cheese had a prepared date of 6/6/19, and no use by date; four bowls of fruit had no label and no use by date; three pitchers of thickened liquid had a prepared date of 6/8/19, and no use by date; two quarts of lime juice had a prepared date of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on an observation, interview, and record review, the facility failed to maintain a comfortable and sanitary environment for both residents by: 1. In room [ROOM NUMBER] and room [ROOM NUMBER] the sliding closet doors did not close, the floors had fluffy particulates under the beds, and there was a thick, brown, sticky substance on the areas between the sliding doors and the clothes racks. 2. A certified nursing assistant (CNA 2) left a basin of water used for grooming on the over-bed table for one of 12 residents (Resident 229). 3. In room [ROOM NUMBER] the closet door was missing, and was replaced by a stained curtain. These failures had the potential for residents to not experience a clean, homelike environment. Findings: 1. During an observation on 6/9/19 at 8:52 a.m., the following findings were observed: the closet doors in room [ROOM NUMBER] and room [ROOM NUMBER] did not close, the floor areas between the sliding doors and the clothes racks had a thick, brown, sticky substance, and the floor areas…

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 an observation, interview and record review, the facility failed to provide grooming assistance for one (Resident 229) of twelve sampled residents. For Resident 229, the failure to provide grooming assistance resulted in presence of brown substances under her fingernails, and facial hair. Findings: A review of the Minimum Data Set (MDS, an assessment tool used to guide care) dated 1/4/19 indicated Resident 229 had severe impairments to thinking and remembering skills. The MDS dated [DATE], indicated Resident 229 required total assistance for all personal hygiene activities including cleaning of face and hands. During an observation on 6/10/19 at 9:05 a.m., the fingernails on Resident 229's left hand extended beyond the end of the finger tips, with brown substances visible underneath the fingernails. Resident 229 also had one-quarter inch long, white facial hair along her jaw line from the left side to the right side. During an interview with Family Member 1 (FM 1) on 6/10/19 at 12:40 p.m., FM1 stated…

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

Based on observation, interview, and record review, the facility failed to follow physician orders to flush the feeding tube (a tube inserted through the nose or mouth into the stomach to deliver food, fluid, and/or medications) between administration of different medications for one of 16 sampled residents (Resident 7). This failure resulted in Resident 7 not receiving flush solution according to physician instructions. Findings: Review of Resident 7's Face sheet dated 3/19/19 showed Resident 7 was admitted to the facility in 2018 with a condition of altered mental state. Review of Resident 7's Physician orders dated 8/29/18 showed Resident 7 was to receive medications through a feeding tube, and the medication administration instructions included, To flush the feeding tube with 30 milliliters (ml) of water in between medications. During medication administration observation on 6/10/19 at 9:12 a.m., Licensed Vocational Nurse (LVN 1) administered six different kinds of tablets and capsules via feeding tube. LVN 1 administered 30 ml of water before the first medication…

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

Based on interview and record review, the facility failed to provide a fortified diet (a diet structured to provide more calories than a regular diet) for one (Resident 229) of 14 residents. For Resident 229 this failure had the potential to result in weight loss. Findings: A review of the Facesheet indicated Resident 229 was re-admitted to the facility with a diagnosis of difficulty swallowing. A review of the physician's orders dated 5/29/19, indicated Resident 229's diet changed from a tube feeding (liquid nutrition delivered by a tube directly into the stomach), to a pureed, fortified diet. A review of Resident 229's dietary lunch ticket (a document delivered with the food tray listing the type of diet, and foods, on the individual resident's tray) dated 6/10/19 reflected the diet was regular, with a puree texture. During an interview with the Dietary Supervisor (DS) on 6/10/19 at 12:48 p.m., DS confirmed Resident 229's dietary lunch ticket did not indicate presence of a fortified diet. During an interview with the Assistant Director of Nursing (ADON) on 6/10/19 at 1:00 p.m.,…

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