Chapman Global Medical Center D/P SNF

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and medical record review, the facility failed to provide the appropriate restorative care and services for one of 12 final sampled residents (Resident 24). * The facility failed to provide a left soft hand roll to Resident 24 as per the physician's orders. This failure posed a risk for Resident 24 to have decreased range of motion and mobility.Findings: On 4/6/26 at 0940 hours, 4/7/26 at 0933 hours, and 4/9/26 0801 hours, Resident 24 was observed lying in bed wearing a PRAFO on her left ankle and a splint on her right hand. Resident 24's left hand was in a fist position. Medical record review for Resident 24 was initiated on 4/6/26. Resident 24 was admitted to the facility on [DATE]. Review of Resident 24's MDS assessment dated [DATE], showed Resident 24's cognitive skills for daily decision making were severely impaired. Resident 24 had diagnoses such as cerebral palsy (a disorder that affected a person's movement and posture), quadriplegia (paralysis affecting all four limbs),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary care and services to prevent accidents for one of 12 final sampled residents (Resident 4). * The facility failed to ensure Resident 4's upper side rail pads were in place as per physician's order for safety/seizure precautions. This failure had the potential to put the resident at risk for serious injuries.Findings: Review of the facility's P&P tilted Seizure Precaution dated 4/2026 showed the facility ensure the safety of residents who had diagnosis of seizures by providing side rails padded with anti-trauma pads. On 4/6/26 at 1117 hours and 4/7/26 at 0801 hours, Resident 4 was observed in bed with both upper side rails elevated and no pads were in place. Medical record review for Resident 4 was initiated on 4/6/26. Resident 4 was admitted to the facility on [DATE]. Review of Resident 4's MDS assessment dated [DATE], showed Resident 4 had 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, medical record review, and facility P&P review, the facility failed to provide the appropriate care and services for the use of an indwelling urinary catheter for one of three final sampled residents (Resident 3) reviewed for indwelling urinary catheter care. * The facility failed to ensure Resident 3's indwelling urinary catheter had no sediments in the tubing. In addition, the facility failed to notify the clinician when Resident 3 had sediments in the indwelling urinary catheter. These failures had the potential for Resident 3 to develop complications associated with the use of indwelling urinary catheter.Findings: Review of the facility's P&P titled Urinary Catheter Management revised 11/2020 showed guidelines for the residents with indwelling urinary catheters that included to observe urinary drainage for cloudiness, odor, mucus, blood or sediment, and to report any abnormal findings. On 4/7/26 at 1308 hours, Resident 3 was observed to have an indwelling urinary catheter…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the appropriate care and services for the use of the GT (Gastrostomy Tube) for two of 21 residents (Residents 3 and 20) with GT feedings. * The facility failed to ensure Resident 3's GT extension feeding tube was disconnected after their tube feeding formula was completed. * The facility failed to ensure Resident 20's GT extension feeding tube was disconnected after their tube feeding formula was completed. These failures posed the risk of tube clogging, leaking, not functioning properly, and for developing bacterial growth (infection) for Residents 3 and 20.Findings: Review of the facility's P&P titled Enteral Feeding revised 12/2020 showed to review the order for feedings such as formula, dose limit, rate, and number of hours for infusion per physician orders. In addition, to check the GT placement by auscultating air and to check feeding residual by aspirating stomach content. Lastly, to discontinue…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure appropriate pain management was provided for one of five final sampled residents (Resident 3) reviewed for unnecessary medications. * The facility failed to assess Resident 3's pain prior to the administration of morphine (pain medication). In addition, the facility failed to reassess Resident 3's pain after the administration of morphine. These failures had the potential to put the resident at risk for ineffective pain management and adverse effects related to the use of unnecessary pain medication.Findings: Review of the facility's P&P titled Pain Management Plan dated 1/2002 showed the purpose of the pain management plan was to provide guidelines for the appropriate assessment and management of pain for all the residents. If a resident was unable to self-report the pain scale from 0-10 using the [NAME] scale, the Objective Pain Scale for Cognitively or Communicatively Impaired Adults and Children More than Three…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary pharmaceutical services to two of 12 final sampled residents (Residents 2 and 7). * The facility failed to monitor for adverse effects for Resident 2's anticoagulant medication and failed to obtain a physician's order to monitor the anticoagulant medication use. * There was no evidence nonpharmacological interventions were ordered, performed and documented for Resident 7's use of psychoactive medications. These failures had the potential to result in unnecessary use of, ineffective and/or lack of monitoring or interventions for psychotropic and anticoagulant medications that could negatively affect the residents highest practicable mental, physical, and psychosocial well-being.Findings: 1. Review of the facility's P&P titled Psychoactive Medications/ Chemical Restraint dated 3/2026 showed residents will receive psychoactive medications only when they are…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medical record was accurate for one of 12 final sampled residents (Resident 3). * The facility failed to ensure the physician's orders for Resident 3's code status was accurate. Resident 3's code status showed full code status; however, Resident 3's POLST showed she was a DNR status. In addition, the facility failed to ensure the physician's order for precautions for Resident 3 was accurate. A contact precaution was ordered; however, Resident 3 no longer needed contact precautions. These failures had the potential for the residents' care needs not met as the medical record was inaccurate.Findings: Medical record review for Resident 3 was initiated on 4/6/26. Resident 3 was admitted to the facility on [DATE]. Review of Resident 3's Patient Orders showed the following physician's orders:- dated 5/30/25, for a full code status;- dated 1/24/26, for an enhanced barrier precaution for C. Auris; and- dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to provide necessary care and services to ensure the residents maintained their highest physical well-being for five of five sampled residents (Residents 1, 2, 3, 4, and 5). * Resident 1 had fracture of the right upper arm. There was no monitoring for pain, redness, swelling and warmth of extremities. * The facility failed to follow the physician's order for PT and OT treatment for Resident 1 and OT treatment for Resident 4. * The facility failed to follow the physician's order for daily RNA services for Residents 1, 2, 3, and 5. These failures had the potential for delayed medical interventions and could negatively impact the residents well-being.Findings: 1. Medical record review for Resident 1 was initiated on 10/1/25. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's MDS assessment dated [DATE], showed a BIMS score of 00 (severe cognitive impairment). Review of Resident 1's Care Plans initiated 7/28/25, showed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary respiratory care and services for two of two sampled residents (Residents 1 and 2) who were dependent on the ventilator with tracheostomy for breathing. * The facility failed to ensure Resident 1's ventilator circuit was effectively monitored. As a result, the resident experienced the respiratory arrest. * The facility failed to ensure the P&Ps for respiratory care and services were followed for Resident 2 when the oxygen therapy and a part of the disposable ventilator circuit was replaced and rinsed by a non-qualified personnel. These failures posed the risk of delayed care and interventions for the residents. Findings: 1. Review of the facility's P&P titled Subacute Ventilator Management reviewed [DATE] showed to establish a mutual understanding and a standard of ventilator management for Nursing staff and Respiratory Therapists, which work as a team to provide quality…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to provide the necessary care and services to promote healing of the pressure injuries for one of two final sampled residents (Resident 18) reviewed for pressure injuries. * The facility failed to ensure Resident 18's air mattress was set at the alternate mode (setting where mattress inflates and deflates with air cyclically to redistribute pressure on the body) as ordered by the physician. This failure had the potential to inhibit the pressure injury healing. Findings: Medical record review for Resident 18 was initiated on 2/10/25. Resident 18 was admitted to the facility on [DATE]. Review of Resident 18's Interventional Wound Care Management Progress Note dated 2/5/25, showed Resident 18 had several wounds which included a Stage 3 pressure injury to the sacrum and Stage 4 pressure injuries to the left and right hips and right ankle. On 2/12/25 at 0830 hours, an observation and concurrent interview was conducted with LVN 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, facility document review, and facility P&P review, the facility failed to ensure two of two final sampled residents (Residents 9 and 11) reviewed for RNA services received the RNA services as ordered. * The facility failed to ensure Residents 9 and 11 received the RNA services daily as ordered by the physician. This failure had the potential for the residents to have a decline in ROM function, which could lead to worsening of contractures or muscle weakness. Findings: Review of the facility's P&P titled Restorative Nursing Program revised 11/2021 showed for the RNA to ensure that all the residents are assessed on admission and ongoing for their restorative/rehabilitative needs and abilities. All the residents will be assessed by rehabilitative services within 48 hours of admission and ongoing for their restorative/rehabilitative needs and abilities. A plan of care will be developed specifically designed to promote and improve functional levels and enhance the quality of life. The RNA program…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary care and services to prevent accidents for three of 12 final sampled residents (Residents 12, 13, and 21). * The facility failed to ensure the low air loss mattress pump of Residents 13 and 21 was placed in a safe area as per the manufacturer's recommendation. * The facility failed to implement the floor mats to both sides of Resident 12's bed for safety, in accordance with the physician's order. These failures put the residents at high risk of serious injury. Findings: Review of the facility's P&P titled Pressure Ulcer Prevention, Management Protocol and Treatment dated 10/2024 showed the residents will be assessed for pressure ulcer to prevent the occurrence and/or progression of a pressure ulcer. The interventions for prevention of pressure ulcer includes the use of pressure relief/low air loss mattress/egg crate/overlay. 1. Review of Resident 13's low air…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the appropriate care and services for the use of GT were provided for two of 12 final sampled residents (Residents 3 and 13). * The facility failed to ensure Resident 3's HOB was elevated at a 30 degree angle or higher when Resident 3 was receiving the enteral feeding via GT. * The facility failed to ensure Resident 13's HOB was elevated at a 30 degree angle or higher when Resident 13 was receiving the enteral feeding via GT. These failures posed the risk for complications related to use of the GT for Residents 3 and 13. Findings: Review of the facility's P&P titled Enteral Feeding dated 10/2024 showed during the enteral feeding, keep the resident's head of the bed at a 30 to 45 degree angle as per the physician's order. 1. Medical record review for Resident 3 was initiated on 2/12/25. Resident 3 was admitted to the facility on [DATE]. On 2/10/25 at 0923 hours, and 2/12/25 at 0835 hours, Resident 3 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to provide the necessary care and services to maintain the intravenous accesses for one of 12 final sampled residents (Resident 21). * The facility failed to obtain a physician's order for the care and maintenance of the IV access and develop a plan of care for Resident 21's IV access to the lower extremity. These failures had the potential to delay identification of intravenous access to lower extremity related complications for the resident. Findings: On 2/10/25 at 0929 hours, Resident 21 was observed in bed with an IVF infusing at 70 ml per hour via IV machine. Resident 21's IV access was unable to locate due to the cover in bed. Medical record review for Resident 21 was initiated on 2/11/25. Resident 21 was admitted to the facility on [DATE]. Review of Resident 21's MDS dated [DATE], showed Resident 21 had moderately impaired cognitive skills. On 2/11/25 at 1533 hours, an observation and concurrent interview was conducted with 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to dispose the unused medication in accordance with the facility's P&P. * LVN 4 disposed Resident 18's unused half tablet fludrocortisone (corticosteroid medication) in a sharps container (container used for the disposal of sharp medical equipment) instead of the pharmaceutical waste container as per the facility's P&P. This failure posed the risk for improper management of pharmaceutical waste. Findings: Review of the facility's P&P titled Pharmaceutical Waste dated 10/2022 showed the pharmaceutical waste includes all the unusable medications. All unusable pharmaceutical waste shall be disposed of in the pharmaceutical waste containers (white with blue lids) including the partially used medications including tablets. Medical record review for Resident 18 was initiated on 2/10/25. Resident 18 was admitted to the facility on [DATE]. Review of Resident 18's the physician's order dated 10/25/23, showed an order to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure the Pharmacy Consultant's recommendations from the MRR were acted upon for one of five final sampled residents (Resident 13) reviewed for the unnecessary medications. * The Pharmacy Consultant's recommendation to discontinue the chlorhexidine (antiseptic medication) and perform a hemoglobin A1c level (a blood test that measures the average blood sugar level over the past two or three months) for Resident 13 were not acted upon. These failures had the potential to put the residents at risk for adverse consequences related to the medications. Findings: Review of the facility's P&P titled Skilled Nursing Facility - Drug Regimen Review dated 09/2022 showed the pharmacist review the drug regimen of the resident monthly and make appropriate recommendations. The pharmacist will report in writing the irregularities in the dispensing and administration of drugs and other matters relating to the review of the drug regimen to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 8%. * The facility failed to administer Resident 18's lactulose (laxative) and clonidine (antihypertensive) medications as ordered by the physician. These failures had the potential to negatively affect the resident's health. Findings: Review of the facility's P&P titled Medication Administration revised 7/2013 showed prior to administering a medication, the healthcare professional shall: verify that the medication selected for the administration is correct based on the medication order and product label. Review of the facility's P&P titled Medication Administration Schedule revised 5/2023 showed a scheduled medication maybe administered 30 minutes before or after the scheduled time. Actual time of medication administration must be documented on the Medication Administration Record. Medical record review for Resident 18 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 facility P&P review, the facility failed to provide the necessary pharmacy services to ensure the proper storage, labeling and disposal of the medications for two of four medication carts (Medication Carts A and B). This failure posed the risk for the occurrence of errors in medication administration. Findings: Review of the facility's P&P titled Medication Storage and Security, Pharmacy Manual dated 9/2023, under the Policy section, showed all the medications shall be stored in appropriately segregated and secure conditions to minimize the potential for medication errors and theft or diversion. The external use medications in liquid, tablet, capsule, or powder form shall be segregated from the medications intended for internal use. The aerosol products shall be stored separately from other topical products. 1. On 2/11/25 at 1155 hours, an observation of Medication Cart A and concurrent interview was conducted with LVN 5. The following was observed: - inside the first drawer, one bottle of loperamide liquid ( medication to treat loose bowel…

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

Based on observation, interview, facility P&P review, and facility document review, the facility failed to ensure the food safety and sanitary requirements were met in the kitchen. * The facility failed to ensure the food preparation utensils and equipment were in good, sanitary, and cleanable working conditions. * The facility failed to ensure the staff's personal food items were not placed in the kitchen refrigerator. * The facility failed to ensure the kitchen staff wore hair restraint. These failures had the potential to cause foodborne illnesses to the medically vulnerable resident population who consumed food prepared in the kitchen. Findings: Review of the facility's census on 2/10/25, showed two of 23 residents received food prepared from the facility's kitchen. 1. According to the USDA Food Code 2022, Section 4-601.11, Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils: (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch. (B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease…

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 facility document review, the facility failed to ensure the Facility Assessment addressed or included the following: 1. Active involvement of required individuals in developing the Facility Assessment; 2. Resources necessary to care for residents including weekends; 3. Include a plan to maximize recruitment and retention of direct care staff; and 4. Include a contingency plan for staffing needs. This failure had the potential to not meet the residents' care needs if the assessed population's needs and resources were not comprehensively identified and addressed. Findings: According to the CMS QSO-24-13-NH dated 6/18/24, with an implementation date of 8/8/24, CMS issued a revised guidance for long-term care facility assessment requirement. The Facility Assessment should address and includes the active involvement of direct care staff in developing the Facility Assessment. Also includes the staffing resources necessary to care for the residents, including the weekends; a plan to maximize…

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

Based on observation, interview, and facility P&P review, the facility failed to ensure the appropriate infection control practices were implemented. * The facility's infection control committee did not meet for one quarter in 2024 to discuss infection control within the subacute unit. This failure posed the risk for transmission of diseases-causing microorganisms and resulted in the committee not being able to discuss quarterly infection control statistics within the subacute unit. Findings: Review of the facility's P&P titled Medical Staff Bylaws, undated, showed the Medical Executive/Quality Improvement Committee shall meet as often as necessary, but at least quarterly and shall maintain a record of its proceedings and actions. On 2/12/25 at 1337 hours, a concurrent interview and document review was conducted with the Director of Infection Prevention/Acting IP. Review of the Infection Control Pharmacy and Therapeutics meeting logs showed no quarterly meeting was held after 8/20/24. When asked about the last infection control committee meeting, the Director of Infection…

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 facility document review, facility failed to have a full-time, dedicated IP. This failure had the potential for the Infection Prevention and Control Program not being implemented without proper oversight. Findings: Review of the Organizational Chart of the facility updated February 2025 showed the position for Infection Control Supervisor/Infection control was vacant. Review of the QSO-22-19 dated 6/29/22, showed the SNFs are required to have an IP who has specialized training onsite at least part-time to effectively oversee the facility's infection prevention and control program. On 2/12/25 at 1105 hours, an interview was conducted with the Director of Infection Prevention/Acting IP. The Director of Infection Prevention/Acting IP stated she was being stationed and stayed most of the time at the acute care unit of the facility. The Director of Infection Prevention/Acting IP stated she was currently helping the facility on their infection control and would stay in the building for only one to two hours including her work in the acute unit of the facility. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the RNA services were provided as ordered to one of three sampled residents (Resident 3) to prevent a decline in the ROM functions. * The facility failed to follow a physician's order for the RNA to apply the bilateral hand splints, bilateral PRAFOs the to lower extremities, and provide the ROM exercises daily to Resident 3. This failure had the potential for Resident 3 to sustain a decline in the ROM functions, which could lead to the worsening of contractures and muscle atrophy. Findings: Review of the facility's P&P titled Restorative Nursing Program (RNA) reviewed August 2023 showed the RNA program is provided seven days a week based on the resident's individual needs and delivered per the physician's order. On 9/25/24 at 1500 hours, a concurrent observation and interview was conducted with Resident 3. Resident 3 was observed lying in bed with both hands contracted and hand rolls in place. Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure nine of 12 final sampled residents (Residents 3, 7, 11, 12, 13, 15, 19, 20, and 23) remained free from accident hazards. * The facility failed to ensure the residents' side rail paddings were properly placed as ordered by the physicians and residents' care plans for Residents 3, 7, 11, 12, 13, 15, 19, and 20. * The facility failed to ensure an informed consent was obtained, conduct an assessment, and implement the least restrictive measures prior to utilizing the enclosed bed (Posey Bed - a hospital bed with canopy and mattress designed to help provide a safe, controlled environment for residents at extreme risk of injury from a fall. It is a restraint and must be prescribed by a licensed physician) for Resident 23. In addition, the facility failed to ensure the monitoring of the device was documented. These failures had the potential risk for injury to the residents. Findings: Review of the facility's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 12 final sampled residents (Resident 7) was free from the physical restraints. * The facility failed to conduct an assessment and implement the least restrictive measures prior to applying a mitten (mitten which look like boxing gloves with a Velcro or tie at the wrist to hold them in place and immobilize the resident's fingers) to Resident 7's left hand. In addition, the facility failed to obtained the physician's order and informed consent from the responsible party. These failures posed the risk of compromising the residents' independence and psychosocial well-being. Findings: Review of the facility's P&P titled Restraints dated 11/2021 showed the restraints will be used only with a written order from a physician, ensure the least possible discomfort to the resident, and informed consent was obtained. All restraints use is documented in the care plan, nurse's notes, and reviewed by the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the baseline care plan for one of 12 final sampled residents (Resident 8) and one nonsampled resident (Resident 9). * The facility failed to develop a care plan problem for Resident 9's use of adaptive device (a beige colored velcro strap that was used to assist in holding utensils during meal times). * The facility failed to develop a care plan problem to address the use of peripheral IV (peripheral intravenous access for IV fluids and/or medications) for Resident 8. These failures posed the risk of not providing the appropriate, consistent, and individualized care to the residents. Findings: 1. Review of the facility's P&P titled Care Planning revised 8/2010 showed the resident care plan will be maintained as part of resident health, will identify the problems or needs. After information has been gathered, the data is analyzed to determine what problems and needs exist. On 2/12/24 at 1148 hours,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to ensure one of 12 final sampled residents (Resident 7) attained and maintained their highest practicable well-being. * The facility failed to ensure Resident 7 was provided with the heel protectors while in bed as per the physician's order and resident's care plan. This failure had the potential for the resident to not receive appropriate care and treatment to prevent a skin problem. Findings: Review of the facility's P&P titled Pressure Ulcer Prevention, Management Protocol and Treatment with a revised date of 10/21 showed the prevention of pressure ulcer techniques included the protection on all bony prominences, application of heel protectors, reposition the resident every two hours, and keep the skin clean and dry. On 2/12/24 at 0926 hours, and 2/13/24 at 0851 hours, Resident 7 was observed in bed and no heel protector in place on both feet. Medical record review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P, the facility failed to ensure the necessary care and services were provided to prevent the development of new pressure injuries and promote the healing of the existing pressure injuries for two of 12 final sampled residents (Residents 8 and 12). * The facility failed to ensure the LAL mattress setting was consistent with Resident 8's weight and the service light on the LAL mattress unit was addressed; and failed to ensure Resident 8 was administered wound treatments as per the physician's orders. These failures put Resident 8 at higher risk for developing new pressure injuries and worsening of the existing pressure injury on the left buttock. * The facility failed to ensure the LAL mattress setting was appropriate for Resident 12's weight. This failure posed the risk for Resident 12 to not benefit from the therapy provided by the LAL mattress. Findings: Review of the facility's P&P titles Pressure Ulcer Prevention, Management Protocol 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 medical record review, the facility failed to ensure the residents with limited ROM functions consistently received the treatments and services. * All 23 residents with orders for RNA services (including the ROM exercises and application of splints) did not consistently receive their treatments on multiple occasions. This failure had the potential for the residents to develop further decrease in ROM functions. Findings: On 2/13/24, the facility census was 23. On 2/14/24, while conducting the sufficient staffing task, the 2/14/22 daily staffing documentation showed one RNA was assigned to perform ROM exercises and application of splints to all residents. Further review of the daily staffing documents showed no staff was assigned to perform ROM exercises and applications of splints to the residents on 1/3, 1/7, 1/20, 1/22, 1/27, 1/28, 1/29, 2/11, and 2/10/24. Review of the facility's RNA binder showed all residents had the orders for daily RNA services. Further review of the RNA binder showed no RNA services were provided to the residents on 1/1, 1/3, 1/7, 1/8,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary enteral feeding (a way of delivering nutrition directly to the stomach or small intestine) care and services for five of 12 final sampled residents (Residents 3, 14, 15, 19, and 20) and one nonsampled resident (Resident 2). * The facility failed to ensure Residents 3, 14, 19, and 20's enteral feeding bottles were completely labeled to include the time and rate. * The facility failed to ensure the medications were administered via GT by gravity for Residents 2 and 15. These failures posed the risk for complications related to the use of the enteral feeding for Residents 2, 3, 14, 15, 19, and 20. Findings: 1. Review of the facility's P&P titled Enteral Feeding revised 8/23 showed the enteral feeding will be administered as ordered by the physician, in collaboration with the Registered Dietitian. The procedure also showed to label bag and tubing with date and time hung. a. During the initial…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the appropriate care and services for IV therapy (the administration of fluids or medications through an IV line) for one of 12 final sampled residents (Resident 8) and one nonsampled resident (Resident 5). * The facility failed to change Resident 8's IV tubing per the date on the label; and the facility failed to ensure Resident 8 had an order for TKO. * The facility failed to label Resident 5's IV tubing with the date to be changed; and the facility failed to ensure Resident 5 had an order for TKO. These failures had the potential for complications related to IV therapy and negative effects related to the residents' medical condition. Findings: Review of the facility's P&P titled Intravenous Therapy Administration reviewed 6/2020 showed specific flow rates or TKO (to keep open) must be ordered by the physician; IV administration set and extension tubing shall be changed two times per week; and all IV…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide safe respiratory care to meet the needs for one of 12 final sampled residents (Resident 13). * The facility failed to ensure Resident 13 was placed on the correct ventilator settings ordered by the physician. In addition, the ventilator machine alarms were not set for high pressure alarms. These failures had the potential to result in poor health outcomes to the resident and posed the risk of delayed intervention in the event of an emergency. Findings: Review of the facility's P&P titled Continuous Mechanical Ventilator revised 7/2023 showed the residents are placed on a mechanical ventilator per the physician's order. The physician will be contacted if the order requires further clarification or if there's a change in the resident condition that requires a change in vent setting. Review of the facility's P&P titled Ventilator Alarm Setting guidelines, troubleshooting and Corrective Action revised…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to ensure the appropriate use of side rails for two of 12 final sampled residents (Residents 8 and 12). The facility failed to ensure the informed consents for side rail use matched the indications for side rail use ordered by the physician for Residents 8 and 12. This failure had the potential to put the residents at risk for entrapment and serious injury. Findings: 1. Medical record review for Resident 8 was initiated on 2/12/24. Resident 8 was admitted to the facility on [DATE]. On 2/12/24 at 0840 hours, during an initial tour of the facility, Resident 8 was observed lying in bed with four side rails elevated. Review of Resident 8's Physician Order Report for February 2024 showed a physician's order dated 8/30/21, for the use of bilateral side rails as per the resident's request for safety, every shift. Review of Resident 8's Consent for Use of Side Rails signed 12/10/17, showed the informed consent was obtained for bilateral side…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. * The facility's medication error rate was 48%. Two of three licensed nurses (LVNs 3 and 5) were found to have made errors during the medication administration. These failures resulted in the residents not receiving the prescribed medications as ordered by the physician, which posed the risk of adverse effects for the residents. Findings: Review of the facility's P&P titled Medication Administration revised 7/2013 showed all medications will be administered throughout the hospital utilizing the same standards of practice. The P&P also showed to verify that the medication is being administered at the proper time, in the prescribed dose, and by the correct route. Review of the facility's P&P titled Medication Administration-Eye Drops dated 6/2016 showed where multiple drops and/or ointment are prescribed for one or both eyes, the order of administration is important…

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

Based on observation, interview, and facility P&P review, the facility failed to ensure the medications were stored and labeled properly in two medication carts (Medication Carts A and B) and failed to ensure an expired medication was not stored in Medication Cart A. * Three medications in Medication Cart B and one medication in Medication Cart A did not have clear labels and were unreadable. * Five medications in Medication Cart B and five medications in Medication Cart A did not have no open dates. * One expired medication was found in Medication Cart B. * One drawer from Medication Cart B contained 3 containers of protein powder stored with alcohol gel and hydrogen peroxide 3% in the same drawer. * Medication Cart B contained one bottle of sterile water without an open date * The medication refrigerator contained tuberculin solution without an open date These failures had the potential for the nurses to administer the incorrect medication or expired medications; and had the potential to negatively impact the residents' well-being. Findings: Review of the facility's P&P titled…

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

Based on observation, interview, facility document review, and P&P review, the facility failed to ensure food safety and sanitation in the kitchen as evidenced by: * The FSS did not perform hand hygiene after removing the gloves and touched the food with the dirty gloves during the food preparation. * Resident 9's culinary utensil was not washed and sanitized as per the facility's P&P. * A handwashing sink was used for purposes other than hand washing when the CNA used hand sink to wash the spoon. * The food contact surfaces were not clean. * A hair restraint was not worn during food preparation, * The following nonfood contact surfaces were not clean. * The nonperishable food brought from the outside was not labeled or dated. * The can opener blade was worn. * The test strips used to test the dish machine sanitizer were expired. These failures had the potential to cause outbreak of foodborne illness to one of the 23 facility residents, staff and visitors who consumed food prepared in the kitchen. Findings: Review of the facility matrix showed one of 23 residents received food…

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 facility P&P review, the facility failed to ensure the staff and visitors who brought food from outside were educated on the safe food handling practices. This failure had the potential to cause the risk of safety of usage, handling, and consumption of foods brought to the residents by the resident's family and visitors. Findings: Review of the facility's P&P titled Food From An Outside Source dated 7/2022 did not show a process to ensure the visitors who brought food from outside or facility staff were educated on the safe food handling guidelines. On 2/13/24 at 0916 hours, an interview was conducted with the DON. The DON stated the staff did not provide the safe food handling education handouts to the visitors who brought food to the residents. On 2/13/24 at 0939 hours, an interview was conducted with the DSD. The DSD stated they did not have copies given for safe food handling education to the visitors. On 2/15/24 at 0945 hours, an interview with the FNSD was conducted. The FNSD confirmed no handouts were given to the visitors regarding education on 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 P&P review, the facility failed to ensure the appropriate infection control practices designed to provide the safe and sanitary environment were implemented. * LVNs 3, 4, and 5 failed to perform hand washing prior to the administration of medications via GT to three nonsampled residents (Residents 2, 4, and 17). * The trash can in Resident 4's room was overfilled with yellow gowns which was used for contact precaution isolation. * The facility's infection control committee did not meet for one quarter to discuss the residents who did not meet McGeer's criteria in November 2023. These failures posed the risk for transmission of disease causing microorganism, and resulted for the committee not able to discuss about the residents on antibiotics who did not meet McGeer's criteria. Findings: 1. Review of the facility P&P titled Medication Administration Via Feeding Tube revised on 8/2021 showed steps in procedure to wash hands before crushing pills and administering…

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

Based on observation, interview, facility document review, and facility P&P review, the facility failed to maintain the essential equipment in a safe operating condition. * The facility failed to ensure the ice machine located in the kitchen was cleaned and sanitized as per the manufacturer's guidelines. * The facility failed to ensure the medication refrigerator was maintained and the freezer compartment inside the medication refrigerator was free of ice buildup. These failures had the potential for the refrigerator not being maintained in a safe operating condition and posed the risk of ice contamination and equipment to function improperly. Findings: Review of the [Manitowoc] ice machine manufacturer's guidelines, Section 4, showed in part, to use only [Manitowoc] approved metal safe ice machine de-scaler (part number 000000084) and [Manitowoc] Sanitizer 9 (part number 9405653). Detailed De-scaling/Sanitizing procedure as follows: to be performed every six months. All ice must be removed from the bin. The ice machine and bin must be disassembled, descaled, and sanitized. The ice…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to implement the resident-centered activity programs to meet the residents' needs and interests for one sampled resident (Resident 2) and 22 nonsampled residents (Residents A, B, C, D, E, F, G, H, I, J, K, L, M, N, O, P, Q, R, S, T, U, and V). This failure had the potential to negatively affectthe residents' psychosocial well-being. Findings: Review of the facility's P&P titled Activities Program, Resident reviewed August 2023 showed a purpose to provide activities designed to appeal to the resident's interests and abilities to assist in achieving the highest level of physical, mental, and psychosocial well-being possible. The P&P also showed to develop the care plan designed to improve the resident's quality of life, develop and arrange suitable activities, and post the scheduled activities on the unit. On 9/7/23 at 1550 hours, an interview was conducted with the Subacute Unit Director. The Subacute Unit…

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.