Healthbridge Children's Hospital - Orange D/P SNF

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 nonsampled resident (Resident 17) was free from accident hazards. * The facility failed to provide padded side rails for seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) precautions per the physician's order for Resident 17. This failure placed Resident 17 at risk for serious injury.Findings: Review of the facility's P&P titled Bed Safety and Bed Rails revised 6/2022 showed that consideration was given to the resident's safety, medical condition, comfort, and freedom of movement, as well as input from the resident and family. On 4/27/26 at 0938 and 1535 hours, 4/28/26 at 1015 hours, and at 4/29/26 at 0914 hours, Resident 17 was observed in bed with side rails in use. The side rails were not padded. Medical record review for Resident 17 was initiated on 4/27/26.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care services for two of 12 final sampled residents (Residents 4 and 10) reviewed for respiratory care. * The facility failed to ensure Resident 4 and 10's oxygen tubing were stored in a sanitary condition when not in use. These failures had the potential to negatively affect the respiratory health and well-being of the residents in the facility.Findings: Review of the facility's P&P titled Changing Respiratory Equipment revised 1/2025 showed the oxygen masks and cannulas will be changed weekly and as needed. All respiratory disposable treatment equipment will be dated when changed weekly. 1. On 4/27/26 at 0918 hours and 4/28/26 at 0852 hours, Resident 4 was observed in bed. Resident 4's oxygen tubing was observed hanging on the wall hook. The tubing was unlabeled, undated, and not stored inside the clear plastic bag setup bag. Medical record review for Resident 4 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 interview, observation, medical record review, and facility P&P review, the facility failed to provide pharmaceutical services to meet the resident's need for one of nine residents observed during the medication administration observation. * LVN 3 failed to ensure Resident 22's eye medications were administered per the physician's order. This failure had the potential to negatively affect Resident 22's well-being.Findings: Review of the facility's P&P titled Medication Administration; Oral; IM; SQ; ID; Metered Dose; NGT; GT; JT; Vaginal; Urethral; Suppository; Eye & Ear Drops revised 4/2022 showed the procedure for administering eye drops included to wash hands prior to administration, to place the resident in a comfortable position, to place the medication in the conjunctival sac or if an ointment to place along the inside of the lower lid from the inner to outer canthus, and if the patient was to receive two or more medication, to wait five minutes in between drops. Medical record review for 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, medical record review, and facility P&P review, the facility failed to ensure the accuracy of the medical record for one nonsampled resident (Resident 18) was accurate. * Resident 18's medical record contained behavior and side-effect monitoring for the use of the quetiapine (antipsychotic) medication; however, there was no physician's order for the quetiapine medication. This failure had the potential for the resident's care team having inaccurate information.Findings: Review of the facility's P&P titled Charting and Documentation date revised 3/2022 showed all the services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Documentation in the medical record will be objective (not opinionated or…

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

Based on interview, medical record review, and facility P&P review, the facility failed to implement their abuse P&P for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150 B of the Social Security Act for one nonsampled resident (Resident 12) as evidenced by: * The facility failed to ensure the reporting of Resident 12's sexual abuse allegation to the local State and Federal agencies in a timely manner. This failure posed the risk for the abuse allegation going unreported and uninvestigated. Findings: Review of the facility's P&P titled Abuse revised 11/2024 showed the facility was required to complete the contact information sheet for state/local reporting agencies. Further review of the P&P showed the facility was to fax a written report to the local state survey agency. On 2/20/25 at 1400 hours, an interview was conducted with Family Member 1. Family Member 1 stated the facility was trying to discharge Resident 12 too soon. Family Member 1 stated the facility was doing this in response to Family Member 1 reporting Resident 12 was sexually…

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 the facility P&P review, the facility failed to implement their abuse P&P related to the investigation of sexual abuse for one nonsampled resident (Resident 12). This failure had the potential for not taking all the necessary corrective actions to protect Resident 12 and other residents from abuse. Findings: Review of the facility's P&P titled Abuse revised 11/2024 showed the facility is to: * document all allegations of abuse; * the licensed nurse is to assess the individual and document injury assessment; * interview family members, visitors, and other residents as applicable; and * interview staff from different shifts. On 2/20/25 at 1400 hours, an interview was conducted with Family Member 1. Family Member 1 stated the facility was trying to discharge Resident 12 too soon. Family Member 1 stated the facility was doing this in response to Family Member 1 reporting Resident 12 was sexually abused by CNA 2. Family Member 1 stated she observed Resident 12 scream 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 interview, medical record review, and facility P&P review, the facility failed to develop and implement the individualized care plans for two of 12 sampled residents (Residents 4 and 19) and one nonsampled resident (Resident 12). * The facility failed to develop a care plan problem to address the resident's family member education regarding the use of gown and glove during high-contact interactions with the resident. This failure posed the risk for Resident 4 to be infected and spread the infection. * The facility failed to ensure the care plan problem for the use of the mechanical lift was implemented when Resident 12 was tansferred by one staff using the mechanica lift instead of two staff assistance. This failure posed the risk of Resident 12 for injury or fall. * The facility failed to develop a care plan problem for Resident 19 to address the use of anticoagulant and antibiotic medications. This failure posed the risk for Resident 19 to develop complications associated with the use of anticoagulant…

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 revise the care plan for one of 12 final sampled residents (Resident 17) and one nonsampled resident (Resident 12). * Resident 12's plan of care was not revised to reflect an abuse allegation reported. * Resident 17's plan of care was not revised to reflect the resident's use of bilateral afo to lower extremity. These failures posed the risk of the residents to not receive the appropriate care. Findings: 1. On 2/20/25 at 1400 hours, an interview was conducted with Family Member 1. Family Member 1 stated Resident 12 communicated that the resident was sexually abused by CNA 2. Family Member 1 stated she reported this allegation to the Administrator in April 2024. On 2/21/25 at 0830 hours, an interview was conducted with the Administrator. The Administrator verified she was aware of Resident 12's abuse allegation. When asked about a care plan problem addressing Resident 12's abuse report, the Administrator stated she would look for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 12 final sampled residents (Resident 1) received the appropriate treatment and services to prevent the occurrences of complications from the GT feeding. * The facility failed to ensure Resident 1's head of bed was positioned safely at 30 to 45 degrees during the GT feeding to reduce the risk of aspiration. In addition, the facility failed to ensure Resident 1's tube feeding formula was properly labeled. These failures posed the risk for developing complications related to GT feedings, which had the potential to negatively impact the resident's well-being. Findings: Medical record review for Resident 1 was initiated on 2/20/25. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's H&P examination dated 3/6/21, showed Resident 1 had no capacity to understand and make decisions. a. Review of the facility's P&P titled Enteral Tube Feeding via Continuous Pump dated 3/2022 showed 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 provide the necessary respiratory care and services for two of 12 final sampled residents (Residents 7 and 9). * The facility failed to ensure Resident 7's cool aerosol therapy (treatment that uses mist of medicine to help relieve upper airway issues by loosening phlegm) plastic bag was dated as per the facility's P&P. * The facility failed to ensure Resident 9's suction canister (bottle connected to suction machine to collect the secretions like phlegm, mucous during suctioning ) was dated when it was installed and hooked to the suction machine (medical device that removes obstructions from a patient's airway by clearing from secretions). These failures had the potential for increased risk of infection. Findings: Review of the facility's P&P titled Changing Respiratory Equipment revised 1/2025 showed the purpose of the P&P is to provide guidelines for changing respiratory therapy equipment. Continuous aerosol…

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's P&P review, the facility failed to ensure one of 12 final sampled residents (Resident 273) were free from the unnecessary psychotropic medications. * The facility failed to monitor the episodes of OMS as one of the behavior manifestations and side effect monitoring for alprazolam (anxiety medication) and sertraline (antidepressant medication) medications for Resident 273. In addition, both medications had the same indication. This failure had the potential for inaccurate behavior and side effects monitoring, which might cause the physician for not having the necessary information to determine the effectiveness of the medications for Resident 273. Findings: Medical review of Resident 273 was initiated on 2/19/25. Resident 273 was admitted to the facility on [DATE]. Review of the Order summary Report dated 2/21/25, showed a physician's order dated 2/19/25, to administer alprazolam oral tablet 0.25 mg via GT two times a day for OMS for 30 Days.…

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 ensure the residents' medications and biologicals were properly stored and labeled for two of 12 final sampled residents (Residents 4 and 273). In addition, the facility failed to ensure three of six medication carts had no expired supplies and medication. * Resident 4 had a six ounce tube of Triad hydrophilic wound dressing (used to provide a moist wound healing environment) with CMC (cellulose gum) at the bedside table. * Resident 273 had a 22-gram tube of mupirocin (used to treat skin infections) 2% ointment and a 60-gram tube of Venelex wound dressing (used to cover wounds) on the bedside table. * Medication Cart 2 had eight packets of SurePrep protective wipe (skin protectant) with an expiration date of [DATE]. * Medication Cart 4 had an AG Cuffill pressure manometer (used for measuring and regulating intra-cuff pressure) with an expiration date of [DATE]. * Medication Cart 6 had…

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

Based on interview and facility document review, the facility failed to submit the complete and accurate direct care staffing information to CMS. This failure posed the risk of inaccurate auditable data reporting. Findings: Review of the CMS CASPER reports showed the facility triggered a One-Star Staffing Rating due to the failure to submit data for the quarter from 7/1/24 to 9/20/24. Review the Pediatric Monthly Subacute Staffing Report showed the following: - For September 2024, the RN and LVN hours were within the requirement. However, there were 17 days that the CNA hours were below the minimum, for a total of 167.66 hours below the minimum. - For October 2024, the RN and LVN hours were within the requirement. However, there were nine days that the CNA hours were below the minimum, for a total of 76.68 hours below the minimum. - For November 2024, the RN and LVN hours were within the requirement. However, there were five days that the CNA hours were below the minimum, for a total of 30.10 hours below the minimum. - For December 2024, the RN and LVN hours were within the…

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

Based on observation, interview, and facility P&P review, the facility failed to ensure the resident care equipment was kept in safe operating condition as evidenced by: * The facility's mechanical lift stopped working during the transfer for one nonsampled resident (Resident 12). * The ice buildup was observed in the enteral feeding refrigerator. These failures posed the risk for equipment hazards or unsafe practices which could affect the residents' well-being in the facility. Findings: 1. Review of the facility's P&P titled Hydro-Lift Instructions for Use dated 5/4/21, showed the lift was to be charged daily, with minimum charging time of eight hours. On 2/20/25 at 1600 hours, an observation was conducted with CNA 1. CNA 1 was observed transferring Resident 12 from the resident's bed to a wheelchair using a mechanical lift. When lifting Resident 12 approximately one and a half feet above her wheelchair, the mechanical lift stopped working. CNA 1 stated the mechanical lift's battery had died. CNA 1 was then observed manually pushing the mechanical lift and placing Resident 12 back…

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 implement their P&P for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act when the facility did not report an allegation of abuse to the CDPH, L&C program for one of two sampled residents (Resident 1). This failure had the potential for the abuse allegation going unreported and uninvestigated. Findings: Review of the facility's P&P with subject Abuse revised 1/2024 showed it is the policy of the facility to report all alleged violations and all substantiated incidents to the state department of health and to all other agencies as required, in a timely manner. When an alleged or suspected case of mistreatment, neglect, injuries of unknown source, or abuse is reported, the Administrator or designee will notify the following individuals or agencies, as applicable, within two hours by telephone and an initial twenty-four hours in writing of the alleged incident: The State…

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 thoroughly investigate an allegation of abuse for one of two sampled residents (Resident 1) when Resident 1 was allegedly abused by an unknown staff on 9/11/24. This failure posed the risk for the potential abuse to remain unidentified and for the residents to go unprotected. Findings: Review of the facility's P&P with subject Abuse revised 1/2024 showed any incident or allegation of abuse, neglect, mistreatment, or misappropriation of resident's property or injury of unknown source, will result in timely and thorough investigation. The staff member assigned to gather the facts will at a minimum review the resident's medical record to determine events leading up to the incident, interview the person(s) reporting the incident, interview any witnesses to the incident, interview staff members (on all shifts) who have had contact with the resident, review all events leading up to the alleged incident. The Administrator will…

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, facility documemt review, and facility P&P review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the transmission of communicable diseases and infections. * The facility failed to ensure the water management program was established and implemented to include an assessment of the facility water systems to identify where Legionella (a bacterium commonly found in natural and man-made aquatic environments, warm stagnant water) and other opportunistic pathogens can grow and spread; implementation of measures to prevent the growth of Legionella and other opportunistic pathogens; and a way to monitor the measures they have in place. This failure increased the risk for the spread of infection. Findings: Review of the facility's P&P titled Waterborne Pathogen and Water Management Plan dated January 2024 showed to conduct facility risk assessment to identify where legionaella and other opportunistic waterborne pathogens (e.g pseudomonas, burkhholderia,…

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 document review, the facility failed to ensure the residents' entrapment assessments were complete and the measurements were recorded during the bed inspection when identifying areas of possible entrapment with the use of side rails for six of 12 final sampled residents (Residents 1, 7, 9, 10, 17, and 22). These failures had the potential to negatively impact the residents resulting in possible entrapment, serious injury, and death. Findings: According to the Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, the term entrapment describes an event in which a patient/resident is caught, trapped, or entangled in the space in or about the bed rail, mattress, or hospital bed frame. Patient entrapments may result in deaths and serious injuries. These entrapment events have occurred in openings within the bed rails, between the bed rails and mattresses, under bed rails, between split rails, and between the bed rails and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 12 final sampled residents (Resident 21) 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 21's hand and abdominal binder. In addition, the facility failed to obtain an informed consent from the responsible party for the use of hand mitten and abdominal binder. 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 1/2024 showed the restraints will be used only with a written order from a physician and should be obtained prior to the application of restraints, ensure the least restrictive alternatives were determined inadequate to protect…

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 develop the comprehensive person-focused care plans for four of 12 final sampled residents (Residents 1, 8, 10, and 21). * The facility failed to develop a care plan problem for Resident 1's use of lap tray (a removable stable surface which can be attached to the wheelchair designed to lean on for support, provide activity, and feeding surfaces) while in the wheelchair for positioning. * The facility failed to develop a care plan problem for Resident 8's use of tobramycin (antibiotic) medication. * The facility failed to develop a care plan problem for Resident 10's use of side rail in bed. * The facility failed to develop a care plan problem Resident 21's use of the mittens and abdominal binder restraints. These failures posed the risk of not providing the appropriate, consistent, and individualized care of the residents. Findings: 1. On 3/14/23, Resident 1 was observed sitting in the wheelchair. A lap tray was observed attached…

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 prevent accidents for four of 12 final sampled residents (Residents 4, 7, 11, and 22). * The facility failed to ensure Resident 11's vital signs were taken, and neurological assessment was completed after a fall incident on 2/20/24, to which a care plan problem was only initiated on 2/29/24. In addition, the medical record did not show the facility addressed the causative factors of the fall and consulted the pharmacist and the physical therapist as per the care plan. Furthermore, the medical record did not show an IDT review was conducted as per the facility's P&P on falls. * The facility failed to ensure Resident 4's stroller was strapped while the resident was in the stroller as per the physician's order. In addition, the facility failed to show documentation Resident 4 was monitored while on the stroller. Furthermore, the facility failed to develop a care plan…

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 maintain the intravenous accesses for one of 12 final sampled residents (Resident 21). * The facility failed to ensure the CVAD (Central Venous Access Device - a type of intravenous catheter) line external catheter measurements were completed and documented in the medical record for Resident 21. In addition, the facility failed to develop a plan of care for the use of CVAD. These failures had the potential to delay the identification of catheter related complications for the resident. Findings: Review of the facility's P&P titled Central Venous Catheter Care and Dressing Changes dated 9/2023 showed to measure the length of the external central vascular access device with each dressing change or if the catheter dislodgement is suspected and compare with the length documented at insertion. Observe the central line catheters insertion site and surrounding areas for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the mechanical ventilation tubing setup bag for one of 12 final sampled residents (Resident 9) was labeled in accordance with the facility's P&P. This failure posed the risk for the resident's equipment to be contaminated which had the potential for increased risk of infection. Findings: Review of the facility's P&P titled Changing Respiratory Equipment revised 4/2023 showed the following: - Bacterial growth in the ventilator circuit will be minimized by changing the ventilation circuit at a routine time interval; - All closed system suction catheters will be changed every Monday, Wednesday, and Friday; - Respiratory disposable treatment equipment will be changed weekly (such as hand-held nebulizer equipment, cough assist circuits, aero chambers, etc), and - All disposable equipment will be dated when changed. On 3/11/24 at 0823 hours, 3/12/24 at 0848 hours, and 3/13/24 at 0927 hours, Resident 9 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, medical record review, and facility P&P review, the facility failed to ensure the least restrictive alternatives were attempted prior to the use of side rails for one of 12 final sampled residents (Resident 9). This failure had the potential to put the resident at risk for entrapment and serious injury. Findings: The FDA issued a Safety Alert entitled Entrapment Hazards with Hospital Bed Side Rails. Residents most at risk for entrapment are those who are frail or elderly or those who have conditions such as agitation, delirium, confusion, pain, uncontrolled body movement, hypoxia, fecal impaction, acute urinary retention, etc., that may cause them to move about the bed or try to exit from the bed. Entrapment may occur when a resident is caught between the mattress and bed rail or in the bed rail itself. Inappropriate positioning or other care related activities could contribute to the risk of entrapment. On 3/11/24 at 0823 hours, 3/12/24 at 0848 hours, 3/13/24 at 0927 and 1116…

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 drug regimen review were acted upon for two of 12 final sampled residents (Residents 4 and 11). * The Pharmacy Consultant's recommendation to add blood pressure monitoring to the Diuril (diuretic) medication order in the MAR for Resident 11 was not acted upon. * The Pharmacy Consultant's recommendation to discuss with the primary physician to evaluate the need for the continuation of the Culturelle (supplement) medication, and to add the word for chronic use to the medication order if it was for chronic use was not acted upon for Resident 4. 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 Medication Regimen Review revised 5/2022 showed the goal of the MRR (Medication Regimen Review) is to promote positive outcomes while minimizing consequences and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 12 final sampled residents (Resident 9) were free from unnecessary psychotropic (any drug that affects brain activity) medications. * The facility failed to monitor episodes of crying inconsolably as one of the behavior manifestations for Risperdal (antipsychotic) medication for Resident 9. The facility failed to ensure Resident 9's monthly behavior summary and monthly summary of the side effects monitoring were accurate related to the use of Risperdal medication. In addition, the facility failed to document the implementation of the non-pharmacological interventions prior to the use of the Risperdal medication. Furthermore, the facility failed to ensure there was a monthly summary of the side effects monitoring related to the use of the diazepam (sedative) medication. These failures had the potential for inaccurate behavior and side effects monitoring, and the physician not having the necessary…

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 staff implemented the proper storage, labeling, and disposal of medications in a safe manner. * The facility failed to dispose of the discontinued medications in Medication Room A. * The facility failed to ensure the medications administered orally were stored separately from the externally used medications inside Medication Cart A. These failures had the potential to result in the unsafe medication administration and cross-contamination of the medications. Findings: Review of the facility's P&P titled Medication Storage revised 5/2023 showed it is the policy of the facility to uphold all local, state and federal laws pertaining to the storage and destruction of medications used in this facility. Discontinued medication may be stored in the medication room for up to 90 days or expiration date should be reordered. 1. On 3/12/24 at 0952 hours, an inspection of Medication Room A was conducted with RN 5…

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 sanitary requirements were met in the kitchen as evidenced by: * The facility failed to ensure the expired and moldy food items in the refrigerator were discarded. * The facility failed to remove a bag of beef patties with freezer burns. * The facility failed to store a bag of sausage patties properly. * The facility failed to air-dry four cutting boards. * The facility failed to ensure the cutting boards were in sanitary condition. These failures had the potential for food broone illness. Findings: Review of the Diet Type Report dated 3/14/24, showed two of 19 residents in the facility received food prepared in the kitchen. 1. According to USDA Food Code 2022, Section 3-501.17, Ready to Eat, Time/ Temperature Control for Safety Food, Date Marking, showed refrigerated, ready-to-eat, time/ temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to implement an accurate antibiotic stewardship program. The facility failed to include the residents on long-term antibiotic in the surveillance listing for two of 21 final sampled residents (Residents 1 and 8). This failure posed the risk of inaccurately identifying residents met the indication of antibiotic use, and inappropriate antibiotic use. Findings: According to the CDC, unnecessary antibiotic use promotes development of antibiotic-resistant bacteria. Every time a person takes antibiotics, sensitive bacteria are killed, but resistant germs may be left to grow and multiply. Repeated and improper use of antibiotics is the primary cause of the increase in drug-resistant bacteria. Review of the facility's P&P titled Antibiotic Stewardship Program revised 1/2022 showed the following: - The IP will be responsible for infection surveillance and MDRO (multi-drug resistance organism) tracking; - 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 care and services to attain or maintain the highest practicable well-being for one of six sampled residents (Resident 1). * The facility failed to ensure the licensed nurse used the approved devices to locate Resident 1's vein during the blood draw as per the facility's P&P. Resident 1 sustained a blister to the left foot from the licensed nurse's LED (light emitting diode) flashlight used during the blood draw. This failure had the potential to negatively impact the resident's well-being. Findings: Review of the facility's P&P titled Phlebotomy revised May 2022 showed phlebotomy (procedure in which a needle is used to take blood from a vein, usually for laboratory testing) is a nursing responsibility. If vein is not visible, see Ultrasound Guided Vein Localization policy. Review of the facility's P&P titled Ultrasound Guided Vein Localization revised May 2022 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.