Orange Healthcare & Wellness Centre, LLC

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 medications were available, administered, and accounted for appropriately for one of five final sampled residents reviewed for unnecessary medication (Resident 116) and for one of two IV E-kit medication kits. * Resident 116's insulin was not available to be administered as ordered. * The facility failed to ensure the IV E-kit in Medication Room A was replaced timely. * The facility failed to ensure the IV E-kit pharmacy log in Medication Room A was accurately completed when accessed by RN 1. These failures resulted in medication not being available to be administered to the residents as well as inaccurate accounting of the emergency medication supply. Findings: 1. Review of the facility's P&P titled Provider Pharmacy Requirements revised January 2025 showed the pharmacy will provide timely services 24 hours a day, seven days a week. All new medication orders will be available…

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, facility P&P review, and facility document review, the facility failed to ensure the menu was followed for two nonsampled residents. * The menu spreadsheet was not followed for Resident 62's CCHO (Consistent Carbohydrate Diet/Controlled Carbohydrate) diet. * Resident 68 did not receive a salad listed on the lunch menu. These failures posed the risk for the residents who received food prepared in the kitchen to not have their nutritional needs met.Findings: Review of the facility's document titled Diet Type Report dated 1/6/26, showed 77 out of 85 residents received food from the kitchen. Review of the facility's P&P titled Therapeutic Diets dated 6/1/2014, showed therapeutic diets are diets that deviate from the regular diet and require a physician order. Per the physician order, therapeutic diets are planned, prepared and served in consultation with the dietitian. Therapeutic diets are reflected on the menu extension. Review of the facility's document titled Winter Menus 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 observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to ensure one of one final sampled resident (Resident 100) reviewed for hospice services attained and maintained their highest practicable well-being. * The facility failed to ensure the hospice visit calendar was available in Resident 100's medical record. * The facility failed to integrate Hospice A's plan of care into Resident 100's care and failed to accurately reconcile the physician's orders. These failures posed the risk of the delay in the communication and provision of hospice care between the hospice provider and facility.Findings: Review of the facility's P&P titled Hospice Care of Residents dated 1/1/12, showed if the resident and/or surrogate decision maker decides to utilize hospice care, attending physician will be contacted to make final determination. The hospice and facility will collaborate on a care plan for the residents. Facility and hospice staff…

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 failed to provide the reasonable accommodations to meet the care needs for two of 13 sampled residents (Residents 2 and 3). * The facility failed to ensure Residents 2 and 3's call lights were answered in a timely manner. This failure had the potential to negatively impact the resident's psychosocial well-being or result in a delay to provide care and services to the residents.Findings: Review of facility's P&P titled Communication-Call System dated 1/1/2012, showed the facility will provide a call system to enable residents to alert the nursing staff from their rooms. The nursing staff will answer the call bells promptly, in a courteous manner. In answering to request, the nursing staff will return to resident with the item or reply promptly. a. On 8/28/25 at 0925 hours, during the initial tour of the facility, an observation and concurrent interview for Resident 3 was conducted with CNA 1. Resident 3's call light was turned on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to maintain an accurate and complete medical record for two of 13 sampled residents (Residents 12 and 13). * The facility failed to ensure the licensed nurses documented their initials on Residents 12 and 13's TARs (indicating the treatments were provided) as per the facility's P&P. This failure had the potential for the residents' care needs not being met as their medical record information was inaccurate and/or incomplete.Findings: Review of the facility's P&P titled Completion and Correction revised 1/1/2012, showed the facility will work to complete and correct medical records in a standardized manner to provide the highest quality and accuracy in documentation. The facility will ensure the medical records are complete and accurate. Entries will be recorded promptly as the event occurs. 1. Medical record review for Resident 12 was initiated 8/29/25. Resident 12 was admitted to the facility on [DATE]. Review of 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 the infection control practices were observed. * LVN 1 failed to follow the EBP infection control practices while performing the wound care for Resident 1. * LVN 2 failed to follow the infection control practices on wearing PPE in the hallway. These failures posed the risk for transmission of disease-causing microorganisms and infections.Findings: Review of the facility's P&P titled Enhanced Barrier Precaution dated 5/28/24, showed it is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. The facility will have the discretion on how to communicate to staff which residents require the use of EBP, as long as staff are aware of which residents require the use of EBP prior to providing high-contact care activities. EBP are indicated for residents with any of the following: wounds (e.g., chronic wounds such as pressure…

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 follow the abuse protocol during the facility investigation process for one of eight sampled residents (Resident 1). * The facility failed to suspend CNA 1 from work when Resident 1 reported an allegation of physical abuse against CNA 1 on 6/17/25. This failure had the potential to place Resident 1 and other residents at risk of not being protected against the alleged abuser. Findings: Review of the facility's P&P titled Reporting Abuse revised 1/8/14, showed upon an allegation of abuse by a facility staff member, the facility staff member will be suspended and removed from the premises during the investigation. On 6/17/25, the CDPH, Licensing and Certification Program received a report from the facility regarding Resident 1's allegation of physical abuse by CNA 1. Medical record review for Resident 1 was initiated on 6/26/25. Resident 1 was admitted to the facility on [DATE], and readmitted to the facility on [DATE].…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to maintain the infection control program and practices to help prevent the development and transmission of diseases and infections. * Treatment Nurse 1 failed to perform hand hygiene before providing the wound care treatment to Resident 2. * Treatment Nurse 2 failed to perform hand hygiene before providing the wound care treatment to Resident 1. * CNA 1 failed to perform hand hygiene and change her gloves in between tasks and before accessing the clean linen cart. These failures had the potential for transmission of disease-causing pathogens and infections. Findings: Review of the facility's P&P titled Hand Hygiene (undated) showed the facility staff are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare associated infections and facility staff follow the hand hygiene procedures to help prevent the spread of infections to other staff, residents,…

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 to prevent UTI for two of two sampled residents (Residents 1 and 2) reviewed for catheter care. * The facility failed to ensure proper positioning of Residents 1 and 2' s urinary drainage bag to prevent urine from flowing back into the residents' bladder. * The staff member failed to monitor or assess the color of Resident 2's urinary output. These failures posed the risk for Residents 1 and 2 to develop CAUTI. Findings: Review of the facility's P&P titled Care of Catheter revised 6/10/21,showed the residents with Foley catheters will be cared for utilizing the most current CDC Guidelines to prevent Urinary Tract Infections. Nursing Staff will assess urinary drainage for signs and symptoms of infection, noting cloudiness, color, sediment, blood, odor, and amount of urine. The catheter tubing, bag or spigot will be anchored to not touch the floor. The catheter 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, facility document review, and facility P&P review, the facility failed to provide thorough investigation and reported the results of the investigations for the allegation of possible financial abuse from the resident's family member to the CDPH, L&C Program within five working days of the incident for one of two sampled residents (Resident 2). This posed the risk for potential abuse to remain unidentified and for Resident 2 to go unprotected. Findings: Review of the facility's P&P titled Abuse - Reporting & Investigations revised 3/2018 showed in part, the facility promptly reports and thoroughly investigates all allegations of resident abuse, mistreatment, neglect, exploitation, abuse facilitated or enabled by the use of technology, misappropriation of resident property, or injuries of an unknown source, and suspicion of crimes. XII. Providing State Survey Agency and Other Agencies of the Results A. The Administrator will provide a written report of the results of all…

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 complete the assessments, attempt the least restrictive alternative measures, obtain the physician's orders and informed consents, and initiate care plans for the use of side rails for five of six sampled residents reviewed for side rail use (Residents 45, 47, 64, 78, and 601). This failure had the potential to put the residents at risk for serious injuries. Findings: Review of the facility's P&P titled Bed Rails revised 5/2024 showed the facility will use bed rails as mobility enablers. Prior to the use of a bed rail, staff will attempt the use of appropriate alternatives. If the alternatives were not adequate to meet the resident's needs, the resident will be evaluated for the use of bed rails. Prior to the installation of bed rails, alternatives will be attempted. An evaluation of the tried alternatives and how they failed to meet the Resident's needs will be documented in the medical record. Prior to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure proper medication storage in three of three medication storage rooms inspection when: * The facility failed to ensure the discharged resident's syringes with needles were discarded and removed from Medication room [ROOM NUMBER]. * Four bottles of lactulose (medication to treat constipation) solution was stored next to 30 lidocaine patches in Medication room [ROOM NUMBER]. * The temperatures for three of three medication room refrigerators used to store medications in Medication rooms [ROOM NUMBER] were out of range. These failures had the potential for the residents to receive ineffective medication dosages and negatively impact their well-being. Findings: Review of the facility's P&P titled Medication Storage in the Facility dated 8/2014 showed the following: - Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure…

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 food safety and sanitation guidelines were followed when: * A food preparation sink did not have a backflow prevention. * A rack used to dry plate covers was not clean. * Resident 64's room was observed with perishable food items brought from the outside. These failures posed the risk for cross contamination which could lead to food poisoning in the 83 residents who consumed food from the kitchen. Findings: Review of the facility matrix showed 83 of 93 residents consumed food from the kitchen. 1. According to the USDA Food Code 2022 Section 5-402.11 Backflow Prevention, (A) .a direct connection may not exist between the sewage system and a drain originating from equipment in which food, portable equipment, or utensils are placed. On 9/9/24 at 1140 hours, an observation of the plumbing of a food preparation sink located adjacent to the DSS's office and concurrent interview was conducted with the Maintenance Assistant. The drain pipe of the food preparation sink did not have backflow prevention.…

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 implement their infection control program and practices designed to provide a safe and sanitary environment to help prevent the transmission of communicable disease and infections. * The facility failed to maintain an accurate infection control surveillance program for the months of January 2024 through August 2024. The facility conducted surveillance only on the residents who exhibited signs and symptoms of an infection and were prescribed antimicrobial medications (medications used to treat infections). The facility failed to ensure the residents who exhibited signs and symptoms of an infection but were not prescribed antimicrobial medications were included in the facility's infection control surveillance log. The facility failed to ensure the Surveillance Data Collection Form was complete and accurate to determine whether the resident's infection met the McGeer's criteria for true…

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 document review, and facility P&P review, the facility failed to inform the physician of the residents prescribed antibiotics with signs and symptoms not meeting McGeer's Criteria (criteria used by long-term care facilities to determine a true infection) for one of 19 final sampled residents (Resident 87) and three nonsampled residents (Residents 59, 77, and 603). This failure had the potential risk for continued use of unnecessary antibiotics, potentially resulting in adverse reactions associated with antibiotics and the development of antibiotic resistant bacteria. Findings: According to the Centers for Disease Control and Prevention (CDC), antibiotics are among the most frequently prescribed medications in nursing homes, with up to 70% of residents in a nursing home receiving one or more courses of systemic antibiotics over a year. Studies have shown that 40-75% of antibiotics prescribed in nursing homes may be unnecessary or inappropriate. Harms from antibiotic overuse are significant for the frail and older adults receiving care in nursing homes.…

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' entrapment assessments were accurate, complete, and the measurements were recorded during the bed inspection when identifying areas of possible entrapment with the use of bed rails for six of six residents (Residents 45, 47, 63, 64, 78, and 601) who were reviewed for grab bar use. These failures had the potential to negatively impact the residents resulting in possible entrapment, serious injury, and death. Findings: According to the FDA's 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…

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 care was provided in a manner which promoted dignity and respect for one of four sampled residents (Resident 76) reviewed for the use of indwelling urinary catheter (flexible tube used to empty the bladder and collect urine in a drainage bag). The facility failed to ensure Resident 76's urinary catheter collection bag was inside the privacy bag. This failure had the potential to negatively impact Resident 76's emotional well-being. Findings: On 9/9/24 at 0849 hours, during the initial tour of the facility, Resident 76 was observed lying in bed with an indwelling urinary catheter draining yellow urine into a urine collection bag. The urine collection bag was observed hanging on the right side of Resident 76's bed, not inside the privacy bag. On 9/9/24 at 0853 hours, an interview and concurrent observation was conducted with CNA 2. CNA 2 verified the above finding. CNA 2 stated the urine collection bag should be inside 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 call light was within reach for three of 19 final sampled residents (Residents 16, 38, and 76) and two nonsampled residents (Residents 39 and 61). This failure had the potential to negatively impact the residents' psychosocial well-being or result in a delay to provide care and services to the residents. Findings: Review of the facility's P&P titled Communication-Call System revised 1/1/12 showed the facility will provide a call system to enable the residents to alert the nursing staff from their rooms and toileting/bathing facilities. Call cords will be placed within the resident's reach in the resident's room. 1. Medical record review for Resident 16 was initiated on 9/9/24. Resident 16 was admitted to the facility on [DATE], and readmitted on [DATE]. On 9/9/24 at 0800 hours, Resident 16 was observed with the call light clipped on edge of the head of the bed. When asked if she could reach the call…

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 provide the written information regarding the advance directives (legal document of a person's wishes regarding medical care when the person is no longer able to make medical decisions), and obtain and/or maintain copies of the advance directives in the medical records for five of 19 final sampled residents (Residents 17, 45, 76, 351, and 601). These failures had the potential for the residents' decisions regarding their healthcare and treatment not being honored. Findings: Review of the facility's P&P titled Advance Directive revised 7/25/24, showed upon admission, the admissions staff or designee will provide written information to the resident concerning his or her right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, and the right to formulate advance directives. During the Social Service Assessment process, the Director of Social Services or designee…

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 two of two residents reviewed for IV access (Residents 89 and 600). * The facility failed to ensure the PICC line external catheter measurements were performed and documented in the medical record upon admission for Resident 600. * The facility failed to ensure the IV antibiotic medication was properly labeled for Resident 89. These failures had the potential to delay the identification of catheter related complications for the residents. Findings: Review of the facility's P&P titled PICC Dressing Change dated 3/2023 showed in part, the length of the external catheter is obtained upon admission, during dressing changes, if signs or symptoms of complications are present. Documentation in the medical record includes but is not limited to date and time, site assessment, length of external catheter . 1. Medical record review 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 two of 19 final sampled residents (Residents 58, and 351) and three nonsampled residents (Resident 69, 75, and 352) were provided with the appropriate respiratory care when: * The facility failed to ensure Resident 58's oxygen nasal cannula (flexible tube to deliver oxygen into the nose) tubing was dated as per the facility's P&P and stored in a set up bag when not in use. * The facility failed to ensure Resident 351's nebulizer mask and tubing were stored in a set up bag when not in use. In addition, the facility failed to formulate a plan of care for the use of the nebulizer therapy. * The facility failed to ensure Resident 352's oxygen tubing was not touching the floor. * The facility failed to ensure Resident 75's nebulizer mask and tubing were stored in a set up bag when not in use * The facility failed to ensure Resident 69's CPAP mask was stored in a set up bag when not in use. These failures had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to offer or provide adequate and appropriate pain management for one of one resident reviewed for pain management (Resident 600). The facility failed to ensure Resident 600 was monitored for side effects related to the use of the narcotic pain medication. Additionally, the facility failed to consistently provide non-pharmacological interventions for pain prior to the administration of a narcotic pain medication to Resident 600. These failures had the potential for not effectively managing the resident's pain. Findings: Review of the facility's P&P titled Pain Management revised 11/2016 showed the facility staff will help the resident attain or maintain their highest level of well-being while working to prevent or manage the resident's pain to the extent possible. The nursing staff will also utilize non-pharmacological interventions to address possible issues contributing to pain. Residents receiving medications for pain…

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 ensure the pharmaceutical services were provided to meet the needs of the residents when: * The facility failed to ensure proper accounting and safeguarding of the controlled medications when the incoming and outgoing licensed nurses were not consistently signing the controlled count each shift for Medication Carts 1 and 3. This failure had the potential for drug diversion. Findings: Review of the facility's P&P titled Medication Storage in the Facility dated 8/2014 showed at each shift change, a physical inventory of all controlled medications, including the emergency supply is conducted by two licensed nurses and is documented on the controlled medications accountability record. Review of the facility's Narcotic Book Guide titled Using the Brigg's Narcotic Record Book dated 2/2021 showed the oncoming licensed nurse will perform a narcotic inventory count at the change of shifts with the off-going licensed nurse according to the facility's policy and procedure. The two…

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 one for five residents (Resident 17) reviewed for unnecessary medications was free from unnecessary psychotropic drugs. The facility failed to ensure Resident 17's orthostatic blood pressure was monitored as ordered by the physician related to the use of an antipsychotic medication. This failure had the potential for Resident 17 to have adverse complications from the medications. Findings: Review of the facility's P&P titled Behavior/Psychoactive Drug Management revised 1/25/24, showed when a resident is admitted with an antipsychotic medication(s), or a resident is prescribed an antipsychotic medication(s), the resident's orthostatic blood pressure is monitored weekly. Depending on the specific classification of psychoactive medication the resident should be observed and/or monitored for side effects and adverse consequences. All complications and side effects should be reported to the healthcare practitioner.…

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 the facility P&P review, the facility failed to ensure food preferences were honored for one nonsampled resident (Resident 30). Resident 30 disliked Brussels sprouts and preferred nonfat milk but was served Brussels sprouts and low fat milk for lunch. This had the potential to negatively impact the resident's well-being. Findings: Review of the facility's P&P titled Dietary Profile and Resident Preference Interview revised 4/21/22, showed resident preferences would be reflected in the medical record and tray-card and updated in a timely manner. The Dietary Department would provide residents with meals consistent with their preferences and physician order as indicated on the tray card. If a preferred item was not available, a suitable substitute should be provided. Medical record review for Resident 30 was initiated on 9/9/24. Resident 30 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 30's…

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

Based on observation, interview and facility P&P review, the facility failed to ensure the facility employees and visitors who brought food from the outside to the facility were educated on safe food handling practices. This failure posed the risk for residents who consumed food brought from the outside to be exposed to unsafe food handling which could lead to food borne illness. Findings: Review of the facility P&P titled Food Brought by Visitors revised June 2018, showed in part, B. Ensuring safe food handling once the food is brought to the facility, including safe reheating and hot/cold food holding, and handling of leftovers. On 9/10/24 at 853 hours, an interview was conducted with RN 2. RN 2 was asked how the facility ensured safe food handling practices were followed when the visitors brought food to the facility from the outside. RN 2 stated he was not sure how the facility ensured safe food handling practices were followed. RN 2 was asked if he had received education on safe food handling practices. RN 2 stated he could not recall if he received education on safe 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure essential kitchen equipment was maintained in proper working condition when: * The ice machine located in the kitchen was not clean and the manufacturer guidelines were not followed. * The walk-in freezer floor was not in a cleanable condition. * The facility failed to ensure the low air loss matress for Resident 69 was functioning properly. These failures had the potential for essential equipment to not function in the way it was intended. Findings: 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 the sight and touch. Review of the ice machine manufacturer guidelines (undated) located on the interior cover of the ice machine showed in part, Scale Removal and Sanitizing Instructions: .7. Mix a cleaning solution of one ounce ice machine scale remover [Scotsman Clear 1 ice machine scale remover] to 12…

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 visual privacy was provided for one of two non-sampled Residents (Resident 6) during care. This failure posed the risk of negatively affecting the resident's dignity. Findings: Review of the facility's P&P title Resident Rights revised 1/1/12, showed the employees are to treat all residents with kindness, respect and dignity and honor the exercise of resident's rights. State and federal laws guarantee certain basic rights to all residents of the Facility. These rights include, but are not limited to, a resident's right to: Privacy and confidentiality. Medical record review was initiated on 6/11/24. Resident 6 was initially admitted to the facility on [DATE] and readmitted [DATE]. Review of Resident 6's MDS dated [DATE], showed Resident 6 had a BIMS Summary Score of 15, indicating cognitively intact. On 6/11/24 at 1108 hours, an observation was conducted along the hallway a few feet away from…

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, facility document review, and facility P&P review, the facility failed to ensure the infection control practices were maintained. * The staff failed to perform hand hygiene during care for one of seven sampled residents (Resident 6) and one of two nonsampled residents (Resident 9). * The facility failed to label the basin found on top of a common dresser table found in room [ROOM NUMBER]. These failures had the potential to result in the spread of infection to the residents. Findings: Review of the facility's P&P titled Hand Hygiene Policy revised 9/1/20, showed the facility considers hand hygiene as the primary means to prevent the spread of infections. Hand hygiene means cleaning your hands by handwashing (washing hands with soap and water), antiseptic hand wash or antiseptic hand rub (i.e. alcohol based hand rub including foam or gel. Facility staff follow the hand hygiene procedures to help prevent the spread of infections to other staff, residents, volunteers and visitors.…

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 staff failed to immediately reported an allegation of abuse to the administrator, CDPH L&C Program, Long-Term Care Ombudsman, and local law enforcement within two hours after the allegation was made for one of nine sampled residents (Resident 7). This failure had the potential to delay the investigation of the alleged abuse and for staff to not take prompt and appropriate corrective actions to prevent the abuse. Findings: Review of the facility's P&P titled Abuse Reporting and Investigation revised 3/2018 showed allegations of abuse, neglect, mistreatment, exploitation, or reasonable suspicion of a crime to be reported to the administrator or designated representative immediately. Under the section notification outside agencies of allegation of abuse with no serious bodily injury…

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 two of five sampled residents (Residents 1 and 3) were provided the treatment and care in accordance with the professional standards of practice, comprehensive person-centered care plan, and resident choices. 1. The facility failed to ensure the medication administration was arranged when Resident 3 was out on pass. Resident 3's order for out on pass did not specify the length of time the resident could be out on pass as per the facility's P&P, nor was a care plan developed to address the out on pass process and how the resident's care needs would be met during the out on pass. 2. The facility failed to ensure Resident 1 received five scheduled evening medications, including Resident 1's insulin and antiseizure medication. These failures had the potential to cause harm to Residents 1 and 3. Findings: Review of the facility's P&P titled Medication - Administration revised January 2012 showed whenever a medication is…

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 personal property of four of 22 sampled residents (Residents 1, 2, 6, and 7) were protected from theft or loss. * The facility failed to ensure Residents 1, 6, and 7's personal items were labeled with the residents' names and includedin the residents' inventory lists. * The facility failed to show documented evidence of personal property was released to Resident 2 upon discharge. These failures had the potential for the residents' property to get lost or stolen. Findings: Review of the facility's P&P titled Personal Property revised 7/2017 showed during the admission process, the admissions staff will inform the resident/resident representative of the need to mark the resident's belongings with the resident's name and to notify nursing when additional items are brought to the facility so that they can be added to the resident's inventory list. Theadmissions staff will also inform…

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 ensurethe abuse allegation was reported to CDPH L&C Program for one of 22 sampled residents (Resident 5). Resident 5 reported a missing ID, debit card, and cash, and reported the debit card had fraudulent charges. This failure had the potential for the abuse allegation going unreported and uninvestigated. Findings: Review of the facility's P&P titled Abuse Reporting and Investigation revised 3/2018 showed under section Notification of Outside Agencies of Allegation of Abuse With No Serious Bodily Injury, the Administrator or designated representative will notify within two (2) hours, by telephone, to the CDPH, Ombudsman, and Law Enforcement; and the Administrator or designated representative will send a written SOC 341 report to the Ombudsman, Law Enforcement and CDPH, Licensing and Certification within two (2) hours. Medical record review for Resident 5 was initiated on 9/21/23. Resident 5 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, medical record review, facility document review, and facility P&P review, the facility failed to thoroughly investigate the abuse allegations for five of 22 sampled residents (Residents 1, 2, 3, 4, and 5). These failures posed the risk of Residents 1, 2, 3, 4, and 5 to not be protected against the alleged abuse and placed other vulnerable residents at risk for abuse. Findings: Review of the facility's P&P titled Abuse Reporting and Investigations revised 3/2018 showed when the Administrator or designated representative receives a report of an incident or suspected incident of resident abuse, mistreatment, neglect, abuse facilitated or enabled by technology, exploitation or injuries of an unknown source, or suspicion of a crime, the Administrator or designated representative will initiate an investigation immediately; and the administrator or designated representative conducting the investigation will interview individuals who may have information relevant to the allegation or suspected crime…

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 ensure five of 22 sampled residents (Residents 12, 17, 18, 19, and 20) were provided necessary care and services to meet their ADL care needs. The facility failed to provide showers to Residents 12, 17, 18, 19, and 20 as scheduled. This failure had the potential to negatively affect the resident's well-being and delay the detection of the new or worsening skin condition. Findings: Review of the facility's P&P titled Showering and Bathing revised 1/2012 showed a tub or shower bath is given to the residents to provide cleanliness, comfort and to prevent body odors, residents are given tub or shower baths unless contraindicated, and observe the skin is performed during bath. Under the section Procedure showed not limited to the following: - assist the resident into the shower chair, - transport the resident to the bath area, - assist the resident into the tub or shower and assist as needed, - take…

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 document review, employee file review, and facility P&P review, the facility failed to ensure one of five registry CNAs (CNA 16) was provided training on abuse before providing the necessary care and services to the residents at the facility. This failure had the potential to put the vulnerable residents at risk for abuse. Findings: Review of the facility's P&P titled Abuse Prevention, Screening & Training Program revised 7/2018 showed the facility conducts mandatory staff training programs during orientation, annually and as needed on the following: i. Prohibiting and preventing abuse, neglect, exploitation, misappropriation of resident property or mistreatment; ii. Identifying what constitutes abuse, neglect, exploitation misappropriation of resident property, or mistreatment; iii. Recognizing signs of abuse, neglect, exploitation, misappropriation of resident property and mistreatment; iv. Reporting abuse, neglect, exploitation, misappropriation of resident property, mistreatment, and injuries of unknown source, to whom and when to report and 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, facility document review, and facility P&P review, the facility failed to provide the pharmaceutical services to meet the residents needs. * The facility failed to ensure the administration of hydrocodone- acetaminophen (an opioid medication used for moderate to severe pain) for Residents 25, 28, and 51a were accurately documented to ensure accurate reconciliation and prevent the medication administration errors. These failures post the risk for loss or diversion of controlled medications. * The facility failed to ensure the incoming and outgoing licensed nurses assigned were consistently signed the Medication Cart A's controlled medication accountability record. This failure post the risk for loss or diversion of controlled medications. * The facility failed to ensure the glucometer for Medication Cart A was calibrated on a regular basis. The glucometer calibration logs had multiple missing entries. This posed the risk for inaccurate blood glucose test…

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, and facility document review, the facility failed to ensure food safety and sanitation requirements were met in the kitchen as evidenced by: * Multiple food items observed in the kitchen were unlabeled, undated, and had expired. * A section of the kitchen wall was damaged. These failures had the potential to cause food borne illnesses in the 82 medically vulnerable residents who consumed food prepared in the kitchen. Findings: Review of the CMS-672 Resident Census and Conditions of Residents completed by the facility dated 11/8/21, showed 82 of 88 residents residing in the facility received food prepared in the kitchen. 1. Review of the facility's P&P titled Food Storage dated 7/25/19, showed all items will be stored, thawed, and prepared in accordance with good sanitary practice. All items will be correctly labeled and dated. During the initial tour of the kitchen with the DSS on 11/8/21 at 0745 hours, the following items were found: * In the refrigerator, - a thawed chicken with the use-by date of 11/3/21. - three small plastic…

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 one of six nonsampled residents (Resident 52) was provided care in a manner that promoted dignity and respect. This failure posed the risk to negatively impact the resident's self-esteem. Findings: Review of the facility's P&P titled Restorative Dining Program dated 1/1/12, showed the staff members should sit while assisting or feeding residents. Medical record review for Resident 52 was initiated on 11/8/21. Resident 52 was readmitted to the facility on [DATE]. Review of Resident 52's MDS dated [DATE], showed Resident 52 required extensive assistance and physical assistance of one person for eating. On 11/8/21 at 1230 hours, a dining observation and concurrent interview with CNA 1 was conducted. CNA 1 was observed standing over Resident 52 while feeding the resident with a spoon. CNA 1 verified he was standing while assisting Resident 52 with lunch. CNA 1 stated they should not have been standing while feeding…

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 accommodate the needs for one of nonsampled residents (Resident 365). The facility failed to ensure Resident 365 was provided the appropriate type of call light and kept in within her reach. This failure placed the resident at risk for her needs to not be met. Findings: Medical record review for Resident 365 was initiated on 11/15/21. Resident 365 was admitted to the facility on [DATE]. Review of the plan of care showed a care plan problem dated 12/28/20, addressing Resident 365's risk for falls. Interventions included to remind the resident to use a call light and the use of a padded call light (used for residents who may have difficulty using standard call lights). On 11/8/21 at 1024 hours, during an initial tour of the facility, Resident 365 was heard yelling for help. Resident 365 was observed sitting in a wheelchair next to her bed. Resident 365's call light was observed tucked under the blankets on her wheelchair, out of her…

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 complete the admission, entry, and quarterly MDS assessments timely for three of 18 final sampled residents (Residents 25, 27, and 51a) and seven of 13 nonsampled residents (Residents 7, 37, 52, 700, 701, 702, and 703). This failure had the potential for the staff not identifying the residents' preferences and goals of care, functional and health status, strengths and needs. Findings: Review of the facility's P&P titled RAI OBRA Required Assessment Summary revised 10/13 showed the following: * For Assessment Type - admission: the MDS completion date is to be no later than the 14th calendar day from the resident's admission date. * For Assessment Type - Entry Tracking Record: the MDS completion date is to be no later than 7 calendar days from the entry date. * For Assessment Type - Quarterly: the MDS completion date is to be no later than 14 calendar days. On 11/10/21 at 1123 hours, review of the facility's MDS submissions…

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 accurate coding of the MDS for two of 18 final sampled residents (Residents 8 and 27). * For Resident 27, the MDS was coded inaccurately for RNA services. * The facility failed to ensure Resident 8's indwelling urinary catheter use was coded accurately. These failures posed the risk of the residents not receiving appropriate care interventions due to incorrect health assessments. Findings: 1. Medical record review for Resident 27 was initiated on 11/8/21. Resident 27 was admitted to the facility on [DATE]. Review of the Physician's Telephone Order showed an order dated 5/29/21, for RNA services to provide AROM (assisted range of motion) exercise to the right upper extremity five times per week. Review of the Restorative Nursing flowsheet dated 9/21, showed Resident 27 received AROM exercise on 9/1, 9/2, 9/3, 9/6, 9/7, 9/8, 9/9, and 9/10/21. Review of Resident 27's MDS dated [DATE], showed under the O - Restorative Nursing…

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 develop a care plan problem for one of 18 final sampled residents (Resident 8) and one nonsampled residents (Resident 365). * Resident 8 was assessed to have moisture-associated skin damage (MASD) problem; however, a care plan problem was not developed to address the MASD. This failure placed Resident 8 at risk of not having her care needs met. * Resident 365 was observed to have bruising to her right arm; however, a care plan problem was not developed and implemented to show the interventions to address the uncontrolled body movements. This failure caused Resident 365 to sustain bruising to her right arm due to her arms repeatedly hitting the sides of the wheelchair. Findings: 1. Review of Resident 8's medical record was initiated on 11/9/21. Resident 8 was admitted to the facility on [DATE]. Review of the Wound Assessment and Plan showed Resident 8 had a MASD. Review of the Physician Orders list showed an order dated 9/16/21, for perineum…

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 necessary care and services were provided to prevent the development and worsening of pressure injury for one of 18 final sampled residents (Residents 11). Resident 11 was on a low air loss mattress for wound management. The facility failed to ensure the low air loss mattress setting was consistently monitored to ensure the appropriate settings of the low air loss mattress for Resident 11. This failure could result in delayed wound healing for Resident 11 and development of new pressure injuries. Findings: According to the facility's P&P titled Mattresses revised 1/1/12, the facility will provide mattresses to provide pressure reduction to residents at risk for skin breakdown; and to check air mattress routinely to ensure it is working properly and record the use of the mattress and resident outcome in the medical record. Review of Resident 11's medical record was initiated on 11/8/21. Resident 11 was admitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to provide the necessary care and services for one nonsampled resident (Resident 365). This had the potential to increase the risk of injury to the resident. Findings: Medical record review for Resident 365 was initiated on 11/15/21. Resident 365 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], showed Resident 365 had severe cognitive impairment and needed assistance from the staff for her ADL care. On 11/8/21 at 1024 hours, Resident 365 was observed sitting in a wheelchair next to her bed. Resident 365 was observed to have uncontrolled body movements. Resident 365's arms were observed banging against the armrests of the wheelchair. Resident 365 was observed to have small red areas and bruising on her right forearm which was the same area observed hitting the arm of the wheelchair. Resident 365 stated, my arm hurts. On 11/8/21 at 1033 hours, a concurrent observation and interview was conducted with the DSD. 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 medical record review, the facility failed to provide the necessary care and services for one of 18 final sampled residents (Resident 25) with an indwelling urinary catheter. The facility failed to ensure Resident 25's urinary catheter drainage bag was changed weekly as ordered by the physician. This failure had the potential for complications related to indwelling urinary catheter use. Findings: Medical record review for Resident 25 was initiated on 11/8/21. Resident 25 was readmitted to the facility on [DATE]. Review of the MDS dated [DATE], showed Resident 25 had severe cognitive impairment. Resident 25 had an indwelling urinary catheter and needed extensive assistance with his ADL care. Review of the Physician Orders list for November 2021 showed an order dated 10/3/21, to place an indwelling urinary catheter for urinary retention and change the resident's urinary catheter drainage bag weekly. Review of the Resident's TAR for October 2021 and November 2021 failed to show…

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 respiratory care and services for two of 18 final sampled residents (Residents 22 and 515). * The facility failed to ensure Resident 22 was administered oxygen as ordered by the physician. * Resident 515 continued to receive oxygen when it had been discontinued by the physician. These failures had the potential for the residents to receive unnecessary supplemental oxygen. Findings: According to the facility's P&P titled Oxygen Therapy revised 4/1/12, showed to administer oxygen per the physician's orders. 1. Medical record review for Resident 22 was initiated on 11/8/21. Resident 22 was admitted to the facility on [DATE]. Review of the Resident 22's Physician Orders list for November 2021 showed the following orders dated 9/21/21: - Oxygen at 2 lpm continuously for shortness of breath/desaturation. - Monitor oxygen saturation level (oxygen level in the blood) every shift and may titrate oxygen from 3-4 lpm if…

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 appropriate pain management for one of 18 final sampled residents (Resident 25). * Resident 25's pain was not appropriately assessed, communicated to their charge nurse, and managed prior to wound care and catheter care treatments. In addition, Resident 25's pain was not being monitored and documented every shift. These failures could result in the resident's pain not being accurately monitored, assessed, and managed. Findings: Review of the facility's P&P tiled Pain Management revised November 2016 showed the facility will ensure the assessment and management of the resident's pain to the extent possible when such services are required. The licensed nurse will assess the resident for pain and document results on the MAR each shift using the 0-10 pain scale, the shift pain score will indicate the highest pain level that occurred on that shift. Nursing staff will implement timely interventions 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 one of 18 final sampled residents (Residents 34) was free from unnecessary psychotropic medications. * The facility failed to ensure Resident 34's episodes of behaviors for the use of risperidone (antipsychotic medication to treat certain mental or mood disorders) were summarized and made available to the prescriber on a monthly basis to serve as reference for gradual dose reduction. This had the potential of not providing the correct data to the prescriber in order to adjust the dose of the psychotropic medications for the residents. Findings: According to the facility's P&P titled Behavior/Psychoactive Drug Management dated 11/2018, under Procedure: III Evaluation showed monthly, the occurrence of behavior will be tallied and entered on the Monthly Psychoactive Drug Management Form in addition to any occurrences of adverse reaction. Review of Resident 34's medical record was initiated on 11/9/21.…

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 ensure the medications and biologicals were stored and disposed of properly. * The skin/wound solution bottles and medication drawer for Treatment Cart B had stains and sticky residues. This posed the risk for unsafe storage of medication that could result to cross-contamination of the solutions. * The facility failed to ensure the refrigerator temperatures were checked and maintained within the acceptable range daily for two of three medication rooms (Medication Rooms A and B) Medication Room B's refrigerator temperature log had multiple missing entries. Medication Room A's refrigerator temperature log showed the temperatures below the acceptable range without the follow-up actions to correct the out-of-range temperatures. These had the potential to affect the potency of the medications requiring storage at room temperature or refrigeration. Findings: 1. According to the facility's P&P titled Storage of Medications dated 8/1/10, under the section Procedures showed outdated,…

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 accurate and complete medical records for six of 18 final sampled residents (Residents 4, 8, 11, 22, 25, and 51a). * Resident 22's supplemental oxygen use was not documented in the resident's MAR. * Resident 4's colostomy bag change scheduled for every three days was not documented in the medical record. * Resident 51a's urinary drainage bag weekly changes were not documented in the medical record. * Residents 25's urinary drainage bag weekly changes were not documented in the medical record. In addition, Resident 25's pain medication dose was handwritten over without clarification. * Residents 8 and 11's monitoring for the low air loss mattress setting in the TAR had missing multiple entries. These failures had the potential for the residents' care needs not being met as their medical information was inconsistent in the medical record. Findings: 1. Medical record review for Resident 22 was initiated on 11/8/21.…

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 ensure one of 18 final sampled residents (Resident 35), one nonsampled resident (Resident 26), and one staff member were offered or received the influenza or pneumococcal vaccine (an injection given to protect from severe pneumococcal disease) as per the facility's P&P. This failure put the residents and staff at risk for poor health outcomes. Findings: Review of the facility's P&P titled Influenza Prevention & Control revised 9/10/20, showed the following: * Vaccinating Residents Against Influenza: - The resident or representative must give consent prior to receiving the vaccine. They can refuse the immunization - with such refusal being noted in the resident's medical record. * Vaccinating Facility Staff Against Influenza: - Employees are offered the influenza vaccine upon hire or during the annual flu season. - The vaccination will be documented in the employee's health record. - The employee…

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.