Oroville Hospital Post-Acute Center

Based on interview and record review, the facility failed to ensure one out of five sampled residents (Resident 12) was free from unnecessary medications when the required psychotropic (a medication that altered the brain) medication informed consent form was not renewed every six months as required.This failure had the potential to compromise Resident 12's ability to maintain their highest practicable mental, physical, and psychosocial well-being.Findings: A review of the facility's undated policy and procedure titled, Informed Consent for Psychotropic Drugs, indicated the facility would follow Federal and State regulations regarding informed consent when the Physician prescribed a psychotropic medication. A review of the All Facilities Letter (an official document that notified facilities of changes to regulations), dated 10/7/25, indicated psychotropic informed consent forms were required to be renewed every six months. A review of Resident 12's admission Record, dated 11/3/20, indicated admission the facility on 11/3/20 with the diagnoses of chronic (long lasting) pain and major…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to protect one of ten sampled residents (Resident 2) when: 1. Registered Nurse (RN) B willfully took the bed remote from Resident 2 and hid it out of reach.2. RN B willfully shut the door while Resident 2 was yelling for help. 3. RN B willfully left Resident 2 in isolation and neglected to provide services needed. This failure caused involuntary seclusion (isolation) to Resident 2, and the potential for emotional distress, and a fall.Findings: During a review of the facility's policy revised 7/15/21 titled, Abuse, Neglect, Exploitation, and Misappropriation of Resident Property Prohibition, indicated each resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. Each resident also has the right to be free from mistreatment, neglect and misappropriation of property. The definition of abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow the care plan for one of three residents (Resident 1) when Resident 1 was left unattended in his room when a hospitality aide (HA - someone hired by the facility to provide non-medical assistance to residents, focused on their comfort, safety, and well-being) took a break and left Resident 1's room. This failure had the potential to result in physical and/or psychosocial harm to other residents when Resident 1 eloped (unsupervised wandering) from his room and entered Resident 2's room. Findings: A record review of facility job description titled Job Description for Hospitality Aide dated 4/1/22 indicated HAs must demonstrate the ability to .understand, plan and carryout resident care plans. A record review of facility policy titled Care Plans (undated) did not indicate any policy related to developing, implementing or following resident care plans. A record review of Resident 1's admission Record indicated he was admitted to the facility 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, and record review, the facility failed to provide five residents (Residents 2, 14, 73, 130, 292) out of a sample of 32 with the bed hold agreement in writing when residents were transferred out of the facility to a hospital or for therapeutic leave. This failure had the potential for residents to be unaware that, for a period of up to seven days after the transfer, the facility must readmit them when the resident is ready to return, and that the resident has only a 24-hour window in which to inform the facility that they intend to return. Findings: A facility document titled, California Standard admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities, undated, was reviewed. The document is a collection of information provided to residents when they are admitted to the facility. Contained in the document is the facility's bed hold policy which outlines that they will hold a resident's bed for seven days upon transfer to a hospital, and that the resident has 24 hours…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete the Comprehensive Minimum Data Set (MDS, a standardized resident assessment) for 12 of 29 sampled residents (Residents 41, 44, 7, 87, 73, 27, 55, 96, 100, 291, 293, and 294) when MDS assessments were not completed within 14 days. These failures had the potential to delay the development of a comprehensive care plan necessary to provide the appropriate individualized care and services for Resident 44 and 41 related to the care areas identified on the Comprehensive MDS. Findings: The Resident Assessment Instrument (RAI) Manual gives clear guidance about how to complete the MDS. According to the RAI, Chapter 2 page 9, Assessment completion refers to the date that all information has been collected and recorded for the particular assessment type and staff have signed and dated that the assessment is complete. Page 10 indicated that Comprehensive MDS assessments include Annual Assessments. Page 17 indicated that the Annual assessment completion…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure seven of twenty-nine sampled residents (Resident 5, 334, 23, 29, 73, 291, and 46) received the necessary treatment and services to maintain ADL's (activities of daily living). when: 1. Resident 5's lunch tray was not set up by staff and therefore she was unable to eat. 2. Resident 334's fingernails were long with black matter underneath them. 3. Resident 23 stated, staff did not assist with oral care or hair brushing unless Resident 23 asked for help. 4. Resident 29's hair was tangled. 5. Resident 73's mucus membranes (the moist, inner lining if the mouth) were dried and contained a thick, white, debris that was attached to the roof of the mouth and the tongue. 6. Resident 291 didn't receive consistent oral care. 7, Resident 46 didn't receive consistent oral care. This deficient practice had the potential for the residents to decline in their abilities to achieve the resident's highest practicable well-being and quality of life.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for two out of 29 sampled residents (Residents 44 and 5) when: 1. Coccyx (the skin over the tailbone) treatments were not provided for Resident 44 who had Moisture Associated Skin Damage (MASD, skin breakdown caused by prolonged expsure to moisture). This failure had the potential for Resident 44's health and wellbeing to decline and her skin redness to worsen. 2. The facility failed to ensure consistent assessments of a skin condition for Resident 5. This failure had the potential for a change in condition to go unattended, with possible negative health outcomes for Resident 5. Findings: During a review of the facility's policy and procedure (P&P) titled Skin Integrity (undated), the P&P indicated, In an effort to maintain the resident's optimal level of skin integrity and promote healing of skin . wounds, the Center has a systematic approach and…

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

Based on observation, interview, and record review, the facility failed to implement downtime policies and procedures (P&P) when there was an internet outage on 12/13/24. This failure caused an inability for facility staff to access the residents electronic medical record (EMR) and could cause a delay in resident care needs. Findings: A review of the undated P&P titled, Downtime Access to Patient Records, indicated, Each day HER Support will run and save a copy of the 24 Hr. Summary. The P&P indicated, Staff members will have access to the downtime folder and will be able to pull up the 24 Hr. Summary for review or print out hard copy. The P&P indicated, In the event of a network outage or scheduled network maintenance, staff will be able to access the EMR system (Point Click Care) by using a jetpack device to connect to wireless network. We will then activate emergency access protocol to allow staff to access the EMR remotely. During a concurrent observation, located at the East Wing nurses' station, and interview on 12/13/24 at 7:11 am, unidentified staff members were observed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility had a 27.59% medication error rate when eight medication errors out of 29 total opportunities were observed during medication passes for two out of six sampled residents (Residents 73 and 184). These failures had the potential to compromise the resident's health status. Findings: A review of the facility's policy and procedure (P&P) titled, Medication Administration, dated 1/1/07, indicated, medication would be administered utilizing good nursing principles and in accordance with physician orders. A review of the undated Admissions Record indicated, Resident 73 was admitted to the facility on [DATE] with the diagnoses of dysphagia, oropharyngeal stage (swallowing difficulty that occurred in the mouth or throat), dementia (memory loss), and gastrostomy status (surgical opening into the stomach, [peg-tube also called g-tube, that delivered liquid nutrition and medication]). Resident 73 was not her own responsible party (did not make own decisions). A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to store and label drugs in accordance with professional standards when: 1. The label attached to a medication container did not match the Physician's order. 2a. The freezer section, located in the medication refrigerator, of the [NAME] Wing medication storage room, contained ice build up and had icicles hanging from the freezer. 2b. An e-kit, (emergency medication) that was in the medication refrigerator of the [NAME] Wing medication storage room, was placed inside a tray like container that contained ice and clear liquid. 3. The medication cart, located on the [NAME] Wing, contained 2 unlabeled medication cups, each containing resident medication, and a pill cutter (a device that was used to cut pills in half) that was covered in residual pill powder. 4. The e-kit, located in the East Wing medication room contained two vials of liquid Ativan (a controlled substance that was used to treat anxiety disorders) was expired (not to be used). 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 observations, interviews and record reviews, the facility failed to ensure staff were trained, competent and following their training when: *1. The kitchen was not sanitary. *2. Staff did not consistently perform standards of professional practice to prevent cross contamination. *3. Staff did not consistently complete or document ambient food cooling temperature checks. *4. Pureed fish did not have a palatable consistency. Findings: Review of an undated document titled New Hire - OHPAC Dietary Employee Orientation Checklist showed that upon hire new employees are trained in 24 different topics, including dress code (jewelry, hair covering, aprons), proper use of aprons, equipment cleaning. Review of employee training files showed these staff completed the training: Kitchen Staff I (KS I) on 4/4/24, and KS K on 4/4/24. Review of a document titled Annual - OHPAC Dietary Employee Orientation Checklist showed 24 topics assessed, such as handwashing and glove use, dress code, apron use, cleaning equipment, cleaning and pest prevention, and monitoring tray line temperatures was…

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

Based on observation, interview and record review the facility did not follow a preplanned standardized menu cycle or cooks spreadsheets for vegetarian meals, and had the potential to not meet the nutritional needs of vegetarian residents. Findings: A review of the Facility Assessment (explains what types of patients/residents a facility will accept and services it will provide) dated 1/31/24 and signed by the Executive Director (Administrator), Director of Nursing (DON), Medical Director, and Governing Body Representative showed We as a facility, make sure we have the staff to meet the unique needs of the individuals at all times. Part 2 Services and Care We Offer Based on our Residents' Needs showed Nutrition - Individualized dietary requirements, liberal diets, specialized diets, tube feeding, cultural or ethnic dietary needs, assistive devices, fluid monitoring or restrictions. A review of the California Health and Safety Code Section §1265.10 showed Availability of plant-based meals: (a) A licensed health facility, as defined in subdivision (a), (b), (c), (d), (f), or (k) of…

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

Based on observation, interview, and record review the facility failed to ensure food was served at an appetizing temperature when four out of twenty nine residents interviewed (Resident 29, 44, 54, 284) stated the food was cold. This failure had the potential to result in decreased resident meal intakes, weight loss, and decline in health status. Findings: During an observation and concurrent interview with KS J on 12/11/24 at 10:00 am he stated he checked his steam table temperatures daily to ensure they were 150°F to 160°F. In a later review of a recipe titled Recipe: Pureed (IDDSI Level 4) Meats dated 2024, it showed Serve on trayline at the recommended temperature of 160°F to 180°F. During an interview conducted on 12/10/24 at 10:16 am, Resident 29 stated the food was terrible. A review of Resident 29's diet orders showed a 4/15/2024 order for regular fortified (extra nutrients added) mechanical soft texture (soft and easy to chew) diet. On 11/27/2024, a calorie dense nutritional supplement 120ml two times a day between meals was added to improve nutrition intake. During an…

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

Based on observation, interview, and record review the facility failed to ensure six resident's (Resident #70, #288, #334, #336, #338) individual texture needs were met when the food consistencies provided did not meet facility diet manual standards or resident preferences. This failure had the potential to result in resident's inability to consume their food resulting in decreased intakes and decline, or to potentially result in choking and death. Findings: Parsley Garnish: Review of the cook's spreadsheets titled Winter Menus, Week 2 Wednesday, dated 12/11/24 showed pureed and mechanical soft diets were to receive parsley flakes as garnish rather than whole parsley sprigs (to reduce risk of choking). Review of the facility diet manual, approved by the facility Registered Dietitian (RD) and Medical Director on 8/24/23 provided this description of the regular pureed diet: The pureed diet is a regular diet that has been designed for residents who have difficulty chewing and/or swallowing. The texture should be of a smooth and moist consistency and able to hold its shape. Under foods…

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

Based on observation, interview, and record review, the facility failed to maintain professional standards of practice to ensure food service safety for the residents of the facility when: 1. The kitchen was not sanitary. 2. Kitchen staff did not follow professional standards of practice to avoid cross contamination in food production processes. 3. Ambient food cool down process was not performed consistently when indicated. 4. There was not an effective process in place for management of dented cans. 5. Three out of three nursing unit nourishment rooms were not sanitary. 6. Chemicals that were not food-safe were used to clean food contact surfaces in nursing unit nourishment rooms. These failures had the potential to spread infection and cause food borne illness for residents consuming food in the facility. An event of food borne illness has the potential to cause a resident' decline or even death. Findings: 1. The kitchen was not sanitary. Review of the 2022 Food and Drug Administration (FDA) Food Code 4-601.11 showed A) Equipment food-contact surfaces and utensils shall be clean…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure sanitary food storage for resident's personal food in three out of three nursing unit nourishment rooms. Resident food stored in the freezer were not labeled with patient identifiers (name, room number and date) to ensure the correct patient received their personal food items. These failures had the potential to cause foodborne illness and decline in residents, and to decrease resident's quality of life if personal foods were discarded or given to someone else due to lack of labeling. Findings: Review of an undated facility policy titled Food for Residents from Outside Sources showed staff were to label residents personal food with their name and the date received. Disposal dates depended on the type of food, storage requirements, opened or unopened, etc. It stated the facility would not heat food from home for residents. Review of the 2022 FDA (Food and Drug Administration) Food Code 4-601.11 showed A) Equipment food-contact…

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

Based on interview and record review, the facility failed to ensure Quality Assessment and Performance Improvement (QAPI - a data driven proactive approach to improvement used to ensure services are meeting quality standards) was utilized effectively for identifying and resolving deficiency related to timely complete residents' assessment for 13of 29 sampled residents (Residents 41, 44, 7, 87, 73, 14, 27, 55, 96, 100, 291, 293, and 294). This failure had the potential to inaccurately reflect the data relative to the residents' health status, and delay the developments of a comprehensive, individualized care plan for the residents. Refer to F 636 Findings: During a review of the facility's policy titled, Quality Assessment and Performance Improvement, no revised date provided, indicated: a. The Goals of the QAPI committee is to: - Help identify actual and potential negative outcomes relative to resident care and resolve them appropriately. - Support the use of root cause analysis to help identify where patterns of negative outcomes point to underlying systematic problems. - Help…

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

Based on interview and record review, the facility's Quality Assessment and Assurance (QAA) committee failed to development and implement appropriate plans of action to correct identified deficiency related to infection control. As a result, deficient practices were present regarding infection control that had the potential to affect the safety and quality of care provided to residents. Refer to F 880. Findings: During a review of the facility's policy titled, Quality Assessment and Performance Improvement, no revised date provided, at the section of QAPI program, indicated: a. Design and scope: Goals, targets and benchmarks are established and measured based on the best available evidence. b. Governance and leadership: - Input is sought from facility staff, residents, family members and individuals who are involved in the care of residents. - Resources are allocated to conduct QAPI efforts. - Feedback, data systems and monitoring c. Systems are in place to monitor care and services: - Systems are designed to incorporate feedback from caregivers, residents, family, and staff as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure effective infection control practices when: 1. Facility staff did not perform hand hygiene during meal service. 2. Nursing unit resident nourishment rooms were not sanitary. (Refer to F812, F813, F925.) 3. Chemicals that were not food-safe were used to clean food contact surfaces in nursing unit nourishment rooms Refer to 812. 4. The RNA (Resource Nursing Assistant) Room was unsanitary and had live cockroaches. Refer to F925. 5. Resident 8's CPAP (continuous positive airway pressure-a breathing machine designed to increase air pressure, keeping the airway open when the person breathes in) and Nebulizer (a small machine that turns liquid medicine into a mist that can be easily inhaled) mask had white and brown spots throughout the masks and oxygen tubing on the floor where a bug was crawling. 6. A bed pan was stored under a resident's bed for her use. 7. Certified Nurse Assistant (CNA) didn't follow infection control policy while…

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 review the facility failed to ensure they maintained an effective pest control program when: 1. An unidentified bug was seen crawling in resident room [ROOM NUMBER]. 2. Cockroaches were seen crawling around in the Restorative Nursing Assistant (RNA)room (the dining room that Residents eat in which includes a small kitchen area). This failure had the potential to cause a health hazard to the residents and did not honor their right for a homelike environment. Findings: During a review of the facility's policy titled Pest Control (undated), the policy indicated The facility is committed to implementing an effective pest control program in compliance with federal, state and local regulations. The purpose of the policy was To maintain a safe and healthy environment for residents, staff and visitors by preventing, identifying, and addressing pest infestations within the skilled nursing facility. 4. Preventive Measures . The maintenance Department will . Maintain…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility to address resident's grievance of staff going through resident's personal belongings without resident's permission for one of eight sampled residents (Resident 183). This deficient practice had the potential for Resident 183's grievance to go unnoticed, causing anger and distress to the resident; and had the potential to result in a delay of care and services. Findings: During a review of the facility's policy titled, Grievance Procedure, no revised date provided, indicated: a. Residents have the right to voice grievances without discrimination or reprisal and without fear of discrimination or reprisal. b. At admission, the patient or patient Responsible Party (RP) informs the Resident/Resident's Authorized Representative about their right to voice grievances orally, in writing, and anonymously regarding the care and treatment/lack of treatment, behavior of staff and of other residents, and other concerns during their stay. c. The Executive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a written notice of transfer or discharge for one of three residents (Resident 292) (or resident representee, RP) was provided to Resident 292 and to the office of the State Long-Term Care (LTC) Ombudsman (a person who investigates and helps resolve complaints for residents) when they were sent to the hospital for emergency care. This failure had the potential to result in the lack of coordination of support for Resident 292 during discharge planning. Findings: A review of the facility's policy titled Attachment F: Resident [NAME] of Rights (undated) indicated on page 26 -27 that before a facility transfers or discharges a resident, the facility must-notify the resident and, if known a, a family member or legal representative of the resident of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The written notice must include the following: a. The reason for the transfer or discharge,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete the Quarterly Minimum Data Set (MDS, a standardized resident assessment) withing 92 days of the previous assessment for two of nine sampled residents (Resident 57 and 8). This failure had the potential to delay the development of a comprehensive care plan necessary to provide the appropriate individualized care and services for Resident 57 and Resident 8 related to the care areas identified on the MDS. Findings: The Resident Assessment Instrument (RAI) Manual dated October 2024, gives clear guidance about how to complete the MDS. According to the RAI, Chapter 2 page 9, Assessment completion refers to the date that all information has been collected and recorded for the particular assessment type and staff have signed and dated that the assessment is complete. Page 35 indicated that Quarterly MDS assessments completion date (item Z0500B) must be no later than 92 days from the previous assessment (previous assessment date +92 calendar days). The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Level 1 Preadmission Screening and Resident Interview (PASARR, an assessment that screened individuals with a mental disorder or intellectual disability to determine if admission to the facility was appropriate) was inaccurate for one out of three sampled residents (Resident 87) when: 1. The Level 1 PASARR was missing the diagnosis of bipolar (extreme mood swings). 2. The Level 1 PASARR included the diagnosis of dementia (memory loss). This failure had the potential for newly admitted residents to be admitted to the facility without knowing if they had a mental disorder or if the facility could provide services that met their needs. Findings: 1. A policy and procedure that outlined the admission PASARR process was requested and not provided. A review of the State Operations Manual, dated 8/8/24, indicated, the PASARR screening process was To ensure each resident in a nursing facility is screened for a mental disorder (MD) or intellectual…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement an individualized patient-centered care plan for one of twenty-nine sampled residents (Resident 288) when: a care plan was not developed for significant weight loss for Resident 288. As a result, Resident 288, who was identified as malnourished at admission, had a weight loss of 11 pounds or 6.24 % in 2 weeks. This failure had the potential to contribute to the risk of further weight loss and decline for Resident 288. Findings: During a review of Resident 288's clinical record, indicated she was originally admitted to the facility on [DATE]. Resident 288 had been in and out of the acute hospital and readmitted back to the facility from times to times in between 8/5/23 to 11/9/24. The most recent re-admission date to the facility was 11/9/24, the admission diagnoses included disruption of external operation (surgical) wound, difficulty in walking, and severe protein-calorie malnutrition (diagnosed on [DATE]). Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide one out of 32 sampled residents (Resident 73) with professional standards of care when Licensed Nurses (LN) utilized a DeClogger (a long, thin, flexible, piece of plastic with a jagged end that was used to de-clog peg-tubes) on Resident 73's peg-tube (a tube that was inserted into the abdomen and delivered liquid nutrition directly into the stomach). There was no Physician's order, no monitor in place that tracked how often LN utilized the DeClogger, and there was no care plan (a document that described the care a resident needed and how that care would be provided). This failure had the potential for peg-tube malfunctions to go unnoticed and could lead to a decline in resident health status. Findings: A policy and procedure (P&P) regarding peg-tube care was requested and not provided. The P&Ps that were provided related to administering medications and feeding via the feeding tube. A review of the Job Description for LVN, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure appropriate care was provided to prevent urinary tract infections (UTI's, a clinically detectable condition associated with invasion by disease causing microorganisms [germ] of some part of the urinary tract) for one of 29 sampled residents (Resident 44) when Certified Nursing Assistances did not do complete and proper peri-care (the process of washing the genital and anal areas) after incontinent episodes. This deficient practice had the potential to cause UTI's for incontinent residents and a decline in health status. A review of Resident 44's admission Record (undated) indicated Resident 44 was admitted to the facility on [DATE] with diagnoses that included Sepsis (serious infection) due to Escherichia Coli (E-Coli, a microorganism [germ] found in the bowel[stool] and commonly causes UTI's), urinary tract infection, chest pain, Parkinson's (a progressive disorder that affects the nervous system and causes tremors, stiffness and slowing of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, and record review, the facility failed to maintain the nutritional status for one of three sampled residents (Resident 288), when Resident 288 had insidious weight loss within a month timeframe (from 11/19/24 to 12/3/24). The weight loss was not identified, and intervention was not implemented. As a result, Resident 288, who was identified as malnourished at admission, had a weight loss of 11 pounds or 6.24 % in 2 weeks. This failure had the potential to contribute to the risk of further weight loss and decline for Resident 288. Findings: During a review of the facility's policy titled, Weight Policy, no revised date provided, indicated, The nursing center utilizes weights as one component of data collection needed to evaluate resident's nutritional status, fluid retention or diuresis. The process, included: a. Weight criteria - New admission: weight resident within 24 hours of admission then weekly for one month; hospital weights are not used as nursing center weights. b.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide necessary monitoring for one out of two sampled residents (Resident 87) while on an antipsychotic (a medication that altered the brain, caused a change in mood, awareness, thought, feelings, or behaviors) medication when: 1. Resident 87 was prescribed Asenapine (an antipsychotic medication that can be used to treat bipolar [a serious mental illness that caused mood swings] disorder) Transdermal Patch (a patched that was placed on the skin) and there was no monitor in place that tracked specific behaviors for the use of Asenapine. 2. Resident 87 was prescribed Haloperidol (Haldol, an antipsychotic medication that can be used to treat bipolar disorder) and there were no monitors in place that assessed for adverse reactions (side effects that could be serious or dangerous). These failures had the potential for serious or dangerous medication side effects to go unnoticed and could cause a decline in Resident 87's physical, mental, and psychosocial…

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

Based on observation, interview, and record review the facility failed to ensure the Registered Dietitian (RD) and Dietary Services Manager (DSM) provided adequate oversight of the Food and Nutrition Services (FNS) when 1. The RD did not provide evidence of regularly scheduled consultation and audits of the kitchen. 2. Effective systems and monitoring were not in place to ensure sanitation of the kitchen, food cooling, the consistency of pureed foods on tray line, and management of dented cans. 3. The facility accepted residents with requirements for Vegetarian diet, the RD and DSM reported the four-week vegetarian menu cycle and cook's spreadsheets had been in place for a while, but kitchen staff were not aware of a pre-planned vegetarian menu and did not follow it. These failures had the potential to result in foodborne illness and decline for residents consuming food from the facility. 1. RD Oversight of the Kitchen During an interview with the RD on 12/16/24 at 1:05 pm, she stated she had worked at the facility full time, 40 hours per week, for 12 years. Recently their part-time…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to explain the terms of the arbitration agreement (arbitration: a private process where disputing parties agree that one or several other individuals can make a decision about the dispute after receiving evidence and hearing arguments.) to the resident in a language that the resident understood for one of five sampled residents (Resident 283). This failure resulted in Resident 283 signing a document that she did not understand and had the potential to result in Resident 283 to not be able to make an informed decision and/or her rights to be denied. Findings: During a review of Resident 283's clinical record, indicated that Resident 283 was admitted to the facility on [DATE] with diagnoses which included left knee osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), and Artificial left knee joint. Resident 283's primary language is Spanish, and she is her own Responsible party (RP) and capable of making her own…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure pain medication was administered, in accordance with the resident ' s comprehensive care plan, and the resident ' s goals for care and preferences for one of three residents (Resident 1) who were sampled for pain management. This failure caused Resident 1 to experience increased pain and discomfort with the potential to experience a decline in her health condition. Findings: The facility ' s policy titled Pain Policy undated, indicated The Center [facility] evaluates for, and attempts to manage/minimize, pain in residents. The facility ' s policy titled Medication Administration undated, indicated Medications are administered in accordance with written orders of the prescriber [Physician]. Medications are to be administered within 60 minutes of scheduled time A review of Resident 1 ' s undated Face Sheet indicated that Resident 1 was admitted on [DATE] with diagnoses including a broken leg, muscle weakness, lung disease, and pain. A review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on in interview and record review the facility failed to provide residents food that is palatable (tasty, and flavorful) .,and an appetizing temperature for 12 of 23 residents (Residents: 101, 289, 57, 94, 66, 231, 230, 100, 52, 20, 44, 41) when residents complained of food regularly not tasting good and being cold. This failure had the potential to result in residents not obtaining appropriate nutritive intake, precarious weight loss, increased health complications, and diminished emotional well-being. Findings: A review of Resident 101's medical record indicated that resident 101 was admitted on [DATE] with diagnoses that included, Acute Respiratory Failure (fluid builds up n lungs due to disease or injury that interferes with the lungs ability to deliver oxygen or remove carbon dioxide), Chronic Atrial Fibrillation (Irregular and often very rapid heart rhythm), Unspecified Protein- Calorie Malnutrition (nutritional status with reduced availability of nutrients). During an interview on 2/12/24 at 12:33…

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 interviews and record reviews the facility failed to notify the provider with the need to review and update the pain treatment plan for 1 of 5 residents (Resident 231), when Resident 231 had continuous pain at levels that indicated pain was not managed by the regimen ordered. This failure had the potential to result in decline of mobility, increased health complications, and diminished emotional well-being. Findings: A review of Resident 231's medical record indicated that resident 231 was admitted on [DATE] with diagnoses that included, status post (s/p) fall, Total Hip Arthroplasty (THA)(hip fracture resulting in hip replacement via surgical procedure), Removal of internal fixation device (removal of hip hardware via surgical procedure), sepsis (serious condition in which the body responds improperly to an infection, causing organs to work poorly). During a review of Medication Administration Record (MAR), dated 2/1/24 to 2/29/24, the MAR indicated, Rate pain every shift (Q-shift): Mild Pain 1-3,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that resident's pain was managed for 1 of 5 residents (Resident 231) when resident 231 Consistently reported pain levels of 4-9 regularly to staff, both prior to, and following pain medication administration, and new orders were not obtained for a more tolerable pain management regimen. This failure had the potential to result in a decline in mobility, increased health complications, and diminished emotional well-being. Findings: A review of Resident 231's medical record indicated that resident 231 was admitted on [DATE] with diagnoses that included, status post (s/p) fall, Total Hip Arthroplasty (THA)(hip fracture resulting in hip replacement via surgical procedure), Removal of internal fixation device (removal of hip hardware via surgical procedure), sepsis (serious condition in which the body responds improperly to an infection, causing organs to work poorly). During a review of Medication Administration Record (MAR), 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 and record review, the facility failed to ensure infection control techniques were implemented when: 1. a vial of blood glucose test strips, that multiple residents use, was brought into Resident 94's room and was left uncapped and placed next to the used, blood-contaminated Glucometer (a device that uses an inserted test strip containing a small amount of blood applied to measure Blood Sugar levels) after testing Resident 94's blood sugar. 2. a used lancet (a small, sterile single-use needle used to draw a drop of blood for testing, as with a glucometer) was wrapped inside a used glove and placed in a trash can that was inside Resident's room. These failures had the potential for cross-contamination, needlestick injuries, and infection to occur. During a review of Centers for Disease Control and Prevention (CDC)'S Infection Safety guideline, titled Infection Prevention During Blood Glucose Monitoring and Insulin Administration, reviewed 3/2/2011, indicated: 1. An underappreciated…

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 and record Review, this requirement was not met when staff caused pain and redness to a resident ' s foot, resulting in a delay in the progress toward his rehabilitation goals. Findings: A review of the Clinical Record indicated Resident 1 was admitted to the facility on [DATE] for rehabilitation of worsening contractures (rigidity, shortening and hardening of the muscles and tendons) in his feet; Resident 1 was wheelchair bound. Review of Resident 1 ' s Minimum Data Set (MDS) Section G, Functional Status, dated 9/7/23, indicated that Resident 1 required Extensive Assistance for transferring from one surface to another, moving side to side in bed, toilet use, and dressing. Review of the facility ' s record titled Physical Therapy Evaluation and Plan of Treatment dated 9/4/23 indicated, Patient admitted to [a nearby hospital] for evaluation and now being seen here secondary to significant loss of function with both lower extremities exhibiting extensor tone [spasticity of the…

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