Oxnard Manor Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the electrical outlet was in good repair and was safe for use in one of the resident's rooms (room [ROOM NUMBER]), when the socket was left opened without a protective plate.This failure had the potential to affect resident safety and increase the risk of injury. During the observation on 7/8/25 inside room [ROOM NUMBER], the wall electrical outlet outside of the bathroom in room [ROOM NUMBER] did not have a cover plate exposing some electrical wiring inside the socket. The maintenance logbook did not have the requisition for the repair of the open electrical outlet. During the interview on 7/8/25 at 3:00 p.m. with the maintenance supervisor (MS), MS stated that the matter was not brought to his attention neither it was entered in the maintenance logbook by any staff, so no repair was done on the issue.During the review of facility's policy and procedure (P&P), titled Maintenance Service, dated 1/1/2012, P&P indicated, The Maintenance Department…

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 staff accurately documented why a medication dose was not given, or that the physician was notified of the missed dose for one of two sampled residents (Resident 1) per their policy and procedure. This failure resulted in an incomplete medical record and had the potential for inaccurrate and delayed medical interventions for Resident 1. Findings: During a review of the admission Record for Resident 1, dated 2/4/25, the admission Record indicated Resident 1 was admitted on [DATE] and had a diagnosis including but not limited to Type 2 Diabetes Mellitus (a chronic disease that causes high blood sugar levels when the body doesn't produce enough insulin, or when the body cannot use insulin properly). During a review of the Medication Administration Record (MAR) for Resident 1, dated 1/1/25-1/31/25, the MAR indicated an order by the physician for Insulin Glargine Solution 100 UNIT/ML Inject subcutaneously two times a day for diabetes. The MAR further…

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 record review and interview, the facility failed to follow physician orders and adhere to its medication administration policy and procedures for one of two sampled residents (Resident 1) when: 1. Staff did not seek physician clarification for a potential frequency change for a Lactulose (a medication which can be used to reduce the amount of ammonia in the blood of residents with liver disease) order when Resident 1 did not have four bowel movements in a day. 2. Staff did not notify Resident 1's physician of their continued inability to obtain an ordered medication of Rifaximin (An antibiotic that is used to treat and prevent complications in patients with cirrhosis). 3. Staff did not check Resident 1's blood pressure or heartrate prior to the administration of Propranolol (a medication used to treat high blood pressure). These failures had the potential to lead to negative outcomes for Resident 1. Findings: 1.During a review of Resident 1's admission Record undated, indicated in part, Resident 1 had diagnoses including cirrhosis of the liver (a chronic liver disease…

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 record review and interview, the facility failed to capture/be aware of, a resident diagnosis of cataracts (a clouding of the lens of the eye) for one of two sampled residents (Resident 1). This facility failure had the potential for Resident 1 to experience negative outcomes in care. Findings: During a concurrent interview and record review, on 1/23/25, at 11:28 a.m., with the Director of Nursing (DON 1), the DON 1 was asked if facility records indicated Resident 1 had a diagnosis of Cataracts. The DON 1 verbalized Resident 1 did not have a diagnosis of Cataracts after examining Resident 1's medical records including but not limited to, the current list of Resident 1's diagnoses, care plan and physician orders. During a review of Resident 1's Eye Health Consult form dated 2/5/24, indicated in part, Resident 1 had a diagnosis of cataracts to both eyes. During a review of Resident 1's Complete Exam/Visit-Office form, dated 7/3/24, from an offsite eye specialty clinic, indicated in part, Resident 1 had an ocular history of OU (oculus uterque [both eyes]) Cataract. The form…

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 label and discard perishable food items, from the resident refrigerator, per policy and procedure. This facility failure had the potential for residents to experience negative outcomes, including foodborne illness. Findings: During a review of the facility's policy and procedure titled Food Brought in by Visitors dated 6/18, indicated in part When food is brought into a nursing home prepared by others, the nursing home is responsible for ensuring that the food container is clearly labeled with the resident's name and date received and stored in a refrigerator designated for this purpose. The policy further indicated Perishable food requiring refrigeration will be discarded after two hours at bedside, and if refrigerated it will then be labeled, dated, and discarded after 48 hours. During a concurrent observation and interview, on 1/21/25, starting at 1:44 p.m., with the Director of Nursing (DON 1) and Administrator (Admin 1), the resident refrigerator was inspected. Inside the resident refrigerator was one…

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 record review and interview, the facility failed to implement fall care planned interventions for one of two sampled Residents (Resident 1). This failure had the potential to lead to negative outcomes for Resident 1. Findings: During a review of Resident 1's Change in Condition Evaluation form, dated 12/2/24, indicated in part on 12/2/24, Resident 1 sustained a fall. The form indicated in part Heard loud noise in [Resident 1's] room. And nurse went to check, [Resident 1] was found lying on the floor, head by the door of the bathroom. During a review of Resident 1's Care Plan undated, indicated in part, Resident 1 was At risk for further falls due to decreased physical mobility, decreased endurance and weakness. Resident 1's Care Plan further indicated an intervention chosen for Q1H (Every one hour) rounding for anticipation of needs. During a concurrent interview and record review on 1/16/25, at 3:51 p.m., with the Director of Nursing (DON 1) and the Administrator (Admin 1), both the DON 1 and the Admin 1 were asked if the facility could provide documentation indicating…

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 Registered Dietitian (RD) failed to ensure her skill set related to nutrition assessments was current when standards of practice were not implemented as follows: 1. The RD utilized a method to assess the nutritional needs for elderly residents classified as obese that had the potential to promote weight loss, and was not in accordance with professional standards of practice, without obtaining and/or discussing Resident 53's and/or responsible party (RP) weight goal or preference and potential risks of weight loss for informed decision making for one of one sampled residents (Resident 53). 2. The RD was unaware an unstageable (a full-thickness skin and tissue loss where the extent of damage is not clear because the wound is covered by eschar [a hardened, dead tissue that forms a scab-like covering over wounds] or slough [yellow/white material in the wound bed] pressure injury (a localized area of skin and tissue damage caused by prolonged or severe 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 observation, interview, and record review, the facility failed to follow the planned menu for therapeutic diets (part of the treatment for a disease or clinical condition, to eliminate, decrease, or increase certain substances in the diet or to provide mechanically altered food) when: 1. Resident 9, Resident 40 and Resident 26 received salad when prescribed a mechanical soft diet (to make it easier to chew and swallow foods, reducing the risk of choking) that was not on the mechanical soft diet menu. The Dietary Supervisor (DS) 1 confirmed the error had the potential to affect the following resident's prescribed a mechanical soft diet: Resident's 378, 54, 233, 4, 67, 21, 53, 14, 52, 42, 70, 129, 41, 127, 60, 49, 24, 349, 10, 27, 28, 30). 2. Resident 59's meal tray card (MTC) (MTC provided resident specific menu directions to staff on what to serve for a meal) was not followed for a lunch meal related to Resident 59's therapeutic renal diet (for kidney disease). These facility failures had the potential…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain a homelike environment in one resident room and two shower rooms. This failure had the potential to negatively impact residents. Findings: During an interview 10/30/24, at 10:40 a.m., with the maintenance assistant (MS 1), the MS 1 was asked if the facility was up to date with repairs. The MS 1 verbalzied yes. During an observation on 10/30/24, starting at 10:45 a.m., the facility was toured. During the tour one unoccupied room (room [ROOM NUMBER]) had wall damage with peeling paint and a damaged bathroom door frame. During an interview on 10/30/24, at 10:50 a.m., with MS 1, the MS 1 confirmed the wall damage and door frame damage in room [ROOM NUMBER]. During a concurrent observation and interview, on 10/30/24, starting at 4:09 p.m., with Environmental Services Director (ES 1), the facility's two shower rooms were toured. The east side shower room had a door frame in disrepair while the west side shower room had broken tiles…

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 a comprehensive person focused care plan for 2 of 5 sampled residents when: 1. Resident 65's preference for warm drinking water was not identified in the resident's careplan. This failure resulted in the resident storing warm water via water [NAME] at the bedside by self , with no facility assessment if ok with medications and other dietary intake /food/meal. 2. Resident 40's interdisciplinary team (IDT) nutrition care plan (detailed plans of care created by representatives from several medical disciplines or specialties) did not contain clear and resident specific measurable objectives with the input of the resident and/or responsible party (RP) on their goals and desired outcomes related to Resident 40's weight and 2b. Ensure risks of refusal of a renal diet (for kidney disease) were explained to the RP for informed decision making. This failure resulted in unclear, weight maintenance goal and could impede the IDT…

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 record review and interview, the facility failed to ensure a resident 's ( Resident 127) electronic medical record (eMAR - a digital version of a resident's medication administration) was accurately signed or accurate documentations were entered when a medication was administered or not administered as ordered by the physician . This failure has the potential for resident not to received the medications as ordered essential for quality of life and well being . Findings: According to Nursing Fundamentals by [NAME], [NAME] and [NAME], second edition, 2010 p. 322, Documentation is the professional responsibility of all health care practitioners. It provides written evidence of the practitioner's accountability to the client, the institution, the profession, and society. Review of [NAME] and [NAME], 6th Edition, Mosby's Fundamentals of Nursing, page 847 in the section titled, Medication Administration indicated, After administering a medication, the nurse records it immediately on the appropriate record…

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 1 of 4 sampled residents (Resident 65) who was hard of hearing, was assessed and assisted in obtaining a hearing device while admitted in the facility to facilitate adequate communication. This failure has the potential for the resident's needs to be not attended and understood by staff . Findings: During an observation and interview on 10/29/24, at 7:39 a.m., in room [ROOM NUMBER]-1, Resident 65 was observed seated in a wheelchair at the bedside. Resident 65 stated, You have to come nearer and speak louder, I can't hear very well, I left my hearting aids at home as , I don't want it to be lost. Review of the medical record for Resident 65 indicated the following : - facility care plan initiated 6/12/24 indicated At risk for miscommunication r/t: Impaired hearing. Interventions included Discuss with resident/family concerns of feelings regarding communication difficulty. Monitor/document for physical/nonverbal indicators 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 observation, interview, and record review, the facility failed to ensure post dialysis assessment and ongoing communication between the facility was completed after 1 of 4 sampled residents (Resident 127), returned from dialysis and failing to communicate with the contracted dialysis company when Resident 127 was sent from the dialysis clinic to the hospital. This failure had the potential to result in undetected complication(s) of dialysis and compromise the safety and well being of the resident. Findings: During an observation on 10/28/24, at 11:25 a.m., inside room [ROOM NUMBER]-1, the dialysis binder book (binder book residents bring to and from dialysis containing forms and information from facility to dialysis clinic and vice versa) of Resident 127 was on the bedside table. Resident 127 indicated the binder book has been in the room since 10/26/24 (Saturday) when resident arrived back from dialysis. The dialysis form inside the binder dated 10/26/24 indicated, 11. Comments or special instructions…

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 pureed recipe for spaghetti with meat sauce was followed when the consistency was not a smooth, pudding or soft mashed potato consistency as directed in the recipe. Dietary Supervisor (DS) 1 verified there were eight residents (Resident 31, 11, 8, 6, 62, 72, 56, 3) with a puree diet order that had the potential to receive an inappropriate texture. This failure had the potential to result in choking and aspiration (food or liquid is breathed into the lungs, instead of being swallowed) in residents who experience difficulty swallowing. There was a total of 75 residents receiving meals from the main kitchen. Findings: During a concurrent observation and interview on 10/28/24, at 10:30 a.m., with the Head [NAME] (HC), HC was observed in the kitchen preparing pureed spaghetti with meat sauce for resident's lunch meal for those with a pureed diet order. HC placed the mixed spaghetti and meat into the food processor and added 1 cup of red sauce. After blending the food, HC transferred the processed…

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 sanitary practices when a dietary aide failed perform hand washing after touching dirty dishes and before handling clean dishes. This failure had the potential to result in cross contamination and foodborne illness to residents. Findings: During a concurrent observation and interview on 10/28/2024 at 8:58 a.m., with Dietary Aide (DA), DA 1 was observed in the kitchen on the dirty side of dish machine wearing gloves while scraping dirty dishes, using a high- pressure water sprayer to spray food debris off from the plate. Without changing gloves or washing hands, DA 1 moved to the clean side of the dish machine and handled clean dishes. The Dietary Aide (DA) 2 then informed DA 1 in Spanish that she had been observed moving from dirty side to the clean side of the dish machine without performing hand washing. DA 1 acknowledged that she did not wash her hands. DA 1 was asked if she had been trained to wash her hands after handling dirty dishes prior to handling clean dishes, DA 1 responded, no. During a…

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

Based on interview and record review, the facility failed to ensure a medical record for one of 18 sampled residents (Resident 12) was updated to reflect the changes in a Physician Orders for Life-Sustaining Treatment (POLST). This failure had the potential to result in a life saving measure or preference of the resident, to be not carried out as ordered by the physician. Findings: During a concurrent interview and record review of Resident 12's Electronic Health Record ( EHR) with the Minimum Data Set Nurse (MDS 1) on 10/29/24 at 12:29 p.m., Resident 12's EHR indicated that the POLST dated 07/11/23, indicated Resident had a POLST for a Full Code (to receive all resuscitative treatment). Another physician order dated 09/19/23 stated Resident 12 is a Do Not Resuscitate (DNR - no life sustaining resuscitation). MDS 1 indicated Resident 12's POLST should have been updated from 7/11/23 of Fullcode to 9/19/23 of DNR and entered into the resident's EHR. During a review of the facility Policy and Procedure (P&P) titled Physicians Orders for Life-Sustaining Treatment (POLST) Nursing Manual…

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 record review and interview, the facility failed to provide an arbitration agreement (a legal contract that requires the parties in a dispute to resolve it through arbitration, rather than a lawsuit) to one resident (Resident 1), in a form and manner the resident or resident representative understood. This failure had the potential to violate Resident 1's rights. Findings: During a review of Resident 1's Minimum Data Set (MDS - a tool used to assess the health needs and functional capabilities of residents in nursing homes) indicated in part, Resident 1 preferred Spanish and needed/wanted an interpreter to communicate with health care staff. During a review of Resident 1's Arbitration Agreement dated 10/5/20, indicated in part, Resident 1's responsible party signed the arbitration agreement on 10/8/24. The agreement was entirely in English. During an interview on 10/29/24, at 12:16 p.m., with the Director of Admissions (DOA 1), the DOA 1 verbalized Resident 1's representative, who signed Resident 1's arbitration agreement, could not communicate in English. When asked if 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 there was adequate supervision for one of two sampled residents (Resident 1). This failure resulted to Resident 1 leaving the facility without staff knowledge and had the potential for an accident while away and without supervision. Findings: During a review of Resident 1's admission record, Resident 1 was admitted to the facility on [DATE] for after surgery care (removal of uterus [body part in human female's reproductive system]), with both parents listed as responsible parties. A review of History and Physical by the physician, dated 9/29/24, indicated Resident 1 can make needs known but can not make medical decisions due to developmental delay with BIMS (Brief Interview for Mental Status- a tool used by caregivers in long term care facilities to screen and identify cognitive condition of a resident upon admission) score of 8 indicating moderate cognitive impairment. admission baseline care plan dated 9/29/24 indicated Resident 1 had no…

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 record review and interview, the facility failed to implement care planned interventions and physician orders, for one of two sampled Residents (Resident 2). This facility failure had the potential to lead to negative outcomes for Resident 2. Findings: During a concurrent record review and interview, on 8/7/24, starting at 3:45 p.m., with the Director of Nursing (DON 1) and Director of Rehab (DOR 1), Resident 2's medical record was reviewed. Resident 2's Order Summary Report undated, indicated in part, Resident 2 had an Order for skilled OT (occupational therapy [a form of therapy for those recovering from physical or mental illness that encourages rehabilitation through the performance of activities required in daily life]) for 3x (times)/week for 4 weeks.Resident 2's Treatment Encounter Note(s) dated 5/16/24 through 5/22/24, indicated Resident 2 only received two of the ordered three treatments. The DOR 1 verbalized it was a missed visit. The DON 1 and the DOR 1 could not provide any documentation as to why Resident 2 did not receive the ordered three OT treatment…

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 one of two residents (Resident 1) was discharged to an appropriate level of care when the resident was discharged to an independent living facility (ILF-a place where residents need no assistance with activities of daily living such as mobility, dressing, eating, toileting, and medication management), instead of a board and care home (homes that provide room, board and 24-hour staffing assistance and care for the seniors with things like dressing, bathing and medication management) or an assisted living facility (ALF -a variety of facilities that provide both housing and personal care). In addition, the facility did not verify the receiving ILF was licensed and fully capable of providing care and supervision to Resident 1. This failure put Resident 1 at risk for harm and not having her basic needs met at the ILF. Findings: During a review of Resident 1's Hospitalist History & Physical (HHP), dated 04/04/23, Resident 1 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.

Based on interview and record review, the facility failed to accurately complete a discharge summary (a review of a residents stay) for one of 2 residents (Resident 1). This failure had the potential for the receiving facility to not have accurate medical information regarding Resident 1's status and her required needs. Findings: During a review of Resident 1's undated Discharge Evaluation Summary this indicated Resident 1 was discharged to an assisted living facility and to have home health nurse and therapy services. This document also indicated Resident 1 used a walker in the facility. There was no evidence of documentation of assessments including Resident 1's mobility status like walking, wheelchair use, transfers, bathing, dressing, using the restroom, preparing meals, eating, transportation, scheduling medical appointments, and taking medications. In addition, this document did not include an accurate and current description of Resident 1's learning needs, skin evaluation, and individualized care instructions. During an interview on 11/06/2023 at 3:48 p.m. with licensed nurse…

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 implement the plan of care for one of two sampled resident's (Resident 1) related to Resident 1's dietary restrictions due to dental needs. This failure had the potential for Resident 1 to experience pain and choking with no assistance. Findings: During a review of the facility's admission Record, Resident 1 was admitted on [DATE]. Resident 1's Care Plan initiated on 12/2/22, indicated in part .Resident 1 has oral and dental health problems likely cavity and broken natural teeth . During a review of Resident 1's Care Plan, revised 8/2/23, indicated in part . 8/2/23 S/P (status post) TEETH EXTRACTION (ORAL SURGERY) and, .Regular-small portion diet, Mechanical Soft Chopped texture, Regular/Thin consistency. TAKE COLD, SOFT DIET. AVOID HOT, SPICY FOODS. During a review of the Resident 1's Order Summary Report dated 10/5/23, indicated in part .Dietary-Diet, Regular-standard portion diet Regular texture . During a review of Resident 1's Dietary Menu Card,…

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 keep air vents clean in four of four sampled residents' rooms (room [ROOM NUMBER], 26, 27, and 28). This facility failure had the potential for airborne diseases to spread in the facility. Findings: During an observation on 7/11/23, at 10:40 a.m. with the Director of Nursing (DON), resident room [ROOM NUMBER] was observed. The air vent had brown particles covering the air vents grills. The DON acknowledged the dirty vent. During a concurrent interview and observation on 7/11/23, at 10:44 a.m., with the Maintenance Director (MD), resident rooms 25, 26, 27, and 28 were observed. All the rooms' vents had brown particles covering the air vent grills. The MD acknowledged the air vents are in need of cleaning. The MD indicated, housekeeping is the one in-charge of cleaning the vent grills. During a concurrent interview and observation on 7/11/23, at 11:22 am., with Housekeeping (HK), resident rooms 25, 26, 27, and 28 were observed. All 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 record review, the facility failed to provide a safe, sanitary, and homelike environment for residents when: 1. [NAME] Patio exit door could not be shut, as posted, Keep closed at all times. 2. [NAME] medication storage room was dirty and in disrepair. 3. Three medication carts were visibly soiled. 4. Resident 4's wall was damaged with a large area of missing plaster, and Resident 4's bed frame was covered with a sticky substance. 5. Resident 63 and Resident 39's room had scratches, peeling paint, and holes in the walls. 6. Windows in the kitchen and dining room had no screens on the windows and a broken window was observed in the dining room. 7. Resident 8's wall was damaged. 8. Outside trash dumpster lid was not closed, and trash was scattered on the ground. 9. Resident 26's room had a large area of drywall scraped away with peeling paint. 10. Resident 60's bathroom had dried crusty brown stains around the toilet and sink. These failures resulted in an unsafe 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 ensure: 1. Three medications were contained in labeled bottles in two of two sampled medication carts (east nurses' station cart - C1 and west nurses' station cart- C2). 2. A medication was labeled for individual use in one of two sampled medication carts -C2. 3. A medication was labeled with an open date in one of two sampled medication carts - C1. This failure had the potential for residents to receive expired, ineffective, and contaminated medications. Findings: During a review of the facility's policy and procedure (P&P), titled Consultant Pharmacist Services Provider Requirements, dated 8/10, the P&P indicated, .Checking the medication storage areas quarterly or upon request, and the medication carts quarterly or upon request, for proper storage and labeling of medications, cleanliness, and removal of expired medications. During a review of the facility's policy and procedure (P&P), titled Storage of Medications, dated 8/10, the P&P indicated, Medications and Biologicals (drugs that are not made 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.

Based on observation, interview and record review, the facility failed to ensure the cook followed the therapeutic puree diet menu as planned on 12/14/21 for residents on puree diet. These failure had the potential for resident's on puree food not to get the calculated nutirional amount their bodies need from each meal. Findings: The facility policy and procedure titled Therapeutic Diets dated revised 6/14 indicated in part, Each food item, served separately in the regular diet, is pureed and served separately for a pureed diet according to the menu spreadsheet and puree recipes. During a record review and interview with cook 1 (CK 1) on 12/14/21 at 10:52 a.m., the Good For Your Health Menus lunch menu for 12/14/21 indicated Mexicali [NAME] and Enchiladas to be served for lunch . CK 1 stated, We have seven patients on the Puree Diet. I will substitute ingredients in the regular diet recipes then puree it to make the puree diet meals. For the Mexicali Rice- one cup of Cream of [NAME] will be used instead of raw brown rice to make seven servings and will not include the 1/2 cup 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 safe food handling and storage when lids on containers of dry foods (flour, sugar, parboiled rice, and spices) were left open. This failure had the potential to decrease food quality, cause food contamination and foodborne illnesses due to unsafe food handling practices. Findings: During an observation and concurrent interview with the dietary supervisor (DS) on 12/14/21 at 9:56 a.m., in the kitchen dry storage area, separate container lids of oatmeal, sugar, and parboiled rice used as ingredients for resident meals were not securely closed and open to air. Further observed the lids on containers of Thyme Leaves Spanish Ground, Ground Black Pepper, Ground Cinnamon, Oregano, and Paprika used in flavoring cooked meals for residents are not securely closed and are open to air. The DS observed the open container lids and stated There are three canister containers of oatmeal, sugar, and parboiled rice with the canister container lids open and not securely closed. The Thyme, Ground Black Pepper, Ground…

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 interventions to prevent and control the spread of COVID-19 (Coronavirus disease, a severe respiratory illness caused by virus and spread from person to person) and other infectious diseases in accordance with Centers for Disease Control (CDC) and the facility's policies and procedures when: 1. Staff did not wear proper (PPE) personal protective equipment before entering a resident's room on transmission - based precautions. 2. Staff were cleaning PPE, a reusable gown with disinfectant wipes that did not contain bleach. These facility failures had the potential to spread COVID-19 and/or other infectious diseases to staff and residents. Findings: 1. Review of the facility policy titled, Resident Isolation - Initiating Transmission - Based Precautions, revised 4/22/2016, indicated in part . Transmission-based precautions are initiated when there is reason to believe that a resident has a communicable infectious disease . protective equipment (i.e., gloves, gowns, masks, etc.) is maintained near the…

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

Based on interview and record review, the facility failed to investigate, document, and update missing eyeglasses in a resident's medical record (MR) on timely manner for one of 24 sampled residents (Resident 11). This failure resulted in the lack of follow -up by the facility's Social Services Director (SSD) in obtaining replacement eyeglasses for Resident 11 which can potentially affect the resident's overall visual fucntion. Findings: During an interview on 12/14/21, at 11:14 a.m., with Resident 11's family member (FM) the FM verbalized two pairs of Resident 11's eyeglasses were lost a month ago at the facility and the SSD was notified. During a concurrent interview and record review, on 12/16/21, at 8:24 a.m., with the SSD, Resident 11's MR /inventory log did not indicate missing eyeglasses or if the missing personal items were replaced. The SSD acknowledged Resident 11's FM reported the 2 missing eyeglasses but it was not documented in the resident's MR /inventory log. The SSD further acknowledged the inventory log should also have been updated when the resident's FM brought in…

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

Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS-Resident Assessment and Care Screening tool used to guide care) was accurate for one of 24 sampled residents (Resident 59) when Resident 59's special treatments, procedures, and programs under section O, for dialysis, was left blank. This failure had the potential to result in Resident 59's identified care needs to go unmet and for the resident's medical record to be inaccurate. Findings: During a concurrent interview and record review on 12/15/21, at 1:55 p.m., with the director of nursing (DON), Resident 59's admission Record, dated 7/26/21 was reviewed. The record indicated Resident 59 had end stage renal disease and was dependent on renal dialysis. During a review of Resident 59's MDS Assessments Section O dated 8/2/21 and 11/1/21, the box under dialysis was blank, indicating Resident 59 was not receiving dialysis. During a concurrent interview and record review on 12/15/21, at 2:04 p.m., with the DON, Resident 59's MDS Assessments for Section O were reviewed. The DON acknowledged the…

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

Based on interview and record review the facility failed to follow and implement the comprehensive care plan for one of 24 sampled residents, (Resident 59), with weight loss when the facility failed to: 1. Weigh Resident 59 weekly. 2. Monitor Resident 59's meal intake daily. 3. Provide RNA (restorative nursing assistants provide range of motion exercises that are vital for health and well-being of residents) with dining every breakfast and lunch as care planned. These failures placed Resident 59 more at risk for continued weight loss. Findings: 1. During a review of Resident 59's Care Plan for altered nutrition/hydration related to weight loss, the care plan interventions indicated to do weekly weights times four starting on 11/11/21. During a concurrent interview and record review, on 12/16/21, at 5:01 p.m., with the infection preventionist (IP) and the director of nursing (DON), Resident 59's Weight Summary was reviewed. Resident 59's weight on 11/3/21 was 129.8 pounds, on 11/23/21 was 126.06 pounds, on 11/30/21 was 120.4 pounds, and on 12/2/21 was 120.4 pounds. When asked about…

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 administer insulin (a medication to lower blood sugar [BS] levels) as ordered by the physician for one of nine sampled residents (Resident 36). This failure had the potential for Resident 36 to develop unstable BS, which could have led to a high or low BS level affecting the resident's already compromised condition. Findings: According to Fundamental of Nursing, by [NAME] and [NAME], Eighth Edition, on page 336, under the section, Physicians' Orders indicated, Nurses follow physician orders unless they believe the orders are in error or harm patients. Review of the facility policy titled, Medication - Administration, revised 1/1/12, indicated in part . Medications and treatments will be administered as prescribed to ensure compliance with dose guidelines. During a concurrent interview and record review, on 12/14/21, at 4:20 p.m., with Licensed Nurse (LN 3), reviewed Resident 36's medication administration record (MAR), dated 10/21 and 11/21 indicated,…

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 residents electrical care equipment was maintained in a safe operating condition for one of 24 sampled residents (Resident 25) when the phone jack wires inside the resident's room was open and exposed . This failure had the potential to result in electrical injury to the resident. Findings: During an observation on 12/14/21, at 11:20 a.m., in room [ROOM NUMBER], Resident 25 was lying in bed next to the wall where exposed wires were hanging out of a broken outlet. During a concurrent observation and interview on 12/14/21, at 11:34 a.m., with the maintenance supervisor (MS), MS acknowledged the exposed wires and verbalized they were from the phone jack. MS further verbalized the wires should not be exposed like that and stated, I need to fix the phone jack. During a review of the facility's policy and procedure titled Maintenance Service dated 1/12, indicated in part . The maintenance department is responsible for maintaining 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.