Oceanview Post Acute

Based on observation, interview and record review, the facility failed to ensure personal privacy were provided for three (Resident 1, Resident 2, and Resident 3) out of three sampled residents when privacy curtains were not provided. This failure had the potential to put residents in physical, social and emotional distress. Findings: During a concurrent observation and interview on 2/24/25 at 3:12 p.m. with the Administrator (ADM), the ADM stated, he received a call round 11 p.m. on 2/21/25 about the car crash incident in the facility. The affected room had a signage on the door that indicated, Unsafe to Occupy. A yellow tape labeled with Caution was in the middle of the room. No residents were observed inside the affected room. The ADM stated, the three residents who occupied the affected room were not injured and were transferred to the Day Room (activity/rehab room) due to unavailable other beds/rooms. In the Day Room, three beds were noted. Resident 1 was lying in the bed. There were no privacy curtains in between Resident 1, Resident 2 and Resident 3. There were thin drapes…

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 the safety and proper monitoring of resident funds for one of three residents investigated, Resident 1, when Resident 1 lost money in his personal bank account. This failure had the potential to affect the resident's psychosocial and general well-being. Findings: During a concurrent observation and interview of Resident 1 on 8/13/24 at 4:20 p.m., Resident 1 was laying in his bed, alert and verbally responsive. He appears calm and comfortable. Resident 1 stated that the previous business office manager (PBOM), who was no longer working with the facility, had taken money from his bank account. Review of Resident 1's clinical records indicated, he was admitted to the facility on [DATE] with diagnoses including unspecified chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe), essential primary hypertension (high blood pressure), and hyperlipidemia (a condition 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that the resident receive proper foot care and treatment for one of three residents investigated, Resident 2, when Resident 2 did not get an immediate appointment to see a podiatrist. This failure had the potential to affect the resident's foot condition, general health and well-being. Findings: During a concurrent observation and interview with Resident 2 on 8/13/24 at 4:30 p.m., Resident 2 was laying in his bed, calm, alert, oriented and verbally responsive. Resident 2 stated that he told the nurses that he wanted to see a podiatrist for his toenails, a few months ago but until now, he was never seen by a podiatrist. His toenails were long and uncut. During another concurrent observation and interview with Resident 2 on 8/22/24 at 4:20 p.m., Resident 2's toenails remained uncut and long. Resident 2 stated that no podiatrist had seen him until this time. During an interview with the minimum data set coordinator (MDSC, collects data…

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 an interview and record review the facility failed to ensure to follow their policy and procedure (P&P) for quality assurance and performance improvement (QAPI: a program to enhance the quality of care provided to residents in healthcare facilities) committee meeting attendees. This failure had the potential to result in to identify, monitor, implement and enhance the quality of facility wide system for infection prevention and control practices. Findings: Review of documents for QAPI Committee Minutes dated 1/24/2024 and 4/24/2024 indicated there was no infection preventionist (IP: a healthcare specialist who make sure healthcare workers and residents are doing all things they should to prevent infections in facility)'s signature under Attendees Present for quarterly QAPI meeting on 1/24/2024 and 4/24/2024. During an interview with minimum data set coordinator (MDSC: clinical and functional assessment tool coordinator) on 8/28/2024 at 2:00 p.m., MDSC stated she attended QAPI meetings on 1/24/2024 and 4/24/2024 but she was not certified for IP. During an interview 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 observation, interview and record review, the facility failed to maintain an infection prevention and control practices when: 1. Wet wash cloth (a small,soft and absorbent cloth that used for washing face and body) on sink and dry wash cloth on the floor in bathroom; 2. Medical doctor (MD) did not use required contact precautions (used for infections, diseases, or germs that spread by touching residents or resident's environment) personal protective equipment (PPE: any piece of clothing or equipment that is worn by healthcare workers to mitigate contracting the infections between residents and staff); 3. Laundry aide did not use required contact precautions PPE. These failures had the potential to result in transmission of infection among residents. Findings: 1.During an initial facility tour on 8/5/2024 at 11:50 a.m., observed one wet wash cloth on laying on sink and another dry washcloth on floor in resident room [ROOM NUMBER]'s bathroom. During an interview with certified nursing assistant A (CNA 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 interview, and record review, the facility failed to ensure interdisciplinary team (IDT, a group of health care professionals with various areas of expertise who work together toward the goals to their residents) quarterly care conference meeting arranged, conducted, and documented for two out of two sampled residents (Resident 1and 2). This failure had the potential for Resident/resident responsible party (RP: healthcare or financial decision maker for resident) to participate in the development and implement of person-centered plan of care decisions for Resident 1 and 2. Findings: Review of Resident 1's face sheet (FS: a document that gives a resident's information at a quick glance) indicated Resident 1 was admitted on [DATE]. Resident 1's FS also indicated Resident 1 was self-responsible for daily decision making. Review of Resident 1's custom IDT care conference forms indicated there was no documented evidence for quarterly IDT care conference was arranged, conducted, and documented for 6/2023,…

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 an observation, interview and record review, the facility failed to ensure medications were administered as ordered by the medical doctor (MD) for 2 of 2 sampled Residents (Resident 1and 2). This failure had the potential to adversely affects the health and well- being of Resident 1 and 2. Findings: A Record review of Resident 1's face sheet (FS: a document that gives a resident's information at a quick glance) indicated Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's FS indicated Resident was admitted with diagnoses included dementia (loss of ability to think, remember, and reason to levels that affect daily life and activities), and anxiety (persistent and excessive worry and fear about active daily living situations). Review of Resident 1's physician's medication orders indicated quetiapine (antipsychotic medication to treat mental illness) 25 mg (mg: milligrams, unit of measurement of mass equal to a thousandth of a gram) 0.5 tablet one time a day, and before lunch for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure to follow their policy and procedure (P&P) for activity assessments and preferred activities for one of two sample resident (Resident 1). This failure had the potential to affect to maintain and improve health, functional, cognitive, and emotional well-being for Resident 1. Findings: Record review of Resident 1's face sheet (FS: a document that gives a resident's information at a quick glance) indicated Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's FS indicated diagnoses included schizoid personality disorder (a condition in which people avoid social activities and interacting with others), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest in daily activities), anxiety (excessive, and persistent worry and fear about situations) and cerebral infarction (disrupted blood flow to brain). Review of Resident 1's assessments for activities-quarterly/annual 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.

Based on observation, interview, and record review, the facility had a medication error rate of 12% when three medication errors occurred out of 25 opportunities during the medication administration for two residents (Residents 98 and 41): 1. Licensed vocational nurse A (LVN A) did not give Resident 98 a medication as scheduled; 2. Licensed Vocational Nurse B (LVN B) did not give Resident 41 the full dose of two ordered medications. Also, LVN B crushed a medication for Resident 41 that cannot be crushed. These failures resulted in medications not given according to the physician's orders and had the potential for them not receiving the full therapeutic effects of the medications. Findings: 1. Review of Resident 98 clinical record indicated he was admitted to the facility with diagnoses including respiratory failure (condition in which lungs cannot get adequate oxygen into the blood) with hypoxia (low levels of oxygen in the body) and chronic obstructive pulmonary disease (COPD, a disease that affects airflow in the lungs and makes it difficult to breathe). Resident 98 had 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 ensure sanitary conditions were maintained in the kitchen when: 1. An undated and unrefrigerated bottle of sauce was found in the dry storage area; 2. Six small packs of sliced apples were beyond the use date; and 3. Potato salad was undated. These failures had the potential to cause food contamination and spread food-borne illness to residents who received their food from the kitchen. Findings: 1. During a concurrent kitchen observation and interview on 5/20/24 at 11:46 a.m. with the Dietary Manager (DM), there was an opened bottle of sauce without an open date in the dry storage area. The food label on the bottle also indicated, Refrigerate after opening. The DM confirmed the above observations and stated the bottle was open with no open date. During a review of the facility's undated policy and procedure (P &P) titled, Food Receiving and Storage, the P&P indicated, Foods shall be received and stored in a manner that complies with safe…

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 refuse (any disposable materials, which includes recyclable and non-recyclable materials) was disposed properly when garbage bags were not placed inside the garbage disposal bins, garbage bins were overflowing, and garbage bags were on the floor. This failure had the potential for an unsafe environment for the residents and visitors due to possible pest infestation and spread of diseases in the facility. Findings: During initial observation on 5/20/24 at 8:34 a.m., three garbage disposal bins were observed with bags of trash on top of the closed bins. There were bags of trash on the floor in front of the bins and one bin was overflowing with a black plastic bag. These garbage disposal bins were located in the facility's parking lot near the basement entrance. During observation on 5/21/24 at 8:31 a.m., six garbage disposal bins were observed with the with bags of trash on top of the closed bins and food boxes on top of a closed bin. One bin was overflowing, one bin's cover was open, and another bin 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 failed to ensure privacy for one of 12 residents (Resident 21) when his body was exposed to public view. This failure had the potential to cause emotional distress to the resident. Findings: During an observation on 5/21/24 at 9:15 a.m., Resident 21 and his two roommates were in Resident 21's room. Resident 21 had a long-sleeved shirt and was sitting in his wheelchair across from his roommate's bed. Resident 21 was not behind a privacy curtain and the door of the room was open. Licensed vocational nurse A (LVN A) asked Resident 21 to remove his sleeve in order to take his blood pressure on his right arm. Resident 21 removed his sleeve. Resident 21's upper chest and abdomen area (stomach) were exposed to public view, including in view of his roommates. During an interview on 5/21/24 at 12:32 p.m., Resident 21 stated he felt exposed when he was asked to remove his sleeve in front of his roommates and with the door was open wide. He stated he preferred if he was in privacy, with the door closed or behind a privacy…

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 documentation of post dialysis (a process that filters and purifies the blood using a machine and helps keep fluids and electrolytes in balance) assessments for one of one resident (Resident 19) when numerous post dialysis assessments were not documented. This failure had the potential to result in not identifying post dialysis complications which could affect Resident 19's health. Findings: Review of Resident 19's clinical record indicated she was admitted to the facility with diagnoses of end stage renal disease. The record also indicated Resident 19 received dialysis in a dialysis center on Tuesdays, Thursdays, and Saturdays. Review of Resident 19's Dialysis Communication Record, dated 3/26/24, 4/18/24, 4/25/24, 5/18/24, and 5/21/24 indicated the post dialysis assessment was left blank. During an interview on 5/23/24 at 10:34 a.m., registered nurse D (RN D) stated after Resident 19 returns from dialysis, nurses should have check her access site, and document on the dialysis form. During an interview on 5/24/24 at…

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 provide sufficient number of nursing staff on a 24-hour basis based on Staffing Data Report, Census and Direct Care Service Hours Per Patient Day (DHPPD, a form containing daily staffing information), submitted to Centers for Medicare & Medicaid Services (CMS) for the Fiscal Year (FY) Quarter 1 2024 (October 1 to December 31). This failure had the potential to affect resident's care, health, and psychosocial well-being. Findings: During a document review titled, DHPPD, from October to December 2023, indicated the Actual Certified Nursing Assistant (CNA) DHPPD (requirement is 2.4) were below 2.4 on the following dates: 10/1/23 - 1.96; 11/4/23 - 2.24; 11/12/23 - 2.21; 11/16/23 - 2.06; 11/24/23 - 2.23; 11/25/23 - 2.34; 12/2/23 - 2.17; 12/10/23 - 2.32; 12/15/23 - 2.27; 12/20/23 - 2.38; and 12/29/23 - 2.29. Further review indicated for actual DHPPD (requirement is 3.5) were below 3.5 on the following dates: 10/1 - 2.99; 11/4/23 - 3.33; 11/12/23 - 3.25; 12/10/23 - 3.34; and 12/17/23 - 3.24. During a concurrent interview and…

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

Based on interview and record review, the facility failed to ensure accurate controlled substance (CS, medications that can be easily abused and are under strict government control) accountability for one out of 12 sampled residents (Resident 299), when a CS medication was signed out of the Controlled Drug Record (CDR, an inventory sheet) but was not documented on the Medication Administration Record (MAR) as given to Resident 299. This failure resulted in the facility not having accurate accountability of CS medication and potential for abuse or misuse of these medications. Findings: A review of Resident 299's physician order, dated 4/26/24, indicated oxycodone (a CS medication for pain management) 5 milligrams (mg, unit of measure) 1 tablet every 4 hours as needed for severe pain. A review of Resident 299's CDR for May 2024, indicated a 5 mg oxycodone dose was documented removed from Resident 299's supply by licensed nursing staff on 5/19/24 at 9:29 p.m. A review of Resident 299's May 2024 MAR indicated no documentation for administration of oxycodone 5 mg dose on 5/19/24. During…

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 medications were stored appropriately when an expired medication was identified in one of two medication rooms and the temperature was not being monitored daily for two of two medication rooms and medication refrigerators. Findings: 1. During an observation of the medication room on [DATE] at 2:31 p.m. with Licensed Vocational Nurse (LVN) C, an expired Lorazepam Oral Concentrate was found. LVN C verified the expiration date was written 3/24. A review of the facility's policy and procedures (P&P) titled, Storage of Medications, dated [DATE], the P&P indicated, .Discontinued, outdated, or deteriorated drugs or biologicals are returned to dispensing pharmacy or destroyed. 2. During an observation on [DATE] at 10:49 a.m. inside the facility's medication room in Station B with Licensed Vocational Nurse A (LVN A), there was a medication refrigerator that contained medications. Review of the facility's temperature logs indicated the…

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

Based on observation, interview, and record review, the facility failed to follow their infection prevention and control policy and procedures when an uncovered nebulizer mouthpiece past its due date was found on Resident 40's bedside table. These failures had the potential for the residents to acquire infection. Findings: During an observation on 5/20/24 at 9:16 a.m., an exposed nebulizer mouthpiece was found on Resident 40's bedside table. During a concurrent observation and interview with Licensed Vocational Nurse (LVN) C on 5/20/24 at 9:47 a.m., LVN C verified the date labeled on the nebulizer mouthpiece was 5/9/24. LVN C stated it should have been changed every week. LVN C stated it should have been change weekly. A review of the facility's policy and procedure (P&P) titled, Administering Medications through a Small Volume (Handheld) Nebulizer, dated October 2010, the P&P indicated, 29. When equipment is completely dry, store in a plastic bag with the resident's name and the date on it. 30. Change equipment and tubing every seven days, or according to facility protocol.

Based on observation and interview, the facility failed to ensure a home like environment for three of five sampled rooms (Room A, C, and E) when the floor was not maintained, and the sliding screen doors were off tract. These failures had the potential to place residents at risk for low self-esteem and at risk for insects to come into to resident's room. Findings: During a concurrent observation and interview on 6/6/22, at 10:47 a.m., in Room A, with Certified Nursing Assistant H (CNA H) , observed the sliding screen door was off track, CNA H stated the door was like that since she started to work here in April 2022. During an observation on 6/7/22, 8:37 a.m., in Room C, the laminate layer of the floor was peeling off exposing pressed black board, and the sliding screen door was off track. During an observation on 6/7/22, 8:45 a.m., in Room E, the sliding screen door was off track. During an environmental tour on 6/9/22, at 08:51 a.m., with Maintenance Assistant (MA), he confirmed the above observations that the laminate layer of the floor was peeling off in Room C, and the sliding…

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 newly hired employees undergo a criminal background check (process used to check for any previous convictions or claims of crimes, including abuse) prior to start of work for four of six randomly selected employees (Employee 1, 2, 3, and 4). This failure had the potential for the facility to hire employees with criminal backgrounds placing residents at risk for harm, abuse, and exploitation. Findings: During a record review of employee files with the infection preventionist (IP) on 6/9/22 at 1:09 p.m., the following employees did not have a criminal background check conducted: 1) Employee 1 was hired for the position of a certified nursing assistant. Certified Nurse Assistant E (CNA E) was hired on 5/26/2020. CNA E's employee file had no record of a background check conducted for CNA E 2) Employee 2 was hired for the position of a registered nurse. Registered Nurse F (RN F) was hired on 3/16/22. RN F's employee file had no record of a background check conducted for RN F. 3) Employee 3 was hired as the Infection…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility had a medication error rate of 8.57% when three medication errors occurred out of thirty opportunities during medication administration for three out of ten residents (Residents 41,17,29). These failures resulted in medications not given in accordance with the prescriber's orders and or manufacturer's specifications, which resulted in residents not receiving the full therapeutic effects of the medication. Findings: 1. During the medication pass observation on [DATE], at 9:20 a.m., with licensed vocational C (LVN C), she did not administer Dulera (a medication to control symptoms of asthma (respiratory disease) to Resident 41 as the medication was not available. A review of Resident 41's Physician Order dated [DATE], indicated Mometasone Furo- Formoterol Fum Aerosol 200 - 5 microgram/act (generic name for Dulera) 2 puffs inhale orally two times a day for SOB (shortness of breath). During a concurrent inspection and interview on [DATE], at 4:10 p.m.,…

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 document review, the facility failed to ensure food was stored and prepared under sanitary conditions when: 1. There were white substances on the outside of the ice machine and black/brown substances on the inside of the ice machine; 2. The drainage pipe for the kitchen's food sink did not have an air gap (unobstructed vertical space) above the rim (top portion) of the floor drainage pipe. These failures had the potential to cause food contamination and spread illness to residents who received their food from the kitchen. Findings: 1. During an observation on 6/7/22 at 9:00 A.M., the ice machine was observed to have a white substance on the outside of the machine where the ice was dispensed During an observation and concurrent interview on 6/7/22 at 9:04 A.M., with the Maintenance Assistant (MA), the MA opened the ice machine, there was a black/brown substance on the inside of the ice machine. The MA acknowledge the substances, both inside and outside the ice machine, should not be there. The MA stated the Maintenance Director cleans the ice…

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

Based on interview and record review, the facility failed to notify Res 13's responsible party (RP D) of interdiciplinary team (IDT, a group of health care professionals with various areas of expertise who work together toward the goals of their residents) care conference meetings to discuss the plan for Resident 13's well-being. This failure denies RP D the right to accept or deny any treatments or plans for Resident 13. Resident 13 was admitted with diagnoses which included schizoaffective disorder (a chronic mental health condition characterized primarily by symptoms of schizophrenia, such as hallucinations or delusions, and symptoms of a mood disorder, such as mania and depression), major depressive disorder, anxiety disorder, difficulty in walking, unsteady on feet, need for assistance with personal care, dementia (the impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance 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 the needs were accommodated for one of four sampled residents (Resident 402) when the resident was not provided with a proper call light (a device to call help when needed) and a call light was not within reach. This failure had the potential to put residents at risk for unmet needs and a diminished quality of life. Findings: During an observation on 6/8/22, at 8:17 a.m., in Resident 402's room, she was observed lying in bed, screaming, and a button call light was on the floor at her bedside. During a concurrent observation and interview on 6/8/22, at 8:36 a.m., in Resident 402's room, with Infection Preventionist (IP), she came into the room and placed the button call light within resident's reach. At 8:40 am, IP replaced the button call light to a soft touch call light and stated: She's always used the soft touch call light and we forget to transfer the soft touch call light for Resident 402 during her room change. During an interview with the Director of Nursing (DON) on 6/10/22, at 9:37 a.m., she…

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 notify the Office of the Ombudsman of transfer when Resident 53 was transferred/discharged to the hospital. This failure had the potential for unsafe discharge. Findings Resident 53 was admitted to the facility with diagnoses which included malignant neoplasm (cancer) of colon, pneumonia (infection), moderate protein-calorie malnutrition, and need for assistance with personal care. Resident 53 had been transferred to the hospital on 4/11/22. During a review of Resident 53's electronic record, a notice of transfer to the hospital was not located by surveyor. During an interview with the director of nursing (DON) on 6/10/22 at 8:34 a.m., DON stated, the Ombudsman should have the transfer reports given at the end of the month and the ombudsman should have the report at end of April 2022.) During an interview with the social service worker (SS) on 6/10/22 at 8:49 a.m., SS stated, she did not find in the chart the a notice of transfer had been generated. During a telephone interview with the Ombudsman on 6/10/22 at 9:25 a.m.,…

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 received treatment and care in accordance with professional standards for three of four sampled residents (Residents 9, 33, 402 and 48) when: 1. Resident 9's right arm was not elevated as ordered by the physician. 2. Staff did not develop resident-centered care plans regarding communication issues for Resident 33 and Resident 402. 3. The facility failed to monitor one of one residents (Resident 48) for signs and symptoms of bleeding related to the use of Clopidogrel Bisulfate (a blood thinning medications to prevent blood clots or stroke). These failures had the potential to negatively affect the residents' health, safety, and well-being. Findings: 1. During a record review of the Resident 9's medical diagnosis record, dated on 9/8/21, indicated she had end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term…

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 one of four sampled residents (Resident 9) receive proper foot treatment and care when Resident 9 did not received podiatrists (a medical doctor who specializes in treating the feet) referral. This failure had the potential to result to pain and discomfort for Resident 9. Findings: During a record review of the Resident 9's medical diagnosis record, dated 9/8/2021, indicated she was admitted with end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life) and type 2 diabetes mellitus (a chronic disease characterized by high levels of sugar in the blood). Her minimum data set (MDS, a resident clinical assessment tool) dated 3/11/22 indicated BIMS 13 (a score of 13 means cognitvely intact). During a concurrent observation and interview on 6/7/22, at 12:56 p.m., in Resident 9's room., Resident 9's toenails were long, thick, and yellowish color. She…

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 acceptable parameters of nutritional status when the registered dietician's (RD's) recommendations for nutritional supplements and a fortified diet (a kind of diet the foods with nutrients added to them) were not carried out for one of 5 sampled residents (Resident 18). This failure had the potential to contribute to the risk of further weight loss and decline in health status for Resident 18. Findings: Review of Resident 18's clinical record indicated she was admitted on [DATE] with diagnoses including Alzheimer's disease (a progressive disease that affects memory, thinking and behavior), dementia with behavioral disturbances (mental disorder caused by brain disease or injury that affects behavior), and major depressive disorder (a mood disorder that causes persistent feelings of sadness or loss of interest). During an observation on 6/6/22 at 12:10 p.m., Resident 18 was sitting on the edge of her bed feeding herself her lunch.…

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 an ongoing assessment and oversight of the resident after dialysis treatments for one of two sampled residents (Resident 9) when licensed nurses did not provide hemodialysis (a medical procedure of removing waste products and excess fluid from the blood through an artificial kidney) access site assessment and complete the post- assessment report upon resident's return from the dialysis center. These failures had the risk of causing Resident 9's health complications. Findings: During a record review of the Resident 9's medical diagnosis record, dated on 9/8/21, it indicated she was admitted with end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life) and type 2 diabetes mellitus (a chronic disease characterized by high levels of sugar in the blood). Her minimum data set (MDS, a resident clinical assessment tool) dated 3/11/22 indicated BIMS 13…

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 controlled mediations (those with high potential for abuse and addiction) were fully accounted for when: 1. Random controlled medication use audit for one of three sampled residents' (Resident 46) routine pain medications did not reconcile. The medications were signed out of the Medication Administration Records (MAR) but not documented on the controlled drugs accountability sheet (Count Sheet, an inventory sheet that keeps the record of the usage of controlled medications) to indicate they were given to the resident. 2. An insulin (medication to treat high sugar level in the blood) was not readily available from the emergency kit (E kit, emergency medication). These failures had the potential for misuse or diversion of controlled medications, and the residents could miss the dose of insulin medication for treatment of diabetes. Findings: 1. During a concurrent interview and record review on [DATE], at 2:07 p.m. with licensed…

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 5. Review of Resident 6's clinical record dated 9/4/20 indicated a diagnosis including anxiety disorder (excessive fear about everyday situations), major depressive disorder, and dementia. A review of the physician's order of Resident 6, dated 3/22/21, indicated Seroquel tablet (medication for major depressive disorder) 50 milligram one tablet by mouth in the afternoon and one tablet by mouth at bedtime. During a concurrent record review and interview on 6/9/22, at 2:00 p.m., with DON, she reviewed the last GDR conducted for Resident 6 and she stated that the facility did not have a signed GDR document from Resident 6s physician since 3/22/21. During a phone interview on 6/9/22, at 2:05 p.m., with pharmacy consultant (PC), she stated that she was not aware of a signed GDR document and she validated that the facility should keep records of a GDR. Review of the facility's policy titled, Antipsychotic Medication Use revised December 2016, indicated, Antipsychotic medications will be prescribed at the lowest…

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 proper medication storage labeling and discarding of medications when: 1. Four expired medications were not removed from stock. 2. Two opened medications were not labeled. 3. One opened pneumococcal vaccine (medication to prevent pneumonia (Pneumonia an infection of the lungs) vial that was not stored in the refrigerator. The failures had the potential for residents to receive medications with reduced potency from expired medications, improperly stored medications, and/or medication errors due to medications not being labeled, Findings: 1. During the medication pass observation on 6/6/22, at 12:11 p.m., with RN B (Registered Nurse B), he checked the blood sugar level of Resident 29 and it was 195. RN B then withdrew into a syringe, 1 unit of the medication from the Insulin Lispro (rapid acting insulin, medication to lower blood sugar level) vial. After RN B, drew up the Insulin Lispro and before he gave it to Resident 29, the surveyor checked the Insulin Lispro box with RN B. A date written on the box…

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 and interview, the facility failed to ensure garbage was disposed properly and a clean environment was maintained for the residents and visitors when garbage bags were not placed in garbage disposal bins located outside, a dumpster was overflowing, and a dumpster was left open. This failure had the potential for an unsafe environment for the residents and visitors due to possible pest infestation and spread of diseases in the facility. Findings: During observation on 6/6/22 at 11:34 A.M, four garbage disposal bins were observed with bags trash and boxes on top of the closed bin and bags of trash in front of the bins, one bin overflowing and one bin with an open cover. These garbage disposal bins were located outside by the facility's parking lot near the basement entrance. During an interview on 6/6/22 at 11:37 P.M. with the Maintenance Assistant (MA), the MA confirmed the observation and stated, when he sees the trash on the ground, he throws it away. He was not sure who leaves trash there. Review of the facility's policy, Garbage and Refuse Disposal, (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 observation, interview, and record review, the facility failed to ensure infection control practices were implemented when a staff wore gloves in the hallway and worked on multiple tasks using the same gloved hands, staff also did not perform hand hygiene before and after entering resident rooms. These failures have the potential to result in the spread of infection and disease. Findings: During an observation on 6/6/22, at 12:46 p.m., in station 1 hallway, Certified Nursing Assistant I (CNA I) came out from Room D without washing his hands or using alcohol-based hand sanitizer, directly knocked, and opened red zone (Isolated area for Covid 19 positive residents) Room B's door. CNA I used the same gloved hands to remove the trash can in front of the supply room, then opened the supply room door, got a towel, placed the towel on the top of the food tray, closed the supply room door, replaced the trash can in front of the supply room, carried the food tray, and delivered the food tray to red zone Room B. During an interview on 6/6/22, at 12:56 p.m., with CNA I, he confirmed…

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.