Palo Alto Post-Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the proper use of side rails or bed rails (adjustable rigid bars attached to the side of a bed) for two of 20 residents who used side rails, (Residents 19 and 28), when their side rail assessments (determine the appropriateness and safety of using side rails on a bed for an individual) were not updated in a timely manner. This failure had the potential to place the residents at risk for entrapment (danger for the resident, being caught, trapped or entangled in the gap, space or opening) that may lead to injury or death. Findings: 1. During an observation of Resident 19, on 5/27/25 at 10:38 a.m., Resident 19 was in bed, alert, calm, comfortable and verbally responsive. Resident 19's one fourth (quarter) side rail was up. Review of Resident 19's admission record (document created when a resident is admitted to a healthcare facility, containing the vital information about the resident), indicated, Resident 19 was readmitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the effective use of medications for one of 14 residents (112) when Resident 112 received Ferosul (iron, used for prevention/treatment of iron deficiency) and Calcium Citrate (a medication used to prevent or treat low blood calcium levels) at the same time. This failure had the potential for the residents to not receive the amount of prescribed iron supplements. Findings: Review of Resident 112's admission Record indicated he was admitted to the facility on [DATE]. Review of Resident 112's clinical record indicated, he had physician orders for Ferosul 325 milligrams (mg, a metric unit of mass) every 48 hours for anemia (a problem of not having enough healthy red blood cells to carry oxygen to the body's tissues) at 9 a.m., started on 5/23/25, and for Calcium Citrate 250 mg every day at 9 a.m. and 5 p.m., started on 5/22/25. Thus, since 5/23/25, Ferosul and Calcium Citrate were given at the same time at 9 a.m. every 48 hours. During an interview…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the pharmacist consultant's recommendation was acted upon for one of 14 residents (115) when Resident 115's administration record on alendronate (used to prevent and treat osteoporosis [thinning of the bone]) did not include the information the pharmacist consultant asked to be included. This failure had the potential for Residents 115 to receive ineffective medication and adverse effects that could negatively impact her health and well-being. Findings: Review of Resident 115's admission Record indicated she was admitted to the facility on [DATE] with osteoporosis diagnosis. Review of Resident 115's Consultation Report, dated 5/20/25, indicated the pharmacist consultant recommended to include in Resident 115's administration record on alendronate the following information: Administer intact tablet at least 30 minutes before the first food, beverage, or medication of the day with 6 to 8 ounces of plain water. Individuals should not lie down for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of 6 residents (112) were free from unnecessary medications when Resident 112 received dabigatran etexilate mesylate (a blood thinner to prevent blood clots) but was not monitored for the side effects and not care-planned on the use of the medication. This failure had the potential for Resident 112 to experience unrecognized adverse effects. Findings: Review of Resident 112's admission Record indicated he was admitted to the facility on [DATE]. Review of Resident 112's physician order, dated 5/23/25, indicated he had an order for dabigatran etexilate mesylate 110 milligrams (mg, a metric unit of mass) two times a day. However, review of Resident 112's clinical record did not indicate that Resident 112 was monitored for the side effects and was care-planned on the use of the medication. During an interview with the director of nursing (DON) on 5/30/25, at 2:26 p.m., she reviewed Resident 112's clinical record and confirmed that Resident 112…

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 12% medication error rate when three medication errors out of 25 opportunities were observed during a medication pass for three out of five sampled residents (Residents 44, Resident 2, and Resident 8) when: 1. Resident 44 did not receive Calcium Carbonate with Vitamin D tablet (used to treat conditions caused by low calcium levels such as bone loss) as ordered by the physician. 2. Resident 2 received Diroximel Fumarate capsule (medication used for the treatment of relapsing forms of multiple sclerosis, a disease that causes breakdown of the protective covering of nerves) without food. 3. Resident 8 did not receive Fluticasone-Salmeterol inhalation (used to treat difficulty breathing, wheezing, shortness of breath, coughing, and chest tightness caused by asthma) as ordered by the physician. These failures resulted in medications not given in accordance with the manufacturer's instructions and/or physician's order and had the potential for residents not receiving the full therapeutic effects of medications.…

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 medications and biologicals were stored appropriately and in good sanitary condition when: 1. Medication refrigerator had ice build up in the freezer and had a streak of yellowish-brown substance on the shelf bracket. 2. Five expired over-the-counter medications, and an opened bottle of medication for a discharged resident were found in the Central Supply Room. These failures put residents at risk for contaminated medications and had the potential for residents to receive outdated and/or ineffective medications which could lead to residents not receiving the full benefit of the medications and negative health outcomes. Findings: 1. During an inspection of the medication room on 5/27/25 at 10:21 a.m. with the Director of Nursing (DON), a mini refrigerator was inside. The DON confirmed there was an ice buildup in the freezer. The DON verified the ice buildup blocked the freezer door and cannot be closed and was hard to open. The DON also verified there was a streak of yellowish-brown substance found…

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 in accordance with professional standards for food service safety when: 1. There was an unlabeled and undated crate of oranges and apples in the dry storage area of the kitchen; 2. There was a dented can of kidney beans in the dry storage area of the kitchen; 3. There was no internal thermometer in two kitchen freezers; and 4. There were multiple brown substances on the metal racks in the kitchen reach-in refrigerator. These failures had the potential to cause food contamination and spread foodborne illness to all residents who received their food from the kitchen. Findings: 1. During an observation and concurrent interview with the dietary manager (DM) on 2/20/24 at approximately 8:56 a.m., there was one unlabeled and undated crate of oranges and apples in the dry storage area of the kitchen. The DM confirmed this observation and stated everything should have a label with the date the food was received. The facility's undated document titled Cook Training/Orientation Checklist…

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 garbage was stored properly when the lid for the outside dumpster was not closed. This failure had the potential to attract insects, rodents, and other pests to the facility. Findings: During an observation and concurrent interview with the dietary manager (DM) and registered dietician (RD) on 2/21/24 at 8:15 a.m., the facility's outside dumpsters were inspected. There was one dumpster designated for garbage. This dumpster had garbage bags inside that were situated in such a way that the bags were stacked above the dumpster's brim, and the dumpster lid was not able to close. Both the DM and the RD confirmed this observation. The DM looked inside the garbage dumpster and stated there was actually more room inside. The DM rearranged the garbage bags and the dumpster lid was then able to close. The RD confirmed the lid to the garbage dumpster should have been closed. The facility's policy titled Garbage & Rubbish Disposal, dated 2/2009 indicated, 2. All containers are provided with tight-fitting lids or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop and implement comprehensive, person-centered, care plans for four out of seventeen sampled residents, (Residents 217, 29, 47 and 220), when the activity care plans of Residents 217, 29, 47 and 220, were not comprehensive and person-centered. These failures had the potential to result in the residents, not receiving the interventions necessary to maintain their highest level of well-being. Findings: 1. Review of Resident 217's face sheet (a document that gives resident's information at a quick glance) indicated, Resident 217 was admitted to the facility on [DATE] with diagnoses including systemic sclerosis (an autoimmune disorder in which the immune system attacks own body, affecting many systems of the body) with lung involvement, dysphagia (difficulty swallowing), oropharyngeal phase (swallowing problems occurring in the mouth and/or throat) and essential primary hypertension (abnormally high blood pressure that's not the result…

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 their policy regarding use of bed rails (also called side rails, metal or plastic bars attached to the bed ranging in size from full to one-half, one quarter, or one-eighth lengths) for seven out of 19 sampled residents (Residents 4, 20, 21, 43, 213, 32 and 47). For Residents 4, 20, 21, 43, 213, 32, and 47, there was no documentation that indicated the facility attempted alternatives prior to installing bed rails. For Residents 20 and 43, there was no documentation that indicated the facility assessed for risk of entrapment (getting caught, trapped, or entangled in the space in or around the bed rail). This failure had the potential to compromise the residents' safety. Findings: 1. During an observation on 2/21/24 from 9:41 a.m. to 9:58 a.m., the beds of Residents 4, 20, 21, and 43 were inspected. All of these residents' beds had bed rails. Review of Resident 4's medical record indicated she had a physician's order, dated 2/20/24…

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 2. Review of Resident 57's medical record indicated he was admitted on [DATE] and had the diagnosis of acute pancreatitis (a condition where the pancreas becomes inflamed). Review of Resident 57's Order Summary Report indicated he had a physician's order, dated 2/19/24, to administer Osmolite 1.5 (a type of GT formula) via enteral pump (machine that delivers GT formula) and infuse at 70 milliliters per hour (rate of delivery) for 12 hours. During an observation in Resident 57's room on 2/20/24 at 1:01 p.m., there was a metal pole near Resident 57's bed with a bottle of Osmolite 1.5 hanging from the top of the pole. Some of the Osmolite 1.5 had already been administered, as the bottle was not full and the GT administration tubing was already attached to the bottle. The Osmolite 1.5 bottle and the administration tubing were both unlabeled and undated. During an observation and concurrent interview with licensed vocational nurse A (LVN A) on 2/20/24 at approximately 1:05 p.m., LVN A entered Resident 57's room and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and policy review, the facility failed to ensure Level 1 Preadmission Screening and Resident Review (PASARR) was accurately completed upon admission for one of 3 sampled residents (Resident 16), who had diagnosis of mental illness and did not also receive a Level II screening (a comprehensive evaluation conducted by the appropriate state-designated authority to determine whether an individual has a mental disorder or an intellectual disability for the appropriate setting for the individual). This failure had the potential to delay the care when diagnoses of mental illness was not included on the PASARR form, leading to the resident not receiving appropriate care and services in the most integrated setting appropriate to their needs. Findings: A review of Resident 16's admission record (face sheet, a document that gives resident's information at a quick glance) indicated, the resident was admitted to the facility on [DATE], with diagnoses that included vascular dementia (loss 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 accurate accountability of controlled medication (medication with high potential for abuse and addiction) and safe use of emergency medications when: 1. Random controlled medication use audit for one of seven residents (Resident 43) did not reconcile. The medication was signed out of the Controlled Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications) but not documented on the Medication Administration Record (MAR, used to document medications taken by each individual) to indicate they were administered to the resident. The failure resulted in inaccurate accountability and had the potential for misuse or diversion of controlled medications; and 2. One of five emergency kits (e-kit; a kit/box containing medications and supplies for immediate use during a medical emergency) was not replaced timely after being opened. The failure had the potential for not having emergency medications/supply on hand when needed for the residents. Findings: 1. The Controlled Drug…

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 and labeling of medications when: 1. Medication refrigerator temperature was not monitored twice a day; 2. Resident's own medications brought from home were stored in biohazard bag and were not labeled and, 3. Five nasal sprays in medication carts were not labeled. These failures had the potential for residents to receive medications with reduced efficacy, inadequately monitored medications, unlabelled medications and wrong medications and could compromise residents' safety. Findings: 1. During an inspection of the medication refrigerator at Station 2 on 2/20/24 at 10:12 a.m. with Registered Nurse (RN) C, the temperature logs indicated one type of vaccine, insulin and, infusion therapy products. The medication refrigerator temperature was not monitored twice a day. RN C acknowledged the temperature was not monitored twice a day. During a concurrent interview and record review, on 2/22/24 at 9:45 a.m., with the Director of Nursing (DON), the DON confirmed that the medication…

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 accommodate food preferences for one of three residents (Resident 114). This failure had the potential to result in decrease meal intake, which could compromise the resident's overall health and well-being. Findings: Review of Resident 114's medical record indicated she was admitted on [DATE] and had diagnoses that included diabetes (disease that affects the body's ability to control blood sugar) and muscle weakness. During an interview with Resident 114 on 2/20/24 at 12:09 p.m., she stated the facility would serve her eggs in the morning, even though she requested not to have eggs. During an observation and concurrent interview with Resident 114 on 2/26/24 at 8:10 a.m., accompanied by the director of nursing (DON), there were scrambled eggs on Resident 114's breakfast plate. Resident 114's tray ticket (piece of paper that shows the resident's diet order, likes, and dislikes) indicated to serve no eggs at all. The DON confirmed this…

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 the call light system (system in which the resident presses a button that activates a light in the hallway to alert staff that assistance is needed) was adequately functioning for one of 15 resident bathrooms (Bathroom AA). This failure had the potential to result in residents not receiving necessary care and assistance in a timely manner. Findings: During an interview with Resident 43 on 2/22/24 at 1:12 p.m., he stated the facility's call light system was not functioning properly. Resident 43 stated the buttons do not work. During an observation and concurrent interview with the director of maintenance (DOM) on 2/23/24 at 9:24 a.m., Bathroom AA was inspected. This was a bathroom shared by residents in two rooms. One of these rooms had three residents and the other had two residents. The DOM entered Bathroom AA and pushed the button that was supposed to activate the call light system. The call light in the hallway did not turn on. The DOM confirmed this observation. During a follow-up observation 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 complete and submit an investigation summary regarding an alleged abuse incident for one of two sampled residents (Resident 1). This failure had the potential to compromise the facility's ability to determine the circumstances surrounding the incident and could have compromised the residents' safety. Findings: Review of Resident 1 medical record indicated she was admitted to the facility with diagnoses that included bipolar disorder (a mental disorder which a person can experience periods of overly happy or periods of feeling sad). The medical record indicated Resident 1 was discharged from the facility on 4/5/23. During an interview with the administrator (ADM) on 7/12/23 at 9:36 a.m., the ADM stated the facility was not aware of Resident 1's allegation of abuse, until the police walked into the facility on the evening of 7/11/23. The ADM stated Resident 1 went to a local hospital and reported that the alleged abuse happened 4/8/23 when certified nursing assistant A (CNA A) had put a hot towel on Resident 1's groin area…

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 were free of accidents and hazards and receive adequate supervision during smoking sessions to prevent accidents for three of five sampled residents (Residents 92, 192, and 193). When: 1. Resident 92 was not assessed for smoking safety upon admission, was not provided adequate supervision during smoking sessions, and the facility did not initiate smoking care plan timely; and, 2. For Residents 192 and 193, the residents had no smoking assessment and smoking related care plans upon admission and facility staff did not provide supervision during the scheduled smoking time. This failure had potential to cause smoking related accidents/harm of these residents Findings: 1. Review of Resident 92's clinical record indicated he was admitted on [DATE] with infection of left hip joint, chronic kidney disease (a gradual loss of kidney function), pneumonia (an infection of one or both of the lungs caused by bacteria, viruses, or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to act on reports from the pharmacist for two of five residents (Residents 11 and 24) when: 1. For Resident 11, the physician did not document patient-specific rationales describing the reason for gradual dose reductions (GDR, stepwise tapering of a dose to determine if conditions can be managed by a lower dose or if the medication can be discontinued altogether) are clinically contraindicated for the use of quetiapine (antipsychotic medication used to treat mental or mood disorders) and sertraline (medication used to treat depression) and the facility did not act on the pharmacist's Medication Regimen Review (MRR) recommendation to perform an Abnormal Involuntary Movement Scale (AIMS) assessment; and, 2. For Resident 24, the physician did not document patient-specific rationales describing the reason GDRs are clinically contraindicated for the use of quetiapine and bupropion (medication for the treatment of depression). These 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 interview and record review, the facility failed to ensure three of five residents (Residents 11, 34, and 242) were free from unnecessary psychotropic (drug that affects brain activities associated with mental processes and behavior) medications. 1. For Resident 11, there was no documented clinical rationale by the physician to extend an as-needed (PRN) Ativan (medication used to treat anxiety) order beyond 14 days, there was no documented evaluation by the physician to renew a PRN Ativan order, and the Abnormal Involuntary Movement Scale (AIMS) assessment was not completed timely; 2. For Resident 34, there was no side effect monitoring and behavior monitoring for the use of citalopram (medication used to treat depression) and nortriptyline (medication used to treat depression); and 3. For Resident 242, there was no side effect monitoring for the use of nortriptyline. These failures had the potential to result in lack of adequate monitoring and for the residents to receive unnecessary medications.…

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

Based on observation, interview, and facility document review, the facility failed to ensure food was stored and prepared in accordance with professional standards for food safety when: 1. Undated food, over used by date food, expired food, and dented cans were found in the freezer and on the shelves in the kitchen; 2. [NAME] F (CK F) used his bare hand to pick up a lid which dropped inside the sliced peach can; and, 3. [NAME] G (CK G) and the dietary manager (DM) did not sanitize the thermometer before checking the temperature of the sliced peach and sugar free lemonade. These failures had the potential to cause the growth of micro-organisms which could cause foodborne illness and cross-contaminated food for the 40 residents eating at the facility. Findings: 1. On 4/4/22 at 8:50 a.m., during an observation of the freezer, in the dry food storage room, with the registered dietician (RD), one bag of frozen french fries, with the use-by date (the last date recommended for the use of the product) of 3/11/22, and one bag of undated frozen tortillas were found. On 4/4/22 at 9 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 infection control practices were implemented when: 1. The facility stored clean pillows and residents' clothing next to the dirty laundry; 2. Blood pressure stand machine had five medication cups and one Opti foam dressing together with a blood pressure cuff; 3. The dressing of Resident 26's peripherally inserted central catheter (PICC, a long, flexible thin tube that is put into a vein in the upper arm) was not changed weekly; 4. Certified nursing assistant H (CNA H) carried dirty linen in the hallway out of a resident's room; and, 5. Facility staff did not wear full personal protective equipment (PPE, equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) when entering a resident's room who was on COVID-19 quarantine. These failures had the potential to result in the spread of infection throughout the facility. Findings: 1. During a concurrent observation and interview on 4/7/22 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of 12 sampled residents (Resident 17) had a Minimum Data Set (MDS, an assessment tool) Significant Change in Status Assessment (SCSA) completed when Resident 17 was discharged from hospice care (physical and emotional care for the terminally ill). This failure had the potential to result in Resident 17 not receiving necessary care and treatments. Findings: A review of Resident 17's admission Face Sheet indicated the resident was admitted to the facility on [DATE] with multiple diagnoses that included hemiparesis (weakness or the inability to move on one side of the body) following unspecified cerebrovascular disease (relating to the brain and its blood vessels) affecting left non-dominant side, cerebella stroke syndrome (blood flow to the brain is interrupted). Review of Resident 17's minimum data set (MDS, an assessment tool), dated 2/10/22, indicated Resident 17 had a brief interview for mental status (BIMS) score of 1 (a score 0 - 7…

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 12 residents (Resident 20) received necessary and proper care and services when Resident 20's psychological evaluation (used to determine a resident's mental state and guide recommendations for the best treatment) was not done as requested by the physician.These failures had the potential to affect the residents' care, health and well-being. Findings: Review of Resident 20's admission Record indicated he was admitted to the facility on [DATE] with diagnoses including bipolar disorder (a mental disorder that causes unusual shifts in mood, energy, activity levels, concentration, and the ability to carry out day-to-day tasks). Review of Resident 20's physician order indicated he had orders for divalproex (used to treat the manic phase of bipolar disorder) 2000 mg every day for bipolar disorder, started on 3/19/21, quetiapine (used to treat bipolar disorder) 200 mg two times a day for bipolar disorder, started on 3/26/21, and trazodone (used…

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 store medications appropriately when the following were observed: 1. Two of three medication carts were left unlocked and unattended; and, 2. For Residents 295, 193, and 24, medications were left at their bedside. These failures had the potential to result in the access of medications by unauthorized personnel or residents. Findings: 1. During an observation on 4/4/22 at 11:28 a.m., the medication cart at Station 2 was unlocked and unattended. During an observation on 4/4/22 at 11:31 a.m., two visitors passed by the unlocked medication cart. During an interview on 4/4/22 at 11:33 a.m., registered nurse C (RN C) confirmed she forgot to lock the medication cart and stated the medication cart should be locked. RN C stated if the medication cart was left unlocked and unattended, anybody can get to the medications inside. During a medication pass observation on 4/5/22 at 8:20 a.m., registered nurse D (RN D) prepared medications for Resident 3. During concurrent observation and interview on 4/5/22 at 8:31 a.m., RN…

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 17 of 27 bedrooms had at least 80 square feet per resident. Having less than 80 square feet per resident could potentially compromise the care and services the residents receive. Findings: The room measurement indicated multiple rooms were less than 80 square feet per resident. Room Number Number of Beds Square Feet Per Resident 1 3 72.8 5 2 71.37 7 2 71.95 9 2 75 12 3 73.2 14 3 73.2 15 3 73.2 16 3 74 17 3 74 18 2 75 19 2 73.2 20 2 74.4 23 3 73.2 24 3 73.6 25 3 73.6 27 3 73.6 29 3 73.2 During the survey, residents and staff were observed and interviewed to determine if there were any concerns or issues with the lack of space or privacy. The residents and staff verbalized no complaints or concerns regarding space and privacy affecting residents' care. Recommend to continue room waivers.