Pittsburg Skilled Nursing Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to treat Resident 10 with dignity and respect when the resident was observed to be eating her pureed (cooked food that had been ground, pressed and blended to the consistency of creamy paste) breakfast in plastic cups. This failure had the potential to cause emotional distress to the resident. Findings: During a review of Resident 10's admission Record, dated 8/27/24, indicated Resident 10 was admitted to the facility on [DATE] with diagnosis of major depressive disorder (a persistent feeling of sadness). During a review of Resident 10's Physician's Order (PO), dated 6/29/22, the PO indicated Resident 10 had a diet order of pureed consistency. During a concurrent observation and interview on 8/25/24 at 10:08 a.m., Resident 10 sat up in bed in her room and ate pureed food in two plastic cups on top of her bed table with a spoon. When asked about the plastic cups, Resident 10 stated, I don't know why they serve my food in cups. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure family representative (FR) of one of three sampled residents (Resident 36) made an informed decision for the use of bed rails for Resident 36. Facility did not share and maintain a record of accurate assessment of medical needs, alternative attempts that failed to meet resident's needs, alternatives considered but not attempted because they were inappropriate, prior to the use of bedrails, with Resident 36's FR. Facility designated a non-licensed professional (admission Coordinator-AC) to obtain informed consents for use of bed rails during admission process. This failure placed Resident 36's FR to be unaware of the medical necessity, and alternative options available instead of using bed rails. (Cross Reference F 700) Findings: A review of Resident 36's admission Record printed on 8/25/24 indicated Resident 36 was admitted to the facility on [DATE]. During a record review of Resident 36's Minimum Data Set (MDS, a resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete and submit the Death in Facility Tracking Record to Centers for Medicare & Medicaid Services (CMS) for one of one sampled resident (Resident 5) when Resident 5 died in the facility on [DATE]. This failure resulted in Resident 5's specific payment information and quality measure data to be out of date. Findings: During a review of Resident 5's undated admission Record, the record indicated, Resident 5 was admitted in the facility on [DATE] with a diagnoses of Cervical Disc Disorder, Malignant Neoplasm of Prostate, Combined Systolic and Diastolic Heart Failure and Chronic Obstructive Pulmonary Disease. During a review of Resident 5's Nurses Notes dated [DATE], the record indicated Resident 5 died in the facility on [DATE] at 6:00 p.m. During an interview on [DATE] at 10:58 a.m. with the Minimum Data Set Coordinator (MDSC), the MDSC stated Resident 5's Death in Facility Tracking Record was missed and was not completed for submission. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to accurately assess and code one of 15 sampled residents (Resident 36) for diagnosis of Pneumonia (an infection of one or both lungs caused by bacteria, viruses or fungi causing difficulty in breathing, cough, fever, and chills) in the quarterly Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan) when the MDS was coded Yes for an active diagnosis of Pneumonia and Resident 36 did not have Pneumonia. This failure resulted in an outdated and inaccurate reflection of Resident 36's medical condition. Findings: A review of Resident 36's admission Record printed on 8/25/24 indicated Resident 36 was admitted to the facility on [DATE]. During an observation and interview with Certified Nursing Assistant (CNA) 2 on 8/25/24 at 9:35 a.m., Resident 36 was lying in bed. CNA 2 stated Resident 36 was not able to communicate her needs and/or understand others.…

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 (Resident 15) of one sampled resident completed a Preadmission Screening and Resident Review (PASRR, a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care. PASRR requires that 1. all applicants to a Medicaid-certified nursing facility be evaluated for a serious mental disorder and/or intellectual disability; 2. be offered the most appropriate setting for their needs (in the community, a nursing facility, or acute care setting); and 3. receive the services they need in those settings.) evaluation when Resident 15 had Schizophrenia (a mental condition which makes it difficult to think clearly, have normal emotional responses, act normally in social situations, and tell the difference between what is real and what is not real) and was not screened for PASRR Level II (A Level 2 Evaluation is a person-centered evaluation that…

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 monitor and document specific behavior and side effects related to the use of Sertraline (a medication used to treat depression) for one of five sampled residents (Resident 36) being used for a behavior of uncontrollable scratching. This failure placed Resident 36 at risk for not receiving individualized care to address her medical, mental and psychosocial needs. Findings: A review of Resident 36's admission Record printed on 8/25/24 indicated Resident 36 was admitted to the facility on [DATE]. During an observation and interview with Certified Nursing Assistant (CNA) 2 on 8/25/24 at 9:35 a.m., Resident 36 was lying in bed. CNA 2 stated Resident 36 was not able to communicate her needs and/or understand others. CNA 2 stated Resident 36 had a habit of scratching herself. During a concurrent interview and record review with Director of Nursing (DON) on 8/26/24 at 12:19 p.m., Resident 36's Electronic Health Record (EHR) for Physician orders…

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 allow one of five sampled residents (Resident 14) to store food brought by family member in the facility's refrigerator. This failure resulted in Resident 14 feeling disappointed. Findings: During an interview on 8/25/24 at 4:13 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated the facility does not have a refrigerator to store residents' food brought by family. CNA 1 stated residents who had foods from outside the facility were asked to finish the food if they can and leftovers were thrown away. CNA 1 stated residents were told there was no place to keep leftover foods. During an interview on 8/25/24 at 4:20 p.m. with the Administrator (ADM), the ADM stated the facility does not reheat residents' food brought by family and the food was to be consumed for the day. The ADM stated any remaining food was thrown away and cannot be placed in the kitchen refrigerator. The ADM stated there was no personal refrigerator inside residents' rooms. During an interview on 8/27/24 at 2:01 p.m. with Resident 14 in Resident 14's…

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

Based on observation, interview, and record review, the facility failed to ensure accuracy of medical record for one of one sampled resident (Resident 40), when a physician order to implement bed rails (a barrier attached to the side of a bed) was created on 8/27/24 for a four-month older date, 4/13/24 without any verification. This failure resulted in inaccurate reflection of physician orders to implement bed rails for Resident 40. Findings: During a record review of Resident 40's admission Record dated 8/28/24, AR indicated Resident 40 was admitted to the facility with diagnosis of post hemorrhagic anemia (large volume blood loss). During an observation and interview on 8/27/24 at 9:37 a.m. with Licensed Vocational Nurse (LVN) 6, Resident 40 was observed lying in his bed with both half-sized bed rails were raised. LVN 6 stated the half-sized bed rails was provided by the hospice agency (a program for terminally ill persons where an array of services is provided for the palliation and management of terminal illness and related conditions.). During a concurrent record review 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 observation, interview, and record review, for one of two sampled residents (Resident 1), the facility failed to ensure Resident 1, who received nutrition through g-tube feeding, received appropriate treatment and services to prevent complications of enteral feeding when: a. Resident 1's head was not elevated during and after feeding, b. Aspiration precautions were not observed even after multiple hospitalizations related to aspiration. These failures had contributed in multiple admissions to the hospital for aspiration pneumonia (lung infection caused by something other than air being inhaled into the respiratory tract, can be food, liquid, stomach contents). Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included dysphagia (difficulty swallowing) and gastrostomy tube (also referred to as g-tube, a tube is surgically inserted through the abdominal wall into the stomach for the introduction…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) and Notice of Medicare Non-Coverage (NOMNC) to three of three sampled residents (Resident 26, 31, 34) after they were discharged from Medicare Part A services and continued to live in the facility. This deficient practice resulted in Resident 26, Resident 31, Resident 34, and their responsible parties being uninformed about their potential liability for payment and related standard claim appeal rights. Findings: During a record review of Resident 26's admission Record, dated 6/22/22, the record indicated Resident 26 was admitted to the facility on [DATE]. During a review of Resident 26's undated Notice of Medicare Non-Coverage, indicated Resident 26's Medicare Part A coverage services will end on 3/16/22. During a record review of Resident 31's admission Record, dated 6/22/22, the record indicated Resident 31 was admitted to facility on 8/22/16. During a review of Resident 31's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to accurately complete the Minimum Data Set (MDS- an assessment tool used to guide care) for two of 14 sampled residents (Resident 27 and 29) when: 1. Resident 27's MDS assessment inaccurately reflected significant weight loss; and 2. Resident 29's MDS assessment inaccurately reflected Resident 29 walking with one-staff total assistance and not receiving any physical restraints. This deficient practice resulted in an inaccurate reflection of Resident 27 and Resident 29's comprehensive assessment and had the potential for inadequate weight management for Resident 27 and inadequate care to meet Resident 29's needs. Findings: 1. During a review of Resident 27's admission Record, dated 6/23/22, the record indicated Resident 27 was admitted to the facility on [DATE]. During a phone interview on 6/23/22, at 11:00 a.m., with Minimum Data Set Coordinator (MDSC) 1, Resident 27's section K for MDS assessment, dated 4/24/22 was reviewed. The MDSC 1…

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, for three of 34 sampled residents (Resident 31, 9, 21), the facility failed to provide the necessary care to maintain good grooming and personal hygiene when Resident 31, 9, and 21 had long, dirty, and/or jagged fingernails. This failure resulted to Resident 31, 9, and 21 not receiving adequate nail care and had the potential for the spread of infection. Findings: During an initial observation on 6/20/22, at 11:45 a.m., Resident 31 had long, dirty and jagged fingernails. A review of Resident 31's admission Record, dated 6/21/22, indicated Resident 31 was admitted to the facility on [DATE], with hemiplegia (paralysis of one side of the body), hemiparesis following cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it) affecting right dominant side, muscle weakness, and other abnormalities of gait (walking) and mobility. A review of Resident 31's Minimum Data Set (MDS, an assessment tool used to guide care),…

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 were dated and labeled, emergency medications were replaced, and emergency medications and controlled substances (medications with high abuse or misuse potential) were correctly logged when: 1. One 2.5 mL (milliliter, unit of measurement) bottle of bimatoprost (medication to treat glaucoma) ophthalmic solution was opened but not dated and one Multi-Dose Inhaler (MDI) of budesonide 80 mcg (microgram, unit of measuring weight)/formoterol fumarate dihydrate 4.5 mcg (medication used to help with breathing) was opened but not dated or labeled with resident identifier; 2. The opened Oral Emergency Kit (E-Kit, a box with emergency medications) was not replaced by the pharmacy within 24 hours; 3. Emergency Drug Kit Use Log had inaccurate medication usage records; 4. The controlled substances disposition record did not indicate a method of destruction, witness signature, or date of disposal. These failures had the potential to result in residents receiving wrong or expired medications, residents not…

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 3. During a review of Resident 27's admission Record dated 6/23/22, the record indicated Resident 27 was admitted to the facility on [DATE] with unspecified dementia with behavioral disturbance and major depressive disorder. During a review of Resident 27's Physician's order summary report dated 6/22/22 indicated Resident 27 received one tablet of 50 milligrams (mg) of Quetiapine Fumarate [a psychotropic medication used to treat mental disorders] by mouth at bedtime for unspecified dementia with behavioral disturbance manifested by seeing, feeling or hearing things that are not there since 11/30/2019. During a record review and interview with RN, on 6/24/22, at 8:30 a.m., facility's document titled, Consultant Pharmacist Medication Regimen Review . dated 4/1/22 through 4/26/22 for Resident 27 was reviewed. RN stated, for Resident 27, the consultant pharmacist recommended to indicate the appropriate clinical situation to support the continued use of quetiapine fumarate. RN further stated facility did not follow…

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 medication error was not five percent or greater for two of six sampled residents (Resident 19 and 8) when: 1. Resident 19 was administered lactobacillus acidophilus (medication helps with digestive issues) 75 million cells (unit of measure) instead of 500 million cells, as prescribed; and 2. Resident 8 was administered sennosides (medication to treat constipation) 8.6 milligram (mg, unit of measure) tablet as a whole tablet and not crushed. This failure resulted in two medication errors out of 28 opportunities, resulted in a medication error rate of 7.14%, and put the residents at risk of receiving a subtherapeutic dose of medication or increased risk of aspiration (accidentally inhaling food or liquid into airway) and choking. Findings: 1. During a medication pass observation on 6/21/22, at 8:21 a.m., with Registered Nurse (RN), RN was observed administering to Resident 19, one 8.6 mg tablet of lactobacillus acidophilus with pectin containing 140 mg calcium, 100 mg pectin, and 75 million live…

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 were stored and labeled appropriately when: 1. the medication room (MR) temperature was out of range; 2. the refrigerator containing controlled medications was unlocked; 3. loose pills were found in two medication carts (Medication Cart 1 and 2); 4. medications not administered were stored unlabeled in a drawer in the med carts; 5. controlled medications to be disposed were store in a single locked, not permanently affixed drawer; and 6. disposed controlled substances were kept in an openly accessible container. These failures had the potential for administration of medication to the wrong resident, temperature sensitive medications to degrade, diversion of medications, and miscount of medications. Findings: 1. During a concurrent observation of MR and interview with Licensed Vocational Nurse (LVN) 1, on 6/21/22, at 1:51 p.m., MR temperature was observed to be 79° F (Fahrenheit, unit for measuring temperature). LVN 1 confirmed the MR temperature was 79°F and medication room temperature 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 store, prepare, and serve food under sanitary conditions when: 1. four packages of bread in the freezer were unlabeled and undated; 2. four pieces of pie crust were undated; 3. the dietary aide did not wear a face mask; 4. two white electric fans were brownish and dusty; and 5. the condiment rack was brownish and sticky. These failures had the potential to cause food contamination and food borne illness to 34 residents who received food from the kitchen. Findings: 1. During s concurrent initial tour of the kitchen on 6/20/22, at 9:15 a.m., and interview with the Dietary Services Supervisor (DSS), four packages of garlic bread and four pieces of pie crust in the freezer were unlabeled and undated. The DSS stated all items in the kitchen needed to have a received date. A review of the facility's policy and procedure titled, Labeling and Dating of Foods, dated 2018, indicated, Food delivered to the facility needs to be marked with a received date. 2. During the initial kitchen tour observation on 6/20/22, 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.

Based on observation, interview, and record review, the facility failed to maintain an effective infection control program when one of three sampled residents (Resident 8) did not have a date on the tubing of the nebulizer (a small machine that turns liquid medicine into a mist, and the tip of the tubing with the mouthpiece was on the floor. This failure placed Resident 8 at risk for healthcare-associated infections. Findings: During observation on 6/24/22, at 9:20 a.m., at Resident 8's bedside, Resident 8 had two nebulizers on the nightstand by his bedside. Each nebulizer was set up with a tube connected to the machine, while the other tip of the tube was connected to a mouthpiece. The tube did not have a date, and the tip of the tube with the mouthpiece was on the floor behind the nightstand. During an interview on 6/24/22, at 9:30 a.m., with the Registered Nurse Supervisor (RN), RN stated the tubes must be dated when they were changed every seven days, and they must be rolled and put in a plastic bag when not in use. A review of the facility's policy and procedure titled, Care 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 attempt to use the least restrictive alternatives and to reevaluate the use of a Posey bed (a hospital bed, canopy, and mattress system where all walls are zipped up from outside and the resident cannot exit out of it without assistance) for one of 14 sampled residents (Resident 29) when Resident 29 used a Posey bed and was not reevaluated. This failure placed Resident 29 at risk of impaired psychosocial well-being. Findings: During a record review of Resident 29's admission Record, dated 6/20/22, the record indicated Resident 29 was admitted to the facility on [DATE]. During a record review Resident 29's Minimum Data Set (MDS, an assessment tool used to guide care), dated 5/5/22, the MDS indicated Resident 29's cognitive skills for daily decision making was severely impaired. The MDS further indicated Resident 29 required total dependence on staff for activities of daily living (activities related to personal care including walking,…

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 accurately complete the Pre-admission Screening and Resident Review (PASRR) assessment for one of two sampled residents (Resident 3) when Resident 3's PASRR did not reflect the diagnosis of Parkinson's Disease (a gradual and progressive movement disorder that initially causes tremor [vibration] in one hand, stiffness or slowing of movement). This failure placed Resident 3 at risk to not receive an in-depth mental illness evaluation and care appropriate to his needs. Findings: A review of Resident 3's admission Record, dated 6/20/22, indicated Resident 3 was originally admitted to the facility on [DATE] with Parkinson's Disease. During a concurrent interview and record review on 6/20/22, at 12:00 p.m., with Medical Records Director (MRD), Resident 3's clinical paper chart was reviewed. MRD 1 stated Resident 3's most recent PASRR Level I assessment was completed on 8/28/18. Resident 3's PASRR Level I screening Document indicated facility answered No to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to review and revise the care plan for one of 14 sampled residents (Resident 29) when Resident 29's care plan for a Posey bed restraint (a hospital bed, canopy and mattress system where all walls are zipped up from outside and the resident cannot exit out of it without assistance) was not reviewed and revised for two years and ten months. This failure placed Resident 29 at risk for impaired psychosocial well-being and had the potential to not meet Resident 29's care needs. Findings: During a record review of Resident 29's admission Record, dated 6/20/22, the record indicated Resident 29 was admitted to the facility on [DATE]. During a concurrent observation and interview with Certified Nursing Assistant (CNA) 5, on 6/20/22, at 9:37 a.m., Resident 29 was observed sleeping in a Posey bed with the walls zipped up. CNA 5 stated Resident 29 has been in the Posey bed for at least 5 years due to risk of falls. CNA 5 further stated Resident 29 did…

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 one of 14 sampled residents (Resident 28) received dental care services when Resident 28 did not receive treatment for tooth extraction for over three consecutive months. This failure resulted in Resident 28 to experience teeth pain and placed Resident 28 at potential risk for inability to eat or chew well. Findings: During a review of Resident 28's admission Record, dated 6/21/22, the record indicated Resident 28 was admitted to the facility on [DATE] with chronic pain syndrome. During a record review of Resident 28's Minimum Data Set (MDS, a resident assessment tool used to guide care) dated 4/25/22, the MDS Section B indicated Resident 28 was usually understood by others and was able to make herself understood. During a concurrent observation and interview on 6/20/22, at 10:19 a.m., with Resident 28, Resident 28 stated she needed three left upper teeth pulled out. Resident 28 opened her mouth, she had brownish black colored…

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, for one of 13 sampled residents (Resident 37), the facility failed to implement their written policies and procedures when a staff member witnessed Resident 37 being called disparaging and derogatory names by her roommate, Resident 38. The facility did not prevent further incidents, did not identify the incident as abuse, did not conduct an investigation, did not protect Resident 37 from abuse, and did not report the abuse. This failure resulted in continuing verbal abuse of Resident 37 by Resident 38 and caused Resident 37 to feel stressed, angry, heavy in the chest, cold, and clammy. Findings: A review of Resident 37's admission Record indicated Resident 37 was admitted to the facility with multiple diagnoses, including dyspnea (difficult or labored breathing). A review of Resident Resident 37's Brief Interview for Mental Status (BIMS, a tool used to assess mental function) in the Minimum Data Set (MDS, an assessment tool used to guide care), dated 8/14/19, indicated 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 observation, interview, and record review, the facility failed to ensure two of 13 sampled residents (Residents 20 and 46) were provided with respiratory care per physicians' orders when: 1. Resident 20 was given 4 Liters per minute (L/min) of oxygen instead of 2 L/min per doctor's orders. 2. Resident 46 was given 4.5 L/min of oxygen instead of 2 L/min per doctor's orders. These deficient practices had the potential for life-threatening complications related to oxygen toxicity. Findings: 1. A review of Resident 20's admission Record indicated Resident 20 was admitted with multiple diagnoses, including a malignant neoplasm (cancer) of the left bronchus (lung) and acute respiratory failure. During an observation on 9/9/19 at 9 a.m., Resident 20 was sitting on her bed, and oxygen was being administered to her at 4 L/min through a nasal cannula (NC, a tubing device that fits in the nose). Resident 20 was not able to answer questions at that time. A review of the Resident 20's Medication Review Report showed a physician's order dated 7/2/19 for Oxygen at 2 L/min via NC as needed…

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 ensure one of 13 sampled residents (Resident 6) was able to carry out activities of daily living (ADLs) when staff repeatedly failed to assist the resident with inserting his dentures. This failure resulted in Resident 6 feeling humiliated and neglected and had the potential to effect the resident's nutrition and oral hygiene. Findings: A review of Resident 6's dental exam dated 2/12/19 indicated Resident 6 had full upper dentures (FUD) and full lower dentures (FLD). During an observation and concurrent interview with Resident 6 on 9/9/19 at 8:33 a.m., the resident did not have his FUD and FLD in his mouth. Resident 6 stated, No one puts on my dentures. I don't know how to put them on. It has been at least two months since I have worn them. They are just sitting on my bedside table. During an observation and concurrent interview with Resident 6 on 9/9/19 at 2:30 p.m., the resident was observed in the activity room without his FUD and FLD in his mouth. Resident 6 stated, I always eat without my dentures, because…

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.