Sequoia Transitional Care

null Based on observation, interview, and record review, the facility failed to implement the care plan (CP) for two of two sampled residents (Resident 6 and Resident 7) on Falling Star Program (fall prevention program) when:1. The call light, the remote control, and water pitcher were not within one of one sampled resident's (Resident 6) reach.2. The bowel and bladder (toileting) program every two hours was not implemented for one of one sampled resident's (Resident 7).These failures had the potential to place Resident 6 and Resident 7 at a greater fall risk. Findings:1. During a concurrent observation and interview on 6/17/25 at 10:10 am, in Resident 6's room with Assistant Director of Nursing (ADON), there was a gold star on Resident 6's name plate by the entry door. Resident 6 was in bed. Resident 6's call light and remote control were on the floor. The water pitcher was on the over bed table out of Resident 6's reach. ADON stated, I seeDuring a concurrent observation and interview on 6/17/25, at 10:25 am, in Resident 6's room with Certified Nursing Assistant (CNA) 4, Resident 6…

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

Based on interview and record review, the facility failed to ensure a Registered Nurse (RN) was scheduled and on duty eight hours a day, seven days a week. This failure had the potential for resident care to be negatively impacted. Findings: During a concurrent interview and record review on 1/8/25 at 9:09 a.m. with Director of Staff Development (DSD), the Nursing Staff Assignment and Sign-in Sheet (NSASS) dated July 2024 was reviewed. The NSASS indicated, there was no RN for 8 hours a day on 7/1/24, 7/2/24, 7/3/24, 7/4/24, and 7/5/24. DSD stated there was not an RN on duty for 8 hours a day on those days. During a concurrent interview and record review on 1/8/25 at 11:07 a.m. with DSD, the NSASS dated August 2024 was reviewed. The NSASS indicated, there was no RN for 8 hours a day on 8/5/24, 8/6/24, 8/7/24, 8/8/24, and 8/9/24. DSD stated there was not an RN on duty for 8 hours a day on those days. During a concurrent interview and record review on 1/8/25 at 11:50 a.m. with DSD, the NSASS dated September 2024 was reviewed. The NSASS indicated, there was no RN for 8 hours a day on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the resident's representative and the state long term care ombudsman (representatives who assist residents in long-term care facilities with issues related to day-to day care, health, safety, and personal preferences) were notified, in writing, when two of seven sampled residents (Resident 52 and Resident 82) were transferred to the hospital. This failure resulted in the resident representative and the ombudsman to not be aware of resident's healthcare status and location. Findings: During an interview on 1/7/25 at 2:37 p.m. with Resident 52, Resident 52 stated he had been to the hospital several times because of his diabetes (disorder characterized by difficulty in blood sugar control and poor wound healing) and high blood pressure. During a concurrent interview and record review on 1/8/25 at 3:36 p.m. with Minimum Data Set (MDS - a federally mandated resident assessment tool) Consultant (MDSCL), Resident 52's medical record was reviewed. MDSCL…

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 individualized, person-centered care plans were developed and implemented for three of six residents (Resident 46, Resident 52, and Resident 79). This failure had the potential for care needs to not be met. Findings: a. During an observation on 1/7/25 at 10:41 a.m. in Resident 46's room, Resident 46 was in her wheelchair, and she was speaking in short clips of gibberish with no discernable words. During an interview on 1/8/25 at 3:46 p.m. with Certified Nursing Assistant (CNA) 6, CNA 6 stated she can understand Resident 46's needs from having cared for her for the past year. During a concurrent interview and record review on 1/8/25 3:36 p.m. with Minimum Data Set (MDS - a federally mandated resident assessment tool) Consultant (MDSCL), Resident 52's medical record was reviewed. MDSCL stated Resident 52 was transferred to the hospital on 3/27/24 for GI [gastro (stomach)-intestinal] bleeding and nausea and vomiting. Resident 52's History & Physical (H&P) dated 4/12/24 indicated Resident 52 was discharged…

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 a communication tool was used for one of one sampled resident (Resident 46) with a speech impairment. This failure had the potential for Resident 46's concerns and needs to be unmet and for her psychosocial health to be negatively impacted. Findings: During an observation on 1/7/25 at 10:41 a.m. in Resident 46's room, Resident 46 was in her wheelchair, and she was speaking in short clips of gibberish with no discernable words. During an interview on 1/8/25 at 3:46 p.m. with Certified Nursing Assistant (CNA) 6, CNA 6 stated she can understand Resident 46's needs from having cared for her for the past year. During a concurrent interview and record review on 1/9/25 at 2:11 p.m. with Minimum Data Set Consultant (MDSCL), Resident 46's medical record was reviewed. The Minimum Data Set (MDS- Assessment tool) Section B indicated, Speech Clarity 1. Unclear speech. Makes Self Understood 3. Rarely/never understood. During an interview on 1/9/25 at 2:26 p.m. with Minimum Data Set Coordinator (MDSC), MDSC stated 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.

Based on interview and record review, the facility failed to follow its policy and procedure (P&P) titled, Repositioning, for three of three sampled residents (Resident 71, and Resident 52) who were dependent on staff to change position or transfer. This failure had the potential to result in further loss of mobility and skin breakdown. Findings: a. During an interview on 1/7/25 at 9:10 a.m. with Resident 71, Resident 71 stated she does not get out of bed or do any exercising because it might interfere with her brittle bones. During a concurrent interview and record review on 1/8/25 at 10:55 a.m. with Assistant Director of Nursing (ADON), Resident 71's medical record was reviewed. The Minimum Data Set (MDS- Assessment tool) Section GG Functional Abilities indicated, Resident 71 was Dependent on facility staff to A. Roll left and right: B. Sit to lying: C. Lying to sitting on side of bed: D. Sit to stand: E. Chair/bed-to-chair transfer . FF. Tub/shower transfer. The Task: Turn and Reposition (TTR) dated 12/26/24 to 1/8/25 was reviewed and the following was noted: 12/26/24 Resident 71…

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 one of one sampled resident (Resident 79) was assessed for a Bowel and Bladder Training program (structured plan designed to help residents regain control over their bowel and bladder functions). This failure had the potential for Resident 79 to be unable to maintain toileting abilities. Findings: During a concurrent interview and record review on 1/9/25 at 10:41 a.m. with Minimum Data Set (MDS - a federally mandated resident assessment tool) Consultant (MDSCL), Resident 79's medical record was reviewed. Resident 79's Bowel and Bladder Observation/Assessment (BBOA) dated 12/12/24 indicated, Incontinence [inability to control bladder and/or bowel] Assessment 1. Length of incontinence 1. Days and 3. Needs assistance getting to toilet. MDS Section H indicated, Urinary continence 3. Always incontinent and Bowel Continence 3. Always incontinent. MDSCL stated she was unable to find a care plan for incontinence and no documentation of Resident 79 being placed on a bowel and bladder training program. During an 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their policy and procedure (P&P) titled, Anti-coagulation [medication used to thin blood] Clinical Protocol to monitor for possible complications for two of two sampled residents (Resident 10 and Resident 57) on an anti-coagulant. This failure had the potential for Resident 10 and Resident 57 to have adverse effects. Findings: During a concurrent interview and record review on 1/9/25 at 2:03 p.m. with Assistant Director of Nursing (ADON), Resident 10's Medication Administration Record (MAR) dated 12/1/24 - 12/31/24 and 1/1/25 - 1/9/25 were reviewed. The MARs indicated, Give Eliquis [medication to prevent blood clots] 2.5 mg [milligram] Give 1 tablet by mouth two times a day for DVT [deep vein thrombosis - blood clot] prevention. ADON stated there was no documentation that the blood thinning medication was monitored for adverse effects and there should be. During a concurrent interview and record review on 1/9/25 at 11:12 a.m. with Minimum 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 observation, interview and record review, the facility failed to: 1. Implement their policy and procedure (P&P) titled, Expired Medication for two of two sampled residents (Resident 68 and Resident 41) when expired medications were not removed from medication administration carts. This failure had the potential for expired medications to be administered to Resident 68 and Resident 41. 2. Ensure Resident 15's medications were safely and securely stored from unauthorized personnel and other residents. This failure had the potential for medication to be accessed by unauthorized staff and residents. Findings: 1a. During a concurrent observation and interview on 1/8/25 at 9:01 a.m. with Licensed Vocational Nurse (LVN) 3, in the South Hallway, Resident 68 had three expired medications stored in the south medication cart: a. Hyosyne [used to decrease stomach acid] 0.125 mg/ml [milligram per milliliter] oral drops, with an expiration date of 9/19/24; b. Acetaminophen [pain medication] 650 mg 2 suppositories [medication administered in the rectum] with an expiration date of 9/19/24;…

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.

Based on observation, interview, and record review, the facility failed to follow the physician prescribed therapeutic (person-centered) diet for one of one sampled resident (Resident 64) which had the potential for adverse outcomes to Resident 64. Findings: During a review of Resident 64's Order Summary Report (OSR) dated 3/12/24, the OSR indicated, Regular Diet Regular with chopped meat texture, Thin Liquids consistency. During a concurrent observation and interview on 1/9/25 at 12:45 p.m. with Licensed Vocational Nurse (LVN) 1 and Resident 64, in Resident 64's room, the chicken fried steak on Resident 64's food tray was not chopped and uneaten. Resident 64 stated, look at my teeth, I cannot eat it. Resident 64 opened her mouth and had multiple missing teeth. LVN 1 stated, Resident 64's chicken fried steak was not chopped and should be chopped. During a review of the facility's policy and procedure (P&P) dated 10/2017, the P&P indicated, Therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care and in accordance with his 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.

Based on interview and record review, the facility failed to ensure the terms and conditions of the facility's arbitration agreement (a contract in which you agree to settle out of court, any dispute that arises with the other party) was clearly explained to five of eight sampled residents (Resident 26, Resident 57, Resident 70, Resident 80, and Resident 135) in a form and manner that they understood. This failure resulted in Resident 26, Resident 51, Resident 57, Resident 70, Resident 80, and Resident 135 signing the arbitration agreement without fully understanding that they had given up their rights to a court proceeding should a dispute happen. Findings: 1. During a review of Resident 26's admission Record (AR), dated 1/19/23, the AR indicated, Resident 26's primary language was Spanish. During a review of Resident 26's Minimum Data Set [MDS-an assessment tool] Section C- Cognitive Patterns (MDSCP), dated 10/15/24, the MDSCP indicated, Resident 26 had a Brief Interview for Mental Status (BIMS, cognition assessment tool, 15-point scale: 0-7 severe impairment, 8-12 moderate…

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: 1. Ensure proper discharge information was provided on a 30-day notice for one of three sampled residents (Resident 1). 2. Ensure the Ombudsman was made aware of a facility-initiated discharge for one of three sampled residents (Resident 1). These failures resulted in Resident 1 having the incorrect appeal information and the Ombudsman not being aware of the discharge. Findings: 1. During a review of Resident 1 ' s Notice of Proposed Discharge (NOPD) dated 11/5/24, the NOPD indicated, Reason(s) for the discharge.The transfer or discharge is appropriate because your health has improved sufficiently so that you no longer need the services provided by the facility. The safety of individuals in the facility is endangered by your presence.If you believe that the proposed discharge is inappropriate in your case, you have right to file an appeal. An appeal can be filed by writing to or calling the following: California Department of Public Health,…

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 notify one of three sampled residents (Resident 1), Responsible Party (RP), prior to room change. This failure resulted in violation of Resident 1 ' s rights. Findings: During an observation on 10/14/24 at 10 a.m., Resident 1 was in the front lobby sitting in a wheelchair. During an interview on 10/14/24 at 10:40 a.m., with the Director of Nurses (DON), DON stated on 8/15/24, a room change was done for Resident 1 and Resident 2. DON stated Resident 1 was originally in room [ROOM NUMBER] and Resident 2 was in room [ROOM NUMBER]. DON stated when Resident 2 requested for another room, the facility had decided to swapped rooms with Resident 1. DON stated on 8/15/24, Resident 1 was moved to room [ROOM NUMBER] and Resident 2 was moved to room [ROOM NUMBER]. During a concurrent observation and interview on 10/14/24 at 11:52 a.m., in room [ROOM NUMBER], Resident 2 was observed lying in bed. Resident 2 stated he was previously in room [ROOM…

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 one of three sampled residents (Resident 1) was referred to a neurologist (a medical specialist in the diagnosis and treatment of disorders of the nervous system) as ordered by the physician. This failure resulted in a delay of care. Findings: During a review of Resident 1 ' s Order Entry (OE), dated 5/25/24, OE indicated, Refer to (Physician Name [neurologist]) for consult r/t [related to] G61.0 [Diagnosis code (Guillain-Barre syndrome- a condition in which the immune system attacks the nerves)]. During an interview on 8/7/24 at 12:35 p.m. with Receptionist (RT), RT stated when there were referrals made for the residents, she was responsible to call and schedule the appointments. RT stated she had attempted to schedule a neurology appointment for Resident 1 but was unable to provide evidence of the attempts. During an interview on 8/9/24 at 1:10 p.m. with Director of Nursing (DON), DON stated she was unable to locate documentation of the attempts to schedule Resident 1 ' s neurology appointments. DON stated when…

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 there was a full-time licensed Director of Nursing (DON). This failure had the potential for unmet needs for all 94 residents residing at the facility. Findings: During an interview on 6/12/24 at 3:31 p.m. with Resident 1, Resident 1 stated the facility did not have a DON. During an interview on 6/12/24 at 4:12 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated the prior DON had not worked at the facility since March 2024. LVN 1 stated currently there was an interim (An RN applicant whose application for licensure in California by examination has been approved) DON that had completed the Registered Nursing (RN) program but was waiting on a testing date. During an interview on 7/22/24 at 4:10 p.m. with LVN 2, LVN 2 stated the DON was taking her RN boards and was going to be off for a couple of days. During an interview on 7/23/24 at 3:57 p.m. with Administrator, Administrator stated the previous DON last worked 3/7/24 and currently have no DON. Administrator stated the position is currently assigned to an…

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

Based on interview and record review, the facility failed to follow their policy and procedure on Advance Directives (AD a written instruction, such as living will or durable power of attorney for health care, recognized by the state law) for seven of seven sampled residents (Resident 58, Resident 59, Resident 13, Resident 67, Resident 47, Resident 7, and Resident 17). This failure had the potential to keep the residents uninformed of their rights to have their wishes honored regarding health care decisions during incapacitation (unable to make decisions for ones-self). Findings: During a concurrent interview and record review on 10/12/23 at 2:01 p.m. with Social Service Support (SSS), Resident 58's Physician Orders for Life-Sustaining Treatment (POLST), dated 12/19/22, was reviewed. The POLST indicated, Resident 58 did not have an AD. Resident 58 had indicated he was interested in executing an AD and was referred to social services. SSS confirmed she nor the other social service staff in her department had assisted the resident in establishing an AD. During a concurrent 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.

Based on interview and record review, the facility failed to ensure a Registered Nurse (RN) was scheduled and in the facility for at least eight consecutive hours a day, seven day per week. This failure had the potential to adversely affect resident care. Findings: During an interview on 10/11/23 at 10:03 a.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated the Director of Nursing (DON) is working as the RN on the weekdays. During an interview on 10/11/23 at 10:20 a.m. with LVN 3, LVN 3 stated the DON is working as the RN during the week and there is an RN supervisor that works on the weekends. During an interview on 10/11/23 at 11:31 a.m. with DON, DON stated she is the only RN working Monday through Friday. DON stated the facility's census averages over 60 residents, and she is unsure if she can work as both the DON and RN during her shifts. During a concurrent interview and record review on 10/11/23 at 3:40 p.m. with DON, the facility's Nursing Schedule (NS), dated September 2023 was reviewed. The NS indicated, the DON was the only RN working in the facility on 9/1/23,…

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 a method of food preparation which maintained nutritive value of food, when pureed (smooth or liquidized) foods were not prepared as close as possible to serving time for four of four sampled residents (Resident 10, Resident 20, Resident 25 and Resident 47). This had the potential to decrease the nutritional value of the food and compromise the resident's nutritional status. Findings: During a concurrent observation and interview, on 10/10/23 at 9:05 a.m. with Dietary Aid (DA) 1, in the kitchen, containers with pureed foods were in the oven, set at 200 degrees Fahrenheit (F - a measure of temperature). DA 1 stated, the pureed foods for lunch had already been prepared and chicken, pasta, and spinach were holding in the oven which is set at 200 degrees F. DA 1 stated, she finished the pureed foods around 8:15 a.m. and these will be served for lunch at 11:45 a.m. During a record review of Diet Type Report (DTR), dated 10/10/23, the DTR indicated, Resident 10, Resident 20, Resident 25 and Resident 47,…

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 have a functioning call light system in place for three of nine sampled residents (Resident 64, Resident 37, and Resident 67). This failurehad the potential for residents (Resident 37, Resident 64 and Resident 67) not to have their needs met. Findings: During a concurrent observation and interview on 10/11/23 at 8:37 a.m. with Resident 64 in Resident 64's room, Resident 64 was laying in his bed. Resident 64 stated he was soiled and needed to be changed, but no one comes when he pushes the call light. Resident 64 stated, They see the light is for [this room] and they run away from area 51 like its infected. Resident 64 stated it makes him feel like he is disgusting and doesn't matter. Resident 64 attempted to press the call light, but the light outside of the room door was not turning on. Resident 64 stated he has told maintenance, the Administrator, social services, and activities. He stated, It's been like this for weeks, and they just gave me this new one. Resident 64 showed that he had a flat, pressure…

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

Based on interview and record review, the facility failed to ensure the Responsible Party (RP) was notified for a change in condition for two of six sampled residents (Resident 48 and Resident 13) when: 1. Resident 48 refused a vaccination (a substance used to protect against certain diseases). 2. Resident 13's RP was not notified of 3 fall incidents on 7/2/23, 8/12/23 and 8/13/23. These failures had the potential for the residents to not receive necessary care and treatment and to develop further medical complications. Findings: 1. During a concurrent interview and record review on 10/12/23 at 11:12 a.m. with Infection Preventionist (IP), Resident 48's Clinical Record was reviewed. Resident 48's Vaccination Record (VR), undated indicated, Resident 48 refused her pneumococcal vaccination (vaccine used to prevent serious lung infections). IP stated there was no documentation found in the clinical record that Resident 48's RP was notified of the refusal. During a review of the facility's policy and procedure (P&P) titled, Requesting, Refusing and/or Discontinuing Care or Treatment,…

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

Based on observation, interview, record review, the facility failed to develop and implement a comprehensive person focused care plan for one of five sampled residents (Resident 57) when Resident 57 did not have a bed in his room. This failure placed Resident 57 at risk of not having his care needs met. Findings: During a concurrent observation and interview on 10/9/23 at 10:09 a.m. with Resident 57, in Resident 57's room, Resident 57 was sitting in a recliner and there was no bed on his side of the room. Resident 57 stated he prefers to sleep in recliner. During a concurrent interview and record review on 10/12/23 at 11:49 a.m. with Director of Nursing (DON) Resident 57's Clinical Record (CR), was reviewed. The CR indicated, no care plan was developed for Resident 57 sleeping in a recliner. DON stated there is no care plan for Resident 57 sleeping in a recliner. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 2022, the P&P indicated, A comprehensive, person-centered care plan should include measurable objectives…

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 physician's orders for two of two sampled residents (Resident 13 and Resident 6) when: 1. Facility staff did not ensure Resident 13's geri sleeves (cloth sleeve used to provide protection for sensitive skin from friction and shearing) were placed in accordance with physicians orders. This failure had the potential to result in bruising, skin tears, or other avoidable injuries to the Resident 13. 2. Facility staff did not ensure Resident 6's oxygen tank was set up to administer the flow rate of oxygen at 3 liters per minute (LPM) as ordered by the physician. This failure had the potential for Resident 6 to experience shortness of breath (SOB) or hypoxia (absence of enough oxygen in the tissues to sustain bodily functions). Findings: 1. During an observation on 10/10/23 at 11:00 a.m. in the north hallway Resident 13 was up in the wheelchair without geri sleeves on. During a concurrent interview and record review on 10/12/23 at 12:02 p.m. with Assistant Director of Nursing (ADON), Resident 13's Clinical…

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 administer oxygen to one of two sampled residents (Resident 6) according to a physician's order. This failure had the potential to result in Resident 6 experiencing respiratory distress and hypoxia (absence of enough oxygen in the tissues to sustain bodily functions). Findings: During a concurrent observation and interview on 10/9/23 at 11:57 a.m. with Assistant Director of Nursing (ADON), in the dining room, Resident 6 had an oxygen canula in place, the oxygen tank was empty. ADON stated residents should not be brought to the dining room with an empty oxygen tank. During an interview on 10/9/23 at 12:14 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she did not check the tank before Resident 6 went to the dining room. LVN 1 stated, It's the nurses job to check and change the tanks, we should be checking. During a review of the facility's policy and procedure (P&P) titled, Oxygen Administration dated October 2010, the P&P indicated, Steps in the Procedure.10. Adjust the oxygen delivery device so…

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 the menu as planned for a mechanical soft diet order for one of one sampled residents (Resident 58). This failure resulted in Resident 58's nutritional needs not being met. Findings: During a concurrent observation and interview on 10/9/23 at 11:54 a.m. with Registered Dietitian (RD), in the main dining room, Resident 58's meal tray included intact cauliflower and parsley sprig. Resident 58's tray ticket indicated a mechanical soft/chopped meats diet (diet for individuals who have trouble chewing or swallowing). RD stated, the cauliflower should have been chopped and the parsley should have been flaked for a mechanical soft diet. During a record review of Fall Menus, dated 10/9/23, the menu indicated, Mech Soft, vegetable soft, chop ½ [1/2 inch - unit of measure] and Parsley Sprig Garnish, Flakes. During a review of Resident 58's Physician's Dietary - Diet Order (PDO), dated 2/12/23, the PDO indicated, CCHO [Controlled Carbohydrate - same amount of carbohydrates each day] diet Mechanical Soft 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.

Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 64) food was served in a form to meet the resident's needs. This had the potential for Resident 64 to not have his nutritional needs met. Findings: During a review of Resident 64's Order Entry (OE), dated 7/7/22, the OE indicated, Fortified, Large Portions diet, Regular texture, Thin Liquids consistency. During a review of Resident 64's Restorative Nursing Program Referral (RNPR), dated 6/15/23, the RNPR indicated, RNA [Restorative Nursing Assistant] Program Referral: b. Dining Program. During a concurrent observation and interview on 10/9/23 at 12:19 p.m. with Resident 64, in the family dining room, Resident 64's meal plate had meat cut in large slices. Resident 64 stated, the meat was tough, and he could not eat it. Resident 64 stated, the chicken is frequently tough, and he wanted it served differently so he could eat it. During an interview on 10/9/23 at 12:21 p.m. with RNA, RNA stated, she had not communicated to anyone that Resident 64 was being served meat…

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 a sanitary kitchen environment when: 1. Dietary Aid (DA) 2 failed to perform hand hygiene after scraping dirty dishes, before touching a utility cart. 2. DA 3 failed to perform hand hygiene after touching the same utility cart, before picking up a stack of clean plates. 3. DA 4 failed to perform hand hygiene after handling dirty dishes and draining dirty dish water from the sink, before wiping hands on her shirt and touching container in the clean food prep area. These failures had the potential to result in foodborne illness (illness caused by food contaminated with bacteria, viruses, parasites, or toxins) to all of the facility's at-risk population. Findings: 1. During a concurrent observation and interview on 10/10/23 at 8:29 a.m. with DA 2 in the kitchen dishwashing area, DA 2 was wearing gloves while rinsing dishes from the breakfast trays. While wearing those same gloves, DA 2 walked to the food prep area and touched a utility cart. DA 2 stated she should have removed the gloves and washed her…

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 policy and procedure (P&P) titled, Handwashing/Hand Hygiene for two of four sampled Residents (Resident 81 and Resident 68) when: 1. One staff member entered Resident 81's room, to administer medication without washing their hands or using hand sanitizer. 2. One staff member entered Resident 68's room to administer medication without washing their hands or using hand sanitizer. These failures had the potential to spread infectious diseases to other residents, staff, and visitors of the facility. Findings: 1. During a concurrent observation and interview on 10/11/23 at 7:30 a.m. with Licensed Vocational Nurse (LVN) 1 outside Resident 81's room, LVN 1 entered Resident 81's room without applying hand sanitizer prior to administering medication to Resident 81. LVN 1 stated, I am pretty sure, I hand sanitized prior to entering the room. LVN 1 stated the process is to use hand sanitizer prior to room entry. 2. During a concurrent observation and interview on 10/11/23 at 7:40 a.m. with LVN 4 outside…

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 sling (wraps around and supports the patient who needs transferring with the use a mechanical lift) for the Hoyer lift (mechanical lift that allows a person to be lifted and transferred with a minimum of physical effort) was in good repair for one of 19 sampled residents. This failure resulted in the loop of Resident 1's sling snapping off while Resident 1 was being transferred and Resident 1 falling to the floor. Findings: During a review of Resident 1's Progress Notes (PN) dated 4/5/23 at 11:23 p.m., the PN indicated, Incident Note.while doing med [medication] pass at around 2035 [8:35 pm], this writer was notified by CNA [Certified Nursing Assistant] that resident fell while [Resident 1] was being transferred back to bed. Went to room [ROOM NUMBER] and assessed the situation and found [Resident 1] laying on the floor at the foot of bed facing the wall. CNAs [CNA 1], [CNA 2] and [CNA 3] were in the room with resident, stated…

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 care plan was implemented for one of three sampled residents (Resident 1) when a psychological evaluation was not completed. This failure had the potential for Resident 1 to experience subsequent falls. Findings: During an observation, on 8/9/23 at 2:08 p.m., in Resident 1's room, Resident 1 was lying in bed with a fall mat on the right side of the bed and a bed alarm was in use. During a review of Resident 1's Progress Notes (PN), dated 2/28/23 at 11:27 a.m., the PN indicated, IDT (Interdisciplinary Team-group of healthcare professionals who work together to provide the care needed) met in regards to resident having a witnessed fall on 2/27/23 @ [at] approx. [approximately] 1754, charge nurse was informed by staff that resident was noted to get up from her w/c [wheelchair] and attempted to grab her walker, resident was noted to be agitated throughout the day, resident was noted to be going in and out of residents rooms, being restless, resident noted to have a change in behavior.Current…

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.