Sierra Valley Rehab Center

Based on interview and record review, the facility failed to ensure annual competencies were completed for one of five sampled Certified Nursing Assistants (CNA) 1. This failure had the potential for CNA 1 to not be competent when providing care to residents. Findings: During a concurrent interview and record review on 2/26/25 at 3:47 p.m. with Director of Staff Development (DSD), CNA 1's Employee Orientation Checklist (EOC), undated was reviewed. The EOC indicated, CNA 1 date of hire was 12/26/23. CNA 1's new employee orientation began on 12/26/23 and was completed on 12/27/23. CNA 1's Nurse Assistant Competency Checklist (NACC), [undated] was reviewed. The NACC indicated, CNA 1 had completed the competency checklist on 12/27/23. DSD was unable to provide a 2024 annual competency for CNA 1. DSD stated CNA 1 did not have a current annual competency completed as required. Policy requested from facility and was not provided.

Based on observation, interview, and record review, the facility failed to follow their policy and procedure (P&P) titled, Food Preparation, for one of one cooks (Cook 1) when [NAME] 1 did not measure recipe ingredients. This failure had the potential for residents' nutritional needs to not be met. Findings: During a review of the facility's RECIPE: ZESTY SPINACH, (RZS) dated 2/24/25, the RZS indicated, add 1 tsp to 1 1/2 tsp of garlic powder, add 1/4 tsp to 3/4 tsp of salt, and add 1/2 tsp to 1 tsp of red pepper flakes. During a concurrent observation and interview on 2/25/25 at 9:14 a.m. with [NAME] 1, Certified Dietary Manager (CDM), and Registered Dietician (RD), in the kitchen, [NAME] 1 was preparing spinach to be pureed. [NAME] 1 poured all the pureed spinach into a larger dish then added unmeasured amounts of garlic powder, iodized salt, chili powder, and melted butter into the spinach. [NAME] 1 stated she does not use the recipe, she went by taste. [NAME] 1 stated she should have measured the seasoning as listed in the RZS. During an interview on 2/25/25 at 3:17 p.m. with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure assistive feeding devices were available for one of one sampled resident (Resident 72). This failure had the potential to prevent Resident 72 from maintaining or improving his independence in self-feeding skills when consuming meals and snacks. Findings: During a review of Resident 72's admission Record (AR), dated 2/27/25, the AR indicated, Resident 72 was readmitted on [DATE] with a diagnosis hemiplegia (inability to move one side of the body) following cerebral infarction (stroke resulting in blockage in the blood vessels supplying blood to the brain) affecting right dominate side. During a concurrent observation and interview on 2/24/25 at 1:34 p.m. with Resident 72 in Resident 72's room, Resident 72's lunch tray had a cup of tea with one handle, four small bowls containing pureed food, and two regular eating spoons. Resident 72's meal ticket was reviewed. The meal ticket indicated ADAP [adaptive] Equip [equipment] 2 Handle sip…

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 implement its Policy and Procedure (P&P) titled, Smoking, for one of 21 Residents (Resident 4) when tobacco was at the bedside, a smoking care plan and smoking assessment were not completed. These failures had the potential to place residents, visitors, and staff at risk for injury/harm due to potential unsafe smoking practices and access to tobacco. Findings: During a concurrent observation and interview on 2/25/25 at 11:31 a.m. with Licensed Vocational Nurse (LVN) 4 in Resident 4's room, Resident 4 had a can of tobacco at the bedside. LVN 4 stated the tobacco should be locked up and not left at the bedside. During an interview on 2/26/25 at 11:18 a.m. with Activities Assistant (AA), AA stated, If [Resident 4] had full access to his chewing tobacco he will use too much .It is supposed to be locked up. During a concurrent interview and record review on 2/27/25 at 11:52 a.m. with Director of Nursing (DON), Resident 4's, clinical record was reviewed. DON was stated there was no tobacco use care plan or safe…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect one of three sampled residents (Resident 1) from verbal abuse inflicted by his roommate (Resident 2). This failure resulted in Resident 1 being agitated, noisy, restless and the inability to sleep with the potential for psychosocial harm. Findings: During a review of Resident 1's Minimum Data Set (MDS), dated [DATE], the MDS indicated, Brief Interview for Mental Status (BIMS).05 (severe cognitive impairment). During a review of Resident 2's MDS dated [DATE], the MDS indicated, BIMS.13 (cognition is intact). During a review of Resident 1's admission Record (AR), dated 3/3/25, the AR indicated, Resident 1 was admitted [DATE] and had the following diagnoses.quadriplegia c-1-c-4 complete (spinal cord injury resulting in total paralysis of both arms and legs), dysphasia (condition that affects the ability to understand, use, or produce language) following cerebral infarction (lack of oxygen causing an area of dead tissue in the brain). 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 interview and record review, the facility failed to follow its policy and procedure for one of three sampled residents (Resident 1) when verbal abuse was not reported to the Administrator. This failure resulted in Resident 1 experiencing persistent verbal abuse from his roommate (Resident 2). Findings: During a review of Resident 1's Minimum Data Set (MDS), dated [DATE], the MDS indicated, Brief Interview for Mental Status (BIMS).05 (severe cognitive impairment). During a review of Resident 2's MDS dated [DATE], the MDS indicated, BIMS.13 (cognition is intact). During a review of Resident 1's admission Record (AR), dated 3/3/25, the AR indicated, Resident 1 was admitted [DATE] and had the following diagnoses.quadriplegia c-1-c-4 complete (spinal cord injury resulting in total paralysis of both arms and legs), dysphasia (condition that affects the ability to understand, use, or produce language) following cerebral infarction (lack of oxygen causing an area of necrotic tissue in the brain). During a…

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

Based on interview and record review, the facility failed to follow their policy and procedure when a resident-to-resident allegation of abuse was not reported to California Department of Public Health (CDPH-state agency) per facility policy and procedure for two of two sampled residents (Resident 4 and Resident 5). This failure resulted in the allegation of abuse not being reported to CDPH timely. Findings: During a review of the Initial Facility Reported Event (IFRE), (undated), the IFRE indicated, Date/Time Reported: 12/16/24 approx. (approximately) 5 p.m. CDPH.Obtained knowledge 12/16/24 of incident on 12/14/24 at approx. 5:44 p.m. (approximately 48 hours prior to the abuse being reported) .Type of Incident. resident-to-resident physical contact.An incident of resident-to-resident mistreatment occurred between (Resident 5) and (Resident 4). Per staff witness, both residents were initially arguing when (Resident 4) kicked (Resident 5). During a review of Resident 4's Minimum Data Set (MDS-resident assessment tool) dated 12/8/24, the MDS indicated, Brief Interview for Mental…

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 followed for one of three sampled residents (Resident 3) when the mesh stop sign on Resident 3's door was not in use. This failure had the potential for residents to wander into Resident 3's room. Findings: During a review of Resident 3's Care Plan (CP), (undated), the CP indicated, 12/3/24 Alleged receiver of inappropriate touching from another resident.Interventions/Tasks.Place a bright colored stop sign at the entrance to deter wandering residents. During a concurrent observation and interview on 12/30/24 at 3:29 p.m. with Certified Nursing Assistant (CNA) 1 in the hallway, the mesh stop sign on Resident 3's door was not in use. CNA 1 confirmed the findings and stated the mesh stop sign was used to keep wandering resident's out of Resident 3's room and it should have been in use. During an interview on 12/30/24 at 3:45 p.m. with Social Service Director (SSD), SSD stated Resident 3's stop sign should always be used to deter the wandering residents from entering the room. During a…

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

Based on interview and record review, the facility failed to ensure the physician orders were implemented for one of three sampled residents (Resident 3). This failure resulted in Resident 3 not receiving the medication as ordered by the physician and had the potential for adverse health outcomes. Findings: During a review of Resident 3's Physician's Orders (PO), dated 12/11/24, the PO indicated, 12/11/24 Increase Xanax (medication used to treat anxiety) 1mg (milligram-a unit of measurement) TID (three times a day). During a review of Resident 3's Order Summary Report (OSR), dated 12/30/24, the OSR indicated, Resident 3 had a physician order for Alprazolam (also known as Xanax) oral tablet 1 mg give 1 tablet by mouth two times a day.start date 10/24/24. During a review of Resident 3's Medication Administration Record (MAR), dated 12/24, the MAR indicated, Alprazolam.1 mg. two times a day was being administered daily. During an interview on 12/30/24 at 2:34 p.m. with Social Service Director (SSD), SSD stated she was the one who received Resident 3's PO from the psychologist. SSD…

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 staff Licensed Vocational Nurses (LVN 1) competencies were completed. This failure had the potential for LVN 1 to be incompetent when providing care for the residents'. Findings: During a review of LVN 1's L.V.N. Competency Skills Checklist (LVNCSC) (undated), the LVNCSC indicated, Competency 2.Communicates effectively in professional relationships.Competency 3.Utilizes the nursing process in providing nursing care to residents.Competency 5.Provides nursing care based on scientific principles and sound theoretical knowledge.Competency 6.Demonstrates knowledge of emergency procedures.Competency 7.Demonstrates knowledge of unit rounds and nursing documentation.Competency 8.Transcribes and administers medications according to policy and procedures.Competency 9.Demonstrates knowledge of principles of Pain Management Program.Competency 10.Demonstrates knowledge of discharge process.Competency 11.Verbalizes the importance of acting as a resident advocate.Competency 12.Verbalizes accountability 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.

Based on interview and record review, the facility failed to ensure medication was documented when administered for one of three sampled residents (Resident 1). This failure had the potential for Resident 1's medical record to be inaccurate. Findings: During an interview on 12/16/24 at 1:05 p.m. with Resident 1, Resident 1 stated she does not receive her medications that are scheduled at 6 a.m. on time. During a concurrent interview and record review on 12/30/24 at 2:30 p.m. with Assistant Director of Nursing (ADON) 2, Resident 2's Administration History (AH), dated 12/30/24 was reviewed. The AH indicated, Levothyroxine Sodium (thyroid medication) oral tablet 150 mcg (micrograms-a unit of measurement) .scheduled for 6 am on 12/9/24. The AH indicated, Administration by (ADON 2) .Documented 12/19/24 (10 days after administration) 1:19 p.m. ADON 2 stated she administered Resident 2's Levothyroxine Sodium on 12/9 (no time given) but did not document it until 12/19. ADON 2 stated when the medication was administered it should have been documented as soon as it was given. During a review…

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 nutritional interventions were implemented for one of three sampled residents (Resident 1). This failure had the potential for Resident 1 to have unmet nutritional needs. Findings: During a review of Resident 1 ' s Nutritional Risk Assessment (NRA), dated 9/6/24, the NRA indicated, Recommendations.recommend to add boost (nutritional supplement) 4oz (ounce-unit of measurement) QD (every day) prostat (protein supplement) 30ml (milliliters-unit of measurement), zinc (mineral supplement), and vitamin C (supplement). During a concurrent interview and record review, on 10/1/24 at 11:44 a.m. with Director of Nursing (DON), Resident 1 ' s clinical record was reviewed. DON was unable to provide evidence of the nutritional recommendations being implemented. DON stated the nutritional recommendations were not carried out and they should have been addressed within 72 hours. During a review of the facility ' s policy and procedure (P&P) titled, Nutritional Screening/Assessments/Resident Care Plan dated 2023, the P&P indicated,…

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

Based on observation, interview, and record review, the facility failed to ensure the care plan was implemented for one of six sampled residents (Resident 1) when Resident 1 was not provided a bed alarm (device that alerts staff when a resident gets out of bed). This failure had the potential to place Resident 1 at risk for falls resulting in injuries. Findings: During a review of Resident 1's Care Plan (CP) , dated 5/16/17, the CP indicated, [Resident 1] is at risk for falls with or without injury related to poor safety awareness. Interventions: Bed alarm, ensure in proper working order, answer promptly. During an observation on 7/19/24 at 11:30 a.m. in Resident 1's room, Resident 1 did not have a bed alarm on his bed. During an interview on 7/19/24 at 12:35 p.m. with Assistant Director of Nursing (ADON), ADON stated Resident 1 is at risk for falls. ADON stated, [Resident 1] will hang his feet on the side of the bed. He will attempt to transfer. During an interview on 7/19/24 at 12:39 p.m. with Minimum Data Set Coordinator (MDSC), MDSC stated, [Resident 1] tries to get out of bed…

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 call light was within reach for one of six sampled residents (Resident 5). This failure had the potential for Resident 5 to be unable to call for help and his needs not being met. Findings: During a concurrent observation and interview on 7/24/24 at 11:46 a.m. with Resident 5 in Resident 5's room, Resident 5 was lying in bed and his call light was hanging on the wall behind his bedside drawer. Resident 5 stated he cannot find his call light. He stated, Where is it [call light]? During an interview on 7/24/24 at 11:50 a.m. with Certified Nursing Assistant (CNA) 2, CNA 2 stated Resident 5's call light was not within his reach. CNA 2 stated Resident 5's call light should have been placed within his reach. During a review of Resident 5's Minimum Data Set (MDS – an assessment tool), dated 5/17/24, the MDS indicated Resident 5 had a BIMS (Brief Interview for Mental Status) of 7 (score of 0-7 means severe cognitive impairment). The MDS indicated Resident 5's both lower extremities have limitation 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.

Based on observation, interview, and record review, the facility failed to ensure three of four sampled residents (Resident 103, Resident 281, and Resident 49) dialysis (procedure to mechanically remove waste products and excess fluid from the blood when the kidneys stop working properly) assessments were completed. This failure had the potential for dialysis related complications to occur/worsening of residents health condition. Findings: During a concurrent observation and interview on 1/29/24 at 9:46 a.m. with Licensed Vocational Nurse (LVN) 1, in Resident 103's room, Resident 103 was not in his room. LVN 1 stated Resident 103 was at dialysis. During a concurrent observation and interview on 1/30/24 at 10:07 a.m. with Resident 103, in Resident 103's room, Resident 103 stated he goes for dialysis on Mondays, Wednesdays, and Fridays. Resident 103 pointed to an area on his upper right arm where an AV fistula (connection made between an artery and a vein for dialysis access) could be seen. During a concurrent interview and record review on 2/1/24 at 9:54 a.m. with Minimum Data Set…

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 develop a system to demonstrate nursing competencies for licensed nursing staff. This failure had the potential to result in nursing staff not being competently skilled to meet the care needs of the facility's residents. Findings: During a concurrent interview and record review of personnel files on 2/1/24 at 3:47 p.m. with Staff Development Designee (SDD) and Consultant 1, Licensed Nurse Skills Inventory lists were reviewed, and the following were noted: Licensed Vocational Nurse (LVN) 6's skills inventory was signed off as completed by the Director of Nursing (DON) on 1/17/24. LVN 1's skills inventory was signed off as completed by the DON on 1/28/24. LVN 7's skills inventory was signed off and completed by the DON on 3/31/21. The skills lists did not indicate if competency was shown by a return demonstration, or by pre- or post-testing. SDD stated the skills lists are done on hire and annually. The Licensed Nurse Skills Inventory indicated Prepare, administer and record medications and treatments- see separate MED…

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 discontinue Seroquel (a psychotropic medication used to treat mental disorders that affect a person's ability to think, feel, and behave clearly) for one of four sampled residents (Resident 95) when the physician agreed with the pharmacist's recommendation to discontinue the medication. This failure resulted in Resident 95 receiving a mind-altering medication unnecessarily for 89 days. Findings: During a review of Resident 95's Consultant Pharmacist's Recommendation To Inter-Disciplinary Team (CPRIDT), dated [DATE], the CPRIDT indicated, This resident is currently administered Seroquel 25 mg [milligram-metric unit of weight] qhs [every evening] . since [DATE]. Since last review, behaviors have declined quite a bit. Her anxiety [feelings of worry] behaviors have also decreased. I defer it to your opinion if we may . D/C [Discontinue] Seroquel (dose at 25mg is more sedative [causing sleep] than anything else). Resident 95's physician circled the…

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

Based on interview, and record review, the facility failed to utilize the Registered Dietitian(s) (RD) expertise and skills sets to carry out the functions of the food and nutrition services when: 1. The RD documented imposed limitations of allowed hours the RD had at the facility impeded the following: timely weight reviews for residents, timely admission nutrition assessments for residents (Resident 18 and Resident 23), and inconsistent ability to conduct a monthly kitchen inspection to provide oversight over food safety, sanitation, evaluation of menus and therapeutic diets and lack of nutritional products/resources to offer choices to residents, when needed. 2. The RD was not incorporated into the IDT (interdisciplinary) weight review (care planning for weight change), in a timely manner, to address Resident's 10 significant weight loss. 3. The facility did not ensure the RD's skills sets were sufficiently incorporated into the facility's quality assurance and performance improvement (QAPI) by the facility not requiring the participation of the RD during the QAPI meetings. These…

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 contract for Registered Dietitian (RD) services included clear guidelines for the development of action plans, prompt implementation and monitoring of the Registered Dietitian's recommendations to address the nutritional needs of the residents. This failure resulted in an untimely RD assessment for Resident 10, and had the potential for delay in identifying and addressing other residents' nutritional needs in a timely manner. Findings: During a concurrent interview and record review on 2/1/24 at 12:24 p.m. with Administrator and Corporate Consultant (CC), RD's Nutrition Consultant Report (NCR), dated 11/9/23 to 1/12/24 were reviewed. The NCR's indicated, concerns with insufficient time to work on QAPI (quality assurance performance improvement-committee that addresses quality concerns), monthly kitchen inspections being missed, incomplete reviews of monthly weights, and not an adequate amount of time to meet the required comprehensive admission nutrition assessments in a timely manner for residents.…

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 one sampled resident (Resident 53) was assessed by the Interdisciplinary Team (IDT) for his ability to safely self-administer medication Cough Drops Mouth/Throat Lozenge 5.8 MG [milligrams-metric unit of weight]. This failure had the potential to adversely affect Resident 53's health condition. Findings: During an observation on 1/29/24 at 9:55 a.m. in Resident 53's room, Resident 53 was in his bed with his eyes closed and cough drops were on his bedside table. During a concurrent observation and interview on 1/29/24 at 10:03 a.m. with Licensed Vocational Nurse (LVN) 2 in Resident 53's room, LVN 2 pointed to the bedside table with a locked drawer. LVN 2 stated the cough drops should have been locked up in the drawer. LVN 2 stated Resident 53 should have had a care plan, an assessment, and an order for the cough drops before he was permitted to keep them at the bedside. During a concurrent interview and record review on 2/1/24 at 5:41 p.m. with Minimum Data Set Coordinator (MDSC), Resident 53'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 interview and record review, the facility failed to ensure one of 50 sampled residents (Resident 119) and her Responsible Party (RP) were provided a copy of the baseline care plan (BCP). This failure had the potential for Resident 119 and her RP to be unaware of her plan of care. Findings: During a concurrent interview and record review on 2/1/24 at 1:58 p.m. with Medical Records (MR) staff, Resident 119's BCP, dated 1/4/24 was reviewed. MR staff stated Resident 119 had an incomplete BCP because there was no indication a printed copy of the BCP was given to Resident 119 or Resident 119's RP. MR staff stated she reviewed Resident 119's clinical record and there was no documentation that a printed copy of the BCP was given. During a review of the facility's policy and procedure (P&P) titled, Care Plans-Baseline, dated 2022, the P&P indicated, 1. The baseline care plan should include instructions needed to provide effective, person-centered care of the resident.4. The resident and/or representative should be provided a written summary of the baseline care plan.

Based on interview, and record review, the facility failed to develop and implement a person-centered care plan for 1 of 50 sampled residents (Resident 18) when the facility continued to offer an oral nutrition supplement (ONS) after Resident 18 expressed dislike of the ONS. This failure had the potential to result in further significant weight loss. Findings: During a review of Resident 18's Weights and Vitals Summary (WVS), the WVS indicated the following weights: 8/1/23 - 151 pounds (lbs) 9/5/23 - 144 lbs 10/3/23 - 142 lbs 11/7/23 - 142 lbs 12/27/23 - 132 lbs 1/23/24 - 135 lbs During a review of Resident 18's WVS, the WVS indicated from 8/1/23 to 1/23/24, she had a significant weight changed of 16 lbs/10.6 %. During a review of Resident 18's Order Listing Report(OLR), dated 8/11/23, the OLR indicated, Boost Glucose Control Oral Liquid (Nutritional Supplements) Give 4 ml [milliliter-unit of volume] by mouth two times a day for supplement give after meals. During a review of Resident 18's IDT [interdisciplinary team] Significant Weight Change (IDTSWC), dated 12/29/23, the IDTSWC…

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 50 sampled residents (Resident 10) care plan was updated and revised after Resident 10's order for tube feeding (TF-a way to provide nutrition when you cannot eat or drink safely by mouth) was changed. This failure had the potential to result in further significant weight loss. Findings: During a review of Resident 10's RD [Registered Dietitian] Tube Feeding / wt [weight] (RDTF), note dated 1/27/24, the RDTF note indicated, TF order: 2 cans of Jevity 1.2 [liquid nutrition for TF) via G-Tube [a tube inserted through the belly that brings nutrition directly to the stomach] at 0600 [6:00 a.m.], 1200 [12:00 p.m.], 1800 [6:00 p.m.], and 1 can Jevity 1.2 (8 oz [ounces- unit of weight]) at 0000 [12:00 a.m.].Totals 7 cans, Res [resident] was reviewed d/t [due to] wt [weight] loss of.-13# [pounds] (-7.7%) [of body weight] x 3 m [months], likely d/t inadequate intake of TF. Recommend adding 1 can Jevity 1.2 (8 oz) at 0900 [9:00 a.m.]. During an interview on 2/1/24 at 11:19 a.m. with Assistant Director of Nursing…

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 nail care was provided for two of 50 sampled residents (Resident 42 and Resident 10). This failure had the potential to result in skin injuries, infections, and pain. Findings: During a concurrent observation and interview on 1/29/24 at 9:12 a.m. with Resident 42 outside of Resident 42's room, Resident 42's nails were long, thick and brown in color. Resident 42 stated she would love to get some help cutting them and thought she might need a specialist because of how long and thick they were. Resident 42 stated they were painful anytime they got caught on something. During an interview on 2/1/24 at 9:57 a.m. with Registered Nurse (RN) 1, RN 1 stated she thinks Resident 42 had fungus under her nails and Resident 42's nails would not have been so difficult to cut if it had been taken care of sooner. RN 1 stated she did not notify the doctor of the suspected fungal infection because the social services department had already been working on a referral to a specialist. During an interview on 2/1/24 at 9:59…

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 50 sampled residents (Resident 18) bowel (the tubes in your body through which digested food passes from your stomach to your anus) management protocol was followed. This failure resulted in Resident 18 not having bowel movement for four days and had the potential to result in worsening of his health condition. Findings: During a concurrent interview and record review on 1/31/24 at 3:41 p.m. with Director of Nursing (DON), Resident 18's Task: Bowel Continence (BC), dated 1/18/24 through 1/27/24 was reviewed. The BC indicated, Resident 18 did not have a bowel movement (BM) from 1/22/24 through 1/25/24 (four days) as indicated by a check mark in the column labeled as No Bowel Movement. DON stated the facility's bowel protocol was not followed when Resident 18 did not receive treatment in a timely manner, after having no bowel movement for four (4) consecutive days, as treatment should have been provided after three (3) days of no BM. During a concurrent interview and record review on 1/31/24 at 3:43 p.m. 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 one sampled resident (Resident 10) was accurately assess for risk of elopement (leaving an area without supervision or permission). This failure had the potential for Resident 10 to get out of the facility without supervision and compromise his safety. Findings: During a concurrent observation and interview on 1/29/24 at 12:15 p.m. in Resident 10's room with Licensed Vocational Nurse (LVN) 7, Resident 10 was wearing a code alert bracelet on his right wrist. LVN 7 stated Resident 10 used to get sad and would try to leave. During an interview on 2/1/24 at 11:27 a.m. with Assistant Director of Nursing (ADON), ADON stated Resident 10 tries to leave the facility at times. During a concurrent interview and record review on 2/1/24 at 11:37 a.m. with Administrator, Resident 10's Elopement Risk Observation/Assessment (EROA), dated 12/2/23 was reviewed. The EROA indicated, Elopement Risk Score 8. If the total score is 10 or greater, the Resident would be considered to be At Risk for Elopement.…

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

Based on observation, interview, and record review, the facility failed to ensure one of four sampled resident's (Resident 54) Foley Catheter (FC - flexible tube inserted into the bladder to drain urine) was monitored. This failure had the potential to result in FC dislodgement. Findings: During a concurrent observation and interview on 1/31/24 at 7 a.m. with Minimum Data Set Coordinator (MDSC) in front of nurses' station 2, Resident 54 was sitting in his wheelchair with the tubing for his Foley catheter on the floor, laying directly behind the front wheel of the wheelchair. MDSC stated the tubing could have been pulled out and caused pain. MDSC stated the tubing being on the floor could have also caused infection. MDSC stated the Foley catheter tubing should have been positioned off the ground. During a review of Resident 54's Physician's Order (PO), dated 4/21/23, the PO indicated, Monitor Foley Catheter induced laceration [cut] to Penis for signs of worsening and infection. During a review of the facility's policy and procedure (P&P) titled, Catheter Care, Urinary, dated August…

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 timeliness of Registered Dietitian (RD) nutrition assessment after a significant weight loss for one of four sampled residents (Resident 10) who received nutrition via G-tube (a tube inserted through the belly that brings nutrition directly to the stomach). This failure resulted in delayed nutrition interventions. Findings: During a review of Resident 10's Weights and Vitals Summary (WVS), the WVS indicated, the following weights: 7/25/23 - 174 pounds (lbs) 8/29/23 - 168 lbs 9/26/23 - 167 lbs 10/10/23 - 168 lbs 11/14/23 - 164 lbs 12/12/23 - 161 lbs 1/16/24 - 155 lbs 1/23/24 - 152 lbs During a concurrent interview and record review on 1/31/24 at 1:59 p.m. with RD 1, Resident 10's IDT [interdisciplinary] Significant Weight Change (IDTSWC), dated 1/19/24 was reviewed. The IDTSWC indicated, Resident 10 had a significant weight change as of 1/16/24 of - 6 lb x 1 month 3.7% [loss of body weight], -13 lb x 3 month 7.7%, -18 lb x 6 month 10.4%, Current weight: 155# [pounds].Current Diet: GTube Feeding Jevity 1.2 [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 follow its policy and procedure (P&P) titled, Medication Administration for one of six sampled residents (Resident 93) when nursing staff did not administer the correct medication and dose ordered by the physician. This failure had the potential to adversely affect Resident 93's health condition. Findings: During an observation on 1/31/24 at 7:40 a.m. outside of Resident 93's room, Licensed Vocational Nurse (LVN) 1 prepared and administered 2 tablets of Oyster Shell Calcium (calcium supplement) 500 milligrams (mg-metric unit of weight). During a review of the Order Summary Report (OSR), dated 1/31/24, the OSR indicated, Oyster Calcium + D Oral Tablet 250-3.125 MG-MCG [microgram-unit of weight] (Calcium Carbonate [calcium supplement]-Vitamin D [supplement essential in the absorption of calcium]) Give 2 tablet by mouth one time a day for supplement. During an interview on 1/31/24 at 11:58 a.m. with LVN 1, LVN 1 stated she gave Resident 93 the wrong oyster shell calcium. During a review of the facility's P&P…

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. Obtain a physician's order for one of four sampled residents (Resident 95) to discontinue Seroquel (medication used to treat mental disorders that affect a person's ability to think, feel, and behave clearly) after the physician had agreed to the recommendation of the pharmacy consultant. 2. Follow-up/obtain physician's order for one of four sampled residents (Resident 42) to include parameter/recommendation by pharmacy consultant in administering Percocet (Oxycodone-Acetaminophen - pain medication used to treat moderate to severe pain, known to cause drowsiness and respiratory distress or even death when taken in high doses or combined with other substances). These failures had the potential for Resident 95 and Resident 42 to received unnecessary medications for prolonged period of time. Findings: 1. During a review of Resident 95's Consultant Pharmacist's Recommendation To Inter-Disciplinary Team (CPRIDT), dated [DATE], the CPRIDT indicated, 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 interview and record review, the facility failed to ensure one of one sampled resident (Resident 15) pain level was properly assess prior to administering narcotic (highly addictive controlled medication used to relieve pain) pain medication. This failure had the potential for Resident 15's pain to not appropriately treated and worsening of her health condition. Finding: During a review of Resident's 15 Medication Administration Note (MAN), dated 1/8/24, the MAN indicated, Percocet [narcotic pain medication] Tablet 5-325 MG [milligram -a unit of measure] Give 1 tablet by mouth every 6 hours as needed for Moderate to Severe Pain (4-10) [0 no pain, 1-3 mild pain, 4-6 moderate pain, and 7-10 severe pain]. During an interview on 2/1/24 at 2:08 p.m. with Licensed Vocational Nurse (LVN) 4, LVN 4 stated Resident 15 is only able to verbalize two words, mama and yes. During a concurrent interview and record review on 2/1/24 at 3:24 p.m. with Minimum Data Set Coordinator (MDSC), Resident's 15's Medication Administration Record (MAR), dated October 2023, November 2023, December 2023…

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

Based on observation, interview, and record review, the facility failed to ensure one of one sampled Dietary Aide (DA)1 demonstrated the correct technique for testing the sanitation of dishes after running dishes through the low temperature dish machine. This failure had the potential to cause foodborne illness (illness caused by contaminated food). Findings: During a concurrent observation and interview on 1/29/24 at 9:15 a.m. with DA 1, in the facility's kitchen, DA 1 obtained a chlorine (chemical element) chemistry strip (strip used to check concentration of sanitizer) and inserted it into the low temperature dish machine's water tank. DA 1 compared the chemistry strip to the color-coded graph on the chlorine vial. DA 1 stated it was 100 PPM [parts per million]. During an interview on 1/29/24 at 9:17 a.m. with Dietary Services Supervisor (DSS), DSS stated DA 1 should have checked the sanitizer concentration at the plate level to ensure the dishes were properly sanitized. DSS stated DA 1 did not demonstrate the correct way to test the sanitizer concentration to ensure the dishes…

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 and/or facility's diet manual as planned for two of eight sampled residents (Resident 23 and Resident 85) when: 1. Lettuce in the tossed green salad and whole, sliced tomatoes were served that were larger than 1/2 (inch) pieces for Resident 23's mechanical soft (diet designed for people that have trouble chewing and swallowing) diet order. 2. Entree alternates were not nutritionally evaluated by a registered dietitian (RD) for Resident 85's CCHO (controlled carbohydrate diet for diabetes) diet. This failure had the potential for Resident 23 to choke and Resident 85 to have elevated blood sugars. Findings: 1. During a concurrent observation and interview on 1/29/24 at 11:56 a.m. with Resident 23 in Station 3 Dining Room, Resident 23 ate all the food that was on her tray except for most of the salad. Resident 23 stated she would have eaten all of her salad if it was cut up smaller. During a concurrent observation and interview on 1/29/24 at 12:08 p.m. with Certified Nursing Assistant (CNA) 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.

Based on observation, interview, and record review, the facility failed to ensure safe food handling and sanitation when: 1. A Time Temperature Control for Safety (TCS- food that requires time-temperature control to prevent the growth of bacteria) food was not cooled down according to facility's policy. 2. One of one sampled dietary aide (DA 2) washed her hands after handling dirty dishes and prior to handling clean dishes. These failures had the potential to result in the development of foodborne (caused by contaminated food) illness. Findings: 1. During a concurrent interview and record review on 1/30/24 at 9:08 a.m. with Dietary Services Supervisor (DSS), the facility's Cooling/Chilling Temperature Control Log (CTCL), dated October 2023 to January 2024 were reviewed. The CTCL indicated, on 11/14/23, roast beef was documented at a starting cooling temperature (temp) of 179 degrees (°) Fahrenheit (F- unit of temperature measurement) at 1 p.m. The next temperature noted in the log was documented at 3:30 p.m. 2 1/2 (two and half hours) after the start of the initial cool down. The…

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

Based on interview, and record review, the facility failed to: 1. Ensure an accurate and complete clinical record (CR) for one of one sampled resident (Resident 10). This failure resulted in weight loss interventions not carried out in a timely manner. 2. Follow its policy and procedure (P&P) titled, Resident Participation - Assessment/Care Plans for one of six sampled residents (Resident 52). This failure had the potential for Resident 52 to not have the opportunity to participate in, be aware of and develop care goals and outcomes, and incorporate his personal and cultural preferences. Findings: 1. During a concurrent interview and record review on 1/31/24 at 1:59 p.m. with RD 1, Resident 10's IDT [interdisciplinary] Significant Weight Change (IDTSWC), dated 1/19/24 was reviewed. The IDTSWC indicated, Resident 10 had a significant weight change as of 1/16/24 of - 6 lb x 1 month 3.7% [loss of body weight], -13 lb x 3 month 7.7%, -18 lb x 6 month 10.4%, Current weight: 155# [pounds].Current Diet: GTube Feeding Jevity 1.2 [a nutrition liquid formula delivered via a tube].IDT…

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

Based on observation, interview, and record review, the facility failed to follow its policy and procedure (P&P) titled, Handwashing/Hand Hygiene when a Licensed Vocational Nurse (LVN) 1 did not change gloves or perform hand hygiene after checking the blood sugar for one of two sampled residents (Resident 126). This failure had the potential to result in the spread of bloodborne pathogens (germs that are carried in the blood and can cause disease in people). Findings: During an observation on 1/31/24 11:12 a.m. in Resident 126's room, LVN 1 applied gloves and tested the blood sugar for Resident 126. There was an error with test strip. LVN 1 grabbed a new test strip from the vial of test strips on the medication cart but did not change her gloves or wash her hands. During an interview on 1/31/24 at 11:16 a.m. with LVN 1, LVN 1 stated she did not wash hands or change gloves after she checked Resident 126's blood sugar. LVN 1 stated she should have changed her gloves before grabbing a new strip and taking the Resident 126's blood sugar a second time. During an interview on 2/1/24 at…

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

Based on interview and record review the facility failed to follow its policy and procedure titled Consent to Treat for three of 50 sampled residents (Resident 10, Resident 280, and Resident 282 when: 1. Resident 10 was given Flu (contagious respiratory illness) vaccine without obtaining a consent. 2. Resident 280 and Resident 282 were not assessed and offered Flu vaccines on admission. These failures had the potential to spread miss information and infectious diseases. Finding: 1. During an interview on 2/1/24 at 1:22 p.m. with Administrator, Administrator stated he could not find a consent for Flu vaccine for Resident 10 and he should have a consent. During a review of Resident 10's Infection Note (IN), dated 9/26/23, the IN indicated, To receive season influenza vaccine administer 0.5 ml IM (intramuscular- muscle to absorbing administered medication) one time. Administer per facility protocol. Orders carried out as planned no signs and symptoms of adverse reaction. 2. During a concurrent interview and record review on 1/31/24 at 1:42 p.m. with Infection Preventionist (IP),…

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 three sampled residents (Resident 1) was transferred using a Hoyer (assistive device that allows patients to be transferred between a bed and a chair) lift according to the comprehensive care plan. This failure resulted in Resident 1 falling and sustaining an acute intertrochanteric (fracture [broken bone] of the proximal [near the center of the body] femur [thigh bone] that occur between the greater and lesser trochanter [part of the femur near its joint with the hip bone]) fracture to the left hip. Findings: During a review of Resident 1's admission Record (AR), dated 7/27/23, the AR indicated, Resident 1 was admitted on [DATE], diagnoses included hemiplegia (paralysis of one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body) following cerebral (brain) infarction (obstruction of the blood supply to an organ or region of tissue) affecting left dominant side. During a review of Resident 1'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 follow the physician's order to apply an immobilizer (or sling to reduce or eliminate motion of the body or a part of the body) for one of three sampled residents (Resident 1). This failure had the potential to result in worsening of Resident 1 ' s fracture (broken bone) of the right upper arm. Findings: During a review of Resident 1 ' s MD Progress Notes (PN), dated July 31, 2023, the PN indicated, Right proximal spiral humerus fracture (broken bone of the upper arm). Right arm sling (a device to limit movement, also known as immobilizer). During a review of Resident 1 ' s Care Plan (CP), dated, July 31, 2023, the CP indicated, Focus: Pain due to right shoulder fracture. Intervention: Use immobilizer per MD (Medical Doctor) order. During a review of Resident 1 ' s IDT (Interdisciplinary team - collaborative care, where physicians, nurses, therapists, social workers, and other professionals work together to plan and coordinate resident care) Care Conference (IDTCC), dated July 31, 2023, the IDTCC indicated,…

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

Based on observation, interview, and record review, the facility failed to ensure one of five dietary aides (DA) performed handwashing upon entering the kitchen. This failure had the potential to result in contamination of residents' food which may lead to foodborne illnesses. Findings: During a concurrent observation and interview, on 3/9/22, at 11:20 AM, with Dietary Manager (DM) in the kitchen tray line, DA was observed pushing the lunch tray carts out of the kitchen and coming back to the kitchen tray line without performing handwashing. DM stated, it would be a nice practice to wash her (DA) hands after pushing out the cart, and coming back inside. During a review of the facility's policy and procedure (P&P) titled, Sanitation and Infection Control, [undated], the P&P indicated, Subject: Handwashing; Policy: The food service workers will keep their hands and exposed portion of their arms clean. Hands must be properly and frequently washed to prevent cross contamination . Procedures: 1. All food service employees are educated on the importance of hand washing at orientation and…

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

Based on observation, interview, and record review, the facility failed to ensure nursing staff have competencies necessary to care for two of 33 sampled residents (Resident 32, Resident 46) based on the resident's needs. This failure had the potential for the resident's unmet care needs and delay in provision of care and services. Findings: During a review of Resident 32's Order Summary Report (OSR), dated 3/10/22, the OSR indicated, Cranberry Tablet 400 mg give 1 tablet by mouth one time a day for Supplement. During a concurrent observation and interview on 3/10/22, at 8:32 AM, with Assistant Director of Nursing (ADON), in the medication storage room, ADON stated, the facility only stored Cranberry supplements of 425 mgs but not in the 400 mgs per the physician orders for Resident 32. During an interview on 3/10/22, at 7:55 AM, with Licensed Vocational Nurse (LVN) 1, while being followed for Medication Administration for Resident 32, LVN 1 stated, I am a registry nurse. I am nervous. This is my first day here. I thought I'd get an orientation like a run down of the facility. I…

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 dignity was maintained for two of 33 sampled residents (Resident 17 and Resident 71) when: 1. Licensed Vocational Nurse (LVN) 3 did not pull the privacy curtain while administering medication to Resident 17's gastrostomy tube (G-tube - tube inserted through the stomach that brings nutrition directly to the stomach). 2. Resident 71's urinary catheter drainage bag (bag that collects urine) was not covered with a privacy bag. These failures had the potential for Resident 17 and Resident 71 to have a decrease in feelings of self worth and self esteem. Findings: 1. During a concurrent observation and interview on 3/9/22, at 4:20 PM, with LVN 3, of a medication pass administration to Resident 17, LVN 3 lifted up Resident 17's gown exposing Resident 17's abdominal area to access Resident 17's G-tube. Resident 17's bed was located next to the door and the door and privacy curtain were open. LVN 3 stated, she had realized she had not pulled and closed the privacy curtain. 2. During a review of Resident 71'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 interview and record review, the facility failed to develop a care plan for a diabetic ulcer (injury to the skin) for one of 33 sampled residents, (Resident 296). This failure had the potential for not providing the appropriate care and adversely affect Resident 296's health condition. Findings: During a review of Resident 296's Physician's Orders (PO), dated 3/4/22, the PO indicated, Betadine (solution used to prevent and treat infection) diabetic ulcer to right heel, notify Medical Doctor (MD) of worsening every shift. During a concurrent interview and record review, on 3/9/22, at 9:44 AM, with Minimum Data Set Supervisor (MDSS), Resident 296's Care Plans (CP) were reviewed. MDSS reviewed Resident 296's CP, and did not find a CP addressing Resident 296's diabetic ulcer. MDSS stated, there should have been a care plan written. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person- Centered, dated 1/18, the P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the…

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

Based on observation, interview, and record review, the facility failed to ensure physician's orders were followed for two of 33 sampled residents (Resident 32 and Resident 71). These failures had the potential for adverse outcomes of residents care. Findings: During a concurrent observation and interview on 3/10/22, at 7:55 AM, with Licensed Vocational Nurse (LVN) 1, of a medication pass preparation, LVN 1 was preparing medications to be administered to Resident 32 for his morning medications. LVN 1 stated, she would not be able to administer Residents 32's physicians order for Cranberry supplement (pill that provides nutrients) 400 milligram (mg - a unit of measure) as in her medication cart were only Cranberry supplements of 425 mgs. During a review of Resident 32's Order Summary Report (OSR), dated 3/10/22, the OSR indicated, Cranberry Tablet 400 mg give 1 tablet by mouth one time a day for Supplement. During a concurrent observation and interview on 3/10/22, at 8:32 AM, with Assistant Director of Nursing (ADON), in the medication storage room, ADON stated, the facility only…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide services to ensure residents maintain the highest level of range of motion (ROM - measurement of movement around a specific joint or body part) and mobility (the ability to move or be moved freely and easily), for two of 33 sampled residents, (Resident 46, and Resident 36). These failures had the potential for a decline in ROM and an avoidable change of condition. Findings: During an observation on 3/7/22, at 11 AM, Resident 46 was observed in bed watching TV, with a left wrist contracture (a permanent tightening of the muscles, tendons, skin that causes the joints to shorten and become very stiff) without a rolled towel inside her hand. Resident 46's both feet were observed with foot drop (weakness or difficulty lifting both the front part of the foot) without an Ankle Foot Orthosis (AFO- brace worn around the lower leg and foot to support the ankle and holds both foot and ankle in a flexed position). During a review of 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.

Based on observation, interview, and record review, the facility failed to ensure the nurse staffing information was posted daily, readily accessible and visible to all residents and visitors for one of three nursing stations (Nursing Station One). This failure had the potential to result in data regarding the number of staff and the actual hours worked of staff was not accurate, accessible and posted visibly by residents and visitors. Findings: During a concurrent observation and interview on 3/7/22, at 12 PM, with Director of Staff Development (DSD), across Nursing Station One, a tall white partition (divider) was observed against the wall. DSD stated, the posted nurse staffing was posted at the back of the tall white partition. DSD stated, it should be visible and not covered by the tall white partition. During a concurrent interview and record review on 3/7/22, at 12:05 PM, with the DSD, the facility's Posted Nurse Staffing Information (PNSI), dated 3/6/22 was reviewed. DSD stated, the PNSI should be updated to 3/7/22 and not yesterday's date. The facility's PNSI policy was 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 Based on interview and record review, the facility failed to ensure the pharmacist psychotropic medication (drug that affects brain activities associated with mental processes and behaviors) recommendation was acted upon for one of 33 sampled residents (Resident 66). This failure had the potential for adverse drug reactions, excessive duration, excessive dose and/or unnecessary use of psychotropic medication. Findings: During a review of Resident 66's Director of Nursing Summary Report (DNSR), dated 2/28/22, Resident 66's DNSR indicated, the resident is currently administered Lexapro (a drug used to treat depression or anxiety) 5 milligrams (mg - unit of measure) daily (QD - everyday) this dose was last assessed back in September of 2020. Since this assessment, his behaviors have been noted as minimal . may we discontinue/GDR [gradual dose reduction - tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or can be discontinued] Lexapro therapy due to over all 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 implement infection prevention and control standards, when a certified nursing assistant (CNA) 1 did not don (put on) the proper personal protective equipment (PPE - protective clothing designed to protect the wearer's body from injury or clothing). This failure had the potential to result in spreading infection to residents, other staff, and visitors. Findings: During an observation on 3/10/22, at 10:52 AM, at nursing station one, CNA 1 demonstrated the process of donning and doffing (taking off) PPE. CNA 1 failed to remove her surgical mask and replace it with an N-95 respirator (specialty mask capable of filtering up to 95% of airborne particles) as required by the Centers for Disease Control and Prevention (CDC) for preventing the spread of COVID-19 (highly contagious virus which resulted in a global pandemic). During an interview on 3/10/22, at 11:05 AM, with CNA 1, CNA 1 stated, I forgot to put on the N-95 mask. During a review of the facility's Infection Prevention Quality Control Program (IPQCP),…

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.