Boulder Creek Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to respond to a pharmacist recommendation related to high levels of fat in the blood, for one of 30 sampled residents (23). This failure had the potential to affect Resident 23's health and well-being. Findings: Per the facility's admission Record, Resident 23 was admitted to the facility on [DATE] with diagnoses of hyperlipidemia (high levels of fat in the blood). On 2/14/25 a review of the facility's Consultant Pharmacist's Medication Regimen Review, dated 12/5/24, was conducted. This record included a recommendation for the facility to provide a lipid panel (check the level of fat in the blood) for Resident 23. There was no documentation that the facility responded to the pharmacists's recommendation. On 2/14/25 a review of Resident 23's electronic medical record was conducted. There was no evidence that a lipid panel was completed for Resident 23. On 2/14/25 at 1:20 P.M., an interview was conducted with the Director of Nursing (DON). The DON 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately document a resident's medications on the weekly summary for one of 30 sampled residents (2). This failure had the potential to miscommunicate Resident 2's status, care, and treatment. Findings: Per the facility's admission Record, Resident 2 was admitted to the facility on [DATE] with diagnoses to include schizoaffective disorder (a mental disconnection from reality). On 2/14/25 a review of Resident 2's electronic medical record was conducted. Licensed nurse (LN) 21 completed the weekly summary for Resident 2 on 1/12/25, 1/19/25, 1/26/25, and 2/9/25. On all of the listed weekly summaries, LN 21 documented that Resident 2 had not been using antipsychotic (medication to treat a disconnection from reality) medication over the last seven days. Per the facility's Orders, there was an order dated 6/20/24 for Resident 2 to take risperidone (an antipsychotic medication) for schizoaffective disorder. On 2/14/25 at 10:17 A.M., an interview was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to promote infection control practices according to standards of practice for one or 30 sampled residents (Resident 38) to prevent respiratory illnesses and infection. This failure had the potential for Resident 38 to experience respiratory complications and infections from improper maintenance and storage of their nebulizer treatment equipment. Findings: A review of Resident 38's admission Record indicated Resident 38 was re-admitted to the facility on [DATE] with diagnoses which included a history of chronic obstructive pulmonary disease (COPD; chronic lung disease causing difficulty in breathing). A record review of Resident 38's minimum data set (MDS; nursing facility assessment tool) dated 12/23/24 indicated that Resident 38 was rarely or never understood with severe cognitive (the mental processes that take place in the brain, including thinking, attention, language, learning, memory, and perception) deficits to understand and make…

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 handrails were appropriately secured. This failure had the potential to cause injury to all facility residents. Findings: On 2/13/25 and 2/14/25, observations were made of the handrails inside of the facility. One loose handrail was observed. The ends of the handrail moved in both directions from level. During an interview on 2/13/25 at 9:38 A.M. with certified nursing assistant (CNA) 11, CNA 11 stated the handrails should not move like that. CNA 11 further stated a resident could get really hurt if it tilted while they were holding it. During an interview on 2/14/25 at 9:40 A.M. with licensed nurse (LN) 11, LN 11 stated that the residents used the handrails for support. LN 11 further stated, not being secured could cause a major injury. During a review of the facility's policy titled Maintenance Service, the policy indicated .2. Functions of Maintenance personnel include .b. Maintaining the building in good repair and free from hazards .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement a self administration recommendation for one resident (Resident 3) when a licensed nurse (LN 1) left medications which were not approve for self medication administration on Resident 3' s bedside table. As a result, the unattended medications on Resident 3's bedside table were not witnessed as administered as ordered. Findings: Resident 3 was admitted to the facility on [DATE] per the facility admission Record. A review of the admission orders dated 8/6/24 indicated Resident 3 was approved to self administer the following medications: topical diclofenac pain gel and cyclosporine eye drops for dry eyes. On 1/13/25 at 4:39 P.M. an interview and review of Resident 3's medication orders was conducted with LN 1 and the Assistant Director of Nursing (ADON). LN 1 stated on 12/31/24, she left the following medications aspirin, furosemide and two vitamins on Resident 3's bedside table. LN 1 stated after she left the unattended medications…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop a resident's (Resident 4) baseline care plan (detailed plan with information about a patient's treatment, goal, and interventions) for one of one resident reviewed, related to the placement of a used urinal on top of the meal tray table. As a result, the lack of resident centered care plan with specific interventions to prevent contamination of the surface and the lack of education to Resident 4 had the potential for Resident 4 to acquire an infection. Findings: An unannounced onsite to the facility was conducted on 7/9/24 related to a complaint on physical environment and infection control. Resident 4 was admitted to the facility on [DATE], with diagnoses which included diabetes (high blood sugar), per the facility's admission Record. On 7/9/24, Resident 4's clinical record was reviewed. Resident 4's history and physical dated 5/18/24 indicated Resident 1 had the capacity to understand and make decisions. Resident 4's 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement their infection control program when a used urinal was placed on top of the resident's meal tray table for one of four sampled residents (Resident 1). This failure had the potential for contamination of the surface and could cause an infection to Resident 1. Findings: An unannounced onsite to the facility was conducted on 7/9/24 related to a complaint on physical environment and infection control. Resident 1 was readmitted to the facility on [DATE] with diagnoses which included aftercare following a surgery and diabetes (high blood sugar), per the facility's admission Record. On 7/9/24, Resident 1's clinical record was reviewed. Resident 1's history and physical dated 5/18/24 indicated Resident 1 had the capacity to understand and make decisions. Resident 1's minimum data set (MDS, an assessment tool) dated 5/28/24 indicated Resident 1 had a brief interview for mental status (BIMS, ability to recall) score was 15/15 (a score of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to fully implement their post fall protocol for a resident who self -reported a fall. This had the potential to compromise the safety and well-being of Resident 1. Findings: On 11/03/23 the Department of Public Health received a complaint of a fall for Resident 1 on 11/03/23. On 11/15/23, Resident 1 ' s records were reviewed. Resident 1 was admitted to the facility on [DATE] with diagnoses to include osteoarthritis of knee (swelling of knee joints), syncope (passing out) and collapse, opioid dependence (drug for pain relief and causing sleepiness) per the facility admission Record. A review of Resident 1 ' s facility record indicated on 11/3/23 at 1:00 A.M., .Resident came down to nurses station mobile wheelchair stating he fell on his buttocks in his room at his bedside no c/o[sic] pain/discomfort v/s[sic] wnl[sic] breathing even and unlabored neurochecks initiated RN/MD[sic] made aware . Fall risk evaluation on 3/2/21 was 19, high risk for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure the call bell system alerted staff to a resident requesting an assistant when the call bell system only lighted up. As a result, call light may not have been answered in a timely manner. Findings: On 5/17/22 at 8:55 A.M., Resident 12 was interviewed. Resident 12 stated, I had to wait 2 hours to be changed after pressing the call light. On 5/17/22 at 9:535 A.M., Resident 46 was interviewed. Resident 46 stated, I waited 1 hour for the call bell to be answered. On 5/17/22 at 9:50 A.M., Resident 90 was interviewed. Resident 90 stated that his roommate waited 3 hours for someone to answer the call light. On 5/17/22 at 9:18 A.M., room [ROOM NUMBER] was toured. The resident in room [ROOM NUMBER] required assistance and the in room call bell was activated. There was no audible alert to the call bell, and the call light outside of room did not light up. The Social Services Director was just outside the room, and she stated the call bell had no audible…

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

Based on interview and record review, the facility failed to allow the resident council to meet without staff. As a result, the residents were not able have a confidential meeting. Finding: On 5/18/22 at 10:30 A.M., a resident council meeting was held. During the meeting, a majority consensus of confidential residents attending stated that they could not meet without a staff member present. Residents stated Activity Director (AD) insisted to attend all meetings. On 5/18/22 at 12:04 P.M., an interview was conducted with the Activity Director (AD). The AD stated that she needed to attend resident council meetings to take the meeting minutes. She stated that a staff present at the meeting might make the residents uncomfortable with expressing their concerns openly. The AD's expectation was that the residents had the right to run the meeting themselves without staff present. On 5/20/22 at 2:28 P.M., an interview with the ADM was conducted. ADM stated that staff present at all the meetings could make the residents uncomfortable speaking honestly about the facility. He stated 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 inform the residents and staff on how to file a grievance. As a result, residents were not able to exercise their rights to file a grievance. Findings: On 5/18/22 at 10:30 A.M., a resident council meeting was conducted. The following statements about grievances were made: 1. The majority of residents attending stated that they did not know how to file a grievance or were unable to file a grievance. 2. CR 1 stated that they could not get a grievance form when she asked the nurses for one. She went to every nurses' station and was unable to get a form. She wrote a grievance on a blank sheet of paper and handed that to the staff, but she was afraid that the staff would read her paper. 3. CR 2 stated that they were afraid of speaking up or writing a grievance out of fear of retribution by the facility. 4. CR 3 stated they thought the Social Services director was too busy to respond to grievances, so they didn't bother writing them. 5. CR 4 stated that they had made grievances but had never received rationale back…

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 did not ensure infection prevention in facility when: 1. The facility did not clean up feces on residents' floor. 2. The facility did not ensure unvaccinated staff wore proper PPE in a transmission-based precaution room. 3. The facility did not ensure screeners performed Covid screening on vendors and doctors. These failures had the potential for infection to spread in the facility. Findings: 1. On 5/17/22 at 2 P.M., a concurrent interview with Resident 63 and observation of his room was conducted. He stated that there was often feces on the floor, and under closer inspection it was determined that at time of observation, it was observed there was smeared brown material in the middle of the floor. On 5/17/22 at 2:25 P.M., a concurrent interview and observation with the IP was conducted. The IP observed smeared brown material. She stated that the expectation was that feces should cleaned off the floor as soon as it was seen by staff. She stated that by not cleaning the floors of feces, there could be a spread of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure dignity and respect was provided for two of two sampled residents ( 50 &110) when staff was standing over, while assisting and feeding the residents (50 &110). This failure had the potential to affect the resident's self-esteem, self-worth, and quality of care. Findings: 1. Resident 50 was admitted to the facility on [DATE] with diagnoses which included dysphasia (difficulty swallowing), per the facility's admission Record. On 5/18/22 at 12:35 P.M., a lunch observation was conducted in front of Resident 50's room. Resident 50 was observed sitting in a wheelchair in the room. Certified Nursing Assistant (CNA) 30 was standing over while assisting and feeding Resident 50. On 5/18/22 at 12:40 P.M., an interview with CNA 30 was conducted. CNA 30 stated she was standing over while feeding Resident 50 because there was no chair in the room. She stated the expectation was to sit while assisting the residents with meals. 2. Resident 110 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to obtain informed consent from a physician prior to administering psychotropic medications (a medication which affects the mind) and did not obtain a consent from responsible party prior to applying restraints (a measure that keeps resident within limits) for two of two sampled residents (126 & 54 ). As a result, the residents may not have been fully informed of the risks and benefits of the psychotropic medications and restraints. Findings: 1. Resident 126 was admitted to the facility on [DATE] with diagnoses which included schizoaffective disorder (mental health disorder) and anxiety (a mental disorder characterized by excessive worrisome), per the facility's admission Record. Per facility's Physician Order, the physician wrote an order for Resident 126 for venlafaxine (medication for depression) for depression and lorazepam (medication for anxiety) for anxiety. On 5/19/22 at 3:43 P.M., a concurrent interview and record review with LN 31 was conducted.…

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 provide a homelike environment for two of two sampled residents (63& 90). As a result the residents did not feel comfortable in their room. Findings: On 5/17/22 at 12:58 P.M., a concurrent interview and observation of Resident 90 in his room was conducted. Resident 90 stated that the NOC shift staff often threw dirty linen and diapers on the floor when cleaning them. Grime and dirt were noted around the floor at the edges of the bed, by bed wheels and also by the residents' drawers. It was noted that the walls had torn drywall and scraped paint in many areas behind his bed. Resident 90 stated that the wall had been damaged by the bed and mechanical lift (resident lifting device) going into the wall. He stated he had not seen anyone clean the room in a while. On 5/17/22 at 2 P.M., a concurrent interview and observation of Resident 63 in his room was conducted. Resident 63 was Resident 90's roommate. Resident 63 stated the only problem he had with the facility was that his room was dirty and there was often…

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 26 sampled residents (54) was free from restraints that the restraint was the least restrictive, used for the least amount of time, and was re-evaluated when they repeatedly applied mittens to both hands. As a result, resident 54 was subject to an unnecessary restraint. Findings: On 5/19/22, at 9:44 A.M., Resident 54, was observed awake in bed with mittens on both hands. Resident 54 was constantly moving his hands in an attempt to remove the mittens and trying to scratch. Resident 54's clinical record was reviewed on 5/19/22, there was a note from the dermatologist dated 4/27/22, to keep mittens on bilateral hands to prevent patient from scratching. There was a single care plan developed for the use of the mittens. The care plan only directed staff to monitor every shift for breakdown and placement. There was no care plan or assessment or consent or orders found in the record for the mittens as a restraint. On 5/19/22 at 3:04 P.M., the MDS Coordinator was interviewed. The MDS coordinator 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 one of 26 sampled residents (54) was free from restraints. In addition, the facility did not ensure a resident's restraint was least restricted alternative for the least amount of time and re-evaluated, when they repeatedly applied mittens to both hands. As a result, resident 54 was subject to an unnecessary restraint. Findings: On 5/19/22, At 9:44 A.M., Resident 54, was observed awake in bed with mittens on both hands. Resident 54 was constantly moving his hands in an attempt to remove the mittens and trying to scratch. Resident 54's clinical record was reviewed on 5/19/22, there was a note from the dermatologist dated 4/27/22 to keep mittens on bilateral hands to prevent patient from scratching. There was a single care plan developed for the use of the mittens the care plan only directed staff to monitor every shift for breakdown and placement. There was no care plan or assessment or consent or orders found in the record for the mittens as a restraint. On 5/19/22 at 3:04 P.M., the MDS Coordinator was…

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

Based on observation interview and record review, the facility failed to ensure one of 26 sampled residents (54) restraint use was documented on the MDS (assessment tool that directs resident care). As result, Resident 54's mittens were not correctly identified. Findings: On 5/19/22, At 9:44 A.M., Resident 54, was observed awake in bed with mittens on both hands. Resident 54 was constantly moving his hands in an attempt to remove the mittens and trying to scratch. Resident 54's clinical record was reviewed on 5/19/22. A note from the dermatologist, dated 4/27/22, indicated to keep mittens on bilateral hands to prevent patient from scratching. There was a single care plan developed for the use of the mittens the care plan only directed staff to monitor every shift for breakdown and placement. There was nothing on the most recent MDS to indicate Resident 54 had mittens. On 5/19/22 at 3:04 P.M., the MDS Coordinator was interviewed. The MDS coordinator stated the mittens were not a restraint, they were to stop him from scratching. The MDS coordinator felt the mittens were for safety,…

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 a comprehensive person-centered care plan was provided for one of 26 sampled residents (Resident 104). As a result, Resident 104's hearing loss was not addressed. Findings: Per the admission record, Resident 104 was admitted on [DATE] with diagnoses including hemiplegia (paralysis of one side of the body) following cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area). Resident 104 had a BIMS (Brief Interview of mental status, mental status assessment; score 8-12, moderately impaired cognition, 13-15 intact cognition) of 10. On 5/17/22 at 8:45 A.M., Resident 104 was observed in her room laying in bed. Resident 104 was interviewed at this time. Resident 104 stated, I can't hear you. Come closer. My ears are plugged. I can't hear you. On 5/17/22 at 8:50 A.M, the CNA 21 who was assigned to Resident 104 was interviewed. CNA 21 stated, You have to talk loud. She's hard of hearing. On 5/18/22 at 8 A.M.,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow a physician's order for a Restorative Nursing Assistant (RNA) dining program as ordered for one of one sampled resident (102). This failure had the potential to result in Resident 102 to lose more weight. Findings: Resident 102 was admitted to the facility on [DATE] with diagnoses which included cerebral infarction (damage to the brain), dysphasia (difficulty swallowing), and adult failure to thrive (poor nutrition and weight loss) per the facility's admission Record. Per Resident 1's Physician Order Summary Report, dated 5/19/22, the physician wrote an order for RNA RDP [restorative dining program] for all meals on 4/8/22. On 5/18/22 at 8:30 A.M., Resident 102's breakfast observation was conducted in the room. There was a breakfast tray with slightly eaten pureed pancake on the bedside table in front of Resident 102. No staff was observed during breakfast in the room. On 5/18/22 at 1:03 P.M., a concurrent observation and interview 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to safely position one of two sampled resident (Resident 104) during a meal. This deficient practice put Resident 104 at risk for choking and aspiration. Findings: Per the admission Record, Resident 104 was admitted on [DATE] with diagnoses including hemiplegia (paralysis of one side of the body) following cerebral infarction (disrupted blood flow to the brain tissues which cause parts of the brain to die off) affecting left non-dominant side. On 05/17/22 at 8:45 A.M., during a meal observation, Resident 104 was observed in her room. Resident 104 was awake, on her right side with the head of her bed at a 20 degree angle. Resident 104 was observed using her right hand to attempt to feed herself as she slowly reached for the food on her tray. On 05/17/22 at 8:50 A.M., CNA 21 was interviewed. CNA 21 stated, The head of the bed should be higher and she should be closer to her tray. On 05/17/22 at 9 A.M., the activities assistant (AA) was…

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

Based on observation, interview, and record review the facility failed to provide one of 26 sampled resident (33) who was non-English speaking resident with a communication board. As a result, the resident had difficulty communicating with staff. Findings: Resident 33 was admitted to facility with diagnoses including Respiratory Failure ( a condition in which your blood doesn't have enough oxygen or has too much carbon dioxide), Chronic Obstructive Pulmonary Disease (a group of diseases that cause airflow blockage and breathing-related problems), and Dysphagia (difficulty swallowing) per facility's admission record. Record review of MDS Section C, Cognitive Patterns was conducted. Resident 33 had a BIMS score(Brief Interview of mental status, mental status assessment; score 8-12, moderately impaired cognition, 13-15 intact cognition) of 10. On 5/18/22 at 12:48 P.M., an interview and observation of Resident 33 was conducted. Resident 33 stated he preferred to speak Spanish, but understood a lot of English. He was able to respond in single word responses in Spanish, but some garbling…

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 midline catheter (a catheter placed into a vein in the upper arm) dressing was changed accordance to the facility's policy for one of 26 sampled resident (55). As a result, Resident 55 was placed at risk for infection. Findings: Resident 55 was admitted on [DATE] with diagnoses that included Type 2 Diabetes (illness with high blood sugar level), per the facility's admission Record. Per facility's progress note, dated 5/4/22, Resident 55 had a midline on the left upper arm upon admission to the facility. On 5/17/22 at 3:55 P.M., an observation and interview were conducted with Resident 55. Resident 55 was observed in bed with a dressing dated 5/3, covering a vascular access device on the left upper arm. Resident 55 stated the dressing had never been changed since she arrived at the facility. On 5/18/22 at 10:08 A.M., a concurrent observation and interview of Resident 55's midline dressing was conducted with LN 30. LN 30 stated 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 post their actual staffing hours when they only posted projected staffing for the day. As a result, due to changes in staffing these numbers may have been incorrect. Findings: On 5/18/22 at 10:30 A. M., the facility Administrator was asked for posted staffing information for the last 2 weeks including today. The DON presented posted staffing information for 5/1/22 to 5/14/22, at that time the DON was asked for actual staffing hours as the information provided was only the projected staffing. The DON provided the Census and Direct Care Service Hours Per Patient Day, for this period. This form contained the actual staffing for each day. On 5/10/22, the Projected Boulder Creek Post Acute Care, documented the total staff hours as 476.5, the Census and Direct Care Service Hours Per Patient Day documented the actual hours as 448.57, a difference of 29 staffing hours. On 5/11/22, the Projected Boulder Creek Post Acute Care, documented the total staff hours as 468, the Census and Direct Care Service Hours Per Patient Day…

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 use the correct scoop size for vegetables during tray line. As a result, the residents did not receive the appropriate amount of vegetables served. Findings: On 5/18/22 at 11:45 A.M., the CK was observed placing scoops with different colored handles next to the food inserts on the steam table. CK was interviewed at this time. CK stated, The gray scoop, #8 will be used for the (starch), the green scoop, #12 will be used for the vegetables, a gray scoop, #8 will be used for pureed meat. Tray line started production at 11:50 A.M., and ended at 12:58 P.M. On 5/18/22 at 1:30 P.M., the CK was interviewed. The CK stated, The gray scoops are equal to 4 ounces, the green scoops are equal to 3 ounces. On 5/18/22 at 3 P.M., a concurrent record review and interview was conducted with the DS. The DS stated, The cook's spreadsheet indicates, the vegetables should have been served with a gray scoop which is equal to 4 ounces. The cook used a green scoop which is 3 ounces. We should have used a 4 ounce scoop. On 5/19/22 at…

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

Based on observation, interview and record review, the facility failed to provide food that was palatable. As a result the residents did not enjoy their food and had the potential to skip meals. Findings: On 5/18/22 at 10:30 A.M., during the resident council meeting, 12 of 12 residents complained about the food. On 5/18/22 at 11:45 A.M., trayline was observed. At 12:58 P.M., the last tray on the trayline was taken to station one. A test tray was requested and tasted by the survey team and DS. The menu included Garden Fresh Meatloaf and gravy, mashed potatoes, Spinach AuGratin, garlic bread and chocolate peanut butter bars. The potatoes, spinach, bread and dessert were found to be palatable. The tasters found the meatloaf and gravy to have an unusually sweet taste. On 5/18/22 at 2:30 P.M., Resident 39 stated, The gravy had an off taste. It did not taste like gravy, I didn't like it. On 5/19/22 at 2:30 P.M., the DS was interviewed. The DS stated, The gravy was a little sweet. The DS further stated, I interviewed the cook. He said he added a little brown sugar to the gravy to take away…

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 prevent residents from using multiple power strips plugged directly into each other. As a result, the facility had increased potential risk for electrical fire. Findings: On 5/17/22 at 9:50 A.M., a concurrent interview and observation was conducted of Resident 90's room. It was observed that Resident 90 had at least 3 power strips plugged into each other from one wall outlet. Resident 90 stated he had a lot of electronics that he liked to keep plugged in to charge. Resident 90 stated that the facility was aware that he used multiple power strips in this manner. On 5/18/22 at 9:45 A.M., a concurrent observation and interview of Resident 44's room was conducted with the MS. Five medical equipments were all plugged into one power strips. The MS stated Resident 44's power strip was non-medical grade power strip and should not had been any medical equipments plugged in. On 5/19/22 at 9:45 A.M., a concurrent interview and observation was done of Resident 90's power strip setup with the MS. The MS stated that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the handrails in the hallway was safe for the residents, staff, and visitors. This failure had the potential for all residents using the handrails to be at risk for injuries. Findings: On 5/18/22 at 12:26 P.M., a handrail on the hallway in station 1 across from room [ROOM NUMBER] was observed to have a square shaped plastic patched on the original handrail. The edges of the plastic patch had rough and sharp edges upon touch. On 5/19/22 at 11:20 A.M., a concurrent observation and interview with MS was conducted. The MS stated the handrail across from room [ROOM NUMBER] was patched up with rough edges and it was not safe for the residents. The MS stated this needed to be taped until the new parts came in. He further stated the maintenance did environmental rounds on each station but was not aware of this handrail's condition. On 5/20/22 at 9:48 A.M., an interview with the Director of Nursing (DON) was conducted. The DON stated the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and records review, the facility failed to develop and implement comprehensive person-center care plans to reflect four of 31 residents individual needs related to: 1. Resident 20's need for Range of Motion (ROM-staff assisted movement of the joints); 2. Resident 77's podiatry care and treatment; 3. Resident 65's dental needs; and, 4. Resident 51's use of a seat belt, when sitting up in his wheelchair. As a result, there was the potential for residents to receive inconsistent care due staff being unaware of the residents specific needs and the interventions required to meet those needs. Findings: 1. Resident 20 was admitted to the facility on [DATE], per the facility's admission Record. On 10/28/19 at 8:19 A.M., an observation and interview was conducted of Resident 20. Resident 20 was in bed eating breakfast, with a fall mat on the floor. Resident 20 stated she preferred to stay in bed, because she did not feel strong enough to get out of bed. On 10/28/19, a record review was conducted 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 observation, interview, and record review, the facility failed to follow the pureed recipe for fried rice for 22 of 22 residents reviewed for pureed diet. As a result, the nutrition of the pureed diets was compromised potentially affecting residents' health. Findings: On 10/28/19, the weekly menu was obtained from the facility. The menu for 10/29/19 was listed with the following starch: Fried Rice. On 10/29/19 at 11:40 A.M., the pureed starch had already been prepared, and was on the tray line for plating. The pureed fried rice appeared to be a bright white color. The regular fried rice appeared brownish with green peas. Near the end of tray line, a test tray ( a sample tray) was requested for both a regular diet and a pureed diet. After the final tray was served to a resident in unit 3, the test tray was removed from the transport cart. The RD 1, DNS, and this writer sampled the starch on the sample tray. The pureed starch had a thick white appearance and did not have the same flavor as the fried rice from the regular diet. On 10/29/19 at 1:55 P.M., an interview with CK 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 did not follow the recipe for pureed fried rice or for pureed carrots for 22 of 22 residents reviewed for pureed diet. As a result, 22 residents were served rice which was bland and carrots which were not seasoned per the recipes. Findings: On 10/28/19, the weekly menu was obtained from the facility. The lunch menu for 10/29/19 was listed with the following starch: Fried Rice. On 10/29/19 at 11:40 A.M., the pureed starch had already been prepared, and was on the tray line for plating. The pureed fried rice appeared to be a bright white color. The fried rice appeared brownish with green peas. Near the end of tray line, a test tray (a sample tray) was requested for both a regular diet and a pureed diet. After the final tray was served to a resident in unit 3, the test tray was removed from the transport cart. RD 1, DNS, and this writer sampled the starch from the test tray. The pureed starch had a thick white appearance and did not have the same flavor as the fried rice from the sampled regular diet. RD 1 and the DNS…

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 did not display respect for residents when: 1. Staff did not announce themselves for one of 31 residents when entering one resident's room; (77) 2. Staff were rude and disrespectful to Resident 28 and staff spoke non-English in the presence of eight of eight CR residents. (28, CR 1, CR 2, CR 3, CR 4, CR 5, CR 6, CR 7, CR 8) These failures had the potential to devalue the residents' self-esteem and self-worth. Findings: 1. Per the facility's policy, titled Quality of Life-Dignity, dated August 2009, . 11.Staff shall promote dignity and assist residents as needed by: .b. Promptly responding to the resident's request for toileting assistance . On 10/31/19 11:29 A.M. an observation was conducted with LN 3. LN 3 was followed into Resident 77's room, to examine a wound. LN 3 entered Resident 77's room without knocking or asking permission to enter. On 10/31/19 at 11:31 A.M., an interview was conducted with LN 3 outside Resident 77's room. LN 3 stated she…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to update a Physician Order for Life-Sustaining Treatment (POLST) for one of two residents (50) reviewed for advanced directives. This failure had the potential for Resident 50 to not get her wishes met when receiving life-sustaining treatment. Findings: Resident 50 was admitted to the facility on [DATE] with diagnoses which included heart failure (a chronic condition in which the heart does not pump blood as well as it should) per the facility's admission Record. On 10/30/19, a review of Resident 50's paper chart was conducted. Resident 50's POLST, dated 11/25/15, indicated selective treatment, goal of treating medical conditions while voiding burdensome measures, was selected and signed by the physician on 11/25/15. On 10/30/19, a review of Resident 50's hospice documents, located in a separate binder, was conducted. Resident 50's POLST, dated 11/25/15, indicated revised as of 8/13/19-new one to be signed by the MD. Selective treatment was crossed out,…

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 meal assistance to one of five residents (17) reviewed for ADLs. This failure had the potential to result in Resident 17 to experience a decrease in ADLs and weight loss. Findings: Resident 17 was admitted on [DATE], with diagnoses which included dysphagia (difficulty swallowing food or liquids) and muscle weakness per the facility's admission Record. On 10/30/19, a review of Resident 17's MDS (an assessment tool) Section C, dated 10/14/19, indicated Resident 17's BIMS Summary Score (test for cognitive function) was 2 out of 15 indicating severe cognitive impairment. On 10/28/19 at 8:26 A.M., an observation and interview with Resident 17 was conducted. Resident 17 was lying in her bed, with a breakfast tray on her bedside table. The bedside table was angled away from Resident 17. The food on the tray was uncovered, and two drinks on the tray had plastic covering the tops of them. Resident 17 stated she could not eat on her own 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 did not implement a physician's order for an ophthalmology (a doctor with specialization of eye treatment including surgery) referral for one of three residents reviewed for vision (59). As a result, Resident 59 had the potential for low vision or decreased vision. Findings: Resident 59 was admitted to the facility on [DATE] per the facility's admission Record. On 10/28/19 at 1:01 P.M., an interview with Resident 59 was conducted. Resident 59 stated she had been asking staff about her eye appointment, but had not received any response. On 10/29/19 at 4:07 P.M., an interview with the SSD was conducted. The SSD stated she had to check the Optometrist (provides eye health/ may provide glasses) book. The SSD stated she did not make ophthalmology appointments for residents. On 10/30/19 at 11:30 A.M., an interview with the SSD was conducted. The SSD stated she had not followed up on the appointment for Resident 59 because she had another priority to deal with first.…

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 Restorative Nursing Services (RNA-CNAs with specialized training to help improve residents' strength and mobility), as ordered by their physician for one of five residents reviewed for Activities of Daily Living. (20) This failure had the potential to affect Resident 20's highest level of function and possible result in avoidable decline of Range of Motion (ROM). Findings: Resident 20 was admitted to the facility on [DATE], with diagnoses, which included heart failure (heart can't pump blood to the rest of the body with enough force), per the facility's admission record. On 10/28/19 at 8:19 A.M., Resident 20 was observed and interviewed. Resident 20 was in bed eating breakfast. Resident 20 stated she preferred to stay in bed, because she did not feel strong enough to get out of bed. On 10/28/19. Resident 20's clinical record was reviewed. The quarterly MDS (an assessment tool), dated 7/22/19, indicated a BIMS (a cognitive…

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 asess two of three residents reviewed for accident hazards (51, ) when: 1. Resident 51 had not documentation or assessment for a safety device and, These failures had the potential to result in physical harm. Findings: Resident 51 was admitted to the facility on [DATE] with diagnoses that included Parkinson's Disease (a disorder that affects movement) and dementia (decline in memory, language, and other thinking skills) per the facility's admission Record. On 10/30/19, a review of Resident 51's MDS (health status screening and assessment tool) Section C, dated 8/16/19, indicated Resident 51 had severe cognitive impairment for daily decision making. On 10/28/19 at 8:58 A.M., an observation of Resident 51 was conducted in his room. Resident 51 was sitting in his wheelchair and a two-point seatbelt was observed buckled across his hips. On 10/29/19 at 8:11 A.M., an observation of Resident 51 was conducted in his room. Resident 51 was sitting in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure three of four residents reviewed for urinary catheters and urinary infections had: 1. Secured urinary catheters (a device inserted into the bladder to drain urine) drainage tubes for Residents 45 and 279, 2. A urinal (a plastic container used to collect urine) provided to Resident 6 to promote independence. These failure had the potential for the urinary catheters to be pulled out of the urinary canal which would cause pain. There was the potential for Resident 65 to have a urinary infection that went untreated, and for Resident 6 to not achieve their highest practicability of independence when a urinal was not routinely provided. Findings: 1a. Resident 45 was re-admitted to the facility on [DATE] with diagnoses which included obstructive uropathy (urine can't be expelled from the urinary system due to some type of obstruction), per the facility's admission Record. A review of Resident 45's clinical record was conducted 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.

Based on interview and record review, the facility failed to monitor one of five residents reviewed for nutrition (78). As a result Resident 78 experienced altered nutrition and experienced a significant weight loss. Findings: On 10/28/19 at 9:52 A.M., an interview was conducted with Resident 78. Resident 78 stated although he had a gastrostomy tube (feeding tube) in place, recently the tube was no longer used to provide nutrition to his body since he started eating by mouth. Resident 78 stated the facility had not weighed him since the beginning of the month. On 10/30/19 at 1:21 P.M., LN 13 was interviewed. LN 13 stated his appetite was coming back now that he was eating by mouth. Resident 78's record was reviewed: Per the Weights and Vitals Summary document dated 10/31/19. Resident weights were as follows: 8/1/19 174 lbs 9/1/19 172 lbs 10/01/19 159 lbs Resident 78's weight from 9/1/19 to 10/1/19 was not recorded on the summary document. Per Resident 78's care plan dated 2/26/19: Focus: At risk for losing weight .Goal: minimize any unplanned weight changes daily, Interventions:…

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 professional standards of practice were implemented when a physician's order was not followed for the use of a humidifier (moisturized oxygen) with oxygen for one of three residents (62) reviewed for respiratory care. This failure caused Resident 62 to have an dry throat. Findings: Resident 62 was re-admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (COPD - a progressive lung disease characterized by shortness of breath, wheezing, or a chronic cough), and the need for supplemental oxygen per the facility's admission Record. Resident 62's clinical record was reviewed on 10/31/19. The Order Summary Report, dated 10/31/19, indicated an order was initiated on 7/9/19 for Humidified oxygen at 2 LPM (liters per minute) via Nasal Cannula (device to deliver oxygen directly into the nostrils) every shift for COPD. On 10/28/19 at 8:30 A.M., a joint observation and interview was conducted…

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 two of two residents (16, 49) reviewed for pain were administered adequate pain medication when: 1. Resident 16 did not receive a physician ordered Lidocaine (slowly released pain medication) patch as scheduled five times in October 2019 and, 2. Resident 49 did not receive adequate pain medication for scheduled pressure ulcer and range of motion (ROM - exercises to decrease contractures, defined as shortening and hardening of muscles, tendons, or other tissue, often leading to deformity) treatments. These failures placed both Residents' 16 and 49 at risk for unnecessary pain. Findings: 1. Resident 16 was re-admitted to the facility on [DATE] with diagnoses which included fibromyalgia (causes aching and deep stabbing pain) per the facility's admission Record. Resident 16's clinical record was reviewed on 10/29/19. The Order Summary Sheet, dated 10/31/19, indicated an order was initiated on 10/8/19 for a Lidocaine patch 5%, Apply to…

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

Based on interview and record review the facility failed to ensure the narcotic count inventory sheet (CDR) reflected the medications administered to residents as documented on the Medication Administration Record (MAR), for one of two residents (20) reviewed for medication storage. This deficient practice had the potential to cause the facility to not be able to readily identify loss and drug diversion (illegal distribution or abuse of prescription drugs as their use for unintended purposes) of controlled medication. Findings: On 10/29/19 at 10:41 A.M., an observation and interview was conducted with LN 1 during inspection of medication cart #2, located at Station One. A random narcotic bubble pack card (a method of packaging medications, where each dose is enclosed in a clear plastic bubble, on a cardboard sheet) was removed for inspection. The narcotic bubble back was assigned to Resident 110, and labeled Percocet 10-325 milligrams tablets. LN 1 stated 36 tablets remained sealed in the bubble pack card. On 10/29/19 at 11:23 A.M., Resident 110's CDR for October 2019, was compared…

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 PRN (as needed) psychotropic (mind altering) medications were limited to 14 days (unless documentation of a physician's order to extend the medication), for one of five residents (15) reviewed for unnecessary medications. This failure put Resident 15 at risk for complications resulting from potentially unnecessary medications. Findings: Resident 15 was admitted to the facility on [DATE], with diagnoses which included dementia (memory loss) with behavioral disturbances, per the facility's admission record. On 10/31/19, Resident 15's clinical record was reviewed. The physician order, dated 8/3/19, indicated, Lorazepam (antipsychotic medication used to treat anxiety) be administered as needed for anxiety. The physician's order included behavior monitoring every shift, for episodes of agitation manifested by chasing and hitting staff. Resident 15's MAR was reviewed from 8/3/19 through 10/31/19. Lorazepam was administered three times, with documented…

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 secure medications when: 1. Medications were left unattended at the beside for one of 31 sampled residents (20); and 2. One of three treatment carts was left unlocked and unattended. These failures had the potential for staff, residents, or visitors to have access to medication not attended for them. 1. On 10/28/19 at 8:19 A.M., an observation and interview was conducted with Resident 20. Resident 20 was sitting up in bed, eating breakfast. A small clear medication cup was on the bedside table, which contained a small oval yellow pill and a small oval pink pill. Resident 20 stated she was supposed to take the pills. No staff were in the room and a medication cart was not visible outside the resident's room. On 10/28/19 at 8:22 A.M., LN 3 was observed entering Resident 20's room. On 10/28/19 at 8:24 A.M., a subsequent observation and interview was conducted with Resident 20. Resident 20 was sitting up in bed and her breakfast tray was gone.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of 31 sampled residents (65), reviewed for dental needs, was provided dental services to meet the resident's needs. This deficient practice had a potential for Resident 65 to experience difficulty chewing and weight loss, due to not having any teeth or dentures. Findings: Resident 65 was admitted on [DATE], with diagnoses which included difficulty walking and lack of coordination, per the facility's admission Record. On 10/28/19 at 8:54 A.M., an observation and interview was conducted with Resident 65, while he sat in a wheel chair beside his bed. Resident 65 had no teeth or dentures in his mouth. A partially consumed breakfast tray sat on a near-by table. Resident 65 stated he had been without teeth for over a year. Resident 65 stated when he arrived, they said they would try to get him dentures. Resident 65 stated he had not seen a dentist since he arrived. On 10/30/19, a record review was conducted for Resident 65: 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 food safety requirements were followed when: 1. Dented cans were not removed from stock, 2. Juices were not labeled or dated and, 3. Staff did not wear a beard restraint in the kitchen. As a result, residents were subject to bacterial illness and foodborne illnesses from dented cans, undated juices, and potential hair falling into residents' food. Findings: 1. On 10/28/19 at 7:50 A.M., the dry storage area of the kitchen was inspected. One can of peaches had an indentation in the middle of the can. One can of tuna had two accordion dents in the can. On 10/28/19 at 7:51 A.M., an interview with the DNS was conducted. The DNS stated all dented cans must be removed and placed in the bin for return to the supplier. Per the facility policy, Food Storage-Dented Cans, dated 2018, .All dented cans (defined as side seam or or rim dents) and rusty can are to be separated from remaining stock and placed in a specified labeled area for return to purveyor for refund . 2. On 10/29/19 at 8:10 A.M., a joint observation…

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 CNA 31 had a current professional license. This failure created the potential for the facility to be unaware of an active disciplinary action against CNA 31. Findings: On [DATE], a record review was conducted of CNA 31's employee file. CNA 31's date of hire with the facility was [DATE]. The California Department of Public Health L&C (Licensing and Certification) Verification Detail Page, dated [DATE], indicated CNA 31's license was effective on [DATE], had a criminal record clearance, and CNA 31 was deemed employable. The Verification Detail page indicated CNA 31's license expired on [DATE]. A review of the Daily Staffing Assignments which included the employee's sign in with signatures that indicated CNA 31 had signed in and worked 19 shifts since [DATE]. On [DATE] at 11:38 A.M., a joint interview was conducted with the ADM and the DSD. The ADM confirmed CNA 31 was employed by the facility and was working shifts. The ADM acknowledged CNA 31's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately document two of two residents reviewed for resident documentation when: 1. Resident 77's toenail treatment was documented as being performed according to the physician's order; and, 2. Resident 429's did not have an accurate fall assessment completed, after a recent fall. As a result, Resident 77 and Resident 429 were at risk of not receiving the appropriate care and treatment. Findings: 1. Resident 77 was admitted to the facility on [DATE], per the facility's admission Records. On 10/28/19 at 10:27 A.M., an interview was conducted with Resident 77, while he laid in bed. Resident 77 stated a podiatrist (foot doctor) came to see him last week for a toe issue. Resident 77 stated the podiatrist ordered a treatment, saying he needed to soak the toe every other day, or else he would lose his toenail, due to an infection. Resident 77 stated the staff had not yet soaked his toe and he was afraid his toe infection would get worse. On 10/29/19,…

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 did not ensure infection control practices were followed when: 1. Hand hygiene was not performed by 2 of 6 CNAs ( CNA 8, CNA 35) during a meal service when passing meal trays to residents in the dining room and, 2. A CPAP mask (continuous positive air pressure - provides air pressure to keep lung airways open) was left lying on the bedside table open to potential infection for one of two residents reviewed for respiratory care (62). As a result, there was a potential to transmit infectious agents between residents during food service and the potential for the CPAP mask to pick up germs from the bedside table potentially causing Resident 62 to become sick when using the mask. Findings: 1. On 10/28/19 at 12 P.M., a lunch observation was conducted in the residents' dining room. There was one hand wash sink and only one bottle of hand sanitizer observed in the dining room, during the meal service. The one bottle of hand sanitizer observed was on 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.