Poway Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to hold a blood pressure (BP) medication as prescribed by the physician for one resident (Resident 1) with a low BP. As a result, Resident 1's BP had the potential to further decrease below normal and increase the risk of harmful side effects. Findings: Resident 1 was admitted to the facility on [DATE] with heart failure (a condition where the heart dose not pump enough oxygen rich blood to the body), per the resident's admission record. A review of Resident 1's physician orders, active January 2024, indicated Resident 1 was prescribed one 25 milligram (mg) tablet of metoprolol (a medication used to decrease blood pressure and heart rate) two times a day for hypertension (high blood pressure). The physician's order indicated instructions to hold the metoprolol if Resident 1's systolic blood pressure (SBP, the number of the BP reading that indicates the pressure on the blood vessels when it contracts) number was below 110 or heart rate below 60. On 2/14/24…

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

Based on interview and record review, the facility failed to employ a qualified full time Infection Preventionist (IP, the person(s) designated by the facility to be responsible for the infection prevention and control program) with primary professional training, education, and experience as a Licensed Nurse. This failure had the potential to compromise the facility's ability to maintain a safe and effective infection prevention and control program (IPCP) for all residents residing in the facility. Findings: On 11/28/23 at 12:17 PM an interview was conducted with Licensed Nurse (LN) 1. LN 1 stated the facility's current infection preventionist was IP/CNA (certified nursing assistant). On 11/28/23 at 1:36 PM an interview was conducted with the IP/CNA. The IP/CNA stated she had been working in role of IP since May 2023. The IP stated she was responsible for educating staff on infection control practices and transmission-based precautions as well as the monitoring and reporting of disease outbreaks in the facility. The IP/CNA stated she had worked in the facility as a Certified 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to consistently provide non-English communication boards (a board in a specific language use to communicate) to non- English speaking residents for one of one sampled resident (Resident 53) and three non-sampled residents (Resident 141, 140, 46) reviewed for communication. This failure had the potential for Residents' 46, 53, 140, and 141, to not have their needs known or met, and for decreased socialization. 1. Resident 141 was admitted to the facility on [DATE], with diagnoses which included dementia (progressive memory loss), per the facility's admission Record. On 3/14/22 at 9 A.M., an observation was conducted inside Resident 141's room. Resident 141 was lying flat in bed with his eyes open, with the lights off, curtain pulled, and no TV or radio on. Resident 141 did not communicate when questions were asked. The wall near the foot of the bed, and the bedside night stand had no communication board or communication tools available 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, interview, and record review, the facility failed to ensure nursing standards of practice were followed when: 1a. A peripherally inserted central catheter (PICC-a main intravenous line) was not consistently monitored or documented for one of two residents (Resident 11), reviewed for Professional Standards of Practice; 1b. Intravenous (IV) antibiotic medication was not documented as administered via the PICC line for one of two residents (Resident 11), reviewed for Professional Standards of Practice; and 2. Medication injection sites were not consistently rotated for two of two residents (Residents 4 and 22), reviewed for medication administration of insulin (a hormone normally produced by the body, which regulates sugar in the blood). As a result, there was a potential for occlusion (blockage) of Resident 11's PICC line and worsening of infection due to the antibiotics not consistently being administered. In addition, there was the potential for insulin to not be fully absorbed by the body,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow infection control practices when: 1. A glucometer (a device used for measuring sugar levels in the blood) was not disinfected between the use of two of two residents (Resident 4 and 22), observed for medication administration. 2. A urinary Foley (brand name) catheter bag was touching the floor for one of one resident, (Resident 79), reviewed for urinary catheter care. As a result, there was the potential for Residents 4, 22, and 79 to be at risk for a facility acquired infection, which would negatively impact their quality of life. Findings: 1a. Resident 4 was admitted to the facility on [DATE], with diagnoses which included diabetes (abnormal blood sugar levels) and long-term use of insulin (a hormone normally produced by the body, which regulates sugar in the blood), per the facility's admission Record. On 3/16/22 at 8:57 A.M., an observation was conducted with Licensed Nurse (LN) 1 on the Cambridge Medication cart for Station 1.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident was treated with dignity for one of one sampled resident (79) reviewed for dignity. This failure had the potential to affect Resident 79's dignity, causing a negative effect on his quality of life. Findings: Resident 79 was admitted to the facility on [DATE], with a diagnoses that included nonspecific developmental delay (a brain disorder affecting ability to function cognitively and physically), per the facility's admission Record. The following observations of Resident 79's Foley (brand) urinary catheter bag were conducted: On 3/14/22 at 10:52 A.M., Resident 79 was inside his room with a urinary bag hanging on the right side of the resident's bed without a cover, visible from the hallway. On 3/15/22 at 1:32 P.M., Resident 79 was inside his room with a urinary bag hanging on the left side of his bed without a cover. On 3/16/22 at 12:38 P.M., Resident 79 was in the common dining room seated on a wheelchair with a urinary…

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 nail care to a resident who was dependent on staff for activities of daily living (ADL-basic hygiene) for one of one resident, (Resident 27) reviewed for ADL care. This failure had the potential to result in Resident 27 to experience psychosocial distress, infection and compromised hygiene. Findings: Resident 27 was admitted to the facility on [DATE] with diagnoses which included hemiplegia (weakness on one side of the body), per the facility's Record of Admission. A review of Resident 27's Minimum Data Set (MDS - assessment tool) and comprehensive assessment of a resident's mental and functional capabilities sections C, G and GG, dated 1/10/22, indicated Resident 27 had a Brief Interview of Mental Status (BIMS) score of 99 (unable to complete) and required extensive assistance with ADL (activities of daily living) care. On 3/15/22 at 9:54 A.M., an observation of Resident 27 in his room was conducted. Resident 27 was awake,…

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 one to one (1:1) feeding assistance (staff sit and assist resident with eating) and supervision in the dining room during a lunch meal for one of one resident, (Resident 24), reviewed for Supervision. As a result, Resident 24 was unsupervised and grabbed another resident's food bowl and spilled the food content onto herself, while attempting to ingest the food contents. Findings: Resident 24 was admitted to the facility on [DATE], with a diagnoses which included dementia (progressive memory loss), per the facility's admission Record. On 3/17/22 a review of Resident 24's medical record was conducted: The MDS (Minimum Data Set- an assessment tool) and comprehensive assessment sections C and G, dated 1/5/22, indicated Resident 24's Cognitive Patterns were severely impaired. Section G Functional Status indicated the resident was dependent on staff for activities of daily living (ADL). Per the facility Order Summary Report, dated…

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 policy review the facility failed to ensure: 1. Licensed nursing staff demonstrated sufficient knowledge with monitoring and documenting continuous tube feeding (a flexible tube surgically inserted into the body to provide nourishment) for one of one residents (Resident 6), reviewed for tube feeding; and 2. The facility did not have or use a standardized pain assessment tool with parameters to determine the amount of pain medication to be administered for one of one resident, (Resident 69), reviewed for pain. This failure had the potential to adversely impact Resident's 6 and Resident's 69's care. Findings: 1. Resident 6 was admitted to the facility on [DATE], with diagnoses that included Alzheimer's disease (a progressive brain disorder affecting memory) and dysphagia (difficulty with swallowing), per the facility admission Record. On 3/14/22 at 10:26 A.M., an observation of Resident 6 was conducted in her room. The following was noted: Resident 6 was laying in a bed with 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 observation, interview, and document review, the facility failed to ensure the medication error rate was less than five percent. The facility's medication error rate was 6.25 percent. Two (2) medications were omitted for one of six residents (Resident 47), randomly selected for medication administration. As a result, Resident 47 did not receive two anti-depressant medications (to prevent and treat depression) which had the potential for mood alternations. Findings: Resident 47 was re-admitted to the facility on [DATE], with diagnoses which included depressive disorder and schizoaffective (a mental health disease) disorder, per the facility's admission Record. On 3/16/22 at 9:34 A.M. an observation and interview was conducted with Licensed Nurse (LN) 3, who was administering medication on the Heritage medication cart of Station 2. LN 3 was preparing morning medication for Resident 47. LN 3 stated Resident 47 was recently admitted to hospice (a care focused to a terminally ill patients) on the and her…

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

Based on observation, interview and facility policy review, the facility failed to implement their policy and procedure related to storing of food items for one of one resident reviewed for Resident Food Storage. The food stored inside the refrigerator were not labeled, dated, and expired food were not discarded. This failure had the potential to expose the facility's residents to unsafe food storage practices which could lead to foodborne-illnesses. Findings: On 3/14/22, at 11:58 A.M., an observation and interview with Certified Nurse Assistant (CNA) 6 of the residents' refrigerator on station 2 was conducted. The following food items were observed without label when it was opened, received, and expiration date: a. An undated clear plastic bag with a candy bar and a residents' first name and room number on it. b. An undated opened plastic store bought juice container with a residents' first name and room number. c. An undated bag, pre-printer biohazard with five unopened store bought protein shakes with a residents' initials and room number. d. An undated Target bad with an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to accurately document fluid intake and output (I&0), for one of two residents (Resident 43), reviewed for hydration. This failure had the potential to inaccurately portray Resident 43's current hydration status. Findings: Resident 43 was admitted to the facility on [DATE], with diagnoses which included infection to urethral catheter (a flexible tube that is inserted in the body to drain urine from the bladder into an external collection bag), per the facility's admission Record. On 3/14/22 at 10:20 A.M., Resident 43 was observed in bed with a urinary drainage bag hanging from the left bed frame. The urinary drainage had a blue covering as a dignity bag. On 3/15/22, Resident 43's clinical record was reviewed: According to the physician's order, dated 2/9/22, .Indwelling urinary catheter .Hydration-Record intake and output every shift . The Medication Administration Record (MARs) Hydration-Record Intake and Output, was reviewed from 3/1/22…

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 establish and implement a routine monitoring of the disinfecting system within the laundry area. This failure had a potential to put residents' linens and personal laundry at risk for contamination of pathogens (organisms causing disease). Findings: On 4/11/19 at 8:48 A.M., a joint observation, interview, and record review with LS 1 was conducted. LS 1 explained the laundry process. LS 1 stated every morning he recorded the temperature of the hot water tank. The logs only contained daily temperature readings of 154°F to 159°F (F, a temperature scale). LS 1 did not know the temperature goal, or why the water needed to be hot. LS 1 stated, They did not explain to me. Three stainless-steel tubes, with blue ultra-violet (UV) lights, were connected to the washers. LS 1 stated he did not know what the stainless-steel tubes were for. LS 1 stated, only non-facility service men came twice a month to check the stainless-steel tubes. On 4/11/19 at 9:18 A.M., an observation and interview with the HD and the DOM 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 ensure staff answered residents' call lights in a timely manner for one of one residents reviewed for dignity (55), two confidential residents (CR 1, CR 3) interviewed during a confidential group, and an unsampled resident (86). These failures resulted in residents dignity and needs to not be met in a timely manner, which had the potential to result in physical and psychosocial harm. Findings: 1. Resident 55 was admitted to the facility on [DATE] with diagnoses to include muscle weakness, difficulty in walking, and lack of coordination, per the facility's Resident Face Sheet. On 4/8/19 at 1:35 P.M., an interview with Resident 55 was conducted. Resident 55 stated, staff response to call lights were slow, many times over 20 minutes. Resident 55 stated, he had bowel movements in bed several times because the staff did not come fast enough. Resident 55 further stated, he was left on the toilet for at least a half hour, which made me really angry. 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 ensure a language line for personal interpretation via telephone was available or utilized to communicate with two of two residents (40, 60) reviewed for language/communication who did not speak English. As a result, Resident's 40 and 60 may not have had their need mets. Findings: 1. Resident 40 was admitted to the facility on [DATE], per the Resident Face sheet. A review of Resident 40's clinical record was conducted on [DATE]. The Resident Face sheet indicated Resident 40 did not speak English. On [DATE] at 10:03 A.M., an interview was conducted with the SSD in Resident 40's room. Resident 40 was lying in bed and waved when the SSD asked if she could come into the residents' room. The SSD confirmed the facility did not have an onsite interpreter who spoke Resident 40's language. The SSD stated the facility used the foreign translation services to communicate with Resident 40. When the SSD used the residents' telephone to call 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 observation, interview, and record review, the facility failed to provide treatments according to the physician's order when surgical wound dressing changes were not done as ordered, for one of one resident (34) reviewed for dressing changes. This failure had the potential to cause infection and delayed healing of the surgical wound. Findings: Resident 34 was admitted to the facility on [DATE], with diagnoses to include left below the knee amputation (BKA), which required dressing changes, per the facility's Resident Face Sheet. Resident 34's MDS (an assessment tool), dated 2/4/19, indicated Resident 34 had a BIMS (mental status assessment tool) score of 15 (13-15 is considered cognitively intact). On 4/8/19 at 11:15 A.M., an observation and interview with Resident 34 was conducted. Resident 34 was in his room, sitting up in his wheelchair with a special sock over his left BKA stump. Resident 34 stated, when LN 16, the treatment nurse, was not working, the LNs did the dressing changes. Resident 34…

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 standards of practice were followed for one of one residents (48) reviewed for dialysis (blood is cleaned by a machine then returned to the body) when the pressure dressing (a gauze and tape dressing which stops a dialysis site from bleeding) was not removed in a timely manner. As a result, there was a potential for Resident 48 to have complications that may not have been identified. Findings: 1. Resident 48 was admitted to the facility on [DATE] with diagnoses to include chronic kidney disease and dependence on dialysis, per the Resident Face Sheet. On 4/11/19 at 8:24 A.M., a concurrent interview and observation was conducted with LN 1 in Resident 48's room. LN 1 pulled up Resident 48's left arm sleeve, showing a pressure dressing, which covered Resident 48's fistula (an access site for dialysis). LN 1 stated the dressing should have been removed the evening before, when Resident 48 returned to the facility. Per LN 1, We need to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a medication order for Ativan (lorazepam - an anxiety reducing medication) was processed in a timely manner for one of one residents (45) reviewed for discharge. This failure had the potential to have caused Resident 45 to experience anxiety unnecessarily in the final days of his life (Resident 45 expired on [DATE]). Findings: Resident 45 was readmitted to the facility on [DATE] with diagnoses which included lung cancer and chronic obstructive pulmonary disease (a progressive lung disease making breathing difficult), per the Resident Face Sheet. The clinical record of Resident 45 was reviewed. Physician Orders for Resident 45 showed an order was written on [DATE] for Ativan .tablet, 0.5 mg, oral, every 4 hours as needed . Resident Progress Notes for Resident 45 showed an entry on [DATE] at 2:58 P.M., .resident has an episode of anxiety and family wants him to have antianxiety medication. MD notified and got an order for Ativan 0.5…

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: 1. Documentation of clinical justification for not performing a gradual dose reduction (GDR) on a psychotropic (drugs that affect mental state) medication for one of three residents (16) reviewed for psychotropic medications, and 2. Non-pharmacological interventions (methods, programs or services that aim to prevent, care, or cure health problems) for one of three residents (58) reviewed for the use of psychotropic medications. These failures created the potential for Resident's 16 and 58 to receive unnecessary medications. Findings: 1. Resident 16 was readmitted to the facility on [DATE] with diagnoses that included depression and insomnia, per the Resident Face Sheet. The clinical record for Resident 16 was reviewed on 4/9/19. The Physician Order Report, indicated trazodone (a psychotropic medication used to treat depression and insomnia) was ordered and initiated on 10/4/18 for insomnia at bedtime. The Consultant Pharmacist's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: 1. Provide a breakfast which followed the physician's orders for one resident reviewed for dialysis care (48), and 2. Obtain input from residents and resident groups regarding a new menu implementation. These failures had the potential to place Resident 48 at risk for complications related to his kidney failure, and placed all residents at risk for poor nutrition intake and weight loss. Findings: 1. Resident 48 was admitted to the facility on [DATE] with diagnoses to include end stage kidney disease and dependence on renal dialysis (blood is cleaned by a machine then returned to the body), per the Resident Face Sheet. On 4/10/19 at 8:00 A.M., 8:15 A.M., and 8:30 A.M., Resident 48 was observed sitting up in bed, with an over-bed table positioned over his lap. No breakfast tray was on the table. A record review was conducted. Resident 48 was scheduled for dialysis on 4/10/19 at 10 A.M. A physician's order, dated 4/3/19 listed Resident 48's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a physician ordered therapeutic diet was provided to one sampled resident (48). As a result, Resident 48 did not receive an appropriate meal to take with him during his dialysis (a treatment using a machine to clean and filter a person blood) treatment. Findings: Resident 48 was admitted to the facility on [DATE] with diagnoses to include chronic kidney disease and dependence on dialysis, per the Resident Face Sheet. On 4/10/19 at 10:10 A.M., Resident 48 was observed preparing to be transported to dialysis. The facility provided a cooler bag with lunch items for the resident. The bag contained a turkey sandwich, vanilla pudding, sugar-free cookies, and a 12-ounce bottle of water. A record review was conducted. Per Resident 48's physician's orders, the diet was regular with ground meat, and a fluid restriction of 1200 ml per day. On 4/10/19 at 10:20 A.M., a concurrent interview and observation was conducted in the kitchen. DA 1 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 maintain the proper air gap between the dishwasher drain pipe and the flood level rim (kitchen floor level) of the floor drain apparatus (a drain that is set approximately six inches below the level of a kitchen floor). This failure created the potential for contaminated water to go back up into the dishwasher potentially causing the dishwasher to operate with unclean water and cause residents to be eating from unsanitized dishes. Findings: On 4/9/19 at 10:35 A.M., an observation was made of the dishwasher dirty water discharge drain pipe. The discharge end of the drain pipe was approximately one inch below the flood level rim of the floor drain. The drain pipe was observed to be held in place by plastic wrap. On 4/9/19 at 11:01 A.M., a concurrent interview and observation was conducted with the RD. The RD confirmed the drain pipe was about one inch below the level of the kitchen floor (flood level rim of the floor drain), and not at the correct height. The RD confirmed the drain pipe was being held in place…

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

Based on interview and record review, the facility failed to ensure a comprehensive facility assessment was completed. The facility assessment failed to include the care and resources required for the resident population it serves. This deficient practice had the potential to place residents at risk of the inability to identify their needs, and evaluating the resources needed to provide the care and services necessary. Findings: On 4/11/19 at 3 P.M., an interview and record review was conducted with the Admin and DON. The document provided, dated 4/8/19 and titled Survey Report was reviewed. The facility assessment includes a minimum of 11 components, the Survey Report provided had only three of the components. The Admin stated he did not know what additional information needed to be included in the Facility Assessment. The facility was unable to provide a policy on Facility Assessment.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure medical records were complete and accurate for one sampled resident (16) when: 1. A consent was not completed related to an increased dose of a psychotropic (drugs that affect mental state) medication, and; 2. Multiple medication administrations were not charted at the time the medications were given. These failures had the potential for incorrect information to be shared between staff in regards to whether Resident 16 received knowledge of the risk and benefits related to the increased dose in medication or if the medication was administered on time. Findings: 1a. Resident 16 was readmitted to the facility on [DATE] with diagnoses which included depression, per the Resident Face Sheet. The clinical record for Resident 16 was reviewed on 4/9/19. A physicians order for sertraline (an antidepressant medication) 25 mg, once a day, was initiated on 10/4/18. A physicians order to increase sertraline to 50 mg, once a day, was initiated on 10/4/18. 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.