The Villas At Poway

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure accurate documentation related to: 1. Advance Directives for two residents (10, 131). 2. A documentation for a resident's capacity to understand and make decisions was missing for one resident (40) 3. Resident's consent for treatment was incomplete (40). This failure resulted in conflicting records regarding the presence of Advance Directives (10, 31) and did not provide an accurate representation of the care provided and had the potential to cause confusion amongst care providers (40). Findings: 1a. On 5/19/25 Resident 10's clinical record was reviewed. Resident 10 was admitted to the facility on [DATE] per the facility's Patient Information. A document titled Advance Directive Acknowledgment dated 2/19/19, 4/19/19, and 2/13/24 indicated, I do not have an Advance Directive, however, I am interested in receiving an Advance Directive Brochure . and was initialed by Resident 10 and Resident 10's family member. On 05/21/25 at 10:57 A.M., a joint…

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 policies and procedures for abuse when: a licensed nurse (LN) did not report a witnessed abuse of one resident. (Resident 7). This failure resulted in an incomplete investigation and protection of residents from the perpetrators. Findings: Resident 7 was admitted to the facility on [DATE], per Resident 7 ' s face sheet. The Physician Progress Note, dated 8/8/24, indicated Resident 7 ' s diagnoses included senile dementia (a progressive decline leading to loss of memory, language, problem solving, other thinking abilities and loss of independence in daily activities). Resident 7 ' s Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 7/31/24, section C0700 through section C1000, indicated that Resident 7 had short and long-term memory problem, memory/recall problem, and had severely impaired daily decision making. An interview with certified nursing assistant (CNA) 5 was conducted on 9/4/24 at 10:50 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 observation, interview, and record review, the facility failed to ensure staff reported a witnessed physical abuse of a resident (Resident 7) who was cognitively impaired (problem with the ability to think, learn, remember, use judgement, and make decisions) to the facility's administration. This deficient practice had the potential for actual and/or alleged abuse incidents to be unreported and not investigated. In addition, this failure had the potential for residents to be unprotected from abuse. Findings: A review of Resident 7 ' s clinical record was conducted. Resident 7 was admitted to the facility on [DATE], per Resident 7 ' s face sheet. The Physician Progress Note, dated 8/8/24, indicated Resident 7 ' s diagnoses included senile dementia (a progressive decline leading to loss of memory, language, problem solving, other thinking abilities and loss of independence in daily activities). Resident 7 ' s Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 7/31/24, section…

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 a person-centered care plan was updated for one of three residents (Resident 1) reviewed with osteoporosis (bone disease; weak, brittle bones). This failure had the potential to miscommunicate care related to Resident 1 ' s health and safety when providing care, assistance, and repositioning for Resident 1. Findings: A record review of Resident 1's face sheet (contains demographic information) indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included respiratory failure (a serious health condition; difficulty breathing). A record review of Resident 1's Minimum Data Set (MDS; nursing assessment tool), section B0100, dated 11/14/23, indicated .comatose . persistent vegetative state /no discernible consciousness (individual does not show signs of awareness). This section was coded as yes. A record review of Resident 1's portable chest x-ray, signed by the medical doctor (MD), dated 1/5/23, indicated .Probable small…

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 transmission based infection control measures when Licensed Nurse (LN) 2 entered the room of a resident (Resident 1) who tested positive for COVID-19 (an infectious disease caused by the SARS-CoV-2 virus) without the required personal protective equipment (PPE, equipment worn to minimize exposure to infection and injury in the workplace). This failure had the potential to increase the risk of COVID-19 transmission to all residents, staff, and visitors at the facility. Findings Include: Resident 1 was admitted to the facility on [DATE] with a diagnosis of respiratory failure, per the residents admission record. On 12/5/23 at 11:31 AM an interview was conducted with LN 1 in the hallway outside Resident 1's room. LN 1 stated Resident 1 had tested positive on the routine rapid antigen test for COVID-19 this morning. On 12/5/23 at 11:53 AM an observation and interview were conducted with LN 2 outside of Resident 1's room. LN 2 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 offer bed hold for two residents who were transferred to the acute hospital. (Resident 5 and Resident 6) This failure had the potential for the residents to not be aware of their choice to hold a bed at the facility when transferred to the hospital. Findings: Resident 5 was admitted to the facility on [DATE] with diagnoses including wound care, leaking colostomy (an opening for the colon or large intestine through the abdomen) according to the facility ' s Patient Information. On 9/14/23, at 11:36 A.M., a concurrent review of Resident 5 ' s nursing note with the Director of Nursing (DON) was conducted. The DON stated Resident 5 was transferred to the hospital on 3/23/23 due to shortness of breath, with cold and clammy skin. During an interview and concurrent record review on 9/14/23, at 12:10 P.M., with the nursing supervisor (NS), the NS stated if a resident was transferred to the hospital, the nursing staff called the resident or the responsible party…

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 observations, interviews, and document reviews, the facility failed to ensure the menu was designed to meet the nutritional needs of the residents on pureed diets. This failure led to twelve (12) residents on pureed diets to receive fewer calories and nutrients which had the potential to further impair their nutrition and health status. Cross reference F804 Findings: During a review of the facility's undated therapeutic menu spreadsheet titled Week 2, Tuesday, 3/21/23, the Regular Diet lunch meal was 3 ounces (oz.) oven fried chicken breast, ½ cup mashed potatoes, ½ cup sauteed green beans and cherry tomatoes, 8 ounces (oz.) 1% milk, 6 oz. creamy lentil soup, 2 saltine crackers, and 1 iced brownie. The Dysphagia Pureed Diet lunch meal included a 3 oz. turkey puree with 1 oz. chicken gravy, 3 oz. corn puree, 3 oz. green beans puree, 8 oz. 1% milk, and 1 orange jello gelatin cup. During an observation and interview on 3/21/23 at 10:03 A.M. of the lunch meal food production in the main kitchen, the A.M. [NAME] (CK) 1 prepared 15 pre-packaged pureed food items, entrées, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure food safety and sanitation protocols were maintained in the kitchen according to standards of practice and facility policy when: 1. Loading dock area, dumpster cart, and area in front of the dumpster were not free of kitchen waste. 2. Ten (10) kitchen floor sink drains were dirty and filled with food waste. 3. An Ice Machine was not properly maintained and cleaned per manufacturer guidelines. 4. An expired supplement was found in a nourishment room refrigerator in the facility nursing station. These failures exposed residents to unsanitary practices in the kitchen, which had the potential to contaminate the food and place residents at risk of developing a foodborne illness. Cross reference F814, F908, and F925 Findings: 1. During a concurrent observation and interview on 03/20/23 at 2:34 P.M. with Food Service Worker 1 (FSW1), FSW 1 demonstrated how he removed trash from the kitchen. There were several foul soiled kitchen wastes…

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: 1. Loading dock, dumpster cart, and area in front of the dumpster were free of kitchen waste. 2. Food and Nutrition department floor sink drains were free from food waste. These failures provided an unsanitary environment in the kitchen that harbored pests and had the potential to contaminate resident food. The nursing home census was 109 residents. Cross reference F812, F925 Findings: 1. During a kitchen observation of the garbage disposal and concurrent interview on 03/20/23 at 2:34 P.M., Food Service Worker 1 (FSW1) demonstrated the trash removal process from the kitchen. FSW1 brought trash bags in garbage can to dock. FSW1 went down service lift to get dumpster cart. Food debris and garbage from kitchen was observed between lift and dock. FSW1 put the trash bags in the trash cart from the dock. FSW1 then climbed down from the loading dock and then he pushed trash cart to dumpster lift, which put the cart contents into dumpster and compressed contents. Foul smelling kitchen waste was observed 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 observations, interviews, and document reviews the facility failed to ensure: 1. One ice machine in the main kitchen was maintained in a safe operating condition. 2. One ice machine in the skilled nursing facility (SNF) was maintained and cleaned according to manufacturer's guidelines and standards of practice. This failure created the potential for residents to receive and consume ice from machines that were contaminated with substances resembling mold and other hazardous chemicals, that could lead to foodborne illness and impair health status. The facility census was 109. Cross reference F812 Findings: 1. On 3/20/23 at 8:40 A.M., during the initial kitchen tour, a concurrent observation and interview was conducted with the Patient Service Supervisor (PSS). Ice machine #15 was observed to be empty, no ice in bin. Machine log read machine was cleaned on 3/19/23. No signs indicating the ice machine was out of service were present on the machine. PSS stated she believed the Ice machine #15 in the main kitchen, stopped working on 3/19/23 during the night shift. The ice bin 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 the main kitchen area and the skilled nursing home (SNF) were free of pests. This failure had the potential to contaminate food prepared, stored and served to facility residents, which could lead to widespread foodborne illness. The facility census was 109. Cross reference F812, F814 Findings: During the initial kitchen tour on 3/20/23 at 8:45 A.M., multiple fruit flies were observed flying around hand washing sinks and food prep sinks. On 3/20/23 at 2:35 P.M., an observation of exterior loading dock was conducted enroute to trash disposal area. A large electronic bug zapper light was on the outside wall at the back exit door entrance exit to kitchen with dozens of dead flies, other insects, and spider webs. The Foodservice Manager (FSM) and Foodservice Director (FSD) acknowledged the dirty electronic bug light with dead insect carcasses and spider webs and stated it should be clean. During an observation on 3/21/23 at 8:05 A.M. of the SNF's Education Room there were multiple dead pest carcasses…

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 4. Resident 39 was admitted to the facility on [DATE], with diagnoses which included respiratory failure, per the facility's Patient Information record. On 3/20/23 at 1:53 P.M., and 3/21/23 at 8:26 A.M., an observation was conducted of Resident 39 as she laid in bed. A urinary catheter bag was attached to the right side of the bed frame. The urinary catheter drainage bag contained pale yellow urine and was visible from the hallway. A dignity bag (a dark colored bag, used to promote dignity of catheterized patients by concealing urinary drainage bags from public view) was not present. On 3/20/23, Resident 39's clinical record was reviewed: According to the physician's order, dated 7/20/22, .Foley (brand name) Catheter FR #16 (size) monitor every shift . According to the quarterly MDS, (a clinical assessment tool), dated 1/6/23, the cognitive assessment, section C1000, was listed as moderately impaired cognition. Section H0100, indicated the resident had an indwelling urinary catheter. Per the care plan, titled…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide a written summary of the baseline care plans for three of five residents and/or their representatives (Resident 58, 85 and 402), reviewed for comprehensive care plans. This failure had the potential for residents and/or their representatives of not being informed of the resident's initial plan of care and services. Findings: 1. Resident 58 was admitted to the facility on [DATE]. According to the physician's History and Physical, dated 3/6/23, the admitting diagnoses included pelvic (hip bone) fracture (a break in the bone). During a review of Resident 58's MDS (a clinical assessment tool), dated 3/11/23, the MDS indicated, a cognitive score of 13, indicating cognition was intact. During observation and interview on 3/20/23, at 9:55 A.M., Resident 58 was lying in bed with oxygen being administered. Resident 58 stated she had a fall and was receiving therapy at the facility. Resident 58 stated she did not require oxygen before the fall. An alarm…

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 comprehensive care plans were revised and/or updated for three of five residents (Resident 58, 87 and Resident 402), reviewed for comprehensive care plans when: 1. Resident 58's care plan was not developed for the use of oxygen. 2. Resident 87's care plan for skin integrity did not indicate the current pressure ulcer status, and the use of Negative Wound Pressure Therapy (NWPT- wound vac-suction tubing, and wound dressing to remove excess fluid and any infectious material present in the wound), and Resident 87's wound center follow up appointments. 3. Resident 402's care plan was not updated when Resident 402's current pain medication was ineffective. Failure to revised and/or update the care plans had the potential for delayed care, miscommunication among caregivers, and decreased physical well-being. Findings: 1. Resident 58 was admitted to the facility on [DATE]. According to the physician's History and Physical, dated 3/2/23,…

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

Based on observation, interview, and record review, the Quality Assessment and Improvement Plan (QAPI-a plan to improve the overall quality of life and quality of care and services delivered to nursing home residents), failed to identify areas of improvement related to: 1. Weight loss (F-692) 2. Kitchen (F-803, F-812, F-814, F-908, F-925 3. Infection control (F-880) As a result, there was the potential to affect the safety and quality of care for residents. Findings: 1. On 3/23/23 at 2:43 P.M., an interview was conducted with the ADM, I-DON, RD 1 and RD 2. The department heads were informed the Centers for Medicare and Medicaid Services (CMS) had not reported any weight loss, according to the last MDS submission. The facility also reported to the survey team via their current Matrix Rooster (a list of residents used by the facility to identify pertinent care areas), dated 3/20/23, there were no residents reported with weight lost. The survey team later identified a resident with significant weight loss. According to RD 2, there was no current QAPI plan identifying issues with weight…

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 2a. Resident 83 was admitted to the facility on [DATE], with diagnoses which included right hip fracture with surgical repair, per the facility's Patient Information record. On 3/20/23 at 10:20 A.M., and on 3/21/23 at 8:11 A.M., an observation was conducted of Resident 83 as she laid in bed. Resident 83 was receiving oxygen at 2 liters (Al) via nasal annular, (NC-a flexible plastic tube that delivers oxygen via the nasal cavities). The oxygen tubing had a handwritten label, dated 3/5/23. On 3/20/23, Resident 83's clinical record was reviewed: According to the physician orders, dated 3/4/23, .O 2 at 2 LP (liters per minute) via NC . There was no physician's order of when to change the oxygen tubing and there was documented evidence on Resident 83's MAR or TAR that oxygen tubing had been changed. On 3/21/23 at 12:03 P.M., an interview was conducted with the ICN. The ICN stated oxygen tubing was changed every Sunday night on the P.M. shift (3 P.M. - 11:30 P.M.), for every resident receiving oxygen therapy. The ICN…

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 a sensitive (touch pad) call light was available for one of one resident, (Resident 13) reviewed for accommodation of needs. This failure resulted in Resident 13 not getting his needs met. Findings: Resident 13 was admitted to the facility on [DATE], with diagnoses that included Quadriplegia (paralysis of arms, legs, and body from the neck down), per facility's Patient Information record. During an observation and interview on 3/20/23, at 11:09 A.M., with Resident 13, Resident 13 was in bed sitting upright. Resident 13 stated, he had to yell out for help, because he could not use the push button call light. Resident13 was observed with upper & lower extremity contractures (a stiffening of the muscles). A push button call light was clipped on Resident 13's bed and the resident could not reach for it. During a review of Resident 13's MDS (a assessment tool), dated 2/21/23, the MDS indicated, a cognitive score of 15, indicating he was cognitively…

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 conduct a quarterly (every three months) MDS assessment (a clinical tool which is submitted to Centers for Medicare & Medicaid Services [CMS]) and submit it to CMS in a timely manner for one of four residents (Resident 74) reviewed for Resident Assessments. As a result, the facility and CMS were delayed in knowing Resident 74's current health status. Findings: Resident 74 was admitted to the facility on [DATE], per the facility's Patient Information record. On 3/22/23 at 7:57 A.M., an interview and record review was conducted with the MDSN. The MDSN stated Resident 74 was originally admitted to the sub-acute unit (medically fragile residents who require special services, such as inhalation therapy), and then transferred to Station C on 12/29/21, where she has remained since. The MDSN reviewed Resident 74's MDS assessments and CMS submissions. Resident 74 had a quarterly assessment completed on 10/6/22, and another quarterly assessment should have been…

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 the manufacture's guidelines for low air loss (LAL- a special mattress that provides alternating airflow within the mattress, to relieve pressure), to maintain skin integrity for three of five residents, (Resident 64, 80, 83) reviewed for pressure ulcers. As a result, Residents 64, 80 and 83, had the potential to develop pressure ulcers from incorrect mattress settings. Findings: 1. Resident 64 was admitted to the facility on [DATE] with diagnoses which included respiratory failure, per the facility's Patient Information record. On 3/20/23 at 2:09 P.M., an observation was conducted of Resident 64 as she laid in bed. Resident 64's LAL mattress was set for a weight of 175-200, with 15-minute intervals of inflation/deflation. Resident 64's weight appeared under 175 pounds. On 3/21/23 at 3:23 P.M., an interview was conducted with CNA 11. CNA 11 stated only the LNs or NP changed the settings on the LAL mattresses, and CNAs did not touch…

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 with very low body weight and severe malnutrition risk was assessed according to the facility policy and standards of practice. This failure had the potential to cause additional weight loss and further compromise the one of 22 sampled residents (Resident 85) nutrition and health status. Cross reference F803, F804, F867 Findings: Per a review of Resident 85's admission Record dated 3/22/23, Resident 85 was admitted on [DATE] with diagnoses of Acute hypoxemic respiratory failure (impaired air exchange between the lungs and blood), and prior medical history of high blood pressure and chronic obstructive pulmonary disease (COPD-diseases of the lung that block airflow and makes it difficult to breathe). A review of Resident 85's LTC Nutritional Status document dated 2/3/23 completed by RD 3, indicated .Nutrition Risk Symptoms LTC: Diagnosed Malnutrition .Nutritional Intake Meets Needs (GOAL)= Not Met .decreased appetite;…

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 medical record review, the facility failed to ensure two of five residents (Resident 46 and 92) were monitored for side effects of unnecessary drugs. These failures had the potential for Resident 46 and 92 to have side effects that went undetected by staff. Findings: 1. Resident 46's admitted to the facility on [DATE]. According to the physician's history and physical, dated 5/30/22, Resident 46 diagnoses included traumatic brain injury (TBI) and neurocognitive impairment (decreased mental ability) with behavioral problems. A review of Resident 46's initial psychiatric consultation, dated 1/8/20, indicated Resident 46, .has been resistant, easily agitated, and aggressive. He strikes out at caregivers and is refusing all care. A review of physician medication orders for Resident 46, indicated Seroquel (an antipsychotic; class of psychotropic medication used to treat mental/mood disorders), 50 mg (milligram) tablet once a day at bedtime (HS) was started on 12/27/22. The orders indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interviews and review of facility documents, the facility failed to ensure that residents meals were served at a palatable and appetizing temperature. This finding had the potential to cause reduced food intake and affect nutrition status among medically vulnerable residents on therapeutic diets. The facility census was 109. Cross reference F803 Finding: During a concurrent interview and document review of the lunch menu on 3/21/23 at 10:03 A.M., the [NAME] 1, (CK1) stated lunch menu for that day consisted of oven fried chicken, mashed potato with gravy, and green beans. CK1 further stated the puree menu consisted of roast turkey with green beans, and corn; the puree were bought pre made frozen in individual molds. On 3/21/23 at 11:50 A.M., an interview with Resident 403 was conducted. Resident 403 stated that, .the veggies were not cooked well enough .and the oatmeal is always cold . Resident 403 further stated his food was not chopped like it was at his previous…

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 to have a full-time, certified infection control nurse (ICN-a professional who ensures healthcare workers and patients are doing all the things they should be doing to prevent infections and the spread of infections), who provides assessment, monitoring, development, implementation and management of the facility's infection prevention and control program. This failure had the potential of negatively affecting the quality of care provided to all residents. Findings: On 3/22/23 at 3:40 P.M., an interview was conducted with the facility's ICN. The ICN stated she worked as the ICN for four hours a day and was fully certified as a ICN. The ICN stated she shared the infection prevention duties with the DSD, who provided education, monitoring, and teaching to residents and staff members. On 3/22/23, at 3:40 p.m., an interview was conducted with the DSD. The DSD stated she was currently in training for certification as an ICN, an was not yet certified. The DSD stated she assisted with infection control training to staff…

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 two residents reviewed for dignity, was assisted with meal service in a respectful, and dignified manner (87). As a result, there was the potential for Resident 87 to experience decreased self-worth and self-esteem. Findings: Resident 87 was admitted to the facility on [DATE], with diagnoses which included cerebrovascular accident (stroke), per the facility's History and Physical. On 1/29/20 at 12:19 P.M., an observation was conducted during lunch meal service in the dining room. Resident 87 was observed in a wheelchair with a table in front of him. Fourteen other resident's were present, seated around tables. A female staff member (LN 11) stood next to Resident 87's left side, holding a soup bowl in the left hand and a spoon in her right hand. The female staff member looked down at Resident 87 while she assisted the resident with eating. On 1/29/20 at 12:22 P.M., an interview was conducted with LN 11. LN 11 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 observation, interview, and record review, the facility failed to develop a care plan for one of three residents (78), reviewed for hearing needs. As a result, there was a potential for Resident 78 to experience decreased socialization and isolation. Findings: On 1/27/20 at 11:16 A.M., an observation was conducted with Resident 78, in her room. Resident 78 did not communicate when asked questions and repeatedly pointed to her left ear. On 1/29/20 at 7:52 A.M., an interview was conducted with CNA 14. CNA 14 stated Resident 78 spoke some English and pointed at things in order to make her needs known. CNA 14 stated he was unaware if Resident 78 had any hearing issues and he had not noticed any hearing assistive devices in her room. On 1/29/20 at 8:02 A.M., an interview and record review was conducted with LN 13, regarding Resident 78. LN 13 stated Resident 78 could not hear very well and she did not have hearing aids. LN 13 could not locate a plan of care for Resident 78's impaired hearing. LN 13 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 review, evaluate and document Ativan (a medication to treat anxiety) prn (as needed) in the 14 day time frame for continued usage for three of 13 residents reviewed for psychotropic (mind altering) medications (37,54,57). This failure had the potential for residents to receive unnecessary medication. Findings: 1. Resident 37 was admitted to the facility on [DATE] with diagnoses that included vascular dementia (brain damage caused by multiple strokes) and depressive disorder (depressed mood) per the facility's Patient Information sheet. A review of Resident 37's medical record indicated a physician's order, dated 12/5/19, . Ativan 0.5 mg PO (by mouth) q (every) 6 hours prn for anxiety x 2 months until 2/5/20 . An interview and record review was conducted with LN 6 on 1/30/20 at 10:01 A.M. LN 6 stated that Resident 37 had episodes of anxiety and had received Ativan 0.5 mg 8 times between 12/5/19 and 1/30/20 per the eMar. An interview 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to honor one of two residents meal preferences for a cola beverage (70). This failure had the potential to decrease fluid intake by not honoring resident's preferences. Findings: Resident 70 was admitted to the facility on [DATE] with diagnoses that included abdominal pain per the facility's Patient Information sheet. An observation was conducted in the facility's dining room on 1/27/20 at 12 P.M. Resident 70's tray had an 8 ounce can of Sprite ( a citrus-flavored soda). Resident 70's meal ticket indicated a request for Coke (a cola-flavored beverage). A concurrent interview and review of Resident 70's lunch ticket was conducted on 1/28/20 at 1:36 P.M. with the DOO/FSN and the FSN Manager. The DOO/FSN stated, He (Resident 70) requested coke, but was served Sprite yesterday (1/27/20). We ran out of coke, because our stock levels were short, and gave Sprite, we should have told the resident; it was a preference issue. A review of the facility's…

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

Based on observation, interview and record review, the facility failed to follow the menu related to Tuscan vegetables and 2% milk. This failure had the potential to not meet the nutritional needs of residents. Findings: During a dining observations in the facility's dining room on 1/27/20 at 12 P.M., and 1/28/20 at 8:20 A.M., the following were noted: 1. Resident 7 received green beans instead of the Tuscan vegetables that were selected on the luncheon menu; 2. All residents who were supposed to receive 2% milk for breakfast received 1% milk. 1. An interview was conducted with Resident 7 on 1/27/20 at 12:15 P.M. Resident 70 stated, Hey, where are the Tuscan vegetables? Everyone else has them! A review of Resident 7's meal ticket indicated that Tuscan vegetables were selected by Resident 7. An interview and menu review was conducted on 1/28/20 at 1:36 P.M., with the DOO/FNS and the FNS Manager. Resident 7's lunch ticket indicated that he was on a dysphagia chopped diet and that Tuscan vegetables were a choice on the select menu. A review of the facility's dysphagia chopped menu…

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 remove expired food from one of three refrigerators, and there was no process in place to determine freshness of produce. This failure had the potential to expose residents to foodborne illness. Findings: A tour of the facility's kitchen was conducted on 1/27/20 at 8 A.M., with the FNS Manager. In one refrigerator, there were 1/2 gallons of 2% milk (x 2) that had expiration dates of 1/26/20. The FNS Manager stated, Those are expired, they should not be in here. In addition, there were 4 boxes of portobello mushrooms, five pounds each, in the refrigerator. There was no use by date on the boxes. The mushrooms were inspected and found to be either dried out or covered with a wet, opaque substance. The FNS Manager stated that the mushrooms did not look fresh. The FNS Manager stated, Fresh produce doesn't have a use by date, we look at it to see if it is fresh. An interview was conducted with the DHR on 1/29/20 at 9:47 A.M. The DHR stated, Just looking at produce to see if it is fresh is subjective; a more specific…

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.