Marquis Care At Shasta

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to review and revise a comprehensive care plan for two of eight sampled residents (Resident 81 and Resident 131) when: 1.Resident 81 did not have activity interventions for specific needs and preferences. 2.Resident 131 did not have specific nursing interventions for shaving himself and getting out of bed. These failures had the potential to result in the residents' needs not being identified, feeling depressed with poor self-esteem, and had the potential to contribute to skin breakdown, infection, and negatively impact their ability to attain or maintain their highest practicable level of well-being. Findings: 1. During a review of the facility's policy and procedure (P&P), titled, Care Planning-Interdisciplinary Team (IDT, a group of experts from different fields working together to provide comprehensive care), revised 11/2017, the P&P indicated, Care planning begins the day of admission for all residents. The care plan is recognized as 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 ensure a telephone order (when the doctor calls the nurse to give an order for a resident) for a medication was correctly transcribed for one of eleven sampled residents when an order to give a medication in the eye was mistakenly written to be given in the ear. (Resident 58)This error has the potential for residents to receive medication via the incorrect route. Not receiving the medication via the correct route, the medication would be ineffective to treat what it was prescribed for.Findings A record review of facility policy titled, Physicians Medication Orders revised 1/16 indicated on line 6, Orders for medication must include d. Route of administration if other than oral. Line 11 stated, Physicians orders are reviewed and sent to the primary care provider monthly for ongoing order reviewing.A record review of facility policy and procedures titled, Identifying and Managing Medication Errors and Adverse Consequences revised 4/15/21…

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 medications from one of four treatment carts and were available for resident use.This had the potential for residents to receive expired medications which would not be effective or safe for use.Findings:A record review of facility policy titled, Storage of Medications revised 5/10, indicated under Policy Interpretation and Implementation Line 2. The nursing staff shall be responsible for maintaining medication storage AND preparation areas in a clean, safe, and sanitary manner.A record review of facility pharmacy policy and procedures titled, Medication Storage in the Facility revised 1/1/23, indicated under Procedures, line J stated, Medication storage conditions are monitored on a periodic basis by the consultant pharmacist or consultant nurse and corrective action taken if problems are identified. Line G stated, All expired medications will be removed from the active supply and destroyed in the facility, regardless of amount remaining. The medication will be destroyed in the usual manner.An…

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

Based on observation, interview, and facility document review, the facility failed to ensure:1.One of three sampled resident's minced and moist (MM5) therapeutic diets (special needs diet plans), was prepared according to the recipe. (Resident 143)2. Nursing staff had a current and complete diet manual reference.These failures had the potential to result in residents receiving diets that do not match physicians' orders and incorrect preparation of special therapeutic diets and for nursing staff not to have reference material to recognize when a diet is served incorrectly. Findings:1.On 03/03/2026 at 10:30 AM, during a kitchen observation, [NAME] 1 (CK 1) was preparing minced and moist diet (MM5, foods are finely chopped and kept moist so they are easier to chew and swallow) minced (foods that have been cut or chopped into very small, fine pieces), chicken without referring to the recipe.On 03/03/2026 at 11:50 AM, during a kitchen observation during lunch trayline, a MM5 diet tray for Resident 143 included minced chicken with BBQ sauce on top.A review of the facility document 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.

Based on interview, and record review, the facility failed to ensure one of three sampled residents, (Resident 1) was treated with respect and dignity during direct personal care when Certified Nursing Assistant (CNA) I rushed Resident 1 and held his arms to prevent hitting staff when the bed linen was changed. This failure had the potential to result in emotional stress, embarrassment, feelings of neglect, and the potential for negative clinical outcomes.Findings: During a review of the facility's policy revised 8/2017, titled, Quality of Life-Dignity, indicated each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Residents shall be treated with respect and dignity at all times. Treated with respect and dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. This facility's policy indicated staff shall treat cognitively impaired residents with dignity and sensitivity addressing the underlying motives or root causes for behavior and not challenging or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that staff responded in a timely manner to residents' requests for assistance for one of four sampled residents, (Resident 1), when call-lights were not answered for greater than 20 minutes multiple times. These failures had the potential to negatively impact residents' physical, emotional and psychosocial well-being and left Resident 4 feeling unfairly treated. Findings: During a review of the facility policy titled, Resident Rights dated 5/2010, the policy indicated that 3. Our facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity . Review of admission records for Resident 4 indicated Resident 4 was admitted to the facility on [DATE], with diagnoses including depression, adult failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor…

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 and revise the care plan for one of four sampled residents (Resident 4), when Resident 4 had an unintentional significant weight loss of 5 percent (%) in one month. This failure had to potential for Resident 4 to have unwanted weight loss and negatively impact his physical well-being. Findings: Review of admission records for Resident 4 indicated Resident 4 was admitted to the facility on [DATE], with diagnoses including depression, adult failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity), diabetes, insomnia, high blood pressure, chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), pressure ulcer (localized, pressure-related damage to the skin and/or underlying tissue), muscle weakness. Review of the facility's policy titled, Weight Assessment and Intervention dated 5/2018, 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 interview and record review, the facility failed to ensure staff demonstrated appropriate competencies (knowledge, skills, and abilities that were required to provide safe and effective care to residents) when providing care for three out of three sampled residents (Residents 1, 2, and 3) when: 1. Licensed Nurses (LN) did not perform an assessment of Resident 1 ' s surgical site. 2. A Certified Nurse Assistant (CNA) documented Resident 2 received a shower when Resident 2 did not receive a shower. 3. Residents 1, 2, and 3 experienced long call light wait times. 4. The competency checklist for registry staff (third party staff, employed by a registry agency and travels to different facilities to work) consisted of a self-evaluation and did not include oversight for evaluation of competencies or skills. These failures had the potential for an infection to go unnoticed and to negatively impact resident ' s physical, mental, and psychosocial well-being. Findings: 1. A review of the facility ' s policy and…

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

Based on observation, interview, and record review, the facility failed to ensure that the pureed food (food that is either ground, mashed or blended into a pudding like consistency), recipes were followed. This failure resulted in unappetizing food and had the potential for 11 residents who received pureed food, to receive diets that had not met their nutritional needs. Findings: A review of the facility Matrix (a record of residents and their needs), showed that 11 of 115 residents received pureed diets. A review of the facility's policy titled, Cooking Food dated 8/23/23, indicated, Recipes will be followed for the menu items. A review of the facility's recipe titled, P Seas Spinach no date, indicated that this recipe made 5 servings and called for 2.5 cups of seas spinach, and 3 tablespoons of thickener. The recipe provided instructions to reserve cooking liquid and add the liquid back to the spinach when pureeing it in the Robot Coupe (RC a device used to grind or puree food), and reheat to 165 degrees Fahrenheit (F). During a concurrent observation and interview on 10/8/24 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to ensure the facility food was appetizing and palatable when 14 of 115 residents (Residents 328, 329, 36, 576, 72, 26, 529, 86, 580, 119, 587 and three confidential residents), who received food prepared in the facility kitchen were not satisfied with the facility food. This failure had the potential for 14 residents to have decreased intake which could lead to unplanned weight loss and other medically related concerns. Findings: 1. A review of Resident 328's medical record indicated that Resident 328 was admitted on [DATE] with diagnoses that included Hypertension, Atrial Fibrillation (irregular, often rapid heart rate causes poor blood flow), and Chronic Obstructive Pulmonary Disease (COPD, a group of lung diseases that blocks airflow and make it difficult to breathe). A review of Resident 328's Minimum Data Set, (MDS, a standardized assessment tool), dated 10/2/24, indicated that the Brief Interview for Mental Status (BIMS) score in Section C, rated…

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, facility document, and policy and procedure review, the facility failed to ensure seven of 116 resident's (Resident 577, 61, 579, 580, 69, 587 and 114) food preferences were honored. This failure posed the potential for facility residents to not be satisfied with their meals which could contribute to decreased intake and further lead to unintentional weight loss. Findings: Review of the facility policy titled, Resident Food Preferences updated May 12, 2021, showed nutritional assessments will include an evaluation of individual food preferences. 1. During a review of Resident 577's clinical record. Resident 577 was admitted to the facility on [DATE] with diagnoses that included, numbness of feet and hands, irregular heart rate, and wounds to right foot and left foot. The most recent Minimum Data Set, (MDS, an assessment tool), dated 09/27/24, indicated that Resident 577 was cognitively intact. During an interview on 10/07/24 at 12:28 pm, with Resident 577. Resident 577 stated, I…

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

Based on observation, interview, and record review, the facility failed to ensure food safety and sanitation guidelines were followed when: 1. The cool down process for time, temperature control, and safety of food (TSC, foods that need to be kept at specific temperatures to prevent bacteria growth and foodborne illness), was not monitored. 2. Dish machine wash and rinse temperatures did not meet manufacturer's guidelines. 3. Hair restraints were not worn. 4. Food preparation equipment was not in proper working order. 5. Kitchen equipment was not clean. 6. Food preparation equipment and silverware were not air dried. 7. Food was not stored properly in the kitchen. 8. Kitchen cleaning supplies were not stored properly. 9. Non-functioning kitchen equipment was not discarded. These failures had the potential of causing foodborne illness in 115 of 116 residents who consumed food prepared in the facility's kitchen. Findings: A review of the facility Matrix (a list of residents and thieir care needs), showed that 115 of 116 residents consumed food prepared in the kitchen. 1. A review 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 four out of 25 sampled residents' (Resident 19, 36, 112, and Resident 121) care plans were develped, reviewed and revised when: 1. Significant unplanned weight loss for Resident 19 was not updated on the care plan. 2. Unplanned weight loss and a room change for Resident 36 was not updated on the care plan. 3. End of life care for Resident 112 was not updated on the care plan. 4. A Urinary Tract Infection (UTI, a bladder infection), for Resident 121 was not updated on the care plan. These failures had the potential to result in the residents' needs not being identified, and resident's feeling depressed with poor self-esteem, and had the potential to contribute to skin breakdown, infection, and negatively impact their ability to attain or maintain their highest practicable level of well-being. Findings: 1. A review of the facility's policy revised 11/2017 titled, Care Plans-Person Centered Comprehensive, indicated an individualized…

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 activities of daily living (ADLs, basic needs as personal hygiene, dressing, toileting, transferring, walking, and eating), were provided for three of eight sampled dependent residents (residents who depend on staff to help them), (Resident's 2, 29 and 112), when: 1. Routine grooming activities were not completed for Resident 2 and Resident 29. 2. Routine and scheduled showers were not completed for Resident 112. These failures had the potential to result in the residents feeling depressed with poor self-esteem, and had the potential to contribute to skin breakdown, infection, and negatively impact their ability to attain or maintain their highest practicable level of well-being. Findings: 1. During a review of the facility's policy revised 8/2017 titled, Care of Fingernails/Toenails-Level II, indicated this purpose of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infection. Nail care includes…

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 pharmaceutical services to meet the needs of each resident when expired medications and an expired Emergency Drug Kit (E-Kit, medications that are readily available for use when the Pharmacy is closed), were available for use in the [NAME] Unit medication room. This had the potential for the residents to receive expired medications that are no longer considered viable, safe or effective for treating their illnesses. Findings: During an observation of the [NAME] Unit medication room conducted on 10/09/24 at 1:13 pm, the following expired medications were found to be available for resident use; Two bottles of unopened Acetaminophen (pain reliever and fever reducer), 500 milligram tablet (mg, a unit of measure), expired 09/2024. Soothing 12 Hour Nasal Decongestant (relieves nasal congestion) Spray, 30 milliliter (ml, a unit of measure), expired 09/2024. An E-Kit that expired 09/2024, and contained the following; Cefazolin (antibiotic), 1 gram (gm, a unit of measure), 4 vials Cefepime (antibiotic),1 gm, 2…

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 observations, interviews, and record reviews, the facility failed to maintain a medication error rate below five percent (5%). During the medication pass on 10/08/24 and 10/09/24, four medication errors were observed out of twenty-seven opportunities for four of six residents (Residents 17, 328, 103), which resulted in an overall medication error rate of 14.81%, when: 1. Licensed Nurse (LN) 4 administered an iron supplement to Resident 17 with milk. This failure had the potential to reduce absorption of the iron supplement. 2. LN 6 did not follow the manufacturer's instruction for administration of the Breo Ellipta Inhaler (a medical device for administering a respiratory medication, which is to be inhaled). This failure had the potential for Resident 328 to not receive the full dose of the medication and could possibly cause contamination of the inhaler and its contents. 3. LN 7 did not follow the manufacturer's instruction for administration the Breo Ellipta Inhaler. The omissions in instruction could…

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 document review, the facility failed to ensure the facility was free from pests. This failure posed the risk of 116 residents who resided in the facility to be exposed to pests. Findings: Review of the facility policy titled, Vermin Control dated 4/2018, showed the Food and Nutrition Services Department must be free from vermin (pests), at all times. The Food and Nutrition Services Department must be kept free of soil and clutter. Arrangements will be made by the Administrator for an effective pest control program to provide routine service. Review of the facility documents from the outside pest company dated 7/18/24, 8/13/24 and 9/19/24 showed that two fly bait stations located in the kitchen and one fly bait station located outside the facility were serviced. During the initial tour of the kitchen on 10/7/24 at 10:40 am, with the Certified Dietary Manager (CDM), one fly was observed in the kitchen near the food preparation sink. On 10/7/24 at 11:49 an, an observation of the kitchen was conducted. The air curtain, a device used 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 the dignity of one of eight sampled residents (Resident 36) when she was left in a soiled brief, and not changed in a timely manner. This failure resulted in Resident 36 to feel increased anxiety, and depression and had the potential to result in emotional stress, embarrassment, feelings of neglect, and the potential for negative clinical outcomes. Findings: The facility's policy revised 8/2017 titled, Quality of Life-Dignity, indicated each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. Residents shall be treated with dignity and respect at all times, to include promptly responding to the resident's request for toileting assistance. The facility's policy revised 5/2010 titled, Resident Rights, indicated employees shall treat all residents with kindness, respect, and dignity. This facility's policy indicated the facility will make every effort to assure each…

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 that one of eight sampled residents' bedroom (Resident 29) was maintained in a comfortable and homelike setting, when Resident 29 could not see his wife's pictures due to clutter on his dresser. This failure resulted in Resident 29 becoming frustrated and violated the right to have a home like environment. Findings: A review of the facility's policy dated 5/2011 titled, Quality of Life-Homelike Environment, indicated residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible. This policy also indicated the facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include cleanliness and order, personalized furniture, and room arrangements. A review of Resident 29's clinical record indicated Resident 29 was admitted to 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, medical record review and Policy and Procedure (P&P) review, the facility failed to ensure one of 25 sampled residents (Resident 19), received acceptable nutritional services when: 1. Resident 19's nutritional status was not assessed by the Registered Dietitian (RD) upon admission. 2. Resident 19's significant unplanned weight loss was not assessed by the RD and the Interdisciplinary Team (IDT, facility managers who discuss resident concerns and develop plans to correct them). 3. Resident 19's admission weight was not obtained in a timely manner upon readmission, in accordance with the facility policy. As a result of these failures, Resident 19's compromised nutritional status was not addressed timely, which could lead to further medical complications. Findings: 1. A review of the facility policy titled, Nutritional Assessment revised 5/2028, showed, that a nutrition assessment, including current nutritional status and risk factors for impaired nutrition, shall be 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, and interview, the facility failed to ensure federal regulations related to the education qualification requirements of the dietary manager were followed as outlined in the California Code, Health and Safety Code (HSC 1265.4). This failure had the potential to result in inadequate oversight of the food and nutrition services department associated with meal distribution accuracy, safe food handling and sanitation guidelines. Findings: According to the HSC 1265.4, (4) Is a graduate of a dietetic services training program approved by the Dietary Managers Association and is a certified dietary manager credentialed by the Certifying Board of the Dietary Managers Association, maintains this certification, and has received at least six hours of in-service training on the specific California dietary service requirements contained in Title 22 of the California Code of Regulations prior to assuming full-time duties as a dietetic services supervisor at the health facility. On 10/7/24 at 10:31 AM, an interview was conducted with the Certified Dietary Manager (CDM). The CDM…

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 facility record review, the facility failed to ensure one of 116 resident's (Resident 48) received the appropriate textured diet when chopped meats were not the appropriate size. This failure had the potential for residents who received chopped meats to not receive the appropriate texture which could lead to chewing and/or swallowing concerns. Findings: Review of the facility document titled, Therapeutic Spreadsheet Week 2 Monday dated 10/7/24, showed Easy to Chew diets should have received chopped meat for the lunch meal. Review of the facility Diet Manual, revised September 2024, showed, Mechanical Soft diet Recommendations: All meat (such as beef, fish, poultry and pork), should be ground or chopped. Definition of Menu Terms: Chopped was defined as ¼ inch to ½ inch pieces. A review of Resident 48's clinical record showed Resident 48 was admitted to the facility on [DATE] with diagnoses which included fracture of left humerus (upper arm), unspecified dementia, and major…

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 dispose of garbage properly. These failures had the potential to result in attracting insects and rodents affecting all 116 residents who resided in the facility. Findings: According to the USDA Food Code 2022, Section 5-501.19 Storage Areas, Redeeming Machines, Receptacles and Waste Handling Units, Location. (A) An area designated for refuse, recyclables, returnables, and, except as specified in (B) of this section, a redeeming machine for recyclables or returnables shall be located so that it is separate from food, equipment, utensils, linens, and single-service and single-use articles and a public health hazard or nuisance is not created. According to the USDA Food Code 2022, Section 5-501.110 Storing Refuse, Recyclables, and Returnables. refuse, recyclables, and returnables shall be stored in receptacles or waste handling units so that they are inaccessible to insects and rodents. A review of the facility's policy titled, Food/Waste Disposal, dated 8/2/24 indicated, The Food and Nutrition Services…

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 they coordinated resident care needs with the Hospice Agency (an outside agency that specializes in end of life care), for one of four sampled residents (Resident 112). This failure caused a delay in personal care, comfort, and had the potential to result in emotional stress, feelings of neglect, and negative clinical outcomes for residents who received Hospice services. Findings: A review of the facility's policy dated 5/2010 titled, Hospice Program, indicated the facility contracts for hospice services for residents who wish to participate in such programs. A Coordinated Plan of Care between the facility, hospice agency, and resident/family will be developed and shall include directives for managing pain and other uncomfortable symptoms. The care plan shall be revised and updated as necessary to reflect the resident's current status. A review of Resident 112's clinical record indicated Resident 112 was admitted to the facility 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 protect one of three residents sampled for abuse (Resident 1), from physical abuse received by staff, when a registry staff aggressively grabbed the resident ' s wrists while providing care. This failure had the potential to result in long term ill effects on the residents physical and mental health resulting in the resident ' s lack of trust towards staff for all care and negative emotional interactions. Findings: A review of Resident 1 ' s medical record indicated that Resident 1 was admitted on [DATE] with diagnoses that included, Hemiplegia and Hemiparesis following Cerebral infarct (weakness and paralysis on one side of the body following a disruption of blood supply and restricted oxygen to the brain resulting in an area of necrotic tissue in the brain), Vascular dementia (brain damage from impaired blood flow to the brain causing problems with reasoning judgment, and thought process), and Kidney Cancer. During a review of 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 record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from verbal abuse when Certified Nursing Assistant (CNA) 1 cursed at her while providing care. This had the potential to cause a decline in Resident 1's psychosocial well being. Findings: A review of the facility's Abuse Prevention Program policy, dated 12/2020, included the following policy statement, Our residents have the right to be free from abuse, neglect, exploitation and misappropriation of resident property, corporal punishment and involuntary seclusion. A review of the facility's Resident Rights policy, dated 5/2010, included the following policy statement, Employees shall treat all residents with kindness, respect, and dignity. A review of Resident 1's record indicated she was admitted on [DATE] with diagnoses that include intracranial hemorrhage (bleeding in the brain), anxiety, and dementia. The California Department of Public Health received a report from the facility of possible…

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 two of three sampled Hospice (end of life care) residents (Residents 1 and 2), were free from unnecessary medications when: 1. Resident 1 was ordered morphine sulfate (an opioid narcotic), without adequate indications of what level of pain (mild, moderate or severe), this medication was expected to treat. 2. Resident 2 was ordered Dilaudid (an opioid narcotic), without adequate indications of what level of pain the medication was expected to treat. This failure had the potential for Licensed Nursing (LN) to administer too much pain medication which could lead to over sedation and negative clinical outcomes, or give too little and subject the residents to uncontrolled pain, which could have a negative psychosocial and emotional impact on the quality of end of life care that Residents 1 and 2 received. Findings: 1. A review of the facility's policy and procedure titled, Medication Orders , revised 5/1/10, indicated, When recording PRN pain…

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 was stored, prepared, and distributed in accordance with professional food safety standards when: 1. Kitchen staff did not follow professional standards of practice to minimize cross contamination. 2. Two out of three observed nursing unit pantries contained expired resident food. 3. Kitchen equipment was not maintained in a sanitary manner These practices had the potential to result in foodborne illness for residents consuming food in the facility, which could lead to negative clinical outcomes. Findings: During observations, beginning 1/9/23 at 9:08 am, through four out of four days of the survey, Nutritional Services staff personal items were observed in the kitchen. This included a used N 95 mask on the dish machine, a used face shield on top of the coffee maker, two phone charger cords and a container of energy drink mix in the cook's area, a can of personal energy drink on the shelf in the walk-in refrigerator, and…

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

Based on observation, interview, and record review, the facility failed to ensure resident grievances and complaints were promptly reviewed, investigated, resolved, and documented for five confidential residents. This failure resulted in the loss of personal property, and the potential for psychosocial issues and concerns related to the resident's loss of personal property. Findings: The facility's policy, revised 11/16, titled, Concerns and Grievances, was reviewed, and indicated that any resident, or representative may voice or file a grievance, or complaint regarding theft, or loss of property without reprisal in any form. The filing of a grievance can be done anonymously. This policy also indicated upon receipt of a grievance or complaint, the facility will investigate the allegations and resolve the grievance promptly. The grievance official in the facility shall be the Social Services Director (SSD), or as designated by the facility. The grievance officer will maintain a log of concerns and grievance reports to be used in Quality Assurance, (QAPI) monitoring 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 interview, and record review, the facility failed to provide sufficient staff to meet the individual care needs for one out of sample resident (Resident 24), three of five confidentially interviewed residents, and eight of 25 sampled residents (Residents 32, 41, 53, 56, 68, 70, 93, and 409), when these residents complained of long wait times (up to 30 minutes) for their calls for staff assistance to be answered. The facility's failure to ensure sufficient staff to answer resident calls for assistance promptly contributed to residents' frustration and had the potential to cause emotional and physical harm to residents who did not receive the care when needed. Findings: 1. During an interview, on 1/09/23 at 3:45 pm, Resident 24 said they are short staffed especially on the night shift when sometimes there are only two Certified Nursing Assistants (CNAs) on the whole side. Resident 24 said that she is incontinent so sometimes it takes a while to get cleaned up. Resident 24 was alert and oriented. A review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to properly label and store medications and biologicals when: 1. Glucometer (a small portable device used for blood sugar testing) calibration control solution had expired on the Transitional Care Unit (TCU)-B medication cart which affected two residents (Residents 97, and 410). 2. Blood specimen collection tubes had expired in the [NAME] Hall Medication Room. 3. Loose wasted pills and a used bupenorphine (narcotic medication) patch were in a large, unlocked bin in the TCU Medication Room. 4. Two signed prescriptions for a controlled substance written on a physician prescription pad for two residents (Residents 31, and 36) were loose in the [NAME] Hall Medication Room. This failure had the potential to cause Residents 97, and 410, to receive care and treatment based on inaccurate blood glucose level results; to cause residents who had blood work done to receive care and treatment based on inaccurate lab values; to risk exposure of residents…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility document review, the facility failed to ensure the qualifications, competencies, and skill sets of the Registered Dietitian (RD), and the Dietary Services Supervisor (DSS) were in place and supported to carry out the functions of the food and nutrition service when: 1. There was inadequate oversight and mentoring provided by the RD to the DSS to make sure an effective system was in place to ensure food was prepared in a safe and sanitary environment. 2. The RD and Certified Dietary Manager (CDM) had ineffective oversight, training, and competence of staff. 3. Nutrition assessment, monitoring, and response to resident weight loss were not performed timely. These failures had the potential to result in foodborne illness, compromised nutritional status, ineffective resident care interventions, and decreased quality of life impacting all residents in the facility which could lead to negative clinical outcomes. Findings: A review of an undated facility's job description…

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 kitchen staff were competent to carry out the responsibilities of the Food and Nutrition Services when: 1. Staff were unable to determine food use-by dates. 2. The Dish Room staff were unclear regarding dish machine water temperature requirements in a machine that used hot water to sanitize dishes. 3. Staff did not state or follow manufacturer's instructions when testing quaternary ammonia sanitizer concentration. 4. Staff did not label or store chemicals per policy, and two staff interviewed were unclear regarding the correct number of tablets to use for the disinfectant they mixed. 5. Staff did not follow professional standards of practice These failures had the potential to result in foodborne illness, decreased nutritional status, decreased meal satisfaction, and medical decline for residents consuming food prepared in the kitchen and food areas. [ Findings: A review of an undated facility's job description titled, Cook, 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 ensure that all resident meals were palatable when 5 of the 25 sampled residents (Resident 32, 41, 70, 81, and 93) complained that their meals were consistently served too cold. This failure had the potential to negatively affect the health and nutrition of all residents and may have contributed to ongoing and significant weight loss for the residents leading to negative clinical outcomes. Findings: During interviews, conducted during initial tour, on 1/9/23 at 10 am, five sampled residents (Resident 32, 41, 70, 81, and 93) all stated that the meals they are served at the facility are consistently too cold, making the food unpalatable. 1. Resident 32's medical record was reviewed. Resident 32 was admitted on [DATE], with diagnoses that included adult failure to thrive (syndrome of weight loss, decreased appetite and poor nutrition, often accompanied by dehydration and impaired immune function), type 2 diabetes, and age-related…

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 review and revise the care plan for one of 25 sampled residents (Resident 41), when the resident experienced a series of falls. This lack of revision had the potential for interventions to be inconsistently utilized placing Resident 41 at risk of further falls that could result in injury, or further negative clinical outcomes. Findings: Resident 41's medical record was reviewed. Resident 41 was admitted on [DATE], with diagnoses that included Adult Failure to Thrive (syndrome of weight loss, decreased appetite and poor nutrition, accompanied by dehydration, and impaired immune function) Cerebral infarction with monoplegia of lower limb (a stroke which effected the ability to use and move one leg), and a history of falls. Resident 41's most recent MDS (Minimum Data Set, a resident assessment tool) dated 10/27/22, indicated that Resident 41 required the extensive assistance of two staff for her to change position while in bed, or when…

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

Based on interview, and record review, medication administration did not meet professional standards of quality, when laxatives (treats constipation) were not given according to the physician orders, for one of 25 sampled residents (Resident 77). This had the potential to result in severe constipation or intestinal blockage, which could lead to negative clinical outcomes. Findings: Resident 77's medical record was reviewed. Resident 77 was admitted with diagnoses that included cognitive decline, diabetes, depression, and chorea (abnormal involuntary movement disorder). A review of physician's orders included to give Senna if there was no bowel movement after two days, give Milk of Magnesia (MOM) if there was no bowel movement after three days, then give a Bisacodyl suppository (inserted in rectum) if MOM was ineffective, then a Fleets enema rectally if suppository was ineffective. A review of the bowel movements records indicated, that Resident 77 had no bowel movements from 12/30/22, until 1/6/23 (seven days). She was given Senna on 1/2/23, but did not have a bowel movement. MOM…

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 grooming and hygiene when one of 25 sampled residents (Resident 18) had long, dirty fingernails. This failure had the potential to cause skin scratches that could have become infected which could lead to negative clinical outcomes. Findings: The facility's policy titled, Care of Fingernails/Toenails - Level II, revised 8/1/17, was reviewed, and indicated that staff are to clean the nail beds, to keep the nails trimmed, and to prevent infection. Diabetic nail care was to be completed by a Licensed Nurse. Nail care included daily cleaning and regular trimming. Trimmed and smooth nails prevented the resident from accidentally scratching and injuring their skin. The policy indicated that the steps in the procedure for nail care included gently removing the dirt from around each nail with an orange stick, and smoothing the nails with a file or emery board. Resident 18's medical record was reviewed. Resident 18 was admitted to 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 ensure that one of 25 sampled residents (Resident 41) maintained acceptable parameters of nutritional status. This failure had the potential for the lack of nutritional goals to be maintained which could lead to negative clinical outcomes. Findings: Resident 41's medical record was reviewed. Resident 41 was admitted on [DATE], with diagnoses that included Adult Failure to Thrive (syndrome of weight loss, decreased appetite and poor nutrition, often accompanied by dehydration, and impaired immune function), cerebral infarction with monoplegia of lower limb (a stroke which effected the ability to use and move one leg), and a history of falls. Resident 41's physician's orders, dated 1/11/23, indicated, Regular diet, mechanical soft, easy to chew texture, NEM (Nutritionally Enhanced Meal - indicated that staff was to add extra butter and gravy to meals). A physician's order, dated 5/10/22, indicated, House Supplement three times a day, for…

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

Based on interview, and record review, the facility's pharmacy consultant failed to identify drug irregularities which included Centers for Medicare and Medicaid Services' (CMS) requirement to limit as needed (PRN) psychotropic (any drug that affects brain activities associated with mental processes and behavior) medications to 14 days, unless there was a documented rationale which included why the medication needed to be extended past 14 days, and the duration, for one of five sampled resident records reviewed for unnecessary medications (Resident 65). This resulted in, or had the potential to result in residents receiving unnecessary medication with adverse side effects, some of which could include permanent neurological side effects, and a deterioration in the clinical condition of residents. Findings: Resident 65's medical record was reviewed. Resident 65 was admitted with diagnoses that included unspecified dementia with behavioral disturbances, delusional disorder (characterized by the presence of one or more delusions that persist for at least one month), and anxiety…

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 make sure that one resident (Resident 46) was free of significant medication errors when they received less than the prescribed dose of aspirin (an anti-platelet agent given to prevent blood clots). This failure had the potential to threaten Resident 46's health and well-being, which could lead to negative clinical outcomes. Findings: Resident 46's medical record was reviewed. Resident 46's was admitted to the facility on [DATE], with diagnoses that included malignant neoplasm of the brain (brain cancer), high blood pressure, and cerebral infarction (a stroke). A review of Resident 46's physician's orders, dated 1/11/23, indicated an order for Aspirin 325 mg (milligrams), one tablet by mouth, one time a day, related to cerebral infarction. The order had been written on 10/31/17. During a medication administration observation, on 1/11/23, at 9:50 am, Licensed Nurse (LN) D administered one Aspirin 81 mg enteric coated from a stock supply…

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 that resident preferences were honored for two of 25 sampled residents (Residents 9, and 70). This failure not to provide food in accordance with resident preferences could result in decreased meal satisfaction and overall caloric intake which could lead to undesired weight loss. Findings: 1. During an interview, on 1/09/23 at 11 am, Resident 9 said she gets to pick her food preferences from a select menu, when staff bring it in, which is not every day. She said even when she does select her food from the menu, she still often does not get what she asks for, and she hasn't been eating as much as a result. She showed surveyor the white menu and it was blank for breakfast, although she said she had completed it. She said the residents get a pink menu and they circle their selection or write it on the menu, then the Certified Nursing Assistants (CNAs) write the resident choices on a white menu that goes to the kitchen, but that does…

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 the physician ordered diet for one of six sampled residents, (Resident 56) when the Consistent-Carbohydrate Diet (CC), diet for diabetics to control blood sugar management) was not followed. This failure resulted in high blood sugars and did cause Resident 56 increased anxiety, which could lead to negative clinical outcomes. Findings: The facility's policy, revised 5/21, titled, Therapeutic Diets, indicated that diets modified for medical needs will be considered therapeutic diets. A therapeutic diet must be prescribed by the resident's attending physician and the terminology used by food services. The regular diet will be modified by the Registered Dietician (RD), for therapeutic diets, with input from the Dietary Manager (DM), for feasibility of kitchen production. The DM will establish and use tray identification system to ensure each resident receives his or her diet as ordered. Residents on therapeutic diets will not receive…

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.