Quartz Hill Post Acute

Based on observation, and interview, the facility failed to clean the assistive devices used to transfer residents for five out of six mechanical lifts. This failed action had the potential for the spread of infection to clients, staff, and visitors. Findings: A review of the facility's policy revised 7/2017, titled, Lifting Machine, Using a Mechanical, indicated the purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device. This policy also indicated to wash and sanitize lift according to manufacturer's instructions, disinfect lift surfaces, wipe with a clean towel until dry. During concurrent observations and interviews on 6/21/24 at 12:09 through 12:24 pm with Licensed Nurse (LN) 1, five out of six mechanical lifts were soiled with cumulative dust, sticky yellow and brown colored substances, dried food particles, and grime. LN 1 confirmed these lifts were not clean and could cause the spread of infection to other residents, staff, and visitors and needed to be cleaned as soon as possible. During an interview on 6/21/24 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 observation, interview, and record review, the facility failed to ensure that one of five sampled residents (Resident 2), received assistance with activities of daily living (ADLs) to attain or maintain their independence when routine and scheduled showers and bathing were not completed. This failure had the potential to result in Resident 2 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: A review of the facility's policy revised 2/2018, titled, Bath, Shower/Tub, indicated the purposes of this procedure are to promote cleanliness, provide comfort to the resident, and to observe the condition of the resident's skin. This facility's policy also indicated to Notify the supervisor if the resident refuses the shower/tub bath. A review of the facility's policy revised 2/2021, titled, Dignity, indicated, Each resident shall be cared for in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and the facility's policy, the facility failed to complete assessments and add pertinent interventions on the care plan developed for one of three residents, (Resident 2) requiring renal (kidney) dialysis. This failure had the potential for re-hospitalization, and a negative clinical outcome. Findings: A review of the facility's policy revised 9/2010, titled, End-Stage Renal Disease, Care of the Resident with, indicated residents with end-stage renal (ESRD, kidney disease) will be cared for according to currently recognized standards of care. This policy also indicated staff caring for residents with ESRD, including residents receiving dialysis (removing toxins from the body) care outside the facility, shall be trained in the care and special needs of these residents. Number five of this policy indicated the resident's comprehensive care plan will reflect the resident's needs related to ESRD/dialysis care. A review of Resident 2's medical record, the admission Record, indicated…

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

Based on interview, and record review, the facility failed to ensure professional staff were licensed in accordance with California state laws, when registered nurse (RN) 1 was employed from 11/2/23 through 1/4/2024 without a valid registered nursing license issued by the Board of Registered Nursing This failure had the potential to result in substandard quality of care to all the residents in the facility and negatively impact their quality of life and ability to attain or maintain their highest practicable level of physical, emotional, and psychosocial well-being. Findings: A review of the Employee Information Form, dated 11/2/23, indicated that RN 1 was hired full-time on the day shift with a date of hire of 10/30/23. A review of the facility ' s job description titled RN-Charge Nurse, dated 11/2/23, indicated the position Must possess a current, unencumbered, active license to practice as an RN in this state. The primary purpose of the position was to provide direct nursing care to residents and to supervise day-to-day nursing activities, and to ensure that the highest degree 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 follow the skin assessment care plan and monitor the skin condition for one of 3 sample Residents (Resident 1). This failure resulted in Resident 1 did not have skin assessment and wound care treatment until 2 days after his re-admission and had the potential to contribute to wound infection. Findings: A review of Resident 1's admission record, indicated he was admitted to the facility on [DATE] with diagnoses which included metabolic encephalopathy (a problem in the brain. It is caused by a chemical imbalance in the blood), Alcoholic Cirrhosis (Cirrhosis is scarring of the liver caused by long-term liver damage after many years of heavy drinking. The scar tissue prevents the liver working properly) of Liver with ascites (the build-up of fluid in the space between the lining of the abdomen and abdominal organs), diabetes (elevated blood sugar), and difficulty in walking. Resident 1 was transferred to the local hospital on 7/31/2023 for…

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

Based on observation, interview and record review, the facility failed to ensure professional food safety and sanitation practices were in place when: 1. Inappropriate use of hats and hairnets were observed for three dietary staff members. 2. Four out of four chicken breasts were not stored and handled according to professional standards of practice. 3. Chlorine test strips were not available to all staff, two out of two staff used the wrong test strip, and chlorine test strip results were incorrectly. 4a.The walk-in freezer floor, dry storage rice bin, prep area drawers, stationary and non-stationary fans, reach-in refrigerator, and the ice machine were not clean. b. The stove, oven, tray line, stationary can opener, and sheet pans were non cleanable due to a black residue build up and grime. c. The tray line cutting board was severely scored with non-cleanable blacked surfaces that appeared to be melted. 5. Dietary staff were not cleaning equipment prior to sanitizing. These failures had the potential to result in foodborne illness for a facility with a census of 89 residents who…

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

Based on observation, interview and record review, the facility failed to maintain resident food in safe storage when the facility's walk-in freezer had severe ice buildup and was not maintained in a safe operating condition. This had the potential for equipment failure. Findings: During a concurrent observation and interview with Dietary Manager (DM) on 3/7/23 at 9:40 AM, the walk-in freezer was observed to have severe ice buildup on the floor, shelves, walls, ceiling, condenser fans, the piping that hooks up to the condenser fans, and black mat that covered the floor. DM confirmed the severe ice found in all locations of the walk-in freezer and stated the walk-in freezer floor is cleaned weekly or as needed, including the black mat that covered the floor. During an interview on 3/8/23 at 2:54 PM, Maintenance Director (MND) confirmed the freezer had a severe buildup of ice and stated the defrost cycle came on four times a day and caused condensation (water that collects as droplets on a cold surface when humid air comes into contact with it). MND stated the freezer had new parts…

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 individualized needs were met for two of 18 residents when: 1. Resident 70's call light device was not within his reach or his line of sight. This failure had the potential for the resident's needs not being met promptly and an increase in accidents and injury. 2. Resident 85 was not provided a trained and competent language translator for his communication with facility staff. This failure had the potential for the resident's needs not being met and psychosocial harm. Findings: 1. Review of Resident 70's record noted that he was admitted on [DATE] withdiagnoses that included stroke, repeated falls, communication problems and muscle weakness. Resident 70 had 8 falls since June of 2022 which made him a high fall risk. Review of Resident 70's Minimum Data Set (MDS- a resident assessment) indicated Resident 70 needed extensive assistance for transfers and walking. A review of policy and procedure titled, Answering the Call…

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 four of four sampled residents (Resident 50, 7, 25 and 16), and five of six confidential resident interviewed, were not protected from loss when the facility had no system to return lost clothing items to residents. This failure resulted in residents feeling angry and frustrated because they did not have their own clothes to wear. Findings: Review of the facility's policy titled, Personal Property dated March 2021 indicated that Residents are permitted to retain and use personal possessions, including furniture and clothing, as space permits, unless doing so would infringe on the rights or health and safety of others. The policy states further that resident's personal belongings and clothing are inventoried and documented upon admission and updated as necessary, and that the facility promptly investigates any complaints of misappropriation or mistreatment of resident property. 1. In an interview on 3/07/23 at 4:11 PM, FAM A, Resident 50's son, stated that the facility has repeatedly lost his father's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop and implement comprehensive care plans for five of 18 sampled residents (Resident 2, 38, 68, 72, and 73) when: 1. Resident 2 for potential risk of choking hazards during mealtimes (Refer F689); 2. Resident 68 for impaired visual function ; 3. Resident 38 for severe depression; 4. Resident 73 wandering around the facility and; 5. Resident 72 the use of arm brace. These failures had the potential for care plans to inaccurately reflect the care needed, being provided, or resident care needs to go unmet or the conditions to worsen. Findings: A review of a facility policy titled, Comprehensive Assessments, revised March 2022, indicated comprehensive assessments are conducted to assist in developing person centered care plans. 1. Resident 2 was admitted to the facility on [DATE] with diagnoses that included dementia, history of falling and dysphagia ( difficulty swallowing). The most recent Minimum Data Set (MDS-a resident assessment)…

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 3. Review of Resident 38 medical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included diabetes, heart failure, muscle weakness and bilateral (both sides) groin wounds. During a review of the the facility's policy and procedure titled, Activities of Daily Living (ADL), revised March 2018, indicated that a resident's ability to perform ADLs will be measured using clinical tools, including the MDS. During record review of Resident 38's MDS dated [DATE], indicated he required staff assistance with all ADLs. During record review of shower/bath schedule dated 2/8/23-3/8/23, Resident 38 was scheduled for baths on Sundays and Wednesdays. He missed 4 out of 10 bed baths scheduled. No record of nail care performed was found. During concurrent interview and record review on 3/10/23 at 8:50 AM with DSD, confirmed that Resident 38 was on the shower schedule for twice weekly bed baths on Sundays and Wednesdays and did not receive 4 of 10 baths scheduled. She confirmed that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a plan of care to address the safety of two of 18 residents when: 1. Resident 2 did not have assistance during meals. 2. Resident 73 was wandering into other resident rooms frequently without supervision. This resulted a choking hazard and had the potential to put all residents at risk for falls and resident to resident altercations. Findings: The facility's policy and procedure titled, Safety and Supervision of Residents, revised 7/2017, indicated that the facility strives to make an environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Also, resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. 1. Resident 2 was admitted to the facility on [DATE] with diagnoses that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure nursing staff had appropriate competencies and skills sets for developing and implementing plan of care for 18 sampled residents when: 1. Resident 2 did not have the direct care staff supervision for safety during meals. 2. Direct care staff did not ensure Resident 68 had eye glasses available for use. 3. Direct care staff did not provide necessary grooming, nail care, and bed bath services for three of seven dependent residents (Residents 8, 38 and 70). 4. Nursing staff did not develop and implement a plan of care for severe depression for Resident 38. 5. Resident 73 had no interventions in place to mitigate his wandering behavior. This had the potential to put all residents at risk for accidents and hazards and decreased quality of care and life. Findings: 1. During a concurrent observation and interview with CNA C on 3/9/23 at 9 AM, stated that she was assigned to Resident 2 but not too often. CNA C stated that Resident 2 needed…

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, observation and record review, the facility failed to ensure safe medication storage in two out of three medication rooms (a locked room storing the drugs and supplies) and three out of six medication carts (a secure mobile cart storing resident's medications) when: 1. Medication refrigerators (a locked temperature-controlled unit for medication storage) were frosted where vaccines, and insulin (Medicine for blood sugar or diabetic disease) products were stored. 2. Multi dose containers (a bulk container that can be used more than once) of medication and supplies were not dated when first opened and not stored per manufacturer labeling (the drug maker's label on how to store or use the product). 3. Medication refrigerator and emergency kit for narcotic medications (or Ekit contained supply of narcotics or controlled drugs with abuse potential) were not secured with a lock in the medication room. These failures could contribute to unsafe or ineffective medications use in the facility. Findings: 1A. During a concurrent observations and inspection 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the qualifications, competencies, and skill sets of the Registered Dietitian (RD) and the Dietary Manager (DM) were in place and supported to carry out the functions of the food and nutrition service when: 1. A qualified dietician or other clinically qualified nutrition professional was not employed at the facility full time. 2a. The RD did not monitor or implement weekly weights for three out of three residents: Resident 4 2b. Resident 59 2c. Resident 85 3. The DM did not meet the minimum qualifications. 4. The DM did not evaluate new staff for competencies. (Refer to F802) These failures had the potential to result in foodborne illness, compromise nutritional status, weight loss, ineffective resident care interventions and decreased quality of life impacting 89 residents who lived in the facility. Findings: 1. During an interview on 3/8/23, at 2:10 PM, RD stated hours worked at this facility were approximately 24-25 hours a week and divided…

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 staff were competent to perform food safety processes according to professional standards when: 1. Equipment was not cleaned according to professional standards of practice. (Refer to F812) 2. Four out of four chicken breasts were thawing at room temperature. (Refer to F812) 3. Staff used the wrong test strips and documented incorrect results when testing the dishwasher's chlorine level. (Refer to F812) 4. Dietary Manager (DM) did not evaluate new staff for competencies. Failure to ensure staff were competent in food safety processes had the potential to result in foodborne illness for 89 residents consuming food from the facility. Findings: 1. During a concurrent observation and interview on 3/7/23 at 9:35 AM, in the kitchen's dry storage area, the lid that covered the brown rice was upside down and was covered in gray substance buildup. In the food prep area, two drawers containing food prep items were soiled. The wall mounted fan located in the food prep area pointed towards the tray line had thick…

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 two out of two residents (Residents 85 and 4) with plant-based (vegetarian) meals that met the nutritive needs of the residents when: 1. Planned vegetarian menus, prepared in advance, that included a nutrient analysis and alternates (a meal substitute provided when the served menu item was not wanted by the resident) for Resident 85 and Resident 4, were not followed, and were not available for residents or staff. 2. Alternate menu food items did not have a recipe. These failures created the potential for vegetarian residents to receive food that did not meet their nutrient needs and or provide the variety in foods and flavors needed to encourage meal intakes, enhance resident's quality of life, and had the potential to contribute to weight loss. Findings: 1. A review of Resident 85's records indicated admission to the facility on [DATE] with the diagnoses that included unspecified dementia (memory loss) and unspecified…

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 food was served at an appetizing temperature when four out of four residents (Resident 4, 19, 38, and 59) stated the food was cold. This failure had the potential for a decrease in meal intake and could contribute to weight loss resulting in compromised nutritional status. Findings: During an interview on 3/8/23 at 1:05 PM, Resident 19 and Resident 59, both stated when meals got delivered to them, their food was cold. During an interview on 3/8/23 at 1:06 PM, Resident 38 stated the eggs served were always cold. During an observation on 3/8/23 at 11:37 AM, the dining cart that contained lunch trays for the residents who ate meals in the assisted dining room (dining area for residents who needed assistance to eat) was placed in the independent dining room (where residents eat meals who do not require assistance). An overhead page on the facility intercom system had been made stating that the dining cart was ready for staff pickup. During an observation on 3/8/23 at 11:43 AM, the Social Services Assistant arrived 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 implement and maintain an effective, comprehensive Quality Assurance and Performance Improvement (QAPI) program that addressed the full range of services the facility provided when: 1. A qualified Registered Dietician (RD) or other clinically qualified nutritional professional were not employed at the facility full time who was responsible to carry out the functions of the food and nutrition service and that their Dietary Manager (DM) did not meet the minimum qualifications. 2. Licensed Nursing staff did not develop and implement a plan of care for five of 18 sampled residents (Resident 2, 38, 68, 72, and 73). 3. Certified Nursing Assistants (CNA)s had the skills and competencies to assist dependent residents with their Activities of Daily Living (ADL). This failure had the potential for all residents to be at risk for decreased quality of care and quality of life. Findings: A facility policy and procedured titled, QAPI Program, revised 2/1/20, was reviewed. The policy indicated the facility should have…

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 safe infection control practices when: 1. Licensed nurses (LNs) did not sanitize their hands upon entering or exiting five resident's rooms when direct care was provided. 2. Licensed nurse did not sanitize the shared glucometer (a device used to measure blood sugar) in between resident care for Resident 80, Resident 19, and Resident 7. 3. Licensed nurse did not sanitize the shared blood pressure device (or BP device that measured the pressure of blood pushing against the walls of the arteries) in between resident care provided for Resident 80 and Resident 19. These failed practices may result in spread of infection in the facility. Findings: 1A. Review of the facility's policy titled, Handwashing/Hand Hygiene, dated [DATE], indicated, This facility considers hand hygiene the primary means to prevent the spread of infection, and, .7. Use an alcohol-based hand rub containing at least 62% alcohol .for the following situations: f.…

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 issue complete and timely Beneficiary (a person who received Medicare insurance benefits) Notifications to three of 18 sampled residents (Residents 48, 50, and 77). This failure had the potential to prevent the residents from making informed decisions about their care which could have threatened their health and well-being. Findings: A review of Resident 48's record showed an original admission date of 8/7/21. Resident 48's diagnoses included cerebral infarction (a stroke), osteomyelitis left femur (infection of the left thigh bone), and chronic pain. Resident 48's representative assisting with healthcare decisions was Family Member (FAM) D. Record review of Resident 48's Centers for Medicare & Medicaid Services (CMS) Notice of Medicare Non-Coverage (NOMNC) indicated, The Effective Date Coverage of Your Current MEDICARE A Services Will End: 2/2/23. Record review of Resident 48's CMS Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage…

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 an accurate and complete assessment for one of five sampled residents (Resident 68) when an assessment dated [DATE] documented that vision was adequate and no activity assessment after admission. These failures had the potential for staff to not be fully informed of his health status, to determine the need for further assessment and interventions that could result in delays in care and decline in resident's condition. Findings: The facility policy and procedure titled, Comprehensive Assessments, revised 3/2022 indicated that comprehensive assessments are conducted to assist in developing person-centered care plans and also in accordance with criteria and timeframes established in the Resident Assessment Instrument (RAI) manual. a. Resident 68 was originally admitted to the facility on [DATE] and re-admitted on [DATE]/23 with diagnoses that included dementia with behavioral disturbances and with repeated falls. Resident 68 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 accurate documentation with specific psychiatric (mental health illness) diagnosis for the use of mind-altering drug called quetiapine (also known as Seroquel, a medication used to treat mental illness) in one out of 18 sampled residents (Resident 40). This failure may pose unsafe medications use in the facility with inconsistent diagnosis. Findings: During a concurrent interview and observation of Resident 40, in her room, at [NAME] station, on 3/9/23, at 10:30 AM, accompanied with Certified Nurse Assistant (CNA) C, Resident 40 was in bed, eyes closed and then opened her eyes starring randomly with face in distress, she held her hands to the face and kept moving in her bed. CNA C stated Resident 40 needed total assistance for daily care, and she was in bed most of the time. CNA C stated Resident 40's verbal response was mostly Yes or No, Stop that or Don't do that. During an interview with Licensed Nurse (LN) B, who was Resident 40's nurse, at [NAME] station, on 3/9/23, at 11:02 AM, LN B 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 develop a complete Discharge Plan for one of 18 sampled residents (Resident 77). This failure had the potential to prevent a smooth and safe transition for Resident 77 from the facility to the community. Findings: A facility policy titled, Discharge Summary and Plan, revised 12/1/16, was reviewed. The policy indicated that when a resident's discharge was anticipated, a post-discharge plan would have been developed to assist the resident to adjust to their new living environment. Every resident would have been evaluated for their discharge needs and would have an individualized post-discharge plan. The post-discharge plan would have been developed by the care planning/interdisciplinary team (IDT-a group of professionals from different disciplines that met to discuss the residents' care) with the assistance of the resident and their family and would have included: where the individual planned to reside; arrangements that had been made for follow-up care…

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 accommodate one out of one resident (Resident 85) with preferred food preferences that met cultural needs when dietary staff did not update Resident 85's medical record with preferences. This failure created the potential for a lack of the variety in foods and flavors needed to encourage meal intakes, enhance resident's quality of life, and had the potential to contribute to weight loss. Findings: A review of Resident 85's records indicated admission to the facility on [DATE] with the diagnoses that included unspecified dementia (memory loss) and unspecified protein-calorie malnutrition (a lack of proper nutrition or inability to absorb nutrients from food). Resident 85's cognition (ability to reason, think and make decisions) was intact and he was able to make his own decisions. Resident 85 did not speak English, was a vegetarian and required the assistance of one person and supervision during all meals. A review of the record titled, Weight Note,…

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, review of the facility's document and review of the facility's policy, the facility failed to ensure one of 21 sampled residents (Resident (R) R58) was assisted with her meal in the dining room in a dignified manner. Findings: A review of R58's record indicated she was admitted to the facility on [DATE] with diagnoses that included depression and dementia (impaired memory loss and judgment). During an observation of the noon meal on 09/02/19 at 12:40 PM, the Activity Director/Certified Nurse Aide (AD/CNA) was seated on a stool assisting R36 with her meal. R58 was seated in a wheelchair at the same table. The AD/CNA then stood up and gave R58 a bite of food. The AD/CNA continued to assist R58 with bites of food as she stood over the resident and then would sit down to assist the other resident throughout the entire meal. During an interview on 09/04/19 at 2:37 PM, the AD/CNA stated that she was a CNA since 2015 and continues her training to keep her can certification. The AD/CNA…

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

Based on observation, interview and record review, the facility failed to ensure one of 21 sampled residents (Resident (R) R64) received oxygen (O2) therapy as prescribed by the physician. Findings: A review of R64's record (EMR) revealed an undated, admission Record with an original admission date of 04/30/14 and a readmission date of 02/20/18. R64 was admitted with diagnosis of chronic obstructive pulmonary disease (COPD). On 09/03/19 at 9:58 AM, R64 was observed wearing a nasal cannula and the liter flow on the O2 concentrator was set between two and a half and three liter per minute (LPM). The resident was interviewed at this time regarding how much O2 he was to receive. R64 stated, two liters I think. On 09/04/19 at 4:00 PM, R64's O2 flow rate was set between two and a half and three LPM. Review of R64's physician's orders dated 02/03/19 revealed, Oxygen at 2 liter/ min via Nasal Cannula . During an interview on 09/04/19 at 4:15 PM, the Director of Nursing (DON) observed R64's oxygen concentrator and stated that it looked like the O2 was set at three LPM. The DON reviewed R64'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.