Extended Care Hospital Of Riverside

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure an allegation of abuse was reported to the State survey agency within two hours for two of five residents, (Residents 2 and 3).This failure had the potential for a delay in the investigations and interventions to prevent further incidents of abuse. Findings:On December 9, 2025, at 10:14 a.m., an unannounced visit to the facility to investigate an allegation of physical abuse. A review of Resident 2's medical record indicated the resident was admitted on [DATE], with diagnoses of dementia, (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) and pressure ulcer injury stage 4 (PUI - full thickness tissue loss with exposed bone, tendon, or muscle).A review of Resident 2's History and Physical dated September 22, 2025, indicated resident was not capable of understanding and making decisions.A review of Resident 3's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure care and treatment were provided for four of seven residents reviewed (Residents 1, 4, 5, and 6) when:1. For Resident 1, the licensed nurses did not timely assess and monitor the resident who experienced a change in condition on June 16, 2025. This failure resulted in the hospitalization of Resident 1 on June 20, 2025, with a diagnosis of urinary tract infection (an infection that occurs in any part of the urinary system [how the body gets rid of extra water and waste]). 2. For Residents 4, 5, and 6, peripheral intravenous (IV - administration of fluids or medication through the vein) sites were not documented as assessed or changed for the duration of the admission. This failure had the potential to place Residents 4, 5, and 6 at risk for infection and injury due to prolonged use of the same IV access.Findings: 1 . On July 10, 2025, Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses…

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 physician was notified of a significant change in condition and refusal of treatment for one of seven sampled residents (Resident 1).This failure had the potential for further confusion, aggressive behaviors, and refusal of care, and led to discomfort with the potential for complications related to untreated infection.Findings: On July 10, 2025, Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses including toxic encephalopathy (a condition of chemical imbalance in the blood) and urinary tract infection (UTI - an infection that occurs in any part of the urinary system [how the body gets rid of extra water and waste]). A review of Resident 1's Care Plan dated March 26, 2025, indicated, .the resident has impaired immunity .the resident will remain free from infection through the review date.the resident will not display any complications related to immune deficiency…

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 report an allegation of physical abuse to the California Department of Public Health (CDPH) within two hours after the allegation was made, for one of six sampled residents (Resident A). This failure had the potential to result in psychosocial harm to Resident A and other residents in the facility. Findings: A review of Resident A's admission record indicated, Resident A was admitted to the facility on [DATE], with diagnoses which included osteomyelitis (inflammation of the bone tissue). A review of Resident A's Minimum Data Set (MDS - an assessment tool) dated May 9, 2025, indicated Resident A had a Brief Interview for Mental Status (BIMS - [screener for mental and cognitive status] score of 12 (moderate cognitive impairment). A review of Resident A's Social Service Progress Note, dated May 27, 2025, at 3 p.m., indicated, .This resident (Resident A) is alert able to make needs known .On 5/27/25 [sic] This resident believes ithad been 8 or 8:30 pm,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR- a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) Level I screening accurately reflected the presence of diagnosed mental disorders for one of three sampled residents (Resident A). This failure had the potential to result in the inappropriate admission of residents who may not meet the criteria for nursing facility placement, and in the resident not receiving the appropriate services for their diagnosed mental health conditions. Findings: A review of Resident A's admission Record indicated Resident A was admitted to the facility on [DATE], with diagnoses which included bipolar disorder (mental disorder) and anxiety disorder. A review of Resident A's PASARR Level 1 screening, dated May 20, 2025, indicated .Level 1 negative for SMI (serious mental illness) .Section III- SMI .Does the individual have a serious diagnosed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a post discharge follow-up was conducted and documented in the medical records for one of three residents reviewed (Resident 1). This failure had the potential to compromise Resident 1's safety and well-being by not ensuring post-discharge needs were met. Findings: A review of Resident 1's medical record indicated he was admitted to the facility on [DATE], with diagnoses which included left tibia (leg bone) fracture and type 2 diabetes mellitus (abnormal high sugar). Resident 1 was discharged on January 22, 2025. A review of Resident 1's History and Physical, dated September 5, 2024, indicated he had capacity to understand and make decisions. A review of Resident 1's Order Summary, dated January 21, 2025, indicated, .LCD (last cover day) 1.21.25 (January 21, 2025) D.C. (discharge) 1/22/25 (January 22, 2025) at 11:00am, to address (provided) . A review of Resident 1's NOTICE OF PROPOSED TRANSFER/DISCHARGE, effective date of January 22, 2025,…

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, for one of four residents (Resident 1), to ensure the Office of the State Long-Term Care Ombudsman (LTC Ombudsman - an advocate for residents to protect residents' rights and ensure quality care) received timely notification of Proposed Transfer/Discharge (a planned or suggested move of a resident from a healthcare facility to another location) when Resident 1 was discharged on January 31, 2025. This failure has the potential to result in Resident 1 lacking an advocate to protect their rights and ensure an appropriate and safe discharge plan. Findings: Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses including esophageal cancer (a rare cancer that occurs when cells in the esophagus is a muscular tube that moves food and liquids from the throat to the stomach mutate and grow out of control). A review of Resident 1's History and Physical, dated October 14, 2024, indicated Resident 1 had the capacity 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 interview and record review, the facility failed to ensure staff discussed the decisions and the rationale regarding issues or concerns raised by the Resident Council (a group of residents who come together to discuss concerns, make suggestions, and advocate for improvements in their living environment). This failure had the potential to feel that their voices were not heard which could result in dissatisfaction and a decline in quality of life. Findings: On January 22, 2025, at 5:25 p.m., during an interview with Resident 1, she stated the dining room/activity room closes at 7 p.m. and reopens at 9 a.m. Resident 1 further stated the access to the patio and vending machine is only available thru the dining room. On January 22, 2025, at 5:40 p.m., during an interview with Certified Nurse Assistant (CNA) 1, he stated the dining room closes at 6:15 p.m. and the key is held by the Registered Nurse Supervisor (RNS). On January 22, 2025, at 5:40 p.m., during an interview with the Dietary Service Supervisor…

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, record review, and facility policy review, the facility failed to assess for self-administration of medication for 1 (Resident #93) of 1 sampled resident that expressed a desire to self-administer medications. Findings included: A facility policy titled, Resident Self-Administration of Medication, dated 12/19/2022, indicated, It is the policy of this facility to support each resident's right to self-administer medication. A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely. An admission Record revealed the facility admitted Resident #93 on 11/05/2024. According to the admission Record, the resident had a medical history that included a diagnosis of atelectasis (complete or partial collapse of a lung). An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/09/2024, revealed Resident #93 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS also…

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, record review, and facility policy review, the facility failed to submit a new Preadmission Screening and Resident Review (PASARR) following a newly diagnosed mental disorder for 1 (Resident #45) of 2 sampled residents reviewed for PASARR requirements. Findings included: A facility policy titled, Resident Assessment-Coordination with PASARR Program, revised 12/18/2023, indicated, This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. The policy specified, 9. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a Level II resident review. An admission Record revealed the facility admitted Resident #45 on 10/14/2022. According to the admission Record,…

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 facility policy review, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) Level I screening accurately reflected the presence of diagnosed mental disorders for 1 (Resident #23) of 2 sampled residents reviewed for PASARR requirements. Findings included: A facility policy titled, Resident Assessment-Coordination with PASARR Program, revised 12/18/2023, indicated, This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. The policy specified, 1. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening. a. PASARR Level I- initial pre-screening that is completed prior to…

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

Based on observation, interview, record review, and facility policy review, the facility failed to ensure staff provided needed assistance with activities of daily living (ADLs) for 1 (Resident #85) of 1 sampled resident reviewed for ADLs. Specifically, staff failed to assist Resident #85 with facial hair grooming and nail care. Findings included: A facility policy titled, Grooming a Resident's Facial Hair, dated 12/19/2022, indicated, It is the practice of this facility to assist residents with grooming facial hair to help maintain proper hygiene as per current standards of practice. A facility policy titled, Nail Care, dated 12/19/2022, revealed, 3. Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis. 4. Routine nail care, to include trimming and filing, will be provided on a regular schedule. Nail care will be provided between scheduled occasions as the need arises. An admission Record revealed the facility admitted Resident #85 on 10/09/2024. According to the admission Record, the resident had a medical history that included a diagnosis…

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, record review, and facility policy review, the facility failed to provide tube feeding formula as ordered to 1 (Resident #85) of 3 sampled residents reviewed for nutrition. Specifically, Resident #85's order directed staff to provide Isosource 1.5 (a type of tube feeding formula that provided 1.5 calories per milliliter) to the resident at a rate of 60 milliliters (mL) per hour for 16 hours per day, but staff provided Fibersource HN (a type of tube feeding formula that provided 1.2 calories per mL) instead, which created a potential for weight loss and for the resident's nutritional needs to not be met. Findings included: A facility policy titled, Appropriate Use of Feeding Tubes, revised 12/19/2022, indicated, It is a policy of this facility to ensure that a resident maintains acceptable parameters of nutritional and hydration status. An admission Record revealed the facility originally admitted Resident #85 on 10/09/2024 and most recently admitted the resident on 12/12/2024. According to the admission Record, the resident had a medical history 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.

Based on observation, interview, and facility policy review, the facility failed to properly store a nebulizer mask between uses for 1 (Resident #7) of 1 sampled resident reviewed for respiratory care. Findings included: A facility policy titled, Nebulizer Therapy, revised 02/23/2024, revealed the section titled, Care of Equipment specified, 1. Clean after each use. 2. Wash hands before handling equipment. 3. Disassemble parts after every treatment. 4. Rinse the nebulizer cup and mouthpiece with sterile or distilled water. 5. Shake off excess water. 6. Air dry on absorbent towel. 7. Once completely dry, store the nebulizer cup and the mouthpiece in a storage bag. An admission Record revealed the facility admitted Resident #7 on 11/10/2024. According to the admission Record, the resident had a medical history that included a diagnosis of pneumonia. Resident #7's care plan included a focus area, initiated on 11/26/2024, that indicated the resident had shortness of breath related to a cough. An intervention dated 11/26/2024 directed staff to administer DuoNeb (ipratropium-albuterol; a…

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, record review, and facility policy review, the facility failed to ensure pain was treated after a request for an ordered as needed (PRN) pain medication for 1 (Resident #210) of 1 sampled resident reviewed for pain management. Findings included: A facility policy titled, Pain Management, dated 12/19/2022, indicated, The facility must ensure that pain management is provide to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. The policy specified, 1. In order to help a resident attain or maintain his/her highest practicable level of physical, mental and psychosocial well-being and to prevent or manage pain, the facility will: a. Recognize when the resident is experiencing pain and identify circumstances when the pain can be anticipated. b. Evaluate the resident for pain and the cause(s) upon admission, during ongoing scheduled assessments, and when a significant change in condition or status occurs. c. Manage or prevent 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.

2. An admission Record revealed the facility admitted Resident #5 on 12/14/2023. According to the admission Record, the resident had a medical history that included a diagnosis of colostomy malfunction. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/06/2024, revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident had an ostomy. Resident #5's care plan included a focus area, initiated 10/08/2024, that indicated the resident was on EBP related to a history of extended-spectrum beta-lactamase (ESBL; a type of enzyme causing some antibiotics to be ineffective in treating bacterial infections). The care plan indicated the goal was to prevent/reduce the transmission of multi-drug resistant organisms (MDROs) through the use of gowns and gloves while caring for residents at high risk for MDRO transmission at the point of care during specific activities with the greatest risk for MDRO contamination of health care personnel's hands,…

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 complaint can be substantiated that the facility failed to ensure the temperature was between 71- and 81-degrees Fahrenheit for 46 of 96 residents. This failure caused residents to be uncomfortable and had a potential for heat related illnesses in a vulnerable population. Findings: On September 6, 2024, at 5:58 p.m., an unannounced visit to the facility on a complaint investigation was initiated. On September 6, 2024, at 6:13 p.m., an interview was conducted with the Maintenance Director, (MAD). The MAD stated that earlier this morning approximately midnight, he was called in due to a breaker fuse going bad. The MAD stated that the generator power went on, and they have been working on replacing the fuse all day. On September 6, 2024, at 6:15 p.m., an observation of room temperatures was conducted with the MAD: a. room [ROOM NUMBER] (has two residents)- 82 degrees Fahrenheit; b. Rooms 25 (has three residents), 26 (three residents), 27 (three residents), 28…

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 weigh two of three residents reviewed (Resident A and Resident B), on admission and every week for the first four weeks, to establish a baseline weight. In addition, there was no consistent weight changes monitoring conducted for Resident B. These failures had the potential to result in delayed provision of treatment and care in accordance with professional standards of practice, for Residents A and B. Findings: On June 10, 2024, at 9:00 a.m., an unannounced visit was made to the facility for an allegation of quality of care and treatment. A review of Resident A ' s medical record indicated, Resident A was admitted to the facility on [DATE], with diagnoses which included Type II Diabetes Mellitus (a long-term condition in which the body has trouble controlling blood sugar), Sepsis (a life-threatening complication from an infection), and Alzheimer ' s (set of symptoms memory impairment, thinking skills, behavior changes). A review of Resident A ' s…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the resident's water temperatures were maintained at a comfortable level for one of three residents reviewed, (Resident 1) when the resident's and/or resident ' s representatives (RR) complained the hot water took too long to heat in their bathrooms. This failure had the potential for Resident 1 to feel uncomfortable and affect their quality of life. Findings: On May 3, 2024, at 11:54 a.m., an unannounced visit to the facility on a complaint investigation was initiated. A review of Resident 1 ' s medical record indicated he was admitted on [DATE], with diagnoses of malignant neoplasm (a cancerous tumor), of the lung, secondary malignant neoplasm of brain, type 2 diabetes mellitus, diabetes mellitus type 2 (a chronic condition that affects the way the body uses sugar. The body either resists the effects of insulin — a hormone that regulates the movement of sugar into the cells — or doesn't produce enough insulin to maintain normal…

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 maintenance and repairs were performed timely for three of six residents reviewed (Residents 1, 2, and 3), when: 1. The bathroom wall for Residents 1 and 2, had missing drywall, and the open areas of the wall were observed to have brown and black speckled particles; 2. The wall beside the resident ' s closet for Residents 1 and 2, was missing drywall and the baseboard under the closet was warped; and 3. The bathroom baseboard was lifted and pulling away from the wall, near the toilet for Residents 2 and 3. These failures had the potential to negatively impact the residents ' psychosocial well-being, potentially expose Residents 1 and 2 to mold growth, and had the potential for Resident 2 and 3 to be at risk for skin tears. Findings: On January 11, 2023, at 10:10 a.m., an unannounced visit was conducted at the facility for a physical environment complaint. On January 11, 2023, at 10:30 a.m., an interview was conducted with the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to remove the indwelling catheter (a tube inserted into the bladder allowing urine to drain freely into a bag outside your body), for one of three sampled resident (Resident A), as ordered by the physician. This failure resulted in the resident having an indwelling catheter without an indication for its use and increasing the risk of having a urinary tract infection (when bacteria gets into the urinary tract [body's drainage system for removing urine]. Findings: On October 17, 2023, at 1:15 p.m., Resident A was observed in her room with an indwelling catheter draining yellow urine. A review of Resident A's record indicated Resident A was admitted to the facility on [DATE], with diagnoses which included right ankle fracture (broken joint between the food and the leg). A review of Resident A's physician order dated October 5, 2023, indicated: - Indwelling catheter: Foley Catheter .Change for blockage, leaking, pulled out, excessive…

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 store, prepare, and distribute food in accordance with professional standards for food service safety when: 1. The ice machine was not cleaned and sanitized properly per manufacturer's guidance; 2. Three various sizes of cooking pans, readily available for use, had a dry and heavy black substance buildup on the cooking surfaces, and 3. Several various size of metal pans were stacked and stored wet. These failures had the potential to cause food-borne illness in a medically vulnerable resident population who consumed food from the kitchen in the facility. The facility census was 79. Findings: 1. During the kitchen initial tour on June 6, 2022, at 10:15 a.m., the Dietary Supervisor (DS) stated the ice machine located in utility room. She stated dietary staff was responsible for exterior cleaning of the ice machine and ice scoop daily, and the Maintenance department was responsible for the deep cleaning for the ice machine monthly. During an observation on June 6, 2022, at 10:21 a.m., the ice machine had visible…

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

Based on observation, interview, and record review, the facility failed to ensure the menu was followed for the therapeutic diet (a diet that is usually a modification of a regular diet. It is modified or tailored to fit the nutrition needs of a particular person. It could be a part of the treatment of a medical condition and normally prescribed by a physician) during the lunch meal on June 7, 2022, when: 1. 11 residents (Residents 4, 32, 38, 40, 45, 46, 49, 76, 79, 85, and 86) with CCHO (consistent carbohydrate) diet (a diet used in the treatment for diabetes) received one serving of dessert cake instead of a half serving; 2. Two residents (Residents 54 and 63) with Mechanical Soft texture diet (a diet with food texture modified into a soft, chopped, or ground consistency for person who has chewing or swallowing difficulties) received four ounces (oz.) of grinded roast beef instead of three oz., and 3. Three residents (Residents 5,13, and 18) with meal tickets (a ticket including resident's diet, date, allergies, specific food and beverage items, dislikes, likes) showed three…

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 implement a policy and procedure on Foods For Residents From Outside Sources that included provisions on facility providing education and information about safe food handling practices to residents, family and visitors, and provisions on facility providing training to all facility personnel regarding safe food handling practices who are involved in preparing, handling, serving, or assisting the resident with meals or snacks. This failure had the potential to cause foodborne illnesses in a medically vulnerable population of 67 out of 79 residents who could consume food and receive food from family or visitors. Findings: During an interview on June 6, 2022, at 3:12 p.m., Registered Nurse (RN) 1 stated the facility has allowed the family or visitor to bring in food for residents. She stated when the family or visitors brought in food for resident, nurses were responsible to check for the food if appropriate for the physician's ordered diets. RN 1 stated the facility preferred them to bring in prepackaged food but ok with home…

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 for two residents reviewed to ensure that quality care was provided when: 1. For Resident 73, during medication pass observation, the facility staff failed to do hand hygiene in between picking dropped equipment from the floor and medication preparation. This failure had the potential to cause cross contamination; and 2. For Resident 141, the facility failed to follow doctor's order to perform intake and output monitoring. This failure had the potential to cause fluid overload. Findings: 1. Resident 73 was admitted to the facility on [DATE], with diagnoses which included hemiplegia (one sided paralysis). On June 9, 2022, at 10 a.m., during medication pass observation, Licensed Vocational Nurse (LVN 4) dropped the thermometer she was holding. LVN 4 picked thermometer from the floor and placed it on the cart without sanitizing. The LVN 4 was observed pouring liquid medication UTI-STAT (is a concentrated liquid medical food .formulated 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: 1. One medication, Diabetic Tussin- (used to relieve coughs caused by the common cold, bronchitis, and other breathing illnesses), was stored in the medication cart at station 2, in a drawer without a verified pharmacy label. This failure had the potential for the resident to receive medication without a physician order. 2. The refrigerator temperature in the medication refrigerator at station two was documented at 73 degrees on June 1, 2022, and 48 degrees on June 2, 2022. This failure had the potential for medication to become ineffective and unstable. Findings: 1. On June 8, 2022, at 11:33 a.m. a bottle of Diabetic Tussin 30/40 milliliters (unit of measurement) was observed in the medication cart on Station 2. In a concurrent interview with LVN 5, she confirmed the medication did not have a verified pharmacy label on it. A review of a facility policy titled, Medications brought to the facility by a resident or family member dated September 2019, indicated the following: Medications brought into the…

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

Based on observation, interview, and record review, the facility failed to ensure that the antibiotic prescribed by the physician was adjusted after the culture and sensitivity result (A culture is a test to find germs (such as bacteria or a fungus) that can cause an infection. A sensitivity test checks to see what kind of medicine, such as an antibiotic, will work best to treat the illness or infection) of wound does not show the antibiotic (Vancomycin-is an antibiotic used to treat infections) to be sensitive. This failure had the potential to cause adverse event like antibiotic-resistant organism from inappropriate antibiotic use. Findings: On June 6, 2022, at 3:14 p.m., Resident 84 was observed in her wheelchair with ongoing IV (intravenous) antibiotics through a pump (machine use to administer medication). A review of Resident 84's record, indicated, Resident 84 was admitted to the facility with diagnoses which included, diabetes (high blood sugar) and cellulitis (deep infection of the skin) of right lower limb. In a concurrent record review and interview with the Director 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 provide a safe, and sanitary environment when one staff member was observed entering and exiting a room in the yellow zone (persons under investigation for COVID-19) without following the proper sanitary precautions, and one staff member did not prevent the potential for cross contamination when a medication tray was placed on the sink in the bathroom while performing hand hygiene. These failures had the potential to result in the development of an unsafe and unsanitary environment to a vulnerable resident population. Findings: 1. On June 6, 2022, at 11:13 a.m., the Certified Nursing Assistant (CNA) 4 was observed to enter into room [ROOM NUMBER]B located in the yellow zone without donning (putting on) or doffing (taking off) personal protective equipment (PPE - gown, gloves, face shield, and N95 face mask). CNA 4 was observed to be wearing goggles and a N95 face mask only. CNA 4 proceeded to grab a water pitcher from a bedside table 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.