Coastal Post Acute

Based on observation, interview, and document review, the facility failed to ensure food was stored and/or prepared under sanitary conditions when: 1. There was a crusty white substance on several areas of the ice machine; and 2. Kitchen staff did not follow manufacturer's instructions when testing the kitchen surface sanitizer (solution used to kill microorganisms on kitchen surfaces). These failures had the potential to cause foodborne illness (illness caused by contaminated food) for 66 out of 66 residents. Findings: 1. During an observation on 7/26/23 at 7:45 a.m., accompanied by the dietary manager (DM), the facility's ice machine was inspected. There were streaks of a crusty white substance running along the top and down the left side of the ice machine. This crusty white substance was also found under the ice machine's lid. More of this crusty white substance was found in the area where the lid contacted the body of the ice machine. During a concurrent interview with the DM, she confirmed the presence of the crusty white substance on the ice machine. The DM acknowledged 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 their pest control program was effective when there were several fruit flies (small flying insects that have the potential to contaminate food) in the kitchen, even though the kitchen had recently been treated for fruit flies. The presence of pests in the kitchen had the potential to result in foodborne illness (illness caused by contaminated food) for 66 out of 66 residents. Findings: Review of the facility's pest control summary, dated 7/6/23, indicated 22 live fruit flies were found in the kitchen. The summary further indicated the pest control company applied treatment in response to the fruit flies that were found in the kitchen. During an observation on 7/26/23 at 7:54 a.m., accompanied by the dietary manager (DM), there was a white bucket on the floor near one corner of the kitchen. There were approximately 11 live, small, black, flying insects observed on this white bucket. During a concurrent interview with the DM, she confirmed the presence of the live, small, black, flying insects in 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 the temperature (temp) in one of two medication refrigerators (Ref #2) was maintained within acceptable range from 36 to 46 degrees Fahrenheit (ºF) as per the manufacturers' and the facility's guidelines. Ref #2 had out-of-range temp readings 4 times in June 2023, and 23 out of 47 times in July 2023, without any documented action taken by the staff to correct the out-of-range temps. Exposing medications to out-of-range temps, such as too hot or cold, can cause them to become unstable and even degrade, posing a risk of negative side effects and decreasing their effectiveness. Findings: On 7/24/23 at 9:37 a.m., a visit to the medication room with the director of nursing (DON) identified two medication refrigerators: one small Immunization Refrigerator and a larger house-hold type medication refrigerator (Ref #2). A review of the thermometer inside Ref #2 with the DON indicated temp reading of 34ºF. Ref #2 was observed to contain 19 pre-filled insulin (medication to lower blood sugar) pens, 2 insulin…

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 palatability was maintained, when six of 17 sampled residents (Residents 11, 41, 12, 269, 270 and 6) complained about the taste of the food being served. This failure had the potential to result in decreased food intake and weight loss, compromising the resident's nutritional status. Findings: 1. During an interview with Resident 11 on 7/24/23 at 8:15 a.m., he stated he did not like the food in the facility because the food tasted bland. Review of Resident 11's clinical records indicated, was admitted to the facility on [DATE] and had a brief interview for mental status (BIMS, widely used tool, to screen and identify the cognitive condition of residents) score of 15 (a score 15 indicated the resident was cognitively intact). 2. During an interview with Resident 41 on 7/24/23 at 8:53 a.m., she stated she had issues with her food since the change of management about a year and a half ago. Resident 41 further stated the food…

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 an interview, and record review, the facility failed to ensure the dignity of one of 17 sampled residents (Resident 317), when certified nursing assistant G (CNA G) did not use proper technique in modestly covering Resident 317's unclothed lower body. This failure was against the resident's right to dignity. Findings: Resident 317 was admitted with diagnoses which included Parkinson's disease, dementia with behavioral disturbance and agitation, unsteadiness on feet, age-related osteoporosis (bone mineral density and bone mass decreases, increasing risk of broken bones), major depressive disorder, pancytopenia (a decrease in all three blood cell types), dysphagia (trouble swallowing) following cerebrovascular disease, weakness, repeated falls, psychotic disorder with delusions, nutritional deficiency, acute kidney failure, anxiety disorder, intellectual disabilities, cognitive communication deficit, and history of falling. During an interview with the director of nursing (DON) on 7/27/23 at 9:52 a.m., she stated CNA H came in to her office to tell her that Resident 317 had 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 interview and record review, the facility failed to ensure one of 17 sampled residents (Resident 35) had been informed about having an advance directive (legal form directing their wishes about their healthcare, whether from them or a named individual on their behalf), when no documentation was found about advance directive. This failure had the potential to result with inability to make medical decisions and could lead to the delivery of unnecessary or inappropriate medical services. Findings: Resident 35 was admitted to the facility with diagnoses which included dysphagia following unspecified cerebrovascular disease (stroke), dysphagia (swallowing difficulties), metabolic encephalopathy (a problem in the brain), adult failure to thrive, acute kidney failure, nephrogenic diabetes insipidus (kidneys do not function correctly, so too much fluid gets flushed out in the urine), and history of pulmonary embolism (a sudden blockage in the pulmonary arteries, the blood vessels that send blood to the lungs). Review of Resident 35's electronic health record (EHR), there was no…

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 1. one of 17 sampled residents (Resident 35) or their responsible party (RP, person who is accountable in making decision on behalf of the resident) received a notice of transfer and discharged to the general acute care hospital (GACH) and 2. the State Long-Term Care Ombudsman (Ombudsman, an advocate for residents in the nursing homes) office was not notified about two of 17 residents (Residents 35 and 317) transfer to the GACH. These failures had the potential of not providing the residents and/or their RPs with an access to an advocate who could inform them of their rights. Findings: 1. Resident 35 was admitted to the facility with diagnoses which included Parkinson's disease, Dementia with behavioral disturbance, mild protein-calorie malnutrition, dysphagia following unspecified cerebrovascular disease (stroke), schizophrenia (a chronic brain disorder that can include symptoms of delusions, hallucinations, disorganized speech, trouble with thinking and lack of motivation.), unsteady on feet, weakness, dysphagia…

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 accurately complete the Minimum Data Set (MDS, an assessment tool) for one of 17 sampled residents (Resident 52). Failure to accurately assess the resident had the potential to compromise the facility's ability to provide resident-centered care plan interventions. Findings: Review of Resident 52's medical record indicated she was admitted on [DATE] and had the diagnoses of Alzheimer's Disease (brain disorder that destroys memory and thinking skills), dementia (mental disorder caused by brain disease or injury), and repeated falls. Review of Resident 52's SBAR [situation, background, assessment, recommendation] Communication Form, dated 5/9/22, indicated Resident 52 had a fall. Review of Resident 52's Fall Scene Investigation Report, dated 5/9/22 indicated, Resident was seen on the floor in her room at the left side of her bed. During an interview and concurrent record review with the Minimum Data Set Coordinator (MDSC) on 7/25/23 at 3:37 p.m., she…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide care and services in accordance with professional standards and facility policy and procedures for three of 17 sampled residents (Residents 7, 20, and 41), when: 1. Licensed Vocational Nurse (LVN) C failed notify the physician when Resident 7 refused his diabetic medication 8 times in June and 12 times in July 2023; 2. For Resident 41, LVN E administered 13 units of insulin (medication to lower blood sugar) while the order indicated to give 6 units, and informed the physician after he administered it; 3. For Resident 20, 72 hour alert charting was not completed post fall. These failures had the potential to cause complications of the residents' medical conditions. Findings: 1. A review of Resident 7's clinical record indicated he was admitted to the facility with diagnoses including type 2 diabetes mellitus (disease that impairs the body's ability to regulate blood sugar [BS]) and diabetic neuropathy (nerve damage due 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 provide activities for one of 17 sampled residents (Resident 52). This failure had the potential to negatively affect the resident's overall well-being. Findings: Review of Resident 52's medical record indicated she was admitted on [DATE] and had the diagnoses of Alzheimer's Disease (brain disorder that destroys memory and thinking skills), dementia (mental disorder caused by brain disease or injury), and major depressive disorder (mood disorder that causes persistent feelings of sadness and loss of interest). Review of Resident 52's Minimum Data Set (MDS, an assessment tool), dated 9/27/22, indicated doing her favorite activities was very important to Resident 52. Review of Resident 52's care plan, revised 10/20/22 indicated, The resident is dependent on staff for activities, cognitive stimulation, social interaction. The care plan also indicated, The resident needs 1 to 1 bedside/in-room visits and activities if unable to attend out 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 monitor, evaluate and managed residents behavior for one of 11 sampled residents (Resident 24), when Resident 24 had episodes of shaking her side rails when in bed. The failure had the potential for Resident 24, not attaining her highest well-being and caused discomforts to her roommate Resident 41. Findings: During an interview with Resident 41 on 7/24/23 at 8:53 a.m., she stated her roommate Resident 24 had episodes of banging or shaking her side rails when in bed. Resident 41 further stated, Resident 24 had this behavior going on for about a year [already] and she had been complaining to the facility but nothing had been done. During an observation and concurrent interview of Resident 24 on 7/24/23 at 12:50 p.m., Resident 24 was sitting in her wheelchair in the dining area, eating her lunch. She was confused and could not respond to questions when asked. Review of Resident 24's clinical records indicated, she 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.

Based on interview and record review, the facility failed to ensure controlled medications (those with high potential for abuse and addiction) were fully accounted and given according to the physician's orders for two of two sampled residents (Residents 2 and 267). Controlled medications were signed out of the Controlled Drug Record (CDR, or an inventory sheet that keeps record of the usage of controlled medications) but not documented on the Medication Administration Record (MAR) as administered to the residents; furthermore, there were no physician's orders for the administrations. The failure resulted in inaccurate accountability and had the potential for misuse or diversion (illegal distribution or abuse of prescription drugs or their use for purposes not intended by the prescriber) of controlled medications. Findings: During the survey, CDRs for two random residents (Residents 2 and 267) were requested for review. 1. A review of Resident 2's clinical record indicated he had a physician's order, dated 9/19/22, for hydrocodone-acetaminophen (Norco, a controlled medication 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 failed to ensure the medication regimen for one of 17 sampled residents (Resident 57) was free from unnecessary medications. Resident 57 had been receiving Reglan (metoclopramide; medication to treat nausea and vomiting) exceeding 12 weeks duration, as specified by the manufacturer, without a risk/benefit (R/B) assessment. This had the potential for the resident to experience side effects, specifically tardive dyskinesia (an involuntary movement disorder that causes a range of repetitive muscle movements in the face, neck, arms and legs) from prolonged use. Findings: A review of Resident 57's clinical record indicated a physician's order for metoclopramide 5 milligrams (mg) 1 tablet by mouth before meals for nausea/vomiting (N/V) since 2/24/2023 (5 months ago). The resident's July 2023 medication administration record (MAR) indicated the resident had been receiving it routinely three times daily at 8 a.m., 11 a.m., and 4 p.m. A review of Lexicomp, a nationally recognized drug information resource, indicated under Adult Dosing: 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 one of 17 sampled residents (Resident 35) was free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behaviors) when Resident 35 received Remeron (generic name: mirtazepine, an antidepressant medication) for poor appetite related to depression without staff consistently monitoring for his meal intakes. The failure resulted in inadequate monitoring for the effectiveness of the medication. Findings: A review of Lexi-comp, a nationally recognized drug information resource, indicated Remeron is used to treat various medical conditions including depression. One of its side effects included increased appetite. A review of Resident 35's clinical record indicated he was an elderly resident admitted to the facility with diagnoses including unspecified dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's…

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

Based on observation, interview, and document review, the facility failed to ensure refuse (any disposable materials, which includes recyclable and non-recyclable materials) was stored properly when one out of four dumpsters was overfilled and the lid was not closed. This failure had the potential to attract insects, rodents, and other pests to the facility. Findings: During an observation on 7/25/23 at 9:46 a.m., accompanied by the dietary manager (DM), there were four dumpsters in the facility's designated waste storage area. One dumpster was overfilled with cardboard. The dumpster was so full that the lid would not close, as it was propped open by the cardboard inside. There were also several large cardboard boxes stored on top of the dumpster lid. During a concurrent interview with the DM, she confirmed the above observation and confirmed the dumpster lid should have been closed. The DM stated all her staff knew the dumpster lids were supposed to be closed. The DM acknowledged, an open dumpster could attract pests. The United States Food and Drug Administration's 2022 Food Code…

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, licensed vocational nurse A (LVN A) failed to perform hand hygiene during wound treatment for one of two sampled residents (Resident 6). This failure had the potential to cause infection or other complications to Resident 6's wound. Findings: Review of Resident 6's medical record indicated he was admitted on [DATE] and had a pressure ulcer (damage to the skin or underlying tissue as a result of prolonged pressure) on the left buttock. During an observation on 7/26/23 at 2:00 p.m., LVN A performed treatment on Resident 6's left buttock pressure ulcer. While wearing a pair of clean gloves, LVN A cleaned Resident 6's pressure ulcer with a piece of gauze soaked in normal saline (solution used to clean wounds). She then removed her gloves and without performing hand hygiene, she put on a new pair of gloves. LVN A then took a piece of dry gauze, dried Resident 6's pressure ulcer, and removed her gloves again. Without performing hand hygiene, LVN A put on another pair…

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 safely when: 1. refrigerator #1 had torn, dirty gaskets and racks with peeling coating and rust; 2. refrigerator #2 had torn, dirty gaskets; racks with rust; and a discolored pork roast; and 3. freezer #2 had torn, dirty gaskets; racks with peeling coating and rust; and poultry and salmon with freezer burn These failures had the potential to cause food borne illness to a highly susceptible population of 75 residents who received food from the kitchen. Findings: During an initial tour and observation of the kitchen on 6/23/19 at 8:58 a.m. with the dietary aide (DA), refrigerator #1 had torn, dirty gaskets and racks with peeling coating and rust; refrigerator #2 had torn, dirty gaskets; racks with rust; and a discolored (gray/green) pork roast; and freezer #2 had torn, dirty gaskets; racks with peeling coating and rust; and poultry (turkey deli meat, chicken breasts, turkey pieces) and salmon fillets with freezer burn. During a concurrent interview, the DA confirmed 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 care and services were provided to prevent accidents or harm for five of 20 sampled residents, when: 1) There was no bolster (cushion for support) in Resident 39's bed and the bed level was raised. 2) A neurological assessment was not completed after seven unwitnessed falls for Resident 19 and the alarming devices were non-functional and not in place for Resident 19. 3) There were fire hazard items placed on three residents room light (Residents 23, 36 and 45). These failures had the potential to place residents at risk for accidental burns, repeated falls, injury, or even death. Findings: 1) Review of Resident 39's clinical record, Resident 39 was admitted on [DATE] with diagnoses included chronic kidney disease , hypertension (high blood pressure) and dementia (memory loss). Record Review of Resident 39 's MDS (resident tool assessment) dated 11/03/18, Resident 39 was severely cognitively impaired and required extensive…

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 promote resident's dignity when three certified nursing assistants (CNAs) were standing while assisting with meals for four of eight residents (Resident 6, Resident 11, Resident 15 and Resident 39) reviewed, which had the potential to decrease residents' self-esteem. Findings: During observation on 6/23/19 at 10:18 a.m., CNA E was standing in the dining area, while trying to feed Resident 15 with tapioca pudding. Resident 15 who was sitting in a geri-chair, coughed as CNA E spoon feeds her. During observation on 6/24/19, at 8:29 a.m., CNA G was standing while offering milk. Residents 6 and 11 while the residents were seated. During observation on 6/26/19 at 8:17 a.m., CNA F was standing while assisting Resident 39 to eat breakfast. Resident 39 was sitting in her wheelchair. During the interview with the DSD on 6/26/19, at 11:33 a.m., DSD stated CNAs should be seated at eye level with the residents while assisting with their meals to promote dignity.

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 residents (Residents 25 and 44) discharged from Medicare Part A services received a Notice of Medicare Non-Coverage (NOMNC, a form given to Medicare recipients notifying them that Part A coverage is being terminated and providing information on how to file an appeal of that decision). This failure had the potential to prevent the residents from filing a timely appeal of the decision to discharge from Medicare Part A services. Findings: A review of Resident 25's clinical record indicated he was admitted to the facility on [DATE] with a primary diagnosis of pneumonia. The facility initiated a discharge from Medicare Part A services on 4/15/19 with benefit days remaining. A NOMNC was not found in the clinical record. A review of Resident 44's clinical record indicated he was admitted to the facility on [DATE] with a primary diagnosis of chronic kidney disease. The facility initiated a discharge from Medicare Part A services 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 interview and record review, the facility failed to provide restorative nursing assistant (RNA) services (exercise program intended to improve or maintain level of function) as ordered for two of 18 sampled residents (9 and 44). This failure had the potential to result in a decline in the residents functional abilities. Findings: 1. Review of Resident 44's clinical record indicated he was admitted on [DATE] with diagnoses including hemiplegia and hemiparesis (partial or total loss of ability to move one side of the body), abnormalities of gait and mobility, unsteadiness on feet, and generalized weakness. Review of Resident 44's physician's order, dated 4/18/19, indicated he was to receive RNA treatments consisting of omnicycle (arm and leg pedal exerciser), shoulder and elbow exercises, sitting in wheelchair with ankle weights, and knee and hip exercises. Review of Resident 44's document Rehabilitation and Restorative Nursing Program dated 4/16/19, indicated he was to receive the above RNA treatments…

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 of an intravenous (IV, within a vein) site dressing and accurate measurement of arm circumference and external length catheter were completed as per physician orders for one (Resident 66) of one resident reviewed with IV catheters, which had the potential to result to IV complication. Findings: Review of Resident 66 's clinical record, Resident 66 was admitted on [DATE] with diagnoses included sepsis (serious complication of infection) disruption of external operation (surgical) wound, and muscle weakness. Review of Resident 66's MDS dated [DATE], Resident 66 was cognitively alert and required supervision during activities of daily living. During concurrent observation and interview on 06/23/19 at 9:28 a.m., Resident 66 had rashes and bruise on the right upper arm skin surrounding the transparent dressing of the IV site. Resident 66 also stated that nurses had pulled his external length catheter every time they changed the IV…

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 dialysis (the clinical purification of blood as a substitute for normal function of the kidney) communication record were completed, for one of one resident receiving dialysis (21). This failure had a potential to put Resident 21 at risk in developing undetected, potentially life-threatening complications related to dialysis treatment. Findings: During a review of clinical record for Resident 21, the admission Record dated 6/26/19 indicated Resident 21 was admitted on [DATE] with diagnosis of end stage renal disease (gradual loss of kidney function), acute on chronic combine systolic (congestive) and diastolic (congestive) heart failure (a progressive heart disease that affects pumping action of the heart muscle) and hypertension (high blood pressure). During a review of clinical record for Resident 21, the following Nurse's Dialysis Communication Records dated 3/8/19, 5/17/19, 6/10/19 and 6/21/19 were incomplete. During an interview 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 interview and record review, the facility failed to ensure adequate indication, behavioral and adverse/side-effects monitoring for one of 20 sampled residents (Resident 122) related to use of Seroquel (treats mental/mood disorder), which had the potential to result to adverse drug reactions. Findings: Review of Resident 122 's clinical record, Resident 122 was admitted on [DATE], with diagnoses included dementia (memory loss), muscle weakness, and parkinson's disease (central nervous system disorder, often including tremors). Review of Resident 122 physician's order dated 6/2019 indicated Seroquel 200 mg po OD for dementia. Review of Resident 122's care plan, medication and treatment administration record dated 6/2019, there was no targeted behavior that includes its monitoring related to the use of Seroquel. Additionally, there was no adverse or side-effects monitoring of the drug. Interview with LVN J on 6/24/19, at 9:01 a.m., LVN J confirmed lack of targeted behavioral and adverse/side-effects…

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 that the Alprazolam (anti-anxiety) for one of 20 sampled residents (Resident 122) was limited to 14 days, which had the potential to cause adverse drug reactions. Findings: Review of Resident 122 physician's order dated 6/15/19, indicated Alprazolam tablet Disintegrating 0.25 mg. Give 1 tablet by mouth as needed for anxiety. Interview with LVN J on 6/24/19 at 9:01 a.m., LVN J confirmed that Alprazolam as needed had no stopped date within duration of 14 days.

Based on observation, interview, and record review, the facility failed to ensure: 1) resident medications were sufficiently labeled; 2) unused narcotics were disposed of; and 3) discontinued narcotics were secured. This failure had the potential to result in the accidental administration of a wrong medication to the wrong resident and/or drug diversion. Findings: 1. During an observation of medication cart TEAM 1 on 6/23/19 at 1:08 p.m., three opened boxes of Natural Balance Tears (eye drops) were in the medication cart each labeled with only a room number. During a concurrent interview with the associate director of nurses (ADON), she confirmed the observation. 2. During an observation of medication cart TEAM 2 on 6/23/19 at 1:15 p.m., the narcotic drawer contained three small plastic envelopes each containing a single tablet. One envelope was labeled with a room number and date; a second envelope was labeled with a room number, resident name, and date: and a third envelope was labeled with a resident name and a partially illegible drug name. During a concurrent interview 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.

Based on observation, interview and record review, the facility failed to provide plateguard (stainless steel food guard to secure food spill) during lunch meal for one of seven residents (Resident 61) reviewed with adaptive devices, which had the potential to affect resident's ability to complete self-feeding task. Findings: During dining observation on 6/23/19 at 12:15 p.m., Resident 61 had no plate guard during lunch meal which had caused some food particles to have been spilled on the table. The plateguard was left on the tray cart. CNA H did not attach the plateguard on top of the plate. During interview with CNA H on 6/23/19 at 12:16 p.m., when asked where's the plateguard of Resident 61, CNA H pointed out the silverware underneath the plate. During interview with DSD on 06/26/19 at 11:33 a.m., the DSD stated the CNA should be responsible for putting the plateguard on top of the plate. The DSD showed that the silverware underneath the plate which the CNA pointed out was not the plateguard. Review of Resident 61's meal card dated 6/23/19, indicated devices: Plate Guard.

Based on observation, interview, and record review, the facility failed to implement infection control practices when used lancets (a spring-loaded device that contains a needle) were stored in an unlocked freezer in an unlocked biohazardous waste storage area. This failure had the potential to expose the residents to infectious disease. During an observation of the biohazardous waste storage area with the associate director of nursing (ADON) and the van driver (VD) on 6/24/19 at 8:45 a.m., the door to the storage area was unlocked. A freezer used to contain biohazardous waste was also unlocked. Thirteen lancets and caps (lancet covers) were scattered on the bottom of the freezer. During a concurrent interview, both the ADON and VD confirmed the observations. During an interview with the maintenance supervisor (MS) on 6/24/19 at 8:53 a.m., when asked if the biohazardous waste storage area should be locked, he stated it should be locked. A review of the facility's policy, Disposal of Medications and Medication-Related Supplies: Syringe and Needle Disposal dated April 2008, 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.