Pacific Coast Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of 29 sampled residents (86) was served with the appropriate diet texture. This failure had the potential to result in choking for the resident. Findings: Review of Resident 86's admission Record indicated she was admitted to the facility on [DATE] with a dysphagia (difficulty swallowing) diagnosis. During a tray line observation and concurrent record review with the dietary director (DD) on 2/11/25 at 1 p.m., Resident 86's lunch ticket indicated her diet texture was mechanical soft (a modified diet that consists of soft, easy-to-chew foods that require minimal chewing or grinding; it is designed for individuals who have difficulty swallowing or chewing due to condition such as dysphagia) and ground meats. Chopped meats was served for Resident 86's lunch. During a concurrent interview with the DD, he confirmed that Resident 86's diet texture was mechanical soft/ground meats, but chopped meats was served for her. The DD 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 comprehensive person-centered care plan for one of three sampled residents (Resident 1) when: 1. The facility staff did not develop a care plan for Resident 1's antibiotic (ATB, used to treat bacterial infections) therapy, which was prescribed on 11/3/24 to treat burning urination (a possible sign of infection); and 2. The facility staff did not develop a care plan to address Resident1's change in condition on 11/11/24. These failures placed Resident 1 at risk of not receiving necessary care and services to maintain resident's health, safety and well-being. Findings: 1.Review of Resident 1's clinical record indicated she was admitted on [DATE] with diagnoses including unspecified dementia (impaired ability to remember, think, or make decisions that interfere with doing everyday activities). Review of Resident 1's physician's order dated 11/3/24, indicated to give Cipro (an antibiotic used to treat bacterial infections) 500 milligrams (mg,…

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 follow their policy and procedure for one of three residents (Resident 1) when an allegation of abuse was not reported to proper authorities. This failure had the potential for residents being at risk of abuse/harm. Findings: Resident 1 was admitted with diagnoses which included cerebral vascular disease (a group of conditions that affect blood flow and the blood vessels in the brain), Alzheimer's disease (a brain disorder that gradually destroys memory and thinking skills, and eventually the ability to perform daily tasks), major depressive disorder, anxiety disorder, and a history of falling. During an interview with the director of nursing (DON) on 10/4/24 @ 1:50 p.m., the DON had been notified of an allegation of abuse against licensed vocational nurse A (LVN A), the DON stated they had not had any problems with LVN A. During an interview with the DON on 11/20/24 at 10:42 a.m., the DON stated the allegation of abuse brought to her attention was not reported to the police. The DON further stated if they were notified by…

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 an advance directive (legal form directing their wishes about their healthcare, whether from them or a named individual on their behalf) and POLST (Physician Orders for Life-Sustaining Treatment) had been formulated and completed, for eight of 27 residents (Residents 1, 44, 68, 85, 117, 135, 241, and 242). These failures had the potential to result with inability to make medical decisions when residents cannot make for themselves and could lead to the delivery of unnecessary or inappropriate medical services, which are against the resident's goal and wishes. Findings: During a review of electronic records (record) for residents 1, 44, 68, 85, 117, 135, 241, and 242, advance directive forms were not located. The residents POLST indicated an incomplete section regarding advance directive. During an interview on 5/24/23 at 12:06 p.m., with the social services director (SSD), who stated We understood that if we talked with the Resident, then we just stopped at section D, but if we discussed with the Legally Recognized…

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 there was documented evidence that risks and benefits were explained and informed consent was obtained for the use of bed rails (side rails, safety rails and grab/assist bars) for 23 of 27 sampled residents (Residents 292, 67 123, 135, 241, 117, 242, 125, 128, 11, 53, 57, 75, 83, 87, 93, 1, 44, 47, 68, 80, 85 and 86). These failures had the potential to compromise the residents' rights to be fully informed and make decisions regarding their care and treatment. Findings: 1. During an observation on 5/25/23 at 7:32 a.m., Resident 292 was lying in bed and had grab bars (short rails attached to the sides of the bed to help the resident move around in bed) up bilaterally (on both sides). Resident 292's Bed Rail Observation/Assessment, dated 4/12/23 was reviewed. The section of the assessment designated for documenting that risks and benefits were explained and informed consent was obtained was left blank. During an observation on 5/25/23 at 8:05 a.m., Resident 67 was sitting up in bed and had grab bars up…

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

Based on observation, interview, and record review, the facility failed to ensure food was stored and labeled in accordance with professional standards for food service safety for 133 of 136 residents who received food from the kitchen when: 1. Undated milk was stored in the kitchen refrigerator; 2. Outdated milk was stored in the kitchen refrigerator; and 3. Undated food was stored in the resident food refrigerator. These failures had the potential to cause foodborne illness for 133 residents who received food from the kitchen. Findings: 1. During the initial kitchen tour on 5/22/23 at 8:04 a.m. with the Dietary Supervisor (DS), three 236-millimeter (ml, a type of unit measurement) cartons of milk without a use-by date were stored in the kitchen refrigerator. The DS confirmed the observation and removed the three milk cartons from the refrigerator. The DS stated he did not know its use-by date and/or why it didn't have a use-by date. The DS stated those milks should not be stored in the refrigerator. 2. During the initial kitchen tour on 5/22/23 at 8:06 a.m. with the DS, one 236-ml…

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 resident's right to dignity was provided for one of five residents (Resident 125) when her urinary drainage bag (catheter drainage bag [cath], container to catch the urine from an indwelling urinary catheter [tube into bladder]) was visible and not put into an outer bag to conceal the cath bag. This caused undo anxiety (feeling of worry)/embarrassment to Resident 125. Findings: Resident 125 was admitted to the facility with diagnoses including type 2 diabetes (a chronic condition that affects the way body processes blood sugar), muscle weakness, difficulty in walking, spina bifida (a condition that affects the spine and is usually apparent at birth), hemiplegia and hemiparesis (hemiplegia refers to complete paralysis, while hemiparesis refers to partial weakness) following cerebral infarction (disrupted blood flow to brain cells), and neuromuscular dysfunction of bladder (urinary condition in people who lack bladder control due to a brain, spinal cord or nerve problem). During an observation and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement their policy regarding self-administration of medication for one of 27 sampled residents (Resident 22). This failure had the potential to compromise Resident 22's health, safety and well-being. Findings: Review of Resident 22's medical record indicated she was readmitted on [DATE] and had the diagnoses of unspecified injury to the head and history of transient ischemic attack (TIA, neurological dysfunction resulting from interrupted blood supply to the brain). Review of Resident 22's Minimum Data Set (MDS, an assessment tool), dated 3/20/23, indicated she had a brief interview for mental status (BIMS) score of 10 (a score of 8 to 12 indicates moderate cognitive impairment). During an observation and concurrent interview on 5/23/23 at 9:02 a.m., Resident 22 was lying in bed awake. There was no facility staff in the room. On Resident 22's overbed table, there was an unlabeled medicine cup with a white substance inside. Resident 22…

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 Pre-admission Screening and Resident Review (PASRR-screening for residents with a mental disorder and residents with intellectual disability) screening document was accurately completed for one out of three resident (Resident 53). This failure had the potential for Resident 53 not to receive the required care and services. Findings: Review of Resident 53's readmission record dated 3/7/23 indicated, she was readmitted to the facility with diagnoses including schizophrenia (a serious mental disorder that affects how a person thinks, feels, behaves, and reality orientation), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety (a disorder that involves more than temporary worry or fear that can be mild or severe). Review of Resident 53's readmission physician's orders dated 3/7/23 indicated, she had an order of risperidone (a psychotropic medication used to treat mental/mood disorders) 1 milligram (mg- a metric unit of mass) every day at bedtime 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. A review of Resident 294's clinical record indicated she was admitted to the facility with diagnoses including Type 2 diabetes mellitus (adult-onset diabetes, disease that impairs the body's ability to regulate blood sugar) and pulmonary embolism (a sudden blockage in your pulmonary arteries, the blood vessels that send blood to your lungs). A review of Resident 294's medication orders included a maximum dose order for apixaban 5 milligrams (mg, unit of measurement) 2 tablets twice daily, dated 5/16/23. Resident 294 was also receiving two anti-diabetic medications, both dating 5/16/23: an insulin glargine injection inject 13 units subcutaneously in the morning and glipizide 2.5 mg every morning for diabetes mellitus. A review of Resident 294's clinical record indicated there was no comprehensive care plans developed to address goals, approaches, and interventions related to diabetes, nor was there one for the bleeding precautions related to the apixaban use, such as the monitoring for signs and symptoms 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 care and services in accordance with professional standards for four of 27 sampled residents (Residents 1, 22, 51, and 294) when: 1. For Resident 1, the facility did not follow a physician's order for the use of booties (boots worn to help prevent skin break down) to both feet and 4x4 gauze between each finger to left hand; 2. For Resident 22, the facility did not follow the physician's order when giving a medication; 3. For Resident 294, a nursing staff documented he administered a medication to the resident when he did not; and 4. For Resident 51, the nursing staff failed to hold two medications as prescribed. These failures had the potential to negatively affect the residents' health, safety, and well-being. Findings: 1. During a review of Resident 1's physician order, dated 6/25/16, indicated, Apply booties to both feet for protection every shift. Review of Resident 1's physician order, dated 9/01/15, indicated, Apply 4x4…

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 there was documented evidence that pressure ulcer (damage to the skin and underlying tissues as a result of prolonged pressure) treatments were provided for one of two sampled residents (Resident 51). This failure had the potential to result in worsening of Resident 51's pressure ulcer. Findings: Review of Resident 51's medical record indicated he was admitted on [DATE] and had the diagnoses of kyphosis (excessive curvature of the spine that causes hunching) and peripheral vascular disease (disease that causes narrowing of blood vessels and decreased circulation). During an interview with Resident 51 on 5/22/23 at 9:52 a.m., he stated he had a wound on his back for which he was receiving daily treatments. Resident 51 stated he had this wound since he was admitted to the facility. During an interview with licensed vocational nurse N (LVN N) on 5/24/23 at 12:54 p.m., she stated Resident 51 had an unhealed pressure ulcer on his mid-back. LVN N…

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 their fall and fall risk management policy and procedure (P&P) for two out of five residents (Resident 80 and 83) when no new interventions were implemented after a fall. This failure had the potential to result in further falls. Findings: Review of Resident 83's clinical record indicated she was admitted to facility with diagnoses including cerebral infarction (occurs when blood supply to part of the brain interrupted or reduced, preventing brain tissue from getting oxygen and nutrients), heart failure (condition in which heart muscle cannot pump enough blood to meet the body's needs for blood and oxygen), dementia (loss of ability to think, remember, and reason to levels that affect daily life and activities), type 2 diabetes (a chronic condition that affects the way the body processes blood sugar), and atrial fibrillation (irregular heart beat). During a review of Resident 83's SBAR (situation, background, 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 Based on observation, interview, and record review, the facility failed to ensure appropriate treatment was rendered for one of two sampled residents (Resident 1) to prevent complications of enteral feeding (refers to the intake of liquid food into the stomach, duodenum, or jejunum). This failure could result in health complications. Findings: During a review of Resident 1's clinical record, indicated she was admitted on [DATE] and had the diagnoses including disorder of brain (different problems with the brain can have various causes such as illness, genetics, or injury), gastrostomy (a surgical opening into the stomach for the introduction of food) status, and quadriplegia (paralysis that affects all four limbs). During a review of Resident 1's physician order, dated 10/21/18, the order indicated Enteral feed order: elevated head of bed (HOB) 30-45 degrees at all times during feeding and at least 30-60 minutes after feeding is stopped, every shift. During a review of Resident 1's care plan, Resident requires…

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 controlled medications (those with high potential for abuse and addiction) were fully accounted when random review of medication use for one of five sampled residents (Resident 295) did not reconcile. Five (5) Norco (hydrocodone with acetaminophen, a potent controlled medication for moderate to severe pain) tablets were removed from the the automated dispensing unit (ADU, where medications are stored and electronically tracked) without being documented as administered to the resident. This failure resulted in inaccurate accountability and potential for abuse or diversion of controlled medications. Findings: During a visit to one of the medication rooms in Nursing Station 2 on 5/22/23 at 3:10 p.m., the facility's ADU was observed in the presence of Registered Nurse K (RN K). She stated the facility had the ADU for a few months; it contained medications for routine as well as PRN (or as-needed) medication use. She explained, for PRN medications, the nursing staff would sign in, remove the desired…

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 physician provided the clinical rationale when declining the consultant pharmacist's (CP) recommendations for one of 27 sampled residents (Resident 57). Also, the CP failed to identify Resident 57's seizures as a potential side effect and made recommendation to the facility for the reduction or discontinuance of the medications that may be causing the seizures. These failures resulted in unnecessary medications and potential for unrecognized and prolonged side effects related to psychotropic medications. Findings: A review of Resident 57's clinical record indicated she was an elderly resident admitted to the facility with diagnoses including anxiety, unspecified dementia [impaired ability to remember, think, or make decisions that interferes with doing everyday activities], unspecified severity with other behavioral disturbance, and other seizures [sudden, uncontrolled electrical disturbance in the brain. It can cause changes in your behavior, movements or feelings, and in levels of consciousness].…

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 two of 27 sampled residents (Residents 57 and 128) were free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behaviors) when: 1. Resident 57 received Seroquel (an antipsychotic medication) and trazodone (an anti-depressant) without gradual dose reduction (GDR) in the presence of having had episodes of seizures (a potential side effect from both medications) and in the absence of target behaviors; and 2. Resident 128 received trazodone without staff identified and monitoring for target symptoms/behaviors in order to assess the effectiveness of the medication. The failures resulted in inadequate monitoring for effectiveness and unnecessary medications, which had the potential for increased risks associated with psychotropic medication use that include but not limited to sedation, respiratory depression, falls, constipation, anxiety, agitation, abnormal involuntary movements, and memory loss. Findings: 1. A review of Resident 57's clinical…

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 had a medication error rate of 6.45% when two medication errors occurred out of 31 opportunities during the medication administration for one of six residents (Resident 22). Resident 22 did not receive two medications with meals, as prescribed. The failure had the potential for the resident to suffer side effects from the medications such as stomach upset or pain. Findings: During a medication pass observation with Licensed Vocational Nurse E (LVN E) on 5/22/23 at 10:16 a.m., she was observed preparing eight medications for Resident 22. Included in the medications was one tablet of metformin (medication used to treat diabetes [high levels of blood sugar]) 500 milligrams (mg-unit of measurement). On 5/22/23 at 10:34 a.m., at Resident 22's bedside, LVN E administered the medications to Resident 22 with a small cup of water. There was no breakfast tray or food observed on the over-bed table. Resident 22 complained of a sore throat while taking her medications. During an interview on 5/22/23 at 10:40 a.m., Resident 22…

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 insulin pens and other medications were safely labeled; and an expired medication was removed from active stock, to avoid mix-up errors or medication given beyond its effective date. Findings: During a visit to the Station 3 Medication Room on [DATE] at 11:20 a.m. with Facility Staff G (Staff G), the medication refrigerator was identified. It contained eight insulin pens (pre-filled pen containing medication to lower blood sugar); two of the pens had the pharmacy label (one containing information such as patient name, medication name, direction for use, prescription number) on the cap (instead of the body) of the pens. Staff G stated sometimes the pharmacy would send the pens with the label on the cap; and the staff would usually re-label it by moving the label from the cap to the body. She confirmed the patient's label should not be on the cap to avoid mix-up errors. The inspection of the medication refrigerator also identified an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide milk for dry cereal during breakfast meal for one out of seven resident (Resident 11). This failure had the potential to compromise Resident 11 nutritional needs. Findings: Review of Resident 11's clinical record indicated, she was admitted on [DATE] with diagnoses including anemia (a condition in which lower than normal amount of red blood cells in blood), anxiety (a feeling of worry or fear that can be mild or severe),depression (mood disorder that causes a persistent feeling of sadness and loss of interest), and dementia (loss of ability to think, remember and reason to levels that affect daily life and activities). Review of Resident 11's minimum data set (MDS- clinical and functional assessment tool) dated 1/14/2023, indicated her brief interview for mental status (BIMS) score was 14 (a score of 13 to 15 indicates intact cognition). During an observation and concurrent interview with Resident 11 on 5/23/23 at 8:40 a.m., there…

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 diet order for one of 27 sampled residents (Resident 292). This failure had the potential to compromise Resident 292's health and safety. Findings: Review of Resident 292's medical record indicated she was admitted on [DATE] and had the diagnosis of dysphagia (difficulty or discomfort in swallowing). Review of Resident 292's care plan, dated 4/18/23, indicated she was at risk for aspiration (food or liquids accidentally entering into the lungs) due to dysphagia. The care plan further indicated, Provide appropriate food/fluid consistency. Review of Resident 292's Order Summary Report indicated she had a physician's order, dated 5/22/23, for a fortified diet (food with increased nutrients) with mechanical soft texture (diet that restricts foods that are difficult to chew or swallow). During an observation on 5/26/23 at 8:42 a.m., Resident 292 was sitting in bed eating breakfast. There were two slices of toast on her plate. 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 a sippy cup (a cup with a lid and a spout) during lunch for one of 27 sampled residents (Resident 80). This failure had the potential to affect the resident's ability to complete self-feeding task. Findings: During a dining room observation on 5/22/23, Resident 80 had regular cups for milk, juice, and coffee. There was no sippy cup during the lunch meal. Resident 80's meal card on the dining table indicated, Adaptive equip: Built up fork, built up spoon, sippy cup. During a review of Resident 80's physician order, dated 4/20/23, the order indicated, Fortified diet: mechanical soft ground texture, thin liquids consistency, built up/non-weighted spoon/fork and sippy cup with meals. During a concurrent observation and interview on 5/22/23 at 12:52 p.m., with Restorative Nursing Assistant L (RNA L), Resident 80 was using regular cups for her drinks. When asked where was the sippy cup for Resident 80, RNA L stated the sippy cup was not provided from the kitchen. RNA L further stated that the sippy cup…

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 maintain an infection prevention and control program to prevent the spread of infection when one of 16 bathrooms had: 1a. Unlabeled emesis basin (a plastic kidney-shaped emesis basin used to collect body fluids and for oral hygiene) was placed on top of paper towel holder and 1b. Three wet wash cloths hanging on a grab bar (a metal bar fixed on wall, helps resident to keep balance while standing, moving around, or getting in and out) next to commode; and charge nurse did not change gloves in between tasks for one of three opportunities during preparation of enteral feeding. These failures had the potential for disease transmission among residents. Findings: 1a.During a concurrent observation and interview with certified nursing assistant F (CNA F) on 5/22/23 at 11:35 a.m., there was an unlabeled emesis basin contained toothbrush and toothpaste placed on top of the paper towel holder in residents' room [ROOM NUMBER] bathroom. CNA 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 ensure that two of three sampled residents (Residents 127 and 293) discharged from Medicare Part A services (or their representatives) received mailed copies of the 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 result in an inability of the resident's representative to file a timely appeal due to not having the contact information for the Quality Improvement Organization (QIO, an independent reviewer authorized by Medicare to review the decision to end services). Findings: A review of Resident 127's clinical record indicated she was admitted to the facility on [DATE] with a primary diagnosis of urinary tract infection. Other diagnoses included weakness and abnormalities in gait and mobility. The record indicated she had plateaued with therapy services and 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 notify one of 29 sampled residents (Resident 22) and/or Resident 22's representative of the facility's bed hold policy when Resident 22 was transferred to a general acute care hospital (GACH). This failure had the potential for Resident 22 not to be able to come back to the facility after being discharged from the GACH. Findings: During a review of the clinical record for Resident 22, the Nursing Home to Hospital Transfer Form dated 5/27/18 indicated Resident 22 was transferred to the emergency department (ED). During a review of the clinical record for Resident 22, the Progress Notes dated 5/27/18 at 2:45 p.m. indicated Resident 22 was transferred to the ED for further evaluation and treatment, but no indication of the facility's bed hold form being given to the resident or representative. During an interview on 3/14/19 at 1:08 p.m. with the AR consultant, she reviewed the clinical record for Resident 22 and was unable to find documentation of the bed hold form, and stated it had not been given. The facility's policy and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide personal hygiene and grooming services for one of 29 sampled residents (Resident 9) when his fingernails were long and he had dirt underneath his fingernails. This failure could potentially affect the resident's heath and safety. Findings: During an observation of Resident 9 on 3/14/19 at 10:55 a.m., Resident 9 was sitting in his wheelchair outside the facility. He had his hands in his vest pockets. When he removed his hands from his pockets, he had long fingernails with dirt underneath all his fingernails. The left thumbnail appeared hypertrophied (overgrowth or thickening of nails). Resident 9 stated it had been over a month or longer since they last cut his fingernails. During an interview with certified nursing assistant F (CNA F) on 3/14/19 at 11 a.m., she stated she was not sure who would cut the resident's nails but she would ask the nurse. During a concurrent interview with licensed vocational nurse E (LVN E), he 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 observation, interview,and record review, the facility failed to administer oxygen (O2) according to professional standards of practice for one of 29 sampled residents (Resident 54), when the facility did not administer O2 according to the physician's order. This failure could potentially affect the resident's health and safety. Findings: During the initial observation tour on 3/11/19 at 10:55 a.m., Resident 54 was up in the wheelchair with O2 on at 3.5 liters per minute (3L/NC) via nasal cannula (two prong plastic tube hooked to an oxygen concentrator (a machine that supplies oxygen -enriched gas)). Resident 54 stated the nurse turned up the O2 last night. During a concurrent interview with licensed vocation nurse A (LVN A), she confirmed the finding and stated it should be at 2L/NC. She then adjusted the O2 rate down to 2 L/NC. Review of Resident 54's clinical record indicated he was admitted to the facility on [DATE] with diagnoses to include chronic obstructive pulmonary disease (COPD, chronic lung…

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 three of 29 sampled residents were free from unnecessary psychotropic medications (alters mood and behavior) when: (1) possible side-effects from Aripiprazole (medication used to treat mental health disorder) or Depakote (mood stabilizer medication) were not properly assessed and documented for Resident 88, and (2) behavioral approaches were not consistently implemented for Residents 35 and 125. These failures had the potential to place residents at risk for adverse consequences related to prolonged use of psychotropic. Findings: 1. Review of Resident 88's admission record indicated, he was admitted on [DATE], with diagnoses to include psychosis (mental disorder) and depression (mood disorder). During a concurrent observation and interview with Resident 88 on 3/11/19 at 11:46 a.m., Resident 88 had tremors (unintentional trembling or shaking movements) in her hands and jaw and edema on both legs while she was sitting in her…

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.