Salinas Valley Post Acute

Based on observation, interview, and record review, the facility failed to ensure proper medication storage and labeling of medications for one of two medication carts (a mobile, secured, and organized cart to store, transport and administer medications to residents) (Medication Cart AA), when expired bottle of brimonidine eyedrop (used primarily as eye drops to lower high pressure in the eye caused by open-angle glaucoma [group of eye diseases that can cause vision loss and blindness]) or ocular hypertension (high pressure inside your eye) and latanoprost eyedrop (used to treat glaucoma) medications were not removed from medication cart's active stock. These failures had the potential for residents to receive medications with reduced efficacy. During an inspection of Medication Cart AA on 2/9/26 at 10:23 a.m., with Registered Nurse I (RN I), RN I confirmed the following findings: a. A bottle of Brimonidine eyedrop had an open date of 1/7/26. Upon reviewing with RN I, he confirmed it expired on 2/6/26. b. A bottle of latanoprost eyedrop had an open date of 12/27/25. Upon reviewing…

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 offer the influenza (flu, respiratory infection) vaccine timely for one of five sampled residents (Resident 4). This failure had the potential to negatively affect the resident's health and well-being.Review of Resident 4's clinical record indicated she was admitted to the facility on [DATE] with diagnoses including diabetes (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing) and hypertension (high blood pressure). Review of Resident 4's Immunization Audit Report indicated there was no documentation that the resident received or was offered the flu vaccine in 2025. During an interview on 2/12/26 at 12:32 p.m., the infection preventionist (IP) confirmed Resident 4 was admitted to the facility in March 2025. The IP stated Resident 4 was offered and recieved the flu vaccine on 2/11/26. The IP stated she was not sure why yesterday was the only time Resident 4 was offered the flu vaccine. Review of the facility's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure fall management was implemented for one of three sampled residents (Resident 1) when: 1. Resident 1 was not monitored after 5 falls;2. No interdisciplinary team meeting was conducted after 3 falls;3. No care plan was developed after one fall; and4. Resident 1's Responsible Party was not notified after 2 falls. These failures had the potential for Resident 1 to develop ill effects from a fall, to result in future falls and injury, and for Resident 1's responsible party being uninformed and unaware of his condition.A review of Resident 1's clinical record indicated he was admitted on [DATE] and had diagnoses including unspecified fall, muscle weakness, abnormalities of gait and mobility, and cellulitis (bacterial infection of the skin) of the left lower limb. A review of Resident 1's admission Fall Risk Observation/Assessment, dated 3/12/25, indicated his fall risk score was 16 which indicated a high risk for falls. Review of Resident 1'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.

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 three sampled residents (Resident 1). This failure had the potential to compromise the facility's ability to develop care plans and implement interventions to meet the resident's needs. Findings: 1. Review of Resident 1's medical record indicated the resident was admitted on [DATE] and had diagnoses including hemiplegia/hemiparesis (one side of the body is paralyzed or weak), difficulty in walking, and muscle weakness. Review of Resident 1's Change in Condition Evaluation, dated 8/22/24, indicated Resident 1 had an unwitnessed fall. Resident 1's MDS, dated [DATE], was reviewed. Section J1800 of the MDS was designated to indicate if the resident had any falls during the specified time frame. The individual who completed the MDS coded 0, which indicated the resident did not have any falls during the specified time frame. During an interview and concurrent record review 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 interview and record review, the facility failed to follow their policy and procedure (P&P) for an advance directive (AD: a written instruction, such as a living will or durable power of attorney [a document that authorizes to act on behalf of resident] for healthcare when the individual is incapacitated) and completion of physician orders for life-sustaining treatment (POLST: a document that specifies the medical treatments the resident wants to receive during serious illness) form for 9 of 9 sampled residents (Residents 39, 37, 92, 43, 11, 85, 58, 91, and 78). These failures could lead to the delivery of unnecessary or inappropriate medical services against sampled resident's goals and wishes. Findings: Review of Resident 39's face sheet (FS: a document that gives a resident's information at a quick glance) indicated Resident 39 was admitted to facility on 7/3/2018. Review of Resident 39's POLST form dated 7/3/2018 indicated, section D for AD documented No Advance Directive. Further review of Resident 39's clinical record indicated there was no documented evidence 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 Based on observation, interview and record review, the facility failed to ensure the proper use of side rails for six (Residents 303, 304, 91, 44, 75, and 12) of 30 residents when: 1. For Residents 303 and 304, there were no signed informed consents for the use of side rails by the resident or the responsible party for either resident. 2. For Resident 91, the informed consent on file was missing a signature from the resident or responsible party. 3. For Residents 44, 75 and 12, there were no care plans for the use of side rails for any of the three residents These failures had the potential to compromise the resident's rights to fully make informed decisions on the use of side rails, and had the potential to put residents at risk for entrapment or serious injury. Findings: 1. During an observation on 9/16/24 at 10:11 AM, Resident 303 was observed lying in bed, with two siderails up in the upright position. Review of Resident 303's facesheet indicated she was admitted to the facility on [DATE] with a diagnosis 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.

Based on observation, interview, and record review, the facility failed to ensure safe use and disposition of medications, and accurate accountability of controlled drugs (those with high potential for abuse and addiction), when: 1. There were discrepancies between the controlled drug record (CDR, an inventory/accountability sheet) and the medication administration record (MAR) for 2 out of 4 residents (Residents 34 and 83). The failure had the potential for abuse or misuse of controlled drugs; 2. The pharmacy failed to label 3 insulin pens in accordance with the current standards of practice to prevent mix-ups or administration errors; and 3. There was no process in place for the disposition of hazardous drugs (HDs, medications capable of toxic effects on humans) in accordance with the current standards of practice (See United States Pharmacopeia 800 or USP 800, a scientific non-profit organization that sets standards for safe handling of HDs to minimize the risk of exposure to healthcare personnel, patients, and the environment). This deficiency had the potential for exposing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure the consultant pharmacist (CP) identified irregularities and make recommendations to the facility during the monthly medication regimen review (MRR) for 4 of 23 sampled residents (Residents 72, 40, 44 and 2). This failure had the potential for unsafe medication use and/or residents not achieving highest therapeutic outcomes. Findings: 1. A review of Resident 72's medical record indicated he was an elderly resident admitted to the facility with diagnoses including Parkinson's disease with dyskinesia (progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement), unspecified dementia (a condition characterized by memory loss) unspecified severity, without behavioral disturbance, mood disturbance, and anxiety, unspecified psychosis (condition that affect the mind, where there has been some loss of contact with reality), depression unspecified and anxiety disorder, unspecified. A review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure two of 23 sampled residents (Residents 72 and 91) were free from unnecessary psychotropic (drugs that affects brain activities associated with mental processes and behavior) medications when: 1. Resident 72 received pimavanserin (an antipsychotic medication to treat hallucinations and delusions associated with Parkinson's disease psychosis) without specific target behaviors, side effect monitoring, quarterly psychotropic review, care plan, and evidence of informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for over 8 months. Also, Resident 72 did not receive periodic monitoring of the blood lipids while being on Seroquel (antipsychotic medication) that would affect the blood lipids). 2. Resident 91 received Remeron (anti-depressant medication) without monitoring for potential side effects of the medication. The failures resulted in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility had a medication error rate of 11.11% when four (5) medication errors occurred out of 45 opportunities during the medication administration for four out of nine residents (Resident 3, 38, 45, and 78). The deficient practice resulted in medications not given in accordance with the prescriber's orders and/or manufacturer's specifications, which resulted in residents not receiving the full therapeutic effect of the medications and may cause preventable side effects for the residents. Findings: 1. During the medication pass observation on 9/16/24 at 9:15 a.m., registered nurse (RN) A was observed preparing and administering 6 medications to Resident 45. The medications included 1 tablet of calcium acetate (a phosphate binder, medication to control high blood levels of phosphorus, a mineral found in food, in people with kidney disease who are on dialysis) 667 milligrams (mg, unit of measurement) and 1 tablet of carvedilol (medication to control high…

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 proper medication storage as per facility's policy and procedures (P&P) and/or manufacturer's specifications, and expired medications were removed from active stock. Inspection of two of two medication refrigerators and three of four medication carts identified: 1. Four medications were not stored as in accordance with the manufacturer's guidance, and a discontinued medication for a resident was not discarded to prevent medication errors; 2. An insulin pen without visible resident's name on it. This had potential for it to be given to the wrong resident; and 3. One opened inhaler and four eye drop medications did not have an open date; and eight eye medications were used past their respective discard date. The failure had the potential for medication errors and/or medications being ineffective for the residents. Findings: 1. During a visit to the Medication room [ROOM NUMBER] with the Director of Nursing (DON) on 9/17/24 at 10:26…

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 sanitary practices in the kitchen and foods were stored under sanitary conditions when: 1. The kitchen floor and corner were seen with dark black areas; 2. Kitchen cleaning cloths were found in the sink and on a food storage container; 3. A container with sliced cheese had no opened date; 4. A food blender was seen with dry and dark brown particles. These failures had the potential to result in food borne illnesses among residents in the facility. Findings: 1. During a concurrent initial kitchen tour and interview with facility's registered dietitian (RD: a health care professional who had special training in nutrition and food) on 9/16/2024 at 9:26 a.m., dark black areas were noted on the kitchen floor near food preparation, cooking stove, front and under refrigerators 1,2, and 3, under stream table, 3-way sink (used to clean and sanitize [removing germs after cleaning] dishes), vegetable washing sink areas, on chemical stand (place to store sanitizing solution[used to sanitize dishes]) located next…

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 infection control practices were implemented when: 1. The blood pressure cuff was not disinfected between resident use; 2. The shared glucometer (blood glucose meter to measure and display the amount of sugar (glucose) in your blood) was not sanitized and disinfected between resident use; 3. Unlabeled urinals, wash basins, and resident's care items in residents bathrooms; and 4. Resident's care items on the floor. These failures could result in cross-contamination and the spread of infection throughout the facility. Findings: 1. During a medication pass observation on 9/16/24 at 9:15 a.m., Registered Nurse (RN) A was observed giving medications to Resident 45. RN A was called away immediately to assist staff with an incident with another resident, Resident 91. RN A used the blood pressure (BP) cuff to obtain reading for Resident 91. After finished, it was put back on the BP cart outside of Resident 45's room. On 9/16/24 at 9:29…

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 accurately code the minimum date set (MDS, an assessment tool) for 2 of 3 sample residents (Resident 39 and 78) when their MDS assessments did not reflect the current status of the residents. This failure had the potential to affect inappropriate care and interventions. Findings: During an initial tour observation on 9/17/2024 at 9:26 a.m., Resident 39 had tracheostomy with mask on. Further observation indicated mask tube attached to cool mist humidifier (a medical device to add moisture to the air). Review of Resident 39's face sheet (FS: a document that gives a resident's information at a quick glance) indicated Resident was admitted to facility on 7/3/2018, with diagnoses including tracheostomy (a tube placed in to the hole made by surgery the front of the neck and into the windpipe (the tube in the body that carries air that has been breathed in from the upper end of the throat to the lungs [a pair of organs in the chest that perform…

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 was completed and submitted for two of three sample residents (Resident 43 and 85). This failure had the potential for the mentally ill sample residents to not specialized health care and services. Findings: Review of Resident 43 face sheet (FS: a document that gives a resident's information at a quick glance) indicated Resident 43 admitted to facility on 8/14/2024. Resident FS also indicated Resident 43 admitted with diagnoses included psychosis (a serious mental disorder characterized by a disconnect from reality), anxiety (excessive and persistent worry and fear of everyday situations), obsessive-compulsive disorder (uncontrollable, recurring thoughts and engages in repetitive behaviors), and adult personality disorder (a disorder of thinking, feeling, behaving, and relating to others in a way that is different to the average person). Review of Resident 43'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 maintain a safe and secure environment for three sampled residents (48, 74, and 91) when: 1. Resident 48 and 74 Wander Guard (a device that activates an alarm when a resident attempts to leave a safe area) devices were not checked for proper functioning; 2. The interdisciplinary team (IDT: a group of healthcare professionals with various areas of expertise who work together toward the goals of resident's care) 's reommendation and care plan intervetnion was not followed for Resident 91 after a fall; 3. Cleaning supplies were left in a shared bathroom used by multiple residents. These failures had the potential for elopement (leave a facility without staff knowledge) and compromise the residents safety of the residents. Findings: During an observation on 9/19/24 at 4:20 p.m., Resident 48 was dressed in street clothes and laying on top of her bed sleeping. There was a Wander Guard on her right ankle. Review of Resident 48's physician order…

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 care according to facility policy and procedures for one of 23 sampled residents (Resident 20) when a registered nurse (RN A) did not check gastrostomy tube (G-tube, a tube that goes directly into the stomach [part of digestive system] and used for giving tube feeding formula and medications) placement (by injecting air and listening to the stomach with a stethoscope) before tube feeding administration. This failure had the potential for enteral feeding complications that could cause harm to this resident. Findings: During a concurrent observation and interview on 9/18/24 at 12:20 p.m., RN A stated she gave a water flush in Resident 20's G-tube without checking the placement in the stomach and the tube feeding was running continuously for some time that why she did not check the placement. During an interview with the director of nursing (DON) on 9/18/24 at 3:50 p.m., the DON stated I expect the nursing staff to check placement by injecting an air bolus, listening to gurgling sounds in the stomach, and…

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

Based on observation, interview, and record review, the facility failed to provide respiratory care in accordance with professional standards of practice for five sampled residents (5, 11, 32, 58, and 92) when: 1. For Resident 5 and 32, the facility administered oxygen with no physician order; 2. For Residents 58 and 92, the oxygen tubing was undated and uncovered when not in use. 3. For Resident 11, the facility administered oxygen without physician order and the oxygen tubing was undated. These failures had the potential to affect the residents' care and could jeopardize their health and well-being. Findings: 1. Review of Resident 5's clinical record indicated she had diagnoses including chronic obstructive pulmonary disease (a lung disease that makes it difficult to breathe) and respiratory disorders. During an observation on 9/16/24 at 10:33 a.m., Resident 5 was lying in bed receiving oxygen through a nasal cannula (NC, plastic tubing inserted into the nostrils and attached to an oxygen source). The oxygen concentrator (device used to deliver oxygen) was set at four liters per…

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 accommodate food preferences for two of four sample residents (Resident 46 and 16). This failure had the potential for decreased meal intake, negative effect on health and well-being for the residents. Findings: Review of Resident 46's lunch tray card for 9/16/2024 indicated, Notes and Alert: Ground Meat. Review of facility's lunch menu cycle 4 2023 indicated for Monday, Polish Sausage During lunch meal observation on 9/16/2024 at 12;45 p.m., noted Resident 46 served lunch plate with bite size cut meat pieces along with other menu food items. During an interview with certified nursing assistant B (CNA B) on 9/16/2024 at 12:50 p.m., CNA B confirmed Resident 46 received bite size cut polish sausage for lunch meal. CNA B also reviewed and confirmed Resident 46's lunch tray card indicated ground meat under notes and alerts. CNA B stated kitchen staff should have served ground meat to Resident 46 instead of bite size cut sausage pieces. CNA B took Resident 46's lunch plate to kitchen, came back with another lunch…

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 a Minimum Data Set (MDS, an assessment tool) for one of three sampled residents (Resident 1), when Resident 1's MDS weight and continence were inaccurately documented. Failure to accurately assess had the potential to compromise the facility's ability to develop and implement interventions to meet the resident's needs. Findings: 1. Review of Resident 1's medical record indicated the resident was admitted on [DATE] and had diagnoses including femur fracture (a break in the thigh bone), sepsis (an extreme bodily response to an infection), obesity (a disorder that involves having excessive body fat), and kidney disease. Review of Resident 1's Weights and Vitals Summary indicated Resident 1 weighed 231.4 pounds (lbs, unit of weight measurement) on 7/17/24. The Weights and Vitals Summary further indicated Resident 1 weighed 220.8 lbs on 7/22/24. Resident 1's MDS, dated [DATE], was reviewed. Section K0200 was designated to document 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 develop a care plan to address non-compliance (not cooperating with care) for one of three sampled residents (Resident 1). This failure had the potential to compromise the facility's ability to implement interventions. Findings: Review of Resident 1's medical record indicated Resident 1 was admitted on [DATE] and had diagnoses including chronic obstructive pulmonary disease (COPD, a disease that causes breathing difficulty due to blocked airflow from the lungs) and respiratory failure (a condition in which the blood does not have enough oxygen or has too much carbon dioxide). During an interview with respiratory therapist B (RT B) on 8/12/24, at 10:49 a.m., RT B stated Resident 1 had a laryngectomy (surgical removal of the voice box) and would breath through the laryngectomy stoma (surgically created opening in the neck created during laryngectormy). RT B stated Resident 1 also had a laryngectomy tube (also known as a larytube, a small flexible tube…

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 pain medication order was signed by the physician for one of three sampled residents (Resident 2). This failure had the potential to compromise the facility's ability to administer the pain medication to Resident 2 when needed. Findings: Review of Resident 2's medical record indicated Resident 2 was admitted on [DATE] and had diagnoses including polyneuropathy (a condition of the nerves that often causes weakness, numbness, and pain). During an interview with Resident 2 on 8/12/24, at 2:40 p.m., Resident 2 stated that over the past weekend, she was told she could not receive her oxycodone (medication used to treat pain) because the physician had not signed the order for the medication. Resident 2 explained the oxycodone was ordered as needed (PRN, only to be administered when requested by the resident) and she would normally be able to receive it every six hours. Review of Resident 2's physician's orders indicated there was an order, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Ombudsman (resident advocate) office was notified of hospital transfers for two of three sampled residents (Residents 2 and 3). This failure had the potential to result in the residents not having someone to advocate for their admission, transfer, and discharge rights. Findings: 1. Review of Resident 2's clinical record indicated he was admitted on [DATE] and had a fracture (break) of the left foot and a laceration (cut) on the left hand. Review of Resident 2's Progress Notes, dated 11/9/23, indicated the physician examined Resident 2's left hand wound and told the facility to transfer the resident to the hospital. Review of Resident 2's Hospital Transfer Form, dated 11/9/23, indicated he was transferred to the hospital at 6:58 p.m. There was no documentation in the clinical record that indicated the facility notified the Ombudsman office of Resident 2's hospital transfer. During an interview and concurrent record review with social services…

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

Based on interview and record review, the facility failed to provide skin treatments as ordered by the physician for one of three sampled residents (Resident 1). This failure put the resident as risk for developing further skin breakdown. Findings: Resident 1's physician's order, dated 4/9/24, indicated, MASD (Moisture Associated Skin Damage) to perineum (genital area or the triangle area between the thighs). Apply Calmoseptine (ointment used to provide moisture barrier that protects and helps skin heal) to affected area every shift for 21 days. Resident 1's 4/2024 treatment administration record (TAR) was reviewed. The TAR indicated that Resident 1's skin treatments with Calmoseptine were not documented as completed on 4/10/24 during the evening shift, on 4/11/24 during the day shift, on 4/13/24 during both the day and the evening shift, on 4/14/24 during the day shift, on 4/15/24 during the evening shift, on 4/17/24 during the day shift, on 4/19/24 during the evening shift, and on 4/21/24 during the day shift. Resident 1's physician's order, dated 4/17/24, indicated, MASD 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 interview and record review, the facility failed to ensure care and treatment was provided in accordance with professional standards of practice for 6 of 8 sampled residents (Resident 1, 2, 3, 4, 5, and 6) when physician orders for monitoring of indwelling urinary catheters (tube placed inside the urinary bladder to drain urine) were not followed. These failures resulted in physician orders to monitor for changes to the urine character to not be carried out as ordered. Findings: Review of Resident 1's physician order dated 7/26/21 indicated, Indwelling catheter: Monitor for change in urine character: Document 0 = none/ C = Cloudiness/ S = Sediment/ FS = Foul Smell/ B = Blood in urine/ DC = Deepening or Concentrating urine output. Notify MD for potential UTI (Urinary Tract Infection) every shift. Review of Resident 1's physician order dated 7/26/21 indicated Indwelling Catheter: Monitor for S/S (signs and symptoms) of possible urinary infection and notify MD. Document 0 = none/ FP = Flank Pain or SP = suprapubic pain or T = Tenderness/ CU = Change in character of urine (New…

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 licensed nurses had specific competencies (the ability to do something successfully or efficiently) and skills sets necessary to care for residents' needs when: 1. Performance evaluations (a formal and productive procedure to measure an employee's work and results based on their job responsibilities) were not completed for licensed vocational nurses (LVN F (hire date 1/2/2012), LVN H (hire date 2/1/22), LVN J (hire date 1/17/22). 2. Skill check list (practical lists that detail for employees the skills they are required to perform and the level of performance that is expected for each skill) were not completed for five of six licensed nurses (LVN E, LVN F, LVN H, LVN J, and LVN L). 3. Registry staff orientation (the process of introducing temporary employees to their responsibilities, co-workers and workplace, company expectations and policies) was not complete for three of three Registry Licensed vocational Nurses (LVN E, LVN J, LVN L). These failures had the potential for residents not to receive appropriate…

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, interviews, and record review, the facility failed to provide pharmaceutical services to meet the needs of four of 19 sampled residents (Residents 7, 22, 39, and 45) and one non-sampled Resident (Resident 194) in regards to controlled medications (medications with high potential for abuse and addiction) in that they were not fully reconciled after removal and accounted for during shift change when: 1. Resident 194 did not receive his Norco (a potent controlled medication for pain) timely, resulting in unnecessary and preventable pain for the resident; 2. Resident 45 did not receive his routine pain medication, buprenorphine (a potent narcotic for pain) for four and a half days, subjecting the resident to unnecessary pain; 3. Resident 22's Daptomycin (an antibiotic to treat various infections) was delayed for two days after it was ordered. This had the potential for worsening of the resident's infection; 4. Resident 39 did not receive his routine medications timely, subjecting the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure proper labeling and storage of medications according to the facility policy and procedures (P&P) and/or manufacturer's specifications when: - Temperature (temp) monitoring was missing and/or not consistently documented twice daily on the temp log sheets for 3 months for one of one observed medication refrigerator; and - Medications were not properly labeled and stored in two of four inspected medication carts. These deficient practices had the potential for inadequately monitored medications, which could lead to unsafe and ineffective medications for the residents, unsafe and reduced efficacy from being used past their discard date, and medication errors due to medications not being labeled. Findings: 1. During a visit to the main medication room with Licensed Vocational Nurse (LVN) D on [DATE] at 11:05 a.m., a large medication refrigerator (fridge) was identified. The thermometer reading inside the fridge indicated 34 degrees…

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 dignity of one of 87 residents (Resident 33) when a staff member was standing over the resident while helping him to eat, instead of sitting down. This failure had the potential to have a negative effect on the resident's psychosocial well-being. Findings: During a dining room observation on 8/8/23 at 1:00 p.m., Certified Nursing Assistant N (CNA N) was observed standing in front of Resident 33 while feeding him. During an interview on 8/8/23 at 1:10 p.m. with CNA N, she confirmed above observation, she stated she was not sure if she should sit down. During a review of Resident 33's Activity of Daily Living (ADL) care plan, it indicated the resident was total dependent for eating. During an interview on 8/11/23 at 10:37 a.m. with Director of Nursing (DON), he stated staffs should be sitting down at an eye level while feeding the residents. During a review of the facility's policy and procedure (P&P) titled, Assistance with Meals, revised March 2022, the P&P indicated, Dining Room Residents: [ .] 3.…

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 notify the Office of the State Long-Term Care Ombudsman (organization that advocates for the residents) when two of 19 sampled residents (Residents 9 and 55) were transferred to the acute care hospital from the facility without notifying the Ombudsman. This failure had the potential to compromise the residents' admission, transfer, and discharge rights. Findings: Review of Resident 9's clinical record indicated he was admitted to the facility on [DATE]. Resident 9 was transferred to the acute hospital from the dialysis center on [DATE]. Resident 9 became unresponsive during dialysis treatment, was given CPR, and then transferred to the acute hospital. Resident 9 was admitted to the acute care hospital and returned to the facility on [DATE]. Review of Resident 55's clinical record indicated he was admitted to the facility on [DATE]. Resident 55 was transferred to the acute care hospital on [DATE] due to severe groin pain. Resident 55 was admitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide care and services in accordance with professional standards and facility policy and procedures for three of 19 sampled residents (Residents 6, 44, and 82), when: 1. The nursing staff failed notify the physician when Resident 82 repeatedly refused his blood sugar checks and insulin (medication to lower blood sugar); 2. For Resident 44, Licensed Vocational Nurse (LVN) H failed to document his routine medication administration on the medication administration record (MAR) for 4 days in July and one day in August 2023 during her shift; and 3. For Resident 6, the facility staff did not carry out the physician's order timely. These failures had the potential to cause complications for the residents' medical conditions. Findings: 1. Resident 82 was admitted to the facility with diagnoses including Alzheimer's dementia (progressive disease that destroys memory and other important mental functions) and diabetes (disease that impairs 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 recorder review, the facility failed to ensure one of four hospice residents (Resident 17), received needed care and services when hospice orders were not transcribed into resident's chart timely. This failures had the potential to compromise the resident's comfort and well-being. Findings: During an interview on 8/8/23 at 10:35 p.m. with Resident 17, he stated he had pain with pain level 13 out of 10 last night, and he requested pain medication, but the staff told him there was nothing to give him for pain. During a review of Resident 17's hospice admission assessment dated [DATE], it indicated, Resident 17 was admitted to hospice care (a type of care prioritized comfort and quality of life by reducing pain and suffering for terminally ill residents) on 8/6/23 with order: Morphine concentrate (a medication commonly utilized for imminently dying residents to control pain and relieve breathing problems) 100mg/5mL (20mg/mL) oral solution, take 5mg, 10mg, 20mg by mouth or under the tongue…

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 a safe environment was maintained when a bottle of disinfectant was found at the bedside of Resident 42. This had the potential for residents to access a hazardous substance. Findings: During an observation of Resident 42 's room on 8/7/23 at 11:10 a.m., Resident 42's bedside tabletop had a 1-gallon container of antiseptic solution (liquid substance that stops or slows down the growth of microorganisms) without the lid and reddish liquid residuals on the sides of the bottle. The label on the bottle of antiseptic solution indicated Warnings - For external use only and Drug Facts - Keep out of eyes, ears, and mouth . If swallowed, get medical help or contact a Poison Control Center right away. Next to the bottle of antiseptic solution was a plastic cup with this same reddish liquid along with some gauze inside of it, an open bottle of tabasco with no lid, and a plastic container of cashews. During a concurrent observation and interview with licensed vocational nurse B (LVN B) on 8/7/23 at 11:17 a.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.

Based on observation, interview, and record review, the facility failed to provide care according to facility policy and procedures for two of 19 sampled residents (Residents 6 and 55) and two non-sampled Residents (Residents 19 and 51) when: 1. Licensed Vocational Nurse (LVN) A did not check the tube placement before medication adminisration for Resident 19, 2. Tube feeding formula for Residents 6 was unlabeled, 3. An unlabeled and opened bag of tube feeding formula was left at Resident 55's bedside. These failures had the potential for enteral feeding complications that could cause harm to residents. Findings: 1. During a medication administration observation on 8/7/23 at 8:30 a.m., Licensed Vocational Nurse (LVN) A was observed preparing 10 medications for Resident 19. She crushed each solid medication individually and diluted each with about 30 mL of water. After she finished, she brought the medications, along with an 8-ounce cup of water, to the resident's bedside. On 8/7/23 at 8:35 a.m., LVN A was observed attaching a syringe to Resident 19's gastrotomy tube (GT or G-tube - 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide necessary care and services for one of 19 sampled residents (Resident 9) receiving renal dialysis (medical procedure for removing waste products and excess fluid from the blood through an artificial kidney) when: 1. There was no documentation of assesments and/or monitoring of the arteriovenous fistula shunt (AVF shunt, a connection surgically made between an artery and a vein for dialysis access), 2. Dialysis communication records (DCRs) were incomplete, 3. A dialysis care plan was not resident-centered, and 4. Licensed nurses were not trained on monitoring Resident 9's AVF shunt. These deficient practices had the potential for Resident 9 to be inadequately assessed and be at risk for developing undetected complications related to dialysis treatment. Findings: Review of Resident 9's medical record indicated he was admitted on [DATE] and had the diagnosis of end stage renal disease (ESRD, the kidneys no longer function as they…

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 Consultant Pharmacist (CP) failed to identify and report to the facility medication-related irregularities during the monthly medication regimen review (MRR) for two of 19 sampled residents (Residents 7 and 82). The failure resulted in inadequate medication monitoring for the residents which had the potential to compromise their health. Findings: 1. A review of Resident 7's clinical record indicated he was admitted to the facility with diagnoses including hypertensive heart disease (long-term condition that develops over many years in people who have high blood pressure) and hyperlipidemia (high lipids in the blood). A review of Resident 7's physician orders indicated an order for atorvastatin 20 milligrams (mg, unit of measurement) one time a day for hyperlipidemia since 1/20/23. A review of Lexicomp, a nationally recognized drug information, indicated, for patients receiving atorvastatin, Fasting lipid profile should be rechecked 4 to 12 weeks after starting therapy…

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 two of 19 sampled residents (Resident 7 and 193) were free from unnecessary medications when Resident 7 received atorvastatin (Lipitor: medication to treat high cholesterol and triglyceride levels in the blood) without lab work for lipid panel; and Resident 193 received an anticoagulant (a blood thinner to prevent blood clots) without the staff monitoring for signs and symptoms of bleeding. The failure resulted inadequate monitoring for effectiveness and side effects of medications for the residents. Findings: 1. A review of Resident 7's clinical record indicated he was admitted to the facility with diagnoses including hypertensive heart disease (long-term condition that develops over many years in people who have high blood pressure) and hyperlipidemia (high lipids in the blood). A review of Resident 7's physician orders indicated an order for atorvastatin 20 milligrams (mg, unit of measurement) one time a day for hyperlipidemia, dated 1/20/23. A review of Lexicomp, a nationally recognized drug information…

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 three of 19 sampled residents (Residents 30, 45, and 82) were free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behaviors), when: 1. Resident 82 received medications, Seroquel (quetiapine, an antipsychotic medication) and simvastatin (medication to treat high blood lipids), that could affect blood lipids without the monitoring for lipids; 2. Residents 45 and 82 received long-term use of Seroquel without periodic Abnormal Involuntary Movement Scale (AIMS, a rating scale designed to measure involuntary movements known as tardive dyskinesia [TD], a disorder that sometimes develops as a side effect of long-term treatment with antipsychotic medications) assessment; and 3. Resident 30's physician order for as-needed Ativan (lorazepam, medication to treat agitation or anxiety) did not have a specified duration. The deficient practices resulted in inadequately monitored drug therapy…

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 5.41% when two medication errors occurred out of 37 opportunities during the medication administration observation for two out of seven residents (Residents 19 and 43). The nursing staff did not flush the resident's gastrostomy tube (G-tube; a tube surgically inserted through the abdomen into the stomach to administer nutrition and medications) prior to and after medication administration in accordance with accepted professional standards of practice. Resident 43 received his insulin (medication to lower blood sugar) 1 hour and 10 minutes before a meal, a practice inconsistent with the manufacturer's specifications. The failure had the potential for complications or adverse effects (such as clogging of G-tube or uncontrolled blood sugar) for the residents. Findings: 1. A review of the American Society for Parenteral and Enteral Nutrition (ASPEN) Consensus Recommendation titled Safe Practices for Enteral Nutrition Therapy, dated 1/2017, indicated that when administering medication via…

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 infection prevention practices were followed when two facility staff did not wear the appropriate personal protective equipment (PPE; gloves, gown, mask, and face shield) while providing care to Resident 4, who was on Contact Precaution (intended to prevent transmission of infectious agents spread by direct or indirect contact with the patient or the patient's environment). This failure had the potential to compromise the health and well-being of residents and staff members in the facility. Findings: During a concurrent observation and interview on 8/7/2023, at 3:45 p.m. with Certified Nursing Assistant P (CNA P) in front of Resident 4's room, it was observed that a sign was posted on Resident 4's doorway indicating the necessity of Contact Precautions. Providers and staff were required to put on gloves and gowns before entering the room. CNA P was observed applying gloves outside Resident 4's doorway and stated they were going to help Resident 4 with his shower. CNA P did not put on an isolation gown…

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.