Del Rosa Villa

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to protect against verbal abuse for one of three sampled residents (Resident 1) when a Certified Nursing Assistant 1 (CNA 1) called Resident 1 a Bch! when Resident 1 was voicing criticism of CNA 1's perineal care (the cleaning and maintenance of the perineum, the area between the anus and the genitals) indicating rough handling with pain.This failure caused Resident 1 to suffer pain, fear, and anxiety.Findings:An unannounced visit was made to the facility on August 13, 2025, at 11:18 AM, to investigate a facility reported incident regarding an allegation of verbal abuse.A review of Resident 1's face sheet (a document that gives a summary of resident's information), undated, indicated an admission date of July 6, 2025. Resident 1 had diagnoses that included stroke and left sided paralysis (complete or partial loss of muscle function). Resident 1 was discharged home on August 6, 2025.A review of Resident 1's victim statement dated August 2, 2025,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two residents (Residents 1 and 2) were treated with dignity and respect when a Certified Nursing Assistant (CNA 1) used profanity in the immediate presence of the residents, while in the resident's room. This failure resulted in both Residents 1 and 2 to feel disrespected as both residents believed the staff member was directing the profanity toward them in a demeaning manner. Findings: During a review of Resident 1's admission Record (contains medical and demographic information), the admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included major depressive disorder (condition characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities), bipolar disorder (mental health condition characterized by extreme shifts in mood, energy, and behavior), chronic pain, and alcoholic polyneuropathy (a neurological disorder that occurs when 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 follow its Change of Condition (COC) and Documentation Policies for 1 of 3 sampled residents (Resident 1) when: 1. Resident 1 had a (COC), and responsible party was not notified, left as unreachable. 2. No documentation of when responsible party was notified of COC. This failure placed a clinically compromised Resident (Resident 1) health and safety at risk by causing a delay in notification and family involvement. Findings: During review of Residents 1 ' s admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses to include: rhabdomyolysis (breakdown of muscle tissue damaging protein released into the blood), Cirrhosis (liver disease causing liver failure) , hepatic encephalopathy (liver, buildup of toxins in blood), type 2 diabetes mellitus ( body does not make enough insulin or does not use insulin well), Hepatitis C (infection caused by virus affecting the liver). During a…

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

Based on observation, interview, and record review, the facility failed to follow the menu when: 1. six (6) of six (6) Residents on pureed diet (a diet of smooth, blended foods that require no chewing) was served 2/3 cup of pureed Jambalaya instead of one cup that the menu called for during lunch on January 21, 2025. 2. 33 of 33 Residents on regular carbohydrate controlled (CCHO-consistent, constant, or controlled carbohydrate [sugars, starches and fiber]) diet, were served one whole slice of garlic bread instead of half a slice the menu called for during lunch on January 21, 2025. This failure had the potential to compromise residents' nutritional status when menus were not followed for 39 of 39 Residents on a Pureed and CCHO diet. Findings: 1. During tray line (when cook serves food on plates for each resident according to the menu) observation on January 21, 2025, at 11:50 AM in the kitchen, the Dietary [NAME] served a pureed Chicken Jambalaya using a 2/3 cup scoop to Resident 4 receiving a pureed diet, instead of one cup as indicated on the facility approved menu. During 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 interview, and record review, the facility failed to ensure a copy of the notice of transfer or discharge were sent to the Ombudsman for one (1) of three (3) sampled residents (Resident 63) reviewed for hospitalizations when: 1. Resident 63 was sent to the hospital on February 16, 2024, and there was no copy of notice of transfer or discharge sent to the Ombudsman. 2. Resident 63 was sent to the hospital on July 6, 2024, and there was no copy of notice of transfer or discharge sent to the Ombudsman. This failure had the potential for Resident 63 to be inappropriately transferred or discharged . Findings: 1. A review of Resident 63's clinical record, the admission Record (a document that gives a summary of resident's information), indicated Resident 63 was admitted to the facility on [DATE], with diagnoses of Hemiplegia and Hemiparesis (weakness or unable to move one side of the body) following cerebral infarction affecting left non-dominant side (parts of the brain dies when the blood flow is reduced)…

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 medications were administered according to the facility's policy and procedure (P&P) for one (1) of 92 residents (Resident 75) when five tablets were found in a medication cup, on the bedside table, unattended by staff. This failure had the potential to cause ineffective drug therapy, significant side effects, and adversely affect the health and safety of Resident 75. Findings: During a review of Resident 75's clinical records, the admission Record (contains demographic and medical information) indicated, Resident 75 was admitted to the facility on [DATE], with diagnoses of traumatic subarachnoid hemorrhage without loss of consciousness (bleeding in the brain without passing out), and displaced fracture of body of right talus subsequent encounter for fracture (a break of the bone that connects the ankle to the foot, and the neck area). During a concurrent observation and interview on January 21, 2025, at 12:42 PM, with Resident 75,…

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

Based on observation, interview, and record review, the facility failed to store residents' food according to professional standards for food service safety when a dark brownish-reddish frozen spill was found on the bottom part of the freezer of the residents' refrigerator on January 21, 2025. This failure had the potential for bacteria to growth and to cause foodborne illness in residents who store food in the the residents' refrigerator. Findings: During an observation of the residents' refrigerator on January 21, 2025, at 10:55 AM, a dark brownish-reddish frozen spill was on the bottom part of the freezer. During an interview with the Registered Nurse 1 (RN 1) on January 21, 2025, at 10:57 AM, RN 1 stated that usually the Licensed Vocational Nurse on duty or the housekeeping is responsible for cleaning the residents' refrigerator and does not know why the freezer is dirty. During an interview with the Dietary Supervisor (DS), on January 23, 2025, at 10:49 AM, the DS stated his expectation is that the residents' refrigerator is clean with no frozen spills. The DS stated he wasn't…

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 Enhanced Barrier Precautions (EBP-are a set of infection control practices that use gowns and gloves to reduce the spread of multidrug-resistant organisms [MDROs- germs that resist treatment with more than one antibiotic]) were maintained for one (1) of five (5) sampled residents (Resident 97) when one Certified Nurse Assistant (CNA 1) did not wear a gown when providing incontinence care. This failure had the potential to result in an increased risk of cross-contamination (the transfer of harmful bacteria) to 92 highly vulnerable residents whose health conditions are already compromised. Finding: During an observation on January 22, 2025, at 9:50 AM, in Residents 97's room, there was a sign outside the room indicating Resident 97 was on EBP precautions. Resident 97 was lying in bed while CNA 1 was changing the incontinence brief without wearing a gown. During an interview on January 22, 2025, at 9:55 AM, with CNA 1, CNA 1 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.

Based on interview and record review, the facility failed to protect against verbal abuse for one of three sampled residents (Resident 1) when a Physical Therapy Assistant (PTA 1) yelled Get the fk up! at Resident 1 when Resident 1 was uncooperative during a transfer. This failure caused Resident 1 to suffer fear, confusion and anxiety. Findings: An unannounced visit was made to the facility on September 24, 2024, at 9:54 AM, to investigate a facility reported incident regarding an allegation of verbal abuse. A review of Resident 1 ' s face sheet (a document that gives a summary of resident ' s information), undated, indicated an admission date of September 20, 2024. Resident 1 had diagnoses that included stroke and left sided paralysis (complete or partial loss of muscle function). During an interview with a Certified Nursing Assistant (CNA 1) on September 24, 2024, at 12:02 PM, CNA 1 stated she was walking down the hall and saw Resident 1 on the floor next to her bed. CNA 1 stated she entered the room to assist Resident 1 to her bed and a Physical Therapy Assistant (PTA 1)…

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 the facility ' s policy regarding falls was implemented, when one of the four sampled residents (Resident 1) experienced a change of cognition or level of consciousness was not promptly reported to the physician following an unwitnessed fall. This failure potentially led to a deterioration in Resident ' s 1 condition necessitating his transfer to a general acute hospital for evaluation and treatment. Findings: During a review of Resident 1's clinical record, the face sheet (contains demographic and medical information), indicated Resident 1 was admitted on [DATE], with a diagnosis that included unsteadiness on feet, and unspecified dementia (a condition characterized by memory loss and judgement). During an interview on 9/4/2024, at 4:10 p.m., with Licensed Vocational Nurse (LVN 1), LVN 1 stated, Resident 1 fell in his room. Additionally, neurological checks (an assessment of resident ' s nervous system that assesses the residents mental…

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 observations, record reviews, interviews, and facility policy review, the facility failed to ensure the facility medication error rate was e less than 5%. There were two medication errors out of 34 opportunities, which yielded a medication error rate of 5.88%, for 2 (Resident #10 and Resident #60) of 5 residents observed for medication administration. Findings included: A review of the facility policy titled Administering Medications, revised in April 2019, revealed, 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. A review of Resident #10's admission Record, revealed the facility admitted the resident on 04/09/2023. A review of Resident #10's physician order, dated 04/09/2023, revealed an order for multi-vitamin/minerals tablet, give one table by mouth one time a day for dietary supplement. A review of Resident #10's physician order, dated 04/09/2023, revealed an order for vitamin D3 oral capsule,…

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 record review, interviews, and facility policy review, the facility failed to have evidence to indicate 1 (Resident #79) of 20 sampled residents were invited to their care plan meeting. Findings included: Review of a facility policy titled, Resident Participation - Assessment and Care Plans, revised in February 2021, indicated, The resident and his or her representative are encouraged to participate in the resident's assessment and in the development and implementation of the resident's care plan. A review of Resident #79's admission Record, revealed the facility admitted Resident #79 on 11/06/2023, with diagnoses that included heart failure, ulcerative colitis, and chronic kidney disease. Per the admission Record, the resident was their own responsible party. A review of Resident #79's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/13/2023, revealed Resident #79 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. A review of Resident #79's care plan revealed no evidence to…

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

Based on observation, record review, interviews, and facility policy review, the facility failed to ensure privacy was provided during personal care for 1 (Resident #57) of 1 sampled resident reviewed for privacy. Findings included: A review of the facility policy titled, Dignity, last revised in February 2021, revealed, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem, The policy revealed, 11. Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. A review of an admission Record indicated the facility admitted Resident #57 on 05/24/2023, with diagnoses that included paraplegia and stage 4 pressure ulcer of the sacral region. A review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/01/2023, revealed Resident #57 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact.…

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 interviews, record review, and facility policy review, the facility failed to implement abuse policy when they failed to investigate a potential allegation of misappropriation of resident property reported by 1 (Resident #15) of 20 sampled residents. Findings included: A review of a facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program revised in April 2021, revealed, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. The policy reviewed, 8. Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. A review of Resident #15's admission Record indicated the facility admitted Resident #15 on 07/25/2023. A review of Resident #15's Inventory of Personal effects, dated 07/25/2023, revealed Resident #15 had seven cards, including an identification card, bank card, and hospital card. A review of Resident #15's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/03/2023, revealed 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.

Based on interviews, record reviews, and facility policy review, the facility failed to report an allegation to the state agency within the required time frame that involved 2 (Resident #38 and Resident #42) of 20 sampled residents. Findings included: Review of a facility policy titled, Abuse Neglect, Exploitation or Misappropriation - Reporting and Investigating, with a revised date of April 2021, revealed, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. The policy specified, 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility. Per the policy, 3. Immediately is defined as: a. within two hours of an allegation involving…

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 record review, interviews, and facility policy review, the facility failed to ensure an admission Minimum Data Set (MDS) assessment was completed in a timely manner for 1 (Resident #187) of 20 sampled residents. Findings included: A review of the facility policy titled, MDS Completion and Submission Timeframes, revised in July 2017, revealed, Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes. A review of an admission Record indicated the facility admitted Resident #187 on 11/06/2023. A review of Resident #187's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/17/2023, revealed the MDS was not signed as being completed by the MDS Coordinator. During an interview on 12/13/2023 at 10:08 AM, the MDS Coordinator stated an admission MDS should be completed within 14 days of admission. The MDS Coordinator acknowledged she was late with the completion of Resident #187's admission MDS. Per the MDS Coordinator, the resident's admission MDS should have signed as being complete 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 interviews, record review, document review, and facility policy review, the facility failed to ensure a quarterly Minimum Data Set (MDS) assessment was completed timely for 1 (Resident #2) of 1 sampled resident reviewed for resident assessment. Findings included: Review of the facility policy titled, MDS Completion and Submission Timeframes, revised in July 2017, revealed, Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes. The policy specified, 2. Timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument Manual. Review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2023, revealed, For all non-admission OBRA [Omnibus Budget Reconciliation Act] and PPS [Prospective Payment System] assessments, the MDS Completion Date must be no later than 14 days after the Assessment Reference Date (ARD). A review of Resident #2's admission Record…

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

Based on interviews, record reviews, and facility policy review, the facility failed to ensure Minimum Data Set (MDS) assessments were accurate for 1 (Resident #83) of 20 sampled residents. Findings included: Review of the facility policy titled, MDS Completion and Submission Timeframes, revised in July 2017, revealed, Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes. A review of Resident #83's admission Record revealed the facility admitted the resident on 09/19/2023. Per the admission Record, the resident discharged from the facility on 10/09/2023 against medical advice (AMA). A review of the discharge Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/09/2023, revealed the resident discharged to a short-term general hospital. A review of the Release from Responsibility for discharge form dated 10/09/2023, revealed Resident #83 discharged from the facility AMA of the attending doctor. In an interview on 12/13/2023 at 10:09 AM, the MDS Coordinator stated Resident #83 did not discharge 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 interviews, record review, and facility policy review, the facility failed to have a level II preadmission screening and resident review (PASARR) completed after the addition of a new mental health diagnosis for 1 (Resident #42) of 20 sampled residents. Findings included: Review of a facility policy titled, admission Criteria PASARR, revised in March 2019, revealed, (1) The admitting nurse notifies the social services department when a resident is identified as having a possible (or evident) MD [mental disorder], ID [intellectual disorder] or RD [related disorder]. (2) The social worker is responsible for making referrals to the appropriate state-designated authority. A review of Resident #42's admission Record revealed the facility admitted the resident on 09/27/2023. Per the admission Record, on 10/10/2023, the resident received a diagnosis of dysthymic disorder (a persistent depressive disorder). A review of Resident #42's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/10/2023, revealed Resident #42 had a Brief Interview for Mental Status…

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 observations, record review, interviews, and facility policy review, the facility failed to ensure the risk, benefits, and informed consent for the use of bed rails was completed for 1 (Resident #191) of 3 sampled residents reviewed for accident hazards. Findings included: A review of the facility policy titled, Bed Safety and Bed Rails, revised in August 2022, revealed, The use of bed rails is prohibited unless the criteria for use of bed rails have been met. The policy revealed, 3. The use of bed rails is prohibited unless the criteria for use of bed rails have been met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent. Per the policy, 8. Before using bed rails for any reason, the staff shall inform the resident or representative about the benefits and potential hazards associated with bed rails and obtain informed consent. A review of Resident #191's admission Record revealed the facility admitted the resident on 11/14/2023 with diagnoses that included diabetes mellites with foot ulcer and a history 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 interviews, record review, and facility policy review, the facility failed to ensure the ordered four times a day fingerstick blood sugar checks were necessary for 1 (Resident #48) of 6 sampled residents reviewed for unnecessary medications, psychotropic medications, and medication regimen review. Findings included: Review of a facility policy titled, Diabetes - Clinical Protocol, revised in November 2020, revealed, (3) For the resident receiving insulin who is well controlled: monitor blood glucose levels twice a day if on insulin. A review of Resident #48's admission Record indicated the facility admitted the resident on 02/22/2023, with diagnoses that included type 2 diabetes mellitus without complications. A review of Resident #48's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/24/2023, revealed Resident #48 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. The MDS indicated Resident #48 received insulin injections one out of seven days during the assessment period. A review…

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, interviews, document review, facility policy review, the facility failed to ensure staff properly cleaned and disinfected a glucometer used to obtain a blood glucose level for 1 (Resident #289) of 4 residents observed for fingerstick blood sugar checks. Findings included: A review of the facility policy titled, Obtaining a Fingerstick Glucose Level, revised in October 2011, revealed, 3. Always ensure that blood glucose meters intended for reuse are cleaned and disinfected between resident uses. The policy revealed, 18. Clean and disinfect reusable equipment between uses according to the manufacturer's instructions and current infection control standards of practice. A review of the undated manufacturer's guidelines for the glucometer used by the facility, revealed The EVENCARE G3 Meter should be cleaned and disinfected between each patient. The meter is validated to withstand a cleaning and disinfection cycle of ten times per day for an average period of three years. The following products have been approved for cleaning and disinfecting the EVENCARE G3 Meter:…

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, record review, and facility policy review, the facility failed to have evidence residents received influenza and pneumococcal vaccines and education for 2 (Resident #3 and Resident 12) of 6 sampled residents reviewed for immunizations. Findings included: Review of a facility policy titled, Influenza Vaccine, revised in August 2016, revealed, All residents and employees who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccinations against influenza. The policy revealed, 1. Between October 1st and April 30th each year, the influenza vaccine shall be offered to residents and employees, unless the vaccine is medically contraindicated or the resident or employee has already been immunized. A review of an admission Record indicated Resident #3 was originally admitted to the facility on [DATE] with diagnoses to include quadriplegia and muscle weakness. A review of Resident #3's significant…

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.