Waterman Canyon Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to follow their change of condition policy when one of three sampled residents, Resident 1 ' s daughter notified a license nurse of her Mothers (Resident 1 ' s) shortness of breath and stomach pains. This failure had placed a clinically compromised Residents (Resident 1) health and safety at risk by causing delay in treatment when no assessment, no documentation, and no physician notification, was done on a change in condition. 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: hypertension (high blood pressure), hemiplegia and hemiparesis following cerebrovascular disease affecting right dominant side (paralysis to one side, partial weakness , conditions affection blood flow to the brain), gastrointestinal hemorrhage (bleeding in digestive tract), alcoholic cirrhosis with ascites (liver disease, cause fluid to accumulate 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 interview and record review, the facility failed to provide a safe and abuse free environment for one of three sampled resident (Resident 3) when Resident 3 was hit in the face by CNA 1 on November 26, 2023. This failure had the potential to cause emotional distress that could affect Resident 3's highest practicable level of psychosocial health and well- being. Findings: A review of Resident 3's admission Record, (document containing clinical and demographic data), indicated Resident 3 was admitted to the facility on [DATE], with a diagnoses of acute pulmonary edema (a condition in which the fluid accumulates in the lungs, making it hard to breathe, hypertension(blood pressure that is higher than normal), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) A review of Resident 3's History and Physical, dated September 2, 2023, indicated Resident 3 .has fluctuating [continually change or shift back and forth] capacity to understand and make decisions . 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 interview and record review the facility failed to follow their policy when one of three residents (Resident 1) was allowed to leave the facility and the appropriate agencies (police, ombudsman, and adult protective services) were not notified of this discharge. Resident 1 did not have the capacity to make her own decisions. This failure resulted in a unsafe discharge for a confused resident (Resident 1). Findings: A review of Residents 1's admission Record (general demographics and medical information), indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included: Multiple sclerosis (disabling disease that affects the nervous system), traumatic brain injury (damage to the brain) and epilepsy (disorder in which nerve cell activity in the brain is disturbed, causing seizures - loss of consciousness). The admission record indicated Resident 1 did not have a responsible person to notify in case of an emergency. Date of discharge: [DATE]. During a review of Resident 1's medical…

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 maintain a sanitary kitchen when: 1. The liners, inside the drawers and cabinets, were painted over, and was lifting and had a sticky residue underneath. 2. A green bucket, containing black water, and a sponge was stored in a cupboard under the sink. 3. There were black dirt, trash, and food residue on the floor, under the stove. There were yellow debris on the wall behind the stove. 4. There was an accumulation of leftover food in the gap between the floor and the stainless-steel island (isolated workstation/table in the kitchen area, away from the walls). 5. The liners on the closet drawers and drawers near dry storage were not smooth and not easy to clean. 6. The cabinets and drawers on the wall, near the dishwasher, had peeling linings. The drawers were sticky and not smooth and had debris. 7. The floor, under the ice machine, was raised and the bottom was black. There were three two-by-four (common lumber, measuring two inches [unit of measurement] in depth, and four inches in width, with varying length)…

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 5.a. During a review of Resident 55's clinical records, the admission Record, indicated Resident 55 was admitted on [DATE], with diagnoses which included hypertension (elevated blood pressure), neuralgia (nerve pain caused by inflammation, injury, or infection) and malaise (general feeling of discomfort). During a review of Resident 55's physician's order, dated February 22, 2018, it indicated, Morphine Sulfate ER (controlled medication used for pain) Tablet Extended Release 15 MG, give 1 Tablet by mouth every 12 hours for Pain Management . During a concurrent observation and interview with a LVN 2, on June 8, 2023, at 6:10 AM, LVN 2 inspected the bubble pack (a card that packages doses of medications within plastic bubbles organized by day and time of the day) containing Resident 55's Morphine Sulfate ER 15 MG tablets. The label on the bubble pack indicated it contained 60 quantities of one tablet upon receipt on May 27, 2023. The LVN 2 counted the contents of the bubble pack and stated there were 38 remaining…

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 maintain kitchen equipment in safe operating condition, when: 1. Eight dish racks had cracks and chips. 2. One ice chest had a crack and hole in the bottom of the outer corner. These failures can lead to nests of pathogenic microorganisms, insects, and rodents, affecting 158 highly susceptible residents who receives food from the kitchen. Findings: During the tour of the kitchen, on June 6, 2023, at 8:57 AM, eight dish racks were observed to have cracks and chips. There was one ice chest, which had a crack and a hole, at the bottom of its outer corners. During an interview with the DSS 1, on June 7, 2023, at 11:29 AM, the DSS 1 acknowledged the findings and stated she expects the equipment to be kept in good working order without cracks and chips. During a review of the facility's policy and procedure (P&P) titled, Sanitation, dated 2023, the P&P indicated, .11. All utensil, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free form breaks, corrosions, open seam,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. During an observation and interview with Resident 39, on June 7, 2023, at 8:09 AM, in Resident 39's room, Resident 39 was lying in bed, with the head of the bed elevated, eating breakfast. Resident 39 stated she needed a cup to pour her drink and pushed the red button at the end of the call light cord, to call for assistance. The call light indicator, above the door of room [ROOM NUMBER], did not turn on. During a concurrent observation and interview, on June 7, 2023, at 8:11 AM, with the Certified Nursing Assistant (CNA 4) in room [ROOM NUMBER], the CNA 4 inspected the call light for bed A, and it was inoperable. CNA 4 stated she was aware of the light not working for room [ROOM NUMBER]'s doorway but she did not notify the nurse supervisor. CNA 4 further stated the light on the doorway was expected to be on, when residents press the red button requesting assistance from the staff. During a concurrent observation and interview, on June 7, 2023, at 8:17 AM, with the Environmental Services Supervisor (ESS),…

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 a safe, comfortable, and homelike environment when: 1. There was water damage found in the ceiling in one of 57 resident rooms (Resident 26's room). 2. A report for a missing personal belonging was not addressed in accordance with the facility's policy for one of two residents (Resident 14) reviewed for personal belongings. These failures had the potential to negatively affect the mental and emotional well-being of Residents 26 and 14. Findings: 1. During a review of Resident 26's clinical records, the admission Record (contains demographic and medical information), indicated Resident 26 was admitted on [DATE], with diagnoses which included pleural effusion (fluid between the layers of tissue that line the lungs and chest wall), chronic pulmonary edema (buildup of fluid in the lungs), and major depressive disorder (always feeling sad). During a concurrent observation and interview with Resident 26, on June 6, 2023, at 10:58 AM, 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 failed to accurately code the Minimum Data Set Assessment (MDS- a computerized assessment instrument) for one resident (Resident 89) reviewed for restraints (device used to prevent someone from doing something). This failure had the potential to cause inaccuracy in identifying Resident 89's care and support needs. Findings: During a review of Resident 89's clinical record, the admission Record (contains demographic and clinical data) indicated Resident 89 was admitted to the facility on [DATE], with diagnoses which included hemiplegia (loss of strength in the arm, leg, and sometimes face on one side of the body) and hypertension (blood pressure that is higher than normal). During a review of Resident 89's MDS Quarterly Assessment (an assessment for a resident that must be completed every 92 days following the previous assessment), dated April 19, 2023, under Section P titled Restrains and Alarm, it indicated Resident 89 had a trunk restraint (vest…

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 care plans (a summary of a resident's health conditions, specific care needs, and current treatments) were updated and revised for 3 of 5 residents (Residents 96, 17, and 28) reviewed for care planning when: 1. For Resident 96, a care plan was not developed when Resident 96 had a change in condition on June 4, 2023. 2. For Resident 17, a care plan was not developed when Resident 17 was admitted to hospice (specialized end-of-life care for all patients with a terminal illness with a prognosis of 6 months or less) on May 22, 2023. 3. For Resident 28, a care plan was not developed when Resident 28 was admitted to hospice on May 11, 2023. These failures had the potential for Residents 96, 17, and 28 to not receive care and services that were appropriate to the residents' current needs and goals. Findings: 1. A review of Resident 96's clinical record, the admission Record (a document that gives a summary of resident's information) indicated 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 monitor and document resident progress after a change in condition for one of three residents (Resident 88) reviewed for hospitalization when Resident 88 had change in condition on April 20, 2023. (Resident 88 had a decreased potassium [an essential mineral that helps the body's nerves to function and for muscles to contract] laboratory (lab) value.) This failure had the potential to result in the lack of coordination of care and monitoring for Resident 88 placing him at risk for an abnormal heart rhythm due to decreased potassium levels. Findings: During an interview with Resident 88, on June 7, 2023, at 8:49 AM, in Resident 88's room, Resident 88 stated he was transferred to the hospital a few months ago. During a review of Resident 88's clinical record, the admission Record (containing demographic information) indicated Resident 88 was admitted to the facility on [DATE], with the diagnoses of respiratory failure (serious condition that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the post fall protocol was implemented in accordance with the facility's policy and procedure for one resident (Resident 17) reviewed for falls, when the Interdisciplinary Team (IDT - a group of healthcare professionals from different disciplines working towards a common goal for a resident) conducted a review of Resident 17's fall which occurred on May 7, 2023, 29 days after the incident, on June 5, 2023. This failure had the potential for Resident 17 to be at risk of further falls and injuries. Findings: During an observation and interview with Resident 17, on June 6, 2023, at 9:08 AM, in Resident 17's room, Resident 17 was lying in bed, with the head of the bed elevated. Resident 17 stated she was doing fine, and she had no concerns. A review of Resident 17's clinical record, the admission Record (a document that gives a summary of resident's information) indicated Resident 17 was admitted to the facility on [DATE], with 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 ensure the nutrition screening had the correct information for one of four residents (Resident 73) reviewed for nutrition. This failure had the potential for Resident 73 to be at risk for malnutrition (an unhealthy and unbalanced diet) and significant weight loss due to him not receiving the appropriate therapeutic diet (a diet ordered by a physician or other delegated provider that is part of the treatment for a disease or clinical condition, to eliminate, decrease, or increase certain substances in the diet, or to provide mechanically altered food when indicated) he needed. Findings: During an observation and interview with Resident 73, on June 6, 2023, at 10:28 AM, in Resident 73's room, Resident 73 stated he had no natural teeth or dentures. Resident 73 smiled and showed he had no natural teeth. During a follow up observation and interview, with Resident 73, on June 6, 2023, at 12:35 PM, in Resident 73's room, Resident 73 stated he…

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 one resident (Resident 94) reviewed for antibiotics received antibiotic medication in accordance with the physician's orders. This failure resulted in Resident 94 to miss a prescribed antibiotic placing his health at risk. Findings: During a review of Resident 94's clinical record, the admission Record (contains demographic and medical information), indicated Resident 94 was admitted to the facility on [DATE], with diagnoses of type 2 diabetes (high sugar levels), history of infectious and parasitic disease (illness that is caused by an organism [living thing that can reproduce and adapt), resistance to multiple antibiotics, and immunodeficiency (body's decreased ability to fight infections or other diseases). During an observation, on June 6, 2023, at 11:38 AM, Resident 94 was lying in bed, sleeping. An IV (intravenously- administers fluids, medications and nutrients directly into a person's vein) pole, which was located at the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a secure storage of medications for one of nine medication carts (used by licensed nurses to transport medication to resident rooms)(Medication Cart) when Medication Cart 6 was unlocked while unattended by a licensed nurse. This failure had the potential for medications to be accessed and dispersed by an unauthorized person, in a vulnerable population of 159 residents. Findings: During an observation on June 8, 2023, at 5:50 AM, a Licensed Vocational Nurse (LVN 2) was utilizing Medication Cart 6 prior to entering room [ROOM NUMBER]. Medication Cart 6 was parked at the hallway, by room [ROOM NUMBER]. LVN 2 went inside room [ROOM NUMBER], leaving Medication Cart 6 unlocked and unattended. During further observation and concurrent interview, on June 8, 2023, at 5:54 AM, with LVN 2, LVN 2 exited room [ROOM NUMBER] and proceeded to Medication Cart 6. LVN 2 opened its drawers, and stated Oh my God! She stated the cart was left unlocked.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure food was served fresh and at an appetizing temperature for one of three residents (Resident 14) reviewed for dialysis (a treatment that cleans the blood of people with kidney failure). This failure resulted in Resident 14 to purchase her own less nutritious dinners approximately three times a week which had the potential to lead to malnutrition (an unhealthy and unbalanced diet) and significant weight loss. Findings: A review of Resident 14's clinical records, the admission Records (contains demographic information) indicated Resident 14 was admitted to the facility on [DATE], with the diagnosis that included End Stage Renal Disease (kidney failure). During an interview with Resident 14, on June 6, 2023, at 8:59 AM, Resident 14 stated a cold dinner tray was always waiting on the bedside table after returning from dialysis. Resident 14 stated nurses had no way to heat up the tray and were not able to return it to the kitchen.…

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 maintain complete and accurate medical records for one of five residents (Resident 560) reviewed for hospitalization when Resident 560's change in condition and hospitalization were not documented in accordance with the facility's policy and procedure. This failure had the potential for inaccurate communication between health care professionals, which can lead to delays in treatment, follow-up evaluations, and treatment plans. Findings: During a review of Resident 560's medical record, the admission Records (contains demographic information) indicated Resident 560 was admitted to the facility on [DATE], with diagnosis of hydrocephalus (increased pressure on the brain). Further review indicated Resident 560 was transferred to the hospital on June 6, 2023. During an interview on June 6, 2023, at 2:05 PM, with Resident 560's family member, the family member stated Resident 560 was transferred to the hospital on June 6, 2023, due to fever, abdominal pain,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure coordination with contracted hospice (specialized end-of-life care for all patients with a terminal illness with a prognosis of 6 months or less) services was being implemented for two of four residents (Residents 17 and 28) reviewed for hospice when: 1. For Resident 17, there was no current hospice plan of care (specific written instructions ordered by a physician that specify the hospice care and services a resident will receive) for recertification period of May 22, 2023, to August 19, 2023, available in Resident 17's health records. 2. For Resident 28, there was no current hospice plan of care for recertification period of April 22, 2023, to June 20, 2023, available in Resident 28's health record. These failures had the potential to cause Residents 17 and 28 to not receive hospice services based on a comprehensive person-centered care plan. Findings: 1. During a review of Resident 17's clinical record, the admission Record (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 maintain infection control practices to prevent the possible spread of infection during and after care on residents under contact precautions (used when a patient has an infectious disease that may be spread by touching other objects the patient has handled) when: 1. Two Certified Nurse Assistant (CNA 1 and 2) did not wash their hands with soap and water, according to facility's policy, after contact with Resident 18 (a resident on contact precautions for C-difficile (bacteria that causes diarrhea and inflammation of the colon and can be transmitted from person to person by spores [resistant to alcohol-based hand rub]). 2. Registered Nurse (RN 2) did not clean and disinfectant a work area, according to facility's policy before IV (Intravenous- method of putting fluids, including drugs, into the bloodstream) medication administration for Resident 123 (a resident on contact precaution for bacteremia [happens when germs from infections 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 failed to maintain an effective pest control program for two of fifty-seven residents' rooms (rooms [ROOM NUMBERS]), when small ants were found crawling in both rooms. This failure had the potential to cause skin irritation to residents and could spread infectious bacteria to 159 residents residing in the facility. Findings: 1. During a concurrent observation and an interview, on June 6, 2023, at 10:35 AM, with Resident 657, in room [ROOM NUMBER], Resident 657 was sitting on his wheelchair, watching television. Resident 657 pointed at the bathroom's wall located in front of his bed. There were roughly 20 small black ants crawling from an opening at the ceiling, located on top of the bathroom door frame, and 15 small black ants crawling at the right lower corner of the bathroom door frame, next to the floor. There was no food observed near the ants. Resident 657 stated it has been a week since he reported ants on his room. During a concurrent…

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 facility record review, the facility failed to maintain a medication error rate of less than 5%. The medication error rate was 28.13%, when three random sampled residents (Residents 117, 63, and 67) received their prescribed medications which were to be administered at 9:00 AM during the afternoon medication pass on May 20, 2021. These failures had the potential to negatively impact the health and well-being of three of 155 residents in the facility receiving medications. Findings: a) During an observation on May 20, 2021, at 12:12 PM with Licensed Vocational Nurse 6 (LVN 6), LVN 6 was observed removing a medication, memantine (used to treat the symptoms of Alzheimer's disease (AD; a brain disease that slowly destroys the memory and the ability to think, learn, communicate and handle daily activities)) HCI 10 mg (milligrams a unit of measure) from a bubble pack (a pack with single doses of the medication in order of day of the month) and placing the medication in a 30 ml…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility record review, the facility failed to ensure: 1. Internal and external (medication routes, i.e., oral medications, eye drops, injectable medication) medications were stored separately. 2. Proper Disposal of eight, prescription medication, bubble packs (cardboard medication holders with plastic bubbles containing medication) for five of 155 Residents per facility policy. These failures had the potential to increase medication errors and have medications available for inappropriate usage. Findings: 1. During a concurrent observation and interview on May 20, 2021, at 5:15 PM, with Registered Nurse 2, RN 2 unlocked and opened Station 2's hallway medication refrigerator. In the butter bin of Station 2's medication refrigerator, a residents eye drops, and two residents injectable medications were stored together in the butter bin. Also observed in one large bin in the refrigerator were two insulin pens (an injectable medication for diabetes), and a bottle of an oral…

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 whole potatoes stored in a bin within the kitchen, were labeled with the date they were received at the facility. This failure had the potential for food available for resident consumption, to become outdated past its shelf-life which may lead to a deterioration of peak flavor (taste), texture, and appearance, and may also lead to food-borne illness. Findings: During a concurrent observation and interview on May, 17, 2021, at 7:57 AM, with the Dietary Services Supervisor (DSS), a storage area within the kitchen was observed to contain a plastic bin with approximately 30 whole potatoes. The plastic bin nor the potatoes, were dated or labeled with a delivery date or a use-by date. The DSS acknowledged the potatoes were not dated and stated the potatoes should have been labeled with the date they were received at the facility. During an interview on May 20, 2021, at 11:33 AM, with the Registered Dietitian (RD), the RD stated food items at the facility should be dated with the received date and a use-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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to implement their infection control program by not following their policy and procedures when: 1. For one out of eight residents, (Resident 85) the oxygen tubing and oxygen humidifier bottle (a device which keeps the air moist) were not changed as per the facility's policy and procedure. This had a potential to place the resident at risk for bacterial infection, nasal ulcerations, and discomfort. 2. The facility failed to report to the dialysis clinic the status of their COVID-19 (an infectious respiratory ailment that can be fatal in compromised residents) residents. This had the potential for the three of eight Residents to expose patients at the dialysis unit to COVID-19. Findings: 1. During an observation on May 18, 2021, at 11:05 AM, it was noted that the humidifier bottle on Resident 85's oxygen concentrator was empty and the oxygen tubing delivering oxygen through his nose had a date showing that it was last changed on May 8, 2021…

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 did not ensure accurate coding for aspirin in the Minimum Data Set (MDS - facility assessment tool) assessment for one of 155 residents (Resident 124) when it was coded as an anticoagulant (a drug used to inhibit clotting of blood). This failure resulted inaccurate documentation in the MDS assessment that potentially affect quality measure monitoring for the health and safety for Resident 124. Findings: During a review of Resident 124's Face Sheet (contains demographic information) indicated, Resident 124 was admitted to the facility on [DATE], with diagnoses of Rheumatoid Arthritis (inflammation of joints) and Hypertensive Urgency (high blood pressure with no organ damage). During a review of Resident 124's MDS, dated [DATE], under section N- Medications, indicated, Resident 124 received an anticoagulant for seven days. During a further review of Resident 124's Physician's Order from April 2021 to May 2021, indicated Resident 124 had an order dated as…

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 facility record review, the facility failed to develop a comprehensive, person-centered care plan for Resident 78 when: 1. A care plan for prescribed antidepressants was not developed and implemented. 2. A care plan for prescribed narcotic pain medication was not developed and implemented. These failures had the potential to negatively impact the health and well-being of Resident 78 due to lack a of a person-centered care plan with treatment goals and interventions. Findings: 1. During a record review of Resident 78's Medication Administration Record (MAR), dated May 2021, the MAR indicated, Resident 78 was receiving sertraline (an antidepressant). A review of the admission Record (contains demographic information) for Resident 78, it indicated Resident 78 was admitted to the facility on [DATE], with diagnoses which major depressive disorder (depression) and low back pain. During a record review of Resident 78's MDS [Minimum Data Set - primary screening and assessment tool of health…

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 body weight assessments were obtained and documented for one newly admitted resident (Resident 4) in the frequency specified in the facility's policy and procedures. This failure had the potential to result in a delay in the facility's ability to identify undesirable weight loss, and/or nutritional needs for Resident 4. Findings: During a review of Resident 4's clinical record, the admission Record (contains demographic and medical information) indicated Resident 4 was admitted on [DATE], with diagnoses which included critical illness polyneuropathy (damage to multiple nerves throughout the body), muscle weakness, Primary Generalized (osteo) arthritis (breakdown of cartilage within the joints), hypothyroidism (a condition in which the thyroid does not produce enough thyroid hormones), and morbid (severe) obesity. During further review of the clinical record for Resident 4, the Electronic Health Record (EHR) tab titled Wts/Vitals…

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 pain medication was provided consistent with professional standards of practice when medication intended for moderate to severe pain was given to a resident when there was no pain or only mild pain present. This had the potential to cause harm to the resident due to the risks for constipation, addiction, sedation and confusion. Findings: During a record review of Resident 16's physician orders, there was an order dated April 17, 2020, which indicated : to monitor for the presence of pain using pain scale 0-10 as follows: 0 = no pain; 1-3 = mild; 4-5 = moderate; 6-9 = severe; 10 = excruciating pain. The physician had ordered pain medication as follows: a. Tylenol (a non-narcotic pain medicine) 325mg (Mg-milligrams- a unit of measurement) give two tablets by mouth every four hours as needed for mild pain. b. Hydrocodone-Acetaminophen (a narcotic pain medicine) 10-325mg tablet give one tablet by mouth every four hours as needed for moderate to severe pain. During a review of the Medication Administration Record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure the correct administration of acetaminophen (a drug used to treat minor pain and fever) medication should not exceed the maximum dose of 3 grams per day for one of 79 residents (Resident 110), who was receiving both acetaminophen and Norco (a narcotic pain medication which contains acetaminophen). This failure had the potential to result physical harm due to potential adverse effects related to excess use of acetaminophen. Findings: During a review of Resident 110's Face Sheet (contains demographic information) indicated, Resident 110 was admitted to the facility on [DATE], with diagnoses of muscle weakness, abnormal posture and pneumonia (infection of the lungs). During a review of Resident 110's Medication Administration Record (MAR) for May 1, 2021 to May 31, 2021, indicated that Resident 110 is taking Acetaminophen tablet 500MG (milligram- a unit of measurement); give 2 tablets [1,000mg] by mouth every 8 hours for pain management (NTE (not…

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.