San Bruno Skilled Nursing

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Number of residents sampled:2Number of residents cited:1Based on observation, interview and record review, the facility did not ensure one of two residents, (Resident 5) is receiving the correct amount of oxygen according to physician's order, when order indicates 1L/min. Resident observed to have 2 L/min for three consecutive days.This failure has potential for resident to have oxygen toxicity (lung damage that happens from breathing in too much extra supplemental oxygen. Review of Resident 5's admission Record, indicated admitted on [DATE] with diagnoses including: Chronic Obstructive Pulmonary Disease (COPD)(chronic lung condition causing shortness of breath), Pneumonia, (a lung infection),Shortness of Breath, Anxiety Disorder ( a mental condition like persistent worry, fear and nervousness), Major Depression(condition with persistent sadness, hopelessness and loss of interest). Review of Order Summary Report, dated 10/25-12/5/25, indicated, Continuous oxygen via NC @1L/min Goal sat of 88%. Begin weaning from…

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 did not ensure one out of two sampled residents (Resident 11) had adequate monitoring of their dialysis (a life sustaining medical treatment that filters waste products, excess fluid, and salt from the blood when kidneys fail, performing the kidneys job of cleaning the blood and balancing minerals) access site (a surgically created connected to the bloods stream that allows blood to be removed, cleaned by a dialysis machine); when it had been surgically changed from one site of the body to another.This failure in inadequate nursing assessment and documentation of Resident 11's current dialysis access stie had the potential for missed bleeding or other untoward side effects a dialysis resident could experience without adequate monitoring of the access site resulting in harm and even death.During a review of Resident 11's, admission Record, dated 6/19/24 indicated Resident 11 had been admitted to the facility on [DATE] with a history of diabetes 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 secure medications for one out of three residents (Resident 8) in a locked storage area and to limit access to non- authorized personnel.This failure resulted in Resident 8's medication being stored in unsecured and unsafe storage location, accessible to non-authorized personnel and other residents.Findings:During a concurrent current observation and interview on 12/04/2025 at 3:01 PM in Resident 8's room, with a certified nursing assistant (CNA2), CNA 2 reached in Resident 8's top drawer in the bedside cabinet and removed an individually wrapped pre- moistened packet of OCuSOFT LID SCRUB eyelid cleanser from a blue box.During a phone interview on 12/05/2025 at 10:23 AM with the consulting pharmacist (PharmD), PharmD stated, due to the active ingredients in OCuSOFT LID SCRUB eyelid cleanser it is a medication that must have an active physician order, administered by a licensed nurse, and stored in a locked location.During a concurrent observation and interview on 12/05/2025 at 12:54 PM with the Assistant…

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 establish and implement infection prevention measures when; Enhanced barrier precautions were not implemented for one of three sampled residents (Resident 7) during high contact care. One out of four sampled residents (Resident 15), had flecks of debris and crust in their oxygen tubing (delivers supplemental oxygen from a source like a machine or oxygen tank, to a resident usually through tube through the nose also called a nasal cannula). This failure had the potential to result in Resident 7 and 15 developing a transmission based communicable disease or infection. Findings: 1. During a concurrent observation and interview on 12/04/2025 at 2:22 PM with Certified Nursing Assistant 2 (CNA 2) in Resident 7's room, Resident 7 received wound care for a stage three pressure injury (a deep wound where skin is lost, revealing the yellow, fatty tissue underneath) on her sacrum (a triangular bone in the lower back). CNA 2 stated, I'm going to get…

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 a review of records, the facility failed to ensure that one of 9 sampled residents (Resident 1) receive consistent range of motion (ROM) exercises to the left lower extremity (LLE) during the period from admission on [DATE] to hospital transfer on 07/16/2025, to prevent contractures. This failure resulted in the development of contractures in the resident's LLE.During a review of Resident 1's Physical Therapy Medicare, PT Evaluation & Plan of Treatment (PTEPT), dated 11/20/2024, the PTEPT indicated, Resident 1 did not have contractures and that Resident 1's right lower extremity (RLE) and the left lower extremity (LLE) had range of motion (ROM) that was within normal limits (WNL). During a review of Resident 1's Joint Mobility Screen (JMS), dated 01/02/2025, the JMS indicated Resident 1 had full ROM of the left and right hips, knees, and ankles. During a review of the Occupational Therapy Treatment Encounter Notes ([NAME]) dated 01/22/2025 to 03/06/2025, the documentation…

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, intervention and record review, the facility did not ensure that re-assessment of one of two residents, Resident 1, when Resident 1 developed an ulcer of left leg, no weekly skin assessment and no MD assessment done to evaluate for healing or change of treatment. This failure has the potential for other residents to not receive necessary care Review of admission Record, dated 8/6/25, indicated, admitted on [DATE] with diagnoses including : Severe Dementia with Psychotic Disturbance, Adult Failure to Thrive, Moderate Protein - Calorie Malnutrition, Altered Mental Status. Full Code Status.Resident transferred to acute 7/16/25.During an interview with Marketing/Admission, on 8/1/25 at 12:10 PM, per Marketing, she assessed resident from Alameda Hospital, approved of her admission meeting skilled criteria. Plan is short term rehab and discharge to Assisted Living facility per daughter, as RP. Patient was skilled for 2 months and discontinued and work on discharge plan.Interview on 8/1/25 at 1:25…

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 a sufficient space to accommodate group activities and communal dining for 43 residents. This failure resulted in limiting residents to participate in group activities and communal dining; caused inconvenience to residents whose rooms were in the hallway where the activities are conducted; and placed residents at risk for feelings of being isolated or depressed. Findings: The facility is licensed for 45 beds and the resident census on 6/11/24 was 43. During an observation on 6/11/24 at 9:29 AM, in the hallway between room [ROOM NUMBER] and 5, four residents were sitting on their wheelchair with one staff in front of them playing music on an iPad (a brand of a tablet computer). During an interview on 6/11/24 at 9:48 AM, Resident 32 mentioned about the noise outside his room especially when they play music or karaoke in the hallway. Resident 32 stated, a man comes every Wednesday to sing karaoke together with the residents in the…

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

Based on observation, interview and record review, the facility did not ensure that resident's unique care instructions for one resident (Resident 12) are made private, when care instructions are posted in two places in her bedroom wall. This failure can result in exposing her medical condition to other residents and visitors. Findings: Review of admission Record, dated, 6/18/24, indicated, admitted to SNF on 10/28/22 with diagnoses including: Parkinson's Disease(a disorder of the central nervous system that affects movement including tremors), Diabetes Mellitus(a condition when the body has trouble controlling blood sugar) Major Depressive Disorder( a mental health disorder characterized loss of interest in activities causing impairment in daily life). Review of MDS (Minimum Data Set) Section C, BIMS (Brief Interview for Mental Status) result is 8= with cognitive impairment. During an interview on 6/12/24 at 3:30 PM, with CNA 2, per CNA 2, the daughter was the one who posted it for her mother's care. Not sure if we can post it here. During an interview on 6/12/24 at 3:40PM, with…

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 that a resident could safely administer a medication when one out of one sampled residents (Resident 11) did not receive an assessment or education regarding the self-administration of doxycycline (an antibiotic). This failure could result in the resident inappropriately taking the medication resulting in overdose (taking beyond the safe amount of a medication), drug interactions (typically unwanted reaction between two medications that someone takes), or unrecognized side effects of the medication. Findings: A review of the facility policy and procedure titled, Self-Administration of Medications, undated, indicated that the interdisciplinary team (IDT) should assess each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident. The policy and procedure further indicated that The IDT considers the following factors when determine whether self-administration of medication is safe and appropriate . the resident can…

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 have a valid copy of a resident's Physician Orders for Life-Sustaining Treatment (POLST, a written medical order that assists people in making decisions about medical treatment and life saving measures during end-of-life care or medical crisis) when one of twelve sampled residents (Resident 47) had a POLST lacking a clear signature or identity of who the POLST was discussed with. This failure has the potential to result in a resident's end-of-life choices not being honored. Findings: A review of Resident 47's Minimum Data Set (MDS, a resident assessment tool), dated 04/30/24, indicated that Resident 47 was admitted in April of 2024. It further indicated that the resident has a Brief Interview for Mental Status (BIMS, a cognitive screening tool) score of 13 (scores of 0-7 suggest severe cognitive impairment, 8 to 12 suggests moderate cognitive impairment, and 13 to 15 suggest that cognition is intact). A review of Resident 47's POLST, dated 04/27/24, indicated that To be valid a POLST form must be signed by (1) a physician,…

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 the required Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage, Form CMS-10055 (SNF ABN, Form Centers for Medicare & Medicaid Services-10055 - a written notice used to inform the resident/beneficiary of potential financial liability for the non-covered stay and the right to appeal to receive care and services which may not be covered by Medicare) for one of three sampled residents (Resident 32) receiving Medicare Part A services. This failure had the potential for residents and/or resident representative not being aware of the financial liability and the right to appeal for the denial or termination of resident's Medicare Part A services. Findings: Review of Resident 32's admission record indicated, was admitted on [DATE] with diagnoses including orthopedic aftercare following surgical amputation of right lower extremity, non-pressure wound on left calf, type 2 diabetes mellitus (high blood sugar), and end stage kidney…

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 report an injury of unknown origin within the required timeframes in one out of one sampled resident (Resident 8) when Resident 8 reported hip pain that was later diagnosed as a pathological fracture (a break in the bone because of disease rather than physical trauma). This failure has the potential to result in delayed identification and investigation of possible harm occurring from abuse. Findings: A review of Resident 8's face sheet (summary of resident's demographic and admitting information), dated 06/14/24, indicated that Resident 8 was initially admitted on January of 2024 with multiple diagnoses including END STAGE RENAL DISEASE [failure of the kidneys to function properly], ANEMIA [lack of healthy blood cells], and MUSCLE WASTING AND ATROPHY [thinning or loss of muscle] A review of Resident 8's Minimum Data Set (MDS, a resident assessment tool), dated 05/08/24, indicated that Resident 8 had a Brief Interview for Mental Status (BIMS, a cognitive screening tool) score of 8 (scores of 0-7 suggest severe cognitive…

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 admission and annual Minimum Data Set (MDS, a resident assessment tool) assessment was completed within the required period of 14 calendar days of admission and Assessment Reference Date (ARD, specific endpoint for the look-back periods in the MDS assessment process) for four of 12 sampled residents (Resident 29, Resident 16, Resident 17, and Resident 8). Failure to complete a comprehensive resident assessment within the required timeframe could result in delayed identification of needs and significant issues that may affect the physical, mental, and psychosocial well-being of Resident 29, Resident 16, Resident 17, and Resident 8. Findings: 1. Review of Resident 29's admission record indicated, was admitted to the facility on [DATE]. Review of Resident 29's 5-day/admission MDS assessment with an ARD of 4/16/24 indicated, the assessment was signed by the RN assessment coordinator as complete on 4/30/24, 16 days after admission. During…

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 complete a Significant Change in Status Assessment (SCSA, is a comprehensive assessment for a resident that must be completed when the IDT has determined that a resident meets the significant change guidelines for either major improvement or decline) for one of 12 sampled residents (Resident 3) who was admitted to hospice care on 11/11/23. This failure could potentially delay the provision of appropriate treatment and services for Resident 3. Findings: Review of Resident 3's admission record indicated, was admitted to hospice on 11/11/24 with diagnoses including stroke, respiratory failure, pulmonary fibrosis (a disease where there is scarring of the lungs which makes it difficult to breathe), and lung involvement in systemic lupus erythematosus (an illness that occurs when the immune system attacks healthy tissues and organs). Review of Resident 3's Minimum Data Set (MDS, a resident assessment tool) with an Assessment Reference Date (ARD, specific endpoint for the look-back periods in the MDS assessment process) 11/14/23,…

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 Minimum Data Set (MDS, a resident assessment tool) quarterly assessment was completed at least every 92 days following the previous OBRA (Omnibus Budget Reconciliation Act of 1987) assessment for three of 12 sampled residents (Resident 20, Resident 3, and Resident 17). Failure to complete quarterly resident assessment within the required timeframe could result in delayed identification of needs and significant issues that may affect the physical, mental, and psychosocial well-being of the residents. Findings: 1. Review of Resident 20's admission record indicated, was admitted to the facility on [DATE]. Review of Resident 20's quarterly MDS with an Assessment Reference Date (ARD, specific endpoint for the look-back periods in the MDS assessment process) of 5/9/24 indicated, the assessment was signed by the RN assessment coordinator as complete on 6/4/24, 26 days after the ARD. During concurrent interview and record review on 6/14/24, at 10:39 AM,…

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 person-centered care plan was implemented for three of 12 sampled residents (Resident 3, Resident 29, and Resident 16) when: 1. The facility did not ensure oxygen (O2) at 5 liters per minute (LPM) via nasal cannula (NC, a device that delivers extra oxygen through a tube and into the nose) was administered to Resident 3. 2. The facility did not ensure O2 at 2 LPM via NC was administered to Resident 29. 3. The facility did not ensure two-persons assist was provided for Resident 16 during transfer from bed to wheelchair using a sit-to-stand/standing lift. The deficient practice resulted in Resident 3 and Resident 29 to not receive the appropriate amount of oxygen as prescribed by the physician; and can increase the risk for an accident such as a fall and/or injury to Resident 16. Findings: 1. Review of Resident 3's admission record indicated, was readmitted on [DATE] with diagnoses including stroke, respiratory failure, pulmonary…

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 update a care plan after an interdisciplinary team (IDT) assessment when one of twelve sampled residents (Resident 41) with care plans had a body weight that was beyond the recommendation from their care plan. This failure has the potential to result in the clinical staff not recognizing significant changes in weight due to a difference in care planned goals versus those decided by an interdisciplinary team. Findings: During a concurrent interview and record review on 06/13/24 at 9:48 AM with the Director of Nursing (DON), Resident 41's care plan for nutrition, initiated on 05/14/24, was reviewed. The care plan indicated a focus of Nutritional Risk: Resident has the potential for altered nutrition and/or hydration status related to medical diagnosis . The DON reviewed the care plan and stated that Resident 41's goal was to maintain a body weight within 5% of 195 pounds (lbs). During a concurrent interview and record review on 06/13/24 at 9:48 AM with the Director of Nursing (DON), Resident 41's most current body weight…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure care and treatment provided meet professional standards when the physician's order for oxygen (O2) administration was not followed for two of 12 sampled residents (Resident 29 and Resident 3). The deficient practice had the potential to compromise the health and safety of Resident 29 and Resident 3. Findings: 1. Review of Resident 3's admission record indicated, was readmitted on [DATE] with diagnoses including stroke, respiratory failure, pulmonary fibrosis (a disease where there is scarring of the lungs which makes it difficult to breathe), and lung involvement in systemic lupus erythematosus (an illness that occurs when the immune system attacks healthy tissues and organs). Review of Resident 3's Minimum Data Set (MDS, a resident assessment tool) dated 5/14/24, indicated, problem with memory and cognitive (thought process) skills for daily decision making. During an observation on 6/11/24 at 11:58 AM, in resident's room,…

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 adequate supervision and safe transfer technique for one of 12 sampled residents (Resident 16) when: a. The Restorative Nursing Assistant (RNA) transferred Resident 16 from bed to wheelchair using a sit-to-stand lift (or standing lift) by herself when the care plan indicated two persons. b. The mesh and/or material of the standing sling used for Resident 16 were frayed and torn and one of the belts had a missing buckle. Failure to provide adequate supervision and safe transfer technique may result in an accident and can increase the risk for fall and/or injury. Findings: Review of Resident 16's admission record, indicated, was admitted on [DATE] with diagnoses including hemiplegia (paralysis on one side of the body) and hemiparesis (weakness or partial paralysis on one side of the body) following a stroke affecting right dominant side, aphasia (a language disorder that affects a person's ability to communicate), and vascular…

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, interviews, and record reviews, the facility failed to maintain a medication error rate below five percent (5%). During the medication pass on 6/11/24, three medication errors were observed out of twenty-six opportunities for two out of four residents, resulting in an error rate of 11%. This failure had the potential to result in more than minimal harm in the health and safety of residents. Findings: A review on 6/11/24 of the facility's policy, titled Administering Medications, indicates that the individual administering medication must verify the resident's identity prior to dispensing medication. Accepted methods of identification include checking photo identification via the medical record, and, if necessary, seeking verification of resident identification from other facility personnel. During an observation on 06/11/24 at 9:36 AM Registered Nurse 1 was observed preparing medications for Resident 10. The nurse attempted to identify Resident 10 by asking for her name; however, Resident 10 did not speak English. RN 1 did not speak Resident 10's language. RN…

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 did not ensure safe food handling practices when jewelries were worn during food handling, when two kitchen staff observed wearing yellow bracelets on both arms during food preparation and handling. This failure can result in food contamination, when it touches food products. Findings: During the initial tour of the kitchen, on 6/11/24, at 9:30 AM, observed CDM(Certified Dietary Manager), with yellow bracelets in both arms and kitchen [NAME] wearing yellow bracelets in both arms while preparing food for lunch. During an interview on 6/11/24 at 11 AM, with CDM, and Cook, CDM stated, I know, we took them out now. We Indians feel bare if we don't have anything on our arms. Sorry, but its out now. Per Cook, it's a sign that you're married for Indians, but I took it out. Review of facility Policy and Procedure, Food Prepararion and Service, dated, 11/22, indicated, under Food and Distribution and Service, 9.Food and nutrition service staff keep fingernails trimmed and clean. Jewelry is worn minimally and hand jewelry (i.e)…

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

Based on observation, interview, and document reviews it was found that the facilities' Quality Assessment Performance Improvement (QAPI) program was ineffective. Despite its purpose to proactively identify and prevent medication administration errors, it fell short. This was evident during a medication pass observation conducted during the survey, which revealed a concerning 11% medication error rate (See F759). Findings Based on observation, interview and document reviews (See deficiency under F759) the facility was found to have a medication error rate of 11% during a medication pass on 06/11/24 between the times of 9:00 AM and 10:45 AM, which exceeds the acceptable threshold of 5%. This rate was derived from observing three errors out of twenty-six medication administration opportunities involving two of four residents. Such a high error rate poses a risk to the residents' health and safety. The first error involved a failure to properly identify Resident 10 before administering medication. Registered Nurse 1 attempted to verify the resident's identity by asking for her name,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement and maintain its infection control program for two of two sampled residents (Resident 32 and Resident 34) on transmission-based precautions (specific protections used when a someone has an infection that could be spread easily) when: 1. Resident 32 did not have personal protective equipment (PPE, equipment used to minimize exposure to a hazard) directly outside of the room. 2. Licensed Vocational Nurse (LVN) 1 did not wear full PPE when handling the urine collection bag (Foley bag) of Resident 34, who's on enhanced barrier precautions (EBP- refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities). Additionally, the PPE cart for Resident 34, was placed next to his roommate and not in his care area. Failure to implement infection prevention practices has the potential to result in increased…

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 and record review, the facility failed to ensure Residents 20, 28, and 32, three out of 14 sampled residents, were protected from neglect. All three residents reported delayed response from staff to their requests for assistance. This pattern of delayed staff response resulted in Residents 20, 28, and 32 being left in pain for prolonged periods of time. These residents reported: increased pain while waiting, feelings of frustrations, feelings of anger and feelings of being neglected. Findings: Resident 20 Review of Resident 20's record titled Minimum Data Set (MDS, a standardized resident assessment tool), dated 1/12/2023, indicated her BIMS (Brief Interview for Mental status, a standardized test for memory and reasoning functions) score was 15 out of 15. A score of 15 indicated no impairment in memory and reasoning. According to her MDS, she required: supervision of one staff for bed mobility, transfers, toilet use, and personal hygiene. According to her MDS she was occasionally incontinent of bowel; she displayed no episodes of hallucination…

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

Based on observation and interview the facility failed to provide pharmaceutical services to meet the needs of each resident when multiple expired medications were available for resident use in the medication room. Findings: During an observation on 2/6/23 at 1:30 PM in the facility medication room, there were seven bottles of Magnesium Citrate Saline Laxative non-pasteurized oral solution that were found to have expired. The expiration date was August 2022. The expiration date, based on the manufacturer, indicated that the Magnesium Citrate should not have been available for resident use. During an observation on 2/6/23 at 1:30 PM in the facility medication room medication refrigerator it was observed there were multiple expired emergency kits. The emergency kits had multiple medications that were used when the pharmacy was closed. The following expiration dates were found on the emergency kits: COVID Kit 8/23/22 Refrigerator Kit 1/2023 Refrigerator Kit 1/2023 During an interview on 2/6/23 at 1:30 PM the Registered Pharmacist 1 stated that he was the facility pharmacist. He also…

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

Based on observation, interview, and document review the facility failed to maintain a medication error rate less than five percent when three medications errors were observed for thirty three observed opportunities which would equal a medication error rate of nine percent. Findings: During an observation on 2/6/23 at 11:56 AM Licensed Vocational Nurse (LVN 1) administered four different medications (Allopurinol, Amlodopine, Eliquis, and Hydralazine) to Resident 101. LVN 1 flushed with 1-3 ml of water between each medication. During an interview on 2/6/23 at 2:30 PM LVN 1 stated that she flushed with 1-3 ml of water instead of the policy required 15 ml. LVN 1 also stated she did not know that 15 ml flushes were required between medications when administering through an enteral tube. During an observation on 2/7/23 at 8:05 AM LVN 2 prepared Fluticasone Nasal Spray (medication used for allergies) and then left the nasal spray unattended on the meal tray in front of Resident 20. Resident 20 pick up the Fluticasone Nasal Spray and administered the spray into her right nostril. LVN 2…

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.