Balboa Nursing & Rehabilitation Center

Based on observation, interview and record review, the facility failed to ensure the presence of a full-time Director of Nursing (DON) to manage and oversee nursing services. This deficient practice placed all 188 residents at risk for uncoordinated care, delays in addressing clinical concerns, and inconsistent implementation of nursing policies and procedures. On 7/23/25 10:30 A.M., a complaint investigation was initiated with the Administrator (ADM). The ADM stated the facility did not have a Director of Nursing (DON) and would be assisted by the Quality Assurance (QA) nurse for any assistance during the complaint investigation. On 7/23/25 at 1:22 P.M., an interview was conducted with LN 2. LN 2 stated we don't have a full-time DON yet. LN 2 stated the QA nurse was the former DON. On 7/24/25 at 4:02 P.M., an interview was conducted with the Director of Staff Development (DSD). The DSD stated she had only been working as a DSD for one month, so she was not sure if the facility was short or had any staffing waivers. The DSD stated the facility did not have a DON. On 7/30/25 at 10:06…

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 for one resident, Resident 1, who eloped (a patient leaving a healthcare facility without proper authorization or staff awareness)from the facility late at night, was unlocatable by the facility for nearly 14 hours, and sustained a fall while away from the facility. This failure had the potential for Resident 1 to suffer serious injury. Findings: According to a report filed to the Department by Adult Protective Services (APS): On 6/2/25, the police department Psychiatric Emergency Response Team ([NAME]) unit responded to a call for a missing person at risk. During investigation, a clinician learned that Licensed Nurse (LN) 1 knew that Resident 1 left the facility at approximately 1:30 AM and never returned. LN 1 did not report this until shift change at 7:30 AM. A phone call was made to the police at 8:17 AM. The police department filed a missing person at risk report. An unannounced visit was conducted 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.

Based on observation, interview, facility document and policy review, the facility failed to follow the prepared menu for residents who received diets with mechanical soft or ground meat for 30 of 183 residents who resided in the facility and failed to follow the prepared menu for residents who received diets with pureed meat for 21 of 183 residents who resided in the facility. Findings included: An undated facility policy titled, Menus, indicated, Menus are developed and prepared to meet resident choices including religious, cultural and ethnic needs while following established national guidelines for nutritional adequacy. The policy revealed the section titled, Policy Interpretation and Implementation, included, 6. Menus must be followed. Deviations from posted menus are recorded (including the reason for the substitution and/or deviation) and archived. Further review revealed, 8. Menus provide a variety of foods from the basic daily food groups and indicate standard portions at each meal. The facility's Spring Cycle Menus, revealed that the planned lunch meal on 05/13/2025…

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.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure a dignified dining experience for 1 (Resident #92) of 6 sampled residents reviewed for nutrition. Findings included: A facility policy titled, Dignity revised 02/2021, indicated, 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 specified, 5. When assisting with care, residents are supported in exercising their rights. For example, residents are: a. groomed as they wish to be groomed; b. encouraged to attend activities of their choice, including religious, political, civic, recreational, or social activities; c. encouraged to dress in clothing that they prefer; d. allowed to choose when to sleep, eat and conduct activities of daily living; and e. provided with a dignified dining experience. A facility policy titled, Assistance with Meals revised 03/2022, indicated, Residents shall receive assistance with meals in a manner that meets the…

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

Based on interview, record review, and facility policy review, the facility failed to accurately complete a Minimum Data Set (MDS) assessment for 2 (Resident #77 and Resident #185) of 38 residents whose MDSs were reviewed. Findings included: A facility policy titled, Resident Assessments, revised 10/2023, revealed the section titled, Policy Interpretation and Implementation, included, 11. All persons who have completed any portion of the MDS resident assessment form must sign the document attesting to the accuracy of such information. 12. Information in the MDS assessments will consistently reflect information in the progress notes, plans of care and resident observations/interviews. 1. An admission Record indicated the facility admitted Resident #185 on 01/21/2025. According to the admission Record, the resident had a medical history that included diagnoses of multiple rib fractures, a history of falling, and dementia. A discharge MDS, with an Assessment Reference Date (ARD) of 02/12/2025, revealed Resident #185 had a Brief Interview for Mental Status (BIMS) score of 6, which…

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, record review, and facility policy review, the facility failed to ensure a care plan was followed for 1 (Resident #30) of 7 residents reviewed for nutrition. Findings included: A facility policy titled, Assistance with Meals, revised 03/2022, specified, Residents shall receive assistance with meals in a manner that meets the individual needs of each resident. An admission Record revealed the facility admitted Resident #30 on 02/25/2013. According to the admission Record, the resident had a medical history that included hemiplegia and hemiparesis (partial weakness on one side of the body) following a cerebral infarction (stroke), dysphagia (difficulty swallowing), and functional quadriplegia. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/06/2024, revealed Resident #30 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment. The MDS indicated Resident #30 required supervision or…

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, record review, and facility policy review, the facility failed to ensure staff followed a physician's order for supervision during meals for 1 (Resident #30) of 7 residents reviewed for nutrition. Findings included: A facility policy titled, Assistance with Meals, revised 03/2022, specified, Residents shall receive assistance with meals in a manner that meets the individual needs of each resident. The policy revealed the section titled, Policy Interpretation and Implementation, included, 2. Facility staff will serve resident trays and will help residents who require assistance with eating. An admission Record revealed the facility admitted Resident #30 on 02/25/2013. According to the admission Record, the resident had a medical history that included hemiplegia and hemiparesis (partial weakness on one side of the body) following a cerebral infarction (stroke), dysphagia (difficulty swallowing), and functional quadriplegia. A quarterly Minimum Data Set (MDS), with an Assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review, the facility failed to provide timely podiatry services for 1 (Resident #388) of 3 sampled residents reviewed for activities of daily living. Findings included: A facility policy titled, Podiatry Services revised 02/2023, indicated, It is the policy of this facility to ensure residents receive proper treatment and care within professional standards of practice and state scope of practice, as applicable, to maintain mobility and good foot health. The policy specified, 5. The social worker or designer will assist residents in making appointments and arranging transportation to obtain needed services. An admission Record revealed the facility admitted Resident #388 on 04/14/2025. According to the admission Record, the resident had a medical history that included diagnoses of muscle weakness and dorsalgia (back pain). An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/21/2025, revealed Resident #388 had 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 interviews and record review, the facility failed to communicate and develop a baseline care plan (detailed plan with information about a patient's treatment, goal, and interventions) related to a resident ' s (Resident 1) suicidal ideation (SI, when you think about, consider or feel preoccupied with the idea of death and suicide) tendency for one of one sampled resident. As a result, the lack of communication among facility staff related to Resident 1 ' s SI and a resident centered care plan with specific interventions to monitor Resident 1 from harming herself with overdosing of medications and cutting herself with a butter knife on 1/20/25. Findings: A record review was conducted of Resident 1. Resident 1 was readmitted to the facility on [DATE], with diagnoses which included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness or the inability to move on one side of the body), per the facility ' s admission Record. A record review was…

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 document review, the facility failed to prevent Resident 1 from physically assaulting Resident 2. This failure resulted in Resident 2 sustaining a physical injury and feeling fearful. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses that included bipolar disorder (a mental health condition that causes extreme mood swings). Resident 2 was admitted to the facility on [DATE] with diagnoses that included displaced fracture of 6thand 7th vertebra (bones of the spine). On 7/22/24 the State Agency (SA) received a report from the facility which indicated, (Resident 1) walked up to (Resident 2) and hit him on the left cheek.(Resident 2) had verbalized he did not feel safe until (Resident 1) was discharged . On 8/2/24 at 9:50 AM, a concurrent interview and record review of the 7/21/24 11:26 A.M. Event Note was conducted with the Director of Nursing (DON). The Event Note indicated, (Resident 1) was noted striking (Resident 2) in the dining room by staff member .…

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 responsible party (RP) was notified timely of resident's skin issues and resident's change of condition (COC) for one of seven residents (Resident 1), reviewed for quality of care. This failure resulted in Resident 1's responsible party unaware of Resident 1's current health status. Findings: An unannounced onsite to the facility was conducted on 6/10/24 related to complaints on quality of care that happened in 2022. Resident 1 was admitted to the facility on [DATE], with diagnoses which included bacteremia (blood stream infection) and diabetes (high blood sugar), per the facility's admission Record. The admission record indicated the RP, and first emergency contact number was Resident 1's family member (FM). On 6/10/24, 6/13/24 and 6/25/24, Resident 1's clinical record was reviewed: The Minimum Data Set (MDS, a clinical assessment tool), dated 1/13/22, listed a cognitive (ability to recall) score of six out of 15 (0-7, indicating severe…

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 consistently provide skin care and administer intravenous (IV) antibiotics (anti-infective) medication, as ordered by the physician, for one of seven residents (Resident 1) reviewed for quality of care. These failures had the potential to affect Resident 1's health and well-being. Findings: An unannounced onsite to the facility was conducted on 6/10/24 related to complaints on quality of care that happened in 2022. 1. Resident 1 was admitted to the facility on [DATE], with diagnoses which included bacteremia (blood stream infection) and diabetes (high blood sugar), per the facility's admission Record. On 6/13/24 and 6/25/24, Resident 1's clinical record was reviewed: The Minimum Data Set (MDS, a clinical assessment tool), dated 1/13/22, listed a cognitive (ability to recall) score of six out of 15 (0-7, indicating severe cognitive impairment, 8-12, indicating moderate cognitive impairment, 13-15 suggests cognition is intact). 1a. According to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a Licensed Nurse (LN) 1 signed a resident's initial skin evaluation timely for one of one sampled resident (Resident 1) reviewed for skin conditions. As a result, Resident 1's medical record did not reflect timely completion of assessment. Findings: An unannounced onsite to the facility was conducted on 6/10/24 related to complaints on quality of care that happened in 2022. Resident 1 was admitted to the facility on [DATE], per the admission Record. Resident 1 was discharged from the facility on 2/5/22. On 6/10/24 and 6/25/24, Resident 1's clinical record was reviewed: According to the skin and wound evaluation conducted to Resident 1 on 1/7/22, LN 1 conducted the skin assessment on Resident 1. LN 1 identified the following Resident 1's skin conditions on admission: - Abrasion to the left elbow, - Abrasion to left outer forearm, - Rash on spine [sic], - Rash on upper left abdomen, - Rash on sternum [sic], - MASD on coccyx, and - MASD on groin.…

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 medical records were accurate for one of two sampled residents (Resident 1) when Resident 1's medical record indicated a licensed vocational nurse (LVN 1) administered an intravenous (IV) antibiotics (anti-infective) medication. As a result, documenting that an IV medication was administered to Resident 1 by a LVN, was not acceptable per standards of practice and could cause confusion among the healthcare providers. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses which included osteomyelitits (inflammation or swelling that occurs in the bone) of the backbone, per the facility's admission Record. During a record review of Resident 1's Medication Administration Record (MAR, is used to document medications taken by a patient that includes the type of medication given and the signature of the licensed staff member) for May 2024, the MAR for 5/15/24 at 12 midnight and at 4 A.M. indicated LVN 1 signed the MAR for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide consistent RNA (CNAs with specialized certification to provide rehabilitation services) to five of 12 residents (Resident 44, 55, 82, 112, 162) reviewed for limited range of motion (ROM). This failure had the potential for residents to experience a decrease in mobility and worsening contractures (permanent tightening of the muscles and tendons causing the joints to stiffen). Findings: 1. Resident 44 was admitted to the facility on [DATE], with diagnoses which included complete traumatic left lower leg amputation, per the facility's admission Record. On 8/23/22 at 9 A.M., an observation was conducted with Resident 44 as he sat on the side of his bed. Resident 44 had a left leg prosthesis (artificial limb) standing next to the bed. On 8/24/22 at 10:42 A.M., an interview and record review was conducted with the Director of Rehabilitation (DOR). The DOR stated Resident 44 was last seen for physical therapy on 4/26/22. The DOR stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide communication tools for two of four (Residents 48 and 114), reviewed for communication. This failure had the potential for staff to be unaware of the needs of Residents 48 and 114. Findings: 1. Resident 48 was admitted to the facility on [DATE], per the admission Record. 1. On 8/22/22 at 9:52 A.M., an observation was conducted of Resident 48 as he laid in bed. Resident 48 was unable to converse, due to a language barrier. The walls and the table tops contained no language tools for translation. Observed next to the telephone on the bedside table, were three handwritten phone numbers. On 8/23/22 Resident 48's clinical record was reviewed. The admission MDS (an assessment tool), dated 6/24/22, listed a cognitive score of 10, indicating moderate impaired cognition. The MDS section A1100, listed Language as, Vietnam/Cantonese. The care plan, titled Language Barrier, dated 6/9/22, listed Chinese, with an intervention of, Assist 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 protect confidential information for one of one resident reviewed for privacy (5). This failure had the potential for residents' private medical information to be visible to unauthorized persons. Findings: On 8/24/22 at 8:30 A.M., an observation was conducted of one of three nursing stations. On the upper counter of the nurses' station were two documents, with one document taped on the countertop. Two residents walked by the counter where the documents were observed. In addition, three facility staff members walked by the counter. One paper indicated, Day and date, [Facility Name Visitation Schedule] and listed five resident names. The document listed the time of the residents' outdoor, indoor, and Facetime video call with contact information. The second document indicated, 1:1 Monitoring Assignment, with the residents' name and room number written on the page. On 8/24/22 at 8:37 A.M., a concurrent interview and record review was conducted with the DSD. The DSD stated she did not know how long the documents…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow a physician's order for: 1. Oral hygiene for one of three residents reviewed for dental concerns (107) and, 2. Application of a medicated shampoo for one of one residents reviewed for skin conditions (107). This failure had the potential to place Resident 107 at risk for further dental complications and worsening skin condition. Findings: 1. Resident 107 was admitted to the facility on [DATE], per the admission Record. On 8/22/22 at 10:31 A.M., an interview was conducted with Resident 107. Resident 107 stated nobody had brushed or flossed her teeth that morning. On 8/22/22 at 11:59 A.M., an interview was conducted with CNA 1. CNA 1 stated the CNA's were to brush and floss Resident 107's teeth after every meal. CNA 1 stated she had not brushed or flossed Resident 107's teeth yet that morning. On 8/23/22 at 9:59 A.M., an interview was conducted with LN 1. LN 1 stated the physician had ordered tooth brushing using an electric…

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 medicated shampoo was applied as stipulated by facility policy, for one of one residents reviewed for skin conditions (107). This failure had the potential to place Resident 107 at risk for further skin complications. Findings: Resident 107 was admitted to the facility on [DATE], per the admission Record. Per a facility policy, revised 10/2018 and titled Medication Administration, Drug Administration refers to the act in which a single dose of a prescribed drug .is given to a resident by an authorized person .I. Who may administer: Only a licensed nurse .may administer medication . Per a facility policy, revised October 2010 and titled Administering Topical Medications, .The purpose of this procedure is to provide guidelines for the safe administration of topical medication .3. Place the MAR within easy viewing distance. 4. Unlock the medication cart. 5. Select the drug from the .drawer .9. Prepare the correct dose of medication.…

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 nail care was provided for one of two residents (69) reviewed for ADLs. This failure had the potential to result in an increased risk for infection. Findings: Resident 69 was readmitted to the facility on [DATE], with diagnoses which included diabetes (high blood sugar), per the facility's admission Record. A review of Resident 69's MDS (an assessment tool), dated 7/8/22, indicated his brief interview for mental status (BIMS - test the resident's cognition status) was 14 (13- 15 indicated intact cognition). The MDS section G indicated Resident 69 needed a one-person physical assist on personal hygiene. On 8/22/22 at 9:55 A.M., an observation and interview of Resident 69 was conducted. Resident 69 was lying in bed and placed his hands on top of his chest. Resident 69's fingernails were long, and had dirt underneath. Resident 69 stated his nails were long and needed to be trimmed. Resident 69 stated he told the staff and he was still…

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 staff provided assistance with eating for two of two residents reviewed for ADLs (40, 32). As a result, Residents 40 and 32 were unable to eat their meals. Findings: 1. Resident 40 was admitted to the facility on [DATE] with diagnoses which included dysphasia (difficulty swallowing) per the facility's admission Record. On 8/24/22 at 8:17 A.M., a concurrent observation and interview of Resident 40 was conducted. Resident 40 was awake, in bed with a breakfast tray in front of him on top of the bedside table. Resident 40's head of bed was noted to be lower than the bedside table. Resident 40 attempted to reach up for the utensils but was unable to. Resident 40 stated he had been waiting for the staff to assist him with his breakfast for about ten minutes. At 8:25 A.M., Resident 40 attempted to reach up for the utensils again and was unsuccessful. On 8/24/22 at 8:40 A.M., a joint observation of Resident 40 and an interview with CNA…

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 provision of pharmacy services met the needs of the residents when: 1. Discontinued medications were left in the medication cart for resident use; 2. Metoprolol (medication to treat high blood pressure) was not administered as ordered by the physician for Resident 29. This had the potential to increase the risk for dizziness, confusion, and fainting; and 3. Midodrine (medication to treat low blood pressure) was not administered as ordered by the physician for Resident 112. This had the potential to increase the risk for heart disease and stroke. Findings: 1. On 8/23/22, at 3:30 P.M., the medication cart on third floor was inspected with LN 41 and there were two discontinued medications stored in the medication cart along with active medications: One blister pack containing clonidine (medication to treat high blood pressure) 0.1 milligram (mg) tablets for Resident 104 that was discontinued on 5/18/22; and One box containing 30 tablets of Zofran…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the consultant pharmacist, in their monthly medication regimen review, identified and reported irregularities in the medication therapy of the residents when: 1. Resident 96 had two physician orders for ropinirole (medication to treat restless leg syndrome, uncontrollable urge to move the legs due to uncomfortable sensation) that could potentially exceed the maximum dose for ropinirole specified by the manufacturer; 2. Resident 112 had a physician's order for Norco (narcotic pain medication) despite the resident's documented allergy to morphine (narcotic pain medication similar in structure to Norco); and 3. Resident 112 had physician's orders for citalopram (medication to treat depression, mood disorder causing one to feel sad, empty, loss of interest), Geodon and Seroquel (medications to treat schizophrenia, a serious mental disorder in which people interpret reality abnormally) in the presence of major drug interactions. These failures could…

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 residents were free from unnecessary medications when: 1. Resident 121 was receiving apixaban (blood thinner that prevents blood clotting) and was not monitored for signs and symptoms of bleeding; and 2. Resident 112 was receiving levetiracetam (medication to prevent seizures or convulsions) without monitoring for seizure activity or episodes to assess the effectiveness of the medication. Findings: 1. On 8/24/22, Resident 121's medical record was reviewed and the following was noted: The resident was admitted to the facility on [DATE], with diagnoses that included congestive heart failure, hypertension (high blood pressure), and atrial fibrillation (irregular beating of the heart). There was a physician's order on 8/7/22 for apixaban 5 milligram (mg - unit of measurement) with the direction to give the resident one tablet by mouth two times a day for non-valvular (related to heart valve) atrial fibrillation and monitor for signs and symptoms of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure residents were free from excessive, unnecessary psychotropic medications when: 1. Resident 29 had physician orders for two antidepressant medications for depression (sad mood and lack of interest) in the same therapeutic class without documented rationale for use; and 2. Resident 112 had physician's orders for two antipsychotic medications without documented rationale for use. These failures could result in medication related adverse events from duplicate medication therapy. Findings: 1. On 8/24/22, Resident 29's medical record was reviewed and the following was noted: The resident was admitted to the facility on [DATE] with diagnoses that included major depressive disorder. There was a physician's order on 5/25/22 for fluoxetine (brand name: Prozac; medication to treat depression, sad mood and lack of interest) 20 mg (milligram - unit of measurement) with the direction to give the resident one tablet by mouth two times a day for depression.…

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 medication error rate for medication pass observation did not exceed 5 percent. There were 29 opportunities. Two medication errors were identified. The error rate was 6.9 percent. Findings: 1. On 8/23/22, at 9:35 A.M., during a medication pass observation, it was observed LN 41 administered four sprays, two in each nostril, from the bottle of fluticasone (medication to treat allergy symptoms such as sneezing, itching, and runny or stuffy nose) nasal spray to Resident 104 without shaking the bottle. The label on the bottle indicated shake gently before using. The resident's medical record indicated there was a physician's order on 8/17/22 for fluticasone suspension with the direction to administer two sprays in each nostril in the morning for allergy. On 8/23/22, at 3:20 P.M., in an interview, LN 41 acknowledged he did not shake the bottle. 2. On 8/23/22, at 9:35 A.M., during a medication pass observation, it was observed LN 41 administered to Resident 104, two puffs of Pulmicort (medication to treat…

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 conduct an antibiotic stewardship (an ongoing program to monitor and review antibiotic use) for one of three residents (Resident 41), reviewed for infections. This failure had the potential for Resident 41 to become resistant to antibiotic therapy from the prolonged use. Findings: Resident 41 was admitted to the facility on [DATE], with diagnoses which include encephalopathy (a disease of the brain that alters brain function), per the facility's admission Record. On 8/22/22 Resident 41's clinical record was reviewed. The physician's order dated 6/2/22, listed doxycycline (an broad-spectrum antibiotic used to treat bacterial infections in the body) 100 milligrams (mg) one time a day for infection. There was no documentation of where the infection was in the body. There were no documentation of laboratory results, cultures or x-rays results following the 6/2/22 start date. There was no documentation of an antibiotic stewardship review by the infection…

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 clinicians followed accepted Resident Assessment Instrument (resident care planning) guidelines to accurately assess anticoagulant (blood thinner) use on the Minimum Data Set (MDS-screening tool) for 11 of 36 sampled residents (8, 45, 48, 91, 95, 113, 121, 128, 130, 135, and 138). This failure provided inaccurate resident information to the federal database, and had the potential to affect the residents' care. Findings: Per Section N0410E of the RAI Version 3.0, dated October 2018, . Per N0410E, Anticoagulant (e.g.,warfarin, heparin, or low-molecular weight heparin) 1. Resident 8 was readmitted to the facility on [DATE] with diagnoses to include heart failure, per the facility's admission Record. On 1/17/19, Resident 8's record was reviewed. The MDS assessment, dated 1/8/19, indicated Resident 8 had received medication classified as an anticoagulant over the last 7 days. No anticoagulant medication had been ordered by the physician. 2. 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 observation, interview and record review. The facility did not provide accommodations for a wheel chair bound resident when 1 of 36 residents, Resident 50, could not reach the shirts hanging in his closet and the paper towels in his bathroom. This deficient practice prevented Resident 50 from achieving independent functioning, dignity, and well-being in accordance with his needs and preferences. Findings: Resident 50's initial admission to the facility was on 5/23/13 with diagnoses which included, paraplegia (inability to move the legs). On 1/15/19 at 2 P.M., Resident 50 was observed in his room. Resident 50 was observed pulling on the bottom of a shirt that was hanging in his closet. Resident 50 stated, I've been trying to get my shirt off the hanger, but now I need to call the CNA because it is not coming down. On 1/16/19 at 7:45 A.M., CNA 3 was interviewed. CNA 3 stated staff routinely helped Resident 50 by getting clothes down from his closet. On 1/18/19 at 2:15 P.M., an observation and interview was conducted with Resident 50. Resident 50 stated he could not reach the…

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

Based on observation, interview, and record review the facility failed to correctly administer an antibiotic medications to 1 of 36 sampled residents (364 ). This failure had the potential to negatively affect Resident 364's treatment for an infection. Findings: On 1/11/19 Resident 364 was admitted to the facility with diagnosis which included cellulitis (an infection of the skin) of the right lower limb per the facility's admission Record. On 1/16/19 at 8:25 A.M., an interview was conducted with LN 16. LN 16 stated Resident 364 had an infection and took Cipro (an antibiotic) for treatment. LN 16 read the label on the Cipro bottle, give PO (by mouth) every 12 hours for 9 days, to be taken 2 hours before or after antacids, iron, and zinc. On 1/16/19 at 8:29 A.M., LN 16 was observed administering medications to Resident 364. LN 16 administered a 500 mg tablet of Cipro, 1 tablet multivitamin (which contained iron and zinc), and a 220 mg tablet of zinc to Resident 364. On 1/18/18 at 2:40 P.M., an interview with LN 16 was conducted. LN 16 stated she did not follow the Cipro label…

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 prepare therapeutic diets (diets prescribed by a physician for treatment of a medical condition) for 1 of 36 sampled residents (176). This failure had the potential for Resident 176 to experience difficulty swallowing when eating and drinking. Findings: Resident 176 was admitted on [DATE] with diagnosis of dysphagia (difficulty swallowing) per the facility's admission Record. During a meal observation on 1/16/19 at 7:45 A.M., Resident 176 had no breakfast while other residents sitting beside him in the dining room were eating their breakfast. CNA 11 was interviewed on 1/16/19 at 7:48 A.M. CNA 11 stated Resident 176's meal tray had been returned to the kitchen because the wrong texture of liquids were on the tray. CNA 11 stated Resident 176's liquids were changed from thickened liquids to thin liquids per the physician's order. During an interview with LN 13 on 1/16/19 at 8:01 A.M., LN 13 stated Resident 176's therapeutic diet changes had…

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 hospice agency's contact information, documentation of services, and prospective visit calendar was present in the clinical record for one of two hospice residents (60). As a result, there was the potential to put Resident 60 at risk for delayed or uncoordinated care between the facility healthcare team and the hospice agency. Findings: Resident 60 was admitted to the facility on [DATE] under hospice (comfort) care, per the facility's admission Record. On 1/16/19 at 9:40 A.M., an interview was conducted with CNA 21. CNA 21 stated she did not know when the HA (hospice aide) came to care for Resident 60. On 1/16/19 at 10:30 A.M., an interview and record review was conducted with LN 21. LN 21 looked at Resident 60's medical record and was unable to find a schedule for hospice visits for December 2018, or January 2019. LN 21 could not find documentation of hospice visits from 11/22/18 to 1/16/19. LN 21 stated she could not find 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 implement their smoking policy when 1 of 36 sampled residents was not informed, assessed, or referred to the DON when smoking. (364) As a result, Resident 364 was not provided a safe smoking environment. Findings: Resident 364 was admitted to the facility on [DATE] with diagnoses to include nicotine dependence, per the facility's admission Record. On 1/17/19 at 3:21 P.M., an interview with Resident 364 was conducted. Resident 364 stated he was not provided with paperwork related to non-smoking. Resident 364 stated, during his admission, the staff had not gone through his belongings, nor asked if he was a smoker. Resident 364 stated, he had 2 cigarettes left. Resident 364 stated the staff accompanied him when he smoked on the sidewalk, and by the parking lot. On 1/17/19 at 3:35 P.M., an interview with CNA 40 was conducted. CNA 40 stated she followed and assisted Resident 364 to go out to smoke. On 1/17/19 at 4:15 P.M., an interview with the Admissions…

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.