Brighton Place San Diego

Based on observation and interview, the facility failed to ensure: 1. Food was discarded before the expiration date 2. Food containers were labeled after opening 3. Dietary staff had their facial hair covered while in the kitchen for one of one kitchens. These failures placed residents at an increased risk of food-borne illness. Findings: 1. On 1/12/25 at 7:50 A.M., an observation was conducted of the walk-in refrigerator in the kitchen. There was a container of dill pickle relish with a use by date of 12/11/24. On 1/12/25 at 7:55 A.M., a concurrent observation and interview was conducted with [NAME] 1. [NAME] 1 stated, the dill pickle relish was past it's use by date and should have been thrown out. On 1/13/25 at 9:10 A.M., an interview was conducted with Dietary Supervisor (DS) 1. DS 1 stated, the expired relish should have been thrown out. The facility's policy, titled Food Storage and Handling, revised 2/29/24, did not have guidance on how to handle pickled food, or general guidance on use by dates. 2. On 1/12/25 at 7:50 A.M., an observation was conducted of the walk-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 observations, interviews, and record review, the facility failed to follow their infection control policies and procedures to prevent the spread of infection and cross contamination when: 1. Resident 72's oxygen supplies were not stored properly. 2. The facility did not have an infection surveillance tracker to properly conduct a contact tracing for residents with respiratory illness. 3. The facility did not properly screen staff and visitors during an active coronavirus (COVID19- a virus that can cause severe respiratory illness) outbreak. This failure had the potential to increase the spread of infection for all residents, staff and visitors in the facility. The facility census was: 95. Findings: 1. A review of Resident 72's admission Record indicated Resident 72 was re-admitted to the facility on [DATE] with diagnoses which included a history of cerebral Infarction (type of stroke, when the part of the brain tissues dies and loss of blood flow to the brain). A record review of Resident 72's minimum…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two of 32 rooms (room [ROOM NUMBER] and room [ROOM NUMBER]) were not occupied by more than four residents This failure could potentially cause overcrowding and compromise the quality of care for the residents occupying the six-bed rooms. Findings: A tour of the facility was conducted on 1/12/25 at 7:41 A.M. At 8:12 A.M., room [ROOM NUMBER] was observed to occupy six residents. room [ROOM NUMBER] was also observed to occupy six residents. An interview and record review was conducted with the Administrator (ADM) on 1/13/25 at 3:08 P.M. The Client Accommodations Analysis was received indicating rooms [ROOM NUMBERS] each had a capacity for six residents. The Analysis indicated Bedroom [ROOM NUMBER] and 132 had a bedroom waiver. The ADM stated the facility did not have any room waivers. The ADM stated the last room waiver was from 2012. A follow-up interview was conducted with the ADM on 1/15/25 at 9:02 A.M. The ADM stated it 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 interviews, and record reviews, the facility failed to send a copy of the notice to transfer/discharge form to the Ombudsman office for two of six reviewed residents (Resident 6 and 72) that required immediate transfer to an acute care hospital for urgent needs. These failures resulted in a lack of resident discharge notification to the State Long Term Care (LTC) Ombudsman to advocate and assist the residents (Resident 6 and 72) with appeal rights as needed. Findings: 1. A review of Resident 6's admission Record indicated Resident 6 was re-admitted to the facility on [DATE] with diagnoses which included a history of cerebrovascular accident (CVA-stroke, loss of blood flow to a part of the brain). On 1/12/25 at 3:46 P.M., a record review was conducted. Resident 6 had a change of condition (COC) progress note dated 12/11/24 that indicated Resident 6 was transferred to acute care related to an abnormal heart rate (HR) of 35 with notification given to the Medical Doctor (MD) and son. On 1/14/25 at 9:06…

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.

Based on observation, interview, and record review the facility failed to complete a comprehensive elopement assessment for one of six sampled residents (Resident 198). As a result, Resident 198 eloped from the facility. Findings A review of Resident 198's admission Record dated 12/27/24, indicated that Resident 198 had a diagnosis of Alzheimer's disease (a disease characterized by a progressive decline in mental abilities). During an observation on 1/12/25 at 10:50 A.M. Resident 198 was observed ambulating without assistance or assistive devices in the main hallway of the building. Resident 198 was accompanied by a facility staff member. During an observation on 1/13/25 at 8:50 A.M. The location of Resident 198's elopement was identified and found to provide access to Highway on and off ramps. During an interview on 1/13/25 at 8:50 A.M. with the Administrator (ADM). The ADM stated on 1/2/25, Resident 198 came out of the door, set off the alarm, went past two residents, climbed over the fence, and went toward the church. The staff followed and Resident 198 was found at the church…

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 reviews, the facility failed to accurately code the Minimum Data Set (MDS-a federally mandated resident assessment tool) according to the Resident Assessment Instrument (RAI-instructions for MDS) manual and the facility's MDS policies and procedures for three of 29 sampled residents (Resident 72, 29, and 23) when: 1. Resident 72's fall incident was not accurately coded. 2. Resident 29's fall incident was not accurately coded. 3. Resident 23's pneumonia diagnosis was coded as active without supporting documentation. As a result, the facility sent Residents (Resident 72, 29, and 23) MDS's to the federal database with inaccurate health status. Findings: 1. A review of Resident 72's admission Record indicated Resident 72 was re-admitted to the facility on [DATE] with diagnoses which included a history of cerebral Infarction (type of stroke, when the part of the brain tissues dies and loss of blood flow to the brain). A record review of Resident 72's MDS dated [DATE]…

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 Preadmission Screening Resident Review (PASRR, a federal requirement to help ensure that individuals were not inappropriately placed in nursing homes) was accurate for one of six sampled residents (Resident 69). This failure had the potential for Resident 69's mental health needs to be unmet. Findings: Resident 69 was admitted to the facility on [DATE] with diagnoses including psychosis (a mental illness involving hallucinations and delusions) and depression (a mental illness involving long periods of being sad or hopeless) per the admission Record. A review of Resident 69's medical record was conducted on 1/12/25. Resident 69 was discharged from a hospital prior to his admission to the facility with medications including aripiprazole (an antipsychotic medication) to start on 12/15/24. A review of Resident 69's physician's orders for January 2025 indicated a current order for aripiprazole. An interview and record review was conducted 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to implement or develop a person centered care plan for two of 29 sampled residents (Resident 84, 9, 198) when: 1. Resident 84's nutritional care plan did not address nutritional preferences and dislikes. 2. Resident 9's care plan did not include a Hospice care plan. 3. Resident 198's care plan did not indicate a person-centered approach to prevent future wandering/elopement while at the facility. As a result, Resident 84's and Resident 9's plan of care was not personalized that promotes or maintains their highest practicable physical, mental, and psychosocial well-being. Cross-Reference F803 Findings: 1. A review of Resident 84's admission Record indicated Resident 84 was admitted to the facility on [DATE] with diagnoses which included a history of Chronic Kidney Disease Stage four (CKD stage 4- kidneys are moderately or severely damaged and are not properly filtering waste from your blood). A record review of Resident 84's minimum data…

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 interventions for skin breakdown and/or pressure injury (bed sores) for one of five sampled residents (47) was maintained. Resident 47 had a low air loss mattress (LAL mattress: An air mattress to prevent pressure injury) for prevention of skin breakdown that were not set to the residents' current weight. This failure had the potential for Resident 47 to develop a pressure injury. Findings: 1. Resident 47 was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD, a lung disease making it difficult to breathe) per the admission Record. An observation was conducted on 1/12/25 at 9:17 A.M. Resident 47 was observed laying in bed with a LAL mattress set to static mode (no alternating pressure) and set for a resident weighing 400 pounds. A review of Resident 47's record was conducted on 1/14/25. Resident 47 had an active physician's order for Bariatric low air loss mattress, set to resident 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 one of 29 sampled residents' (Resident 84) planned meal tray card (guidance to staff on what to serve for a meal to a resident) and menu was nutritionally substituted according to preferences to promote nutritional adequacy to current health status. This failure had the potential to result in a poor nutritional intake and weight loss. Cross-reference F656 Findings: 1. A review of Resident 84's admission Record indicated Resident 84 was admitted to the facility on [DATE] with diagnoses which included a history of Chronic Kidney Disease Stage four (CKD stage 4- kidneys are moderately or severely damaged and are not properly filtering waste from your blood). A record review of Resident 84's minimum data set (MDS - a federally mandated resident assessment tool) dated 10/28/24 indicated, a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of 12 points out of 15…

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 food in a form to meet the needs of one of six sampled residents (Resident 27). This failure had the potential to cause unintended weight loss and medical complications. Findings Per Resident 27's admission record, Resident 27 was admitted on [DATE] with diagnoses including Cerebral Infarction (blood loss to the brain) and End Stage Renal Disease (ESRD-irreversible kidney failure). A record review of Resident 27's minimum data set (MDS - a federally mandated resident assessment tool) dated 12/12/24 indicated, a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of 12 points out of 15 possible points which indicated Resident 27 had moderate cognitive (pertaining to memory, judgement and reasoning ability) deficits. During an observation on 1/12/25 at 12:45 P.M. A lunch time meal tray was delivered to Resident 27. The Meal ticket stated chopped meat. 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 observations, interviews, and record reviews, the facility failed to follow their smoking policy for two of 17 residents (Residents 18 and 40) reviewed for smoking and tobacco use. This deficient practice had the potential for accidents and injuries. Findings: 1. A review of Resident 18's admission Record indicated Resident 18 was re-admitted to the facility on [DATE] with diagnoses which included a history of diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). A record review of Resident 18's minimum data set (MDS - a federally mandated resident assessment tool) dated 4/29/24 indicated, a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of 15 points out of 15 possible points which indicated Resident 18 had no cognitive (pertaining to memory, judgement and reasoning ability) deficits. Resident 18's MDS also indicated Resident 18 was a smoker. On 1/14/25 at 12:41 P.M., 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 staff failed to monitor and document urine output (UO) per the facility's policy, for one of three sampled residents (Resident 2) with a urinary catheter (a tube inserted into the bladder to aid in urine flow). This failure had the potential for Resident 2 to have urinary retention and developed urinary tract infection (UTI). Findings: On 11/15/24, the Department received a complaint related to Resident Assessment. On 11/26/24, an unannounced visit to the facility was conducted. Resident 2 was admitted to the facility on [DATE], with diagnoses which included fracture of the cervical bones and needed assistance with personal care, per the facility's admission Record. On 11/26/24, a review of Resident 2's minimum data set (MDS - a federally mandated assessment tool), dated 11/5/24, indicated Resident 2 had a urinary catheter on admission. On 11/26/24 at 1:20 P.M., an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated Resident 2 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 interview, and record review, the facility failed to ensure proper medication administration for one of three sampled residents (Resident 1), when an anti-rejection medication (are medicines that keep organ transplants from being attacked by the immune system) was not administered per the physician's order. As a result, there was an increased risk for Resident 1's transplanted organ to be rejected by her body. Findings: On 11/12/24, the Department received a complaint related to quality of care. On 11/26/24, an unannounced visit to the facility was conducted. A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included liver transplant. A review of Resident 1's physician order dated 9/27/24 indicated the following order: - Tacrolimus (anti-rejection medication) 1 mg 3 caps (3 mgs total) twice a day (given at 8 A.M. and 5 P.M.) via gastrostomy tube (Gtube, a surgical opening fitted with a device to allow feedings and medications to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of two sampled residents (1) who had a colostomy (a surgical procedure that creates an opening in the large intestine, or colon, through the abdominal wall for the stool to pass into a bag) received the necessary care and treatment when the facility did not develop a baseline care plan (sufficient information to provide care properly), get a physician order, and treatments provided to Resident 1 was documented in the resident's treatment administration record (TAR). These failures had the potential for Resident 1 not to receive colostomy care timely as prescribed by the physician and not receive consistent care from the licensed nurses during colostomy bag changes. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses that included colostomy status and was transferred to the hospital on 8/4/24 per the admission Record. A review of Resident 1's medical record was conducted. There was no documented evidence of Resident 1's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to implement measures to keep a resident from elopement (leaving the facility without permission) and provide monitoring for one sampled resident (Resident 1). In addition, the Licensed Nurse (LN) 2 failed to clarify an out on pass (therapeutic leave) order for Resident 1 on 5/28/24. As a result, Resident 1 eloped on 6/1/24 and returned to the facility on 6/2/24. This failure had the potential to compromise Resident 1's health, safety and well- being. Findings: On 6/3/24, the Department received a facility reported incident (FRI) related to Resident 1 ' s elopement. On 6/5/24, an unannounced onsite to the facility was conducted. Resident 1 was admitted to the facility on [DATE] per the facility's admission Record. During a review of Resident 1's History and Physical (H&P), dated 5/22/24, the H & P indicated Resident 1 had the mental capacity to make medical decisions. During a concurrent interview and a review of Resident 1's clinical record on 6/5/24…

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 conduct reference checks prior to hiring a certified nursing assistant (CNA)1. This failure had the potential to increase the risk of abuse for facility residents. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder (a mental health disorder involving mood) and anxiety disorder (excessive worrying) per the facility's admission Record. A report of physical abuse was received by the district office on 4/8/24. An unannounced on-site visit was conducted on 4/18/24. An observation/interview was conducted with Resident 1 on 4/18/24 at 11 A.M. Resident 1 was in the dining room and stated, I don't want to talk about it. An interview was conducted with the Director of Social Services (SSD) on 4/18/24 at 10 A.M. The SSD stated, Resident 1 stated a CNA pulled off her clothes and pushed her against the side rails. No bruises were noted. In addition, the CNA was suspended from his duties. 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 consistently provide dialysis (treatment to remove waste from the body) access care, including removal of dressing and assessment of the site for one of three sampled residents (Resident 1). In addition, the dialysis communication form was not completed consistently for three of three sampled residents (Resident 1, Resident 2, and Resident 3), reviewed for dialysis. As a result, there was the potential for complications after dialysis. Findings: 1. Resident 1 was readmitted to the facility on [DATE], with diagnoses which included end stage renal disease (irreversible kidney damage) and dependence on dialysis, per the facility's admission Record. Resident 1's history and physical (H&P) dated 10/3/23, indicated Resident 1 was alert and oriented to person, place, and time. On 4/3/24 at 1:52 P.M., an observation and an interview of Resident 1 was conducted. Resident 1 was assisted by the certified nursing assistant (CNA) 1 back to her bed.…

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 be provided prescribed medication to two of three residents reviewed (Resident 1, 2). This failure had the potential to cause a decrease in health status of Resident 1 and 2. Findings: On 1/31/24 and 2/2/24, the Department of Public Health received two complaints related to quality of care/medication not given. 1.Resident 1 was admitted to the facility on [DATE] with diagnoses to include osteomyelitis left leg (bone infection, sepsis due to methicillin susceptible staphylococcus aureus (severe infection caused by germs), muscle weakness, paraplegia (loss of movement in lower extremities), paroxysmal atrial fibrillation (irregular heart movement causing fatigue, lightheadedness or stroke), venous thrombosis and embolism (blood clots) per the admission Record. A review of Resident 1 ' s records was conducted. On 12/15/23, Resident 1 ' s Minimum Data Set, (MDS, assessment tool) indicated Resident 1 ' s cognition (the understanding of thought…

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, record review, review of a technical brief from the manufacturer of the facility's blood glucose monitoring system, review of the Environmental Protection Agency's (EPA) list of approved disinfectants, and facility policy review, the facility failed to ensure staff cleaned and disinfected a multi-resident glucometer in accordance with manufacturer's instructions between use for 2 (Resident #48 and Resident #83) of 4 total residents observed for fingerstick blood sugars. In addition, the facility failed to implement their Water Management policy to prevent the potential growth and spread of Legionella (a bacteria known to cause Legionnaires' disease) and other water-borne pathogens. This had the potential to affect all 89 residents residing in the facility. Findings included: 1. Review of Resident #48's admission Record revealed the facility admitted the resident on 05/23/2020 with diagnoses that included type two diabetes mellitus. Review of Resident #48's Order Summary Report, listing active orders as of 02/22/2024, revealed an order dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and facility document review, the facility failed to ensure rooms were not occupied by more than four residents. Specifically, room [ROOM NUMBER] was occupied by six residents, and room [ROOM NUMBER] was occupied by five residents, with an additional bed available for a total occupancy of six residents when the room was at full capacity. This deficiency affected 2 (room [ROOM NUMBER] and room [ROOM NUMBER]) of 32 rooms in the facility. Findings included: Review of the facility's Midnight Census report, dated 02/22/2024, revealed the facility had two rooms set up to occupy more than four residents. room [ROOM NUMBER] was at full capacity and was occupied by six residents. room [ROOM NUMBER] was equipped to house six residents but was occupied by five residents; room [ROOM NUMBER]-6 was listed as Empty. During the entrance conference on 02/20/2024 at 9:15 AM, the Administrator reported the facility had a waiver for their rooms with six beds. Review of a waiver approval letter to…

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

Based on record review, interviews, and facility policy review, the facility failed to notify the physician that 1 (Resident # 84) of 5 sampled residents reviewed for unnecessary medications was consistently refusing medications. Findings included: A review of a facility policy titled, Medication - Administration, revised on 01/01/2012, revealed, VIII. Refusing Medication A. If a resident is refusing to take medication, time of refusal must be circled in the Medication Administration Record (MAR) and initialed by the Licensed Nurse who is passing meds [medications] and documentation will be entered on the back of the MAR stating the reason for refusal. The Licensed Nurse will attempt to give the medications several times, but if the resident continues to refuse after one hour, the refused medications will be destroyed. Licensed Nurse will notify M.D. [Medical Doctor] and document in the medical record. A review of an admission Record revealed the facility admitted Resident #84 on 07/27/2023. According to the admission Record, the resident had a medical history that included…

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 record review, interviews, facility policy review, and review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument [RAI] 3.0 User's Manual, the facility failed to ensure Minimum Data Set (MDS) assessments reflected current tobacco use for 1 (Resident #50) of 2 sampled residents reviewed for smoking. Findings included: Review of a facility policy titled, RAI Process, revised on 10/04/2016, revealed, Purpose To provide resident-assessments that accurately depict and identify resident-specific issues and objectives as required, while meeting state and federal guidelines and data submission requirements. Review of the CMS Long-Term Care Facility Resident Assessment Instrument [RAI] 3.0 User's Manual, Version 1.18.11, dated October 2023, Chapter 3: Overview to the Item-by-Item Guide to the MDS 3.0, Section J revealed, Section J1300: Current Tobacco Use specified, Steps for Assessment 1. Ask resident if they used tobacco in any form during the 7-day…

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

Based on interviews, record review, facility policy review, and review of the California Department of Health Care Services Preadmission Screening and Resident Review (PASRR) Level 1 Assessment Guide, the facility failed to submit a status change to a Pre-admission Screening and Resident Review (PASRR) Level I Screening Document following a new mental illness diagnosis for 1 (Resident #48) of 2 sampled residents reviewed for PASRR requirements. Specifically, Resident #48 had a negative PASRR Level 1 Screening upon admission to the facility but was later diagnosed with a new mental illness diagnosis, and the facility failed to submit a status change to the resident's PASRR Level I Screening. Findings included: Review of a facility policy titled, Pre-admission Screening Resident Review (PASRR), revised on 08/15/2016, revealed, Purpose To ensure that all Facility applicants are screened for mental illness and mental retardation prior to admission. The facility's policy did not address what steps should be taken when a resident was diagnosed with a new mental illness diagnosis. Review…

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

Based on interviews, record review, facility policy review, and review of the California Department of Health Care Services Preadmission Screening and Resident Review (PASRR) Level 1 Assessment Guide, the facility failed to ensure a Pre-admission Screening and Resident Review (PASRR) Level I Screening Document reflected the presence of a diagnosed mental illness at the time of admission for 1 (Resident #48) of 2 sampled residents reviewed for PASRR requirements. Specifically, Resident #48 had a diagnosis of major depressive disorder at the time of admission to the facility, but their PASRR Level I Screening reflected they had no diagnosed mental illnesses, resulting in a negative PASRR Level 1 Screening. Findings included: Review of a facility policy titled, Pre-admission Screening Resident Review (PASRR), revised on 08/15/2016, revealed, Purpose To ensure that all Facility applicants are screened for mental illness and mental retardation prior to admission. Review of the California Department of Health Care Services Preadmission Screening and Resident Review (PASRR) Level 1…

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

Based on observations, interviews, record reviews, and facility policy review, the facility failed to provide nail care and remove facial hair for 2 (Resident #33 and Resident #84) of 4 sampled residents reviewed for assistance with activities of daily living (ADLs). Findings included: A review of a facility policy titled, Grooming, revised on 01/01/2012, revealed the purpose of the policy was To promote independence, hygiene, comfort, self-esteem and dignity for residents through improving their ability to dress themselves. The policy indicated, The Facility will work with residents to improve their ability to groom him/herself to promote independence, hygiene, comfort, self-esteem and dignity by teaching the resident to groom him/herself with the use of assistive devices or techniques and with the appropriate types and amount of assistance. 1. A review of an admission Record revealed the facility admitted Resident #84 on 07/27/2023. According to the admission Record, the resident had a medical history that included diagnoses of type two diabetes mellitus, unspecified dementia, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure the electronic medical record (EMR) for 1 (Resident #26) of 4 sampled residents reviewed for advance directives accurately reflected the resident's desired code status (describes the type of resuscitation procedures, if any, a person would like their healthcare team to provide in the event their heart stopped beating, or they stopped breathing). Specifically, Resident #26's EMR reflected the resident was to receive cardiopulmonary resuscitation (CPR) instead of do not resuscitate (DNR) as desired by Resident #26 and as indicated by their Physician Orders for Life Sustaining Treatment (POLST). Findings included: A review of an admission Record revealed the facility originally admitted Resident #26 on [DATE] and readmitted the resident on [DATE]. The Advanced Directive section of the admission Record listed the resident's code status as CPR. A review of an After Visit Summary, from Resident #26's [DATE] to [DATE] hospitalization, revealed 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 record review and interviews, the facility failed to ensure medication delivered by the pharmacy for 1 (Resident #245) of 22 sampled residents was appropriately received by facility staff in a manner to ensure the medication was placed in the resident's medication storage area and readily available for administration. Findings included: Review of an admission Record revealed the facility admitted Resident #225 on 02/15/2024 with diagnoses that included hypokalemia (low potassium level in the bloodstream) and hypertension (high blood pressure). Review of Resident #245's Order Summary Report, listing active orders as of 02/22/2024, revealed an order dated 02/16/2024 for metoprolol tartrate (a medication classified as a beta-blocker) 25 milligrams (mg), give one tablet by mouth twice a day, hold if systolic blood pressure (SBP) is less than (<) 110 millimeters of mercury (mmHg). Review of Resident #245's February 2024 Medication Administration Record (MAR) revealed documentation that staff did not administer the resident's 5 PM dose of metoprolol tartrate on 02/16/2024,…

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

Based on record review, interviews, and facility policy review, the facility failed to ensure 1 (Resident #48) of 5 sampled residents reviewed for unnecessary medications and 6 residents observed during medication administration was free from significant medication errors. Specifically, facility staff failed to hold (not give) Resident #48's medications when their systolic blood pressure was outside of parameters ordered by the physician. Findings included: Review of a facility policy titled, Medication - Administration, revised on 01/01/2012, revealed, Purpose To ensure the accurate administration of medications for residents in the Facility. The policy further indicated, C. Tests and taking of vital signs, upon which administration of medications or treatments are conditioned, will be performed as required and the results recorded. i. When administration of the drug is dependent upon vital signs or testing, the vital signs/testing will be completed prior to administration of the medication and recorded in the medical record i.e. [id est, that is] BP [blood pressure], pulse, finger…

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 prescribed medication, Xifaxan (a medication prescribed to treat symptoms of liver failure) to one of three residents reviewed (Resident 1). This failure had the potential to cause a decrease in health status for Resident 1. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses to include cirrhosis of the liver (damage to the liver which leads to scarring and liver failure) and hepatic encephalopathy (loss of brain function that occurs when a damaged liver does not remove toxins from the blood), per a facility admission Record. A review of Resident 1's electronic medical record (eMR) was conducted. On 5/5/23, the day of admission to the facility, Licensed Nurse (LN) documented Resident 1 was oriented, or aware of her name, the time, and her location. On 5/5/23, the physician (MD 1) ordered Xifaxan twice a day for hepatic encephalopathy, to start on 5/6/23. Starting on 5/6/23, the LNs documented the code of 9 on the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow physician orders for four of six residents reviewed (Residents 3, 90, 241 and 30), when: 1. Insulin was administered two hours after breakfast for Resident 3; and 2. Resident 90's 72 hour neurological checks were not completed, following an unwitnessed fall; and, 3. Resident 241's medication administration via G-tube (a gastric tube inserted through the belly directly to the stomach for administration of liquid nourishment, fluids and medications) were crushed and administered together, along with liquid medications and the LN did not flush between medication administrations; and, 4. Resident 30's crushed mediations were not flushed between G-tube administrations as ordered. As a result, there was a potential for Resident 3's blood sugar to be uncontrolled, Resident 90 to have a head injury to go unrecognized and Resident's 241 and 30 to have drug interactions when medications were not administered separately and to have clogged the G-tube due…

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 monitor fluid intake for three of three residents (Residents 10, 47, 82), reviewed for fluid restrictions, (a limited amount of liquids each day), due to dialysis (a treatment for kidney failure, which removed toxins and excess fluid by filtering the blood) treatments. This failure had the potential for Residents 10, 47, and 82, to develop fluid overload or dehydration. Findings: 1. Resident 10 was re-admitted to the facility on [DATE], with diagnoses, which included end stage renal disease, per the facility's Facesheet. On 5/13/21, Resident 10's clinical record was reviewed: Physician's order, dated 4/26/21, .1 liter (a metric unit of capacity) fluid restriction ever 24 hours . Care plan, titled Risk of Dehydration, dated 11/16/21, list interventions, .Maintain intake and output Log as indicated . MAR from 5/1/21 through 5/13/21, for fluid restrictions indicated no nursing initials or fluid monitoring. Facility's LN Intake book, had Resident 10…

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 medication error rate was less than five percent. Eleven medication errors out of 42 opportunities were identified during medication administration, when nursing: 1. Administered five crushed medications via G-tube (a gastric tube inserted through the belly directly to the stomach for administration of liquid nourishment, fluids and medications) at the same time. In addition, to administering a combination of four separate liquid medications via G-tube at the same time to Resident 241. 2. Administered two crushed medications via G-tube at the same time to Resident 30. This failure resulted in the medication error rate of 26.1%. Findings: 1. Resident 241 was admitted on to the facility on 3/26/21 with diagnoses that include CVA (a lack of blood supply to the brain) and Dysphagia (a difficulty with swallowing) per the facility's face sheet. On 5/10/21, a review of Resident 241's MDS (Health status screening and assessment tool),…

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 consistently provide snacks for two of two unsampled residents (CN 3, and CN 4). In addition, the facility did not provide a variety of fresh fruits such as bananas for two of five unsampled residents (CN 2, CN 5). As a result, there was potential for residents to experience hunger for long periods of time. Findings: On 5/11/21 at 10:05 A.M., CN 3, and CN 4, reported they were not receiving evening snacks. In addition, CN 2 and CN 5 reported they were not receiving fresh fruits like bananas. On 5/11/21 at 2:17 P.M., an interview was conducted with CNA 14. CNA 14 stated snacks were provided to the resident around 10 A.M., and 2 P.M. CNA 14 stated this morning she did not give the snacks for 10 A.M., and 2 P.M., CNA 14 further stated she did not know who distributed the snacks or if her assigned residents had snacks. CNA 14 stated she did not know if her residents received snacks and therefore would leave the CNA ADL flowsheet blank. On 5/11/21 at 2:22 P.M., an interview was conducted with CNA 15. CNA 15 stated residents…

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 foods were stored and prepared in the kitchen in accordance with the professional standard for food service safety when: (1) The sanitation bucket's chemical concentration was out-of-range; and (2) Opened food items in the dry storage were not labeled or stored in a sanitary manner; and (3) The utensils stored in the drawer had dried food particles; and (4) A scooper was left inside the container bin with potato flakes; and (5) Inside the walk-in refrigerator had the following: (a) opened and undated food items, and (b) the container full of lettuce was labeled with one month used-by-date, and (c) thawing items were not labeled and dated, and (d) the raw meat, vegetables and dairy were not separated, and (e) broken reach-in freezer had no signage, and (f) the walk-in refrigerator temperature was not monitored on a daily basis; and (6) the reach-in freezer outside the kitchen area had opened food items not stored properly and 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 reimburse the RP for dental implants that went missing for one of one resident, (Resident 240), reviewed for dignity. This failure had the potential to cause the resident unnecessary emotional embarrassment. Finding: Resident 240 was admitted to the facility on [DATE], with diagnosis that include a fracture of the sacrum (broken bone of the lower spine), per the facility's face sheet. On 4/28/21, a review of Resident 240's MDS, Section C dated 11/05/20, indicated Resident 240's BIMS score was 11 out of 15 (mild impairment). No opportunity for interview and observation were available as Resident 240 had been discharged from the facility on 12/7/20. On 4/28/21 at 9:08 A.M., an interview with Resident 240's RP was conducted via telephone. The RP stated, Resident 240 had permanent implants and had no missing teeth when she was admitted on [DATE]. The RP stated, he noticed her missing front teeth during a video visit on 11/25/20 at 4:30 P.M. The RP 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 interview and record review, the facility failed to provide bi-weekly (two times a week) showers for one of three residents, (Resident 10) reviewed for Activities of Daily Living (ADL). This failure had the potential for Resident 10 to develop skin issues and to experience a decline in self-esteem. Findings: Resident 10 was re-admitted to the facility on [DATE], with diagnoses which included muscle weakness and abnormal posture, per the facility's Facesheet. On 5/10/21 at 9:35 A.M., an observation and interview was conducted with Resident 10, while she sat up in bed. Resident 10 was wearing a hospital gown and had wound dressings wrapped around both feet. Resident 10 stated she had not been provided a shower for weeks, which was her preference, not a sponge bed bath. Resident 10 stated she was supposed to have a shower every Tuesday and Friday evening, but the staff kept telling her they will do it later or that it was not her scheduled day. On 5/11/21 at 3:23 P.M., Resident 10's clinical record 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 record review, the facility failed to clarify parameters of oxygen use within a physician's order for one of two residents (Resident 10), reviewed for oxygen use. This failure had the potential for Resident 10 to develop oxygen toxicity (too much supplemental oxygen, which could damage the lungs). Findings: Resident 10 was re-admitted to the facility on [DATE], with diagnoses which included acute respiratory failure with hypoxia (not enough oxygen in the blood), per the facility's Facesheet. On 05/10/21 at 9:34 A.M., an observation and interview was conducted with Resident 10 in her room. Resident 10 was sitting up in bed with a nasal cannula (NC-plastic tubing that delivers oxygen to the nostrils) prongs in each nostril. Resident 10 stated she was suppose to be on 2 liters (a flow rate per minute) of oxygen. Resident 10's oxygen concentrator (an electrical medical devices that supplies oxygen) was resting on the floor, next to the bed. The concentrator flow rate setting 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 The facility failed to ensure multi use (used for more than 1 resident) house supply of topical medications had labels of when they were opened for one of one treatment cart reviewed. This failure had the potential for administration of expired medications to residents. Findings: On 5/12/21, at 9:11 A.M., a concurrent observation of the treatment cart and interview was conducted with LN 15. LN 15 stated, she was responsible for checking the treatment cart prior to use. The following medications were observed without labels of when they were opened: Bottom Drawer 1. Derma Cerin (a skin protectant) 16oz 2. Hibiclens 4% (antiseptic / antimicrobial skin cleanser) 8oz 3. CetaKlenz (skin cleanser) 16oz 4. Selenium Sulfide (antidandruff Shampoo) 7oz Top Drawer 1. Antifungal Powder 3oz 2. Muscle & Joint Gel 3oz 3. [NAME] Septin Ointment (reduces itching & redness) 4oz 4. Silver Sorb Gel (a wound cleaning gel) 0.25oz 5. 1% Hydrocortizone Cream (relieves rash and itching) 3oz 6. Derma Fungal (antifungal agent) 4oz 7.…

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 an expired medication was discarded from the medication storage room, for one of one medication room reviewed for Medication Storage. This failure had the potential for administration of expired medications to be administered to residents. Findings: On 5/12/21 at 10:51 A.M., a joint observation and interview of the medication storage room was conducted with LN 9. LN 9 stated, only LN's had access to the medication storage room. An open bottle of Motrin 200mg tabs (pain medication) was found on a shelve with an expiration date of 3/2021. LN 9 stated, the medication should have been discarded on the expiration date to avoid potentially being administered to a resident. On 5/13/21 at 11:49 A.M., a concurrent interview and policy review with the DON was conducted. The DON stated, the LN's should have discarded the expired medication. The DON stated, it was the responsibility of the LN's on the night shift to check the medication storage room for expired medications. According to the facility's policy,…

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 implement their policy and procedure related to food brought into the facility from the outside and stored in the facility's resident-only designated refrigerator, when items inside the refrigerator were not labeled with resident's name, date and expiration. In addition, there was no assigned staff with the responsibility for maintaining the contents and cleanliness of the residents' refrigerator. As a result, the residents' refrigerator was not kept in a sanitary manner which had the potential to cause foodborne illnesses. Findings: According to the facility's policy, titled Food Brought in by Visitors, revised 6/2018, indicated, . II .Perishable food if refrigerated will then be labeled, dated and discarded after 48 hours. On 5/12/21 at 9:03 A.M., an observation of the residents' refrigerator and concurrent interview with LN 9, the following food items were observed with the following: 1. Blue bowl of unidentifiable pink item with clear lid with no resident's name - no date. 2. Clear plastic blue trim…

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 LN 15 performed hand hygiene between glove changes for 1 unsampled resident (54). In addition, a urinal with yellow liquid was left on the table while Resident (3) was eating. As a result, there was a potential for the spread of infection. Findings: 1. Resident 54 was admitted to the facility on [DATE], with diagnosis which included Sepsis, (a serious condition resulting from the presence of harmful microorganism in the blood), per the facility's Facesheet. On 5/12/21 at 1:29 P.M., a wound care observation and interview was conducted with LN 15. During the wound care with Resident 54 on the right elbow, LN 15 did not perform hand hygiene between glove changes. LN 15 stated she did not perform hand hygiene between gloves changes. LN 15 further stated she was not aware that she should have been performing the hand hygiene regimen between glove changes. On 5/13/21 at 10:08 A.M., an interview was conducted with the DSD. The DSD 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.