Casa De Las Campanas

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to notify a resident and/or the resident's representative notices of transfer/discharge and bed hold for one of two residents reviewed for hospitalization. (Resident 45). This failure had the potential for the resident and/or the resident's representative not to have information regarding the transfer/discharge as well as bed hold rights.Findings:Resident 45 was re-admitted to the facility on [DATE] with diagnoses including displaced fracture of olecranon process (bony point of elbow) and dislocation of left shoulder joint according to the facility's admission Record.During an observation and interview on 8/5/25 at 9:15 A.M. with Resident 45, Resident 45 was observed sitting up in a wheelchair next to his bed. A floor mat was observed on the right side of the bed and Resident 45 had a dressing on the right arm close to the elbow. Resident 45 stated he had a fall in the facility in the middle of the night and sustained a skin tear 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 observation, interview and record review, the facility failed to provide services to promote healing when a pressure injury (a wound caused by prolonged pressure) had developed for one of four sampled residents (Resident 3) when weekly wound assessments were not conducted and Resident 3's wound stages were not accurately assessed. These failures had the potential for Resident 3 to have delayed wound healing. Findings:A record review of Resident 3's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes (a condition in which the body has trouble controlling blood sugar and using it for energy), functional quadriplegia (the inability to move all limbs due to severe disability or weakness), gastro-esophageal reflux disease (a condition in which stomach contents move up into the esophagus), and a history of falling. A record review of Resident 3's Minimum Data Set (MDS- a standardized comprehensive assessment of residents' health…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement a comprehensive systematic approach to ensure effective monitoring to maintain acceptable parameters of nutritional status for 1 of 5 sampled Residents (Resident 3) when: 1. The facility did not follow their policy for change of condition (physical change-weight loss) when Resident 3 was not placed on weekly weights (measurement of body weight).2. The Registered Dietitian (RD) did not reassess Resident 3's weight loss to determine appropriate interventions.3. Resident 3's weight loss was not communicated to the physician.4. The Interdisciplinary Team (IDT- a team comprised of professionals from various disciplines who work in collaboration to address residents' needs) did not address the severe unplanned weight loss.5. Resident 3's care plan did not reflect the severe unplanned weight loss, and no interventions (an action taken to address Resident 3's weight loss) were implemented.As a result, Resident 3 experienced a 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 observation, interview and record review the facility failed to administer blood pressure medication for one of four residents reviewed for medication errors. (Resident 25)This failure has the potential to affect Resident 25's health and wellbeing. Findings:Resident 25 was re-admitted to the facility on [DATE] with diagnoses including hypertensive heart (heart condition caused by long-term high blood pressure) and chronic kidney disease according to the facility's admission Record.A medication observation was conducted on 8/7/25 at 11:23 A.M. with Licensed Nurse (LN) 2. LN 2 administered nine medications to Resident 25: bumetanide (increases urine production) 2 mg (milligrams), flecainide acetate (for irregular heart beat) 50 mg, famotidine (for stomach acid) 10 mg, vitamin C 500 mg, vitamin D3 25 mcg (microgram), multivitamin one tablet, fluticasone nasal (for allergies) spray 50 mcg, chewable aspirin 81 mg, and amlodipine (for blood pressure).A review of Resident 25's physician's orders was conducted.…

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 proper medication administration for one of three residents (Resident 1) observed during medication pass when a medication for an overactive bladder (a condition where there is a frequent sensation of needing to urinate) was not administered per the physician's order. This deficient practice had the potential to cause the resident harm. Findings: According to the admission Record, Resident 1 was admitted to the facility on [DATE] with diagnoses that included overactive bladder. On 11/14/24 at 9:16 A.M., a medication pass was observed with Licensed Nurse (LN) 1. Resident 1 ' s Oxybutynin Chloride (a medication to treat overactive bladder) was not available in the medication cart. A review of Resident 1 ' s Order Summary indicated, Oxybutynin Chloride ER Oral Tablet Extended Release 24 Hour 5 MG Give 1 tablet by mouth one time a day for Overactive Bladder. A review of Resident 1 ' s Medication Administration Record (MAR) 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.

Based on observation, and interview the facility failed to ensure staff followed infection control precautions when staff were observed without face masks. This failure had the potential for the spread of infection to residents, staff, and visitors. Findings: On 9/24/24 an unanounced visit was made to the facility in response to a report of a Covid-19 outbreak. On the entrance door a sign noted the presence of Covid-19 in the facility and directed visitors to not visit if they had symptoms of illness and to wear a mask while in the facility. On 9/24/24 at 5 A.M. an observation and interview was held with LN 1. LN 1 was sitting at nursing station 1, not wearing a surgical mask. LN 1 stated there is one resident infected with Covid-19 in the facility at this time. Certified Nursing Assistant (CNA) 1 and CNA 2 were observed entering the hallway from resident rooms. CNA 1 was carrying a bag of disposable items, and put the bag into the trash receptacle in the dirty utility room. CNA 1 and CNA 1 were observed not wearing masks. On 9/24/24 at 5:06 A.M. CNA 1 and CNA 2 were interviewed.…

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 the kitchen staff received appropriate training in food sanitation and food safety according to standards of practice and facility policy when: 1. Three dietary aides did not demonstrate the proper method of testing the sanitizer solution used for sanitization (the process of safely removing waste to prevent disease transmission and improve hygiene) on equipment and prep surfaces to prevent cross contamination. 2. Two Cooks did not correctly verbalize the 2-step cool down process for foods that require a cool down process prior to serving. 3. Staff In-services were not being conducted by a qualified kitchen staff member with the proper credentials and to carry out in-service trainings. These failures had the potential to expose residents to bacterial contamination, that could result in food borne illnesses for all residents who consume food from the kitchen. The facility census was 50. Cross references F812. Findings: 1. A) During the initial Skilled Nursing Facility (SNF) Health center kitchen tour on…

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, staff interview, and document review, the facility failed to ensure an emergency menu with the appropriate food and water supplies was developed to meet the nutritional and therapeutic needs of the residents, according to facility policy and regulation standards. This failure had the potential to result in further compromising the nutritional and health status of the facility's 50 medically vulnerable residents, or its 97 licensed beds. Cross reference F804 Findings: During a concurrent observation and interview on 6/6/24 starting at 9:11 A.M of the facility's emergency food and water supplies, the AADM (Acting Administrator), the STD (Safety and Transportation Director), Dietary Supervisor (DS), Food and Beverage Director (FBD), Executive Chef (EC), and Sous Chef (SC) stated the facility did not have a therapeutic menu for three days to feed the facility 50 residents. The AADM, DS, and SC the facility abides with the regulations to have a 3-day food supply. The AADM stated the skilled nursing facility-health center's 3-day food supply was combined with all the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the failed to ensure food safety and sanitation practices in dietary services were maintained for food storage according to standards of practice when: 1. Two ice machines were not cleaned and maintained according to manufacturer's instructions. 2. Three ice machines and one dish machine did not have a proper air gap system to adequately prevent backflow of contaminated fluids. 3. Two reach-in refrigerators used to store facility resident food contained a brownish colored sticky grimy debris on the door gasket (inner rubber sealant that helps to create a vacuum and air-tight seal, forming a barrier to cool the inside of the refrigerator and freezer); and one reach-in refrigerator door had several black and grayish spots on the inside door panel. 4. Four green, three white and three red rubber cutting boards had white discoloration and severely worn with large cuts and groves in the center. 5. Multiple food items including individual desserts, were left…

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, observation, and interview, the facility failed to ensure implementation of their policy regarding use and storage of foods brought in from the outside food to ensure safe and sanitary storage, handling, and consumption was followed. This failure had the potential to contaminate residents' outside food stored at the facility, which may result in foodborne illness. The facility census was 50. Findings: During a concurrent interview and observation on 6/5/24 at 4:24 P.M. with Certified Nursing Assistant (CNA) 1, at nursing station 2, CNA 1 stated outside food or food brought in by family members for residents is stored in the nursing station nourishment room in the fridge. CNA 1 stated food items must be labeled with the resident's name and date on the container to identify who the items belong to. The CNA stated that outside food items should not be kept more than a week. An observation of the nourishment room refrigerator with CNA 1 indicated a large 32-ounce bottle of unopened orange juice labeled with a room number, and best if used by 10/2023. CNA 1 stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a comfortable environment to one of 13 residents (Resident 216) when Resident 216's room temperature was 88°F (degrees Fahrenheit - unit of temperature measurement). This failure had the potential to negatively impact the resident's comfort and well-being. Findings: Resident 216 was admitted to the facility on [DATE] with diagnoses which included right knee pain and history of fall per facility's admission Record. A review of Resident 216's Minimum Data Set (MDS - assessment tool), Section C dated 6/1/24 indicated Resident 216 was cognitively intact. An observation and interview were conducted on 6/4/24 at 9:43 A.M. inside Resident 216's room. Resident 216 was observed fanning himself with a table napkin. Resident 216 stated It is hot in here. An observation and interview were conducted on 6/4/24 at 10:05 A.M. with the facility's maintenance technician (MT) inside Resident 216's room. The MT used the facility thermal gun (device 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 observation, interview and record review, the facility failed to implement safe administration of medications for one of 13 residents (Resident 500) when Licensed Nurse (LN) 31 administered Resident 500's medications prepared by LN 2. This failure had the potential for unsafe medication administration and affect the resident's well-being. Findings: Resident 500 was admitted to the facility on [DATE] with diagnoses which included Parkinson's disease (disorder that affects movement), muscle weakness, and restless legs per facility's admission Record. An observation was conducted on 6/6/24 at 9:30 A.M. with LN 31 inside Resident 500's room. Resident 500 was observed asking LN 31 what medications were in the medication cup. LN 31 responded she did not prepare the medications, and will ask LN 2 what medications were prepared to be administered. An interview was conducted on 6/6/24 at 9:33 A.M. with LN 31. LN 31 stated she should have not administered Resident 500's medications because she did not prepare the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the physician's orders were implemented and the physician was notified for 3 of 13 residents (Resident 61, Resident 45 and Resident 55) when: 1. Resident 61's physician order for physical therapy (PT) was not done and was refused. 2. Resident 45's physician order for daily weights was not done and was refused. 3. Resident 55's physician order for wound treatment was not provided. These failures had the potential for further decline in the residents' health and well-being as physician's ordered treatment and services were not provided. Findings: 1. Resident 61 was admitted to the facility on [DATE] with diagnoses which included fracture (broken) of left femur (left hip) per facility's admission Record. A review of physician order dated 5/8/24 indicated Physical Therapy to treat 5 times per week for 60 days for skilled services to include Physical Therapy Evaluation . An interview was conducted on 6/6/24 at 8:37 A.M. with Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure procedures for accurate acquiring, receiving, dispensing, and administering of medications for 4 of 13 residents (Resident 314, Resident 315, Resident 316 and Resident 61) when: 1. Resident 314 and 315's pro re nata (PRN - as needed) medication for pain did not have parameters for medication administration. 2. Resident 316's medication was not administered timely per physician's order. 3. Resident 61's Zinc sulfate (supplemental mineral) was not made available and administered per physician's order. These failures had the potential for the facility to provide unsafe medication administration and inability to provide treatment to the residents. Findings 1. Resident 314 was admitted to the facility on [DATE] for diagnoses which included displaced fracture of the left olecranon process (left elbow) per facility's admission Records. A review of Resident 314's physician orders dated 5/30/24 indicated Roxicodone Oral Tablet 5 MG. Give 1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility had a medication error rate of 6.67% when two medication errors occurred out of 30 opportunities during medication administration. These failures resulted in medications not given to residents in accordance with the physician's orders. Findings: 1. Resident 61 was admitted to the facility on [DATE] with diagnoses which included fracture (broken) of left femur (left hip) per facility's admission Record. Resident 61's physician's order dated 5/31/24 indicated Zinc Sulfate 220 milligrams, (mg unit of measurement) , one tablet every day for wound healing. An observation was conducted on 6/6/24 at 9:21 A.M. with License Nurse (LN) 34. LN 34 did not administer Resident 61's Zinc Sulfate during medication administration. A record review of Resident 61's Medication Administration Record (MAR) indicated, LN 34 did not administer Resident 61's Zinc Sulfate during medication administration. An interview was conducted on 6/6/24 at 3:21 P.M. with LN 34. LN 34…

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 medications were securely locked inside a medication cart when a medication drawer was left open and unattended by a nursing staff. This failure had the potential for unauthorized persons to gain access to medications. Findings: During an observation on 6/4/24 at 9:27 A.M. in the facility hallway. A medication cart's drawer containing residents medications was left unlocked and unattended by a nursing staff. A joint observation and interview were conducted on 6/6/24 at 9:29 A.M. with Licensed Nurse (LN) 34. LN 34 stated the medication cart's drawer was unlocked and was unattended by staff. LN 34 further stated all medication cart's drawers should be securely locked when unattended by nursing staff to prevent unauthorized people to gain access to medications. An interview was conducted on 6/7/24 at 11:17 A.M. with the Director of Nursing (DON). The DON stated the nursing staff should always securely lock the medication carts to prevent residents and unauthorized personnel to gain access to the stored…

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 food served was in a palatable, flavorful manner that maintained the nutritional value of the menu items served. This failure had the potential to decrease residents' meal intake and contribute to weight loss. The facility census was 50. Findings: During a dining observation on 6/4/24 at 12:00 P.M., the following resident food concerns occurred: - One resident reported she did not like the food that was being served (Pizza and mashed potatoes). - One resident stated, the salad sucks. - One resident stated, the food is dry. Review of the facility's Resident Council meeting minutes dated February 2024, March 2024, and April 2024 the following dietary concerns were identified: .beef and pork at dinner to tuff [sic] to eat. Soup is not good and meat to cook [sic] or under cook. Need help with menus and get food I need [sic]. Food needs more flavor. During an interview on 6/5/24 at 4:22 PM with the resident council president (Resident 3), Resident 3 stated the meat items served at the facility seemed…

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 the dietary recommendations for the finger food diet for an unsampled resident, (Resident 60), reviewed for weight loss. This failure had the potential to negatively impact Resident 60's food intake which could further impair nutrition status and lead to weight loss. The facility census was 50. Findings: A review of Resident 60's admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses which included, paroxysmal atrial fibrillation (an irregular heart rhythm that cause symptoms of shortness of breath, pounding heart beats, and weakness). A review of Resident 60's admission Minimum Data Set (MDS, a standardized care screening and assessment tool), dated 5/10/24, indicated that Resident 60 usually made herself-understood or understood others, and had moderate impairment in cognitive (mental process involved in knowing, learning, and understanding things) skills. Resident 60 required…

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 a staff adhered to proper infection control practice for one of 13 residents (Resident 1) when the staff did not perform hand hygiene (HH- washing hands with soap and water or use of hand sanitizer to kill microorganisms) before entering a resident's room. This failure had the potential for cross contamination (spread of germs and bacteria) and infection to residents, staff and visitors. Findings : On 6/4/24 at 9:24 A.M., an observation was conducted inside of Resident 1's room. The Medical Records Staff (MRS) entered Resident 1's room to answer the call light. The MRS did not perform HH before entering the Resident 1's room. On 6/4/24 at 9:30 A.M., an interview was conducted with the MRS. The MRS stated she should have performed HH before entering Resident 1's room. On 6/6/24 at 8:35 A.M. an interview was conducted with the Director of Staff Development (DSD). The DSD stated the MRS should have performed HH before entering Resident 1's room. The DSD further stated all staff should perform HH before…

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, staff interviews, and policy review, the facility failed to ensure kitchen equipment was maintained in safe operating condition when two reach-in refrigerators and an ice machine were not maintained according to standards of practice and facility policy. This failure had the potential to expose the facility's 50 residents to potential contaminants that could cause widespread foodborne illness. Cross Reference 812 Findings: 1. During an initial kitchen tour observation on 6/4/24 at 9:41 A.M. in the health facility, a reach-in refrigerator door gasket (a gasket helps to create a vacuum and air-tight seal, forming a barrier for the cool inside your refrigerator and freeze) was worn, with tears at the top and bottom right corners and detaching on the sides. During an observation and interview on 6/4/24 at 2:45 P.M., with the Dietary Supervisor (DS) and the Food and Beverage Director (FBD) in the health facility kitchen, the DS and FBD acknowledged the torn and detached reach-in refrigerator…

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 3 of 3 Residents were not cared for according to their physician orders and plan of care when staff failed to administer medications to treat chronic conditions, as ordered by physicians. This failure had the potential to have negative affect on residents health and placed residents at risk. Findings: On 1/26/24 a complaint was received that on 1/14/24, day shift medications were not received for a group of residents. On 2/8/24 at 4:10 P.M., an interview was conducted with the Director of Nursing (DON) the Administrator (ADM), and the Director of Staff Development (DSD). The DON stated that she was aware of two nurse call-ins (would not arrive for work) on the evening of 1/13/24, and was able to cover one shift with a nurse from a staffing agency. On 1/14/24 the DON was notified approximately 7-7:30 A.M. that the nurse from the agency had not shown up. There were two nurses on the unit for the 60 residents. The DON reports she directed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to address the nutritional needs for three (Resident 203, Resident 11, Resident 30) of five residents reviewed for nutritional services when: 1. Resident 11 and Resident 30 were not assessed for food preferences. 2. Resident 203 was not offered an alternate meal after the resident refused the meal served and was not offered condiments to enhance the food's palatability. These failures resulted in Resident 203's continued refusals to eat the meals served by the facility, which could negatively impact the resident's health. In addition, this failure had the potential for Resident 11 and Resident 30 to have decreased food intake, which could lead to weight loss. Findings: 1a. Resident 11 was admitted to the facility on [DATE] with diagnoses of an intertrochanteric fracture of left femur (thigh bone) and falls per the facility's admission record. Resident 11 was observed at Resident Council on 6/6/23 at 10 A.M., in her wheelchair and dressed and…

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

Based on observation, interview and record review, the facility failed to ensure that all food items were labeled and dated. In addition, the facility did not ensure that there were no expired food items. This failure had the potential for residents to become ill due to increased bacteria growth in the food, and/or have decreased food intake leading to weight loss due to poor food palatability. Findings: An initial tour/observation of the facility's main kitchen was conducted on 6/5/23 at 9:00 A.M., with the facility's Executive Chef (EC). In the walk-in refrigerator, there was a container of pickled ginger with an expiration date of 6/4/23; and a 3 lb. bucket of blueberry muffin mix with an expiration date of 6/4/23; and a container of wilted celery with no use by date. In the dry storage area, there were five (5) 24 ounce cans of tomato soup with a use by date of 6/4/23; the following dry spices had an expiration date of 4/23: herbs de Provence; cream of tartar; whole cloves; ground turmeric; star anise; coriander; oregano; onion powder; chipotle; and lemon pepper. In addition,…

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 policy and ensure one of 13 sampled residents (Resident 2) who kept medications at bedside had a physician order, care plan, and an Interdisciplinary Team (IDT, a group of staff meeting and working together for the benefit of the resident) assessment to determine if safe and clinically appropriate for the resident to self-administer medications. These failures had the potential to result in unsafe medication administration and could have allowed other residents to access unlocked medications. Findings: A review of Resident 2's medical record indicated she was admitted to the facility on [DATE]. During a medication pass observation for Resident 2 on 6/5/23, at 9:15 A.M., Licensed Nurse (LN 24) was observed administering six medications including baclofen (used to treat muscle spasms) tablet, FeroSul (an iron supplement) tablet, amlodipine (used to treat high blood pressure) tablet, loratadine (used to treat allergies) tablet, vitamin B12…

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 physician notification regarding a significant weight loss for 1 of 5 residents reviewed for weight loss (Resident 203). This failure had the potential for delayed treatment plan for the resident. Findings: Resident 203 was admitted to the facility on [DATE] with the diagnosis of Hemiplegia (severe or complete loss of strength) and Hemiparesis (weakness or the inability to move on one side of the body) following Cerebral Infarction (the disrupted blood flow to the brain, also known as a stroke), according to Resident 203's admission Record. During observation and interview with Resident 203 on 6/5/23, at 10:40 A.M., Resident 203 was in bed with food untouched on her breakfast tray. Resident 203 stated she disliked the food served at the facility. Resident 203 stated the food was always bland. Resident 203 stated her family brought in food from home and had to request for staff to bring it in. Resident 203 stated she had lost 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 implement a resident's care plan related to weight monitoring for one of 13 residents reviewed for care plans. (Resident 203). This failure resulted in Resident's 203's weekly weights to not be monitored weekly as planned, which could result in a delayed identification of a weight change. Findings: Resident 203 was admitted to the facility on [DATE] with the diagnosis of Hemiplegia (severe or complete loss of strength) and Hemiparesis (weakness or the inability to move on one side of the body) following Cerebral Infarction (the disrupted blood flow to the brain, also known as a stroke), according to Resident 203's admission Record. During observation and interview with Resident 203 on 6/5/23, at 10:40 A.M., Resident 203 was in bed with food untouched on her breakfast tray. Resident 203 stated she disliked the food served at the facility. Resident 203 stated her family brought in food from home and had to request for staff to bring it 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.

Based on observation, interview, and record review, the facility failed to provide treatment in accordance with the facility's policy and procedure when physician's orders were not clarified for one of 13 sampled residents (Resident 23). During medication administration, five medications were administered by mouth when the physician's orders were written to be given via a G-Tube (gastrostomy tube, a tube inserted through the belly that brings nutrition or medications directly to the stomach). This failure had the potential for not meeting Resident 23's therapeutic needs and had the potential of causing aspiration (breathing in medication or fluid into the lungs), which could lead to serious lung problems such as pneumonia (lung infection). Findings: During a medication pass observation for Resident 23 on 6/6/23, at 7:54 A.M., Licensed Nurse (LN 21) was observed preparing 12 medications which included one aspirin (used to prevent blood clot) chewable tablet, two atenolol (used to treat high blood pressure) tablets, one-half losartan (used to treat high blood pressure) tablet, one…

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

Based on interview and record review, the facility failed to ensure controlled medications (those with high potential for abuse and addiction) were fully accounted when a random controlled medication use audit for one of four sampled residents (Resident 8) did not reconcile. The medication was signed out of the controlled drugs accountability sheet (Count Sheet, an inventory sheet that keeps record of the usage of controlled medications) but not documented on the Medication Administration Records (MAR) to indicate it was given to the resident. This failure had the potential to result in misuse or diversion (the illegal distribution or abuse of prescription drugs or their use for purposes not intended by the prescriber) and inaccurate accountability of controlled medications. Finding: The controlled medication Count Sheets for four random residents receiving controlled medications were requested for review during the survey. Resident 8 had a physician's order for oxycodone (a controlled medication for pain) 7.5 milligrams (mg, unit of measurement) tablet, give 1 tablet by mouth every…

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 request a medication regimen review (MRR) following changes in condition (worsening of an existing problem or the emergence of new signs or symptoms, such as falls); and failed to ensure the consultant pharmacist (CP) identified potential medications contributing to falls and make recommendations to the facility for reduction or discontinuation of one of the medications during the monthly MRRs for one out of two sampled residents (Resident 28). This failure had the potential for medications not being optimized for best possible health outcome, and unnecessary or prolonged use of medications which could lead to medication adverse effects (such as falls) for the resident. Findings: A review of the hospital History and Physical (H&P), dated 9/10/22, the H&P indicated, Resident 28 Fell at her memory care facility .and subsequently hit the back of her head. She presented to the emergency room .and was found to have a .subdural hematoma [a serious condition…

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.