Golden Hill Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide routine nail care to one of three residents (Resident 48), reviewed for Activities of Daily Living (ADL, activities related to personal care) for dependent residents. As a result, Resident 48 was at risk for skin injury and infection.Findings: 1.Resident 48 was admitted to the facility on [DATE], with diagnoses which included stroke, per the facility's admission Record. Resident 48's history and physical (H&P), dated 7/17/25, indicated Resident 48 had altered mental status. On 8/25/25, a review of Resident 48's minimum data set (MDS - a federally mandated resident assessment tool) dated 7/22/25, indicated Resident 48's brief interview for mental status (BIMS, ability to recall) score was 12/15, which meant Resident 48's cognition was moderately impaired. The MDS also indicated Resident 48's functional abilities indicated he had upper extremity impairment and that he required assistance from the staff on his activities of daily…

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 individualized therapeutic and/or social activities according to their plan of care for one of one reviewed resident (Resident 40) that promotes their highest physical, mental, and psychosocial well-being. This deficient practice placed Resident 40 at risk for decreased emotional well-being, social isolation, and reduced quality of life due to the lack of meaningful engagement. Cross Reference F 656.Findings: Resident 40 was admitted to the facility on [DATE], with diagnoses which included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness or the inability to move on one side of the body, making it hard to perform everyday activities like transferring), per the facility's admission Record. On 8/25/25, a review of Resident 40's history and physical (H&P), dated 7/4/25, indicated Resident 40 had the capacity to make decisions. On 8/25/25, a review of Resident 40'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 a tube feeding formula was labeled for one of one resident (58) reviewed for Parenteral Nutrition. This failure had the potential to affect Resident 58's health conditions and decline.Findings: A review of Resident 58's admission Record indicated that Resident 58 was admitted to the facility on [DATE] with diagnoses that included malignant neoplasm (cancerous tumors) of the tongue. Resident 58's history and physical (H&P), dated 7/17/25, indicated Resident 58 was alert and oriented to person, place and time. On 8/25/25, a review of Resident 58's minimum data set (MDS - a federally mandated resident assessment tool) dated 7/21/25, indicated Resident 58's brief interview for mental status (BIMS, ability to recall) score was 8/15, which meant Resident 58's cognition was moderately impaired. The MDS also indicated Resident 58's nutritional status indicated she was on feeding tube (a tube inserted through the stomach) upon admission. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide care and treatment consistently for a Midline catheter (a thin, flexible tube inserted into a vein in the upper arm) for one of one resident (Resident 23) reviewed for Intravenous therapy. This failure had the potential to cause infection and affect Resident 23's health. Findings:Per the facility's admission Record , Resident 23 was admitted to the facility on [DATE] with diagnoses which included chronic kidney disease. (kidneys can no longer fully clean toxins from the blood) . On 8/25/25 at 9:17 A.M., a joint observation and interview with Resident 23 was conducted. Resident 23 had a midline catheter on her right arm with an unclear dated transparent dressing. Resident 23 stated she stated the midline catheter has not been flushed for a few days and that no one has changed the dressing since it was last done. Resident 23 stated she had been asking the licensed nurses if she still needed the midline catheter since Resident 23 knew…

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 an oxygen tubing was dated on 2 out of 2 residents (Resident 81,Resident 25) reviewed for Oxygen needs.This failure had the potential to affect Resident 81's and Resident 25's respiratory health.Findings:1) Per the facility's undated admission Record ,Resident 81 was admitted to the facility on [DATE] with diagnoses that included Acute Respiratory failure with Hypoxia (absence of enough oxygen) . On 8/25/25 at 10:15 A.M., an observation during the initial tour was conducted. Resident 81 had the oxygen nasal cannula (NC-a two-pronged plastic tubing used to deliver oxygen through the nose) regulated at 3 liters per minute via oxygen concentrator. Resident 81's oxygen tubing was not dated. On 8/25/25 at 10:20 A.M., an interview with Resident 81 was conducted. Resident 81 stated she used the oxygen almost twenty-four hours due to Resident 81 could not breathe without the oxygen. A review of the Minimum Data Set (MDS- a federally…

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 assess and manage pain for one of two residents investigated for pain management (Resident 72). As a result, the deficient practice had the potential for unmanaged pain. Cross Reference F 655.Findings: Resident 72 was admitted to the facility on [DATE], with diagnoses which included pressure ulcer of right buttock (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence), per the facility 's admission Record. Resident 72's H&P, dated 6/26/25, indicated Resident 72 had the capacity to make decisions. On 8/25/25, a review of Resident 72's minimum data set (MDS - a federally mandated resident assessment tool) dated 7/2/25, indicated Resident 72's brief interview for mental status (BIMS, ability to recall) score was 15/15, which meant Resident 72's cognition was intact. On 8/25/25 at 10:04 A.M., an observation and an interview of Resident 72 was conducted in her room. Resident 72 sat up in 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.

Based on interview and record review, the facility failed to ensure one out of five residents (Resident 72) was free from unnecessary medications when blood pressure (BP) and heart rate (HR) hold parameters were not followed with the administration of medications.This failure had the potential for Resident 72 to experience low BP and low HR.A review of Resident 72's clinical record indicated she had an active order for atenolol 50 milligram (mg, unit of measure) tablet, give one and half tablet by mouth two times a day (at 9 a.m. and 5 p.m.) for hypertension (HTN, high blood pressure). Hold if HR less than 60, originally dated 6/28/25. Resident 72 received doses, as documented on her July 2025 and August 2025 Medication Administration Record (MAR), despite a HR less than 60 on the following dates:7/6/25 HR 53 the 9 a.m. dose was administered7/13/25 HR 57 the 9 a.m. dose was administered7/18/25 HR 57 the 9 a.m. dose was administered8/2/25 HR 57 the 5 p.m. dose was administered8/12/25 HR 55 the 5 p.m. dose was administered8/13/25 HR 56 the 5 p.m. dose was administeredA review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility had a medication error rate of 10% when three medication errors occurred out of 30 opportunities during the medication administration observation for two out of five residents (Residents 5 and 58). This failure resulted in Residents 5 and 58 not receiving medications as ordered and had the potential for both residents not to get the full therapeutic benefit of their medications. This failure also had the potential for Resident 58 to experience complications from her medications clogging in her gastrostomy tube (G-tube, a device used to administer food and medications to individuals with difficulty swallowing). 1. During the medication administration observation on 8/25/25 at 8:45 a.m., Licensed Nurse (LN) 11 was observed preparing and administering a total of 10 medications for Resident 58. LN 11 stated Resident 58 received two medications through her G-tube and the rest were administered by mouth. LN 11 prepared the following two medications for…

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

Based on observation, interviews and record review, the facility failed to ensure safe and sanitary measures were met in the kitchen during dietary operations according to standards of practice when food items were free from contaminants. This finding had the potential to expose the facility's residents to unsafe and unsanitary food practices that could lead to widespread foodborne illnesses.Findings: On 8/25/25 at 8:08 A.M., an observation of the produce walk-in refrigerator and an interview was conducted with the Certified Dietary Manager (CDM). There were two packs of strawberries with white porous materials and a jar of Caesar salad dressings with sticky material around the edges of the jar. On 8/25/25 at 9:01 A.M., an interview was conducted with the CDM with the presence of the Registered Dietitian (RD). The CDM stated the strawberries will be discarded. The CDM stated the staff will not serve strawberries. The CDM stated the dietary staff should have rotated the produce. The CDM asked a dietary aide to clean the edges of the jar of the Caesar salad dressing. The CDM 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.

Based on observation, interview, and record review, the facility failed to store, prepare and distribute food in a sanitary manner when: 1. Foods were not labeled and dated in the walk-in cooler, 2. A juice dispenser was not sanitized, 3. A damaged spatula was used during food preparation, 4. Racks with compromised surfaces were used for holding sanitized dishes, and, 5. Coffee mugs and bowls appeared to have a white residue on the inside surface. These failures may result in risk for foodborne illness, as well as bacterial, chemical and foreign object contamination to the residents. Findings: 1. On 10/18/21 at 7:53 A.M., a kitchen tour was conducted with the Dietary Services Supervisor (DSS). The walk-in cooler contained the following items with no label or date identified: One package of 12 flour tortillas, expiration date 9/20/21 peanut butter and jelly sandwich five portions fruit in bowls five portions thickened juice three fortified shakes one dinner plate, with entree and starch On 10/18/21 at 8:10 A.M., an interview was conducted with the DSS. The DSS stated all foods should…

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 Physicians Orders for Life Sustaining Treatment (POLST, a form which outlines a person's choices for end of life care, or Advanced Directive) form was accurate and matched the facility's code status (the level of medical interventions a person wishes to have if their heart or breathing stops), for one of one residents (27) reviewed for Advance Directives. This failure had the potential for Resident 27 to receive the incorrect care in the event of an emergency. Findings: Resident 27 was admitted to the facility on [DATE], with diagnosis to include chronic respiratory failure (a long-term condition where lungs do not work well), per the facility's admission Record. On 10/18/21 at 4:11 P.M., an observation and interview was conducted with Resident 27. Resident 27 was in bed, with markers and a white board (a board used for communicating through writing) at his bedside. When asked questions, Resident 27 was able to nod yes or no in response.…

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: 1. Ensure a care plan was developed related to catheter (tubing connected to the bladder) care for two of five residents (76, 12) reviewed for catheter care, and, 2. Ensure a care plan for fall precautions was implemented for one of three residents (49) reviewed for falls. As a result, the residents (76, 12) were at risk of developing urinary infections, and Resident 49 was at risk for injury from falls. Findings: 1a. Resident 76 was readmitted to the facility on [DATE], with diagnoses that included obstructive and reflux uropathy (urine backs up to the kidneys), per the facility's admission Record. An observations of Resident 76 was conducted: On 10/18/21 at 10:54 A.M. Resident 76 was lying in bed with a catheter attached to a covered urine bag at the side of the bed. On 10/20/21 at 3:47 P.M. Resident 76 was sitting in a wheelchair in the activity room. His catheter appeared to contain bloody urine output. An interview 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 observation, interview, and record review, the facility failed to consistently provide hygiene for three of five residents (29, 76, and 12) reviewed for catheter (tube inserted into the bladder) care. This failure had the potential to increase the risk of infection for residents. Findings: 1. Resident 29 was readmitted to the facility on [DATE], with diagnoses that included neuromuscular dysfunction of bladder (lack of bladder control), per the facility's admission Record. According to the Minimum Data Set (MDS, assessment tool), dated 10/5/21, Resident 29 had a Brief Interview of Mental Status (BIMS, an assessment of the resident's ability to remember and reason) score of 14 (13-15 meant cognitively intact) which indicated, the resident was cognitively intact. On 10/20/21 at 3:59 P.M., an observation and interview with Resident 29 was conducted. Resident 29 was sitting in bed, with a catheter attached to the bed. Resident 29 stated the Certified Nursing Assistant (CNA) 2 assigned to her did a poor job…

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 recipe was followed for a pureed food. This failure had the potential to affect the nutritional value of the food prepared, and further compromise the health of residents receiving the pureed food. Findings: On 10/20/21 at 10:45 A.M., a concurrent interview and observation of Dietary Aide (DA) 11 was conducted in the kitchen. DA 11 prepared pureed chicken to serve at the next meal. DA 11 pulled the recipe for pureed meat from a binder and began preparing four portions of the recipe. DA 11 added a liquid to the pureed meat, and stated it was chicken broth. DA 11 stated the broth was added to make the pureed meat smoother and less thick. A record review was conducted. The recipe, dated 4/2017, titled Recipe: Pureed Meats, indicated to add, .warm fluid such as gravy, or low sodium broth .Directions: .3. Gradually add warm liquid (low sodium broth or gravy) . On 10/20/21 at 11 A.M., a concurrent interview and observation was conducted with the Dietary Services Supervisor (DSS). The DSS pulled 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 nursing interventions to monitor one of 20 (30) sampled residents. This failure had the potential to place Resident 30 at risk for dehydration. Findings: Resident 30 was admitted to the facility on [DATE] with diagnoses which included dysphagia (difficulty swallowing) and gastrostomy (creation of an artificial external opening into the stomach for nutritional support) per the facility's admission Record. On 10/10/19, a review of Resident 30's MDS (health status screening and assessment tool) Section C, dated 9/6/19, indicated Resident 30's BIMS Summary Score (test for cognitive function) was 3 out of 15 (severe cognitive impairment). On 10/7/19 at 8:10 A.M., an observation of Resident 30 was conducted. Resident 30 was lying in bed. Resident 30's lips were dry and cracked, with peeling skin. Resident 30's lips stuck together when he was speaking. On 10/8/19 at 1:11 P.M., an observation and interview with Resident 30 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 a care plan was revised/updated to reflect the current status of two of 20 residents (70, 7) reviewed for care plans when: 1. Resident 70's care plan was not updated to reflect his current wound dressing change procedure which resulted in miscommunication amongst care givers and delay in treatment and, 2. Resident 7's care plan was not revised to reflect discharge plans or goals which had the potential to result in a delayed discharge. Findings: 1. Resident 70 was admitted on [DATE] with diagnoses which included paraplegia (the loss of the ability to move and feel anything in the legs and lower body), pressure ulcers (injuries to skin and underlying tissue resulting from prolonged pressure on the skin) of sacral region stage 4 (the pressure injury is very deep, reaching into muscle and bone and causing extensive damage), pressure ulcer of right hip stage 2 ( the skin breaks open, wears away, or forms an ulcer, which is usually…

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 document discharge planning for one of two residents reviewed for discharge (7). This failure had the potential for Resident 7 to not receive the appropriate discharge plan. Findings: Resident 7 was admitted to the facility on [DATE] with diagnoses which included traumatic brain injury (brain dysfunction caused by an outside force) per the facility's admission Record. On 10/10/19, a record review of Resident 7's MDS (health status screening and assessment tool) Section C, dated 7/17/19, indicated Resident 7's BIMS Summary Score (test for cognitive function) was 10 out of 15 (moderate cognitive impairment). On 10/7/19 at 9 A.M., an interview with Resident 7 was conducted. Resident 7 stated he would like to go home, and had not spoken with social services regarding this issue. Resident 7 stated he wanted to be closer to home and his family. Resident 7 proceeded to ask a staff member to speak to social services. On 10/8/19 at 9:57 A.M., an interview 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 observation, interview, and record review, the facility failed to provide out of bed assistance for one of three residents reviewed for ADLs (30). This failure had the potential to result in Resident 30 to experience a further decline in ADLs. Findings: Resident 30 was admitted to the facility on [DATE] with diagnoses that include traumatic subdural hemorrhage (a condition due to bleeding under the membrane covering the brain), need for assistance with personal care, and muscle weakness, per the facility's admission Record. On 10/10/19, a review of Resident 30's MDS (health status screening and assessment tool) Section C, dated 9/6/19, indicated Resident 30's BIMS Summary Score (test for cognitive function) was 3 out of 15 (severe cognitive impairment). On 10/7/19 at 8:10 A.M., an observation and interview was conducted in Resident 30's room. Resident 30 was lying in bed staring at the ceiling. Resident 30 stated he would like to get out of bed and walk. Resident 30 further stated staff does not get him…

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 treatment and care in accordance with professional standards of practice for two of 20 residents (30, 66) reviewed for quality of care when: 1a. A physician's order was not followed for Resident 30's enteral feeds (also known as tube feeding, a device used to provide nutrition to those who are unable to swallow safely), 1b. An order was not obtained for Resident 30 before a dressing change and, 2. A physician's order was not followed for Resident 66 who required assistance with meals. These failures had the potential to result in Resident 66 and Resident 30's physical needs not being met. Findings: 1a. Resident 30 was admitted to the facility on [DATE] with diagnoses which included dysphagia (difficulty swallowing) and gastrostomy (creation of an artificial external opening into the stomach for nutritional support) per the facility's admission Record. On 10/10/19, a record review of Resident 30's MDS (health status screening 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 observation, interview and record review, the facility failed to ensure that range of motion treatments provided by Restorative Nursing Assistants (RNA) was provided for two of four residents (55,16) reviewed for contractures (hardening of muscle and tissues leading to rigidity of joints). This failure had the potential for residents to experience further decrease in range of motion. Findings: 1. Resident 55 was admitted to the facility on [DATE] with diagnoses which included contracture, unspecified joint, and contracture of muscle, multiple sites, per the facility's admission Record. An observation of Resident 55 was made on 10/7/19 at 2:46 P.M., Resident 55 was reclining in bed; his left leg was contracted at the knee. An observation of Resident 55 was made on 10/9/19 at 8:30 A.M., Resident 55 was reclining in bed; his left leg was contracted at the knee. A review of Resident 55's medical record on 10/9/19 at 8:58 A.M., indicated no orders, care plans, or other documentation for RNA. A concurrent…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure effective pain management for one of one residents reviewed for pain (70). This failure had the potential for Resident 70 to have unrelieved pain. Findings: Resident 70 was admitted on [DATE] with diagnoses which included paraplegia (the loss of the ability to move and feel anything in the legs and lower body), pressure ulcer (injuries to skin and underlying tissue resulting from prolonged pressure on the skin) of sacral region stage 4 (the pressure injury is very deep, reaching into muscle and bone and causing extensive damage), pressure ulcer of right hip stage 2 ( the skin breaks open, wears away, or forms an ulcer, which is usually tender and painful), pressure ulcer of left heel, un-stage able (a bedsore whose severity cannot be determined with a visual exam) and pressure ulcer of other site, unspecified state per Resident's admission Record. On 10/7/19 at 4:20 P.M., An interview was conducted with Resident 70. Resident 70…

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 appropriate food portions were served to residents. This failure had the potential for residents to not have their nutritional and special dietary needs met. Findings: An observation of the kitchen during tray line was conducted on 10/8/19 at 12 P.M. The facility's menu indicated meat sauce and pasta with Scandinavian mixed vegetables were the lunch items for that day. [NAME] 1 used the same ladle (1/2 cup=regular portions) for all portion sizes of the meat sauce. Per the daily diet spread sheet a small portion was 1/4 cup and a large portion was 3/4 cup. The residents' meal ticket indicated the portion size to be served. [NAME] 1 used the regular size ladle and would shake off some meat sauce for a small portion and add some additional meat sauce for the large portions. [NAME] 1 stated: I estimate. In addition, [NAME] 1 would use tongs to pick up the pasta, and shake some off for a small portion and add some extra for a large portion. No measuring device was used for the pasta. [NAME] 1 stated, I…

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 have complete accurate medical records for two of 20 residents reviewed for documentation (22, 77) when: 1. Documentation was not completed regarding a lab result for Resident 22. 2. Documentation for a vaccine was not completed for Resident 77. These failures had the potential to result in Resident 22 and Resident 77 to not receive the appropriate treatment or care. 1. Resident 22 was admitted to the facility on [DATE] per the facility's admission Record. Findings: On 10/10/19 a review of Resident 22's medical record was conducted: According to Resident 22's progress notes, dated 9/17/19, a urine specimen was collected for a urinalysis (analysis that examines the urine contents for abnormalities that indicate a disease condition or infection). According to Resident 22's Laboratory Report, dated 9/18/19, Resident 22's urinalysis had abnormal results and was sent to MD on 9/19/19. On 10/8/19 at 3:49 P.M., an interview and record review with LN 22 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 ensure infection prevention practices were followed for three of 22 residents (40, 70, CR 1) when: 1a. The DSD failed to wash hands before performing wound care for one resident (40), in between glove changes while performing wound care for two residents (40, 70) and after performing wound care for one resident (70) and, 1b. One staff member did not wash his hands after providing peri-care (cleaning of private areas) to CR 1. 2. In addition, two staff members did not follow the facility's dress code/infection control regarding fingernails. These failures had the potential to cause the spread of infection to residents, staff and visitors. Findings: 1a. Resident 70 was admitted on [DATE] with diagnoses which included, chronic respiratory failure (narrowing of the airways in the lungs), anoxic brain damage (occurs when the brain is deprived of oxygen) per the Resident admission Record. Per the facility physician order, dated 10/1/19, cleanse…

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.