Mission Hills Post Acute Care

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to evaluate the nutritional status of one of two residents reviewed for nutrition (Resident 19). This failure had the potential to result in weight loss or further compromise their health. Findings: Resident 19 was admitted to the facility on [DATE] with diagnoses to include adult failure to thrive (FTT, a loss of appetite, decreased activity, and weight loss), per the facility admission Record. An observation and interview was conducted with Resident 19 in her room on 6/16/25 at 8:30 A.M. Resident 19 had eaten less than half of the foods on her breakfast tray, and stated the food did not taste good to her. Resident 19 stated she had complained about the food to staff, but it did not get better. A record review was conducted on 6/19/25. Resident 19's Brief Interview for Mental Status (BIMS, an assessment tool) indicated moderately impaired cognition. Resident 19's scaled weights indicated she had been weighed twice over the last year. Resident 19's care…

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 attempt and evaluate the use of nonpharmacological interventions (NPIs, healthcare treatments that do not involve medications, such as music or massage) for one of one resident reviewed for behaviors (Resident 16). This failure had the potential to result in overmedication. Findings: Resident 16 was admitted to the facility on [DATE] with diagnoses to include dementia (a loss of memory, thinking or language and changes in behavior), per the facility admission Record. An observation was conducted of Resident 16 in her room on 6/16/25 at 3:15 P.M. Resident 16 was screaming, not making eye contact. No words were identifiable. Staff did not respond to the screaming, which continued for approximately three minutes. The television was off, no music was heard in the room. An observation was conducted of Resident 16 in her room on 6/17/25 at 3:53 P.M. Resident 16 was again screaming, scratching at her right shoulder. A Certified Nursing Assistant…

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

Based on observation, interview and record review, the facility failed to ensure the medication error rate was less than five percent when two out of 26 medications were administered incorrectly. The facility's error rate was 7.69%. These failures had the potential to negatively affect the residents' health and safety. Findings: On 6/18/25 at 8:51 A.M., a medication administration observation was conducted with licensed nurse (LN) 21. LN 21 prepared and administered medications to Resident 19. During the medication administration observation, there were seven (7) total oral pills counted but LN 21 had six (6) medication pills in the medication cup. LN 21 stated total count of medications were two capsules and four tablets. LN 21 stated the total number of oral pills should be seven (7). One of the medication LN 21 did not include was Citalopram (medication for depression). The following medication pills were in the medication cup (six total number): Gabapentin 300 (milligram) mg one yellow capsule Potassium chloride 20 meq ER (milli-equivalent, extended release) one tablet…

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 appropriate storage of respiratory (related to breathing) equipment for one of one resident reviewed for infection control. (Resident 31) This failure had the potential for cross contamination (spread of germs and bacteria) and infection. Findings: Resident 31 was admitted to the facility on [DATE] with diagnoses including obstructive sleep apnea (OSA- a problem in which breathing pauses during sleep due to blocked airways) according to the facility's admission Record. During an observation and interview on 6/16/25 at 9:19 A.M., Resident 31 was in bed with two small machines on top of the bedside drawer. Resident 31 stated one machine was a bilevel positive airway pressure (BIPAP-machine as breathing support and administered through a face mask or nasal mask) machine and the other was for a breathing treatment. The BIPAP tubing was hanging from the BIPAP machine and connected to a face mask. The mask was observed to be 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 protect 1 of 5 residents from physical abuse from another resident of the facility. (Resident 2). This failure resulted in Resident 2 being kicked in the shins. In addition, there was a potential for a repeat physical abuse from the same resident. Findings: Resident 2 was admitted to the facility on [DATE] with diagnoses including muscle weakness and anxiety (feeling of fear, dread and uneasiness) according to the facility's admission Record. An interview was conducted on 3/4/25 at 9:45 A.M. with Resident 2. Resident 2 was on a wheelchair in her room. Resident 2 stated she had another altercation with Resident 1 whose room was two doors away from her room. Resident 2 stated Resident 1 came to the doorway and offered coffee to her roommate. Resident 2 stated she told Resident 1 not to enter the room and Resident 1 got angry and told Resident 2 that the room was not just hers. Resident 2 stated she responded that it was her room 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 interview and record review, the facility failed to ensure a baseline care plan (the minimum healthcare information necessary to properly care for each resident immediately upon their admission) meeting was conducted within 48 hours for two residents (Resident 2 and 6) reviewed for baseline care planning. This failure had the potential for an incomplete and lack of care interventions for residents in an event of a serious change of condition to potentially occur to residents after admission. In addition, the lack of communication among facility staff and responsible party had the potential to affect the quality of care to the resident. Findings: 1. Resident 2 was admitted to the facility on [DATE] with diagnoses including cardiomyopathy (a disease of the heart muscle causing the heart to have a harder time pumping blood to the rest of the body) and prostate (part of the reproductive system in men) cancer according to the facility's admission Record. During an interview on 1/10/24 at 1:39 pm 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 ensure three of four residents were provided care in a manner that promoted dignity and respect. (Resident 2, 3 and 4) These failures resulted in not ensuring resident's rights to be treated with respect and dignity with the potential to cause psychosocial harm to the involved residents. Cross reference F725 Findings: 1. Resident 2 was admitted to the facility on [DATE] with diagnoses including need for assistance with personal care and obstructive (hindrance of normal urine flow) and reflux uropathy (urine flowing backwards) according to the facility ' s admission Record. During a review of Resident 2 ' s Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 7/19/24, section C0500 indicated Resident 2 ' s score was 15, cognition (thinking, reasoning, or remembering) was intact. Section GG0130 indicated Resident 2 was dependent with toileting hygiene. During an observation and interview on 9/20/24 at 10:16 A.M.,…

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 sufficient staffing was provided for the residents of the facility when: 1. Resident 2 ' s brief was not changed for over nine hours. 2. Resident 3 held her urine for an hour before staff came to assist. 3. Resident 4 ' s brief was not changed for over four hours. As a result, Residents 2 and 3 sat on a soiled and wet pad, and Resident 4 waited over 4 hours to be changed. Failure to change a soiled, wet pads had the potential for residents to develop a skin breakdown and the potential to affect their emotional and psychosocial well-being. Cross reference F550 Findings: 1. Resident 2 was admitted to the facility on [DATE] with diagnoses including need for assistance with personal care and obstructive (hindrance of normal urine flow) and reflux uropathy (urine flowing backwards) according to the facility ' s admission Record. During a review of Resident 2 ' s Minimum Data Set (MDS- a federally mandated resident assessment tool) 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 observation, interview, and record review the facility failed to prevent an avoidable fall for one resident (Resident 2) who had a previous fall history. This failure caused the resident to sustain a right femoral neck fracture (a type of hip fracture). Review of Resident 2 ' s history and physical dated 10/12/23 indicated Resident 2 was admitted on [DATE] for diagnoses which include Pathological Fractures, Fracture of Odontoid Process (a bone in resident ' s spine), recurrent falls, and orthostatic hypotension(symptomatic low blood pressure when changing position). Per History and Physical, Resident 2 was .transferred from another SNF, where she was admitted after an unwitnessed fall and was unable to get up. Reportedly she had walked into dining room, felt lightheaded, then passed out .She also has history of another fall in 2/23 .Plan .Orthostatic vitals, careful position changed, Fall precautions . On 5/31/21 at 10 A.M. an interview with Certified Nursing Assistant (CNA) 3 was conducted. CNA 3…

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 respiratory care services for three residents (Resident 5, 6 and 7) who used CPAP machines (continuous positive airway pressure-a machine that delivers mild air pressure through the nose to keep breathing airways open while asleep) when: 1. There was no ongoing assessment to evaluate resident's respiratory status and response to the use of the CPAP machine. (Resident 5 and Resident 6) 2. The medication administration record was signed when Resident 5's CPAP was not available. In addition, Resident 5's medical record did not indicate staff follow up of Resident 5's CPAP according to physician's order. 3. Resident 7 used a CPAP machine but did not have a physician's order. These failures had the potential for residents to receive inappropriate care and treatment to address their respiratory problems. Findings: 1. Resident 5 was admitted to the facility on [DATE] with diagnoses including obstructive sleep apnea (OSA- a problem 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 observation, interview, and record review, the facility failed to implement infection control standards of practice when respiratory equipment were not stored appropriately for two residents (Resident 5 and Resident 6). This failure had the potential for residents to acquire an infection. Resident 5 was admitted to the facility on [DATE] with diagnoses including obstructive sleep apnea (OSA- a problem in which breathing pauses during sleep due to blocked airways) according to the facility's admission Record. During an observation and interview on 4/4/24 at 9:42 A.M., Resident 5 was sitting at the edge of her bed with a CPAP machine on top of the bedside drawer. The CPAP machine was connected to a tubing and mask exposed on top of the machine. Resident 5 further stated nobody from the facility had checked the machine or if she had applied it or not. A small oxygen tank was also observed at Resident 5's bedside with an oxygen tubing hanging on the tank. The tubing did not have a date. Resident 6 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 assess a resident ' s ability to self-administer medications for one of one resident reviewed for self-administration of medications. (Resident 2). This failure had the potential to affect Resident 2 ' s health and safety. In addition, this failure resulted in Resident 2 to run out of the medication without staff knowledge. Findings: Resident 2 was re-admitted to the facility on [DATE] with diagnoses including psoriasis (skin condition which skin cells build up and form scales and itchy, dry patches) according to the facility ' s admission Record. During an interview on 3/5/24, at 9:54 A.M. with Resident 2, Resident 2 stated her primary physician ordered betamethasone cream for her psoriatic arthritis (type of arthritis causing painful swelling in the joints). Resident 2 stated the medication helped with the discomfort caused by the psoriatic arthritis. During an interview with the treatment nurse (TN) on 3/5/24, at 11:29 A.M., the TN…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide adequate assistance to a resident who required total dependence on activities of daily living (ADL). (Resident 4) As a result, Resident 4 fell off the bed. Findings: Resident 4 was admitted to the facility on [DATE] with diagnoses including quadriplegia (loss of ability to move both arms and legs) according to the facility ' s admission Record. An observation and interview of Resident 4 was conducted on 3/5/24, at 10:21 A.M. Resident 4 was lying in bed with head slightly elevated. Resident 4 stated a nurse pushed him off the bed and landed on the floor. Resident 4 stated the nurse was providing care, rolled him to his right side and told the nurse to stop but did not stop rolling him which caused him to fall off the bed. Resident 4 further stated he could not move his arms or legs and required staff assistance with ADLs. During an interview on 3/5/24, at 11:42 A.M. with certified nurse assistant (CNA) 1, CNA 1 stated Resident 4 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 safely store a medication for one of one resident reviewed for drug storage. (Resident 2) This failure had the potential for unauthorized people or residents to have access to the medication. Findings: Resident 2 was re-admitted to the facility on [DATE] with diagnoses including psoriasis (skin condition which skin cells build up and form scales and itchy, dry patches) according to the facility ' s admission Record. During an interview on 3/5/24, at 9:54 A.M. with Resident 2, Resident 2 stated her primary physician ordered betamethasone cream for her psoriatic arthritis (type of arthritis causing painful swelling in the joints). Resident 2 stated the medication helped with the discomfort caused by the psoriatic arthritis. An interview and concurrent record review was conducted with licensed nurse (LN) 1 on 3/5/34, at 10:48 A.M. LN 1 stated Resident 1 had a physician ' s order for Betamethasone to be applied to affected area every day 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 maintain accurate and complete medical records when: 1. A treatment administration record for a resident (Resident 2) was inaccurately signed by a licensed nurse and 2. A resident ' s (Resident 9) inventory of personal belongings was not completed upon resident ' s discharge. As a result, Resident 2 ' s clinical record contained an inaccurate documentation and Resident 2 did not receive the care and skin treatment as ordered by the physician. In addition, Resident 9 ' s personal belongings went missing. Findings: 1. Resident 2 was re-admitted to the facility on [DATE] with diagnoses including psoriasis (skin condition which skin cells build up and form scales and itchy, dry patches) according to the facility ' s admission Record. During an interview on 3/5/24, at 9:54 A.M. with Resident 2, Resident 2 stated her primary physician ordered betamethasone cream for her psoriatic arthritis (type of arthritis causing painful swelling in the…

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

Based on observation, interview, and record review the facility failed to ensure overall systematic operations of the food and nutrition services with the necessary oversight to ensure the daily nutritional needs of the residents were met. This deficient practice led to a resident (Resident 29), to experience severe avoidable weight loss in six months, the potential for other facility residents to experience weight loss, malnutrition, and widespread food borne illness, which can affect all residents in the facility. The facility census was 66. Cross reference F692, F802, F803, F806, F809 and F812 Findings: During the survey from January 24 through January 27, 2022, the survey team observed several deficient practices in the execution of food and nutrition services in the areas of food preparation, storage, safety, kitchen sanitation, food availability, and menu and recipe compliance. In addition, inconsistent nutrition care evaluations and recommendations for vulnerable residents resulted in further decline in nutrition status and a severe weight loss for a sampled resident. 1. Food…

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 ensure snacks were consistently offered to residents three times a day, particularly an evening snack as per facility policy. This failure had the potential to negatively alter nutrition status and not meet the nutritional needs of residents in need of an evening snack. Cross reference F800, F806 Findings: 1. Resident 54 was readmitted to the facility on [DATE], due to diabetes (high blood sugar), per the facility's admission Record. On 1/25/22 at 4:19 P.M., a review of Resident 54's electronic record was conducted. Resident 54's record indicated a weight loss of 15.7 pounds (lbs) from September 2021 (137.8 lbs on 9/14/21) to January 2022 (122.1 lbs on 1/14/22). Resident 54's nutrition evaluation on 12/8/21 indicated one of the interventions for Resident 54 was to receive daily snacks between meals. On 1/26/22 at 9:27 A.M., an interview with CNA 21 was conducted. CNA 21 stated Resident 54 got graham crackers only when she asked for it.…

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 safe and sanitary measures were met in the kitchen during dietary operations according to standards of practice when: 1. A Diet Aide (DA 1) found 12 oatmeal/soup bowls stored as clean with crusted brown oats, dirt and food debris; 2. Food items were not properly labeled and dated, including thawed ReadyCare (protein shakes), an opened clear bin of dried black eyed peas, and a bag of cilantro leaves; 3. The following items were stored inappropriately in a food preparation area: a gallon of liquid bleach, a staff personal belonging, and a radio; and 4. Six scoopers and one spatula were stored wet in a drawer. These findings had the potential to expose the facility's residents to unsafe and unsanitary food practices that could lead to widespread foodborne illnesses. Findings: 1. On 1/24/22 at 8:06 A.M., an observation and interview was conducted with DA 1 and the DSS. There were 12 oatmeal/soup bowls stacked side by side in a large gray rack. The bowls had several pieces of crusted brown oat flakes, dirt…

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 RNA (Restorative Nursing Assistant) range of motion (ROM) exercises per physician's order for Residents 31, 38, and 43. This had the potential to promote the development of contractures (condition of shortening and hardening of muscles, tendons, or other tissue leading to deformity and rigidity of joints). Findings: 1. Resident 31 was readmitted to the facility on [DATE] with diagnoses to include hemiplegia (paralysis of one side of the body), per the admission Record. On 1/24/21 at 8:52 A.M., an observation of Resident 31 was conducted. Resident 31 was in bed, with her left arm supported by pillows. LN 2 repositioned Resident 31, and stated, She cannot move her arms or legs herself due to a stroke. We reposition her for comfort and to prevent skin problems. I think she gets RNA. On 1/27/22 a record review was conducted. Resident 31 had physician's orders, dated 6/20/21, for an RNA referral to provide exercises, or ROM, seven times…

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 facility document review, the facility failed to ensure the Food and Nutrition Services staff maintained current competency in dietetic task operations to safely carry out the kitchen functions in a sanitary manner according to the facility's policies and standards of practice when: 1. The A.M. and P.M. cooks did not take food temperatures of the lunch meal served on 1/24/22, including the chicken breast, green beans, pureed rice and pureed black beans; 2. CK1 and the DSS were unable to verbalize the proper final cooking temperature of chicken; 3. CK1 poured sanitizer solution from a red bucket in the food preparation (prep) sink that splashed on three trays of uncovered sliced chicken breast; and 4. CK 2 improperly calibrated a food thermometer. These failures had the potential to result in contamination of food leading to widespread food borne illness for 66 residents who consume food from the kitchen. Cross reference F803 and F812 Findings: 1. On 1/24/22, a review of the facility's cooks spreadsheet titled Winter Menus, was conducted. 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 observations, interviews, and document reviews, the facility failed to ensure the recipes for the beef enchilada, chicken jambalaya, and alternate menu's chef's salad and turkey sandwich, were followed as printed and per menu guidance. These failures led to residents not receiving food on the menu or a substitution, as planned, which had the potential to reduce food intake and impact nutritional status. Cross reference F800, F802 Findings: 1. On 1/24/22 a review of the facility's diet menu spreadsheet titled Winter Menus Week 4 Monday 1/24/22 signed by the RD, was conducted. The lunch meal entree for Monday, 1/24/22 listed beef enchiladas. A review of the recipe titled, Beef Enchiladas Week 4 Monday, was conducted. The beef enchilada recipe ingredients indicated to use beef, cooked (ground or shredded) or ground, raw beef. On 1/24/22 at 10:33 A.M., an observation of the lunch preparation and trayline was conducted. CK 1 removed pre packaged beef enchiladas from a brown case. CK 1 stated the menu for 1/24/22 was beef enchiladas, black beans and cilantro lime rice. CK 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 interview and record review, the facility failed to ensure the Physicians Orders for Life Sustaining Treatment (POLST) forms were 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 nine residents (Resident 4) reviewed for advanced directives. This failure had the potential for Resident 4 to receive the incorrect care in the event of an emergency. Findings: Resident 4 was readmitted to the facility on [DATE], per the admission Record. On [DATE] at 9:08 A.M., a record review was conducted. A POLST, dated [DATE], indicated Resident 4 wanted a Do Not Resuscitate status (DNR, allowing a natural death). The Physician's Orders were reviewed, and no order indicating code status was identified. On [DATE] at 3:30 P.M., an interview was conducted with LN 1. LN 1 stated the computer system used by the facility had two places where code status would be documented. Per LN 1, the Physician Orders would indicate DNR…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a safe and comfortable homelike environment was provided to its residents when: 1. Three of four residents reviewed for personal belongings reported items missing and not replaced (35, 43, 50), and, 2. A medication was found in a public hallway. These failures had the potential to negatively impact the residents' health and well-being. Findings: 1 a. Resident 35 was admitted to the facility on [DATE] per the facility admission Record. Per Resident 35's Resident's Clothing and Possession document on admission dated 12/17/21, Resident 35 had 1 belt, 1 shoes, 2 slacks, 1 sweater 1 watch, 1 shirt, 1 cane and money in safe. The following was listed as Resident 35's list of his clothing on admission: one gray jeans, one brown carpenter jeans, one long sleeve royal blue shirt, one red polo shirt, one red, white and blue sweater. On 1/24/22 at 9:34 A.M., an interview was conducted with Resident 35. Resident 35 stated he lost his clothes during the first…

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 multiple red and black discolorations observed on both arms and both legs for one of two residents reviewed for skin conditions (Resident 52). This failure had the potential to result in delayed provision of care and treatment for the resident's skin condition. Findings: Resident 52 was admitted to the facility on [DATE], with diagnoses to include muscle weakness and dementia (a disease of the brain which affects memory and thinking), per the admission Record. On 1/24/22 at 10:30 A.M., a concurrent interview and observation was conducted with Resident 52. Resident 52 was in bed, dressed in a short-sleeved shirt and pants. Resident 52's arms had multiple, irregular shaped areas which appeared dark red to black in color. Resident 52 stated she did not know what happened to her arms. Resident 52's lower legs were visible below her pants, and also had multiple discolored areas dark red to black in color. Resident 52 stated she did not…

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 2 followed the facility's policy and procedure prior to administering medications through a tube feeding for one of one residents observed for tube feeding (Resident 31). This failure had the potential for Resident 31 to further develop medical complications. Findings: Resident 31 was readmitted to the facility on [DATE] with diagnoses to include hemiplegia (paralysis on one side of the body) and gastrostomy (a tube for feeding directly into the stomach), per the admission Record. On 1/26/22 at 8:52 A.M., an observation of medication administration was conducted with LN 2 in Resident 31's room. LN 2 flushed the gastrostomy tube with 30 milliliters (mL) of water, then administered each medication separately through the tube. On 1/26/22, a record review was conducted. Resident 31's Physician's Orders indicated to check the tube every shift for residuals (tube feeding which remained in the stomach), and to hold the tube feeding if…

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 medication error rate was less than five percent. The facility's medication error rate was 7.14%. Two medication errors were observed, a total of 28 opportunities, during the medication administration process for two of six randomly observed residents (Residents 2, 5, 15, 31, 47, and 256). As a result, the facility could not ensure medications were correctly administered to all residents. Findings: 1. On 1/26/22 at 8:02 A.M., an observation of medication administration was conducted with LN 2. LN 2 prepared and administered medication to Resident 47, including a multivitamin. On 1/26/22 at 10 A.M., a record review was conducted. Resident 47 had a Physician's Order for one tablet of multivitamin with minerals to be administered daily. On 1/26/22 at 10:11 A.M., an interview was conducted with LN 2. LN 2 stated the wrong medication had been given. LN 2 stated she had the multivitamins with minerals in the medication cart, but she did not choose the right bottle. Per LN 2, she should have administered…

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 substitutes and meal alternatives were offered and made available to accommodate a resident's allergies and food preferences for one of three residents reviewed for food preferences (Resident 21). This failure led to Resident 21 to receive foods listed as dislikes or allergies on his meal card, and had the potential to impair food intake and nutrition status. Cross Reference F800, F802 and F803 Findings: Per the facility's admission Record, Resident 21 was admitted to the facility on [DATE]. On 1/24/22 at 12:47 P.M., an observation and interview of Resident 21 in his room was conducted. Resident 21 stated he was allergic to beef and oranges, and can only have turkey, chicken and fish. Resident 21 stated he often received the alternative entree of chicken from the kitchen, but it was sometimes undercooked and raw. Resident 21 stated he liked the turkey sandwich but sometimes did not get it. On 1/26/22 at 11:37 A.M., an…

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 and kitchen equipment were maintained in accordance with professional standards of food service safety when: 1. Frozen dough was not sealed properly inside one of one freezers; 2. An ice machine was not cleaned thoroughly for one of one ice machines; and 3. Raisins stored in the dry storage area were not stored properly. These failures had the potential for cross contamination and to placed residents at risk for food borne illness. Findings: 1. On 10/7/19 at 7:23 A.M., an observation and interview was conducted with the DSS during initial inspection of the freezer. A cardboard box on a middle shelf of the freezer was partially opened. The box was removed and a plastic bag, containing frozen dough balls was observed through the opening of the box. The plastic bag was not tied or secured and the dough had been exposed to the freezer elements. The DSS stated the dough within the plastic bag was not secured and the product was exposed to air. The DSS stated particles could have fallen in the unsecured…

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 maintain acceptable noise levels at night for two of 18 sampled residents (34, 213), and for three of five CRs (CR 2, CR 3, CR 4). This failure resulted in residents being unable to sleep at night. Findings: 1. Resident 34 was admitted to the facility on [DATE], per the facility's admission Record. On 10/7/19 at 9:27 A.M., an interview with Resident 34 was conducted. Resident 34 stated, Noisy, that's my only complaint, night shift Resident 34 stated, the NOC did so much laughing, he could not sleep. Resident 34 stated, the staff did not realize there were people living in their work-place. Resident 34 further stated, the NOC would be quiet for a few nights, but when a new set of NOC staff started, the noise level would increase again. On 10/8/19 at 11:57 A.M., a second interview with Resident 34 was conducted. Resident 34 stated the noise level the previous night was still the same. A review of Resident 34's medical record was conducted. The MDS (an…

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 develop and implement a baseline care plan for PTSD (Post traumatic stress disorder-an anxiety disorder that develops following distressing life events. Symptoms include flashbacks, nightmares of the incident, avoiding people or memories of the trauma, anger, and difficulty sleeping) for one of twenty-one sampled residents (162) reviewed for care plans. This deficient practice created the potential for Resident 162 to not receive services related to the PTSD. Findings: Resident 162 was admitted to the facility on [DATE], with diagnoses which included PTSD per the facility's admission Record. On 10/8/19 at 9:03 A.M., an interview and observation of Resident 162 was conducted. Resident 162 stated she had been taking Ambien (medication for sleep) for her nightmares and Xanax (medication for anxiety) for her panic attacks for over 18 years. Resident 162 stated she had PTSD and needed both medications to keep from having flashbacks 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 failed to ensure one of two residents reviewed for psychosocial well-being, received a psychosocial assessment (162). This deficient practice created the potential for Resident 162 to not have received needed mental health treatment. Findings: Resident 162 was admitted to the facility on [DATE], with diagnoses which included PTSD (Post traumatic stress disorder is an anxiety disorder that develops following distressing life events. Symptoms include flashbacks, nightmares of the incident, avoiding people or memories of the trauma, anger, and difficulty sleeping) per the facility's admission Record. On 10/8/19 at 9:03 A.M., an observation and interview was conducted with Resident 162. Resident 162 stated she had PTSD. Resident 162 had tears in her eyes, looked away, and did not provide eye contact. Resident 162 stated she would stay in her room and use her headphones to drown out the screaming outside in the hallway. On 10/8/19, a review of 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 one of two residents (162) reviewed for mental conditions, received treatment. This deficient practice resulted in Resident 162 to have experienced emotional distress. Findings: Resident 162 was admitted to the facility on [DATE] with diagnoses which included PTSD (Post traumatic stress disorder is an anxiety disorder that develops following distressing life events. Symptoms include flashbacks, nightmares of the incident, avoiding people, memories of the trauma, anger, and difficulty sleeping) per the facility's admission Record. On [DATE] at 9:03 A.M., an observation and interview of Resident 162 was conducted. Resident 162 stated she had PTSD for over 18 years and took medications that helped to prevent nightmares, flashbacks of the traumatic event, and panic attacks. Resident 162 stated she took Ambien (a medication) for sleep to keep from having nightmares or flashbacks. Resident 162 stated she took Xanax (anxiety medication)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure: 1. A medication card was labeled accurately for Resident 215 during medication administration observation. 2. An expired IV (intravenous) solution bag was removed from one of one IV carts inspected. These failures had the potential for adverse reactions. Findings: 1. On [DATE] at 8:17 A.M., an observation of LN 1 was conducted during a medication administration for Resident 215. LN 1 removed a medication card labeled, Bupropion (medication to treat depression) 75 mg tab #42. Generic for Wellbutrin 75 mg tab take 3 tablets (150 mg) by mouth daily. The medication card contained three packaged pink tablets per dose. LN 1 removed one dose and administered the medication to Resident 215. On [DATE] at 1:44 P.M., an interview and joint record review with LN 1 was conducted. LN 1 compared the medication label for Resident 215's Wellbutrin to the eMAR. Resident 215 was to receive a total of 150 mg (two 75mg tablets), according to the…

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

Based on dietary staff observations, interviews, and document reviews, the facility failed to ensure safe and effective Dietetic Service oversight between the facility and the Registered Dietician. Failure to ensure effective oversight of the day to day dietary operations had the potential to place 74 residents at nutritional risk, and in turn, further compromising the residents medical status. Findings: During the annual recertification survey from 10/7/19 through 10/10/19, issues were identified surrounding the delivery of dietetic services in relation to: 1) The oversight of food safety, sanitation, food storage within the kitchen and resident food brought in by visitors. (cross reference F812 and F813); and 2) The evaluation of dietary staff competency (cross reference F802), On 10/8/19 at 9:39 A.M., an interview was conducted with RD 1. RD 1 stated she worked part time, two days a week at the facility. Her duties included assessing residents dietary needs, clinical reviews, oversite of the dietary department, approving menus and attending quality assurance meetings. RD 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.

Based on observation, interview, and record review, the facility failed to employ dietary staff with the competencies and skills to carry out the daily functions of food and nutrition services, when: 1. DA 1 did not know the correct concentration of the sanitizing solution used to sanitize kitchen surfaces; and, 2. CK 2 performed and documented food temperature checks 45 minutes before lunch was served. Theses failures had the potential for kitchen surfaces not being sanitized correctly and food temperature to be incorrect at the time of plating, which could have placed residents at risk of gastrointestinal illnesses. Findings: 1. On 10/08/19 at 10:45 A.M., an observation and interview was conducted with DA 1. DA 1 stated the chlorine based sanitizer test strips should read 200-300 ppm (parts per million) when tested. DA 1 demonstrated, leaving the test strip in the chlorine based solution for five seconds. DA 1 estimated his test strip concentration was between 200 ppm or 300 ppm on the test strip container. On 10/8/19 at 10:49 P.M., the DSS approached and stated the test strip…

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 personal food brought in for residents by family and friends was stored in a safe manner for one of one designated refrigerators when: 1. Refrigerator temperatures were not being monitored daily to ensure correct temperatures were maintained; and, 2. Resident food was not labeled and dated properly when placed in the residents refrigerator. This failure had the potential for residents to be exposed to foodborne illnesses (food poisoning) if consumed. Findings: 1. On 10/8/19 at 8:34 A.M., a concurrent observation and interview was conducted with the DON of the resident's personal food refrigerator, located in the staff lounge. A temperature log for the interior refrigerator and freezer could not be located. There was no documented evidence of daily temperature monitoring being performed. The freezer contained no thermometer. The DON stated he did not know who was responsible for monitoring the refrigerator temperatures, but there should be a temperature log with daily entries. On 10/8/19 at 8:47 A.M.,…

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 accurately and consistently document urine outputs (a method used to measure fluid balance within the body), according to professional standards for one of three residents (59) reviewed for catheter care. This failure had the potential for Resident 59's fluid imbalances not to being identified by staff in a timely manner. Findings: Resident 59 was admitted to the facility on [DATE], with diagnoses which included obstructive and reflux uropathy (urine flow is blocked), per the facility's admission Record. On 10/7/19 at 8:49 A.M., an observation was conducted of Resident 59. Resident 59 was lying in bed, with a urine catheter (a clear flexible tube that drains urine from the bladder to a collection bag) draining yellow fluid to a collection bag clipped to the lower bed frame. On 10/10/19, a record review was conducted for Resident 59's catheter care. According to the physician's order, dated 9/13/19, .monitor intake (fluid taken in) 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 follow infection control practices when: 1. A blood pressure cuff was not sanitized (to clean and make free of disease causing elements) between resident use. (34, 216); and, 2. A urinary catheter collection bag was not positioned below Resident 59's bladder and was allowed to touch the floor. These failures had the potential to spread infection and cause illnesses. Findings: 1. On 10/9/19 at 9:03 A.M., an observation was conducted of LN 21 obtaining Resident 216's blood pressure. LN 21 used ABHR to sanitize his hands, removed the BP cuff from the medication cart, and obtained Resident 216's BP. LN 21 returned to the medication cart, placed the BP cuff on the medication cart, and sanitized his hands with the ABHR. LN 21 proceeded to Resident 34. On 10/9/19 at 9:14 A.M., an observation was conducted of LN 21 obtaining Resident 34's blood pressure. LN 21 hand-sanitized using the ABHR, removed the BP cuff from the medication cart, 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.