St. Pauls Health Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2c. A review of Resident 50's admission record indicated the resident was admitted on [DATE] with diagnoses including hemiplegia (paralysis on one side of the body) following cerebral infarction (a type of stroke). Resident 50 had a physician's order, dated 6/12/25, for enoxaparin (generic for Lovenox, an anticoagulant) 40 milligrams (mg) injected under the skin every morning for deep vein thrombosis (DVT, life-threatening blood clots in the legs) prevention. During a concurrent interview and record review on 6/25/25 at 11:03 A.M. with Licensed Nurse 1 (LN 1), Resident 50's anticoagulant care plan, dated 5/6/25, was reviewed. The care plan indicated Resident is at risk for active bleeding [due to] use of anticoagulant meds. The care plan further indicated Observe for S/S [signs and symptoms] of bleeding (bleeding gums, epistaxis [nosebleed], hematemesis [vomiting blood] and report. LVN 1 stated she did not see any documentation in Resident 50's medical record that Resident 50 was monitored for signs of bleeding.…

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 proper pharmaceutical services when: 1. The documentation on Controlled Drug Record (CDR) and Medication Administration Record (MAR) did not reconcile for two of three randomly selected residents (Resident 23 and 45). This failure had the potential for diversion and/or inadequate pain management. 2. The facility did not verify the accuracy of outside medications for three residents (Resident 9, 25, and 306). This failure had the potential for inaccurate medications to be administered to the residents. 3. The medication storage room and its refrigerator temperature logs were missing entries. This failure had the potential for undetected inappropriate temperature storage which could alter the efficacy of medications. Findings: 1a. A review of Resident 23's admission record indicated the resident was admitted to the facility on [DATE] with diagnosis including polyneuropathy (damage or disease affecting peripheral nerves) and pain 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 interview and record review, the facility failed to respond to the consultant pharmacist's monthly medication regimen review (MRR) recommendations for two of five sampled residents (Residents 17 and 28). This failure had the potential for unaddressed medication irregularities and inadequately monitored medications. Findings: 1. A review of Resident 17's admission record indicated the resident was admitted on [DATE] with diagnoses including major depressive disorder (also known as depression), dementia (memory loss that gets worse over time) with behavioral disturbances, and anxiety disorder. Resident 17 had physician's orders for the following medications: - Mirtazapine (generic for Remeron, a medication to treat depression) 15 milligrams (mg) by mouth daily at bedtime for major depressive disorder, dated 10/30/24; - Effexor XR (brand name for venlafaxine, a medication to treat depression) 75 mg by mouth every morning for major depressive disorder, dated 10/30/24; - Lorazepam (generic for Ativan, a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure four sampled residents (Residents 50, 32, 13, and 3) were free of unnecessary medications when: 1. Residents 50, 13, and 3 received anticoagulant (blood thinner) medications without staff monitoring for signs and symptoms of side effects; and 2. Resident 32 received an inappropriate dose of insulin and was not monitored for hypoglycemic (low blood sugar) side effects. These deficiencies had the potential to cause harm due to lack of monitoring for negative side effects of anticoagulant therapy, including excessive bleeding or bruising, and hypoglycemic side effects, including hunger, profuse sweating and tremors. Findings: 1a. A review of Resident 50's admission record indicated the resident was admitted on [DATE] with diagnoses including hemiplegia (paralysis on one side of the body) following cerebral infarction (a type of stroke). Resident 50 had a physician's order, dated 6/12/25, for enoxaparin (generic for Lovenox, an anticoagulant) 40…

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 medications/biologicals were labeled and stored according to acceptable standards of practice when: 1. Medication and medication Vials were stored opened and undated. 2. There were expired vials and medications stored in medication carts and the medication storage room. 3. Medications in the medication room and medication refrigerator were not stored in the acceptable range of temperatures. 4. An unauthorized facility staff had access to the medications in the medication room. These failures had the potential for medications to be ineffective and potentially harmful to residents. In addition, the medications were not stored securely from unauthorized access. Findings: 1. On 6/23/25 at 8:41 A.M., a concurrent observation of the medication storage room and interview with Licensed Nurse (LN) 12 was conducted. The refrigerator in the room was observed. The refrigerator contained one open vial of tuberculin, purified protein derivative…

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 appropriate infection prevention and control practices when: 1. A nurse did not disinfect the rubber seal (the point of connection between the needle and the body of the pen) of a multi-dose insulin pen while preparing the medication for one resident. 2. A nurse did not clean the blood pressure machine after it was used for one resident. 3. Expired and opened intravenous (IV, into the vein) access supplies and wound treatment supplies were not removed from the carts. 4a. Staff did not provide an opportunity for hand hygiene for 12 residents (Resident 44, 6, 10, 309, 7, 24, 29, 23, 16, 47, 12, 255) before eating lunch. 4b. Two staff did not wash their hands after leaving an isolation room where a Resident (308) was positive for Clostridium difficile (C-diff, a bacteria that causes infectious diarrhea). 5. Urinary catheter bags for two Residents (28 and 51) were laying on the floor. 6. Both shower rooms (north and south) and a shower…

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 a physician obtain informed consent (process in which a health care provider educates a patient about the risks, benefits, and alternatives of an intervention in order to obtain agreement or permission for care) for two of five sampled residents (Residents 17 and 28) on psychotropic (affecting brain activities associated with mental processes and behavior) medications. This failure had the potential for residents or their representatives to not be fully informed of the risks and benefits of psychotropic medications before receiving treatment. Findings: 1. A review of Resident 17's admission record indicated the resident was admitted on [DATE] with diagnoses including major depressive disorder (also known as depression), dementia (memory loss that gets worse over time) with behavioral disturbances, and anxiety disorder. Resident 17 had physician's orders for the following psychotropic medications: - Mirtazapine (generic for Remeron, a medication to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident's (Resident 13) personal property (a jar of grape jelly) was treated with dignity and respect when the facility did not communicate the food storage policy to the resident prior to disposal of their property. This deficiency violated Resident 13's rights for dignity and respect. Findings: A review of Resident 13's Face Sheet indicated the resident was admitted to the facility on [DATE]. On 6/23/25 at 11:30 A.M., an interview was conducted with Resident 13. Resident 13 stated she was informed earlier this morning by the nurse that her personal food item (jar of jelly) had been thrown away. Resident 13 stated it was a gift from her friend and she was very upset and angry that it had been thrown away. Resident 13 stated she had not been informed of a policy for how long a food item could be kept in the facility's resident refrigerator or when it would be thrown out. On 6/24/25 at 10 A.M., an interview was conducted with the 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 interview and record review, the facility failed to complete a discharge summary for one of three residents (Resident 5) during a closed record review. This failure had the potential for the receiving facility to not receive accurate and timely medical information regarding Resident 5's health status and needs. Findings: A review of Resident 5's Face Sheet indicated the resident was admitted to the facility on [DATE] and was discharged from the facility on 6/11/25 with diagnoses to include acquired absence of the left leg below the knee, acquired absence of the right toes, bipolar disorder (characterized by episodes of mood swings), dementia (group of conditions characterized by cognitive impairment and memory loss), dysphagia (difficulty swallowing) and difficulty walking. A review of Resident 5's Wound assessment dated [DATE], indicated the resident had a facility acquired wound to the lateral side of his right foot that measured three by two centimeters and was 100 % covered by necrotic tissue. A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure nursing staff fed one of 12 residents (Resident 29) who required feeding assistance. As a result of this deficient practice, Resident 29 received feeding assistance from the Activity Coordinator (AC) who was not qualified. The resident could have experienced choking and was at risk for aspiration. (cross reference F689) Findings: Per facility's Face Sheet Resident 29 was admitted to the facility on [DATE], with a diagnosis of Parkinsonism (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements) and Dysphagia (difficulty swallowing). On 6/23/25 at 11:45 A.M, an observation was conducted in the dining room. Resident 29 was observed receiving feeding assistance from the Activities Coordinator (AC). Resident 29's meal consisted of pureed (blended) food. On 6/24/25 at 2:27 P.M., a concurrent interview and record review was conducted with Licensed Nurse (LN) 15. LN 15 reviewed…

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 one (Resident 28) of two sampled resident's Low Air Loss (LAL) mattress was functioning properly. This failure had the potential for Resident 28 to experience skin breakdown and develop pressure ulcers. Findings: A review of Resident 28's Face Sheet, dated [DATE], indicated the resident was admitted to the facility on [DATE] with a diagnosis of Peripheral Vascular Disease (PVD, a condition where blood flow can be limited to the lower part of the body). A review of Resident 28's care plan, dated [DATE], indicated At risk for skin breakdown .LAL mattress in place . A review of Resident 28's physician orders, dated [DATE], indicated Low air loss mattress .Frequency (Scheduled): Three times Daily .monitor placement & that mattress is functioning properly A review of Resident 28's Braden scale for predicting pressure sore risk, dated [DATE], indicated the resident was a moderate risk for developing pressure sores. On [DATE] at 8:12…

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 did not ensure two of four Residents (3, 17) that were reviewed received Restorative Nursing Assistant (RNA) services as ordered by the physician. As a result, Resident 3 and Resident 17 had the potential to experience a further decline in range of motion (ROM). Findings: A review of Resident 3's Face Sheet, indicated the resident was admitted to the facility on [DATE] with a diagnosis of muscle weakness and dementia (a condition that affects memory). A review of Resident 17's Face Sheet, indicated the resident was admitted to the facility on [DATE] with a diagnosis of fracture to the lower end of right femur and fracture of right pubis and dementia. A review of Resident 3's physician orders, dated 5/24/25, indicated .RNA for BLE [Bilateral lower extremity] ROM 3x/week to improve ROM and muscle tissue extensibility A review of Resident 17's physician orders, dated 4/29/25, indicated .RNA for UB [upper body] ROM 5 x week A review of the Residents (3 and 17) RNA…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one sampled resident (Resident 29) was provided a safe and physician ordered snack when the Activity Coordinator (AC) gave the resident baby teething crackers. As a result of this deficient practice, Resident 29 could have experienced choking and was at risk for aspiration. (cross reference F659) Findings: Per facility's Face Sheet Resident 29 was admitted to the facility on [DATE], with a diagnosis of Parkinsonism (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements) and Dysphagia (difficulty swallowing). On 6/25/25, a record review was conducted. A review of Resident 29's Speech Note dated 5/14/25 indicated, .1:1[one staff to one resident] CNA [certified nursing assistant] to provide cues for slow pace, small bites/sips, and for upright positioning . A review of Resident 29's Physician Order Sheet dated 3/14/25 indicated, Diet order fortified large portions, pureed, nectar thick…

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 record review, the facility failed to ensure 4 of 37 administered medications were given in accordance with the physician orders and manufacturer's instructions for two of six residents (Resident 33 and 50). This failure resulted in a 10.81% medication error rate and the potential to affect resident safety and medication effectiveness. Findings: 1. On 6/23/25 at 10:37 A.M., a medication administration observation was conducted with Licensed Nurse (LN) 13. LN 13 prepared, dispensed, and administered 10 medications for Resident 33, including one tablet of cranberry (a supplement) 450 milligrams (mg), one capsule of potassium chloride (a medication to treat low potassium levels) 10 milliequivalents (mEq, a unit of measurement), and one drop of Refresh Classic (to treat dry eyes)1.4 - 0.6 % into each eye. A review of Resident 33's physician order was conducted. The record indicated LN 13 did not follow physician's orders during Resident 33's medication administration observation for the listed medications: - Cranberry 450mg tablet, take two tablets…

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 safety in dietary services were maintained for food storage according to standards of practice when the facility did not ensure the dry food storage room and two of three refrigerator (Unit 2 and Unit 6)temperatures were monitored consistently. These failures had the potential to cause food borne illness among the residents who received food from the kitchen. Findings: During the initial kitchen tour on 6/23/25 at 7:43 A.M., an interview and observation was conducted with the Kitchen Manager (KM) and Registered Dietician (RD). The dry food storage room did not have a thermometer to measure temperature. The KM stated the dry food storage room temperature should have had a thermometer to measure the room temperature. The KM retrieved a thermometer and placed it in the dry food storage room. The KM stated temperatures in the dry food storage room should have been monitored and documented daily to ensure the quality and safety of the food. Two refrigerators (Unit 2 and Unit 6) had written temperature…

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 identify and develop an ongoing QAPI (Quality Assurance and Performance Improvement) plan related to medication storage. (Cross reference F761) This failure had the potential for residents to receive expired medications and supplies. Findings: On 6/26/25 at 4:53 P.M., an interview was conducted with the Director of Nursing (DON), Chief Operating Officer (COO) and Minimum Data Set (MDS) Coordinator. The DON and COO stated that the QAPI committee should have identified medication storage as an ongoing project. A review of the facility's policy titled Quality Assurance and Performance Improvement (QAPI) Program, review dated 2/2025, .to provide a means to measure current and potential indicators for outcomes of care and quality of life .to provide a means to establish and implement performance improvement projects to correct identified negative or problematic indicators

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to prevent multiple significant medication errors when oxycodone/apap (a narcotic pain medication mixed with acetaminophen, also known as Percocet) was administered to one sampled resident (Resident 1), nine times without a physician's order. As a result, Resident 1 was placed at risk for serious adverse drug effects including, oversedation, respiratory depression, or medication interaction, due to repeated administration of a controlled substance without physician oversight or a valid prescription. In addition, the controlled drug record (CDR) used to record the Percocet administration was handwritten and lacked essential labeling information contributing to repeated errors and broader concerns with medication labeling and storage practices. (See tag F761) Findings: Resident 1 was admitted to the facility on [DATE] with a diagnosis of malignant neoplasm (a cancerous tumor) of the bone and a pathological fracture (bone break due to disease) of the left…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation interview and record review the facility failed to ensure that controlled substances were properly labeled and stored for one of two sampled Residents (1) during a medication cart audit when: 1. The facility did not remove discontinued controlled medications from Resident 1's active stock in the north wing medication cart 2. The facility failed to secure and label a bottle of oxycodone/apap (a narcotic pain medication mixed with acetaminophen, also known as Percocet) brought into the facility by Resident 1 which allowed the narcotic to remain in the medication cart and be administered without a valid physician's order (PO, see F760). As a result, resident 1 was given an unprescribed narcotic and was placed at increased risk for administration of additional discontinued unprescribed narcotics due to improper labeling and storage. Findings: Resident 1 was admitted to the facility on [DATE] with a diagnosis of malignant neoplasm (a cancerous tumor) of the bone and a pathological fracture (bone…

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 notify the attending physician of an abuse allegation for one of two sampled residents (Resident 1) reviewed for abuse. As a result, the attending physician was not aware of the abuse allegation placing Resident 1 at risk for further abuse. In addition, there was a potential for Resident 1 to not have appropriate safe interventions and physician evaluation. Findings: On 5/20/25 at 8:30 A.M., an unannounced onsite visit at the facility was conducted related to an abuse allegation. Resident 1 (R1) was admitted to the facility on [DATE] with diagnoses including [NAME] cell carcinoma (skin cancer) according to the facility's Face Sheet. During an observation and interview on 5/20/25 at 8:32 A.M. with Resident 1, Resident 1 was in bed leaning towards the left side of the bed near the bed rail. Resident 1 stated he had a concern with certified nurse assistant (CNA) 3. Resident 1 stated CNA 3 was, Rough while turning him in bed. During 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 interview and record review the facility failed to comply with the current state regulation on maintaining a complete information as to past employment and qualifications. As a result, the facility had no record of employees' past employment history or references and qualifications. Findings: On 5/20/25 at 8:30 A.M., an unannounced onsite visit at the facility was conducted related to an abuse allegation. Resident 1 (R1) was admitted to the facility on [DATE] with diagnoses including [NAME] cell carcinoma (skin cancer) according to the facility's Face Sheet. During an interview on 5/20/25 at 8:32 A.M. with R1, R1 stated he had concerns regarding certified nurse assistant (CNA) 3. An interview was conducted on 5/20/25 at 10:25 A.M. with the Director of Nursing (DON). The DON stated CNA 3 had been employed by the facility since 11/21/2000. The DON stated she checked CNA 3's file and did not find a reference check prior to CNA 3's employment. The DON further stated that the human resources [HR- the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to correctly administer a wound treatment medication for one of four sampled residents reviewed for medication errors (Resident 1). As a result, wrong wound treatment medication was administered. In addition, this failure has the potential to delay Resident 1 ' s wound healing. Findings: On 5/2/25 at 8:30 A.M., an unannounced onsite visit at the facility was conducted related to treatment medication error. Resident 1 was admitted to the facility on [DATE] with diagnoses including bullous pemphigoid (a rare skin condition that causes large fluid-filled blisters) according to the facility ' s Face Sheet. During an observation and interview on 5/2/26 at 8:44 A.M. with Resident 1, Resident 1 was observed in bed with a dressing on his right arm, close to Resident 1 ' s elbow. Resident 1 stated he had a wound on the right arm, and it was not getting better. Resident 1 stated a nurse administered the incorrect medication on his right arm wound. During a 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 failed to complete post fall assessments and resident centered fall preventive measures for four of four residents reviewed for complete resident records. (Residents 1, 2, 3 and 4) This failure had the potential for residents to have repeated fall incidents. Findings: 1. Resident 1 was admitted to the facility on [DATE] with diagnoses including unspecified abnormalities of gait and mobility according to the facility's Face Sheet. During an observation and interview on 6/13/24, at 9:01 A.M. with Resident 1, Resident 1 stated she returned to the facility from the hospital because she fell. Resident 1 stated she did not remember how and where she fell but stated she broke her hip and was pointing on the left hip. A review of Resident 1's Clinical Notes Report, dated 6/7/24 at 7:23 A.M. a Licensed Nurse documented, .resident was found on the floor of the entryway to her room . An interview with Certified Nurse Assistant (CNA) 1 was conducted on 6/13/24,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. A review of Resident 21's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included Wegener's Granulomatosis with renal involvement (a rare blood vessel disease that can cause symptoms in the kidneys) and long term current use of anticoagulants (a blood thinning medication). On 4/4/23 at 3:15 P.M., an observation and interview were conducted with Resident 21. Resident 21 was in bed, on a low air loss mattress (a mattress designed to prevent and treat pressure wounds). Resident 21 was noted to have dark purple bruising from her elbow to her hand on her right side. Resident 21 had areas of redness on her mid forearm and two locations with steri-strips on her right side. Resident 21 was noted to have dark purple bruising from her wrist to her knuckles on her left side. Resident 21 stated that her skin was delicate and that staff needed to be extra careful and gentle when caring for her. On 4/7/23 at 8:29 A.M., an interview and concurrent record review was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure all nursing staff including registry staff (nursing staff provided by a staffing agency) had the necessary training and competencies (measurable pattern of knowledge, skills, abilities, and behaviors, and other characteristics to perform occupational functions successfully) to care for residents with a history of trauma and/or post-traumatic stress disorder (PTSD). In addition, staff providing care to Resident 2 and Resident 24 were unaware of the resident's PTSD diagnosis and history of trauma. This failure had the potential for residents with a history of trauma and/or PTSD to experience triggers and retraumatization that would compromise the residents' safety and their ability to achieve their highest practicable physical, mental, and psychosocial well-being. (Cross reference F699 and F838) Findings: 1. A review of Resident 2's Face Sheet indicated the resident was readmitted to the facility on [DATE] with diagnoses to include PTSD. On 4/5/23…

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 3 of 5 residents (Resident 1, 42 and 9) were free from unnecessary use of psychotropic medications (any drug affecting behavior, mood, thoughts, or perception) when: 1. A Gradual Dose Reduction (GDR) was not completed for Resident 42. 2. Resident 1 and Resident 42 did not have an approved indications for the use of an antipsychotic medication. 3. Resident 9's sleepiness was not identified as a possible side effect of the resident's psychotropic medications. This failure had the potential for Residents to experience unnecessary side effects from the psychotropic medication. Findings: 1. Resident 42 was admitted to the facility on [DATE] with the diagnosis of Alzheirmer's Dementia (A progressive disease that destroys memory and other important mental functions) according to Resident 42's face sheet. During an observation on 4/4/23 9:29 A.M., Resident 42 came out of the restroom in his wheelchair. Resident 42 stated he was admitted…

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 document review, the facility failed to update the facility assessment to reflect the facilities staffing challenges, the usage of staffing agencies, and address the required training and competencies for agency staff, who cared for the facility residents. This failure had the potential to affect the residents' care due to agency staff's lack of training and knowledge. (Cross reference F-tag 699 and F-tag 741) Finding: An interview and joint document review of the facility's facility assessment, dated 8/18/17, was conducted. The Administrator (ADM) reviewed the signature page of the facility assessment, and confirmed that he and the director of nursing (DON) signed the document on 3/28/23. The ADM stated he reviewed the facility assessment on 3/28/23, but did not dissect the document. Both the ADM and the DON confirmed that the facility currently have residents who had been diagnosed with Post-Traumatic Stress Disorder (PTSD - occurs in some individuals who have encountered a shocking, scary, or dangerous situation), and/or residents with history of trauma.…

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 document review, the facility's Quality Assurance and Performance Improvement (QAPI - a systematic, interdisciplinary, comprehensive, and data-driven approach to maintaining, and improving safety and quality in nursing homes) did not identify areas of improvement in the facility's staff education with regard to Trauma Informed Care. (Cross reference F-tag 699 and F-tag 741) This failure placed any residents admitted to the facility with diagnosis of Post Traumatic Stress Disorder (PTSD - occurs in some individuals who have encountered a shocking, scary, or dangerous situation) and history of trauma at increased risk for emotional distress. Findings: A concurrent interview and record review was completed on 4/7/23 at 3:50 P.M., with the Director of Nursing (DON) and Administrator (ADM). The DON stated the facility was working on the facility's identified issues with quality improvement plan. The DON reported these issues to be resident wounds and falls. On 4/7/23 at 3:57 P.M., the DON confirmed there were no improvement projects for Post Traumatic Stress…

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 fully implement infection control standards of practice when hand hygiene (using alcohol-based hand gel or performing hand washing with soap and water) was not performed before and after direct contact with residents, before and after glove use, and before and after providing feeding assistance to a resident (Resident 29). In addition, a resident's oxygen tubing was not stored properly and did not have a date of when it was first used or changed. These failures had the potential to spread infection and disease among residents and staff. Findings: 1. On 4/6/23 at 8:10 A.M., an observation was conducted. Certified nursing assistant (CNA) 35 was observed going into Resident 3's room. CNA 35 put on gloves, assisted Resident 3 by positioning the resident and opening food items for the resident. CNA 35 removed his gloves, left Resident 3's room, and went to room C. CNA 35 did not perform hand hygiene. CNA 35 was observed leaving room C 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 four of 15 residents' (Resident 20, 40, 25, and 14) privacy and confidentiality was respected and maintained when: 1. Staff entered Resident 20 and Resident 40's private space without knocking or announcing themselves. 2. Resident 25 and Resident 14's clinical documentation was found within other residents' medical records. As a result of this deficient practice, the residents had the potential to feel disrespected. In addition, there was a potential for residents' private medical information to be accessed by unauthorized individuals. Findings: 1a. During an observation on 4/5/23, at 8:44 A.M., Staff 1 went into room A without knocking, walked out of room, then went into room B without knocking or announcing himself. An interview was conducted on 4/5/23, at 8:45 A.M., with Resident 20 who was in room A. Resident 20 stated she saw the man who walked in her room and did not know who he was. Resident 20 stated, That was bothersome.…

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 15 residents (Resident 22), reviewed for homelike environment, had a landing mat (a cushioned device similar in shape and size to a mattress that was used to prevent injury if the resident were to fall out of bed) that was maintained in an acceptable condition. As a result, there was the potential for Resident 22's comfort and safety to become compromised. Findings: A review of Resident 22's Face Sheet indicated the resident was admitted to the facility on [DATE]. On 4/4/23 at 4:24 P.M., a joint observation and interview was conducted with certified nursing assistant (CNA) 33 while inside of Resident 22's room. Resident 22 was observed in bed, and on the floor next to the resident's bed, was a landing mat. The landing mat was in two separate sections and appeared to have fallen apart. Each section was ripped and torn with frayed edges and the foam insert was hanging out of each section. There were also stains on the fabric…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide communication devices for two of four residents (Resident 24 and Resident 1) reviewed for communication. This failure had the potential for a lack of communication and residents' inability to have their needs met. Findings: 1. Resident 24 was admitted to the facility on [DATE] with the diagnosis of End Stage Heart Failure (The body can no longer compensate for the lack of blood the heart pumps, and the heart has limited functional recovery) according to Resident 24's face sheet. During an observation on 4/4/23, at 8:20 A.M., Resident 24 was in bed speaking Spanish with staff. Certified Nurse Assistant (CNA) 12 translated in Spanish during an interview with Resident 24 on 4/4/23 at 9:38 A.M. Resident 24 was observed with a blanket over her head. Resident 24 stated some staff were good, and some were not so good. Resident 24 stated some staff pulled her up too much or too quickly. Resident 24 stated, Maybe they didn't like me. During…

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 coordinate care for one of three residents (Resident 14) reviewed for hospice services. This failure had the potential for Resident 14 to suffer harm. Findings: A review of Resident 14's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease (the most common cause of memory loss and other cognitive abilities serious enough to interfere with daily life), other abnormalities of gait (a person's manner of walking) and mobility, generalized muscle weakness, difficulty in walking, repeated falls. On 4/6/23 at 2:35 P.M., an interview was conducted with licensed nurse (LN) 41, who stated, Weeks ago, she (Res 14) verbalized Please God, take me now. LN 41 stated when Res 14 said, 'Please God take me now' I gave her a rosary. I didn't tell anyone because it was at night. I told the incoming LN/ RN. Ln 41 stated, I didn't tell the shift supervisors or the hospice. I could have…

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 an environment free of accident hazards for one of three residents (Resident 14) reviewed for accidents. This failure had the potential for Resident 14's to suffer harm from a fall. Findings: A review of Resident 14's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that include Alzheimer's Disease (the most common cause of memory loss and other cognitive abilities serious enough to interfere with daily life), other abnormalities of gait (a person's manner of walking) and mobility, generalized muscle weakness, difficulty in walking, repeated falls. A record review was conducted of Resident 14's fall care plan, with a goal of 4/19/23, indicated, At risk for falls related to Alzheimer dementia, new oxygen use, diuretic and hypertension medication use. Status: active (current). Interventions: sensor alarm to the bed. Status: Active (current). Place call bell/ light within easy reach.…

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 one sampled resident (Resident 16), had her suction equipment (system that removes/sucks up secretions) adequately maintained. This failure had the potential to result in inadequate clearance of Resident 16's oral secretions causing respiratory distress (trouble breathing). Findings: A review of Resident 16's admission Record indicated the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses included esophageal obstruction (blockage in tube that connects the throat to the stomach), dysphagia (difficulty swallowing), disturbances of salivary secretion (abnormal mouth saliva) and gastroesophageal reflux (stomach contents go up into the esophagus). Physician order dated 5/27/2018 indicated oral suction to be done three times a day as needed. Physician order dated 6/6/2018 indicated continuous aspiration (choking) precautions. On review of Clinical Notes dated 12/14/22 at 2:48 A.M., LN 2…

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 one of two residents (Resident 24) received Trauma Informed Care (TIC- an intervention and organizational approach that focuses on how trauma may affect an individual's life and his or her response to behavioral health). This failure resulted in the facility's inability to identify possible triggers that could result in re-traumatization (the reactivation of trauma symptoms via thoughts, memories, or feelings related to the past traumatic experience). Findings: Resident 24 was admitted to the facility on [DATE] with the diagnosis of End Stage Heart Failure (The body can no longer compensate for the lack of blood the heart pumps, and the heart has limited functional recovery) according to Resident 24's face sheet. Certified Nurse Assistant (CNA) 12 translated in Spanish during an interview with Resident 24 on 4/4/23 at 9:38 A.M. Resident 24 was observed with a blanket over her head. Resident 24 stated some staff were good, and…

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

Based on observations, interviews, and record review, the facility failed to ensure three of 30 administered medications were given in accordance with the physician orders. This failure resulted in 10% medication error rate. In addition, failure to administer medications in accordance with the physician order had the potential to affect resident safety. Findings: A medication administration observation was conducted on 4/6/23 at 8:07 A.M Licensed Nurse (LN) 41 prepared Resident 16's medication. LN 41 prepared the following medications: 1. Amlodipine (blood pressure medication) 5 milligrams (mg) 1 tab (tablet) 2. Benazepril (blood pressure medication) 10 mg 1 tab 3. Buspirone (anti-anxiety medication) 5 mg 1 tab 4. Cranberry (supplement) 450 mg 1 tab 5. Docusate Sodium (stool softener) 100 mg 2 tabs 6. Glycopyrrolate (medication for excessive saliva production) 1 mg (Crush and dissolve in hot water) 7. Multivitamin with minerals (supplement) 30 milliliters (ml) 8. Omeprazole (medication for acid reflux - acidic stomach fluid flows back up) 20 mg/10 ml gave 10 ml 9. Miralax (laxative)…

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 food items in the kitchen and in a resident's room (Resident 3) were stored according to professional standards for food safety. As a result, there was the potential for residents to be exposed to contaminated food and/or experience foodborne illness. Findings: 1. On 4/4/23 at 8 A.M., an initial kitchen tour was conducted with the head chef (HC). Observed in the walk-in refrigerator, was a large box with approximately 24 green bell peppers in it. There were approximately seven green bell peppers that were covered with gray, fuzzy areas. The HC stated the green bell peppers had mold on them and should not have been stored among non-spoiled produce. The general manager joined the observation in the walk-in refrigerator. A large box of bagged shredded lettuce was observed. Two of the three bags of shredded lettuce had lettuce that appeared discolored and slimy. The HC stated the shredded lettuce should have been thrown out. 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 explain care to a resident in their native language for 1 of 13 sampled residents (10). As a result the facility did not identify language as a precipitating factor to Resident 10's combative behavior. Findings: Resident 10 was admitted to the facility on [DATE] with a diagnoses which included dementia (mental decline and impaired memory) per the facility's Face Sheet. On 3/28/19 at 3:45 P.M., an interview was conducted with Resident 10's RP. The RP stated Resident 10 was uncooperative with agressive behaviors when care was provided by certain staff members. The RP stated Resident 10 spoke English and Spanish, but Spanish was her native language. On 3/28/19 at 4:20 P.M., an observation of Resident 10 was conducted with CNA 2. Resident 10 was observed lying in bed, quiet and awake. CNA 2 spoke to Resident 10 in Spanish. On 3/28/10 at 4:22 P.M., an interview was conducted with CNA 2. CNA 2 stated Resident 10 preferred to communicate 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, 1 of 13 residents (7) was not correctly positioned when sitting in a wheel chair. As a result this practice had the potential for Resident 7 to develop a pressure ulcer (injuries to skin and underlying tissue resulting from prolonged pressure on the skin). Findings: Resident 7 was admitted to the facility on [DATE] with a diagnoses to include abnormal posture per the facility's Face Sheet. Per Resident 7's history and physical, dated 3/1/19: Resident 7 was unable to independently move her legs and her knees were in a flexed position and contracted (abnormal shortening of muscle tissue, resistant to stretching ) On 3/27/19 at 11:54 A.M., an observation of Resident 7 was conducted. Resident 7 was seated upright in a wheelchair slumped to the right side. The resident's right lateral foot rested against the right wheel of the wheelchair. On 3/27/19 at 3:56 P.M., 4:05 P.M., and 5:06 P.M., an observation of Resident 7 was conducted. Resident 7 was observed lying on…

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

Based on observation, interview and record review the facility failed to ensure call lights were answered in a timely manner to address resident needs for five residents interviewed on initial tour of the facility, and one resident from the confidential group interview. This failure had the potential to affect the physical and psychosocial well-being of these residents. Findings: According to Resident A's baseline care plan, dated 3/22/19, the resident was alert and cogitatively intact. This document also indicated Resident A had a history of falls, was continent of bowel and bladder, and required assistance of one person for toilet use. During an interview with Resident A on 3/27/19 at 8:40 A.M., the resident stated it took a while for staff to answer her call bell. Resident A stated her call light was broken and she was given a bell to ring. The resident stated it took a long time for anyone to answer her bell when she rang it. During an observation on 3/27/19 between 8:48 A.M. and 9:03 A.M., Resident A rang her bell five separate times before any staff was observed to enter her…

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 procedures for the provision of pharmaceutical services to meet the needs of three of three residents (23, 17, and 99) reviewed during medication pass. 1. The facility failed to administer medications in accordance with the physician's order when metoprolol tartrate (medication used to treat high blood pressure) was administered at half the prescribed dose for more than one month to Resident 23. This failure posed the potential to have a negative effect on the resident's health. 2. The facility failed to ensure accurate documentation of Residents 17 and Resident 99's controlled medications. These failures posed the risk for diversion of controlled medications. Findings: 1. On 3/27/19 at 9:05 A.M., a medication pass was observed. LN 3 administered 12.5 mg of metoprolol to Resident 23. However, LN 3 documented on Resident 23's 3/19 Medication Administration Record (MAR) that she had administered metoprolol 25 mg to Resident 23.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the medication error rate was less than 5% when the physician's orders were not followed for two of 33 residents reviewed for medications (Residents 9 and 23). 1. Furosemide (medication used to treat fluid retention and swelling) was not available for administration for Resident 9 as ordered by the physician. 2. Metoprolol tartrate (medication used to treat high blood pressure) was not given to Resident 23 as ordered by the physician. These failures posed the potential to negatively affect the residents' health and resulted in a medication error rate of 6.06%. Findings: Review of the facility's Policy and Procedure titled, Medication Administration. General Guidelines (California Specific dated 5/16, showed: .Medications are administered in accordance with written orders of the prescriber . 1. On 3/27/19 at 8:15 A.M., an observation of a medication pass performed by LN 22 was conducted. LN 22 prepared medications for Resident 9. LN…

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 medications were stored as per the facility's policy and procedure when one of one medication storage rooms were observed. 1. An expired anti-diarrheal (loperamide) bottle, an expired triple antibiotic ointment box, and an expired container of 10% Zinc Oxide Adult Barrier Spray were removed from the medication storage room. 2. One vial of opened Influenza vaccine Afluria 5 ml was not dated when opened. These failures had the potential to result in unsafe administration of medications. Findings: On [DATE] at 9:54 A.M., an observation of the medication storage room and concurrent interviews with the DON and LN 3 were conducted. The following was observed: 1. One bottle of anti-diarrheal (loperamide) 2 mg (milligram) 96 capsules was expired on 12/18. The DON confirmed the expiration date and stated the bottle should have been discarded. 2. A box of triple antibiotic ointment containing 144 individual packets was expired on 1/19 and 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 observation, interview, and record review, the facility did not provide palatable food at a desired temperature for 5 of 12 residents interviewed during initial tour. This failure had the potential to affect the residents' meal intake and enjoyment of their meals. Findings: On 3/27/19 during an initial tour of the facility, five residents interviewed complained the food was frequently cold. At 8:40 A.M., Resident A stated, The food is cold. At 8:43 A.M., Resident B stated, The food is cold and dry. At 9:59 A.M., Resident C stated, The food could be hotter. At 10:05 A.M., Resident D stated, The food is not always hot. At 10:09 A.M., Resident E's family member stated, The food is not always hot. Resident E's family member further stated Resident E was unable to tell anyone the food was not hot, and would not eat when the food was cold. According to the Resident Council Meeting minutes, dated 1/10/19, two of eight residents stated the food was cold. On 3/28/19 at 12:50 P.M., an observation and tasting of food on a meal tray was conducted with the DSS and the RD. The DSS took…

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

Based on observation, interview and record review, the facility did not assure fresh (within food safety guidelines) produce was available for use when preparing residents meals. This created the potential for unsafe food consumption. Findings: On 3/27/19 at 7:40 A.M., a concurrent observation of the kitchen and interview with the DSS was conducted. Bananas on the counter in a wire basket did not have a received by date or use by date. The DSS stated we need to label the basket with a use by date for the bananas. On 3/27/19 at 8:02 A.M., a concurrent observation of the kitchen and interview with the DSS was conducted. Outside of the freezer on a steel shelf, yellow onions were observed in a gray bin. The onions had an expiration date of 3/20/19 and were available for use when preparing meals for residents. The DSS stated the onions were expired and should not have been available to use for meals. On 3/29/19 at 8:40 A.M., an interview was conducted with the RD and the DSS. The DSS and RD agreed the bananas should have had a received by date or use by date for safe consumption. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure proper infection control practices were implemented for 1 of 13 residents (97) who had a catheter (hollow flexible tube used to drain urine from the bladder) when Resident 97's urine drainage bags were not properly positioned. This failure created the potential for Resident 97 to be exposed to germs in his urinary tract. Findings: Resident 97 was admitted to the facility on [DATE] with a diagnoses of urinary retention (inability to completely empty the bladder) per the facility's Face Sheet. A. On 3/27/19 at 11:09 A.M., a concurrent observation and interview with CNA 6 was conducted. Resident 97 was observed to have a suprapubic catheter attached to a urinary drainage bag. Resident 97's urinary drainage bag was on the floor beside his bed. CNA 6 stated urinary drainage bags should not touch the floor because the floor is dirty. On 3/28/19 at 8:46 A.M., a concurrent observation and interview with PTA 1 was conducted. Resident 97 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure one of five sampled residents (39) received the pneumococcal vaccine in accordance with the Center for Disease Control (CDC) recommendations upon admission to the facility. This failure had the potential to place Resident 39 at risk for acquiring, transmitting, or experiencing complications from pneumococcal disease (bacteria which causes pneumonia - infection in the lung). Findings: Resident 39 was admitted to the facility on [DATE] with diagnoses, which included dementia (a loss of mental abilities that leads to impairments in memory, reasoning, planning, and behavior), and encounter for palliative care (comfort care to treat the symptoms and side effects of serious illness) per the facility's Face Sheet. This document also indicated Resident 39 was over [AGE] years of age. During a concurrent interview and record review with LN 21 on 3/29/19 at 10:21 A.M., LN 21 stated Resident 39's RP consented for the resident to receive the pneumococcal…

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.