Villa Rancho Bernardo Care Center

Based on observation, interviews, and documentation, the facility failed to ensure essential kitchen equipment was maintained in working operational condition when three of four ovens were not working or maintained according to standards of practice or facility policy. This failure affected the ability of the Food and Nutrition Services Department to prepare resident meals safely and efficiently, which had the potential for residents to receive undercooked food, and to develop food borne illness. The facility census was 271. Findings: During a concurrent observation and interview with [NAME] 1 (CK 1) on 12/4/23 at 8:50 A.M., there were two double stackable ovens next to the cooktop gas stove range with an oven underneath. The bottom oven in the stackable oven unit had an out of order, maintenance notified 12/3/23 sign taped to the bottom handle. CK1 stated the oven had not been working since last Thursday (11/30/23) but also stated it may have been not working longer than that. CK 1 attempted to light the lower left oven pilot light three times before it eventually lit and stayed…

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, record review, and document reviews, the facility failed to ensure that low air loss mattresses (LAL - an air flow mattress used to prevent skin breakdown by distributing weight over the mattress to reduce pressure to the skin) were set according to the physician's order for five of five residents (Resident 197, Resident 203, Resident 7, Resident 69, Resident 216) reviewed for pressure ulcer. These failures increased the risk for skin breakdown for all residents. Findings: 1. A review of Resident 197's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included Heart Failure (occurs when the heart muscle doesn't pump blood as well as it should). A review of Resident 197's physician's order, dated 12/17/21, indicated, .LAL Mattress for skin management. License nurse to monitor proper functioning of LAL mattress. License nurse to monitor setting if LAL mattress per pt [patient] weight or comfort QS [every shift]. A record 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 interview and record review, the facility failed to accurately code the Minimum Data Set (MDS - assessment tool) related to the use of an anticoagulant (medicine that prevent or reduce blood clots) for two of 35 residents (Resident 69 and Resident 106) reviewed for MDS accuracy. Resident 69 and Resident 106's MDS assessments, dated 11/19/23, incorrectly coded that both residents received an anticoagulant medication during the 7-day look back period of 11/13/23-11/19/23. These failures had the potential for staff to provide both residents with inappropriate care due to the wrong data inputted in the residents' MDS assessment. Findings: 1. A review of Resident 69's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included Spinal Stenosis (when the space inside the backbone is too small causing pressure to spinal cord [back bone] and nerves that carry sensations to brain and body). A record review of Resident 69's MDS assessment, dated 11/19/23, Section N…

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 PASSAR Level 2 (PSL2) (Preadmission Screening and Resident Review- a form to determine if a resident has or is suspected of having a mental illness) was completed after PASSAR Level 1 (PSL1) was positive for one of 35 residents (Resident 183) reviewed for PASSAR. This failure had the potential to not ensure the appropriate mental health services for Resident 183. Findings: A review of Resident 183's admission Record (AR) indicated Resident 183 was admitted on [DATE] with diagnoses including: Unspecified Dementia (a condition characterized by progressive or persistent loss of intellectual functioning), unspecified severity with other behavioral disturbances, and Depression (persistent sadness and a lack of interest or pleasure). On 12/4/23 at 3:30 P.M., an interview with Resident 183 was attempted. Resident 183 refused interview. On 12/6/23 at 11:15 A.M., a concurrent interview of Licensed Nurse (LN) 2 and record review of Resident 183's chart…

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 develop a patient-centered plan of care for one of 35 residents (Resident 152) related to language. This failure had the potential for Resident 152's care needs to not be addressed due to miscommunication. Findings: A review of Resident 152's admission Record indicated the resident was admitted to the facility on [DATE] with a diagnosis of Cerebral Palsy (is a group of disorders that affect a person's ability to move and maintain balance and posture). Per the admission Record, Resident 152's primary language was Chinese. A record review of the Resident 152's Minimum Data Set (MDS - assessment tool), dated 10/08/23, indicated under Section C100 Cognitive Patterns, Resident 152 was coded 0. Per the Resident Assessment Instrument (RAI)/MDS manual, Resident 152 was rarely/never understood. An interview was conducted on 12/04/23, at 9:00 A.M., with Certified Nursing Assistant (CNA) 11. CNA 11 stated that Resident 152 was verbal and did not speak English.…

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 update the plan of care for one of 35 residents (Resident 101) related to activities of daily living (activities such as eating, toileting, dressing, etc.). This failure had the potential for Resident 101's ADL needs to not be addressed. Findings: A review of Resident 101's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease (a brain disorder that slowly destroys memory, thinking skills, and eventually, the ability to carry out the simplest tasks). A record review of Resident 101's Minimum Data Set (MDS - assessment tool), dated 9/14/23, indicated the resident required extensive assistance with eating and toileting. An interview and record review of Resident 101's medical record was conducted on 12/06/23 at 9:45 A.M., with the Minimum Data Set Nurse (MDSN). The MDSN stated that a significant change of condition (SCSA - when two or more factors of decline is captured with the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to monitor and fully assess a sampled resident, Resident 221, with a severe weight loss of 17.3% in six months, according to the facility's policy. This failure led to further decline in Resident 221's nutritional and health status. Findings: According to the Academy of Nutrition & Dietetics, Nutrition Care Manual, dated 2022, Treatment of unintended weight loss is imperative to ensure optimal outcomes for the older adult. Unintended weight loss is linked to increased mortality (death) among older adults . residents in long-term-care facilities who continue losing weight have a higher mortality rate compared with those who stop losing weight. Weight loss of 5% or more within 30 days is associated with a tenfold increase in the likelihood of death. Unintended weight loss often results in protein-energy undernutrition (low protein or calorie intake resulting in insufficient nutrient absorption), as the older adult loses critical lean body…

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 Medication Regimen Review (MRR - evaluation of a resident's medications with the goal of promoting positive outcomes and minimizing adverse consequences associated with medications) was completed and implemented by the attending physician for one of 35 residents (Resident 66). This failure had the potential for Resident 66 to experience side effects from the medications. Findings: Resident 66 was admitted to the facility on [DATE] with diagnosis of acute renal failure (a sudden episode of kidney failure or damage), per the facility's face sheet. On 12/6/23 at 7:58 A.M., a concurrent interview and review of Resident 66's MRR dated November 2023, was conducted with licensed nurse (LN) 21. Resident 66's MRR indicated inquiry related to continued usage of several medications, dose reduction, or discontinuation of medications, if appropriate, and possible side effects the resident may experience with continued use. LN 21 stated this record was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not ensure food was prepared in a form to meet the nutritional needs for a sampled resident, Resident 132. This failure had the potential to cause poor food intake because the resident did not receive meals that met the correct form according to the Resident 132's physician-ordered diet. Cross reference F804, F806 Findings: Per Resident 132's Facility admission record, Resident 132 was admitted on [DATE] with health conditions that included: Type 2 (adult onset) diabetes (a chronic condition that affects the way the body processes sugar); diabetic retinopathy (an eye condition that can cause vision loss, up to blindness); generalized (all over) muscle weakness; and dementia (a general term for loss of memory, language, problem solving skills and other thinking abilities that interfere with daily life). During a review of Resident 132's Physician Order Sheet, dated 12/7/23, the therapeutic diet order indicated, CCHO (Consistent Carbohydrate),…

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 accommodate one of 35 sampled residents' food preferences (Resident 140). This failure had the potential to result in decreased caloric and nutrient intake. Findings: A review of facility's document admission Record (AR), dated 8/27/2023, indicated Resident 140 was admitted to the facility on [DATE], with diagnoses which include: End Stage Renal Disease(Disease where Kidneys are not functioning) , Dependence on Renal Dialysis (Treatment to filter blood of toxins), Type 2 Diabetes Mellitus(Disease where body unable to regulate own blood sugars), and Iron Deficiency Anemia(Low red blood cell count due to lack of Iron in diet). A review of Resident 140's Minimum Data Set (MDS- assessment tool) section C, Cognitive Patterns, dated 10/17/2023, indicated Resident 140's BIMS (A tool to measure resident's cognitive ability) was measured to be 15, meaning resident had intact cognition. On 12/4/23 at 4:05 P.M., a concurrent observation 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 The facility failed to implement proper infection control practices when: 1. An employee did not wear a gown while touching dirty linens 2. A tube feeding was not disposed of in a timely manner for 1 out of 35 sampled residents (Resident 196). These failures had the potential to spread infection amongst the residents, staff, and visitors. Findings: 1. On 12/7/23 at 9:11 A.M., an observation and interview was conducted with Infection Preventionist (IP) 1 and the Maintenance Director (DM). During the tour of the laundry area, housekeeping (HK) 1 entered the dirty section of the laundry area. HK 1 was observed pulling the cart of dirty linens wearing his gloves. HK 1 did not wear a gown. During the observation, HK 1 transferred bags of dirty linens from one cart to another. During this process, some of the bags ripped, exposing the dirty linens inside. HK 1's arms touched the dirty linens. The DM spoke to HK 1 to wear a gown, but HK 1 continued to transfer the ripped bags of dirty linens while ungowned. On 12/7/23…

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 interview and record review, the facility failed to develop a plan of care which directed staff to remove stitches for one of two sampled residents (1). This failure placed Resident 1 at an increased risk of stitches being left in too long, which carried an increased risk of scarring. Findings: Per the facility's admission Record, Resident 1 was admitted to the facility on [DATE]. Per the document titled Fall, dated 3/29/23, the physician noted that Resident 1 had a right facial laceration (a deep cut to the face), and the Discharge plan included, .Sutures (stitches) should be removed in 5 days . On 8/10/23 at 10 A.M., an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated, Resident 1 returned from the hospital with stitches and an order to remove the stitches in five days. The ADON further stated, the order to remove the stitches was never entered into their system, and there was no documentation to show when the stitches were removed. The ADON stated, the admission…

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 facility policies and standard of practice when: 1. A [NAME] could not correctly demonstrate how to calibrate the food thermometer; 2. A Dietary Aide did not correctly cool down the tuna salad before serving it; 3. A Dishwasher after emptying the garbage bins at the outside dumpster did not wash his hands after entering the kitchen. These failures had the potential to expose residents to unsafe and unsanitary food service practices that could result in widespread food borne illness. Cross reference 803, 804, 806, and 812 Findings: 1. On 11/16/21 at 3:25 P.M., a concurrent observation and interview with CK 2 was conducted in the kitchen. CK 2 stated he calibrated the digital thermometer every time he placed the food out on the tray line. CK 2 demonstrated the thermometer calibration by cleaning it with an alcohol wipe, then…

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 dietary staff correctly followed the recipes and menus as printed and according to the facility policy when: 1. Soup was not included on the menu. 2. White roll was served instead of wheat roll. These failures resulted in a vulnerable resident population receiving inadequate and/or incorrect nutrition. Cross reference 804, 806 Findings: On 11/15/21, a review of the Week- At- A Glance Fall Menu 2021 Week 2 November 11 to November 21 was conducted. Monday, 11/15/21 - Regular lunch menu included: pot roast, wheat roll, brussels sprouts, ice cream, garlic mashed potatoes, and milk. Monday, 11/15/21 - Pureed lunch menu included: pureed pot roast, pureed wheat bread, pureed brussels sprout, ice cream, garlic mashed potato, and milk. On 11/15/21 at 11:27 A.M., an observation and interview with CK 2, FSD and DA 4 was conducted during the tray line meal service. There was a dark brown colored pureed food that was served to 48 residents on pureed diets. DA 4 and CK 2 stated the dark brown textured oatmeal 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 safe and sanitary measures were met in the kitchen during dietary operations according to standards of practice when: 1. Expired and undated foods were found inside the walk-in refrigerator and dry storage room; 2. Several pieces of red meat patties were found on long metal sheet pans uncovered and exposed on an open drying rack in the walk-in refrigerator; 3. Two ice machines were dirty with brown spots inside the ice bin containing ice and was not cleaned according to manufacturer's guidance; 4. Improper cooling procedures were conducted after tuna salad preparation; 5. Three Nursing unit refrigerators had expired foods and the correct temperature was not regularly maintained. These deficient practices exposed all residents who receive food from the kitchen to unsanitary practices and potentially unsafe foods that could lead to widespread foodborne illness. Cross reference 802, 803, 804, and 806 Findings: 1. During the initial…

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 17 of 61 residents reviewed were provided with safe, clean, comfortable and homelike environment when residents' rooms (109, 116, 117, 118, 120, 126, 127, 123, 129, 105, 111, 114, 131, 119, 115, 125, 127) had broken corner walls, broken brown baseboard, stained toilet seats, air vents with white and gray debris. These failures did not promote a homelike environment to the residents. Findings: On 11/15/2021 at 8:36 A.M., an observation was conducted in room [ROOM NUMBER]. The door area next to the doorknob of the resident room had splintered (a small, thin, sharp piece of wood or the like, split or broken off from the main body) wood. The doorknob was loose. The room's hallway and cabinet side corner wall had cracks and broken pieces. The room's hallway and restroom side corner wall were cracked and part of the baseboard was cracked and peeled off from the wall. On 11/15/21 at 9:31 A.M., an observation was conducted in room [ROOM…

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 set a pressure relieving mattress per the resident's weight for 7 of 45 sampled residents (39, 57, 74, 75, 128, 242, 520). As a result, there was the risk of skin breakdown and delayed wound healing. Findings: 1. Per the facility's admission Record, Resident 39 was admitted to the facility on [DATE] with diagnoses to include protein-calorie malnutrition (not enough protein which is important for wound healing) and dementia (a mental and physical decline). Per the facility's careplan, revised 9/3/21, Resident 39 had the potential for pressure ulcer (pressure related wound) development. Per the facility's Medication Review Report, dated 11/17/21, Resident 39 had an order on 1/25/19 for Licensed Nurse to monitor the setting of LAL mattress (pressure relieving mattress) per resident's weight and comfort every shift. Per the facility's Weights and Vitals Summary, dated 11/17/21, Resident 39's weighed 92.4 pounds on 11/4/21. On 11/15/21 at…

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 12 of 56 residents reviewed were free of accidents and hazards when: 1. A removable glass shelf of a mirror bathroom cabinet was found leaning against the wall next to Resident 107's bed. 2. Resident's room (109, 116, 117, 118, 120, 126, 127, 129, 105, 111, 114 131) had cracked and broken corner walls and baseboard that were pointed and had rough and rugged edges. 3. Two double doors going to the Dining area had pointed metal astragal (a piece of hardware that is used on a pair of doors to seal the gap between the doors when they are closed). Three corner wall guards' bottom area of the hallway in front of nursing station were broken and had pointed and rough edges. These failures had the potential to cause injury and harm to residents, staff and visitors. Findings: 1. Resident 107 was admitted to the facility on [DATE] with diagnoses that included Unspecified Dementia with behavioral disturbance (agitation including verbal 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, staff interview and review of menus, the facility failed to ensure that substitutes and meal alternatives of equal nutritive value, including vegetarian food options, were offered and made available to residents as per facility policy. This finding had the potential to cause reduced food intake which could lead to weight loss and impaired nutritional status because of insufficient calories and protein. Cross reference 803, 804, 805 Findings: On 11/16/21 and 11/17/21, a record review was conducted. Per the facility's admission Record, Resident 29 was admitted on [DATE] with diagnoses to include heart disease, kidney failure, and bladder dysfunction. Per the facility's admission Record, Resident 30 was admitted on [DATE] with diagnoses to include stroke (disruption of blood supply to the brain), type 2 diabetes (impairment of blood sugar regulation), and dysphagia (difficulty swallowing). Per the facility's admission Record, Resident 31 was admitted on [DATE] with diagnoses to include…

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 residents (Resident 57) reviewed for restraint, was free from unnecessary restraint, when the facility staff applied a restraint without a physician's order. As a result, Resident 57's freedom of movement was restricted. Findings: According to Resident 57's document titled, admission Record, Resident 57 was originally admitted to the facility on [DATE], with the diagnoses to include Dementia with Behavioral Disturbance (loss of cognitive functioning) and Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Dominant Side (left-sided weakness and paralysis after a stroke). On 11/15/21, at 09:15 AM, an observation of Resident 57 was conducted. Resident 57 laid in bed and was observed wearing a non-skid sock on her right hand. On 11/15/21, at 12:07 PM, an observation of Resident 57 was conducted. Resident 57 laid in bed and was observed wearing a non-skid sock on her right hand. On 11/15/21, at 12:41 PM,…

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, interviews, and record reviews, the facility did not develop new fall preventative intervention for one of 45 sampled residents (Resident 175) after an incident of a fall. This failure had the potential for Resident 175 to have future falls. Findings: Per Resident 175's Facesheet, Resident 175 was admitted to the facility on [DATE] with diagnoses that included: Repeated Falls, Contact with and Suspected Exposure to COVID-19 (Corona Virus Disease 2019 [an illness caused by a virus]). On 11/15/21 at 9:42 AM, an observation was conducted on Resident 175. Resident 175 was awake in bed with the right bed rail up. A landing mat was observed on the floor on the left side of the bed. On 11/17/21 at 9:04 AM, a concurrent interview and record review was conducted with LN 31 (Licensed Nurse 31). A review of Resident 175's nursing progress notes, dated 10/6/21, indicated that the resident had an episode of an unwitnessed fall and that the resident sustained a laceration on the left forehead. A review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record reviews, the facility failed to provide an interpreter service for one of three residents (Resident 25) reviewed for communication. This had the potential for the healthcare provider to misinterpret Resident 25's needs and health situation. Findings: Per Resident 25's facehseet, Resident 25 was admitted to the facility on [DATE]. On 11/15/21 at 10:18 AM, an observation of Resident 25 was conducted. Resident 25 was sitting in her wheelchair. Resident 25 was observed not understanding or speaking any English. Resident 25 was Vietnamese. Certified Nurse Assistant (CNA) 33 came in the room and was observed doing only hand gestures to communicate with Resident 25 and vice versa. On 11/17/21 at 10:11 AM, an interview was conducted with CNA 34. CNA 34 stated she and Resident 25 communicated through hand gestures, and by reading Resident 25's facial expressions. CNA 34 also stated she used an (brand of phone) interpreter app to communicate with Resident 25. CNA 34 stated she…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow the physician's orders for one of 45 sampled residents (Resident 57) when: 1. The licensed nurses (LNs) did not apply compression stockings to Resident 57. 2. The LNs did not apply Scopolamine patch (medicated patch to prevent excessive secretions) to Resident 57. As a result, Resident 57 had the potential for developing deep venous thrombosis (DVT, a blood clot in a deep vein, usually in the legs). Also, Resident 57 had the potential to develop a secretion build up in the airways. Findings: 1. According to the facility's document titled, admission Record, Resident 57 was originally admitted to the facility on [DATE], with the diagnoses to include Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Dominant Side (left-sided paralysis and weakness after a stroke). According to Resident 57's document titled, Medication Review Report (physician's orders), dated 7/26/21, .Knee high ted hose (compression stockings)…

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 address weight loss for one sampled resident (14). As a result, Resident 14 was at an increased risk of decline in health. Findings: Per the facility's admission Record, Resident 14 was admitted to the facility on [DATE] with diagnoses to include heart failure, weakness, dysphagia (difficulty swallowing), and dementia (a mental and physical decline). Per the facility's Weights and Vitals Summary dated 11/18/21, Resident 14 weighed 115 pounds on 11/3/21, which was a 5.6% loss compared to her weight of 121.8 pounds on 10/6/21, and a 15.3% loss compared to her weight of 135.8 pounds on 8/11/21. Per the facility's Nutritional assessment dated [DATE], Resident 14 had a significant weight loss of 5.6% of body weight in one month. The Nutritional Assessment did not contain any recommendations to manage the weight loss. On 11/18/21 at 1:20 P.M., an interview was conducted with RD 1. RD 1 stated, on 11/3/21 Resident 14's weight indicated a weight loss from the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure the food was prepared by methods that conserved nutritive value and appearance when residents stated facility food was served cold without flavor and not at the appropriate texture. This deficient practice had the potential to decrease the food intake of residents and would negatively impact their nutritional status. Cross reference 800, 803, 805 and 806 Findings: During the initial survey tour on 11/15/21 at 8:00 A.M., multiple observations and interviews were conducted by Surveyors with residents about the facility food. Resident comments included I do not like the food because I only get sandwiches and they're hard, The food is cold, The food doesn't taste good or have flavor. On 11/16/21 at 10:00 A.M., during a resident council meeting, ten residents made comments about the facility food. Seven of the residents stated the food was served cold, without flavor, and at the incorrect texture. On 11/16/21, a review of 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 one of 45 sampled residents' (Resident 235) food was prepared in a form designed to meet her nutritional needs. As a result, there was a potential for Resident 235's nutritional intake to be compromised. Findings: Resident 235 was admitted to the facility on [DATE] per the admission Record. On 11/15/21, at 9:38 AM, a joint observation and interview was conducted with Resident 235. Resident 235 was observed with no teeth. Resident 235 stated she had no dentures and had been eating regular food with difficulty. Resident 235 stated she was not offered an alternative diet. On 11/15/21, at 1:17 PM, a joint observation and interview was conducted with Resident 235. Resident 235 was observed finishing lunch in her room. The meal tray ticket on Resident 235's tray indicated a diet restriction of NAS (No Added Salt) only. Resident 235 stated she could not eat the brussels sprouts and that they would be easier to eat if they were cut into…

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 sampled 45 residents' (Resident 57) medical record was accurate related to the application of the resident's compression stockings. As a result, Resident 57's medical record incorrectly indicated that the resident's compressions stockings have been applied, when they were not. Findings: According to the facility's document titled, admission Record, Resident 57 was originally admitted to the facility on [DATE], with the diagnoses to include Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Dominant Side (left-sided paralysis and weakness after a stroke). On 11/17/21, at 9:21 A.M., a joint observation and interview was conducted with Certified Nursing Assistant (CNA) 62. Resident 57 was observed not wearing compression stockings. CNA 62 stated she had never seen Resident 57 wear compression stockings. On 11/17/21, at 2:17 PM, an interview was conducted with CNA 63. CNA 63 stated she had not seen 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.