Casa Bonita Convalescent Hospital

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure three of five sampled residents (Residents 11, 20, & 96) did not receive unnecessary psychotropic medications (medications used to treat mental health disorders that alter neurotransmitters [transmit messages from neurons to muscles] in the brain, affects brain activities associated with mental processes and behavior) by failing to: A. Monitor the side effects upon administration of Resident 11's duloxetine (psychotropic drug used to treat major depressive disorder [depression, mental disorder with persistently depressed mood or loss of interest in activities that interfere with daily life]. B. Provide a documented rationale for the continuation of Resident 20's as needed (PRN) Ativan (generic name lorazepam, psychotropic medication to treat anxiety [excessive and persistent feelings of worry, fear, dread, and uneasiness that interfere with daily life]) physician orders. C. Ensure Resident 96's order for PRN Lorazepam (psychotropic medication…

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

Based on observation, interview and record review, the facility failed ensure three of four sampled glasses of milk/mocha mix were served at 40 degrees Fahrenheit (F, a unit used to measure temperature) or lower as indicated in the facility's policy. This deficient practice had the potential to compromise the residents' taste by serving unfresh or spoiled milk/mocha mix to the residents. Findings: During an observation with the Dietary Supervisor (DS) and Kitchen Aid 1 (KA 1), in the facility kitchen, on 5/29/2024 at 12:27 PM, several 8 ounces of glasses of milk were on the trays ready to be served with the residents' lunch. Three of the four glasses of milk were randomly selected and observed to have a temperature higher than 41F. The first glass measured at 42 F, the third glass measured at 44 F and the fourth glass measured at 51 F. During an interview with KA 1, on 5/29/2024 at 12:29 PM, KA 1 stated the milk temperature should be below 41 F because above 41F is the danger zone (the temperature range between 40F and 140F in which bacteria can grow rapidly) and the residents could…

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 resident-centered care plans (CP) related to risk of side effects of medication use for Depakote (medication used to control seizures, a sudden uncontrolled burst of electrical activity in the brain) and a CP related to Resident 2's allergies were developed for one of one sampled resident (Resident 2) in accordance with the facility's policy and procedure (P&P). This failure had the potential for Resident 2 to not receive the necessary care and services to achieve their optimal level of functioning. Findings: During a review of Resident 2's admission Record (AR), the AR indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes Mellitus (disease that occurs when a person's blood sugar is too high), generalized anxiety disorder (a condition in which a person has excessive worry and feelings of fear, dread and uneasiness) and bipolar disorder (serious mental illness that causes unusual shifts in mood). 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 provide necessary care and services for one of one sampled resident (Resident 96) when Certified Nursing Assistant (CNA) 2 did not utilize a communication board when attempting to communicate with Resident 96 as indicated in the facility's Policy and Procedure (P&P) titled, Accommodation of Needs Related to Communication. This failure had the potential to result in unmet needs to Resident 96. Findings: During a review of Resident 96's admission Record (AR), the AR indicated Resident 96 was admitted to the facility on [DATE] with severe dementia (a group of conditions, decline in mental ability, that interfere with daily activities) with agitation, hypertension (high blood pressure), and dysphagia (difficulty swallowing foods or liquids). During a review of Resident 96's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 4/22/2024, the MDS indicated Resident 96 was severely impaired with cognitive skills (ability to make…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide care and services, for one of three sampled residents (Resident 30), to reduce the risk of developing pressure ulcer-injuries [PU/PI, localized injury to the skin and or underlying tissue usually over a bony prominence as result of pressure or pressure in combination with shear (mechanical force that cause the skin to break off) and/or friction (movement of one surface of the skin against the other]) by failing to: follow the facility's Policy and Procedures (P&P), titled, Prevention of Pressure Injuries, Pressure Sore Management, and the, Certified Nursing Assistant [CNA] Job Description, for Resident 30, who was on a low air loss (LAL, a mattress designed to distribute body weight and prevent and treat pressure wounds) mattress and who was at high risk for developing PIs. This deficient practice had the potential to result in a physical decline and the development of PIs to Resident 30. Findings: During a review of Resident 30's…

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 interviews and record review, the facility failed to ensure one of two sampled residents (Resident 41), who had limited range of motion (ROM, full movement potential of a joint), received the necessary rehabilitation services to maintain or prevent further decline in ROM by failing to follow up on the Occupational Therapist 2's (OT 2's, healthcare professional who involves the use of daily activities [occupations] to treat the physical, mental, and emotional ailments that impact a resident's ability perform daily tasks) recommendation to obtain an OT evaluation/treatment order on 5/30/2022. This failure had the potential to cause further decline in ROM with worsening contractures (deformity and joint stiffness) to both upper extremities (arms), which could lead to increased pain to Resident 41. Findings: During a review of Resident 41's admission Record (AR 1), AR 1 indicated the facility admitted Resident 41 on 9/29/2020 with multiple diagnoses including dementia (impaired ability to remember, think, or make decisions that interferes with daily activities), osteoarthritis…

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 an observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 61) received proper respiratory (relating to breathing) care such as oxygen (02 [a colorless, odorless, tasteless gas essential for living]) therapy to meet Resident 61's needs and in accordance with the physician's order. This failure resulted in Resident 61 receiving 02 therapy at a lower level and had the potential to result in compromised respiratory status (the movement of air in and out of the lungs and exchange of carbon dioxide [a colorless, odorless gas] and 02 at the alveolar level [alveoli, the functional units of the lung with the overall task to warrant gas exchange, i.e., 02 supply and carbon dioxide removal from the body]) to Resident 61. Findings: During a review of Resident 61's admission Record (AR), the AR indicated Resident 61 was admitted to the facility on [DATE] with multiple diagnoses including respiratory failure, unspecified with hypoxia (absence of enough oxygen in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 49) was administered an eye drop medication properly in accordance with the facility's policy and procedure (P&P). This failure had the potential for Resident 49 to not receive the full benefits of the eye drop medication. Findings: During a review of Resident 49's admission Record (AR), the AR indicated, Resident 49 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including ventricular fibrillation (a life-threatening heart rhythm that results in a rapid, inadequate heartbeat), tracheostomy (a surgically created hole [stoma] in your windpipe [trachea] that provides an alternative airway for breathing) status, and gastrostomy (a surgical procedure used to insert a tube, often referred to as G-Tube [GT] through the belly that brings nutrition and/or medications directly to the stomach). During a review of Resident 49's Care Plan (CP) titled,…

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 interviews and record review, the facility failed to ensure irregularities in the monthly Medication Regimen Review (MRR, thorough evaluation a resident's medication regimen) was identified for one of one sampled resident (Resident 11) who was on psychotropic medications (used to treat mental health disorders, alter neurotransmitters [transmit messages from neurons to muscles] in the brain). The facility's Consultant Pharmacist (FCP) failed to identify and report inadequate monitoring of duloxetine (psychotropic medication used to treat depression [a mental disorder with persistently depressed mood or loss of interest in activities that interferes with daily life] during the MRR done on 5/14/2024 to 5/15/2024. This failure had the potential to cause a decline Resident 11's physical and psychosocial well-being related to the administration of unnecessary psychotropic medications. Findings: During a review of Resident 11' s admission Record (AR), the AR indicated the facility admitted Resident 11 on 4/27/2024 with multiple diagnoses including Alzheimer's disease (progressive…

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 provide a snack to one of one sampled resident (Resident 48) in accordance with the facility's Policy and Procedure (P&P) titled, Frequency of Meals. This deficient practice had the potential for Resident 48 to be hungry and to negatively affect his feeling of well-being. Findings: During a review of Resident 48's admission Record (AR), the AR indicated Resident 48 was admitted to the facility on [DATE] with spinal stenosis (the spaces in the spine narrow and create pressure on the spinal cord and nerve roots), post laminectomy syndrome (a condition in which the patient continues to feel pain after undergoing a laminectomy [back surgery] or another form of back surgery), and type 2 diabetes mellitus (a chronic [long standing] condition that affects the way the body processes blood sugar). During a review of Resident 48's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 5/6/2024, the MDS indicated Resident 48 had no…

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

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary conditions were maintained in the kitchen as indicated in the facility's policy when one of one sampled Registered Dietician (RD 1) did not wear a beard cover, while working in the kitchen food preparation area. This deficient practices had the potential for the RD's beard/facial hair to fall into the residents food and contaminate the residents' food. Findings: During an observation in the facility kitchen, on 5/29/2024 from 11:49 AM to 12:44 PM, the Registered Dietician (RD), who had visible beard, was observed walking around the kitchen while the residents' lunch was being prepared. The RD walked from the cold drinks preparation area to the food assembly tray line that served food to the residents. The RD did not wear a beard cover. The RD wore a surgical mask. The RD's beard was uncovered from the mid of the RD's left and right cheeks to the RD's ear. The RD's goatee beard (a small, pointed beard) was protruding under the RD's chin, outside of the RD's surgical mask. 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.

Based on observation, interview, and record review, the facility failed to follow infection prevention and control practices and implement interventions to prevent and control the spread of infections in the facility for one of five sampled residents (Resident 41) in accordance with the facility's policy and procedure (P&P) on Enhanced Standard Precautions (ESP, approach for preventing the transmission on Multidrug-Resistant Organisms [MDROs, germs resistant to many antibiotics] in skilled nursing facilities [SNFs]). This failure had the potential to result in the increased spread of infections throughout the facility. Findings: During a review of Resident 41's admission Record (AR 1), AR 1 indicated the facility admitted Resident 41 on 9/29/2020 with multiple diagnoses including dementia (impaired ability to remember, think, or make decisions that interferes with daily activities), type 2 diabetes mellitus (disorder causing elevated sugar level in the blood), and presence of gastrostomy (surgical opening into the stomach for the introduction of food). During a review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to readmit one of one sampled resident (Resident 1) from the General Acute Care Hospital (GACH) after the resident was cleared by the GACH to return to the facility on 5/13/2024, according to the facility's Policy and Procedure (P&P). This deficient practice had the potential to result in the denial of Resident 1's rights to return to the facility. Findings: During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses that included hemiplegia (muscle weakness or partial paralysis on one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body) following unspecified cerebrovascular (relating to the brain and its blood vessels) disease affecting left dominant side, respiratory failure (when the lungs can't get enough oxygen into the blood), and dysphagia (difficulty swallowing foods or liquids). During 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, interview, and record review, the facility failed to follow the repositioning (turning) schedule for one of two sampled residents (Resident 1). This failure had the potential for Resident 1 to be at risk for worsening skin condition and/or pressure injury (damage to an area of the skin caused by constant pressure on the area for a long time). Findings: During a review of Resident 1's admission Record (AR), the AR indicated, the facility admitted Resident 1 to the facility on [DATE] with diagnoses of acute respiratory failure (a condition in which the lungs were not able to release enough oxygen into the blood), dependence on ventilator (a machine to support or replace the breathing of a person who was ill or injured), type 2 diabetes mellitus (characterized by high levels of blood sugar in the blood) with foot ulcer (an open sore or wound), and pressure induced deep tissue damage (area of intact skin that looks purple or dark red due to damage to tissues under the skin) of right and 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 interview and record review, the facility failed to complete and electronically transmit the Discharge Resident Assessment timely to Centers for Medicaid and Medicare (CMS) Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) system for three of three sampled residents (Residents 2, 3 and 4). This deficient practice had the potential to affect the facility's quality monitoring data at transition points, such as when residents enter or leave the nursing home. This also had the potential for residents not to be reassessed accurately and receive the necessary care if and when readmitted to the facility. Findings: a. A review of the admission Record indicated Resident 2 was admitted to the facility on [DATE], with diagnoses that included urinary tract infection ( presence of bacteria in the bladder, urethra, ureter and kidney) and the resident was discharged to home on 7/22/2021. A review of the Minimum Data Set (MDS) a resident assessment and care screening tool,…

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, interview, and record review, the facility failed to ensure the Low Air Loss Mattress (LALM, a mattress that has small air holes in its top surface which continually blow out air causing the patient to float which reduces skin pressure at the mattress surface) were set at the correct setting for four of four sampled residents (Resident 65, 70, 84, and 85). a. Resident 65's LAL mattress pump was set to level four instead of the correct setting of level three. b. Resident 70's LAL mattress pump was set on a level of seven instead of the correct setting of level two. b. Resident 84's LAL mattress was set to firm instead of setting of three. c. Resident 85's LAL mattress was set to setting three instead of setting two. These deficient practices placed the residents at risk for developing pressure injuries (PI, injuries to the skin and underlying tissue resulting from prolonged pressure on the skin). Findings: a. A review of Resident 65's admission Record indicated Resident 65 was originally…

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 four of five sampled residents (Resident 5, 57, 65, and 74) with contractures (permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff, this prevents normal movement of a joint or other body part), the appropriate treatment and services to increase and/or prevent further decrease in range of motion (ROM, how far a person can move or stretch a part of the body, such as a joint or a muscle). a. For Resident 5, the facility did not provide ROM exercises, and did not apply splints (a firm material used for supporting and immobilizing a broken bone), to both of the resident's hands and right elbow. b. For Resident 57, the facility staff did not apply a hand splint to the resident's left hand. c. For Resident 74, the facility staff failed to apply left elbow splint. d. For Resident 65, the facility staff failed to provide ROM exercises. This failure had the potential…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide adequate assessment and interventions for two of two sampled residents (Resident 40 and 85) with indwelling urinary catheters (a flexible tube that is put through the urinary opening and into the bladder used to drain urine into a drainage bag, a small balloon filled with sterile water is placed inside the bladder to hold the catheter in place). This failure led to the presence of sediment (particles that may be indicative of an infection), in the urinary catheter which can lead to a Urinary Tract Infection (UTI, an infection in any part of the urinary system). Findings: a. A review of Resident 40's admission Record indicated Resident 40 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 40's diagnoses included chronic respiratory failure (a condition that develops over a long period of time in which the lungs have a problem getting gases, such as oxygen and carbon dioxide, in and out 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.

Based on interview and record review the facility failed to ensure three of three staff (Licensed Vocational Nurse 2, 3, and 4) assigned to perform Range of Motion exercises (ROM, activity aimed at improving movement of a specific joint, a point where two bones make contact), apply splint (a supportive device that protects a broken bone or injury to help with pain and promote healing), and apply hand roll (a roll used for patients with contracted hands) placement to residents with limited ROM were trained, assessed and evaluated for adequate competency. This deficient practice had the potential to result for the residents not to received the appropriate ROM exercises, as ordered by the physician that could result in injury or decline in the residents's conditions. Cross reference to F688 Findings: During an interview on 12/15/2021 at 3 pm, the DSD stated Licensed Nurses performed the ROM, applied hand roll and splints if the Rehabilitation Nurse Assistant (RNA, nursing aide program that helps residents maintain their function and joint mobility) were not available to perform the…

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

Based on observation, interview and record review, the facility failed to follow safe food storage and food handling practices in accordance with professional standards for food service safety and the facility's policy and procedure (P&P) by failing to: 1. Store dishware covered and/or inverted. 2. Discard old fresh produce food items stored in the kitchen's refrigerator. 3. Practice appropriate hand hygiene and glove use when necessary before handling food in the kitchen. 4. Store non-food items away from food items in the pantry. 5. Label opened/used food item stored on the shelf above the prep counter in the kitchen. These deficient practices could result in a risk for serious complications from food borne illness (illness caused by the ingestion of contaminated food or beverage) and/or affect the palatability of the meal to the residents. Findings: During a concurrent observation and interview on 12/13/2021, at 9:25 am, with Dietary Supervisor (DS), in the initial brief tour of the kitchen, the open dishware storage rack located by the entrance of the kitchen was observed to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow infection control practices as indicated in the facility's policy and procedure by failing to: a. Perform surveillance (closed observation) and monitoring (observe and check the progress or quality of work over a period of time to keep under systematic review), of the staff's non-compliance or compliance with proper hand washing, donning (put on), doffing (remove) personal protective equipment (PPE) such as the gown, goggles, gloves and face mask and other infection control practices to identify the possible cause(s) of the residents facility's acquired infections (an infection that was not present prior to the admission to the facility) from September 2021 to November 2021 such as: 1. Urinary tract infection (infection in the bladder, ureter, urethra and kidney). 2. cellulitis (skin infection) 3. Pneumonia (severe infection in the lungs) b. Ensure Resident 23's resident's nasal cannula tubing (a device used to deliver oxygen to 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 three of 19 sampled residents (Resident 64, Resident 81, Resident 246) were provided a safe and sanitary environment by failing to store resident care equipment/supply properly in accordance with the facility policy. This failure could result in the spread of disease-causing organisms from residents to residents. Findings: a. A review of the admission Record indicated Resident 64 was originally admitted on [DATE] and readmitted last on 4/7/2020 with multiple diagnoses including chronic respiratory failure (a problem getting gases in and out of the blood), tracheostomy status (a tube inserted in the windpipe for breathing), multiple sclerosis (a potentially disabling disease of the brain and spinal cord), functional quadriplegia (complete inability to move due to severe disability or frailty) and type 2 diabetes mellitus (an adult onset characterized by high levels of sugar in the blood). A review of Resident 64's Minimum Data Set…

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 and implement a comprehensive, resident specific plan of care for two of 19 sampled residents (Residents 26 and 76). a. Resident 76 did not have a plan of care for contact isolation (is the state of being in a place or situation that is separate from others) for Clostridium difficile (C-diff a bacterium that causes an infection of the large intestine [colon]) as indicated in the physician's order and facility policy. b. Resident 26 did not have a plan of care for the use of Xarelto (a medication used as blood thinner). These deficient practices had the potential for the residents not to receive the care and services needed which could lead to a decline in their wellbeing or maintain their highest potentials. Findings: a. A review of Resident 76's admission Record indicated Resident 76 was admitted to the facility on [DATE]. Resident 76's diagnoses included enterocolitis (an inflammation that occurs in a person's digestive tract…

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 refer one of 19 sampled residents (Resident 21) to an audiologist (a physician who evaluates hearing disorders) for the need of a hearing device (a device used to improve hearing). Resident 21 did not receive an Audiology consultation in accordance with the physician's order. This deficient practice had the potential to result in increased hearing loss, difficulty with communication and decline in Resident 21's quality of life. Findings: A review of Resident 21's admission Record, indicated Resident 21 was originally admitted on [DATE] and readmitted last on 2/22/2020 with multiple diagnoses including essential (primary) hypertension (high blood pressure), [NAME]-[NAME] syndrome (a rare, serious disorder of the skin and mucous membranes) and unspecified hearing loss, unspecified ear. A review of Resident 21's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 9/2/2021, indicated Resident 21 had no impairment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to document specific indication for psychotropic (any medication capable of affecting the mind, emotions, and behavior) drug for one of five sampled residents (Residents 80) as indicated on the facility policy. This deficient practice had the potential to result in the use of unnecessary psychotropic drug, which may result in significant adverse (harmful) consequences to the residents. Findings: A review of Resident 80's admission Record indicated Resident 80 was admitted to the facility on [DATE]. Resident 80's diagnoses included schizophrenia ([serious mental disorder in which people interpret reality abnormally) and major depressive disorder (mental disorder characterized by a persistently depressed mood and long-term loss of pleasure or interest in life, often with other symptoms such as disturbed sleep, feelings of guilt or inadequacy, and suicidal thoughts). A review of Resident 80's Minimum Data Set (MDS - a comprehensive assessment and care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility staff failed to ensure the opened (in-use) Basaglar KwikPen insulin (Insulin Glargine - long-acting insulin- a hormone that works by lowering levels of sugar in the blood) was marked with the date opened as indicated in the facility policy. This deficient practice had the potential to result in the loss of efficacy of the Basaglar KwikPen insulin. Finding: A review of Resident 296's admission Record indicated Resident 296 was admitted to the facility on [DATE]. Resident 296's diagnoses included diabetes mellitus (a condition that affects the way the body processes blood sugar) and weakness. A review of Resident 296's History and Physical (H&P) dated 12/3/2021, indicated Resident 296 had the capacity to understand and made decisions. A review of Resident 296's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool), dated 12/7/2021, indicated Resident 296's brief interview of mental status (BIMS, screening that aids…

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.