The Bradley Gardens

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure an allegation of abuse was reported to the state survey agency within two hours for two of four residents (Residents 1 and 2). This failure had the potential for the state survey agency to investigate the allegation and ensure residents were safe. Findings: A review of Resident 1's medical records indicated he was admitted on [DATE], with diagnoses of schizophrenia, (a mental illness that is characterized by disturbances in thought), chronic obstructive pulmonary disease, (COPD - a chronic inflammatory lung disease that causes obstructed airflow from the lungs), depression, (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety disorder, (a chronic condition characterized by an excessive and persistent sense of apprehension). A review of Resident 1's History and Physical dated January 3, 2025, indicated he did not have the capacity to make decisions. A review of Resident 1's Progress Notes…

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 transfer or discharge requirements were met and the transfer was appropriate and necessary for two of 22 residents (Residents 1 and 2), when two cognitively impaired residents were transferred to another skilled nursing facility. This failure had the potential to cause confusion and discomfort for these residents due to unfamiliar environment. Findings: 1. A review of Resident 1's admission records indicated the resident was initially admitted to the facility on [DATE], with diagnoses which included cognitive communication deficit, unspecified dementia (loss of memory, language, problem solving and other thinking abilities), unspecified psychosis (collection of symptoms that affect the mind), and bipolar disorder (episodes of mood swings ranging from depressive lows to manic highs). A review of Resident 1 ' s history and physical (a reference document that gives concise information about a patient ' s history and examination findings at 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 a written notice of transfer or discharge to two of 22 residents reviewed (Residents 1 and 2). Residents 1 and 2 were deemed with cognitive impairment and had no legal representative. In addition, the written notice of transfer or discharge for Residents 1 and 2, was not provided timely to the Office of the Long Term Care (LTC) Ombudsman. These failures had the potential to result in violation of the resident ' s rights, as issues related to the transfer or discharge may not be addressed promptly, leading to harm to the resident, especially if the transfer or discharge was not in the best interest of the resident or was done without proper procedure. This failure did not provide opportunity for the Ombudsman to advocate for the residents to ensure the transfer or discharge was necessary. Findings: 1. A review of Resident 1 ' s admission RECORD, indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses which included cognitive…

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 two of 22 sampled residents (Residents 1 and 2), was provided orientation in the form the residents could understand, to ensure a safe and orderly transfer from a skilled nursing facility (SNF A) to another skilled nursing facility (SNF B). Residents 1 and 2 were deemed with cognitive impairment, lacked the capacity to make decisions, and had no listed legal representatives. This failure of the facility had the potential to negatively affect the psychosocial well-being of Residents 1 and 2. Findings: A review of the facility discharged and transferred list from May 2024 to July 2024, indicated there were two residents who were transferred to another SNF with no family representative's involvement, and were deemed incapable of making decisions. A review of Resident 1's admission records indicated the resident was initially admitted to the facility on [DATE], with diagnoses which included cognitive communication deficit, unspecified dementia (loss…

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 safe and sanitary food preparation and storage practices in the kitchen when: 1. The Prep sink did not have an air gap (is vertical space between the end of a pipe and the top of a nearby sink that prevents the backflow of contaminated water); 2. The Quat sanitizer used to sanitize food preparation surfaces did not meet the right concentration requirements on 3/26/2024, 3/27/2024 and 3/28/2024; ( Cross referred 802) 3. Dust was observed on several areas in the kitchen; 4. Reach in refrigerator shelves had chipped paint; 5. Several equipment in the kitchen found to have buildup; 6. Trash were found in multiple areas in the kitchen; 7. Inside the containers used to store clean scoops, utensils and lids had food residuals; 8. Broken tiles found under reach in refrigerator and utility area; 9. During thawing process, ground meat not fully submerged into running water; 10. [NAME] with facial hair did not wear hair restraint; 11. 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 electronically submit staffing information based on payroll data to the Federal (Center for Medicare & Medicaid Services- CMS) database for the first Fiscal Qaurter of the year. This deficient practice prevented the provision of complete and accurate direct care staffing information to the public. Findings: During a review of the CMS PBJ (pay roll based journal) Staffing Data Report CASPER (Certification and Survey Provider Enhanced Report) FY (fiscal year) Quarter 1 (October 1- December 31) indicated, .Failed to submit Data for the Quarter . During an interview on March 28, 2024, at 3:30 p.m., with the Business Office Manager (BOM), the BOM stated, the Payroll Manager (PM) was responsible for submitting the report to CMS. During an interview on March 28, 2024, at 3:35 p.m., the PM stated, she had outsourced the PBJ reporting to a third party. The PM stated, the company contracted to handle the PBJ reporting encountered difficulties in submitting the report on February 9, 2024. The PM stated, she did not take any action…

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 reviews the facility failed to ensure dietary staff were able to carry out the functions of food and nutrition services safely and effectively when: 1. Food service workers did not recognize that the Quat sanitizer concentration was not at the right concentration; (Cross referred F 812) This failure had the potential to cause foodborne illness for 30 out of 31 sampled residents who received foods from the kitchen. 2. Diet Aide 1 and [NAME] 2 were unable to properly clean working surface; This failure had the potential to cause foodborne illness for 30 out of 31 sampled residents who received foods from the kitchen. 3. [NAME] 2 did not follow the menu for serving on 3/27/24 lunch; (Cross referred F 803 and F 804) This failure had the potential for 30 out of 31 residents receiving food prepared in the kitchen do not meet their nutritional needs which may lead to nutritional related health complications. 4. Diet Aide served Jello to residents who require nectar thick consistency (Cross referred F 805); and 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.

Based on observation, interview, and facility document review, the facility failed to ensure the menus were followed and resident nutritional needs were met when: 1. Correct portion sizes were not followed; 2. The [NAME] did not serve biscuit during lunch on 3/27/2024; and 3. The [NAME] did not serve gravy for pureed diet during lunch on 3/27/2024. These failures had the potential for 30 out of 31 residents receiving food prepared in the kitchen do not meet their nutritional needs which may lead to nutritional related health complications. Finding: (Cross referred 802) 1. On March 27, 2024, at 12:21 p.m., an interview was conducted with [NAME] 2 (CK 2) in front of Trayline (a system of food preparation in which trays move along an assembly line). CK 2 stated he was going to use a grey scoop numbered 8 to serve pureed chicken, and an ivory scoop numbered 10 to serve Spinach. On March 27, 2024, at 12:30 p.m., an observation of the lunch meal plating service was conducted with CK 2. The following were observed: Pureed chicken was being served to the pureed diets using a # 8 scoop;…

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

Based on observation, interview, and record review, the facility failed to ensure the recipe for preparing puree was followed for seven of seven residents (Residents 1, 6, 8, 9, 10, 14 and 24) receiving pureed (any food item that has been processed into a smooth and uniform texture) foods. This failure had the potential to compromise the nutritional status of Residents 1, 6, 8, 9, 10, 14, and 24 resulting in decreased oral intake and weight loss. Findings: (Cross referred 802) On March 27, 2024, at 11:40 a.m., a concurrent observation of the puree preparation for lunch and interview with [NAME] (CK) 2 were conducted. CK 2 placed seven pieces of chicken into the blender, added unmeasured hot water, and blended. After the chicken was pureed, CK 2 transferred the chicken into a pan, and the end product of pureed chicken came out with a running/ watery consistency. CK 2 stated he added about a quart (a unit of measurement) of water to the chicken in the blender. CK 2 stated he added 1/2 cup of thickener (a thickening agent that increases the viscosity of a liquid) to the pureed chicken…

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

Based on observation, interview and record review, the facility failed to ensure the appropriate liquid texture was provided when two of two (Residents 6 and 24) did not receive nectar thick liquids as prescribed by the physician and the residents were served jello during lunch on March 27, 2024 . This failure had the potential to place the residents at risk for aspiration (when food is breathed into the lungs). Findings: (Cross referred F802) a. A review of Resident 6's physician orders for March 2024, indicated a fortified pureed diet with nectar thick liquids was ordered on November 22, 2022. On March 27, 2024, at 1:14 p.m., a concurrent observation of Resident 6 and an interview with Certified Nurse Assistant (CNA) 1 were conducted. Resident 6 was observed in her room, head of bed elevated and was being fed by CNA 1. CNA 1 stated he fed Resident 6 jello and was offered to drink milk served with her meal tray. On March 27, 2024, at 1:31 p.m., an interview with the Dietary Service Supervisor (DSS) was conducted. The DSS stated Resident 6's milk had chunks of thickener (a…

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

Based on interview and record review, the facility failed, for one of 12 sampled residents (Resident 38), to ensure the resident or resident representative was informed and provided a written information regarding the formulation of an advance directive (written instruction such as living will or durable power of attorney for health care about the provision of care and services the resident preferred when he is no longer able to decide for himself) upon admission to the facility. This failure had the potential for the residents to have inappropriate treatment and services in the event of a medical emergency. Findings: A review of Resident 38's document titled, Physician Orders for Life Sustaining Treatment (POLST- form completed by the resident and/or legal representative that records the resident's treatment preferences in the event of a medical emergency), dated January 31, 2024, indicated, Resident 38 did not provide information regarding advance directive. A review of Residetn 38's document titled, Residents Receipt of Self-Determination Act Information, dated February 1, 2024,…

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 written notice of bed-hold policy (reserving a resident's bed while resident is out of the facility for therapeutic leave or hospitalization) was provided to the resident/and or resident representative, for one of one resident reviewed for hospitalization (Resident 34) when Resident 34 was transferred to the acute hospital. This failure had the potential for the resident or resident representative not to be informed of their right to hold the bed while out of the facility and the right to be readmitted back to the facility. Findings: On March 29, 2024, Resident 34's record was reviewed. Resident 34 was admitted to the facility on [DATE], with diagnoses which included osteomyelitis (bone infection), end stage renal disease (a permanent kidney failure that requires a regular course of dialysis-a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly). Further review of Resident 34's document…

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 resident reviewed (Resident 24) received care and treatment to maintain their highest practicable physical well-being when a dietitian recommendation for a diet upgrade was not made known to the physician by the licensed nurses. This failure resulted in the resident remaining on her current diet, which could potentially lead to a decline in resident's overall condition. Findings: On March 28, 2024, a review of Resident 24's Face Sheet, indicated, Resident 24 was admitted to the facility on [DATE], with a diagnosis which included, cerebral infarction (lack of oxygen to the brain), and dementia (memory loss). A review of Resident 24's, Minimum Data Set, (a standardized assessment for the management of care) dated, December 17, 2023, indicated, .BIMS (Brief Interview for Mental Status- screening tool to assess mental capability) Summary Score . 3 .(severe cognitive impairment). A review of Resident 24's document 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 interview and record review, the facility failed to ensure accurate accountability of controlled medications (those with high potential for abuse or addiction) when random controlled medication use audits did not reconcile for two out of three residents (Residents 23 and 27). There was a total of 4 unaccounted controlled medications. This failure had the potential for misuse or abuse of controlled medications. Findings: The controlled drugs record (CDR, an inventory count sheet that keeps record of the usage of controlled medications) for three random residents receiving controlled medications were reviewed during the survey. 1. Resident 27 had a physician's order, dated February 3, 2024, for hydrocodone-acetaminophen (a potent controlled medication for pain) 10/325 milligrams (mg, unit of measurement) tablet, take 1 tablet by mouth every 6 hours as needed for moderate pain 4-6. During a concurrent interview and record review on March 26, 2024 at 3:09 p.m. with licensed vocational nurse (LVN) 2, Resident 27's CDR for hydrocodone-acetaminophen 10/325 mg and the Medication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported irregularities during the monthly medication regimen review (MRR) for one of five sampled residents (Resident 4) when Resident 4 was administered Seroquel (an antipsychotic medication for bipolar disorder, depression, and schizophrenia) without manufacturer specified monitoring. This failure had the potential for the medication not being optimized for best possible health outcome, and unnecessary or prolonged use of the medication which could lead to adverse effects and unidentified risks associated with the use of psychotropic medications that included but not limited to sedation, respiratory depression, constipation, anxiety, agitation, and memory loss. Finding: During a review of Resident 4's Physician's Orders, dated June, 9, 2021, the Physician's Orders indicated, Resident 4 was admitted to the facility on [DATE] under the care of Hospice (focused on the care, comfort, and quality 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 ensure one of five sampled residents (Resident 4) was free from unnecessary psychotropic (drugs that affects brain activities associated with mental processes and behavior) medications when Resident 4 was administered Seroquel (quetiapine, an antipsychotic medication for bipolar disorder, depression, and schizophrenia) without manufacturer specified monitoring. This failure had the potential for the medication not being optimized for best possible health outcome, and unnecessary or prolonged use of the medication which could lead to adverse effects and unidentified risks associated with the use of psychotropic medications that included but not limited to sedation, respiratory depression, constipation, anxiety, agitation, and memory loss. Finding: During a review of Resident 4's Physician's Orders, dated June, 9, 2021, the Physician's Orders indicated, Resident 4 was admitted to the facility on [DATE] under the care of Hospice (focuses on the 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.

Based on observation, interview, and record review, the facility failed to have a full-time director of food and nutrition services. The lack of a full-time, qualified supervision over Food and Nutrition services had the potential to result in residents not being assessed regarding their nutritional needs, as well as lack of oversight of food preparations, services, and storage for 30 residents. Findings: On March 26, 2024, at 9:31 a.m., an interview with [NAME] (CK) 1 was conducted. CK 1 stated there was no Dietary Supervisor (DSS) for about a month now. On March 26, 2024, at 3:15 p.m., an interview was conducted with the DSS. The DSS stated she worked full time until February 28, 2024, then transitioned to on-call (expected to be available at any time, usually with short notice) until the facility could find a replacement. On March 28, 2024, at 10:04 a.m., an interview with the Administrator (ADM) was conducted. The ADM acknowleged the facility did not have a full-time DSS. On March 28, 2024, at 11:05 a.m., an interview with the Registered Dietitian (RD) was conducted. The RD…

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

Based on observation, interview, and record review, the facility failed to ensure the infection prevention program was implemented when a facility staff did not disinfect the automatic blood pressure (BP-pressure of blood in blood vessels) cuff machine before and after residents' use according to the facility policy. This failure had the potential for the vulnerable residents to be exposed to cross-contamination and the development of infections. Findings: On March 27, 2024 at 8:43 a.m., a medication pass observation was conducted with Licensed Vocational Nurse (LVN) 2. LVN 2 was observed carrying an automatic BP cuff machine from on top the medication cart and then proceeded to Resident 21's room. LVN 2 applied the automatic BP cuff on Resident 21's right arm. After obtaining Resident 21's BP reading, LVN 2 removed the automatic BP cuff from Resident 21's arm and placed the automatic BP cuff machine on top of the medication cart. LVN 2 was not observed to have disinfected the automatic BP cuff machine before and after use on Resident 21. On March 27, 2024 at 8:53 a.m., a medication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide food that accommodates one of three sampled residents' (Resident A) allergies and preferences. Resident A has peanut butter allergy and was provided peanut butter and jelly sandwich. This failure had the potential for Resident A to not receive the caloric intake needed when his preferences were not followed, this could result in poor nutrition and further compromised to Resident A ' s medical status. Findings: On January 25, 2024, at 1:15 p.m., an unannounced visit was made to the facility to investigate an allegation of quality of care and treatment. A review of the Resident A's medical record indicated the resident was admitted to the facility on [DATE], with diagnoses which included diabetes mellitus (metabolic disease, involving inappropriately elevated blood glucose levels). A review of Resident A's Dietary Progress Notes, dated December 28, 2023, indicated, Quarterly update note .resident on regular diet, mechanical soft…

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 policy and procedure review, the facility failed to ensure the kitchen staff had the appropriate skill set to prepare meals that met the nutritional needs of the facility residents when: 1. Two cooks did not follow the facility menu; 2. One cook did not follow the puree recipes; and 3. One [NAME] did not cook puree vegetables to preserve nutritive value. These failures posed a risk of 37 out of 39 highly susceptible residents who received food prepared in the kitchen to not meet their nutritional needs which could lead to nutritional related health concerns. Findings: 1. A review of the facility policy and procedure titled Menu Guidelines, dated January 1, 2017, read, To prepare foods according to the menu . Purees: 1. This is a texture and not a diet. Follow the menu pattern indicated then puree those items. Follow the recipe instructions for the puree texture for all food items. During the lunch meal dining service on August 9, 2021, at 12:20 p.m., more than 4 puree diet meal trays in the dining room and more than 3 puree diet meal…

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 facility document review, the facility failed to ensure the menus were followed and resident nutritional needs were met when: 1. Correct portion sizes were not followed; 2. Puree recipes were not followed; and 3. Fortified diets were not followed. These failures had the potential for 37 out of 38 residents receiving food prepared in the kitchen to not meet their nutritional needs which may lead to nutritional related health complications. Finding: 1. A review of the facility policy and procedure titled Menu Guidelines dated January 1, 2017, read, To prepare foods according to the menu . Purees: 1. This is a texture and not a diet. Follow the menu pattern indicated then puree those items. Follow the recipe instructions for the puree texture for all food items. During the lunch meal dining service on August 9, 2021, at 12:20 p.m., more than four puree diet meal trays in the dining room and more than three (3) puree diet meal trays on the cart for room tray service were observed…

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 and sanitation requirements were met in the kitchen as evidenced by: 1. A sanitizing solution used to sanitize food preparation surfaces did not meet the proper sanitizing requirements; 2. The ice machine splash curtain (a plastic cover for the evaporator and water spillway; the parts of the ice machine that produce ice) had a thick white residue and the manufacturer's cleaning instructions were not followed for the splash curtain; 3. Inadequate hand washing; 4. Food was not properly labeled and dated; 5. Kitchen equipment was not clean; 6. Kitchen equipment was in poor condition; 7. Non dietary personnel in the kitchen did not wear hair nets; and 8. A drainpipe on the ice machine did not have an air gap. These failures had the potential to pose the risk for exposure to food-borne illnesses in a medical vulnerable population of 38 that received food prepared in the kitchen. Findings: 1. A review of the facility policy and procedure titled Sanitizer Bucket for Cleaning Cloths, dated 2018…

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 Advance Directives (AD-written instruction, such as a living will or durable power of attorney for healthcare, recognized under State Law, relating to the provision of healthcare when the individual is incapacitated) was discussed with the resident or resident representatives for three of seven residents reviewed for Advance Directives (Residents 18, 24, and 37). This failure had the potential for the residents to not receive their preplanned treatment and services in the event they were incapacitated and or unable to speak for themselves. Findings: 1. Resident 18's record was reviewed. Resident 18 was admitted to the facility on [DATE], with diagnosis which included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). The document titled, Physician Orders for Life-Sustaining Treatment (POLST), dated September 27, 2014, indicated, .No Advance Directive . On August 11, 2021, at 08:50…

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 act upon the pharmacist's Drug Regimen Review (DRR) recommendations for four of seven residents reviewed for unnecessary medications (Residents 6, 34, 30, and 37), when: 1a. For Resident 6, there were recommendations for a Gradual Dose Reduction (GDR) on Risperdal (medication used to treat psychosis- a mental illness) and Remeron (a medication used to treat depressive disorder) dated June 28, 2021; and 1b. For Resident 6, there was a recommendation for a review on the Prilosec (medication used to treat Peptic Ulcer Disease [PUD]-type of digestive illness) maintenance dose dated July 28, 2021; 2. For Resident 34, there were recommendations for GDR on Zyprexa (medication used to treat psychosis-a type of mental illness), Zoloft (medication used to treat depression- a mental illness), Remeron, and Atarax (medication used to treat anxiety, nausea, vomiting, and allergies) dated June 28, 2021; 3. For Resident 30, there was a recommendation for a review if…

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

Based on observation and interview, the facility failed to ensure the following items in the medication room were not expired and stored readily available for use: 1. Seven pre-filled 10 ml (milliliter) saline syringes; 2. 27 pre-filled 0.5 ml syringes of afluria Quadrivalent (brand name of influenza vaccine); 3. Four multi-dose vials of Fluzone (brand name of influenza vaccine); 4. Three vials of 10 ml sterile water (used for diluting medications); and 5. One vial of Ondansetron (medication used to treat nausea and vomiting) 4 mg (milligrams)/ 2 ml in the emergency kit (E-Kit-sealed container of medications used for emergency treatment). These failures had the potential for the residents to have ineffective treatments due to the use of expired medications. Findings: 1. On August 12, 2021, at 2:12 p.m., an inspection of the medication room was conducted with Licensed Vocational Nurse (LVN) 4. The following items were observed readily available for use; a. Stored in a drawer containing IV (intravenous) medication supplies were the following: - Three pre-filled 10 ml saline syringes…

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 for one of three residents reviewed for closed record (Resident 39), the physician was notified when the resident was transferred to the hospital. This failure had the potential to result in the physician not being aware of the medical condition of the resident. Findings: Resident 39's record was reviewed. Resident 39 was admitted to the facility on [DATE], with diagnoses which included atrial fibrillation (abnormal heart rate). The document titled, LICENSED NURSES PROGRESS NOTES, indicated the following: - Dated June 15, 2021, at 1 p.m., Resident 39 requested to be discharged to the hospital; and - Dated June 15, 2021, at 8:30 p.m., Resident 39 was discharged to the hospital. There was no documentation Resident 39's physician was notified of the resident's discharge to the hospital . In addition, there was no physician's order for the resident's discharge. On August 12, 2021, at 4:18 p.m., the Director of Nursing (DON) was interviewed. The DON…

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 Notice of Medicare Provider Non-Coverage (NONMC - a notice when the care the resident is receiving from a skilled nursing facility [SNF] is ending and how the resident can contact the agency to appeal) to the resident or resident representative for one of three residents reviewed for beneficiary notification (Resident 33). This failure had the potential for the resident not to be aware of the opportunity to appeal for the skilled services that was discontinued by the facility. Findings: A review of Resident 33's record indicated Resident 33 was admitted to the facility on [DATE]. The form titled, SNF Beneficiary Protection Notification Review, indicated, Medicare Part A Skilled Services Episode Start Date: 12/17/2020 (December 17, 2020) .Last covered day of Part A Service: 3-2-21 (March 2, 2021) . There was no documented evidence the resident or the resident representative was provided the NONMC. On August 12, 2021, at 3:02 p.m., the [NAME]…

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, for one of two residents reviewed for PASRR (a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) (Resident 37), the PASRR level I assessment was coded accurately. This failure had the potential for having residents that were not appropriate in the facility and for Resident 37 not to receive the appropriate services. Findings: Resident 37's record was reviewed. Resident 37 was admitted to the facility on [DATE], with diagnoses which included psychosis (mental disorder characterized by disconnection from reality), major depressive disorder (persistent feeling of sadness and loss of interest), and anxiety disorder (intense excessive and persistent feeling of worry and fear). Resident 37's document titled, Preadmission Screening and Resident Review (PASRR) Level 1 Screening Document, dated October 24, 2020, indicated .Level 1 - Negative .Section V- Mental Illness .No .Does 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 for one of 39 residents, (Resident 24), a care plan was developed and implemented to address the resident's contractures (shortening and hardening of the muscles, tendons or other tissues leading to deformity and rigidity of joints) to the right lower leg and left hand. This failure had the potential for the resident to not receive the necessary care and services and not be provided with the appropriate treatment. Findings: On August 9, 2021, at 12:13 p.m., Resident 24 was observed with contractures to the right lower leg and the left hand. Resident 24's record was reviewed. Resident 24 was admitted to the facility on [DATE], with diagnoses of senile degeneration of brain (a decline in an elder's cognitive and physical health). The document titled History and Physical, dated March 22, 2021, indicated Resident 24 had a right leg contracture. The document titled, Physician's Progress Notes, dated May 12, 2021, indicated, .extremities…

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, for one of 13 residents reviewed (Resident 19), to ensure Resident 19 was provided care when she requested for the staff to clean her ears. This failure resulted in Resident 19 being placed at risk for unattended daily needs and concerns. Findings: On August 12, 2021, at 11:44 a.m., Resident 19 was observed with contractures (a condition of shortening and hardening of muscles, tendons, or other tissue often leading to deformity and rigidity of joints) of both hands. In a concurrent interview with Resident 19, she stated she requested the staff to clean her ears. Resident 19 stated the staff would not clean her ears. She stated she requested to clean her ears everyday. Resident 19's record was reviewed. Resident 19 was admitted to the facility on [DATE], with diagnoses which included muscular dystrophy (MS - muscle weakness and loss of muscle mass). Resident 19's Minimum Data Set (an assessment tool) dated June 2, 2021, indicated, Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure resident's change in skin condition was assessed and monitored for one of 13 residents reviewed (Resident 37). This failure had the potential to result in the delay in treatment which could lead to skin infection. Findings: On August 9, 2021, at 11:09 a.m., Resident 37 was observed with red, bumpy areas and red linear marks on the upper chest area. In a concurrent interview with Resident 37, she stated she was itchy and she scratched it. Resident 37's record was reviewed. Resident 37 was admitted to the facility on [DATE], with diagnoses which included hypothyroidism (underactive thyroid gland) and diabetic neuropathy (nerve damage associated with diabetes mellitus [abnormal blood sugar]). Resident 37's WEEKLY SUMMARY, dated August 8, 2021, indicated, .Skin Conditions .None . The facility document titled SHOWER SHEET, dated August 6, 2021, indicated Resident 37 had scratches on lower left leg. There was no documentation 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 the medication error rate was less than five percent, when during medication pass observation the medication order for Doxycline (antibiotic) and senokot (laxative) were not administered as ordered by the physician for one of five residents (Resident 12). This failure resulted in a medication error rate of 6.25% (two errors out of 32 opportunities). Findings: On August 11, 2021, at 9:40 a.m., a medication administration observation for Resident 12 was conducted with Licensed Vocational Nurse (LVN) 5. LVN 5 was observed administering the following medications to Resident 12: - Finasteride (medication to treat an enlarged prostate) 5 mg (milligrams), 1 tablet; - Carvedilol (blood pressure medication) 3.125 mg, 1 tablet; - Amlodipine (blood pressure medication) 10 mg, 1 tablet; - Magnesium Oxide (mineral supplement) 400 mg, 1 tablet; - Senokot S (laxative) 1 tablet; -Tamsulosin (medication used for an enlarged prostate) 0.4 mg, 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.

Based on interview, and record review, the facility failed to ensure the Director of Food and Nutrition Services (DFNS) met the qualifications necessary to oversee the day to day operations of the Food and Nutrition Services department. This failure had the potential to put 37 residents who received food from the facility kitchen out of a census of 38 at risk for food borne illness and compromise their nutritional status. Findings: A review of the facility document titled Job description-Director of Food and Nutrition Services, revised 1/1/2018 and signed by the DFNS, showed under the section titled, Education Requirements, the DFNS who meets the requirements for the California Health and Safety Code 1265.4 and the CMS regulation 801 §483.60 (a)(2). On August 9, 2021, at 3:37 p.m., an interview was conducted with the DFNS regarding her qualifications. The DFNS stated she started her present position in November 2020. The DFNS stated she was currently enrolled in a Certified Dietary Manager course and was expected to graduate within the next few months. When asked if she had any…

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 and staff interviews, the facility failed to ensure 10 out of 38 residents received pureed foods that were prepared by methods to conserve nutritive value. This failure placed residents receiving a pureed diet at risk for compromised nutritional status. Findings: On August 10, 2021, at 8:53 a.m., a pot of green peas was observed cooking on the stove in the facility kitchen. On August 10, 2021, at 9:11 a.m., an observation of the puree preparation for the lunch meal was conducted with [NAME] 3. [NAME] 3 removed the green peas from the stove and pureed the peas in the blender. After the peas were pureed, [NAME] 3 transferred the peas to a serving pan. The serving pan was placed on the steam table until lunch meal service at 12:00 p.m. On August 10, 2021, at 9:33 a.m., an interview was conducted with [NAME] 3. [NAME] 3 stated he put the green peas on the stove to cook at 8:30 a.m. On August 11, 2021, at 9:04 a.m., [NAME] 3 was observed in the kitchen cooking broccoli on the stoved for the lunch meal. On August 12, 2021, at 10:00 a.m., an interview was conducted…

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

Based on observation, interview, and record review, the facility failed to ensure the infection prevention program was implemented when a facility staff did not disinfect the wrist blood pressure (BP-pressure of blood in blood vessels) cuff machine before and after residents' use according to the facility policy. This failure had the potential for the vulnerable residents to be exposed to cross-contamination and the development of infections. Findings: On August 11, 2021, at 9:32 a.m., a medication pass observation was conducted with Licensed Vocational Nurse (LVN) 5. LVN 5 was observed carrying an automatic wrist BP cuff machine from atop the medication cart and then proceeded to Resident 5's room. LVN 5 applied the wrist BP cuff on Resident 5's left wrist. After obtaining Resident 5's BP reading, LVN 5 removed the wrist BP cuff machine from Resident 5's wrist and placed the wrist BP cuff machine on top of the medication cart. LVN 5 was not observed to have disinfected the wrist BP cuff machine before and after use on Resident 5. On August 11, 2021, at 9:38 a.m., an observation 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.