Almaden Health And Rehabilitation Center

Based on observation, interview and record review, the facility failed to ensure safe environment when the screen that covers the window leading to the kitchen sink was broken. This failure had the potential for the rodents and pests to enter the kitchen and had the potential to put residents' health and safety at risk. Findings: During an observation with the Director of Maintenance (DM) on 8/28/24 at 10:02 a.m., the screen mesh that covering the window leading to kitchen sink was observed broken on the bottom part creating a small gap. The DM confirmed the observation and acknowledged the window screen should have been maintained in good repair to prevent possible entrance of pests and rodents in the kitchen and facility. Review of the facility's undated policy and procedures titled Pest Control indicated, Maintain intact screens on windows that open.

Based on observation, interview, and policy review, the facility failed to implement infection control practices when: 1. Licensed vocational nurse B (LVN B) walked in the hallway with gloves on; 2. Housekeeper C (HKP C) wore the same gloves to wipe resident Room AA and Room BB; and 3. Certified nursing assistant D (CNA D) brought the lunch tray to Resident 2's room which was an isolation room for Coronavirus disease (COVID-19, an infectious disease caused by the SARS-CoV-2 virus which can spread from an infected person's mouth or nose in small liquid particles when they cough, sneeze, speak, sing or breathe) and fed her in the room wearing a surgical mask. These failures had the potential to spread infection in the facility. Findings: 1. During an observation and interview on 8/14/24 at 11:55 a.m., LVN B was walking in the hallway wearing gloves on her hands. LVN B stated she came to help a resident in her room. LVN B acknowledged that she should not wear gloves in the hallway. During an interview with the director of nursing (DON,) on 8/14/24 at 12:15 p.m., she stated staff should…

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 maintain an effective pest control to keep the facility free of cockroaches when live cockroaches were observed in Resident 4's room even though the room was inspected and treated for roaches. This failure had the potential to result in pest transferred disease to residents. Findings: During an interview with Resident 3, on 8/14/24 at 2:40 p.m., she stated about two weeks ago she saw a cockroach on her lunch tray. Review of the facility's Crossfire Pest Rodents and Termites Report indicated Resident 4's room was inspected and treated for cockroach and rodent on 5/31/24. However, on 6/10/24, the facility's Maintenance Work Request indicated pest control spray was requested for Resident 4's room because cockroaches were seen crawling on Resident 4's bed side rails and closet. It also indicated the request was completed on 6/12/24. Review of the facility's Ecolab Customer Services Report indicated Resident 4's room was treated for cockroaches again on 7/2/24. During an observation and interview with…

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

Based on observation, interview, and policy review, the facility failed to treat one of three sampled residents (Resident 1) with respect and dignity when certified nursing assistant A (CNA A) did not provide privacy to Resident 1 during transporting Resident 1 from her room to the shower room. This failure had the potential to cause embarrassment for the resident. Findings: During an observation on 8/14/24 at 4 p.m., CNA A transported Resident 1 in the hallway from her room to the shower room. Resident 1 was sitting on a shower chair. The front of Resident 1 was covered with a linen sheet, but her back and her buttocks were not covered and were exposed. During a concurrent interview with CNA A, she confirmed Resident 1's back and buttocks were not covered and were exposed. CNA A stated she missed the back of Resident 1's body, and she should cover Resident 1's body before transporting her in the hallway. During an interview with the director of nursing (DON), on 8/15/24 at 1:45 p.m., she stated staff should cover the resident's body before transporting the resident in the hallway.…

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 a comfortable, safe temperature level was maintained in the range of 71 to 81 degrees Fahrenheit (a unit of measurement of temperature) in the facility hallway, and three resident rooms (room [ROOM NUMBER], 2, and 3). This failure had the potential for the residents to have an uncomfortable environment. Findings: Review of Resident 1's face sheet (a document that gives a resident's information at a quick glance) indicated Resident 1 admitted to facility on 7/12/2023 with diagnoses right tibia fracture (a broken right lower leg bone), left femur fracture (a broken left thigh bone), congestive heart failure (a chronic condition in which the heart does not not pump blood as well as it should), asthma (a condition in which airways narrow, swell, and may produce extra mucus, which makes it difficult to breathe), and diabetes type 2 (a chronic condition that affects the way the body processes blood sugar). Resident'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 observation, interview, and record review, the facility failed to provide care and services in accordance with professional standards of practice for four of 18 sampled residents (Residents 35, 37, 23, and 172) when: 1. For Resident 35, the facility failed to change the wound dressing as ordered and failed to label the wound dressing with the initial, date, and time; 2. For Resident 37, medication was left unattended in the room; 3. Creatinine with estimated glomerular filtration rate (creatinine with eGFR, a test that measures the level of kidney function and determines the stage of kidney disease) test was not done for Resident 23 as ordered; and 4. The wound care nurse (WCN) did not provide treatment to Resident 172's sacrum wound as ordered by the physician. These failures had the potential to negatively affect the health and safety of the residents. Findings: 1. Review of Resident 35's clinical record indicated he was admitted on [DATE] and had the diagnosis of diabetes (a disease that causes high…

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 residents had an environment free from accident hazards when red sharps (objects with sharp points or edges such as needles or syringes) containers were left open, unattended, and accessible on two out of three medication carts. This failure had the potential to put residents and staff at risk for injuries from needlesticks and sharp objects. Findings: During a concurrent observation and interview on 4/24/23, at 12:33 p.m., at Medication Cart 2, with registered nurse B (RN B), a red sharps container was observed sitting on top of the medication cart. The lid was open and the container was approximately 70-80% full. RN B placed a used insulin syringe and needle into the open container on top of the cart. She stated she agreed that the sharps container can be tampered with by residents who are curious, or those with dementia who might want to put their hands in or dump the contents out. RN B stated the sharps container on the side of the medication cart did not have a lid and that's why she had to use…

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 food was stored and distributed and the kitchen floor was maintained in accordance with professional standards for food service safety when: 1. The resident food refrigerator was found out of the safe temperature range; 2. Multiple resident meal trays had crack, rough edges; 3. The floor below the dish machine had two broken tiles; and 4. The ice machines had rough whitish build up on parts. These failures had the potential to cause the growth of microorganisms or attract pests which could cause foodborne illness or cross contaminate food or ice (cross contamination occurs when unclean surfaces or utensils spread germs to food and could potentially cause foodborne illness) for the 68 residents eating at the facility. Findings: 1. During an observation on 4/24/23 at 8:33 a.m., the resident food refrigerator had one bag of shredded cheese inside. The two thermometers inside the refrigerator read 48 F (degrees Fahrenheit - a unit of temperature measurement) and 47 F and the cheese was 46 F.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain proper infection control practices when: 1. Resident 17's suction tubing and canister were undated; 2. The wound care nurse (WCN) placed Resident 172's urine bag on his bed and let it touching the floor, opened Resident 172's night stand with contaminated gloved hand, and asked certified nursing assistant L (CNA L) to hold the clean dressing on Resident 172's left heel wound with her contaminated gloved hand; 3. Speech therapist (ST) did not practice standard precautions; 4. CNA did not use proper personal protective equipment (PPE) for contact precautions; 5. CNA wore PPE in the hallway and disposed of a unsealed trash bag from the contact isolation room on the storage room floor. 6. Registered Nurse B (RN B) failed to disinfect the rubber stopper of a medication vial before inserting the adaptor (a device) to dilute the medication; and 7. RN B did not properly dispose of personal protective equipment (PPE, gown and gloves) 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 develop and/or implement a comprehensive person-centered care plan for three of 18 sampled residents (Resident 61, 7, and 56) when 1. For Resident 61,who could not speak English, the facility failed to develop a care plan to address the communication barriers; 2. For Resident 7, the facility failed to develop a care plan to address the management of seizures; and 3. For Resident 56, the facility failed to develop a care plan to address the management of diabetis mellitus (DM, increase blood sugar) foot. These failures had the potential to result in the residents not receiving the care and services necessary to maintain their health, safety and well-being. Findings: 1. A review of Resident 61's clinical record indicated she was admitted on [DATE] with diagnoses including unspecified dementia (impaired ability to remember, think, or make decisions that interfere with doing everyday activities) and dysphagia (difficulty swallowing and taking…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide communication services to one of 18 sampled residents (Resident 28) who spoke in their non-English language. This failure had the potential for the resident not to maintain or improve her ability to carry out the activities of daily living (ADL). Findings: Review of Resident 28's clinical records indicated she was admitted on [DATE] and had diagnoses including dementia (a decline in mental capacity affecting daily function), major depressive disorder (a mood disorder that causes a feeling of sadness and loss of interest), and left radius fracture (broken forearm bone). During an observation and interview on 4/24/23 at 8:29 a.m., Resident 28 was trying to communicate with certified nursing assistant E (CNA E) in her non-English language, and CNA E stated she could not understand Resident 28. CNA E further stated she could only communicate with the resident through gestures and assumed the resident's needs. Review of Resident 28'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide necessary podiatry services for one of 18 sampled residents (Resident 56) when his toenails were long enough to curl under. This failure had the potential to affect the resident's foot health and contribute to injury and/or infection. Findings: Review of Resident 56's clinical records indicated he was admitted on [DATE] and had diagnoses including hemiplegia (a symptom that involves the loss of the ability to move on one-side of body) and hemiparesis (one-sided weakness), hypertension (high blood pressure), and type 2 diabetes (high blood sugar). During an observation and interview with Resident 56 on 4/24/23 at 10 a.m., he stated that his toenails were very long, and he needed a podiatry service. Resident 56's great toenail was long and hypertrophied (excessively enlarged), and his 2nd to 5th toenails were discolored and curled under the toes. Resident 56 stated he had not seen a podiatrist since his admission. Review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide dialysis services consistent with professional standards for one of three residents (22) who received hemodialysis (medical procedure to remove fluid and waste products from the blood and to correct electrolyte, i.e. salts and mineral imbalances by using a machine and an artificial kidney) when staff and Resident 22's clinical record indicated the wrong dialysis access site; and Resident 22's dialysis communication records were missing. These failures had the potential for the resident to be inaccurately assessed and be at risk for complications. Findings: Review of Resident 22's admission Record indicated he was admitted to the facility on [DATE] with diagnoses including end stage renal disease and dependence on renal dialysis. During an observation and interview with Resident 22 on 4/26/23 at 1:55 p.m., indicated Resident 22's dialysis access site was on his left upper arm. Resident 22 stated that was the only dialysis site he…

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 review the risks and benefits of bed rails (adjustable metal or rigid plastic bars that attach to the bed) with the resident or resident representative (RR, a person empowered to make decisions for the resident/person legally responsible and liable for a decision or an action) and obtain the physician's order and informed consent prior to the use of bed rails for one of 18 sampled residents (Resident 7). This failure had the potential to put the resident at risk for entrapment and serious injury due to not being aware of the risks and benefits of bed rails. Findings: Review of Resident 7's clinical records indicated he was admitted on [DATE] and had diagnoses including type 2 diabetes (high blood sugar), seizures (uncontrolled jerking movements of the arms and legs caused by abnormal brain activity), and depressive episodes. During the initial tour of the facility conducted on 4/24/23 at 10:18 a.m., Residents 7 had half bed rails…

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 implement procedures to ensure safe handling of hazardous drugs (medications capable of causing serious effects); and ensure controlled medications (those with high potential for abuse and addiction) were fully accounted when: 1. Hazardous drug handling procedures were not implemented during medication pass observation for Resident 274; 2. Random controlled medication use audit for two of six sampled residents (Residents 12 and 322) did not reconcile. The medications were signed out of the controlled drugs accountability sheet (Count Sheet, an inventory sheet that keeps record of the usage of controlled medications) but not documented on the Medication Administration Records (MAR) to indicate they were given to the residents. These failures had the potential for exposing staff and residents to serious side effects from hazardous drugs including cancer and fertility problems; and misuse or diversion (the illegal distribution or abuse of prescription drugs or their use for purposes not intended by 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 request a medication regimen review (MRR) following changes in condition (worsening of an existing problem or the emergence of new signs or symptoms, such as falls or seizures) for two out of five sampled residents (Resident 48 and 59); and failed to ensure the consultant pharmacist (CP) identified potential medications contributing to falls and make recommendations to the facility for reduction or discontinuation of one of the medications during the monthly MMRs for Resident 59. This failure had the potential for medications not being optimized for best possible health outcome, and unnecessary or prolonged use of medications which could lead to medication adverse effects (such as falls) for the residents. Findings: 1. A review of Resident 59's clinical record indicated she was admitted to the facility with diagnoses including fracture of right femur (thigh), Alzheimer's disease (memory problem), brief psychotic (condition that affect the mind, where there has been some loss of contact with reality) disorder, unspecified…

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 1 of 18 sampled residents (Resident 33) was free from unnecessary medications when the nursing staff did not monitor for signs and symptoms of adverse effects related to the use of blood thinning medications. Resident 33 was receiving Xarelto (generic name rivaroxaban, an anti-coagulant, or blood thinning medication). This failure had the potential for side effects of this medication (such as bleeding, excessive bruising, etc.) to go undetected or recognized for timely intervention. Findings: On 4/26/23, a review of Resident 33's clinical record indicated he was admitted to the facility on [DATE] with diagnoses including paraplegia (the inability to voluntarily move the lower parts of the body). A review of Resident 33's hospital record's History and Physical (H&P), dated 4/8/22, indicated a medication list which included Xarelto. A review of Resident 33's clinical record indicated a physician's order, dated 11/21/22, for Xarelto (rivaroxaban)…

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 facility medication error rate did not exceed five percent or greater when observation of 34 opportunities during the medication pass resulted in two errors. The calculated medication error rate was 5.88 percent. These failures placed Residents 38 and 274 at risk for not receiving the full therapeutic effects of medications when medications were not given according to the manufacturer's specifications. Findings: 1. During a medication pass observation for Resident 38 on 4/24/23, at 7:54 a.m., registered nurse A (RN A) was observed administering six medications, which included potassium chloride (used to treat low levels of potassium) extended-release tablet, with a cup containing about 6 ounces (or 180 milliliters [ml], unit of measurement) of water. At the bedside, Resident 38 was observed taking all his medications with two sips of water or about half of the water cup. RN A did not insist on the resident taking more water with his medications. During an interview on 4/24/23, at 8:08 a.m., with RN…

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 proper medication storage and labeling of medications in two of two medication carts inspected when: 1. Medication Cart 3 contained two (2) expired medications and one (1) test strip (thin plastic strips which measures blood sugar levels) vial opened without an open date label; 2. Medication Cart 1 contained one (1) expired medication and one (1) test strip vial opened without an open date label. The deficient practices had a potential for residents to receive unsafe and ineffective medications (reduced potency) from being used past their discard (expiration) date and not being removed from active stock. Findings: 1. On 4/24/23 at 10:36 a.m., an inspection of Medication Cart 3 with licensed vocational nurse C (LVN C) identified: a. one opened and expired Rocklatan (used to treat glaucoma) eye drop bottle, dated opened on 3/9/23; b. one opened and expired medication inhaler Trelegy Ellipta (medication for lung disease), dated opened on 3/1/23; c. one test strip (material for testing blood sugar) vial…

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 six residents (Resident 51) received pneumococcal vaccinations based on the facility's policy. This failure had the potential to expose the resident to pneumococcal infections (caused by common bacteria [streptococcus pneumonia] that can affect different parts of the body). Findings: Review of Resident 51's clinical record indicated he was admitted to the facility on [DATE]. Review of Resident 51's Pneumococcal Vaccination Consent Form dated 6/24/22 indicated, responsible party (RP, person who is accountable in making decision on behalf of the resident) consented for the pneumococcal vaccine to be given. Review of the immunization list provided by the facility, indicated Resident 51 did not have the pneumococcal vaccine. During an interview with infection preventionist (IP) on 4/26/23 at 10:44 a.m., she confirmed the pneumococcal vaccine was not followed up. The IP acknowledged the pneumococcal vaccine should have been given to the…

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

Based on observation, interview, and record review, the facility failed to ensure sanitary conditions were maintained in the food and nutrition services, when: 1. There was ice-build up on the ceiling in the walk-in freezer. 2. There was no adequate amount of sanitizing solution (quat) in one of the red bucket containers. 3. The wall fan had black matter on the blades and front grill. 4. One dietary staff was not properly wearing a hair restraint. These failures had the potential to result in food borne illness among residents. Findings: 1. During an observation on 1/21/2020 at 8:15 a.m., there was ice-build up on the ceiling in the walk-in freezer. During a review of the power refrigerator invoice dated 1/21/2020, the description of work done, indicated the door heater has failed and needs to be replaced . 2. During an observation on 1/22/2020 at 2:23 p.m., the dietary staff manager (DSM) dipped the quat strip (to test the amount of solution) in the red bucket (near the hand washing sink) for 10 seconds and the strip turned orange (equals zero) . There was no adequate amount 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.

Based on observation, interview and record review, the facility failed to provide safe and homelike environment for five of 18 residents when, (1) The armrests of Resident 2's wheelchair and Resident 45's bed bolster (long pillow or cushion used to suppport the body part of persons lying on bed) were ripped, and (2) Residents 39, 63 and 221's bed privacy curtains had brown stains. These failures had the potential to result for psychosocial harm should residents experience decreased sense of well-being. Findings: 1. During an observation on 1/22/2020 at 9:00 a.m., the armrests of Resident 21's wheelchair were ripped. During an interview with Resident 21 on 01/22/2020 at 9:01 a.m., she stated, It looks really bad. 2. During an observation on 1/22/2020 at 8:20 a.m., Resident 45's bed bolster on her right lower body part was ripped. During an interview with licensed vocational nurse A (LVN A) on 1/22/2020, at 8:30 a.m., LVN A stated it needs to be replaced because it might cause a skin tear to the resident. 3. During an observation on 1/21/2020 and 1/22/2020 at 1:05 p.m., Residents 39,…

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 revise the care plan (a document which provides direction for and communicates to staff the individualized care of the resident) for two of 18 sampled residents (Residents 4 and 56) when: Residents 4 and 56's fall care plans were not revised to include interdisciplinary team (IDT) recommendations made to prevent further falls. This failure had the potential to result in the repeat occurrence of falls for the residents. Findings: 1. Review of Resident 4's clinical record indicated admission to the facility on 8/10/17 with diagnoses including muscle weakness, repeated falls and dementia (decline in mental capacity affecting thinking and memory). During an observation on 1/21/2020 at 1:33 p.m., Resident 4 was sitting in a wheelchair (WC) inside her room. Resident 4 stated, I am supposed to call for help but I don't always do it when I have to go to the bathroom. Review of Resident 4's Incident/Accident Post Review: Summary of IDTs, indicated the following dates of falls and new recommendations made by the team following each…

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 change the midline catheter (put into a vein by the bend in elbow or upper arm) dressing for one of two residents (Resident 18). This failure had the potential to result to intravenous (into a vein) complications. Findings: During an observation on 1/21/2020 at 12:45 p.m., Resident 18 's midline catheter site on left upper arm was covered with transparent dressing and had brown color discharge underneath. The date marked on dressing was 1/12. During an interview with LVN B on 1/21/2020 at 1:15 p.m., LVN B stated the catheter dressing change was two days past due, and was supposed to be changed by a registered nurse. During a review of the facility's policy and procedure (P&P), Dressing Change for Vascular Access Devices, dated 2011, indicated 2. Transparent semi-permeable membrane dressings are changed every 7 days and PRN.

Based on observation, interview, and record review, the facility failed to adequately provide activities for two of five sampled residents (Residents 8 and 61) to support their physical, mental, and psychosocial well-being when activities for Residents 8 and 61 were limited in number and not following the care plans. 1. Resident 8 was admitted with diagnoses which included muscle weakness, dementia, and altered mental status. Multiple observations during the survey, Resident was observed in bed. During an interview with the activities director (AD) on 1/23/2020 at 3:19 p.m., she stated she played music for Resident 8 from her phone for five minutes, which is about two songs. The AD stated she also him pictures from a showed calendar, did reality orientation (the day, month, year from the calendar), and sometimes aroma therapy with unscented lotion. The AD stated Resident 8 used to have a radio, but it fell in 12/2019 and it has not been replaced yet. The AD stated sometimes staff took him to activities to listen to music. The AD stated she stayed with him five to ten minutes per…

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.