Courtyard Care Center

Based on observation, interview, and record review, the facility failed to implement and develop a comprehensive care plan for one of 18 residents (Resident 67), when Resident 67's dementia (a general term for a group of brain disorders that cause a decline in cognitive abilities, such as memory, thinking, reasoning, and problem-solving) diagnosis was not addressed. This failure had the potential to result in the inability to identify the residents' individualized care issues and implement person-centered care. Findings: During a review of Resident 67's care plans, in his electronic health record, a care plan regarding his dementia was not found. During an interview with the facility's nurse consultant (NC) on 1/29/25 at 8:43 a.m., the NC stated Resident 67 should have a specific cognitive care plan. The NC acknowledged Resident 67 did not have a dementia care plan. During a review of the facility's policy, titled Dementia Care, revised 12/19/2022, the policy indicated .3. The care plan interventions will be related to each resident's individual symptomology and rate of dementia (or…

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 needed care and services were provided in accordance with the resident's goals for care for one resident (Resident 38) out of six sampled residents, when Resident 38's physician's order for interaction was not followed. This failure had the potential to put Resident 38 at risk for decline in physical, mental and psychosocial well-being. Findings: During a concurrent observation and interview on 1/27/25 at 8:55 a.m. with Resident 38, Resident 38 was lying in bed, awake, alert and oriented. Resident 38 stated I'm trying to get counseling for emotional situation. I get very irritable at people and I scream. During a concurrent observation and interview on 1/30/25 at 10:55 a.m. with Licensed Vocational Nurse (LVN) A, Resident 38 was lying in his bed. LVN A stated that Resident 38 was not in a wheelchair this morning. LVN A also stated that she never saw Resident 38 in a wheelchair even when Resident 38 was in a different station. During a concurrent observation and interview on 1/31/25 at 9:23 a.m. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a resident receiving dialysis (removal of waste and excess fluid from the body) treatment received consistent care with professional standards for one out of two sampled residents (Resident 32) when their dialysis communication sheets (DCS) were missing for several treatment days. This failure had the potential for Resident 32's dialysis care not being properly communicated and putting Resident 32 at risk for complications. Findings: Review of Resident 32's clinical record indicated she was admitted on [DATE] with a diagnosis of cerebrovascular accident (CVA, also known as stroke, a brain disorder caused by lack of blood flow to the brain), and end-stage renal disease (when the kidneys no longer function to remove waste from the blood). Review of Resident 32's clinical record further indicated Resident 32 received dialysis on Tuesday, Thursday and Saturday. Review of Resident 32's dialysis record indicated there were missing DCS…

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 consultant pharmacist (CP) failed to identify and report irregularities during the medication regimen review (MRR) for two (Resident 25 and Resident 174) out of 23 sampled residents when: 1. Abnormal Involuntary Movement Scale (AIMS, a rating scale that measures the severity of abnormal movements) was not done for Resident 25; and 2. AIMS was not done for Resident 174. This failure had the potential to result in unnecessary or prolonged use of the psychotropic medication, which could increase the resident's risk of experiencing side effects (undesirable effects from the medication). Findings: 1. A review of Resident 25's medical record indicated a diagnosis of but is not limited to Schizoaffective Disorder (chronic mental health condition in which people experience mood disorder, symptoms include hallucinations and/or delusions; feelings of intense sadness). A review of Resident 25's Physician Order dated 7/4/24 indicated, Seroquel Oral Tablet [antipsychotic medication] 300 mg [milligram, a unit of measurement]; give one tablet by mouth in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure four of 18 sampled residents (Residents 23, 25, 70 and 174) were free from unnecessary psychotropic (drug that affects brain activities associated with mental processes and behavior) medications when Abnormal Involuntary Movement Scale (AIMS, a rating scale designed to measure involuntary movements known as tardive dyskinesia [TD], a disorder that sometimes develops as a side effect of long-term treatment with antipsychotic medications) assessment was not done. The failure resulted in lack of adequate monitoring and unnecessary medications for the residents, which had the potential for increased risks associated with the use of psychotropic medications. Findings: 1a. A review of Resident 25's medical record indicated a diagnosis of but is not limited to Schizoaffective Disorder (chronic mental health condition in which people experience mood disorder, symptoms include hallucinations and/or delusions; feelings of intense sadness) A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident's private medical information was protected against unauthorized disclosure for 1 of 3 residents, when Resident 1 was furnished with medications labeled with medical information relevant to Resident 2 and Resident 3 upon discharge from the facility. This failure resulted in Resident 2 and Resident 3's private information being disclosed to another resident without their permission. Review of Resident 1's clinical record indicated she was admitted on [DATE]. Resident 1had a brief interview for mental status (BIMS) score of 15 (a score of 13 to 15 indicates cognitively intact). Review of Resident 1's social service progress note dated 12/19/23, indicated Resident 1 was accepted at another skilled nursing facility (SNF) and would discharge on [DATE]. Review of social service progress notes dated, 1/7/24, indicated Resident 1's friend (R1F) came to the facility to return medications given to Resident 1 upon her discharge that did not…

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.

During an observation 10/2/23 at 8:49 a.m., Residents 36, 43 and 56 were in their beds with quarter side rails up. Review for Resident 36's Bed Rails assessments lacked documented evidence that Resident 36 was assessed for bed rails safety between 4/27/21 and 10/2/23. Review for Resident 43's Bed Rails assessments lacked documented evidence that Resident 43 was assessed for bed rails safety between 4/29/21 and 10/2/23. Review for Resident 56's Bed Rails assessments lacked evidence that Resident 56 was assessed for bed rails safety. Based on observation, interview, and record review, the facility failed to assess bed rails (adjustable metal or rigid plastic bars that attach to the bed) safety for 12 of 17 residents (Residents 6, 11, 12, 21, 26, 28, 36, 43, 46, 52, 54 and 56) periodically, according to their policy. This failure placed the residents at risk for entrapment and injury. Findings: During the initial tour of the facility conducted on 10/2/23, at 9:00 a.m., Residents 12, 52, and 54, all had quarter bed rails elevated. Review for Resident 12's Bed Rails assessments lacked…

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 was stored in accordance with professional standards for food safety when: 1. A dented can of applesauce was stored on a the dry storage shelf. 2. An outdated bag of pinto beans was stored on a dry storage shelf. 3. Outdated onions were stored on a dry storage shelf; and, 4. Outdated ground herbs were stored on top of the kitchen condiment shelf. These failures had the potential to cause foodborne illness for residents who received food from the kitchen. Finding: 1. During a concurrent kitchen observation and interview with the Registered Dietician (RD) on 10/02/23 at 9:11 a.m., a dented can of unsweetened applesauce was on a shelf in the dry storage area intended for items to be consumed. The RD confirmed this observation and stated dented cans should be stored in an area designated for dented cans. Review of the facility's policy and procedure titled, Food Storage, revised 8/29/23, indicated, dented or bulging cans should be placed on Damaged Goods Shelf and returned for credits. 2. During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when: 1. Certified Nursing Assistant (CNA) B did not remove their gloves or perform hand hygiene after placing dirty laundry in a bin before taking a wheelchair into a room; and, 2. Licensed Vocational Nurse (LVN) C did not clean a blood pressure (BP) cuff after obtaining vital signs for 4 of 4 residents (Residents 2, 46, 63, and 220) during medication pass. These failures increased the potential for the spread of communicable diseases among residents. Findings: 1. During an observation on 10/2/23 at 9:26 AM, CNA B, walked to the hallway from room [ROOM NUMBER] wearing gloves and carrying a full linen bag. CNA B placed the linen bag in the dirty linen bin and, without removing the gloves worn, took a clean wheelchair from the hallway into room [ROOM NUMBER]. During an interview with CNA B on 10/2/23 at 9:48 AM, he confirmed he took the wheelchair into room [ROOM NUMBER] without changing…

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 complete a quarterly minimum data set (MDS, a resident clinical assessment tool) assessment in a timely manner for one of 17 sampled residents (Resident 61). This failure resulted in Resident 61's MDS to not be reviewed timely. Findings: During a concurrent interview and record review on 10/05/23 at 9:24 a.m. with the MDS Director (MDSD), Resident 61's MDS schedule was reviewed. The schedule indicated Resident 61's comprehensive MDS Assessment Reference Date (ARD) was 5/22/23; however, the quarterly MDS ARD was 9/14/23. The MDSD stated Resident 61's quarterly MDS assessment was not scheduled in a timely manner. Review of the facility's policy and procedure (P&P) titled, MDS 3.0 Completion, dated 12/19/2022, indicated, Quarterly Assessment - completed using an ARD no >92 days from the most recent prior quarterly or comprehensive assessment (counting ARD to ARD).

Based on observation, interview and record review, the facility failed to ensure activities of daily living (ADL) were provided to maintain good grooming and personal hygiene for one of 17 sampled residents (Resident 46) when Resident 46's fingernails were unkept. This failure left the resident incompletely groomed. Findings: Review of Resident 46's clinical record indicated she had the diagnoses of dementia (conditions characterized by impairment of least two brain functions, such as memory loss and judgement), and muscles weakness. During a concurrent observation and interview with the Certified Nursing Assistant (CNA) B in Resident 46's room on 10/4/23 at 9:06 a.m., resident's fingernails were long with black matter underneath the nails. CNA B confirmed this observation and stated the nails should be cleaned during ADL care. During an interview with Resident 46's responsible party (RP, person designated to make decisions on behalf of a resident) on 10/5/23 at 11:32 a.m., she stated she spoke with facility staff a month ago regarding Resident 46's nail care not being done. During…

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

Based on observation, interview, and record review, the facility failed to maintain professional standards of practice for one of four sampled residents (Resident 28) when oxygen was not administered per a physician's order. This failure resulted in Resident 28 receiving oxygen at a higher setting than prescribed. Findings: During an observation 10/2/23 at 9:32 a.m. in Resident 28's room, the resident was observed receiving oxygen at 5 liters (L, a metric unit of volume) via nasal cannula (NC, a flexible tubing placed into the nostrils and connected to an oxygen source). During an interview and record review with licensed vocational nurse (LVN) G on 10/04/23 at 8:56 a.m., Resident 28's oxygen order, dated 1/27/23, indicated 2 L via NC as needed for shortness of breath. LVN G confirmed Resident 28 was on 5 L oxygen, while the physician's order for 2 L oxygen was not followed. During an interview with the director of nursing (DON) on 10/6/23 at 1:46 p.m., she stated nursing staff should follow physicians' orders when administering medications or oxygen. Review of the facility's policy…

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 medications from one of three emergency kits (e-kits) were locked and replaced after use. This failure had the potential to result in medications not being available during emergency situations. Findings: During a concurrent observation and interview in the medication storage room with Registered Nurse (RN) D on 10/2/23 at 11:02 a.m., the e-kit containing injectable medications (administered with a needle and syringe) was found unlocked. RN D stated e-kits should be locked and restocked within 24 to 48 hours, so medications are available for residents. During concurrent interview and record review with RN D on 10/2/23 at 11:02 a.m., the e-kit pharmacy log indicated Ertapenem, an intravenous (within a vein) antibiotic used to treat infections, was removed 9/18/23. RN D confirmed the e-kit was open at that time but not relocked or restocked. During an interview with the Director of Nursing (DON) on 10/4/23 at 3:40 p.m., she confirmed the e-kit should be locked and replaced. Review of the facility's policy…

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 had a 5.13% (percent, a specified amount of units for every hundred units) medication error rate when two medication errors out of 39 opportunities were identified during medication pass for two of ten residents (Resident 2 and Resident 220). These failures had the potential to result in ineffective drug therapy. Findings: Review of Resident 2's clinical record. An Order Summary Report, dated 10/4/23, indicated Lidocaine External Patch 4% (Lidocaine patches are generally used to help relieve pain) Apply to generalized painful areas topically (on the skin) one time a day for generalized pain. Apply to the area resident requests. Start date 2/22/23. Teview of Resident 220's clinical record titled, Order Summary Report, dated 10/4/23, indicated, Propranolol HCL (Propranolol HCL, medication used to treat high blood pressure) oral tablet 10 mg (milligrams, a unit of measure)(BP -the pressure of circulating blood against the walls of blood vessels) Give 1 tablet by mouth two times a day for HTN (hypertension - elevated blood…

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

Based on observation, interview, and record review the facility failed to follow their policy for medication self-administration for 1 of 3 residents (Resident 25) when Resident 25 had medications on her bedside table without an IDT (interdisciplinary team, composed of a group of healthcare staff from various disciplines who work together to discuss care for individual residents) evaluation allowing for it. This failure left medications accessible to a resident, who lacked an evaluation for whether such medications should be left at her bedside. Findings: During an observation on 10/3/23 at 9:40 a.m., there was a bottle of Pepto-Bismol and Ibuprofen 200 mg tablets on the bedside table of Resident 25. During a concurrent interview with Resident 25, Resident 25 stated, I take the medication when needed, but not often. During an observation on 10/5/23 at 8:19 a.m., there was an albuterol inhaler (inhalable medication used to improve breathing) on the bedside table of Resident 25. During a concurrent interview with Resident 25, she stated she sent home the Pepto-Bismol and Ibuprofen…

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 administer the correct pneumococcal vaccine (vaccine to prevent bacterial pneumonia [infection of the lungs]) for one of five sampled residents (Resident 25) per the Centers for Disease Control and Prevention (CDC)'s pneumococcal vaccine schedule guidelines. This failure resulted in Resident 25 receiving an additional unnecessary pneumococcal vaccine. Findings: Review of Resident 25's facesheet (a document that gives a resident's information at a quick glance, including contact details and a brief medical history), indicated Resident 25's date of birth was 8/5/1956, and she was admitted on [DATE]. During a concurrent interview and record review with the director of staff development (DSD)/interim infection preventionist (IIP) on 10/05/23 at 01:57 p.m., Resident 25's Immunization Report, dated 10/5/23, indicated Resident 25 received pneumovax 23 (PPSV23, a type of pneumococcal vaccine) on 3/27/17 and 4/7/23. The DSD/IIP stated, per CDC new pneumococcal…

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

Based on observation, interview, and facility document review, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety when: 1. Food service equipment was stored wet, and 2. The floor below the dish machine was not smooth and cleanable. These failures had the potential to cause the growth of microorganisms or attract pests which could cause foodborne illness or cross-contaminate food (cross-contamination occurs when unclean surfaces or utensils spread germs to food and can potentially cause foodborne illness) for the 68 residents eating at the facility. Findings: 1. During the initial kitchen tour on 1/24/22 starting at 8:55 a.m., the following was found on a storage rack in the middle of the kitchen: Three four-quart plastic containers were wet inside and stacked together, one twelve-quart plastic container was wet inside and stacked with other similar containers, one large plastic bowl was wet inside and stacked with similar items, and five metal pans were wet inside and stacked together.…

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 routinely assess the arteriovenous fistula (AV fistula, a connection surgically made between an artery and a vein for dialysis access) for one of three sampled residents (Resident 22) who received dialysis (a procedure in which a machine filters wastes and fluid from the blood). This failure had the potential to result in unidentified complications with Resident 22's AV fistula. Findings: Review of Resident 22's medical record indicated she was admitted on [DATE] and had the diagnosis of end stage renal disease (ESRD, the kidneys no longer function as they should to meet the body's needs). The medical record further indicated Resident 22 received dialysis every Tuesday, Thursday and Saturday. Review of Resident 22's Order Summary Report indicated she had a physician's order dated 10/30/2021, to check dialysis site for bleeding, redness and tenderness every shift. She also had a physician's order dated 10/29/2021, to auscultate bruit (use a…

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

Based on observation, interview and record review, the facility failed to provide pharmaceutical services to meet the needs of each resident when: 1. The facility did not reorder two out of 12 emergency medication kits (E-kits) after using them; and 2. The facility failed to ensure controlled medications (medications regulated by the government because they may be abused or cause addiction) for four out of six residents (Residents 31, 371, 20 and 66) were accounted for. Failure to reorder the E-kits had the potential to result in medications not being available to the residents when needed. Failure to account for controlled medications had the potential to result in diversion (transfer for illicit use) of the medications. Findings: 1. During an observation on 1/24/2022 at 10:12 a.m., one E-kit containing narcotic medications (medications that dull the senses and have the potential to cause addiction) was inspected. The medication list on the outside of the E-kit indicated there were supposed to be eight tablets of Dilaudid (pain medication) 2 milligrams (mg, unit of dose…

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 residents were provided a well-balanced diet that met nutrition needs when serving sizes on the meal tray tickets did not match the planned and approved menu for Regular diets, Regular Puree diets (texture modified diets that do not require chewing), Carbohydrate Controlled (CCHO, therapeutic diets designed for people with diabetes to keep the carbohydrate levels in meals evenly spaced throughout the day), Mechanical Soft diets (texture modified diets that require less chewing than regular diets), and Renal 80 gram (therapeutic diet that is low in sodium, phosphorus, and protein for people with kidney disease) CCHO Mechanical Soft diets. This failure had the potential to result in not meeting the nutritional needs thus further compromising the medical status of 32 out of 68 residents eating in the facility. Findings: Review of facility document titled Winter Menu (spreadsheet), dated 12/27/21 - 2/27/22, indicated for 1/24/22 Monday Lunch, the serving sizes for the Regular diet were: one Beef…

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 notify all residents, their representatives, and families of a confirmed case of COVID-19 in the facility in a timely manner, when the communication was not sent for five days after a positive COVID-19 case was identified in the facility. This failure could potentially cause a spread of COVID-19 in the facility and is in violation of federal regulations to mitigate the spread of COVID-19 virus. Findings: During an interview on 1/28/22 at 2:14 p.m. with the Infection Preventionist (IP), IP stated she had first learned of a resident having a positive COVID-19 test on 1/8/22. During an interview on 1/31/22 at 9:10 a.m. with the administrator (ADM), ADM stated he used text them all service to notify families. ADM stated this was done on 1/13/22. ADM stated he was first aware of a positive COVID-19 case on 1/8/22. During a review of the facility's Mitigation Plan, it indicated, .Facilities must inform residents and their representatives by 5:00 PM the day after an occurrence of a single confirmed infection of COVID-19, or three…

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 provide a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN, notice that transfers potential financial liability) to one of three residents (Resident 30). This failure had the potential to compromise Resident 30's right to appeal (apply for reversal of) the facility's decision to discontinue Medicare Part A services (skilled treatments paid by Medicare). This failure also had the potential to result in Resident 30 not being informed of his payment responsibilities to the facility after Medicare Part A services ended. Findings: Review of Resident 30's medical record indicated he was admitted to the facility under Medicare Part A on 7/28/2021. The medical record further indicated Resident 30 came off Medicare Part A services on 8/3/2021, but continued living in the facility. Review of Resident 30's SNF Beneficiary Protection Notification Review, filled out by the facility on 1/27/2022, indicated the facility initiated Resident 30's discharge from Medicare Part A services when benefit days were not…

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 interview and record review, the facility failed to follow its own policy and procedure to report the allegations of resident-to-resident verbal abuse of two encounters, for two (Resident 4 and Resident 44) of 17 sampled residents to the California Department of Public Health (CDPH), the ombudsman and law enforcement immediately, but not later than 2 hours when: 1. Resident 4 was involved in an altercation on 7/29/21 at 6:00 p.m., 2. Resident 44 was involved in an altercation on 7/29/21 at 6:00 p.m. and 8/21/21 at noon. This failure had the potential to result in delay of investigation and the reporting of further allegations of abuse. 1. Review of Resident 4's admission record indicated Resident 4 was admitted with multiple diagnoses including cerebral infarction (a condition resulting from a lack of oxygen in the brain potentially causing a loss of sensory and motor function), hemiplegia (paralysis of one side of the body) and hemiparesis (weakness such as mild loss of strength in a leg, arm, or face),…

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 notify one of six residents (Resident 19) and/or the resident's representative regarding the facility's policy for the bed hold when they were transferred to the hospital without receiving notice. This failure has the potential to violate the resident's right to allow the resident to return to the facility. Findings: Resident 19 was admitted to the facility with diagnoses included a history of Transient Ischemic Attack (TIA, similar to a stroke, but only lasts for a short duration), and cerebral infarction (disrupted blood flow to the brain, causing part of the brain to die off), chronic obstructive pulmonary disease (COPD, disease which causes airflow blockage and breathing-related problems), and dementia (the loss of cognitive functioning, thinking, remembering, and reasoning). Review of Resident 19's electronic record (eRecord) indicated Resident 19 had a hospital leave which started on 9/25/21 and she had returned on 9/29/21. During an interview on 1/28/22 at 9:44 a.m. with the director of nursing (DON), DON stated she…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately complete the Minimum Data Set (MDS, an assessment tool) for one of 17 sampled residents (Resident 1) and one resident (Resident 68). Failure to accurately assess had the potential to compromise the facility's ability to develop and implement resident-centered care plans and interventions. Findings: 1. Review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR, a tool used to communicate information to the doctor) Communication Form and Progress Notes indicated she fell in the facility on 9/4/2020, 1/22/2021 and 3/12/2021. Resident 1's MDS, dated [DATE] and 4/17/2021 were reviewed. Section J1800 asked the question, Has the resident had any falls since admission/entry or reentry or the prior assessment? The answer to this question was coded 0 to indicate Resident 1 did not have any falls during the specified time frames. Resident 1's falls on 9/4/2020, 1/22/2021 and 3/12/2021 were not coded on the MDS. During an interview…

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 adequate supervision and security for one of three residents (Resident 47) when facility staff was unaware Resident 47 wandered away outside the facility for several hours. This failure compromised the resident's safety and put her at high risk for injury. Findings: During record review of Resident 47's clinical record, Resident 47 was admitted on [DATE] with diagnoses included dementia (memory loss), diabetes mellitus (high blood sugar) and osteoporosis (a condition in which bones become weak and brittle). Review of Resident 47's minimum data set (MDS, a resident assessment tool) dated 12/08/21, indicated Resident 47 was severely cognitively impaired and required supervision during activities of daily living (ADLs). Review of Resident 47's elopement risk assessment dated [DATE], indicated Resident 47 was at risk for elopement. During interview with licensed vocational nurse (LVN E) on 01/28/22 at 1:30 p.m., LVN E stated he was not aware…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to address whether one of 17 sampled residents (Resident 1) would benefit from gradual dose reduction (GDR, stepwise tapering of a dose to determine if conditions can be managed by a lower dose or if the medication can be discontinued altogether) of a psychotropic medication (medication capable of affecting the mind, emotions and behavior). This failure had the potential to result in unnecessary or prolonged use of the psychotropic medication, which could increase the resident's risk of experiencing side effects (undesirable effects from the medication). Findings: Review of Resident 1's medical record indicated she was admitted on [DATE] and had the diagnosis of dementia (mental disorder caused by brain disease or injury) and psychosis (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality). Review of Resident 1's Order Summary Report indicated she had a physician's order, dated 7/21/2021, for…

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 three of 17 sampled residents (Residents 43, 38 and 47) were free from unnecessary psychotropic medications (medications capable of affecting the mind, emotions and behavior) when: 1. For Resident 43, the facility did not identify and monitor target behaviors (specific behaviors intended to be reduced or eliminated by the medication), did not monitor side effects (undesirable effects from the medication), and did not identify appropriate indications for the use of psychotropic medications; 2. For Resident 38, the facility did not identify and monitor target behaviors for psychotropic medications; and 3. For Resident 47, the facility did not identify and monitor target behaviors for psychotropic medications. These failures compromised the facility's ability to determine whether or not the psychotropic medications were effective. These failures also increased the residents' risk of experiencing harmful effects from the psychotropic medications.…

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 obtain consents to either receive or refuse pneumonia vaccine for one of five residents (Resident 23). This failure put the resident at risk of not being informed of the risks and benefits of the pneumonia vaccines, and not giving them the ability to make an informed decision. Findings: Review of Resident 23's electronic record (eRecord) for vaccine status, the eRecord indicated a consent was needed for pneumovax (a pneumonia vaccine). Neither a consent nor refusal was located by the surveyor. During an interview on 1/28/22 at 10:21 a.m. with the Infection Preventionist (IP), IP stated she had not found a consent to accept or refuse the pneumovax vaccine for Resident 23. During a review of the facility's policy and procedure (P&P) titled, Pneumococcal Vaccination, revised 05/2009, the P&P indicated, .1. Upon admission the resident will be assessed for eligibility to receive the pneumococcal vaccine, and when indicated, provided the vaccination within sixty (60) days of admission to the facility unless medically…

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 failed to maintain comfortable and sanitary shared bathroom for one of three residents, when there was a black matter and long, narrow piece of black material that was sticky on one side in the bathroom tile surfaces. Also, the two tissue holder beside the toilet had no rollers. This had the potential to affect resident's psychosocial well-being. Findings: During observation on 01/26/22 at 10:15 a.m., in the bathroom commonly shared by Residents 9, 53 and 55, there was a black matter and long, narrow piece of black material that was sticky on one side in the bathroom tile surfaces. The door was hard to open because it was stuck. Also, the two tissue holder had no rollers beside the toilet. During an interview with Resident 55 on 01/26/22 at 10:30 a.m., Resident 55 stated it felt awful to look it that way. Resident 55 stated that housekeepers did not clean daily. During an interview with registered nurse F (RN F) on 01/26/22 at 10:35 a.m., RN F acknowledged…

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.