Herman Health Care Center

Based on observation, interview and record review, the facility failed to maintain resident's privacy or dignity for one of 25 sampled residents (Resident 76) when her back was halfway exposed from the Coccyx or tailbone (the last bone at the bottom (base) of the spine) up to the upper part of her back to public view in the hallway. This failure had the potential to affect Resident 76's self-esteem and self-worth. Findings:Review of Resident 76's clinical record indicated she had diagnosis of lower back pain, sciatica (pain or other symptoms-like numbness, tingling, or weakness-that occur when pressure is applied to or irritation affects one or more of the five nerve roots that form the sciatic nerve (sciatic nerve is the largest nerve in the body, extending from the lower back down to the foot) , Schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), Bipolar type (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). The physician order dated 4/2/25 indicated…

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 report allegations of abuse to the appropriate agencies, including the California Department of Public Health (CDPH), within the required timeframe involving two of six sampled residents (Residents 37 and 91). This failure to report allegations of abuse placed Residents 37 and 91 at risk of potential abuse.Findings: Review of Resident 37's Face Sheet (summary page of a patient's important information) indicated Resident 37 was admitted to the facility on [DATE] with diagnoses including Schizophrenia (a chronic mental health condition that affects a person's thoughts, perceptions, and behaviors), Anxiety Disorder (a mental health condition characterized by excessive and persistent worry, fear, and nervousness), Depression (a common mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest in activities previously enjoyed). Review of Resident 37's Minimum Data Set (MDS, a standardized assessment tool),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure, the resident's discharge minimum data set (MDS, a standardized assessment and care screening tool) assessment was transmitted within 14 days after the assessment reference date (ARD, the specific end point of look-back periods in the MDS assessment process) for one (Resident 43), out of twenty-five sampled residents.This deficient practice had the potential to result in delayed services for the resident.Findings: Review of Resident 43's admission record (document created when a resident is admitted to a healthcare facility, containing the vital information about the resident) indicated, Resident 43 was initially admitted to the facility on [DATE] and was discharged on 5/23/25. Resident 43 was then readmitted on [DATE]. Review of the Centers for Medicare and Medicaid Services (CMS, a federal agency within the United States Department of Health and Human Services that administers the Medicare program) submission report indicated that 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 ensure an accurate smoking assessment and complete smoking assessment were done every three months for two of 19 sampled residents who smoke (Residents 37 and 72).These failures had potential to cause accident/harm to these residents and potential to compromise the facility's ability to develop and implement resident-centered care plans and interventions.Findings: 1.Review of Resident 37's Face Sheet (summary page of a patient's important information) indicated Resident 37 was admitted to the facility on [DATE] with diagnoses including Schizophrenia (a chronic mental health condition that affects a person's thoughts, perceptions, and behaviors), Anxiety Disorder (a mental health condition characterized by excessive and persistent worry, fear, and nervousness), Depression (a common mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest in activities previously enjoyed). During an observation on…

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 that the resident with Level 1 (involves completion of an evaluation to determine if the individual has, or is suspected of having serious mental illness, intellectual disability, developmental disability or related condition) preadmission screening and resident review (PASARR, federal requirement under the Medicaid program or public health insurance program that provides health care coverage to low-income individuals, families and people with disabilities, to screen all applicants and residents for serious mental illness, intellectual or developmental disabilities, and related conditions before they are admitted to the nursing facility) was coded accurately and those with positive Level 1 PASARR were evaluated for Level 2, for three of twenty-five sampled residents, (Residents 22, 92 and 72) when:1.For Residents 22 and 92, there were no documentations that Level 2 PASARR screening (comprehensive evaluation by the appropriate state-designated…

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 that the preadmission screening and resident review (PASARR, federal requirement under the Medicaid program or public health insurance program that provides health care coverage to low-income individuals, families and people with disabilities, to screen all applicants and residents for serious mental illness, intellectual or developmental disabilities, and related conditions before they are admitted to the nursing facility) was done and accurately implemented to two of twenty-five sampled residents, (Residents 85 and 6) when: 1.For Resident 85, there was no level 1 PASARR screening (involves completion of an evaluation to determine if the individual has, or is suspected of having serious mental illness, intellectual disability, developmental disability or related condition) and 2. For Resident 6, the level 1 PASARR screening was not accurately done. These failures had the potential to cause the delay, in the care of the residents and 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 on observation, interview, and record review, the facility failed to ensure a care plan (CP) was revised based on preferences and needs of the residents for two of 25 sampled residents (Resident 72 and 73.This failure had the potential for Resident 72 and 73 not to receive the necessary care and services to achieve the highest practicable well-being and communicate necessary interventions to the staff. Findings:1. Review of Resident 72's clinical record indicated she was admitted to the facility on [DATE] and re admitted on [DATE] with diagnosis of Schizoaffective disorder, Bipolar type, muscle weakness, Chronic obstructive pulmonary disease (COPD, a disease that affects airflow in the lungs and makes it difficult to breathe) and other symptoms and signs involving cognitive functions and awareness.Resident 72's minimum data set (MDS, an assessment tool) dated 6/18/25 indicated her cognition (ability to remember, judge and use reason) with a brief interview for mental status (BIMS- an assessment tool used…

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 in accordance with professional standards of practice for one of twenty-five sampled residents, (Resident 22), when for Resident 22: 1.The care plan for the risk of elopement was not followed;2. There was MDS assessment inaccuracy; and3. The care plan was not person-centered.These failures caused the resident to have an episode of elopement and potentially, not attaining or maintaining the highest practicable physical, mental and psychosocial well-being.Findings: 1.During the concurrent lunch observation and interview of Resident 22 on 8/18/25 at 12:18 p.m., Resident 22 was sitting in the dining area table, eating her lunch. Resident 22 was alert, calm and verbally responsive and stated that she was fine.Review of Resident 22's admission record (document created when a resident is admitted to a healthcare facility, containing the vital information about the resident) indicated, Resident 22 was admitted to the facility on…

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 that one of five emergency kits (e-kits; kits containing medications and supplies for immediate use during a medical emergency) was replaced in a timely manner.This failure resulted in two medications (a total of 16 tablets) expiring, which had the potential to make medications unavailable for use during an emergency.Findings:1. During an inspection of Medication Cart (MC) 1 with Licensed Vocational Nurse (LVN) E on [DATE] at 10:29 a.m., an e-kit was found containing two expired controlled medications (16 tablets total) with an expiration date of [DATE].a. Oxycodone/acetaminophen 10/325 mg(milligram, a unit of measurement for weight in the metric system), quantity 8, expiration date [DATE].b. Morphine Sul ER (Morphine Sulfate Extended Release) 15 mg, quantity 8, expiration date [DATE].During an interview with LVN E on [DATE] at 10:35 a.m., LVN E confirmed the above observations and stated that nurses should order replacements prior…

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 9.68 percent (%) medication error rate, with three medication errors out of 31 opportunities observed during the medication administration for three of the five residents (Residents 107, 41, and 55). when1. Resident 107's lactulose oral solution (a colonic acidifier that works by increasing stool water content and softening the stool) was not available during medication administration.2. Resident 41' polyethylene glycol 3350 powder was not available during medication administration.3. Resident 55's lactulose oral solution was not available during medication administration, and the nurse used another resident's medication instead.These failures had the potential to compromise the health and safety of the residents.Findings:1. A review of Resident 107's clinical record indicated a physician's order, for lactulose oral solution 10 mg/mL(milligram/milliliter), give 30 mL(milliliter, a unit of volume in the metric system) by mouth two times daily for hepatic encephalopathy, starting on 8/15/2025.During an observation…

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 proper medication storage and labeling when:1. Expired medications were not removed from the medication refrigerator to prevent medication errors.2. A bottle of lactulose oral solution (a colonic acidifier that works by increasing stool water content and softening the stool) was sticky in the medication cart.3. One tuberculin purified protein derivative (PPD) vial and five bottles of multi-dose medications were not labeled with an open date.These deficient practices had the potential to result in residents receiving medications with reduced potency or unsafe properties, as well as medication errors due to improper labeling or failure to remove expired medications from active stock.Findings: 1. During a visit to the Medication room [ROOM NUMBER] with Licensed Vocational Nurse (LVN) E on 8/18/2025 at 9:50 a.m., a vial of tuberculin (PPD) in the medication refrigerator was labeled with an open date of 6/22/2025 (expired on 7/21/2025).…

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 timely notify a representative of the Office of the State Long-Term Care Ombudsman (an entity that serves as an impartial advocate for individuals or groups who have concerns or complaints about a particular organization) regarding discharges for two of two sampled residents (Residents 1 and 2). The facility faxed discharge notices on the day of discharge. This failure resulted in missed opportunities for an ombudsman to advocate if residents had concerns about their discharge. Findings: 1. Review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 11/11/24, indicated his Brief Interview for Mental Status (BIMS) was 3, indicating he had severe cognitive impairment in daily decision-making skills. Resident 1's Psychosocial Note, dated 1/20/25 at 2:56 p.m., indicated the resident would like to be back in his hometown community. Review of the Notice of Proposed Transfer/Discharge form dated 1/24/25 indicated the ombudsman's office was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide care in accordance with professional standards of practice for one of two residents investigated, (Resident 1), when Resident 1 was not provided with appropriate assistance with his activities of daily living (ADL, basic tasks individuals perform to take care of themselves on a daily basis) to prevent accident. This failure resulted in the safety of Resident 1, being compromised, thus having multiple falls. Findings: During a concurrent observation and interview of Resident 1 on 10/25/24 at 3:30 p.m., Resident 1 was laying in his bed, alert, calm and comfortable. He was watched one on one by a certified nursing assistant. Resident 1 was confused and could not recall his falling incidents. Review of Resident 1's admission record dated 10/15/24 indicated, Resident 1 was initially admitted to the facility on [DATE]. Resident 1's latest readmission was 9/24/24 with diagnoses including fracture (break or crack in a bone) of 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.

Based on interview and record review, the facility failed to protect a resident's right to be free from any type of abuse, including corporal punishment (type of physical punishment), and neglect, that could results in, or has the likelihood to result in physical harm, pain, or mental anguish for one of two sampled Residents (Resident 1), when Resident 1 was physically abused by Resident 2. This failure resulted in Resident 1 being physically abused by Resident 2 and sustaining a minor injury (bruising to back of head). Findings: During a review of Resident 1's SOC 341 (Mandated Report for Elder/Dependent Adult Abuse Allegation) dated 6/14/24, indicated, and abuse allegation was reported to the California Department of Public Health (CDPH) indicating Resident 1 as the victim and Resident 2 as the abuser. Report indicated, At approx [sic] 1530 [charge nurse] reported that [Resident 2] pushed [Resident 1] to the floor while they were having an argument over a chair. Both residents were separated immediately. Investigation Initiated. During a review of the Facility's 5 day…

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 an interview and record review, the facility failed to ensure medications were administered as ordered by the medical doctor (MD) for 1 of 2 sampled Resident (Resident 1). This failure had the potential to adversely affect the health and well- being of Resident 1. Findings: A Record review of Resident 1's face sheet (FS: a document that gives a resident's information at a quick glance) indicated Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's FS indicated Resident admitted with diagnoses included dementia (loss of ability to think, remember, and reason to levels that affect daily life and activities), alcohol abuse (disorder when can't stop drinking even when its puts health and safety at risk), cognitive communication deficit (condition with trouble reasoning and making decisions while talking), and encephalopathy (disturbance of brain function). Review of Resident 1's physician's medication orders indicated divalproex (to treat mental illness) 250 mg (mg: milligrams, unit 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 interview, and record review, the facility failed to ensure to follow psychiatric nurse practitioner (PNP: licensed as nurse practitioner or clinical nurse specialist, provides the full range of mental health care needs)'s recommendations and medication regimen review (MRR: a thorough evaluation of medication regimen for resident with the goal of promoting positive outcomes) for 2 of 2 sampled Residents (Resident 1 and 2) when; 1. Failed to follow up for PNP's recommendations for medication, and blood tests (common tests healthcare providers use to monitor overall health or help diagnose medical condition) for Resident 1; 2. Failed to follow up for MRR request for Resident 1; and 3. Failed to follow up for psychologist (a trained mental health professional who specializes in the study and treatment of mind and behavioral disorders)'s recommendations for Resident 2. These failures had the potential to effect on health and psychosocial well-being for Resident 1 and 2. Findings: Review of Resident 1's face sheet (FS: a document that gives a resident's information at a quick…

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 follow it's Policy & Procedure (P&P) titled, Abuse Reporting and Investigation for three of four sampled residents (Resident 1, Resident 2, and Resident 3) when: 1. The facility failed to complete a 5-day investigative report for Resident 1's abuse allegation and send the report to the California Department of Public Health (CDPH). 2. The facility failed to complete a 5-day investigative report for Resident 2's abuse allegation and send the report to the CDPH. 3. The facility failed to complete a 5-day investigative report for Resident 3's abuse allegation and send the report to the CDPH. These failures had the potential for Resident 1, 2, and 3's abuse allegations to not be investigated thoroughly and resulted in CDPH being unaware of the outcome of each investigation by the facility. Findings: 1. During a review of Residents 1's SOC 341 (Report of Suspected Dependent Adult/Elder abuse) dated 12/18/23 indicated, an allegation of abuse was reported to CDPH. Report indicated, Resident 1 reported a physical abuse allegation…

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 an interview and record review, the facility failed for 2 of 2 sampled residents (Resident 1 and 2): a) to ensure medications were administered as ordered by the medical doctor (MD) and b) to follow their policy and procedure (P&P) for administering medications. These failures had the potential to adversely affect the health and well-being of Residents 1 and 2. Findings: A Record review of Resident 1's face sheet (a document that gives a resident's information at a quick glance) indicated Resident 1 was admitted to the facility on [DATE] and discharged on 3/11/2024. Review of Resident 1's medications orders included: Oxybutynin (medication to relax the muscles in the bladder [body organ that stores urine]) 5mg (mg: milligram, a unit of measurement of mass or weight) twice a day; Benztropine (used to treat side effects of other medications) 1mg twice a day; Fish Oil (dietary supplement) 2,000mg twice a day; Polyethylene glycol powder (medication for constipation, makes it easier to have a bowel movement)…

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 necessary activities of daily living (ADL-skills required to independently care for oneself, such as eating, bathing, and mobility) for one of three sampled residents (Resident 1) when Resident 1's shower sheets was not available and not documented for a period of one month (3/4/24-4/4/24). This failure had the potential to negatively affect Resident 1's physical and mental health. Findings: During an interview on 4/4/24, at 2:00 p.m., with Resident 1, Resident 1 stated she was not showered regularly according to her scheduled shower days. Resident 1 stated she is supposed to be showered on Mondays, Wednesdays, and Fridays. Resident 1 stated she was dependent on staff to bathe her due to weakness from a chronic medical condition and she was unable to bathe herself. During a concurrent interview and record review on 4/4/24, at 2:40 p.m., with Certified Nursing Assistant (CNA) A, the shower sheet binder dated 3/4/24 to 4/4/24 was reviewed. The shower sheet binder indicated, no documentation Resident 1 was showered…

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 care according to professional standards of practice for two of two residents (Resident 1 & Resident 2), when nursing staff failed to order two medications timely. This failure had the potential for negative health outcomes related to not receiving prescribed medications as ordered. During a review of Resident 1's Physician Orders dated March 2024, Orders indicated, Hydroxyzine [Antihistamine that can treat anxiety] HCL[hydrochloride] 25MG [milligrams] tablet. Give 1 tablet by mouth every 12 hours for anxiety. During a concurrent interview and record review on 3/19/24, at 2:32 p.m., with Licensed Vocational Nurse (LVN) A, Resident 1's Medication Administration Record (MAR) dated March 2024 was reviewed. The MAR indicated, Resident 1 did not receive Hydroxyzine on 3/18/24 for the AM dose or the PM dose. Resident 1 also did not receive Hydroxyzine for 3/19/24 AM dose. LVN A stated, I was working yesterday, when I went to give Resident 1 the Hydroxyzine for the AM dose, I noticed we were out of the medication, so I…

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 proper use of side or bed rails (adjustable rigid bars attached to the side of a bed) for 40 (Residents 3, 6, 8, 10, 12, 14, 18, 20, 22, 24, 27, 28, 32, 41, 42, 45, 49, 50, 52, 55, 56, 58, 59, 64, 67, 69, 70, 74, 78, 91, 96, 98, 100, 103, 105, 113, 319, 320, 321, and 369) of 40 sampled residents (residents who used bed or side rails) when: 1. There was no documentation that indicated the facility conducted consistent routine maintenance of the facility's beds and side rails for 40 of 40 sampled residents; 2. There was no documentation of informed consents (A process in which patients are given important information, including possible risks and benefits, about a medical procedure or treatment) were obtained prior to bed rail use for 40 of 40 sampled residents; 3. There was no documentation that indicated alternatives were offered and/or attempted prior to the use of side rails for 38 of 40 sampled residents (Residents 3, 6, 10,…

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, prepared, and served in accordance with professional standards for food safety when: 1. The kitchen refrigerator door has ice buildup in the rubber gasket (a flexible elastic strip attached to the outer edge of a refrigerator); 2. Three pieces of colored chopping board are stained and two cloudy and one cracked blender container in the kitchen sink; and 3 The snacks /nourishment in the unit refrigerator were outdated. These failures had the potential to cause food contamination and spread food-borne illness to residents who received their food from the kitchen. Findings: 1.During an initial kitchen concurrent observation and interview on 2/12/24 at 11:06 a.m., with the Dietary Staff V (DS V) inside the kitchen's one of the refrigerators. There were some ice buildups and leak at the surrounding refrigerator door rubber gasket . DS V confirmed the observation above. DS V stated the refrigerator should not have ice buildup. DS V further stated the refrigerator was cleaned every day and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure respect and dignity was maintained for seven of 24 sampled residents (Residents 28, 84, 55, 621, 46, 40, and 52) when: 1. Staff provided feeding assistance to Residents 28 and 84 while standing; 2. Staff failed to provide privacy bags for Residents 55 and 621's urinary bags; 3. Resident 46's privacy was not maintained during patient care; 4. Resident 40's dignity was not maintained by staff; and 5. Staff did not provide a privacy curtain inside Resident 52's room. These failures had the potential to affect the emotional and psychosocial well-being of the residents. Findings: 1a. Review of Resident 28's Minimum Data Set (MDS, an assessment tool) 5-day assessment, dated 1/15/2024, indicated her cognition was severely impaired and she required partial/moderate assistance (helper does less than half the effort) on staff for eating. During lunch meal observation on 2/12/2024 at 12:29 p.m., Resident 28 was in her room, lying in bed.…

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 informed consent (process in which a health care provider educates a patient about the risks, benefits, and alternatives of a given procedure or intervention in order to obtain agreement or permission for care, treatment, or services) was in place (or verified) prior to the initiation and administration of psychotropic medication (drugs that affects brain activities associated with mental processes and behaviors) for three of 24 sampled residents (Resident 58, 75, and 370). This deficient practice had the potential for the residents or the responsible party (RP) to not be informed of the risk and benefits of the psychotropic medications, and to make an informed decision, before receiving the medications. Findings: 1. A review of Resident 58's medical record indicated she was admitted to the facility with diagnoses including bipolar disorder (condition associated with episodes of mood swings ranging from depressive lows to manic highs), major depressive disorder (a mood disorder that causes a persistent feeling…

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 needs were accommodated for five of 24 sampled residents when: 1. Residents 11, 2, and 18's call light button (a cord with a button used by residents to request assistance) were not within reach to use; 2. Resident 41's call light button was not within reach to use; and 3. Resident 52's call light was broken and unable to use. These failures had the potential to affect these resident's physical and psychosocial well-being. Findings: 1a. Review of Resident 11's face sheet (a document that contains a summary of patient's personal and demographic information) indicated, Resident 11 was admitted to the facility with diagnoses including Alzheimer's disease (a progressive disease that destroys memory and mental functions), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), Bell's palsy (a condition affecting the nerve that controls facial muscles, resulting in facial…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete and transmit the Minimum Data Set (MDS, an assessment tool) discharge assessment and death tracking record in a timely manner for three of five residents (Residents 47, 82, and 15). These failures resulted in the resident's discharge assessment and death tracking record not being transmitted and received by the Center for Medicare and Medicaid System (CMS) within the time requirement. Findings: 1. During a concurrent interview and record review with Minimum Data Set Coordinator (MDSC, a nurse who assess and evaluate the quality of care being given to long-term care residents) on [DATE] at 11:37 a.m., MDSC reviewed Resident 47's clinical records. Resident 47's clinical records indicated, Resident 47 was admitted to the facility on [DATE] and was discharged on [DATE] to home. MDSC confirmed the MDS discharge assessment dated [DATE] was completed but not signed by a Registered Nurse Coordinator (RNC) to verify the assessment completion. MDSC…

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 implement individualized, resident-centered a care plans for five of 24 sampled residents (Residents 22, 28, 52, 369, and 79) when: 1. Staff did not follow Resident 22's care plan for wandering (when a person roams around and becomes lost or confused about their location) and elopement (an individual's behavior of leaving an area without permission or supervision); 2. Staff did not develop care plan for Resident 28's diagnosis of chronic obstructive pulmonary disease (COPD, a disease that affects airflow in the lungs and makes it difficult to breathe) and use of oxygen for Resident 28; 3. For Resident 52, there was no care plan developed to address mood disorder (a mental health condition) or skin discoloration; 4. For Resident 369, there was no care plan developed to address chronic obstructive pulmonary disease (COPD, a disease that affects airflow in the lungs and makes it difficult to breathe); and 5. The facility failed…

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 an ongoing activity program that meet the resident's needs, interests, and preferences for five of 24 sampled residents when Residents 22, 61, 75, 70, and 41's activity care plan were not updated and followed. This failure had the potential to affect the residents' physical, mental, psychosocial well-being, and self-worth. Findings: 1. Review of Resident 22's face sheet (a document that contains a summary of patient's personal and demographic information) indicated, Resident 22 was admitted to the facility with diagnoses including unspecified dementia (decline in mental capacity affecting daily function), unspecified severity, with agitation (a state of anxiety or nervous excitement), schizoaffective disorder (a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania), and bipolar disorder (mental disorder…

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 seven of 24 sampled residents (Residents 28, 34, 35, 56, 58, 369 and 370) received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, when: 1. Resident 56's antibiotic order from the hospital was not carried out. This placed the resident at risk for untreated and worsening infection; 2. For Resident 58, the facility staff failed to evaluate and report to the physician when the resident did not sleep for multiple days. The inability to have quality sleep may affect the resident's quality of life and lead to psychosocial outcomes (such as depression, anxiety, distress); 3. For Resident 34 and Resident 35's food tray ticket was not checked during food distribution . 4. For Resident 28, staff administered oxygen without physician's order and staff did not follow the physician's order for the use of Prevalon Boots (type of boots that have a cushioned bottom that…

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 that proper care and treatment services for oxygen (O2) was provided for five of nine sampled residents (Resident 61, 28, 58, 369, and 1) when: 1. Staff did not follow the physician's order for Resident 61's oxygen therapy; 2. Staff did not post an Oxygen in use/No Smoking sign at Resident 28's door; 3. Staff did not post an Oxygen in use/No Smoking sign at Resident 58's door. 4. Staff did not post an Oxygen in use/No Smoking sign at Resident 369's door; and 5. Licensed vocational nurse (LVN) J failed to ensure oxygen (a colorless and odorless gas that people need to breath) was administered as specified in the physician's order and the nasal cannula (NC, flexible tubing inserted into the nostrils and attached to an oxygen source) was outdated for Resident 1; and These failures had the potential to result in complications related to improper treatment while receiving O2 therapy. Findings: 1. Review of Resident 61's face sheet…

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 nursing staff were competent in the use of the facility's charting system prior to their first shift. This failure had the potential for incorrect documentation of patient care, assessments, and medication administration. Findings: During an interview on 2/15/24, at 12:46 p.m., with the Interim Director of Staffing Development (IDSD), IDSD stated, he took over this position on 2/8/24. IDSD stated, he was not able to locate the onboarding binder which oriented new staff to the charting system. IDSD stated, our charting system was not as common as other Long Term Care Facilities so with the prior DSD, staff were trained on how to use the software prior to starting work. IDSD stated, we recently lost over 10 Licensed Nurses in the past two weeks so we utilize registry staff from three different companies. IDSD stated, I do not have any documentation showing that the registry staff were oriented or competent in use of our charting system prior to starting work. IDSD stated, currently we are relying on other staff who…

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 post direct care staffing numbers, and nursing staff responsible for direct care to residents for two days (2/14/24-2/15/24) in each three halls of the facility. This failure resulted in residents and visitors not knowing the accurate number of hours of staff working and which staff were scheduled. Findings: During an observation on 2/14/24 at 9 a.m., in Hall BB. No staff schedule or direct patient care hours were seen posted. During an observation on 2/14/24 at 9:15 a.m., in Hall CC . No staff schedule or direct patient care hours were seen posted. During an observation on 2/14/24 at 9:30 a.m., in Hall AA. No staff schedule or direct patient care hours were seen posted. During an observation on 2/15/24 at 9:45 a.m., in Hall BB. No staff schedule or direct patient care hours were seen posted. During an observation on 2/15/24 at 10:01 a.m., in Hall CC. No staff schedule or direct patient care hours were seen posted. During an observation on 2/15/24 at 10:06 a.m., in Hall AA. No staff schedule or direct patient…

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, interviews, and record review, the facility failed to provide pharmaceutical services to meet the needs of three out of 24 sampled residents (Residents 56, 76, and 95). Also, the facility failed to ensure morning medication administration was given timely as per facility and procedures for two out of three halls (Hall CC) with the potential to affect 14 residents in this hall; and controlled medications (those with high potential for abuse and addiction) were fully accounted. These happened when: 1. Resident 56's Depakote (medication to treat mood disorder) was not available for administration. This had the potential for untreated medical conditions and withdrawal symptoms; 2. The morning medication administration in Hall CC was given late for two days during the survey. Late medication administration resulted in a medication not given to Resident 56 due to its scheduled time; and may lead to residents' discomfort (such as unnecessary pain) and affecting their health and safety (such as too low/high blood sugar, blood pressure, etc.); 3. There was no…

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

Based on interviews and record review, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported irregularities during the monthly medication regimen review (MRR), and conducted an interim or immediate MRR (iMRR, an MRR when the medication regimen is thought to contribute to an acute change in condition or adverse effect, or when resident is not expected to stay less than 30 days), for three of 24 sampled residents (Residents 58, 75, and 370) when: 1. The facility did not request for an iMRR by the pharmacist to evaluate whether Resident 58's multiple falls were caused or contributed by medications; 2. The CP failed to make recommendations for Resident 75 who received four medications to control blood sugar (BS) without a hold order when the BS is too low; without hypoglycemia protocol (intervention instructions for when the BS is too low); and without staff monitoring for signs and symptoms of hypo/hyperglycemia (too low/too high blood sugar); 3. The CP failed to make recommendations for Resident 370 who received Lovenox (an anticoagulant to prevent 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 had a medication error rate of 14.29% when five medication errors occurred out of 35 opportunities during the medication administration for one out of five residents (Resident 56). The failures resulted in medications not given according to the physician's orders and had the potential for Resident 56 to not receive the full therapeutic effects of the medications. Findings: 1. During an observation on 2/12/24 at 10:08 a.m., while preparing medications for Resident 56, Licensed Vocational Nurse C (LVN C) stated she needed Refresh Tears eye drops. On 2/12/24 at 10:20 am., LVN D was observed bringing a bottle of Gericare Artificial Tears eye drops for LVN C to give to Resident 56. During a medication pass observation on 2/12/24 at 10:26 a.m., LVN C was observed administering 11 medications to Resident 56. The medications included Gericare Artificial Tears eye drops. A review of Resident 56's physician's order, dated 12/27/23, indicated Refresh Tears 0.5% eye drop, give 1-2 drops in both eyes three times daily for dry eyes…

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 medications were stored and labeled appropriately when: - One of three medication refrigerators was identified unlocked when not in use; and its temperature was not being monitored and maintained twice daily as per professional standards of practice. This failure could lead to loss of medications and loss of drug potency due to unmonitored temperatures; - An opened multi-dose eye drop in the medication cart was not labeled with a resident name. The failure had the potential for the medication being used for the incorrect resident; - A package of expired blood sugar test strips was found in the medication cart. The failure could lead to the product being used past its effective date; - A bottle of Lorazepam (medication to treat anxiety) Intensol solution was found stored at room temperature in the medication cart. The medication was supposed to be stored in the fridge. This failure could lead to loss of drug potency and product…

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 document review, the facility failed to ensure garbage was properly contained when one of the receptacles lid was not tight-fitting and cannot close. This failure had the potential to attract insects, rodents, and other pests to the facility. Findings: During a concurrent observation and interview on 2/14/24 at 8:35 a.m., accompanied by the maintenance director (MD), there were two dumpsters in the facility's designated waste area, one of the receptacles was for cardboard and one receptacle for garbage. The receptacle lids for the garbage were defective and cannot close. MD confirmed the above observation on defective receptacle lid. The MD stated the receptacle lids were supposed to be closed and acknowledged the defective receptacles lid could attract pests. The United States Food and Drug Administration's 2022 Food Code indicated, Refuse, recyclables, and returnable shall be stored in receptacles or waste handling units so that they are inaccessible to insects and rodents. The Food Code further indicated, Outside receptacles must be…

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.

2. During an observation on 2/12/2024 at 9:36 a.m., Resident 61 was lying in bed, with oxygen concentrator at bedside and the NC was on the floor. During a concurrent observation and interview with LVN E on 2/12/2024 at 10:19 a.m., in Resident 61's room, LVN E placed the NC back to Resident 61's nostrils and turned on the oxygen at 3 liters per minute (LPM). LVN E confirmed she did not clean the NC prior to application back to Resident 61's nostrils. LVN E stated she should have cleaned or changed the NC to prevent Resident 61 from having respiratory infection. Review of Centers for Disease Control and Prevention's (CDC) recommendations and reports titled, Guidelines for Preventing Health-Care-Associated Pneumonia, 2003, dated March 26, 2004, indicated, 1. General measures: a. Thoroughly clean all equipment and devices to be sterilized or disinfected .c. Preferably use sterile water for rinsing reusable semicritical respiratory equipment and devices when rinsing is needed after they have been chemically disinfected. If this is not feasible, rinse the device with filtered water 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their abuse policy for one of 24 sampled residents (Resident 52) when staff did not report and investigate Resident 52's allegation of abuse timely. This failure had the potential to compromise Resident 52's safety and delay abuse investigations. Findings: Resident 52 was admitted on [DATE] with diagnoses including hemiplegia following cerebral infarction (damage to the brain tissues, also known as a stroke) affecting left nondominated side, mood disorder (a mental health condition), type 2 diabetes (high blood sugar), and chronic obstructive pulmonary disease (COPD, a disease that affects airflow in the lungs and makes it difficult to breathe). During a review of Resident 52's Minimum Data Set (MDS, an assessment tool) dated 1/22/2024, the MDS indicated she had a brief interview of mental status (BIMS, a structured cognitive test) scoring 03 (severe cognitive impairment). During a review of Resident 52's Nurses Notes dated 1/28/2024 at 2:00…

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 hospital transfer information was documented in the medical record for one of 24 sampled residents (Resident 56). The facility did not document the date and time of transfer, where she was transferred to, how she was transported, and the summary of her condition when she was transferred. The failure resulted in lack of information regarding the resident's transfer, and the potential for not providing necessary care and services to the resident. Findings: A review of Resident 56's medical record indicated she was admitted to the facility with diagnoses including urinary tract infection (UTI). A review of Resident 56's Minimum Data Set (a resident assessment and screening tool), dated 12/15/23, indicated she had a BIMS score of 15 (Brief Interview for Mental Status, a test given by medical professionals that helps determine a patient's cognitive understanding, scored from 1 to 15), which indicated she was cognitively intact. During an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately assess and complete the Minimum Data Set (MDS, an assessment tool) for two of 24 sampled residents (Residents 12 and 46). This failure had the potential to compromise the facility's ability to develop and implement resident-centered care plans and interventions. Findings: 1. A review of Resident 12's physician's order indicated she was admitted to hospice with the admitting diagnosis of heart failure (a chronic condition in which the heart cannot pump blood as well as it should) on 8/21/2023. Resident 12's MDS dated [DATE] was reviewed. Section O0100 asked to check all of the following treatments, procedures, and programs that were performed during the last 14 days, and K. hospice care was not checked. Resident 12's MDS dated [DATE] was reviewed. Section O0100 indicated K. hospice care was not checked. During an interview and concurrent record review on 2/14/2024 at 11:22 a.m. with the Minimum Data Set Coordinator (MDSC), the MDSC reviewed…

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 to follow their Policy and Procedure for one of 5 sampled residents (Resident 1) Preadmission Screening and Resident Review (PASSR a federal requirement to help ensure that individuals who have mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) to reopen and submit annual level I screening. These failures had the potential for inaccurate care and services provided to residents with a mental disorder, intellectual disability, or related conditions. Findings: Review of Resident 1's clinical record indicated he was readmitted on [DATE] and had a diagnoses of cognitive communication deficit (difficulty with thinking and how someone uses language), seizure (a sudden, uncontrolled burst of electrical activity in the brain), paranoid schizophrenia (a lifelong brain disorder that causes people to interpret reality abnormally), another idiopathic peripheral autonomic neuropathy. 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.

Based on observation, interview, and record review, the facility failed to ensure the environment was safe and free of accident hazards for two of 97 residents in the facility (Residents 40 and 81). Resident 81's broken pieces of glass from the wall clock in his room were not cleaned up timely, posing a risk of injury for the residents and staff. For Resident 40, the facility staff placed a wet shower sheet blanket on the floor near the bed, presenting a fall risk for the resident. Findings: 1. During the medication administration observation with Licensed Vocational Nurse (LVN) C and LVN D on 2/12/24 at 9:09 a.m., eight pieces of sharp, broken glass, in various sizes, were observed on the floor, near Resident 81's bed and wheelchair. Both nursing staff acknowledged this observation. LVN D stated the glass wall clock fell off the wall last night, and the night shift staff must have missed it when they did the cleaning. During an interview with LVN D on 2/12/24 at 9:18 a.m., LVN D stated the wall clock broke around 4 a.m. (five hours ago). She explained that Resident 81 was asking…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide adequate pain management in accordance with physician orders and resident needs for one of 24 sampled residents (Resident 370). This failure could result in ineffective pain management. Findings: A review of Resident 370's clinical record indicated he was admitted on [DATE] and had diagnoses including acute osteomyelitis (inflammation of bone caused by infection), type 2 diabetes (high blood sugar) with diabetic neuropathy (a nerve damage that occurs with diabetes), and bipolar disorder (a mental health disorder). His minimum data set (MDS, an assessment tool) dated 1/11/2024 indicated he had a brief interview of mental status (BIMS, a structured cognitive test) scoring 15 (cognitively intact). During an interview on 2/13/2024 at 9:50 a.m. with Resident 370, he stated he didn't receive his Norco (a pain medication) to control his pain on his feet for a week. Resident 370 also stated that the nurse told him that they had no Norco…

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

Based on interviews and record review, the facility failed to ensure two of 24 sampled residents (Residents 75 and 370) were free from unnecessary medications when: 1. Resident 75 received two routine insulin (medication to lower blood sugar [BS]) and two other medications to control BS without a hold order when the BS is too low; without hypoglycemia protocol (intervention instructions for when the BS is too low); without staff monitoring for signs and symptoms of hypo/hyperglycemia (too low/too high blood sugar); and without a written care plan for diabetes; and 2. Resident 370 received Lovenox (an anticoagulant to prevent blood clots) and aspirin (an anti-platelet medication; the combined use increases the risk of bleeding) without staff monitoring for signs and symptoms related to anticoagulant use (such as bruising/bleeding); and received two insulin orders without written hypoglycemia protocol and staff monitoring for signs and symptoms of hypo/hyperglycemia. These failures had the potential for side effects of these medications to go undetected or recognized for timely…

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 update and/or revised their policy and procedure in compliance with Federal regulations and with accepted professional standards and principles when the facility did not revise the facility's bed safety policy and procedure upon completion of the facility's recertification survey's plan of correction (POC). This failure had the potential to compromise resident's health and safety. Findings: Review of the facility's policy and procedure titled, Bed Safety, indicated the revision date was December 2007. During an interview with director of nursing (DON) on 4/12/2024 at 10:59 a.m., DON stated the policy and procedure should have been updated when the POC was completed. DON further stated, based on my practice, we should have reviewed the policy and procedure quarterly since the regulations changed. During an interview with administrator (ADM) on 4/12/2024 at 1:25 p.m., ADM stated facility's policy and procedure should have been reviewed annually or if something needed to be changed. ADM confirmed the policy and procedure…

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 offer, administer, and track Influenza vaccine (known as flu shot, immunization against infection by influenza viruses), pneumococcal vaccine (PV, immunization against bacterial that causes pneumonia, one type of lung infection), and COVID-19 vaccine (immunization against COVID-19 [Coronavirus, a severe respiratory illness caused by a virus and spread from person to person]) for three of 24 sampled residents (Residents 12, 52, and 370). This failure had the potential to cause the health complications for the residents. Findings: 1. A review of Resident 12's clinical record indicated that Resident 12 was admitted on [DATE]. A review of Resident 12's informed consent for the influenza vaccine dated 9/22/2022 indicated that the responsible party (RP, the person who is accountable for making decisions on behalf of the resident) consented for the influenza vaccine to be given. A review of the immunization list provided by the facility, indicated there was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when: 1. Laboratory staff (LS) was wearing gloves in the hallway; 2. COVID-19 (Coronavirus disease 2019); a highly contagious respiratory disease) screening process was not done properly; 3. The facility's COVID-19 screening logs were incomplete; 4. a. The nurse placed the glucometer (machine used to measure how much glucose or sugar is in the blood) on the unsanitized medication tray after the glucometer was disinfected; b. The nurse placed the syringe with medication in the unsanitized bedside table before administering it to the resident; c. The nurse did not sanitize the blood pressure apparatus after use; 5. The hospice aide (HA) did not perform hand hygiene after removing gloves; and 6. For Resident 56, licensed vocational nurse M (LVN M) did not use sterile gloves during Permacath (a dialysis catheter placed through a vein into or near the right upper chamber of the heart)…

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 safety for nine out of 22 sampled residents (Resident 17, 53, 73, 60, 46, 3, 10, 1, and 34) when: 1. For Resident 17, there was no fall risk assessment (tool, used to identify fall risk factors and to predict patients' chance of falling) completed on 3/21/22 after a fall and the bowel and bladder program fall intervention was not implemented; 2. Resident 53 was on oxygen and had a roommate who smoked, but No Smoking/Oxygen in Use sign was not posted on the resident's door. 3. For Resident 73, there was no quarterly fall risk assessment between 4/2021 to 11/2021; 4. One stall in the communal (shared by many residents) bathroom in building C (bldg C) had no call button; 5. For Resident 60, the facility did not develop and implement new and relevant interventions to prevent future falls; 6. For Resident 60 and Resident 46, the facility did not complete fall risk assessments after the residents fell; 7. For Resident 3, the fall risk…

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 pharmaceutical services to meet the needs of each resident when: 1. The facility failed to ensure controlled medications (medications regulated by the government because they may be abused or cause addiction) for four out of five residents (Residents 39, 56, 72 and 82) were accounted for, and the consultant pharmacist (CP) did not identify this failure; and 2. The CP did not identify irregularities for two residents (Residents 87 and 27) who were receiving psychotropic medications (medications that cause changes in mood, feelings or behavior). Failure to account for controlled medications had the potential to result in diversion (transfer for illicit use) of the medications and lack of pain control for the residents. Failure to identify irregularities had the potential to result in residents receiving psychotropic medications without adequate monitoring and without appropriate indications for use. Findings: 1. Review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure nine of 22 sampled residents (Residents 1, 10, 16, 27, 30, 72, 76, 77 and 87) were free from unnecessary psychotropic medications (medications that cause changes in mood, feelings or behavior) when: 1. For Resident 1, the facility failed to ensure there was an indication for the use of Seroquel (medication to treat psychotic disorder); 2. For Resident 72, the facility failed to ensure there was an indication and a target behavior (behavior intended to be changed by the medication) for the use of Depakote (medication to treat seizures); 3. For Resident 77, the facility failed to ensure the order for as needed (PRN) Lorazepam (ativan, a medication used to treat anxiety) and Haloperidol (medication to treat psychotic disorder) was limited to 14 days; 4. For Resident 30, the facility did not monitor potential side effects for Wellbutrin (medication used to treat depression) and Ativan; 5. For Resident 76, the facility did not identify a target…

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 2. During an observation and concurrent interview with the ADON on [DATE] at 9:12 a.m., in medication room A (Med Rm A), the medication refrigerator temperature was 29 degrees Fahrenheit (F, unit of temperature measurement). The ADON confirmed this observation and stated the medication refrigerator temperature should be between 36 and 46 degrees F. During an interview with the consultant pharmacist (CP) on [DATE] at 4:54 p.m., he stated the medication refrigerator temperature should be maintained between 36 and 46 degrees F. The CP explained that if the medication refrigerator temperature is too low, the medications could freeze or lose potency. Review of the facility's Medication Refrigerator Temperature Log, dated 4/2022, indicated the medication refrigerator temperature should be maintained between 36 and 46 degrees F. The facility's policy titled Medication Storage In the Facility, dated 4/2008 indicated, Medications requiring 'refrigeration' or 'temperatures between 36 [degrees] F and 46 [degrees] F' are…

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, prepared, and served under sanitary conditions when: 1. Several clear shallow pans and aluminum pans were stacked together and was not air dried; and 2. Dietary staff O (DS O) did not wear hairnet properly. These failures had the potential to cause foodborne illness (illness resulting from contaminated food ) for 93 residents who received food from the kitchen. Findings: 1. During an initial kitchen tour on 4/4/22 at 8:45 a.m., several shallow clear plastic pans were wet and stacked together. During a concurrent interview with dietary staff N (DS N), she confirmed the above observation and stated the pans were wet. DS N further acknowledged the pans should not be stored in the dry rack area. During an additional kitchen observation with DS N on 4/4/22 at 4:30 p.m., several clear plastic and aluminum pans were wet and stacked together. DS N confirmed the observation and stated the food containers should be air dried before storing. Review of the facility's policy, Dish Washing dated…

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 treat three of 22 sampled residents (Residents 3, 48 and 57) with respect and dignity when staff were observed standing while feeding the residents. This failure resulted in not ensuring resident's rights to be treated with respect and dignity and could potentially affect the resident's self-worth. Findings: 1. During an observation on 4/05/22 7:54 a.m., certified nursing assistant B (CNA B) was observed standing while feeding Resident 3. During an interview with CNA B on 4/5/22 at 7:56 a.m., CNA B confirmed the above observation and stated she should sit down when feeding residents. 2. During an observation on 4/04/22 at 12:37 p.m., restorative nurse assistant I (RNA I) was standing while feeding Resident 48. During an interview with RNA I on 4/04/22 at 12:51 p.m., RNA I confirmed she was standing while feeding Resident 48. During an interview with registered nurse H (RN H) on 4/04/22 at 12:53 p.m., RN H confirmed RNA I was standing while feeding Resident 48 and stated RNA I should sit down when feeding…

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 three of 22 sampled residents (Residents 60, 46 and 1). Failure to accurately assess the residents had the potential to compromise the facility's ability to develop and implement resident-centered care plans and interventions. Findings: 1. Review of Resident 60's SBAR (situation, background, assessment, recommendation) Communication Forms indicated he fell on 7/25/20, 8/10/20 and 8/16/20. Resident 60's MDS dated [DATE] was reviewed. Section J1800 asked the question, Has the resident had any falls since admission/entry or reentry or the prior assessment, whichever is more recent? The person who completed the MDS coded 0, which indicated Resident 60 did not have any falls during the specified time frame. During an interview and concurrent record review with the Minimum Data Set Coordinator (MDSC) on 4/11/22 at 3:01 p.m., the MDSC reviewed Resident 60's medical record and confirmed 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 provide care and services in accordance with professional standards of practice for one of ten residents observed for medication administration (Resident 39) and one of 22 sampled residents (Resident 30), when: 1. For Resident 39, the licensed nurse did not follow the physician's order for the administration of: a. pantoprazole (medication that decreases the amount of acid produced in the stomach); b. vitamin D3 (supplement for building and maintaining healthy bones); and 2. For Resident 30, the licensed nurse did not follow the proper timing of the administration of Amoxicillin (antibiotic used to treat bacterial infections). These failures had the potential to compromise the residents' health and well-being. Findings: 1.a. During the medication pass observation on 4/7/22 at 9:10 a.m. with registered nurse J (RN J), she was observed giving twelve medications including a tablet of pantoprazole, delayed release (DR), 20 milligrams (mg, 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.