Inspire Behavioral Health

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to prevent two of three residents (1 and 2) from elopement when the staff and visitors did not look around to make sure Resident 1 and Resident 2 were not close by in the area when they opened the locked exit door to prevent the residents from exiting the locked door immediately when the door was opened. This failure placed the residents at risk for accident and injury. Findings: Review of Resident 1's admission Record indicated she was admitted to the facility on [DATE] with schizoaffective disorder (a mental health condition that is marked by a mix of seeing things or hearing voices that others don't observe, believing things that are not real, persistent feeling of sadness and loss of interest, and having great excitement and occasionally violent behavior) diagnosis. Review of Resident 1's Risk for Elopement, dated 12/20/23 and 1/7/24, indicated Resident 1 was high risk of elopement. Review of Resident 1's Change in Condition Evaluations, 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 interview and record review, the facility failed to conduct performance review at least once every 12 months for three of three certified nursing assistants (CNA A, CNA B, and CNA C). This failure resulted in unidentified the needed training for the CNAs to improve their skills in resident care every year. Findings: Review of CNA A's personnel file indicated she was hired on 8/14/20, and she did not have the performance review done in the year 2021, 2022, and 2023. During an interview with the director of staff development (DSD) on 9/23/24 at 4:10 p.m., she reviewed CNA A's personnell file and confirmed that CNA A did not have the performance review done in the year 2021, 2022, and 2023. Review of CNA B's and CNA C's personnel files indicated they were hired on 4/15/13 and 8/22/12, and they did not have the performance review done in the year 2021 and 2022. During an interview with the DSD on 9/24/24 at 11:45 a.m., she reviewed CNA B's and CNA C's personnel files and confirmed that CNA B and CNA C did not have the performance review done in the year 2021 and 2022. The DSD…

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 supervision to prevent one out of three sampled residents (Resident 1) from leaving the facility without staff's knowledge and permission. This failure had a potential risk to compromise Resident 1's health and safety, as she was found walking toward the parking lot outside the facility on 8/11/24. Findings: A review of Resident 1's medical record indicated she was admitted to the facility on [DATE] with diagnoses including unspecified schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves). A review of Resident 1's minimum data set (MDS, an assessment tool) dated 6/25/24 indicated his brief interview for mental status (BIMS, cognition level) score was 12 (8 to 12 points suggests moderate cognitive impairment). During an interview with the Program Consultant (PC) on 9/6/24 at 9:13 a.m., the PC stated that she looked through her glass window in her office around 10:46 a.m. and found Resident 1 was walking 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 implement their policies and procedures to report a sexual allegation within the required two hours timeframe to the local law enforcement, the California Department of Public Health (CDPH) and Ombudsman as required for one of three sampled residents (Resident 1); and prevent the recurrence of sexual allegation for of three sampled residents (Resident 2) when: 1. Resident 1 claimed Resident 2 held her breast on 6/18/24. 2. Resident 2 had two sexual assault incidents involving two female residents in a period of one week. The failure to report the sexual allegation within two hours to reporting entities could compromise the welfare, health and safety of Resident 1 and other vulnerable residents; and the failure to prevent recurrence of sexual assaults could potentially put all vulnerable residents at risk. Findings: 1. Review of Resident 1's Situation Background Assessment Recommendation (SBAR, a verbal or written communication 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.

Based on interview, record review, and facility policy, the facility failed to notify the Ombudsman when a resident transferred or discharged from the facility for 3 (Residents #75, #78, and #118) of 3 sampled residents reviewed for hospitalization. Findings included: A facility policy titled, Transfer or Discharge, Emergency, revised in 09/2012, indicated, 1. Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will implement the following procedures: a. Notify the resident's Attending Physician; b. Notify the receiving facility that the transfer is being made; c. Prepare the resident for transfer; d. Prepare a transfer form to send with the resident; e. Notify the representative or other family member; f. Assist in obtaining transportation; and g. Others as appropriate or as necessary. 1. An admission Record revealed the facility admitted Resident #75 on 05/12/2020. According to the admission Record, the resident had a medical history that included a diagnosis of hypertension. Resident #75's Progress Notes,…

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

Based on observation, interview, and facility policy review, the facility failed to staff washed their hands before they applied gloves during the preparation of food. This deficient practice had the potential to affect all residents who received food from the kitchen. Findings included: A facility policy titled, Glove Use Policy, dated 2023, revealed 3. Wash hands when changing to a fresh pair. Gloves must never be used in place of hand washing. On 07/10/2024 at 10:32 AM, Specialist Dining Services Aide (SDSA) #16 answered the locked kitchen door, while he was in the middle of making peanut butter and jelly sandwiches. After SDSA #16 answered the door, he applied a new pair of gloves without washing his hands first, and then continued to make the peanut butter and jelly sandwiches. During an interview on 07/10/2024 at 1:00 PM, SDSA #16 confirmed that he did not wash his hands before he applied a new pair of gloves. SDSA #16 stated he understood handwashing was important to prevent contamination. During an interview on 07/10/2024 at 1:19 PM, the Dining Services Manager stated staff…

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, resident interview, staff interview, and facility policy review, the facility ensure 1 (Station 2 dining room) of 2 dining room provided sufficient space to accommodate all the residents who wished to eat their meals in the dining room. Findings included: An undated facility policy titled, Social Dining, specified, Our recovery-oriented program offers a structured environment designed to assist residents in managing daily living tasks. Social Dining, a key component of this program, is specifically tailored to meet residents' needs in developing and practicing a range of skills. These include, but are not limited to, fairness, patience, courtesy, mood regulation, acceptance of reality, and learning the benefits of orderly conduct like queuing. Residents are given the opportunity to request preferred meals, wait patiently for their meal to be served, appreciate the communal aspect of dining, await their turn for seconds, and manage their emotions when their preferences cannot be met. During an observation of dining on 07/09/2024 at 12:32 PM, it was noted 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.

Based on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurate for 1 (Resident #33) of 1 sampled resident reviewed for respiratory care. Findings included: An admission Record revealed the facility admitted Resident #33 on 07/21/2017. According to the admission Record, the resident had a medical history that included a diagnosis of chronic obstructive pulmonary disease (COPD). Resident #33's care plan, initiated on 01/07/2022, revealed the resident was on oxygen therapy due to decreased oxygen, diagnoses of COPD, acute respiratory failure and a history of COVID-19 and pneumonia. A quarterly MDS, with an Assessment Reference Date (ARD) of 06/27/2024, revealed Resident #33 has a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. The MDS revealed the resident did not receive oxygen therapy. Resident #33's Order Summary Report with active orders as of 07/02/2024, revealed an order dated 11/29/2018, that directed the staff to monitor the resident's…

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

Based on interview and record review, the facility failed to provide trauma-informed care to 1 (Resident #67) of 1 sampled resident reviewed for behavior-emotional, with a diagnosis of post-traumatic stress disorder. Findings included: An admission Record revealed the facility admitted Resident #67 on 06/01/2022. According to the admission Record, the resident had a medical history that included diagnoses of schizoaffective disorder, post-traumatic stress disorder (PTSD), mood disorder due to a known physiological condition, and depression. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/08/2024, revealed Resident #67 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. Resident #67's care plan, initiated on 06/02/2022 revealed the resident was at risk for impaired cognitive status related to diagnoses of schizoaffective disorder, depression, mood disorder, and PTSD. Interventions initiated on 06/02/2022, directed staff to assist in activities of daily living (ADLs) as needed; assure 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.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure staff documented the administration of medications for 1 (Resident #35) of 5 residents observed for medication administration. Findings included: An undated facility policy titled, Specific Facility Medication Administration Procedure for [facility name], indicated Policy To administer medications in safe and effective manner. The policy specified, 3. Licensed Nurse who prepared the medication shall administer medication and document administration accordingly. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/17/2024, revealed the facility admitted Resident #35 on 10/12/2023. The MDS revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. Resident #35's Order Summary Report, with active orders as of 07/11/2024, revealed an order dated 01/06/2021, for benztropine mesylate tablet 0.5 milligram by mouth one time a day. During medication administration 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.

Based on observation, interview, and facility policy review, the facility failed to soak soiled linen in a machine or sink as directed by their policy for 1 of 116 residents who resided in the facility. Findings included: An undated facility policy titled, Sorting, Washing, and Drying, revealed 8. Soak kitchen linen, towels, aprons, etc. [et cetera, and other similar things], in machine or sink using a degreasing presoak or detergent for at least an hour to remove grease and stains prior to washing. During a concurrent observation and interview on 07/10/2024 at 10:11 AM, outside of the laundry exit, there were two buckets filled with a liquid and clothing that was covered with a trash bag. The Laundry Aid stated the clothes in the bucket were from 07/09/2024 and they belonged to a resident who had heavily soiled their pants and the staff allowed the items to soak. During an interview on 07/10/2024 at 10:20 AM, the interim Laundry Manager stated the soiled items should have been washed. During an interview on 07/11/2024 at 11:21 AM, the Administrator stated he expected staff to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and facility document review, the facility failed to ensure the registered dietitian comprehensively carried out the functions and evaluated the effectiveness of Food and Nutrition Services as evidenced by: 1. Lapses in the delivery of services associated with: staff competency (cross-reference F802), following the menu (cross-reference F803), accommodating resident food preferences (cross-reference F806), food safety and sanitation (cross-reference F812), providing physician prescribed nutrition supplements (cross reference F692), 2. A lack of a full-time supervisor in the kitchen in August 2021 and September 2021, 3. Resident 85 's Nutritional Assessments were not completed. 4. Resident 3's and Resident 9's Nutritional Assessments were not completed. Failure to ensure dietetic services systems are accurately and effectively delivered may result in compromising the nutritional status of the residents by not assessing their nutritional needs, the potential transmission of…

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

Based on observation, interview, and facility document review, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food safety when: 1. An ice machine was not kept in a sanitary condition, 2. The handwashing sink in the kitchen did not have hot water, 3. Multiple food service pans and equipment were stored wet, 4. One staff washed hands in the dishwashing sink on the dirty side of the dish machine, 5. Multiple expired items were stored in the kitchen refrigerators, 6. The meat slicer was stored dirty, and 7. The plates of hot food for the lunch meal were not covered during delivery. These failures had the potential to cause cross-contamination of food cross-contamination occurs when unclean surfaces or utensils spread germs to food and can potentially cause foodborne illness), the growth of microorganisms, and foodborne illness for the 113 residents eating at the facility. Findings: 1. During an observation and concurrent interview on 11/3/21 starting at 8:47 a.m. of the ice machine (Brand A) outside the…

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

Based on observation, interview and record review, the facility failed to ensure accurate medication administration in accordance with standards of practice, when registered nurses prepared medications ahead of the scheduled time. This failure had the potential to resultin an increased risk of medication error. Findings: During concurrent observation and interview on 11/02/21, at 4:24 p.m., RN W prepared medications ahead of scheduled time for 9:00 p.m. She stated the eMAR would not allow her to click Yes (it was given) at this time because the medications for 9:00 p.m. were not yet due to give. It will only allow to click Yes (it was given) in the EMR one hour before and one hour after the scheduled administration times. During observation on 11/02/21 at 4:38 p.m., there were several medicine cups containing prepared meds ahead of time that did not have drug label found inside the drawer of medication cart. Each of the medicine cups had a piece of paper underneath with the residents' names written. The following were noted: During interview with RN W, on 11/02/21 at 5:00 p.m., RN W…

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 residents were free of unnecessary drugs for four residents reviewed, when: 1. There was a duplicate of Resident 32's target behavior symptoms indicated for use of Haldol (antipsychotic), which was prescribed in two different routes of administration. 2. For Resident 266, there was no monitoring for adverse consequences for the use of Risperidone (antipsychotic) and Lorazepam (anti-anxiety). 3. There was no target behavior for Resident 267's use of Invega (antipsychotic). 4. For Resident 46, there was no specific target behavior indicated for use of chlorpromazine hydrochloride (antipsychotic medication) and thiothixene (antipsychotic medication). These posed the risk to negatively impact the residents due to the medication adverse reactions. Findings: 1. During review of Resident 32's physician order dated 11/2021, indicated Haloperidol 10 mg by mouth two times a day manifested by (m/b) responding to internal stimuli and non-factual statement…

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, staff interview, and facility document review, the facility failed to ensure the planned menu was followed for 16 out of 16 residents (Residents: 48, 75, 73, 39, 9, 76, 80, 57, 68, 11, 109, 35, 104, 36, 92, 81) on Regular Mechanical Soft texture diets. This failure had the potential to result in not meeting the nutritional needs thus further compromising the nutritional status of the residents. Findings: Review of the facility menu titled Fall Menus for Week 1 Tuesday 11/2/21 indicated for the Regular Mechanical Soft diet, the following items: Baked Chicken with [NAME] Sauce Grd (ground) #10 (3/8 cup), Boiled Red Potatoes Soft ½ c (cup), Seasoned Peas Soft ½ c. During an observation of the lunch meal service on 11/2/21 starting at 12:09 p.m., a green scoop was in the mechanical soft chicken. During a concurrent interview with FSW K at this time, she confirmed the green scoop was for serving the mechanical soft chicken and it was a #12 (1/3 cup) scoop. FSW K placed a #12 scoop of mechanical soft chicken, a #8 (1/2 cup) mashed potatoes, and 4 ounces (1/2 cup) of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the food preferences for five (Residents 48, 62, 81, 113, and 10) of 32 residents were followed, when these five residents did not receive their choice of foods they liked, or received food they did not like. This failure infringed on residents' choices and had the potential to adversely affect the psychosocial well-being of the residents. 1. During an observation on 11/01/2021 at 12:46 p.m. in Resident 48's room of her lunch tray, there was beef on her lunch tray which she did not eat. During an interview on 11/01/21 at 12:48 p.m. with certified nursing assistant H (CNA H), CNA H stated Resident 48 does not like beef. She received beef, and was not eating it. Resident 48's meal ticket hd beef as her dislike. During an interview on 11/01/21 at 12:56 p.m. with CNA H, CNA H stated she was not sure why the resident received beef, since it's on the card as dislike. I need to check when I bring in the tray. During an interview 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.

Based on observation, interview and record review, the facility failed to maintain effective infection control practices, when: 1. For six of 12 residents observed during the medication pass administration, the facility staff did not sanitize the surface area in the nursing station with disinfecting wipes, after each resident had received their medication. 2. For Resident 72, the licensed nurse did not replace the two medications that dropped on to the unsanitized counter surface area. Resident 72 took it by his mouth after he picked it up with his bare hand. 3. The meal cart was left open in the hallway while delivering meals, and 4. Two CNA T and CNA U did not perform hand hygiene between each meal tray delivered to residents' rooms. These failures had the potential to place residents at increased risk of healthcare-associated infection. Findings: 1. During medication pass observation on 11/02/21 at 9:15 a.m., the facility staff did not sanitize the counter surface area in nursing station Y, with disinfecting wipes, every after each resident had received their medication. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to offer to one of 23 sampled residents (Resident 83) a bedside table to use during meals. This failure prevented Resident 83 from eating her meals safely and properly. Findings: Review of Resident 83's clinical record indicated the resident was admitted on [DATE] and had diagnosis of Paranoid Schizophrenia (mental illness characterized by delusions and hallucinations), acute cholecystitis (swelling of the gallbladder), major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). Review of Resident 83's current Minimum Data Set (MDS, an assessment tool) indicated Brief Interview for Mental Status (BIMS) score of 9, which indicates moderate cognitive impairment. During an observation and interview on 11/1/2021, at 12:20 p.m., the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain a clean, safe, and sanitary homelike environment for two of 23 sampled residents (Resident 81 and, Resident 113) when the facility shower rooms drainage was not working properly and clogged. This failure had the potential to place the residents in an unsafe and unsanitary environment. Findings: 1. Review of Resident 81's clinical record indicated she had diagnoses of diabetes (increase blood sugar), heart disease, and hypertension (increased blood pressure). Review of Resident 81's minimum data set (MDS, an assessment tool) dated 9/9/21, indicated Resident 81 was cognitively intact, required staff to set-up for bathing, eating, and personal hygiene. During a resident council meeting on 11/2/21 at 2:03 p.m., Resident 81 stated the shower room drainage was clogged. During an interview with Resident 81 on 11/3/21 at 12:54 p.m., she stated the shower room drainage was clogged and she would slip on the floor. 2. 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.

Based on observation, interview and record review, the facility failed to keep corrosive cleaning supplies out of the reach of two of ten ambulatory residents (Residents 47 and 72). This failure had the potential to place residents at a safety risk. Findings: During observation on 11/03/21 at 03:39 p.m. , there was a solution container labeled bleach (corrosive cleaning supply to whiten by chemical) found in the sink of a residents' room. During interview with registered nurse (RN I) on 11/03/21 at 03:45 .p.m., RN I stated it poses a safety risk because residents might ingest it accidentally. The housekeeper should not have left it there. The facility's undated policy and procedure titled Safety First, did not indicate measures on the safekeeping of corrosive cleaning supplies out of the reach of ambulatory residents.

Based on interview and record review, the facility failed to follow the policy and procedure for incontinence management for two sampled residents (Resident 85 and Resident 17) when the residents bowel and bladder (B&B, to manage urinary incontinence, restore, improve, and maintain the normal bladder function) program was not implemented. This deficient practice had the potential to cause a decline in B&B control. Findings: 1. Review of Resident 85's clinical record indicated she had diagnoses of diabetes (increase blood sugar), hypertension (increased blood pressure), and hypothyroidism (a condition in which the thyroid gland does not produce enough of certain crucial hormones). Review of Resident 85's bowel and bladder evaluation dated 1/8/21, indicated Resident 85 was incontinent of both bowel and bladder. Resident 85's bowel and bladder program was to provide a retraining treatment. Review of Resident 85's documentation survey report dated 1/2021, indicated the B&B was documented every shift. There was no documented evidence Resident 85 had a B&B retraining program. During an…

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

Based on interview and facility document review, the facility failed to provide physician ordered nutrition supplements (products that are used to complement a resident's dietary needs, a high calorie drink in this case) for one resident (Resident 62) with a history of weight loss. This failure had the potential to cause further weight loss and decline in health status. Findings: Review of the facility document titled Order Summary Report for Resident 62, dated 11/5/21, indicated under Dietary supplements 2 Cal (calorie) Supplement 60 cc (cubic centimeter, a measurement of volume) two times a day for supplement with an order date and start date of 4/1/2020 and House supplement two times a day 4 oz (ounce) house supplement with an order date and start date of 6/14/21. During an interview with certified nursing assistant V (CNA V) on 11/4/21 starting at 11:00 a.m., CNA V stated the kitchen did not bring the nutrition supplement for Resident 62 that morning which usually comes at 9-9:30 a.m. CNA V stated Resident 62 usually gets one milkshake in the morning and did not know if she gets…

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 evaluate level of pain numeric scale for one (Resident 5) of three residents reviewed for pain, prior to giving pain medication as needed. This failure had the potential for residents to not receive effective treatment for their pain. Findings: Review of Resident 5's clinical record revealed, Resident 5 was admitted on [DATE], with diagnoses included schizoaffective disorder (mood depression), hypertension (high blood pressure) and epilepsy (seizure disorder). Review of Resident 5's MDS dated [DATE], indicated Resident 5 was cognitively intact and independent during activies of dsaily living (ADL). During observation with registered nurse J (RN J) during medication administration, on 11/02/21 at 08:55 am , RN J administered two tablets of Ibuprofen 200 mg each with Resident 5. RN J did not ask for the pain score prior to giving the pain medication. During interview with RN J, at 11:58 a.m., RN J stated she forgot to ask. RN J further…

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 store all drugs and biologicals appropriately, when: 1. There was an expired emergency kit found in the medication room, which had the potential to result in ineffective drug regimen, when administered to residents. 2. A box of dulcolax (laxative to treat constipation) suppository (inserted into the rectum, vagina, or urethra) was found mixed with oral over-the-counter medications, These failure had the potential to result in an increased risk of medication errors. Findings: 1. During observation on [DATE] at 01:48 p.m. , in the medication room in Nursing Station Y, the emergency kit stored in an unlocked cabinet had an expiration date of 10/21. A box of lorazepam 0.5 mg tab contained eight tablets and a box of temazepam (Restoril) 7.5 mg/cap with four capsules had an expiration date of 10/21. During interview with licensing vocational nurse X (LVN X) on [DATE] at 1:50 pm, LVN X stated no one followed-up for replacement. During 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.

Based on observation, interview, and facility document review, the facility failed to ensure two kitchen staff had appropriate competencies when: 1. One kitchen staff did not follow recipes for the puree diet (a diet for people who have difficulty chewing and/or swallowing), and did not know the correct cool down procedure for cooling hot Time/Temperature Control for Safety Food (TCS foods that require time/temperature control for safety to limit pathogen growth or toxin formation), and 2. One kitchen staff did not properly sanitize dishware. These failures had the potential to place the 113 residents who received food prepared in the kitchen at risk for food borne illness or to not meet their nutritional needs. Findings: 1a. During a concurrent observation and interview in the kitchen on 11/2/21 at 11:17 a.m., Food Service Worker K (FSW K) was preparing the puree baked chicken, seasoned peas, and cornbread for the one resident on a puree diet. She placed, and confirmed, one #8 scoop (1/2 cup) of chopped chicken and added two #8 (1/2 cup) scoops of hot water in the food processor…

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 appropriate use of antibiotic (medication for the infection) were properly documented based on the facility policy for one sampled resident and two non-sampled residents (Resident 10, 25 and 87). This failure had the potential for the residents to take unnecessary antibiotics which could lead to resistance to the antibiotics. Findings: Review of the facility Infection Prevention and Control Surveillance Log, indicated Resident 10, Resident 25, and Resident 87 had received antibiotics for the months of June 2021 and July 2021. There was no documented evidence related how the residents meet the criteria for infection, culture and sensitivity of antibiotics. During an interview with the infection preventionist (IP) on 11/5/21 at 10:16 a.m., she confirmed Resident 10, Resident 25, and Resident 87 had received antibiotics. IP also stated she needed to develop a process regarding the appropriate use of antibiotics to reduce the adverse effect of the medications. Review of the facility's undated policy, Antibiotic…

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.