Mission De La Casa

Based on interview and record review the facility failed to follow its Policy & Procedure (P&P) titled, Dignity and Respect Psychoactive Medications, dated 2025, for one of 30 sampled residents (Resident 15), when the facility failed to monitor Resident 15 for behaviors related to her diagnosed mental illness. This failure had the potential for Resident 15's behavior related to a diagnosed mental illness to go unnoticed by staff, contributing to a potential in psychosocial harm to Resident 15.Findings:During a review of Resident 15's facesheet (one-page summary of a patient's key information within their medical record), dated 8/14/25, the facesheet indicated a diagnosis of Schizophrenia (a chronic mental health condition that affects how a person thinks, feels, and behaves), dated 2/9/23.During a concurrent interview and record review with the Director of Nursing (DON) on 8/15/25 at 3:56 p.m., Resident 15's physician orders indicated no order for behavioral monitoring. DON stated, Resident 15 should have an order for behavioral monitoring, since she has a diagnosed mental…

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 have a system for physician prescribed fortified diets (a diet with added nutrients, such as calories and protein, to increase the nutritional value of the diet, especially for individuals with or at risk for weight loss and/or malnutrition). This failure had the potential to result in weight loss and or further complicate medical conditions for 1 sampled resident (Resident 3) who was on a physician prescribed fortified diet. Findings:Review of Resident 3's electronic medical record showed Resident 3 was initially admitted on [DATE] and had diagnoses including but not limited to a stage 4 pressure ulcer (most severe stage of a pressure ulcer, characterized by full-thickness skin tissue loss, with exposed bone, tendon, or muscle).Review of Resident 3's electronic medical record showed in the Order Summary Report, Fortified diet Minced & Moist. ordered on 6/15/25. During an observation of trayline lunch service (a food assembly system,…

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 lunch menus were followed on 08/11/2025 as evidenced by:Resident 163 received a mixed fruit cup instead of 1 fresh apple as indicated on the menu.Resident 143 received tarter sauce when it was not indicated on the menu.These deficiencies had the potential to compromise the medical and nutritional status of Residents 163 out of 143.Findings:1. Resident 163 received a mixed fruit cup instead of 1 fresh apple as indicated on the menu.During a concurrent observation, interview, and record review on 08/11/2025 at 12:01 PM with Diet Aide K (DA K) in the kitchen during lunchtime tray line, lunch tray for Resident 163 showed a mixed fruit cup that included cubes of melons and peaches. DA K was asked if the mixed fruit cup was appropriate for Resident 163's lunch tray and DA K stated the mixed fruit cup was appropriate. DA K was asked to verify that the mixed fruit cup was appropriate using diet menu spreadsheet for Monday 08/11/2025, and after reviewing the spreadsheet, DA K removed a pink colored juice from…

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 a dryer's lint filter compartment and lint trap cleaning log were routinely maintained. The facility's documentation indicated laundry staff did not clean the dryer lint for several hours on multiple days. This failure had the potential to for an excess accumulation of lint that could catch on fire. Findings:During a concurrent observation and interview with the environmental director (ED) in linen room on 8/19/25 at 8:25 a.m., one of the clothes dryer's lint compartment (an area of the clothes dryer designed to catch lint and debris from clothing and linen as they are tumble dried) contained laundry lint fibers from the tumble drying of clothing and linen. The ED stated lint traps were supposed to be cleaned every two hours. During an interview and concurrent record review with the ED on 8/19/25, at 9:03 a.m., the ED reviewed the facility's laundry lint trap cleaning log. The laundry lint trap cleaning log was missing signatures on 8/1/25 at 10:00 p.m., 8/7/25 at 3:00 p.m., 8/9/25 at 1:00 p.m., 7:00…

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.

Based on observation, interview, and record review, the facility failed to ensure the kitchen was free from flies. This failure had the potential to compromise food safety and increase the risk of foodborne illness for 144 of the 151 residents who consumed meals prepared in the facility's kitchen.Findings:During an observation on 08/11/2025 at 10:02 AM in the kitchen, multiple flies were observed throughout the kitchen area.During an interview on 08/12/2025 at 9:49 AM with [NAME] B, [NAME] B confirmed the presence of flies and added that the flies have been seen around the kitchen for 1 week.During an observation on 08/12/2025 at 10:15 AM in the kitchen, a fly was observed landing on a can of spray used for coating pans. Another fly was seen landing on the foil covering a pan containing a pureed entree. Additionally, a third fly was observed flying around a pan of cake.During an interview on 08/12/2025 at 11:16 AM with Assistant Dietary Supervisor (ADS), the ADS reported the presence of flies in the kitchen to the Environmental Director (ED) on 08/06/2025, and the ED subsequently…

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 sanitize the food thermometer between measuring the temperatures of different food items. This had the potential to affect 138 of 138 residents who received food from the dietary department. Findings included: A facility policy titled, Safe Food Preparation, revised in March 2023, revealed, Cross-Contamination 2. Cross-contamination can occur when harmful substances, i.e. [id est, such as] chemical or disease-causing microorganisms are transferred to food by hands, (including gloved hands), food contact surfaces, sponges, cloth towels, or utensils that are not adequately cleaned. 3. Examples of ways to reduce cross-contamination include, but are not limited to: d. Clean and sanitize work surfaces, including cutting-boards and food-contact equipment (e.g. [exempli gratia, for example] food processors, blenders, preparation tables, knife blades, can openers, and slicers), between uses and consistent with applicable code. A facility policy titled, Food Temperatures, revised on 03/19/2020, revealed, 1.…

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. An admission Record revealed the facility admitted Resident #67 on 03/31/2023. According to the admission Record, the resident had a medical history that included diagnoses of major depressive disorder (11/04/2018) and post-traumatic stress disorder (PTSD) (onset date 11/05/2018). Resident #67's Level I PASARR, dated 03/31/2023, revealed the resident was diagnosed with major depressive disorder; however, the resident's diagnosis of PTSD was not reflected. The Level I PASARR was Positive, due to a suspected MI [mental illness]. A letter from the Department of Health Care Services to the facility, dated 04/12/2023, indicated the Level II evaluation was not completed because the resident had no serious mental illness (SMI). The letter indicated the case was closed. During an interview on 06/26/2024 at 12:20 PM, Registered Nurse (RN) #3 stated she was responsible for ensuring the Level I PASARR was completed for new admissions. RN #3 stated the hospital initiated the PASARR, and she checked them for accuracy. RN #3 stated Resident #67's diagnosis of PTSD should be reflected on their…

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, record review, interview, and facility policy review, the facility failed to ensure the medication error rate was five percent (%) or less. Medication administration observations revealed 2 medication errors out of 25 total opportunities, resulting in a medication error rate of 8%, affecting 2 (Resident #137 and Resident #105) out of 5 residents observed during medication administration. Findings included: A facility policy titled, Administering Medications, revised in March 2023, revealed, 3. Medications must be administered in accordance with the orders. The policy further revealed, 8. The licensed nurse must check the label three (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. An admission Record revealed the facility admitted Resident #137 on 01/02/2024. According to the admission Record, the resident had a medical history that included a diagnosis of depression. Resident #137's Order Summary Report, listing active orders as of 06/25/2024, contained…

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 for ensuring the reporting of injuries of unknown source for one of two sampled residents (1) to other officials (including to the California Department Public Health (CDPH) and adult protective services (APS) where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures after when Resident 1 sustained a subdural hemorrhage (is a kind of intracranial hemorrhage, which is the bleeding in the area between the brain and the skull) with multiple rib fractures on 2/19/24 and transferred to an acute hospital for intensive care unit (ICU, provides the critical care and life support for actually ill and injured patients) monitoring and management, and facility's investigation did not identify the reason or cause of Resident 1's injuries. Failure to report alleged violations to the proper authorities could compromise the protection 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 infection control practices were implemented when: 1. Licensed vocational nurse L (LVN L) did not wear face mask properly while in the nurses station with other staff; 2. A certified nursing assistant was wearing a disposable face mask underneath another disposable facemask; 3. Clean linen in the hallway was not covered; 4. Gloves were worn in the hallway; 5. Housekeeping staff did not properly wear a face mask; 6. Resident 119 was not monitored daily for signs and symptoms of COVID 19 (corona virus disease 19; a highly contagious respiratory disease); 7. Activity assistant did not wear face mask properly; 8. Certified nursing assistant did not wear face mask properly; and 9. Certified nursing assistant did not provide hand hygene after care. These failures could result in the spread of infection and cross-contamination that could affect the 119 residents that reside in the facility. Findings: 1. During a concurrent observation 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 residents' privacy, dignity and respect for three of 24 sampled residents (Residents 48, 47 and 99) when: 1. The activity aid (ACA) was standing in front of Resident 48 while assisting the resident in the hallway with the lunch meal. 2. Resident 47 was using the bathroom and the door was left opened. 3. During GT administration observation Resident 99's room door was open, and her abdomen was exposed to public view in the hallway. These failures had the potential to affect Resident 48 47 and 99's self-esteem and self-worth. Findings: 1. During multiple observations on 7/6/21 at 12:15 p.m., 12:30 p.m., 12:40p.m., and 12:51 p.m., the ACA was standing in front of Resident 48 while assisting the resident with her lunch meal. During a concurrent observation and interview on 7/6/21 at 12:51 p.m., with ACA, he confirmed the above observations and stated that he should have been sitting while assisting Resident 48 with her meal. 2. During an observation on 7/6/21 at 10:27 a.m., certified nursing assistant N…

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 needs were accommodated for five of 24 sampled residents (Residents 99, 52, 119, 114, 122) when call light devices were not within reach of the residents. This failure had the potential for a delayed response and not meeting the resident's needs. Findings: 1. Review of Resident 99's clinical record indicated she was admitted to the facility on [DATE] with diagnoses including hemiplegia (loss of muscle function of one side of the body) hemiparesis (partial weakness of one side of the body) affecting the right dominant side During an observation of Resident 99's room on 7/6/21 at 9:50 a.m., Resident 99 was in bed and her call light was on the floor. Resident 99 was moving her hand but was not able to reach the call light. During a concurrent observation and interview with licensed vocational nurse F (LVN F) on 7/6/21 at 9:52 a.m., she confirmed the above observation and stated Resident 99 could not reach the call light that was on 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 an observation, interview and record review, the facility failed to complete a significant change in status assessment (SCSA) in minimum data set (MDS, an assessment tool) for one of 24 sampled residents (Resident 61). The resident had declined in activities of daily living (ADL, daily self-care tasks, e.g., bathing, toileting, and transferring), balance during transition and walking, and declined in bowel and bladder continence. These failures had the potential to result in Resident 61 being unable to achieve or maintain optimal status of health, function and quality of life. Findings: Review of Resident 61's face sheet (summary page of a patient's important information) indicated he was admitted to the facility on [DATE] with diagnoses including dysphagia (difficulty swallowing), major depressive disorder (mood disorder that interferes with daily life), dementia with behavioral disturbance (decline in mental capacity affecting daily function) and Alzheimer's disease (progressive disease that destroys…

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 Review of Resident 47's clinical record indicated she was admitted on [DATE] with diagnosis including schizoaffective disorder (mental disorder including schizophrenia [serious mental disorder in which people cannot distinguish reality] and mood disorder), dementia (memory loss). Further review of Resident 47's clinical record, there was no PASARR documentation found. During an interview with the regional consultant (RC) on 7/8/21 at 10:07 a.m., the RC stated the facility could not find the PASARR. During an interview with the assistant director of nursing (ADON) on 7/8/21 at 11:29 a.m., the ADON stated she could not find Resident 47's completed PASARR. During an interview with the medical records director (MRD) on 7/8/21 at 2:14 p.m., the MRD stated he could not find Resident 47's PASARR. During an interview with the ADON on 7/9/21 at 11:18 a.m., the ADON could not provide a completed PASARR and stated Resident 47's PASSAR should have been done. Review of the facility's undated policy, PASRR indicated 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 5. During observation and concurrent interview with RN G, on 7/6/21 at 8:15 a.m., RN G was observed preparing medications for Resident 84. As RN G withdrew Dutasteride (medication for urine retention), the capsule still containing medication fell to the floor. RN G administered to Resident 84 what she withdrew from the capsule. Further examination of the capsule that fell on the floor indicated medication was left in the capsule. RN G confirmed this observation and confirmed the Resident 84 received a partial dose. Review of Resident 84's physician orders, dated 6/18/19, indicated the order was for Dutasteride capsule 0.5 mg by mouth once daily. During an interview with the director of nursing (DON), on 7/7/21 at 10:25 a.m., the DON stated RN G should not have given a partial dose to Resident 84. The DON stated RN G should have discarded the medication she withdrew and given Resident 84 the full dose the physician ordered. Review of the facility's policy, Medication Administration, revised 6/1/2020, 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 observation, interview, and record review, the facility failed to provide showers for one of 24 sampled residents (Resident 88) when the resident was unable to carry out showers independently. This failure had the potential to negatively affect the resident's physical and psychosocial well-being. Findings: Review of Resident 88's clinical record indicated she was admitted [DATE] with diagnoses including urinary tract infection (infection in any part of urinary system), diabetes (increased blood sugar), and peripheral vascular disease (PVD, circulatory problem in which narrowed blood vessels and reduce blood flow). Review of Resident 88's minimum data set (MDS, an assessment tool) dated 6/11/21, indicated Resident 88 was moderately impaired in cognition, required staff assistance for bed mobility, transfer, toileting, and personal hygiene. The MDS also indicated bathing did not occur the entire 7 day look back period. During an observation and interview with Resident 88 on 7/6/21 at 9:50 a.m., Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to initiate new intervention on a fall care plan for a resident with multiple falls, revise, update an individualized and comprehensive person-centered fall care plan and person-centered interventions for three of 24 sampled residents (Residents 32, 61 and 16.) This failure had the potential to put the resident at risk of sustaining injuries and had the potential to result in not meeting the resident's needs. Findings: 1. During a record review of Resident 32's care plans for her five falls, one of the care plans did not have a new intervention to decrease her chance of falling. The care plan initiated on 12/12/2020 indicated an intervention to reinforce staff to frequently check the resident for safety. The care plan initiated on 12/14/2020 indicated an intervention to reinforce staff to monitor the resident closely for safety. During an interview with licensed vocational nurse F (LVN F) on 7/12/21 at 1:33 p.m., LVN F stated 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 implement the policy and procedure for continence management for one of 24 sampled residents (Resident 88) when the resident was not properly assessed for bowel and bladder (B&B) training. This deficient practice had the potential to cause a decline in B&B control. Findings: Review of Resident 88's clinical record indicated she was admitted [DATE] with diagnoses including urinary tract infection (infection in any part of urinary system), diabetes (increased blood sugar), and peripheral vascular disease (PVD, circulatory problem in which narrowed blood vessels and reduce blood flow) Review of Resident 88's minimum data set (MDS, an assessment tool) dated 6/11/21, indicated Resident 88 was moderately impaired in cognition, required staff assistance for bed mobility, transfer, toileting, and personal hygiene. Review of Resident 88's nursing bowel and bladder assessment dated [DATE], indicated Resident 88 was continent and the recommendation was to assist…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide dialysis services consistently with professional standards and to ensure staff had coordinated residents' care with the dialysis center for one of five sampled residents (Resident 53) receiving hemodialysis (medical procedure to remove fluid and waste products from the blood and to correct electrolyte, i.e., salts and mineral imbalances by using a machine and an artificial kidney) when: 1. Communication with the dialysis center was not properly coordinated when dialysis communication records (DCR) were not completed; 2. Inaccurate access site information and communication with the facility to dialysis center; 3. There was no emergency dialysis kit available in the unit; and 4. The dialysis care plan was not resident- person centered. These failures may affect the quality of dialysis care being provided to the residents. Findings: 1. Review of Resident 53's clinical record indicated she was admitted to the facility on [DATE] with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to properly store medication when: 1. One of two medication refrigerators were not within the facility's acceptable temperature range of 36 to 36 degrees Fahrenheit (F); 2. A&D ointments were found at Resident 41 and Resident 43's bedside tables. These failures had the potential for medications to lose their potency and effectiveness when administered to the residents. Findings: 1. Record review of the Temperature Log, on 7/6/21 at 12:31 p.m., for the medication refrigerator in medications room one indicated for the month of May 21 the temperature written on the log was out of range eight times. The form indicated the acceptable range was 36 to 46 degrees Fahrenheit (F) and if outside the range to call maintenance. During observation, interview, and concurrent record review with Unit Manager B (UM B), on 7/6/21 at 12:32 p.m., the UM B confirmed refrigerator temperatures were to be checked by staff twice daily and confirmed medications…

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

Based on observation, interview, and record review, the facility failed to ensure the kitchen staff are aware of the process to measure the sanitizer level of the dishwasher, when cook E (KC E) did not dip the test strip in the sanitizer water for the directed length of time. This failure had the potential to cause food-borne illness in the already immune compromised residents. Findings: During an observation and concurrent interview on 7/07/21 at 1:55 p.m., KC E dipped the chlorine test paper in the water of the dishwasher, which contained the chlorine sanitizer, for approximately three seconds, then took it out and compared the color to the insert of the strip container. KC E stated she had the test strip in the water for longer than three seconds. During a review of the direction insert of the test strip container on 7/07/21 at 1:57 p.m., the directions indicated to dip the strip into the solution to be tested, without agitation and compare immediately with the color chart on the label. The directions also indicated Time of Test - one second.

Based on observation, interview, and record review, the facility failed to properly store food for one of 24 sampled residents (Resident 74) when a family member brought food from home and the resident did not consume it within one (1) hour after receiving it. This failure had the potential to lead to food-borne illness (an illness caused by food contaminated with bacteria, viruses, parasites, or toxins) and could compromise the medical condition of the resident. Findings: Review of Resident 74's clinical record indicated she had diagnoses including diabetes (increased blood sugar), hypertension (increased blood pressure), dysphagia (difficulty in swallowing) and hyperlipidemia (an abnormal high concentration of fats and lipids in the blood). Review of Resident 74's physician order dated 5/31/21, indicated Resident 74 was on CCHO (controlled carbohydrate) and NAS (no added salt) diet. During an observation and interview with the resident on 7/6/21 at 11:58 a.m., Resident 74 was observed eating food from home and she stated she would also eat the food for dinner. Resident 74 stated…

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 appropriate use of antibiotic (medication for the infection) for one of 24 sampled residents (Resident 66). This failure had the potential for the resident to take unnecessary antibiotics which could lead to resistance to the antibiotic. Findings: Review of Resident 66's clinical record indicated he was admitted on [DATE] with diagnoses including hemiplegia (paralysis of one side of the body), dementia (memory problem), hypertension (increased blood pressure), and a history of falling. Review of Resident 66's surveillance data collection form for urinary tract infection dated 7/1/21, indicated Resident 66 was on Amoxicillin 500 milligrams every eight hours for 10 days. It also indicated Resident 66 had a urine culture on 6/28/21 with invalid results and the criteria for urinary tract infection was not met for the antibiotic. During an interview with the infection preventionist (IP) on 7/721 at 2:26 p.m., she confirmed Resident 66 was 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.