San Jose Healthcare & Wellness Center

Based on observation, interview and record review, the facility failed to store and label medications and biologicals according to manufacturer instructions and facility policy. These failures had the potential for residents to receive incorrect or unsafe medications. Findings: During an observation on 3/4/25, at 3:50 p.m., in Station 2, while inspecting the medication cart with Registered Nurse E (RN E), the following issues were identified: 1. One unopened bottle of Latanoprost eye drops (a medication used to treat glaucoma, which is increased pressure inside the eye) for Resident 3 was found in the top drawer of the medication cart. The pharmacy label indicated that it should be refrigerated until opened, it was not stored in the refrigerator. 2. An inhaler Breo Ellipta (an inhaled medication to treat breathing problems) for Resident 15 was opened but did not have an open date indicated on the label. 3. One unopened Humalog (a fast-acting insulin used to control blood sugar) insulin vial (a small glass or plastic bottles used to store liquids, or powder medication) for 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 explain the arbitration agreement (a contract requires that person who signed it resolve disputes by a neutral third party, rather than in court before a judge and/or jury) which Resident 23 and Resident 31 signed during their admission to the facility. This failure resulted in Resident 23 and Resident 31 signing the facility's arbitration agreement without their full understanding of the same. Findings: Review of Resident 23's clinical record indicated he was admitted to the facility on [DATE], and he signed the facility's arbitration agreement on 1/20/25. Review of Resident 23's Minimum Data Set (MDS, a clinical assessment tool), dated 1/9/25, indicated his cognition was intact. Review of Resident 31's clinical record indicated she was admitted to the facility on [DATE], and she signed the facility's arbitration agreement on 1/22/25. Review of Resident 31's MDS, dated [DATE], indicated her cognition was intact. During an interview with Resident 23,…

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 one (Resident 14) out of 14 sampled residents was free from abuse when staff shouted at and did not acknowledge Resident 14's statement for hunger. This failure had the potential to impact the physical and mental well-being of the resident. Findings: A review of Resident 14's clinical record indicated admission date of 6/8/2021 with diagnoses including Unspecified Dementia [decline in mental abilities, like memory, thinking, and reasoning], Type 2 Diabetes Mellitus [a condition where the body either does not make enough insulin or cannot use insulin properly, leading to high blood sugar levels] with diabetic chronic kidney disease [occurs when high blood sugar levels from diabetes damage the kidneys' ability to filter waste and excess fluid] and, Major Depressive Disorder [a mood disorder that causes a persistent feeling of sadness and loss of interest]. A review of Resident 14's Minimum Data Set (MDS, an assessment tool), dated 2/4/25, indicated a brief interview for mental status score of 12 [BIMS, a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three residents (Resident 1) received medications as ordered by the physician. This failure had the potential to compromise the resident's health and well-being. Findings: Review of Resident 1's medical record indicated she was admitted on [DATE] and had diagnoses including cellulitis (a type of skin infection) and other disorders of the skin and subcutaneous tissue (the deepest layer of skin). Review of Resident 1's Order Summary Report indicated she had physician orders, dated 8/3/24, for the following medications: 1. Cleocin-T External Lotion (antibiotic lotion used to treat infection) 1% (unit of dose measurement) apply to affected areas topically (to the skin) two times a day for infection; 2. Mupirocin External Ointment (medication used to treat infection) 2% apply to affected area topically three times a day for infected skin; 3. Diclofenac Sodium External Gel (medication used to treat pain) 1% apply to affected area topically four…

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 medical record was complete and accurate for one of three sampled residents (Resident 1) when there was no documentation that the nurse notified Resident 1's physician of multiple medications that were not administered. This failure had the potential to compromise the facility's ability to track and communicate care relevant to Resident 1. Findings: Review of Resident 1's medical record indicated she was admitted on [DATE] and had diagnoses including cellulitis (a type of skin infection) and other disorders of the skin and subcutaneous tissue (the deepest layer of skin). Review of Resident 1's Order Summary Report indicated she had physician orders, dated 8/3/24, for the following medications: 1. Cleocin-T External Lotion (antibiotic lotion used to treat infection) 1% (unit of dose measurement) apply to affected areas topically (to the skin) two times a day for infection; 2. Mupirocin External Ointment (medication used to treat infection) 2%…

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 in accordance with professional standards of practice for two of three sampled residents (Resident 1 and 2) when: 1. Staff did not complete an SBAR (situation, background, assessment, recommendation, a communication tool) and did not notify the physician and the responsible party (RP, person designated to make decisions on behalf of a resident) when an altercation occurred between Resident 1 and Resident 2; 2. Licensed nurse did not do a skin assessment for Resident 1 when Resident 2 threw coffee on Resident 1; 3. Licensed nurses did not put Resident 1 and Resident 2 on alert charting (nurses on each shift closely monitor and document in the medical record for 72 hours about a specific condition) when an altercation between Resident 1 and Resident 2 occurred; 4. Staff did not follow up with Resident 2 following a room change. These failures had the potential to result in inadequate monitoring of the resident's conditions, and the potential to negatively affect the residents' health, safety and well-being.…

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 Ombudsman (resident advocate) was notified of discharges for three of three residents (Residents 1, 2, and 3). This failure had the potential to result in the residents not having someone to advocate for their admission, transfer, and discharge rights. Findings: Review of Resident 1's medical record indicated she was admitted to the facility on [DATE]. Review of Resident 1's Progress Notes, dated 4/22/24, indicated the facility informed Resident 1 that her insurance issued a last covered date of 4/25/24 (this indicated the insurance would not pay for Resident 1's stay in the facility after 4/25/24). Review of Resident 1's Progress Notes, dated 4/26/24, indicated Resident 1 was discharged from the facility at 10:50 a.m. There was no documentation in the Progress Notes that indicated the facility notified the Ombudsman of Resident 1's discharge. During an interview with the director of nursing (DON) on 5/31/24 at 12:39 p.m., the DON 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 observation, interview, and record review, the facility failed to follow its Oxygen Therapy policy for two of three sampled residents (Residents 4 and 5) who used oxygen when: 1. Resident 4's nasal cannula (flexible tubing inserted into the nostrils and attached to an oxygen source) was unlabeled and undated; and 2. There was no No Smoking sign posted for Resident 5's room. These failures had the potential to compromise the residents' health and safety. Findings: 1. Review of Resident 4's medical record indicated she was admitted on [DATE] and had the diagnosis of chronic respiratory failure (a condition in which the respiratory system does not exchange oxygen and carbon dioxide properly). Review of Resident 4's Order Summary Report indicated she had a physician's order, dated 2/6/24, for oxygen to by administered via nasal cannula as needed. During observations on 5/31/24, at 11:52 a.m. and 1:23 a.m., Resident 4 was in her room receiving oxygen via nasal cannula. The nasal cannula was not labeled with…

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

Based on interview and record review, the facility failed to ensure complete records for controlled medications (those with high potential for abuse and addiction) when controlled medication use audit for three of six residents (Residents 13, 43, and 153) were not reconciled. The medications were signed out of the Individual Narcotic Record count sheet (an inventory sheet that keeps record of the usage of controlled medications); however, they were not documented on the Medication Administration Record (MAR) to indicate they were given to the residents. This failure had the potential for misuse or diversion (illegal distribution or abuse of prescription drugs or their use for purposes not intended by the prescriber) of controlled medications. Findings: On 10/17/23, six random Individual Narcotic Records count sheets for six residents were requested for review. Review of Resident 13's clinical record indicated he had a physician's order, dated 6/7/23 for tramadol (a potent narcotic for pain) 50 mg one tablet every six hours as needed (PRN) for pain. Review of the count sheet for…

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

Based on observation, interview and record review, the facility failed to ensure food was stored in accordance to professional standards of food safety when: 1. Outdated graham cracker crumbs in a plastic container was stored in an active use area of the dry storage; 2. An ice chest containing ice was stored on the floor. These failures had the potential to cause foodborne illness for residents who received food from the kitchen. Findings: 1. During a concurrent kitchen observation and interview with the Dietary Director (DD) on 10/6/23 at 9:00 a.m., there was a plastic container containing graham cracker crumbs in an active use area of the dry storage. The container had a label that indicated, 7/17/23, UB [use by]: 9/17/23. The DD confirmed the graham cracker crumbs had passed its use by date. She stated it should be discarded. 2. During a concurrent observation and interview with the Registered Dietician Nutritionist (RDN) on 10/18/23 at 10:24 a.m., an 85-liter (L, unit of volume) ice chest was on the floor. The RDN confirmed the ice chest was on the floor and stated ice for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 34) received a replacement of her personal belongings when her bilateral (affecting both sides) hearing aids (small, wearable electronic device to facilitate better communication) were missing since the end of December 2022. This deficient practice resulted in Resident 34 to be without hearing aids for over nine months. Findings: During a concurrent observation and interview of Resident 34's room on 10/16/23 at 9:55 a.m., Resident 34 stated she was hard-of-hearing and did not have hearing aids on. She stated her hearing aids were with the medication nurse. During an interview with certified nursing aide B (CNA B) on 10/18/23 at 9:23 a.m., she stated Resident 34 did not have hearing aids. CNA B stated Resident 34 was hard of hearing and she (CNA B) had to raise her voice when talking to Resident 34. During an interview with Licensed Vocational Nurse C (LVN C) on 10/18/23 at 9:47 a.m., she…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to follow physician's orders when a licensed vocational nurse (LVN F) did not administer a medication to Resident 152 according to the physician's order for it. This failure resulted in Resident 152 to not receive the physician's ordered medication as prescribed. Findings: Review of Resident 152's Order Summary Report, dated 10/19/23 indicated the resident was admitted to the facility on [DATE] with diagnoses including muscle weakness and myocardial infarction (heart attack). It also indicated Resident 152 had a physician's order, dated 10/5/23, for Polyethylene Glycol 3350 powder (medication used to manage or treat constipation) Give 17 gram (g, unit of measurement) by mouth two times a day for constipation prevention. During an observation and concurrent interview on 10/17/23 at 4:30 p.m., LVN F poured polyethylene glycol powder into a cap of the container until it filled approximately halfway to the top of a white line. When asked how much…

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 one of two sampled residents (Resident 34) received assistive devices when when her bilateral (affecting both sides) hearing aids (small, wearable electronic device to facilitate better communication) were missing since the end of December 2022. This deficient practice resulted in Resident 34 to be without hearing aids for over nine months. Findings: During a concurrent observation and interview of Resident 34's room on 10/16/23 at 9:55 a.m., Resident 34 stated she was hard-of-hearing and did not have hearing aids on. She stated her hearing aids were with the medication nurse. During an interview with certified nursing aide B (CNA B) on 10/18/23 at 9:23 a.m., she stated Resident 34 did not have hearing aids. CNA B stated Resident 34 was hard of hearing and she (CNA B) had to raise her voice when talking to Resident 34. During an interview with Licensed Vocational Nurse C (LVN C) on 10/18/23 at 9:47 a.m., she stated Resident 34 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.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 16), was provided Restorative Nursing Assistance (RNA; restorative care for individuals recovering from illnesses or injuries) services as ordered. This failed practice could result in decreases in mobility and complications for residents requiring RNA services. Findings: During an interview with Restorative Nursing Aide A (RNA A) on 10/19/23 at 9:29 a.m., she stated she works as an RNA 4 days a week on Mondays, Tuesdays, Wednesdays, and Thursdays. She stated there was currently no other RNA for 27 patients. She stated about once a month for the past 6 months, she was pulled out of the schedule to work as a CNA (Certified Nursing Assistant, an entry-level role that provides vital support to both patients and nurses). She stated some residents missed their RNA therapy when she was pulled out to work as a CNA. Review of Resident 16's clinical record, on 10/19/2023 at 1:37 p.m., indicated a physician's order, dated 8/17/2023, for RNA services four times a week for…

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

Based on interview and record review, the facility failed to complete a performance review for one of three certified nursing assistants (CNA) at least once every 12 months for CNA E. This failure resulted in a lack of evaluation and feedback related to CNA E's performance. Findings: Review of CNA E's personnel file indicated she was hired on 9/25/12 and had an employee performance review with competency assessments on 4/23/21. During concurrent interview and record review on 10/20/23 at 1:28 p.m., the director of staff development provided competency assessments for CNA E, completed on 8/26/23. The DSD stated it looked like there was no performance review/competency assessment completed for CNA E in the year 2022. Review of the facility's policy, revised 3/17/22 indicated, Competency assessments will be performed . annually . The annual evaluation of an employee will include review of completed competency assessments which may have been done throughout the year.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to follow their policy and procedure (P&P) for pneumococcal vaccination for one of six sampled residents (Resident 1). Resident 1 pneumococcal vaccine (vaccination to protect resident from pneumococcal disease) was not offered and not administered in accordance with the current Center for Disease Control and Prevention (CDC) recommendations. This deficient practice had the potential for acquiring pneumococcal disease for Resident 1. Findings: Review of Resident 1's face sheet (a document that gives a resident's information at a quick glance) indicated Resident 1 admitted to facility on 5/23/2023 with diagnoses including diabetes mellitus type 2 (a chronic condition that affects the way the body processes blood sugar), sepsis (condition in which the body responds to an infection), and protein calorie malnutrition (deficiency of energy, protein and other nutrients causes measurable adverse effects on body function and clinical outcome). Resident 1 had 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 observation, staff interview, and facility document review, the facility failed to ensure the planned menu was followed for four residents (Residents #1, 14, 20, 33) on Regular Carbohydrate Controlled (CCHO) diets (diets designed for people with Diabetes to assist in keeping blood sugars within normal range). 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 Winter Menus for Week 1 Monday 12/6/21 indicated for the CCHO Regular diet, the following items: Three Bean Chili 1 cup, Tossed [NAME] Salad ½ c (cup), Cornbread with [NAME] Chilies ½. During an observation of the lunch meal service on 12/6/21 starting at 11:56 a.m., Food Service Worker A (FSW A) plated food for Resident's 1, 14, 20, 33 in the presence of Registered Dietitian (RD). FSW A put one whole piece of cornbread on each of Resident's 1, 14, 20, 33 plates, and RD placed the plate cover on the plate on the tray in cart ready to go out to residents. During a concurrent…

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

Based on observation, interview and facility document review, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety when: 1. Nursing refrigerators were out of temperature range two times in a week, 2. An air gap was not present in the food preparation sink, and 3. Food service equipment was stored wet. These failures had the potential to cause the growth of microorganisms which could cause foodborne illness or cross contaminate food (cross contamination occurs when unclean surfaces or utensils spread germs to food and can potentially cause foodborne illness) for the 47 residents eating at the facility. Findings: 1. During an interview with the Director of Nursing (DON) in the presence of the Registered Dietitian (RD) by the nursing refrigerator (that holds resident food brought in by visitors) the DON stated the nurses are responsible for monitoring the temperatures of the refrigerator. During a concurrent record review at that time of a facility document titled Daily Temperature Record 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 follow proper infection control procedures when: 1. Resident 3's oxygen nasal cannula (a device consisting a lightweight tube, split on one end into two prongs which are placed in the nostrils and from which a mixture of air and oxygen flows) was lying on her bed and not covered; 2. Certified nursing assistant J (CNA J) did not sanitize or wash her hands after touching the curtain and before feeding Resident 43; 3. Resident 43's syringe which was used to flush and administer the medications through his gastrostomy tube (GT, a tube inserted through the wall of the abdomen directly into the stomach; it can be used to give drugs and liquids, including liquid food, to the resident) was not changed daily; 4. Staff did not wear a gown while providing direct resident care in the yellow zone; 5. A housekeeper did not wear appropriate PPE (personal protective equipment such as gloves, gown, faceshiled, and goggles) and remove PPE properly while…

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 Pre-admission Screening and Resident Review (PASRR, screening for individuals with a mental disorder and individuals with intellectual disability) screening document was accurately completed for two of two residents (39 and 43). This failure had the potential for mentally ill residents not to receive the required care and services. Findings: 1. Review of Resident 39's admission Record and physician orders indicated she was admitted to the facility with diagnoses including psychosis (hearing or seeing things that do not exist, or believing things that other people do not) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). Resident 39 was prescribed aripiprazole (used to treat mental/mood disorders) 5 milligrams (mg, a metric unit of mass) daily for psychotic mood disorder, started on 4/4/21, and sertraline (used to treat depression) 25 mg daily for depressive disorder, started on 5/5/21. However, review of Resident 39's PASRR Level I Screening document, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the risk for fall care plan was implemented for one of two residents (43) by not placing the landing pad on the right side of Resident 43's bed for his safety. This failure had the potential for Resident 43 to sustain injury if he fell from his bed. Findings: Review of Resident 43's admission Record indicated he was admitted to the facility on [DATE] with diagnoses including difficulty in walking, muscle weakness, and osteoporosis (a disease that thins and weakens the bones). Review of Resident 43's Fall Risk Evaluation, dated 11/10/21, indicated he was at risk for fall. Review of Resident 43's physician orders, dated 12/6/21, indicated he had an order for a landing pad on the right side of the bed for safety and its placement was to be checked every shift. Review of Resident 43's care plan for risk for fall, initiated on 12/6/21, indicated a landing pad on the right side of the bed was one of the risk for fall interventions.…

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 comprehensive care plan was revised for one of three residents reviewed (Resident 3), to include new intervention/s to prevent recurrence of elopement (wandering). This failure had the potential to present imminent threat to resident's safety. Findings: During review of Resident 3's clinical record, Resident 3 was admitted on [DATE] with diagnoses included dementia (memory loss), diabetes mellitus (high blood sugar), and psychosis (mental disorder). During review of Resident 3's minimum data set (MDS, a resident tool assessment) dated 8/21/2021, indicated Resident 3 was moderately cognitively impaired, independent during activities of daily living (ADLS), and ambulates thru wheelchair. During observation on 12/08/21 at 3:45 pm, Resident 3 was alert, seated in her wheelchair, able to get up by herself, but had periods of confusion. Her Wander Guard was placed on the back of her wheelchair . During an interview with licensed…

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 residents received the necessary care and services to attain and/or maintain their highest practicable well-being for two of twelve sampled residents (39 and 43) when: 1. Licensed nurses did not hold midodrine (used to treat low blood pressure) 10 milligrams (mg, a metric unit of mass) as ordered for Resident 39, when her systolic blood pressure (SBP, the pressure in the arteries when the heart beats) was higher than 130 millimeters of mercury (mmHg, a measurement of pressure); and 2. Physician's laboratory orders for Resident 43 were not done: prothrombin time (PT, a blood test that measures how long it takes blood to clot)/international normalized ratio (INR, a way of standardizing the results of prothrombin time tests, no matter the testing method), complete blood count (CBC, a blood test that helps to detect a range of disorders and conditions), comprehensive metabolic panel (CMP, it provides important information about the body'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 maintain a consistent process of drug reconciliation (maintenance of an accurate count) when incoming and outgoing licensed nurses did not consistently sign the controlled drug count document at change of shift, 13 times in 6 weeks (10/24/21 - 12/6/21) for one of two medication carts. This failure had the potential to result in the delay of identification of medication discrepancy (the difference in the actual count versus the recorded amount) and possible inappropriate use of controlled narcotic (drugs used to reduce pain, induce sleep and may alter mood or behavior) medication. Findings: During a concurrent interview and record review on 12/06/21 at 11:10 a.m. with Licensed Vocational Nurse (LVN) E and the Director of Nursing (DON), LVN E, stated that the narcotic controlled drug count was conducted by two licensed nurses; and the document should be signed off by them at each change of shift. A review of the controlled drug count document with LVN E identified that it was incomplete, missing signatures/initials of 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 the consultant pharmacist's (CP) recommendations were acted upon for one of 12 sampled residents (39) when the CP indicated hemoglobin A1c (HbA1c, a test measures the amount of blood sugar attached to part of the red blood cells that carries oxygen from the lungs to the rest of the body) and electrocardiogram (EKG, a test measures electrical signals in the heart; an abnormal EKG can be a sign of heart disease or damage) for Resident 39, and the facility did not present these recommendations to the physician. This failure had the potential for Resident 39 to receive unnecessary medication and to suffer unnecessary adverse side effects that could negatively impact her physical, mental, and psychosocial well-being. Findings: Review of Resident 39's admission record indicated she was admitted to the facility on [DATE], with diagnoses including psychosis (hearing or seeing things that do not exist, or believing things that other people do not) 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 had a 5.56% medication error rate when two medication errors out of 36 opportunities were observed during medication passes for two residents (Residents 2 and 32). These failures had the potential to compromise the residents' medical health. Findings: 1. During a medication administration observation and interview on 12/6/21 at 9:40 a.m., with Registered Nurse (RN) B, RN B administered the scheduled medications to Resident 2 at the scheduled medication pass. However, RN B did not administer the furosemide (a diuretic, used to treat fluid retention and swelling) 20 milligrams (mg, unit of measure). RN B stated she could not find the furosemide 20 mg which was due during this medication pass. She stated she would notify the pharmacy. A review of Resident 2's medical record indicated a physician's order, dated 6/28/21, for furosemide 20 mg by mouth, once a day for edema (swelling caused by excess fluid trapped in the body's tissues). The medication was scheduled to be administered daily at 9:00 a.m. During a follow-up…

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 medication and biologicals were stored and labeled appropriately when undated medications and an expired medication were found in the medication carts; and internal and external medications were not stored separately. These failures had the potential for residents to receive expired, incorrect, and unsafe medications. Findings: A. During an observation on [DATE] at 10:58 a.m. in Station 1 for medication cart review with Licensed Vocational Nurse (LVN) E and the Director of Nursing (DON), the following were identified: 1. Two of two glucose test strip (a thin plastic strips that measures blood sugar) bottles were opened, not dated. 2. An eye drop medication, 3 bags of suppositories (solid but readily meltable cone or cylinder of usually medicated material for insertion into a bodily passage or cavity) and 2 nitroglycerin (used to prevent chest pain, placed under the tongue) bottles were stored in the same bin of the drawer in 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 facility document review, the facility failed to ensure one kitchen staff had appropriate competencies when the staff did not know the correct final temperature for cooked chicken and did not calibrate three thermometers correctly. These failures had the potential to place the 47 residents who received food prepared in the kitchen at risk for food borne illness. Findings: a. During an interview on 12/6/21 at 10:14 a.m., Food Service Worker A (FSW A) stated she had been working here 30 years. During an observation of food preparation on 12/6/21 starting at 11:06 a.m., Food Service Worker A (FSW A) took temperatures of chicken coming out of the oven. During a concurrent interview at that time with FSW A, FSW A stated she is looking for 160 degrees Fahrenheit (°F) to make sure the chicken is cooked thoroughly. FSW A confirmed that if the final cooked chicken temperature was 160°F that the chicken would be fine to serve to residents. It was noted the cooked chicken temperatures were observed to be 180°F and 179°F. Review of facility policy titled…

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.