The Redwoods Post-Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide services to promote healing of pressure ulcers (damage to the skin and underlying tissue as a result of prolonged pressure) for one of 3 residents (Resident 1) when the licensed nurse did not obtain pressure ulcer measurements and no treatment order was obtained for 6 days for Resident 1's pressure ulcer. These failures had the potential to delay treatment and potentially lead to new or worsening pressure ulcers. Failure to obtain measurements had the potential to compromise the facility's ability to determine whether Resident 1's pressure ulcer was increasing or decreasing in size. Findings: Review of Resident 1's clinical record indicated she was admitted to the facility on [DATE] with diagnoses including fracture of second and third lumbar vertebrae (small bones forming the backbone in the lower back), hemiplegia and hemiparesis (paralysis and weakness) affecting left side, obesity (too much body fat), type 2 diabetes (a condition which…

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 written notice prior to multiple room changes for one of four sampled residents (Resident 1). This failure had the potential to compromise Resident 1's rights. Also, there was no documentation that the facility monitored Resident 1 after one room change. This failure had the potential to compromise the facility's ability to identify complications related to the room change and implement interventions accordingly. Findings: Review of Resident 1's clinical record indicated he was admitted on [DATE]. Further review of the clinical record indicated the facility implemented room changes for Resident 1 on 11/15/23, 11/17/23, and 1/2/24. During a telephone interview and concurrent record review with social services staff C (SS C) on 6/25/24, at 1:13 p.m., SS C reviewed Resident 1's clinical record remotely (from a location outside of the facility) and confirmed Resident 1 had room changes on the dates mentioned above. SS C explained when the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately complete a Minimum Data Set (MDS, an assessment tool) for one of four sampled residents (Resident 1). The failure to accurately assess had the potential to compromise the facility's ability to develop and implement interventions to meet the resident's needs. Findings: Review of Resident 1's clinical record indicated he was admitted on [DATE] and had diagnoses including congestive heart failure (a condition in which the heart does not pump blood as well as it should), ascites (fluid in the abdominal cavity that causes swelling), muscle weakness, and abnormalities of gait (walking) and mobility (ability to move freely). Review of Resident 1's situation, background, assessment, recommendation (SBAR, a communication form), dated 12/21/23, indicated Resident 1 was seen on the floor. During an interview and concurrent record review with MDS nurse A (MDSN A) on 6/25/24, at 10:46 a.m., MDSN A reviewed Resident 1's clinical record and confirmed 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 care and services were provided in accordance with professional standards for one of four residents (Resident 1) when: 1. There were multiple days for which there was no documentation that the facility obtained Resident 1's daily weight as ordered by the physician, and 2. There were multiple days for which there was no documentation that the facility notified Resident 1's physician of an abdominal girth (measurement of distance around the abdomen) increase of more than three centimeters (cm, unit of measurement). These failures had the potential to negatively affect the resident's health and well-being. Findings: 1. Review of Resident 1's clinical record indicated he was admitted on [DATE] and had diagnoses including congestive heart failure (a condition in which the heart does not pump blood as well as it should) and ascites (fluid in the abdominal cavity that causes swelling). Review of Resident 1's Order Summary Report indicated he had a…

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

Based on interview and record review, the facility failed to follow their policy and procedure to develop a comprehensive person-centered care plan (plan that identifies residents' needs and outlines the care and services to be provided to meet those needs) for one of two sampled residents (Resident 1) to address management of onychomycosis (fungal infection of the nails). This failure had the potential to result in Resident 1 not receiving necessary care and services. Findings: Review of Resident 1's face sheet indicated the following diagnoses: paraplegia (the lower body is paralyzed), schizoaffective disorder (a mental health condition that can cause hallucinations, delusions, and mood disorder), and tinea unguium (onychomycosis). During an interview and concurrent record review with the Director of Nursing (DON) on 12/14/23 at 2:02 p.m., the DON reviewed Resident 1's clinical record and confirmed there was no care plan to address management of onychomycosis. The facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised 3/2022 indicated, A…

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

Based on observation, interview, and record review, the facility failed to provide care and services in accordance with acceptable professional standards of quality for two of 29 sampled residents (Resident 15, 46) when: 1. Nursing staff failed to clarify an unsafe insulin order for Resident 15, posing a risk of adverse outcomes such as severely low blood glucose (BG, or blood sugar) for the resident; and 2. Nursing staff failed to identify duplicate orders for Resident 46's Seroquel (generic name: quetiapine, an anti-psychotic medication to treat mental illnesses), resulting in Seroquel given in excess and more than prescribed for two months. Findings: 1. During a medication pass observation on 2/7/23 at 12:31 p.m., Licensed Vocational Nurse L (LVN L) was observed obtaining the BG level by pricking Resident 15's right ring finger. His BG reading was 142 milligrams/deciLiter (mg/dL, unit of measurement; normal BG is less than 100 mg/dL) at this time. LVN L stated Resident 15 needed 6 units of insulin (medication to lower BG) for the BG reading of 142 mg/dL. On 2/7/23 at 12:37 p.m.,…

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 its nursing staff was competent and knowledgeable about the proper disinfection of shared glucometers (blood glucose meter to measure and display the amount of sugar [glucose] in your blood) according to the manufacturer's instructions and accepted professional standards of practice. Seven nursing staff in three out of three nursing stations, the director of nursing (DON), and the Infection Preventionist/Director of Staff Development (IP/DSD) did not know about the appropriate disinfectant product to use and/or the allowance of wet time (the amount of time disinfectants need to remain wet on surfaces to properly disinfect) when disinfecting shared glucometers. The failure had the potential for widespread transmission of bloodborne diseases (such as Hepatitis B [a serious liver infection caused by the hepatitis B virus that is most commonly spread by exposure to infected body fluids], Hepatitis C, and HIV [human immunodeficiency virus, is a virus that attacks the body's immune system]) among residents.…

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 controlled medications (those with high potential for abuse and addiction) were fully accounted when: 1. Four of four controlled drug sign-in/sign out sheets (a sheet used to reconcile inventory of controlled medications in the medication cart) by the incoming and outgoing nurses during a shift change were missing signatures; 2. Random as-needed controlled medication use audits for three of five sampled residents (Residents 13, 14, and 139) did not reconcile. The medications were signed out of the controlled drugs accountability sheet (Count Sheet, an inventory sheet that keeps record of the usage of controlled medications), but not documented on the Medication Administration Records (MAR) to indicate they were given to the residents. These failures had the potential for misuse or diversion (the illegal distribution or abuse of prescription drugs or their use for purposes not intended by the prescriber) and inaccurate accountability of controlled medications. Findings: 1. Four controlled drug sign-in/sign out sheets…

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 facility medication error rate did not exceed five percent or greater when observation of 25 opportunities during the medication pass resulted in three errors. The calculated medication error rate was 12 percent. These failures placed Residents 9 and 25 at risk for not receiving the full therapeutic effects of medications when medications were not given according to the physician's orders and/or the manufacturer's specifications. Findings: 1. During a medication administration observation on [DATE], at 8:36 a.m., with Licensed Vocational Nurse (LVN A), she was observed drawing 5 units of Admelog (fast-acting insulin, medication to lower blood sugar level) from the Admelog vial stored in the medication cart. At the resident's bedside, she injected the insulin in the resident's right upper arm. A review of the Admelog vial with LVN A shortly after the medication administration revealed it had a small sticker indicating it was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two of 29 sampled residents (Residents 9 and 46) and Residents 13, 25, 45, and 250 were free of a significant medication errors when: 1. Five residents (Resident 9, 13, 25, 45, and 250) received insulin past the discard (expiration) date. These failures had the potential for ineffective use of the insulin, resulting in uncontrolled high blood sugar for the residents; and, 2. Resident 46 received excessive doses of Seroquel (generic name quetiapine, an antipsychotic medication to manage mental illnesses) more than prescribed for 2 months. This had the potential for the resident to suffer severe adverse effects such as excessive sedation, drowsiness, blurred vision, loss of appetite, urinary retention, low blood pressure, seizure, diabetes, and abnormal involuntary movements. Findings: 1a. During a medication administration observation on [DATE], at 8:36 a.m., with Licensed Vocational Nurse (LVN A), she was observed drawing 5 units…

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 proper medication storage and labeling of medications in three of three medication carts inspected and one of two medication rooms inspected when: a) Medication Cart 3B contained eight (8) expired medications, two (2) opened medications without an open date label, and two (2) test strip (thin plastic strips which measures blood sugar levels) vials opened without an open date label; b) Medication Cart 1A contained two (2) expired medications, four (4) opened medications without an open date label, and one (1) test strip vial opened without an open date; c) Medication Cart 2A contained two (2) expired medications and two (2) opened medications without an open date label; d) Station 3 Medication Room contained one (1) expired emergency kit and one (1) opened Aplisol (a solution for skin test to help diagnose tuberculosis infections) vial without an open date. The deficient practices had a potential for residents to receive medications with unsafe and ineffective medications (reduced potency) from 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 observation, interview, and record review, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food services safety when: 1. Resident 139's opened condensed milk (a sweetened cow's milk product) was not properly labeled and stored in the refrigerator (Cross reference F813), 2. An unlabeled bucket of white powder was in dry storage, 3. Cutting boards with deep cuts with stains, food residuals and and loose plastic particles were found on a clean storage rack, 4. A can opener had black matter on its cutting surface, and 5. A serving scoop storage drawer contained crumbs and orange matter. Theses failures had the potential to harbor the growth of microorganisms that could cause foodborne illness or cross contamination of food (cross contamination occurs when unclean surfaces or serving scoops spread germs to food that may cause foodborne illness) for the residents eating at the facility. Findings: 1. During an observation, on 2/6/23…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe, sanitary, and comfortable environment for residents when: 1. Bed side rails were not stable or installed properly; 2. Toilet doorknobs were either missing, broken and/or loose, and a tissue holder was broken; 3. A Doorknob was missing and a tissue holder broken; 4. Cabinet drawers were broken and a tray table had chipped paint and chipped edges; 5. A bathroom door was out of order and had stains; 6. Four bed footboards were loose; 7. Window blinds were broken; 8. The Bathroom of Room F lacked a door. These failures had potential to compromise residents' safety, well-being and health. Findings: 1. During room rounds and concurrent observation and interview, on [DATE] at 9:12 a.m., with the director of nursing (DON), the DON confirmed the following: 1.a. In Room H, Resident 69's bilateral bed rails were loose. 1.b. In Room I, Resident 101's bedrails were loose. 2.a. In Room J, the shared bathroom for four residents, had a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure respect and dignity was maintained for three residents (Residents 3, 31, and 41). 1. For residents 3 and 41 staff provided feeding assistance while standing. 2. For resident 3, staff did not provide privacy during therapy treatment. These failures had the potential to negatively affect the emotional and psychosocial well-being of the residents. Findings: 1. Review of Resident 3's minimum data set (MDS, an assessment tool), dated 1/6/23, indicated her cognition was severely impaired and she needed one-person physical assistance for eating. During a lunch meal observation, on 2/6/23 at 1:23 p.m., Resident 3 sat upright in bed in her room. CNA W stood beside Resident 3 providing feeding assistance to her. During a concurrent interview with CNA W, she confirmed she stood while she fed Resident 3. When asked if she should be standing while feeding a resident she stated, No I should be sitting . I usually do sit when I feed my residents.…

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 four sampled residents (Resident 145) discharged from Medicare Part A services received a Notice of Medicare Non-Coverage (NOMNC, a form given to Medicare recipients notifying that Part A coverage is being terminated and providing information on how to file an appeal of that decision) letter in a timely manner. This failure had the potential to prevent the resident from filing a timely appeal of the decision to discharge from Medicare Part A services. Findings: Review of Resident 145's clinical records indicated, Resident 145 was admitted to the facility on [DATE] with a diagnosis of fracture of the neck part of the left femur (broken hip bone). The facility initiated a discharge of Medicare Part A services on 12/21/2022. Review of Resident 145's NOMNC letter, dated 12/21/2022, indicated, The effective date coverage of your current Medicare coverage will end: 12/21/2022. Further review of the NOMNC letter's second page indicated, I have…

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 and interview, the facility failed to maintain a organized and sanitary environment for one non-sampled resident (Resident 116) when the room was disorganized, her tray table used for meals had chipped areas, and one wooden cabinet drawer was broken. These failures created a disorganized and unsanitary environment that could pose safety risks for Resident 116 . Findings: During an observation, on 2/7/23 at 12:24 p.m., Resident 116 sat in a wheelchair in her room among multiple personal belongings scattered throughout the room and under her bed, such as dirty or used clothes, linens, sheets, blankets. During a concurrent interview, Resident 116 stated she needed help to organize her room and that she could not do it by herself. During an observation with the director of nursing (DON), on 2/13/23 at 9:24 a.m., a wooden cabinet next to Resident 116's personal belongings were still scattered throughout her room and under her bed, such as dirty or used clothes, linens, sheets, blankets. A wooden cabinet next to Resident 116's bed contained unlabeled/undated food…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their policy and procedure to notify the Office of the State Long-Term Care Ombudsman (organization that advocates for the residents) when four of four sampled residents (Residents 6, 135, and 146) were transferred to the acute care hospital or discharged from the facility without notifying the Ombudsman. This failure had the potential to compromise the residents' admission, transfer, and discharge rights. Findings: Review of Resident 135's clinical record indicated she was transferred to an acute care hospital on [DATE] following a fall. Review of Resident 146's clinical record indicated he was discharged from the facility on 12/18/22 AMA (leaving the facility against medical advice). During an interview with the social services director (SSD) on 2/9/23 at 8:15 a. m., he reviewed the list of transfers and discharges for November 2022 and December 2022. He confirmed that Resident 135 had been transferred to the acute care hospital on [DATE], and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete and transmit the Minimum Data Set (MDS, a comprehensive assessment tool) discharge assessment in a timely manner for one of 29 sampled residents (Residents 126). This failure resulted in the resident's discharge assessment not being transmitted and received by the Center for Medicare and Medicaid System within the time requirement. Findings: During the record review and concurrent interview with the minimum data set nurse (MDSN), on 2/14/23 at 2:32 p.m., the MDSN reviewed Resident 126's closed record that indicated he was admitted on [DATE] and was discharged home on [DATE]. The MDSN confirmed Resident 126's discharge MDS was not completed. The MDSN stated she would complete and transmit Resident 126's discharge MDS to the Center for Medicare and Medicaid System. Review of the Resident Assessment Instrument Process (RAI-guidance and information gathering for resident's strengths, needs, care plan, and tracking of changes in residents'…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately code in the MDS (Minimum Data Set- an assessment tool) for three of 29 sampled residents (Resident 103, 108 and 90) when the completed and transmitted MDS did not include: 1. Resident 103's three fall incidents, one of which resulted in minor injury. 2. Resident 108's functional limitation on one side of an upper extremity. 3. Resident 90's special treatments and procedures. These ommissions in coding resulted in an inaccurate MDS. Findings: 1. Review of Resident 103's clinical record with the minimum data set coordinator (MDSC) and the assistant director of nursing B (ADON B), on 2/8/23 at 4:45 p.m., indicated fall incidents with no injury occurred on 8/19/22 and 8/25/22; and, a fall incident with minor injury occurred on 11/5/22. Both MDS C and ADON B verified Resident 103's fall incidents were unaccounted for in Resident 103's MDS, dated [DATE]. During a concurrent interview with the MDSC, she stated, . will make modification right now.…

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 develop and implement individualized, resident-centered care plans for three of 29 sampled residents when care plans for: 1. bilateral upper side rails for Resident 6 were not followed, 2. risk for fall/further falls (to provide floor mat and keep bed in lowest position) was not followed for Resident 66, 3. skin discoloration was not developed for Resident 107. The failure to developed and/or follow care plans had the potential unmet care needs for residents. Findings: 1. During an observation with the director of nursing (DON), on 2/14/23 at 10:09 a.m., Resident 6 was in bed with bilateral side rails placed on the middle part of the bed. During a concurrent interview and record review, the DON verified the observation and confirmed a physician's order, dated 12/5/22, indicated, . may have 1/4 bilateral upper side rails up when in bed to assist resident on bed mobility . The DON confirmed Resident 6's care plan for multiple falls, dated 2/3/23, included bilateral upper side rails up for bed mobility,…

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 care and services were provided in accordance with professional standards of practice for three sampled residents (Residents 59, 90, and 122) when: 1. For Resident 90, there was no documentation or monitoring of the cardiac defibrillator. 2. For Resident 59, licensed nurses did not follow the physician's order and care plan to use the bed's 1/4 bilateral upper side rails up. 3. For Resident 122, licensed nurses did not follow the physician's order to administer the medication Niacin (B vitamin that's made and used by the body to turn food into energy) with meals. These failures had the potential to compromise the resident's health and well-being. Findings: 1. Review of Resident 90's clinical record indicated he was admitted on [DATE] with diagnoses including presence of automatic (implantable) cardiac defibrillator (small battery-powered device placed in the chest to detect and stop irregular heartbeats), obesity, end stage renal…

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 appropriate care and services for a suprapubic catheter (SPC, a type of catheter that is inserted through a hole in an abdomen [tummy] directly to the bladder [the organ that stores urine] and left in place) when (1) Resident 93's SPC site was unclean and (2) the urinary drainage bag was not changed as ordered. This failure in care had the potential for the patient to develop a urinary tract infection (UTI, an infection caused by a bacteria (germs) that get into the bladder or kidneys (a pair of organs that are on either side of the spine, just below the rib cage of a person's back). Findings: 1. Review of Resident 93's hospital DISCHARGE SUMMARY, dated 1/18/2022, indicated Resident 93 had diagnoses including UTI, chronic (persisting for a long time or constantly recurring) paraplegia (paralysis of the lower half of the body) and neurogenic bladder (a urinary condition when people lack bladder control due to a brain and/o nerve…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Review of Resident 90's clinical record indicated he was admitted on [DATE] with diagnoses including end stage renal disease (kidney failure, kidneys no longer function to meet the body's needs), dependance on renal dialysis (dialysis: a procedure in which a machine filters wastes and fluid from the blood), congestive heart failure (condition when the heart cannot pump and fill adequately), and obesity. Resident 90 was scheduled for dialysis every Monday, Wednesday, Friday, and Saturday. Resident 90's had an arteriovenous fistula (AVF, surgically created connection between an artery and vein to allow dialysis to occur) in his left forearm. Review of Resident 90's physician order, dated 2/9/23, indicated to monitor dialysis access site LFA (left forearm) QS (every shift) for S&S (signs and symptoms) of infection, bleeding, redness, pain, swelling, discharge (notify MD immediately if noted). There were no physician orders in Resident 90's clinical record to monitor dialysis access site for bruit (an audible…

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 person-centered care and services for one of eight residents (Resident 248), when a negative behavior was not care planned or monitored. This failure had the potential of a decline in Resident 248's physical and emotional well-being. Findings: Resident 248 was admitted with diagnoses which included Traumatic subdural hemorrhage, Encephalopathy, Unspecified Psychosis, Cognitive communication deficit, and Unspecified dementia. During an interview, on 2/7/23 at 11:51 a.m., with Resident 248's family member, he stated he wanted staff to focus on Resident 248, since she had taken all of her clothes and taken the blankets off of the bed. During an interview, on 2/9/23 at 1:48 p.m., with registered nurse O (RN O), she stated Resident 248 had behaviors of talking gibberish, coming close to pulling her feeding tube out, and taking her clothes off. During an interview, on 2/9/23 at 2:17 p.m. with RN O, she stated Resident 248 had these behaviors since…

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's consultant pharmacist (CP) failed to identify and report to the facility irregularities in the residents' monthly drug regimen review (DRR) for two of 29 sampled residents (Residents 15 and 32). Undetected medication irregularities had the potential for unsafe medication use and/or residents not achieving highest therapeutic outcomes. Findings; 1. During a medication administration observation on 2/7/23 at 12:31 p.m., Licensed Vocational Nurse L (LVN L) was observed pricking Resident 15's right ring finger to obtain a blood sample to measure his blood glucose (BG) level. The BG reading was 142 milligrams/deciLiter (mg/dL, unit of measurement; normal BG is less than 100 mg/dL) at this time. LVN L stated Resident 15 needed 6 units of insulin (medication to lower BG) for the BG reading of 142 mg/dL. On 2/7/23 at 12:37 p.m., LVN L was observed administering 6 units of Novolog (a rapid-acting insulin that helps lower mealtime blood sugar spikes) to Resident 15 by injection on his abdomen. According to the Center 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 ensure one of 29 sampled residents (Resident 46) was free from unnecessary psychotropic medication (drugs that affects brain activities associated with mental processes and behavior). Resident 46 received Seroquel (generic name quetiapine, an antipsychotic medication to manage mental illnesses) in excessive doses, higher than prescribed, for 2 months. This failure had the potential for the resident to suffer severe adverse effects such as excessive sedation, drowsiness, blurred vision, loss of appetite, urinary retention, low blood pressure, seizure, diabetes, and abnormal involuntary movements. Findings: Resident 46 was admitted to the facility in September 2022 with diagnoses including vascular dementia (a condition characterized by memory loss), aphasia (loss of ability to understand or express speech, caused by brain damage), hemiplegia (paralysis of one side of the body), and cerebral infarction (stroke). A review of the Minimum Data Set (MDS, a care area assessment and screening tool), dated 9/1/22, 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 develop and implement a policy to ensure safe and sanitary storage, handling, and consumption for the food brought in by family when Resident 139's room had multiple unlabeled open food items. This failure had the potential to limit the resident rights and enjoyment of the food brought in by the family (Cross reference F812). Finding: During an observation and interview, on 2/6/23 at 8:29 a.m., in Resident 139's room, a half full bottle of condensed milk (a sweetened cow's milk product) on the resident's overbed table was without a labeln for its open dates. Resident 139 stated the bottle of condensed milk had been opened for a week and she used it for coffee every day. Review of Resident 139's Face Sheet (a document that gives a resident's information at a quick glance, including contact details and a brief medical history), indicated she was was admitted on [DATE]. Review of Resident 139's Minimum Data Set (MDS, a resident assessment…

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 8/13/19 menu was followed. This failure could result to resident's dissatisfaction to the food served and dietary services. Findings: Review of the weekly menu dated 8/12/19 to 8/18/19 indicated, the menu for 8/13/19 was chicken cordon bleu, the menu further indicated French Day. During an interview with the dietary cook (DC) on 8/13/19 at 10:19 a.m., she stated she was preparing chicken [NAME]. During an interview with the registered dietitian (RD) on 8/13/19 at 10:32 a.m., the RD stated the DC would follow the chicken [NAME] menu because they don't observe the French Day. The RD confirmed the menu posted for residents was chicken cordon bleu. During concurrent observation and interview with the DC on 8/13/19 at 10:36 a.m., the DC prepared unbreaded baked chicken to puree. The DC confirmed she followed the chicken [NAME] recipe in preparing for the puree food. During the resident council meeting on 8/13/19 at 2:03 p.m., Residents…

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

Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared and served under sanitary conditions when: 1. There were five uncovered deli containers filled with salad dressing; 2. The kitchen drawer used to put kitchen utensils had reddish yellowish flaky color substances; 3. The can opener had a black substance; 4. The walk in refrigerator condenser fan cover had grayish substance; 5. Fruit cocktail was uncovered in the preparation sink area and the dietary aide R (DA R) disposed the quaternary solution in the preparation sink; 6. DA R did not demonstrate the proper procedures for testing the strength of sanitizer used for sanitizing food contact surfaces; 7. Quaternary ammonium log policy was not implemented; 8. The dishwasher log was not completely filled out. These failures had the potential to cause food borne illness (illness resulting from contaminated food) for 128 residents who received food from the kitchen. Findings: 1. During concurrent kitchen observation and interview with the dietary manager (DM) on 8/11/19 at 10:42 a.m.,…

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.

8. During a kitchen observation on 8/12/19 at 3:35 p.m., maintenance staff Q (MS Q) washed his hands in the food preparation sink. MS Q confirmed observation and stated he should wash hands in the sink designated for hand washing. According to the FDA Food Code 2017 as specified in paragraph 2-301.15 indicated sink used for food preparation may not be used for handwashing. Based on observation, interview and record review, the facility failed to maintain proper infection control practices when: 1. Resident 390's oxygen nasal cannula (NC) tubing (a device that consists of a plastic tube that fits behind the ears, and a set of two prongs that are placed in the nostrils) was undated and was touching the bedside table; 2. Resident 66's unlabeled oxygen nasal cannula prongs and tubing was exposed, hanging and touching to the wheel of the wheelchair; 3. Resident 70's oxygen nasal cannula tubing was undated; 4. Resident 15's nebulizer tubing with mask piece (plastic mask and tubing used as a connection from compressor to deliver breathing mist to client) and yankauer suction tube (oral…

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

Based on interview and record review, the facility failed to notify the responsible party (RP) for one of 27 sampled residents (Resident 78) when Resident 78 was transferred to an acute hospital. This failure had potential to result in Resident 78 receiving inadequate care. Findings: Review of Resident 78's Health Status note dated 6/25/19, indicated a licensed nurse was informed Resident 78 was sent to an acute hospital from a dialysis facility, where Resident 78 received the routine dialysis treatment. There was no documentation indicating Resident 78's RP was informed about the hospital transfer. During an interview on 8/13/19 at 12:41 p.m., registered nurse C (RN C) reviewed the record and stated she did not find documentation Resident 78's RP was notified regarding the hospital transfer. RN C stated the facility should notify the RP for Resident 78's hospital transfer. Review of the facility's policy, Change in a Resident's Condition or Status dated May 2017, indicated a nurse was to notify the resident's representative when it was necessary to transfer the resident to 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 notify the physician for one of 27 sampled residents (Resident 100) when Resident 100 had episodes of orthostatic hypotension (a form of low blood pressure that happens when changing position, such as standing up from a sitting or lying down position, this can cause dizziness or lightheadedness, or fainting). This failure had potential to result in Resident 100 at risk for fall . Findings: 1. Review of Resident 100's clinical record indicated he was readmitted on [DATE] with diagnoses including hypertension and history of falls. Resident 100's physician orders included orders to check for orthostatic hypotension and notify the physician if systolic BP (upper value of blood pressure) dropped more than 10 millimeters of mercury (mmHg, blood pressure measure unit) when changing positions. Review of Resident 100's clinical record indicated in August 2018, Resident 100 had four episodes of orthostatic hypotension with systolic BP more than 10 mmHg. During…

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

Based on observation, interview, and record review, the facility failed to ensure a safe and homelike environment when the carpet in the dining/activity area door was protruding (stick out) . This failure had the potential to be harmful for residents who were going to the dining/activity room. Findings: During an observation and interview on 8/11/19 at 1:33 p.m., the carpet in the dining/activity area door was protruding. The administrator (ADM) confirmed the observation and stated he was aware of the carpet issue. Review of the facility's policy, Cleaning/Repairing Carpeting and Cloth Furnishings dated 12/2009, indicated carpeting shall be promptly repaired.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to document that family or responsible party (RP) was notified for one of 27 sampled Resident (Resident 124) when Resident 124 was sent from her wound care clinic appointment to acute hospital and was discharged from the facility. This failure had potential to affect Resident 124's medical condition. Findings: Review of Resident 124's clinical record indicated she was readmitted to the facility on [DATE]. There was no documents indicated Resident 124 was sent to the acute hospital from the wound clinic nor notified RP regarding the resident's hospitalization. Nurse progress notes dated from 7/18/19 to 7/24/19 only indicated Resident still in hospital. During a concurrent interview and record review with registered nurse K (RN K) on 8/14/19 at 10:21 a.m., RN K reviewed the clinical record and stated Resident 124 went to the wound clinic on 7/18/19 and then due to change of condition was sent to the hospital from the wound clinic. RN K stated the facility…

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 complete a significant change in status assessment (SCSA) in minimum data set (MDS, an assessment tool) for one of 27 sampled residents (Resident 113) when the resident had an indwelling catheter (surgical procedure to drain urine from the bladder into a drainage bag) and had significant weight loss. These failures had the potential to result in Resident 113 unable to achieve or maintain optimal status of health, function and quality of life. Findings: Review of Resident 113's face sheet (summary page of a patient's important information) indicated she was admitted to the facility on [DATE], with diagnoses including Parkinson's disease (disorder of the nervous systems that affects movement and can cause tremors), major depressive disorder (mood disorder that interferes with daily life), dehydration (a significant loss of body fluid that impairs normal body functions), and type 2 diabetes mellitus (a chronic condition that affects the way…

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 3. Review of Resident 55's clinical record indicated he had diagnoses including altered mental status (change in brain function that can cause confusion or sleepiness). Resident 55 had four falls in the facility. Review of Resident 55's fall notes, dated 5/5/19 indicated Resident 55 tried to get a shirt from his closet and slipped when trying to get up. It indicated a new intervention to prevent reoccurrence of a fall was to provide Resident 55 with a grabber tool to prevent overreaching for items. During an observation and interview on 8/15/19 at 7:34 a.m., unit manager A (UM A) was unable to find the grabber tool in Resident 55's room. UM A stated Resident 55 should have a grabber tool. 4. Review of Resident 65's clinical record indicated he had diagnoses including dementia (a group of symptoms affecting thinking and social abilities interfering with daily functioning) and cerebrovascular accident (CVA, or stroke, a condition resulting from a lack of oxygen in the brain potentially causing a loss of sensory…

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

Based on observation, interview and record review, the facility failed to provide quality care and services for three of 27 sampled residents (Residents 42, 98 and 99) when: 1. Resident 98 had a diagnosis of diabetes mellitus (DM, a condition which affects the way the body processes blood sugar) and licensed nurses did not properly manage an episode of hyperglycemia (high blood sugar). 2. Resident 99 had a change of condition and nursing staff failed to adequately monitor the resident up to the time she was transferred to an acute care hospital. 3. Resident 42 had a generalized red, itchy rash and nursing staff did not provide appropriate incontinence care when paper towels were used. These failures had the potential to cause health complications to Resident 98 and 99, and to cause discomfort to Resident 42. Findings: 1. Review of Resident 98's record indicated he was admitted with diagnosis including diabetes mellitus with hyperglycemia and exocrine pancreatic insufficiency (inability to properly digest food from a lack of digestive enzymes made by the pancreas). Resident 98 had…

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 prevent accidents for one of 27 residents (Resident 83) when the interdisciplinary team (IDT- group of different disciplines that meet to discuss and review resident care needs) When Resident 83 fell three times in the facility and the IDT did not discuss and evaluate the root causes for these falls. This failure resulted in Resident 83's multiple falls and one fall resulted with lower inner lip laceration. Findings: Review of Resident 83's face sheet (document that contains the resident's key information) indicated he was admitted to the facility on [DATE] with diagnosis including difficulty in walking, muscle weakness (decrease in strength in one or more muscles), lack of coordination, repeated falls and dementia (decline in mental capacity affecting thinking and social abilities interfering with daily functioning) with behavioral disturbance. Review of Resident 83's minimum data set (MDS, an assessment tool) dated 7/9/19, indicated his cognition was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure staff had coordinated residents' care with the dialysis facilities for two of two sampled residents 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) for Residents 78 and 380 when: 1. Resident 78 had two physician's orders indicating different amounts of fluids he was allowed to consume and his care plan was not revised to indicate his dialysis access site and care had changed. 2. Resident 380 had incomplete communication between the facility and dialysis center. This failure had the potential to result in a break with continuity of care and in causing resident health complications. Findings: 1. During an observation on 8/13/19 at 8 a.m., Resident 78 did not have a permacath (long, flexible tube inserted into a vein most commonly in the neck and into the heart to allow dialysis to occur) in place.…

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 timely replace one of 13 emergency kits (E-Kit, emergency medications that needed for immediate administration) medications from the provider pharmacy. This failure had the potential to cause delay in treatment and compromise residents' medical health. Findings: During a medication storage observation and concurrent interview with unit manager A (UM A) on 8/11/19 at 9:19 a.m., a requisition slip indicated the intravenous (IV) E-Kit was opened on 8/3/19. UM A confirmed the IV E-Kit was opened eight days ago. She confirmed a replacement for the IV E-Kit had not been delivered. Review of the facility's policy, Medication Ordering and Receiving from Pharmacy Provider dated 9/10, indicated Emergency medications and supplies are provided by the pharmacy in compliance with the applicable state and federal regulations. According to the California Code of Regulations, Chapter 3. Skilled Nursing Facilities: § 72377(b)(2), indicated emergency drugs shall be replaced within 72 hours.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of 27 sampled residents (Resident 39) was free from unnecessary drugs when Resident 39's A1C (A1C test result reflects the average blood sugar level for the past two to three months) laboratory sample was not drawn for monitoring. This failure had the potential affect Resident 39's medical condition. Findings: Review of Resident 39 clinical record, indicated she was admitted to the facility on [DATE] with diagnoses including diabetes mellitus (DM, chronic disease characterized by high levels of sugar in the blood). Resident 39's current physician (MD) orders included an order for insulin (a hormone that lowers the level of sugar in the blood) glargine (type of long-acting insulin) solution 12 units subcutaneous at bedtime related to type 2 DM and laboratory (lab) order for A1C for the use of insulin every [DATE] and August 4. Resident 39's clinical record indicated the last A1C result was drawn on 12/21/18. During an interview 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 observation, interview and record review, the facility failed to ensure a pureed diet was provided to one of 27 sampled residents (Resident 116) per order when the certified nursing assistant B (CNA B) assisted fed Resident 116 with regular scrambled eggs and bacon during breakfast. This failure had the potential to prevent meeting Resident 116's special dietary needs. Findings: 1. Review of Resident 116's clinical record indicated he had diagnoses including dysphagia (difficulty swallowing) and multiple sclerosis (MS, a long-term progressive disease can affect central nervous system to disable functional of body). Review of Resident 116's physician's orders dated 7/9/19, indicated the physician prescribed a fortified diet, with pureed texture and thin liquids consistency. Review of Resident 116's a care plan dated 7/10/19, indicated he was identified at risk for aspiration. During an observation on 8/13/19 at 8:24 a.m., CNA B assist fed Resident 116 with regular scrambled eggs. During a concurrent interview with CNA B, she stated she also fed Resident 116 two pieces 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 record review, the facility failed to ensure garbage was disposed properly when one of three facility dumpsters lid was left opened. This failure had the potential to result in spread of disease from vermin infestation and unsanitary environment for the residents. Findings: During a concurrent observation and interview with the maintenance director (MD) on 8/12/19 at 3:49 p.m., the lid of one dumpsters located near the kitchen was not closed. The MD confirmed this observation. Review of the facility's policy, Waste Management/Disposal, dated 3/25/11, indicated dumpster lids are to be closed at all times. According to the FDA Food Code 2017 as specified in paragraph 5-501.113, Covering Receptacles, indicated waste handling for refuse shall be kept covered.

Based on observation, interview and record review, the facility failed to coordinate care with a hospice provider (service that provides care for the sick or terminally ill) for one of one sampled resident (Resident 99) who was on hospice services. There was no hospice calendar and facility staff did not follow-up on hospice notes of Resident 99's desire to change her diet and a black discoloration of her right foot. These failures had the potential of not meeting the needs or not improving the quality of life for the resident. Findings: Review of Resident 99's clinical record, indicated she was admitted to hospice services on 7/12/19 and had diagnoses including peripheral vascular disease (poor circulation to the extremities) and chronic ulcer of right lower leg. Resident 99's physician's order dated 6/14/19 indicated to provide a no added salt pureed texture, thin liquids consistency. Resident 99 did not have a current wound treatment order to her right foot. During an observation and interview on 8/11/19 at 8:54 a.m., Resident 99 was eating breakfast and consumed about 25% of her…

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.