San Juan Hills Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure the monitoring of output and fluid restriction were followed for two of two final sampled residents (Residents 71 and 72) reviewed for dialysis. * The facility failed to ensure the output was properly monitored for Resident 71. * The facility failed to ensure the physician's order for 1500 ml of fluid restriction was followed and carried out accordingly for Resident 72. These failures had the potential of not identifying potential negative outcomes for the dialysis residents.Findings: Review of the facility's P&P titled Intake, Measuring and Recording revised 10/2010 showed the purpose of this procedure is to accurately determine the amount of liquid a resident consumes in a 24-hour period. If the resident is medically capable of understanding the procedure, ask him or her to assist you in telling you when he or she drank some fluid and how much he or she drank. Record the fluid intake as soon as possible after 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, medical record review, and facility P&P review, the facility failed to ensure one of three final sampled residents (Resident 72) reviewed for the use of bed rails remained free from accident hazards associated with the use of elevated bed rails. * The facility failed to ensure the physician's order was obtained for the use of the right upper bed rail for Resident 72. In addition, an IDT assessment was not conducted prior to the use of the right upper bed rail. This failure had the potential to put the resident at risk for serious injuries.Findings: Review of the facility's P&P titled Bed Rails - Safe Use Policy revised 10/2025 showed the following:- when bed rail use is desired/considered, Resident's sleeping environment shall be assessed by the Interdisciplinary Team, considering safety needs, entrapment risks, medical conditions/symptoms, cognitive/behavioral status, functional needs, comfort, freedom of movement, and input from the resident and family regarding previous…

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, facility document review, and facility P&P review, the facility failed to ensure the food items were served in the appetizing and safe temperatures. * The food temperatures were above the recommended temperature for cold desserts. This failure posed the risk of not providing safe food for the residents receiving a meal tray from the kitchen.Findings: Review of the facility's Diet Type Report dated 1/20/26, showed 42 of 42 residents consumed the food prepared in the kitchen. According to the USDA Food Code 2022 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding, bacterial growth and/or toxin production can occur if time/temperature control for safety food remains in the temperature Danger Zone of 5 degrees Celsius to 57 degrees Celsius (41 degrees Fahrenheit to 135 degrees Fahrenheit) too long. Maintaining temperature controlled foods under the cold temperature control requirements prescribed in this code will limit the growth of pathogens that may be present in or on the food and may help prevent foodborne illness. Review 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 facility document review, the facility failed to ensure the Facility Assessment was complete. * The facility failed to ensure the Facility Assessment addressed or included the active involvement of required individuals in developing the Facility Assessment and resources necessary to care for residents including weekends. This failure had the potential not to meet the residents' care needs if the assessed population's needs and resources were not comprehensively identified and addressed.Findings: According to the CMS QSO-24-13-NH dated 6/18/24, with an implementation date of 8/8/24, CMS had issued a revised guidance for long-term care facility assessment requirement. The Facility Assessment should address and included the active involvement of the direct care staff in developing the Facility Assessment. Also included the staffing resources necessary to care for the residents, including the weekends; a plan to maximize recruitment and retention of direct care staff member, and a contingency…

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, medical record review, facility document review, and facility P&P review, the facility failed to ensure the residents' entrapment assessments were completed and the measurements were recorded during the bed inspection when identifying areas of possible entrapment with the use of side rails for two of three final sampled residents (Residents 72 and 75) reviewed for side rails use. * The facility failed to ensure the entrapment assessment of bed rails were completed for Residents 72 and 75. These failures had the potential to negatively impact the residents resulting in possible entrapment, serious injury, and death.Findings: According to the Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, the term entrapment describes an event in which a patient/resident is caught, trapped, or entangled in the space in or about the bed rail, mattress, or hospital bed frame. Patient entrapment may result in deaths and serious injuries. These entrapment events 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to notify the physician when the resident had a change in condition for one of three sampled residents (Resident 1). * The facility failed to notify the physician when Resident 1 had low blood pressure readings. This had the potential for a delay in the physician prescribing necessary treatments and interventions for the resident.Findings: Review of the facility's P&P titled Administering Medications revised 12/2012 showed if a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication shall contact the resident's Attending Physician of the facility's Medical Director to discuss the concerns. Review of the facility's P&P titled Change in a Resident's Condition or Status revised 5/2017 showed our facility shall…

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, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary care and services for one of four sampled residents (Resident 1). * The facility failed to properly assess Resident 1's bowel function and provided the timely interventions as ordered by the physician when Resident 1 had no bowel movement. This failure posed a risk for the resident not to receive the necessary care and interventions to maintain the resident's normal bowel function.Findings: Review of the facility's P&P titled Bowel and Bladder Program revised 6/2021 showed it is the policy of this facility that the bowel and bladder assessment of the resident will be performed to attain and maintain the highest bowel and bladder function. Closed medical review for Resident 1 was initiated on 7/15/25. Resident 1 was admitted to the facility on [DATE], and discharged on 6/6/25. Review of Resident 1's Care Plan Report showed a care plan problem initiated on 5/28/25, addressing…

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 ensure the sanitary conditions in the satellite and main kitchens. This failure posed the risk of food services not meeting professional standards Findings: Review of the Residents' Order Summary Report dated 11/12/24, showed 41 of 42 residents received meals prepared in the facility's kitchen. 1. On 11/12/24 at 0750 hours, an inspection of the facility's satellite kitchen was initiated. The following findings were observed: - a plastic see through container of juice was observed defrosting under running water in the hand wash sink of the satellite kitchen. The sink was observed with yellow and black stains, and a piece of wet paper towel in it. When asked about this finding, Dietary Aide 1 verified the findings. - a gnat was observed flying inside the satellite kitchen. - the portable plate lowerator was observed with rust. CDM 1 verified the finding and verified there was no cleaning log for the lowerator. - the drain near the dishwasher was dirty and with food particles in it. CDM 1 verified the finding. b. On 11/12/24 at…

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 medical record review, the facility failed to ensure the self-administration of medications was safe for one of 14 final sampled resident (Resident 132) and one nonsampled resident (Resident 14). This failure had the potential to negatively impact the residents' physiological well-being and administer the medications inaccurately. Findings: 1. During an initial tour of the facility on 11/12/24 at 0814 hours, a concurrent observation and interview with Resident 132. Resident 132 was observed lying in bed. Resident 132 was noted with one bottle of Biotin (supplement) 10,000 mcg, one bottle of coconut oil extra virgin oil 1000 mg, one bottle of hair growth medication on the TV (television) stand drawer. Resident 132 stated she had been taking the medications since she was admitted in the facility. On 11/12/24 at 0823 hours, an observation and concurrent interview with the MDS Coordinator was conducted. The MDS Coordinator was asked about the process of self-administering…

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, facility document review, and facility P&P review, the facility failed to address the concerns brought forth in the resident council meetings (a group of residents gathered to discuss interest and issues noted in the facility) and failed to notify two nonsampled residents (Residents 12 and 137) who filed the grievances regarding the outcomes of investigation. These failures had the potential for the residents' identified issues to go uncorrected. Findings: Review of the facility's P&P titled Resident Council revised 4/2017 showed a Resident Council Response Form will be utilized to track issues and their resolution. The facility department related to any issues will be responsible for addressing the item(s) of concern. Review of the facility's Resident Council Departmental Feedback Form showed the Department to return the response to the Activity Director within two to three days of the meeting date. a. Review of the facility's document titled Resident Council Meeting Agenda & Notes dated 8/9/24, showed the following concerns: - The staff were loud 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of one final sampled resident (Resident 16) who had a mental disorder was referred to state PASARR representative for Level II evaluation and determination screening process. This failure pose risk for the resident not to receive adequate level of services, comprehensive assessment, intervention, and evaluation for conditions related to mental disorder. Findings: Review of the facility's P&P titled Preadmission Screening & Resident Review (PASRR) dated 11/30/23, showed the facility will confirm the PASARR process was completed by the hospital by accepting and reviewing the PASRR documentation submitted. If the facility determines that the hospital did not initiate the PASARR, the facility will contact the hospital and request to initiate the file exchange prior to discharge. Medical record review for Resident 16 was initiated on 11/12/24. Resident 16 was admitted to the facility on [DATE]. Review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, facility's P&P review, and facility document review, the facility failed to provide the safe environment free from potentially serious accident hazards for two of two final sampled residents (Residents 383 and 432) who smoked in the facility. - Resident 383 was not accurately and thoroughly assessed to determine if they required supervision or any adaptive equipment while smoking, nor if they could safely store their own cigarettes or lighters. - Resident 432's smoking paraphernalia was left unsupervised. The residents who were assessed as requiring supervision or those with a history of non-compliance with the facility's smoking P&P were permitted to keep the cigarettes, lighters, and other smoking materials in their possession. - The facility failed to ensure the designated area for smoking outside the facility have readily available and accessible portable fire extinguishers and fire-retardant smoking aprons as per the facility's smoking P&P. These…

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, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for one of 14 final sampled residents (Resident 285) and one nonsampled resident (Resident 436) to maintain or restore their bladder functions. * The facility failed to provide a bladder retraining for Resident 285 as identified in the care plan and facility's P&P. * The facility failed to ensure Resident 436 was placed on toileting program and a care plan to address Resident 436's toileting needs was developed. These failures posed the risk for these residents to lose their bladder control. Findings: Review of the facility's P&P titled Bowel and Bladder Program dated 6/2021 showed on admission of the resident, the admission nurse will initiate an elimination schedule every two hours regardless if the resident is continent or incontinent. The admission Nurse will communicate to the CNAs and licensed nurse. The CNAs will document the result of their visit with 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, medical record review, and facility P&P review, the facility failed to ensure two of two final sampled residents (Residents 132 and 282) reviewed for respiratory care were provided with the appropriate respiratory care. * The facility failed to ensure Residents 132 and 282's physician's order for administration of oxygen was clarified with the physician for continuous or PRN use. This failure had the potential to effect the respiratory health and well-being of the residents. Findings: Review of the facility's P&P titled Oxygen Administration revised October 2010 showed to verify there is a physician's order for this procedure and review the physician's order or facility protocol for the oxygen administration. 1. On 11/13/24 at 1441 hours, Resident 132 was observed in bed with oxygen via nasal cannula at 2 liters per minute. Medical record review for Resident 132 was initiated on 11/13/24. Resident 132 was admitted to the facility on [DATE]. Review of Resident 132's Order Summary…

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, facility document review, and facility P&P review, the facility failed to ensure the pharmaceutical services were provided when: * The facility failed to ensure all controlled medications were accurately accounted for and documented for one of 14 final sampled residents (Resident 432). * The medications received from pharmacy were accounted and signed for by the licensed staff who received the medications at the facility. * The facility failed to ensure the proper disposal of medications was followed. These failures posed the risk of drug diversion. Findings: 1. Review of the facility's P&P titled Medication Storage in the Facility ID3: Controlled Medication Storage dated 8/2014 showed the medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handing, storage, disposal and recordkeeping in the facility in accordance with federal, state and other applicable laws and regulations. Further review of the facility's P&P showed at each shift change, a physical inventory of all…

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, medical record review, and facility P&P review, the facility failed to ensure the orthostatic blood pressure monitoring was accurately performed as ordered by the physician related to the use of antipsychotic medication for one of one final resident (Resident 132) reviewed for antipsychotic medications. This failure had the potential for the resident to have adverse complications from the medication and the potential of not providing the correct data to the prescriber to adjust the dose of the psychotropic medication for the resident. Findings: Review of the facility's P&P titled Measuring Blood Pressure dated 9/2010 showed the orthostatic (postural) hypotension is defined as a 20 mm/hg (or greater) decline in systolic blood pressure (top number) or a 10 mm/hg (or greater) decline in diastolic blood pressure (bottom number) upon standing. Note the changes in both systolic and diastolic measurements compare to the reading taken while the resident was in a seated position. Medical record review…

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, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 7.14% One licensed nurse (LVN 4) was found to have made error during the medication administration. * Resident 134 had a physician's order for Calcium Carbonate Tablet Chewable 500 mg one tablet by mouth one time a day for indigestion, chew and swallow. LVN 4 did not administer the medication as ordered by the physician. * Resident 4 had a physician's order for Effexor XR (medication to treat depression) Oral Capsule Extended Release 24 hour 75 mg one capsule by mouth one time a day for depression m/b persistent expression of hopelessness, give with food. LVN 4 did not administer the medication with food as ordered by the physician. These failures resulted in the residents not receiving the medications as ordered by the physicians, posed the risk of adverse effects, and had the potential to negatively affect the 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 observation, interview, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure the proper medication storage. * The facility failed to ensure the expired treatment medications were removed from the medication cart. * The facility failed to ensure to separate the externally and internally medications from the medication cart and Medication Room A. * The facility failed to ensure proper storage of feeding formula and temperature monitoring. These failures had the potential to negatively impact the residents' well-being, and medication errors. Findings Review of the facility's P&P titled Medication Storage in the Facility dated 4/2008 showed orally administered medications are kept separate from externally used medication, such as suppositories, liquids and lotion. 1.a. On [DATE] at 1046 hours, a medication cart inspection for Medication Cart A was conducted with RN 1. During the inspection of Medication Cart A, the following was observed: - seven individual packs…

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 P&P review, the facility failed to ensure the dietary staff were competent in the skills needed to carry out the functions of the food and nutrition services. This failure posed the risk of the residents not receiving appropriate food and nutrition services. Findings: Review of the Residents' Order Summary Report dated 11/12/24, showed 41 of 42 residents received food prepared from the kitchen. 1.a. On 11/12/24 at 0750 hours, a kitchen inspection of the facility's satellite kitchen was initiated with CDM 1. CDM 1 was asked about checking the dishwasher located inside the facility's kitchen. The dishwasher was observed to have a label with the words prewash temperature 120 degrees F. CDM 1 pointed to the label on the dishwasher and stated that was the cycle to check the temperature for the dishwasher. The temperature was a low temperature dishwasher and supposed to be checked during the wash cycle to ensure it was working properly. Review of the Temperature Log Dish Machine Low temp showed the wash cycle temperature was to be checked. 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 facility document review, the facility failed to ensure the menu and diet orders were followed as evidenced by: * Chicken salad was not documented on the cool down log. * The kitchen staff did not use the correct serving size scoop. * The temperatures for milk and cottage cheese were not taken at the tray line. Cottage cheese was not maintained at the acceptable temperature. * Plates of dessert were near the dirty sink. * Tray ticket was inaccurate for one of 14 final sampled resident (Resident 383) * Food item was not served as per the tray ticket for one nonsampled resident (Resident A). * The lunch tray included a food item not appropriate for the resident's prescribed diet order for one nonsampled resident (Resident 136). * The facility failed to ensure the menu and diet order were followed for one of 14 final sampled residents (Resident 9). These findings posed the risk of the residents not receiving nutritional adequacy. Findings: Review of the Residents' Order Summary…

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 follow the puree recipe for seven residents on puree diet. This failure posed the risk of the residents not receiving foods prepared by methods that conserve nutritive value. Findings: Review of the Residents' Order Summary Report dated 11/12/24, showed seven residents received puree food prepared from the kitchen. On 11/14/24 at 1000 hours, an observation of puree meals preparation was conducted with [NAME] 1. Cook 1 stated she was preparing puree the foods for a total of seven residents and would prepare the foods for 10 servings. During the puree preparation for peas, [NAME] 1 was observed adding chicken broth to the cooked peas while the recipe showed to add liquid used to cook peas. [NAME] 1 was then observed to keep adding thickener to obtain the right consistency for the peas and manually mixing the food item with a whisk. The recipe showed to use one and one half tablespoons of thickener. [NAME] 1 was then observed to puree other main entree items and continue to add multiple tablespoons of thickener to the 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.

Based on observation and interview, the facility failed to ensure the therapeutic diets were served as prescribed by the residents' physicians for one of 14 final sampled resident (Resident 16) and one nonsampled resident (Resident 284). * Resident 284 was not served the prescribed diet. * Resident 16 was served Magic cup (supplement) but not listed on the physician's orders. These failures had the potential for the residents not meeting the therapeutic needs. Findings: Review of the Residents' Order Summary Report dated 11/12/24, showed 41 of 42 residents received food prepared from the kitchen. 1. On 11/12/14 at 1120 hours, during a dining room observation, LVN 2 was observed checking the residents' meal trays against the residents' meal tickets. When asked about verifying diets against the physician's orders, LVN 2 verbalized she had most of the residents' diets memorized. When asked to check the meal served, meal ticket, and list of the physician's orders for Resident 284, LVN 2 stated the meal served was no added salt, regular diet while the physician's diet order showed no…

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

Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the infection control practices were followed for two of 14 final sampled residents (Resident 132 and 435) and one nonsampled resident (Resident 134); in the laundry area; hand washing; and preventing Legionella. * The facility failed to perform handwashing before and after assisting Resident 435 with meals * The facility failed to perform handwashing before and after medication administration for Residents 132 and 134. * The facility failed to ensure infection control practices was maintained in the facility's laundry room when a facility staff personal clothing was stored with the rack of clean pillows. * The facility failed to ensure the water management program was established and implemented to include the implementation of measures to prevent the growth of Legionella and other opportunistic pathogens; and a way to monitor the measures they had in place These failures posed the risk for transmission of disease-causing microorganisms 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, facility document review, and facility P&P review, the facility failed to monitor and address the use of antibiotics when the resident's condition did not meet McGeer's criteria (a set of specific definitions to identify true infections in long term nursing facilities) for two residents (one discharged resident, Resident 10; and one nonsampled resident, Resident 7) on the surveillance log. This failure had the potential for antibiotics to be used when it was not indicated and the development of antibiotic-resistant bacteria. Findings: Review of the facility's P&P titled Antibiotic Stewardship Program dated 6/2021 showed appropriate use of antibiotic included criteria met for clinical definition of active infection or suspected sepsis and pathogen susceptibility, based on culture and sensitivity, to antimicrobial (or therapy begun while culture is pending). The IP will track, collect and review data whether McGeer criteria was met to consider prescribing antibiotics. Review of the Survillance…

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 the freezer compartment inside the medication refrigerator inside Medication Room A was free of ice buildup. In addition, the facility failed to ensure the freezer temperature was monitored and recorded in the temperature log. These failure had the potential for not maintaining the acceptable temperature for medication storage in the refrigerator. Findings: Review of the facility's document titled Medication Room, Refrigerator, Temperature Log dated 11/2024 showed to verify and document refrigerator, freezer, and room temperatures twice per day (AM/PM). If any temperature is outside of the range(s) below, notify the Nurse Leader or Health Care Administrator. On 11/14/24 at 0837 hours, an inspection of Medication Room A and concurrent interview was conducted with the DON. On 11/14/24 at 0956 hours, during Medication Room A inspection, the medication refrigerator was observed to have ice build up in the freezer compartment. There were ice packs stored in the freezer compartment and there was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the residents' entrapment assessments were accurate and complete, and the measurements were recorded during the bed inspection when identifying areas of possible entrapment with the use of bed rails for one of 14 final sampled residents (Resident 132). This failure had the potential to negatively impact the resident resulting in possible entrapment, serious injury, and death. Findings: According to the Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, the term entrapment describes an event in which a patient/resident is caught, trapped, or entangled in the space in or about the bed rail, mattress, or hospital bed frame. Patient entrapments may result in deaths and serious injuries. These entrapment events have occurred in openings within the bed rails, between the bed rails and mattresses, under bed rails, between split rails, and between the bed…

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

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food safety and sanitation requirements were met in the kitchen when: * Time/Temperature Control for Safety (TCS) foods (food that require time and temperature controls to limit the growth of illness causing bacteria) were not accurately monitored to ensure proper cool down process was followed. * The thawing process for meats was not performed as per the facility's P&P. * The expired food item in the kitchen was not discarded and was consumed by the resident. * One kitchen staff and one maintenance staff did not perform proper hand hygiene in the kitchen. * The handwashing sink was used for duties other than handwashing. * Trash was stored inappropriately in the kitchen. * Two kitchen staff and one non-staff personnel did not don hair or beard coverings in the kitchen. * The kitchen utensils and equipment were not stored or kept in sanitary conditions. * The kitchen utensils were not in good condition. * The dry storage bin was not labeled correctly. * Food was not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to determine if it was safe for one of 12 final sampled residents (Resident 580) and one nonsampled resident (Resident 22) to self-administer the medication left at the bedside. * Resident 22 was observed with clobetasol propionate ointment (corticosteroid medication used to treat skin conditions) medication at bedside. Resident 22 did not have the assessment, physician's order, and care plan problem addressing the resident's self-administration of medication. * Resident 580 was observed with one bottle of Systane (eye drop lubricant) medication left unattended at bedside. Resident 580 did not have a physician's order, assessment, and care plan for self-administration of medications. These failures had the potential for Residents 22 and 580 to administer the medications inaccurately. Findings: Review of the facility's P&P titled Bedside Medication Storage dated 4/2008 showed the bedside medication storage is…

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, medical record review, and facility P&P review, the facility failed to ensure one of three closed record sampled residents (Resident 8) and/or their representative were provided with the written information regarding the facility's bed-hold policy when the resident was transferred to the acute care hospital. This failure had the potential for Resident 8 and/or their representative to be unaware of their rights to request a bed hold and return to the first available bed should the resident's hospital stay exceed the seven-day bed-hold period. Findings: Review of the facility's P&P titled Bed-Holds and Returns revised 3/2017 showed prior to transfer or therapeutic leave, the residents or resident representatives will be informed in writing of the bed-hold and return policy. Closed medical record review for Resident 8 was initiated on 11/15/23. Resident 8 was admitted to the facility on [DATE], and transferred to the acute care hospital on [DATE]. Review of the Resident 8's Progress Note showed…

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, medical record review, and facility P&P review, the facility failed to develop and implement the comprehensive person-centered care plan for one of the 12 final sampled residents (Resident 332). * The facility failed to implement the plan of care to provide the padded side rails for Resident 332. This failure posed the risk of not providing appropriate, consistent, and individualized care to Resident 332. Findings: On 11/14/23 at 0901 hours, and 11/16/23 at 1400, 1411, and 1430 hours, Resident 332 was observed lying in bed with a right side hand assist rail elevated. The hand assist rail was not padded. Medical record review for Resident 332 was initiated on 11/14/23. Resident 332 was admitted to the facility on [DATE]. Review of Resident 332's Order Summary Report showed the following physician's orders: - On 11/9/23, to administer lacosamide (antiseizure medication) 100 mg 1/2 tablet by mouth two times a day; and - On 11/14/23, to use the right hand-assist rails for bed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility document review, the facility failed to provide the individualized and ongoing activity program to meet the needs and interests of one of 12 final sampled residents (Resident 6). * The facility failed to provide activities for Resident 6 to meet the resident's identified interests. Resident 6 was provided with the children's coloring page, connect the dot activity sheet, and [NAME] sheet. This failure had the potential for Resident 6 to experience feelings of social isolation and frustration. Findings: On 11/14/23 at 1051 hours, Resident 6 was observed sitting in the activity room. When asked about the activities provided by the facility, Resident 6 stated the activities provided to her and the residents in the facility were for children. Resident 6 stated she was provided with children's coloring pages, and she wanted more productive activities. Medical record review for Resident 6 was initiated on 11/14/23. Resident 6 was readmitted to the facility on [DATE].…

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, medical record review, facility document review, and facility P&P review, the facility failed to ensure monitoring of the neurological status was conducted after a fall with head injury for one of 12 sampled residents (Resident 17). This failure had the potential for Resident 17 to not receive the necessary care and services. Findings: Review of the facility's P&P titled Falls Management Program revised 2019 showed the facility is to provide residents with hazard free environment, adequate supervision, and reduce risk factors leading to falls and injury. Further review of the the P&P showed neuro check will be initiated by the licensed nurse for unwitnessed fall and when there was identified head injury. Review of the facility's document titled Neurological Evaluation Flowsheet revised 11/2011 showed the following frequency to perform the neuro checks: - Every 15 minutes times for 1 hour; - Every 30 minutes for 2 hours; - Every 1 hour for 2 hours; and, - Every shift for 72 hours. Medical…

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, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care for two of 12 final sampled residents (Residents 1 and 581). * The facility failed to ensure Resident 1's nebulizer mask (a mask connected to a nebulizer machine used to deliver a liquid/ solution medication via inhalation directly into the lungs) was stored in the set-up bag when not in use and changed weekly as per the facility's P&P. In addition, the facility failed to ensure Resident 1's nasal cannula tubing was stored in the set-up bag when not in use as per the facility's P&P. * The facility failed to ensure Resident 581 received oxygen as ordered. These failures had the potential for these residents to not receive appropriate respiratory care, and for increased risks of infection and respiratory distress. Findings: 1. Review of the facility's P&P titled Departmental (Respiratory Therapy) - Prevention of Infection revised November 2011. under the Infection Control…

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, medical record review, facility document review, and facility P&P review, * The facility failed to ensure the narcotic disposition bin was securely locked and sealed. Furthermore, the narcotic disposition bin included whole pills of disposed controlled medications not fully dissolved. * The facility failed to ensure the controlled medications signed out of the controlled medication report was accurately reflected on the eMAR for one nonsampled resident (Residents 9). * The facility failed to ensure LVN 1 administered albuterol-ipratropium solution as ordered for one of 12 final smapled residents (Resident 1). These failures had the potential to negatively impact the residents' well-being. Findings: 1. Review of the facility's P&P titled Controlled Medication Disposal dated 1/2013 showed Schedule II-V controlled substances remaining in the facility after a resident has been discharged , or the order discontinued, are disposed of in the facility by the Director of Nursing or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of 12 final sampled residents (Resident 17) was free from unnecessary psychotropic drugs (any drug that affects brain activity associated with mental processes and behavior). * The facility failed to ensure nonpharmacological interventions were implemented for depression behaviors exhibited by Resident 17. This failure had the potential to place the resident at risk for receiving unnecessary medications and increased risk of serious medication adverse reactions. Findings: Review of the facility's P&P titled Use of Psychotropic Medication use dated 6/2021 showed in part, a psychotropic drug is any drug that affects brain activities associated with mental processes and behavior, which includes but is not limited to antipsychotics, anxiolytics, hypnotics, and antidepressants . Facility should involve the resident or the resident's representative(s) in the discussion of potential no-drug and medication 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.

Based on observation, interview, and facility P&P review, the facility failed to store medications, biologicals, and medical supplies in a safe manner. The facility also failed to replace three of four E-Kits (emergency medications in a portable sealed containers) within 72 hours of opening as required by the facility's P&P. * The facility failed to ensure the expired medications and medical supplies were not available for resident use. This failure had the potential for the outdated medications and medical supplies to be accidentally administered and/or used and the IV medical supplies not maintaining sterility (free from germs). * The facility failed to replace the IV, controlled medication, and oral E-kits within 72 hours of opening the kits. These failures had the potential for the medications not to be available when needed for the residents, resulting in poor resident outcomes. Findings: 1. Review of the facility's P&P titled Storage of Medications dated 4/2008 showed outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or…

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

Based on observation, interview, and facility document review, the facility failed to ensure the following: 1. Federal regulations related to the oversight of food service operations were followed when the facility did not employ of a full-time qualified individual, defined as 35 hours per week, to manage and oversee food operation services for the skilled nursing facility. 2. The Certified Dietary Manager who was responsible to oversee the main kitchen which produced food for the skilled nursing facility was competent in managing the day-to-day functions of the food services department. Failure to employ staff with the skills and abilities to effectively implement departmental processes in accordance with standards of practice, may jeopardize the health and well-being of the 33 residents who received food prepared in the kitchen. Findings: Review of the facility's matrix showed 33 residents who consumed food prepared in the kitchen. 1. According to the California Code, Health, and Safety Code - HSC § 1265.4: A licensed health facility shall employ a full-time, part-time, or…

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

Based on observation, interview, facility document, and P&P review, the facility failed to ensure the kitchen staff had the skill set necessary to safely perform manual dishwashing in the event of an emergency when one of one diet aides was not competent to describe or demonstrate the manual dishwashing process used in an emergency. This failure had the potential for resident dishes to not be washed correctly in an emergency which could lead to sanitation concerns. Findings: Review of the facility's P&P titled How to Clean and Sanitize Pots, Pans, Utensils, and Dishes dated 2019 showed 1) Fill appropriate temperature water to fill lines. Add appropriate amount of detergent and sanitizer. Test and record on Pot and Pan Litmus Test Log. Scrape and flush out food particles. 2) Wash with detergent (100-120 degrees F). Change water every 30 minutes. 3) Rinse (110-120 degrees F). Change water frequently. 4) Sanitize - test with appropriate litmus test strips and leave in sanitizing solution for appropriate contact time. 5) Air dry - do not towel, inspect, and store dry. Review 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, facility document review, and facility P&P review, the facility failed to ensure the food items brought to the facility for the residents were stored or reheated for future resident consumption; and failed to ensure education was provided to staff and family/visitor regarding safe handling of the food brought into the facility. These failures had the potential to limit the residents' rights and enjoyment of food brought in by the family or visitors. Findings: Review of the facility's P&P titled San [NAME] Hills Foods Brought by family/Visitors Policy revised 10/23 showed (6) Perishable foods will not be stored in facility. Perishable foods can be brought in by family members and checked by nursing and can be used by residents on that meal; the leftover will be discarded after two hours. On 11/16/23 at 0840 hours, an interview was conducted with LVN 1. LVN 1 stated when family or visitors brought in outside food, the staff would check the food to ensure appropriate diet. LVN 1 stated he…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to monitor and address the use of antibiotics when the resident's condition did not meet McGeer's criteria (a set of specific definitions to identify true infections in long term nursing facilities) for one of four nonsampled residents (Resident 632). This failure had the potential for antibiotics to be used when it was not indicated and the development of antibiotic-resistant bacteria. Findings: Review of the facility's P&P titled Antibiotic Stewardship- Order for Antibiotics dated December 2016 showed appropriate use of antibiotic included criteria met for clinical definition of active infection or suspected sepsis and pathogen susceptibility, based on culture and sensitivity, to antimicrobial (or therapy begun while culture is pending). Review of the facility's P&P titled Antibiotic Stewardship- Review and Surveillance of Antibiotic Use and Outcome revised December 2016 showed the IP or designee, will review antibiotic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the essential equipment were maintained in safe operating condition when: * Two ice machines were not cleaned and/or sanitized as per the manufacturer's guidelines. * The [NAME] dishwashing machine temperature was not monitored as per the dishwashing machine and facility P&P guidelines; and the temperature dial for the dishwashing machine failed to accurately measure the water temperature. These failures had the potential for equipment to not function in the way they were intended to. Findings: 1. Review of the facility's P&P titled Ice Machine Cleaning Procedures dated 2018 showed to clean inside of the ice machine with a sanitizing agent per the manufacturer's instructions. Review of the Hoshizaki America, INC Low-Profile Modular Crescent Cuber Cleaning and Sanitizing Instructions dated 8/19/13, showed for sanitizing: dilute a 5.25% sodium hypochlorite solution (chlorine bleach) with warm water .…

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, medical record review, and facility P&P review, the facility failed to ensure the residents' entrapment assessments were accurate and complete, and the measurements were recorded during the bed inspection when identifying areas of possible entrapment with the use of bed rails for all three residents with side rails. These failures had the potential to negatively impact the residents resulting in possible entrapment, serious injury, and death. Findings: According to the Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, the term entrapment describes an event in which a patient/resident is caught, trapped, or entangled in the space in or about the bed rail, mattress, or hospital bed frame. Patient entrapments may result in deaths and serious injuries. These entrapment events have occurred in openings within the bed rails, between the bed rails and mattresses, under bed rails, between split rails, and between the bed rails and head or foot boards. 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.