San Mateo Medical Center D/P SNF

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the annual Minimum Data Set (MDS, a federally mandated resident assessment tool) assessment was completed within the required period of 14 calendar days from the Assessment Reference Date (ARD, specific endpoint for the look-back periods in the MDS assessment process) for one of 35 sampled residents (Resident 165).Failure to complete a comprehensive resident assessment within the required timeframe could result in delayed identification of needs and significant issues that may affect the physical, mental, and psychosocial well-being of Resident 165.Review of Resident 165's admission record indicated, was admitted to the facility on [DATE]. Review of Resident 165's annual MDS assessment with an ARD of 5/14/25, indicated, the assessment was signed as complete by the Registered Nurse (RN) Assessment Coordinator on 6/2/25, 19 days after the ARD. During a concurrent record review and interview on 7/3/25 at 4:07 PM, the MDS Coordinator (MDSC) reviewed…

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 a Significant Change in Status Assessment (SCSA - a comprehensive assessment for a resident that must be completed when the IDT has determined that a resident meets the significant change guidelines for either major improvement or decline) for one of one sampled resident (Resident 53) when Resident 53 was admitted for hospice services.This failure could potentially delay the provision of appropriate treatment and services for Resident 53.Resident 53 was admitted on [DATE] with diagnoses that included cerebral infarction (also known as ischemic stroke, a medical condition where a part of the brain is damaged due to a lack of blood supply), hemiplegia (paralysis on one side of the body), and hemiparesis (condition characterized by weakness on one side of the body).During a concurrent interview and record review on 7/2/25 at 9:48 AM, with the MDS Coordinator (MDSC), Resident 53's Minimum Data Set (MDS - a resident assessment tool) with 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.

Based on observation, interview, and record review, the facility failed to ensure safe medication administration for one of five residents (Resident 182) when Licensed Vocational Nurse (LVN) 1 did not observe Resident 182 take his medication after leaving one prescription medication on the overbed table with the presence of an ambulatory roommate. The deficient practice resulted in a medication error for Resident 182; and may result in medication error and/or adverse health reactions when taken by the roommate. During medication pass observation on 7/2/25 at 9:20 AM, LVN 1 prepared fifteen (15) medications for Resident 182 including ClearLax Polyethylene Glycol 3350 Powder for Solution (used to treat occasional constipation). LVN 1 filled the measuring cap (purple bottle cap/cover) up to the rim which was above the 17 grams (g) mark (or line) and poured it in a cup with seven (7) ounces of water. During concurrent interview, LVN 1 was not aware of the 17 g mark/line inside the cap and stated that 17 g of the ClearLax was measured up to the rim of the cap. Review of Resident 182's…

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

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 to one of three sampled residents (Resident 14) who had an indwelling urinary catheter, by failing to consistently monitor for catheter kinks.This deficient practice had the potential for Resident 14 to develop urinary tract infection.Definition of Terms:The MedicineNet Medical Dictionary define indwelling Foley catheter as a flexible plastic tube (a catheter) inserted into the bladder that remains ( dwells) there to provide continuous urinary drainageUrinary Tract Infection (UTI) - an infection in any part of the urinary system -the kidneys, ureters, bladder, and urethraCatheter-Associated Urinary Tract Infection (CAUTI) - occurs when germs enter the urinary tract through a urinary catheter and cause infectionDuring an observation on 6/23/25 at 10:13 AM, Resident 14 was in bed, with a Foley catheter attached to a collecting bag. Light yellowish urine was noted on the tubing, not draining to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the consultant pharmacist's (CP) recommendation for the use of psychotropic medication was acted upon for one of six sampled residents (Resident 53).This failure had the potential for Resident 53 to receive unnecessary psychotropic medication, be exposed to adverse health consequences from the medication, which could negatively impact the resident's mental, physical, and psychosocial well-being.Resident 53 was admitted on [DATE] with diagnoses that included cerebral infarction (also known as ischemic stroke, a medical condition where a part of the brain is damaged due to a lack of blood supply), hemiplegia (paralysis on one side of the body) and hemiparesis (condition characterized by weakness on one side of the body). Resident 53 was in hospice care.Review of Resident 53's Order Review History Report for the month of June 2025 indicated, .Lorazepam (medication used to treat anxiety) Oral Tablet 0.5 mg (milligram) Give 1 tablet via G-tube…

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 pneumococcal immunization (known as pneumococcal vaccination, refers to the process of administering vaccines to protect against pneumococcal disease, caused by the bacteria Streptococcus pneumoniae, also known as pneumococcus. These vaccines work by triggering the body's immune system to produce antibodies that fight off the bacteria, preventing or reducing the severity of these infections) for one of 5 sampled residents (Resident 650) when there was no evidence that the pneumococcal vaccine was given to Resident 650 even after a phone consent had been received from the responsible party on 2/26/25.This failure had the potential to result in putting Resident 650 at risk for acquiring (getting), transmitting (causing infections to pass on from one place or person to another), or experiencing complications from pneumococcal disease.Review of Resident 650's clinical record indicated, Resident 650 was admitted to the facility with diagnoses…

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 COVID-19 immunization (also known as COVID-19 vaccine that helps our bodies develop immunity to the virus that causes COVID-19 without us having to get the illness. Different COVID-19 vaccines may work in our bodies differently, but all provide protection against the virus that causes COVID-19) for one of 5 sampled residents (Resident 650) when there was no evidence that the COVID-19 vaccine was given to Resident 650 even after a phone consent had been received from the responsible party on 2/26/25.This failure had the potential to result in putting Resident 650 at risk for acquiring (getting), transmitting (causing infections to pass on from one place or person to another), or experiencing complications from Coronavirus disease (COVID-19, an infectious disease caused by the SARS-CoV-2 virus. Most people infected with the virus will experience mild to moderate respiratory illness and recover without requiring special treatment. However, some…

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

Based on interview and record review, the facility failed to conduct a thorough investigation into an allegation of sexual abuse between Resident 116 and Resident 223, 2 of 8 sample residents with allegations of abuse. Failure to thoroughly investigate an allegation of abuse did not ensure other residents were protected from abuse.Findings: Review of a facility's document titled Re: Five (5) Days Summary of Investigation, dated 05/30/2025, indicated .On 05/27/2025; .(Resident 223) told the receptionist on duty .that his male friend .(Resident 116) went to his room to visit him.However, this time on his visit, .(Resident 116) showed his private part(penis) and asked .(Resident 223) to touch it. On 06/26/2025 at 09:00 AM the Director of Nursing (DON) was asked to provide all documents regarding the facility's investigation into this allegation. Review of the documents requested, not titled and not dated, indicated the facility interviewed and assessed both Residents 116 and Resident 223. There was also a statement made by Activity Staff 1 (AS 1) who witnessed the alleged incident.…

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 serve food and substitutes according to residents' preferences when: Residents with food preferences such as Jook and soups were not honored. This failure has the potential to deny the basic rights of 31 residents in a census of 264 residents to receive the services and care necessary to achieve or maintain their quality of life. Findings: During a concurrent observation and interview with cook1 on 3/12/24 at 10:45 AM in the kitchen, observed him cooking pasta in a large skillet. He stated, today, we will serve meatballs, pasta, and spinach. During tray line observation, interview, and record review on 3/12/24 between 11:15 AM to 2:30 PM in the kitchen, observed some Residents' meal tickets indicated, likes Jook (porridge or Congee) and/or soup. During an interview with kitchen aide1, inquired, what is Jook? Kitchen aide1 stated, Jook is rice soup. There is no jook or soup today. During tray line observed several residents' meal tickets…

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 meals according to the facility's serving hour schedule when: During mealtimes observation, the meal cart was observed arriving late on the second floor for breakfast and lunch. This failure to follow the 14-hour rule for mealtimes especially at breakfast time have the potential to deny the residents patient centered care that will affect their psychosocial well-being and health outcome. Findings: During a concurrent observation and interview on 3/11/24 at 10:15 AM, observed staff passing out trays into residents' room on the second floor. One HFEN Surveyor stated, they are just serving breakfast. During an interview with a certified nursing assistant (CNA5) on 3/11/24 at 10:26 AM on the second floor, she stated, yes, every day, the meal cart is always late. Breakfast just came in. During an interview with the Dietary Manager (DM) at 11 AM in the kitchen, the DM stated, the meal cart starts to go out at . Breakfast is served between 7 - 9AM, lunch at 11:30 -1:30 PM and dinner at 5-7 PM. During 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 ensure food safety requirements in accordance with professional standards for food service when: 1. Serving plastic bowls, large plastic food containers and baking pans were not dried appropriately. 2. Plate warmers were not cleaned. 3. Serving trays were stacked and stored on a dusty cart outside of the kitchen door. 4. The kitchen staff still uses the hand sanitizer in the kitchen. 5. Bowls of cream of rice and bowls of oatmeal in the refrigerator were undated. 6. Two packs of grapes in the refrigerator were overripe, and some of them were mushy. The failure to store, serve, hand sanitize and distribute food in an unsafe and sanitary manner had the potential to put residents at risk for foodborne illness leading to severe illness and even death for 262 residents who consumed food by mouth. Findings: 1.During a concurrent observation, interview, and record review in the kitchen with the facility's Consultant, the Regional Registered Dietician (RD) on 3/11/24 at around 10:30 AM, observed on the rack by the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure dignity and respect were maintained for one sampled (Resident 255) and two random residents (Residents 165 and 162) when: 1. Staff stood over Resident 255 and Resident 165 to assist with meals. 2. Facility failed to provide access to communication with staff in a language that is clear and understandable to the resident when a language translation service was not available for use by Resident 162. These deficient practices would not allow for social interaction and had the potential to lower Resident 255 and Resident 165's self-esteem and had the potential for Resident 162 to feel frustrated for being unable to communicate with staff and relaying her needs and concerns and had the potential for the other residents with limited proficiency in English to not have access to communication with persons inside and outside the facility. Findings: 1. Resident 255 was admitted on [DATE] with diagnoses including dementia (the loss of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record reviews, facility did not ensure hospice services and interventions were addressed for three of five residents (Resident 155, Resident A, Resident B) when: 1. No coordination for plan of communication with facility and hospice agency regarding changes in Resident A's condition and death, and the staff were not trained on the protocol of who is the responsible provider for each specific function, to notify family,MD and Hospice. 2. The care plan did not include specific interventions of coordination of care between facility and hospice agency for Resident 155 and Resident B. These failure resulted in family not notified of change in condition and death of Resident A, and had the potential to result in not providing the needed treatment care and services for Resident 155 and Resident B. Findings: 1. During a review of Resident A's admission Record, dated [DATE], indicated, resident admitted on [DATE] original date. admitted to Palliative Care on [DATE] with the diagnosis…

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 three of three sampled residents (Residents 66, 118, and 255) were free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behavior) when: 1. For Resident 66, consent was not obtained for the use of Mirtazapine (medication used to treat depression). 2. For Resident 118, consents were not obtained for the use of Aripiprazole (medication used to treat depression and Tourette syndrome [a nervous system disorder involving repetitive movements or unwanted sounds]), Haloperidol (medication used to control symptoms of Tourette syndrome), and Buspirone (medication used to treat anxiety [[a feeling of fear, dread, and uneasiness]). 3. For Resident 255, consents were not obtained for the use of Lorazepam (medication used to treat anxiety) and Trazodone (medication used to treat depression), and order for Lorazepam PRN (as needed) did not have a stop date. These deficient practices had the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure medications were not expired and stored properly when: 1. One out of six sampled medication carts had two prescription eye drops that were found to be expired or not labeled after opening, 2. Multiple medications were found to be stored in the garage without temperature control. This failure has the potential to result in medications being administered to residents that are expired, ineffective, or potentially hazardous to the resident. Findings: 1. During a concurrent observation and interview on [DATE] at 3:23 PM with Licensed Vocational Nurse (LVN) 3 at the Unit 3 nurse's station, an opened Latanoprost Ophthalmic solution (eye drops used to lower pressure in the eyes) was observed inside the medication cart drawer. The ophthalmic solution had an open date of [DATE] and an expiration date of [DATE]. LVN 3 stated that the medication was expired and should have been discarded. During a concurrent observation and interview 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 observation, interview and record review, the facility failed to develop a comprehensive care plan (CP) for each resident that included measurable objectives and specific interventions for 2 of 38 sampled residents (Residents 111and 66) when: 1. No individualized person-centered CP was developed to address Resident 111's pressure ulcer (PU). 2. No individualized person-centered CP was developed for the use of Lorazepam (medication used to treat anxiety) for Resident 66. This failure had the potential for not meeting the residents' nursing needs and goals to attain their highest practicable well-being. Findings: 1. Resident 111 was readmitted on [DATE] with diagnoses including diabetes (abnormally high sugar level in the blood), congestive heart failure (a serious condition where the heart doesn't pump blood as efficiently as it should) and malnutrition. Review of Resident 111's Weekly Skin/Wound Assessment (WSWA) dated 3/13/24 indicated, Resident 111 had the following skin impairments: a. An initial…

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 post complete nurse staffing data daily from 3/11/24 to 3/15/24. Findings: During an observation on 3/11/24, on the initial tour, the nurse staffing posted for 3/11/14, indicated, name of facility, date, number of employees all shift, census. No total number and actual hours worked by each categories. During an observation on 3/12/24, the nurse staffing posted indicated, name of facility, date, number of employees all shifts, census. No actual number of hours worked by each categories. During an interview on 3/12/24 at 11AM, with Administrator, per Administrator there is a staffing person doing the posting, as a D/P SNF not obliged to comply with the DHPPD. (Direct Care Service Hours Per Patient Day). During an observation on 3/13/24, the nurse staffing posted indicated the same data. This posting remained till 3/15/24. During an interview with Administrator on 3/15/24 at 2:45 PM, showed him the posting dated 3/13/24. Administrator pulled posting and left. During an interview on 3/19/24 at 10:28 AM 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 keep an accurate reconciliation (recordkeeping) for a controlled substance (a chemical or medication regulated by the federal government due to high risk for abuse or dependence) when one out of six sampled narcotic records (a logbook used to keep track of controlled substances used/discarded and still available in supply) had an inaccurate count of medication. This failure has the potential to result in medication diversion (the transfer of a controlled substance from lawful to unlawful use). Findings: A review of a policy titled CONTROLLED MEDICATIONS, undated, indicated that When a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and the medication administration record (MAR): Date and time of administration, Amount administered, Signature of the nurse administering the dose, completed after the medication is actually administered. A review of a Resident 233's medication administration record,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure the pharmacy consultant's recommendation for the use of psychotropic medication was acted upon for one of three sampled residents (Resident 255). This failure had the potential for Resident 255 to receive unnecessary psychotropic medications, be exposed to adverse health consequences from the medications, which could negatively impact the resident's mental, physical, and psychosocial well-being. Findings: Resident 255 was admitted on [DATE] with diagnoses including dementia (the loss of cognitive functioning -thinking, remembering, and reasoning -to such an extent that it interferes with a person's daily life and activities) and anxiety (a feeling of fear, dread, and uneasiness). Review of Resident 255's Order Summary Report for the month of March 2024 indicated, .Lorazepam (medication used to treat anxiety) Oral Tablet 0.5 mg (milligram) Give 1 tablet by mouth every 4 hours as needed for anxiety .Start Date 11/25/23 . Review of Resident 255's…

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

Based on observation, interview, and record review, the facility failed to follow physician's order of parameters regarding a pain medication for one of two sampled residents (Resident 233) when Resident 233 received an excessive dose of Hydromorphone (a potent pain medication). This failure has the potential to result in an adverse reaction (a harmful and unexpected effect of a medication) such as respiratory depression (slow breathing resulting in poor oxygen intake) Findings: A review of a policy titled Medication - Administration, last revised January 2012, indicated that If the PRN medication [Pro re nata, medication that is only given as needed for a specific reason or situation] is for complaint of pain, the Nurse will document the pain score prior to giving the medication . In addition, the policy indicated that Nursing Staff will keep in mind the seven 'rights' of medication [seven checks used to reduce risk of medication administration error] when administering medication . 'rights' of medication are: . the right amount [or dose of a medication]. During a concurrent…

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

Based on observation, interview, and record review, the facility failed to ensure a refuse (solid waste not carried by water through the sewage system) container were disposed in a proper manner with the lid. This failure had the potential to promote development and spread of communicable diseases and infections that could jeopardize the health of the residents in the facility. Findings: During a concurrent observation and interview on 3/12/24 at 10:05 AM with Director of Food and Nutrition Services (DoFNS), and Clinical Services Manager (CSM) in the kitchen, a blue colored recycle container near flat top griddle was half-open and almost full of empty chocolate pudding cans with small pudding residue. CSM stated, Close when asked what to do with the lid of the blue colored recycle container. DoFNS disagreed, then stated, the lid of the container can be closed at the end of the day. During an interview on 3/13/24 at 2:23 PM with Infection Preventionist (IP) 2, and IP 3, when showed the pictures of the half-opened blue colored recycle container in the kitchen, IP 2 stated, the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain infection control program and practices designed to help prevent the development and transmission of diseases and infections when: 1. There was unopened Biohazard Spill Kit (a cleaning supply to remove the biohazard and disinfect the area) with expiration date of [DATE] in the garage storage. 2. The facility did not implement the correct cleaning and disinfecting practices of a glucometer (a machine used to test a resident's blood sugar at the bedside) after obtaining a blood glucose (sugar) for one of two sampled residents (Resident 133). These failures had the potential for spread of infection or bloodborne pathogens (bacteria or viruses in blood that can spread disease) to residents and staff. Findings: 1. During a concurrent observation and interview on [DATE] at 11:30 AM with Infection Preventionist (IP) 1 in the garage storage, there was an unopened Biohazard Spill Kit indicated, . Expiration: [DATE] . IP 1 acknowledged, it…

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, interviews and record review, the facility did not ensure staff were trained on infection control practices for oral suctioning, when eight residents have orders for suctioning PRN, nurses unable to tell protocol on change of tubes and cleaning the canister. This failure could result in break in infection control practice that could spread infection among residents. Findings: During an observation on 3/11/24, observed resident's bedside table with a suction machine with a suction tip, not dated, with all other personal hygiene items including oral care items. During an interview on 3/11/24 at 2:45PM, with Certified Nursing Assistant (CNA) 2 , CNA 2 stated, resident is bedbound, total care, bedside table is like that, son's preference, I have not seen any nurse use this machine, son comes in the evening and use it per report to us. During an interview on 3/11/24 at 2:45 PM with Licensed Vocational Nurse (LVN) 3, per LVN 3 its' son's preference, he is the RP (responsible party) There is an order for suctioning . Have not seen him do it, it is care planned. The…

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

Based on observation, interview, and record review, the facility failed to provide reasonable accommodation for one of one sampled resident (Resident 122) when resident preference for a female Certified Nurse Assistant (CNA) as caregiver was not provided. This failure resulted to Resident 122 verbalized she felt disrespected. Findings: A review of the face sheet indicated Resident 122 was admitted with diagnoses including stroke and anoxic brain damage (caused by lack of oxygen to the brain). A review of Minimum Data Set (MDS, a standard assessment tool) dated 2/2/24, Brief memory test to help determine cognitive functioning (BIMS, includes thinking, learning and decision making ability) score of 15 indicated Resident 122 was cognitively intact. During an interview oon 3/14/24, at 9:08 AM, Resident 122 stated, I told them that I prefer a female CNA but I get male CNA a lot of times. [CNA 7] said to me, I don't know why you don't want a male CNA. I don't want to be touched by a male. They continue to assign a male CNA to me. I feel disrespected. During an interview on 3/14/24, 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 record review, the facility failed to follow their fall risk care plan for one of two sampled residents (Resident 209) when Resident 209 was transferred (moving a resident from one position to another) from the wheelchair to the bed with a two-person manual transfer (when two people physically lift someone to move them). This failure had the potential to result in a fall during transfers. Findings: A review of facility policy titled Fall Management Program, last revised 03/13/21, indicated that In an effort to prevent more falls, the IDT [Interdisciplinary Team, a collaborative group of people involved in a resident's care] will review and revised the care plan as necessary. A review of a face sheet (summary of resident's demographic and admitting information) for Resident 209, dated March 2024, indicated that Resident 209 has diagnoses including MUSCLE WEAKNESS and REPEATED FALLS. A review of Resident 209's Minimum Data Set (MDS, an assessment tool), dated 03/14/24,…

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 treatment and care in accordance with professional standards of practice when: 1. There was no evidence that the physician was notified of Resident 1's abnormal urinalysis (a medical test where the urine is examined to diagnose and monitor various illnesses). 2. There was no evidence Resident 1 was transferred to wheelchair daily as per the physician's order. These failures caused a delay in provision of treatment to Resident 1 and could have compromised Resident 1's ability to maintain her highest practicable physical, mental, and/or psychosocial wellbeing. Findings: 1. Review of Resident 1's clinical records indicated Resident 1 was admitted on [DATE] with diagnoses that include congestive heart failure (a long-term condition in which the heart cannot pump blood well enough to meet the body's needs), chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 9), was free from misappropriation of resident's property when Former Director of Nursing (FDON) took Resident 9's Ozempic medication and kept it in his office. This failure resulted in Resident 9 not receiving his Ozempic medication. Findings: Resident 9 was admitted on [DATE], with diagnoses including Multiple sclerosis (Disabling disease of the brain and spinal cord), Diabetes mellitus (Disease that affect how the body uses blood sugar), Heart Failure (heart can't pump blood well enough to meet body's need). Resident 9 Brief interview for mental status indicated 15, which means intact cognitive response. During an Interview on 10/5/23, at 2:05 PM., with Resident 9, Resident 9 stated FDON took and kept my Ozempic pen for a week and did not return it. I noticed when it was returned to me that 1 needle was missing. After a few weeks it was then that I found out that one dose was missing. I have no idea…

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 accurate assessment was completed for one of 3 sampled residents (Resident 1) when Resident 1's physical behavioral symptom of abusing others sexually was not coded on the Minimum Data Set (MDS, a resident assessment tool) as of the Assessment Reference Date (ARD, specific endpoint for the look-back periods in the MDS assessment process). This failure had the potential to result in delayed identification and implementation of interventions for Resident 1's sexually inappropriate behavior; and the potential to place residents in the facility at risk for sexual abuse by Resident 1. Findings: Review of Resident 1's admission record indicated, was admitted to facility on 8/30/22 with diagnoses including schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), dementia (a group of symptoms affecting memory, thinking and social abilities), history of alcohol abuse, mild cognitive impairment (trouble remembering,…

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 person-centered care plan (CP, a road map for patient care) for two of two sampled residents (Resident 7 and Resident 9) when: a. Resident 7 did not have a CP to address osteopenia (bone loss). This failure puts Resident 7 at risk to not receive necessary care and services to manage the possible complication from osteopenia. b. There was no care plan developed to address alleged incident of missing medication and medication not being given timely for Resident 9. This failure had the potential to delay the identification and implementation of appropriate corrective actions for a possible misappropriation of property. Findings: a. A review of the face sheet indicated Resident 7 was admitted with diagnoses including dementia (a decline in memory or other thinking skills), diabetes mellitus (abnormally high sugar level in the blood), and hypertension (abnormally high blood pressure). A review of the Minimum Data Set…

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 necessary care and services to two of two sampled residents (Resident 10 and Resident 9) according to standards of practice when: a. There was no evidence of documentation of progress or decline during the stay in the facility for Resident 10. b. There was no evidence of documentation of pain assessment and management for Resident 10. c. There was no evidence of documentation prescribed medication was administered as ordered by the physician for Resident 10 and Resident 9. The facility failure has the potential for the residents to not receive necessary care and services and experience adverse effects due to untreated medical conditions. Findings: a. A review of the admission Summary for Resident 10 dated 10/24/22, indicated, . Diagnosis of closed left hip intertrochanteric (bones of the thigh) fracture status post (s/p) fall; s/p post open reduction and internal fixation (ORIF, a surgical procedure) of the fractured (broken bone)…

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 did not ensure safe and sanitation requirements were met when: 1. Handwashing sink faucet hot water was below the required temperature: 2. kitchen appliances, can opener, industrial mixer, plate warmer, ice machine, were found soiled during inspection. 3. food stuff found in open, unsealed, and undated packaging. These failures had the potential to place residents at risk for serious complications from food borne illness because of a compromised health status, in a susceptible population of 222 residents who received food from the kitchen out of a census of 231 residents. Findings: Review of the form CMS-672 Resident Census and Conditions of Residents completed by the facility dated 5/4/21, showed 222 of 235 residents residing in the facility received food prepared in the kitchen. 1. According to the USDA Food Code 2017, Warm water is more effective than cold water in removing fatty soils encountered in kitchens. An adequate flow of warm water will cause soap to lather and aid in flushing soil quickly from…

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

Based on observation, interview and record review, the facility failed to ensure safe medication storage and distribution practice when: 1) Twelve out of 13 eye drop bottles for seven residents, in nursing unit 2, were not labeled with residents names or with the date the medication was first open for use. 2) The facility did not provide any documented evidence that refrigerated medications were stored under appropriate temperature in one out of two medications room inspected. The refrigerator temperature for five days in May, May 1 to May 5, 2021 were not recorded. These failure had the potential for resident to receive wrong medications, contaminated medication, and/or ineffective medication. Findings: 1. During an inspection of the medication cart on 5/5/21, at 11:05 AM, in unit 2, accompanied by Licensed Nurse (LN) 4, 12 bottles of eye drop belonging to seven residents did not have labels which included the residents' names. These bottles also did not have the date when these bottles were first opened. The eye drops belonged to the following residents: Resident 165 Dorzolamide…

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 implement infection control practices when: 1. Urinals (portable receptacles for urine) were found on the over bed table of three residents (Resident 99, Resident 150, and Resident 222); 2. The nebulizer set (a medical device used to administer medication directly and quickly to the lungs) placed at bedside of Resident 135 was uncovered and unlabeled; 3. A nasal cannula (a small, flexible tube that contains two open prongs intended to sit just inside the nostrils to deliver oxygen) for Resident 148 was found on the floor in his room; These failures could potentially lead to cross-contamination, placing the residents at risk for infections. Findings: 1. During an observation on 5/4/21 at 9:36 AM, Resident 150 was in bed and reading a book. On the left side of Resident 150's bed were a night stand and an over bed table (a table that often has a rectangular table-top and has a four-wheeled base that slides beneath the bed, and is used to provide a solid surface over a bed or chair to enable activities like…

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 record review and interview, the facility failed to ensure the Physician's Orders for Life Sustaining Treatment [POLST- Patient indicated preferences regarding end-of-life care such as resuscitation measures and other life-sustaining treatment] was completed for one of eight sampled residents (Resident 102). This failure had the potential for the resident to receive incorrect or delayed treatment which is not compatible with the resident's or responsible party (RP)'s wishes during an emergency situation. Findings: A review of admission record indicated Resident 102 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses including Type 2 diabetes mellitus (an impairment in the way the body regulates and uses blood sugar), hypertensive heart disease, dementia (impairment in memory, communication, and thinking). A review of the Minimum Data Set [MDS, a resident assessment and care screening], dated 3/8/21, indicated Resident 102 had severe cognitive impairment (ability to think…

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 notice of changes in Medicare coverage to the responsible party (RP) of one of three residents (Resident 59) when there was no evidence Resident 59's RP received the Notice of Medicare Non-Coverage (NOMNC) and the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN). This failure may result in Resident 59's RP of not being sufficiently informed of their right to appeal to end Medicare coverage of skilled services, and of the potential financial responsibility for services rendered no longer covered by Medicare. Definition of Terms: NOMNC - a notice that informs the resident or the resident RP when the skilled services the resident is receiving is ending, and provides information on how to make an appeal. SNFABN - A notice that provides information to the resident or the resident RP of the potential financial responsibility if they wish to continue to receive skilled services that are no longer covered by Medicare.…

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 a person-centered care plan with specific interventions addressing fall prevention for one of 35 sampled residents (Resident 107) who had a history of repeated falls. This deficient practice placed Resident 107 at risk for further falls that could potentially result to harm and injuries. Findings: A review of Resident 107's clinical records indicated Resident 107 was admitted on [DATE] with diagnoses including anxiety disorder (psychiatric disorder that involve extreme fear or worry), osteoarthritis of knee (inflammation, breakdown, and eventual loss of cartilage in the joints), glaucoma (damage to the eye's optic nerve which could cause vision loss), depression (a constant feeling of sadness and loss of interest, which stops you doing your normal activities), hypertension (high blood pressure), seizure (uncontrollable shaking that is rapid and rhythmic, with the muscles contracting and relaxing repeatedly), post-traumatic stress…

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 a safe environment when there was no fire safety signage indicating the administration of oxygen in room [ROOM NUMBER]. This failure could potentially compromise the safety of the residents, staff, and visitors. Findings: During a concurrent observation of room [ROOM NUMBER], and interview with Licensed Nurse (LN) 1, on 5/4/21 at 9:58 AM, Resident 100 was lying in bed, with a nasal cannula inserted into the resident's nostrils. The nasal cannula (a small, flexible tube that contains two open prongs intended to sit just inside the nostrils to deliver oxygen) was attached to an oxygen concentrator set at two liters per minute. There was no signage indicating the use of oxygen inside nor outside Resident 100's room. LN 1 verified the observation, and stated, . It (resident's room) must have a 'No Smoking' sign . we will put a sign . When asked of importance of placing a No Smoking sign, LN stated that the use of oxygen was a fire…

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.