Marin Post Acute

Based on observation, interview, and record review, the facility failed to provide a safe environment when one sharps container (a specially made box used to safely discard sharp items) was overfilled in Unit 2, Shower Room A.This failure had the potential to cause harm to residents and staff.Findings:During a concurrent observation and interview on 12/1/25 at 4:42 p.m. in Unit 2, Shower Room A with Licensed Vocational Nurse (LVN) 1, there was an overfilled sharps container that had razors sticking out of the opening. LVN 1 stated that housekeeping and nursing staff were responsible for emptying the sharps container.During a review of the facility's policy and procedure (P&P) titled, Sharps Disposal, dated January 2012, the P&P indicated, Designated individuals will be responsible for sealing and replacing containers when they are 75% to 80% full to protect employees from punctures and/or needlesticks when attempting to push sharps into the container.

Based on observation, interview, and record review, the facility failed to ensure 1 of 30 sampled residents (Resident 8) care plan interventions were implemented when Resident 8's indwelling urinary catheter (a flexible tube that drains urine from the bladder) collection bag was not positioned below the bladder. This failure placed Resident 8 at risk for urinary tract infections. Findings:During a concurrent observation and interview on 12/1/25 at 3:34 p.m. with Licensed Vocational Nurse (LVN) 2, in Resident 8's room, Resident 8's catheter collection bag was positioned above the bladder. LVN 2 stated the catheter collection bag was not positioned correctly to allow urine to drain into the collection bag. LVN 2 stated the catheter collection bag should have been positioned below Resident 8's bladder.During a review of Resident 8's care plan, dated 1/30/25, the care plan indicated, .position catheter bag and tubing below the level of the bladder .During an interview on 12/3/25 at 3:48 p.m. with the Director of Nursing (DON), the DON stated the urinary catheter collection bag should be…

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

Based on observation, interview, and record review, the facility failed to ensure the residents' environment remained free of accident and hazards for 3 of 30 sampled residents (Residents 4, 17, and 53) when:1. A portable space heater was on the floor in the middle of Resident 4,17, and 53's shared room. This failure had the potential to result in a fire and tripping hazard for the residents.2. Resident 53's, who was at risk for falls, floor pad was not on the floor as ordered. This failure had the potential to result in significant injuries for the resident. Findings:1. During a concurrent observation and interview on 12/1/25 at 2:32 p.m. with Resident 17, in Resident 17's room (shared by Resident 4 and 53), a portable space heater was on the floor in the middle of the room. Resident 17 stated a Certified Nursing Assistant (CNA) brought it to her room about a week ago because she was cold. During an interview on 12/2/25 at 9:59 a.m. with Licensed Vocational Nurse (LVN) 4, LVN 4 stated she was aware the portable space heater was on the floor in the middle of the room.During an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to safely store drugs and supplies in accordance with acceptable standards of practice when: 1. One medication cart (Medication Cart A) was left unlocked and unattended.2. One treatment cart (Treatment Cart A) was left unlocked and unattended.These failures had the potential for residents and staff to have unauthorized access to medications and treatments.Findings:1. During a concurrent observation and interview on 12/1/25 at 3:31 p.m., with LVN 2, Medication Cart A was left unlocked and unattended next to the Beauty Shop against the wall. LVN 2 walked out of room [ROOM NUMBER] towards Medication Cart A and confirmed Medication Cart A was unlocked. LVN 2 stated that Medication Cart A should have been locked when unattended to prevent unauthorized access. 2. During a concurrent observation and interview on 12/2/25 at 4:27 p.m. with Registered Nurse (RN) 1, Treatment Cart A was unlocked and unattended. RN 1 stated Treatment Cart A should 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 and record review, the facility failed to protect the resident's right to be free from physical abuse by another resident for one of four sampled residents (Resident 1) when Resident 2 entered his room and struck him with a hanger.This failure had the potential to result in serious physical injury to Resident 1.Findings:A review of Resident 1's admission record indicated he was last admitted in 5/25 with diagnoses of severe obesity and bed confinement.A review of Resident 1's Minimum Data Set (MDS- a federally mandated resident assessment tool), 6/18/25, indicated he had severe cognitive impairment.A review of Resident 1's Social Services note, dated 7/25/25, indicated the Social Services Director (SSD) had spoken to him and he confirmed a female resident had entered his room and hit him.A nursing note, dated 7/25/25 and written by Licensed Nurse 1 (LN 1), indicated Resident 1 had been assessed by her and found to have had two 1-centimeter (cm- a unit of measurement) scratches on his left…

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 rehabilitative services were provided for one resident (Resident 2) of three sampled residents when restorative nursing services (nursing interventions that focus on helping residents maintain and improve their ability to function independently in activities of daily living and mobility) were not performed according to physician ' s orders. This failure decreased the facility ' s potential to ensure residents attained their highest practicable level of physical and functional well-being. Findings: A review of Resident 2 ' s admission record indicated she was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis (muscle weakness or partial paralysis) following unspecified cerebrovascular disease (a term used for conditions that affect blood flow to the brain) affecting her left side. A review of Resident 2 ' s clinical record included the following documents: -A Minimum Data Set (MDS- a federally mandated resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one resident (Resident 2) of three sampled residents received care which met professional standards when a Licensed Nurse B (LN B) left a cup of medications by the Resident 2 ' s bedside, unattended, without a physician ' s order. This failure decreased the facility ' s potential to safely administer medications to residents. Findings: A review of Resident 2 ' s admission record indicated she was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis (muscle weakness or partial paralysis) following unspecified cerebrovascular disease (a term used for conditions that affect blood flow to the brain) affecting her left side. A review of Resident 2 ' s Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 2/9/25, indicated she had no memory impairment. During a concurrent observation and interview with Resident 2 on 5/1/25 at 10:40 a.m., a plastic cup containing nine pills were…

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 call lights for two residents (Resident 1 & Resident 2) of three sampled residents were answered promptly when the Surveyor observed Resident 2 ' s call light ringing for 25 minutes before intervening. This failure decreased the facility ' s potential to provide prompt assistance to residents and resulted in Resident 2 feeling neglected. Findings: A review of Resident 1 ' s admission record indicated she was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (brain dysfunction caused by the body ' s metabolism). A review of Resident 1 ' s Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 2/26/25, indicated she had no memory impairment. During a phone interview on 5/1/25 at 3:02 p.m., Resident 1 stated the call light took from 30 minutes to an hour-and-a-half to be answered by staff. Resident 1 stated she pressed it on behalf of her roommate who required staff assistance,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one resident (Resident 2) of three sampled residents was kept free of significant medication errors, when Licensed Nurse B ( LN B) administered her morning medications more than one hour late, left her medications by the resident ' s bedside unattended, and missed an important morning medication that was required to be administered with breakfast. These findings increased the potential to result in elevated blood pressure, elevated glucose levels, and harm to Resident 2. Findings: A review of Resident 2 ' s admission record indicated she was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis (muscle weakness or partial paralysis) following unspecified cerebrovascular disease (a term used for conditions that affect blood flow to the brain) affecting her left side. A review of Resident 2 ' s Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 2/9/25, indicated she had 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 interview and record review, the facility failed to ensure the Social Service Director's (SSD) met the minimum qualifications of their positions per federal regulations, when one SSD did not have a Bachelor's Degree, and the other SSD did not have a Bachelor's degree in Social Work or in a Human Services field. This failure decreased the facility's potential to meet the social service needs of the residents. Findings: A review of the facility's license, dated 2/3/25 to 5/31/25, indicated the facility had 168 beds. During an interview on 3/13/25 at 11:11 a.m., the Human Resource Director (HRD) stated Social Services Director A (SSD A) worked on Unit One and Social Services Director B (SSD B) worked on Unit Two. During an interview on 3/13/25 at 11:28 a.m., SSD A stated she had a Bachelor's Degree in communications. During an interview on 3/13/25 at 11:42 a.m., SSD B stated she did not have a college degree. During a concurrent record review and interview on 3/13/25 at 12:05 p.m., the HRD confirmed SSD A had a signed job description in SSD A's employee file and SSD B had a…

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

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure 1 (Resident #134) of 2 sampled residents reviewed for choices was assessed to self-administer their medication before the licensed nurse left the medication(s) with the resident to administer on their own. Findings included: A review of the facility policy, titled, Self-Administration of Medications, revised in February 2021 revealed, Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. Policy Interpretation and Implementation 1. As part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident. Per the policy, 3. If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan. A review of Resident #134'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 interviews, record review, document review, and facility policy review, the facility failed to ensure their grievance policy revealed who the Grievance Official was, their contact information, and the contact information for independent entities to whom grievances may be files. The facility further failed to ensure there was documentation of a resident's grievance to include, the receipt of the grievance, a summary statement of the grievance, the steps taken to investigate the grievance , a summary of the pertinent findings/conclusion, any corrective action taken, whether the grievance was confirmed or not, and the date the written decision was issued to the resident for 1 (Resident #19) of 6 sampled residents reviewed for personal property. Findings included: A review of the facility policy titled, Resident Grievance/Complaint Procedures, revised in January 2017, revealed Any resident, family member, or appointed resident representative may file a grievance or complaint concerning care, treatment, behavior of other residents, staff members, theft of property, or any other…

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 record reviews, interviews, and facility policy review, the facility failed to ensure 1 (Resident #22) of 1 sampled resident reviewed for abuse, was not physically abused by another resident. Findings included: A review of a facility policy titled, Abuse Prevention Program, revised in December 2016, revealed, Policy Statement Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Policy Interpretation and Implementation As part of the resident abuse prevention, the administration will: 1. Protect our residents from abuse by anyone including, but not necessarily limited to : facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual. A review of Resident #22's admission Record revealed 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 interviews, record reviews, document review, and facility policy review, the facility failed to timely report an allegation of physical abuse to the state agency that involved 1 (Resident #22) of 1 sampled resident reviewed for abuse. Findings included: A review of a facility policy titled, Abuse Investigation and Reporting, revised in July 2017, revealed, All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. Per the policy, 2. An alleged violation of abuse, neglect, exploitation or mistreatment will be reported immediately, but not later than: a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or b. Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury. A 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.

Based on interviews, record review, and facility policy review, the facility failed to ensure a Level II mental health evaluation was completed for 1 (Resident #56) of 2 sampled residents reviewed for preadmission screening and resident review (PASARR). Findings included: A review of the facility policy titled, Pre-admission Screening and Resident Review, revised in December 2016 revealed, The objective of the PASARR policy is to ensure that individuals with mental illness and intellectual disabilities receive the care and services that they need in the most appropriate setting. Per the policy, c. Upon completion of the Level II screen, the facility will review the screen recommendations and determine the facility's ability to provide the specialized services outlined. A review of Resident #56's admission Record, revealed the facility admitted the resident on 05/23/2023, with diagnoses that included chronic post-traumatic stress disorder and depression. A review of Resident #56's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/30/2023, revealed 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 observations, interviews, record review, and facility policy review, the facility failed to ensure 1 (Resident #57) of 3 sampled residents reviewed for accidents was assessed for smoking. Findings included: A review of the facility policy titled, Smoking Policy-Residents, revised in October 2023, revealed, This facility has established and maintains safe resident smoking practices. Per the policy, 7. Resident smoking status is evaluated upon admission. If a smoker, the evaluation includes: a. current level of tobacco consumption; b. method of tobacco consumption; c. desire to quit smoking; and d. ability to smoke safely with or without supervision (per a completed Safe Smoking Evaluation). A review of Resident #57's admission Record revealed the facility admitted the resident on 01/09/2024 with diagnoses that included nicotine dependence and chronic obstructive pulmonary disease. A review of Resident #57's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/13/2024, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14,…

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 observations, record reviews, interviews, and facility policy review, the facility failed to ensure the medication error rate was 5% or less. There were two medication errors out of 29 opportunities, which yielded a medication error rate of 6.89%. This deficient practice was affected 2 (Resident #54 and Resident #75) of 8 residents observed for medication administration. Findings included: A review of the facility policy titled, Administering Medications, revised in April 2019, revealed, Medications are administered in a safe and timely manner, and as prescribed. Per the policy, 4. Medications are administered in accordance with the prescriber orders, including any required time frame. The policy revealed, 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. 1. A review of Resident #75's Order Summary Report, revealed the facility admitted the resident on 07/28/2021. The Order Summary Report revealed an…

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

Based on Observation, interview and record review, the facility failed to provide sufficient staffing for basic care needs for two acute rehabilitation Residents (Resident 1) and (Resident 2). This failure resulted in the potential for injury for Resident 1 to endure Skin breakdown and Resident 2 to suffer a fall. Findings: During an interview on 12/14/23 at 10:30 a.m., Family Member 1 stated, whenever Family Member 1 or Resident 1 pushed the nurses call light, it could take as long as 45 minutes before a Certified Nursing Assistant (CNA) answered Resident 1 ' s call light. Family Member 1 stated, This long wait time has caused Resident 1 to become Incontinent of urine and that is a potential for skin breakdown. Family Member 1 stated, I am at the facility a lot because I do not trust there is sufficient staffing scheduled to care for [Resident 1 ' s] needs. Family Member 1 stated, I spoke with the Nursing Home Administrator (NHA) and Social Service Director (SSD) about the long wait periods for [Resident 1 ' s] call light to be answered, as well as my concerns about the lack of…

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

Based on observation and interview, the facility failed to respect the right of two of 27 sampled residents (Resident 294 and 109) and two unsampled residents (Unsampled Residents 38 and 13) to refuse care, when staff checked vital signs at night despite Resident 294 informing staff he did not want vital signs checked at night. This failure resulted in residents having their sleep disturbed. Findings: Resident 294 During an interview on 5/3/21, at 10:20 a.m., Resident 294 stated he had not been able to sleep in the past week because staff woke him up every night to check his vital signs. Resident 294 stated he did not want vital signs checked at night and had so informed the facility. Resident 294 pointed to a note placed on the foot of his bed that read: Do not wake up patient between 9 p.m. - 6 a.m. please. Resident 294 stated staff did not respect his refusal of vital signs and continued to wake him up every night for vital signs. A review of Resident 294's vital signs flowsheets indicated, during the period of 4/27/21 to 5/3/21, Resident 294 had vital signs taken at 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 honor the bath and shower preferences of two of 27 sampled residents, Resident 109 and Resident 242. This failure had the potential to affect residents' quality of life. Findings: Resident 109 During an interview on 5/3/21 at 3:17 p.m., Resident 109 stated he had only gotten one shower the week prior to the survey. When asked how this made him feel, Resident 109 stated, It's hard because it's hot. During a record review on 5/5/21 at 9:59 a.m., Resident 109's electronic medical record revealed documentation of four showers in the past 30 days. During a record review on 5/6/21 at 11:59 a.m., the unit shower schedule revealed Resident 109 was scheduled for a shower every Tuesday, Thursday, and Saturday morning. During an interview on 5/6/21 at 12:14 p.m., which was a Thursday, Resident 109 stated he had not received a shower that morning. Resident 109 stated, Maybe I'll get one on Saturday. When queried, Resident 109 stated he preferred showers over 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, and record review, the facility failed to make the facility's survey results accessible to residents, when eight out of eight residents at a resident council interview (Residents 9, 14, 42, 43, 66, 101, 122, 125), and one sampled resident (Resident 129), did not know the location of the binder containing the results, which was on the first floor, and not easily accessible to those who lived on the second floor. This failure was a violation of the residents' right to have survey results readily available to them for review. Findings: During a resident council interview on 5/4/21 at 10:33 a.m., when queried, eight out of eight residents were unable to verbalize where the results of previous surveys were located. Seven of the eight residents lived on the second floor: Residents 9, 14, 42, 43, 101, 122, 125. During an observation on 5/4/21 at 12 p.m., a binder containing survey results was sitting on a table in the main lobby near the entrance on the first floor. During interview on 5/4/21 at 3:11 p.m., the Administrator in Training stated that the State…

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 create a comprehensive care plan which met the needs of residents, for four of four residents (Residents 30, 39, 48 and 76). This failure had the potential for Residents 30, 39, 48 and 76 not having their care needs met. Findings: RESIDENT 30 A review of Resident 30's admission Record indicated she was admitted to the facility on [DATE], with diagnoses including cerebral infarction and dysphagia. During an interview on 5/6/21, at 1:55 p.m., the MDS Coordinator reviewed Resident 30's record, and stated Resident 30 had a nasogastric tube (NG Tube) and was receiving feeding through the NG tube. The MDS Coordinator stated Resident 30 was admitted from the hospital with the NG tube, on 11/24/20. The MDS Coordinator was asked if a care plan for maintenance and care of the NG tube was created for Resident 30. After reviewing Resident 30's care plans, the MDS Coordinator stated such care plan had not been created. RESIDENT 39 A review of Resident 39's…

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

Based on interview and record review, the facility failed to provide Restorative Nursing Assistant (RNA) services, as ordered, to three of 27 sampled residents (Residents 109, 127 and 33). This failure could potentially lead to residents' functional decline and contracture (loss of range of motion in a joint) development in a vulnerable population. Findings: Resident 109 During an interview on 5/3/21 at 3:17 p.m., Resident 109 stated he was scheduled for RNA sessions five days per week, but was only getting two or three sessions per week. Resident 109 stated he sometimes missed his appointment because he did not feel good, but he stated it was also because the RNA was getting pulled to be a CNA (Certified Nursing Assistant). During a record review on 5/5/21 at 9:45 a.m., Resident 109's medical record revealed an admission date of 9/20/20, and diagnoses including cerebrovascular (blood vessels in the brain) disease, muscle weakness, and abnormalities of gait and mobility. Resident 109's physical therapy note, dated 3/17/21, indicated, [Patient] to be placed on RNA program for BUE and…

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

Based on observation, interview, and record review, the facility failed to provide enough staff to meet the needs of three of 27 sampled residents (Residents 76, 109, and 129) and eleven unsampled residents (Residents 13, 14, 16, 24, 26, 42, 43, 71, 92, 119 and 192). This failure caused delays in resident care, long waits while residents were soiled, residents missing scheduled sessions with Restorative Nursing Assistants, missed showers, missed medication, and caused residents to be cared for by staff who were, irritated, and threatening. Findings: During an interview on 5/3/21 at 11 a.m., Unsampled Resident 26 stated the facility needed more Certified Nursing Assistants (CNAs) because the care would be better if there were more. Unsampled Resident 26 stated the CNAs were overwhelmed, and he had to wait one and a half hours for help when he pressed his call light. During initial tour and concurrent interview on 05/03/21 at 11:14 AM, Resident 192 stated that facility staff took care of a lot, and the staff were slow. She broke her right hip and was admitted for physical therapy. She…

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

Based on observation, interview and record review, the facility failed to follow professional standards of food safety, (1) when the hand washing station, used by dietary staff in the kitchen, lacked soap and paper towels and, (2) when one of the two ice machines, used to supply ice to the kitchen and the residents, was stored in a room with spider webs and a spider. These failures had the potential for food not to be prepared and served to residents in a sanitary manner, resulting in gastrointestinal illnesses. Findings: 1) During an observation of the kitchen on 5/3/21, at 9:30 a.m., the hand washing station, used by dietary staff, lacked soap and paper towels. During a concurrent interview, the Dietary Services Manager (DSM) confirmed the hand washing station lacked soap and paper towels. On 5/3/21 at 11:53 a.m., during observation of residents dining in their respective rooms, CNA K was serving Resident 191 her lunch on an overbed table. CNA K asked Resident 191 if she would like him to mix her pureed food. Resident 191 declined and took the spoon from the CNA. Resident 191 was…

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

Based on observation, interview and record review, the facility failed to dispose of garbage and refuse properly, when there was kitchen trash scattered on the ground behind the trash disposal bins. This failure had the potential to attract pests to the facility. Findings: During an observation on 5/4/21, at 2:18 p.m., there was kitchen trash, such as fruit and open food cans and containers, scattered on the ground behind the trash disposal bins. During a concurrent interview, the Dietary Service Manager (DSM) and the Registered Dietician (RD) stated kitchen trash was supposed to be put in trash bags and placed inside the trash containers to be later collected and disposed of. A review of facility policy titled, Sanitation, Revised October 2008, indicated, Kitchen wastes that are not disposed of by mechanical means shall be kept in clean, leakproof, nonabsorbent, tightly closed containers .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an effective infection control program when: 1. Residents and staff in the common room did not maintain six feet distance from each other while not wearing masks; 2. A staff member passing lunch trays did not perform hand hygiene; 3. One out of two residents sampled for tube feeding did not have a label on their tube feeding set; and, 4. Staff failed to ensure visitors complied with Transmission-based Precautions, when four out of five visitors were not wearing gowns properly in residents' rooms in the Yellow Zone (designated area to quarantine newly-admitted residents to rule out COVID-19). These failures could potentially spread infectious agents, including SARS-COV-2, throughout a vulnerable population. Findings: 1. During an observation on 5/3/21 at 11:58 a.m., ten residents were in the common room watching a movie, eight did not have their nose and mouth covered, and they were not all six feet apart. During an interview on…

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

Based on observation, interview, and record review, the facility failed to maintain a functioning call system, when three of 27 sampled residents and two unsampled residents (Sampled Residents 109 and 129) and Unsampled Residents 13, 14 and 71) stated their call lights were not functioning properly. This failure caused delays in meeting residents' needs and one resident to feel hopeless. Findings: During an interview on 5/3/21 at 3:17 p.m., Resident 109 stated he had moved from bed-three to bed-two because the call light for bed-three did not work. During an observation and concurrent interview on 5/3/21 at 3:17 p.m., Unsampled Resident 71 had a red cow bell on his overbed table. He stated he had the bell because sometimes his call bell did not work. Unsampled Resident 71 pressed his call light. The light on the wall lit up and a buzzer sounded. When this surveyor pressed the call light for bed-three, there was no light on the wall and there was no buzzer. Unsampled Resident 71 stated, It must not be working. During an interview on 5/4/21 at 9:57 p.m. Resident 129 stated she had to…

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 a safe, functional, and comfortable environment for ten residents: (1) when the bed light string for Resident 295 was broken, (2) the window blinds in Resident 19's room were broken and bent, (3) the window screens in the rooms and bathroom of Residents 19, 39, 73, 98, 99, 133, 293, 294, 295 and 296, were not properly fitted to the window frames, with gaps through which insects and pests could enter facility and resident rooms. These failures prevented the residents from having a safe, functional, and comfortable environment. Findings: During an observation on 5/3/21, at 10:20 a.m., Resident 295 stated he could not turn on his bed light because the string used to operate the bed light was broken. Resident 295 stated it had been broken for about a week, and he requested it to be fixed but to no avail. During a concurrent observation, the string used by Resident 295 to turn on and off his bed light was broken. During an observation on 5/3/21, at 10:11 a.m., some of the window blinds in Resident 19's room…

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 inform two of three reviewed residents (Resident 43 and Resident 13), that Medicare would not pay for other items or services, the facility offered, that the resident would be required to pay for. This failure had the potential to cause confusion and anxiety for patients who did not understand why they were charged for services they expected Medicare to pay. Findings: On a concurrent observation and interview on 05/04/21 at 9:14 AM, Resident 43 stated he had been in the facility for about four months. He stated he had incurred charges on his bank account from this facility that he was not aware of. He stated he had several hundred dollars in his bank account when he was admitted . He was surprised one day that he had less than a hundred dollars left in the account. During record review on 05/04/21 at 1:06 PM, three residents, from the list of residents who were discharged from Medicare covered Part A stay, with benefit days remaining in the past six months, were selected. A SNF Beneficiary Protection…

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 create a baseline care plan within 48 hours of admission, for one of two residents at risk for pressure ulcers (Resident 54). This failure had the potential for Resident 54 not to receive treatment and care to prevent pressure ulcers. One week after admission, Resident 54 developed a Stage 2 Pressure Ulcer. Findings: A review of Resident 54's admission Record indicated she was admitted to the facility on [DATE], with diagnoses including generalized muscle weakness, morbid obesity and abnormalities of gate and mobility. A review on Resident 54's record indicated, on 12/8/20, the facility assessed Resident 54's risk for pressure ulcers using the Braden Scale (a standardized tool for predicting a patient's risk for developing pressure ulcers). A review of Resident 54's Braden Scale indicated a score of 15, and Resident 54 was, AT RISK for developing pressure ulcers. A review of Resident 54's care plans indicated no care plans for prevention of pressure…

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.

On 05/06/21 at 3:03 PM, a review of Resident 76's pain medication orders, pain assessment records and care plans was done with the Director of Nursing (DON). Reviewed records showed there were no changes in the physician orders. Pain assessments prior to scheduled pain medication administration were documented, but there were no pain assessments after medication administration of scheduled and as needed pain medications. The Progress Notes of Nurse J were reviewed. No documentation of pain assessments on her shift report could be found. There was also no mention of calling the ordering physician to request resumption of a discontinued medication as was mentioned by the Administrator on 5/5/21. The DON could not find any other documentation of pain assessment after pain medication administration. In addition, the Care Plan on Pain management also indicated Resident 76's acceptable pain level or goal was not identified. It only indicated, ensure patient's comfort level. When asked why the specific acceptable or tolerable pain level was not documented, the DON stated they did 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.

Based on interview and record review, the facility failed to offer two sampled residents (Residents 109 and 43) and three unsampled residents (Residents 119, 122, and 108) a choice of an alternate meal when they did not want to eat what they were served on their tray. This failure could potentially affect residents' nutritional status or quality of life. Findings: During an interview on 5/3/21 at 3:17 p.m., Resident 109 stated he did not like the food. When queried, Resident 109 stated the staff did not offer him an alternate because they were too busy. During an interview on 5/4/21 at 9:47 a.m., Unsampled Resident 119 stated he did not like the fish, but he had not told anyone he did not like fish. When queried, Resident 119 stated the alternate was just a sandwich, which was not appealing to him. Unsampled Resident 122 and Unsampled Resident 108 both agreed. During a concurrent record review and interview on 5/5/21 at 2:03 p.m., the alternate menu indicated, Sandwiches: Egg Salad, Tuna Salad, Turkey, Ham, Cheese, Peanut butter and jelly, Grilled Cheese, Chef's Salads, Soup 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.