Professional Post Acute Center

Based on observations, interviews, and record reviews, the facility failed to ensure the right one of seven sampled residents, Resident 1, to be free from physical abuse when, Resident 1, who had a history of yelling and screaming due to hallucinations, was slapped on the left side of her face by another resident, Resident 2, who had a care planned intervention to modify her environment by reducing the noise level due to a potential to demonstrate aggressive behavior. Resident 1 and Resident 2 were in rooms close to each other. This failure had the potential to result in physical injuries to Resident 1. Findings: A review of Resident 1's Progress Notes, dated 8/25/24, at 5:44 p.m., authored by Licensed Nurse A, indicated, .Resident 1 was yelling in her room when Resident 2 went into the room and slapped Resident 1 on the left cheek. Resident 1 was visibly red on the left cheek following the incident . A review of Resident 1's Progress Notes, dated 8/25/24, at 11:35 p.m., authored by Licensed Nurse B indicated, Resident 1 being monitored for emotional distress related to being…

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

Based on observations, interviews, and record reviews, the facility failed to ensure that an alleged violation of physical abuse to one of seven sample residents, Resident 1, was reported to the State Survey Agency immediately, but not later than 2 hours after the allegation of physical abuse was made, when Certified Nursing Assistant C witnessed Resident 2 slapped Resident 1 on the left side of her face on 8/25/24, at 3:30 p.m., and Licensed Nurse A reported the incident to the State Survey Agency via voicemail on 8/25/24, at 9:02 p.m., followed by a fax transmitted to the State Survey Agency on 8/25/24, at 9:13 p.m. The physical abuse allegation was reported by Licensed Nurse A to the State Survey Agency more than 5 hours after Certified Nursing Assistant C's allegation was made. This failure had the potential to result in further escalation and recurrence of physical abuse of Resident 1 by Resident 2 pending an investigation and identification of new measures to protect Resident 1 from Resident 2. Findings: A review of Resident 1's Progress Notes, dated 8/25/24, at 5:44 p.m.,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to ensure a safe and functional environment to three of seven sampled residents (Resident 3, 4, and 5) in room [ROOM NUMBER], when the sliding door and screen door locking mechanisms were broken. This failure had the potential to result in harm to these residents in case of a violent break-in situation or when accidentally left open during extreme weather patterns, jeopardizing their health and safety. Findings: On 7/17/24, at 8:38 a.m., the California Department of Public Health (CDPH) received a complaint that included an allegation that door locks inside one of the resident rooms were broken and not able to be locked. During a concurrent observation and interview on 9/3/24, at 2 p.m., with the facility's Maintenance Supervisor in room [ROOM NUMBER], 2, and 3, it was observed that the original sliding door locking mechanisms were broken and not able to lock. It was also observed that the screen door in room [ROOM NUMBER] was not locking because it was…

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

Based on observation, interviews and record review, the facility did not ensure the safety of 1 out of 5 sampled residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5), when Resident 4 eloped from the facility and was found .4 miles away by the Police Department. This failure had the potential for all residents at risk of elopement, to be at risk of falls, injury and possible death. Findings: During an observation on 6/11/24, at 8:25 a.m., the front of the facility located at 81 Professional Center Parkway sat on the side of a hill, with a steep inclined driveway up to the front entrance. The facility was located on a street with moderate traffic in the middle of a hill that contained high-density housing, offices and a convenience store. The street began on a frontage road at the base of a steep incline up to where the facility was located. During an observation 6/11/24, at 10:29 a.m. the hallway corridor that ended at the north side of facility, led to the outside courtyard. The metal door that led outside was not locked or alarmed and allowed unsupervised passage…

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's pharmacy failed to provide 1 resident (Resident 1) in a census of 86 residents with his routine pain medication (Hydromorphone, also known as Dilaudid) timely and failed to ensure nursing staff had access to the Hydromorphone located in the facility's e-kit (container with emergency medication storage). These failures contributed to Resident 1 to missing his Hydromorphone doses for approximately 24 hours on 10/28/2023 and missing his pain medication again multiple times from 12/11/23 through 12/14/23 which in turn: 1) Caused Resident 1 to experience increased pain, 2) Caused Resident 1 to feel suicidal, hopeless, out of control, angry and depressed, 3) Caused Resident 1 to experience symptoms of narcotic withdrawal, and 4) Prevented Physician J from being aware of the ongoing issues related to Resident 1's Hydromorphone delivery and administration and therefore, prevented him from evaluating and addressing the issue.(Online review of the Mayo Clinic website revealed a pain scale provides a standardized means of measuring pain…

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 protect one of three sampled residents (Resident 1) from possible abuse and self-injurious behavior, when: 1. Two injuries of unknown origin, discovered on 1/01/24, were not investigated by the facility, and; 2. Resident 1, who had a history of skin lesions (A region in an organ or tissue which has suffered damage through injury or disease), was not protected from self-injurious behavior, nor were several new skin lesions documented, care planned or receiving any type of treatment at the time of discovery by the DEPARTMENT Surveyor. These findings had the potential to result in abuse and harm, including death from serious skin infections to Resident 1. Findings: Record review indicated Resident 1 was admitted to the facility on [DATE], with medical diagnoses including Hemiplegia (Severe or complete loss of strength leading to paralysis on one side of the body) and Hemiparesis (Weakness on one side of the body) affecting left side and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure professional standards of practice were implemented for one of three sampled residents (Resident 1) when Administrator B (Facility ' s previous Administrator) failed to follow-up on an antipsychotic (A medication that affects brain activity associated with mental processes and behavior and treats symptoms of mental illness) consent form that was needed for Resident 1 to resume his preadmission antipsychotic therapy. This finding had the potential to result in harm, neglect, and inability for Resident 1 to reach his maximum health care potential. Findings: Record review indicated Resident 1 was admitted to the facility on [DATE] with medical diagnoses including Hemiplegia (Severe or complete loss of strength leading to paralysis on one side of the body) and Hemiparesis (Weakness on one side of the body) affecting his left side and Anxiety Disorder, (Persistent and excessive worry that interferes with daily activities. This ongoing worry 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 ensure the daily nursing staffing information was posted in a conspicuous place during a time of the day when visitors were allowed to enter the facility, during one of three visits by the Surveyor (On 12/14/24). This finding had the potential to result in inability for residents, visitors, and staff to review the staffing information, advocate for the residents ' care, and identify issues with staffing numbers, which could have contributed to decreased quality of care. Findings: During an observation on 2/14/24 at 9:30 a.m., the posting that included the nursing staffing information, located in the lobby area of the facility, on top of the receptionist ' s desk, had staffing posting information from the day before, 2/13/24. At that time, there was a lot of activity going on at the facility. More than ten residents were observed in the dining area involved in recreational activities, and staff were busy with their morning work routines. During an interview with Unlicensed Staff D on 2/14/24 at 9:32 a.m., he…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and records review, the facility failed to ensure care plan conferences were conducted for two or two sampled residents (Residents 1 and 2). This failure resulted to Resident 1 ' s Representative and Resident 2 not being able to exercise their right to participate with care planning on continuing or changes in care, treatment, and healthcare goals that could affect Resident 1 and Resident 2 ' s quality of care and quality of life. Findings: Resident 1 During an interview with Witness C on 12/20/23 at 1:26 p.m., Witness C stated Resident 1 had no capacity to make healthcare decisions due to Dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). He stated he expected the facility to invite him every scheduled care plan meetings as he was Resident 1 ' s Representative to make healthcare decisions and would not miss any of the care plan meetings if he was invited; however, he stated he was not invited to participate with most of the care…

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 interviews and records review, the facility failed to implement timely revision of ADL (Activities of Daily Living) Self Care Performance Deficit Care Plan for one of two residents (Resident 1) when the facility did not update the Care Plan for Resident 1 reflecting the decline in Resident 1 ' s functional status. These failure had the potential for facility staff to provide inadequate care and supervision to ensure Resident 1 ' s health and safety needs. (Reference F689, F686) Findings: During a review of the Face sheet (A one-page summary of important information about a resident) indicated Resident 1 was admitted on [DATE] with diagnosis including but not limited to: Diabetes Mellitus (disease that result in too much sugar in the blood); Hypertension (High Blood Pressure); and Neurocognitive Disorder (decreased mental function due to a medical disease other than a psychiatric [relating to mental] illness). During a review of the document titled Post-Fall Review dated 10/21/23 indicated Resident 1 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 observations, interviews and records review, the facility failed to meet nursing professional standards for one of two sampled residents (Resident 1) when a facility licensed staff provided wound treatment to Resident 1 without a physician ' s order. This failure had a potential risk for Resident 1 of adverse drug reaction. (Reference F686) Findings: During a review of the Progress Note dated 11/22/23 at 7:49 p.m. and concurrent interview with Licensed Staff B on 2/08/24 at 11:14 a.m., the progress note indicated Resident 1 was noted with 4.5 cm x 4.5 cm of non-blanchable redness (skin redness that do not fade when a person presses on them) to sacrococcyx area (pertaining to both the sacrum and coccyx) with an open wound measuring 0.5 cm x 0.7 cm., and was treated with Medihoney (a brand name wound and burn gel). When Licensed Staff B was asked if Resident 1 ' s physician gave the order to treat the wound with medihoney, Licensed Staff B stated yes; however, after review of the Physician ' s Order with Licensed Staff B, she stated there was no order written for medihoney 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and records review, the facility failed to provide necessary services for one of two sampled residents (Resident 1) when: 1. The facility did not perform a rehabilitation screening for Resident 1 after the fall to evaluate any adverse effects from the fall and the potential need for rehabilitation services. 2. The facility waited for eight (8) days to perform a right hip X-ray (a type of medical imaging that creates pictures of the bones and soft tissues) after Resident 1 had complained of right hip pain and waited for another 8 days to obtain an order for weight bearing precaution after Resident 1 was found with right femoral fracture (a break in the thigh bone). These failure resulted to a delayed treatment and could have resulted to a more serious injury when facility staff allowed Resident 1 to bear weight to her right leg during sit to stand activity (the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed) without knowing Resident 1 had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement a Plan of Correction (POC-a document submitted by licensed health care facilities to respond to deficiencies identified in a survey of the facility conducted by state field staff) after they were cited on 4/20/23 for not having replaced or reimbursed several missing items for one of three residents (Resident 4). In this POC, which was approved by the DEPARTMENT 7/20/23, the facility agreed to reimburse Resident 4 for a list of missing items provided by Resident 1 ' s resident representative (Witness AA) but did not do it. This finding resulted in frustration, resentment, and anger to Resident 4 ' s family, which added to the grief of her loss in August of 2023. Findings: Record review indicated Resident 1 was admitted to the facility on [DATE] with medical 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…

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 adequately manage one of one resident's (Resident 5) pain control. This failure resulted in Resident 5 suffering unnecessary pain for eight days until the diagnosis of a fracture had been confirmed. Findings: During a review of Resident 5 ' s admission record, dated 3/5/21, indicated Resident 5 had been admitted to the facility on [DATE] with a history of high blood pressure, osteoporosis (a bone disease when mineral density and bone mass decreases or when the structure and strength of bone chances, leading to increased risk of fracture) and dementia (a general term for the impaired ability to remember, think or make decisions that interferes with doing everyday activities). A review of Resident 5 ' s, Progress Note, dated 10/9/23, indicated (name of company) (mobile x-ray company) had been contacted on 10/8/23 and the order from the doctor was faxed to the company but when (name of company) was contacted by telephone, the person receiving the call…

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 radiological services were provided in a timely manner for one of one resident (Resident 5) when a STAT (immediately) x-ray (a form of electromagnetic radiation, which is used to generate images of tissues and structures inside of the body) of the left knee was not completed for eight days. This failure resulted in a delayed diagnosis and treatment causing pain and suffering. Findings: Review of Resident 5 ' s admission record, dated 3/5/21, indicated Resident 5 had been admitted to the facility on [DATE] with a history of high blood pressure, osteoporosis (a bone disease when mineral density and bone mass decreases or when the structure and strength of bone chances, leading to increase risk of fracture) and dementia (a general term for the impaired ability to remember, think or make decisions that interferes with doing everyday activities). A review of Resident 5 ' s, Progress Note dated 10/8/23, indicated Resident 5 had a redness and swelling…

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 treat four of ten sampled residents (Resident 1, Resident 2, Resident 6, and Resident 8) with respect and dignity when Resident 1 was not ensured access to a call light, assistance with answering phone calls from family, and had to call out/yell and wait for assistance, Resident 2 was left sitting or lying in his urine or feces for prolonged period of time, Resident 6 was left waiting a long time to get cleaned up, and Resident 8 feeling staff in the graveyard shift avoid cleaning him and left him lying in his feces and waiting for the morning to clean him up. These failures caused Resident 1 to feel frustrated, Resident 2 to feel staff did not care, Resident 6 to cry stating she felt like she was in a concentration camp, and Resident 8 stating he felt staff were doing it on purpose, and he felt bad and hurt. Findings: During a concurrent observation and interview on 10/25/23 at 2:16 p.m., Resident 2 was lying in a low bed gesturing to 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain a safe and homelike environment when one of nine air conditioning (AC) units of the facility was not replaced or repaired, and the emergency exit door by Nursing Station 2 and 3 was not repaired for an undisclosed long period of time, and the iron gate at the top of the stairs leading from the emergency exit door was not secured and left accessible to anyone from the driveway in front of the building. These failures exposed residents in at least 6 of 38 rooms (approximately 16 of 82 residents) and staff in the facility to uncomfortably hot environment in the summer and potentially extreme cold conditions this winter that could worsen the frail health conditions of the residents, cause an accident from the door falling or a break-in and harm to residents and staff from intruders through the open gate. Findings: A review of a complaint to the Department dated 10/17/23, alleged four to five AC/heating units in the facility were 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 establish a system for disposition of controlled substances in sufficient detail when two Licensed Nurses (Licensed Nurse G and Licensed Nurse H) did not know how to properly dispose of unused or wasted narcotic medication. This failure increased the risk for potential misuse and abuse of narcotic medication or could result in water pollution and unintentionally expose of the public to chemical from the medications. Findings: During a concurrent observation and interview on 10/26/23, at 4:14 p.m., Licensed Nurse G was observed administering medication to a resident. When asked how she would dispose of a narcotic medication, Licensed Nurse G responded, two licensed nurses signed out the narcotic medication as wasted, crushed the narcotic medication, added water, and disposed of it in the sink. During the interview on 10/26/23, at 4:28 p.m., after acknowledging Licensed Nurse G's response to the question on disposal of narcotic medication, the Director of Nursing (DON) stated she needed to gather the nurses and in-service…

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 practice proper hand hygiene when four of seven Certified Nursing Assistants (CNAs) (CNA A, CNA B, CNA E, and CNA F) did not offer, encourage, clean or wash residents' hands prior to serving meal trays or before letting residents eat. The failure increased the potential to spread communicable diseases or infection among residents and staff in the facility and further compromise the already frail condition of the residents. Findings: During a concurrent observation and interview on 10/25/23, at 12:32 p.m., CNA A went into a resident's room and served a resident the meal tray. When asked if he offered to clean the hands of the resident, CNA A stated the CNA assigned to this resident could have done it already. CNA A confirmed he had not offered to clean the resident's hands and acknowledged he should have. During a concurrent observation and interview on 10/25/23, at 12:35 p.m., CNA B brought the meal tray to a resident. CNA B was not heard…

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 report within 2 hours a suspected abuse incident between two residents (Resident 7 and Resident 11). This failure had the potential of placing residents at risk for further abuse, delay the assessment, and evaluation of the involved residents and management of psychosocial or physical injury, delay the investigation to determine the cause and extent of the conflict, or rule out abuse. Findings: A review of a report dated 10/19/23, indicated staff witnessed resident-to-resident abuse but did not report the incident until a day after, leaving the victim and abuser sharing a room. A review of the facility abuse log between 9/23 and 10/23, indicated the incident between Resident 7 and Resident 11 happened on 9/28/23 at 3:27 p.m. A review of Progress Notes (PN) dated 9/28/23, at 3:27 p.m., titled Social Service Note (SSN) indicated, Resident 7 reported to Social Service Staff (SS Staff) that Resident 11 hit her on the neck with a cane. SSN dated 9/29/23 at 1:16 p.m., indicated the report of suspected dependent adult/elder abuse…

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 did not ensure licensed nursing staff followed professional standards of care for 2 of 3 Sampled Residents (Resident 1 and Resident 2) when Licensed Nurse A (LN A) did not follow manufacturer ' s directions nor facility policy when administering rapid acting insulin (Insulin is a hormone made by the pancreas to control blood sugar; a person who ' s pancreas does not make or release insulin has Diabetes, and may need to take synthetic insulin [insulin medication]). This failure placed Residents 1 and 2 at risk for hypoglycemia, and potential harm, when LN A administered their rapid acting insulin (insulin that begins to lower blood sugar 15 minutes after administration) too early (approximately 20–35 minutes before the lunch trays arrived on the resident ' s hall). (Hypoglycemia, also called low blood sugar, is a fall in blood sugar to an abnormal level; symptoms include headache, tiredness, clumsiness, trouble talking, confusion, loss of consciousness, seizures, or death; hypoglycemia is most commonly caused by…

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 nursing staff demonstrated competency in clinical care and services, when the facility did verify ongoing competency of: 1) Licensed nurse ability to perform accurate blood sugar monitoring; 2) Licensed nurse skill at administering medication to residents; 3) Licensed nurse ability to ensure controlled wasting of narcotic medication; These failures had the potential to cause inappropriate monitoring of blood sugar, medication errors during administration, and not meeting residents' safety and infection control needs. Findings: 1) During a concurrent interview and record review on 5/10/21 at 1:50 p.m., with Staff B, the facility did not have records of staff who received annual in-service and skills test. Staff B stated the facility did not have a DSD (Director of Staff Development). During an interview on 5/10/2021 at 2 p.m., Staff A stated that he is searching for a DSD to hire. During an interview on 5/11/2021 at 11 a.m., Staff R stated that the facility did not have any current in-service or…

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

Based on observation, interview and record review, the facility failed to ensure staffing requirements where met, when: 1. The facility did not have a designated Registered Nurse covering for the DON for several days, while the DON was out on medical leave. 2. The facility did not use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week, These findings resulted in missed doses of IV (Intravenous) Antibiotic medication for Resident 137 on 5/6/21 and 5/7/21 due to not having a Registered Nurse employed on those dates, and had the potential to result in the inability to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of reach resident. Findings: 1. During an interview on 5/17/21 at 10:00 a.m., STAFF L stated the Director of Nursing (DON) was on sick leave. STAFF L stated the DON's last day working at the facility was 5/05/21. STAFF L confirmed there was no DON or staff covering for DON from 5/05/21 to 5/11/21. During an interview on 5/17/21 at 11:26 a.m., STAFF A,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to promote residents' respect and dignity to residents when: 1) Resident 141 did not get his meal tray at the same time as everyone else in the dining room. 2) Resident 25 watched other residents eat while he could not eat by mouth. 3) Resident 58 listened to Speech therapist conducted work in the day room. 4) Residents voiced grievance but did not get response from the facility. 5) Residents 2 and 62 had photographs taken while they were sleeping without their awareness or approval. These failures resulted in residents feeling angry, neglected, and disrespected. Findings: 1) During an observation on 5/10/21 at 12:00 p.m., in the dining room, Resident 141 did not receive his meal tray while other residents in front of him were eating. A review of the Dining Meal Schedule revealed, Lunch served in the Dining room at 12 noon. During an observation on 5/10/21 at 12:20 p.m., Resident 141 did not get his lunch tray while and appeared upset, raised…

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 keep residents informed of their rights and responsibilities when admission Agreements (A legal contract that states the rights of the residents and responsibilities of both the facility and the residents) were not provided to several residents upon admission to the facility and consents to treatment were not signed. This failure had the potential to result in violation of residents' rights. Findings: Resident 23 was admitted to the facility on [DATE] with medical diagnoses including Diabetes Mellitus, according to the facility Face Sheet (Facility Demographic). Resident 23's MDS (Minimum Data Set-An assessment tool) dated 4/15/21 indicated his BIMS (Brief Interview of Mental Status-A cognition assessment) score was 13, which indicated his cognition was intact. During an interview on 5/13/21 at 9:59 a.m., Resident 23 stated he never received the facility's admission Agreement. Resident 23 also stated he was never asked to sign any…

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, clean, comfortable and homelike environment to all residents in the facility when: 1) Flying pests were observed in the dining room, conference room, and one resident room 2) Residents were exposed to rodents inside the facility 3) Staff stored cooked meat stored cooked meat for a pet's meal in a drawer inside one resident room. These failures had the potential to result in a decline of residents' psychosocial functioning and resident discomfort. Findings: 1) During an observation on 5/10/2021 at 12 p.m., seven residents eating lunch in the dining room, this surveyor noted two flies, flying over residents. During a concurrent observation and interview on 5/10/2021 at 12:30 p.m., Staff B (Infection Preventionist) entered the dining room and sat between two occupied tables. This Surveyor called Staff B's attention to the presence of flies. Staff B stated that she noticed that there were flies in the dining room. During an observation on 5/11/2021 at 11 a.m., Resident 41's room had fresh ripe…

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 care plans for activities for two of six residents (Resident 78 and Resident 72). This failure had the potential to result in deterioration of the residents' mental and physical health, and decreased quality of life. Findings: Resident 78 was admitted to the facility on [DATE] with medical diagnoses including Atrial Fibrillation (Irregular heartbeat) and Personal History of Unspecified Adult Abuse according to the facility Face Sheet (Facility Demographic). Resident 78's MDS (Minimum Data Set-An assessment tool) dated 3/25/21 indicated her BIMS (Brief Interview of Mental Status-A cognition assessment) score was 13, which indicated her cognition was intact. During an observation on 5/12/21 at 9:46 a.m., Resident 78 was observed in a chair, in her room, alone, awake, not engaged in any activities. During a second observation on 5/14/21 at 11:42 a.m., Resident 78 was observed in a chair in her room, alone, awake, not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure care plans were revised and updated for two of six residents (Resident 23 and Resident 41) after suffering falls at the facility. As a result, the residents continued to suffer falls, which could have resulted in serious injuries and harm. Findings: Resident 23 was admitted to the facility on [DATE] with medical diagnoses including Diabetes Mellitus, Difficulty in Walking, and Blindness on One Eye, according to the facility Face Sheet (Facility Demographic). Resident 23's MDS (Minimum Data Set-An assessment tool) dated 4/15/21 indicated his BIMS (Brief Interview of Mental Status-A cognition assessment) score was 13, which indicated his cognition was intact. During record review on 5/11/21 at 11:24 a.m., it was noted Resident 23 suffered multiple falls at the facility since the January 1, 2021. First Fall: A Health Status Note dated 1/18/21 at 9:02 pm., indicated, At around 18:45 (6:45 p.m.,) when the CNA (Certified Nursing Assistant) enter 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure professional standards of practice were implemented when: 1. A Licensed Nurse (STAFF I) did not inform other Licensed Staff on the floor that she was taking her lunch so they could cover for her during her leave. This failure had the potential to result in inability for other nurses to respond to medical emergencies and needs of the residents in STAFF I's assigned section. 2. Facility staff, including department heads, were observed using their cell phones for personal business during work hours. 3. Facility staff did not sign the MAR to indicate administration of opioid medication for Resident 56 after removing the medication from a pill pack. These failures had the potential to result in neglect and abandonment of residents, inability for staff to timely respond to medical emergencies, and did not ensure the facility maintained control over controlled substances. Findings: 1. Resident 183 was admitted to the facility on [DATE]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe and accident free facility when: 1. The facility stored two unsecured oxygen tanks inside one of 19 resident's (Resident 58) room; 2. Two of six residents (Resident 23 and Resident 41) were not provided adequate care and supervision to prevent them from suffering multiple falls; 3. The facility did not perform a smoking assessment for one of six residents (Resident 5), and allowed Resident 5 to keep his own smoking supplies in his room; 4. Trained, licensed nursing staff did not observe residents who were eating during mealtime. 5. Flammable liquid was not stored in accordance with facility policy. These failures had the potential to cause resident resident harm, and did not ensure a safe environment for delivering care and services. Findings: 1. During observations and initial screening of residents on 5/10/21 at 12:50 p.m., behind the entry door to Resident 58's room were two oxygen tanks. The two oxygen tanks were free…

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 sufficent staff available during the night shift to respond to residents' calls for assistance in a timely manner. This failure had the potential to result in poor quality of care and accidents to the residents requiring assistance in the middle of the night. Findings: Resident 23 During resident council interviews on 5/11/21 at 2:00 p.m., Resident 23 stated call lights took a long time to be answered at night, sometimes more than thirty minutes. Resident 23's MDS (Minimum Data Set-An assessment tool) dated 4/15/21 indicated his BIMS (Brief Interview of Mental Status-A cognition assessment) score was 13, which indicated his cognition was intact. Resident 51 During an interview on 5/13/21 at 10:46 a.m., Reside 51 stated it took from 25 minutes to an hour for staff to respond to call lights at night. During a second interview on 5/18/21 at 2:17 p.m., Resident 51 stated he had to wait an hour once for staff to respond to call lights, and as 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 post the daily nursing staffing schedule daily. This failure could have resulted in unavailability of staffing information to residents and visitors for review. Findings: During an observation on 5/17/21 at 9:05 a.m., the posting of the daily nursing staffing schedule could not be located. During an interview on 5/17/21 at 9:17 a.m., STAFF L, Staffing Coordinator, confirmed they did not post the daily nursing schedule. During a concurrent interview and observation on 5/17/21 at 9:41 a.m., STAFF L stated the daily staffing schedule was on a binder in the nursing station, but it was not posted. STAFF L also stated the facility posted the monthly schedule in the wall in one of the wings of the facility. Upon observation, the monthly staffing schedule for April of 2021 was posted, but not the one for May of 2021. STAFF L stated the May staffing schedule had not been posted yet.

Based on observation, interview and record review, the facility failed to ensure one kitchen staff (STAFF Y) performed adequate hand hygiene during meal preparation. This failure had the potential to result in food-borne illness to the residents of the facility. Findings: During an observation on 5/12/21 at 12:18 p.m., STAFF Y, Cook, was observed using disposable gloves during meal preparation. STAFF Y was observed wearing gloves that became soiled with grease and food particles during meal preparation. At one point during the observation, STAFF Y removed his gloves, and donned new gloves, but did not wash his hands in between. This was also observed by the STAFF X, Registered Dietician, who asked him to remove his new gloves and wash his hands. During a second observation on 5/12/21 at 12:30 p.m., cook STAFF Y was observed resting his gloved hands on a soiled counter that contained food particles and stains. Without washing his hands or changing gloves, STAFF Y was observed grabbing bread for residents' sandwiches, and slicing sandwiches, to put them in plates for residents. STAFF…

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 clinical documentation was complete and accurate when supplemental oxygen administration was not documented for one resident (Resident 183), and neurological checks (Evaluation of a patient's nervous system) indicated for one resident (Resident 41) where not completed. This failure had the potential to result in inability for staff to respond to the status and needs of the residents, and lack of availability of information to facilitate communication among the interdisciplinary team. Findings: Resident 183 Resident 183 was admitted to the facility on [DATE] with medical diagnoses including Heart Failure (A chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's needs) and Chronic Obstructive Pulmonary Disease (COPD- A chronic inflammatory lung disease that causes obstructed airflow from the lungs), according to the facility Face Sheet (Facility demographic). A physician order initiated 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 interview and record review, the facility failed to ensure their Quality Assessment and Performance Improvement (QAPI) effectively identified and resolved concerns related to: 1. Allegations of abuse and neglect against staff, and; 2. Staff sleeping on duty. These failure had the potential to affect every resident's ability to maintain the highest level of well-being, and had the potential to expose residents to continued physician and/or psychosocial harm if concerns remained unresolved. Findings: During an Interview on 5/18/21 at 2:17 p.m., Administrator stated the facility's QAPI committee developed projects to reconcile employee records, improve staffing of the facility, and improve staff adherence to infection prevention practices and implementation of Center for Disease Control (CDC) guidance. During an Interview on 5/18/21 at 2:17 p.m., Administrator stated that since the QAPI meeting in April 2021, the facility developed logs to track processes such as discharges and abuse reporting. The log to track abuse was based on the many resident-to-resident altercations…

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 prevention and control practices, when: 1. Staff did not practice hand hygiene during mealtime and did not offer residents hand hygiene during mealtime. 2. A Licensed Nurse did not wear a face mask properly, placing the residents at risk for the spread of infections. These failures have the potential for the transmission of infections or causing food borne diseases. Findings: 1. During an observation on 5/10/21 at 11:25 a.m., STAFF I, Licensed Nurse, was observed wearing a surgical facemask that covered her mouth but not her nose. STAFF I was not wearing a face shield at the time. STAFF B, Infection Preventionist, was notified, and she confirmed the finding. STAFF B stated she had told STAFF I on several occasions to ensure her mouth and nose were covered with the facemask, but STAFF I continued to wear it like that (With the nose uncovered). During an interview on 5/10/21 at 11:40 a.m., STAFF I stated she wore her facemask under her nose because it kept falling off. STAFF I was asked if…

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 an effective pest control program, when it did not follow policy or take measures recommended by the pest control company to minimize pests. This failure enabled known pest problems to continue and had the potential to expose resident to diseases transmitted by rodents, flies and other insects, leading to unnecessary illness or death. Findings: During an observation on 5/10/21 at 8:30 a.m., a tour of the outdoor patio and outside of the front entrance of the Facility revealed multiple large mousetraps placed near and underneath the building of the facility. During an interview on 5/10/21 at 9:00 a.m., Staff J (Maintenance Supervisor) stated that the Pest Control Company advised to place mousetraps around the facility for safety measures, to prevent rodent entering the facility. Staff J stated that the Pest Control Company placed about 15 mousetraps on the grounds surrounding and underneath the facility. Staff J stated that he had not seen any rodents inside the facility. During an observation 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of six residents (Resident 51) received his scheduled showers twice per week. This failure had the potential to result in discomfort, skin infections and feelings of frustration and helplessness to Resident 51. Findings: Resident 51 was admitted to the facility on [DATE] with medical diagnoses including Obesity and Diseases of the Skin and Subcutaneous Tissue (The innermost layer of skin), according to the facility Face Sheet (Facility Demographic). Resident 72's MDS (Minimum Data Set-An assessment tool) dated 2/16/21 indicated his BIMS (Brief Interview of Mental Status-A cognition assessment) score was 15, which indicated his cognition was intact. Resident 72's MDS also indicated he required physical help from one person in part of the bathing activity. Resident 72's Nursing Plan of Care for activities of daily living (ADLs), including bathing, indicated, The resident has an ADL Self Care Performance Deficit r/t (Related 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide an on-going activities program for two of six residents (Resident 78 and Resident 72) designed to meet the residents' interests. This failure had the potential to result in deterioration of the residents' mental and physical health, and decreased quality of life. Findings: Resident 78 was admitted to the facility on [DATE] with medical diagnoses including Atrial Fibrillation (Irregular heartbeat) and Personal History of Unspecified Adult Abuse according to the facility Face Sheet (Facility Demographic). Resident 78's MDS (Minimum Data Set-An assessment tool) dated 3/25/21 indicated her BIMS (Brief Interview of Mental Status-A cognition assessment) score was 13, which indicated her cognition was intact. During an observation on 5/12/21 at 9:46 a.m., Resident 78 was observed in a chair, in her room, alone, awake, not engaged in any activities. During a second observation on 5/14/21 at 11:42 a.m., Resident 78 was observed in a chair…

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 did not determine the indication for one of five residents (Resident 140) to continue using a urinary catheter (a tube to drain the urine from one's bladder.) This failure resulted in Resident 140 missing a follow up Medical appointment. In addition, there is potential for the resident to develop a urinary tract infection from the external tube. Findings: During observations and initial screening of residents on 5/10/21 at 12:20 p.m., Resident 140 was seen in bed with a urinary catheter bag resting on the floor. During an observation and concurrent interview on 5/12/21 at 3:00 p.m., Resident 140's urinary catheter bag was hanging from the bedside and in a blue cloth bag. Resident 140 did not know why he had a urinary catheter. Review of Resident 140's Physician Orders dated 4/6/21, contained orders for Resident 140 to have a urinary catheter with reason of Diagnosis (none listed) Orders for the catheter were also written. Resident 140's medical diagnosis included Respiratory failure, Alcohol abuse, Emphysema…

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 failed to store and label medication appropriately, when the facility: 1) Did not use the appropriate temperature controls when storing medication. 2) Stored expired medication with medication intended for resident use 3) Stored medication in containers with an inappropriate labels These failures had the potential to result in administration of contaminated or unstable medication as well as use of medication beyond the medication's date of expiration, which could cause resident harm. Findings: 1 ) During a concurrent observation, interview, and record review inside one of two medication storage rooms in the facility, on [DATE] at 10:30 a.m., Staff R (acting Director of Nurses) was present. Prevnar 13 10x5 was stored under room temperature. The label for Prevnar 13 10x5 indicated to refrigerate the medication. Staff R stated the medication should have been refrigerated and then removed the medication from stock. 2) During a concurrent observation, interview,…

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 residents with a nourishing, palatable, well-balanced diet that met daily nutritional and special dietary needs when: 1. Diet orders and considerations were not accurately transcribed to kitchen staff; 2. There was insufficient dietary management and oversight as of 3/18/19; 3. Food supply was not sufficient to prepare the menu as approved by the Registered Dietician; 4. The menu was not followed for 2 menu types; 5. Therapeutic diet orders were not followed; 6. Recipes were not followed; 7. Resident preferences were not honored; and 8. Substitutions were not documented and not nutritionally equal. These failures resulted in nutrition services not meeting the needs for all 87 residents, and had the potential to result in impaired nutritional status for at risk residents. Impaired nutrition may be associated with an increased risk of mortality and other negative outcomes, such as impairment of anticipated wound healing, decline in function, fluid and electrolyte imbalance/dehydration, and unplanned…

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 employ sufficient staff with the appropriate competencies and skills sets to carry out the management and supervision of nutritional services which had the potential for dietary deficient practices to go unchecked and unresolved. Findings: During the initial kitchen tour, on 4/23/19, at 8:45 a.m., observed 3 staff working in the kitchen. Tour was conducted without staff involvement. When asked if the Dietary Manager (DM) was in the building, all three stated no and continued to work. During a review of the Active Employee List, dated 4/23/19, provided by the Administrator, indicated the facility did not have a Dietary Manager. During an interview, with the consultant Registered Dietician (RD), on 4/24/19, at 12:48 p.m., she stated every month she performed a kitchen sanitation check. Daily work included resident assessments, nutritional recommendations for at risk residents, resident weight loss monitoring, interdisciplinary team meetings, facility committee meetings, and day to day kitchen support. 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.

Based on observation, interview, and record review, the facility failed to ensure staff had the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, which resulted in subpar dining experiences for all 87 residents in the facility. Findings: During kitchen observations, from 4/22/19-4/30/19, dietary staff were observed performing duties that did not ensure: menus and nutritional adequacy, resident preferences allergies and substitutions, therapeutic diets, and food service safety. Cooks A and B were observed not following recipes when pureeing food. Cooks A and B did not modify texture according to the altered texture manual. An entire lunch meal was called out by dietary aides and plated by cooks without the diet type being honored. The Registered Dietitian (RD) was present during observation. When asked how the residents requiring lower sodium, reduced carbohydrate, or low fat diets were identified [NAME] A stated she did not understand. the RD stated she did not realize no diet types were called out. The RD reviewed the spreadsheet…

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 store, prepare, and serve food in accordance with the facility's policies and procedures when: 1. Dinnerware was not properly sanitized during the dish washing process, and 2. Potentially Hazardous Food (PHF) was prepared without verifying and/or documenting proper final internal cooking temperature had been reached and maintained for 15 seconds, 3. Nutritional supplements, located on the Nursing Medication Administration carts, were held for extended amounts of time without monitoring for safe temperature, 4. Dietary staff did not have hair consistently restrained, 5. Dietary staff did not consistently wear aprons or change aprons to prevent cross contamination, 6. One cardboard box of red potatoes, located in the dry storage room, was half full of potatoes that were squishy to the touch and had a white fuzzy substance growing on them. 7. Dietary cooks did not consistently perform hand hygiene and change gloves to prevent cross…

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 their Quality Assessment and Performance Improvement (QPIA) had effective oversight of the following: 1. Food and Nutrition Services (Refer to 800, 801, 802, 803, 806, 808, and 812), and 2. Antibiotic Stewardship (Refer to 881). This failure had the potential to negatively affect the health and well-being of all the residents in the facility. Findings: During an interview with the administrator on 4/30/19 at 3:45 PM, he stated the Department Heads met monthly for QAPI. He stated that problems were identified by department heads and discussed at QAPI. The facility's Performance Improvement Goals were to have the 5 Star quality measures show improvement. When asked if there was a Performance Improvement project for Infection control or Antibiotic Stewardship, he stated that the Director of Staff Development would need to get one going. When asked if there was a Performance Improvement project for Food and Nutritional services, he stated the facility did not have a Performance improvement project. He…

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

Based on interview and record review, the facility failed to ensure an effective Antibiotic stewardship program was present and functioning, including promoting the appropriate use of antibiotics and consistent monitoring of antibiotic use to improve resident outcomes for two (Resident 39 and 59) out of 19 sampled residents and reduction of antibiotic resistance, according to facility policy and procedure (P&P). This failure had the potential for inappropriate use of antibiotics resulting in adverse events associated with antibiotic use and subsequent antibiotic resistance (drugs designed to kill bacteria are no longer effective and bacteria are able to multiply. Findings: During a concurrent interview and document review with Director of Staff Development on 4/30/19 at 11:03 a.m., she stated Resident 39 had been diagnosed with a Urinary Tract Infection (UTI) as identified from an Infection Prevention and Control Surveillance Log (form). Director of Staff Development (DSD) stated, she had to find the supporting documentation of how Resident 39 was diagnosed with a UTI and why she…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility was only discussing Advance Directives on admission but was not discussing Advance Directives with residents during care conferences or when changes occurred. This was checked for 3 of 3 long term residents, (Residents 26, 37 and 38.) This had the potential for Resident's advanced care planning decisions regarding their health care and treatment options not being honored. Findings: During a review of the clinical record for Resident 37, The Physician Orders for Life Sustaining Treatments (POLST) dated [DATE] indicated Cardio Pulmonary Resuscitation (CPR) was to be performed. The California POLST form, Section D has boxes to mark if Advance Directives are available and reviewed, Not available, or no Advance Directives. Resident 37's POLST did not have any box marked to indicate if he had Advanced Directives. During a review of the clinical record for Resident 38, The POLST dated [DATE] indicated Do not attempt resuscitation. Resident 37's POLST did not have any…

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

Based on observation, interview and record review, the facility failed to develop and implement a person centered care plan for one of 19 sampled residents (Resident 42) with regard to nutrition and weight loss. This failure had the potential for further weigh loss, which could negatively impact Resident 42's health. Findings: During an observation on 4/23/19 at 9:42 a.m., Resident 42 was in her room with a breakfast tray on her bedside table uneaten. Resident 42 was asked if she was hungry and she did not answer with discernable language. A review of Resident 42's admission Record indicated she was admitted the facility on 10/20/18 with a history of Dementia (a general term used to describe a group of symptoms associated with a decline in memory, other thinking skills severe enough to reduce a person's ability to perform everyday activities), high blood pressure, muscle weakness causing an unsteady walking and low thyroid (a gland in the body that regulates metabolism, resulting in potentially feeling tired). A review of Resident 42's admission Assessment Minimum Data Set (MDS), a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that person centered care plans were revised for 1 resident, Resident 38. This failure had the potential for Resident 38 to be injured by a fall and suffer increased deformity form a contracture of the left wrist. Other residents were at risk of injury due to Resident 38's unpleasant behavior. Findings: During an observation on 4/22/19 at 10 AM, in Resident 38's room, her wheelchair was parked between the beds, and she was motioning for help from the roommate. Resident 38's roommate put on the call bell. After 5 minutes a CNA answered the call light and stated I do not know what we do for [Resident 38], she is not my resident. During an observation on 4/22/19 at 12:10 PM in the dining room, Resident 38 was at the table for lunch. She was pulling on the tablecloth, and another resident had to call out for staff to see her. A few minutes later she was observed to throw a fork and knife at the other resident's head. She also was seen…

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, the facility failed to provide the necessary Activities of Daily Living and documentation for showers for 2 out of 19 sampled residents (Resident 2 and 242). This failure resulted in Resident 2 not receiving her showers twice weekly and Resident 242 having disheveled appearance. Findings: During an interview with Resident 2 on 4/23/19 at 3:31 p.m., she stated she was not getting her twice weekly showers. Resident 2 stated some of the reasons for her not getting her weekly showers included: not enough staff due to someone calling in sick, too busy and new staff not knowing how to take care of her. Resident 2 stated she did not walk very well and most used a wheelchair to get around due to legs being weak and not being able to see. A review of Resident 2's admission Record indicated she was admitted to the facility on [DATE] with a history of high blood pressure, generalized muscle weakness and adult failure to thrive (syndrome of weight loss and depressive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide appropriate treatment and services to prevent urinary tract infections for 1 of 5 residents who had indwelling catheters (Resident 57), which resulted in Resident 57 contracting an infection. Findings: During a review of the clinical record for Resident 57, the admission Report, dated 4/23/19, indicated Resident 57 was admitted to the facility on [DATE]. At the time of admission, Resident 57 had active medical diagnoses of; Amyotrophic Lateral Sclerosis (a progressive disease affecting nerve cells in the brain and spinal cord, the main symptom is muscle weakness, and there is no cure), respiratory failure (condition in which your blood doesn't have enough oxygen or has too much carbon dioxide), and quadriplegia (paralysis of all four limbs). The report further indicated Resident 57 was alert and oriented to person, place, time, and situation. Resident 57 was able to make his needs known, and answered questions appropriately.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. During an observation and concurrent interview with Resident 90, on 4/23/19, at 12:08 p.m., observed colostomy bag attached to the resident's abdomen. Neither the bag or attachment site was dated. Resident 90 confirmed she had the colostomy prior to admission. Resident 90 confirmed staff were emptying the colostomy bag. Resident 90 did not recall any staff assessing the skin or the colostomy site. Resident 90 stated she did not know how to answer the question because she did not know what staff did or did not do regarding her colostomy. During a review of the clinical record for Resident 90, the admission Report, dated 4/23/19, indicated Resident 90 was admitted to the facility on [DATE]. At the time of admission, Resident 90 had active medical diagnoses of; partial intestinal obstruction, colostomy, pneumonia (a lung inflammation caused by bacterial or viral infection, in which the air sacs fill with pus and may become solid), and septic shock (a bacterial infection elsewhere in the body, such as the lungs…

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 and record review, the facility failed to provide ostomy care to meet the professional standards of 1 (Resident 35) out of 19 sampled residents. This failure had the potential of the inappropriate ostomy care resulting in harm for those residents with an ostomy. Findings: During an interview with Resident 35 on 4/23/19 at 10:46 a.m., he indicated by showing his colostomy pouch (a bag that contains the excrement emptying out of the colon through a surgical opening from the colon (colostomy) to the abdominal wall that empties into a bag) was full and that it needed to be emptied so he put on his call light on. CNA Q (Certified Nursing Assistant Q) stated he did not know how to empty the colostomy bag and exited to find someone who could. CNA O entered Resident 35's room at 10:55 a.m. and stated she had not been trained on how to empty the colostomy bag and exited to find the nurse who could do it. Assistant Director of Nurses entered Resident 35's room at 11:05 a.m. and stated she could empty the colostomy bag. CNA O assisted the Assistant Director of…

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

Based on observation, interview, and record review, the facility failed to ensure menus met the individual needs of residents when; 1. Menus were not followed, 2. Alternate entree items were not nutritionally equivalent to the original entree offered, 3. And menus were not culturally appropriate for 2 unsampled residents (Resident 5 and 243). These failures resulted in multiple residents expressing frustration that the food was redundant, disappointing, and there was nothing acceptable provided for some residents to eat. Findings: 1. During an interview with Resident 75 on 4/22/19, at 9:39 a.m., she stated she had diabetes and several food allergies. Resident 75 felt her meals were always high in carbohydrates and sweets. Resident 75 also stated she always had to check what they were serving her because on several occasions she was served something she was allergic to. She said residents that had the ability to go to the kitchen door and knock could get an egg salad sandwich. Resident 75 was a long term resident at the facility for the past 3 years, she was alert and oriented 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 honor resident preferences when: 1. 2 residents (Resident 10 and Resident 75) received a food item they were allergic too. This failure could have potentially led to food illness and an allergic reaction requiring medical intervention; 2. 3 residents (Resident 54, 76, and 77), with a documented dislike of gravy, were served gravy, which resulted in residents not being satisfied with their meal; 3. 4 residents (Resident 57, Resident 75, Resident 80, Resident 35) and anonymous members of the resident council with a preference for fresh fruit, were given canned fruit; which resulted in residents feeling like they had no control over their food choices. Findings: 1. During a dining observation on 4/22/19, at 16:00 p.m., Resident 10 was eating dinner which consisted of beef stew, a roll, a cup of vanilla ice cream, and a glass of water. Review of the resident's tray card revealed, the resident was allergic to milk. Review of the clinical record for Resident 10, on 4/22/19, indicated the resident had allergies 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 ensure physician prescribed therapeutic diet orders were followed when: 1. Resident 27, that required food to be a pureed texture, was given a regular meal, 2. 7 unsampled residents that required food to be a mechanical soft texture were given regular texture grilled cheese sandwiches for lunch, 3. 4 unsampled residents that required food to be a mechanical soft texture were given regular texture corn bread with their lunch meal, 4. And 2 residents (Resident 61 and 86), that required food to be a mechanical soft texture were given regular texture grilled cheese sandwiches for dinner. Failure to follow food texture requirements had the potential for serious harm, injury, or death as a result of residents choking on food they could not safely swallow. Findings: 1. During an observation on 4/22/19 at 12:10 PM in the dining room, Resident 27 was served a lunch tray with regular textured food. Resident 27 began to eat right away. At 12:15 p.m. an unlicensed staff person removed his tray and replaced it with a tray…

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

Based on observation and interview, the facility failed to ensure a homelike and safe environment when the paving just off of the buildings wall in the Back Patio with the Smoking Area was moist with discolored brown and green. This was concerning to one resident, Resident 39. This failure could have resulted in growing mold and a slipping hazard to any of the ambulatory residents. Findings: During an interview and concurrent observation on 4/23/19 at 1:42 PM, Resident 39 voiced concerns about seeing mold within the facility and outside on the back patio. While walking with the resident she pointed out the 2 wet areas of the pavement that were green and brown and could possibly be the source of the mold. She stated that it should be cleaned up. During an interview on 4/24/19 at 11:35 AM, Maintenance Director was shown the wet brown and green Pavement on the back patio. He stated it was not mold. He stated that the air conditioner was on the roof and moisture from the air conditioner was directed down the 2 drainage pipes on the back of the building, leaving the moisture there on 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 a comprehensive assessment was completed which included the dental status and mouth constrictors for 1 out of 19 sampled residents, (Resident 35). This failure had the potential for development or worsening of the limitation of the mouth opening and not being able to use dentures. Findings: During an interview and observation on 4/23/19 at 2:54 p.m., Resident 35 was observed to not have teeth in his mouth and was asked where his dentures were or if he had dentures. Resident 35 stated he had dentures and motioned to the nightstand next to his bed. Resident 35 stated he could not wear the dentures because they did not fit in his mouth. A review of the Resident 35's admission Record on 4/24/19 at 0930 a.m., indicated he was admitted to the facility on [DATE] with a history of a colostomy (a surgical operation which a piece of the colon (bowel) is diverted to an opening in the abdomen so as to bypass the portion of the bowel that was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide care consistent with professional standard and practice for 1 out of 19 sampled residents (Resident 35). This failure could have resulted in skin breakdown. Findings: During an interview and observation with Resident 35 on 4/23/19 at 10:08 a.m., he was observed to be a tall man over 6 feet and sitting in a wheelchair. Resident 35 stated he had a sore on his bottom and it hurt, especially when they cleaned him. Resident 35 stated he could not walk and had to be lifted out of bed and into his wheelchair by using a machine. A review of the Resident 35's admission Record on 4/24/19 at 0930 a.m., indicated he was admitted to the facility on [DATE] with a history of a colostomy (a surgical operation which a piece of the colon (bowel) is diverted to an opening in the abdomen so as to bypass the portion of the bowel that was damaged and stool excreted through the opening, into a bag rather than the rectum), thrombosis (a blood clot which…

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