Advanced Rehab Center Of Tustin

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure resident care was provided in a manner that maintained and enhanced dignity for one of 20 final sample residents (Resident 19). * The facility failed to ensure CNA 2 sat next to Resident 19 while assisting the resident to eat. This failure had the potential to negatively impact Resident 19's sense of dignity, self-worth, and well-being.Findings: Review of the facility's P&P titled Assisting the Impaired Resident with In-Room Meals dated 2001 showed if the staff is going to be seated during the feeding, to position a chair where it will be convenient for you and the resident. On 5/5/26 at 0800 and 0805 hours, Resident 19 was observed being assisted with eating by CNA 2. CNA 2 was observed standing over Resident 19, who was seated upright in bed. On 5/5/26 at 0810 hours, an observation for Resident 19 and concurrent interview was conducted with CNA 2. CNA 2 verified she had been standing over Resident 19…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure two of five sampled residents for unnecessary medications (Residents 19 and 148) and two of 20 final sampled residents (Residents 8 and 93) reviewed for informed consents were provided the right to self-determination regarding the use of the psychotropic medications and treatments. * The facility failed to ensure the informed consents for buspirone (antianxiety) and Seroquel (antipsychotic) medications were accurate for Resident 93. * The facility failed to ensure the informed consent for buspirone medication included the indication of use and manifested behavior, and the informed consent for fluoxetine (antidepressant) medication was verified by two licensed nurses for Resident 148. * The facility failed to ensure the informed consent for risperidone (antianxiety) and Depakote (antimanic) medications included administration method and whether the medications had caution and warning summary, FDA-approved use, 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 observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medications were safely administered for one of 91 residents (Resident 59). * Resident 59 had Vitamin A and D (skin protectant) ointment at bedside. However, Resident 59 did not have a physician's order to keep the medication at the bedside. This failure had the potential for the resident to administer the medication inaccurately, develop adverse reactions, and negatively affect the resident's well-being.Findings: Review of the facility's P&P titled Resident Self-Administration of Medications dated 2001 showed as part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident. If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide a reasonable accommodation to meet the needs of one of 90 residents (Resident 136) observed for call light accessibility. * The facility failed to ensure Resident 136's call light was within the resident's reach. This failure had the potential to negatively impact the resident's psychosocial well-being and may cause delays in receiving necessary care.Findings: Review of the facility's P&P titled Answering the Call Light revised 3/2021 showed the purpose of the procedure to ensure timely responses to the resident's request and needs. Under the section General Guidelines, showed when the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. Review of the facility P&P titled Accommodation of Needs dated 3/2021 showed in order to accommodate individual needs and preferences, adaptation may be made to the physical environment, including resident's bedroom…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to timely notify the resident's physician for changes in condition for one of one final sampled resident (Resident 4) reviewed for change of condition. * The facility failed to timely follow-up on and notify Resident 4's physician regarding the resident's urinary changes. This failure resulted in a delay in obtaining and implementing physician interventions.Findings: Review of the facility's P&P titled Change in a Resident's Condition or Status dated 2001 showed the facility will promptly notify the physician of changes in the resident's medical condition or with specific instructions to do so. Medical record review for Resident 4 was initiated on 5/5/26. Resident 4 was readmitted to the facility on [DATE]. Review of Resident 4's Care Plan Report showed a care plan problem initiated on 12/4/25, addressing the resident's alteration in bowel and bladder related to use of an indwelling urinary catheter and frequent…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of five final sampled residents (Resident 148) reviewed for unnecessary medication was free from unnecessary psychotropic medications. * The facility failed to ensure Resident 148 was monitored for the side effects related to the use of lorazepam (antianxiety), buspirone (antianxiety), fluoxetine (antidepressant) and mirtazapine (antidepressant). In addition, the monthly behavior summary for mirtazapine medication did not match the documentation of the episodes when Resident 148 ate less than 50%. These failures had the potential to result in unrecognized adverse medication effects, delayed or inadequate clinical intervention, and inaccurate clinical decision-making regarding the continued use of the psychotropic medications for Resident 148.Findings: Review of the facility's P&P titled Psychotropic Medication Use dated 2001 showed psychotropic medication management includes adequate monitoring for efficacy 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, medical record review, and facility P&P review, the facility failed to ensure accurate and timely PASARR Level I screenings for two of two final sampled residents (Residents 10 and 32) reviewed for PASARR. * The facility failed to ensure PASARR level I screening was completed when Resident 10 entered the facility as an exception (an exempted acute care hospital discharge) and stayed more than 30 days. * The facility failed to ensure the accuracy of the PASARR Level 1 screening for Resident 32. These failures posed the risk for Residents 10 and 32 of not properly screened for serious mental illness, intellectual disability, or related conditions, potentially resulting in inadequate levels of service, incomplete assessments, and lack of appropriate interventions and evaluations.Findings: Review of the facility's P&P titled admission Criteria revised 3/2019 showed all new admission and readmissions are screened for mental disorder (MD), intellectual disabilities (ID) or related disorder (RD) per…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to develop a comprehensive, person-centered plan of care to reflect the individual care needs for two of 20 final sampled residents (Residents 143 and 148). * The facility failed to address Resident 143's use of the hydroxyzine HCl medication for anxiety in the care plan. * The facility failed to develop a care plan problem and interventions to address the use of the buspirone medication (antianxiety) for Resident 148. These failures had the potential to result in inconsistent, incomplete, and non individualized care for the residents.Findings: Review of the facility's P&P titled Care Plans, Comprehensive Person-Centered revised 3/2022 showed the following: - Comprehensive, person-centered care plan describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; and - Assessments of residents are ongoing and care plans are…

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 medical record review, the facility failed to provide necessary treatment and follow-up care to maintain the vision needs for one of one final sampled resident (Resident 123) reviewed for vision and hearing. * The facility failed to ensure Resident 123's follow-up eye specialize appointment was scheduled. This failure posed a risk of the resident not receiving appropriate care for the resident's vision needs.Findings: On 5/5/26 at 935 hours, an interview was conducted with Resident 123. Resident 123 stated she had not been able to see her eye specialist and had not received any information regarding a follow-up appointment. Medical record review for Resident 123 was initiated on 5/5/26. Resident 123 was readmitted to the facility on [DATE]. Review of Resident 123's H&P examination dated 3/10/26, showed Resident 126 had the capacity to understand and make decisions. Resident 123's diagnoses included bilateral eye blindness. Further review of Resident 123's medical record showed an eye…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to properly maintain and assess the IV access for one of one final sampled resident (Resident 148) reviewed for IV catheter care. * The facility failed to ensure Resident 148's PICC line was monitored accurately, and the physician was notified when there was a change in the external catheter length measurement as per the physician's order. In addition, the facility failed to measure and document Resident 148's arm circumference after the initial assessment on 4/2/26. These failures had the potential to delay the identification of PICC related complications and place the resident at increased risk for harm.Findings: Review of the facility's P&P titled PICC Dressing Change dated 3/2023 showed the following:- Dressing changes using transparent dressings are performed upon admission (if not dated or site is not visible for assessment), at least weekly, and if the integrity of the dressing has been compromised (wet,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure appropriate pain management for two of five final sampled residents (Residents 83 and 148) reviewed for pain management. * The facility failed to provide nonpharmacological interventions for pain management to Resident 83 prior to administering the pain medication. * The facility failed to provide nonpharmacological interventions for pain management to Resident 148 prior to administering the pain medication. In addition, the Norco (narcotic pain medication) medication was administered to Resident 148 when the documented pain level was 0/10 (on the pain scale of 0 to 10 with 0 = no pain and 10 = worst). These failures had the potential to result in ineffective pain management and/or expose the residents to unnecessary medication use and associated adverse effects.Findings: Review of the facility's P&P titled Pain Assessment and Management dated 2001 showed the pain management program is based on a facility-wide…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure necessary pharmaceutical services were provided to maintain safe and appropriate medication administration for one nonsampled resident (Resident 99) and one of three medication carts (Medication Cart A) inspected. * The facility failed to ensure LVN 4 checked Resident 99's respiratory rate prior to administering the gabapentin (nerve pain medication), as prescribed by the physician. This failure placed the resident at risk for potential side effects or complications. * The facility failed to document when the glucagon emergency kit (used to treat sever, life threatening low blood sugar) was opened and failed to replace it within 72 hours as required by the facility's P&P. This failure had the potential to delay timely emergency treatment for residents experiencing severe hypoglycemia.Findings: 1. On 5/6/26 at 0826 hours, a medication administration observation for Resident 99 was conducted with LVN 4.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility document review, the facility failed to ensure the irregularities in a resident's drug regimen were identified and reported for one of one final sampled resident (Resident 123) reviewed for insulin (hormone produced by the body to regulate blood sugar) use. * The facility's pharmacy review binder did not contain pharmacy recommendations addressing Resident 123's repeated refusal of insulin injections and related blood sugar checks. This failure posed the risk of Resident 123 not receiving appropriate care and monitoring for diabetes management.Findings: Review of the facility's Matrix (undated) showed Resident 123 was receiving insulin therapy. Medical record review for Resident 123 was initiated on 5/5/26. Resident 123 was readmitted to the facility on [DATE]. Review of Resident 123's Face Sheet dated 5/6/26, showed under the Diagnosis Information the resident had Type 2 Diabetes Mellitus. Review of Resident 123's MARs for April and May 2026 showed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to ensure one of five sampled residents (Resident 148) reviewed for unnecessary medications was free from unnecessary medications. * The facility failed to ensure Resident 148's heart rate was checked prior to administering the amiodarone (antiarrhythmic medication), as prescribed by the physician. This failure increased the risk of medication related adverse effects and had the potential to negatively impact the resident's health and well being.Findings: Medical record review for Resident 148 was initiated on 5/5/26. Resident 148 was readmitted to the facility on [DATE]. Review of Resident 148's Order Summary Report showed a physician's order dated 3/23/26, to administer amiodarone 200 mg one tablet by mouth two times a day for arrythmia. Hold for heart rate less than 60 beats per minute. Review of Resident 148's MAR for April and May 2026 showed Resident 148 was administered the amiodarone medication from 4/1 to 4/26/26 at 0900 and 1700 hours,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure the laboratory testing was completed as ordered by the physician for one of five sampled residents (Resident 83) reviewed for unnecessary medication. * The facility failed to ensure Resident 83's baseline laboratory tests, including a CBC (a blood test to determine health status, including anemia and infection), lipid panel (a blood test measuring cholesterol and triglycerides to assess cardiovascular risk), CMP (a blood panel test that measures sugar (glucose) levels, electrolyte/fluid balance, kidney function, and liver function), glycohemoglobin A1C (measures the average amount of glucose (sugar) attached to hemoglobin in red blood cells over the past two to three months), magnesium (a blood test to measure magnesium levels in the serum to diagnose deficiencies or excesses which are crucial for heart, nerve, and muscle function) and phosphorus (measures the amount of phosphate in the blood, which is essential for…

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

Based on observation, interview, and facility document review, the facility failed to ensure the menus were followed for 25 of 91 residents receiving mechanically altered diets. * The facility failed to follow the menu for the residents receiving mechanically altered diets when the residents did not receive the correct meal portion sizes as specified in the menu and spreadsheet. These failures posed the risk that residents' nutritional needs would not be met, potentially leading to unintentional weight loss and further medical complications.Findings: Review of the facility's document titled Diet Tally dated 5/6/26, showed three residents had a physician's order for an IDDSI Level 4 (Puree) diet, four residents had a physician's order for an IDDSI Level 5 (Minced and Moist) diet, and 18 residents had a physician's order for an IDDSI Level 6 (Soft & Bite Sized) diet. Review of the facility's document titled Cooks Spreadsheet dated 5/6/26, showed for the following for the lunch meal:- The IDDSI Level 4 diet should have received 3/4 cup (scoop #10 x 2) pureed sweet and sour chicken, 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 facility document review, the facility failed to ensure food for the residents on textured-modified diet was prepared in accordance with accepted standards for four of 91 residents received IDDSI Level 5 diets. * The facility failed to follow the guidelines for the IDDSI Level 5 Minced and Moist diet when the minced and moist foods were not served in the correct consistency. This failure had the potential to increase the risk of choking, aspiration, and inadequate nutrition for residents requiring a modified texture diet.Findings: According to the IDDSI Framework 2.0 dated July 2019 Level 5 Minced and Moist should be soft and moist with no separate thin liquid. Meat should be finely minced and served in mildly, moderately or extremely thick smooth, sauce or gravy, draining any excess liquid. Review of the facility's document titled Diet Tally dated 5/6/26, showed four residents received a Level 5 Minced and Moist diet. Review of the facility's document titled Cooks Spreadsheet dated 5/6/26, showed Level 5 Minced and Moist diets should receive 3/4…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to ensure one of 20 final sampled residents (Resident 107) food preferences were honored. * The facility failed to ensure Resident 107's eggs were prepared to her stated preference, resulting in her receiving and eating eggs that were too runny and not consistent with her preference. This failure had the potential to negatively affect the resident's dining experience and overall satisfaction with care.Findings: On 5/5/26, at 815 hours, an observation and concurrent interview was conducted with Resident 107. Resident 107 was observed with her breakfast tray on her overbed table. The breakfast tray included sunny side-up eggs that appeared runnier than typically served. Resident 107 was observed gesturing to the Dietary Supervisor to indicate she disliked the runny eggs served. The Dietary Supervisor was then observed telling Resident 107 the facility had run out of eggs. Medical record review for Resident 107 was initiated on 5/5/26.…

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

Based on observation and interview, the facility failed to ensure the food safety and sanitation guidelines were followed. * The facility failed to ensure a floor drain in the kitchen was clean. This failure had the potential to compromise kitchen sanitation and cause foodborne illnesses to the medically vulnerable residents population who consumed food prepared in the kitchen.Findings: According to the USDA Food Code Section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood Contact Surfaces and Utensils (C) showed, the nonfood contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. On 5/5/26 at 0829 hours, during the initial tour of the kitchen, an observation and concurrent interview was conducted with the Dietary Supervisor. A floor drain located under a food preparation sink was observed with excessive black residue and food remnants. The Dietary Supervisor verified the floor drain was not clean.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and facility document review, the facility failed to ensure the Facility Assessment was complete and accurate. * The facility failed to ensure the Facility Assessment included input from residents and resident representatives. In addition, the Facility Assessment inaccurately indicated the facility employed a Social Services Director and only one treatment nurse. These failures posed the risk that the facility may not have identified or planned for the necessary resources to meet residents' needs.Findings: Review of the Facility assessment dated [DATE], failed to show input from the residents and resident representatives was obtained to complete the facility assessment. The assessment further showed the facility had one Social Services Director employed and one LVN treatment nurse. On 5/6/26 at 0946 hours, an interview was conducted with the Social Services Assistant. The Social Services Assistant stated the facility had not had a Social Services Director since March or April 2026. Review of…

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

Based on observation and interview, the facility failed to ensure for a safe and comfortable environment for two of 43 resident rooms (Rooms A and B). * The facility failed to ensure the room temperature was maintained in comfortable level for Rooms A and B, when the residents residing in the rooms complained of the room temperature being too cold. The temperature was 71 degree Fahrenheit. This failure posed the risk of the residents not being able to sleep comfortably.Findings: On 5/5/26 at 0815 hours, during the initial tour, there were two residents observed inside Room A with blankets covering their bodies. Both residents stated the temperature inside Room A was cold after 1730 hours. The temperature inside Room A felt cold. On 5/6/26 at 0750 hours, during an observation, a cold breeze was felt inside Room A. On 5/6/26 at 0750 hours, a subsequent observation was conducted inside Room B. There was a cool strong breeze coming out of Room B's vent and moving a privacy curtain near the vent. On 5/6/26 at 0843 hours, an interview was conducted with the Maintenance Assistant. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure an allegation of abuse was immediately reported to the CDPH, L&C Program, Ombudsman Office, and local law enforcement agency for one of four sampled residents (Resident 1). * Resident 1 alleged CNA 1 shook the resident's shower chair, pulled and yanked their hands, and kicked them. This failure had the potential for Resident 1 to be vulnerable to further abuse and emotional distress.Findings: Review of the facility's P&P titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating revised 4/2024 showed all the reports of resident abuse, neglect, exploitation, or theft/ misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by the facility management. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must 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 interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure one of five sampled residents (Resident 1) was provided quality care. * The facility failed to conduct a skin assessment following a newly observed skin impairment for Resident 1. In addition, the facility failed to document and monitor Resident 1's bilateral lower extremities wounds. These failures had the potential for delay in providing the necessary care and services to Resident 1.Findings: Review of the facility's P&P titled Change in a Resident's Condition or Status revised 2/2021 showed the facility promptly notifies the resident, his or her attending physician, and the resident representatives of changes in the resident's medical/mental condition and/or status. The nurse will notify the resident's attending physician or physician on call when there has been a(an): a. accident or incident involving the resident; b. discovery of injury or an unknown source. Prior to notifying the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure the Braden scale assessment was performed for one of the three sampled residents (Resident 1) reviewed for the pressure injury. This failure had the potential to result in a delay in interventions being put in place to prevent further decline.Findings: Review of the facility's P&P titled Pressure Injury/Ulcer Risk Assessment revised 3/2024 showed the purpose of this procedure is to provide guidelines for the structured assessment and identification of residents at risk of developing new pressure injuries or worsening of existing pressure injuries or pressure ulcers. The General Guidelines section showed to repeat the risk assessment/Braden scale assessment weekly for the first four weeks, if there is a significant change in condition, or as often as is required based on the resident's condition. Closed medical record review for Resident 1 was initiated on 7/16/25. Resident 1 was readmitted to the facility on [DATE],…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, facility record review, and facility P&P review, the facility failed to protect the resident's rights to be free from the physical abuse by a resident for one of five sampled residents (Resident 1). * Resident 1 was hit on the nose by another resident (Resident 2), which resulted in Resident 1 having a nasal fracture (broken nose). This failure had the potential to negatively impact Resident 1's well-being.Findings:Review of the facility's P&P titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program revised 4/2021 showed the residents have the right to be free from abuse, this includes but not limited to freedom of physical abuse, protect residents from abuse by anyone including other residents. Review of the facility's SOC 341 Report of Suspected Dependent Adult/Elder Abuse dated 6/24/25, showed a report of a resident-to-resident altercation between Residents 1 and 2 by the ADON. Medical record review for Resident 1 was initiated on 7/9/25. Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of two sampled residents (Resident 2) who was receiving aripiprazole (antipsychotic-class of medications that treat mental illness) was monitored for its side effects. This failure had the potential for increased risk of medication adverse reactions to be undetected.Findings: Review of the facility's P&P titled Antipsychotic Medication Use revised 12/2015 showed the nursing staff shall monitor for and report the side effects of antipsychotic medications to the attending physician. Medical record review for Resident 2 was initiated on 7/8/25. Resident 2 was admitted to the facility on [DATE].Review of Resident 2's H&P examination dated 6/24/25, showed Resident 2 had fluctuating capacity to understand and make decisions. The resident had a diagnosis of psychosis. Review of Resident 2's MDS assessment dated [DATE], showed Resident 2 was cognitively intact. Further review of the MDS assessment showed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, facility document review, and facility P&P review, the facility failed ensure timely reporting of a staff to resident abuse allegation for one of eight sampled residents (Resident 1). * CNA 3 allegedly sat next to Resident 1, put his hand on the resident's shoulder and made the resident feel uncomfortable. This failure had the potential for abuse to go unreported at a facility with a highly vulnerable resident population and posed the risk of continued abuse of the residents. Findings: Review of facility's P&P titled Abuse, Neglect, Exploitation or Misappropriation – Reporting and Investigating revised April 2024 showed resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management at the time to ensure resident is safe. Findings of all confined investigations are…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were coordinated to meet the resident's needs when discharged from the facility for one of two sampled residents (Resident 4). This failure resulted in Resident 4 not having appropriate care at home, which had the potential to negatively affect Resident 1's health. Findings: Closed medical record review for Resident 4 was initiated on 4/10/25. Resident was admitted in the facility on 1/2/25 and was discharged on 3/17/25. Review of Resident 4's H&P examination showed the resident had fluctuating capacity to understand and make decisions. Review of Resident 4's MDS assessment dated [DATE], showed the resident had a BIMS score of 6, indicating severe cognitive impairment. Resident 4's functional abilities showed the resident required substantial to maximal assistance in eating, oral hygiene and upper body dressing. Resident 4 was dependent with toileting, lower body dressing, transfers…

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

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen. * The facility failed to ensure proper labeling and dating of foods in the kitchen and failed to ensure the expired food items in the kitchen were discarded. * The facility failed to ensure the kitchen equipment were in good condition. * The facility failed to ensure proper labeling and dating of foods in the refrigerator used for the residents' food brought in by visitors and failed to ensure the expired foods were discarded. * The facility failed to ensure the microwave used to warm up the residents' food brought in from the outside was maintained in sanitary condition and free of food residue. * The facility failed to ensure the kitchen staff correctly tested the chemical concentration measured in parts per million for the quaternary sanitizing solution used to sanitize food contact surfaces. These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to implement the infection control practices designed to provide a safe and sanitary environment and help prevent the development and transmission of diseases and infections. * The facility failed to ensure the facility's monthly Infection Prevention and Control Surveillance Log was accurate. * The facility failed to ensure the laundry staff did not reuse the dirty gowns. * The facility failed to ensure there were no facility staff's personal belongings in the extra clean linen cart. * The facility failed to ensure Resident 36 was placed on contact isolation precautions while the clostridum difficile (bacteria that causes diarrhea and inflammation of the colon) test was pending. In addition, Resident 36's shared toilet was observed with brown stains. * The facility failed to implement the EBP per the facility's P&P for Residents 421 and 423 with central lines (thin, flexible tube…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the development of new pressure ulcers (areas of damaged skin caused by staying in one position for a long time which reduces blood flow to the area and causes the skin to die and develop a sore) and promote healing of existing pressure ulcer for one of one final sampled resident (Resident 72) reviewed for pressure ulcers. * The facility failed to ensure the LAL mattress unit was not on the static setting(in static mode, the mattress provides a firm surface that makes it easier to transfer or reposition) when care or repositioning was not being rendered. This failure posed the potential risk for Resident 72 to not benefit from the therapy provided by the LAL mattress. Findings: Review of the facility's P&P titled Pressure Ulcers/Skin Breakdown-Clinical Protocol revised 4/2018 showed the physician will order pertinent…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary care and services to prevent accidents for one of 20 final sample residents (Resident 421) and four nonsampled residents (Resident 120, 424, 425, and 771). * The facility failed to ensure the safe smoking practices were followed for three residents (Residents 421, 424, and 425) who smoked in the facility as evidenced by: - The residents were not accurately and thoroughly assessed to determine if they could safely store their own cigarettes or lighters. - The residents who were assessed as requiring supervision while smoking or those with a history of non-compliance with the facility's smoking P&P were permitted to keep the cigarettes, lighters, and other smoking articles/materials in their possession. * The facility failed to ensure the fall admission assessment was accurate and fall care plan was developed for Resident 120. * The facility failed to ensure a 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 observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to maintain the IV accesses for two of 20 final sampled residents (Residents 421 and 671), and two nonsampled residents (Residents 422 and 423). * The facility failed to ensure the PICC line external catheter baseline measurements were obtained and documented for Residents 421 and 423. * The facility failed to ensure Residents 422 and 671's PIV sites were labeled with the date, time, and licensed nurse's initials. These failures had the potential to delay the identification of intravenous catheter related complications for the residents. Findings: Review of the facility's P&P titled General Policies for IV Therapy dated March 2023 showed confirmation of the PICC placement is to be on the resident's medical record and recommended the PICC insertion documentation included the internal and external lengths of the catheter. Review of the facility's P&P titled PICC Dressing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 20 final sampled residents (Resident 58) and three nonsampled residents (Residents 92, 106, and 423) were provided with the appropriate respiratory care when: * The facility failed to ensure Resident 58's oxygen tubing was labeled, dated, and not on the floor. In addition, there was no physician's order obtained and a care plan developed for the use of oxygen. There was no posted signage for the oxygen use in the doorway as per the facility's P&P. * The facility failed to ensure Resident 92's oxygen tubing and mask were labeled and dated. In addition, there was no posted signage for the oxygen use in the doorway as per the facility's P&P. * The facility failed to ensure Resident 106's nebulizer tubing was dated and placed inside a clear plastic bag when not in use. * The facility failed to ensure Resident 423's nasal cannula was not touching the floor, and the nebulizer tubing was dated 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, medical record review, and facility P&P review, the facility failed to provide the appropriate pain management for two of three final sampled resident (Residents 8 and 94) reviewed for pain management. * The facility failed to administer the pain medication according to the physician's order for Resident 8 and develop a care plan to address Resident 8's pain and use of the Norco (narcotic) pain medication. * The facility failed to accurately document the monitoring of pain for Resident 94 and administer the pain medication according to the physician's order. In addition, the facility failed to ensure the non-pharmacological pain interventions were provided prior to the administration of the pain medication and develop a care plan to address Resident 94's pain and the use of the Norco pain medication. These failures had the potential to put Residents 8 and 94 at risk for ineffective pain management and adverse effects related to the use of unnecessary pain medication. Findings: Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary pharmaceutical services for four of 20 sampled residents (Residents 3, 36, 43, and 47) and one nonsampled residents (Resident 113). * The facility failed to ensure the Controlled Drug Record matched the MAR for Residents 3 and 371's hydrocodone-acetaminophen (narcotic pain medication) administration. In addition, the facility failed to document the residents' pain assessment before and after the administration of the hydrocodone-acetaminophen medication. This failure posed the risk of diversion of the controlled medication. * Resident 43's insulin (used to lower blood sugar level) injection sites were not rotated. This failure had the potential for the resident to suffer from unnecessary side effects. * One of five licensed nurses (LVN 5) who was observed during the medication administration observation was found to have an error. LVN 5 failed to instruct…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure three of five final sampled residents (Residents 3, 10, and 61) reviewed for unnecessary medications were free from unnecessary psychotropic drugs. * Resident 61 was prescribed lorazepam (antianxiety medication) PRN for anxiety starting on 1/27/25. There was no documented diagnosis of anxiety prior to Resident 61 starting the PRN lorazepam medication. Resident 61 did not have an informed consent signed by the resident or responsible party prior to starting the lorazepam medication. Resident 61's physician's orders for the PRN lorazepam medication on 1/27/25, did not have a manifested behavior or stop date for the PRN medication. Additionally, Resident 61's physician's orders for the PRN lorazepam medication were continuously renewed without evaluation from the prescribing practitioner. * The facility failed to ensure Resident 3's monthly behavioral monitoring for the use of Zyprexa (antipsychotic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the medications were stored appropriately as evidenced by: * Resident 371's pack of hydrocodone-acetaminophen tablets was stored inside IV cart after the resident discharged . * Four Calmoseptine ointments (a multipurpose, over-the-counter ointment containing menthol and zinc oxide, used to treat and prevent minor skin irritations like diaper rash, burns, cuts, scrapes, and skin irritation from moisture or irritants) without expiration date were stored inside the treatment cart. * Two bins used to dispose medications were unlocked with insulin pens inside. * A bottle of Pro-stat Advanced Wound Care (supplement) was observed with sticky brown residue on and around the cap and bottle. These failures had the potential for diversion of medications and for the residents to experience adverse effects. Findings: 1.a. On 3/20/25 at 0829 hours, an observation of the IV cart 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, facility document review, and facility P&P review, the facility failed to ensure the menus were followed for 20 of 93 residents who received food prepared in the kitchen as evidenced by: * 19 residents who were on a CCHO diet were served the canned fruit instead of the diet gelatin with whip topping as shown on the posted menu. * Resident 87 was not served the gelatin with whipped topping as per the menu. These failures had the potential for the residents to not receive an adequate nutrition and appropriate servings to meet the residents' individual needs. Findings: Review of the facility's Diet Type Report dated 3/17/25, showed 93 of 96 residents residing in the facility received food prepared in the kitchen and 19 of the 96 residents had a CCHO diet. Review of the facility's P&P titled Menus revised 10/2017 showed menus provide a variety of foods from the basic daily food groups and indicate standard portions at each meal. Copies of the menus are posted in at least two resident areas, in positions and in print large enough for residents to read…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility document review, the facility failed to ensure the residents received food with preserved nutritive content and palatibility as evidenced by: * The pureed carrots were cooked and held in a hot oven for more than two hours prior to the meal service. This failure had the potential to not meet the nutritional needs for the residents consuming food prepared in the kitchen. * The facility failed to ensure the facility food was palatable when one of 93 final sampled residents (Resident 94) and one nonsampled resident (Resident 57) who received food prepared in the facility kitchen were not satisfied with the facility food. This failure had the potential for the 4 residents to have decreased intake which could lead to unplanned weight loss and other medically related concerns. Findings: 1. Review of the facility's Diet Type Report dated 3/17/25, showed 93 of 96 residents residing in the facility received food prepared in the kitchen and 11 of the 96 residents received…

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

Based on observation, interview, facility document review and facility P&P review, the facility failed to ensure the residents on mechanically altered diets received food in a form that met their individual needs. * One of 11 residents (final sampled resident, Resident 3) who had physician's orders for a regular pureed diet received a regular dysphagia mechanical soft diet. * The pureed BBQ chicken was observed with small chunks of chicken. These failures posed the risk for complications such as choking for the 11 residents who were on pureed diets. Findings: Review of the facility's Diet Type Report dated 3/17/25, showed 93 of 96 residents residing in the facility received food prepared in the kitchen. Review of the facility's document titled Diet Type Report dated 3/17/25, showed 11 residents were on pureed diets. Review of the facility's P&P titled Therapeutic Diets revised 10/2017 showed therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care in accordance with his or her goals and preferences. Review of the facility's…

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

Based on interview, facility document review, and facility P&P review, the facility failed to ensure the education on safe food handling of outside food was provided to the staff, residents, and visitors. This failure had the potential to cause foodborne illnesses to the medically vulnerable resident population who consumed food brought from the outside sources. Findings: Review of the facility's P&P titled Foods Brought by Family/Visitors revised 12/2023 showed the residents, residents' representatives, families, and visitors will be educated on the facility's food policy including safe food handling of foods brought from outside. The educational material on food handling and safety will be available at the reception desk. The admission Coordinator or designee will review the food policy with emphasis on safe food handling to the resident, and/or representative during initial admission agreement packet review. On 3/19/25 at 1336 hours, an interview was conducted with CNA 2. CNA 2 stated she had the residents who brought in food from the outside. CNA 2 stated she would microwave the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and facility document review, the facility failed to ensure the Facility Assessment addressed or included the following: 1. Active involvement of required individuals in developing the Facility Assessment; 2. Resources necessary to care for residents including weekends; 3. A plan to maximize recruitment and retention of direct care staff; and 4. A contingency plan for staffing needs. This failure had the potential to not meet the residents' care needs if the assessed population's needs and resources were not comprehensively identified and addressed. Findings: According to the CMS QSO-24-13-NH dated 6/18/24, with an implementation date of 8/8/24, CMS had issued a revised guidance for long-term care facility assessment requirement. The Facility Assessment should address and included the active involvement of the direct care staff in developing the Facility Assessment. Also included the staffing resources necessary to care for the residents, including the weekends; a plan to maximize recruitment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to implement the antibiotic stewardship program. * The facility failed to ensure if the McGeer's criteria for true infection was completed and accurate for one of 20 final sampled residents (Resident 61) . This failure had the potential for inaccurately identifying true infections and potentially inhibiting residents from receiving the appropriate treatment and care. Findings: According to the CDC, antibiotics are some of the most commonly prescribed medications in nursing homes. Over the course of a year, up to 70% of nursing home residents get an antibiotic. Roughly 40% to 75% of antibiotics are prescribed incorrectly. In nursing homes, high rates of antibiotics are prescribed to prevent UTI and RTI. Prescribing antibiotics before there is an infection often contributes to misuse. Often residents are given antibiotics just because they are colonized with (carrying) bacteria that are not making the person sick. Prescribing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure the preparation for a safe and orderly discharge for one of two sampled residents (Resident 1). * Resident 1 was transferred to an acute care hospital without the hospital being notified and without the medical records being sent. * Resident 1 was transferred to an acute care hospital without the transferring nurse providing any report to the nurse at the receiving facility. * Resident 1's personal and demographic information, H&P examination, medication list, physician's orders, and POLST were not provided to Acute Care Hospital 1. These failures posed the resident at risk for not meeting the resident's medical needs when the receiving facility did not receive the needed documents for the transfer with the necessary medical information. Findings: Review of the facility's P&P titled Transfer or Discharge, Emergency revised 8/2018 showed if it is necessary to make an emergency transfer or discharge to a hospital or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure the medical records for two of eight sampled residents (Residents 3 and 7) and two nonsampled residents (Residents C and D) were complete and accurate. This failure had the potential for the resident care needs not being met as the medical information was incomplete and inaccurate. Findings: Review of the facility's P&P titled Document of Medication Administration revised 11/2022 showed a nurse or certified medication aide (where applicable) documents all medications administered to each resident on the resident's medication administration record (MAR) and is documented immediately after it is given. 1. Medical record review for Resident 3 was initiated on 10/30/24. Resident 3 was admitted to the facility on [DATE]. Review of Resident 3's MAR for October 2024 showed the following medication was scheduled to be administered daily at 0630 hours: regular insulin (diabetic medication) injection subcutaneously before…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and the facility P&P review, the facility failed to provide the necessary care and services to maintain the highest practicable well-being for one of five sampled residents (Resident 1). * The facility failed to show documented evidence the physician was notified of Resident 1's missed dialysis appointments on 9/10 and 9/11/24. * The facility failed to follow through on Resident 1's Dialysis Unit Communication form to notify the attending physician for Resident 1's complaints of blood in her bowel movements. * The facility failed to follow through with the attending physician for Resident 1's change in condition regarding the right ear redness. These failures had the potential to negatively affect the resident's health and well-being. Findings: Review of the facility's P&P titled End Stage Renal Disease, Care of a Resident revised 11/2023 showed the nursing staff, dialysis provider staff, and the attending physician will collaborate on a regular basis…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to implement the P&P to ensure the reporting of a reasonable suspicion of a crime in accordance with section 1150B for one of four sampled residents (Resident 4) as evidenced by: * The facility failed to ensure Resident 4's sexual abuse allegation by Resident 3 was reported timely to the CDPH L&C Program and local law enforcement agency. This failure had the potential for abuse and injury of unknown origin allegations to go unreported and uninvestigated timely. Findings: Review of the facility's P&P titled Abuse, Neglect, Exploitation or Misappropriation Reporting and Investigating revised 4/2024 showed all reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary care and services to maintain the highest practicable well-being for three of four sampled residents (Residents 1, 2, and 4). * The facility failed to ensure the nursing staff reported and documented the unwitnessed fall for Resident 1 on 8/28/24. Furthermore, the 72-hours neurological and post fall risk assessments were not completed following Resident 1's unwitnessed fall. * The facility failed to monitor the psychosocial harm for Residents 2 and 4 post abuse allegations. This failure had the potential to negatively affect the residents' health and well-being. Findings: 1. Review of the facility's P&P titled Neurological Assessment revised 10/2010 showed the general guidelines for neurological assessments are indicated following an unwitnessed fall. Review of the facility's P&P titled Falls and Fall Risk Managing revised 3/2018 showed a fall is defined as: unintentionally…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to prevent or minimize injuries of a fall for one of four sampled residents (Resident 1). * Resident 1 had a history of falls; however, the floor mats were not provided as per the resident care plan and the fall risk assessment was inaccurate. This failure had the potential to place the resident at risk for further serious injury. Findings: Review of the facility's P&P titled Neurological Assessment revised 10/2010 showed the general guidelines for neurological assessments are indicated following an unwitnessed fall. Review of the facility's P&P titled Falls and Fall Risk Managing revised 3/2018 showed a fall is defined as: unintentionally coming to rest on the ground, floor, or other lower level but not as a result of an overwhelming external force. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to offer or provide the adequate and appropriate pain management for one of four sampled residents (Resident 1). * The facility failed to offer and provide Resident 1 pain medication when Resident 1 complained of pain on 8/28/24. This failure had the potential to negatively affect Resident 1's well-being. Findings: Review of the facility's P&P titled Pain revised 3/2018 showed the physician and staff will identify individuals who have pain or who at risk for having pain, which includes a review for any treatment that the resident currently is receiving for pain, including complementary and non-pharmacologic treatments. Review of the facility's Change in Resident's Condition or Status revised 7/2024, showed the nurse will notify the resident's attending physician or physician on call when there has been a (an): need to alter the resident's medical treatment significantly. Review of Resident 1's Care Plan dated 8/29/24, showed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to ensure the care plan was implemented related to informing all staff caring for Resident 1 of the special feeding needs for Resident 1. This failure had the potential for Resident 1 not receiving care and services to meet the care needs. Findings: Closed medical record review for Resident 1 was initiated on 8/21/24. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 1's Physician Progress Note dated 8/6/24, showed Resident 1's diagnoses included dementia. Review of Resident 1's Plan of Care showed a care plan problem initiated on 7/15/24, addressing Resident 1's swallowing problem related to dysphagia. The interventions included for all staff to be informed of the resident's special dietary and safety needs, alternate small bites and sips, use a teaspoon for eating, and instruct the resident to eat in upright position, eat slowly and chew each bit thoroughly. Further review Resident 1's closed medical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to implement their P&P for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act when the facility failed to report an allegation of resident-to-resident altercation to the law enforcement agency, CDPH L&C Program, and Ombudsman office for three of six sampled residents (Residents 1, 2 and 3). This failure had the potential to put the residents at risk for further abuse. Findings: Review of the facility ' s P&P titled Abuse, Neglect, Exploitation or Misappropriation – Reporting and Investigating revised 9/2022 showed all reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations and thoroughly investigated by facility management. The administrator or the individual making the allegation…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P& P review, the facility failed to ensure one of three sampled residents (Resident 3) was free from the unnecessary psychotropic (any drug that affects brain activity) medications. * The facility failed to obtain the informed consent from Resident 3 for the use of Ativan (its generic name, lorazepam, anti-anxiety medication). * The facility failed to ensure Resident 3's informed consent for the use of Seroquel (antipsychotic medication) was signed and dated by the physician. * The facility failed to ensure the monitoring for Resident 3's behaviors of agitation and restlessness for the use of PRN Ativan medication and the inability to sleep for the use of PRN Restoril (medication used to aid with sleep) medication were completed. * The facility failed to ensure the PRN Ativan and Restoril medications were administered only when Resident 3 had the behaviors of agitation and restlessness, and inability to sleep as ordered. * The facility failed to monitor…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of three residents (Resident 2) was free from the significant medication errors when Resident 2 was not given the medications as ordered by the physician on multiple occasions. In addition, the facility failed to notify the resident's physician. These failures had the potential to cause significant adverse effects to the residents. Findings: Review of the facility's P&P titled Administering Medications revised 4/2019 showed the medications are administered in a safe and timely manner, and as prescribed. Medical record review for Resident 2 was initiated on 8/8/24. Resident 2 was readmitted to the facility on [DATE]. Review of Resident 2's Order Summary Report showed the following physician's orders dated 8/19/23, to administer the following medications: - amlodipine besylate (a medication used to treat high blood pressure) oral tablet 10 mg orally one time a day for hypertension; - apixaban (its brand name is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to notify the physician of changes for one of seven sampled residents (Resident 1). * Resident 1's physician was not notified when Resident 1's inhaler ran out and Resident 1 had increased anxiety. This failure had the potential for the resident not to get the necessary care and services as the physician was not notified of changes. Findings: Review of the facility's P&P titled Change in Resident's Condition or Status revised 02/2021 showed the nurse will notify the resident's attending physician or physician on call where there has been a significant change in resident's physical/emotional/mental condition and a specific instruction to notify the physician of changes in resident's condition. Closed medical record review for Resident 1 was initiated on [DATE]. Resident 1 was admitted to the facility on [DATE], and discharged on [DATE]. Review of Resident 1's Order Summary Report showed a physician's order to administer the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, medical record review, and facility P&P review, the facility failed to implement their P&P for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act when the report of an abuse allegation was not reported to the State Agency, Ombudsman, and local law enforcement for one of seven sampled residents (Resident 2). This failure had the potential for delay of investigation. Findings: Review of the facility's P&P titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program revised 4/2021 showed the facility will report all allegations of abuse within the required timeframes and will identify and investigate any allegations of abuse within the required timeframes. Medical record review for Resident 2 was initiated on 6/13/24. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's Social Services Note dated 5/31/24 at 1718 hours, showed while the SSD was sitting in on a tele-visit with Resident 2 and the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to timely investigate an abuse allegation for one of seven sampled residents (Resident 2). This failure had the potential for not protecting the resident from abuse. Findings: Review of the facility's P&P titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program revised 04/2021 showed the facility will identify and investigate any allegations of abuse within the required timeframes. Medical record review for Resident 2 was initiated on 6/13/24. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's Social Services Note dated 5/31/24 at 1718 hours, showed while the SSD was sitting in on a tele-visit with Resident 2 and the psychologist, Resident 2 alleged Family Members 3 and 4 had been verbally abusing her, and the psychologist felt it was appropriate to report the allegation to the APS and Ombudsman office. On 6/13/24 at 1500 hours, an interview was conducted with the Administrator. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided for two of seven sampled residents (Residents 1 and 3). In addition, the facility failed to ensure the facility's Emergency Procedure – Cardiopulmonary Resuscitation P&P was current. * The Daily Skilled Nursing Notes were not completed for Resident 1 who received skilled services. * Resident 3's psychiatry (a branch of medicine dealing with mental illness) consult was not completed timely. These failures had the potential to negatively impact the resident's quality of care due to incomplete medical records, delay of care and the facility P&P not being followed. Findings: 1. Closed medical record review for Resident 1 was initiated on [DATE]. Resident 1 was admitted to the facility on [DATE], and discharged on [DATE]. Review of Resident 1's Order Summary Report dated [DATE], showed the following: - Medicare Initial Certification to certify skilled services…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to implement the safety interventions and provided supervision to 21 of 27 sampled residents (Residents 4, 5, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26) who smoked. This failure had the potential for the residents to be at risk for injury while smoking. Findings: Review of the facility's P&P titled Smoking Policy - Residents approved 1/2024 showed this facility shall establish and maintain safe resident smoking practices, - Prior to, and upon admission, residents shall be informed of the facility smoking policy, including designated smoking areas, and the extent to which the facility can accommodate their smoking or non-smoking preferences. - Smoking is only permitted in designated resident smoking patio. - The resident will be evaluated on admission to determine if they are a smoker or non-smoker. If a smoker, a smoking assessment/evaluation will be completed. - Only disposable…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of seven sampled residents (Resident 1) received the respiratory medications as per the physician's orders. This failure had the potential for the resident not having their ordered medications being available when needed. Findings: Closed medical record review for Resident 1 was initiated on 6/12/24. Resident 1 was admitted to the facility on [DATE], and discharged on 4/22/24. Review of Resident 1's Order Summary Report dated 3/23/24, showed the following physician's orders: - An order dated 4/1/24, for albuterol sulfate inhalation aerosol powder (bronchodilator), inhale two puffs every six hours as needed for SOB/wheezing. - An order dated 4/6/24, ipratropium-albuterol solution 0.5 – 2.5 mg (bronchodilator), inhale orally via nebulizer every six hours for shortness of breath/wheezing. Review of Resident 1's MAR for April 2024 showed the resident hadlast received albuterol on 4/13/24 at 1922 hours. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the accurate controlled medication reconciliation for two of seven sampled residents (Residents 1 and 3). * Residents 1 and 3's Ativan (a controlled medication for anxiety) administration were not documented accurately as the controlled count sheet did not match the residents' MAR. This failure had the potential for drug diversion. Findings: Review of the facility's P&P titled Controlled Substances, revised 11/2022 showed the following: - Receipt, dispensing and disposition of controlled medications include records of personnel access usage, medication administration records, declining inventory records, and destruction, waste records. - Waste of controlled medication are done in the presence of the nurse and a witness who also signs the disposition sheet. 1. Medical record review for Resident 3 was initiated on 6/26/24. Resident 3 was readmitted to the facility on [DATE]. Review of Resident 3's…

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

Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to maintain the infection control practices to help prevent the development and transmission of diseases and infections. * CNA 4 failed to perform hand hygiene before entering a room with Enhanced Barrier Precautions signage. This failure had the potential to increase the risk for the spread of infection. Findings: Review of the facility's P&P titled Hand Hygiene revised 10/2022 showed the facility considers hand hygiene the primary means to prevent the spread of infections. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. On 7/11/24 at 0840 hours, an Enhanced Barrier Precautions sign was observed outside Room A's doorway. The sign showed everyone must clean their hands, including before entering and when leaving the room. The isolation cart and hand sanitizer were also available before entering Room A. On 7/11/24 at 0842 hours, CNA 4 was observed…

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 medical record review, the facility failed to protect one of two sampled residents (Resident 1) to be free from the verbal abuse by a facility's staff member. * Resident 1 had episodes of seeking to leave the facility and calling 911 (an emergency services). LVN 1 failed to respond appropriately by yelling at Resident 1. This failure had the potential to negatively impact Resident 1 's mental and emotional well-being. Findings: Medical record review for Resident 1 was initiated on 1/17/24. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's MDS dated [DATE], showed Resident 1 had moderately cognitive impairment. Review of Resident 1's SBAR Communication Form dated 12/25/23 at 2302 hours, showed Resident 1 called 911 twice from her personal phone and stated she was being held hostage for money. The nursing staff spoke to the dispatcher both times to clarify Resident 1 was in a skilled nursing facility and confused. Resident 1 was redirected to her room. 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 observation, interview, facility document review, and facility P&P review, the facility failed to ensure food safety and sanitation requirements were met in the kitchen when: * Time/Temperature Control for Safety (TCS) foods (food that required time and temperature controls to limit the growth of illness causing bacteria) were not monitored to ensure proper cool down process was followed. * The thawing process was not performed as per the facility's P&P. * Two of two ice machines were not clean. * The expired food items in the kitchen and residents' refrigerator were not discarded . * One of kitchen staff did not follow the facility's dress code during the food preparation. * The food preparation equipment were not in proper operating condition. * The kitchen utensils and dishware were not stored in a sanitary condition. * The floor of the walk-in refrigerator had missing tiles. * The chemical and emergency water supply were no properly stored. These failures had the potential to cause foodborne illnesses in a highly susceptible resident population who consumed food…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to implement and maintain their infection control program as evidenced by: * The facility failed to implement their infection control surveillance programs from October through November 2023. The facility failed to ensure the Infection Prevention and Control Surveillance Logs were complete and accurate to determine if the resident's infection met the McGeer's criteria for true infection. * The facility failed to ensure the staff practiced the special droplet/contact precautions when exiting Room B that had a posted signage outside the room for special droplet/contact precautions. * The facility failed to ensure Resident 993's oxygen nasal cannula tubing and nebulizer mask were stored properly, and the storage bag was not on the floor. * LVN 11 failed to perform the handwashing in between oral, oral inhalation, and eye drop administration for Resident 13. * LVN 14 failed to perform the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the reasonable accommodations to meet the needs of one of 19 final sampled residents (Resident 13) and two nonsampled residents (Residents 24 and 30). * The facility failed to ensure the call lights for Residents 24 and 30 were within the residents' reach. * The facility failed to provide Resident 13's preferred room temperature water during the medication administration. These failures had the potential to negatively impact the residents' well-being. Findings: Review of the facility's P&P titled Call Light revised October 2010 showed when the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. 1. During the initial tour of the facility on 11/6/23 at 1110 hours, Resident 30 was observed sitting towards the foot of the bed and calling out for assistance to help her find pants to wear. Resident 30's call light was observed on the floor closed to the head…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the physician and resident's responsible party were notified of the changes in conditions of two of 19 final sampled residents (Residents 7 and 69) as evidence by: * The facility failed to notify the physician and Resident 7's responsible party for the resident's back of the right hand skin discoloration. * The facility failed to ensure Resident 69's responsible party was notified of Resident 69's positive for C. diff and use of Vancomycin (antibiotic medication) to treat C. diff. These failures had the potential for Residents 7 and 69 not to receive the appropriate treatment to address his medical needs and to have a delay in care and treatment. Findings: Review of the facility's P&P titled Acute Condition Changes-Clinical Protocol revised March 2018 showed direct care staff, including nursing assistants will be trained in recognizing subtle but significant changes in the resident (for example, 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, medical record review, and facility P&P review, the facility failed to ensure one of 19 final sampled residents (Resident 51) was free from the physical restraints. This failure had the potential to negatively affect Resident 51's physical and psychosocial well-being. Findings: Review of the facility's P&P titled Use of Restraints revised 4/2017 showed the restraints shall only be used for the safety and well-being of the residents and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls. When the use of restraints is indicated, the least restrictive alternative will be used for the amount of time necessary, an ongoing reevaluation for the need of restraints will be documented. The policy defined physical restraints as any manual method or physical or mechanical device, material or equipment attached or adjacent to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to develop the comprehensive plans of care to reflect the individual care needs of four of 19 final sampled residents (Residents 6, 44, 51, and 69) and one nonsampled resident (Resident 36). * The facility failed to develop a care plan problem to address Resident 69's antibiotic use, contact precaution, and infection for Clostridioides difficile (C. difficile or C. diff, a germ that causes diarrhea and inflammation of the colon). * The facility failed to develop a care plan goal and interventions to address and monitor the risk of dehydration for Resident 6. * The facility failed to develop an individualized care plan problem to address Resident 51's use of quetiapine fumarate (an antipsychotic medication that treats several kinds of mental health conditions including schizophrenia and bipolar disorder) and mirtazapine (can raise blood cholesterol levels, raise your appetite, and cause weight gain). This failure…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure to provide the necessary services to attain or maintain the highest practicable well-being for two of 19 final sampled residents (Residents 6 and 7). * The facility failed to ensure the Geri-sleeves and heel protectors were applied to Resident 7 as ordered. In addition, the facility failed to identify and assess for Resident 7's back of the right hand black colored skin discoloration. These failures had the potential risk of not providing appropriate care for Resident 7. * The facility failed to obtain weekly weights and laboratory test as ordered for Resident 6. This failure had the potential to negatively impact the resident's well-being. Findings: Review of the facility's P&P titled Acute Condition Changes-Clinical Protocol revised March 2018 showed direct care staff, including nursing assistants will be trained in recognizing subtle but significant changes in the resident (for example, a decrease in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure two of 19 final sampled residents (Residents 28 and 87) and one nonsampled (Resident 9) remained free from accident hazards. * The facility failed to implement the care plan interventions to store Residents 9 and 28's smoking lighter by the nursing station. This failure posed the risk of fire and serious injuries to the residents who smoked and other residents who resided in the facility. * The facility failed to ensure Resident 87's side table was place in an area where it is not a safety hazard. This failure had the potential to cause injury to Resident 87 during a fall. These failures posed the risk of fire and serious injuries to the residents who smoked and to the other residents who resided in the facility. Findings: Review of the facility's P&P titled Smoking Policy-Residents (undated), showed only facility-approved ashtrays and other smoking equipment/paraphernalia (with staff assistance) shall…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary enteral feeding (a way of delivering nutrition directly to the stomach or small intestine) care and services were provided to two of 19 final sampled residents (Residents 40 and 51). * Resident 51's enteral feeding infusion was started prior to the time ordered by the physician. This failure had the potential to negatively affect Resident 51's physical well-being. * The facility failed to ensure Resident 40's Glucerna 1.5 (an enteral feeding formula) bottle was labeled and dated. This failure posed the risk of providing the resident with an outdated formula. Findings: 1. Review of the facility's P&P titled Enteral Nutrition revised 11/2018 showed the enteral feedings are scheduled to try to optimize the resident's independence whenever possible. On 11/7/23 at 1223 hours, an observation and concurrent interview was conducted with LVN 2. Resident 51 was observed in her bed, asleep. Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the safe respiratory care to three of 19 final sampled residents (Residents 40, 51, and 65) and two nonsampled residents (Residents 64 and 993). * The facility failed to ensure the supplies used for Resident 40's respiratory care were dated and stored in a labeled and dated plastic bag and failed to ensure Resident 40's respiratory treatment medication was not left at bedside. * The facility failed to ensure the supplies used for Resident 65's respiratory care were dated and not touching the floor. * The facility failed to follow the physician's order for oxygen administration for Resident 64 was followed and oxygen humidifier bottle was replaced when empty. * The facility failed to ensure Resident 993's nebulizer mask was labeled and dated, and nebulizer mask and oxygen nasal cannula were stored properly. *The facility administered Resident 51 continuous oxygen via nasal cannula without a physician's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the dialysis care was provided for one of 19 final sampled residents (Resident 28). * The facility failed to ensure the physician's order for 1200 ml fluid restriction (a diet which limits the amount of daily fluid consumption) per 24 hours was followed and carried out accordingly for Resident 28. * The facility failed to ensure the water pitcher was not in Resident 28's room when on a fluid restriction as per the facility's P&P. * The facility failed to ensure the facility and dialysis center communication forms were completed for Resident 28. These failures had the potential for Resident 28 to experience medical complications. Findings: Review of the facility's P&P titled Encouraging and Restricting Fluids revised 10/2010 showed follow specific instructions concerning fluid intake or restrictions. Be accurate when recording fluid intake. Record fluid intake on the intake side of the intake and output…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to provide the environment free from accident hazards for one of 19 sampled residents (Resident 18). * The facility failed to obtain a physician's order and develop the comprehensive plan of care for the use bilateral ¼ side rails for Resident 18. This failure had the potential to place Resident 18 at risk for serious injury. Findings: On [DATE] at 0958 hours, Resident 18 was observed lying in bed with the left ¼ side rail elevated. During an observation on [DATE] at 1055 hours, Resident 18 was lying on his bed holding the left side rail turned himself halfway to the left side using his right hand, while the nurse was changing his suprapubic catheter dressing. On [DATE] at 0832 hours, an observation and concurrent interview was conducted with Resident 18. Resident 18 used his right hand to grab the left side rail when he needed to turn to the side. Resident 18 stated he used the side rail when he needed to turn to the side. When…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to develop the care plan to address one of 19 final sampled residents (Resident 51). This failure had the potential for Resident 51 to not receive the appropriate treatment and services needed for her dementia. Findings: Review of the facility's P&P titled Dementia-Clinical Protocol revised November 2018 showed for the individual with confirmed dementia, the IDT will identify a resident-centered care plan to maximize remaining function and quality of life. Medical record review for Resident 51 was initiated on 11/6/23. Resident 51 was originally admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 51's History and Physical Examination dated 10/4/23, showed Resident 51 did not have capacity to understand and make decisions. Review of Resident 51's Physician's Progress Notes dated 10/26/23, showed Resident 51's diagnoses included dementia. Further review of Resident 51's medical record failed to show…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to ensure the pharmaceutical services met the residents' needs as evidenced by: - The routine medications were not available for two of 19 final sampled residents (Residents 13 and 40) and one nonsampled resident (Resident 994). - The licensed nurse left the medications unattended at Resident 40's bedside when performed other tasks. - The controlled medications were not accurately documented on the controlled medication record and MAR for one of 19 final sampled residents (Resident 60) and one nonsampled resident (Resident 593). These failures posed the risk for negatively affecting the residents' health and diversion of controlled medications. Findings: Review of the facility's P&P titled Medication Administration-General Guidelines with effective date October 2017 showed the following: - Medications are administered in accordance with written orders of the attending physician. - Medications are administered without unnecessary…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the necessary care and monitoring were provided to two of 19 final sampled residents (Residents 44 and 51) regarding the use of anticoagulant medication. * Residents 44 and 51 received anticoagulant medication without monitoring of the side effects, including bleeding and bruising. This failure had the potential for poor health outcomes for these residents. Findings: Review of Lexicomp, an online reference for clinical drug information, showed precautions and concerns related to the adverse effects of enoxaparin sodium included bleeding and residents should be monitored closely for signs and symptoms of bleeding. Review of the facility's P&P titled Anticoagulation-Clinical Protocol revised in November 2018 showed the following: 1. As part of the initial assessment, the physician and staff will identify individuals who are currently anticoagulated; for example, those with a recent history of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure four of the 19 final sampled residents (Residents 44, 47, 50, and 51) were free from unnecessary psychotropic medications (medication that affects the brain activity). * The facility failed to provide non-pharmacological interventions to Resident 47's episodes of persistent yelling and screaming to minimize the use of quetiapine (antipsychotic medication). * The facility failed to provide the non-pharmacological interventions to Resident 44's pain, inability to sleep, combative and aggressive behavior to minimize the use of Cymbalta, mirtazapine, and quetiapine fumarate (psychotropic medications). * The facility failed to ensure Resident 51's quetiapine (is an antipsychotic medication that treats several kinds of mental health conditions including schizophrenia and bipolar disorder) had a proper documented diagnosis by the provider. The facility failed to implement any nonpharmacological intervention…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. The facility's mediation error rate was 27.59% during the medication administration observation as evidenced by: * LVN 11 failed to administer tiotropium bromide to Resident 13 per the physician's order because it was not available. * Resident 13 had a physician's order to administer Ventolin. However, LVN 11 did not provide instructions to Resident 13 prior to administration. Resident 13 coughed immediately after Ventolin administration. * LVN 13 failed to administer the lidocaine patch to Resident 40 per the physician's order because it was not available. * LVN 13 failed to administer a full dosage of four out of seven crushed medications to Resident 40 via G-Tube as evidenced by residues found on four of seven cups containing medicaitons. * LVN 9 failed to administer the albuterol sulfate to Resident 994 as per the physician's order because it was not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure the proper storage, labeling, and disposal medications as evidenced by: * The facility failed to ensure an outdated influenza vaccine was removed from the refrigerator in Medication room [ROOM NUMBER]. * The facility failed to ensure the expired alcohol wipes were removed from Medication Cart 1. * The facility failed to ensure three opened insulin pens in Medication Cart 3 had no open date labeled. * The facility failed to ensure the expired IV supplies were removed from Medication Cart 2. * The facility failed to ensure the medications were secured and attended by the licensed nurses. These failures had the potential to negatively impact the residents. Findings: Review of the facility's P&P titled Storage of Medications and Supplies revised in 4/2022 showed the facility shall not use discontinued, outdated, or deteriorated drugs, biologicals and medical supplies. All such drugs 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, facility document review, and facility P&P review, the facility failed to ensure the kitchen staff had the appropriate skill sets to safely prepare meals served to the facility residents when: * Two of two cooks (Cooks 1 and 2) were not competent in monitoring the time and temperature for TCS (time/temperature control for safety) foods. This failure had the potential to place the 87 residents who received food prepared in the kitchen at risk for foodborne illness and to not meet their nutritional needs which could lead to nutritional related health concerns. Findings: According to the USDA Food Code 2022, Section 3-501.14 Cooling, (A) Cooked time/temperature control for safety food shall be cooled: (1) within two hours from 135 degrees Fahrenheit (F) to 70 degrees F; and (2) within a total of six hours from 135 degrees F to 41 degrees F or less. Review of the facility's P&P titled Cooling and Reheating of Potentially Hazardous or Time/Temperature Control for Safety (TCS) Food dated 2023 showed cooked Potentially Hazardous Food (PHF) or TCS food shall…

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

Based on observation, interview, facility document review and facility P&P review, the facility failed to ensure the nutritional needs were met for one of 19 final sampled residents (Resident 1) and one nonsampled resident (Resident 17) when: * Resident 1 disliked corn but was not served a substitute for the corn salad on her lunch tray. * Resident 17 disliked salad but was not served a substitute for the salad on her lunch tray. This failure posed the risk for the residents' nutritional needs to not be met. Findings: Review of the facility's P&P titled Food Substitutions During Tray Line an Alternate for a Food Item Resident Does Not Like That is Recorded on the Tray Card dated 2023 showed the cook will provide a food substitute at each meal for a food item that a resident may dislike, which has been noted on their tray card. Review of the facility's record titled Fall Menus showed the following: -Week 2 Monday dated 11/6/23, showed for the lunch meal, pot roast, mashed potatoes, gravy over the meat and potatoes, brussels sprouts, sweet corn salad, ice cream, and milk. -Week 2…

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

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the P&P for resident food brought by the visitors was followed. * The facility's P&P for Food for Residents from Outside Sources did not meet the current federal regulation. * The facility failed to ensure the staff were aware of the process of storing and discarding the resident food brought in by the visitors. * The facility failed to ensure the staff were educated on safe food handling practices when handling the resident food brought in by the visitors. * The facility failed to ensure the policy, guidelines, and safe food handling practices were communicated to the resident's family/visitors who brought the resident food from the outside. These failures had the potential to cause foodborne illness to the residents who received food brought by the visitors. Findings: 1. According to the Code of Federal Regulations, Section §483.60(i)(3) Food Safety Requirements, the facility must have a policy regarding use and storage of food brought to residents by family and other…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medical record for one of 19 final sampled residents (Resident 65) and one of the closed record sampled residents (Resident 91) were complete and accurate. * The facility failed to document Resident 65's indwelling urinary catheter care and monitoring of urine. This failure had the potential for the resident's care not being met as the clinical information were not complete. * The facility failed to ensure the accurate elopement risk assessment was conducted for Resident 91. This failure had the potential to affect the implementation of preventative elopement measures to ensure the safety of Resident 91. Findings: 1. Review of the facility's P&P titled Catheter Care - Urinary revised 08/2022 showed the purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infection and the following information should be recorded in the resident's medical record:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility record review, the facility failed to ensure the arbitration agreement provided to one nonsampled resident (Resident 74) was in a language that she understood. This failure had the potential to result in Resident 74 not understanding the purpose of the arbitration agreement she signed with the facility. Findings: Medical record review for Resident 74 was initiated on 11/7/23. Resident 74 was admitted to the facility on [DATE]. Review of Resident 74's admission Record showed her primary language was Spanish. Review of Resident 74's History and Physical examination dated 8/2/23, showed Resident 74 was able to make her own medical decisions. Review of Resident 74's Social Services admission Assessment-V1 dated 8/3/23, showed Resident 74 was alert and oriented. The document also showed Resident 74 spoke Spanish and had limited English. Review of Resident 74's Arbitration Agreement with the facility dated 9/18/23, showed the document was written in English 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, medical record review, facility document review, and facility P&P review, the facility failed to monitor and address the use of antibiotic when the resident's condition did not meet the McGeer's criteria (a set of specific definitions to identify true infections in long term nursing facilities) for one of 19 final sampled residents (Resident 54). This failure had the potential for antibiotics to be used when it was not indicated and the development of antibiotic-resistant bacteria. Findings: Review of the facility's P&P titled Antibiotic Stewardship revised 11/2019 showed identifying an Infection Preventionist to oversee the Antibiotic Stewardship Program ensuring that policies regarding stewardship are monitored and enforced. The IP will collect and analyze infection surveillance data, coordinate data collection, and monitor adherence to infection control policies and procedures. The facility has chosen to use guidelines developed by McGeer/Loeb and Stone and include newer surveillance…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of 35 final sampled residents (Resident 51) and one nonsampled resident (Resident 14) were offered the influenza vaccine (a vaccine given to protect the resident from influenza disease) and pneumococcal vaccine (a vaccine given to protect the resident from pneumococcal disease) when the residents were eligible to receive, in accordance with the current CDC's guidelines and recommendations. This failure posed the risk of Resident 14 and 51 acquiring influenza and pneumonia. Findings: Review of the facility's P&P titled Influenza Vaccine revised September 2023 showed the influenza vaccine shall be offered to residents unless the vaccine is medically contraindicated, or the resident or employee had already been immunized. Residents admitted shall be the vaccine within five working days of the employee's job assignment or the resident's admission to the facility. Review of the facility's P&P titled Pneumococcal…

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

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

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.