Citrus Post-Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to maintain a homelike environment for one nonsampled resident (Resident 86). * Resident 86 resided in Room A. Resident 86 was observed sitting on his bed eating breakfast. A live pest (later identified as a water bug or roach) was observed on top of Resident 86's bed linen, next to Resident 86. This failure had the potential to negatively impact the resident's quality of life. Findings: Medical record review for Resident 86 was initiated on 5/7/25. Resident 86 was admitted to the facility on [DATE], and readmitted on [DATE]. On 5/12/25 at 0750 hours, an observation and concurrent interview was conducted with Resident 86 and CNA 10. Resident 86 was observed sitting on his bed eating breakfast. A live water bug/roach was observed on top of Resident 86's bed linen, next to Resident 86. CNA 10 verified the findings and then attempted to remove the bug/roach from Resident 86's bed, at which time the water bug/roach moved onto the floor. CNA 10 then stepped on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Medical record review for Resident 23 was initiated on 5/7/25. Resident 23 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 23's H&P examination dated 1/19/25, showed Resident 23 had no capacity to understand and make decisions. Review of Resident 23's Order Summary Report dated 5/9/25, showed the following physician's orders dated 4/4/25: - to monitor Resident 23's orthostatic BP sitting up every week on Wednesday, during the evening shift; and to notify the physician if there was a drop of 20 mmHg in the systolic BP, or a drop of 10 mmHg in the diastolic BP, - to monitor Resident 23's orthostatic BP lying down every week on Wednesday, during the evening shift; and to notify the physician if there was a drop of 20 mmHg in the systolic BP, or a drop of 10 mmHg in the diastolic BP, and - to administer Seroquel (antipsychotic) 25 mg by mouth two times a day for psychosis manifested by constant repetitive movements. Review of Resident 23's plan of care showed a care plan…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the physician's recommendation was carried out as ordered for one nonsampled resident (Resident 94). This failure had the potential of Resident 94 not receiving care as ordered. Findings: Review of the facility's P&P titled Record Content - Laboratory and Radiology Reports dated 1/2004 showed the facility shall obtain laboratory, radiology, or other diagnostic service to meet the needs of the residents as prescribed by the physician. Contact the laboratory and/or radiology services in accordance with the physician's order. Log this in the lab and/or x-ray control log and complete the appropriate requisition form. The P&P further showed to sign and date the reports when reviewed. The license nurse or other will be responsible for faxing each report to the attending physician promptly after nurse's review. Moreover, the P&P showed to file the reports in the resident's health record when the nurse has…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 physician's order for a health shake with every meal for one of 30 final sampled residents (Resident 115). * Resident 115 had a physician's order to receive a four ounces of the health shake three times a day with meals. However, Resident 115 did not receive the health shake with meals. This failure had the potential to compromise Resident 115's nutritional status and posed the risk for negative health outcomes. Findings: Medical record review for Resident 115 was initiated on 5/8/25. Resident 115 was admitted to the facility on [DATE]. Review of Resident 115's H&P examination dated 10/31/24, showed Resident 115 had no capacity to understand and make decisions. Review of Resident 115's Order Summary Report showed a physician's order dated 11/14/24, to provide supplement health shake four oz three times a day with meals. On 5/8/25 at 1256 hours, an observation and concurrent interview was conducted with CNA 8. CNA 8…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 five of eight final sampled residents (Residents 52, 65, 70, 84, and 537) and two nonsampled residents (Residents 40 and 90) reviewed for respiratory care were provided with the appropriate respiratory care and services when: * The facility failed to ensure Resident 40's storage bag for the nebulizer was changed weekly and PRN as per the facility's P&P. * The facility failed to ensure Resident 52's storage bag for the nebulizer was changed weekly and PRN as per the facility's P&P. * The facility failed to ensure Resident 65's nebulizer mask and the storage bag was changed every seven days. * Resident 70's nasal cannula was improperly stored, as evidenced by hanging from a portable oxygen tank instead of stored in a clean bag. * The facility failed to ensure Resident 84's oxygen bag was changed weekly and PRN as per the facility's P&P. * The facility failed to ensure Resident 90's nebulizer mask and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to provide adequate and appropriate pain management for one of one final sampled resident (Resident 129) reviewed for pain management. * The facility failed to ensure the pain medication was administered as per the physicians' orders for Resident 129. This failure had the potential for Resident 129 not to receive the appropriate treatment for pain. Findings: Medical record review for Resident 129 was initiated on 5/7/25. Resident 129 was admitted to the facility on [DATE]. Review of Resident 129's Order Review Report showed a physician's order dated 5/5/25, showed to administer tramadol HCL (pain medication) 50 mg one tablet by mouth every six hours as needed for severe pain 7-10 (on a 0-10 pain scale, with 0 = no pain and 10 = worst pain). Review of Resident 129's MAR for May 2025 showed Resident 129 was administered the tramadol HCL 50 mg medication on 5/7/25 at 0933 hours, when the resident's pain level was six, not within the pain levels 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, facility document review, and facility P&P review, the facility failed to ensure the necessary pharmaceutical services were provided to meet the needs for three of 30 final sampled residents (Residents 98, 102, and 104 (not in the roster)) and two nonsampled residents (Residents 7 and 90). * The facility failed to ensure accountability for the controlled medications (medications that have the potential for abuse or dependence) for Resident 102 when the hydromorphone (a controlled medication used to treat severe pain) HCl 2 mg tablet was signed out of the Resident 102's Controlled Medication Count Sheet but was not documented as administered in the MAR. * The facility failed to ensure accountability for the controlled medications for Residents 7, 90, and 104 when the unused, discontinued controlled medications were not removed from the medication carts timely. * The facility failed to ensure the medications were not left unattended on Resident 102's bedside…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medication side effects were monitored for the use of mirtazapine (antidepressant medication) for one of five final sampled residents (Resident 112) reviewed for unnecessary medications. This failure had the potential for Resident 112 to experience negative side effects of the mirtazapine medication without adequate monitoring. Findings: Review of the facility's P&P titled Consultant Pharmacist Reports IIIA1: Medication Regimen Review (Monthly Report) revised 08/2019, showed the consultant pharmacist performs a comprehensive medication regimen review (MRR) of each resident at least monthly to evaluate the response to medication therapy, determine that the resident maintains the highest practicable level of functioning , and to prevent or minimizes adverse consequences related to medication therapy. Resident-specific irregularities and/or clinically significant risks resulting from or associated with medications…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 final sampled residents (Resident 112) reviewed for unnecessary medications was free from unnecessary medications. * Resident 112 had a physician's order for clonidine (medication to treat hypertension) without an active diagnosis of hypertension (high BP). * Resident 112 was administered sodium chloride daily without regular blood work monitoring her sodium levels. These failures had the potential for Resident 112 to receive the medications unnecessarily and experience adverse effects which could negatively impact the resident's well being. Findings: Medical record review for Resident 112 was initiated on 5/7/25. Resident 112 was admitted to the facility on [DATE], and readmitted to the facility on [DATE]. Review of Resident 112's H&P examination dated 2/9/25, showed Resident 112 had no capacity to make medical decisions. a. Review of Resident 112's Order Summary Report dated 5/9/25, showed a physician's order dated 2/6/25,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 five percent. The facility's medication error rate was 26.67% for eight medication errors out of 30 medication administration observations. Three of four licensed nurses (LVNs 3, 4, and 6) observed during the medication administration were found to have made errors for one final sampled resident (Resident 102) and two nonsampled residents (Residents 40 and 43). * LVN 6 failed to ensure the potassium liquid medication given to Resident 102 via the GT was diluted as ordered by the physician. LVN 6 failed to ensure the medications were not administered together when administering medications via the GT to Resident 102, and to flush the GT in between the medications. * LVN 4 failed to administer the Refresh Tears (lubricating eye drops) medication to Resident 40 as ordered by the physician. * LVN 3 failed to administer the calcium with vitamin D (supplement) medication to…

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

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure 133 of 137 residents who received food from the kitchen received the proper diets and portion sizes when the facility's menus were not followed. * The facility failed to ensure the new Vietnamese menu was posted and communicated to the residents who received Vietnamese menu meals. * The facility failed to ensure the kitchen staff served the correct portion size as per the menu and menu spreadsheet. These failures had the potential for the residents' nutritional needs not being met. Findings: Review of the facility's document titled Resident Count by Diet Order Report dated 5/7/25, showed 133 of 137 residents received food which was prepared in the facility's kitchen. Review of the facility's untitled and undated document showed 22 residents received food from the Vietnamese menu. Review of the facility's P&P titled Menus dated 2/2017 showed the menus are planned in advance to meet the nutritional needs of the residents and are in accordance with the recommended dietary…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 nutritive content of the pureed foods for the Vietnamese menu, particularly the pureed stir fry vegetables, were preserved when the pureed vegetables were cooked and held on the steam table for two hours prior to meal service. This failure had the potential to not meet the nutritional needs of the five residents who received a Vietnamese menu pureed diet. Findings: Review of the professional reference titled How Cooking Affects the Nutrient Content of Foods dated 11/7/19, showed the following nutrients are often reduced during cooking: water-soluble vitamins: vitamin C and the B vitamins - thiamine (B1), riboflavin (B2), niacin (B3), pantothenic acid (B5), pyridoxine (B6), folic acid (B9), and cobalamin (B12), fat-soluble vitamins: vitamins A, D, E, and K, and minerals: primarily potassium, magnesium, sodium, and calcium . https://www.healthline.com/nutrition/cooking-nutrient-content. Review of the facility's document titled Resident Count by Diet Order Report dated 5/7/25, showed 133 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, facility record review, and facility P&P review, the facility failed to protect the resident's right to be free from physical abuse by a resident for one of two sampled residents (final sampled resident, Resident 113) reviewed for abuse. * Resident 113 was hit in the face with a rehabilitation dowel by another resident (Resident 86). This failure resulted in Resident 113 suffering pain to the left side of his face and experiencing feelings of anger. Findings: Review of the facility's P&P titled Alleged or Suspected Abuse and Crime Reporting revised 10/2022 showed each resident has the right to be free from abuse. Physical abuse includes, but is not limited to, hitting, slapping, pinching and kicking. The facility will implement policies and procedures to prevent and prohibit all types of abuse. Medical record review for Resident 113 was initiated on 5/7/25. Resident 113 was admitted to the facility on [DATE]. Review of Resident 113's BIMS dated 5/5/25,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 daily fluid restriction for one of three sampled residents (Resident 2) was monitored and documented as ordered by the physician. This failurehad the potential to result in Resident 2 having an excess of fluid which could lead to negative health consequences due to impaired kidney function and the potential to negatively affect Resident 2's continuity of care while receiving dialysis at an outpatient dialysis center. Findings: Medical record review for Resident 2 was initiated on 2/13/25. Resident 2 was readmitted to the facility on [DATE], with a diagnosis including ESRD requiring the dialysis treatments at an outpatient dialysis center three times a week. Review of Resident 2's Order Summary Report showed a physician's order dated 1/13/24, for fluid restriction of 1500 ml per 24 hours as follows: - dietary department: 840 ml on meals trays (breakfast: 360 ml, lunch 240 ml, dinner 240 ml); and - nursing department: 660…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and implement an individualized care plan for one of two sampled residents (Resident 1). * The facility failed to develop and implement an accurate care plan for Resident 1 to address the use of a PICC line. This failure posed the risk for Resident 1 having developed complications associated with the PICC. Findings: Review of the facility's P&P titled Comprehensive Care Plan dated 12/2017 showed it is the policy of the facility to develop, in conjunction with the resident and resident representative, the comprehensive resident care plan. The care plan is directed toward achieving and maintaining optimal status of health, functional ability, and quality of life. The care plan becomes a comprehensive tool for the IDT to utilize as a reference for identified concerns and approaches to establish guidance for meeting resident individual needs. Medical record review for Resident 1 was initiated on 8/19/24. 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.

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 PICC line assessments were conducted and documented, failed to ensure the PICC unused lumens were flushed, and failed to conduct and document a change of condition assessment for the resident who exhibited pain and swelling at the PICC site for one of two sampled residents (Resident 1). These failures posed the risk for not identifying and treating potential complications associated with the PICC line, as evidenced by Resident 1 having sustained an occlusive right axillary deep vein thrombosis. Findings: Review of the facility's P&P titled Central Access Guidelines and Procedures (undated) showed an occlusive dressing shall be maintained over the central venous access site at all times. The PICC dressings shall be changed every seven days from date of insertion. The PICC catheter dressing changes shall be done every seven days and as needed. Document the (resident's) arm circumference in centimeters on the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure Resident 1's medications were administered as ordered for one of two sampled residents (Resident 1). * Resident 1 did not receive the following medications as ordered by the physician due to a lack of availability: enoxaparin sodium (medication to prevent blood clots), levetiracetam (anti-seizure medication), desmopressin acetate (medication to treat cranial diabetes insipidus), and methocarbamol (muscle relaxant medication). * The facility failed to notify Resident 1's physician when Resident 1 did not receive his medications as ordered as per the facility's P&P. These failures posed the risk for negative health outcomes to Resident 1. Findings: Review of the facility's P&P titled Medication Administration dated 5/2022 showed the medications are administered as prescribed in accordance with written orders of the prescriber. Medications are administered without necessary interruptions. Medications are administered…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 document review, the facility failed to follow the infection control practices while cleaning the resident rooms for two of two sampled residents (Residents 1 and 2) and 10 nonsampled residents (Residents 3, 4, 5, 6, 7, 8, 9, 10, 11, and 12.) * Housekeepers 1 and 2 did not use a new cloth while cleaning the individually used equipment between Residents 1, 2, 3, 4, 5, 6, 7, 8, and 9. * Housekeepers 1 and 2 did not wear a gown while cleaning the resident rooms with the EBP signage. * Housekeeper 1 scrubbed the toilet seats for Rooms A and B's shared restroom, and Room C's restroom with a toilet scrub brush for toilet bowl use only. * Housekeeper 1 failed to clean the restroom grab bars for Rooms A and B's shared restroom, and Room C's restroom. These failures had the potential to spread infection to the residents in the facility. Findings: Review of the facility's Infection Prevention Manual for Long Term Care revised 5/2024 showed EBP are an…

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

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the kitchen staff were competent in the position related duties when: 1. Three of 11 kitchen staff (Cooks 1, 2 and DA 1) failed to follow proper hand hygiene. 2. Two of 11 kitchen staff (Cooks 1 and 2) failed to monitor and be competent in knowledge of the cool down procedure for TCS (time/temperature control for safety) foods. 3. One of 11 kitchen staff (Cook 2) failed to sanitize food preparation surfaces. 4. One of 11 kitchen employees (DA 1) failed to perform the following : a. DA 1 did not know the correct temperature of the rinse cycle of the dish machine, b. Demonstrate how to test the sanitizing solution of the dish machine according to the manufacturer guidelines, and c. Demonstrate how to test the sanitizing solution of the manual ware washing sink according to the manufacturer guidelines. These failures had the potential for unsafe food handling practices which could lead to food borne illness in the 122 vulnerable residents who received food prepared in the…

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

Based on observation, interview, and facility document review, the facility failed to ensure the nutritive content of the pureed foods for the American menu, in particular the pureed vegetables were preserved when the pureed vegetables were cooked and held in a hot oven more than one hour prior to meal service. This failure had the potential to not meet the nutritional needs of the 23 residents who received an American menu pureed diet. Findings: Review of the reference titled How Cooking Affects the Nutrient Content of Foods, dated 11/7/19, showed the following nutrients are often reduced during cooking: water-soluble vitamins: vitamin C and the B vitamins - thiamine (B1), riboflavin (B2), niacin (B3), pantothenic acid (B5), pyridoxine (B6), folic acid (B9), and cobalamin (B12). https://www.healthline.com/nutrition/cooking-nutrient-content Review of the facility's document titled Production Recipe, [NAME] peas, pureed dated 5/15/24, showed to prepare frozen green peas according to the regular recipe. Process until smooth using ½ teaspoon food thickener per serving. Reheat to a…

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

Based on observation, interview, facility document review and facility P&P review, the facility failed to ensure food safety and sanitation guidelines were followed when: 1. The cool down process for time, temperature control for safety (TCS) food, food that need to be kept at specific temperatures to prevent bacteria growth and foodborne illnesses, was not monitored. 2. Food preparation surfaces were not sanitized properly. 3. A thawing process was not followed for meats. 4. Hand washing was not performed for three of eleven kitchen staff. 5. Food preparation equipment was not clean and in good working condition. 6. Hair restraints were not worn properly for six out of ten kitchen employees. 7. Kitchen equipment was not clean. 8. The kitchen environment was not clean. 9. The kitchen floor was not in a cleanable condition. 10. The ice machine and a food preparation sink did not have an air gap. These failures posed the risk for food borne illnesses in highly susceptible resident population of 122 facility residents who received food prepared in the kitchen. 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 4. Medical record review for Resident 8 was initiated on 6/19/24. Resident 8 was admitted to the facility on [DATE], and readmitted on [DATE]. a. On 6/19/24 at 0900 hours, Resident 8 was observed lying in bed and the indwelling urinary catheter drainage bag was touching the floor. On 6/19/24 at 1000 hours, LVN 3 was summoned to the Resident 8's Room. LVN 3 verified Resident 8's indwelling urinary catheter drainage bag was touching the floor. LVN acknowledged the urinary collection bag should not be touching the floor. b. Review of the facility's P&P titled Enhanced Barrier Precaution dated 5/2024 showed the enhanced barrier precaution refers to an infection control intervention designed to reduce the transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities. Review of Resident 8's Order Summary Report showed a physician order dated 6/18/24, for enhanced based precaution every shift for the indwelling urinary catheter and GT. On 6/19/24 at…

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

Based on observation, interview, facility document review, and facility P&P review, the facility failed to maintain the essential equipment in safe operating condition when: * The ice machine was not cleaned and sanitized in according to the manufacturer specifications. * The dish machine water temperature was below the manufacturer specifications for the wash and rinse cycles. * A metal screen door on the back door of the kitchen was not flush with the door jamb creating a gap. * A screen above a food preparation counter was not intact. * A fire sprinkler on the ceiling of the walk-in refrigerator had a brown residue resembling rust and was not intact with the ceiling of the walk-in refrigerator. These failures had the potential for the essential equipment to not function in the way it was intended. Findings: Review of the facility matrix showed 122 residents received food prepared in the kitchen. 1. Review of the ice machine manufacturer guidelines posted on the wall of the kitchen showed in part, the following: 6. Pour eight ounces or ten ounces or 12 ounces of [Scotsman Clear 1]…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 informed consents were obtained prior to the use of the psychotropic medications (medications affecting brain activities associated with mental processes and behavior) for two of six final residents (Residents 32, and 540) reviewed for psychotropic medication use . * The facility failed to ensure an informed consent was obtained prior to administering the iloperidone medication (antipsychotic medication) for Resident 32. * The facility failed to ensure an informed consent was obtained prior to administering the lorazepam medication (antianxiety medication) for Resident 540. These failures had the potential for Residents 32 and 540 to not be informed of the psychotropic medications, and the potential side effects of the medications. Findings: Review of the facility's P&P titled Psychotropic Medication Management dated 12/2017 showed informed consent for psychoactive medications must be verified prior to use. 1.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to determine if it was safe for one of 27 final sampled residents (Resident 95) to self-administer the medications. * Resident 95 was observed with the medications at bedside. Resident 95 did not have a physician's order, assessment, and care plan for the self-administration of medications. This failure had the potential for Resident 95 to administer the medications inaccurately. Findings: Review of the facility's P&P titled Self-Administration of Medication dated 2008 showed it is the policy of the facility to allow resident who request self-administration of medication to do so if the facility IDT has determined the resident is capable of doing so in a safe manner that does not present a risk to other residents of the facility. If a resident expresses a desire to self-administer their medications, or a physician orders self-administration, the facility will not allow the resident to self-administer meds until…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 promote the dignity and respect for two of 27 final sampled residents (Residents 81 and 540) and one nonsampled resident (Resident 96). * The call light was not within reach for Residents 81, 96, and 540. This failure created the potential to result in a delay to provide care and negatively impact the resident's psychosocial well-being. Findings: 1. Review of the facility's P&P titled Call light : Accessibility and Timely response dated 10/22 showed the staff will ensure the call light is within reach of the resident and secured as needed. Medical record review for Resident 81 was initiated on 2/4/22. Resident 81 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 81's Plan of Care dated 6/17/24, showed a care plan problem addressing Resident 81 had self-care deficit as evidenced by needs assistance with ADL care. The interventions included one-person…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 clearly identify the current code status for one of seven final sampled residents (Resident 32) reviewed for advance directives. * The facility failed to clarify and honor Resident 32's desire to have a full code status. In addition, the facility failed to ensure the correct individual signed Resident 32's POLST. Resident 32's POLST showed Resident 32 was a DNR and another individual (not Resident 32) signed Resident 32's POLST. These failures had the potential to not provide care in accordance with the resident's treatment wishes. Findings: Review of the facility's P&P titled Advance Directives dated 11/2016 showed the following: - POLST (Physician Order for Life Sustaining Treatment), this form is often mistaken as an advanced directive, it is actually a physician order that travels from location to location with the resident; and - DNR (Do Not Resuscitate) order is a written order from a doctor that resuscitation should not be attempted if 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 provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one of 27 final sampled residents (Residents 8) and one nonsampled resident (Resident 107). * The facility failed to follow the physician's order for Resident 8 to administer the antibiotic as ordered intravenously. This failure created the risk of not providing the appropriate care for Resident 8. * The facility failed to follow the physician's order for Resident 107 to receive a health shake (nutritional suppplement)with meals. This failure posed the risk for Resident 107 to not receive adequate calories which could lead to weight loss. Findings: 1. Review of the facility's P&P titled General Infusion undated showed a pump shall be provided (unless the facility had their own supply) on all medications pharmacy services recommends be administered by electronic infusion pump:…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 post fall assessments were appropriately completed for two of three residents (Residents 42 and 124) reviewed for falls. * Resident 42's post fall neuro checks were incomplete for two falls. * The facility failed to continue to monitor and document assessment every shift for 72 hours post fall incident for Resident 124. These failures had the potential to delay identifying and responding to post fall changes. Findings: Review of the facility's P&P titled Fall Prevention and Response revised 8/20/23, showed when a resident has a fall, to neurological check for known, reasonably suspected, or verbalized head injury. 1. Medical record review for Resident 42 was initiated on 6/18/24. Resident 42 was readmitted to the facility on [DATE]. Review of Resident 42's MDS dated [DATE], showed the resident was rarely understood and short-term and long-term memory problems. The MDS also showed the resident's cognitive skills…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 accurately monitor the hydrations status for one of 27 sampled residents (Resident 539). * The facility failed to ensure accurate monitoring of Resident 539's fluid intake which included from meals, medication administration, free water, liquid supplements, IV (intravenous) hydration, IV therapy intake, and IV flushes. In addition, the facility failed to ensure the monitoring of Resident 539's fluid output showed the actual number of urine output from the resident's indwelling catheter, and not just the frequency of voiding. These failures had the potential to compromise Resident 539's hydration status and posed the risk for negative health outcomes. Findings: Review of the facility's P&P titled Intake and Output (I&O) dated 8/2014 showed it is the policy of the facility to monitor intake and output and accurately document when it is determined that monitoring is necessary to evaluate hydration status, compliance with…

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

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 intravenous accesses for one nonsampled resident (Resident 12) and one of one final sampled resident (Resident 539) reviewed for IV devices. * The facility failed to ensure the PICC line external catheter and arm circumference measurements were performed and documented in the medical record for Residents 12. * The facility failed to ensure the external catheter length and arm circumference measurements were performed as per the resident's plan of care. In addition, the facility failed to ensure Resident 539's midline catheter (an eight to twelve cm catheter inserted in the upper arm with the tip located just below the axilla) dressing was not soiled and dated. These failures had the potential to delay identification of catheter related complications for the resident. Findings: Review of the facility's P&P titled Central Access Guidelines and Procedures…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 five of five residents (Residents 8, 12, 16, 79, and 86) reviewed for respiratory care were provided the appropriate respiratory care when: * The facility staff administered oxygen to Resident 8 without a physician's order and care plan to address oxygen use and monitoring of oxygen saturation level when the resident was using the oxygen continuously. *The facility failed to ensure Residents 12 and 86's nasal cannula (flexible tube to deliver oxygen to the nose) tubing were dated, labeled, and not touching the floor for Resident 12. *The facility failed to ensure Resident 16's CPAP (continuous positive airway pressure, a machine that uses mild air pressure to keep breathing airways open) mask was stored in a bag when not in use. * The facility failed to ensure Resident 79's oxygen tubing and humidifier were dated and labeled. In addition, the facility failed to ensure Resident 79's CPAP mask was stored…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 pharmaceutical services were provided to meet the needs of the residents for two of five residents (Residents 7 and 23) reviewed for unnecessary medications and one nonsampled resident (Resident 339). In addition, the facility failed to ensure the process for opening the E-kit was followed and failed to ensure the controlled count were documented each shift. * The facility failed to ensure Resident 7's carvedilol, losartan, and furosemide (medication to treat high blood pressure) were administered and held as ordered. * The facility failed to ensure Resident 7 had an insulin coverage for blood sugar results between 351-401 mg/dl, and had a physician's order to notify the physician for blood sugar of less than 70 mg/dl. * The facility failed to ensure the parameter to administer Glucose Oral Gel 40% was clarified to address the need for intervention for signs of low blood sugar for Resident 23. * 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 medical record review, the facility failed to ensure four of five final sampled residents (Residents 7, 17, 78, and 540) reviewed for unnecessary drugs were free from unnecessary drugs. * The facility failed to ensure Resident 540's heart rate was checked prior to administering the amiodarone (a medication that works directly on the heart tissue and slows the nerve impulses in the heart) and carvedilol (a medication that works by affecting the nerve impulses in the body such as the heart, and slows the heart beat and decreases blood pressure) medications nor the resident's blood glucose checked prior to administering insulin glargine (a long-acting insulin) as per the physician's orders. * The facility failed to ensure Resident 7's order for losartan (medication to treat high blood pressure) and ProStat had diagnoses for the medications ordered by the physician. * The facility failed to ensure Resident 17's heart rate was checked prior to administering metoprolol succinate (a beta-blocker,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 final sampled residents (Residents 7 and 540) reviewed for unnecessary drugs were free from unnecessary psychotropic drugs (any drug that affects brain activity associated with mental processes and behavior). * The facility failed to ensure the physician's order for lorazepam (antianxiety medication) 0.5 mg as needed for Resident 540 was limited to a 14-day duration. In addition, the facility failed to show documentation by the attending physician or prescribing practitioner for the rationale for the extended time in the medical record. Furthermore, the facility failed to develop a care plan to address the lorazepam use. * The facility failed to ensure Resident 7's behavior was monitored for the use of duloxetine (medication to treat depression) These failures had the potential for the Residents 7 and 540 to develop significant side effects from the psychotropic drugs. Findings: 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. * The facility's medication error rate was 10.34%. One of three licensed nurses (LVN 7) was found to have made errors during the medication administration observation for two nonsampled residents (Residents 66 and 339). This failure had the potential to negatively impact the resident's heal outcomes. Findings: Review of the facility's P&P titled Medication Administration-General Guidelines dated 11/2021 showed the medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. The medications are administered in accordance with written orders of the attending physician. 1. On 6/19/24 0836 hours, a medication administration observation for Resident 66 was conducted with LVN 7. LVN 7 prepared the following medications for Resident 66: - carvedilol (medication to treat high blood…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 proper medication storage. * The facility failed to properly label an opened tuberculin solution with the open date to include the year it was opened. * The facility failed to remove the expired dextrose (a sterile solution used to provide the body with extra water and carbohydrates) injection solution. * The facility failed to remove the expired Heparain (blood thinner to prevent clots) lock flush solution. * The facility failed to store Gamunex-C (medication used to strengthen the body's natural defense system to lower the risk of infection in persons with a weakened immune system) 10% vials as per storage instructions. * The facility failed to ensure the refrigerator containing medications was kept in sanitary condition. * The facility failed to ensure an unused/unopened insulin Gargine (medication to treat diabetes) pen was stored inside a refrigerator. * The facility failed to…

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

Based on observation, interview, and facility document review, the facility failed to ensure the Certified Dietary Manager (CDM) who was responsible to oversee the food services department was competent in managing the day-to-day functions of the food services department. Failure to employ staff with the skills and abilities to effectively implement departmental processes in accordance with standards of practice, may jeopardize the health and well-being of the 122 residents who received food prepared in the kitchen. Findings: Review of the facility's matrix showed 122 residents who consumed food prepared in the kitchen. Review of the facility's document titled Director of Food Services signed and dated by the CDM on 4/18/11, showed the primary purpose of the Director of Food Services was to assist the RD in planning, organizing, developing and directing the overall operation of the Food Services Department in accordance with current federal, state and local standards, guidelines and regulations governing our facility, and as may be directed by the Administrator, to assure that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 American and Vietnamese menus met the resident's nutritional needs when * The Vietnamese menus did not have puree recipes. * The Vietnamese menus did not have a nutritional analysis. * The Vietnamese menus were not updated periodically. * The Vietnamese menus did not reflect the standard of practice for IDDSI (International Dysphagia Diet Standardization Initiative). * The American menu puree recipes were not followed for puree ham, puree green peas, and puree sweet potatoes. * The facility failed to ensure the coleslaw was served to Residents 51 and 115 as per the spreadsheet. * The facility failed to ensure lettuce, tomato, and onions with the hamburger were served to Resident 16. These failures had the potential for the residents not receiving adequate nutrition, and appropriate food texture based on their diet. Findings: 1. According to the International Dysphagia Diet Standardization Initiative (IDDSI)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility document review, the facility failed to provide a meal substitute equivalent in nutritive value when: * The pureed ham served to 23 of 122 residents who received an American menu puree diet had a higher sodium content than the regular ham and, * The grilled cheese sandwich served to Resident 7 was not equivalent in protein to the entrée served. Theses failures had the potential for residents who received a meal alternate from the kitchen to not meet their nutritional needs. Findings: Review of the lunch meal tray ticket report dated 6/19/24, showed 23 residents received a pureed diet. 1. Review of the facility's recipe titled Grilled Ham dated 5/15/24, showed 1. Place 4.5-ounce slice of ham on preheated 350 degrees F (Fahrenheit) grill. 2. [NAME] both side until internal temperature of final product reaches 155 degrees F for 17 seconds. Review of the facility's recipe titled Grilled Ham puree dated 5/15/24, showed for ingredients and instructions: 1. Grilled Ham 4.5…

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

Based on interview and facility P&P review, the facility failed to ensure food brought to the facility by the family members or visitors was stored and prepared; and safe food handling practices were followed. This failure had the potential for unsafe food handling which could lead to food borne illness. Findings: Review of the facility P&P titled Use and Storage of Food Brought in by Family and Visitors dated 8/2023 showed, prepared food items brought in by the family or visitor must be labeled and dated. A. Facility may refrigerate labeled/dated prepared items in a designated unit or pantry refrigerator. On 6/19/24 at 0857 hours, an interview was conducted with the ADON. The ADON stated the facility did not allow storage of perishable food brought in by the family or visitors. The ADON stated the facility did not have a refrigerator for storage of food brought in by the family or visitors. The ADON added any food brought in by the family or visitors must be eaten and not stored. When asked if the family members or visitors were educated on safe food handling practices, the ADON…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 complete and accurate medical records for four of 27 final sampled residents (Residents 7, 23, 56, and 540) and one of three closed record sampled residents (Resident 138). * Resident 7's POLST was not included in their medical record. * Resident 56's POLST was incomplete and did not show if the resident had an advanced directive. * Resident 540's POLST was not updated to show the resident had advance directive. * Resident 23's MAR was incomplete for medication administration. * Resident 138's medical record failed to show a CPR was initiated prior to paramedics' arrival. These failures had the potential for resident's care needs not being met as the clinical information were incomplete and/or inaccurate. Findings: 1. Medical record review for Resident 7 was initiated on [DATE]. Resident 7 was admitted to the facility on [DATE]. Review of Resident 7's medical record showed no documented evidnce of the resident'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, 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 side rails for three of three residents (Residents 30, 79 and 87) reviewed for 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…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the kitchen and dining room were free of pests. This failure posed the risk of the residents residing in the facility to be exposed to pests. Findings: 1. Review of the facility's P&P titled Pest Control dated 2/2009 showed in part, 3. Garbage is held, transferred, and disposed of in a manner that does not create a breeding place for insects or rodents. 6. Windows and vents must be screened with at least 16-mesh per square inch screens. 7. Gaps and cracks in doorframes and thresholds are repaired . 8. All foods are kept tightly covered or wrapped. 9. Spills are cleaned up as they occur. Keep the kitchen clean. Review of the facility's documents titled Professional Pest Management Service Inspection Report dated 5/22 and 6/12/24, showed the facility was treated for roaches, ants, spiders, and mosquitoes. During the initial tour of the kitchen on 6/18/24 at 0819 hours, one fly was observed in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to develop the comprehensive plan of care to reflect the individual care needs for one of three sampled residents (Resident 1). * The facility failed to develop a care plan problem to address Resident 1's allergy requiring medication. This failure posed the risk of not providing appropriate, consistent, and individualized care to Resident 1. Findings: Medical record review for Resident 1 was initiated on 5/10/24. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's H&P examination dated 10/23/23, showed Resident 1 had the capacity to understand and make decisions. Review of Resident 1's Order Summary Report dated 5/10/24, showed a physician's order dated 2/19/24, for Flonase allergy relief nasal suspension, instill two sprays in both nostrils one time a day for allergic rhinitis. Review of Resident 1's MARs for April and May 2024 showed Flonase nasal spray was administered to Resident 1 at 1800 hours daily by the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to ensure the comprehensive plan of care for one of three sampled residents (Resident 1) was revised to reflect the resident's current care needs and interventions. * The facility failed to revise Resident 1's care plan to address the change in insulin and monitoring of blood sugar. This failure posed the risk of not providing the resident with appropriate, consistent, and individualized care individualized and person-centered care. Findings: Medical record review for Resident 1 was initiated on 5/10/24. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's H&P examination dated 10/23/23, showed Resident 1 had the capacity to understand and make decisions. Review of Resident 1's Order Summary Report dated 5/10/24, showed the following physician's orders: - dated 1/30/24 for insulin glargine solution (antidiabetic medication), inject 18 units subcutaneously in the evening for diabetes and hold for blood sugar levelsless than 100…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to monitor the blood sugar levels daily for one of three sampled residents (Resident 1) were free from unnecessary drugs. This failure had the potential to adversely affect and negatively impact the resident. Findings: Medical record review for Resident 1 was initiated on 5/10/24. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's H&P examination dated 10/23/23, showed Resident 1 had the capacity to understand and make decisions. Review of Resident 1's Order Summary Report dated 5/10/24, showed the following physician's orders: - dated 1/30/24 for insulin glargine solution, inject 18 units subcutaneously in the evening for diabetes and hold for blood sugar levels less than 100 mg/dl; and - dated 2/19/24 for insulin glargine solution, inject 10 units subcutaneously one time a day for diabetes and hold for blood sugar levels less than 100 mg/dl. Review of Resident 1's MARs from February to May 2024 failed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the residents' medications were stored properly for one of three sampled residents (Resident 1). * The facility failed to ensure the nasal spray was stored properly for Resident 1 when Flonase allergy relief nasal suspension was observed on Resident 1's overbed table. This failureposed the potential for unauthorized access to the medications, medication error, and negatively affected the residents' well-being. Findings: Review of facility's P&P titled Self-Administration of Medication dated 2008 showed it is the policy of the facility to allow residents who request self-administration of medication to do if the facility interdisciplinary team has determined the resident is capable of doing so in a safe manner that does not present a risk to other residents of the facility. The decision to either approve or deny self-administration will be documented and the resident will be notified. If the IDT approves…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 implement their P&P for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B as evidenced by: * The facility failed to ensure Resident 3's sexual abuse allegation was reported timely to the CDPH L&C Program and local law enforcement for one of six sampled residents (Resident 3). This failure had the potential for abuse allegations to go unreported and uninvestigated timely. Findings: Review of the facility's P&P titled Abuse Prevention, Intervention, Investigation & Crime Reporting Policy dated 11/2016showed in response to allegations of abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, and misappropriation of resident property are reported immediately but not later than 2 hours after allegation is made; to the administrator of the facility and to other officials including: a. state survey agency b. adult protective 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 interview, medical record review, facility document review, and facility P&P review, the facility failed to implement the P&P for reporting the investigative findings to the CDPH, L&C Program within five working days for an allegation of staff to resident abuse for one of six sampled residents (Resident 1). This failure had the potential for the abuse allegation going unreported and uninvestigated. Findings: Review of the facility's P&P titled Abuse Prevention, Intervention, Investigation & Crime Reporting Policy dated 11/2016showed the facility Administrator, or designee shall report investigative findings to officials in accordance with state law, including State Licensing and Certification agency, within five working days of incident. Medical Record review for Resident 1 was initiated on 3/20/24. Resident 1 was admitted to the facility on [DATE]. Review of the SBAR-Alleged Abuse Report of Incident dated 3/11/24, showed Resident 1 reported that around 4 AM on 3/11/24, when a male CNA was changing his…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 low air loss mattress for one of six sampled residents (Resident 6) was kept at the correct settings for the resident. This failure posed the risk of the resident not receiving appropriate care. Findings: On 3/5/24, medical record review was initiated for Resident 6. Resident 6 was readmitted to the facility on [DATE]. Review of Resident 6's H&P examination dated 8/5/23, showed Resident 6's diagnoses included unstageable pressure injury to the sacrum. Resident 6 was bed bound. Further review of the medical record showed Resident 6's weight was 129 lbs on 3/1/24. On 3/5/24 at 1615 hours, an observation and concurrent interview was conducted with Resident 6. Resident 6's low air loss mattress was observed to be set at 400 pounds. Per Resident 6, she was on a low air loss mattress due to a reopened pressure injury wound status post a hospital stay. Review of Resident 6's March 2024 TAR showed the staff were monitoring 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility document review, the facility failed to allow one of four sampled residents (Resident 2) to return and resume residence in the facility after the acute care hospital determined Resident 2 was ready for discharge from the acute care hospital. This failure caused Resident 2 to remain in the acute care hospital for approximately an additional 10 days, which had the potential to negatively impact the resident's well-being. Findings: Medical record review for Resident 2 was initiated on 2/6/24. Resident 2 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 2's H&P examination dated 10/16/23, showed Resident 2 had the capacity to understand and make medical decisions. The H&P examination also showed the resident was homeless. Review of Residents 2's MDS dated [DATE], showed the resident was cognitively intact. Review of the Messages-Referral for Resident 2 dated 1/25/24, showed the facility's response as unable to accept…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 document review, the facility failed to ensure the necessary care and services were provided to prevent the worsening of pressure injuries for one of four sampled residents (Resident 3). This failure had the potential to cause the pressure injury to get worse. * Resident 3's pressure injury was not measured and assessed weekly. In addition, the licensed nurse did not notify the wound specialist to evaluate Resident 3's wound. Findings: Review of the facility's P&P titled Documentation of Wound Treatments (undated) showed the wound assessments are documented upon admission, weekly, and as needed if the resident or wound deteriorates. The following elements are documented as part of a complete wound assessment: (a) the type of wound, and anatomical location, (b) stage of the wound, (c) measurements (height, width, depth, undermining, and tunneling), and (d) description of wound characteristics. Closed medical record review for Resident 3 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility document review, the facility failed to ensure to assess or identify fall risk for one of eight sampled residents (Resident 8). * Resident 8 was admitted to the facility after a fall with fracture. Resident 8 had unsteady gait and poor balance. The facility failed to assess or identify the fall risks to develop the plan of care to prevent falls. This failure created the risk to not provide the necessary care and services to prevent falls for this resident. Findings: Review of the facility's P&P titled Fall Management dated 8/2014 showed the purpose of the policy is to evaluate risk factors and provide interventions to minimize risk, injury, and occurrences of falls. Under the Fall Prevention Procedure section, it showed to evaluate the risk factors for sustaining falls upon admission with comprehensive assessments and while conducting interdisciplinary care plan reviews; and to initiate the fall prevention care plan when appropriate with strategies to…

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

Based on observation, interview, and facility P&P review, the facility failed to ensure the food storage and delivering met the standards of safety and sanitation requirements. * The facility failed to ensure the boxes of fruits in the walk-in refrigerator were labeled with received dates. * The facility failed to ensure the opened bottle of spices on the kitchen shelves were labeled with the opened dates. * The facility failed to ensure the food items were covered when transported from the kitchen to the resident rooms for one sampled resident (Resident 43) and one nonsampled resident (Resident 79). These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food prepared in the kitchen. Findings: Review of the CMS 672 Resident Census and Conditions of Residents completed and submitted by the facility on 1/5/22, showed 100 of 112 residents consumed food prepared from the kitchen. 1. Review of the facility's P&P titled Food Safety in Receiving and Storage dated 2/2009 showed all food is received and stored by methods to…

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

Based on observation, interview, facility document review, and facility P&P review, the facility failed to implement their infection control program and practices designed to help prevent the development and transmission of diseases and infections. * The facility failed to accurately identify and conduct the surveillance of residents with HAIs and CAIs from July 2021 through December 2021. The facility documented 215 resident infections (CAIs and HAIs) from July 2021 through December 2021. The facility failed to classify infections as CAIs for the residents who met McGeer's criteria within 72 hours of admission. This failure posed the risk for inaccurate infection surveillance data used to identify, manage, and contain infectious diseases. * LVN 4 failed to perform hand hygiene during the medication administration for Resident 665. This failure posed the risk for transmission of disease-causing microorganisms. Findings: 1. Review of the facility's IP job description dated 2012 showed the IP evaluates quality of resident care and resident outcomes as they relate to HAIs; collects,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 25 final sampled residents (Resident 35) was assessed to determine if the resident was safe to self-administer the medications. This failure had the potential to negatively impact the resident's physiological well-being and posed the risk of medication administration errors. Findings: Review of the facility's P&P titled Self-Administration of Medication dated 2008 showed it is the policy of this facility to allow residents who request self-administration of medication to do so if the facility Interdisciplinary Team (IDT) has determined the resident is capable of doing so in a safe manner that does not present a risk to other residents of the facility. Residents will be notified upon admission of their right to self-administer medications. A Licensed Nurse will complete the Self-Administration Assessment Review which includes the resident's physical and cognitive ability to safely administer 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 develop and implement the comprehensive care plans for two of 25 final sampled residents (Residents 42 and 83). * The facility failed to implement Resident 42's care plan for the use of bilateral floor mats. Resident 42 had poor safety awareness and a history of falls in the facility. * The facility failed to develop a comprehensive plan of care to address the use of a Podus boot for Resident 83. Resident 83 had been wearing a Podus boot (a medical brace used to prevent and manage heel pressure and foot drops) to her left lower leg. These failures posed the risks for the residents not receiving the necessary care and services. Findings: Review of the facility's P&P titled Comprehensive Care Plan dated 12/2017 showed it is the policy of the facility to develop in conjunction with the resident and/or representative, the comprehensive resident care plan. The care plan is directed toward achieving and maintaining…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 comprehensive care plan was revised for one of 25 final sampled residents (Resident 42). * The facility failed to ensure Resident 42's comprehensive care plan was revised to reflect a physician's order for a change of Resident 42's diet from a mechanical soft texture to pureed texture. This failure placed the residents at risk of not being provide appropriate, consistent, and individualized care. Findings: Review of the facility's P&P titled Comprehensive Care Plan dated 12/2017, showed care plans are individualized through the identification of resident concerns, unique characteristics, strengths and individual needs. Medical record review for Resident 42 was initiated on 1/5/22. Resident 42 was admitted to the facility on [DATE]. Review of the physician's order dated 12/11/21, showed an order to discontinue Resident 42's soft and bite sized textured diet (mechanical soft), and to start Resident 42…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 necessary care and services to prevent the skin breakdown for one of 25 final sampled residents (Resident 83). * The facility failed to ensure the physician's order for wound consultation was carried out. This had the potential for the resident to develop further skin breakdown and not receive the appropriate care and services to promote wound healing. Findings: Medical record review for Resident 83 was initiated on 1/5/22. Resident 83 was admitted to the facility on [DATE]. Review of the History and Physical examination dated 2/26/21, showed Resident 83's diagnoses included the right side hemiplegia (paralysis on one side of the body). The examination showed Resident 83 did not have a skin breakdown. Review of the MDS dated [DATE], showed Resident 83 had severe cognitive impairment. Review of the Progress Notes showed an SBAR form 12/10/21, showing Resident 83's physician was notified of an open wound on the left…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide safe respiratory care for three of 25 final sampled residents (Residents 85, 110, and 364). * Residents 85 and 110's oxygen rates were not administered as ordered by the physician. Residents 85 and 110's oxygen tubings were on the floor. Resident 110's oxygen tubing was not dated to show when it was last changed. * The facility failed to ensure Resident 364's nebulizer mask was stored in a sanitary manner. The facility's practice for storage of the resident's nebulizer mask consisted of storing the mask in a clean plastic bag; however, Resident 364's nebulizer mask was observed lying directly on a nightstand. These failures posed the risk for equipment contamination and respiratory complications. Findings: According to the facility's P&P titled Oxygen Administration dated 8/2014, the licensed nurses check the physician's order for liter flow and method of oxygen administration. The licensed nurse…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 to meet the needs for two nonsampled residents (Residents 15 and 665). * LVN 4 failed to provide the necessary instructions to Resident 665 when he administered Combivent Respimat (inhalation spray to treat and prevent symptoms, wheezing and shortness of breath caused by ongoing lung disease). This failure had the potential to result in an incomplete drug dose administration for Resident 665. * The facility failed to ensure accurate reconciliation of the controlled medications for one Resident 15. LVN 5 failed to document in the MAR when he administered Resident 15's lorazepam (anti-anxiety medication). Resident 15's Controlled or Antibiotic Drug Record did not reconcile with the MAR. This posed the risk for loss or diversion of the controlled medications. Findings: 1. Review of the facility's P&P titled General Dose Preparation 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, medical record review, and facility document review, the facility failed to ensure the medication error rate was below 5%. The medication error rate was 10%. * LVN 4 failed to wait for 5-10 minutes in between the administration of Resident 655's three eye drop medications. This failure had the potential for drug interactions that may negatively affect the resident's wellbeing. Findings: Review of the product information for dorzolamide ophthalmic solution, under the section for Dosage and Administration, showed the medication may be used concomitantly with other topical ophthalmic drug products to lower intraocular pressure. If more than one topical ophthalmic drug is being used, the drugs should be administered at least ten minutes apart. Review of the latanoprost eye drops product insert, under the section Dosage and Administration, showed latanoprost may be used concomitantly with other topical ophthalmic drug products to lower intraocular pressure. If more than one topical ophthalmic drug is being used, the drugs should be administered at least…

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

Based on observation, interview, and facility P&P review, the facility failed to provide the pharmaceutical services to meet the needs of each resident. * Expired medications and supplies were stored in the medication storage rooms available for resident use. This failure had the potential to expose the residents to medications and supplies, which could be compromised or ineffective. Findings: Review of the facility's P&P titled Disposal/Destruction of Expired or Discontinued Medication revised 3/5/20, showed the facility should dispose of discontinued medication, outdated medications, or medications left in facility after a resident has been discharged in a timely fashion or no more than 90 days of the date the medication was discontinued by Physician/Prescriber, or sooner per applicable law. 1. During a concurrent interview and medication storage room inspection with LVN 1 on 1/6/22 at 1407 hours, the following was identified: - One bottle of Docu Liquid Stool Softener had expired on 10/2021. - One bottle of glucosamine & chondroitin (vitamin supplement) had expired on 5/2021. -…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a system was in place to accurately verify the ordered diets for four of 25 final sampled residents (Residents 7, 20, 42, and 61) and four nonsampled residents (Residents 5, 56, 400, and 401). * Resident 42 received and consumed a mechanical soft textured diet, however, the physician's order showed Resident 42 was to receive a pureed textured diet. * Residents 5, 7, 20, 56, 61, 400, and 401's diet orders printed in their meal tickets did not match the physician's order. These failures had the potential to lead to choking or aspiration (a condition in which food, liquids, saliva, or vomit is breathed into the airway) and posed the risk for residents to receive inadequate nutrition. Findings: Review of the facility's P&P titled Therapeutic Diets dated 2/2009 showed a mechanically altered diet is a diet specifically prepared to alter the consistency of food to facilitate oral…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 maintain a safe and sanitary environment for the residents and staff. * The facility failed to ensure the boxes of foam plates and foam cups were properly stored in the dry storage room. This failure posed a potential safety hazard for the residents and staff. Findings: Review of the Code of Federal Regulations, Section 29 - Occupational Safety and Health Standards dated, 10/5/13, showed nothing may be stored within 18 inches from the ceiling in sprinkled buildings. Review of the facility's P&P titled Food Safety in Receiving and Storage dated 2/2009 showed foods will be stored six inches off the floor and 18 inches from sprinkler heads. On 1/5/22 at 0730 hours, during the initial tour of the kitchen with [NAME] 1, the box of foam plates and box of foam cups were observed stacked up high and closed to the ceiling immediately below the water sprinklers in the dry storage room. [NAME] 1 verified the findings.