French Park Care Center

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food safety and sanitation requirements were met in the kitchen. * The facility failed to ensure the proper labeling of food in the kitchen. * The facility failed to ensure the kitchen utensils and equipment were stored or kept in sanitary conditions. * The facility failed to ensure the kitchen utensils were in good condition. * The facility failed to ensure the items in the kitchen was discarded after the use-by date. These failures had the potential for exposure to food-borne illnesses for a medical vulnerable population of 155 residents who received food prepared in the kitchen.Findings: Review of the facility's document titled Diet Type Report dated 4/20/26, showed 155 of 191 residents in the facility received food prepared in the kitchen. 1. According to USDA Food Code 2022, Section 3-501.17, Ready-To-Eat, Time/Temperature Control for Safety Food, Date Marking (undated), showed date marking requirements apply to containers of processed food that have been opened…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, medical record review, facility document review, and facility P&P review, the facility failed to establish and maintain the infection control program and practices designed to help prevent the development and transmission of diseases and infections. * The facility failed to maintain an accurate infection control surveillance program for January through April 2026. The facility conducted surveillance only on the residents who exhibited signs and symptoms of infection and were prescribed antimicrobial medications. The facility failed to ensure the residents exhibited signs and symptoms of an infection, met the facility's criteria of a true infection (Mc Geer's Criteria) but were not prescribed antimicrobial medications. * The facility failed to ensure Residents 2, 8, 44 and 93's tube feeding pump were clean and free from dusts and dried up formula. * The facility failed to ensure infection control practices were maintained when Resident 19's respiratory suction machine was observed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical records review, facility document and facility P&P review, the facility failed to implement their antibiotic stewardship program when the facility failed to conduct an assessment for the McGeer's criteria to determine the true infection for two of two residents (Residents 10 and 11) who were located at the SNF and sub acute unit. * The facility failed to ensure the infection treated for Residents 10 and 11 reviewed was classified as CAI, HAI, if met or did not meet the Mc Geer's criteria. This failure had the potential for inaccurately identification of true infections and potentially inhibited the residents' physicians from discontinuing unnecessary antimicrobials.Findings: Review of the facility's P&P titled Antibiotic Stewardship Program dated 12/19/22, showed it is the policy of this facility to implement an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. The purpose of the program is to optimize the treatment 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, and medical record review, the facility failed to provide dignity and respect for one of one final sampled resident (Resident 203) and one nonsampled resident (Resident 123) reviewed for dignity. * CNA 7 was observed standing over Resident 123 while assisting the resident with her meal. * The facility failed to provide a privacy bag to cover Resident 203's indwelling urinary catheter drainage bag. These failures posed a risk for the residents to not be treated with dignity and respect.Findings: 1. Medical record review for Resident 123 was initiated on 4/20/26. Resident 123 was admitted to the facility on [DATE]. On 4/20/26 at 0830 hours, an observation for Resident 123 and concurrent interview was conducted with CNA 7. CNA 7 was observed standing over Resident 123 while feeding Resident 123 who was sitting in a reclining chair. CNA 7 verified he was standing over Resident 123 while feeding the resident who was sitting in the reclining chair. CNA 7 stated he was standing because…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident or responsible party was fully informed and an informed consent was obtained prior to the use of the psychotropic medications for one of one final sampled resident (Resident 159) reviewed for the psychotropic medication. * The facility failed to ensure Resident 159's informed consent forms were completed prior to Resident 159's use of olanzapine (antipsychotic medication), escitalopram oxalate (Lexapro, antidepressant), and Depakote (medication used to treat epilepsy, bipolar mania, and prevent migraines) medications. These failures had the potential for the resident and the responsible party to be unaware of the risks associated with the psychotropic medications and the potential side effects.Findings: Review of the facility's P&P titled Use of Psychotropic Medication(s) revised on 3/17/25, showed a psychotropic drug is any drug that affects brain activities associated with mental processes and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medications were safely administered to two of 35 final sampled residents (Residents 20 and 54). * Resident 54 had the Albuterol HFA inhaler (a breathing treatment) at the bedside. Resident 54 did not have a physician's order to keep this medication at bedside. * Resident 20 had Blink geltears (treats moderate to severe dry eye) eye drops, GeriCare artificial tears (lubricating eye drops formula provides extended comfort and hydration for dry, irritated eyes) eye drops, and Comfort Ear natural moisturizer (soothes and comforts dry irritated ears) ear drops on top of the bedside table. These failures had the potential for the residents to administer the medications inaccurately, develop adverse reactions from the medications, and negatively affect the resident's well-being.Findings: Review of the facility's P&P titled Resident Self-Administration of Medications revised 12/19/22, showed a resident may…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 obtain a copy of an advance directive for one of four final sampled residents (Resident 203) reviewed for the advanced directive. * The facility failed to obtain and maintain a copy of Residents 203's advance directive in the medical record. This failure had the potential for Resident 203's wishes not followed related to the provision of medical treatment and services.Findings: Review of the facility's P&P titled Residents' Rights Regarding Treatment and Advance Directives revised 12/19/22, showed upon admission, should the resident have an advance directive, copies will be made and placed on the chart as well as communicated to the staff. Medical record review for Resident 203 was initiated on 4/20/26. Resident 203 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 203's MDS assessment dated [DATE], showed Resident 203 had a BIMS score of 3 (severe cognitive impairment). Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure the physician was notified timely for one of three residents (Resident 41) reviewed for acute care hospitalizations. * The facility failed to notify the physician timely to obtain orders for Resident 41's critically low hemoglobin levels of 6.6 g/dL. When Resident 41's physician was notified, an order to transfer Resident 41 to an acute care hospital for further evaluation and treatment was documented (over nine hours after the licensed nurse reviewed the laboratory results). This failure had the potential to delay the medical interventions for Resident 41. Findings: Review of the facility's P&P titled Notification of Changes reviewed 12/19/22, showed the facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring notification include: significant change 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 interview, medical record review, and facility P&P review, the facility failed to ensure one of six residents (Resident 17) reviewed for unnecessary medications was free from unnecessary psychotropic medications. * The facility failed to ensure Resident 17 was monitored for the specific behavior of restlessness and inability to relax related to the use of the lorazepam (antianxiety medication). This failure had the potential for the resident to receive unnecessary medication and experience the adverse effects from the psychotropic medications. In addition, it has potential for not providing the correct data to the prescriber necessary to adjust the dosage of the psychotropic medication.Findings: Review of the facility's P&P titled Use of Psychotropic Medications reviewed 3/17/25, showed the psychotropic medications are to be used only when a practitioner determines that the medication(s) is appropriate to treat a resident's specific, diagnosed, and documented condition and the medication(s) is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to timely report an abuse allegation for one of four final sampled residents (Resident 12) investigated for abuse. * The facility failed to report Resident 12's allegation of abuse, when the Ombudsman and Family Member 1 (Resident 12's family member) reported Resident 12 stated she felt a sensation of a wooden stick/spoon penetrate her body by a CNA. This failure placed the resident at risk for potential ongoing abuse, lack of protection from potential abuse, and resulted in a delay for CDPH and local law enforcement intervention. Findings: Review of the facility's P&P titled Abuse, Neglect, and Exploitation revised 12/19/22, showed the facility will report all abuse allegations no later than 24 hours. According to the WIC S 15630 effective 1/1/24, showed the facility will report all abuse allegations to CDPH, local law enforcement, and the long-term care ombudsman no later than 24 hours. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to timely investigate an abuse allegation for one of four final sampled residents (Resident 12) investigated for abuse. * The facility failed to investigate Resident 12's allegation of abuse, when the Ombudsman and Family Member 1 (Resident 12's family member) reported Resident 12 stated she felt a sensation of a wooden stick/spoon penetrate her body by a CNA. This failure placed the resident at risk for potential ongoing abuse and lack of protection from potential abuse. Findings: Review of the facility's P&P titled Abuse, Neglect, and Exploitation revised 12/19/22, showed the facility will immediately investigate all reports of abuse to determine if abuse or mistreatment occurred, as well as the extent. The Administrator will report the facility's investigation results within five working days of the incident. Review of the facility's SOC 341 dated 4/22/26, showed during a care conference with 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 PASRR Level 1 screening was performed prior to the resident's admission to the facility for one of two residents (Resident 10) reviewed for PASRR. * The facility failed to ensure the PASRR Level 1 screening was performed prior to Resident 10's admission to the facility. This failure posed the risk for inappropriate placement in a long-term care nursing home and if a PASRR Level II Mental Health Evaluation was required, the facility subsequently could not provide the resident with the necessary recommended specialized mental health service.Findings: Medical record review for Resident 10 was initiated on 4/20/26. Resident 10 was admitted to the facility on [DATE]. Review of Resident 10's H&P examination from Hospital 1 dated 2/27/26, showed Resident 10 had a past medical history of depression and psychoactive substance abuse. Review of Resident 10's medical record showed Resident 10 was admitted to the facility from Hospital 1 on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to meet the resident care needs for five of 35 final sampled residents (Residents 19, 49, 87, 129 and 179). * The facility failed to conduct quarterly care conference meetings and obtained the hospice plan of care for Resident 19. * The facility failed to ensure the insulin injection sites were rotated for Residents 49 and 129. * The facility failed to ensure Resident 87's neurological assessment was complete after Resident 87 had an unwitnessed fall on 4/7/26. * The facility failed to obtain and document the measurements of Resident 179's wound on the initial assessment when Resident 179 sustained an abrasion and large hematoma on her right anterior shin during a staff assisted transfer from her bed to her wheelchair. In addition, the facility failed to obtain and document the measurements of Resident 179's wound on the weekly wound assessments. These…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and the facility P&P review, the facility failed to ensure the necessary care and services were provided for two of eight final sampled residents (Residents 20 and 28) reviewed for weight loss. * The facility failed to ensure the physician was informed of Resident 20's weight loss of 5.19 % in one month. * The facility failed to ensure the RD recommendation for weekly weight for four weeks was followed when Resident 28 had a significant weight loss of 11.8% in six months. These failures had the potential for Residents 20 and 28 to not receive the necessary intervention to prevent further weight loss.Findings: Review of the facility's P&P titled Weight Management Policy revised on 11/1/24, showed the interventions will be identified, implemented, monitored, and modified (as appropriate), consistent with the resident's assessed needs, choices, preferences, goals and current professional standards to maintain acceptable parameters of nutritional status. 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, and medical record review, the facility failed to ensure the appropriate care and services for the use of GT for one of two final sampled residents (Resident 5) reviewed for GT care. * The facility failed to ensure Resident 5's enteral feeding formula bottle was labeled with the start time. This failure had the potential for Resident 5 to receive outdated GT feeding formula and posed a risk for complications related to use of the GT.Findings: Medical record review for Resident 5 was initiated on 4/20/26. Resident 5 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 5's Order Summary Report dated 4/23/26, showed a physician's order dated 9/12/25, to administer the enteral feeding of Peptamen 1.5 (a type of enteral feeding formula) at the rate of 50 ml per hour; to start the feeding at 1200 hours until 1000 ml have infused. On 4/20/26 at 0827 hours, Resident 5 was observed lying in bed and the GT feeding was observed infusing Peptamen 1.5 at 50…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to maintain the IV accesses for one final sampled resident (Resident 159) and one nonsampled resident (Resident 37) who had peripheral IV access. * The facility failed to ensure Resident 37's peripheral IV access was labeled with the date, time, and licensed nurse's initials when it was inserted and discontinue when not in used. *The facility failed to ensure Resident's 159's peripheral IV access was assessed after the completion of intravenous therapy and discontinued when not in use. These failures posed the risk of the residents developing complications related to the use of the peripheral IV catheter.Findings: Review of facility's P&P titled Intravenous Therapy revised 12/19/22, showed the facility will adhere to accepted standards of practice regarding infusion practices. IV sites are changed every seventy-two (72) hours unless otherwise ordered by the physician, if…

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

Based on observation, interview, medical record review, and facility document review, the facility failed to provide the necessary pharmaceutical services to ensure for an accurate reconciliation of the controlled medications in one of two medication carts reviewed for controlled medication reconciliation. * The facility failed to ensure the controlled medication count during the change of shift was completed and the Controlled Drugs - Count Record was signed by two licensed nurses. These failures had the potential for inaccurate reconciliation, and drug diversion of the controlled medications.Findings: On 4/20/26 at 0625 hours, an interview and concurrent facility record review was conducted with RN 5. Review of Controlled Drugs - Count Record for April 2026 of Station C, Cart D showed the Nurse On 3-11 shift (PM shift) and Nurse Off 3-11 shift was not signed on 4/19/26. RN 5 verified the Review of Controlled Drugs - Count Record for April 2026 had missing entry and stated there should be a two license nurses signature during the change of shift to indicate the controlled drug…

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

Based on observations, interviews, and facility P&P review, the facility failed to ensure the facility food was appetizing and palatable for two of 155 residents (Residents 138 and 139) who received food prepared in the facility kitchen. * The facility failed to ensure Residents 138 and 139 received food that was appetizing and palatable. This deficient practice had the potential to impact the residents' nutritional status, and not meet the residents' desires to be served food they felt was palatable and attractive.Findings: Review of the facility's P&P titled Standardized Menus revised on 12/19/22, showed the facility shall provide nourishing, palatable meals to meet the nutritional needs of the residents based on the Recommended Daily Allowances of the Food and Nutrition Board of the National Research Council. On 4/20/26 at 0635 hours, during the initial tour of the facility, an interview was conducted with Resident 139. Resident 139 stated the food was terrible. On 4/20/26 at 0830 hours, during the initial tour of the facility, an interview was conducted with Resident 138.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 accommodate the drink preferences for one of one resident (Resident 49) reviewed for hydration. * The facility failed to ensure Resident 49 was provided with 120 ml of cranberry juice as listed in Resident 49's meal ticket. This failure had the potential to affect Resident 49's overall meal intake and hydration status.Findings: Review of the facility's P&P titled Fluid Restriction revised 12/19/22, showed the fluid restriction distribution will take into consideration the amount of fluid to be given at mealtimes, snacks, and medication passes. Medical record review for Resident 49 was initiated on 4/20/26. Resident 49 was admitted to the facility on [DATE]. Review of Resident 49's H&P examination dated 8/6/25, showed Resident 49 had the capacity to understand and make decision and the diagnoses included ESRD and on hemodialysis. Review of Resident 49's Order Summary Report dated 4/22/26, showed a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medical record for one of 35 final sampled residents (Resident 49) and one nonsampled resident (Resident 97) were complete and accurately documented. * The facility failed to ensure Resident 49's blood pressure access site was accurately documented in the resident's medical record. * The facility failed to ensure Resident 97 's blood pressure access site was accurately documented in the medical record. These failures have the potential for the residents' care needs not being met as their medical information was inaccurate and incomplete.Findings: 1. Review of the facility's P&P titled Hemodialysis revised 6/5/23, showed this facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences, to meet the special medical, nursing, mental, and psychosocial…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 services related the resident discharge for one of seven sampled residents (Resident 1). * The facility failed to ensure Resident 1 was assessed by the physician and deemed safe to be discharged to a board and care facility. In addition, the facility failed to ensure Resident 1 had an order for discharge. This failure posed a risk for unsafe discharge and had the potential to negatively affect the resident's well-being. Findings: Review of the facility's P&P titled Transfer or Discharge (including AMA) revised 12/19/22, showed the physician shall document medical reasons for transfer or discharge in the medical record, when the reason for transfer or discharge is for any reason other than nonpayment of the stay or the facility ceasing to operate. A copy of the physician's order for discharge should be attached to the discharge notice. For a community discharge, a discharge summary and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure documentation for one of three sampled residents (Resident 1) was accurate and maintained within accepted professional standards and practices. * Multiple entries in Resident 1's nursing progress notes incorrectly indicated he was able to verbalize, communicate his needs, and was oriented, despite Resident 1 being nonverbal and having severe cognitive impairment. * Nursing care was documented as being provided to Resident 1 after he had been discharged from the facility. This failure posed the risk for changes in Resident 1's condition to be missed, miscommunication between care providers, and for Resident 1 to receive incorrect treatment.Findings: Review of the facility's P&P titled Documentation in Medical Record revised 12/19/22, showed documentation should be factual, accurate, and reflect objective information based on first-hand knowledge of the assessment. Closed medical record review for 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 a baseline care plan was developed and implemented within 48 hours of admission for one of three sampled residents (Resident 1). * The facility failed to develop and implement a baseline care plan that addressed pressure injuries and wounds for Resident 1, who was admitted with pressure ulcers and other wounds. * The facility incorrectly created a baseline nutritional care plan that included interventions to feed Resident 1 who was not able to take in nutrition or liquids by mouth and was dependent on enteral tube feedings for his nutritional and hydration needs. These failures posed the risk for Resident 1 not to receive the necessary treatment and services to meet Resident 1's individualized care needs and for Resident 1 to potentially suffer harm due to incorrectly rendered care.Findings: Review of the facility's P&P titled Baseline Care Plan revised 12/29/22, showed the facility will develop and implement a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility P&P review, the facility failed to provide the necessary pharmaceutical services for one of six sampled residents (Resident 2). * Resident 2 did not receive the medication as ordered by the physician. This failure posed the risk of Resident 2 receiving unnecessary medication and negative health consequences.Findings: Review of facility's P&P titled Medication Administration revised 12/19/22, showed the medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, with compliance guidelines to include: obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters. Medical record review for Resident 2 was initiated on 1/16/26. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's H&P examination dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 document review, the facility failed to ensure the social worker was qualified to fulfill the job responsibilities and role. * The facility social worker did not have a minimum of a bachelor's degree in social work or a bachelor's degree in a human services field including but not limited to sociology, gerontology, special education, rehabilitation counseling, and psychology. This failure has the potential to jeopardize the health and well-being of 196 residents who required care and psychosocial needs in the facility.Findings: Review of the facility's job description for Social Services Director (undated) showed all facilities must provide medically-related social services to residents. Any facility with more than 120 beds must employ a qualified social worker on a full-time basis. The social services department must be directed by a qualified professional social worker who has a minimum of a bachelor's degree in social work or another human services field to include, but not limited to, sociology, gerontology, special education, rehabilitation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 identification, reporting, and investigation was completed when one of three sampled residents (Resident 1) reviewed for abuse, reported two abuse allegations against another resident. * On 11/16/25, Resident 1 alleged Resident 2 was going to hit her, resulting in Resident 1 feeling threatened, scared, and unsafe. Resident 1 reported the alleged incident to facility staff. * On 11/26/25, Resident 1 alleged Resident 2 threatened to cut her into pieces, resulting in Resident 1 feeling threatened and unsafe. Resident 1 reported the alleged incident to facility staff. These failures of the facility to identify, report, and investigate Resident 1's allegations of abuse posed the risk for resident-to-resident abuse to occur in a highly vulnerable population.Findings: Review of the facility's P&P titled Abuse, Neglect, and Exploitation revised 12/19/22, showed it is the policy of the facility to provide protections 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 P&P review, the facility failed to provide reasonable care for the protection of resident's personal property from loss or theft for one of seven sampled residents (Resident 4). * Resident 4's personal belongings form was not signed by Resident 4, and the form was not accurately completed. This failure had the potential for the resident's property to get lost or stolen.Findings: Review of the facility's P&P titled Resident Personal Belongings revised 12/19/22, showed all the resident's personal items will be inventoried at the time of admission by the Social Services designee or another designated staff member and documentation shall be retained in the medical record. Medical record review for Resident 4 was initiated on 9/4/25. Resident 4 was admitted to the facility on [DATE]. Review of Resident 4's H&P examination dated 3/4/25, showed the resident had the capacity to understand and make decisions. Review of Resident 4's Resident's Clothing and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure the discharge process was properly followed for one of tree sampled residents (Resident 1). * The failed to ensure Resident 1's medical record showed the physician's documentation indicating the resident's health improved sufficiently and ready to be discharged from the facility. This failure had the potential for Resident 1 to unsafely discharge from the facility. Findings: Review of the facility's P&P titled Transfer or Discharge (including AMA) revised 12/19/22, showed the physician shall document medical reasons for the transfer or discharge in the medical record, when the reason for transfer or discharge is for any reason other than nonpayment of the stay or the facility ceasing to operate. A copy of the physician's order for discharge should be attached to the discharge notice. Medical record review for Resident 1 was initiated on 8/14/25. Resident 1 was admitted to the facility on [DATE]. Review of Resident…

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

Based on observation, interview, and manufacturer document review, the facility failed to maintain the essential equipment in the safe operating conditions when:* The facility failed to maintain three of three ice machines in sanitary working condition.* The facility failed to ensure the manufacture specifications were followed for one of three ice machines. These failures had the potential to cause contamination of ice in a highly vulnerable population of 145 residents who received ice from the ice machines.Findings: Review of the Diet Count by Diet report completed by the facility on 7/15/25, showed 145 residents in the facility received an oral diet. Review of the USDA Food Code 2022, Section 4-501.11, Good Repair and Proper Adjustment showed equipment shall be maintained in a state of good repair and sanitary working condition. Review of the USDA Food Code 2022, Section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. A. Equipment, food contact surfaces and utensils shall be clean to sight and touch. 1.a. On 7/15/25 at 1033 hours, an observation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 accurate, complete, and the measurements were recorded during the bed inspection when identifying areas of possible entrapment with the use of bed side rails for seven of 10 final sampled residents (Residents 35, 36, 49, 51, 85, 122, and 153) and one nonsampled resident (Resident 146) reviewed for siderails. * The facility failed to ensure the residents' entrapment assessments were accurately completed for Residents 35, 36, 49, 51, 122, and 153. * The facility failed to ensure Residents 85 and 146 's bilateral grab bars bed entrapment assessment was accurate and completed. 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…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of five final sampled residents (Resident 89) was free from the unnecessary psychotropic drugs (any drug that affects brain activity associated with mental processes and behavior).* The facility failed to ensure non-pharmacological interventions were implemented for the depression and behaviors exhibited by Resident 89. This failure had the potential to place the residents at risk of receiving unnecessary medications and an increased risk of serious medication adverse reactions. Findings: Review of the facility's P&P titled Use of Psychotropic Medication use revised 3/17/25, showed in part, a psychotropic drug is any drug that affects the brain activities associated with the mental processes and behavior, which includes the antipsychotics, anxiolytics, hypnotics, and antidepressants . non pharmacological interventions must be attempted unless contraindicated to minimize the need for psychotropic medication, use…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 send a copy of the notice of discharge to the representative of the Office of the State Long Term Care Ombudsman for one of three sampled residents (Resident 194) reviewed for closed records. This failure posed the risk of the LTC (Long term Care) Ombudsman not being aware of the circumstances of the resident's transfer/discharge should the resident and their representative believe the transfer or discharge was inappropriate or involuntary. Findings: Review of the facility's P&P titled Transfer and Discharge (including AMA) revised 12/19/22, showed the facility will maintain evidence that the notice was sent to the Ombudsman. For Non-Emergency Transfers or Discharges - initiated by the facility, return not anticipated .(b.) Provide transfer/discharge notice to the resident/representative and Ombudsman as indicated. Closed medical record review for Resident 194 was initiated on 7/15/25. Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to ensure a comprehensive care plan was developed for one of 35 final sampled residents (Resident 86).* Resident 86's care plan specific to oxygen administration failed to include the oxygen administration parameters. The nursing staff failed to attempt to administer the lowest amount of oxygen required to maintain Resident 86's oxygen saturation level at 92 % or greater, in accordance with the physician's order. This failure placed the resident at risk for not being provided appropriate, consistent, and individualized care. Findings: Medical record review for Resident 86 was initiated on 7/15/25. Resident 86 was admitted to the facility on [DATE]. Review of Resident 86's physician's order dated 6/18/25, showed an order for oxygen to be administered at two liters per minute via nasal cannula, may titrate (oxygen rate) to maintain an oxygen saturation greater than or equal to 92%. On 7/15/25 at 1050 hours, an observation and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure necessary care and services were provided to two out of 35 final sampled residents (Residents 85 and 195). * The facility failed to ensure Resident 85's Infectious Disease Physician's recommendation dated 5/17/25, for an urgent MRI of the right hip was communicated to the ordering Physician and arranged in a timely manner. * The facility failed to ensure Resident 195's Intake and Output (I&O) were documented. These failures had the potential to affect Resident 85 and 195's well-being. Findings: 1. Review of the facility’s P&P titled Provision of Physician Ordered Services dated 5/15/23, showed for Diagnostic tests: a.) Facility will maintain a schedule of diagnostic tests in accordance with physician’s orders. b.) Qualified nursing personnel will submit timely requests for physician ordered services (laboratory, radiology, consultations) to appropriate entity. c.) Qualified nursing personnel will receive the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the development and worsening of pressure injuries and promote the healing of existing pressure injuries four of five final sampled residents (Residents 28, 98, 122, and 131) reviewed for pressure injuries. * The facility failed to ensure the low air loss (LAL) mattress setting was consistent with the residents' weight. This had the potential for the residents to not receive the appropriate care and services to promote healing or prevent the development and worsening of pressure injuries. Findings: 1. Review of the facility P&P titled Use of Support Surfaces revised date 9/12/23, showed support surfaces will be chosen by matching the potential therapeutic benefit with the resident’s specific situation. Further review of the P&P showed support surfaces will be utilized in accordance with manufacturer recommendations. Considerations for utilizing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 treatment was provided to prevent the decline in the ROM functions for one of six final sampled residents (Resident 5) reviewed for ROM functions.* The facility failed to ensure the physician's orders to apply the left AFO and bilateral elbow splints to Resident 5's extremities were followed. In addition, Resident 5's skin was not assessed when the left AFO and bilateral elbow splints were applied. This failure had the potential for Resident 5 to sustain a decline in ROM functions, leading to muscle atrophy (loss of muscle mass and strength) and decrease in functioning.Findings: Review of the facility's P&P titled Restorative Nursing Programs dated 12/19/22, showed the restorative care will be provided to help promote optimal safety and independence. The RNA was performed daily to the residents by maintaining a good body alignment and proper positioning. Residents identified during comprehensive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to prevent an accidents for one of four final sampled residents (Resident 4) reviewed for prevention of accident hazards. The facility failed to implement the floor mats on both sides of Resident 4's bed for safety, in accordance with the physician's order. This failure put the resident at high risk of serious injuries from a fall.Findings: Review of the facility's P&P titled Falls Prevention Program dated 12/19/22, showed the facility's fall prevention on all residents should be assessed for fall risk and receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. The fall interventions included to provide additional interventions as directed by the resident's assessment including assistive devices. During the initial tour of the facility on 7/15/25 at 0816 hours, Resident 4 was observed in bed with the bed in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the appropriate care and services to prevent UTIs for three of three final sampled residents (Residents 12, 63, and 89) reviewed for the use of indwelling urinary catheter (thin, flexible tube inserted into the bladder through the urethra to drain urine). * The facility failed to ensure the urinary catheter tubing was not touching the floor for Residents 12 and 63. * The facility failed to ensure indwelling urinary catheter care was provided as per the care plan to Resident 89. These failures had the potential for the residents to develop UTIs.Findings: 1. Review of the Centers for Disease Control and Prevention's article (undated) titled Catheter-Associated Urinary Tract Infection (CAUTI) showed a UTI is an infection in the urinary tract system (including the bladder and the kidneys). Germs can travel along the catheter, and if they enter the urinary tract, may cause an infection in the bladder or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility's P&P review, the facility failed to ensure the respiratory care and services were provided for six of nine final sampled residents (Residents 36, 54, 86, 89, 104, and 122) and two nonsampled residents (Residents 69 and 80).* The facility failed to ensure the oxygen was administered as per the physician's order for Resident 89. In addition, there was no documentation for the PRN administration of the oxygen and the reason why the oxygen was administered to Resident 89.* Resident 86 had a physician's order to administer continuous oxygen via a nasal cannula and to titrate the oxygen rate to maintain an oxygen saturation level of 92% or greater. Resident 86 received continuous oxygen therapy at a rate of six liters per minute via nasal cannula for approximately five hours. The facility failed to attempt to titrate the oxygen to a lower rate to maintain Resident 86's oxygen saturation level at 92% or greater. Additionally, the facility had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure dialysis care was provided for one of 35 final sampled residents (Resident 9).* The facility failed to assess Resident 9's dialysis access site (AV shunt) for a bruit and thrill every shift in accordance with the facility's P&P. This failure had the potential for the facility staff failing to identify impaired functionality of Resident 9's AV shunt, and posed the risk for negative health outcomes in the event Resident 9's dialysis access site was to become inoperable. Findings: Review of the facility's P&P titled hemodialysis revised 6/5/23, showed the nurse will ensure that the dialysis access site (e.g. AV shunt or graft) is checked before and after dialysis treatments and every shift for patency by auscultating for a bruit and palpating for a thrill. If absent, the nurse will immediately notify the attending physician, dialysis facility and/or nephrologist. Medical record review for Resident 9 was initiated on…

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

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 pharmacy services in accordance with the physician's orders and the facility's P&P for one of six residents (Resident 9) reviewed for unnecessary medications and three of four medication carts observed.* The facility failed to ensure Resident 9's scheduled morning medications were administered after Resident 9 had returned to the facility from his dialysis appointment.* The facility failed to ensure the narcotic log sheets were signed by the licensed nurses during the controlled medication reconciliation for Medication Carts A, B, and C.These failures had the potential for negative health outcomes and posed the risk for diversion of controlled medications.Findings: Review of the facility’s P&P titled Medication Administration revised 12/19/22, showed the medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 pharmacy services to ensure the proper storage and labeling of the residents' medications, for one of four medication rooms, two of eight medication carts, and one of 35 final sampled residents (Resident 1) and one nonsampled resident (Resident 171).* Resident 171's olanzapine (antipsychotic medication) medication bottle was labeled with the incorrect administration time. * The physician's order for ferrous sulfate liquid and the ferrous sulfate liquid supplement medication bottle label failed to show the prescribed dose to be administered to Resident 171.* The facility failed to ensure the orally administered medications were kept separate from externally used medications, e.g., eye drops and suppositories (medication given, inserted rectally or vaginally). * The facility failed to ensure the opened insulin (medication to lower down blood sugar level) pen or vial labeled with an open…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to ensure one sampled resident (Resident 93) received the appropriate consistent carbohydrate diet as ordered by the physician. This failure had the potential to cause elevation of the resident's blood sugar. Findings:On 7/15/25 at 1201 hours, Resident 93 was observed eating lunch in the first floor dining room. Review of Resident 93's meal ticket (used to identify the resident's diet and food preferences for meal service) showed Resident 93 required a consistent carbohydrate diet with no added salt (a diet intended to reduce blood sugar variations). Resident 93 had a blueberry streusel dessert on her meal tray.Review of the facility menu spreadsheet dated 7/15/25, showed the desert for the consistent carbohydrate diet for lunch was two pear halves, not blueberry streusel dessert.On 7/15/25 at 1201 hours, a concurrent interview and observation was conducted with LVN 6 who was in the dining room. LVN 6 verified Resident 93 was…

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

Based on observation and interview, the facility failed to ensure sanitary requirements were met in the kitchen as evidenced by: 1. Two of three ice scoop holders were not clean and one of three ice scoop holders contained standing water. 2. The plate cover rack was not clean. 3. More than ten plate covers did not have a smooth and cleanable surface. These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population of 145 who consumed food prepared in the kitchen and ice from the ice machines. Findings:Review of the facility document titled Diet Count by Diet report dated 7/15/25 showed, 145 of 180 residents in the facility received food prepared in the kitchen. 1. Review of the USDA Food Code 2022 Section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. A. Equipment, food-contact surfaces and utensils shall be clean to sight and touch. On 7/15/25 at 1056 hours, a concurrent interview and observation of the ice machine scoop holders located in the first floor ice machine room was conducted with 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, facility document review, and facility P&P review, the facility failed to implement a safe food handling policy to ensure outside foods brought into the facility for residents by visitors were properly prepared and stored for safe consumption. * The facility failed to ensure the residents' foods inside Refrigerator A were labeled with the residents' names. * The facility failed to provide specific documentation on Resident 49's care plan addressing the problem of risk on storage of food in Resident 49's restroom bathtub. * The facility failed to ensure the facility's P&P for the use and storage of foods brought in by the family or visitors included any food safety related concerns such as time and temperature control and safe food handling and preparation. These failures had the potential to result in foodborne illnesses in a highly susceptible resident population.Findings: 1. On 7/15/25 at 1021 hours, an observation and concurrent interview was conducted with the IP. An…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and facility document review, the facility failed to ensure the Facility Assessment addressed or included the following: 1. Active involvement of required individuals in developing the Facility Assessment;2. A plan to maximize recruitment and retention of direct care staff; and3. A contingency plan for staffing needs.This failure had the potential to not meet the residents' care needs if the assessed population's needs and resources were not comprehensively identified and addressed. Findings:According to the CMS QSO-24-13-NH dated 6/18/24, with an implementation date of 8/8/24, CMS had issued a revised guidance for long-term care facility assessment requirement. The Facility Assessment should address and included the active involvement of the direct care staff in developing the Facility Assessment. Also included the staffing resources necessary to care for the residents, including the weekends; a plan to maximize recruitment and retention of direct care staff member, and a contingency plan 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 observation, interview, and facility P&P review, the facility failed to implement the infection control practices designed to provide a safe and sanitary environment and help prevent the development and transmission of diseases and infections.* The facility failed to ensure the soiled laundry was not stored in the clean laundry area.* The facility failed to ensure the facility staff performed hand hygiene before and after wearing gloves during the wound treatment observation for one nonsampled resident (Resident 120).* The facility failed to ensure the appropriate transmission-based precaution door signage was placed for one final sampled resident (Resident 162).These failures had the potential for cross-contamination and spread of infectious organisms in the facility. Findings:1. Review of the facility’s P&P titled Handling Soiled Linen dated 12/19/22, showed it is the policy of the facility to handle, store, process, and transport linen in a safe and sanitary method to prevent the spread of infection.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, facility document review, and facility P&P review, the facility failed to accurately monitor and address the use of the antibiotics when the resident's condition did not meet the McGeer's criteria (a set of criteria used in long term care facilities to identify if residents' symptoms meet the criteria of a true infection) or Loeb minimum criteria (a set of minimum clinical criteria used to guide the initiation of antibiotic therapy for suspected infections in residents of long term care facilities) for one of five final sampled residents (Resident 89) reviewed for antibiotic stewardship. This failure had the potential risk for continued use of unnecessary antibiotics, potentially resulting in adverse reactions associated with antibiotics and the development of antibiotic resistant bacteria. Findings: Review of the facility's P&P titled Antibiotic Stewardship Program revised 12/19/22, showed it is the policy of the facility to implement an Antibiotic Stewardship Program as part of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the necessary pharmacy services were provided to 16 of 16 sampled residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, and 16) when the medications were not provided within their prescribed time. This failure had the potential for negative health outcomes to the residents. Findings: Review of the facility's P&P titled Medication Administration dated 12/19/22, showed the medications are administered within 60 minutes of scheduled time unless otherwise ordered by the physician. Review of the facility's document titled Medication Administration Times (undated) showed the medications are scheduled to be administered as follows: - daily, administer at 0900 hours; - twice a day, administer at 0900 and 1700 hours; - three times a day, administer at 0900, 1300, and 1700 hours; - bedtime, administer at 2100 hours; - four times a day, administer at 0900, 1300, 1700,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided for one of three sampled residents (Resident 1). * The facility failed to ensure Resident 1's IV and oral fluid intakes were monitored and recorded. This failure had the potential for Resident 1 to have fluid overload, which had the potential to negatively impact the resident's well-being. Findings: Review of the facility's P&P titled Intake and Output Policy dated December 2024 showed the intake and output may be recorded when the following conditions exist or upon the order of the physician. a. Indwelling urinary catheter - all residents who have a newly inserted catheter and new admit with indwelling catheter will have intake and output recorded for 30 days. After 30 days, they will be evaluated to determine if intake and output needs to be continued. readmitted residents who have chronic indwelling catheters will have intake and output recorded for 7 days. After 7…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to ensure one of seven sampled residents (Resident 6) attained and maintained the highest practicable physical well-being. * The facility failed to ensure the physician was timely notified of Resident 6's change in condition. This failure posed the risk for Resident 6 to not receive the necessary care and services to maintain the resident's highest physical well-being. Findings: Review of the facility's P&P titled Notification of Changes dated 12/19/22, showed the facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring notification include significant change in the resident's physical, mental, psychosocial condition such as deterioration in health, mental or psychosocial status this may include life threatening conditions, or clinical complications. Review of the facility's P&P titled Medical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the development of pressure injuries for two of seven sampled residents (Residents 4 and 6). * The licensed nurse failed to assess and manage Resident 4's pain when providing the wound care treatment. * The facility failed to develop a care plan problem to address Resident 6's MASD to the bilateral buttocks extending to sacrococcyx (base of the spine and tailbone), which had deteriorated to a sacrococcyx unstageable pressure injury. In addition, there was no care plan problem developed to address Resident 6's purplish nonblanchable (skin abnormality when the skin does not turn white when pressed) area to the right heel. These failures had the potential for not providing the necessary care and services and effectively managing the residents' needs. Findings: Review of the facility's P&P titled Pressure Injury Prevention and Management dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 maintain the infection control program and practices designed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections as evidenced by: * The facility failed to ensure Resident 5 had a physician's order for contact precautions related to Klebsiella pneumoniae ESBL (Extended-Spectrum Beta-Lactamase, a bacterium that produces enzymes that make it resistant to many antibiotic). In addition, the facility failed to ensure the facility staff were informed of the resident's contact precautions. * The facility failed to ensure Room B (EBP room) had a trash can inside the resident room and near the exit for discarding PPE after removal as per the facility's policy. These failures had the potential for the spread of infections in the facility. Findings: 1. Review of facility's P&P titled Transmission-Based (Isolation) Precautions revised 7/18/23,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to implement their P&P to ensure the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act when the facility failed to immediately report an allegation of sexual abuse to the CDPH, L&C Program, Long Term Care (LTC) Ombudsman office, and local law enforcement agency within two hours after the allegation was made for one of three sampled residents (Resident 1). This failure had the potential to delay the investigation of the alleged abuse and for staff to no take prompt and appropriate corrective actions to prevent the abuse. Findings: Review of the facility's P&P titled Abuse, Neglect and Exploitation revised on 12/2022 showed reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the reasonable accommodations to meet the needs of two of 12 sampled residents (Residents 9 and 12). * Resident 12 was observed lying in bed without his call light in reach. * Resident 9 was observed lying in bed callingout repeatedly for water and without his call light in reach. These failures had the potential for their care needs to go unmet. Findings: Review of the facility's P&P titled Call Lights: Accessibility and Timely Response revised 12/19/2022,showed the staff will ensure the call light is within reach of the resident and secured as needed. a. Medical record review for Resident 12 was initiated on 5/14/23. Resident 12 was admitted to the facility on [DATE]. Review of Resident 12's H&P examination dated 5/16/23, showed Resident 12 had the capacity to understand and make medical decisions. Review of Resident 12's MDS dated [DATE], showed Resident 12 had severe cognitive impairment. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary services to attain or maintain the highest practicable well-being for two of 12 sampled residents (Residents 1 and 10). * The facility failed to ensure Resident 1 did not exceed the maximum hours for her therapeutic leave as ordered by the physician. In addition, the facility failed to notify the physician that Resident 1 was staying out longer than ordered during her therapeutic leave. * The facility failed to ensure Resident 1 was assessed upon leaving and/or returning to the facility and the Release for Temporary Absence sign-in and sign-out sheets were completed each time Resident 1 left and returned from her therapeutic leave. * The facility failed to ensure Resident 10 was assessed upon leaving and returning to the facility from his therapeutic leave. In addition, the facility failed to ensure the Release for Temporary sign-in and sign-out sheet was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the infection control practices designed to provide a safe and sanitary environment were followed for three of 12 sampled residents (Resident 5, 6, and 7). * The facility failed to ensure the ESP was practiced related to the PICC line for Resident 6 and GT for Residents 5, and 7. This failure had the potential to result in the spread of infection to the residents in the facility. Findings: Review of the facility's P&P titled Enhanced Barrier Precautions revised 4/22/24, showed it was the facility's policy to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. The P&P also showed enhanced barrier precautions/enhanced standard precautions were indicated for residents with chronic wounds and/or indwelling medical devices such as central lines, hemodialysis catheters, urinary catheters, feeding tubes, tracheostomy tubes, 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 infection control practices were maintained. * The staff failed to perform hand hygiene during care provided to two of two sampled residents (Residents 1 and 3). * The facility failed to ensure proper handling, storing, processing, and transporting of the linens to prevent the spread of infection. * CNA 5 failed to perform hand hygiene when leaving an Enhanced Precaution room and touched clean linen with their soiled gloves. These failures had the potential to result in the spread of infection to the residents. Findings: 1. Review of the facility's P&P titled Hand Hygiene Policy revised 12/2024 showed all staff will perform proper hand hygiene procedures to prevent spread of infection to other personnel, residents and visitors, the use of gloves does not replace hand hygiene, if a task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. Hand…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 maintain an accurate and complete medical record for one of seven sampled residents (Resident 1). This failure posed the risk for changes in Resident 1's health condition not being identified and delay in necessary care and treatment. Findings: Review of the facility's P&P titled Documentation in Medical Record revised 12/2022 showed each resident's medical record shall contain a representation of the experiences of the resident and include enough information to provide a picture of the resident's progress. The P&P further showed documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care and/or responses to care. Closed medical record review for Resident 1 was initiated on 3/12/24. Resident 1 was admitted to the facility on [DATE], and transferred to the acute care hospital on 4/9/23. a. Review of Resident 1's eINTERACT Change in Condition Evaluation dated 4/9/23 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to maintain the infection control practices to help prevent the transmission of diseases and infections. * The facility failed to ensure the housekeeping staff performed hand hygiene practices after removing the gown and glove and leaving room [ROOM NUMBER] (a Covid isolation room). * The facility failed to ensure CNA 4 wore the appropriate PPE when providing care for one of 11 nonsampled residents (Resident 9) who was on the enhanced barrier precautions. These failures posed the risk of infection and the transmission of disease-causing microorganisms. Findings: 1. Review of the facility's P&P titled Hand Hygiene revised 12/19/22, showed all staff will perform hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Hand hygiene is defined as a general term for cleaning your hands by hand washing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 store the drugs, biologicals, and medical supplies in a safe manner as evidenced by: * The facility failed to ensure one of 11 medication carts (Medication Cart 3) were properly locked when left unattended. This failure had the potential for unauthorized personnel access to the residents' medications. * The facility failed to ensure the expired medications and opened IV medical supplies in Medication rooms [ROOM NUMBERS] and Medication Carts 1, 5, 6, 7, 8, 9, 10, and 11 were disposed of. This failure had the potential for the medications to be accidentally administered and/or used and the IV medical supplies not maintaining sterility (free from germs). * The facility failed to ensure the medication was not left at the resident's bedside for one of 35 final sampled residents (Resident 160). This failure had a potential for unauthorized use of medication. Findings: Review of the facility's P&P titled Medication Storage revised on…

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

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by: * The facility failed to ensure the cutting boards were kept in a sanitary condition and with cleanable surface. * The facility failed to ensure the scoops used for food portioning were air dried and clean prior to storing. * The facility failed to ensure the kitchen utensils had a smooth cleanable surface and were in good conditions. * The facility failed to ensure the kitchen utensils were clean and free of food particle or residue. These failures had the potential to cause foodborne illnesses for the residents in the facility. Findings: Review of the facility's census and verified by the DON and ADON on 10/30/23, showed 145 of 180 residents in the facility received food prepared in the kitchen. 1. Review of the facility's P&P titled Dish and Utensil Procedure revised date 3/3/20, showed the cutting boards need to be washed and sanitized between each use. Replaced cutting boards once lined with knife…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and maintain their infection control program as evidenced by: - The facility failed to implement their infection control surveillance program from July through September 2023. The facility conducted surveillance of the residents' infections based on whether the residents were prescribed the antimicrobial medications. The facility failed to determine whether the residents who were not prescribed antimicrobial medications met the facility's criteria for infection (utilizing McGeer's Criteria) and thus failed to include these residents in facility's infection control surveillance program. * The facility failed to ensure to practice infection control before giving back the contaminated call light to Resident 61. This failure has the potential to cause infections. * The facility failed to offer hand hygiene after meals to Residents 3 and 145. * The facility failed to ensure the staff performed hand hygiene between medication routes during the medication pass observation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interview, and facility P&P review, the facility failed to ensure the residents' entrapment assessments were accurate, complete including the measurements during the bed inspection when identifying areas of possible entrapment with the use of bed side rails for seven of 35 final sampled residents (Residents 38, 79, 104, 123, 142, 146, 161, and 528). 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,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure two of 35 final sampled residents (Residents 58 and 152) were assessed to determine if the residents were safe to self-administer their medications prior to self-administering their medications. * The facility failed to ensure Resident 152 was assessed to safely self-administer ProAir HFA Aerosol Solution (Albuterol Sulfate-medication to help control symptoms of lung diseases). * The facility failed to ensure Resident 58 did not have multiple bottles of medications at bedside. These failures had the potential to negatively impact the residents' physiological well-being, and posed the risk of inaccurate medication administration. Findings: Review or the facility's P&P titled Resident Self-Administration of Medication revised 12/19/22, showed a resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely. 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, medical record review, and facility P&P review, the facility failed to provide the reasonable accommodations to meet the needs for three of 35 final sampled residents (Residents 85, 104, and 109) and one nonsampled residents (Resident 94). * The facility failed to ensure the call lights for Residents 85, 94, 104, and 109 were within the residents' reach. This failure had the potential to negatively impact the residents' physical and psychosocial well-being or would result in delayed provision of care. Findings: Review of the facility's P&P titled Call Lights: Accessibility and Timely Response dated 12/19/22, showed staff will ensure the call light is within reach of resident and secured, as needed. The call system will be accessible to the residents while in their bed or other sleeping accommodations within the resident's room. 1. On 10/23/23 at 0941 hours, Resident 94 was observed lying in bed. The call light was observed to be clipped onto his privacy curtain and not visible. Resident 94 stated he was not able to find the call light. CNA 1 verified…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 privacy for one of 35 final sampled residents (Resident 109) was provided during care. This failure had the potential to violate the resident's right to privacy. Findings: Review of the facility's P&P titled Promoting/Maintaining Resident Dignity dated 12/2022 showed all staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident's rights. Maintain resident privacy. During an observation on 10/23/23 at 1203 hours, Resident 109's room door was closed. Upon entering, Resident 109 was seen fully exposed lying in bed as LVN 3 and CNA 5 were performing care. The privacy curtains were not observed to be drawn. Resident 109's two roommates were observed awake in their wheelchairs and able to see Resident 109 fully exposed in bed. On 10/23/23 at 1203 hours, an interview was conducted with CNA 5. CNA 5 stated LVN 3 was doing a treatment and forgot to close the privacy curtains when they were getting Resident 109 ready for the treatment. CNA 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to protect one nonsampled resident's (Resident 145) right to be free from verbal abuse by another resident (Resident 173). This had the potential for negatively impact Resident 145's well-being. Findings: Review of the facility's P&P titled, Abuse, Neglect and Exploitation dated 12/2022 showed the facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves the identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect. The facility will make efforts to ensure all resident are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation, examples include room or staffing changes, if necessary to protect the resident(s) from the alleged perpetrator. On 10/25/23 at 0849 hours, an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 35 final sampled residents (Resident 159) and one nonsampled residents (Resident 83) were free from physical restraints. * The facility failed to conduct an assessment and implement the least restrictive measures prior to applying a mitten (mitten which look like boxing gloves with a Velcro or tie at the wrist to hold them in place and immobilize the resident's fingers) to Resident 159's left hand. In addition, the facility failed to ensure the mitten was released every two hours as per the resident's care plan. * The facility failed to ensure Resident 83's right hand mitten use was monitored and released every two hours as per the resident's care plan. These failures posed the risk of compromising the residents' independence and psychosocial well-being. Findings: Review of the facility's P&P titled Restraint Free Environment dated 12/2022 showed before a resident is restrained, the facility will…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 send a copy of the noticed of transfer/discharge to the representation of the Office of the State-Long Term (LTC) Ombudsman for two of 35 final sampled residents (Residents 66 and 144). This failure posed the risk of the LTC Ombudsman not being aware of the circumstances of the resident's transfer/discharge should an appeal be filed or requested by the resident or their representative regarding the transfer. Findings: Review of the facility's P&P titled Transfer and Discharge (including AMA) revised 12/2022 showed the facility's transfer/discharge notice will be provided to the resident and the resident's representative in a language and manner in which they can understand. The notice must be provided to the resident, resident's representative if appropriate, and the LTC ombudsman as soon as practicable before the transfer or discharge. The facility will maintain evidence that the notice was sent to the Ombudsman. 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 notify two of 35 final sampled residents (Residents 66 and 144) of their rights to a bed hold (holding or reserving a resident's bed while the resident in the acute care hospital) policy upon transfer to the acute care facility. This failure had the potential for Residents 66 and 144 or their representatives to be unaware of his rights to request a bed hold upon transfer. Findings: Review of the facility's P&P titled Bed Hold Notice Upon Transfer revised 12/2022 showed before a resident is transferred to the hospital or goes on therapeutic leave, the facility will provide to the resident and/or the resident representative written information that specifies: a. The duration of the state bed hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility; b. The reserve bed payment policy in the state plan policy if any. c. The facility policies regarding bed-hold period…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to develop the comprehensive plan of care to reflect the individual care needs of two of 35 final sampled residents (Residents 106 and 120). * The facility failed to develop a care plan problem to address Resident 106's weight loss. * The facility failed to ensure a care plan was developed to address Resident 120's MASD. These failures posed the risk of not providing appropriate, consistent, and individualized care to these residents. Findings: Review of the facility's P&P titled Comprehensive Care Plans revised 12/19/22, showed it is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. 1. Medical record review for Resident 106 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, facility document review, and facility P&P review, the facility failed to provide the necessary care and services to ensure two of 35 final sampled residents (Residents 528 and 146) attained and maintained their highest practicable well-being. * The facility failed to coordinate the care of Resident 528 with the contracted hospice. The hospice calendar and the sign-in/out forms did not show complete skilled nursing and CHHA visits were provided as per the physician's orders. In addition, the medication profile list, nursing clinical notes, and hospice aide notes were not updated. Furthermore, a hospice packet containing the Continuous Care Note, Continuous Care Documentation, Continuous Care Initiation Sheet, Hospice Aide Care Plan/Note, Plan of Care, Pain Inventory Scale, and Medication List was not available. * The facility failed to coordinate the care of Resident 146 with the contracted hospice. The hospice forms such as assessments and visit progress notes were not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of 35 final sampled residents (Resident 161) received appropriate services to meet their nutritional needs and maintain desirable weight. The facility failed ensure the physician was notified of the RD's recommendation for nutrition supplement to address the resident's weight loss. Resident 161 did not receive the nutrition supplement as recommended by the RD. This failure creaed the risk of not providing nutritional needs and poor health outcome for this resident. Findings: Review of the facility's P&P titled Weight Management Policy undated showed the facility utilizes a systemic approach to optimize a resident's nutritional status by identifying and assessing the nutritional status and risk factors, developing and consistently implementing pertinent approaches, and monitoring the effectiveness of interventions and revising them as necessary. Interventions will be implemented, monitored, and identified,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 two of 35 final sampled residents (Residents 527 and 177). * The facility failed to ensure the PICC line external catheter and arm circumference measurements were completed and documented in the medical record for Residents 527. * The facility failed to ensure Resident 177's midline IV (a type of peripherally inserted IV catheter) site was labeled with the date and the licensed nurse's initials to show when it was last changed These failures had the potential to delay the identification of catheter related complications for these residents. Findings: 1. Review of the facility's P&P titled Care and Maintenance of Central Venous Catheter dated 12/19/22, showed for central line catheters, to document the indication for use, insertion date, and type of catheter in the resident's medical record. The P&P also showed to obtain physician…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 35 final sampled resident (Resident 61) and three nonsampled residents (Residents 91, 108, and 141) were provided with the appropriate respiratory care when: * The facility failed to follow the physician's order for oxygen for Resident 91. * The facility failed to follow the physician's order for oxygen for Resident 108. In addition, the facility failed to ensure there was a humidifier attached to the oxygen machine, the nasal cannula was dated and labeled, and the nebulizer mask was stored properly. * The facility failed to ensure the oxygen tubing was labeled and oxygen and nebulizer tubing were not touching the floor for Resident 141. * The facility failed to ensure Resident 61's oxygen tubing was not touching the floor. These failures had the potential to affect the respiratory health and well-being of the residents in the facility. Findings: Review of the facility's P&P titled Oxygen…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 accurately record the change in the dialysis (a process of removing excess water solutes and toxins from the blood in people whose kidneys can no longer perform these functions naturally) days for one of 35 final sampled resident (Resident 151). This posed the risk for medical complications if Resident 151 missed the scheduled dialysis services. Findings : On 10/24/23 at 0900 hours, an observation and concurrent interview was conducted with Resident 151. Resident 151 was sitting in the bed and sorting papers in front of him. Resident 151 stated the dialysis schedule was changed to Mondays, Wednesdays, and Fridays. Resident 151 had missed the scheduled dialysis on Monday, 10/23/23, due to the late pickup. On 10/27/23 at 1408 hours, an interview was conducted with SSA 2. SSA 2 stated Resident 151's dialysis schedule was changed to Mondays, Wednesdays, and Fridays on 10/23/23. The scheduled dialysis days used to be Tuesdays,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 complete the assessments, attempt the least restrictive alternative measures, and obtain the physician's orders, and informed consents prior to the use of side rails for six of 35 final sampled residents (Residents 38, 79, 104, 142, 146, and 528). This failure had the potential to put the residents at risk for serious injuries. Findings: Review of the facility's P&P titled Proper Use of Bed Rails revised 12/19/22, showed the resident's assessment must include an evaluation of the alternatives that were attempted prior to the installation or use of a bed rail and how these alternatives failed to meet the resident's assessed needs. The resident assessment must also assess the resident's risk from using bed rails. The resident assessment should assess the resident's risk of entrapment between the mattress and bed rail or in the bed rail itself. Informed consent from the resident or resident representative must be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the narcotic disposition bin was securely locked. In addition, the facility failed to ensure the narcotic medication administration was accurately documented for one of 35 final sampled residents (Resident 151) and two of 13 nonsampled residents (Residents 16 and 165). * The facility failed to ensure the narcotic disposition bin was securely locked and sealed by the consultant pharmacist as per the facility's P&P. Furthermore, the narcotic disposition bin included whole pills of disposed narcotic medications not fully diluted. * The facility failed to ensure the narcotic medication administration accurately reflected on the eMAR for Residents 16, 151, and 165. These failures had the potential to result in medication diversion (the illegal use or distribution of a prescription medication that was not originally intended by the prescriber) and unsafe handling of the narcotic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the lack of non-pharmacological interventions prior to the use of psychotropic medication was identified during the monthly drug regimen review for two of 35 final sampled residents (Residents 85 and 126). This failure put Residents 85 and 126 at risk for receiving the unnecessary medications. Findings: The facility's P&P titled Use of Psychotropic Medication revised on 12/2022 showed a psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. Psychotropic drugs include, but are not limited to the following categories: antipsychotics, antidepressants, anti-anxiety, and hypnotics. The P&P also showed non-pharmacological interventions that have been attempted, and the target symptoms for monitoring shall be included in the documentation. Furthermore, the P&P showed residents who use psychotropic drugs shall also receive non-pharmacological…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 one of 35 final sampled residents (Resident 85) on anticonvulsant medications was monitored for seizure activity and side effects of the medication. This failure had the potential to cause poor health outcomes for Resident 85. Findings: Medical record review for Resident 85 was initiated on 10/24/23. Resident 85 was admitted to the facility on [DATE]. Review of Resident 85's H&P examination showed diagnosis of epilepticus (a seizure with five or more minutes of continuous electrographic seizure activity). Review of Resident 85's physician's order dated 4/21/23, showed divalproex sodium (anticonvulsant medication) 500 mg by mouth once daily for epilepsy (seizure disorder). Review of Resident 85's care plan titled The Resident Has a Seizure Disorder, Potential for Injury and Discomfort revised 6/16/23, showed a black box warning for divalproexs sodium included serious or fatal hepatotoxicity (liver damage). In…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure five of 35 final sampled residents (Residents 85, 106, 120, 123, and 126) were free from unnecessary psychotropic drugs (any drug that affects brain activity associated with mental processes and behavior). * Resident 85 who had diagnoses including dementia (a disorder which causes a progressive decline in memory and behavior that affects the ability to perform everyday activities) was prescribed quetiapine fumarate (antipsychotic medication) for schizophrenia disorder (mental illness that affects how a person thinks, feels, and behaves) manifested by combative during care and buspirone (mood medication) manifested by episodes of repetitive verbalization of concerns with care. There were no side effects monitoring for the use of quetiapine fumarate and buspirone medications. * The facility failed to ensure Resident 85's care plan for buspirone included non-pharmacological interventions. *…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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%. * LVN 8 failed to accurately follow a physician's order to flush the G-tube (a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications) before medication administration and between medications as ordered for Resident 146. * LVN 4 failed to follow a physician's order and provide education to Resident 59 prior to administration of Arnuity Ellipta Aerosol (inhaler medication). LVN 4 also failed to administer Resident 59's lactobacillus (probiotic medication) as ordered. These failures had the potential to cause negative outcomes for the residents. Findings: 1. The facility's P&P titled Enteral Tube Medication Administration dated 8/2014 showed enteral tubes are flushed with at least 15ml of water before administering medications and after all…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of 35 final sampled residents (Resident 106) was offered the pneumococcal vaccine (a vaccine given to protect the resident from pneumococcal disease) when he was eligible to receive, in accordance with current CDC guidelines and recommendations. This failure posed the risk of Resident 106 acquiring pneumonia. Findings: Review of the facility's P&P titled Pneumococcal Vaccine (Series) revised 9/2/22, showed it is our policy to offer our residents, staff, and volunteer workers immunization against pneumococcal disease in accordance with current CDC guidelines and recommendations. Further review of the facility's P&P showed for adults 19 to 64 years' old who have only received PPSV23: give 1 dose of PCV15 or PCV20. The PCV15 or PCV20 dose should be administered at least one year after the most recent PPSV23 vaccination. Medical record review for Resident 106 was initiated on 10/23/23. Resident 106 was readmitted 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 the facility's P&P, the facility failed to ensure the Quality Control Record for one Assure Platinum Glucometer (a device used to measure blood sugar levels) (Glucometer A) from one of 21 Medication Carts (Medication Cart 1) was completed accurately. This failure had the potential for residents requiring blood glucose checks to have inaccurate readings. Findings: Review of the facility's P&P titled Blood Glucose Monitoring revised 12/2022 showed calibration checks on glucometers must be performed as per the manufacture's instructions. Review of the facility's instruction manual titled Assure Dose Control Solution revised 5/2022 showed Assure Platinum Glucometer used a normal control solution (indicates blood glucose of about 80 mg/dL glucose) and high control solution (indicates blood glucose of about 250 mg/dL glucose) to verify the accuracy of blood glucose test results. The instruction manual showed results of the normal and high control solutions are tested with the test strip bottle and if results are within…

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