South Coast Global Medical Center D/P SNF

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below five percent. The facility's medication error rate was 7.69% * Resident 8 had a physician's order for amlodipine 5 mg daily via GT for hypertension (high BP). The order showed to hold the medication if Resident 8's SBP was less than 100 mmHg. However, the licensed nurse held the medication when Resident 8's SBP was not less than 100 mmHg. This failure to administer the antihypertensive medication in accordance with the physician's order had the potential to result in negative health outcomes. * Resident 8 had a physician's order for liquid potassium chloride 10 mEq daily via GT for hypokalemia. The licensed nurse failed to dilute the potassium chloride prior to administering the medication, in accordance with the label affixed to the medication. This failure to dilute liquid potassium chloride had the potential to cause severe stomach irritation and inhibit proper…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 two of four medication carts were clean. * Medication Carts A and B were observed with unclean containers. The unclean containers contained lancets, alcohol pads, insulin syringes, and a pill splitter. This failure to maintain the medication carts in a sanitary condition posed the risk for negative residents health outcomes.Findings: Review of the facility's P&P titled Infection Control Program and Surveillance dated 9/2025 showed the facility has developed and maintains an Infection Control Program that provides a safe, sanitary, and comfortable environment to help prevent the development and transmission of infections. 1. On 1/8/26 at 1245 hours, an inspection of Medication Cart A was conducted with LVN 5. The top drawer of Medication Cart A contained two plastic containers. The two plastic containers contained alcohol pads, lancets, and insulin syringes. The bottom of the containers were observed with brownish/blackish stains and an unknown brownish/blackish substance. LVN 5 verified 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 food safety and sanitation requirements were met in the kitchen. * The facility failed to ensure the proper labeling of food in the freezer. * 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 kitchen utensils were air-dried. * The facility failed to ensure the item in the kitchen was discarded after the use-by date. * The facility failed to ensure proper sanitary condition of the ice machine. These failures had the potential for exposure to food-borne illnesses for a medically vulnerable population.Findings: 1. According to FDA 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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medical record for one of 14 final sampled residents (Resident 5) was accurate. * The facility failed to ensure Resident 5's POLST was complete. This failure had the potential for the resident's care needs not being met as the medical information was inaccurate.Findings: Medical record review for Resident 5 was initiated on 1/5/26. Resident 5 was admitted to the facility on [DATE]. Review of Resident 5's Advance Directive Acknowledgement dated 10/24/22, showed Resident 5's responsible party selected yes to formulating an advance directive. Review of Resident 5's POLST dated 10/24/22, showed Resident 5' responsible party signed on the POLST on 10/24/22. Further review of the POLST showed under section D, showed the information regarding the advance directive was left blank. Review of Resident 5's H&P examination dated 10/13/25, showed Resident 5 had no capacity to understand and make decisions. Review of Resident 5's MDS assessment…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents' PHI was kept confidential for 27 residents. All 27 residents' PHI was displayed on a computer screen and left unattended by the staff member. This failure had the potential to violate the residents' rights to PHI privacy. Findings: Review of the facility's P&P titled Confidentiality of Medical Records revised 8/2023 showed all the information contained within the medical record belongs to the resident and will be kept confidential. Access will be restricted to the authorized users. The records will be viewed by the facility staff member only on a need to know basis. On 1/21/25 at 0914 hours, an ongoing observation was conducted in Hallway 1. A computer was observed with the computer screen displaying the names, dates of birth, and ages of all residents currently residing in the facility. The computer was observed unattended without a staff member nearby and multiple staff members were observed walking pass the computer. On 1/21/25 at 0919 hours, an interview and concurrent…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and facility document review, the facility failed to ensure the Facility Assessment addressed or included the following: 1. Active involvement of required individuals in developing the Facility Assessment; 2. Resources necessary to care for residents including weekends; 3. Include a plan to maximize recruitment and retention of direct care staff; and 4. Include a contingency plan for staffing needs. This failure placed the residents at risk for unmet care needs if their 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 issued a revised guidance for long-term care facility assessment requirement. The Facility Assessment should address and includes the active involvement of direct care staff in developing the Facility Assessment. Also includes the staffing resources necessary to care for the residents, including the weekends; a plan to maximize…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 three of three residents (two final sampled residents, Residents 2 and 27 and one nonsampled, Resident 17) reviewed for hospitalization 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 in writing. This failure had the potential for the residents and/or their representatives to be unaware of their rights to request a bed hold upon transfer. Findings: Review of the facility's P&P titled Bed Hold revised 7/2005 showed the residents will be informed upon admission of their right to have a bed hold in the event the resident must be transferred to an acute facility or during therapeutic leave. Under the Additional Policy Statements section, showed any resident to be transferred to an acute care facility or to go on a therapeutic leave will be offered a bed hold, which may be executed by the resident 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 P&P review, the facility failed to ensure the necessary respiratory care and services were provided for seven of 13 final sample residents (Residents 2, 6, 8, 18, 26, 27, and 28). * The facility failed to ensure Resident 18's Trach Bar (T-Bar) aerosol tubing set-up was labeled with the date. * The facility failed to ensure Resident 26's yanker was labeled with the opened date and changed per the facility's P&P; and failed to ensure the T-Bar aerosol set-up was labeled with the date. * The facility failed to ensure Resident 28's T-Bar aerosol tubing set-up was labeled with the date; failed to ensure the sterile water connected to the oxygen flowmeter was labeled with the opened date; and failed to ensure the yanker was changed per the facility's P&P. * The facility failed to ensure the suction canister (a container used in medical settings to collect and store bodily fluids, secretions, and other waste removed from a patient's body) and suction…

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

Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to implement their infection control program and practices designed to provide a safe and sanitary environment to help prevent the transmission of communicable disease and infections. * The facility failed to maintain an accurate infection control surveillance program for October 2024 through December 2024. The facility failed to ensure the Surveillance Data was complete and accurate to determine whether the resident's infection met the McGeer's criteria for true infection. * The facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the transmission of communicable diseases when one glucometer observed was not cleaned/disinfected per disinfecting wipes manufacturer's instructions. This failure had the potential for spreading serious blood-borne illness to residents who used shared glucometer. These failures have the potential risk for not identifying,…

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

Based on interview, facility document review, and facility P&P review, the facility failed to implement an antibiotic stewardship program to reduce the risk of unnecessary or inappropriate antibiotic use. Residents were being treated for conditions which did not meet the McGeer's criteria (a surveillance data collection tool used in long-term care facilities to identify if residents' symptoms meet the criteria of a true infection). This had the potential to expose the residents to unnecessary antibiotic use, which may increase the residents' risk for multidrug resistant organisms (MDRO, germs that are resistant to many antibiotics). Findings: According to the CDC, antibiotics are among the most frequently prescribed medications in nursing homes, with up to 70% of residents in a nursing home receiving one or more courses of systemic antibiotics over a year. Studies have shown that 40-75% of antibiotics prescribed in nursing homes may be unnecessary or inappropriate. Harms from antibiotic overuse are significant for the frail and older adults receiving care in nursing homes. 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.

Based on observation, interview, and facility P&P review, the facility failed to maintain a clean, safe, and homelike environment for one of 13 final sampled residents (Resident 26). Multiple dry and brown colored residues were observed on Resident 26's enteral feeding pump device. This failure had the potential to negatively impact the resident's safety and quality of life. Findings: Review of the facility's P&P titled Environmental Services/Infection Control reviewed 8/2023 showed nosocomial infections may occur as the result of exposure to contaminated surfaces, equipment, and other inanimate objects. Soil and dust should be removed from the surfaces with clean equipment and facility approved germicide. The Central Supply and Nursing Service will care for the equipment. If the equipment is left in the room, to notify the nursing unit. On 1/22/25 at 0757 hours, an observation was conducted in Resident 26's room. Resident 26's enteral feeding pump device was observed with multiple dry, brownish colored residue. Resident 26's enteral feeding was observed off. On 1/22/25 at 1116…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 notify the resident and/or their representative of the transfer/discharge and the reasons for the transfer in writing for one of three final sampled residents (Resident 2) reviewed for hospitalization. This failure had the potential for the resident and/or their representative not knowing about the appeal process should the resident and their representative believe the transfer or discharge was inappropriate or involuntary. Findings: Medical record review for Resident 2 was initiated on 1/21/25. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2 's H&P examination dated 8/30/24, showed Resident 2 had no capacity to understand and make decisions. Review of Resident 2's Physician's Order dated 11/21/24, showed an order to transfer Resident 2 to the acute care unit and provide bed hold for seven days. Review of Resident 2's Event Note showed following: - On 11/21/24 1703 hours, showed the resident representative was informed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 PASRR (a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) Level 1 assessment was coded inaccurately for one of one final sampled resident reviewed for PASARR (Resident 26). This failure had the potential for having residents that were not appropriate in the facility and for Resident 26 not to receive the appropriate services. Findings: Review of the facility's P&P titled PAS/PASARR reviewed 8/2023 showed all the residents will be screened and identified for Level II and referred in a timely manner to the Department of Health Services and the Department of Mental Health (as appropriate). Medical record review for Resident 26 was initiated on 1/21/25. Resident 26 was admitted to the facility on [DATE]. Review of Resident 26's PASRR Level 1 Screening Form dated 10/14/24, showed Resident 26 had no diagnosed serious…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 low air loss mattress (pressure redistributing support surface) was set appropriately according to the resident's weight for one of three final sampled residents (Resident 24) reviewed for pressure ulcer (skin injury caused by prolonged pressure on an area of the body). This failure had the potential for Residents 24 not receiving the appropriate care and services to promote healing or prevent the development of the pressure ulcers. Findings: Review of the facility's P&P titled Mattresses revised 8/2023 showed the pressure reduction will be provided to the residents who are at risk for skin breakdown. Under the section Procedure, showed facility to be sure to mattress was inflated properly, and to check mattress routinely to ensure it is working properly. Review of the facility's document titled Power Pro Operating Maintenance and Troubleshooting undated, showed to select…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 RNA services as ordered by the physician for two of four final sampled residents reviewed for limited ROM (Residents 2 and 18). This failure had the potential for the residents' decline in ROM functions and deterioration in their ability to perform ADL care. Findings: Review of the facility's P&P titled Restorative Nursing Program dated 8/2023 showed all the residents will be assessed by the registered nurse on admission and ongoing for their restorative/rehabilitative needs and abilities. A plan of care will be developed to place the resident in programs specifically designed to promote functioning levels and enhance the quality of life. The RNA program to be provided seven days a week and will be provided based on physician order. On 1/21/25 at 1035 hours, Resident 2 was observed lying in the bed. Resident 2's legs were in a partially flexed position. There were no splint on both legs. 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, and medical record review, the facility failed to ensure one of 13 final sampled residents (Resident 11) remained free from accident hazards. * The facility failed to ensure Resident 11 had a helmet protective device when out of bed per the physician's order. This failure had the potential risk for injury to Resident 11. Findings: On 1/21/25 at 1040 hours, Resident 11 was observed in his wheelchair in the activity room. No splints were applied on the resident and not wearing a helmet. Medical record review for Resident 11 was initiated on 1/21/25. Resident 11 was admitted on [DATE]. Review of Resident 11's MDS dated [DATE], showed Resident 11 had a diagnosis of siezurre diarder. Review of Resident 11's Physician's Order dated 10/28/24, showed an order for when Resident 11 out of bed, a two person assistance sideways in mechanical lift, applied a helmet. Review of Resident 11's plan of care showed a care plan problem dated 10/28/24, addressing the use of a helmet when Resident 11…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 GT care and services for two of two sampled residents (one nonsampled resident, Resident 12 and one final sampled resident, Resident 18) reviewed for GT care. * The facility failed to ensure the licensed staff elevated Resident 12's HOB at 30 degrees to 45 degrees prior to the administration of medications via GT. * The facility failed to ensure Resident 18 was administered the enteral feeding as per the physician's orders and failed to ensure Resident 18's water flush was labeled with Resident 18's name and the ordered rate. These failures had the potential to negatively impact the residents' well-being. Findings: Review of the facility's P&P titled Medication Administration via Feeding Tube revised 1/2011 showed the medications will be administered via the feeding tube by an RN or LVN, per the physician's order. Review of the textbook titled Foundations and Adult Health Nursing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the pharmaceutical services were provided to meet the needs for two final sampled residents (Residents 23 and 2). * The facility failed to ensure the physician's orders for Residents 23 and 2 were accurate. The medication route was ordered to be oral instead of GT. This failure had the potential for the medications to be administered in errors. Findings: Review of the facility's P&P titled Medication Administration (General) revised 3/2023 showed to follow the six rights: patient, drug, dose, route, reason and check for contraindication, expiration date and stability of medications. Review of the facility's P&P titled Physician Orders revised 12/2008 showed guidelines have been established to aid the team members in obtaining, reviewing, and authenticating the physician's orders in an efficient and correct manner. The procedure section showed all the orders for the medications, procedures, and devices…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 2) reviewed for unnecessary medications was free from the unnecessary psychotropic medications. * The facility failed to ensure the PRN order for the psychotropic medication was limited to 14 days for Residents 2. This failure had the potential to result in unnecessary use of, ineffective and/ or lack of monitoring or interventions for the use of the psychotropic medication that could negatively affect Resident 2 highest practicable mental, physical, and psychosocial well- being. Findings: Medical record review for Resident 2 was initiated on 1/21/25. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's Patient Orders showed an order dated 5/16/23, for lorazepam (antianxiety medication) 1 mg intramuscular (into a muscle) every four hours as needed for seizure (a temporary disruption in brain activity that can cause a person to experience abnormal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 one of four medication carts (Medication Cart B) was properly locked and secured when unattended. This failure had the potential for unauthorized persons having access to the medications kept inside the medication cart. Findings: Review of the facility's P&P titled Medication Storage and Access revised 9/2023 showed all the drugs and biologicals must be kept in a secured area and locked when appropriate. A secure area means that drugs and biologicals are stored in a manner to prevent unmonitored access by unauthorized individuals. Drugs and biologicals must not be stored in areas that are readily accessible to unauthorized persons. An area in which staff is actively providing care to patients or preparing to receive patients, i.e., setting up for procedures before the arrival of a resident would generally be considered a secure area. When a resident care area is not staffed, both controlled and non-controlled substance are expected to be locked. Due to their mobility, mobile nursing medication…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 cook followed the recipe when preparing the puree Swiss steak. This failure had the potential of not meeting the residents' nutritional needs which could lead to nutritional related health complications. Findings: Review of the facility's untitled document for the diet orders for the residents dated 1/21/25, showed one of 27 residents was receiving pureed food prepared from the kitchen. Review of the facility menu dated 1/22/25, showed the lunch menu included Swiss steak. Review of the facility's P&P titled Pureed Diet dated 6/2023 showed to follow the written pureed diet recipe instructions. Under the section How to Make Pureed Diet showed the following instructions: - Measure the amount of food needed to be pureed based on number of patients on the pureed diet and serving size. (for example, if you need six serving of the pureed food and the menu ask for 6 oz per serving, you need to multiply 6 x (times) 6 which equals to 36 oz. - In the food processor add liquid…

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

Based on observation, interview, and facility document review, the facility failed to ensure the food safety and sanitation guidelines were followed when: * The facility failed to ensure a tray and a red blender were not stored wet. * The facility failed to ensure a rack for pots and pans were in a sanitary condition. * The facility failed to ensure four cutting boards were not heavily marred. These failures had the potential to result in foodborne illnesses for the residents receiving kitchen services in the facility. Findings: Review of the facility's untitled document for diet orders for the residents dated 1/21/25, showed one of 27 residents was receiving food prepared from the kitchen. 1. According to the USDA Food Code 2022, Section 4-901.11, Equipment and Utensils, Air-Drying Required, items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items prevents them from drying and may allow an environment where microorganism can begin to grow. On 1/21/25 at 0754 hours, an observation and concurrent interview was conducted with the Clinical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medical record for one of 13 final sampled resident (Resident 26) was accurate and complete. * The facility failed to ensure Resident 26's Restraint Assessment/Restraint Flowsheet was complete. This failure had the potential for Resident 26's care needs not being met as their medical information was inaccurate. Findings: On 1/21/25 at 0847 hours, Resident 26 was observed sleeping in bed with bilateral soft hand mittens observed. Medical record review for Resident 26 was initiated on 1/21/25. Resident 26 was admitted to the facility on [DATE]. Review of Resident 26's Patient Orders dated 1/22/25, showed a physician's order dated 10/16/24, to apply the bilateral hand mittens to prevent the resident from pulling out the medical tubing and to release every two hours for 15 minutes for circulation and skin check. Review of Resident 26's plan of care showed a care plan problem dated 10/16/24, addressing Resident 26's use of…

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

Based on interview, medical record and the facility P&P review, the facility failed to ensure the resident's personal belongings were properly recorded for one of the two sampled residents (Resident 1). This failure had the potential for residents personal belongings being lost. Findings: Review of facility's P&P titled Handling of Personal Effects revised on July 2006, showed all residents will have the right to retain and use personal possessions unless to do so would infringe upon the rights and health or health and safety of other residents. All steps will be taken to protect the personal effects of all residents. On admission, have resident or responsible party sign the form after completion of the inventory. For new items brought to hospital after admission: record, date and sign the back of the Resident's Inventory form when new items are brought to hospital by family members. Review of Resident 1's Resident Inventory of Personal Effects showed: - 3/15/22 failed to show staff signature and responsible party signature - 5/1/22 failed to show responsible party signature -…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and medical record review, the facility failed to provide the necessary care and services to ensure four of four sampled residents (Residents 1, 2, 3, and 5) maintained good grooming, personal hygiene, and transfers for dependent residents. These failures had the potential for the residents to experience physical discomfort, emotional distress, health complications, and a decreased quality of life. * Resident 1 did not received shower as scheduled and was not transferred out of bed as scheduled. * Resident 2 did not received shower as scheduled and has long fingernails. * Resident 3 did not received shower as scheduled and was not transferred out of bed as scheduled. * Resident 4 had long fingernails. Findings: Review of facility's P&P titled Activities of Daily Living (ADL) reviewed on August 2023, showed personal hygiene includes bathing (bed), showering (via gurney), oral care, hair and nail care, skin care and bed mobility and repositioning and pressure reducing devices used.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to implement the plan of care to reflect the individual needs for one of 14 final sampled residents (Resident 23) and one nonsampled resident (Resident 9). * Resident 9's care plan intervention of padded side rails was not implemented by the facility staff. * Resident 23's DNR code status was not included in the resident's comprehensive care plan. * Resident 23's care plan intervention of padded side rails was not implemented by the facility staff. These failures posed the risk of not providing appropriate, consistent, and individualized care to the residents. Findings: 1. Review of the facility's P&P titled Care Planning revised 8/2010 showed the purpose of care planning is to assure a coordinated and comprehensive written plan is developed based on the resident assessment and instrument and on the individual needs of the Resident. Medical record review for Resident 9 was initiated on 10/24/23. Resident 9 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, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the development of new pressure ulcers (areas of damaged skin caused by staying in one position for a long time which reduces blood flow to the area and causes the skin to die and develop a sore) and promote healing of existing pressure ulcer for one of final 14 sampled residents (Resident 32). * The facility failed to ensure Resident 32 was turned and repositioned at least every two hours as per the physician's order and plan of care. This failure put Resident 32 at risk for developing new pressure ulcers and worsening of the existing pressure ulcer on the sacrococcygeal (the tailbone) area and MASD (moisture-associated skin damage; inflammation or skin erosion caused by prolonged exposure to a source of moisture such as urine). Findings: During initial tour of the facility on 10/24/23 at 0843 hours, Resident 32 was observed in bed lying on his…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to ensure two of 14 final sampled residents (Residents 1 and 18) and one nonsampled resident (Resident 9) remained free from accident hazards. * The facility failed to ensure Resident 9's side rails were padded as ordered by the physician and as care planned. * The facility failed to ensure two staff members assisted in obtaining Resident 1's weights. * The facility failed to ensure Resident 18's bilateral side rails were padded as per the resident's physician's order and care plan. These failures had the potential to place the residents at risk for serious injury. Findings: 1. Medical record review for Resident 9 was initiated on 10/24/23. Resident 9 was admitted to the facility on [DATE], readmitted [DATE]. Review of Resident 9's Physician Order Report for October 2023 showed an order dated 8/8/23, for a low bed with padded side rails x 2 when in bed for severe involuntary muscular spasm/coughing spasm for safety per family…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 appropriate care and services for the use of G-tube (a small tube placed through the abdominal wall into the stomach, used to provide enteral feedings and/or administer medications; gastrostomy tube) for two of 14 final sampled residents (Residents 1 and 23) and one nonsampled resident (Resident 19). * The facility failed to ensure the licensed staff managed the G-tube feeding for Resident 1. CNA 1 had put the G-tube feeding on hold to provide incontinence care for Resident 1. In addition, RNA 1 had put the G-tube feeding on hold and resumed G-tube feeding after obtaining Resident 1's weight. * The facility failed to ensure Resident 23's tube feeding bag was labeled with it's contents. * The facility failed to ensure Resident 19's HOB was elevated during enteral feeding to reduce the risk for aspiration. These failures posed the risk for complications related to use of the G-tube for Residents 1,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the appropriate care and services for IV therapy (the administration of fluids or medications through an IV catheter) for two of 14 final sampled residents (Residents 1 and 2). * The facility failed to label Residents 1 and 2's IV medication tubing with the date or time when it was hung. This failure posed the potential risk for infection or phlebitis (inflammation of a vein) for Residents 1 and 2. Findings: Review of the facility's P&P titled Medication - Intravenous Therapy reviewed 9/2023 showed to mark IV tubing with the date hung, nurse's initials, and date to be changed. 1. Medical record review for Resident 1 was initiated on 10/24/23. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 1's Patient Orders for 10/26/23, showed an order dated 10/24/23, for cefepime (an antibiotic) 2 grams IV every eight hours. On 10/24/23 at 0815 hours, 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 observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care for one of 14 final sampled residents (Resident 18) and two nonsampled residents (Residents 6 and 16) with tracheostomy (breathing tube inserted through the neck into the airway to maintain an open airway). * The facility failed to ensure Residents 6 and 18's oxygen flow meters were set to the appropriate liter flow to match their aerosol mist setting as per physician's orders. * The facility failed to ensure the necessary respiratory care provided to Resident 16 was performed by a designated trained or licensed healthcare member. These failures had the potential for these residents to not receive appropriate respiratory care to negatively affect the residents' medical conditions. Findings: Review of the facility's P&P titled Oxygen, Cool Aerosol revised 4/2021 showed the administration of aerosol therapy as an aid to bronchial hygiene is to attempt to hydrate dried…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and least restrictive measures of the side rail use were attempted for four of 14 final sampled residents (Residents 2, 23, 30 and 31). * Resident 2 and 31's medical records failed to show the outcome of least restrictive attempt prior to side rail use. * Resident 23 and 30's medical records failed to show the outcome of least restrictive attempt prior to side rail use and documentation of recent seizure activity for which the side rails were ordered. These failures had the potential to put the resident at risk of injury including entrapment. Findings: Review of the facility's P&P titled Siderails, Assessment & Use reviewed 8/2023 showed the use of side rails will be determined by the most appropriate, least restrictive type of restraint. 1. Medical record review for Resident 2 was initiated on 10/24/23. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's Physician Orders dated 9/26/23,…

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 and medical record review the facility failed to ensure one of 14 final sampled residents (Resident 12) was free from the unnecessary medications (Resident 12). * The facility failed to monitor orthostatic hypotension for Resident 12 who was on quetiapine, an antipsychotic (reduce or relieve symptoms such as delusions (false beliefs) and hallucinations (seeing or hearing something that is not there) medication. This posed the risk of not identifying the potential harmful side effects associated with the medication and a delay in necessary medical interventions for this resident. Findings: According to Lexicomp, quetiapine may cause orthostatic hypotension and accompanying tachycardia and syncope in adults, particularly with rapid titration. Orthostatic hypotension may result in subsequent falling and fracture. Mechanism: Orthostatic hypotension is attributed to alpha-1 adrenergic receptor antagonism. Risk factors: Known cardiovascular disease (history of myocardial infarction or ischemic heart…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the residents' medications were stored properly for one of 14 final sampled residents (Resident 5) and one nonsampled resident (Resident 16), and in two of five medication carts (Medication Carts A and B). * The facility failed to ensure the topical medication was stored properly for Resident 5 when a tube of triamcinolone ointment (a topical ointment used to relieve redness, itching, swelling, or other discomfort caused by skin conditions) was observed on Resident 5's bedside table. * The acetylcysteine (a medication used to help thin and loosen mucus in the airways due to certain lung diseases) and Refresh eye drop (lubricating eye medication to relieve dry eyes) medications were left at Resident 16's bedside. * The facility failed to ensure the internal medications were stored separately from the externally used medications in Medication Carts A and B. These failures had the potential for…

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

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the kitchen staff had the appropriate skill sets to safely perform the daily operation of the Food and Nutrition Services Department. * [NAME] 1 was unable to perform the thermometer calibration as per the facility's P&P. This had the potential for inaccurate food temperature readings and could lead to foodborne illnesses in a highly susceptible populations of residents who received food preparation in the kitchen. Findings: Review of the facility's P&P titled Thermometer Use and Accuracy Monitoring dated 10/2010 showed the purpose of the policy is to ensure accuracy of thermometers and correct measurement of temperatures throughout the facility. The Calibrating a Food Thermometer Using Ice Point Method section showed the following steps: - Fill a large container with crushed ice; - Add clean tap water until container is full; - Stir the mixture well; - Put the thermometer probe into the ice water so sensing area is completely submerged; - Wait 30 seconds or until the…

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

Based on observation, interview, and facility 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. * The facility failed to ensure a safe working area was provided for staff in the dishwashing room when puddle of water was observed on the floor, which was from the broken hot water booster for the dishwasher. * The facility failed to ensure the proper labeling with open date or use by date of the bacon and sausage stored in the kitchen refrigerator. * The facility failed to ensure the kitchen refrigerator shelves were clean. * The facility failed to ensure the freezer was free from any ice buildup. * The facility failed to ensure the expired food items in the kitchen were discarded. * The facility failed to ensure the proper labeling and dating of the foods in the kitchen were utilized once the food item was opened. * The facility failed to air dry the equipment. * The facility failed to ensure the kitchen equipment were clean. These failures…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 six of 14 final sampled residents (Residents 2, 13, 18, 23, 30, and 32) and one nonsampled resident (Resident 19). * The facility failed to ensure Resident 13's bed entrapment assessment was completed with bed inspection gap measurements. * The facility failed to ensure Resident 18's bed entrapment assessment was completed with bed inspection gap measurements. * The facility failed to ensure Resident 19's bed entrapment assessment was completed with bed inspection gap measurements. * The facility failed to ensure Resident 2 was assessed for entrapment on admission and failed to ensure Resident 2's (low air loss) LAL mattress and bed were assessed to be safe and compatible…

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