South Coast Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to implement their P&P for abuse investigation for four of 10 sampled residents (Residents 1, 2, 7, and 8). * The facility failed to immediately remove MHW 1 from duty pending an abuse investigation for Resident 1. * The facility failed to conduct a thorough investigation for Resident 1's abuse allegation against MHW 1 when the resident witnesses were not interviewed regarding the incident. * The facility failed to begin an investigation within two hours following Resident 2's verbal abuse allegation against MHW 5. * The facility failed to implement their P&P to conduct a thorough investigation when Residents 7 and 8 verbalized Resident 7 assaulted Resident 8 on two different occasions. Additionally, the facility failed to separate the residents until the investigation was completed. These failures had the potential for the abuse allegation going unreported and uninvestigated. Findings: Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure the comprehensive care plans were developed and revised for three of 10 residents (Residents 4, 6, and 8). * The facility failed to revise a plan of care for Resident 4's bilateral floor mats for fall prevention. * The facility failed to develop a plan of care for Resident 6's weight loss. * The facility failed to develop the plan of care for Resident 8's facial abrasion following an injury after a physical altercation occurred. These failures had the potential to place the residents at risk of their care needs not being met. Findings: Review of the facility's P&P titled Care Plan Comprehensive dated 8/25/21, showed the following: 1. Assessments of residents are ongoing and care plans are reviewed and revised as information about the resident's condition change; 2. the interdisciplinary team is responsible for evaluation and updating the care plans: a. when there has been a significant change in the resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to prevent Resident 1 from injury. * The facility failed ensure Resident 1 was free from injury during the facility's de-escalation process. This failure resulted in Resident 1 sustaining facial and neck bruising, which had the potential to negatively impact the resident's well-being. Findings: Review of the facility's P&P titled Chapter 5- Why Restrain dated 9/2021 showed in every instance, the facility wants to use the least restrictive method to resolve the situation. Restraint is reserved to contain acute episodes of dangerous behavior. Manual restraint is placing of hands on an individual thereby restricting their ability to move. This can range from two staff members holding an individual's arm to four staff members holding a limb. It may include escorting a patient to a different location or can result in containment on the ground. Medical record review for Resident 1 was initiated on 5/30/25. Resident 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, and medical record review, the facility failed to provide the necessary care and services to maintain the intravenous accesses and properly provide IV care for three of three final sampled residents (Residents 184, 733, and 983) and one nonsampled resident (Resident 932). * The facility failed to ensure Resident 932's IV tubing was free from air bubbles prior to administration. * The facility failed to ensure Resident 184's midline (a long, thin, flexible tube inserted into a large vein in the upper arm used to deliver fluids and medications into the bloodstream) dressing was dated and labeled. In addition, the facility failed to ensure Resident 184's midline was maintained to prevent possible complications. * The facility failed to discontinue Resident 983's PIV line after the antibiotic therapy was completed. In addition, the facility failed to ensure there were physician's orders for the PIV maintenance. * The facility failed to ensure Resident 733's PIV site was dated and labeled. 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, facility document review, and facility P&P review, the facility failed to ensure the food safety and sanitation guidelines were followed as evidenced by: * There were white pieces of plastic trash found on the floor, in the sink area of the pots and pans, and in the main food preparation hallway floor area. Additionally, a pair of gloves and dietary menu forms were found in clean serving areas. * The top clean surface of the soup machine had three unwashed cabbages, cooking mittens, two basins, and a cutting board. * Vegetables in a plastic bag fell onto the floor and was picked up and placed on the food cart by the Dietary Assistant Manager. * There were two fryers baskets with brown residue and a serving utensil used as a scooper was found with food residue. Additionally, a can opener had brownish orange residues. * The microwaves used by the residents in Stations 1, 2, 3, and 4 had food residues. * The Station 4 refrigerator had food residue and a dried brown liquid spill 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 interview, medical record review, and facility P&P review, the facility failed to ensure the informed consents were obtained for the use of psychotropic medications for one of five final sampled residents (Resident 147) reviewed for informed consents (Resident 147). * There were no informal consents prior to administering olanzapine (antipsychotic medication), quetiapine (antipsychotic medication), and valproic acid (mood stabilizer medication) to Resident 147. This failure had the potential for the resident to be unaware of the risks associated with the medications which could have adverse side effects detrimental to the resident's well-being. Findings: Review of the facility's P&P titled Psychotropic Medication Use dated 6/2021 showed the following: - The informed consent will be obtained by the Prescriber prior to initiation of psychotropic medication; and - The facility shall verify informed consent prior to the administration of a psychotropic medication for a resident. Medical record review 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 maintain a copy of an advance directive in the medical record for one of five final sampled residents (Resident 184) reviewed for advance directives. This failure had the potential for Resident 184's decisions regarding his healthcare and treatment options to not be honored. Findings: Review of the facility's P&P titled Advance Directive dated 3/23/22, showed at the time of admission, the admission Staff or designee will inquire about the existence of an Advance Directive. A copy of the Advance Directive is maintained as part of the resident's medical record. Further review of the P&P showed if the resident has an Advanced Directive, admission staff or designee will place a copy or scan of the Advanced Directive in the residence medical record and will notify the director of social services of the existence of the Advanced Directive. Medical record review for Resident 184 was initiated on 2/25/25. Resident 184 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 ensure the PASRR Level 1 (a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) assessment was coded accurately for two of four final sampled residents (Residents 132 and 147) reviewed for PASRR. This failure posed the risk of the residents not receiving specialized care and services appropriate for their condition. Findings: Review of the facility's P&P titled PASRR Completion Policy dated 9/30/24, showed the center will make sure that all admissions have the appropriate Patient Assessment and Resident Review completed. Further review of the P&P showed the facility will follow the State specific guidelines for completion. 1. Medical record review for Resident 132 was initiated on 2/25/25. Resident 132 was admitted to the facility on [DATE]. Review of Resident 132's PASRR Level 1 Screening Form dated 12/20/24, showed Resident 132…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 individualized and ongoing activity program to meet the needs and interests for one of one final sampled resident (Resident 147) reviewed for activities. This failure had the potential to affect the residents' psychosocial well-being. Findings: Review of the facility's P&P titled Activities and Social Services (undated) showed the residents are encouraged to choose the types of recreational, cultural, and religious activities and social events in which they prefer to participate. The Interdisciplinary Care Team will evaluate the individual's personal history and preferences and will consider his or her medical condition and prognosis in identifying relevant recreational and cultural activities. When the care planning team develops the residents' activity and social care plans the residents will be given an opportunity to choose when, where, and how he or she will participate in activities and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary GT care and services for one of three final sampled residents (Resident 735). * The facility failed to ensure Resident 735's GT was checked for placement before administration of the medications and water. In addition, the facility failed to administer each medication and water flushes via gravity. These failures had the potential for the resident to develop complications related to the GT care and management, including tube dislodgement, delayed nutritional feeding, and trauma. Findings: Review of the facility's P&P titled Enteral Tube Medication Administration dated 10/2017 showed the following procedures to verify the tube placement: - Insert a small amount of air into the tube with the syringe and listen to the stomach with the stethoscope for gurgling sounds; - Aspirate the stomach contents with syringe to check for residual feeding.; - Remove the plunger from the syringe and connect…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 three final sampled residents (Residents 96 and 161) reviewed for respiratory care were provided the appropriate respiratory care. * The facility failed to ensure Resident 96's humidifier was labeled and dated and the resident had the physician's order for oxygen use as per the facility's P&P. * The facility failed to ensure Resident 161's oxygen order was carried out as ordered by the physician. 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 Administration (undated) showed to review the physician's orders or facility protocol for oxygen administration. The P&P further showed oxygen therapy is administered by way of an oxygen mask, nasal cannula, and/or nasal catheter. 1. Medical record review for Resident 96 was initiated on 2/25/25. Resident 96 was admitted to the facility on [DATE], 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, facility document review, and facility P&P review, the facility failed to provide the pharmaceutical services to ensure accurate reconciliation of the controlled medications for three of 35 final sampled residents (Residents 27 and 40) and one of six medication carts (Medication Cart A). In addition, the facility failed to provide the medications and/or biologicals, as ordered by the prescriber, to meet the needs of one of 35 final sampled residents (Resident 735). * The facility failed to ensure the administration of the controlled medications for Residents 40 were accurately reconciled and documented in the MAR. * The facility failed to ensure the apical pulse for Resident 735 was obtained before administration of Digoxin medication (a cardiac glycoside medication used to control some heart problems, such as irregular heartbeats including atrial fibrillation) as per the physician's order. * The facility failed to ensure the Narcotic Shift…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure two of five final sampled residents (Residents 146 and 147) reviewed for unnecessary medications were monitored for the use of psychotropic medications. * The facility failed to ensure Resident 146's orthostatic blood pressure related to the use of an antipsychotic medication was monitored as ordered by the physician . * The facility failed to ensure non-pharmacological interventions were provided prior to the administration of quetiapine for Resident 147. In addition, the facility failed to ensure Resident 147's behavior for the use of quetiapine medication was monitored and the AIMS assessment was completed. These failures had the potential to negatively impact the residents' well-being. Findings: Review of the facility's P&P titled Psychotropic Medication Use dated 6/2021 showed the following: - Psychotropic medications may be used to address behaviors only if non-drug approaches and interventions were attempted…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 25.93%. Two of four licensed nurses (LVN 3 and RN 1) observed during the medication administration were found to have made errors. * LVN 3 failed to ensure the correct dosage of the medication was administered to Resident 735 when residue was observed in each medication cup after administration. In addition, LVN 3 failed to administer the correct physician's order dosage form for one medication to Resident 735. * RN 1 failed to ensure the correct dosage of medication was administered to Resident 932. These failures had the potential to negatively affect the residents' health conditions. Findings: Review of the facility's P&P titled Medication Administration General Guidelines dated 10/2017 showed the following: - Prior to administration, the medication and dosage schedule on the resident's medication administration record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Surveyor: Colorado, Star [NAME] Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure proper storage, labeling, and disposal of the medications. * The facility failed to ensure the expired medications in Medication Room A's refrigerator were discarded. In addition, the medication refrigerator's temperature was not maintained within the recommended temperature. * The facility failed to ensure the expired oral and external administered medications were discarded in Medication Room C. * The facility failed to ensure the expired oral administered medication was discarded in Medication Cart B. * The facility failed to ensure the expired medication and culture swab kit were removed from the current treatment supply in Treatment Cart A. In addition, the last drawer of Treatment Cart A was not kept clean. * The facility failed to ensure the expired medication were removed from the current…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 safe handling and collection of regular waste. * There was scattered food residues on the ground next to the food waste dumpster and the open space storage area had trash such as disposable cups with orange liquid, tortilla plastic container, and piles of leaves. * Two of the six soiled linen barrels were observed with trash inside of them, uncovered, and without a lid; one barrel was overfilled with trash bags and the other barrel contained two bags of trash, with a milky substance spilled at the bottom of the barrel. These failures posed the risk for safety and pest contamination. Findings: According to the USDA Food Code 2022 Section 5-501.110. Storing refuse, recyclables and returnables, shall be stored in receptacles or waste handling units so that they are inaccessible to insects and rodents. According to the USDA Food Code 2022 Section 5-502.11. Frequency. refuse, recyclable and returnables, shall be removed from the premises at a frequency that will minimize the development 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, facility document review, and facility P&P review, the facility failed to ensure the appropriate infection control practices designed to provide the safe and sanitary environment were implemented for two of 35 final sampled residents (Resident 184 and 735) and four nonsampled residents (Residents 64, 118, 151, and 932) * The facility failed to ensure LVN 2 wore proper PPE when administering medication for Resident 184 who had a midline catheter. * The facility failed to ensure proper hand hygiene was performed during medication administration to Resident 151. * The facility failed to ensure proper hand hygiene was performed during medication administration to Resident 735. * The facility failed to ensure the Zosyn (antibiotic) vial's septum was disinfected before connecting to the normal saline mini-bag IV solution for Resident 932. * Residents 64 and 118's shared restroom had a strong foul odor and the toilet rim had dried yellow urine. These failures posed the risk for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility document review, and facility P&P review, the facility failed to protect the resident's rights to be free from the physical abuse by another resident for one of five sampled residents (Resident 1). * Resident 2 punched Resident 1 in the face because Resident 1 would not be quiet. This failure caused Resident 1 to have a broken nose, bruising to his left eye, and bruising to the area around the left eye. Findings: Review of the facility's P&P titled Abuse Prohibition Policy and Procedure dated 2/23/21, showed the facility prohibits the abuse of all residents. Review of the SOC 341 Report of Suspected Dependent Adult/Elder Abuse dated 11/19/24, showed Resident 1 alleged Resident 2 hit Resident 1 on the face. Both Residents 1 and 2 were separated, and Resident 2 denied hitting Resident 1. a. Closed medical record review for Resident 1 was initiated on 12/3/24. Resident 1 was admitted to the facility on [DATE], and transferred to the acute care hospital 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 interview, medical record review, and facility P&P review, the facility failed to provide services to attain or maintain the highest practicable well-being for one of five sampled residents (Resident 4). * Resident 4 was noted with bilateral lower extremities swelling after the administration of intravenous fluids on 12/8/23, and transferred to the acute care hospital ED for abdominal pain and increased abdominal girth on 12/8/23. The facility failed to assess Resident 4's bilateral lower extremities swelling upon Resident 4's return to the facility on [DATE], failed to assess and monitor Resident 4's abdominal girth upon his return from the ED, and failed to obtain Resident 4's weekly weights as ordered by the physician. Resident 4 was transferred to the acute care hospital on [DATE], for elevated temperature and abdominal edema. These failures had the potential for Resident 4 to not receive appropriate care and monitoring to prevent the development of complications and/or delayed medical treatments.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of two sampled residents (Resident 8) maintained the acceptable parameters of nutritional status. * The facility failed to ensure the IDT evaluated and monitored the effectiveness of the intervention implemented after 3/13/24, for Resident 8's unplanned severe weight loss. This failure had the potential for Resident 8's compromised nutritional status was not monitored effectively which could lead to further medical complications. Findings: Review of the facility's P&P titled Weight Management dated 8/25/21, showed in the event of a patterned or significant, unplanned weight loss/gain of at least 2% in a week (or +/- 3lbs), 5% in 30 days (or +/- 5lbs), 7.5% in 90 days or 10% in 180 days, the IDT collaborates for determining the need for initiation r discontinuation of weights other than weekly or as ordered by physician; and to request lab work as necessary. Medical record review for Resident 8 was…

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

Based on observation, interview, medical record 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 as evidenced by: * The facility failed to ensure the EBPs were followed for Resident 8 when the staff did not wear a disposable gown before providing care to the resident. * The facility failed to ensure the hand hygiene was performed after using the gloves in between the dressing change. These failures had the potential for spread of infections in the facility. Findings: Review of facility's P&P titled Enhanced Standard/Barrier Precautions (undated) showed Enhanced Standard/Barrier Precautions refer to the use of gown and gloves for use during high contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). Wear gowns and gloves while performing the following tasks associated 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, medical record review, facility document review, and facility P&P review, the facility failed to promote dignity and respect for four nonsampled residents (Residents A, B, C and D) * The facility failed to ensure the resident's call lights were answered in a timely manner for Residents A, B, C and D. These failures posed the risk to negatively affect the residents' physical and emotional well-being. Findings: Review of the facility's P&P titled Call Light/Bell revised 9/2022 showed answer the resident call system immediately. If the resident needs assistance, indicate the approximate time it will take for you to respond. If the president's request requires another staff member, notify the individual. If resident's request is something you can fulfill, complete the task within five minutes if possible. If you are uncertain as to whether a request can be fulfilled, or if you cannot fulfill resident's request, ask the nurse supervisor for assistance. 1. On 5/20/24 at 0910 hours, a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the reasonable accommodations to meet the care needs for two of five residents (Residents 1 and 3) reviewed for call lights. * The facility failed to ensure Resident 1's call light was answered in a timely manner. * The facility failed to ensure Resident 3 was assisted promptly or informed of when the resident would get assistant after the staff answered the call light and was unable to fulfill the resident's request. These failures had the potential to negatively impact the resident's psychosocial well-being or result in a delay to provide care and services to the residents. Findings: Review of the facility's P&P titled Answering the Call Light revised 9/2022 showed answer the resident call system immediately. If the resident needs assistance, indicate the approximate time it will take for you to respond. If you are uncertain as to whether or not a request can be fulfilled, or if you cannot fulfill…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Resident 2's medicationswere administered as per physician's order due to a lack of availability of the medications for one of two sampled residents reviewed for medication administration (Resident 2). * LVN 1 failed to ensure Resident 2's Lasix (medication use to treat fluid retention and swelling caused by congestive heart failure, liver disease, kidney disease, and other medical conditions) supply was available for scheduled administration as per the physician's order. * Resident 2 was admitted to the facility on [DATE]. However, the pharmacy failed to deliver Resident 2's prescribed medication for Entresto (a fixed-dose combined medication used to treat heart failure). * Resident 2's medical record did not show documented evidence Resident 2's physician was notified of Resident 2 not receiving her scheduled Entresto medication on 4/17-4/19/24 at 0900 and 1700 hours. * LVN 1 failed to ensure Refresh…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 one reviewed resident (Resident 2) for unnecessary medication was free from the unnecessary psychotropic drug (any drug that affects brain activity associated with mental processes and behavior). The facility failed to ensure Resident 2's physician's order for Seroquel (antipsychotic medication) had a diagnosis justify for the use of medication, implemented nonpharmacological interventions prior to drug use, monitored targeted behavior, and monitored side-effects of the drug use. These failures had the potential for Resident 2 to have adverse complications from the medication and the potential of not providing the correct data to the prescriber in order to adjust the dose of the psychotropic medication for Resident 2. Findings: Review of the facility's P&P titled Psychotropic Medication Use dated 6/2021 showed the facility should not use psychotropic medications to address behaviors without first determining…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 protect the resident's rights to be free from physical abuse by a resident for one of four sampled residents (Resident 1). * Resident 1 alleged she was shoved and hit on the face by Resident 2. Resident 3 stated he witnessed the physical altercation involving Residents 1 and 2. Resident 3 stated he witnessed Resident 2 push or punch Resident 1 twice in the upper torso region. This failure to prevent the physical altercations between the residents had the potential to cause injury and/or psychological harm to the residents. Findings: Review of the facility's P&P titled Abuse Prohibition Policy and Procedure dated 2/23/21, showed Healthcare Centers prohibit abuse, mistreatment, neglect, misappropriation of resident property, and exploitation for all residents. Physical abuse includes hitting, slapping, pinching, kicking, etc. Actions to prevent abuse will include identifying, correcting, and intervening in situation in which…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to notify the resident's physician immediately after a fall COC as per the facility's P&P for one of six sampled residents (Resident 1) and failed to ensure the physician was informed of the medication not administered as ordered due to the medication was not available for one of six sampled residents (Resident 3). These failures posed the risk for changes in Residents 1 and 3's health conditions not being identified, delay in necessary care and treatment, and the risk for negative health outcomes. Findings: Review of the facility's P&P titled Change in Condition dated 8/2021 showed the facility must immediately inform the resident, consult with the resident's physician and/or NP, and notify, consistent with his/her regular authority when there is a significant change in the resident's complication. Review of the facility's P&P titled Administering Medications revised 4/2019 showed medications are administered in a safe 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 obtain the resident's vital signs and failed to administer the resident's prescribed medications as ordered by the physician for one of two sampled residents (Resident 1). In addition, the facility failed to notify the resident's physician that the resident's vital signs were not obtained and the resident's medications were not administered as ordered for Resident 1. These failures posed the risk for changes in Resident 1's health condition not being identified, potentially delaying necessary care and treatment, which posed the risk for negative health outcomes to Resident 1. Findings: Review of the facility's P&P titled Change in Condition dated 8/2021 showed a facility must immediately inform the resident, consult with the resident's physician when there is a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental or psychosocial status in either…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure Resident 1's medications were administered as per the physician's orders due to a lack of availability of the medications for one of two sampled residents (Resident 1). * Resident 1 was admitted to the facility on [DATE] at 1339 hours; however, the pharmacy failed to deliver Resident 1's prescribed medications until the following day. As a result, Resident 1 did not receive her prescribed medications which were scheduled to be administered on 12/7/23 at 0900 hours. * Resident 1's medical record failed to show Resident 1's physician was notified that Resident 1 did not receive her scheduled medications on 12/7/23 at 0900 hours, in accordance with the facility's P&P. These failures posed the risk for negative health outcomes for Resident 1. Findings: Review of the facility's P&P titled Administering Medications revised 4/2019 showed medications are to be administered in a safe and timely manner, and as prescribed.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents were free from the unnecessary psychotropic medications for eight of 35 final sampled residents (Residents 5, 19, 42, 51, 59, 79, 175, and 182). * The facility failed to ensure the use of of each psychotropic medication had specific behavior manifestations for Residents 5, 19, 42, 59, 79, 175, and 182. * The facility failed to ensure the psychotropic medication behavioral monitoring were accurate, the care plan was revised to reflect the current behavioral manifestation, and the non-pharmacological intervention were documented for Resident 51. * The facility failed to ensure Resident 42 was monitored for the behavior and side effects related to the use of Depakote (medication used to treat manic phase of bipolar disorder), Risperdal (medication used to treat schizophrenia), Seroquel (medication used to treat schizophrenia and bipolar disorder) and Vistaril (medication used a sedative to treat anxiety…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure proper storage, labeling, and disposal of medications. * The facility failed to ensure the medications for Residents 496 and 497 who had expired, and Residents 38 and 498 who were transferred out of the facility had been removed from the current medication supply in Medication Carts 1 and 2, and Medication room [ROOM NUMBER]. * The facility failed to ensure the discontinued IV medication for Resident 126 had been removed from the current medication supply in the IV cart. * The facility failed to ensure the opened inhalation solution medications for Residents 144 and 901 inside Medication Cart 1 were labeled with an opened date. * The facility failed to ensure the bubble packs (a form of tamper-evident packaging where an individual pushes individually sealed tablets through the foil in order to take the medication) containing propranolol (antihypertensive medication) tablets 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 food safety and sanitation requirements were met in the kitchen when: * The leftover (previously served) food was not discarded. * One facility staff (RNA 1) did not use gloves when the resident's food was touched. * The water temperature of the hand sink was less than 85 degrees Fahrenheit (F). * The test strip used to test the sanitizing solution of the manual dishwashing sink had expired. * The food preparation equipment, utensils, and dishware were not airdried. * A drawer which contained clean food preparation utensils was not clean. * One food preparation sink and one steamer did not have an air gap. * A scoop was stored inside a thickener container. * A staff member failed to ensure to put hand gloves before distributing resident's cups for drinks. These failures had the potential to cause foodborne illnesses in a highly susceptible resident population of 227 facility residents who consumed food prepared in the kitchen. Findings: Review of the facility's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the residents' entrapment assessments were complete during the bed inspection when identifying areas of possible entrapment with the use of bed rails for all 35 residents with the use of side rails. These failures had the potential to negatively impact the residents resulting in possible entrapment, serious injury, and death. Findings: According to the Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, the term entrapment describes an event in which a patient/resident is caught, trapped, or entangled in the space in or about the bed rail, mattress, or hospital bed frame. Patient entrapments may result in deaths and serious injuries. These entrapment events have occurred in openings within the bed rails, between the bed rails and mattresses, under bed rails, between split rails, and between the bed rails and head or foot boards. The population most…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure two of 35 final sampled residents (Residents 35 and 912) were provided the opportunity to participate in the care plan conferences. * The facility failed to ensure Resident 35 was offered the opportunity to participate in the quarterly care plan conference. * Resident 912 was not informed of his plan of care. These failures had the potential for Residents 35 and 912 to not be able to choose treatments options and make decisions in care planning. Findings: Review of the facility's P&P titled Care Planning- Interdisciplinary Team dated 8/25/21, showed a comprehensive care plan for each resident is developed within seven days of completion of the comprehensive assessment (MDS). The care plan is based on the resident's comprehensive assessment and is developed by an Interdisciplinary Team. The resident, the resident's family and/or resident's representative are encouraged to participate in the development of 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 one of 35 final sampled residents (Resident 545) who was assessed to not be able to self-administer the medications had the medication in her possession. This failure had the potential to negatively impact the residents' physiological well-being and could administer the medications inaccurately. Findings: Review of the facility's P&P titled Self-Administration of Medications dated October 2012 showed the residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. The IDT assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident. During the initial tour with RN 2 on 12/18/23 at 0911 hours, Resident 545 was observed holding with two medicine cups containing a clear ointment on both hands 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 inform and provide the written information regarding the rights to formulate the advance directives to one of 35 final sampled residents (Resident 745). In addition, the facility failed to ensure the Physician Orders for Life Sustaining Treatment (POLST) and advance directives information were accurate for two of 35 final sampled residents (Residents 34 and 129). These failures had the potential for the facility to provide treatment and services against the resident's wishes. Findings: Review of the facility's P&P titled Advance Directive dated 3/23/22, showed at the time of admission, admission Staff or designee will inquire about the existence of an Advance Directive. The facility will honor resident's Advance Directive and will provide the resident with information related to Advance Directives upon admission. If no Advance Directive exists, the facility provides the resident with an opportunity to complete the Advance…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure three of 35 final sampled residents (Residents 34, 121, and 131) were free from the physical restraints. * The facility failed to ensure the physician's order and informed consent were obtained and the care plan problem was initiated for Resident 34's use of a wheelchair lap tray. * The facility failed to ensure the soft hand mittens used for Resident 121 was necessary and had a physician's order and monitoring for behaviors and skin condition. * The facility failed to ensure the least restrictive measures were attempted before the use of bolsters and the restraint elimination assessment was completed for bolsters and pad alarm for Resident 131. These failures had the potential for the increased risk of physical harm and negatively affect psychosocial well-being to the residents. Findings: Review of the facility's P&P titled Use of Restraints revised April 2017 showed the definition of a restraint 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 P&P, and DHCS PASRR guidelines review, the facility failed to ensure a subsequent PASRR Level 1 Screening was conducted as required for one of 35 final sampled residents (Resident 51). This failure had the potential for Resident 51 to not receive specialized care and services appropriate for their condition. Findings: According to the DHCS, federal law requires all individuals seeking admission to a Medicaid Certified Nursing Facility (NF) to receive a Level 1 Screening. The Level 1 Screening identifies if an individual has a suspected Mental Illness (MI) or an Intellectual/Developmental Disability or Related condition (ID/DD/RC). If MI is suspected, then a Level II Mental Health Evaluation may be conducted to determine if the individual can benefit from specialized mental health services. This process is known as the Preadmission Screening and Resident Review (PASRR). Review of the facility's P&P titled PASRR Completion Policy (undated) showed the facility…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 baseline care plan for two of 35 final sampled residents (Residents 745 and 912) were initiated upon admission. * The facility did not provide Resident 745 a copy of the resident's care plan. * Resident 912's baseline care plan was incomplete. The care plan did not include necessary information to properly care for the resident such as bathing or shower while on isolation precaution. These failures placed Residents 745 and 912 at risk of not receiving resident-centered care. Findings: Review of the facility's P&P titled Care Plan- Baseline dated 8/25/21, showed a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care shall be developed and implemented for each resident by the Interdisciplinary Team. The baseline care plan is developed within 48 hours of a resident's admission. 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 comprehensive plans of care for two of 35 final sampled residents (Residents 14 and 51) were revised to reflect the resident's current care needs and interventions. * The facility failed to ensure Resident 14's plan of care was revised to address Resident 14's use of bilateral 1/2 (half)bed side rails. This posed the risk of not providing Resident 14 with the individualized and person-centered care. * The facility failed to ensure Resident 51's plan of care was revised to reflect the change for indication and manifestation for olanzapine (an antipsychotic medication used to treat several mental health conditions). This posed the risk of Resident 51 not receiving individualized and person-centered care and services required to attain or maintain Resident 51's highest level of physical and mental well-being. Findings: Review of the facility's P&P titled Care Plan Comprehensive dated 8/25/21, showed 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 and medical record review, the facility failed to provide the activities of daily living care for one of 35 sampled residents (Resident 912). * Resident 912 was not assisted with a shower or bed bath as scheduled for two weeks. This failure had the potential to put Resident 912 at risk for further skin breakdown, infection, and psychosocial harm. Findings: Medical record review for Resident 912 initiated on 12/19/23. Resident 912 was admitted on [DATE]. Review of Resident 912's H&P examination dated 12/08/23, showed the resident had the capacity to understand and make decisions. On 12/18/23 at 1131 hours, during an initial tour of the facility, Resident 912 stated he had not taken a shower since he came to the facility because the staff thought he was still infected. This made the resident feel uncomfortable. Review or Resident 912's Task for bathing documentation showed the following: - the check marks in the not applicable column for 12/7, 12/8, 12/9, 12/10, 12/11, 12/12, 12/13, 12/14,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 individualized activity program to meet the needs and interests of one of 35 final sampled residents (Resident 912). This failure had the potential for the resident to experience feelings of social isolation and boredom. Findings: Review of the facility's P&P titled Activity Programs dated June 2018 showed the activity program is designed to meet the interest of and support the physical, mental, and psychosocial well-being of each resident. The activity program is provided to support the well-being of residents and to encourage both independence and community interaction. Activities offered are based on the comprehensive resident-centered assessment and the preferences of each resident. On 12/18/23 at 1131 hours, Resident 912 was observed in room sitting in the wheelchair and watching something on a tablet. Resident 912 expressed wanting to join group activities; however, he stated, I have 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 provide the necessary care and services to ensure three of 35 final sampled residents (Residents 51, 79, and 125) attained and maintained their highest practicable well-being. * The facility failed to ensure Resident 79's orthostatic blood pressure (measure the blood pressure while laying down or sitting and again upon standing up) was monitored as ordered by the physician related to the use of an antipsychotic medication. This failure had the potential for the resident to experience adverse consequences from the psychotropic medication. * The facility failed to coordinate the care of Resident 125 with the contracted hospice. The facility failed to conduct a plan of care meeting with Resident 125, the hospice representatives, and facility representatives. This failure had the potential for Resident 125 to not receive appropriate care and treatment for hospice services. * The Social Service Director failed to coordinate 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 complete the assessment and initiated a care plan prior to the use of the side rails for one of 35 final sampled residents (Resident 14). This failure had the potential to put Resident 14 at risk for serious injuries. Findings: Review of the facility's P&P titled Use of Restraints revised April 2017 showed the definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which the staff applied it given that resident's physical condition (i.e., side rails are put back down, rather than climbed over), and this restricts his/her typical ability to change position or place, that device is considered restraint. Examples of devices that are/may be considered physical restraints include leg restraints, arm restraints, hand mitts, soft ties or vest, wheelchair safety bars, geri-chairs, and lap cushions and trays that…

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

Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the pharmaceutical services to ensure accurate reconciliation and administration of the medications for one of 35 final sampled residents (Resident 745) and two nonsampled residents (Residents 902 and 909). * The facility failed to ensure the administration of the controlled medications for Residents 902 and 909 were documented in the MARs. * The facility failed to ensure the change of medication administration instruction sticker was placed on the medication bubble packs when there was a change of order for Residents 745 and 902. These failures posed the risk for diversion of the controlled medications and medication administration errors. Findings: Review of the facility's P&P titled Documentation of Medication Administration revised 11/2022 showed a nurse documents all medications administered to each resident on the resident's MAR, and the administration of medication is documented immediately after it is given. Review of the facility's P&P…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medication error rate was below 5%. The facility's medication error rate was 22.22%. Two of three licensed nurses (LVNs 3 and 7) who were observed during the medication administration were found to have made errors. * LVN 7 crushed and mixed famotidine (medication used to treat stomach ulcers) and metoprolol (antihypertensive medication) in one medication cup and administered the medications together via GT for Resident 40. * LVN 7 failed to ensure the correct dosage of medications were administered when a residue was observed in the medication cup after administering the famotidine and metoprolol via GT to Resident 40. * LVN 7 failed to ensure the correct dosage of medication was administered when a residue was observed in the medication cup after administering calcium (supplement) via GT to Resident 40. * LVN 7 failed to flush Resident 40's GT with water in between administering ferrous sulfate (supplement), aspirin…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 (Dietary Aide 1) was competent to safely perform manual dishwashing. This failure had the potential for dishes used by residents to not be washed correctly which could lead to sanitation concerns. Findings: Review of the facility's P&P titled Pots and Pans-Sanitizing Solution revised on 8/31/18, showed to add sanitizing agent to third tank according to Environment Protection Agency-registered label use directions. Review of the facility's sanitizing solution directions for use in manual dishwashing showed to expose all surfaces of equipments, ware or utensils to the sanitizing solution for a period of not less than one minute. On 12/19/23 at 1150 hours, an observation and concurrent interview was conducted with Dietary Aide 1 with Dietary Aide 2 as the translator. Dietary Aide 1 was asked to describe the manual dishwashing process use to wash residents' dishes. Dietary Aide 1 stated he would scrub the dishes in the first sink with soap and water 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, facility document review, and facility P&P review, the facility failed to ensure one nonsampled resident (Resident 203) was provided with the CCHO (diet for diabetic) diet as ordered. This failure posed the risk for Resident 203 to have an increased blood sugar level . Findings: Review of the facility's census on 12/18/23, showed 227 of 239 residents in the facility received food prepared in the kitchen. Medical record review for Resident 203 was initiated on 12/18/23. Resident 203 was admitted on [DATE], with a diagnosis of heart failure (when the heart muscle does not pump blood as it should) and diabetes mellitus (a condition that affects the way the body processes blood sugar). Review of Resident 203's Order Summary Report showed to provide CCHO diet starting on 12/01/23. Review of the facility's document titled Daily Spreadsheet Tuesday dated 12/19/23, showed for the lunch meal, spiced apple will be served as dessert for the residents with CCHO diet. On 12/19/23 at 1053…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 provide to one nonsampled resident (Resident 124) adaptive equipment per physician order for the resident's dietary needs. This failure had the potential to negatively impact the resident's well-being. Findings: Review of the facility's P&P titled Adaptive Equipment-Feeding Devices revised on 8/30/19 showed, adaptive feeding equipment is used by residents who need to improve their ability to feed themselves in order to enable residents with physically disabling conditions to improve their eating functions, adaptive equipment should be provided by the dietary department. Type of equipment are: - built-up silverware - built-up dish with inner lip - special cups and glass holders - plate guards Medical record review for Resident 124 was initiated on 12/19/23. Resident 124 was admitted on [DATE]. Further review of the resident's medical record showed Resident 124 had dysphagia (difficulty swallowing). 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, and facility P&P review, the facility failed to ensure the facility staff and visitors who brought resident food from the outside were educated on safe food handling practices. This failure posed the risk for unsafe food handling which could result in food borne illness. Findings: According to the Code of Federal Regulations, Section §483.60(i)(3) Food Safety Requirements, the facility must have a policy regarding use and storage of food brought to residents by family and other visitors to ensure safe and sanitary, handlings, and consumption. Review of the facility's P&P titled Safe Handling of Foods from visitors dated 8/2021 showed the residents will be assisted in properly storing and safely consuming food brought into the facility for residents by visitors. The procedure includes label foods with the resident's name and the current date and use by date. On 12/18/23 at 1457 hours, an interview was conducted with RN 1. RN 1 was asked if she was trained on safe food handling practices and if visitors brought resident food from the outside received…

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

Based on observation, interview, medical record review, and facility document review, the facility failed to implement their infection control program and practices designed to help mitigate the development and transmission of infections in accordance with the facility's P&P. * The facility failed to implement their infection control surveillance program for the SNF from January 2023 through August 2023 and for the TRC from 1/1/23 to 2/4/23. The facility conducted surveillance of resident infections based only on the residents who were prescribed antimicrobials (medication used to treat infections). Residents who had signs and symptoms of infection but did not meet the McGeer's Criteria (a set of specific definitions to identify the infections in long term nursing facilities) for true infection and were not prescribed antimicrobials were not included in the facility's infection control surveillance program. * The facility failed to ensure the infection control practices were implemented in the facility's laundry room. These failures posed the risk for not identifying, managing,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 monitor and optimize the use of antibiotics for their residents as per the antibiotic stewardship. * The facility failed to inform the physician of the residents who had not met the McGeer's Criteria (a set of specific definitions to identify the infections in long term nursing facilities) and were prescribed antibiotics for two nonsampled residents (Residents 91 and 161). * The facility failed to accurately report the three nonsampled residents (Residents 15, 846, and 847) for October 2023 and one nonsampled resident (Resident 3) for November 2023 who had Syphilis (a chronic bacterial disease that is contracted by infection during sexual intercourse). Residents 15, 846, and 847 were reported as not meeting McGeer's Criteria in the Infection Prevention and Control Surveillance Log; however, the infection was met based on the facility's McGeer's Assessment. These failures posed the risk for the use of unnecessary…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of two sampled residents (Resident 1) received care in accordance with professional standards to promote healing of a pressure ulcer. * Resident 1 developed a pressure ulcer on his right heel. The facility failed to provide the treatments and interventions as ordered by the physician and plan of care on the consistent basis. This failure had the potential to delay the resident's healing of the wound. Findings: Review of the facility's P&P titled Skin Integrity Management dated 5/26/21, showed to implement the special wound care treatments/techniques as indicated and ordered. On 11/15/23 at 1031 hours, a wound observation was conducted at Resident 1's bedside with LVN 1 and CNA 1. Resident 1 was observed with a gauze bandage wrapped around his right heel. The bandage was dated 11/14/23. LVN 1 removed the bandage from Resident 1's heel. Observation of the right heel showed a wound covered in eschar,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 glucometer (medical devices to check resident blood sugar) calibration was performed daily to check the residents blood sugar check accurately. This posed the risk of glucometer malfunction to be undetected. Findings: Review of the manufacturer's guidelines titled Blood Glucose Monitoring System showed the purpose of control solution testing is to make sure the glucometer and test strips are working properly. Review of the Quality Control Record Blood Glucose Monitoring System for September 2023 at Station 1 North showed blank entries on 9/1, 9/3, 9/18, 9/21, 9/22, 9/27, 9/29, and 9/30/23. Review of the Quality Control Record Blood Glucose Monitoring System for September 2023 at Station 2 North showed blank entries on 9/1, 9/2, 9/3, and 9/18/23. Review of the Quality Control Record Blood Glucose Monitoring System for September 2023 at Station 3 South showed blank entries on 9/12, 9/13, 9/14, 9/15, and 9/17/23 to 9/30/23. Review of the Order Listing Report dated 10/26/23, showed the following: - 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 interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the grievances from Resident 1 were promptly addressed when Resident 1 expressed the concerns regarding the insulin medication administration, unprofessional staff conduct, and intravenous access. This failure had the potential for Resident 1 to feel hopeless and negatively impact his emotional well-being. Findings: Review of the facility's P&P titled Grievance/Complain, Filling dated 4/2017 showed all grievances, complaints or recommendations stemming from resident or family groups concerning issues of resident care in the facility will be considered. Actions on such issues will be responded to in writing, including a rationale for the response. The Grievance Officer, Administrator and Staff will take immediate action to prevent further potential violations of resident rights while the alleged violation is being investigated. The resident, or person filing the grievance and/or complaint 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, and facility document review, the facility failed to ensure medications were stored securely when: * There was no system for control and accountability of medications waiting for final disposition for controlled and noncontrolled medications. * The facility failed to check the refrigerator temperature to ensure all medications required to be refrigerated were stored at the appropriate temperatures. These failures posed a potential for diversion of non-controlled medications and controlled medications and had the potential for the residents to receive medications with altered integrity or potency. Findings: 1. Review of the facility's P&P titled DISPOSAL OF MEDICATIONS AND MEDICATION-RELATED SUPPLIES dated 6/2016 showed discontinued medications and medications left in the facility after a resident's discharge are destroyed. On 10/24/23 at 1120 hours, an inspection of the facility's Station 1 Medication Room was conducted with LVN 1. There were two open boxes designated for discontinued or remaining medications for discharged residents 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 invite one of six sampled residents (Resident 1) or the resident's representative to participate in the person-centered plan of care. This failure had the potential to violate Resident 1's rights in choosing the treatment options and making the decisions in care planning. Findings: Review of the facility's P&P titled Interdisciplinary Meeting (undated) showed the facility will invite the resident, if capable, and their family to care planning meetings and use its best efforts to schedule care planning meetings at times convenient for the resident and family. When a resident does not have family, or if the resident/ family requests it, the IDT will invite the Ombudsman to attend the care planning meeting. The IDT meetings may be conducted via teleconference. The IDT will revise the Comprehensive Care Plan as needed at the following intervals: - Per RAI schedules; - As dictated by changes in resident's condition; - 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 Intakes: CA00857635, CA00857839 Based on interview, medical record review, and facility P&P review, the facility staff failed to notify the physician for one of six sampled residents (Resident 1) of a change in condition related to low blood pressure. This failure had the potential for Resident 1 to not receive the appropriate care and services to treat medical conditions. Findings: Review of the facility's P& P titled Change of Condition (undated) showed the licensed nurse will notify the resident's attending physician when there is a significant change in resident's condition. Further review of the P&P showed the attending physician will be notified timely with a resident's change in condition. In emergency situations (e.g., a resident experiencing unexpected shortness of breath, intense pain, unexpected bleeding, serious abnormal lab or x-ray), the licensed nurse will immediately call attending physician. Closed medical record review of Resident 1 was initiated on 8/30/23. Resident 1 was admitted to the…

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

Based on interview, facility document review, and facility P&P review, the facility failed to implement their infection control program and practices designed to help mitigate the development and transmission of infections in accordance with the facility's P&P. * The facility failed to implement their infection control surveillance program between the months of February 2021 and March 2022. The facility conducted surveillance of resident infections based only on the residents who were prescribed antimicrobials (medications used to treat infections). Residents who with signs and symptoms of infection but did not meet the McGeer's Criteria for true infection and were not prescribed antimicrobials were not included in the facility's infection control surveillance program. * The facility failed to identify CAIs and HAIs for residents in the TRC, who acquired infections and were administered antibiotics for January and February 2022; and failed to conduct the monthly Infection Surveillance Report. These failures posed the risk for not identifying, managing, containing, and controlling…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 sanitary requirements were met in the kitchen as evidenced by: * The facility failed to ensure the cutting boards were in sanitary condition and with cleanable surface. * The facility failed to ensure the kitchen utensils had a smooth cleanable surface. * The facility failed to ensure the storage buckets were air dried prior to storing. These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food prepared in the kitchen. Findings: Review of the form CMS-672 Resident Census and Conditions of Residents completed by the facility dated 4/12/22, showed 222 of 238 residents residing in the facility received food prepared in the kitchen. 1. According to the 2017 FDA Food Code Section 4-202.11, multi-use food contact surfaces shall be smooth; free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections; free of sharp internal angles, corners, and crevices; and finished to have smooth welds and joints.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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's advanced directive was obtained and maintained in the medical record for one of 35 final sampled residents (Resident 59). This failure had the potential for the resident's decisions regarding her healthcare and treatment options to not be honored. Findings: Review of the facility's P&P titled Advance Directives revised 6/1/21, showed the purpose of an advance directive is to provide residents with the opportunity to make decisions regarding their health are. At the time of admission, the admission staff will inquire about the existence of an advance directive. A copy of the advance directive is maintained as part of the resident's medical record. Medical record review for Resident 59 was initiated on 4/12/22. Resident 59 was admitted to the facility on [DATE]. On 4/14/22 at 1201 hours, an interview was conducted with Resident 59. Resident 59 stated she formulated an advance directive specific to her…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 35 final sampled residents (Resident 91) was free from accident hazards. * The facility failed to implement the floor mats as per the care plan and physician's order to prevent or reduce the risk of injury for Resident 91. This had the potential for recurrent falls and serious injury. Findings: Medical record review was initiated for Resident 91. Resident 91 was admitted to the facility on [DATE], and readmitted to the facility on [DATE]. Review of the Fall Risk assessment dated [DATE], showed Resident 91 was a high risk for falls. Review of the MDS dated [DATE], showed Resident 91 had moderate cognitive impairment and had two or more falls in the last three months. Resident 91 had impairment to lower extremity and required extensive assistance from the staff for bed mobility. Review of Resident 91's plan of care showed a care plan problem revised on 2/4/22, addressing the risk for falls related to poor safety…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 pharmaceutical services to meet the needs of residents. * The emergency kit for injectable and suppository medications was not replaced in a timely manner. This failure had the potential for to contribute to a decreased availability of medications in an emergency. Findings: Review of the facility's P&P titled Medication Ordering and Receiving from Pharmacy revised June 2016, showed the nurse records the medication use from the emergency kit on the medication order and emergency kit use form and calls pharmacy for replacement of the kit and flags the kit with color coded lock to indicate need for replacement of the kit as soon as possible after the medication has been administered. Open kits are replaced within a new sealed kits within 72 hours of opening. On 4/13/22 at 1352 hours, during the inspection of Medication Storage room [ROOM NUMBER] with RN 1, the emergency kit for injectable…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 35 final sampled residents (Resident 87) was free from unnecessary drugs. * The facility failed to ensure Resident 87's pain medications had a unique indication or parameters for its use. Resident 87 had an order to receive ibuprofen (pain medication) and Tylenol (medication for pain and fever) for mild pain. This failure had the potential for the resident to receive unnecessary medication and develop significant side effects. Findings: Medical record review for Resident 87 was initiated on 4/12/22. Resident 87 was readmitted to the facility on [DATE]. Review of the Order Summary Report showed the following orders: - dated 1/9/22, to administer ibuprofen tablet 400 mg one tablet via GT every eight hours as needed for mild pain. - dated 2/22/22, to administer Tylenol 650 mg via GT every four hours as needed for mild pain. On 4/13/22 at 1547 hours, an interview was conducted with LVN 1. LVN 1 was asked how she would define mild,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 pharmaceutical services to meet the needs of each resident when: * The expired medications were stored in Medication Storage room [ROOM NUMBER]. * Residents 43 and 76's Xalatan (medicated eye drops) had expired and stored in Medication Cart 1. These failures had the potential to expose residents to contaminated and/or ineffective medications. Findings: 1. Review of the facility's P&P titled Storage of Medications revised June 2016, showed outdated, contaminated, or deteriorated medication and those in containers that are cracked, soiled or without secure closures are immediately removed from the inventory, disposed of according to procedures for medication disposal, and reordered from the pharmacy. Medication storage area are kept clean, well-lit and free of clutter and extreme temperature and humidity. On 4/13/22 at 1352 hours, during the inspection of Medication Storage room [ROOM NUMBER] with RN 1, the following 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 interview, facility record review, and facility P&P review, the facility failed to monitor the antibiotic use for one of 35 final sampled residents (Resident 15) and one nonsampled resident (Resident 69). * Residents 15 and 69 were prescribed antibiotics for conditions which did not meet 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). In addition, the Infection Control Monthly Summary for March 2022 failed to show the number of antibiotics prescribed for conditions which failed to meet McGeer's Criteria. These failures had the potential to expose the residents to unnecessary antibiotic use. Findings: According to the CDC, repeated and/or improper use of antibiotics is the primary cause of the proliferation of drug-resistant bacteria. Each time a person uses antibiotics, the sensitive bacteria are killed; however, resistant bacteria may result. These resistant bacteria may then grow and multiply. When the antibiotics fail to work, the consequences include longer lasting…

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