Santa Clara Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete multiple Facility-Dialysis Unit Communication Report forms for one of seven residents (Resident 76). This failure had the potential to compromise the facility's ability to identify potential complications and implement interventions accordingly. Findings: Review of Resident 76's medical record indicated she was admitted on [DATE] and had diagnoses including end stage renal disease (ESRD, irreversible kidney failure) and dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificiallythrough a machine when the kidneys have failed). Further review of the medical record indicated Resident 76 received dialysis every Monday, Wednesday, and Friday. Resident 76's Facility-Dialysis Unit Communication Report forms were reviewed. There was a section on the bottom of these forms designated to fill out assessment information after the resident returned from dialysis. This information included the resident's vital…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 record review, the facility failed to ensure bed rails were assessed for the risk of entrapment (person's head, neck or body becoming trapped or entangled in the spaces of a bed's side rails, frame or mattress) for one of 45 residents (Resident 14). Resident 14 was observed to be in bed with two half bed rails elevated at the head of bed. There was no assessment supporting the bed rails were evaluated to be safe from entrapment. This failure created a potential for health and safety risk for the resident.Findings: Review of Resident 14's record indicated his most recent bed entrapment measurement device test results were dated 8/5/25. During an observation and interview with the Director of Maintenance (DOM) on 9/12/25 at 10:18 a.m., the DOM entered Resident 14's room and confirmed the resident had two half bed rails elevated at the head of bed. During the same interview on 9/12/25 at 10:18 a.m., the DOM who reviewed the record stated Resident 14's bariatric bed (hospital bed designed to safely accommodate and support people with higher body…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 record review, the facility failed to ensure two of five residents (Residents 85 and 95) were free from unnecessary medication when.1. Resident 95 had no side effects monitoring for rivaroxaban (an anticoagulant medication used to treat and prevent blood clots); and2. Resident 85 received furosemide (used to treat edema [fluid retention; excess fluid held in body tissues]) without monitoring for edema.These failures resulted in unmonitored side effects of anticoagulant medication and unmonitored medical condition. Findings:1. Review of Resident 95's clinical record indicated Resident 95 was admitted to the facility with diagnoses including type 2 diabetes mellitus (a condition which affects the way the body processes blood sugar) and acute embolism and thrombosis of unspecified deep veins of the left lower extremity (blood clot in the left leg).Review of Resident 95's physician's orders indicated she had an order, dated 12/26/23, for rivaroxaban oral tablet 10 milligrams (mg, unit of dose measurement) give one tablet by mouth one time a day for DVT (Deep vein…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 record review, the facility failed to provide food according to the scheduled menu for three of 172 residents (Residents 84, 89 and 196). The lunch menu for 9/8/25 indicated strawberry poke cake was to be provided and two residents were not served cake. This failure had the potential to cause disappointment for the residents. Findings: Review of the facility's lunch menu for 9/8/25 indicated strawberry poke cake was to be served. During a meal observation on 9/8/25 at 12:39 p.m., Resident 196 was eating lunch in her room and was served canned fruit and there was no cake on her tray. During an interview at the time of observation, Resident 196 stated, I want cake. During an observation on 9/8/25 at 12:40 p.m., Resident 89 received red jello and there was no cake on his lunch tray. During an observation and interview on 9/8/25 at 12:45 p.m., Resident 84 was eating lunch in her room and received red jello and no cake. Resident 84 then stated, I did not get cake. During an interview on 9/11/25 at 9:46 a.m., Registered Dietitian (RD) B stated dietary…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement their antibiotic stewardship program (program intended to prevent overuse of antibiotics) for one of five residents (Resident 168) on antibiotics (medications used to treat bacterial infections) when the McGeer Criteria (a tool used to track infection) and/or Loeb's Criteria (a tool used to determine when to initiate antibiotic treatment for suspected infections) were not done. This failure had the potential to increase the prevalence of multi-drug-resistant organisms in the facility.Findings:Review of Resident 168's admission record indicated Resident 168 was admitted to the facility on [DATE] with diagnoses including acute and subacute infective endocarditis (infection or inflammation of the inner lining of the heart and its valves), bacteremia (presence of bacteria in the bloodstream), methicillin susceptible staphylococcus aureus infection (a common type of infection that can be treated with standard antibiotics).Review of a physician's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a medication was administered as prescribed by the physician for one of three sampled residents (Resident 1) when Resident 1 received 12 doses of Tacrolimus (a medication used to suppress [preventing something] the immune system) 5 milligrams (mg, unit of measurement), which was 10 times the ordered dose of 0.5 mg. This failure had the potential to result in Tacrolimus toxicity (the quality of being poisonous or harmful) for Resident 1 and could potentially contribute to Resident 1's hospitalization on 4/19/25. Findings: A review of the manufacturer's Prescribing Information (PI, detailed description of a drug's uses, dosage range, side effects, drug-drug interactions [a change in a drug's effect on the body when the drug is taken together with a second drug], and contraindications that is available to clinicians) for Tacrolimus, issued in December 2018, indicated it is an immunosuppressant (a medication that weakens or reduces the activity of…

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

Based on observation, interview, and record review, the facility failed to follow guidelines for masking during respiratory illness season when four staff members were observed not wearing face mask. This failure had the potential to spread infection throughout the facility. Findings: During an observation on 2/25/25 at 10:20 a.m., licensed nurse A (LN A) was observed in nursing station BB with his mask down below his mouth, at chin level, which he pulled up when he saw the surveyor. During an observation on 2/25/25 at 10:23 a.m., certified nursing assistant B (CNA B) was observed by the nursing station CC with her mask down below the mouth, at chin level, which she pulled up when she saw the surveyor. During an observation and subsequent interview on 2/25/25 at 10:30 a.m., in the hallway near the director of nursing's office, the administrator in training (AIT) was observed with his face mask down below his mouth, at chin level, which he pulled up upon seeing the surveyor. The AIT stated he was in a patient care area and his face mask should have been pulled up. During an interview…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 record review the facility failed to ensure appropriate treatment and services were provided to one of two residents (Resident 1) when the restorative nursing assistant (RNA, program that helps residents to gain and improve quality of life by increasing their level of strength and mobility) services were not implemented per the physician's order. The deficient practice had the potential to result in residents' decline in range of motion. Findings: Review of Resident 1's clinical record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including Spondylosis without myelopathy or radiculopathy, lumbar region (general wear and tear of the lower back without any pressure on the spinal cord or nerves); post laminectomy lumbar region (a condition of the lower back after surgery to remove part of the vertebra (bone) to relieve pressure on the spinal cord or nerves); and difficulty in walking. Review of Resident 1's Order Summary Report, order date of 2/1/24, indicated,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 record review, the facility failed to ensure, staff performed their job functions competently according to standards of practice when one cook did not properly verbalize the cool down process for cooking any hot foods such as meat dishes. This failure had the potential to expose 175 residents to food borne illnesses. Findings: During an observation on 5/7/24 at 9:39 a.m., [NAME] J was seen attending to pots and pans on the stove. During an interview on 5/7/24 at 9:39 a.m., [NAME] J was asked about the proper coo ldown process for cooked foods such as meat dishes. [NAME] J stated, the food was cooked to 165 degrees Fahrenheit (F, scale for measuring temperature), then cooled down to 145 degrees F in one hour. [NAME] J said, he did not know, what should be the temperature in two hours or after. During an interview with the Dietary Services Supervisor (DSS) on 5/8/24 at 1:55 p.m., the DSS stated, any hot foods should be cooled down to 140 degrees F in one hour, then cooled down to 70 degrees F in two hours, and then cooled down to 41 degrees F 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 2. Review of Resident 55's medical record indicated Resident 55 was admitted on [DATE] and had diagnoses including diabetes (a disease that impairs the body's ability to control blood sugar) and depression (a mood disorder that causes persistent feelings of sadness and loss of interest). Review of Resident 55's Order Summary Report indicated Resident 55 had the following physician's orders, dated 1/24/24, for diabetes: 1. Insulin aspart (medication used to lower blood sugar) 100 units per milliliter (unit/ml, dose measurement) inject 14 units subcutaneously (SQ, under all layers of the skin) before meals; and 2. Insulin NPH (medication used to lower blood sugar) 100 unit/ml inject 7 units SQ two times a day. The Order Summary Report indicated Resident 55 also had a physician's order, dated 1/24/24, for venlafaxine (medication used to treat depression) 37.5 milligrams (mg, dose measurement) give 1 capsule by mouth one time a day for depression manifested by verbalization of sadness. Further review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility failed to ensure significant weight loss was monitored and assessed for one of five sampled residents (Resident 165) when staff did not address significant weight losses, did not initiate weekly weights, and did not convene an interdisciplinary team (IDT, team members from different departments involved in a resident's care) meeting regarding Resident 165's significant weight losses. These failures had the potential to result in Resident 165's further unplanned weight loss. Findings: A review of Resident 165's face sheet (document that supplies pertinent resident information) indicated she had an initial admission date of 11/17/23 and a readmission date of 3/8/24 to the facility. Resident 165's diagnoses included type 2 diabetes (a condition which affects blood sugar), congestive heart failure (heart cannot pump enough blood to meet the body's needs), fracture of the left femur (upper bone of the leg), anemia (low levels of healthy red blood cells), hypertension…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 record review, the facility failed to accurately complete the Minimum Data Set (MDS, an assessment tool) for two of 39 sampled residents (Residents 68 and 50). Failure to accurately assess had the potential to compromise the facility's ability to develop care plans and provide interventions to meet the residents' needs. Findings: Review of Resident 68's medical record indicated Resident 68 was admitted on [DATE] and had diagnoses including cerebral infarction (damage to the brain caused by lack of blood flow and oxygen), hemiplegia (a condition in which one side of the body is paralyzed), paraplegia (a condition in which the legs and lower body are paralyzed), and weakness. Review of Resident 68's Order Summary Report indicated Resident 68 had a physician's order, dated 11/27/23, to have one quarter bed rails (metal or plastic bars attached to the bed ranging in size from full to one-half, one quarter, or one-eighth lengths) as an enabler for turning and repositioning. Review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record reviews, the facility failed to ensure, a complete monitoring and documentation of the change of condition for one out of six residents investigated, (Resident 179), when nurses did not have complete documentation and monitoring for Resident 179's change of condition. These failures had the potential to affect the resident's care and could compromise the resident's health and well-being. Findings: During an observation of Resident 179 on 5/6/24 at 11:54 a.m., Resident 179 was sitting in his wheelchair, eating his lunch. He was able to eat by himself. Resident 179 was alert, oriented, verbally responsive and appeared comfortable. Review of Resident 179's admission record (document created when a resident is admitted to a healthcare facility) indicated, Resident 179 was readmitted on [DATE] with diagnoses including urinary tract infection (UTI, an illness in any part of the urinary tract, the system of organs that makes urine), site not specified, generalized muscle…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 record review, the facility failed to ensure proper care was provided to one of two sampled residents receiving oxygen (Resident 48) when Resident 48 did not have a physician order for her oxygen use. This failure had the potential to compromise Resident 48's health and well-being. Findings: Review of Resident 48's admission record (document created when a resident is admitted to a healthcare facility) indicated, Resident 48 was initially admitted to the facility on [DATE] with diagnoses including chronic respiratory failure with hypoxia (difficulty breathing with low oxygen levels), chronic obstructive pulmonary disease (COPD, a disease affecting breathing and the lungs) and type 2 diabetes (disorder in regulation of blood sugar levels). Review of Resident 48's Minimum Data Set (MDS, a required assessment tool) Section C indicated Resident 48 had a brief interview for mental status (BIMS, screening tool used to assess cognitive impairment in nursing homes and other long-term…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 record review, the facility failed to ensure accurate accountability of controlled medications (those with high potential for abuse and addiction) when random controlled medication use audit for three of eight residents (Residents 64, 173, and 183) did not reconcile. The medications were signed out of the Controlled Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications) but not documented on the Medication Administration Records (MAR) to indicate they were administered to the residents. The failure resulted in inaccurate accountability and had the potential for misuse or diversion of controlled medications. Findings: A review of Resident 64's clinical record indicated he had a physician's order, dated 12/5/23, for Norco (hydrocodone-acetaminophen, a controlled medication for pain) 5/325 milligrams (mg, unit of measurement) 1 tablet by mouth every 6 hours as needed for mild pain and two tablets by mouth every 6 hours as needed for severe pain. Review of Resident 64's CDR for Norco 5/325 mg indicated two…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 record review, the facility failed to follow a menu, approved by the facility's registered dietitian (RD) according to the facility's policy, for three out of three sampled residents, when a fruit cup was served instead of a snickerdoodle cookie for the consistent carbohydrate (CCD, eating the same amount of carbohydrates everyday, a nutritionally balanced diet to meet specific nutrition needs) renal diet and renal diet (diet that is low in sodium, phosphorous and protein). This failure had the potential to cause decreased food intake and compromise the resident's nutritional status. Findings: During an observation on 5/7/24 at 11:30 a.m., during the lunch time trayline process, three residents with either the CCD Renal diet or Renal Diet were seen getting a fruit cup in their tray. During an interview with the Regional Registered Dietitian (RRD) on 5/8/24 at 1:48 p.m., the RRD stated any menu substitutions need to be signed off by the facility's RD and placed on a log. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure hospice services were provided in accordance with professional standards of practice for one of three sampled residents (Resident 68) when Hospice Aide G (HA G) transferred Resident 68 with a Hoyer lift (mechanical lift, machine used to transfer immobile residents with a sling) without assistance from another person. This failure had the potential to compromise Resident 68's safety. Findings: Review of Resident 68's medical record indicated Resident 68 was admitted on [DATE] and had diagnoses including cerebral infarction (damage to the brain caused by lack of blood flow and oxygen), hemiplegia (a condition in which one side of the body is paralyzed), paraplegia (a condition in which the legs and lower body are paralyzed), and weakness. Review of Resident 68's Order Summary Report indicated there was a physician's order, dated 4/10/24, to admit Resident 68 to hospice services (a program that provides end-of-life care to individuals…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 record review, the facility failed to implement infection prevention and control practices for five out of 39 sampled Residents (Residents 5, 82, 37, 47, and 166, ) when: 1. Residents 5 and 82 were fed at the same time by two Certified Nurse Aides without performing hand hygiene; and 2. For Residents 37, 47, and 166, their urine drainage bags (a bag that collect urine) were on the floor; These deficient practices had the potential to result in transmission and spread of infection to the residents and staff in the facility. Findings: 1. During an observation on 5/6/24 at 7:37 a.m., Certified Nurse Aide (CNA) H was feeding Resident 82 and assisting Resident 5 with her meal. Hand hygiene was not performed when CNA H went back and forth in between Residents 5 and 82. During an observation on 5/7/24 at 8:13 a.m. and 5/9/24 at 8 a.m., CNA I was feeding Resident 82. CNA I was also observed assisting Resident 5 with her meal without performing hand hygiene. CNA I did not perform hand hygiene when she went back to feed Resident 82. During an interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were free from physical abuse for one out of two residents (Resident 1) when Resident 2 hit Resident 1 in the face, causing injury to Resident 1's above the eyebrow area and first aid being administered. Resident 2's act of hitting Resident 1 in the face was a deliberate act to inflict harm or injury, not accidental; therefore, his action was deemed a willful act and considered abuse. This failure had the potential to cause both physical and emotional harm to all residents. Findings: On 3/08/24, the facility submitted a facsimile (FAX, a telephonic transmission of scanned printed material) to the California Department of Public Health (CDPH) about a physical altercation between residents. The FAX indicated residents were observed in a physical altercation, and first aid was rendered to victim (Resident 1)'s skin tear on the right eye. Review of Resident 1's clinical record indicated he was admitted to the facility 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 record review, the facility failed to provide a safe and sanitary environment for residents when four of seven shower stalls were found to have molds. This failure had the potential to compromise residents' safety, health and well-being. Findings: During an environmental tour on 4/24/24 at 9:32 a.m., with the Environmental Services Director (EVS), the EVS verified that the shower stalls located in Stations A, B and C had molds on the tiles. The EVS stated he should have paid more attention to the shower stalls. The EVS further stated the floor machine used for cleaning does not reach the corners of the shower stalls. During an interview with Resident 1 on 4/24/24 at 11:22 a.m., Resident 1 stated some of the tiles in the shower stalls were cracked. During an interview with Resident 2 on 4/24/24 at 11:35 a.m., Resident 2 stated the shower stalls had molds. Resident 2 also stated the shower stalls were not cleaned properly. During a review of the facility ' s policy and procedure (P&P) titled, Homelike Environment, dated February 2021, the 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 interview and record review, the facility failed to ensure proper technique was used when transferring one of three sampled residents (Resident 1) with a Hoyer lift (machine used to transfer immobile residents with a sling). This failure resulted in Resident 1's assisted fall and had the potential to result in injury. Findings: Review of Resident 1's medical record indicated he was admitted on [DATE] and had the diagnoses of obesity (excessive body fat accumulation), need for assistance with personal care, and history of falling. Review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 10/6/23, indicated he had a brief interview for mental status (BIMS) score of 14 (a score of 13 to 15 indicates the resident is congnitively intact). The MDS also indicated Resident 1 was dependent on staff for transfers. Review of Resident 1's Progress Notes, dated 11/12/23, indicated he had an assisted fall during transfer from Hoyer lift to bed. The Progress Notes further indicated the Hoyer lift sling…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 record review the facility failed to ensure staff followed their fall policy for two of three sampled residents who fell and sustained injuries (Residents 1 and 2). Resident 1 fell eleven times and there were missing interdisciplinary team (IDT, members of the health care team who meet to discuss and plan residents' care) meetings to indicate comprehensive post fall assessments were conducted and post fall care plans were not consistently updated with preventative measures. For Resident 2, there was a lack of post fall monitoring of the resident's status. These failures placed residents at risk for further falls, pain and suffering and resulted in a delay in treatment for Resident 2's hip fracture. Findings: 1. During an observation on 12/4/23 at 3:16 p.m., Resident 1 was seated in a wheelchair in front of a nurses station, was pleasant and did not answer questions when spoken to. Review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 8/9/23, indicated the resident had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a care conference (a meeting with the resident or representative to discuss and plan care) was conducted for one of three sampled residents (Resident 1). The facility also failed to provide Resident 1 with a written summary of her baseline care plans (care plan developed within the first 48 hours that includes the minimum information necessary to properly care for the resident upon admission). These failures had the potential to compromise the resident's right to participate in developing and implementing her plan of care. Findings: 1. Review of Resident 1's medical record indicated she was admitted on [DATE] and discharged on 9/25/23. There was no documentation in the medical record that indicated a care conference was conducted with Resident 1 at any point during her stay in the facility. During an interview and concurrent record review with the social services director (SSD) on 12/4/23 at 12:36 p.m., the SSD explained care conferences should…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 record review, the facility failed to provide care and service in accordance with professional standards of practice for one of three sampled residents (Resident 1) when: 1. There were multiple days for which there was no documentation that wound treatment was provided as ordered; 2. Nurses did not administer Juven (supplement given to support wound healing) as ordered by the physician; and 3. Nurses inaccurately assessed the resident on multiple days. These failures had the potential to compromise Resident 1's health and well-being. Findings: 1. Review of Resident 1's medical record indicated she was admitted on [DATE] and had the diagnoses of fracture of the right leg (broken right leg), cellulitis (a skin infection), rheumatoid arthritis (disease that causes inflammation of the joints), and reduced mobility. Review of Resident 1's Nursing Documentation Evaluation, dated 7/13/23, indicated she had an open wound on her right outer ankle. Review of Resident 1's treatment administration…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 record review, the facility failed to ensure care and services were provided in accordance with professional standards of practice for four of six sampled residents (Residents 1, 2, 3, and 6) when: 1) Licensed nurses did not follow a physician's order for the administration of oxygen (O2 , a colorless, odorless reactive gas) for Resident 1; 2) Social services (SS) did not conduct an initial assessment and an admission care conference for Resident 1; 3) Registered dietitian's recommendation for Resident 1 was not followed; 4) Licensed nurses did not follow a physician order for Resident 1's follow up appointment with neurologist, cardiologist, orthopedic and spine center; and 5) There were no No Smoking; Oxygen in Use sign posted at the entrance of Resident 2, 3, and 6's bedroom. These failures had the potential to affect the residents' care and could jeopardize their health and well-being. Findings: 1) Review of Resident 1's clinical record titled, admission Record, indicated Resident 1 was admitted at the facility on 6/23/2023 with diagnoses…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 record review the facility failed to provide a thorough five-day investigation addressing an allegation of financial abuse to the California Department of Public Health (CDPH) in a timely manner for one of three sampled incidents of alleged resident abuse (Incident 1). This failure had the potential to delay corrective actions had the allegation had been proven true. Findings: Review of Resident 1's Social Services Note, dated 9/18/23 at 11:26 a.m., indicated the resident verbalized to several staff members of being financially abused by family members cashing her rent check monthly. On 9/18/23, the facility reported to (CDPH) regarding Resident 1's allegation of financial abuse. The 5-day investigation was not furnished. During a phone interview on 10/10/23 at 2 p.m., a request for the facility investigation was made and a Social Services Note, dated 9/22/23 at 2:45 p.m. was emailed. Review of the Social Services Note, dated 9/22/23 at 2:45 p.m. lacked information to support a thorough investigation was performed, it did not indicate if the resident had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for one of three residents investigated, (Resident 1), when the facility failed to ensure, for Resident 1: 1. a care plan specific to Resident 1's altercation with other residents and hitting them with his cane, was developed and 2. his care plan, related to episodes of wanting to have a cane or walker, indicating that it was unsafe for Resident 1 to use a cane or walker, was followed. These failures had the potential to result in the resident, not receiving the interventions and care, necessary to maintain their highest level of well-being. Findings: Review of Resident 1's clinical record indicated, Resident 1 was an [AGE] year-old male, initially admitted to the facility last 4/20/18, with diagnoses including, unspecified degenerative disease of nervous system (chronic condition that damage and destroy parts of the nervous system over time, especially the brain), dementia (loss of…

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

Based on observation, interview, and record review, the facility failed to implement a comprehensive person-centered care plan intervention for one of five sampled residents (Resident 1), when staff failed to ensure Resident 1's bed alarm (device that alerts staff if resident gets out of bed) was in place while Resident 1 was in bed. This failure had the potential for Resident 1 to sustain a fall injury. Findings: Review of Resident 1's at risk for falls/accident/injury care plan dated 3/7/2023 indicated, the interventions was to put pad alarm to bed, verify function, and placement. Review of Resident 1's Order Summary Report (OSR), dated 9/11/23, the OSR indicated, to monitor placement and functional status of pad alarm in bed. The OSR also indicated every shift for resident safety and keep pad alarm on at all times. During an observation on 9/11/23 at 11:45 a.m. in Resident 1's room, Resident 1 was sleeping in bed and no pad alarm observed in Resident 1's bed. Two wires were hanging from Resident 1's bed, one white wire connected to Resident 1's call light, the black wire 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.

Based on observation, interview, and record review, the facility failed to ensure: a. A refrigerated injectable antibiotic (to treat various infections) was stored at the appropriate refrigerated temperature to prevent freezing; b. An eye drop bottle and an inhaler were labeled properly with a pharmacy label to ensure it was used for the right residents; c. Eleven opened biologicals, multi-dose eye medications, inhalers, and insulin (medication to lower blood sugar level) vials were dated with an open and discard date, to make sure they were not used beyond the discard date; d. Twenty-two expired medications were not available for resident use; and e. One medication had the expiration date on the pharmacy label The deficient practices had a potential for residents to receive vaccine and medications with unsafe and reduced potency from being used past their discard date. Findings: 1. On 4/25/22 at 9:25 a.m., an inspection of the Station 4 Medication Room Refrigerator with licensed vocational nurse B (LVN B) identified 1 vial tuberculin vaccine (Brand name: Tubersol, a vaccine for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure 12 of 27 residents (9, 24, 148, 59, 499, 28, 399, 46, 95, 110, 124, and 151) received necessary and proper care and services when: 1. Certified nursing assistant Y (CNA Y) and certified nursing assistant Z (CNA Z) delivered Resident 24's lunch tray to Resident 9 and delivered Resident 101's lunch tray to Resident 24; 2. Resident 148 did not have heel protectors on as ordered; 3. Assessment for pain was not done prior to dressing change for Resident 499; 4. Dressing orders were not followed for Resident 499; 5. For two days, urinary catheter was not secured or anchored to thigh with device for Resident 499; 6. Toenail trimming was not completed for two residents (Resident 59, Resident 499) resulting in long unkempt nails; 7. Licensed nurses did not follow Resident 28's physician order for the rate of flow of the enteral feeding (a liquid nutrition through a tube, inserted into the belly); 8. Licensed nurses did not follow Resident…

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

Based on observation, interview, and record review, the facility failed to ensure accurate accountability and effective storage of controlled medications (those with high potential for abuse or addiction) when: 1. Random controlled medication use audits for four of four residents (Residents 53, 75, 128, and 399) did not reconcile. The medications were signed out of the Controlled Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications) but not documented on the Medication Administration Record (MAR, a medical record documenting administered doses of medication) to indicate they were given to the residents. 2. Four out of 4 medication cart controlled drug sign-in/sign-out sheets (a sheet used to reconcile inventory of controlled medications in the medication cart by the outgoing and incoming nurse during a shift change) were missing signatures of the outgoing and incoming nursing shift. The failure resulted in the facility not having accurate accountability of controlled medications and potential for abuse or misuse of these medications.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to act upon the Consultant Pharmacist's (CP) recommendations in a timely manner for two of 27 sampled residents (Residents 95 and 100). The failure resulted in medication-related problems, errors, or irregularities identified and reported by the CP not acted upon and resolved, and the potential for unnecessary medications (such as prolonged use, excessive dose, unmonitored use, duplication, etc.) for the residents. Findings: 1. A review of Resident 95's medical record (MR) indicated she was admitted to the facility with diagnoses including high blood pressure, chronic kidney disease (the kidneys filter waste and excess fluid from the blood), and dementia (memory problem) without behavioral disturbance. A review of Resident 95's MR indicated the following physician's orders: a. Celexa (an antidepressant) 20 milligrams (mg, unit of measurement) tablet: Give 1.5 tablet (30 mg) by mouth one time a day for depression (a mental health disorder) manifested by…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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, record review, the facility failed to ensure six out of 27 sampled residents (Residents 19, 38, 64, 95, 100, and 104) were free from unnecessary psychotropic medications (drugs that affects brain activities associated with mental processes and behaviors) when: 1. Resident 19 received Seroquel (an anti-psychotic medication) for schizophrenia (a chronic, severe mental disorder that affects how a person thinks, acts, expresses emotions, perceives reality, and relates to others) without evidence of behaviors or symptoms of schizophrenia. Also, there was no documented evidence the facility implemented non-pharmacological (non-drug) interventions before starting the Seroquel; 2. Resident 95 received olanzapine (an antipsychotic medication) without documented clinical indication of hallucinations. Also, she received olanzapine and Celexa (anti-depressant medication) without attempted gradual dose reductions (GDR, a tapering of a dose to determine if symptoms, conditions, or risks…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 record review, the facility had a 20.58% error rate when seven medication errors out of 34 opportunities were observed during a medication pass for 5 of 8 Residents (Residents 15, 62, 72, 96, and 249). These failures resulted in medications not given in accordance with the prescriber's orders and/or manufacturer's specifications, which resulted in residents not receiving the full therapeutic effect of the medications and may cause preventable side effects for the residents. Findings: 1. During a medication pass observation on [DATE], at 8:22 a.m., with licensed vocational nurse S (LVN S), LVN S was observed preparing thirteen medications, including a daily vitamin formula with minerals for Resident 62. A review of Resident 62's medical record indicated a physician's order, dated [DATE], for multivitamin 1 tablet by mouth one time a day for supplement. During an interview on [DATE], at 3:01 p.m., with LVN S, LVN S confirmed he gave Resident 62 a daily vitamin formula with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of 27 sampled residents (Resident 15) was free of a significant medication error when he received insulin lispro (brand name: Humalo) a rapid-acting insulin, medication to lower blood sugar level) twenty-six (26) times (doses) past the discard (expiration) date. This deficient practice had the potential for ineffective use of the insulin, resulting in uncontrolled high blood sugar for the resident. Findings: On [DATE] at 5:09 p.m., at Resident 15's bedside, licensed vocational nurse D (LVN D) was observed obtaining the resident's blood sugar (BS) via the fingerstick. The BS was 290 milligrams per deciliter (mg/dL). During a medication pass administration on [DATE], at 5:15 p.m., with licensed vocational nurse (LVN D), LVN D was observed preparing six medications, including Humalog for Resident 15. LVN D drew 6 units from the Humalog vial. During the same medication pass administration on [DATE], at 5:22 p.m., with LVN D, LVN D…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 provide and served food that was palatable and at an appropriate temperature. These failures placed the 135 residents eating at the facility at risk of poor food intake further compromising their nutritional status. Findings: During an interview with Resident 123 on 4/25/2022 at 8:34 a.m., Resident 123 stated he did not like the food especially the vegetables. During an interview with Resident 86 on 4/252022 at 9:56 a.m., Resident 86 stated the food was terrible, hot food was not served hot and cold food was not served cold. During an interview with Resident 21 on 4/25/2022 at 10:59 a.m., Resident 21 stated she did not like the food at the facility. The Resident 21 further stated, taste terrible. During an interview with Resident 59 on 4/26/2022 at 11:46 a.m., Resident 59 stated she did not like the food at the facility. The Resident 59 further stated, It is awful. No flavor or too strong. The food is honestly the worst. It is disgusting. I just refused to eat it. A review of the facility menu for…

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

Based on observation, interview and facility document review, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety when: 1. The walk-in freezer had ice buildup. 2. The staff did not practice proper hygiene during meal distribution. 3. Food containers were stacked wet. These failures had the potential to cause the growth of microorganisms which could cause foodborne illness or cross contaminate food (cross contamination occurs when unclean surfaces or utensils spread germs to food and can potentially cause foodborne illness) for the residents eating at the facility. Findings: 1. During an initial observation of the kitchen on 4/25/2022 at 8:16 a.m., the walk-in freezer had a stalactite-like (a water droplet freezes) ice buildup at the tubing. The ice buildup made some drippings on top of the box located under it which was frozen. During a concurrent observation and interview with the food and nutrition services director (FNSD) on 4/26/2022 at 9:40 a.m., there was no ice buildup observed. The…

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

Based on observation, interview and record review, the facility failed to implement infection control practices when: 1. Certified nurse assistant F (CNA F) did not perform hand hygiene before and after assisting Resident 21 and Resident 145 with lunch; 2. Licensed nurses did not properly store Resident 36's nasal cannula (a tubing used to deliver oxygen (a colorless and a life supporting component of the air) from the machine through the nostrils) when not in use; 3. A licensed staff failed to wipe down the vial stopper of an insulin (a medication for high blood sugar) vial before drawing up the medication; and 4. Two nursing staff used the incorrect disinfectant wipe to clean/disinfect the glucometer (a medical device used to measure blood sugar levels) after resident use. These failures had the potential for spreading of infections and to compromise the health and safety of the residents in the facility. Findings: 1. During a dining observation on 4/25/2022 at 12:14 p.m., inside station three's dining room, Resident 145 and Resident 21 were having lunch, sitting across the table.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 treat two of four residents (Residents 21 and 36) with respect and dignity when: 1. Certified nurse assistant F (CNA F) was standing while feeding Resident 21; 2. Licensed vocational nurse C (LVN C) was standing while feeding Resident 36. These failures had the potential to negatively affect residents' emotional and psychosocial well-being. Findings: 1. A review of Resident 21's clinical records indicated Resident 21 was admitted to the facility with diagnoses including heart failure (a condition in which the heart does not pump blood as well as it should) and bipolar disorder (mental disorder characterized by periods of elevated mood and depression, often with poor decision-making). A review of Resident 21's minimum data set (MDS, an assessment tool) significant change in status assessment, dated 1/12/2022, indicated Resident 21's brief interview for mental status (BIMS, cognition level) score was 15 meaning Resident 21 had intact cognition. During a dining room observation on station three 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 and record review, the facility failed to ensure two of 12 residents (108 and 127) had informed consents (written permission before implementing a healthcare intervention) prior to initiating psychotropic medication (medication capable of affecting the mind, emotions, and behavior). This failure resulted in the residents receiving psychotropic medications without being informed about their risks and side effects. Findings: 1. Review of Resident 108's admission Record indicated he was admitted to the facility on [DATE] with depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) diagnosis. Review of Resident 108's physician order indicated he received paroxetine (used to treat depression) 20 milligrams (mg, a metric unit of mass) 0.5 tablet every day for depression started on 3/25/22, but there was no informed consent found for Resident 108's paroxetine. During an interview with the director of nursing (DON) on 5/2/22 at 3:35 p.m., she reviewed Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of three residents (148) received services and treatment to prevent further decrease in range of motion (ROM, refers to how far a person can move or stretch a part of the body, such as a joint or a muscle) when a hand roll was not applied to Resident 148's contractured left hand as ordered. This failure had the potential to result in declining of the ROM for Resident 148's left hand. Findings: Review of Resident 148's admission Record indicated he was admitted to the facility on [DATE] with diagnoses including hemiplegia (a severe or complete loss of strength in the arm, leg, and sometimes face on one side of the body), hemiparesis (a relatively mild loss of strength in the arm, leg, and sometimes face on one side of the body), and dementia (the impaired ability to remember, think, or make decisions that interferes with doing everyday activities). Review of Resident 148's Minimum Data Set (MDS, a clinical assessment tool),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 record review, the facility failed to consistently complete the dialysis (the clinical purification of blood as a substitute for the normal function of the kidney) post assessment for four of four residents (Residents 2, 46, 111 and 137) who received dialysis services. Failure to assess had the potential to compromise the facility's ability to identify and address potential complications after dialysis. Findings: 1. Review of Resident 2's clinical record indicated he was admitted on [DATE] and had the diagnosis of end stage renal disease (kidneys are no longer able to work as they should to meet the body's needs). The clinical record further indicated Resident 2 received dialysis on Tuesdays, Thursdays and Saturdays. Review of Resident 2's dialysis assessments indicated the dialysis post assessment was not completed consistently. The dialysis post assessment was to be completed by the facility nurses upon Resident 2's return from dialysis. The dialysis post assessment was to be completed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents' food was stored in a safe and sanitary manner, when one of three refrigerators designated for residents had perishable food (likely to spoil, decay or become unsafe to consume) that were not dated and discarded, and staff food or drinks were stored inside the same refrigerator. This failure had the potential for the contamination of residents' food. Findings: During a concurrent observation and interview with registered nurse AA (RN AA) on 4/29/2022 at 3:41 p.m. in Station 3, the residents' refrigerator was located inside the medication room. The resident refrigerator's door had signage which indicated, ALL FOOD MUST BE LABELED WITH NAME AND DATE PRIOR TO STORAGE IN FRIDGE. FOOD IS ONLY GOOD FOR 72 HOURS. FOOD WITHOUT LABEL WILL BE TOSSED WITHIN 24 HOURS (highlighted in red). PLEASE USE PEEL OFF LABEL AT THE BACK OF THIS FORM. A white plastic bag with Resident 147's last name and room number, dated 4/24 was observed inside the refrigerator. Inside the plastic bag were opened store…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 record review, the facility failed to implement its policy and procedure to ensure all staff were fully vaccinated for COVID-19 (a new infectious viral disease that can cause respiratory illness) when there was no evidence proof of vaccination were obtained for two certified nursing assistants (CNA T and CNA U). This had the potential to spread COVID-19 infection to staff, residents, and visitors. During interview and concurrent record review with the Infection Preventionist (IP), on 4/25/2022 at 2:02 p.m., the IP stated that two certified nursing assistants are booster eligible for the COVID-19 vaccine and had not provided proof of vaccine. The IP stated neither CNA provided a declination from either their clergy or a health care provider to the facility. She stated these staff that should have been vaccinated per the CDC (Centers for Disease Control and Prevention) recommendations and guidelines or they should have a declination on file. The IP was unable to provide a declination for exemption the booster for either CNA. The IP stated she informed the…

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

Based on observation interview, and record review, the facility failed to provide a safe and comfortable environment for seven of seven residents and any visitors when the janitor closet door on the memory care unit was open to the hall with cleaning chemicals inside. This had the potential to adversely affect the health and safety of those seven residents and any visitors. Findings: During observation and concurrent interview with licensed vocational nurse A (LVN A) on 4/29/2022 at 11:52 a.m., LVN A confirmed the observation the door was unlocked, open, and seven residents were sitting around the open door to the janitor closet. LVN A stated the door should be closed and locked because there were cleaning chemicals in the closet and the residents should not have access to the chemicals for safety reasons. During interview with the maintenance director (MD), on 4/29/2022 at 12:01 p.m., MD stated the door should always be shut and locked to the because residents could go in the closet and have access to chemicals. He confirmed the observation there was three bottles of Microkill…

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