Driftwood Healthcare Center - Santa Cruz

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure care plans related to alleged abuse were reviewed and updated by the interdisciplinary team (IDT, a group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for the resident) for three of six residents (Residents 61, 63, and 75). This deficient practice had the potential to place the residents at risk of psychosocial and emotional distress. Findings: 1. Review of Resident 61's face sheet (summary page of a patient's important information) indicated, Resident 61 was admitted to the facility with diagnoses including chronic obstructive pulmonary disease (COPD, a disease that affects airflow in the lungs and makes it difficult to breathe), unspecified asthma (inflammatory disease of the airway that often causes wheezing, coughing, and shortness of breath), and pain in right shoulder. Review of Resident 61's admission minimum data set (MDS, an assessment tool) dated 4/21/2024, indicated 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 the proper use of side or bed rails (adjustable rigid bars attached to the side of a bed) for five (Residents 81, 285, 22, 26, and 28) of 14 residents (residents who used bed or side rails) when: 1. Residents 81 and 285 had side or bed rails even when their siderail evaluation revealed both residents did not require the use of siderails; 2. Residents 22 and 28 had side or bed rails even when their siderail evaluation revealed both residents did not require the use of siderails; and Residents 22 and 26 did not have a documented physician's order for the use of siderails. These failures had the potential to place the residents at risk of entrapment and serious injury. Findings: 1a. During an observation on 6/17/2024 at 10:18 a.m., inside Resident 81's room, Resident 81 was seated on a wheelchair and her bed was observed with right bed rail in upright position while the left bed rail was not raised up. During a concurrent observation and interview with director of nursing (DON) on 6/20/2024 at 10:05 a.m.,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 monitor, evaluate and managed residents' behavior for one of two sampled residents (Resident 285) when Resident 285 had episodes of screaming which sounded like a baby crying. The failure had the potential for Resident 285, not attaining her highest practicable physical, mental, and psychosocial well-being and caused discomforts to other residents in the same hallway (Residents19 and 61). Findings: During an observation on 6/17/2024 at 10:29 a.m., inside Resident 285's room, Resident 285 was lying in bed and her bed had two upper bed rails in upright position. Resident 285 was awake and quiet. During a concurrent observation and interview on 6/17/2024 at 12:44 p.m., inside Resident 19's room, Resident 19 was sitting at the edge of her bed. Resident 19 complained about the screamer, pointing towards Resident 285's room. Resident 19 stated, it was hard for her to sleep at night because of the screamer. During a concurrent observation and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide an appropriate social services (SS) support for four of six residents (Residents 61, 63, 75 and 285) when: 1. There was no documentation of timely SS support following Resident 61's complaint of missing money; 2. There was no SS support following an alleged abuse to Resident 63 and no documentation on SS follow up to address Resident 63's psychosocial needs; 3. There was no SS support following an alleged abuse to Resident 75 and no documentation on SS follow up to address Resident 75's psychosocial needs; and 4. There was no SS follow up to address Resident 285's behavior. These failures resulted in a lack of timely social services interventions and had the potential not to address Residents 61, 63, 75, and 285's psychosocial needs. Findings: 1. Review of Resident 61's face sheet (summary page of a patient's important information) indicated, Resident 61 was admitted to the facility with diagnoses including chronic obstructive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 appropriate pharmacy pharmaceutical services when: 1. A medication, Lamictal (a medication used to treat conditions such as bipolar disorder and seizure disorders) 200 milligrams (mg, unit of measure), was not available for one out of six residents (Resident 8), 2. There were discrepancies between the controlled drug (those with high potential for abuse and addiction) record (CDR, an inventory/accountability sheet) and the medication administration record (MAR) for four out of four residents (Residents 3, 22, 40, and 51), 3. A controlled substance medication was wasted without a witness for Resident 41, 4. The controlled substances medication destruction records did not have a registered nurse (RN) signature for three out of three residents (Residents 82, 335, and 336), and, 5. There was no CDR started for two controlled substances for Resident 47. These failures had the potential for Resident 8 to suffer from withdrawal symptoms; and resulted in the facility not having accurate accountability 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, interviews and record review, the facility failed to ensure 3 of 18 sampled residents (Residents 2, 41, and 59) were free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behaviors) when: 1. Resident 2 received five psychotropic medications without a gradual dose reduction (GDR, a tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) and without documented clinical rationale why the GDR was contraindicated (advised against in specified cases or under specified conditions); 2. Resident 41 received Seroquel (generic name: quetiapine, an antipsychotic medication) without specific and documented indication, and without an initial AIMS (abnormal involuntary movement scale, a rating scale designed to measure involuntary movements known as tardive dyskinesia, a disorder that sometimes develops as a side effect of long-term treatment 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.

Based on observation and interview the facility failed to ensure food served was palatable and attractive. This failure had the potential to affect the amount of food residents consume, which could decrease their food intake and lead to poor nutrition and health outcomes. Findings: As a result of multiple resident complaints about the food, in particular complaints about the meats served being hard and dry, a test tray evaluation was conducted during the lunch service on 6/18/24 at 1:35 p.m. The consultant dietary manager (CDM) was in attendance when the test tray contents were sampled by four surveyors. One meat item served on the test tray was a breaded chicken fillet. The fillet was thin and covered in a breading crust. The breaded chicken fillet was very hard and difficult to cut. The breading was dark brown and appeared to be overcooked. The meat inside was dry. All 4 of the surveyors who tasted the chicken concurred that the meat was hard, dry, and overcooked. The CDM stated the chicken tasted fine. A review of the facility document titled, Job Description: Cook, revised…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 food was stored, prepared, distributed, and served in accordance with professional standards for food safety when: 1. Pans and a bowls used for food preparation and food service were stacked and stored wet; 2. A cup was left inside the sugar container; 3. Unpasteurized eggs were used during a breakfast meal service. These failures had the potential to cause food contamination and food-borne illness to 79 of 79 residents who received their food from the kitchen. Findings: 1. During an observation on 6/17/24 at 9:16 a.m., there were 4 metal pans of various sizes observed to be stacked on a metal wire rack. The pans were stacked upside down inside of one another and were wet inside and outside of the pan's surfaces. There were 2 large metal bowls stacked upside down on top of each other and were wet on the inside and outside of the bowls. The consultant dietary manager (CDM) confirmed the pans and bowls were wet and she stated they should have been air dried before being stacked and stored. 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.

Based on observation, interview, and document review, the facility failed to ensure the dumpster lid was kept closed. This failure had the potential to attract pests in the facility. Findings: During an observation on 6/19/2024 at 11:15 a.m., inside the director of nursing's (DON's) office, the facility's dumpster could be observed through a window. The dumpbster was located at the back of the facility. One staff opened the dumpster's lid and threw a garbage. The staff left the dumpster lid open. During a follow up observation on 6/19/2024 at 11:29 a.m., through the DON's office window, the same dumpster lid was still left open. During a concurrent observation and interview with dietary supervisor (DS) on 6/20/2024 at 10:53 a.m., at the back of the facility, the blue dumpster was overflowing with cartons of boxes which kept the lid open. DS confirmed the observation. DS stated all the dumpsters' lids should be kept closed to prevent from attracting some pests. During a review of the facility's undated policy and procedure titled, Food Handling Practices, indicated, 12. Follow proper…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure call buttons (a red button used by residents to request assistance) were easily accessible for use for seven of 18 sampled residents (Residents 285, 286, 6, 80, 40, 13, and 49). This failure had the potential to cause delays in attending to Residents 285, 286, 6, 80, 40, 13, and 49's needs which could affect their physical and psychosocial well-being. Findings: 1. Review of Resident 285's face sheet (summary page of a patient's important information), indicated, Resident 285 was admitted on [DATE] with diagnoses including sepsis (blood poisoning due to an infection), anemia (a condition in which the body does not have enough healthy red blood cells), type 2 diabetes mellitus with diabetic polyneuropathy (DM, occurs when the body is unable to regulate glucose [sugar] in the blood, with nerve damage), unspecified dementia (a group of symptoms affecting thinking and social abilities interfering with daily functioning), dysphagia…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, functional, sanitary, and comfortable environment for the residents when: 1. Resident 59's room had bent window screens, a big hole on the wall, and the pipe at the toilet in his restroom was leaking every time the toilet was flushed; and 2. The walls at the heads of the beds of Resident 29 and Resident 72 were peeled off and the dry wall was exposed. These failures had the potential to adversely affect the health and safety and to create a poor quality of life for the residents. Findings: 1. During an observation and interview with Resident 59 in his room, on 6/17/24, at 10:39 a.m. the two window screens were bent; the wall next to the restroom door had a big hole; and the pipe at the toilet in the restroom which was shared by four residents was leaking every time the toilet was flushed. Resident 59 stated the bent window screens created spaces, and the bugs came in the room all the times. Resident 59 also stated the toilet pipe leaked and wet the floor, so he had to ask staff for the towels…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews, record review, and policy review, the facility failed to ensure two of eight residents (Residents 6 and 284) had been informed about having an advance directive (AD, legal form directing their wishes about their healthcare, whether from them or a named individual on their behalf), when no documentation was found about AD and the Physician Orders for Life -Sustaining Treatment (POLST, a legal document stating the kinds of medical treatment patients want toward the end of their lives) was not completed and readily available in the event of a medical emergency. This failure had the potential to result in inability to make medical decisions and could lead to the delivery of unnecessary or inappropriate medical services. Findings: 1. Review of Resident 6's face sheet (summary page of a patient's important information) indicated, Resident 6 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (also known as stroke), unspecified lack of expected normal physiological…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 policy review, the facility failed to protect a resident's rights to confidentiality of protected health information (PHI, any information in the medical record that can be used to identify an individual and that was created, used, or disclosed in the course of providing a health care service such as diagnosis or treatment) when the licensed nurse left the computer screen open and unattended on top of the treatment cart for two of eight residents (Residents 31 and 64). This deficient practice had the potential to compromise the resident's privacy and confidentiality. Findings: 1. During an observation on 6/24/2024 at 9:28 a.m., registered nurse K (RN K) left the computer screen open on Resident 31's physician's treatment orders at the hallway facing Resident 31's bedroom door. The physician's orders indicated Resident 31's wound treatments. The computer screen was left on while RN K was with Resident 31 providing incontinent care and wound treatment. During an interview 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.

Based on interview and record review, the facility failed to develop and implement a comprehensive care plan for one out of 18 residents (Resident 59) when they did not include a care plan to include goals, approaches, interventions, and the monitoring for the signs of symptoms of bleeding related to an anti-coagulant medication: Findings: Review of Resident 59's medical record indicated he was admitted to the facility with diagnoses including unspecified mood disorder and history of a traumatic brain injury. Review of Resident 59's physician order, dated 4/4/24, indicated Eliquis [an anticoagulant to prevent blood clots] 5 mg 1 tablet twice a day at 9:00 AM and 5:00 PM for DVT [deep vein thrombosis, a blood clot in a deep vein, usually in the legs] Prevention. A review of Resident 59's medical record indicated there was no comprehensive care plan developed for the use of Eliquis. During an interview and concurrent record review with the director of nursing (DON) on 6/20/24 at 1:02 PM, the DON stated There should be a care plan for Eliquis. Review of facility's policy and procedure,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the residents received the necessary care and services for two of 18 residents (10 and 184) when: 1. Resident 10 had five open skin areas on her face, but there was no treatment order for them; and 2. Resident 184 did not have floor mat at his bed side as ordered by the physician, recommended by the interdisciplinary team (IDT, a team comprises professionals from various disciplines who work in collaboration to address residents' needs), and indicated as one of the interventions in Resident 184's fall care plan. These failures had the potential to affect the residents' care and could jeopardize their health and well-being. Findings: 1. Review of Resident 10's admission Record indicated she was admitted to the facility on [DATE]. During an observation on 6/17/24, at 11:51 a.m., Resident 10 had five open skin areas on her face, but there was no treatment order for them. During the observations on 6/18/24, at 1:09 p.m., and 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 appropriate care and services for indwelling catheter for one of three residents (Resident 31) when Resident 31's indwelling catheter (a catheter which is inserted into the bladder [a sac-shaped muscular organ that stores the urine secreted by the kidneys],via the urethra [the tube through which urine leaves the body] and remains in place to drain urine) was not properly secured and the urinary tube connected to a urine drainage bag was filled with thick yellow sediments(caused by the precipitation of calcium, phosphorus, and magnesium minerals in the urine). This failure had the potential for the resident to develop urinary tract infection (UTI, an infection cause by a bacteria (germs) that get into the bladder or kidneys (a pair of organs that are on either side of the spine, just below the rib cage of a person's back). Findings: Review of Resident 31's Physician Order Report dated 5/21/2024-6/21/2024, indicated an order of indwelling foley catheter for diagnosis of obstructive uropathy (a disorder…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the Consultant Pharmacist (CP) identified and reported drug irregularities during the monthly medication regimen review (MRR); and that there was documented clinical rationale when the physician disagreed with the CP's recommendation, for two of 18 sampled residents (Resident 2 and 29). The failure resulted in Resident 29 receiving concomitant use of two medications in the same therapeutic class, the loop diuretics (a type of medication that exerts its action on certain part of the kidneys; used in the management and treatment of fluid overload conditions such as heart failure and high blood pressure), for over a year; and Resident 2 receiving five psychotropic medications (drugs that affects brain activities associated with mental processes and behavior) without the documented clinical rationale to support continued use. Findings: 1. A review of Resident 29's medical record indicated he was admitted to the facility with diagnoses including congestive heart failure (long-term condition that happens when your heart…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that one out of 18 sampled residents (Resident 29) was not receiving two medications of the same therapeutic class for over one year. This deficient practice had the potential for Resident 29 to receive unnecessary medication from duplicate therapy and increased risk of adverse effects from the medications. Findings: A review of Resident 29's clinical record indicated he was admitted on [DATE] with diagnoses including paroxysmal atrial fibrilliation (an irregular heart rhythm), type 2 diabetes mellitus (poor control of blood sugar levels) and chronic congestive heart failure (failure of the heart caused by enlargement). A review of Resident 29's physician orders indicated Resident 29 had an order, dated 5/23/2023, for furosemide 40 mg 1 tablet twice a day at 9:00 AM and 5:00 PM. Review also indicated Resident 29 had an order, dated 6/7/2024, for torsemide 20 mg 2 tablets once a day at 9:00 AM. Both medications are considered loop diuretics,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 had a medication error rate of 7.41% when two medication errors occurred out of 27 opportunities during medication administration for one out of six residents (Resident 8). This failure resulted in medication not given in accordance with the prescriber's order and facility policy and procedure (P&P), which resulted in resident not receiving the full therapeutic effects of the medications. Findings: 1. During a medication pass observation on 6/17/24 at 9:47 AM with Licensed Vocational Nurse (LVN) A, LVN A stated she did not have Lamictal (a medication used to treat conditions such as bipolar disorder and seizure disorders) 200 milligrams (mg, unit of measure) on hand to give to Resident 8. During the administration, LVN A administered two 25 mg tablets (50 mg total) to Resident 8 but did not administer a 200 mg tablet. During a concurrent interview and inspection of the medication cart with LVN A on 6/17/24 at 10:01 AM, LVN A stated the Lamictal 200 mg dosage was not in stock, and that she reordered the medication from…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medications and biologicals were stored appropriately when: 1. An emergency medication kit (e-kit, a kit/box containing medications for immediate use during a medical emergency) contained an expired medication in it. This had the potential for residents to be given expired medications in an emergency, which would be ineffective for their treatment. 2. A treatment cart with wound care supplies was left unlocked, and the cart's drawer was left opened. This had the potential for access to medications and supplies by unauthorized persons such as residents and visitors Findings: 1. During a concurrent medication storage inspection and interview with Licensed Vocational Nurse (LVN) C on 6/17/24 at 10:05 AM, one e-kit containing 8 tablets of lorazepam (medication to treat agitation or anxiety) 0.5 milligrams (unit of measurement) was observed with the expiration date of 04/2024. LVN C confirmed the expiration date of the lorazepam and…

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

Based on observation, interview, and record review, the facility failed to ensure resident food preferences were honored when Resident 46 disliked the planned lunch entrée. This failure had the potential to result in decreased food intake and potential weight loss. Findings: A review of Resident 46's tray card indicated she had a pureed diet ordered. The tray card indicated that she disliked fish. A review of the facility's lunch menu for 6/18/24 indicated the entrée to be served was breaded fish and baked potato wedges. During a tray line observation in the kitchen on 6/18/24 at 12:35 p.m., [NAME] J was observed plating Resident 46's lunch meal. [NAME] J placed one scoop of pureed fish onto the plate in addition to the other menu items. The kitchen aide covered the plate and placed the entire tray in the food delivery cart. When the cart was ready to be taken out of the kitchen for delivery to the dining room, the registered dietician (RD) was asked to view Resident 46's meal tray and compare it to the diet card of Resident 46. The RD confirmed Resident 46's tray card indicated she…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 snacks was in accordance with resident's needs, preferences, and requests for one (Resident 288) of seven sampled residents (residents who attended the resident council's meeting). This failure resulted in Resident 288's needs and preferences not being met. This failure had the potential for other residents not to have snacks in their requested times. Findings: During an interview in the resident council meeting on 6/19/2024 at 11:01 a.m., Resident 288 stated he was on antibiotics (a drug used to treat infections caused by bacteria and other microorganisms) which made his stomach upset. Resident 288 further stated the staff at night did not have crackers when he requested and so he stopped taking his antibiotics. Review of Resident 288's face sheet (summary page of a patient's important information) indicated, Resident 288 was admitted to the facility on [DATE] with diagnoses including acute on chronic systolic heart failure…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 document review, the facility failed to provide a safe, and comfortable environment for one of six residents (Resident 81) when Resident 81's headboard and footboard of bed were loose and wobbly. This failure had a potential to compromise residents' safety, well-being, and health. Findings: During a concurrent observation and interview with director of nursing (DON) and Resident 81 on 6/20/2024 at 10:05 a.m., inside Resident 81's room, Resident 81 was seated on a wheelchair. The following were observed: the wooden headboard of Resident 81's bed tilted to the left side and one screw on the right side was about to come off, and the footboard of Resident 81's bed was leaning forward and wobbly when touched. DON and Resident 81 confirmed above observations. During an interview with licensed vocational nurse A (LVN A) on 6/20/2024 at 3:58 p.m., LVN A stated staff should write any faulty equipment like bed not working, broken call light, or toilet not flushing to the maintenance log located at the nurse station. LVN A further stated staff should follow…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 sampled residents (1)'s plan of care for fall prevention was implemented during her readmission on [DATE]. This failure had resulted in Resident 1 falling out of bed with injury as bleeding from her nose and a lump on her forehead. Findings: Review of Resident 1's facesheet indicated readmission on [DATE] . During this readmission, Resident 1 was confused and agitated, and during the care coordination betweent the facility staff and hospice (special kind of care that focuses on the quality of life for people who are experiencing an advanced, life-limiting illness) staff, she had a fall. Review of Resident 1's Situation-Background-Assessment-Recommendation (SBAR)-Fall, dated 9/9/23, indicated, Resident 1 was found face down on the floor. She had bleeding from her nose and a lump on her right forehead. She complained pain to her face and was asked to call 911 for sending out to an acute hospital for further evaluation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 prevent accidents for one of two sampled residents (Resident 1) when: 1. Staff did not provide supervision or the required assistance, 2. Staff did not develop a care plan for Activities of Daily Living (ADL), and 3. Staff did not implement resident-centered interventions for falls. These failures resulted in Resident 1's fall in the facility with a fracture (broken) of the second cervical vertebra (vertebra of the neck). Findings: 1. Review of Resident 1's clinical record indicated she was admitted on [DATE] and had the diagnoses of Leigh's disease (a neurometabolic disorder that affects the central nervous system), restlessness and agitation, dementia (a disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), major depressive disorder (a mood disorder that causes persistent feelings of sadness and loss of interest), hypertension (high blood…

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

Based of observation, interview, and facility document review, the facility failed to ensure there was effective oversight for the Food and Nutrition Department as evidenced by: 1. Lapses in the delivery of services associated with staff competency (Cross-reference F802), accommodating resident food preferences (Cross-reference F806), food safety and sanitation (Cross-reference F812), and equipment maintenance (cross-reference F908); and 2. A lack of an effective system to determine portion sizes for therapeutic diets ordered in the facility. This failure to ensure dietetic services systems are accurately and effectively delivered may result in food borne illness for a highly susceptible population and/or not meeting the nutritional needs of the 50 residents who received food from the kitchen out of a facility census of 50. Findings: Review of the job description titled Dietary Lead, revised 5/30/2019 and signed by Dietary Lead (DL) 11/4/21, showed this position was responsible for coordinating the total operations of the dietary department and manages food service operations and…

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

Based on observation, interview and record review, the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service when: 1. Staff did not follow the pureed (foods that has been ground, pressed, blended, or sieved to the consistency of a creamy paste or liquid for people with chewing or swallowing difficulties) recipe. 2. Staff did not demonstrate the proper procedures for testing the strength of chlorine and did not know the standard temperature of the chemical low temperature dishmachine. These failures had the potential to decrease meal attractiveness, flavor, and nutrients, may result in not meeting the residents' nutritional needs, and improper dish machine use may lead to food-borne illness (illness resulting from contaminated food) for 50 out of 50 residents who received food from the kitchen. Findings: 1. During an observation and interview with the [NAME] on 8/16/2022 at 11:08 a.m., in kitchen, the [NAME] stated he was preparing puree green beans. The [NAME] added seven scoops 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 ensure food was stored, prepared, distributed, and served in accordance with professional standards for food safety when: 1. Temperatures for Time/Temperature Control for Safety Foods (TCS=food requires time/temperature control for safety) to limit the growth of pathogens (i.e., bacterial, or viral organisms capable of causing a disease or toxin formation) were above 41°F (°F, degrees Fahrenheit a temperature scale) in the kitchen walk-in refrigerator; 2. The metal part of the can opener blade was chipped off; 3. Staff did not perform hand hygiene when changing gloves; 4. Juice gun was placed nearby handwashing sink without splash guards and, 5. Garbage cans were not covered when not in use. These failures had the potential to cause cross contamination of food (cross contamination occurs when unclean surfaces or utensils spread germs to food and could potentially cause foodborne illness), the growth of microorganisms, and foodborne illness for 50 of 50 residents receiving food from the kitchen at 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 maintain the walk-in refrigerator and ice machines in safe operating and sanitary conditions when: 1. The walk-in refrigerator did not maintain food at safe temperatures, and 2. Staff did not follow manufacturer's guidelines for cleaning and sanitizing the ice machines. These failures may lead to food-borne illness (illness resulting from contaminated food) and infectious disease (disorders caused by organisms such as bacteria, viruses, fungi or parasites) for 50 out of 50 residents who were receiving food from the kitchen and using ice from ice machines at the facility. Findings: 1. During multiple observations on 8/15/2022 and 8/16/22 in the walk-in refrigerator, refrigerator temperatures were above 41°F (degrees Fahrenheit) and multiple Time/Temperature Control for Safety foods (TCS=food requires time/temperature control for safety) were above 41°F. (Cross-reference F812). During multiple observations on 8/15/2022 and 8/16/2022, in the Kitchen, the kitchen staff left the walk-in refrigerator door wide…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 infection control practices were implemented when: 1. Staff did not wear N95 masks properly; 2. Maintenance assistant (MA) did not wear his N95 (a high filtering face mask) while talking to another staff; 3. Housekeeper C (HKS C) did not remove gloves and did not perform hand hygiene in between task; 4. Laboratory staff (LS) was wearing gloves in the hallway. These failures had the potential to result in transmission of infection in the facility. Findings: 1. During an observation on 8/15/22 at 9:05 a.m., housekeeper A (HSK A) was observed wearing an N95 mask (N95, filtering facepiece device designed to achieve a very close facial fit that filters at least 95% of airborne particles) incorrectly. There were two straps of the N95 mask observed behind each ear of HSK A. There were no straps visible on the crown (topmost part of the skull or head) or behind the neck of HSK A. During a concurrent interview, HSK A confirmed there was no strap placed at the crown of her head or behind her neck and she…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 honor the choices of one of 13 residents (Resident 16) when her preference for taking her medication was not followed. This failure had the potential of negatively affecting her psychosocial well-being. Findings: During an observation and concurrent interview on 8/16/22 at 9:29 a.m. with the infection preventionist (IP) and Resident 16, the IP entered Resident 16's room with Resident 16's medications. The medications were in a small medicine cup covered with apple sauce. Resident 16 stated to the IP, that she likes them out of the apple sauce. Resident 16 stated, she prefers her medication in a larger clear cup, so she can see each pill, and apple sauce in a separate cup. Resident 16 further stated LVN D was aware on how she likes her medication. Resident 16 stated the medication started to melt in the apple sauce, and it tasted terrible. Resident 16 made a face of the medication tasted terrible, and she wanted her cranberry juice to get rid of the flavor in her mouth. During an interview on 8/17/22 at 1:37…

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

Based on observation and interview, the facility failed to ensure a safe and home like environment for two of three sampled rooms (Rooms AA and BB) when the sliding screen door and sliding cabinet door were off track. This failure had the potential to cause injury to residents and at risk for insects, rodents to enter the resident's room. Findings: During a concurrent observation and interview with registered nurse G (RN G) on 8/15/22 at 11:54 a.m. in room BB, the sliding screen door was observed off track. RN G stated the sliding screen door should be fixed to keep the residents safe and keep the room free from insects and rodents. During a concurrent observation and interview with certified nursing assistant H (CNA H) on 8/17/22 at 3:00 p.m. in room AA, the sliding door cabinet was observed off track. CNA H stated the sliding door cabinet that was off track could injure the residents using it. During an environmental tour with the department director (DD) on 8/18/22 at 12:16 p.m., he confirmed the above observations and further stated the issues should be fixed for residents'…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 care and service in accordance with professional standards of practice for one of 13 residents (Resident 21) when Resident 21's physician order for ketoconazole 2% shampoo was not administered as ordered. This failure had the potential to compromise the residents' health and could affect his well-being. Findings: During an observation on 8/16/22 at 7:37 a.m., Resident 21 had several red spots on his head and on his face. Review of Resident 21's physician order dated 6/24/22 indicated ketoconazole 2% shampoo (used to treat skin condition) one application topical once a day. Apply daily with showers for 14 days. The order was discontinued on 6/27/22. Review of Resident 21's physician order dated 6/27/22 indicated ketoconazole 2% shampoo one application topical once a day on Tuesday and Friday. Apply daily with showers for 14 days. The order had an end date of 7/8/22. The treatment administration record (TAR) further indicated the ketozonazole 2% shampoo was initialed seven times from 6/27/22 to 7/8/22.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the availability of medications to two of six residents (Resident 46 and Resident 54) when: an inhaler (a portable device for administering a drug used to be breathed in) and vitamin D2 (a nutritional supplement) were not readily available for residents. This failure had the potential for residents to miss the doses for treatment of shortness of breath and receive a supplement. Findings: 1. During a medication pass observation on 8/16/22 at 8:57 a.m., with registered nurse F (RN F), he did not administer Resident 46's Breo Ellipta (brand name for fluticasone-vilanterol, combination medication for the treatment of lung conditions that cause breathing difficulties or shortness of breath) for Resident 46. During a review of Resident 46's physician order dated 10/18/21, indicated to give Breo Ellipta blister; (type of sealed product packaging) with device; 100-25 micrograms (mcg, unit of measurement) per dose, one puff; inhalation, once a day at 9:00 a.m. During an interview with RN F on 8/16/22 at 2:03…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the pharmacy consultant's (PC) medication regimen review (MRR, the process of reviewing medications) recommendations for three out of 13 residents (Resident 11, 21 and 6) was followed-up and acted upon. This failure had the potential for the residents to suffer unnecessary adverse side effects that could negatively impact his/her physical, mental, and psychosocial wellbeing. Findings: 1. Review of Resident 11's MRR dated 7/6/22 indicated Resident has one or more orders for anti-hypertensive with hold parameters. Blood pressure results are not charted with each dose . During a concurrent interview and record review with the interim director of nursing (IDON) on 8/19/22 at 11:25 a.m., the IDON reviewed Resident 11's MRR and medication administration record (MAR) and confirmed Resident 11's blood pressure was not recorded with each dose. The IDON acknowledged the MRR should have been followed-up. 2. Review of Resident 21's MRR dated 1/5/22 indicated add separate monitoring for bleeding and bruising, current way does…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 two of 13 sampled residents (Residents 49 and 21) were free from unnecessary psychotropic medications (medication capable of affecting the mind, emotions and behavior) when: 1. For Resident 49, the facility failed to ensure there was a specific duration of use for a PRN (PRN as needed) psychotropic medication that exceeded 14 days for the use of Lorazepam (a medication for anxiety [persistent feelings of worry and fears]) and, 2. For Resident 21, failed to identify the specific target behavior for the use of Seroquel. These failures could result in lack of adequate monitoring and had the potential for the residents to receive unnecessary medications. Findings: 1. Review of Resident 49's physician order dated 10/18/21 indicated Lorazepam 0.5 milligrams (mg, unit of dose measurement) every 12 hours PRN as needed for agitation. The physician Order Report indicated Lorazepam was discontinued on 3/28/22. During an interview 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.

Based on observation, interview and record review, the facility had a medication error rate of 18.18% when six medication errors occurred out of 33 opportunities during medication administration for three out of six residents (Residents 46, 54, 5). This failure resulted in medications not given in accordance with the prescriber's orders which resulted in residents not receiving the full therapeutic effects of the medication. Findings: 1. During the medication pass observation on 8/16/22 at 7:37 a.m., with registered nurse F (RN F), he did not administer Resident 46's Breo Ellipta (combination medication for the treatment of lung conditions that cause breathing difficulties or shortness of breath). RN F administered one tablet of Amlodipine (medication to treat high blood pressure) when the medication bubble pack (sealed compartments for medications) indicated to 'give two tablets.' A review of Resident 46's physician order indicated to give Breo Ellipta blister; (type of sealed product packaging) with device; 100-25 micrograms (mcg, unit measurement) per dose, one puff; inhalation,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an alternative entrée of equal nutritive value when Resident 33 disliked the planned entrée. This failure had a potential to lead to unmet nutritional needs and weight loss for one of three sampled residents receiving foods from the kitchen at the facility. Findings: A review of Resident 33's lunch menu on 8/15/2022, indicated Resident 33 dislikes chicken, fish, carrots, cauliflower, liquid eggs, pork, spinach and strawberries and her preferences were cheese quesadilla, fruits, salad with dressing, milk (3/4 cup), and orange on her tray card. During a tray line observation in the kitchen and concurrent interview with the registered dietitian nutritionist (RDN) on 8/15/2022 at 12:03 p.m., Resident 33's lunch tray had mashed potato, gravy, broccoli, bread, apple crisp, milk, and cranberry juice. There was no chicken and no substitute for the chicken entrée. The RDN confirmed the observation and confirmed there was no substitute for the chicken entrée. The RDN further stated Resident 33 should have an…

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