Redwood Grove Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement their abuse policy and procedure (P&P) when: 1. For Resident 1, staff did not report an incident of potential abuse to the state agency and other required agencies; and 2. The facility did not provide abuse training to all staff at least quarterly. These failures had the potential to delay the investigation of abuse allegations and place residents at risk for further potential abuse. Findings: 1. Review of Resident 1's clinical record indicated he was admitted on [DATE] and had the diagnoses including cerebral infarction (known as a stroke, a damage to tissues in the brain due to a loss of oxygen), difficulty in walking, muscle weakness, aphasia, type 2 diabetes (high blood sugar), hypertension (high blood pressure), and major depressive disorder (a mood disorder that causes a feeling of sadness and loss of interest). Review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 1/22/24, indicated he had a brief interview 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 record review, the facility failed to ensure: 1. The Registered Dietitian comprehensively evaluated the effectiveness of food service operations as evidenced by lapses in the delivery of services associated with meal palatability and nutritional value (cross-reference F804) food safety (cross-reference F812); and 2. A competent staff was in the position of the Director of Food and Nutrition services to oversee the day-to-day operations of Food and Nutrition Services, when the Registered Dietitian (RD) did not have full time work status. The failure to ensure dietetic services systems were accurately and effectively delivered had the potential to result in a compromise in the nutritional status of residents through the transmission of foodborne illness, and/or decreased nutritional intake due to poor resident acceptance of meals for 87 residents who ate food by mouth out of a facility census of 89. Findings: During the annual recertification survey from 2/14/22 to 2/23/22, there were multiple issues identified with the delivery of food services,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 in a safe and sanitary manner, when food brought in by staff was not separate or easily distinguishable from resident food brought in by family members and/or other visitors. This failure had the potential for the contamination of resident food and/or residents receiving contaminated food, for 87 residents who ate food by mouth out of a facility census of 89. Findings: On 2/14/22 at 9:05 a.m., an observation of the inside of a reach-in refrigerator located in the kitchen, showed a plastic, store bought container was filled with a dark substance. The plastic container was labeled pork blood. The container outside surface was sticky. The container of pork blood was stored inside a plastic tub with other frozen meats, including fish wrapped in an opened plastic wrapper, 3 packages of chicken wings, and 3 pieces of wrapped meat that were not labeled. On 2/14/22 at 10:23 a.m., in an observation and interview with Dietary Aide G (DA G), DA G stated the pork blood was brought in 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.

Based on observation, interview and record review, the facility failed to ensure that wastes were properly contained in garbage dumpsters when two out of three garbage dumpsters were overfilled with garbage, so lids were not closed, and three out of three garbage dumpsters had lids that would not lay flat when lowered. These failures had the potential to attract pests to the facility and expose residents to pest related disease for 89 residents out of a facility census of 89. Findings: According to the 2017 Federal Food Code, outside receptacles and waste handling units for refuse, recyclables, and returnables used with materials containing food residue shall be designed and constructed to have tight-fitting lids, doors, or covers. The tight-fitting lids are to prevent the scattering of garbage or refuse by birds, the breeding of flies, or the entry of rodents. During a concurrent observation of the outside trash area located behind the kitchen and interview with the Maintenance Director (MD), on 2/15/22 at 9:49 a.m., two out of three garbage dumpsters were overfilled with garbage,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a sanitary environment in the staff breakroom where resident foods were stored when used beverage containers were located directly under the sink cabinet of the cabinet's black matter covered floor base. These failures had the potential to affect the health and safety of the staff and 89 residents at the facility by exposure to disease carrying pests. Findings: During an observation on 2/15/22 at 9:05 a.m., inside the the staff breakroom, underneath the cabinet sink were six empty beverage containers on the floor (four flavored iced tea cans, one cola can and one excercise beverage bottle). The floor surface inside the area under the cabinet sink had black matter on it. The refrigerator used to store resident food and the ice machine used to provide ice to the residents were also located inside the staff breakroom. During an interview with the maintenance director (MD), on 2/15/22 at 9:24 a.m., MD verified there should be no empty beverage containers inside the cabinet floor area under the sink 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 record review, the facility failed to consistently monitor temperatures for two out of three medication refrigerators. This failure had the potential to result in residents receiving medications with decreased potency or efficacy. Findings: During an observation on 2/14/2022 at 9:17 a.m., accompanied by the treatment nurse (TN), medication refrigerator A (Med Ref A) was inspected. There were several bottles of eye drops and one Trulicity pen (injectable medication used to control blood sugar) inside Med Ref A. Review of the 1/2022 and 2/2022 temperature logs for Med Ref A indicated the temperatures were to be monitored on the morning (AM) and evening (PM) shifts. From 1/1/2022 to 2/14/2022, there were 26 shifts for which there was no documentation that staff monitored the temperature of Med Ref A. During a concurrent interview with the TN, she confirmed the Med Ref temperature must be monitored on the AM and PM shifts. The TN reviewed the temperature logs for Med Ref A and acknowledged staff did not monitor the temperature during several shifts.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 palatability and nutritive value of cooked foods were maintained when: 1. The recipe for making pureed foods were not followed and 2. Pureed foods were held in the heated oven for an extended time. These failures had the potential to result in decreased palatability leading to decrease in food consumed by residents; and, food held in the heated oven for extended time periods could lose nutritive value, leading to a decreased nutrient intake for 8 residents with a Puree diet order out of a facility census of 89. Findings: During an observation and concurrent interview with [NAME] B, on 2/14/22 at 10:34 a.m., metal pans covered with foil were in the oven. [NAME] B stated the items in the pans were pureed fish and pureed spinach. She stated she did not cook the fish for the Regular textured diets yet. During an interview on 2/15/22 at 9 a.m., [NAME] B stated she usually blended the pureed food for lunch at 9:30 a.m. During an observation and interview with [NAME] B, on 2/15/22 at 9:56 a.m., [NAME] B was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement infection control practices and precautions when: 1. Facility staff did not follow the infection control policy when moving Resident 15 from the red zone (area for residents that tested positive for SARS-CoV-2, a virus that can cause COVID-19, a mild to severe respiratory illness) to the green zone (area for residents that tested negative for SARS-CoV-2) ; 2. Housekeeper supervisor (HS) and visitor did not wear appropriate PPE (personal protective equipment; N-95 (type of particulate filtering facepiece respirator mask), gloves, gown and faceshield) while in the yellow zone (area designated for residents who have had a known exposure to coronavirus 2019), room; 3. Registered Nurse L (RN L) did not wear a complete PPE upon entering a yellow zone room; 4. For Resident 7, the oxygen concentrator's (medical device that gives extra oxygen) humidifier bottle was undated and oxygen filter was dusty; 5. For Resident 32, the treatment…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an advance directive (AD, a written instruction, such as a living will or durable power of attorney for health care when the individual is incapacitated) or Physician Orders for Life-Sustaining Treatment (POLST, a form designed to improve patient care by creating a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency) was available, completed, and accurate for 4 of 18 sampled residents (Residents 12, 25, 29, and 42). These failures had the potential to result in the facility omitting, providing unnecessary or inappropriate medical treatment and services that was against the resident's goals and wishes. During a review of Resident 12's admission Record, the admission Record indicated Resident 12 was admitted with multiple diagnoses including multisystem degeneration of the autonomic nervous system (a disorder affecting the body'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 meet professional standards for one of 18 residents (32) when social service assistant P (SSA P) pasted Resident 32's name, date of birth , and date of admission on Resident 87's A1C (a blood test that measures the average blood sugar level over the past 3 months) test result to produce Resident 32's A1C test result, and the director of nursing (DON) agreed and signed this produced A1C test result that he faxed to the physician. This failure resulted in inaccurate A1C test result for Resident 32 and could have adverse effects on Resident 32's treatment and well-being. Findings: Review of Resident 32's admission Record indicated he was admitted to the facility on [DATE] with diagnoses including depression (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with the daily functioning) and anxiety (intense, excessive, and persistent worry and fear about everyday situations). Review of Resident 32's physician…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Review of Resident 23's medical record indicated he was admitted on [DATE] and had the diagnosis of epilepsy (a disorder that causes seizures). Review of Resident 23's medication administration record (MAR) indicated he had an order, dated 4/9/2020, for Tegretol (medication used to treat seizures) 500 milligrams (mg, unit of dose measurement) by mouth every morning and at bedtime. The MAR further indicated Resident 23's morning dose of Tegretol was scheduled to be administered at 9:00 a.m. During an observation on 2/16/2022 at 9:19 a.m., licensed vocational nurse I (LVN I) administered medications to Resident 23. As LVN I was preparing the medications, she was unable to find Resident 23's Tegretol in the medication cart. She finished preparing the rest of the medications and administered them to Resident 23. LVN I did not administer Tegretol to Resident 23 during the observation. During an interview with LVN I on 2/16/2022 at 10:55 a.m. (almost two hours after the scheduled administration time for Tegretol),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 environment free of accident hazards for two of 18 sampled residents (Residents 54 and 347) when: 1. Facility staff did not complete quarterly smoking assessments for Resident 54; and 2. Facility staff gave coffee to Resident 347, who was not supposed to receive any food or fluids by mouth. These failures placed the residents at risk for accidents and subsequent harm. Findings: 1. Review of Resident 54's medical record indicated he was admitted on [DATE] and had the diagnoses of epilepsy (a disorder that causes seizures), hemiplegia (one side of the body is paralyzed), cataracts (an eye condition that causes blurred vision), and psychosis (a severe mental disorder). During an observation on 2/16/2022 at 1:41 p.m., Resident 54 was sitting in his wheelchair smoking a cigarette in the designated smoking area. Review of Resident 54's care plan, dated 5/9/2020, indicated he smoked daily and was at risk for injury related to smoking.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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. During a review of Resident 25's admission Record, the admission Record indicated Resident 25 was admitted with multiple diagnoses including end stage renal disease (ESRD, kidneys no longer work as they should to meet your body's needs), dependence on renal dialysis (a treatment for people whose kidneys are failing), and type 2 diabetes mellitus (a condition which affects the way the body processes blood sugar). During a review of Resident 25's Minimum Data Set (MDS, anassessment tool), dated 1/24/22, it indicated he had a brief interview for mental status (BIMS) score of 15 (a score of 13 to 15 indicates the resident is cognitively intact). During a review of Residents 25's Medication Administration Record (MAR), for 2/22, the MAR indicated levothyroxine sodium tablet give on an empty stomach or 30 minutes before food. Order dated 7/15/21 scheduled at 6:30 a.m. During a review of Resident 25's MAR for 2/22, it indicated Renvela . (Sevelamer Carbonate) give . by mouth with meals. Order dated 7/14/21,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 three of 11 residents (32, 75, and 88) were free from unnecessary psychotropic medications (drugs that affects brain activities associated with mental processes and behaviors) when: 1. Resident 32 did not have informed consent (the process in which a health care provider educates a resident about the risks, benefits, and alternatives of a given procedure or intervention) for Abilify (used to treat certain mental/mood disorders) 10 milligrams (mg, a metric unit of mass), and his A1C (a blood test that measures the average blood sugar levels over the past 3 months) and lipid panel (a blood test that measures fats and fatty substances used as a source of energy by the body) tests were not done as ordered by the physician; 2. Resident 75 was not monitored for the side effects of Lexapro (used to treat depression, a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with the daily functioning, 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 the policy regarding use of emergency medication kit was implemented when used emergency medication kits were not returned to pharmacy and items removed from the emergency medication kit were not documented. These deficient practices have the potential to compromise the health and safety of the residents due to lack of emergency medication kit accountability which may lead to improper drug use. During a medication storage audit with the director of nursing (DON) on 7/15/19 at 8:49 a.m., the following were observed: 1. Pharmacy emergency kit was found inside a medication cabinet with following labels: a. IV (intravenous) supply emergency kit with a green plastic zip tie. b. IV medication emergency kit with a green plastic zip tie. c. Oral emergency kit with a green plastic zip tie. d. Injectable emergency kit with a green plastic zip tie. e. CIII - CV (Controlled Substances 3 to 5) emergency kit with a green plastic zip tie. f. CII (Controlled Substances 2) Narcotic emergency kit with a green plastic zip…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 safety and sanitation requirements were met as evidenced by: 1. Gas stove was covered with dark substance 2. Back of gas stove was found with dirt and other debris 3. Milk temperature was not within acceptable range 4. Three compartment sink has no observable air gap 5. Rust was found on the ceiling of the walk in refridgetor 6. A pan of ground beef was cooked 8 hours early prior to serving These failures had the potential to result in cross contamination and can cause food borne illnesses in a medically vulnerable population of residents who consumed food from kitchen. Findings: 1. During a kitchen observation with the kitchen supervisor (KS) on 7/15/19 at 7:44 a.m., the bottom part of the gas stove was covered with sticky dark brown residue. The KS confirmed the gas stove was covered with sticky dark brown residue and it was hard for kitchen staff to clean it. A review of the facility's policy, Sanitation dated 2015, indicated kitchen staff is responsible for all the cleaning with the exception…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 follow it's policy for one of one sampled resident (Resident 88) when Resident 88's legal representative was not notified Resident 88 refused to use the splint. This failure had violated the right of the resident and his legal representative to choose treatment alternative or choose other options that resident prefer. Findings: Review of Resident 88's clinical record indicated, Resident 88 had diagnoses including anoxic brain damage (an injury to the brain due to lack of oxygen). Review of Resident 88's Order Summary dated 5/3/19 indicated, he had an order for restorative nursing assistant program (RNA program, exercise program intended to maintain or improve physical function) for orthotic (an artificial support or brace for the limbs) donning (put on) on left upper extremities (LUE) for six hours three times a week. During an interview with restorative nursing assistant E (RNA E) on 7/16/19 at 11:15 a.m., he stated Resident 88 had been refusing to wear the splint on his LUE. Review of Resident 88's Physician…

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

Based on observation, interview, and record review, the facility failed to implement the policy on self-administration of medication for two of two sampled residents (Residents 87 and 86) when medications were kept at Residents 87 and 86 room unattended. These failures had the potential for unsafe and improper administration of medications. Findings : 1. Review of Resident 87's clinical record indicated, she was admitted to the facility with a diagnoses including encephalopathy (a disease that affects the function or structure of the brain). Review of Resident 87's Minimum Data Set (MDS, an assessment tool) dated 5/13/19 indicated, she was cognitively intact. During an observation on 7/14/19 at 10:31 a.m. in Resident 87's room, two bottles of Tums (an anti-acid medication) were found on top of the bedside cabinet and one bottle at the tray table. During an interview with Resident 87, she stated, I take two Tums twice a day and I had those since I came here. During a concurrent interview and record review with registered nurse B (RN B) on 7/14/19 at 10:49 a.m., she confirmed 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 develop a comprehensive care plan for one of 23 (Resident 90) when the interdisciplinary team (IDT, a team of different professional disciplines that work together to provide the greatest benefit for the resident) did not assess Resident 90 to accommodate his food preferences. This failure had the potential for a decline in quality of life. Findings: Review of Resident 90's clinical record, his minimum data set (MDS, an assessment tool) dated 6/26/19, indicated Resident 90 is able to make his needs known and was cognitively intact. During an interview with Resident 90 on 7/14/19 at 11:24 a.m., he stated he wanted regular textured food and does not want pureed food. During an observation on 7/15/19 at 7:50 a.m., certified nursing assistant I (CNA I) fed Resident 90 pureed textured food for breakfast. Resident 90 requested for pancakes and regular textured food; CNA I stated the kitchen sent him pureed food. Review of Resident's 90's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow physician orders for one of one sampled resident (Resident 52), when registered nurse (RN) did not give apple juice and glucagon (hormone) as ordered during hypoglycemic episodes (blood sugar below reference ranges). These failures had the potential to result to life-threatening complications. Finding: During review of clinical record, Resident 52 was admitted on [DATE] with diagnoses including diabetes mellitus (DM, high blood sugar) with non-coma (deep state of prolonged unconsciousness) ketoacidosis (excess blood acids), DM Type 1 (insulin dependent) with hyperglycemia (blood sugar above target levels), and DM Type 2 (adult onset diabetes) with diabetic autonomic neuropathy (type of nerve damage that can occur with diabetes). During observation on 7/14/19 at 9:00 a.m., Resident 52 was lying in bed and his eyes closed in a deep sleep. On 07/15/19 at 4:30 p.m., Resident 52 was sitting in bed and conversant. He stated yesterday…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 oversight to prevent fall for two of six sampled residents (Residents 34 and 101), when Resident 34 and Resident 101 had a fall incident and sustained an injury. Findings: 1. Review of Resident 34's clinical record, Resident 34 was admitted on [DATE] with diagnoses including Alzheimer's disease (memory loss), glaucoma (group of eye conditions that can cause blindness) and benign neoplasm of prostate (age-associated prostate gland enlargement that can cause urination difficulty). Review of Resident 34's MDS dated [DATE], indicated Resident 34 was severely impaired cognitively and required supervision during transfer and ambulation. Review of Resident 34's fall risk assessment dated [DATE] indicated Resident 34 was high risk for fall. During observation on 7/14/19 at 10:16 a.m., Resident 34 was alert and sat in a wheelchair and propelled himself in the hallway. During review of Resident 34's progress note dated 6/14/19, 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 one of one sampled resident (Resident 88) with behavioral problem would be adequately monitored and would received the necessary care and services. This failure had the potential for residents not attaining their highest well-being. Findings: Review of Resident 88's clinical record indicated, he was admitted to the facility with a diagnoses including anoxic brain damage (an injury to the brain due to lack of oxygen). Review of Resident 88's Minimum Data Set (MDS, an assessment tool) dated 6/26/19, indicated he had memory problem and severely impaired cognitively. Review of Resident 88's Order Summary Report dated 3/22/19, indicated Resident 88 was nothing by mouth (NPO, [nil per os] a medical instruction meaning to withhold food and fluids) and required enteral feeding (nutrition taken through the mouth or through a tube that goes directly to the stomach) through his gastrostomy tube (G-tube, a tube inserted through the wall of the abdomen directly into the stomach). Review of Resident 88's care plan…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 adequate monitoring for efficacy of Nuedexta (used to treat uncontrollable laughter or crying) for one of one sampled resident (Resident 38). These medication had the potential to cause medication adverse effects. Finding: Review of clinical record, Resident 38 was admitted on [DATE], with diagnoses including multiple sclerosis (a disease in which the immune system eats away at the protective covering of nerves), pseudobulbar affect (uncontrollable laughter or crying) and paraplegia (paralysis of lower extremities). Review of Resident 38's medication and treatment administration record dated 7/19, there was no behavioral monitoring of Resident 38's laughing or crying episode. During an interview with LVN F on 7/17/19 at 12:13 p.m., she confirmed, no documentation the episode of laughing or crying was monitored. According to http://www.avanir.com/nuedexta (website for Nuedexta), Nuedexta was approved for the treatment of PseudoBulbar Affect…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 one of one sampled resident (Resident 81) was assessed when, Valium (anti-anxiety and sedative) PRN (as needed) order for Resident 81 has no physician justification for the continued PRN use order after 14 days. This failure had the potential to exposed the resident in the use of unnecessary drugs. Findings: During review of Resident 81's physician order dated 5/9/19 indicated Valium 2 milligram (mg, unit of mass). Give 1 tablet by mouth every 12 hours as needed for anxiety manifested by inability to relax. During interview with LVN F on 7/17/19 at 2:00 p.m., LVN F confirmed there was no physician justification for continued use of PRN Valium and stated there should have been one. The facility's policy and procedure, Use of Antipsychotics/Psychotropics, undated, indicated PRN Psychotropic's (excluding antipsychotics): 14 day limitation on all PRN orders. Order may be extended beyond 14 days if the attending physician or prescribing practitioner: 1 Believes it is appropriate to extend the order. 2. Documents clinical…

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

Based on observation, interview and record review, the facility had 15.38 percent medication error rate when four medication errors out of 26 opportunities were observed during medication pass for two out of six residents (38 and 24). These failures had the potential to compromise the resident's medical health. Findings: 1. During a medication pass observation with licensed vocational nurse F (LVN F) on 7/15/19 at 8:12 a.m., LVN F expelled bubble from Glatopa (used to treat multiple sclerosis (MS, a disease in which the immune system eats away at the protective covering of nerves) )20 milligrams/milliliters (mg/ml, a unit of measurement) prefilled syringe, administered two puffs of AirDuo RespiClick 55/14 Aerosol Powder Breath Activated 55-14 MCG/ACT (Fluticasone-Salmeterol, prevent symptoms of asthma and chronic obstructive pulmonary disease) and failed to rinse Resident 38's mouth after. During an interview with LVN F on 7/15/19 at 8:26 a.m., LVN F confirmed she expelled an air bubble from Glatopa 20mg/ml prefilled syringe, administered two puffs of Fluticasone-Salmeterol and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure medications were stored/labeled when: 1 .Refrigerator was out of temperature requirements. 2. One insulin pen with no pharmacy label 3. Two bottles of eye drop medications improperly stored and a bottle of insulin with no open date. 4. Two eye drop medications expired and three insulins improperly stored. These failures could potentially compromise the health and safety of the resident. Findings: 1. During a medication room audit and interview with the director of nursing (DON) on [DATE] at 8:49 a.m., the DON confirmed the refrigerator had an internal temperature of 30 degrees Fahrenheit while several medications requiring refrigeration were inside. A review of the facility's policy, Storage of Medication dated 9/18, indicated Medication requiring refrigeration or temperatures between 2C (Celsius, a unit of measurement) (36F (Farenheit, a unit of measurement) and 8C (46F) are kept in a refrigerator with a thermometer to allow temperature…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 two of three residents (Residents 90 and 26) with adaptive assistive device during meals when Residents 90 and 26 were not given nosey cut cups (a cup with a nose cut out that allows with proper head positioning, avoid neck extension and spillage). This failure could potentially compromise residents' head and neck positioning while drinking and limit the degree of independence of the resident. Findings: Review of Resident 90's clinical record indicated he has diagnoses including quadriplegia (paralysis that results in the partial or total loss of use of all their limbs and torso). During an observation on 7/15/19 at 7:50 a.m., Resident 90 was being fed breakfast by certified nursing assistant I (CNA I). A nosey cut cup was not observed on Resident 90's meal tray and was not used while giving beverages to Resident 90. Review of the facility list of residents needing adaptive equipment indicated Resident 90 required a nosey cut cup. During an interview with the minimum data set coordinator (MDSC) 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 ensure infection prevention practices were followed for five of five sampled residents (Residents 93, 88, 38, 54, and 24) when: 1. Resident 93, his indwelling catheter (a thin, sterile tube inserted into the bladder to drain urine bag) did not have a privacy bag and was placed on the floor 2. Resident 88, he was observed chewing on his treatment dressing 3. Resident 38, a licensed nurse did not use gloves while giving medication via injection 4. Resident 54, a licensed nurse did not clean a rubber cup of insulin vial prior to injecting needle, and 5. Resident 24, a licensed nurse did not perform hand hygiene in between glove changes Findings: 1. During an observation on 7/14/19 at 12:51 p.m, Resident 93 was in bed and his indwelling catheter bag was uncovered and placed on the floor. During an interview with certified nursing assistant L (CNA L) on 7/14/19 at 12:54 p.m., she confirmed the above observation and stated she did not realize the bag was on the floor since she came on duty on 7/14/19. During 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.