Santa Cruz Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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 29 (Residents 21, 80, 302, 15, 40, 11, 68, 94, 23, 85, 106, 77, 27, 30, 12, 74, 4, 287, 29, 66, 91, 13, 299, 103, 75, 59, 53, 114, and 45) of 63 residents who used bed or side rails when: 1. There was no documentation of informed consents (a form in which residents are given important information, including possible risks and benefits, about a medical procedure or treatment) were obtained prior to bed/side rail use for four of 63 residents (Residents 91, 114, 45, and 59); 2. The Bed Rail Observation/Assessment was not updated in a timely manner for three of 63 residents (Residents 287, 29 and 53); 3. There were 18 of 63 residents (Residents 302,15, 40, 11, 94, 77, 27, 30, 12, 74, 287, 66, 91, 13, 103, 75, 59 and 53) who used bed rails without care plans; and 4. There was no physician orders obtained prior to the use of bed rails for 21 of…

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

Based on interview and record review, the facility failed to provide sufficient nursing staff on a 24-hour basis based on the Staffing Data Report submitted to the Centers for Medicare & Medicaid Services (CMS). This failure could potentially affect resident's care, health, and psychosocial well-being. Findings: A record review of the facility's Direct Care Service Hours Per Patient Day (DHPPD) from July 2024 to January 2025 indicated that 63 days had actual DHPPD below 3.5. 5 days in July 2024 7/13/2024 Actual DHPPD 3.38; 7/20/2024 Actual DHPPD 3.04 ;7/21/2024 Actual DHPPD 3.10; 7/27/2024 Actual DHPPD 3.25; 7/28/2024 Actual DHPPD 3.41. 8 days in August 2024 8/3/22024 Actual DHPPD 3.29; 8/4/2024 Actual DHPPD 3.35;8/11/2024 Actual DHPPD 3.19; 8/17/2024 Actual DHPPD 3.45;8/18/2024 Actual DHPPD 3.38;8/24/2024 Actual DHPPD 3.21; 8/25/2024 Actual DHPPD 3.27; 8/31/2024 Actual DHPPD 3.34. 8 days in September 2024 9/7/2024 Actual DHPPD 3.21; 9/14/2024 Actual DHPPD 3.16;9/15/2024 Actual DHPPD 3.17 9/21/2024 Actual DHPPD 3.27; 9/22/2024 Actual DHPPD 3.39; 9/28/2024 Actual DHPPD 3.31 9/29/2024…

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.

2. During the medication pass observation on 2/24/25 at 9:17 a.m., Licensed Vocational Nurse C (LVN C), was observed giving medications to Resident 6. On 2/24/25 at 9:33 a.m., LVN C was also observed administering medications for Resident 47. Review of the facility's records of five nursing staffs' competency checks and medication pass trainings indicated, LVN C did not have a record that she was checked of her nursing care competencies and medication pass trainings. During an interview with the regional director of clinical services (RDCS) on 2/28/25 at 3:40 p.m., RDCS verified that the facility did not have a record that LVN C was checked of her nursing care competencies and medication pass trainings. Review of the facility's policy and procedure titled, Staffing, Sufficient and Competent Nursing, dated 2001, indicated, Our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment . Licensed nurses…

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 provision of pharmaceutical services that included availability of medication, accurate and safe administration of medications, and accurate accountability of controlled substance (that can be easily abused and are under strict government control) when: 1. A medication was not available to administer to Resident 296 for 10 days, and the nursing staff failed to follow up with the pharmacy or notify the physician of the missing medication. This had the potential for untreated and worsening of the resident's medical condition. 2. Two non-crushable medications for Resident 296 were crushed during administration. This had the potential for the resident to suffer from adverse effects of the medications due to too fast delivery of the medication. 3. There was no person-centered, individualized approach for administering medications for Resident 6 who has trouble swallowing medications. This resulted in one of her medications being…

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 Consultant Pharmacist (CP) identified and reported irregularities during the monthly medication regimen review (MRR) for 7 out of 34 sampled residents (10, 38, 54, 104, 111, 121, and 287) and one non-sampled Resident 296. Also, the facility failed to respond to the CP's recommendation for Resident 296. This failures resulted in unnecessary medications for the residents including duplicate therapy and inappropriately monitored medication use for the residents. Findings: 1. During the medication administration observation with RN F above, on 2/24/25 at 8:43 a.m., RN F was observed preparing 9 medications, including a tablet of metoprolol (medication to to treat high blood pressure) extended release (ER, medication is formulated so that the drug is released slowly over time) 25 milligrams (mg, unit of measurement), to give to Resident 296. RN F was observed crushing all the tablets and poured the crushed contents into a medicine cup. RN F stated Resident 296, likes them all crushed together. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure 13 out of 40 sampled residents (Residents 10, 19, 38, 39, 47, 53, 60, 67, 72, 93, 104, 111, and 121) were free from unnecessary medications when there was inadequate monitoring and systemic failure in the management of antihypertensive (medication to manage high blood pressure) and antiarrhythmic (medication to manage arrhythmia [abnormal or irregular heartbeats]) medications, and lack of monitoring for signs and symptoms related to the use of anticoagulants (medication to prevent blood clots). They are as follows: 1. During a medication pass observation, Licensed Vocational Nurse C (LVN C) failed to measure Resident 47's blood pressure (BP) before administering an antihypertensive medication, losartan 50 milligrams (mg, unit of measurement), to Resident 47. 2a. For Resident 104: - Nursing staff did not carry out the physician's order for daily BP monitoring. - He had a routine order for metoprolol (medication to lower BP and 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.

Based on interview and record review, the facility failed to ensure three out of 28 sampled residents (Residents 45, 104, and 107) were free from unnecessary psychotropic medications (drugs that affects brain activities associated with mental processes and behavior) when: 1. Resident 45 received as-needed (PRN) lorazepam (brand name: Ativan; medication to treat agitation and anxiety) beyond 14 days without the physician-documented clinical rationale and a specified duration for the extended period. 2. Resident 107 received Depakote (a medication to treat mood disorder) and quetiapine (brand name: Seroquel, an anti-psychotic medication) without the facility staff monitoring for their side effects, and without laboratory monitoring for A1c (measures your average blood glucose level over the past 3 months) and lipid panel (a blood test that measures the levels of various fats [lipids] in the bloodstream) related to Seroquel use. 3. Resident 104 received PRN lorazepam exceeding 14 days without the physician-documented clinical rationale and a specified duration for the extended period;…

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 12.12% when four medication errors were observed out of 33 opportunities during medication administration for three out of six residents (Residents 6, 47, and 296). Resident 296 and Resident 6 received crushed medications when the manufacturer indicated not to crush; senna (a laxative) was missed for Resident 6; and Resident 47 received the wrong dose of vitamin C. This failure resulted in residents not receiving medications as prescribed and/or according to manufacturers' specifications, and had the potential to result in residents not receiving the full therapeutic benefit of their medications or experiencing negative health outcomes. Findings: 1. During a medication administration observation and interview on 2/24/25 at 8:43 a.m., registered nurse F (RN F) was observed preparing 9 medications, including a tablet of metoprolol (medication to to treat high blood pressure or hypertension) extended release (ER, medication is formulated so that the drug is released slowly over time) 25…

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, record review, the facility failed to ensure medications were properly stored and labeled in three of three medication carts and in two of three medication rooms. Multiple opened inhalers, eye drops, and multi-dose vials were not labeled with open dates, or with an accurate expiration date, or being used past their discard dates. Also, one of three medication refrigerators was identified with incorrect setting and with temperature reading below freezing. These failures had the potential for residents to receive outdated and/or ineffective medications which could result in the residents not receiving the full benefit of the medications and negative health outcomes. Findings: 1. During an inspection of Station 4 Medication Cart on 2/24/25 at 10:57 a.m. with licensed vocational nurse E (LVN E), the following were identified and confirmed with LVN E: a. An eye drop latanoprost (medication to lower pressure in the eye) bottle, for Resident 15, did not have a label indicating when it was opened. LVN E stated it should have an open date. b. Another…

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 palatability and nutritive value of cooked foods were maintained when: 1. Three of 28 sampled residents complained that the food tasted bland (lacking taste or flavor); 2. Pureed foods (a puréed diet is an eating plan where all the foods have a soft, pudding-like consistency. It is a texture-modified diet that is often recommended for people who can't eat solid foods) were held in the heated oven for an extended time; and, 3. The recipe for making pureed food was not followed. These failures resulted in decreased food palatability that could lead to decrease in food consumed by residents, and the food held in the heated oven for extended time periods could lose nutritive value, leading to a decreased nutrient intake for the thirteen residents on puree diet order out of 139 facility residents. Findings: 1. During the concurrent observation and interview of Resident 16 on 2/23/25 at 11:25 a.m., Resident 16 was in his bed, alert,…

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 food items were stored and prepared in accordance with professional standards for food safety when: 1.The food items that were out of their original boxes and stored in the food containers, were not labeled with open dates and use by dates, and 2. The kitchen staff did not wear his face mask properly while preparing the desserts for the residents. These failures had the potential to cause the growth of micro-organisms which could cause foodborne illness (illness resulting from contaminated food) and cross-contaminated food for the 138 residents who received foods from the facility kitchen. Findings: 1. During the initial kitchen tour observation on 2/23/25 at 9:48 a.m., there were packets of sugar, chocolate powder, coffee creamers, coffee powders, tea and cookie bars that were taken out of their boxes, placed in the storage containers of the preparation area, and they were not labeled with open dates and use by dates. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement infection control measures when: 1. A dirty pair of gloves were found inside Resident 287's room floor; 2. Resident 72's used urinal (a plastic bottle for urination) was found on top of the overbed table; 3. Resident's used basins, bedpans (a container used to collect urine or feces), urinals and water pitcher were not labeled, cleaned/disinfected, and stored properly; 4. Certified nursing assistant P (CNA P) did not perform hand hygiene in between resident's meal set up; 5. Two nursing staff touched and opened two medication capsules without wearing gloves; 6. A nursing staff failed to perform hand hygiene between medication administration for residents; 7. One of three medication carts was observed with yellow and brown substances on the bottom drawer; 8. Resident 388's peripherally inserted central catheter (PICC, long, soft, flexible tubes inserted into a vein in the upper arm to administer fluids or medications) line…

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 maintain respect, and dignity to three of 28 sampled residents (Residents 46, 296, and 133) when: 1.Residents 46 and 296's indwelling catheter's (a catheter which is inserted into the bladder, thru the urethra and remains in place to drain urine) urinary bags were exposed and not covered with a privacy bag; and 2.Resident 133's personal information and care guide was posted in the room visible to roommate's visitors. These failures had the potential to negatively affect resident's emotional and psychosocial well-being. Findings: 1a. During an observation on 2/24/2025 at 8:53 a.m., inside Resident 46's room, Resident 46 was resting on her bed, talking to self. A urinary bag was observed hanging under the bed, exposed, and not covered with a privacy bag. During a concurrent observation and interview with registered nurse F (RN F) on 2/25/2025 at 9:55 a.m., inside Resident 46's room, Resident 46's urinary bag was still exposed containing 400…

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 their policy and procedure on self-administration of medication (resident takes medication without staff assistance) when there were no documentation found in resident's records for self-administration of medication, and medications were left at bedside for two of 28 sampled residents (Residents 113 and 44). This failure had the potential for unsafe and improper administration of medications. Findings: 1.Review of Resident 113's clinical record titled, admission Record, dated 2/25/2025, indicated Resident 113 was admitted to the facility with diagnoses including low back pian, opioid use (a chronic disease that involves compulsive use of opioids [a class of drug used to reduce moderate to severe pain], even when it harms a person's life), and chronic pain syndrome (pain that lasts longer than three months, or past the normal healing time). Review of Resident 113's minimum data set (MDS - a federally mandated resident assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure needs were accommodated for one of 28 sampled residents (Resident 296) when the call button (a red or white button used to call for assistance) was not within Resident 296's reach for use. This failure had the potential for a delayed response and not meeting the resident's needs timely. Findings: Review of Resident 296's clinical record titled, admission Record, dated 2/25/2025, indicated Resident 296 was admitted to the facility with diagnoses including nondisplaced fracture (the bone cracks or breaks but retains its proper alignment) of left tibial tuberosity (a bony bump on the front of the upper part of the shin bone), repeated falls, and difficulty walking. Review of Resident 296's minimum data set (MDS - a federally mandated resident assessment tool) admission assessment dated [DATE], indicated Resident 296's brief interview for mental status (BIMS, a tool used to assess cognition [knowing, learning, and understanding…

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 complete a comprehensive minimum data set (MDS - a federally mandated resident assessment tool) admission assessment and a required discharge assessment in a timely manner for one of 10 residents (Resident 120). This failure resulted in Resident 120's admission and discharge assessment not completed within the time requirement and had a potential to result in inappropriate care planning and intervention. Findings: A.Review of Resident 120's clinical record titled, admission Record, dated 2/26/2025, indicated Resident 120 was admitted at the facility on 10/13/2024 with diagnoses including osteoarthritis (OA, a progressive disorder of the joints, caused by a gradual loss of cartilage) of first carpometacarpal joint (the saddle-shaped joint at the base of the thumb that connects the thumb to the wrist), left hand, chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), and asthma (inflammatory disease 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 comply with Federal and State laws and regulations when the approval letter for staffing waiver was not posted where visitors and residents could easily read. This failure had the potential to result in nurse staffing misinformation about residents' care. Findings: During an observation on 2/28/25 at 11:54 a.m., in front of the facility's glass covered cork board, the approval letter for the staffing waiver was not posted. During a concurrent observation and interview with the facility administrator (ADM) on 2/28/2025 at 11:56 a.m., in front of the facility's glass covered cork board, the ADM confirmed the approval letter for staffing waiver should have been posted on the board. During an interview on 03/03/25 at 01:58 p.m. with the staffing coordinator (SC), the SC stated the facility had a staffing waiver. Review of the staffing waiver's approval letter dated 6/18/2024, it indicated, Your request is approved and valid from July 1, 2024, until June 30, 2025, under the following conditions: 1. This approval…

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 approriate and necessary services in accordance with professional standard of practice for three out of three residents (Residents 1, 2, & 3) when: 1. a) For Resident 1, the skin and wound assessment was incomplete and Nursing Care Plan (NCP a detailed document that outlines a patient's specific healthcare needs, identifying potential problems, setting goals, and detailing the nursing interventions required to address those needs) was not specific to wound status and b) Facilitys' Licensed Nurses (LNs) did not recheck and notify the physician for abnormal low blood pressures (the pressure of blood circulating against the walls of the blood vessels) measurements. 2.) For Resident 2, there was no evidence of documentation that physician was notified and treatment order was obtained for right gluteus (buttock) abrasion (a superficial rub or wearing off of the skin, usually caused by a scrape).; there was no evidence of documentation that 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 provide and/or communicate the appropriate information to the receiving facility for one of two residents (Resident 3) regarding the pending laboratory workup. This failure had the potential to negatively affect the continuity of care and may jeopardize Resident 3's health and safety. Findings: Review of Resident 3's medical record indicated she was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included overactive bladder (a problem with bladder function that causes the sudden need to urinate) and urinary tract infection (UTI, infection in any part of urinary system). She was discharged to another facility on 9/28/24. Review of Resident 3's medical record indicated, she received of Cephalexin (antibiotic) 500 milligram (mg, unit of measurement) capsule orally every eight hours for 7 days as ordered by her physician on 9/10/24 for UTI. Review of Resident 3's laboratory workups report indicated, a urine…

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 Activities of Daily Living (ADL -routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) care was provided for one of two sampled residents (Resident 1) when there was no evidence of record by three certified nursing assistants that shower/bed bath was provided for three consecutive scheduled shower days for Resident 1. This failure may result in poor body hygiene and may affect the physical and psychological well-being of the resident. Findings: Review of Resident 1 ' s medical record on 11/13/24 indicated diagnoses that included above the knee amputation of right lower extremity, difficulty of walking and obesity. Review of Resident 1 ' s Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 9/10/24 indicated she had a Brief Interview for Mental Status (BIMS, an assessment tool used by facilities to screen and identified memory, orientation, judgement status of the resident) score of 13 (a score of 13-15 means that her cognition…

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 three of 12 aides (Nursing Assistant A (NA A), Nursing Assistant B (NA B), and Nursing Assistant C (NA C)) completed their state certification program, including an examination to test the aides' knowledge and skills. This failure resulted in staff working as Certified Nurse Assistants (CNA) without proper certification and had the potential to put residents' safety at risk. Findings: Review of the California Department of Public Health L & C (Licensing and Certification) Verification Search Page (This system displays information related to Certified Nurse Assistants [CNA] and other certificate and license types), on 9/6/24 indicated Nursing Assistant A (NA A), Nursing Assistant B (NA B), and Nursing Assistant C (NA C) did not have active certifications as CNAs. Review of NA A's hire letter, dated 4/30/24 indicated the facility is delighted to offer you the Full-Time position as a Certified Nursing Assistant with an anticipated start date of May 1, contingent upon the completion and results of a background check 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 interview and record review, the facility failed to provide proper supervision for one of three residents (Resident 1) when a nurse aide (nursing assistant) did not have the required certification to work as a certified nursing assistant (CNA) and assisted Resident 1 out of the shower room by herself. This failure resulted in Resident 1's fall. Findings: Review of Resident 1's clinical record indicated she was admitted to the facility with diagnoses including intraspinal abscess and granuloma (swelling and inflammation in or around the spinal cord due to infection) and difficulty in walking. Review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 8/27/24 indicated for Tub/Shower transfer (the ability to get in and out of a tub/shower), Resident 2 was dependent, meaning Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity. Review of Resident 1's IDT (interdisciplinary) - Fall notes, dated 9/16/24 indicated on 9/13/24, indicated,…

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

Based on interview and record review, the facility failed to provide appropriate care and services for an indwelling catheter (flexible tube inserted and left in the bladder to drain urine) for one of three residents when Resident 1 did not have a physician's order for an indwelling catheter, there was no care plan for an indwelling catheter, and there was no documentation of the assessment of urine output and whether catheter care was completed. Also, the facility staff did not document the number of times Resident 1 voided per physician's order. These failures had the potential to result in health complications for the resident. Findings: Review of Resident 1's face sheet indicated she was admitted to the facility with diagnoses including displaced (out of alignment) intertrochanteric fracture of right femur (broken hip). Review of Resident 1's Minimum Data Set (MDS, assessment tool), dated 6/20/24 indicated the resident had an indwelling catheter. Review of Resident 1's care plans indicated she did not have a urinary catheter care plan. Review of Resident 1's medical record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure nurses documented the admission for one of three residents (Resident 1). This failure resulted in an incomplete medical record for Resident 1. Findings: Review of Resident 1's face sheet indicated she was admitted to the facility on [DATE] with diagnoses including displaced (out of alignment) intertrochanteric fracture of right femur (broken hip). Review of Resident 1's medical record indicated there was no admission assessment or narrative admission notes when the resident was admitted on [DATE]. During an interview on 8/6/24 at 2:15 p.m., the director of nursing (DON) confirmed Resident 1 did not have an admission assessment or admission notes when the resident was admitted on [DATE]. The DON stated the admission notes should be one of the most detailed notes in order to paint the picture of how the resident got to the facility. Review of the facility's policy, admission Notes, revised 9/2012 indicated, When a reident is admitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a care plan (identifies residents' concerns and outlines the care and services needed to meet their needs) to address foley catheter for two of four sampled residents (Resident 1 and 2). This failure had the potential to result in the inability to identify the residents' individualized care issues and implement a person-centered care. Findings: Review of Resident 1's clinical record, indicated, Resident 1 was admitted on [DATE] with diagnoses including hypertensive heart disease with heart failure (heart problems that occur because of high blood pressure that is present over a long time), acute on chronic diastolic congestive heart failure (heart works less efficiently and can lead to buildup of fluid in the lungs and shortness of breath), acute respiratory failure with hypoxia (A condition where not enough oxygen in the body. A condition in which the lungs have a hard time loading the blood with oxygen or removing carbon dioxide. Lungs cannot…

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 care and services were provided in accordance with professional standards of practice for one of two residents (Resident 2) when: 1. Discharge wound care order from acute hospital to skilled nursing facility was not transcribed, and 2. No physician order to insert foley catheter. This failure had the potential to negatively affect Resident 2's health and well-being. Findings: 1. Review of Resident 2's clinical record, indicated, Resident 2 was admitted on [DATE] with diagnoses including fusion of spine cervical region (surgery to permanently join together two or more bones in the spine), essential hypertension (high blood pressure that does not have a known cause), muscle wasting (the loss of muscle tissue, strength, and mass) and atrophy (the partial or complete wasting away of a body part or tissue), dysphagia (difficulty swallowing). Review of Resident 2's Interagency Discharge Summary and Order from acute hospital, dated 6/6/24, indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to honor two of three residents' (Residents 2 and 3) requests for showers. This failure resulted in the resident's request and preference not being honored. Findings: 1. Review of Resident 2's clinical record indicated Resident 2 was admitted on [DATE] and had diagnoses including acquired absence of right leg above knee (a surgical amputation [the loss or removal of a body part]), obesity (a disorder that has too much body fat), and difficulty in walking. Review of Resident 2's Minimum Data Set (MDS, an assessment tool), dated 6/11/24, indicated she had a brief interview for mental status (BIMS, a structured cognitive [relating to the mental process involved in knowing, learning, and understanding things] test) score of 15 (cognitively intact). During an interview on 7/26/24 at 1:20 p.m. with Resident 2, she was lying in bed and stated she missed showers on her scheduled shower days. Resident 2 stated she asked for a bed bath on her…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure care and services were provided in accordance with professional standards of practice for one of two residents when it did not follow the physician's order to provide 1:1 monitoring for Resident 1. This failure had the potential to compromise residents' safety and health in the facility. Findings: Review of Resident 1's clinical record indicated Resident 1 was admitted on [DATE] and had diagnoses including dementia (a decline in mental capacity affecting daily function), neurosyphilis (an infection of the brain or spinal cord), and unsteadiness on feet. Review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 4/30/24, indicated he had a brief interview for mental status (BIMS, a structured cognitive [relating to the mental process involved in knowing, learning, and understanding things] test) score of 03 (severe cognitive impairment). Review of Resident 1's care plan for episodes of altercation with another resident initiated 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 follow their bed rails (adjustable rigid bars attached to the side of a bed: side rails, safety rails, and grab/assist bars) policy for one of three residents (Resident 4). The facility failed to follow their bed rail policy when: 1. There was no documentation that alternatives were attempted prior to installing bed rails; 2. There was no documentation that the risks and benefits were explained to the residents or responsible parties (RP, individuals designated to make decisions on behalf of the residents) prior to installing bed rails; 3. There was no informed consent obtained prior to installing bed rails; 4. There was no documentation that the facility assessed for risk of entrapment (becoming trapped between the bed rail and mattress) prior to installing bed rails; and 5. There was no documentation that the facility assessed the bed dimensions to ensure they were appropriate for the residents' size and weight. These failures resulted in the resident and the resident's RPs not being fully informed on the…

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

Based on interview and record review, the facility failed to provide a written notice for two of six residents (Resident 1 and 2) prior to a room change. Also, there was no documentation in the medical record regarding a room change for six of six residents (Resident 1, 2, 3, 4, 5 and 6). These failures had a potential to affect the residents' emotional and psychosocial well-being. Findings: Review of Resident 1's Census List, dated 7/3/24 indicated she had a room change with an effective date of 5/7/24. There was no documentation by nurses or social services in the progress notes regarding the Resident 1's room change and the resident's response to the room change. Review of Resident 2's Census List, dated 7/3/24 indicated she had a room change with an effective date of 5/7/24. There was no documentation by nurses or social services regarding the Resident 2's room change and the resident's response to the room change. Review of Resident 3's Census List, dated 7/3/24 indicated he had a room change with an effective date of 5/7/24. There was no documentation by nurses or social…

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 nurses were trained and demonstrated competency in testing the functionality of the Wander Management Transmitters (wander guard, a device placed on a resident's wrist, ankle, or wheelchair that alarms to notify the staff if a resident tries to leave the facility) used for 9 of 9 residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, and 9). This failure had the potential to result in transmitter equipment failure or system failure and resident elopement (to leave a health facility without notification or permission). Findings: Review of Resident 1's face sheet indicated she was admitted to the facility with diagnoses including dementia (decline in mental capacity affecting daily function) and type 2 diabetes mellitus (a condition which affects the way the body processes blood sugar). Review of Resident 1's Elopement Risk Observation/Assessment, dated [DATE], indicated her elopement risk score was 12 (If the score was 10 or greater, the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure care and services were provided in accordance with professional standards of practice for three of four sampled residents (Residents 1, 2, and 3) when: 1. Resident 1's Daily Skilled Charting documentation (documentation including symptoms review [head to toe review of any symptoms a person is experiencing] and assessment of the body systems [such as neurological (mental status and alertness), cardiovascular (examination of the heart), respiratory (examination of lungs and breathing), skin (examination of color, skin integrity), etc.]) from 11/7/23 to 11/16/23 was completed by a licensed vocational nurse working remotely, without physically seeing the resident. The Daily Skilled Charting documentation was not an accurate summary of the assessment and/or care provided to Resident 1 and did not accurately describe Resident 1's condition. The facility did not identify Resident 1's pressure ulcers (injury to skin and tissue below the skin caused 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.

Based on interview and record review, the facility failed to meet professional standard of practice when there were missing licensed nurse's signature entries in the treatment administration record (TAR) that indicated the treatment were done for one of two residents (Resident 1). This failure had the potential to compromise Resident 1's health. Findings: Review of Resident 1's medical record indicated diagnoses that included history of traumatic brain injury (happens when a bump, blow, or other head injury causes damage to the brain), difficulty in walking, and dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain). Review of Resident 1's medical record indicated a physician's order dated 1/4/2024 to 1/9/24, cleanse unstageable pressure injury ( full thickness pressure injuries in which the base is obscured by slough and/or eschar) on sacrococcygeal area (pertaining to both the sacrum and tailbone)…

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 services which meet professional standards for one of three sampled residents (Resident 1) when there was no evidence of documentation that weekly nursing summaries are done consistently. This failure had the potential not to identify new healthcare needs and may compromised the continuity of plan of care that may affect the Resident 1's quality of care. Findings: Review of Resident 1's medical record indicated he was admitted to the facility on [DATE] with diagnoses that includes polyneuropathy (damaged peripheral nerves) , benign prostatic hyperplasia (enlarged prostate gland), depression (a persistent feeling of sadness and loss of interest), anxiety (persistent feeling of worry) , aseptic necrosis (death of tissue due to little blood supply) little of bilateral toes. Resident 1 was discharged from the facility on 9/14/23. During a review Resident 1's medical record indicated the last nursing weekly summary (a summary of informations…

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 safe discharge for one of three sampled residents (Resident 1) when: 1. The licensed nurse A (LN A) did not instruct accurately the dosing frequency of Methadone (medication used to treat moderate to severe pain when round the clock pain relief is needed for a long period of time) tablet to be taken at home as ordered by the physician for Resident 1, and 2. The inventory list of personal effects was not signed off by Resident 1 upon discharged from the facility. These failures had the potential to jeopardize Resident 1's health and safety for not taking the correct dosing frequency of Methadone tablet as prescribed by the physician and potential for missing and inaccurate accounting of personal belongings that may affect Resident1's safety when he got transfered to another facility or home. Findings: 1. Review of Resident 1 indicated he was admitted to the facility on [DATE] with diagnoses that includes polyneuropathy (damaged peripheral…

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 a care plan that reflect the specific care needs for one of three sampled residents (Resident 1) when there was no care plan developed specific to Resident 1's refusals of the weekly wound assessments. This failure had the potential to negatively affect the resident quality of care. Findings: Review of Resident 1's medical record indicated diagnoses that includes aseptic necrosis (death of tissue due to little blood supply) of bilateral toes. During a review of Resident 1's medical record indicated there were no nursing weekly wound assessments of the bilateral toes necroses since he was seen by the podiatry doctor (PD) on 7/13/23 until 9/14/23. During an interview with the assistant director of nursing/treatment nurse (ADON/TN) on 10/13/23 at 10:25 a.m., she stated Resident 1 was refusing weekly wound assessments since 7/13/23. During a concurrent interview and record review of Resident 1's medical record with the ADON/TN on 1/12/24 at 3:12 p.m., indicated there was no specific resident-centered 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 notify the resident's responsible party (RP, a person responsible in making healthcare decision for the resident) and provide the Long-Term Care (LTC) Ombudsman (organization that routinely visits the facility and advocates on behalf of the residents) complete information regarding residents transfers and discharges from the facility when: 1. For Resident 1, there was no evidence of written notification of transfer to the Resident 1's RP when Resident 1 was transferred to the hospital, 'and 2. The information provided to the LTC Ombudsman for 17 of 17 residents who were transferred and discharged from the facility for the month of October 2023 were incomplete. These failures had the potential to result in depriving Resident 1's RP of the information about the admission, transfer, and discharge rights and options and the LTC Ombudsman of all necessary information in determining if transfer and discharge is appropriate and did not violate resident ' s…

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

Based on interview and record review, the facility failed to ensure services were provided to meet professional standard of practice for one of two residents (Resident 1) when: 1. There was no documentation in Resident 1's medical record regarding the change of condition that led the resident to be transferred to the hospital. 2. There was no documentation in Resident 1's medical record regarding nursing intervention/action done for Resident 1's abnormal blood pressure and These failures had the potential to compromise the resident health and safety. Findings: 1. Review of the Resident 1's medical record on 11/29/23 indicated diagnoses including COVID-19, tachycardia (rapid heartbeat), hypertension (persistent elevated blood pressure), acute kidney failure (sudden loss of kidney filtering ability), transient ischemic attack (temporary blockage of blood flow to the brain) and cerebral infarction (damage to tissues in the brain due to loss of oxygen to the area) without residual deficits. Review of the Resident 1's emergency department (ER) record on 11/29/23 indicated Resident 1 was…

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

Based on observation, interview, and record review, the facility failed to ensure quality of care was provided for two out of two residents (Resident 2 & 3) when the weekly wound evaluations were not completed. These failures had the potential for not meeting residents' care needs and affect residents ' quality of care. Findings: During Resident 2's wounds treatment observation with the treatment nurse/assistant director of nursing (TN/ADON) on 11/29/23 at 9:40 a.m., an open wound on right lateral calf and abrasions with scabs on front right lateral lower leg and right lower abdominal quadrant were observed. Review of the Resident 2's weekly wound evaluations on 11/29/23 indicated from the period of 10/12/2023 to 11/15/23 there were 12 wound evaluations that marked still In Progress and not completed. For right lower quadrant abdomen abrasion wound dated 10/25/23 and right calf open lesion wound evaluations dated 11/23/23, the following sections were not filled up such as whether the wound is acquired, how long has the wound has been present, exact date, stage by, wound bed, peri…

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 acceptable parameters of nutrition and hydration when the meal and fluid intake were not monitored and recorded consistently. This failure could potentially place Resident 1, who was already at risk for further decline and compromised in nutritional and hydrational status. Findings: Review of Resident 1's medical record on 11/29/23 indicated she was admitted to the facility on [DATE] with diagnoses including severe protein-calorie malnutrition (reduced availability of nutrients leads to changes in body composition and function), acute kidney failure (sudden loss of kidney filtering ability), and positive for COVID-19. Review of Resident 1's physician order dated 11/11/23 indicated to monitor fluid intake every shift for Resident 1 is at risk for dehydration. Review of Resident 1's nursing care plans for positive COVID-19 dated 11/6/23 indicated .Encourage fluid intake unless contraindicated .; and nutritional problem dated 11/10/23 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 interview and record review, the facility failed to ensure the wound doctor write the progress notes at each visit for Resident 2. The wound doctor physician had no documented written notes in Resident 2 ' s progress notes of her visits from 7/26/23 to 11/25/23 regarding the Resident 2's wounds status/condition. This failure placed the resident at risk of poor continuity of care, poor follow- up, and unidentified resident's status for each wound evaluation visits. Review of Resident 2's medical record on 11/29/23 indicated Resident 2 was seen by wound doctor on 7/26/23, 11/15/23, 11/18/23, 11/22/23, and 11/25/23 for wound consultations for open wound on right calf and abrasions on right lower extremity and right lower abdominal quadrant. Further review of Resident 2's medical record indicated there was no written evidence that the wound doctor documented in Resident 2's progress notes regarding the wound consultation visits on the above dates including the date, time, and the signature and title. During an interview with the TN/ADON on 11/29/23 at 11:18 a.m., she confirmed…

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 resident ' s medical records were complete and readily available for review by official authorized by law for Resident 2 when the wound consultation reports were not found in Resident 2's medical record. This failure had the potential to cause delay for the determination of the quality of care rendered to Resident 2. Findings: During a review of Resident 2's medical record indicated she was seen by wound doctor for an open wound on right calf, and abrasions on right lower extremity and right abdominal lower quadrant on 7/26/23, 11/15/23, 11/18/23, 11/22/23, and 11/25/23. During a concurrent interview and record review with the treatment nurse/assistant director of nursing (TN/ADON) on 11/29/23 at 11:18 a.m., she confirmed Resident 2's wounds doctor ' s consultation reports were not in the Resident 2's medical record at that time. During an interview with the medical record staff (MRS) on 11/29/23 at 12:15 p.m., she confirmed the facility did not receive the copies of Resident 2's the wound consultation reports done…

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 care and services were provided in accordance with professional standards of practice for one of two residents when the facility did not follow the physician's order for diabetes (blood sugar higher than normal) management for Resident 1 when the attending doctor was not notifie dof blood sugar level greater than 400, and the insulin medicationw as not given with meals as ordered. This failure could compromise Resident 1's safety and health. Findings: During a review of Resident 1's clinical record, the record indicated Resident 1 was admitted on [DATE] and had diagnoses of type 2 diabetes mellitus (DM), right humerus fracture (broken arm), bronchitis (inflammation of the bronchial tubes), and major depressive disorder (a mood disorder that causes a feeling of sadness and loss of interest). During a review of Resident 1's physician's order, dated 9/27/23, the order indicated Humalog (insulin, medication for diabetes) solution 100 unit/ml inject…

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 523's Order Summary Report, indicated, Resident 523 was admitted on [DATE], with indwelling Foley catheter (FC, a thin, flexible catheter used especially to drain urine from the bladder by way of the urethra) care orders. During an observation on 5/8/2023 at 12:50 p.m., while inside Resident 523's room, Resident 523 was lying in bed. A FC urine collection bag was observed hanging on the left side of the bed, containing yellow urine. The FC urine collection bag was not covered with a dignity bag. During another observation on 5/9/2023, at 9:53 a.m., Resident 523's FC urine collection bag was still hanging on the left side of the bed, and remained uncovered with a dignity bag. Based on observation, interview, and record review, the facility failed to ensure dignity was maintained for three of nine residents who had the urinary catheters connected to urine collection bags (113, 236, and 523), when the urine collection bags for their indwelling urinary catheters (sterile tube inserted into 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 ensure the provision for safe use of insulin (medication to lower blood glucose) pens; and controlled medications (those with high potential for abuse and addiction) were fully accounted, when: 1. The nursing staff failed to prime or accurately prime the Humalog Kwikpen (a pre-filled pen containing insulin lispro, a short-acting insulin) before administration for three out of three residents (Residents 78, 227, and 523). This had the potential for resident getting too much or too little insulin which would negatively affect the health of 15 residents receiving insulin pens; and 2. Random controlled medication use audit for three of six sampled residents (Residents 31, 223, and 225) did not reconcile. The medications were signed out of the controlled drugs accountability sheet (Count Sheet, an inventory sheet that keeps record of the usage of controlled medications) but not documented on the Medication Administration Records (MAR) to indicate they were given to the residents. This failure resulted in…

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

Based on interview and record review, the facility failed to ensure the consultant pharmacist (CP) identify and report to the facility irregularities related to medication regimen for three of 25 sampled residents (Residents 62, 69, and 101) during the medication regimen review (MRR). The failure resulted in inadequate monitoring and had the potential for medications not being optimized for best possible health outcome. Findings: 1. A review of Resident 62's clinical record indicated she was an elderly resident admitted to the facility with diagnoses including chronic kidney disease (condition in which the kidneys are damaged and cannot filter blood as well as they should) and heart failure (a condition that develops when your heart does not pump enough blood for your body's needs). A review of her clinical record indicated she had a physician's order and been receiving magnesium oxide (an electrolyte to treat low magnesium level in the blood) 400 milligrams (mg, unit of measurement), 1 tablet one time a day for supplement, dated 10/9/2020 (two and a half years ago). There was no…

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 10.34% when three medication errors occurred out of 29 opportunities during the medication administration for three residents (Residents 78, 227, and 523): 1. For Resident 227, there was no priming of insulin (medication to lower blood glucose [BG]) pen before administration; 2. For Resident 78, the nursing staff did not correctly prime the insulin pen before administration; 3. For Resident 523, the nursing staff did not correctly prime the insulin pen before administration, and administered the insulin dose after a meal while the physician's order indicated before meal. The failure resulted in medications not given according to the manufacturer's instructions and/or physician's order, and had the potential for residents not receiving the full therapeutic effects of medications. Findings: 1. During a medication administration observation on 5/8/23 at 11:25 a.m., Licensed Vocational Nurse A (LVN A) was observed preparing an insulin injection for Resident 227 after obtaining the BG reading…

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 food served to two of 25 sampled residents (Resident 63 and one anonymous resident) were maintained at the proper temperature, and food trays were delived late in one of five facility stations (Station 3). These failures had the potential for residents to consume less amount of food due to non-palatable temperature and delayed trays. Findings: During an initial tour with Resident 63 on 5/8/23, at 12:54 p.m., Resident 63 stated food arrives cold and late delivery. During an observation and concurrent interview with another resident who requested to remain anonymous, on 5/9/2023 at 1:40 p.m., the resident was observed eating food brought from outside the facility. The resident stated the food was consistently cold and, at times, delivered late by the facility. During a lunch observation on 5/8/23, at 1:15 p.m., station 3, staff was observed passing the food tray. During another lunch observation on 5/9/23, at 1:36 p.m., station 3, staff was observed passing the food tray During review of facility…

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

Based on observation, interview and record review, the facility failed to ensure the proper disposal of garbage when two of the four receptacles were overfilled so the lids could not be closed. This failure had the potential for pests to harbor and breed on the garbage posing a hazardous environment for the residents and staff. Findings: During an observation and concurrent interview with the Dietary Director (DD) on 5/10/23 at 9:02 a.m., by the facility's parking lot near the kitchen, there were two recycle disposal dumpsters with the lids not closed. Some empty cans of food, cardboard, and plastics were sticking out of the dumpsters. The DD confirmed this observation. During an interview on 5/10/23, at 9:05 a.m., with the Maintenance Director (MD), the MD stated the garbage and recycle bins should be closed. During an interview on 5/10/23, at 9:07 a.m., with Registered Dietitian (RD), the RD stated the dumpster lids should always be closed. Review of the facility's policy and procedure (P&P) titled, Food-related Garbage and Refuse Disposal, dated and revised 2020, the P&P…

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

Based on observation, interview and record review, the facility failed to maintain the call light was within reach for one of 25 sampled residents (Resident 69). The failure could result to untimely delivery of resident's care. Findings: During an initial tour on 5/8/23, at 10:54 a.m., Resident 69's call light was observed on the floor. During an interview on 5/10/23, at 8:33 a.m., with Certified Nursing Assistant D (CNA D), she stated everyone's responsibility was to ensure call light is within resident's reach. During an interview on 5/10/23, at 8:40 a.m., with CNA K, she stated that Resident 69 was able to use the call light. During an interview on 5/12/23, at 8:25 a.m., with the Director of Nursing (DON), she stated that she was aware of call light issue. She further stated that everyone should ensure call light was within resident's reach. Review of facility's Answering the Call Light policy, dated October 2022 , indicated answer the resident's call light as soon as possible; if you have promised the resident you will return with an item or information, do so promptly.

Based on interview and record review, the facility failed to maintain the accuracy of the resident assessment of one of 25 sampled residents (Resident 113). The failure resulted in ineffective care planning of resident's needs. Findings: Resident 113 was admitted with diagnoses including chronic kidney disease, and neuromuscular dysfunction of bladder. Review of facility's Resident Matrix (form to identify pertinent care categories), dated 5/8/23, indicated Resident 113 was on anticoagulant. During a concurrent interview and record review, on 5/11/23 at 8:32 a.m., with Minimum Data Set Coordinator (MDS), she stated that the anticoagulant medication was ordered on 2/18/23, and was discontinued on 2/23/23. She further stated that the assessment was incorrect for Resident 113. During an interview on 5/12/23, at 8:25 a.m., with Director of Nursing (DON), she stated that she was aware that there was a discrepancy with the minimum data set report. Review of facility's Resident Assessments policy, dated March 2022, indicated all persons who have completed any portion of the Minimum Data…

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 services were provided to meet the professional standard of practice for one of two residents (Residents 69) who had a pacemaker (implanted device for a heart condition, a battery-powered device implanted inside the heart to restore a normal heartbeat) when: 1. The licensed nurses did not know the pacemaker location and no pacemaker information in the resident's medical record; 2. The licensed nurse did not check Resident 69's apical pulse (a pulse point on your chest that gives the most accurate reading of your heart rate) to monitor pacemaker malfunction; and 3. A cell phone was placed on the tray table at the bedside near Resident 69's chest. These failures had the potential to compromise residents' health. A review of Resident 69 's clinical records indicated she was admitted on [DATE] and had diagnoses including acute systolic (congestive) heart failure (a chronic condition in which the heart doesn't pump blood as well as it…

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 an eye consultation and/or referral was arranged for one of 25 sampled residents (Resident 73) in a timely manner. This failure had the potential to negatively affect the resident's health, well-being, and quality of life. Findings: Review of Resident 73's clinical record indicated the resident was admitted on [DATE] with diagnoses including type 2 diabetes mellitus (high blood sugar) with ketoacidosis (when there is not enough insulin in the body) with coma (a state of prolonged loss of consciousness), legal blindness and hypertension (high blood pressure). Review of Resident 73 's Minimum Data Set (MDS, an assessment tool), dated 4/27/23, indicated Resident 73 had impaired (diminished in function or ability) vision and used corrective lenses. During an observation on 5/8/23, at 11:37 a.m., there was white tape wrapped around Resident 73's eyeglasses on the left hinge (the part that allows the eyeglasses to fold open and close)…

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 necessary podiatry services for one of 25 sampled residents (Resident 273) when: 1. The licensed nurses failed to assess the toenail issue, 2. The licensed nurses failed to develop a care plan for the toenail care, 3. The facility failed to refer Resident 273 to a podiatrist (foot doctor). These failures had the potential to affect the resident's foot health and contribute to resident's discomfort, injury and infection. Findings: A review of Resident 273 's clinical records indicated he was admitted on [DATE], and had diagnoses including type 2 diabetes (high blood sugar) and long-term (current) use of anticoagulants (medicines that help prevent blood clots). During a concurrent observation and interview with Resident 273 on 5/9/23 at 1:10 p.m., observed Resident 273's both great toenails were long, thick, hypertrophied (excessively enlarged), discolored, protruded, dark brown color, and black debris built-up under his toenails.…

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 nine residents (Resident 273) who had the indwelling urinary catheters (a small, flexible tube that can be inserted through the bladder to drain urine into a urine collection bag) had appropriate urinary management when the Resident 273 wore the urine drainage leg bag on his bed higher than his bladder. This failure could potentially put the Resident at risk of urinary infection. Findings: A review of Resident 273's clinical records indicated he was admitted on [DATE] and had diagnoses including type 2 diabetes (high blood sugar), chronic kidney disease( a type of kidney disease in which a gradual loss of kidney function ), obstructive and reflux uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow and can be either structural or functional). A review of Resident 273's Minimum Data Set (MDS, an assessment tool) dated 5/9/23, indicated his brief interview for mental status (BIMS, cognition…

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 central venous catheter (CVC, a thin, flexible tube that is placed into a large vein above the heart) care for one of three residents (Resident 69) with parenteral lines (one form of route of administration such as intravenous) were performed per professional standards of practice when: 1. The registered nurse (RN) failed to flush the CVC for two days, and no nursing notes indicated why not to flush, 2. The registered nurses failed to change the CVC dressing since admission, 3. The Registered nurse did not develop a person-centered, resident-specific CVC care plan and included CVC-related information such as insertion site/location, date of insertion, number of lumens (openings), type of catheter, etc. in the care plan. These failures pose a risk for Resident 69 to develop complications that could compromise her care, health, and safety. Findings: A review of Resident 69 'S clinical records indicated she was admitted on [DATE],…

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 each resident's medication regimen was free from unnecessary medication for two of 25 sampled residents (Residents 62 and 69). Resident 62 had been receiving magnesium oxide (an electrolyte to treat low magnesium level in the body) for two and a half years without magnesium level monitoring. Resident 69 had been receiving two types of insulin (medication to lower blood glucose [BG] in the body) without staff monitoring the signs and symptoms of hypo/hyperglycemia (too low/high BG). The failure had the potential for adverse effects to go undetected or recognized for timely intervention. Findings: 1. A review of Resident 62's clinical record indicated she was an elderly resident admitted to the facility with diagnoses including chronic kidney disease (condition in which the kidneys are damaged and cannot filter blood as well as they should) and heart failure (a condition that develops when your heart does not pump enough blood for your body's needs). A review of her clinical record indicated she had a physician's…

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

Based on interview and record review, the facility failed to ensure one of 25 sampled residents (Resident 69) was free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behaviors). Resident 69 received trazodone (anti-depressant medication) and Depakote (a medication to treat mood disorder or seizures) without monitoring for hours of sleep related to trazodone use and the potential side effects of the medications. The failure resulted in inadequate monitoring for effectiveness and adverse effects of psychotropic medications. Findings: A review of Resident 69's clinical record indicated she was admitted to the facility with diagnoses including anxiety and depression. A review of Resident 69's physician's orders included the following: - Trazodone 50 milligrams (mg, unit of measurement), 1 tablet by mouth at bedtime for depression manifested by inability to sleep, dated 4/3/23; - Depakote 250 mg, 1 tablet by mouth two times a day for mood stabilizer manifested by yelling out, dated 4/3/23. A review of her April and May…

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 store food under sanitary condition when: 1. For Resident 105, there was an opened tube feeding (a way of giving medicines and liquids, including liquid foods, through a small tube placed through the nose or mouth into the stomach or small intestine) formula at the bedside; and 2. Two dented cans were not removed from the kitchen's dry storage area. These failures had the potential to expose residents to food borne illnesses in the facility. Findings: During an observation on 5/10/2023 at 10:20 a.m., while in Resident 105's room. Resident 105 was lying in bed, and there was a 1000 milliliter (ml, measure of volume) bottle of ready-to-hang Jevity 1.5 calorie (nutritional supplement) on top of the nightstand next to Resident 105's bed. The bottle was labeled, open on 5/10/2023 at 9:00 a.m. The bottle contained approximately 800 ml of formula left in the bottle. During another observation on 5/10/2023 at 1:30 p.m., while in Resident 105's room, the same Jevity 1.5 calorie bottle was still on top of the nightstand…

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 compliance with infection control practices when one Laundry Personnel I (LP I) was wearing gloves in the hallway. This deficient practice had the potential to affect the safety and well-being of residents, visitors, and staff in the facility. Findings: During an observation on 5/9/2023, at 1:10 p.m., while in Station 1, the LP I was wearing gloves on both hands and carrying a cloth while walking in the hallway. The LP I walked passed an open meal tray cart in Station 1, proceeded to Station 5, and continued to wear gloves on both hands while shaking the cloth and interacting with other facility staff in the hallway. The LP I stopped in front of her utility cart, removed her gloves, and disposed of gloves in the trash. During an interview with the Licensed Vocational Nurse F/Infection Preventionist (LVN F/IP) and Laundry Supervisor (LS) on 5/9/2023 at 1:20 p.m., the surveyor informed the LVN F/IP and LS of the above incident. LVN F/IP stated gloves should not be worn in the hallway unless cleaning…

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 peripherally inserted central catheter (PICC, a thin flexible tube was inserted into a vein in the upper arm and guided into a large vein above the right side of the heart) line care for one of two residents (Resident 174) when licensed nurses did not measure the circumference and the length of the arm of Resident 174 as prescribed by the physician. This failure could compromise the health and safety of the resident. Findings: Review of Resident 174's clinical record indicated he had diagnoses sepsis (a potentially life-threatening condition caused by the body's response to an infection), phlebitis (inflammation of the walls of a vein), and muscle weakness. Review of Resident 174's order summary report dated 1/12/2020, indicated PICC line dressing change, measure arm circumference and the length visible every 7 days and as needed. Review of Resident 174's medication administration record (MAR) dated 1/2020, indicated Resident 174's PICC line had no measurement for the arm circumference and the length…

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 respiratory care in accordance with professional standards of practice for two of four sampled residents (Residents 63 and 6) when the licensed nurse failed to ensure oxygen was administered as specified in the physician's order for Resident 6 and facility staff administered oxygen without a physician's order and no No Smoking/oxygen in Use signs at the entrance door for Resident 63. These failures had the potential to compromise the residents' health and safety. Findings: 1. Review of Resident 63's clinical record indicated he had the diagnoses that included pancytopenia (a condition in which a person's body has too few component of blood cells including the one that is responsible for carrying oxygen). During multiple observations on 1/21/2020 at 8:36 a.m. and 3:14 p.m., Resident 63 was lying in bed receiving oxygen at 2 liters per minute (LPM, rate of oxygen administration) via nasal cannula (flexible tubing placed into the nostrils) connected to oxygen concentrator (machine used to deliver oxygen).…

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: 1. The timely replacement of emergency kits (e-kit, a kit/box containing medications and supplies for immediate use during a medical emergency); 2. The accurate accountability of the controlled substance (CS, medications with high potential for abuse and addiction) medications for five of six residents (Residents 39, 55, 67, 75, and 114) 3. The availability of Resident 75's lantus (long-acting insulin). These failures had the potential to cause delay in treatment and compromise residents' medical health. 1. During an observation in medication room A on 1/21/2020 at 10:55 a.m. with licensed vocational nurse B (LVN B), revealed the emergency intravenous medication and supply kits were opened on 1/16/2020. During a concurrent interview, LVN B stated the e-kits should have been ordered the day it was opened. Review of the facility's undated policy, Emergency Medications, indicated medications and supplies used from the emergency medication kit must be replaced upon the next routine drug order. 2. On 1/21/2020 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 the residents were free from unnecessary psychotropic (medication affecting the mind, emotions, and behavior) medications for 8 of 11 sampled residents (Residents 106, 94, 74, 45, 75, 25, 40, and 274) when: 1. For Residents 106, 94, 45, 75, 25, and 40, the facility failed to monitor the side effects of the medications; 2. For Resident 74, facility failed to monitor the specific target behavior and side effects of the medication; 3. For Resident 274, the facility failed to identify and monitor the specific target behavior for the use of the medication; 3. For Resident 25, the facility failed to implement the interdisciplinary team (IDT) recommendation to reduce Seroquel. These failures had the potential to negatively affect the residents' physical and psychosocial well-being. Findings: 1. Review of Resident 106's clinical record indicated she was admitted [DATE] with diagnoses including dementia (a decline in mental ability severe enough to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility had a 12% error rate when three medication errors out of 25 opportunities were observed during a medication pass. Resident 87 did not receive amlodipine besylate (medication for high blood pressure) and amantadine (medication used to treat Parkinson's disease [a movement disorder]) as scheduled. These failures resulted in medications not given in accordance with the prescriber's orders and may affect the resident's clinical condition. Findings: During a medication pass observation on [DATE] at 9:21 a.m., LVN A prepared medications for Resident 87. LVN A removed a Humulin N insulin (injectable medication that lowers blood sugars quickly) vial that was labeled [DATE] and drew up the medication. LVN A took one tablet of aspirin from a bottle. During an observation on [DATE] at 9:36 a.m., LVN A administered the medications to Resident 87. Resident 87 told LVN A that nurses usually give her three pills instead of one. LVN A told Resident 87 she gave her…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to store medication in accordance with professional standards when an Advair (medication that is inhaled and used to improve breathing) inhaler had no open date and was left unattended on the medication cart, latanoprost (eye drops used to lower pressure in the eye) bottle was not labeled with an open date, lorazepam (medication used to treat anxiety) container was not refrigerated, and expired insulin (medication used to lower blood sugar) vials were stored in the medication cart. These failures had the potential to allow residents and unauthorized staff to access medications and affect the integrity of the medications. Findings: 1. During a medication pass observation on [DATE] at 8:40 a.m., licensed vocational nurse H (LVN H) prepared medications for Resident 20. LVN H removed the Advair inhaler from medication cart D and placed it on top of the cart. LVN H continued to put medication inside a medication cup. During an observation 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 safe food storage practices when residents' food were not labeled and dated and when the temperature of two of two resident food refrigerators were not monitored. These failures had a potential for residents to contract food-borne illnesses. Findings: During an observation of medication room B on 1/21/2020 at 8:36 a.m. with the director of nursing (DON) revealed there was a refrigerator for resident's food. There were three containers of food inside the refrigerator that were not labeled with a date. During a concurrent interview, the DON confirmed the food items were not dated. During an observation of medication room C on 1/21/2020 at 9:02 a.m., with licensed vocational nurse C (LVN C), indicated there was a refrigerator for resident's food. One container of food was inside the refrigerator. During a concurrent interview, LVN C stated she did not think there was a log to monitor the temperatures of the resident food refrigerator. During an observation and interview on 1/21/2020, the assistant…

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 staff implemented proper infection control practices for 6 of 26 sampled residents (274, 175, 88, 87, 8, and 20) when: 1. For Resident 274, nebulizer face mask was not properly stored. 2. For Resident 175, indwelling catheter (a flexible plastic tube (a catheter) inserted into the bladder which provide for continuous urinary drainage) bag was not covered; 3. For Resident 88, contact precaution was not followed as prescribed by the physician; 4. For Resident 87, licensed vocational nurse A (LVN A) did not clean the top of the insulin vial with alcohol 5. For Resident 8, licensed vocational nurse J (LVN J) did not perform hand hygiene after touching a trash can and before administering medication 6. For Resident 20, licensed vocational nurse H (LVN H) was not able to pull her gloves on to completely cover her palms and wrists when in a room on contact precautions. These failures had the potential to result in infection for 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 accommodate resident's needs for one of 26 residents (Resident 61) when staff did not attend to Resident 61's needs promptly. This failure resulted in Resident 61 waiting 22 minutes for her call light (a button pressed by a patient that turn on a light and/or sound alerting staff a patient needs their help) to be answered and had the potential for residents' to not receive assistance from staff in a timely manner and not meeting their needs. Findings: Review of Resident 61's clinical record indicated she was admitted in the facility with diagnoses including muscle weakness and diabetes mellitus (group of diseases that result in too much sugar in the). Further review of Resident 61's clinical record indicated she was incontinent on both bladder and bowel and needed limited to extensive assistance with bed mobility, dressing, toilet use and personal hygiene activities of daily living (ADLs, daily activities for self-care). During an observation and interview with Resident 61 on 1/21/2020 at 9:12 a.m., 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.