Santa Maria Post Acute

Based on observation, interview, and record review, the facility failed to ensure a call light was functioning for one of two sampled residents (Resident 2). This failure had the potential to result in Resident 2 not having their needs met and sustain complications. Findings: During a concurrent observation and interview on 12/2/24 at 10:40 a.m. with Resident 2 in Resident 2 ' s room, Resident 2 stated staff did not come when the call light was pushed. Resident 2 pressed the call light and waited five minutes. There was no response, no ringing heard and the light outside of the room above the doorway was not lit. The call bell was observed not plugged into the wall. During a concurrent observation and interview on 12/2/24 at 10:45 a.m. in Resident 2 ' s room, with certified nursing assistant (CNA 1), CNA 1 stated could not hear the call bell ring and the light outside of the room above the doorway was not lit. CNA 1 observed call light plug was not plugged into the wall and stated the call light should always be plugged into the wall. During a concurrent interview and record review…

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

Based on observation, interview, and record review, the facility failed to ensure food safety standards were followed when: 1. A dietary aide/cook (DAC) was observed not following proper hygiene and sanitary practices during lunch tray preparation. 2. The frequency of the facility's ice machine sanitization schedule was not followed according to manufacturer's recommendations. These failures had the potential to cause food-borne illness to vulnerable residents currently residing in the facility. Findings: 1. During a lunch tray line observation on 11/19/24 at 12:15 p.m. inside the facility kitchen, with the registered dietitian (RD), certified dietary manager (CDM), and DAC, DAC was observed preparing cooked food for resident lunch tray distribution. DCA was noted measuring the food temperatures with gloved hands. Using the same pair of gloves, DCA continued to open/close cabinets and drawers, taking out spoons and scoops placing them onto the food trays for serving. Upon further observation, DCA was noted resting the plate against her body while scooping food onto the plate. DCA'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 provide nursing staff on a 24-hour basis to care for the residents' needs. This failure had the potential to result in residents not receiving necessary care. Findings: During a review of Report: Calculated Time by Entry, transmitted by the facility for the Payroll Based Journal (PBJ - quarterly staffing data report submitted to the Centers for Medicare and Medicaid Services [CMS] by long-term care facilities including the hours nursing staff are paid to work each day) Report for Quarter 1, 2024 (October 1, 2023 - December 31, 2023) with infraction dates of 11/05 (Sunday), 11/09 (Thursday), 11/12 (Sunday), 12/10 (Sunday) and 12/25 (Monday), there were no assigned Registered Nurses on the staffing assignments. For Quarter 2, 2024 (January 1, 2024 - March 31, 2024) with infraction dates of 1/19 (Friday), 3/02 (Saturday), 3/03 (Sunday) and 3/15 (Friday), there were no assigned Registered Nurses on the staffing assignments. During an interview on 11/20/24 at 3:15 p.m. with the facility Administrator (ADM), ADM validated 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 ensure there was an informed consent for the use of medication Xanax (drug that helps to control anxiety and panic attacks) in one of two sampled residents (Resident 44). This failure had the potential for Resident 44 to be on Xanax without being informed of the risk and benefits of the drug. Findings: During a concurrent interview and record review on 11/20/24 at 3:35 p.m. with the director of nursing (DON), Resident 44's physician's order was reviewed. The order indicated, Xanax Oral tablet 0.25 mg (milligram) 1 tablet every 8 hours if needed for anxiety and panic. There was no informed consent found for the use of Xanax indicating resident or representative was educated on the risk and benefits of the medication. DON was unable to locate a consent for the Xanax in Resident 44's chart. During a review of the facility's policy and procedures (P&P) titled, Informed Consent-Psychotherapeutic Medications and Restraint Devices, (undated), the P&P indicated in part, The healthcare practitioner ordering a psychotherapeutic…

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 have the most recent recertification survey results available to residents, family members and legal representatives of residents. This facility failure denied the opportunity for residents, family members, and legal representatives of residents to be aware of the facility's survey results. Findings: During an observation on 11/18/24 at 2:40 p.m. at the entrance check-in counter, the survey binder was inspected. The survey binder was missing the recertification survey results and plan of correction from the most recent recertification survey held 8/15/22 - 8/18/22. During an interview on 11/19/24 at 11:45 a.m. with the director of nursing (DON), the DON confirmed the most recent survey results inside the binder was dated July 2021. The DON was unaware a recertification survey had been conducted August 2022 and stated, It was? I will look into it and get back to you. During an interview on 11/19/24 at 12 p.m. with the administrator (ADM), the ADM stated the results of the last recertification survey from…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for two of four sampled residents (Residents 44 and 17) when: 1. No care plan was developed for Resident 44 for the use of the medication Xanax (medication that helps control anxiety and panic attacks). 2. No care plan was developed for Resident 17 for the use of the anticoagulant medication Apixaban (a medication that helps prevent blood clots). These failures had the potential to result in misidentifying potential unneccessary use and abnormal bleeding complications for these residents. Findings: 1. During a concurrent interview and record review on 11/20/24 at 3:50 p.m. with the Director of Nursing (DON), Resident 44's Plan of Care was reviewed and there was no care plan addressing behavior monitoring and continuous use of Xanax found in the record. DON acknowledged there was no care plan regarding the use of the medication Xanax. 2. During a review of Resident 17's admission 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 observation, interview, and record review, the facility failed to ensure the timely revision/update of a comprehensive care plan for one of four sampled residents (Resident 12), to reflect changes in Resident 12's choices and change in condition. This failure resulted in an inaccurate care plan and had the potential to result in placing the resident at risk of not receiving the appropriate care. Findings: During an observation on 11/18/24 at 4:04 p.m. in room [ROOM NUMBER]-2, Resident 12 was observed in bed with a foot cradle (a frame attached to the foot of the bed to keep sheets and blankets away from feet and legs for pressure relief). Resident 12's feet were observed positioned on opposite sides of the pillow instead of above the pillow (used to off load feet to prevent pressure ulcer(s) from developing in the heel(s)), with a very pronounced foot drop (difficulty in lifting the front part of the foot). The foot board distance to the soles of the feet was approximately one (1) foot (12 inches).…

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 followed professional standards to provide quality care for three of seven sampled residents (Residents 403, 50, and 34) when: 1. A medication for Resident 403 was not administered per doctors' order. 2. A physician order was not carried out for Resident 50. 3. Post dialysis (treatment for kidney failure where blood is cleaned through an artificial filter) assessments were not completed for Resident 34. These failures had the potential to inappropriately identify and manage resident's health issues that may lead to serious harm. Findings: 1. During a review of Resident 403's Medication Orders, 11/19/24 the Orders indicated, an order for Furosemide (a medication that increases amount of urine output, helping the body eliminate accumulated/excess fluids) Oral Tablet 20 mg. (milligram). Give one tablet by mouth two times (9 a.m. and 9 p.m.) a day for CHF (Congestive Heart Failure - a long term condition that happens when 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: 1. Acetaminophen (treat minor aches and pains, and reduces fever) was given as ordered for one of four sampled residents (Resident 403) 2. Levothyroxine (to treat an underactive thyroid gland [hypothyroidism]) was given before breakfast for one of four sampled residents (Resident 404) 3. Acamprosate (a medication used to help overcome alcohol dependence), and Magnesium Oxide (a supplement) were administered as prescribed to one of four sampled residents (Resident 202) These failures had the potential for the residents to not receive the maximum benefit from the medications. Findings: 1. During a medication administration observation on 11/19/24 at 08:02 a.m. with Resident 403, licensed nurse (LN 3) administered Acetaminophen (treat minor aches and pains, and reduces fever) 325 mg (milligrams) 1 tablet instead of 2 tablets as per the physician order to give Acetaminophen 650 mg. 2. During a medication administration observation on 11/19/24 at 8:18 a.m. with Resident 404, LN 3 administered Levothyroxine…

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 there was a Medication Regimen Review for Xanax (drug that helps to control anxiety and panic attacks) for one of two sampled residents (Resident 44). This failure had the potential for Resident 44 to have complications from the medication. Findings: During a concurrent interview and record review on 11/20/24 at 3:15 p.m. with the Director of Nursing (DON), Resident 44's physician's order was reviewed and indicated, Xanax oral tablet 0.25 mg (milligrams) was ordered on 10/30/24. Review of Resident 44's Medication Regimen Review (MRR), dated November 2024 indicated, there was no review for Xanax's continued use beyond 14 days. DON confirmed not finding any pharmacist review for Xanax. During a review of facility's policy and procedure (P&P) titled, Consultant Pharmacist Services Provider Requirements, (undated), the P&P indicated in part, Reviewing the medication regimen of each resident at least monthly, or more frequently under certain conditions and Communicating to the responsible prescriber and the facility…

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

Based on interview and record review, the facility failed to ensure there was a practitioner's (physician) justification for the continued use of Xanax (drug that helps to control anxiety and panic attacks) beyond 14 days for one of two sampled residents (Resident 44). This failure had the potential for Resident 44 to receive an unnecessary medication and have complications due to the medication. Findings: During a concurrent interview and record review on 11/20/24 at 3:15 p.m. with the director of nursing (DON), Resident 44's physician's orders and progress notes were reviewed. The order indicated, Xanax Oral tablet 0.25 mg 1 tablet every 8 hours if needed for anxiety and panic. There was no documentation found in the physician's progress notes justifying the need for continuous use of Xanax beyond 14 days. DON acknowledged there was no provider justification for the continued use of the drug (Xanax) beyond 14 days. During a review of facility's policy and procedure (P&P) titled, Psychotropic Medication Use, dated July 2022, the P&P indicated in part, PRN (if needed) orders for…

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

Based on observation, interview, and record review, the facility failed to ensure the medication error rate was less than five percent. During medication administration for three of five residents (Residents 403, 404 and 202) four medication errors were observed out of 27 opportunities which resulted in an error rate of 14.81 percent. This failure had the potential for the residents to not receive the maximum benefit from the medications and sustain complications and side effects. Findings: 1. During a medication administration observation on 11/19/24 at 8:02 a.m. with Resident 403, licensed nurse (LN 3) administered Acetaminophen (treat minor aches and pains, and reduces fever) 325 mg (milligrams) 1 tablet instead of 2 tablets as per the physician order to give Acetaminophen 650 mg. 2. During a medication administration observation on 11/19/24 at 08:18 a.m. with Resident 404, LN 3 administered Levothyroxine (to treat an underactive thyroid gland [hypothyroidism]) 88 mcg (micrograms) after the resident had eaten breakfast and had taken other oral medications. Review of Davis's Drug…

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 medications and biologicals were safely labeled and stored in the medication storage room when: 1. An opened one-liter bottle of 0.9% Sodium Chloride solution (a solution used for wound cleaning) was found without an open date label. 2. Temperature logs for three sampled months for the two refrigerators used to store medications had days when temperature readings were out-of-range. The log did not have a section to indicate if adjustment was done when temperature readings were out-of-range. 3. A box of lemon glycerin swab sticks (cotton swabs used to soothe dry mouth) was found in the freezer. 4. Two plastic bags containing multiple labeled and unlabeled medications were found in the medication storage room sink. 5. One opened container of glucometer strips (a strip inserted in a device used to measure blood sugar level) was found in one medication cart without an open date label. These failures had the potential to result in ineffective and unsafe medication administration. Findings: 1. During a…

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

Based on interview and record review, the facility failed to ensure measures/system were in place to prevent the growth of Legionella (a bacteria found in water systems such as air conditioners, shower, sinks, and water fountains) and other opportunistic waterborne (a disease/infection from infected water) pathogens in their water system. This failure resulted in not having a water management program/system which had the potential to expose the residents of the facility to Legionella and other harmful waterborne pathogens. Findings: During a concurrent interview and record review on 11/20/24 at 4:52 p.m. with the Administrator (ADM) and Director of Nursing (DON), in the ADM's office, the Facility Assessment did not address a water management program. The ADM admitted they did not have a system in place to test and track for Legionella and other waterborne pathogens. The ADM stated they had not conducted water testing to ensure Legionella or other harmful waterborne pathogens were not present in the facility's water system. The ADM added that the facility did not have a water…

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 to provide a safe, functional, sanitary, and comfortable environment for two of four sampled residents (Residents 6 and 12). This failure resulted in compromising the comfort and safety of the residents and had the potential to result in adversely affecting the resident's health and well-being. Findings: During an observation on 11/18/24 at 12:56 p.m. in room [ROOM NUMBER]-2, Resident 6's bed was not in working order. Resident 6 was observed having difficulty feeding self. Attempts to elevate the head of the bed using the bed control switch proved unsuccessful. Resident 6 occupied B bed, next to her was A bed which was fully functional. During an interview on 11/18/24 at 1:04 p.m. with the maintenance supervisor (MS), MS stated was verbally informed on 11/14/24 by a night shift CNA the bed was not working. MS further stated parts have been ordered to repair the defective bed. When asked why Resident 6 was not moved to the other…

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 three residents (Resident 1) Deep Tissue Injury (DTI) did not worsen and the resident did not develop further wounds. This failure resulted in the DTI becoming worse and the development of three additional pressure injuries, an additional hospital stay, and increased pain for Resident 1. Findings: During a review of Resident 1's admission Record, dated 4/20/24, the admission Record indicated, Resident 1 had diagnoses including, a pressure induced deep tissue damage (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) of right heel, spiral fracture of right tibia (break in bone from a twisting motion), Type II Diabetes (a chronic condition that causes high blood sugar levels in the blood which can delay and/or complicate wound healing), hemiplegia (Total paralysis of one side of the body) following a cerebral infarction (stoke, damage to tissue in the brain) muscle weakness and abnormal gait (walking). During a review of Resident 1 ' s Nursing admission…

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 comply with the state requirement of unusual occurrence by not reporting to the Department (State Agency) a fall with injury for one of two sampled residents (Resident 1). This deficient practice resulted in a delayed investigation by the Department for Resident 1's fall. Findings: During a review of Resident 1 ' s clinical record, dated 10/22/22, the clinical record indicated, Resident 1 sustained an unwitnessed fall from a wheelchair in the dining room of the facility, resulting in injuries, requiring emergency medical services (EMS) to be contacted and resident sent to the emergency room (ER). During an interview on 3/12/24 at 11:27 a.m. with the Administrator (ADM), ADM verbalized there was no report filed, the former Administrator at the time, did not report the fall to California Department of Public Health (CDPH) because the patient did not return to the facility from the hospital and therefore, they were not given a diagnosis. During a review of the facility ' s policy and procedure (P&P) titled,…

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

Based on observation, interview, and record review, the facility failed to provide an environment free from restraints for one of two sampled residents (Resident 1) when the facility raised all four side rails. This failure had the potential to negatively affect the Resident 1's physical mobility and psychosocial well-being. Findings: During a review of the facility's policy and procedure (P&P) titled, Use of Restraints, dated 4/17, the P&P indicated in part, Practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted, including: a. using bedrails to keep a resident from voluntary getting out of bed as opposed to enhancing mobility while in bed. During a review of Resident 1's Consent for use of siderails, dated 7/30/19, the Consent indicated, I DO NOT consent to the use of side rail(s) recommended above and understand the related liabilities was marked. During an observation of Resident 1's room on 3/21/2024 at 10:40 a.m., Resident 1 was observed in the bed with all four bed side rails up. During an interview on…

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

Based on observation, interview and record review, the facility failed to ensure one of four sampled residents (Resident 1), was provided a written Bed Hold notice. This failure resulted in Resident 1 being denied readmission to the facility, after hospitalization. Findings: During an interview on 1/6/24 at 3 p.m. with the Business Office Assistant (BOA), BOA verbalized, she spoke to the Resident 1's representative per phone regarding the bed hold notification. The representative was not provided a written copy of the bed hold notification. During a review of Resident I's Bed Hold and Return Notification, dated 11/29/23, the Bed Hold and Return Notification indicated, the form was unsigned by Resident I's representative. During a review of Resident I's California Standard admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities, dated 8/3/23, the Agreement indicated, If you must be transferred to an acute hospital for seven days or less, we will notify you or your representative that we are willing to hold your bed.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately assess the skin status for one resident (Resident 1) upon admission. This failure had the potential for Resident 1 to not receive needed care. Findings: During a review of Resident 1's History & Physical (H&P), the H&P indicated, Resident 1 was a [AGE] year-old female admitted on [DATE] for short term rehab after a Right (R) Total Knee Arthroplasty (TKA). Other diagnoses included, Osteoarthritis of right knee, difficulty in walking, muscle weakness and abnormal gait and mobility. During an interview on 12/13/23 at 5:30 p.m. with Director of Nursing (DON), DON stated Resident 1 came with bruises on her right side - hip, flank, and back. During an interview on 1/24/24 at 12 p.m. with Administrator (ADMIN), ADMIN stated the DON described Resident 1's bruising to have already been black and blue, turning yellow/green and fading. During a review of Resident 1's Nursing admission Screening/History, dated 10/23/23, the Nursing admission…

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 record review and interview, the facility failed to ensure a comprehensive person-centered care plan was developed and implemented with measurable objectives and individualized interventions for four of 13 residents in the sample. (Residents 40, 45, 41 and 14). As a result of this deficient practice, the residents had a potential to be at risk of not attaining or maintaining their highest practicable physical, mental, and psychosocial well-being and, had a potential negative impact on the resident's quality of life, as well as quality of care and services received. Findings: 1. During a review of Resident 40's clinical records on 8/17/22 at 09:23 AM, the record indicated Resident 40 was admitted to the facility on [DATE] with diagnoses including but not limited to anxiety disorder and depression. Concurrent review of the admission Minimum Data Set (MDS-an assessment) dated 7/27/22, in Section E, documented resident 40 has manifested delusions; and in Section N, documented the resident has received…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility staff failed to ensure the facility is free of a medication error rate of 5% or more as evidenced by 4 medication errors out of 42 medication administration opportunities or an error rate of 9.52%. when: 1. Resident 22 received 37.5 mg of metoprolol tartrate (a medication to lower blood pressure) instead of 50 mg. 2. Resident 21 received 1 patch of 4% lidocaine (a numbing agent) instead of 2 patches applied to the lower back. 3. Resident 21 received 2 drops of Dorzolamide HCL 2% (eye drops used to treat residents increased eye pressure) to both eyes immediately followed by 2 drops of Tears Naturale (a viscous solution that acts as an artificial tear). There should be a 3-5-minute interval between the two medications. 4. Resident 21 inhaled 2 puffs of Trelegy Elipta Aerosol Powder, (a combination of drugs used for patients with Chronic Obstructive Pulmonary Disease or COPD which is a group of lung disease that block airflow and make it difficult 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.

Based on observation, interview, and record review, the facility failed to ensure safe food handling and sanitation were implemented when: 1. Food items were unlabeled and/or undated in the utility refrigerator adjacent to the nursing station. 2. Staff could not demonstrate competency during chemical testing of the kitchen sanitizing solution. These failures had the potential to cause foodborne illness to the highly susceptible residents currently residing in the facility. Findings: According to the FDA (Food and Drug Administration) Food Code 2017, A Highly susceptible population means persons who are more likely than other people in the general population to experience foodborne disease because they are: (1) Immunocompromised; . or older adults; and (2) Obtaining food at a facility that provides services such as . health care. 1. During a concurrent observation and interview on 8/17/22, at 10:51 am, with Director of Nursing (DON), the utility room refrigerator was inspected and DON stated it was used to store things for med pass like apple sauce or pudding for residents. The DON…

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 infection control practices when the contact time (time product should stay wet) of a disinfectant/cleaner could not be verbalized by staff. This facility failure had the potential to result in cross-contamination (the transfer of harmful bacteria) that could impact residents' health and safety and cause preventable HAIs (Healthcare Associated Infections) for residents in an already compromised condition. Findings: During an observation and concurrent interview on 8/18/22, at 9:36 am, with a janitor (JA1) and a housekeeper (HK1), HK1 had a bucket with bleach and water to use as disinfectant/cleaner on cleaning cart. HK1 stated the contact time for the bleach and water mixture is one minute. HK1 and JA1 could not verbalize the correct contact time for the products used when asked. The infection preventionist (IP) confirmed that HK1 and JA1 should be able to verbalize contact times for products being used. During a review of the facility policy and procedure (P&P) titled, Cleaning and Disinfection 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 follow its Mitigation Plan for the prevention and containment of COVID-19 when testing for two of three sampled staff were not conducted according to the recommended frequency. This deficient practice had the potential to contribute to the transmission and spread of infectious diseases, such as COVID-19, to residents, staff, and visitors in the facility. Findings: During an interview and concurrent record review on 8/16/22, at 4:01 pm, with the Infection Preventionist (IP), (nurse who helps prevent and identify the spread of infectious agents like bacteria and viruses in a healthcare environment) the IP stated that during an outbreak of COVID-19 the facility test all staff and Residents twice a week. The IP stated due to an outbreak twice weekly testing was being performed from 13/30/21 until 2/4/22. IP was not able to provide documentation for twice weekly testing for licensed nurse (LN2) on1/4/22,1/14/22, and 2/4/22 or for laundry staff (L1) on 1/4/22, missing 1/7/22).The IP confirmed the twice weekly testing was not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a baseline care plan was initiated within forty-eight hours of admission for one sampled resident (Resident 40). This failure had a potential for the staff to not have proper guidelines to follow to ensure proper care and services for Resident 40 were received. Findings: During a review of Resident 40's clinical records on 8/18/22 at 09:17 AM, the record indicated Resident 40 was admitted to the facility on [DATE] with diagnoses including but not limited to displaced comminuted fracture of shaft of left fibula (A fracture where the bones are broken in several fragments and are not aligned of the lower leg), displaced fracture of medial malleolus of left tibia (a break in the bone on the inside of the ankle where the bone fragments are not in alignment) and unspecified fall. Review of the admission minimum data set (MDS-part of the federally mandated process for assessing individuals receiving care in certified skilled nursing facilities) dated…

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 staff failed to ensure for one resident's (Resident 41) comprehensive care plan pertaining to psychotropic (drugs that affect a person's mental state) use was reviewed, evaluated for effectiveness, and revised. This failure resulted in resident 41's behaviors not being monitored to justify the continued use of the psychotropic medications. Findings: Review of the clinical record for Resident 41 on 8/18/22 at 09:37 AM, indicated Resident 41 was admitted to the facility on [DATE] with diagnoses included, but not limited to unspecified anxiety disorder and unspecified depression. Review of the current care plan for Resident 41,dated 6/9/22, indicated in part, The resident uses anti-anxiety medication related to panicky feeling with intervention included to monitor for target behavior. The resident uses antidepressant medication related to episode of tearfulness with intervention included to monitor change in behavior. Review of the admission Minimum Data Set…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure medications were accurately administered to two of 13 sampled residents (Resident 21, Resident 22) when: 1. Resident 22 received 37.5 mg of metoprolol tartrate (a medication to lower blood pressure) instead of 50 mg. 2. Resident 21 received one patch of 4% lidocaine (a numbing agent) instead of two patches applied to the lower back. 3. Resident 21 received two drops of Dorzolamide HCL 2% (eye drops used to treat increased eye pressure) to both eyes and then immediately followed by two drops of Tears Naturale (a solution that act as artificial tears). The three to five minutes interval between the two medications was not observed. 4. Resident 21 inhaled two puffs of Trelegy Elipta Aerosol Powder, (a combination of drugs used for patients with Chronic Obstructive Pulmonary Disease or COPD which is a group of lung disease that block airflow and make it difficult to breathe). Resident 21 was provided with water to rinse the mouth with,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to appropriately label and store drugs when: 1. Two (2) boxes of Tylenol/Paracetamol (a medication for pain relief) suppositories were improperly stored in the medication room based on temperature requirements of 20-25 ºC (68-77º F) or in a cool place. 2. One (1) vials of Purified Protein Derivative (PPD also known as Tuberculin, (used to diagnose tuberculosis) was located in the refrigerator in the medication room. The opened date was documented on the box as [DATE]. 3. A medication of hydrocodone acetaminophen (Norco 5-325 a medication for pain relief) found in the north wing medication cart was expired with a an expiration date of 7/22. These failures had the potential for residents to receive expired, ineffective, and contaminated medications. Findings: 1. During an observation on [DATE], at 03:25 p.m. in the medication storage room, 2 boxes of Tylenol /paracetamol suppository were located in one of the storage cabinets. The Tylenol…

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 physical therapy (PT) services as ordered to one of 13 sampled residents (Resident 22). This failure prevented Resident 22 from receiving PT services to improve functional mobility and had the potential to promote deterioration of muscle strength. Findings: During a review of Resident 22's, admission Record (AR), dated 8/18/22, the AR indicated in part, Resident 22 was an [AGE] year-old, female resident who was admitted in the facility on 12/2/21, with diagnoses including, Hemiplegia/ Hemiparesis following Cerebral Infarction (weakness/paralysis on one entire side of the body caused by stroke), Chronic Kidney Disease (gradual loss of kidney function), and Vascular Dementia (altered thought processes caused by brain damage from impaired blood flow to the brain). During a review of Resident 22's, Order Summary (OS), from 12/1/21 through current, the OS indicated in part, the physician order that read, Continue PT 5x per week for ther ex…

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 document accurately the consent for Pneumococcal (bacterial infection) immunizations for one resident (Resident 40) and provide a Pneumococcal immunization for one resident (Resident 12). This facility failure had the potential to result in residents acquiring complications from Pneumococcal disease. Findings: Review of the facility policy and procedure (P&P) titled, Infection Control - Influenza and Pneumonia Immunizations for Residents, dated 5/12/22, the P&P indicated in par, That the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal. During an interview and concurrent record review on 8/16/22, at 4:01 pm, with the infection preventionist (IP), Resident 12's Pneumococcal Immunization informed consent dated 7/8/22 was reviewed. The consent indicated Resident 12 gave consent to get the Pneumococcal immunization. The IP confirmed Resident 12 has not received…

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

Based on observation, interview, and record review, the facility failed to store and distribute food in accordance with professional standards for food service safety when: 1. Expired food items were found in the dry food storage room. 2. Dented can stored in dry food storage room. 3. Food items were stored on the floor in the emergency supply room. 4. Expired food items were found in the emergency supply room. 5. A dietary staff employee was not wearing protective hair covering while in kitchen. These facility failures had the potential for to spread food borne illnesses. Findings: 1. During an observation and concurrent interview with the food and nutrition manager (Mngr 1) on 5/20/19 at 12:02 p.m., one container of olives was with the expiration date of 4/19/19 and one bottle of red wine vinegar was with the expiration date of 11/4/18 were found in the dry food storage room,. Mngr 1 confirmed the olives and vinegar were expired and stated, Yes it's expired. 2. During an observation and concurrent interview on 5/20/19 at 12:05 p.m., in the dry food storage room, one dented can of…

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

Based on observation, interview and record review, the facility failed to ensure: 1. The appropriate personal protective equipment (PPE) was worn by staff when sorting soiled laundry 2. Hand hygiene was performed in-between patients when passing medications These facility failures had the potential to result in cross contamination of micro-organisms and spread of infectious disease to residents and staff Findings: 1. During an observation on 5/22/19 at 10:22 a.m., in the facility soiled laundry room, the laundry staff (LS1) was wearing an apron with no sleeves, covering only the front of her uniform, and gloves. During an interview with the Maintenance Supervisor(MS) whom the laundry staff report to, on 5/22/19 at 10:35 a.m., the MS acknowledged the apron used by the laundry staff did not cover the arms of LS1 and there was an opportunity for the soiled linen to come in contact with the skin and clothing of LS1. The facility policy and procedure titled Departmental (Environmental Services) - Laundry and Linen revised 2/14, indicates Employees sorting or washing linen must wear a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure the facility's policy and procedure on medication administration was implemented by one licensed nurse (LN2) during a medication pass observation. The facility failure had the potential to cause medication errors. Findings: According to [NAME] and [NAME], seventh Edition, Fundamentals of Nursing. Chapter 35, Medication Administration, page 709, indicates Record medication administration as soon as medications are given. During observation of medication administration and concurrent interview with LN2 on 5/21/19, at 12:02 P.M., LN2 initialed the Medication Administration Record (MAR) prior to administrating medication for one sampled resident, (Resident 13), and four unsampled residents, (Residents 4,11,35, and 37). LN2 stated,I was told to pop, sign and pass and if they refuse then circle and write reason on the back of the MAR. The facility policy and procedure titled: Medication Pass Procedure, revised 02/2017, indicated, 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 results of the most recent survey was posted in a location readily accessible to residents/or responsible parties and the public. This failure had the potential to infringe on the residents right to know the facility's overall rating on resident care issues and the corrected actions being implemented. Findings: During the facility tour on 5/20/19 at 2:40 p.m., no recent survey results was noted posted for residents and public to view inside the facility area. During an interview with administrator (Admin) on 5/20/19 at 2:47 p.m., the ADM acknowledged the binder containing the previous year's survey is usually kept at the main entrance on the credenza (side board/table). Admin further acknowledged the survey binder was not on the credenza and stated they're out looking for it. The facility policy and procedure titled Survey results, Examination of dated 2007, indicated A copy of the most recent standard survey, including any subsequent extended surveys, follow-up revisits reports, etc., along with state…

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 record review and interview, the facility failed to ensure the presence or non presence of an advance directive (legal statement of the residents life sustaining measures choices ) was determined upon admission in one sampled resident (Resident 41). This failure had the potential to not validate the legal life sustaining choices to be implemented on the resident during a life emergency situation. Findings: During a review of the medical record for Resident 41, the face sheet, dated 4/30/19, under the section Advance Directive was left blank. The documentation on the undated Social Services Assessment sheet, under the category advance directive indicated see POLST. Review of Resident 41's POLST dated 4/29/19, indicated the resident was not to be resuscitated (DNR -do not resuscitate) when breathing stops, comfort measures only to relieve pain and trial artificial feeding. Section D for advance directive was left blank. Resident 41's POLST was signed by a responsible party. The facility policy and procedure titled Physician Orders for Life Sustaining Treatment (POLST) dated…

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

Based on observation, interview, and record review the facility failed to ensure a tab alarm (alarming device) was in place on the wheelchair for one of two sampled residents (Resident 49) as careplanned as one of the intervention for falls. This failure had the potential for staff to be not alerted when the resident gets up and out of the wheelchair with no assistance which can result to a fall and injury. Findings: During a review of the clinical record for Resident 49 the care plan titled Falls dated 04/01/16, indicated Resident 49 was a high risk for falls. One of the care plan interventions to prevent falls and maintain a safe environment was a tab alarm in place at all times on the wheelchair and bed. The Fall Risk Assessments dated 10/17/18, 01/17/19, and 4/17/19, indicated the facility assessed Resident 49 to be a high risk for falls During an observation on 5/22/19, at 10:43 a.m., Resident 49 was sitting up in wheelchair and propelling self down the hallway. The resident's whellchair had no tab alarm in place. During an observation and concurrent interview on 5/22/19 at…

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

Based on observation and interview the facility failed ensure a cautionary sign for oxygen usage was posted outside a resident room while oxygen was in use for one of three sampled residents (Resident 5). This failure placed residents and visitors at risk for non knowledge of the cautionary measures to be implemented (like no smoking) when in an environment with oxygen on. The failure can result to fire, explosion, or burns Findings: During an observation on 5/20/19 at 3:00 p.m., Resident 5 was on oxygen via a nasal cannula ( NC-tubing for oxygen via nose). Posted sign indicating oxygen use was not noted outside the resident's room. During an observation and concurrent interview with licensed nurse (LN 3) on 5/20/19 at 3:36 p.m., LN 3 confirmed Resident 5 was receiving oxygen and acknowledged no sign was posted outside the resident's room. LN 3 indicated a sign is supposed to be posted outside a resident's room when oxygen therapy is being administered.

Based on record review and interview, the facility failed to ensure facility staff received the required 5 hours training on dementia care (memory loss) to enable and equipped staff on caring for the needs of residents with mental and or psychosocial disorders. This failure has the potential for residents not to received the needed care to attain or maintain their highest practicable mental and psychosocial well-being. Findings: The facility policy and procedure titled Staff Development Program revised 4/10, indicated All personnel must participate in initial orientation and regularly scheduled in-service training classes . 2. All personnel are required to attend staff development classes . During a review of the facility In-Service Calendar for 2019, the bottom of the page indicates CNA's are required to have 5 hours of dementia specific training per year During the review of the employee file for certified nursing assistant (CNA 4) the Individual In-Service Training Record for 2018 indicated only one hour of dementia training was received. During an interview with the director of…

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

Based on observation, interview and record review, the facility failed to ensure the use of the medication Seroquel (antipsychotic medication used to treat certain mental/mood conditions) in one of four sampled residents (Resident 38) with the condition of dementia (memory loss) was evaluated for necessity and effectiveness. This failure had the potential for the unnecessary use of antipsychotic medication with the risks for complications on the resident. Findings: The facility policy and procedure titled Antipsychotic Medication Use revised 2/14, indicated Antipsychotic medications may be considered for residents with dementia but only after medical, physical, functional, psychological, emotional psychiatric, social and environmental causes of behavioral symptoms have been identified and addressed .6. Antipsychotic medications shall generally be used only for the following conditions/diagnosis as documented in the record, consistent with the definition(s) in the Diagnostic and Statistical Manual of Mental Disorders: .(f) Psychosis in the absence of dementia . During a review of the…

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

Based on observation, interview and record review the facility failed to ensure: 1.A resting hand splint (support device) was in place and worned by Resident 6 as ordered by the physician. This failure had the potential for the resident to developed increased contractures (tightening of bones and muscles). 2. Resident 6 received Range of Motion (ROM) exercises as ordered by the physician. This failure has the potential for the resident to developed muscle weakness which can result to decrease mobility (movement). Findings: 1.During a review of the clinical record for Resident 6 on 5/20/19, the Physician's Order, dated 2/15/19, indicated, right resting hand splint to prevent further contractures and prevent skin breakdown. During an observation on 5/20/19 at 12:55 P.M. inside Resident 6's room, Resident 6 was without a right resting hand splint as ordered on 02/15/19. During a concurrent record review and interview with the occupational therapy assistant (OTA) on 5/20/19 at 3:35 P.M., the OTA stated, I ordered a resting hand for (Resident 6), I think the Administrator may have not…

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

Based on observation interview and record review the facility failed to accurately document in the treatment record when: 1. Resident 18 refuses to wear arm brace/splint. 2. Resident 51's order for range of motion (ROM) exercises at five times per week (5x/wk) was only implemented at three times per week (3x/wk). These failures had potential for inaccurate documentation which can affect the implementation of the care the resident receives with the potential decline in the residents' medical condition. Findings: 1. During an observation on 5/20/19, at 2:26 p.m., Resident 18 was sitting up in bed. Resident 18 had a contracted left hand and not wearing an arm brace. During an observation and concurrent interview on 5/22/19 at 9:48 a.m., the nurse assistant (CNA2) acknowledged Resident 18 was asleep at this time and not wearing the arm brace. CNA 2 indicated the resident refuses to wear the brace sometimes when asleep. During an observation on 5/23/19 at 8:54 a.m. Resident 18 was asleep in bed, in supine position, and not wearing a brace on the left arm. During a review of the clinical…

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