Pacific Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to dispose of medications in a manner that was not retrievable (able to get back,) in one of one inspected medication room (Medication room [ROOM NUMBER].) This failure had the potential to increase the opportunity for medication diversion (the transfer of a medication from a lawful to an unlawful channel of distribution or use,) and increase the risk that residents in the facility could have accidental exposure to harmful medications possibly leading to physical and psychosocial harm, and hospitalization. Findings: During a concurrent observation and interview on [DATE] at 11:21 a.m. with Licensed Vocational Nurse (LVN) 3 in Medication room [ROOM NUMBER], the pharmaceutical waste bin was open and contained a mixture of intact (unchanged from original form) loose medication tablets and capsules out of their manufacturer packaging, medications in manufacturer bottles, creams/ointments and unopened and unused suppositories and patches in their…

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 staff followed the facility's infection control policy and procedure (P&P) by not labeling the personal hygiene belongings (two emesis basins, two toothbrushes, one toothpaste and two bottles of bath soap) in the shared bathroom for four of 14 sampled residents (Resident 25, Resident 27, Resident 28, and Resident 31). This deficient practice had the potential to result in Resident 25, Resident 27, Resident 28, and Resident 31 getting and spreading infection (the establishment of an infective agent in or on a suitable host, producing clinical signs and symptoms such as fever, redness, heat, etc.). Findings: During an observation on 1/21/2025 at 9:24 a.m. in a shared bathroom (shared by Resident 25, 27, 28, and 31), there were two toothbrushes (inside a wall cabinet on top of the sink) , two emesis basins (one was on top of the paper roll machine, the other was on top of the cabinet), two bottles of body soap (one was in 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 to protect resident right's to be treated with respect and dignity for one of two sampled resident (Resident 390). 1.Resident 390 was not provided bathroom assistance during mealtimes, was told that she will eat after she was provided incontinence care but was not provided care timely. 2.Resident 390 was not turned and repositioned when requested. These failures of not getting timely assistance resulted in Resident 390 felt she was treated like a child, had to eat with soiled incontinence (inability to control the release of urine or stool) brief, was left uncomfortable, upset, frustrated, and helpless. Findings: a. During a concurrent observation and interview on 1/21/2025 at 4:22 p.m., in Resident 390's room, Resident 390 appeared upset and stated the staff were quick to answer the call light and turn the call light off, but she had to wait a long time for the CNAs to respond to her request for assistance. Resident 390 stated CNA 3 and CNA 4 (unable to recall exact day) would ask her What do you need?…

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 call light (a device used by a resident to signal his/her need for assistance from staff) was within reach for two of 25 residents (Resident 21 and 390). This failure had the potential to delay the resident's care. Findings: a. During a review of Resident 21's admission Record, (not dated), the admission Record indicated, Resident 21 was admitted on [DATE] with the following diagnoses, but not limited to, cerebrovascular accident(CVA- a stroke, loss of blood flow to a part of the brain), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) with left sided weakness, muscle weakness, left elbow contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion). During a review of Resident 21's care plan (CP) for communication issues, dated 9/12/2023, the CP indicated Resident 21 has communication issues related to unclear speech. The CP interventions indicated Resident 21…

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

Based on observation, interview and record review, the facility failed to ensure to protect one of two sampled residents' (Resident 390) rights to be free from neglect (the failure of the facility, its employees, or service providers to provide goods and services to a patient that are necessary to avoid physical harm, pain, mental anguish, or emotional distress) when Certified Nurse Assistant (CNA) 3 and CNA 4 did not clean Resident 390 after she had bowel movement and did not turn and reposition Resident 390 when she requested to be repositioned. This failure resulted in Resident 390 had to eat with soiled incontinence (inability to control the release of urine or stool) brief, was left uncomfortable, felt upset, frustrated, helpless and neglected. Findings: a. During a concurrent observation, interview on 1/21/2025 at 4:22 p.m., in Resident 390's room, Resident 390 appeared upset and stated CNA 3 and CNA 4 (unable to recall exact day) would speak to her in a harsh and elevated tone of voice when she requested for assistance. Resident 390 stated on 1/19/2025 morning, she requested…

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 two of five Certified Nurse Assistants (CNAs) have the competency to provide care in a respectful and timely manner. This failure resulted in Resident 390's needs not being provided care and services in a timely manner that led to feelings of frustration and disappointment. Findings: a. During a concurrent observation, interview on 1/21/2025 at 4:22 p.m., in Resident 390's room, Resident 390 appeared sad and upset. Resident 390 stated she was told by CNA 3 and CNA 4 (unable to recall exact day) in a harsh and elevated tone of voice that she would need to wait for the CNA to finish taking care of another resident before assisting her with incontinence care. Resident 390 stated that on 1/19/2025 morning, she requested to change her incontinence brief because she had a bowel movement, but CNA 3 told her she needed to wait for CNA 3 to finish passing meal trays before CNA 3 would clean her. Resident 390 stated the CNAs were probably busy but asked if passing meal trays was more important than cleaning 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.

Based on observation, interview and record review, the facility failed to ensure safe and sanitary food storage preparation practices in the kitchen when: 1. The peas and carrots were not dated, labeled in the walk-in freezer. 2. The waffles and cheese were not correctly labeled, dated and stored in the freezer. These failures had the potential to result in harmful bacterial growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness in 42 of 42 medically compromised residents who received food from the kitchen. Findings: During a concurrent observation and interview, on 1/21/2025 at 8:11 a.m., in the kitchen, with the Dietary Manager (DM), Freezer 1 had two bags of peas and one bag of carrots that were not dated and labeled. The DM stated the bags of peas and carrots had just been opened by the cook but must have forgotten to label them with the date it was opened and used by date. The DM stated it was important to label food with the date it was opened and the used by date to know when to dispose of expired food 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 allow and readmit one of four sampled resident (Resident 1) to return to the facility following hospitalization at General Acute Care Hospital 1 (GACH 1) on 1/6/2025 according to the facility's policy and procedure (P&P) titled, Bed Hold Notice Upon Transfer. This deficient practice resulted in Resident 1 remaining in GACH 1 and was not allowed to be readmitted timely to her original facility where she had resided. Findings: A review of Resident 1's admission Record indicated resident was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (a chemical imbalance in the blood affecting the brain), chronic embolism (a condition where a blood clot remains lodged in a blood vessel for an extended period, typically more than three months) and thrombosis (a condition where a blood clot (thrombus) forms within a blood vessel, obstructing blood flow) of deep vein (large veins located deep within the body, typically beneath 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 implement a comprehensive care plan that met the care/services based on the resident's individual assessed needs for one of two sampled residents (Resident 2) by failing to ensure that a comprehensive (CP) was developed after Resident 2 had a change of condition due to urinary tract infection (UTI- an infection in the bladder/urinary tract). This deficient practice had the potential to result negative impact on residents ' health and safety, as well as the quality of care and services received. Findings: A review of the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnosis including fracture of left ilium (the most prominent and topmost hip bone), dysphagia (difficulty swallowing) and paroxysmal atrial fibrillation (afib- an irregular and very rapid heart rhythm that and can lead blood clots in the heart). A review of the Minimum Data Set (MDS – resident assessment tool) dated 11/15/2024, indicated Resident 2 ' s…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Notice of Proposed Transfer and Discharge was provided to the resident as soon as practicable for one out of the three sampled residents (Resident 1). The facility also failed to provide documented evidence that indicated that the State Long Term Care Ombudsman (public advocate) was notified that Resident 1 was transferred discharged from Skilled Nursing Facility 1 (SNF 1 - a type of inpatient facility that provides short or long-term skilled nursing care, and rehabilitation services to patients). This deficient practice denied the residents additional protections from being inappropriately discharged and caused Resident 1 to have feelings of anxiety. Findings: A review of Resident 1's admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including major depressive disorder (a serious mental disorder that affects how a person feels, thinks, and acts. It's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to promote resident's rights to be given an advanced notice when the room and/or roommate changes was performed for three of three sampled residents (Resident 1, 2, 3) as indicated in the facility's policy and procedure titled, Change of Room or Roommate . This deficient practice violated the residents' right to make an informed decision regarding room/roommate changes. Findings: 1. A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe), major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy), and muscle weakness. During a review of the Minimum Data Set (MDS - a comprehensive assessment and screening tool), dated 4/15/2024, 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 interview and record review, the facility failed to ensure prompt attempt was made to resolve grievances for one of four sampled residents (Resident 1). This deficient practice violated Resident 1's right to have grievances addressed. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe), major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy), and muscle weakness. During a review of the Minimum Data Set (MDS - a comprehensive assessment and screening tool), dated 4/15/2024, indicated Resident 1's cognitive skill (mental action or process of acquiring knowledge and understanding) for daily decision-making were intact and required moderate assistance from staff for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide social services to one out of four sampled residents (Resident 1) by failing to provide necessary social services referrals. This deficient practice had the potential for delay in the delivery of care and services. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe), major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy), and muscle weakness. A review of the Minimum Data Set (MDS - a comprehensive assessment and screening tool), dated 4/15/2024, indicated Resident 1's cognitive skill (mental action or process of acquiring knowledge and understanding) for daily decision-making were intact and required moderate…

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 prompt attempt was made to resolve grievances for one of four sampled residents (Resident 1). This deficient practice violated Resident 1 ' s responsible party (R1 RP ' s) right to have grievances addressed and resolved. Findings: A review of Resident 1 ' s admission Record, indicated that Resident 1 was admitted to the facility on [DATE], with diagnoses including cerebral infarction (lack of blood flow resulting in severe damage to some of the brain tissue), dysphagia (difficulty swallowing food or liquid) following cerebral infarction, and major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy. A review of Resident 1's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool), dated 10/10/2023, indicated Resident 1 has severely impaired cognition (mental action or process of acquiring knowledge and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility failed to ensure one of four sampled residents (Resident 4) was free from medication error by failing to ensure the medications were given on time as ordered by the physician. This deficient practice jeopardized Resident 4 ' s health and safety by failing to administer necessary medications in accordance with the physician order. Findings: A review of Resident 4 ' s admission Record indicated resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including atrial fibrillation (afib- an irregular and very rapid heart rhythm that and can lead blood clots in the heart), major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy), and polyneuropathies (a condition in which a person's peripheral nerves are damaged). A review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool) 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 failed to ensure that one of four sampled residents (Resident 1) had a change in condition (COC) assessment completed when Resident 1 ' s pressure ulcer/injury (damaged skin caused by staying in one position for too long) in the sacrococcyx (in human anatomy, is a large, triangular bone at the base of the spine) was changed from unstageable (UTD - unable to determine or unstageable pressure ulcer defined as Stage 3 or 4) to Stage 4 (full thickness tissue loss with exposed bone, tendon, or muscle) pressure ulcer. This deficient practice had the potential to result a negative impact on residents ' health and safety, as well as the quality of care and services received. Findings: A review of Resident 1's admission Record indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including type II diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]), chronic kidney disease…

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 residents' medical records were updated to show documentation that advance directives (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) were discussed and written information were provided to the residents and/or responsible parties for one of five sampled residents (Residents 6, 16, 23, and 24 ). These deficient practices violated the residents' and/or the representatives' right to be fully informed of the option to formulate their advance directives and had the potential to cause conflict with the residents' wishes regarding health care. Findings: 1. A review of Resident 6's admission Record indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with medical history including chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement its protocol for Antibiotic Stewardship (the effort to measure and improve how antibiotics are prescribed by clinicians and used by patients) for four (4) of four (4) sampled residents (Resident 3, 14, 20 and 21). This deficient practice had the potential for Resident 3, 14, 20 and 21, to develop antibiotic resistance (not effective to treat infection) from unnecessary or inappropriate antibiotic use. Findings: 1. A review of Resident 3's admission Record indicated Resident 3 was originally admitted to the facility 3/10/2022, with diagnoses including chronic obstructive pulmonary disease (COPD-group of lung diseases that block airflow and make it difficult to breathe), asthma (respiratory condition marked by spasms in the bronchi of the lungs, causing difficulty in breathing) and obesity (a disorder involving excessive body fat that increases the risk of health problems). A review of Resident 3's Minimum Data Set (MDS-a standardized…

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 Pneumonia (lung infection) vaccines were offered and/or re-offered to four (4) of six (6) sampled residents (Resident 3, 21, 26 and 28) per facility policy. This deficient practice had the potential to place residents at a higher risk of acquiring and transmitting pneumonia infection to other residents in the facility. Findings: 1. A review of Resident 3's admission Record indicated Resident 3 was originally admitted to the facility 3/10/2022, with diagnoses including chronic obstructive pulmonary disease (COPD-group of lung diseases that block airflow and make it difficult to breathe), asthma (a chronic [long-term] condition that affects the airways in the lungs) and obesity (a disorder involving excessive body fat that increases the risk of health problems). A review of Resident 3's Minimum Data Set (MDS-a standardized assessment and care-screening tool), dated 12/20/2023, indicated Resident 3's cognitive (relating to mental action or process…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that COVID-19 (a viral infection, highly contagious, that easily transmits from person to person, causing respiratory problems and may cause death) vaccine was offered/ re-offered to the residents and/or the vaccine was administered with consent for four of six sampled residents (Resident 3, 21, 26 and 28) according to the facility's policy. This deficient practice placed Resident 3, 21, 26 and 28 at risk for COVID-19 infection. Findings: 1. A review of Resident 3's admission Record indicated Resident 3 was originally admitted to the facility 3/10/2022, with diagnoses including chronic obstructive pulmonary disease (COPD-group of lung diseases that block airflow and make it difficult to breathe), asthma (a chronic [long-term] condition that affects the airways in the lungs) and obesity (a disorder involving excessive body fat that increases the risk of health problems). A review of Resident 3's Minimum Data Set (MDS-a standardized assessment and…

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

Based on observation, interview and record review, facility failed to ensure that one of ten sampled residents (Resident 33) was assessed for medication self-administration. This deficient practice had the potential to cause over medication or harm. Findings: A review of Resident 33's admission Record indicates the facility admitted Resident 33 on 10/17/2023 with diagnoses including End stage renal disease (ESRD -decline in the kidney's [removes wastes and extra fluid from the body] when they are no longer able to function on their own), generalized muscle weakness, and asthma (inflammation or swelling, and narrowing of the airway making it difficult to breath). A review of Resident 33's Minimum Data Set (MDS-a standardized assessment and care screening tool), dated 10/21/2023, indicated Resident 33 was intact in cognitive skills (thought processes) for daily decision making and needed some help with self-care, required substantial/maximal assistance on staff for activities of daily living (ADLs-shower/bath, dressing and toileting hygiene). During a concurrent observation and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the assessment entries in the Minimum Data Set (MDS- an assessment and care screening tool) related to smoking status was accurately documented to reflect the resident's smoking status for one of three sampled residents (Resident 34). This deficient practice had the potential to negatively affect Resident 34's plan of care and delivery of necessary care and services. Findings: A review of Resident 34's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses that include tobacco use (habitual use of the tobacco plant leaf and its products), hypertension (HTN - elevated blood pressure) and anxiety (feeling or worry, tense or afraid) disorder. A review of Resident 34's MDS dated [DATE], indicated the resident was intact in cognitive skills (thought processes) for daily decision making and needed some help with self-care, required supervision from staff for activities of daily living (ADLs-shower/bath, dressing…

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 one out of ten sampled residents (Resident 16's) medical records had accurately documented assessment and treatment reflective of the resident's skin condition. This deficient practice resulted in Resident 16's medical records being inaccurate and missing vital information of treatment and services needed to care for three left anterior (front of the body[bicep]) upper arm lacerations (cuts) measuring approximately 0.1 centimeters (cm -unit of measure) by 0.2 cm each. Findings: A review of Resident 16's admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that include hypertension (HTN - elevated blood pressure) and diabetes mellitus (DM- a disorder in which the body does not produce enough or respond normally to insulin [a hormone that lowers the level of glucose) causing blood sugar [glucose] levels to be abnormally high), and unstageable pressure ulcer of sacral…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow through with the Preadmission Screening and Resident Review (PASARR- a federally required screening to help identify individuals with possible serious mental illnesses requiring a specialized follow up evaluation) recommendation to obtain a PASRR level II (assessment that determines if resident's mental condition could be met in the nursing facility or if the individual requires specialized services) evaluation for one of three sampled residents (Resident 6). This deficient practice had the potential to result in inappropriate placement and unidentified specialized services for Resident 6. Findings: A review of Resident 6's admission Record indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with medical history including chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), asthma (a condition in which a person's airways become…

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 skin, wound, and pressure ulcer (injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin) care consistent with professional standards of practice and facility policy and procedure, for one out of ten sampled residents (Resident 16) by failing to ensure the resident's low air loss mattress (LAL -a pressure relieving mattress for the management of pressure ulcers) was set at the appropriate level per the manufacture's guidance. This deficient practice had the potential to delay the healing of or worsen Resident 16's pressure ulcer (localized injury to the skin and or underlying tissue usually over a bony prominence because of pressure or pressure in combination with shear-layers are laterally shifted in relation to each other, and or friction-surfaces sliding against each other caused by prolonged pressure) of the sacrum (tail bone). Findings: A review of Resident 16's admission Record 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 interview and record review, the facility failed to ensure to follow the physical therapy discharge instruction to place one of two sampled resident (Resident 26) on Restorative Nurse Program ([RNP] a formal, planned, and organized program of care which is intended to restore a lost ability or maintain a potentially deteriorating function) to maintain current level of functionality (CLOF). This failure had the potential to result in a decline in Resident 26's functional ability. Findings: During a review of Resident 26's admission Record (Face Sheet), indicated Resident 26 was originally admitted to the facility on [DATE] and was readmitted on [DATE], with diagnoses including type 2 diabetes mellitus (a condition that happens because of a problem in the way the body regulates and uses sugar as fuel), muscle weakness, chronic low-back pain, and scoliosis (a sideways curvature of the spine). During a review of Resident 26's Minimum Data Set ([MDS] a standardized assessment and care screening tool), 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 to observation, interview, and record review the facility failed to ensure one out of 4 sampled Certified Nursing Assistants (CNA1) caring for facility residents had active and unexpired professional certification as per facility policy. CNA1 certification expired on [DATE]. This deficient practice had the potential for all 37 facility residents not to receive the appropriate treatment, care, and services. Findings: A review of Certified Nurse Assistant 1's (CNA 1) employee file on [DATE] at 1:00PM, indicated CNA 1's license expired on [DATE]. During an interview on [DATE] at 2:00 PM, the Director of Staff Development (DSD) stated he could not locate CNA 1's current license. The DSD stated the CNA had been working at the facility since [DATE]. The DSD stated he was not aware that CNA1's license had expired. During the interview the DSD asked CNA1 to provide an updated license. The DSD stated the CNA was looking for proof of continuing education courses and had contacted the license verification for 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 interviews and records review, the facility failed to ensure that the physician order for as needed anti-psychotic drugs (any medication capable of affecting the mind, emotions, and behavior) was not renewed unless the attending physician or prescribing practitioner evaluated the resident for the appropriateness of medication use for one of three sampled resident (Resident 10). This deficient practice had the potential for Resident 10 to experience a decline in quality of life and functional capacity resulted from side effect and adverse consequence due to unnecessary psychotropic drugs use. Findings: A review of Resident 10's admission Record indicated the resident was initially admitted to the facility on [DATE] and was readmitted on [DATE], with diagnoses that included hypertension (HTN - elevated blood pressure) and diabetes mellitus (DM- a condition that happens when blood sugar [glucose] is too high), and major depressive disorder (medical illness that negatively affects how you feel, the you…

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 supervision for one of three sampled residents (Resident 1), who was identified as severe cognitively impaired (confusion or memory loss that is happening more often or is getting worse during the past 12 months), to prevent elopement (leaving the facility unsupervised and without staff knowledge) by failing to: 1.Ensure to evaluate and analyze hazard(s) and risk(s) of elopement when Resident 1 was observed being anxious upon admission looking for his daughter, walking around the room and not wanting to change to a gown on the night of 8/7/2023. 2.Ensure Resident 1's elopement risk was assessed as a high risk because of his diagnosis, new admission, and comorbidities (the simultaneous presence of two or more diseases or medical conditions in a patient) upon admission. These deficient practices resulted in Resident 1 eloping on 8/7/2023 and was found by an individual in the middle of the street, walking barefoot. Paramedics (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.

Based on observation, interview and record review, the facility failed to ensure that staffing information was posted per facility policy on two of two sampled days (8/9/2023 and 8/10/2023). This deficient practice had the potential to result of Direct Care Services Hours Per Patient Day (DHPPD), not readily accessible to the residents and visitors and possibly missed any insufficient nurse staffing. Findings: During an observation of the facility on 8/9/2023 at 9:45 a.m , observed the projected nurse staffing hours posted in the lobby area, but with no actual nursing hours. During an observation of the facility on 8/10/2023 at 12:20 p.m., observed the projected nurse staffing hours posted in the lobby area, but with no actual nursing hours. During a concurrent interview with the Director of Staff and Development (DSD), on 8/10/2023 at 1:52 p.m., DSD stated and confirmed, she posted the projected nursing hours on 8/9/2023 and 8/10/2023 but not the actual hours. DSD stated, she doesn ' t know if the actual hours must be posted. During an interview Director of Nursing (DON), 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.