Santa Monica Health Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a comprehensive care plan for one of five sampled residents (Resident 64) in accordance with the facility's policy and procedures (P&P) titled Comprehensive Plan of Care with approval effective date of 12/13/2024, by failing to initiate a care plan for Resident 64's incontinence (an accidental loss of urine or feces) of bowel (intestine - long, tube-like organ that's part of your digestive system, where food travels and waste is produced) and bladder (a bag-like organ that stores urine, the liquid waste the body produces). This deficient practice had the potential to negatively affect the delivery of necessary care and services needed for Resident 64. Findings: During a record review, Resident 64's admission Record indicated the facility admitted Resident 64 on 3/14/2025 with diagnoses including Muscle wasting (shrinking or loss of muscle tissue), difficulty walking, and hypertension (HTN-high blood pressure) During a record review, Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to create an individualized care for one of three sampled residents (Resident 172) with specific goals and interventions for her dementia (a progressive state of decline in mental abilities) diagnosis. This deficient practice had the potential to result in deterioration of function in Resident 172's quality of life. Findings: During a record review, the admission record for Resident 172 indicated Resident 172 was admitted to the facility on [DATE] with diagnoses including dementia, hypertension (HTN-high blood pressure), and acute kidney failure (a sudden and significant decline in kidney function). During a record review, Resident 172's Minimum Data Set (MDS - a resident assessment tool) dated 3/30/2025, indicated Resident 172 had severe cognitive impairment (a significant decline in thinking, learning, remembering, and reasoning abilities, impacting daily functioning and potentially leading to the inability to live independently). The same…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement its policies and procedures (P&P) for one out of four residents (Resident 31) by failing to ensure that Resident 31's oxygen tubing was changed every seven days. This deficient practice had the potential to cause respiratory infections. Findings: During a record review, Resident 31's admission record indicated Resident 31 was admitted to the facility on [DATE] with diagnoses which included depression (a common mental health condition that affects how you feel, think, and act which is characterized by persistent sadness, loss of interest, and other symptoms that interfere with daily life), HTN, and atrial fibrillation (a common heart rhythm disorder where the heart's upper chambers (atria) beat irregularly and too fast, sometimes causing a rapid and irregular pulse). During a record review, Resident 31's Minimum Data Set (MDS - a resident assessment tool) dated 12/30/2024, indicated Resident 31 had severe cognitive impairment.…

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 information about State Long-Term care Ombudsman (representative appointed by the government who assists residents in long-term care facilities with issues related to day-to-day care, health, safety, and personal preferences) to three of four sampled residents (Resident 15, 45, and 53). This deficient practice had the potential to deprive the residents of assistance from resident advocacy groups of unresolved issues in the facility. Findings: A review of Resident 15's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including hypokalemia (low potassium), unspecified fall, hypertension (HTN - elevated blood pressure), hyperlipidemia (elevated cholesterol), muscle weakness, and left hip fracture. A review of Resident 45's admission Record indicated the resident was admitted on [DATE] with diagnoses including fracture of right patella, fracture of nasal bones, unspecified fall, hypothyroidism (low…

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 standardized recipes for lunch menu were followed on 3/26/2024 when: 1.Cook used small scoop size to serve chicken Dijon for 16 residents on mechanical soft diet and finely chopped diet (consists of foods that are moist, ground, chopped or easily mashed required little chewing.) Residents on both mechanical soft and finely chopped diet received 4 oz (ounces) of chicken instead of 5 oz per menu. 2.Facility failed to ensure 13 residents on mechanical soft finely chopped diet (food that are easily chewed, for resident with chewing problems and minor swallowing problems food should is chopped to 1/8-1/4-inch pieces) received rice in texture and form to meet their needs when they received regular parsley rice instead of pureed parsley rice according to the menu and spreadsheet (food portion and serving guide). 3. [NAME] added long strips of sliced red bell pepper garnish to residents on mechanical soft diet. Nine out of 16 residents on mechanical soft and finely chopped diet received bell pepper garnish…

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 and preparation practices when: 1. Cooked eggs in a bowl were stored on the same shelf and on top of cartons of raw liquid eggs. A large piece of raw pork loin with thaw dates of 3/25/24-3/27/24 stored on top of imitation crab (frozen ready to eat seafood product) with use by date of 3/26/24. 2. One kitchen staff working in the dish machine area did not wash hands before removing the clean and sanitized dishes from the dish machine. 3. Ice machine was not maintained in a sanitary manner and the inside compartment of ice machine was stained with red color residue. 4. Food brought to resident from outside of the facility including leftovers stored in the resident food refrigerator were not dated. There was no monitoring system for the refrigerator temperatures while expired and blue color moldy food were not discarded. These deficient practices had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide care in a manner that maintained or enhanced a resident's dignity, respect, and individuality for one of four sampled residents (Resident 208). On 3/26/2024 at 8 AM, the facility staff was observed standing over Resident 208 while assisting the resident during breakfast. This deficient practice had the potential to negatively affect Resident 208's self-esteem and self-worth. Findings: A review of Resident 208's admission Record indicated the resident was admitted to the facility on [DATE], with medical diagnoses including hyperlipidemia (elevated cholesterol), hypertension (high blood pressure), peripheral vascular disease (the reduced circulation of blood to a body part), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), acute pulmonary edema (a condition caused by too much fluid in the lungs), and of left femur fracture (broken thigh bone). A review of Resident…

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

Based on observation, interview, and record review, the facility failed to investigate lost belongings promptly and thoroughly for one of eight sampled residents (Resident 27). This failure resulted in delay in investigating and replacing Resident 27's personal property/belongings. Findings: A review of Resident 27' s admission Record dated 3/29/2024, indicated the facility initially admitted Resident 27 on 4/6/2022 with diagnoses including abnormal gait (Gait is the pattern or way a person walks) and mobility, pneumonia (an infection in the lungs that may be caused by bacteria, or viruses), gastro-esophageal reflux disease (GERD - a common condition in which the stomach contents move up into the esophagus, chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should), cellulitis (a potentially serious bacterial skin infection) of left lower limb, and asthma (a condition that makes it harder to breath and may cause cough). A review of Resident 27'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 on interview and record review, the facility failed to document that Advance Directive (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) was discussed, and written information was provided to the residents and/or responsible parties for two of five sampled residents (Residents 8 and 22). This deficient practice had the potential to violate the rights of Residents 8 and 22 and/or the representatives' right to be fully informed of the option to formulate advance directives and to cause conflict with the residents' health care wishes. Findings: A review of Resident 8's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including bilateral knee osteoarthritis (degenerative joint disease), pain in left shoulder, pain in right knee, anxiety disorder (a mood disorder), hypertension (elevated blood pressure), major depressive disorder (persistent low…

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 obtain a physician's order for low air loss mattress (LALM - is designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown) for one of five sampled residents (Resident 43). This deficient practice had a potential to result in inappropriate care and treatment for Resident 43. Findings: A review of Resident 43's admission Record, indicated the resident was admitted on [DATE] with diagnoses including cellulitis (common infection of the skin) of right lower limb, tremor (an involuntary muscle contraction), depression (persistent low mood), hypothyroidism (low thyroid ), hyperlipidemia (elevated cholesterol), manic episode (a state of mind characterized by high energy), anxiety disorder (mood disorder), obstructive sleep apnea (intermittent airflow blockage during sleep), and hypertension (elevated blood pressure). A review of Resident 43'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, the facility failed to provide effective pain management to maintain the highest practical level of well-being for one (1) of eight (8) sampled residents (Residents 9) by failing to: 1. Assess, recognize, develop, and implement an individualized pain management care plan for Resident 9 with initiation date, stop date and reevaluation date to determine the effectiveness of the care plan. 2. Respond to Resident 9's continual plea for help due to severe pain to the left leg, hip, and back by notifying a MD (Medical Doctor) concerning the resident's uncontrolled pain. These deficient practices resulted in Resident 9 suffering severe pain to the left leg, hip, back, and nerve pain at a level 8 out of 10 (where 10 is the worst severe pain that can be experienced). Findings: A review of Resident 9' s admission Record dated 3/29/2024, indicated the facility initially admitted Resident 9 on 1/5/2024 with diagnoses that included, fracture of the left femur (Fracture: a partial or complete break in the bone. Femur: is the thigh bone), seizures…

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 revise the care plan after elopement (a form of unsupervised wandering that leads to the resident leaving the facility) and after a fall for one of three sampled residents, (Resident 1). This deficient practice may cause knowledge deficit among staff regarding specific interventions developed to ensure Resident 1 does not elope or fall again. Findings: On 3/18/2024 The California Department of Public Health (CDPH) received a facility reported incident indicating Resident 1 eloped from the facility on 3/14/2024. A. A review of Resident 1's Face Sheet indicated the facility originally admitted this [AGE] year old male on 10/18/2022 and most recently on 12/29/2023 with diagnoses including Syncope and collapse (losing consciousness and falling down), Dementia (a progressive or persistent loss of intellectual functioning and memory impairment), Anxiety (a feeling of worry, nervousness or unease), Essential Hypertension (high blood pressure), Gastroesophageal…

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 a resident identified at risk for elopement (a form of unsupervised wandering that leads to the resident leaving the facility) complete quarterly elopement risk assessments for one of three sampled residents (Resident 1). This deficient practice may have caused Resident 1 to elope and subsequently be found approximately one hour later at the general acute care hospital (GACH). Findings: A review of Resident 1's Face Sheet indicated the facility originally admitted this [AGE] year old male on 10/18/2022 and most recently on 12/29/2023 with diagnoses including Syncope and collapse (losing consciousness and falling down), Dementia (a progressive or persistent loss of intellectual functioning and memory impairment), Anxiety (a feeling of worry, nervousness or unease), Essential Hypertension (high blood pressure), Gastroesophageal reflux disease (GERD- indigestion), history of falling. A review of Resident 1's Minimum…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure one of four sampled residents ' (Resident 2) oxygen humidifier bottle (a medical device used to add moisture to supplemental oxygen to keep air ways from drying out) was changed before it went dry. This deficient practice resulted in Resident 2 receiving non-humidified oxygen via nasal cannula (a medical device used to deliver oxygen through a tube through the nose), which had the potential to cause dryness to the resident ' s nostrils. Findings: A review of Resident 2 ' s Face Sheet (a document with a summary of patient information), undated, indicated, Resident 2 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure with hypoxia (a condition where there is not enough oxygen in the blood), hypertension (high blood pressure), muscle weakness, and unsteadiness on feet. A review of Resident 2 ' s Minimum Data Set (MDS, a comprehensive assessment and care screening tool), dated 2/4/24, the resident '…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow its policy on Physician ' s Orders for Life Sustaining Treatment (POLST) for one of three sampled residents (Resident 1). This deficient practice resulted to an incomplete POLST (a medical order form that ensures the patient ' s treatment wishes are well known and followed by medical professionals during medical crisis) for Resident 1, which had the potential for Resident 1 not to receive the life sustaining treatment she desired. Findings: A review of the admission Record (Face Sheet) indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure (impairment of gas exchange between the lungs and the blood causing hypoxia – low level of oxygen) and Hemangioma (abnormal buildup of blood vessels in the skin or internal organs.). A review of the Skilled Nursing Facility History and Physical examination form (H&P), dated 9/29/2023, indicated Physician 1 examined Resident 1 in the facility. The H&P…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record reviews, the facility staff failed to ensure the safety for one of three sampled residents (Resident 1) by preventing elopement (unsupervised wandering which results in a resident leaving the nursing home facility) on 9/10/2023 from the facility. This deficient practice had the potential for Resident 1 sustaining an accidental injury while outside the facility's premises without supervision from staff. Findings: A review of a history and physical (the most formal and complete assessment of the patient and the problem) from a General Acute Care Hospital (GACH) dated 8/12/2023 at 7:15 pm, indicated resident had diagnoses including: liver cirrhosis (severe scarring of the liver a serious condition which can be caused by many forms of liver diseases and conditions, such as hepatitis or chronic alcoholism), coagulopathy (a condition in which the blood's ability to coagulate (form clots) is impaired), and altered mental status (a change in mental function. It stems from…

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

Based on record review and interview the facility failed to ensure one three sampled residents (Resident 46) had a copy of advanced directive (legal document that provide instructions for medical care and only go into effect if a person cannot communicate his/her own wishes) in the medical chart for Resident 46 in accordance with the facility's policy and procedures titled, Advanced Directive, revised 9/2022. This deficient practice had the potential to violate Resident 46's rights and wishes for end-of-life treatment in case of a medical change in condition. Findings: A review of the admission record indicated the facility originally admitted Resident 46 on 11/01/2018 and was re-admitted Resident 46 on 12/16/2022 with diagnoses including chronic respiratory failure (condition that occurs when the lungs cannot spontaneously get enough oxygen into the blood or eliminate enough carbon dioxide from the body), dependance on ventilator (machine that helps to move air into and out of the lungs), tracheostomy (an incision in the windpipe made to create an opening to breath), and pressure…

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 sign the consolidated delivery sheets upon receipt of medication delivery on the following dates 4/1/2023, 4/2/2023, 4/4/2023, 4/3/2023, 4/6/2023, 4/8/2023 in accordance with the facility's policy and procedures titled, medication ordering and receiving from pharmacy dated April 2008. This deficient practice could lead to missing medication for all residents in the facility. Findings: On 6/9/2023 during a record review at 8:34 AM., the facility's consolidated delivery sheets (receipt received from pharmacy that includes all medication orders for multiple residents delivered on that date) for the month of April 2023 were reviewed. The consolidated delivery sheets indicated there were no facility staff signatures for the following dates 4/1/2023, 4/2/2023, 4/4/2023, 4/3/2023, 4/6/2023, and 4/8/2023. On 6/9/2023 during an interview at 8:35 AM., the interim director of nursing (IDON) confirmed and stated, when the licensed nurse receive medication deliveries, they [nurses] should sign the delivery sheet(s) to indicate the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that one of three sampled residents (Resident 10) drug regimen was free of unnecessary medications in accordance with the the facility's policies and procedures (P &P) titled Medication Regimen Review and Reporting dated January 2023, and Antipsychotic Medication Use dated 3/16/2022, by failing to ensure: 1. Resident 10's physician acted upon the facility consulting pharmacist recommendation in the Medication Regime Review (MRR-a thorough evaluation of the medication regime of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risk associated with medication). 2. Resident 10 would not receive Lorazepam (a medication used to treat anxiety) 0.5 milligram (mg, unit of measurement) PRN (as needed) longer than 14 days without being revaluated by the prescribing physician. 3. Resident 10's psychotropic medication (medications that affect mental function, behavior, and experience), Quetiapine (is…

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, for one of three samples residents (Resident 11), the facility failed to ensure a care plan was developed and implemented for Resident 11's sacral coccyx (bone at the bottom of the spine and lies between the fifth segment of the spine and the tailbone) abscess (an enclosed collection of pus in tissues, organs, or confined spaces in the body) in accordance with the facility's policy and procedures titled Comprehensive plan of care dated 8/17/2021. This deficient practice had the potential to cause insufficient provision of care and services related to the care of an open abscess which can lead to infection and hospitalization. Findings: A review of Resident 11's admission Record indicated the facility initially admitted Resident 11 on 10/19/2022 and re-admitted Resident 11 on 4/5/2023 with diagnoses including vascular dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels [channels that carry blood throughout the body] in the brain), hospice (care focused on comfort, and quality…

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 for one of three sampled residents (Resident 19) and in accordance with the facility's policy and procedures titled Pressure Ulcer & Skin Care Management dated 8/18/2021, the facility failed to: 1. Conduct an interdisciplinary team (IDT- a group of healthcare professionals including, licensed nurses, social services, case management, physicians to provide a resident specific plan of care), after Resident 19 developed moisture associated skin damage (MASD- a general term for inflammation [irritation] or skin erosion caused by prolonged exposure to a moisture) on the right buttock on 4/21/2023. 2. Conduct an IDT after Resident 19 developed a deep tissue injury (DTl - an area of discolored intact skin or blood?filled blister localized purple or maroon localized discoloration due to damage to the skin and underlying soft tissue usually over a bony prominence, DTI may subsequently develop into a stage three III - [pressure injuries, injury which extends through the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to label two opened vials of Influenza Vaccine (also known as flu shots, are vaccines that protect against infection by influenza viruses) found in the medication refrigerator in accordance to the facility's policies and procedures (P &P) titled. Medication Storage in the facility dated [DATE], and Medication Storage in the facility. This deficient practice could lead to administration of expired vaccinations. Findings On [DATE] at 11:32 AM. during an observation of the medication storage refrigerator 2 Influenza (An acute respiratory infection) Vaccine multi-dose vial (a small container, typically round like a cylinder and made from glass used specially to hold liquid medication intended to be given by injection that contains more than one dose) were found out of box with no cap covering insertion point of vial and no date indicating when they were opened. On [DATE] at 11:33 AM. during an interview the registered nurse supervisor (RNS 1)…

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 prepared food was stored in accordance with the facility's policy and procedures titled, Freezer Storage dated 2018. This deficient practice had the potential to place 44 of 44 residents, who consumed food prepared by kitchen in the facility at risk for food borne illness (an illness caused by ingestion of contaminated food or beverages) Findings: On 6/5/2023 at 7:15 AM, during the initial kitchen tour with [NAME] (CK) 1, a loose bag of vegetables was observed in the kitchen freezer. There was no label on the loose bag of vegetables to indicate when it was placed into the freezer or when the vegetables were expired. On 6/5/2023 at 7:16 AM, during an interview with CK 1, CK 1 stated that he was unsure why there was no label placed on the loose bag of vegetables. CK 1 stated that the Dietary Supervisor (DS) was the one who stocked the supplies into the freezer. On 6/7/2023 at 12:25 PM, during an interview with the DS, the DS stated that she was unsure why the vegetables were not labeled. The DS stated…

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 their infection control and prevention program to keep urinary catheter drainage bag off the floor for one of one sampled resident (Resident 46) in accordance with the facility's undated policy and procedures titled, urinary catheter. This deficient practice had a potential to increase the risk of contamination and infection. Findings: A review of Resident 46's admission Record indicated the facility originally admitted the resident on 12/20/2022. Resident 46's most recent admission was 5/11/2023 with diagnoses which included malignant neoplasm of the brain (fast growing cancer that spreads to other areas of the brain and spine), craniotomy (surgical opening of the skull), gastrostomy tube (an opening into the stomach from the abdominal wall made surgically for the introduction of food) , seizures ( rapid and uncoordinated electrical firing in the brain cause tonic like muscle movement), sleep apnea ( sleep disorder where breathing starts and stops periodically) and indwelling urinary catheter (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 and interview, the facility failed to ensure three of 15 sampled Residents (Residents 32 and 37) had call light placed within their reach in accordance with the facility's policy and procedures titled Call lights -Answering of dated 6/2011. This deficient practice had the potential in delaying to meeting the need for assistance, frustration, falls and accidents for Residents 32 and 37. Finding: A review of Resident 32's admission Record indicated the facility admitted Resident 32 initially on 4/26/2022 and re-admitted the resident on 4/6/2023 with diagnoses including other abnormalities of gait (walking pattern) and mobility (ability to move around in bed, including actions like scooting, rolling or moving from lying to sitting and from sitting to lying), other malaise (a general feeling of discomfort, illness or lack of wellbeing) and major depressive disorder (persistent feeling of sadness and loss of interest). A review of Resident 32's Minimum Data Set (MDS - a standardized assessment…

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