Arbol Healthcare Center Of Santa Rosa

Based on interview, and facility record review, the facility failed to have a Registered Nurse (RN) performing the function of the Director of Nursing (DON) on a full-time basis to provide oversight and guidance on the provision of care provided by nursing staff. This failure prevented the facility from having the required management, to adequately assess and meet the needs of residents in a timely manner and had the potential to negatively impact the quality of care delivered by licensed and non-licensed nursing staff to residents. Findings: During an interview on 1/17/25 at 12:35 p.m., Licensed Staff A stated there was no DON at the facility and there has not been a DON since November. Licensed Staff A stated the facility was advertising for a DON, but currently, there were no candidates. During an interview on 1/17/ 25 at 12:45 p.m., the Infection Preventionist (IP) stated the previous DON left at the end of November 2024. The IP also stated she currently occupied the full-time IP role and the interim DON role, until a permanent DON is hired. The IP confirmed she was a Licensed…

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 a facility-wide assessment (a review of a facility's infrastructure, resident population, and services to determine needed resources to provide care) was available, current, and complete. This deficient practice decreased the facility ' s potential to safely admit residents and ensure their care needs were met. Findings: During an interview on 1/17/24 at 1:58 p.m., a copy of the facility assessment was requested from the Director of Staff Development (DSD). The DSD stated the facility assessment was not available and was locked in the Administrator ' s office. During an interview on 1/21/24 at 10:25 a.m., the Infection Preventionist (IP) (who was also the interim Director of Nursing (DON)) stated she could not find the facility assessment. The IP stated she was putting one together over the weekend and what she had was incomplete. A review of the of the document provided to the surveyor on 1/21/24 did not follow the facility ' s policy and procedure for conducting, reviewing, and updating the facility assessment.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure supervision to prevent accidents for one resident (Resident 1) when: 1. Resident 1 eloped from the facility and was found face down on the pavement; and, 2. The Wander Monitoring System (WMS, an alarm system compromised of a monitor placed on the resident and placed on facility exits used to prevent residents from wandering or seeking to leave the facility) ordered by the physician to be implemented for Resident 1 was not functional. These failures resulted in Resident 1 ' s obtaining trauma to the right eyebrow and a laceration which required stiches and decreased the facility ' s potential to ensure the safety of residents at risk of elopement to leave the facility undetected placing the resident at risk for injury or harm. Findings: 1. Review of Resident 1 ' s clinical record showed Resident 1 was admitted to the facility on [DATE], with a diagnosis which included Traumatic Subdural Hemorrhage (a collection of blood between 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 patient care equipment was functioning and maintained under sanitary conditions when oxygen therapy equipment provided to facility residents was dirty and not maintained. This failure decreased the facility ' s potential to prevent infections among respiratory compromised residents who used oxygen concentrators for medical treatments. Findings: During an interview on 1/21/25 at 1:48 p.m., the Maintenance Supervisor (MS) stated he checked the oxygen storage room periodically to ensure the oxygen tanks were secure. The MS also stated he did not have oversight nor did any maintenance on the oxygen concentrators and was unsure who maintained the oxygen concentrators. During an observation and current interview on 1/21/25 at 2:00 p.m., the Infection Preventionist (IP) stated she tracked all residents on respiratory therapy and any respiratory infections that occurred in the facility. The IP stated there were currently six residents on oxygen therapy who used oxygen concentrators provided by the facility. An…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement a person-centered care plan with measurable objectives and appropriate interventions for one resident (Resident 1), that addressed fall precautions when the resident developed an L3 fracture (a fracture of the third vertebra in the lumbar spine) of unknown origin. This failure put Resident 1 at risk for additional injuries and falls and had the potential to cause pain and Resident 1's safety to go unmonitored. Findings: During an interview on 7/22/24 at 10:15 a.m., the DON (Director of Nursing) stated she followed-up on Resident 1's abdominal pain by sending the resident to the hospital where an X-ray and blood test confirmed Resident 1 had an L3 fracture and Osteoporosis (a bone disease that develops when bone mineral density and bone mass decreases, or when the structure and strength of bone changes. This can lead to a decrease in bone strength that can increase the risk of fractures (broken bones). The DON 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to honor (Resident 1) choice for the refusal of end-of-life medical treatment. This failure resulted in Resident 1 receiving Cardiopulmonary conversion (chest compressions) and mechanical ventilation (assisted breaths with a medical device) against Resident 1's decision. During a review of Resident 1's medical record, Physician Orders for Life-Sustaining Treatment (POLST) form, dated [DATE], indicated in box A, Do Not Attempt Resuscitation / (DNR) (Allow Natural Death), Box B indicated, Comfort -Focused Treatment – primary goal of maximizing comfort. Relieve pain and suffering with medication by any route as needed, use oxygen, suctioning, and manual treatment of airway obstruction. Do not use treatments listed in Full treatment (mechanical ventilation and cardioversion) and Selective Treatment unless consistent with comfort goal. Request transfer to hospital only if comfort needs cannot be met in current location. Box D indicated, signature…

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 observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards of food service safety when: 1) the facility failed to store dry foods (staples; mixes and packaged foods; canned and dried foods; spices, herbs, condiments, and other foods not requiring refrigeration) in the optimum temperature between 50°and 70°Fahrenheit (F); and 2) the facility failed to prevent cross-contamination of kitchen dishes when dietary staff operating the dishwasher handled dirty and clean dishes without changing gloves or performing hand hygiene. These failures had the potential for residents to consume degraded food and had the potential to expose residents to gastro-intestinal diseases. Findings: 1) During an observation on 5/30/24, at 3:20 p.m., the dry foods storage felt warm. There was no thermometer in the dry foods storage. During a concurrent interview, the Dietary Services Manager (DSM) was asked to check the room temperature in the dry foods storage. The DSM stated there was no thermometer available 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 report one incident of resident abuse to authorities within the required two-hour time frame after the allegation was made. This failure to report an allegation of abuse within the Federally mandated requirement of two hours, had the potential to result in ongoing resident abuse and physical, mental, and /or emotional harm, and prevented the State Agency from conducting a timely investigation into the allegation. Findings: During a review of a report titled State of California Report of Suspected Dependent/Elder Abuse (SOC 341) dated 1/1/24, the SOC 341 indicated alleged abuse occurred on 12/30/23 with exact time unknown. The SOC 341 indicated telephone report made to the State Agency and Local Ombudsman on 12/31/23 at 12:15 p.m. and written report was faxed 1/1/24 at 10:49 a.m. During a review of a document titled SOC 341 General Instructions, dated 8/22, Instructions indicated, If the abuse occurred in a Long-Term Care (LTC) 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on dietary staff observations, dietary staff interviews and dietary document review, the facility failed to ensure staff competency in relationship to dietary staff position as evidence by dietary staff not 1) knowing how to test the quaternary (quat ammonium compounds designed to kill germs) sanitizer solution used to sanitize the kitchen countertops and sanitize the pots and pans in the manual three-compartment sink process (wash, rinse, and sanitize), 2) using the correct Cool Down Process for hot foods, 3) follow therapeutic diets when portion sizes were not plated correctly and meat needing to be pureed (texture-modified diet with the consistence of pudding for people who have difficulties with chewing and swallowing) was not weighed prior to being pureed, 4) serving pasteurized (heat treated to kill harmful bacteria such as salmonella) eggs, and 5) thawing meat according to the facility's policy/procedure. Failure to ensure comprehensive staff competency may result in practices associated with cross…

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 kitchen observations, dietary staff interview, and dietary document review, the facility failed to ensure safe dietetic services as evidence by 1) meat not thawed according to the facility's policy and procedure, 2) the correct Cool Down Process for cooked meats was not followed per the facility's policy and procedure, 3) dietary staff did not know how to test the quaternary (quat ammonium compounds designed to kill germs) sanitizer solutions, 4) non-pasteurized eggs were being used, 5) the kitchen floors and counter appliances looked dirty, 6) garbage cans in the prep food areas were not covered with lids and the garage bens outside were open and there was garbage surrounding the garbage bins, 7) opened dried food products were not labeled with an open date and use by date, 8) fresh produce located in bins in the refrigerator were not labeled with a received by date, 9) spoiled produce was not thrown away, 10) the high temperature dishwasher wash cycle was not running per the manufactures recommendation, 11) a portion of the kitchen wall near the ovens was not repaired,…

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 observations, interviews and record reviews, the facility failed to maintain an effective infection prevention and control program when: 1. Staff were not following the facility's guidelines for Contact Precautions, donning and doffing of Personal Protective Equipment (PPE, equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses), and appropriate hand hygiene with a resident who was positive for Clostridium Difficile infection (C. diff, also known as Clostridioides difficile or C. difficile, is a bacteria that causes diarrhea and inflammation of the colon. It is a contagious infection that is estimated to cause almost half a million infections in the United States each year. - Centers for Disease Control and Prevention), 2. Staff were not performing and offering hand hygiene (HH, a way of cleaning one's hands that substantially reduces potential harmful microorganisms on the hands) before and after meals for eight out of eight sampled residents (Residents 3, 7,…

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 it had a medication error rate of less than 5%, when three of 30 medications were not given according to the physician's orders. This failure resulted in a 10% error rate and caused one unsampled resident (Resident 183) to be upset and have a bowel movement immediately after her meal, potentially losing the opportunity to absorb the nutrients from her food. Findings: During a med pass observation on 10/25/23 at 8:36 a.m., Resident 183 walked back to her room from the Dining Room and sat on the edge of her bed as Licensed Staff I started to prepare medications by the doorway. Shortly after, Resident 183 stood up, stated she needed to go to the bathroom. Licensed Staff I dispensed a tablet of loperamide (used to treat diarrhea) and Eliquis (used to treat or prevent blood clots) into a medicine cup, and mixed a packet of cholestyramine powder (used to control bile acid-induced diarrhea due to short bowel syndrome) with approximately one-half cup of water. Resident 183 returned to bed, and as Licensed Staff…

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 honor the food preferences for two of three residents sampled for food (Residents 1 and 4). These failures resulted in Residents 1 and 4 to feel ignored and frustrated as they were served food they disliked, which may lead to poor nutritional intake and unplanned weight loss. Findings: During an interview on 10/23/23 at 10:19 a.m., Resident 4 stated she was served eggs despite telling the staff that she disliked eggs. Resident 4 stated it was frustrating to be asked for food preferences if she was still going to be served eggs. During a concurrent observation and interview on 10/24/23 at 08:44 a.m., Resident 1 was seated up in bed for breakfast. On the tray was a plate with seasoned potatoes and a piece of toast, a glass of milk and a cup of tea was on the overbed table. The meal appeared untouched, and Resident 1 stated she was not a big breakfast person. When offered to at least have some milk, Resident 1 stated, I hate milk. A review of Resident 1's meal ticket, located next to the plate, 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 honor the choices for two of two (Residents 20 and 8) sampled residents when: 1. Resident 8 was given a shower despite her refusal, and 2. Resident 20 was not permitted to self-administer medications without being assessed first, contrary to the facility's policies and procedures on medication self-administration. These failures resulted in Resident 8 to lash out in anger at the staff, and had the potential for Resident 8 to experience feelings of decreased self-worth, both of which could negatively impact their psychological well-being. Findings: Resident 8 A review of Resident 8's admission Record, indicated she was admitted on [DATE] and readmitted on [DATE] with diagnoses including muscle weakness, unsteadiness on feet, abnormalities of gait (manner of walking) and mobility, vascular dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain. Cognition and brain function can be…

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 observations, interviews and record reviews, the facility failed to provide care and services in accordance with standards of practice when: 1. A licensed therapist did not reassess a resident for a Restorative Nursing assistant (RNA) program (focused on nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible) and obtain a new physician order for an RNA program after an RNA order had expired for three out of three sampled residents (Residents 5, 13 and 17), 2. Nursing staff were not repositioning and floating bilateral (both sides) heels of Resident 8 per physician's order and per facility policy, and 3. A dispensed medication was left unattended at a resident's bedside (Resident 1). These failures could lead to an ineffective RNA program for Residents 5, 13 and 17, a potential for Resident 8 to develop a skin breakdown, and increased the risk for Resident 1 to consume a potentially-contaminated medication. Findings: 1. A review 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 residents and staff knew the complaint and grievance process and failed to post complaint and grievance notices in a manner accessible to all residents. This failure did not ensure residents rights to file a grievance and had the potential to delay the facility's identification and response to residents' needs or complaints. Findings: During a resident council meeting on 11/29/21 at 10:00 a.m., the resident attendees were asked if they knew how to file a grievance. The Resident Council President (14) stated, she did not know there was a grievance process or how to complete a grievance. When questioning the residents, they did not know where the forms were kept. The Resident Council President (14) stated if she has a problem or a complaint, she goes to the Activities Director for help. During an observation post resident council meeting on 11/29/21 at 1:00 p.m., a bulletin board located outside of the dining room contained an approximate 9x5 card with the name and number of the Social Services director…

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 competent nursing staff when providing care and services for two of 8 residents when: 1. The facility did not evaluate competencies and skills of all licensed nurses and CNAs (Certified Nursing Assistant); 2. Nursing staff held Resident 16's blood pressure medication without a physician order; 3. Nursing staff did not administer medication to reduce excessive oral secretion per physician order; 4. Nursing staff assessed Resident 8's residual (volume of fluid remaining in the stomach at a point in time during enteral nutrition feeding) when the resident had a gastro-jejunosstomy tube (a feeding tube with its distal end placed within the small intestine). These failures resulted in Resident 16 not receiving blood pressure medicine and nutritional supplement, and contributed to Resident 8's multiple hospitalizations due to recurrent aspiration pneumonia. Findings: 1. During a concurrent interview and record review on 12/2/21, at 10:10 a.m., competency and skills check for licensed nurses and CNAs were…

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 in accordance with standards of practice when 1) there was a lack of accurate labeling/dating of thawing meats; 2) lack of sanitary conditions in the food preparation area 3) lack of staff training and review of operational processes, related to food safety within food and nutritional services. Failure to follow safe food practices put all facility residents at risk for contracting foodborne illness and compromise the health of residents who eat prepared food from the kitchen. Findings: 1) During an initial tour of the main facility kitchen and concurrent interviews on 11/29/21 at 9:15 a.m., the kitchen was full of produce, meat and fish boxes from a Sysco food delivery that arrived that morning. The walk-in refrigerator and freezer contained boxes of deli meat, produce, and frozen meat and fish, stocked on the floor of the walk-in refrigerator from the morning delivery. Chubs of pork and deli meats located on a storage rack in the walk-in refrigerator were not labeled and dated. Meats…

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 provide assessment and treatment for one of 8 sampled residents (Resident 8) when the nurses did not assess Resident 8 before and after oral suctioning and did not administer medication to reduce excessive oral secretion. This failure may have contributed to Resident 8 developing pneumonia (infection in the lungs). Findings: During a clinical record review for Resident 8, the Face Sheet indicated facility admitted Resident 8 on 3/11/16 with a diagnosis of Multiple Sclerosis (MS - a chronic, typically progressive disease involving damage to the sheaths of nerve cells in the brain and spinal cord, whose symptoms may include numbness, impairment of speech and of muscular coordination, blurred vision, and severe fatigue); Quadriplegia (to paralysis from the neck down, including the trunk, legs and arms); Dysphagia (difficulty or discomfort in swallowing, as a symptom of disease); and Gastrostomy status (an opening into the stomach from the abdominal wall, made surgically for the introduction of food). 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure safe and secured medication administration and storage were practiced when: 1. Medication carts (Med Cart) A and B were left unlocked and unattended, with one insulin pen left on top of one of the medication carts. 2. One expired allergy medication and three wound gel were in the medication room ready for use These failures could have resulted to resident access to insulin, ingestion of medications inside the med cart and administration of expired medicines and had the potential for adverse consequences needing hospitalization. Findings: 1. During a concurrent observation and interview on [DATE], at 3:55 p.m., Licensed Staff R was observed with medication administration to Resident 19. Licensed Staff R checked the eMAR (electronic medication administration record), prepared the glucometer (a device used to check a resident's blood sugar), removed an insulin pen and placed the pen atop Med Cart B, moved med cart to the side 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 implement infection prevention and control practices when: 1) Transmission based precautions were not implemented timely for one resident (Resident 16) that was being tested for possible COVID-19. 2) Monitoring for the signs and symptoms of COVID-19 was not documented in the residents medical record for two residents (Resident 3 and Resident 16) 3) Infection Prevention (IP) Nurse was wearing PPE gown in the nursing station 4) A trash container for doffing Personal Protective Equipment (PPE) was located outside a yellow-zone resident's room 5) One resident (Resident 7) was not offered hand hygiene prior to self-administering eye drops These cumulative failures had the potential to increase the risk of transmission of communicable diseases such as the COVID-19 virus among the facility residents and staff, which may lead to severe illness and even death. Findings: 1) During an interview on 11/29/21 at 14:15 p.m., Licensed Staff I was asked how long Resident 16 had been coughing. She stated the resident has been…

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 medication self-administration assessment was provided to one of seven residents (Resident 7) who were observed for medicine administration and had a diagnosis of dementia (a condition characterized by impairment of brain functions, such as memory loss and judgement). This failure could have resulted in expired and wrongful administration of medicine. Findings: A review of Resident 7's diagnosis indicated dementia. During a concurrent observation and interview on [DATE], at 8:54 a.m., Licensed Staff I was observed with medicine administration to Resident 7. Resident 7 was observed taking the eyedrops from the bedside table in front of her and administering them by herself. Licensed Staff I did not check how many drops were self-administered in each eye. Licensed Staff I stated Resident 7 had an order to self-administer eyedrops. A review of Resident 7's physician order dated [DATE], it indicated, Refresh Tears 0.5% eye drops (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 interview and record review, the facility failed to ensure transfer notices were provided for two of 8 residents (Resident 18 and 8) when: 1. Resident 18 was transferred to the hospital without notifying the resident's responsible party (RP); 2. Resident 8 was transferred to the hospital without notifying the Long-term Care Ombudsman Program. These failures did not ensure necessary parties were duly notified, to advocate for residents' best interest during transfers from the facility. Findings: 1. A review of Resident 18's Clinical Notes Report dated 11/26/21 indicated, Physician L requested to have Resident 18 sent to the ED (Emergency Department) after she came back from dialysis for further evaluation of her right arm and shoulder .I informed her right away of Physician L's request and she agreed with his recommendation. Clinical notes did not indicate the RP was notified. A review of Resident 18's Capacity Form dated 11/11/21, indicated, Does not have the capacity to make healthcare decisions. During a concurrent interview and record review on 12/1/21, at 12:17 p.m.,…

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 notices of the bed hold policy were provided to two (Resident 18 and 8) of the two hospitalized residents. This failure could have resulted in residents being unaware that they could return to the facility after hospitalization, and if they needed to submit payment to reserve a bed. Findings: A review of Resident 18's Notice of Transfer and Discharge form dated 11/26/21, indicated, Bed Hold Policy informed: Bed hold decision: __Yes (agrees to pay for bed hold charge of $150/daily) __No. Bed hold policy information was not addressed. During an interview on 12/2/21, at 9:41 a.m., Management Staff M stated it was the licensed nurses' responsibility to notify residents and their responsible party of the bed hold policy when residents were transferred to the hospital. During an interview on 12/2/21, at 9:37 a.m., Management Staff A stated bed hold policy was discussed with residents and their representative or responsible party upon 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 interview and record review, the facility failed to implement a person-centered care plan for two of eight sampled residents (Residents 8 and 6) when: 1) The nurses did not perform pre- and post-respiratory assessments to monitor Resident 8 for improvement. This failure resulted in Resident 8 developing recurrent aspiration pneumonia (occurs when food, saliva, liquids, or vomit is breathed into the lungs or airways leading to the lungs, instead of being swallowed into the esophagus and stomach) and multiple hospitalizations. 2) The staff did not follow the activity care plan to provide opera music. This failure resulted in Resident 6 not receiving her preferred activity. Findings: 1) During a clinical record review for Resident 8, the Care Plan, not dated, indicated Resident 8 required suctioning related to increased secretions, recurrent pneumonia, neuromuscular weakness related to MS [(Multiple sclerosis); a potentially disabling disease of the brain and spinal cord] and dysphagia (difficulty or…

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 review and revise the Care Plan quarterly for one of 8 sampled residents (Resident 8) when: 1) One nurse was checking gastric residual when Resident 8 had Gastrojejunostomy (A tube placed into the stomach that passes from the stomach into the small intestine to give liquid nutrition, medications, and other fluids directly into the small intestine). This failure had the potential for disrupting the tube patency. 2) The care plan indicated for staff to offer thickened liquid to Resident 8 who was NPO (Nothing by mouth - a medical instruction meaning to withhold food and fluids by mouth). This failure had a potential for staff to give Resident 8 a thickened liquid that may lead to choking. Findings: 1) During a clinical record review for Resident 8, The Discharge Summary from the hospital dated 7/7/21 indicated Resident 8's PEG tube (Percutaneous endoscopic gastrostomy, or a feeding tube which is passed into a resident's stomach through the abdominal wall) was placed in 2015, and revised to GJ tube (gastrostomy-jejunostomy,…

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.