Seal Beach Health And Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the development and worsening of the pressure injuries for one of the six final sampled residents (Resident 163) reviewed for pressure injury as evidenced by: * The facility failed to provide a low air loss mattress for Resident 163 who had an unstageable pressure injury on the sacrum. * The facility failed to ensure the accurate skin assessment of Resident 163's blisters. * The facility failed to follow the physician's order for a wound consult for Resident 163. These failures had the potential for deterioration of Resident 163's pressure injuries as well as the development of new pressure injuries. Findings: Review of the facility's P&P titled Support Surface Guidelines dated 2/2024 showed guidelines for selecting appropriate pressure relieving devices include individuals at risk for developing pressure ulcers should be placed on 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, medical record review, facility document review, and facility P&P review, the facility failed to ensure two of 32 final sampled residents (Residents 15 and 20) and one nonsampled resident (Resident 83) were free from the accident hazards. * The facility failed to ensure no resident's belongings were placed on top of Resident 15's overhead light fixture. * The facility failed to ensure no items were placed on top of Residents 20 and 83's overbed light fixtures. These failures had the potential for increased risk of accidents or injuries to the residents. Findings: Review of the facility's P&P titled Safety and Supervision of Residents revised 7/2023 showed the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. The Systems Approach to Safety section showed the facility-oriented approaches to safety are used together to implement a systems approach 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 interview, medical record review, and facility P&P review, the facility failed to monitor the new onset of weight loss for one of five final sampled residents (Resident 103) reviewed for nutrition. * The facility failed to monitor Resident 103 after the resident had a significant weight loss of 6.71% for one month. This failure had the potential for not providing the necessary care and services if the resident had a change in condition. Findings: Review of the facility's P&P titled Change in a Resident's Condition or Status revised 2/2021 showed a significant change of condition is a major decline or improvement in the resident's status. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. Review of the facility's P&P titled Nutrition (Impaired)/Unplanned Weight Loss - Clinical Protocol revised 9/2017 showed under the Monitoring section, the physician and staff will monitor status, an individual's response 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, medical record review, and facility P&P review, the facility failed to provide the necessary GT care and services for one of one final sampled resident (Resident 37) reviewed for enteral feeding care. * The facility failed to ensure Resident 37 was positioned safely at 30 to 45 degrees during the enteral feeding via GT. In addition, the facility failed to ensure Resident 37's GT feeding bag was labeled with the date when it was hung. These failures posed the risk for developing complications related to the residents' GT. Findings: According to Taylor's Fundamentals of Nursing seventh edition, Nursing Considerations with Tube Feeding, make sure the resident is as upright as possible during feeding. If the resident is in bed during feedings, elevate the head of the bed at least 30 degrees during feeding and for one hour afterward to prevent reflux and aspiration. Review of the facility's P&P titled Enteral Feedings - Safety Precautions revised 11/2018 showed the following: - 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, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for four of four final sampled residents reviewed for respiratory care (Residents 32, 37, 39, and 136) and three nonsampled residents (Residents 24, 55, and 118) reviewed for respiratory care. * The facility failed to ensure a physician's order was obtained and a care plan was developed to address Resident 37's use of oxygen. In addition, the facility failed to obtain a physician's order was obtained to suction the resident. * The facility failed to administer Resident 136 was receiving the correct rate of oxygen as per the physician's order. In addition, the nasal cannula tubing was undated and the set-up bag was dated 3/13/25. * The facility failed to ensure the nebulizer mask was dated and the set-up bag was changed weekly for Resident 32. * The facility failed to ensure the oxygen tubing was dated and the set-up bag was provided for Resident 39. * The facility failed…

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, facility document review, and facility P&P review, the facility failed to ensure the performance evaluations were completed every 12 months for one of two CNAs' employee files (CNA 1) reviewed. This failure had the potential for the staff to not maintain competencies to provide the residents with needed and appropriate care and services. Findings: Review of the facility's P&P titled Performance Evaluations revised 9/2020 showed the job performance of each employee shall be reviewed and evaluated at least annually. The Policy Interpretation and Implementation section showed the performance evaluations will be completed by the employees' department directors and supervisors and reviewed by the director of human resources. Each employee will be given the opportunity to review his/her evaluation with his/her department director and the director of human services. On 4/17/25 at 1520 hours, an interview and concurrent facility document review was conducted with the DSD. The DSD stated the DSD and QA nurse were supposed to do the performance evaluation yearly so they…

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, medical record review, and facility P&P review, the facility failed to ensure dementia (a decline in mental ability severe enough to interfere with daily life) care interventions were being implemented for one of two final sampled residents (Resident 135) reviewed for dementia care. This failure had the potential for Resident 135 to not receive the appropriate treatment and services needed for her dementia. Findings: Review of the facility's P&P titled Dementia - Clinical Protocol (undated) showed the following: - The staff and physician will evaluate individuals with new or worsening cognitive impairment and behavior and differentiated dementia from other causes; - The staff and physician will review current physical, functional, and psychosocial status of individuals with dementia, and will summarize the individual's condition, related complications, and functional abilities and impairments; and - The staff will monitor the individual with dementia for changes in condition and…

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

Based on interview and facility document review, the facility failed to ensure the proper accounting and safeguarding of the controlled medications to prevent loss, diversion, or accidental exposure. * The facility failed to ensure complete and accurate documentation of the Narcotic Card/Bottle Count Sheets on Medication Cart C for February and March 2025 and Medication Cart D for February and April 2025. This failure had the potential for controlled substance diversion. Findings: a. Review of the facility document titled Narcotic Card/Bottle Count Sheet for February and March 2025 for Medication Cart C showed the following: - dated 2/29, 3/1 and 3/29/25 for the 1500-2300 hours shift, there were no staff signatures for the incoming and outgoing shifts. - dated 2/29 and 3/1/25 for the 2300-0700 hours shifts, there were no signatures for the on duty staff. - dated 3/1 and 3/8/25 for the 0700-1500 hours shifts, there were no signatures for the on duty and off duty staff. - dated 2/29, 3/1, 3/7 and 3/29/25 for the 1500-2300 hours shifts, there were no signatures for the on duty 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 23.07%. Three of three licensed nurses (LVNs 3, 7, and 9) who were observed during medication administration were found to have errors. * LVN 3 failed to ensure an unscored tablet was not cut when administering an oral medication to Resident 25. * LVN 3 failed to administer the correct dosages of medications to Resident 46 as per the physician's orders. LVN 3 failed to ensure the medications were not administered together when administering medications via the GT to Resident 46, and to flush the GT in between the medications. LVN 3 failed to check if Resident 46 had loose stools prior to administering the stool softener medication. * For Resident 120, LVN 7 failed to administered calcium with Vitamin D (supplement) medication following the physician's order, did not instruct the resident not to chew for extended release medication, and did not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the staff implemented the proper storage, labeling, and disposal of medications and supplies in a safe manner. * The facility failed to ensure Treatment Cart 1 was free from expired treatment supplies. * The facility failed to ensure Medication Storage room [ROOM NUMBER] was free from staff's personal belongings. Additionally, Mediation Storage room [ROOM NUMBER] had transdermal (application of medication through the skin, usually via a patch) patches stored with the oral medications. * The facility failed to ensure the medication refrigerator in Medication Storage room [ROOM NUMBER] was maintained at the appropriate temperature. * The facility failed to ensure the artificial tears eyedrops (drops used to lubricate dry eyes) were not stored with the oral medications in Medication Storage room [ROOM NUMBER]. * The facility failed to ensure the antifungal cream was not stored with the oral medication…

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 facility document review, the facility failed to ensure the cooks followed the proper procedure for the preparation of the pureed food. This failure had the risk for an inconsistent pureed product and the potential to not meet the nutritional needs of the 16 residents who received a pureed diet. Findings: 1. Review of the facility's document titled Mandarin Chicken Method (undated) showed the recipe process for 103 servings with a #6 scoop as follows: 1. Preheat grill to 350 degrees F. 2. Spray boneless chicken with vegetable spray and grill the chicken 5 to 6 minutes on each side. Internal temperature of chicken breast must register at 165 degrees F for 15 seconds at completion of cooking time. 3. Cut the chicken into bite sized pieces using sanitized equipment. Cover and set aside. 4. Combine the sugar, soy sauce, orange juice base, oil, garlic and ginger in a saucepan. 5. Heat over medium heat until sugar is dissolved, stirring often. Bring to a boil. 6. Combine the cornstarch and water; add to the sauce, stirring often. Reduce heat and simmer…

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 4. Review of the facility's P&P titled Charting and Documentation dated 7/2017 showed documentation of procedures and treatmnet will include carespecific details, including: a. The dated and time the procedure or treatment was provided b. The name and title of the individuals who provided the care. c. The assessment data and or any unsual findings obtained during procedure or treatment. d. How the resident tolerated the procedure or treatment. e. whether the resident refused the procedure or treatment. f. Notification of family, phsycian or other staff if indicated and g. The signature and title of the individual documenting. Closed medical record review of Resident 54 was initiated on [DATE]. Resident 54 was admitted to the facility on [DATE]. Review of Resident 54's Documentation Survey Report V2 dated [DATE] showed the following entries: - For the oral hygiene, there were missing entries on 3/1, 3/2, 3/5, 3/7, 3/14, 3/15, 3/18, 3/23, 3/25, and [DATE], for the 0700 to 1500 hours shift; and 3/18 and [DATE], 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, medical record review, facility document review, and facility P&P review, the facility failed to ensure one of two final sampled residents (Resident 163) reviewed for hospice services received the necessary care and services. * The facility failed to ensure the hospice visit calendar and the physician certification of terminal illness were available in Resident 163's medical record. Additionally, the facility failed to ensure the staff knew who the hospice coordinator was. These failures posed the risk of delayed communication and provision of hospice care between the hospice provider and the facility. Findings: Medical record review for Resident 163 was initiated on 4/14/25. Resident 163 had been admitted to the facility on [DATE]. Review of the facility's P&P titled Palliative/End of life Car dated 3/2018 showed the assessment will include at least documentation of disease status including diagnosis and prognosis, documentation of comorbid medical and or psychiatric condition, functional…

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 3. Review of the facility's P&P titled Enhanced Barrier Precautions dated 10/2024 showed the EBPs are used an infection prevention and control intervention to reduce the spread of MDRO to residents. EBPs employ targeted gown and glove us during high contact resident care activities when contact precautions do not otherwise apply. Gloves and gown are applied prior to performing the high contact resident care activity as opposed to before entering the room. Examples of high contact resident care activities requiring the use of the gown and gloves for EBPs include: - Dressing; - Bathing/ showering; - Transferring; - Providing hygiene; - Changing linens; - Changing briefs or assisting with toileting; - Device care or use (central line, urinary catheter, feeding tube, tracheostomy/ ventilator, etc.); and - Wound care (any skin opening requiring a dressing). On 4/18/25 at 0929 hours, a GT site wound care observation and concurrent interview for Resident 37 was conducted with LVN 12 and CNA 5. LVN 12 was observed…

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, medical record review, and facility P&P review, the facility failed to maintain the infection control practices to help prevent the development and transmission of diseases and infections for three of five sampled residents (Residents 1, 2, and 3). * The facility staff failed to don PPE prior to entering the residents ' rooms (Rooms A and B) which were on contact isolation. This failure posed the risk for transmission of disease-causing microorganisms. Findings: Review of the facility's P&P titled Isolation-Categories of Transmission-Based Precautions revised 9/2022 showed the staff and visitors will wear gloves (clean, non-sterile) when entering the room. Gloves will be removed, and hand hygiene performed before leaving the room. Staff and visitors will wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed. a. On 3/3/25 at 1218 hours, during an observation, Room A had a sign showing contact precautions. The sign showed everyone must…

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 facility P&P review, the facility failed to provide the necessary care and services to assist the residents in carrying out their activities of daily living and services for personal hygiene for two sampled residents (Residents 7 and 8). * The facility failed to ensure the staff provided the residents' ADL care needs in a timely manner. This failure had the potential to result in poor hygiene, injury, and decreased psychosocial well-beings for the residents. Findings: Review of the facility's P&P titled Answering the Call Lights revised 9/2022 showed the following: - Answer the resident call system immediately. When answering an auditory request for assistance, identify yourself and politely respond to the resident by his/ her name. - If the resident needs assistance, indicate the approximate time it will take for you to respond. - If the resident's request requires another staff member, notify the individual. - If the resident's request is something you can fulfill, complete…

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, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the development or worsening of pressure ulcers for one of eight sampled residents (Resident 1). * The facility failed to notify Resident 1's RP for changes in Resident 1's skin condition, failed to develop and implement a care plan addressing multiple changes in skin condition for Resident 1, and failed to follow Resident 1's care plan intervention to float heels while in bed. These failures had the potential to negatively impact the resident's well-being. Findings: Review of the facility's P&P titled Pressure Injury Risk Assessment (undated) showed the purpose of this procedure is to provide guidelines for the structured assessment and identification of residents at risk of developing new pressure injuries or worsening of existing pressure injuries (PIs). Documentation in medical record addressing family, guardian, or resident notification if new skin…

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, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the development and worsening of pressure injuries for two of six sampled residents (Residents 2 and 3). * The facility failed to complete the discharge skin assessment for Resident 2's coccyx Stage 2 pressure injury. * The facility failed to ensure Resident 3's low air loss mattress was plugged in for Resident 3 who had an unstageable pressure injury to the sacrum. These failures had the potential for not providing the necessary care and services for Residents 2 and 3. Findings: Review of the facility's P&P titled Pressure Ulcers/Skin Breakdown Clinical Protocol revised 4/2018 showed the nurse shall document and report the following including current treatments, including support surfaces. The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing, and debridement approaches, dressings (occlusive,…

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 The following reflects the findings of the California Department of Public Health during an ABBREVIATED survey for COMPLAINT Numbers: CA00912961 and CA00913318, and FACILITY REPORTED INCIDENT (FRI) Numbers: CA00915155 and CA00915180. The survey team entered the facility on 8/14/24 at 1252 hours. The facility identified the census as 186. The survey sample size was 3. Inspection was limited to the complaints and FRIs investigated and did not represent the findings of a full inspection of the facility. * FOR COMPLAINT NUMBER: CA00912961, NO DEFICIENCIES WERE IDENTIFIED. * FOR COMPLAINT NUMBER: CA00913318, NO DEFICIENCIES WERE IDENTIFIED. HOWEVER, DURING THE ABBREVIATED SURVEY, ADDITIONAL DECIFIENCIES WERE IDENTIFIED AND CITED AT F584 * FOR FRI NUMBER: CA00915155, NO DEFICIENCIES WERE IDENTIFIED. * FOR FRI NUMBER: CA00915180, NO DEFICIENCIES WERE IDENTIFIED. GLOSSARY OF ABBREVIATIONS: DON - Director of Nursing P&P - Policy and Procedure F584 - D ([NAME]) Based on interview, medical record review, and facility P&P…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of two sampled residents (Resident 1) was informed of the dosage changes for their psychotropic medications. * The facility failed to ensure Resident 1 was informed of the decrease in dosage of amitriptyline (antidepressant medication) and sertraline (antidepressant medication). * The facility failed to ensure Resident 1's informed consent was obtained prior to administering the increase in dosage of amitriptyline and sertraline. These failures had the potential for Resident 1 not be informed of the medications and their potential side effects. Findings: Review of the facility's P&P titled Psychotropic Medication Use dated July 2022 showed Residents are involved in the medication management process. Psychotropic medication management includes indications for use and dose. Medical record review for Resident 1 was initiated on 5/29/24. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's 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, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure three of eight sampled residents (Residents 4, 8, and 9) were provided quality care when: * The facility failed to assess Resident 8, notify the physician, and document the change of condition regarding an unwitnessed fall. * The facility failed to ensure complete monitoring of the neurological status was conducted after a fall with head injury for Residents 8 and 9. * The facility failed to notify the physician related to the low oxygen saturation levels for Resident 8. * The facility failed to document and obtain a physician's order for a manual fecal disimpaction for Resident 4. * The facility failed to administer the PRN BM medications as ordered for Resident 4. These failures had the potential for delay in providing the necessary care and services to the residents. Findings: Review of the facility's P&P titled Falls and Fall Risk, Managing revised 3/2018 showed according…

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 medical record review, the facility failed to ensure one of two sampled residents (Resident 9) remained free from accident hazards. * The facility failed to implement the floor mats as per the physician's order and resident's plan of care. This failure had the potential to place the resident at risk for serious injury. Findings: On 5/14/24 at 0855 hours, Resident 9 was observed in bed, with the head of bed elevated. No floor mats were observed. Medical record review for Resident 9 was initiated on 5/14/24. Resident 9 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 9's Order Summary Report dated 5/13/24, showed a physician's order dated 2/20/24, to apply the floor mats every shift for fall precautions. Review of Resident 9's plan of care showed the care plan problem dated 4/29/24, addressing Resident 9 ' s actual fall with no injury. The interventions showed to continue the interventions on the at-risk for fall care plan. Further 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of five sampled residents (Resident 8) was free from the unnecessary drugs. * The licensed nurses administered midodrine (medication for blood pressure support) outside of the physician's ordered parameters. This failure had the potential for the resident to experience adverse side effects that could affect the resident's well-being. Findings: Review of the facility's P&P titled Administering Medications revised 4/2019 showed the medications are administered in accordance with prescriber orders, including any required time frame. The following information is checked/verified for each resident prior to administering medications: allergies to medications and vital signs, if necessary. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication. Closed medical record review for Resident 8 was initiated on 5/13/24. Resident 8 was admitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to provide the pharmaceutical services to ensure the medications was administered as ordered for one of two sampled residents (Resident 1). * Resident 1's sevelamer carbonate (phosphorus binder-medication used to lower phosphorus levels) was not administered as ordered on the hemodialysis days (Tuesdays, Thursdays, and Saturdays). This failure had the potential for the residents' medical needs to go untreated. Findings: Review of the facility's P&P titled Documentation of Medication Administration revised 11/2022 showed documentation of medication administration includes, as a minimum, reasons why a medication was withheld, not administered, or refused (as applicable). Review of the facility's P&P titled Administering Medications revised 4/2023 showed the following: - Medications are administered within one hour of their prescribed time, unless specified (for example before and after meal orders). - For residents not 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 interview, medical record review, and facility document review, the facility failed to ensure the discharge process was properly followed for Resident 1. * Resident 1's medical record failed to show the physician's documentation to show Resident 1 was ready for discharge. This failure had the potential for Resident 1 to unsafely discharge from the facility. Findings: Medical record review for Resident 1 was initiated on 2/15/24 at 1330 hours. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's Order Summary Report showed a physician's order dated 1/10/24, to discharge from the facility to the community. Review of Resident 1's Notice of Proposed Transfer/discharge date d 1/17/24, showed Resident 1's discharge was appropriate because their health had improved sufficiently, and the resident had no longer required the services in the facility. Review of Resident 1's medical record failed to show Resident 1's physician documented the basis for the resident's discharge prior to providing…

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 medical record review, the facility failed to ensure the quality care and services were provided to promote healing of surgical wounds for one of eight sampled residents (Resident 6). * LVN 1 failed to administer the wound treatments as per the physician's orders and did not inform the physician of the unavailable supplies. This failure had the potential to delay healing of Resident 6's surgical wounds. Findings: Medical record review for Resident 6 was initiated on 1/30/24. Resident 6 was admitted to the facility on [DATE], with diagnosis of unspecified open wound on the left lower leg. Review of Resident 6's MDS dated [DATE], showed Resident 6 had surgical wounds. Review of Resident 6 TAR for January 2024 showed the following wound care orders: - dated 1/26/24, for the left lower medial leg surgical incision, to cleanse with normal saline, pat dry, apply xeroform (a nonadherent dressing), cover with a foam dressing, every day shift for 21 days and as needed if soiled 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P, the facility failed to ensure one of eight sampled residents (Resident 5) was free from unnecessary drugs. * The licensed nurse did not clarify the hydrocodone-acetaminophen (a narcotic pain medication) order with the physician and failed to inform the physician of the resident's pain levels of 0, 1, and 2 (on a 0 to 10 pain scale with 0 = no pain and 10 = worst pain) on multiple occasions with the routine administration of hydrocodone-acetaminophen every six hours to reevaluate the pain medication regime. This failure had the potential for the resident to experience adverse effects that could affect the resident's well-being. Findings: Review of the facility's P&P titled Pain Assessment and Management revised 10/2022 showed when opioids are used for pain management, the resident is monitored for medication effectiveness, adverse effects, and potential overdose. Further review of the P&P showed the pain medication regimen is implemented as ordered, 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 medical record review, the facility failed to ensure the physical well-being was maintained at the highest practicable level for one of two sampled residents (Resident 1). * The facility failed to ensure Xanax (antianxiety medication) was reordered by the physician and available for Resident 1 as needed. This failure posed the risk of Resident 1 not being provided appropriate care and treatment. Findings: Medical record review for Resident 1 was initiated on 1/9/24. Resident 1 was admitted to the facility on [DATE], and readmitted to the facility on [DATE]. Review of Resident 1' s MDS dated [DATE], showed Resident 1 was cognitively intact. On 1/9/24 at 0920 hours, an interview was conducted with Resident 1 at the bedside. Resident 1 stated she had a physician's order for Xanax. The physician's order for Xanax was dropped and was not reordered for three weeks. Additionally, when Xanax was reordered by the physician, the medication was not available. Review of Resident 1' 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, medical record review, and facility P&P review, the facility failed to notify the RP of the room change for one of nine sampled residents (Resident 8) prior to a room change. This failure put Resident 1 at risk of having their rights being violated. Findings: Review of the facility's P&P titled Transfer, Room to Room revised 12/2016 showed under the Preparation section, to orient the resident to the transfer in a form and manner that the resident can understand. Under the Documentation section showed the following information should be recorded in the resident's medical record: The date and time of the room transfer was made. On 11/22/23 at 1120 hours, an interview was conducted with RP 1. RP 1 stated they were not notified their family member was moved to a new room on or about 11/18/23. Medical record review for Resident 1 was initiated on 11/22/23. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 8's History and Physical Examination 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, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to ensure one of nine sampled resident (Resident9) attained and maintained their highest practicable physical well-being. * The facility failed to administer Resident 9's medications as per the physician's orders. This failure had the potential of the resident not receiving the appropriate care and services to treat their medical conditions. Findings: Review of the facility's P&P titled Administering of Medication revised April 2019 showed under number 21, if a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose. On 11/22/23 at 1142 hours, an interview was conducted with Resident 9. Resident 9 stated they did not receive their evening and night medications on 11/17/23. Medical record review for Resident 9 was initiated on 11/22/23. Resident 9 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the nursing staff provided the care related to the indwelling urinary catheters for one of nine sampled residents (Resident 1) and one of 11 nonsampledresidents (Resident A) * The facility failed to ensure the indwelling urinary catheter care was provided as ordered for Residents 1 and A. This failure had the potential to result in inadequate care and risk for adverse complications for the residents with an indwelling urinary catheter. Findings: Review of the facility's P&P titled Catheter Care, Urinary revised 8/2022 showed the purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections. Review of the facility's P&P titled Documentation of Medication Administration revised 11/2022 showed administration of medication is documented immediately after it is given. 1. Closed medical record review for Resident 1 was initiated on 11/9/23.…

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 facility P&P review, the facility failed to ensure the medications were properly stored and labeled. This failure had the potential for the unauthorized staff to have access to the medications and posed the risk for the residents receiving expired medications. Findings: Review of the facility's P&P titled Storage of Medications (undated) showed the medications requiring refrigeration are stored in a refrigerator located in the drug room at the nurses' station or other secured location. The medications are stored separately from food and labeled accordingly. On 10/24/23 at 1340 hours, an inspection of the medication rooms in Stations 1 and 2 were conducted with the DON and the following was identified: - Inside the medication refrigerator in Station 1, there were one open and undated Novolin Insulin multi-dose vial and a plastic bag of food containing yogurt, boiled eggs, and peach fruits. - The medication refrigerator in Station 2 was unlocked and had two open Novolin Insulin multi-dose vials and three open and undated Tuberculin Purified…

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 medical record review, the facility failed to notify the RP about a resident's change of condition and transfer to the acute care hospital for one of five sampled residents (Resident 1). This failure had the potential to affect the ability of the RP to participate in Resident 1's treatment. Findings: Review of the facility's P&P titled Change in Resident's Condition or Status, undated, showed the facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: a. the resident is involved in any accident or incident that results in an injury including injuries of unknown sources, b. there is a significant change in the resident's physical, mental, or psychosocial status; c. there is a need to change the resident's room assignment; d. a decision has been made to discharge 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 medical record review, the facility failed to accommodate the needs for three of five sampled residents (Residents 2, 4, and 5). Residents 2, 4, and 5 stated they had to wait 30 minutes or longer to get assistance, including assistance to the bathroom. This failure had the potential to negatively impact the residents' well-being. Findings: Review of the facility's P&P titled Answering the Call Light (undated) showed the purpose of this procedure is to ensure timely responses to the resident's requests and needs. 1. Medical Record review of Resident 2 was initiated on 8/22/23. Resident 2 was admitted to the facility on [DATE], and readmitted on [DATE]. On 8/22/23 at 1150 hours, an interview was conducted with Resident 2. Resident 2 stated it took one hour or more to wait for a staff to provide assistance empty for urinal or go to the restroom. The staff told him that they had another 18 residents and were very busy. 2. Medical Record review of Resident 4 was initiated on 8/22/23. Resident 4…

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, medical record review, and facility P&P review, the facility failed to ensure the abdominal binder was applied for one of five sampled residents (Resident 1) to prevent pulling of the GT. This failure posed the risk of injury for the resident. Findings: Medical record review for Resident 1 was initiated on 8/21/23. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 1's order summary report dated 8/21/23, showed a physician's order dated 6/9/23, to apply an abdominal binder to protect the GT every shift, change when soiled, and document (+) for on and clean. On 8/21/23 at 1015 hours, an interview was conducted with Family Member 1. Family Member 1 stated the family visited Resident 1 at different times and did not see the abdominal binder placed on Resident 1. Family Member 1 stated she had informed the staff. On 8/21/23 at 1050 hours, a concurrent observation and interview was conducted with CNA 1. Resident 1 was observed without 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, medical record review, and facility document review, the facility failed to ensure accurate reconciliation of the controlled medications when the medications administered as documented on the Controlled Drug Record did not match with the resident's MAR for one of five sampled residents (Resident 2). This posed the risk for controlled medication diversion. Findings Review of the facility's P&P titled Controlled Substances dated 11/2022 showed the system of reconciling the receipt, dispensing and disposition of controlled substances includes the following: a. Records of personnel access and usage b. Medication administration records. Medical Record review of Resident 2 was initiated on 8/22/23. Resident 2 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 2's Order Summary Report dated 8/22/23, showed the following: - A physician's order dated 8/17/23,to administer hydrocodone-acetaminophen oral tablet 5-325 mg one tablet by mouth every 6 hours as needed 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 observation, interview, medical record review, and facility P&P review, the facility failed to protect the residents' rights to be free from the physical abuse by another resident for two of 14 sampled residents (Residents 9 and 10). Residents 9 and 10 were roommates involved in a physical altercation partially witnessed by CNA 10. The facility failed to ensure the residents were immediately separated and kept safe until nine hours later. This failure had the potential for Residents 9 and/or 10 to experience further abuse. Findings: Review of the facility ' s P&P titled Abuse Prevention Program revised 8/2021 showed administration will protect residents from abuse by anyone including other residents. Review of the facility ' sP&P titled Abuse Investigation and Reporting revised date 7/2017 showed the Administrator will ensure that any further potential abuse, neglect exploitation or mistreatment is prevented. Review of the SOC 341 form showed the facility reported an allegation of abuse to theCDPH, L&C…

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, medical record review, and facility P&P review, the facility failed to implement their P&P for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for two of 14 sampled residents (Residents 9 and 10). CNA 10 was aware of a resident to resident altercation between Residents 9 and 10 at the time of the incident; however the abuse allegation was not reported to the CDPH, L&C Program until over nine hours later. This failure had the potential for Residents 9 and 10 to experience further abuse. Findings: Review of the facility ' s P&P titled Abuse Investigation and Reporting revised date 7/2017 showed all reports of resident abuse shall be promptly reported to local, state, and federal agencies. All alleged violations involving abuse will be reported to: a. The State licensing/certification agency responsible for surveying/licensing the facility; b. The local/State Ombudsman; c. The Resident's Representative (Sponsor) d. Adult…

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 medical record review, the facility failed to provide the necessary care and services to ensure two of 14 sampled residents (Residents 2 and 5) who had diabetes to attain and maintain their highest practicable physical well-being when the facility failed to notify the physician of Resident 2 and 5 ' s refusals of insulin adminstration on multiple occasions. This posed the risk for delayed medical treatment and hospitalization. Findings: Review of the facility ' s P&P titled Change in a Resident ' s Condition or Status dated 2/2021 showed the nurse will notify the resident ' s attending physician or physician on call when there has been a need to alter the resident ' s medical treatment significantly and refusal of treatment or medications two or more consecutive times. 1. Medical record review for Resident 2 was initiated on 7/20/23. Resident 2 was admitted to the facility on [DATE], with diagnoses including type 2 diabetes. Review of Resident 2 ' s admission History and Physical…

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, medical record review, and facility P&P review, the facility failed to ensure the adequate supervision and assistance devices were provided to prevent accidents for three of 14 sampled residents (Resident 6, 7, and 8). * Resident 6 did not have smoking privileges but was observed smoking unsupervised and without a smoking apron on the patio. * Residents 6, 7, and 8 were not offered or provided a smoking apron as per the plan of care prior to smoking. These failures put the residents at risk for smoking related accidents. Findings: Review of the facility ' s P&P titled Smoking Policy - Residents revised date 8/2022 showed the facility may impose smoking restrictions on a resident at any time if it is determined that the resident cannot smoke safely with the available levels of support and supervision. Any resident with smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor, or volunteer worker at all times while smoking.…

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, medical record review, and facility P&P review, the facility failed to ensure one of 14 sampled residents (Resident 4) received the appropriate services needed to maintain acceptable parameters of nutritional status when: * The facility failed to implement the interventions to maintain Resident 4's nutritional status when Resident 4 experienced the following severe weight loss over one month from 6/23/23 to 7/23/23: - 9 lbs (5.6%) in one week from 6/23/23 to 7/2/23 - 11 lbs (6.8%) in two weeks from 6/23/23 to 7/9/23 - 17 lbs (10.5%) in three weeks from 6/23/23 to 7/16/23 - 22 lbs (13.6%) in one month from 6/23/23 to 7/23/23 * The facility failed to ensure the physician was notified of the severe weight loss for Resident 4. * The facility failed to revise the resident-centered plan of care for Resident 4 to reflect the severe weight loss from 6/23/23 to 7/23/23. These failures caused Resident 4 to experience severe weight loss of 22 lbs, 13.58% weightloss in one month from 6/23/23…

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, medical record review, and facility P&P review, the facility failed to provide the necessary GT care and services for one of 14 sampled residents (Resident 1). * The facility failed to ensure Resident 1 was positioned safely at 30 to 45 degrees during feeding administration via GT and failed to ensure Resident 1 ' s GT tubing was free from milky coagulated liquid. These failures posed the risk for developing complications related to GT. Findings: Review of the facility ' s P&P titled Enteral Tube Feeding via Continuous Pump dated 11/2018 showed to position the head of the bed at 30 to 45 degrees for feeding, unless medically contraindicated. Medical record review for Resident 1 was initiated on 7/20/23. Resident 1 was admitted to the facility on [DATE]. a. Review of Resident 1 ' s Order Summary Report dated 7/26/23, showed a physician ' s order dated 6/19/23, to elevate the head of bed 30 to 45 degrees during feeding. On 7/24/23 at 1149 hours, Resident 1 was observed on the geri…

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, medical record review, and facility P&P review, the facility failed to provide the pharmaceutical services to ensure the accurate administration of medication as evidenced by: * The facility failed to ensure the medications were administered in a timely manner for one of 14 sampled residents (Resident 14) and two of eight nonsampled residents (Residents A and H). Residents 14, A, and H received their morning medications up to five hours later than the scheduled times. * The facility failed to ensure the MAR for Resident 3 was signed by LVN 6 immediately after the medication administration. These failures posed risks for double-dosing and had the potential for the resident ' s medical needs to go untreated. Findings: Review of the facility ' s P&P titled Administering Medications revised 4/2019 showed medications are administered in accordance with prescriber orders, including any required time frame. Medications are administered within one hour of their prescribed time, unless…

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, facility document review, and facility P&P review, the facility failed to ensure the kitchen staff had the appropriate skill set to safely perform the daily operation of the Food and Nutrition Services Department as evidenced by: * The Chef was unable to correctly read the measurement of the ingredients per the recipe during the pureed food preparation observation. * [NAME] 1 was unable to show the correct procedure of the thermometer calibration. * [NAME] 2 was unable to correctly show how to check the freezer temperature. * [NAME] 3 was unable to show how to change the Celsius to Fahrenheit mode in a digital thermometer. * Dietary Aide 1 was unable to correctly state the process for testing the sanitizing solution for the manual washing. These failures had the potential to lead to foodborne illnesses in a highly susceptible population of residents who received food prepared in the kitchen. Findings: Review of the CMS 672 Resident Census and Conditions of Residents completed by the facility dated 6/21/23, showed 161 of 174 residents in the facility…

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

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the menus were followed as evidenced by: * The facility served regular bread rolls instead of garlic bread per the facility's menu spreadsheet. * [NAME] 1 failed to follow the recipe for pureed chicken supreme by placing 5.8 cups of water instead of 5/8 cup per the recipe during the pureed food preparation. * The wrong scoop size was used to serve the stewed tomato with basil for residents on pureed diet. * The wrong scoop size was used to serve paprika noodles for residents on regular diet. * The supersoup (soup with extra nutrients added) was not served to the residents on fortified diet. The facility failed to provide supersoup to Residents 103, 148, and 924. * The facility failed to ensure the spreadsheet was followed for the puree/level 4 diet. The facility failed to provide whole milk for Resident 172. These failures had the potential for the residents to not receive adequate nutrition and appropriate servings to meet their individual needs. Findings: Review of the…

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

Based on observation, interview, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by: * The facility failed to ensure the proper labeling and dating of the foods in the kitchen were utilized once the food item was opened. * The facility failed to ensure the proper labeling and dating of the foods in refrigerator was in placed for the residents' food brought in by visitors. In addition, the facility failed to ensure the food items were discarded after 72 hours. * The facility failed to ensure the expired food items in the kitchen were discarded. A bin containing sugar had a use-by date of 4/26/22, and a bin containing powdered milk had a use-by date of 4/25/23 were seen the kitchen's storage. In addition, the facility failed to ensure the plastic liner for the powdered milk and all-purpose flour were not torn and frayed. * The facility failed to ensure the proper storage of the employees' food and belongings in the kitchen was being observed by the staff. * The facility failed to ensure the use hair restraints was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to implement their infection control program in accordance with the facility's P&P. * The facility failed to maintain an accurate infection control surveillance program for the months of May and June 2023. The facility conducted surveillance only on residents who exhibited signs and symptoms of an infection and were prescribed antimicrobial medications. The facility failed to include the residents who exhibited signs and symptoms of infection; however, were not prescribed antimicrobial medications. The facility failed to ensure the Surveillance Data Collection Form was complete and accurate to determine whether the resident's infection met the McGeer's criteria for true infection. * The facility failed to wear proper PPE during high-contact care for Resident 130 who was on enhanced isolation precautions. Resident 130 was placed on enhanced isolation precautions without a physician's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the entrapment assessments were accurate or the measurements were recorded during the bed inspection when identifying areas of possible entrapment with the use of bed side rails for all 31 residents with side rails. These failures had the potential to negatively impact the residents resulting to entrapment, serious injuries, and death. Findings: According to the Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, the term entrapment describes an event in which a patient/resident is caught, trapped, or entangled in the space in or about the bed rail, mattress, or hospital bed frame. Patient entrapments may result in deaths and serious injuries. These entrapment events have occurred in openings within the bed rails, between the bed rails and mattresses, under bed rails, between split rails, and between the bed rails and head or foot boards. The…

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

Based on interview, medical record review, and facility P&P review, the facility failed to obtain the informed consent from one of 36 final sampled residents (Resident 72) or resident's legal representative for the use of psychotropic medications. This failure posed the risk for Resident 72 or resident's legal representative to not be informed of the benefits and risks of the psychotropic medications and not have the opportunity to decline the proposed treatment. Findings: Review of Facility P&P titled Psychotropic Medication Use revised July 2022 showed when determining whether to initiate, modify, or discontinue medication therapy, the IDT conducts an evaluation of the resident. The evaluation will attempt to clarify whether: the actual or intended benefit of the medication is understood by the resident/ representative. Resident (and/ or representatives) have the right to decline treatment with psychotropic medications. Medical record review for Resident 72 was initiated on 6/28/23. Resident 72's Order Summary Report as of 6/1/23, showed an order dated 5/5/23, to administer…

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, medical record review, and facility P&P review, the facility failed to ensure four nonsampled residents (Residents 14, 124, 136, and 146) who were assessed to not self-administer the medications had the medications at the bedside. This failure had the potential to negatively impact the residents' physiological well-being and could administer the medications inaccurately. Findings: Review of the facility's P&P titled Self-Administration of Medications revised February 2021 showed the residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. The IDT assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident. The policy also showed any medications found at the bedside that are not authorized for self-administration are turned over to the nurse in charge for return to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the reasonable accommodations to meet the needs for six of 36 final sampled residents (Residents 10, 103, 157, and 922) and six nonsampled residents (Residents 3, 52, 112, 119, 161, and 874). * The facility failed to ensure the call lights for Residents 3, 10, 52, 103, 119, 161, and 922 were within the residents' reach. * The facility failed to ensure Residents 112, 157, and 874 were provided with assistance in a timely manner. These failures had the potential to negatively impact the residents' physical and psychosocial well-being or would result in delayed provision of care. Findings: Review of the facility's P&P titled Answering the Call Light (undated) showed the purpose of this procedure is to ensure timely responses to the resident's requests and needs. In addition, the general guidelines showed to ensure the call light is accessible to the resident when in bed, from the toilet, from the shower…

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 3. Medical record review for Resident 103 was initiated on 6/21/23. Resident 103 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 103's H&P examination dated 3/25/23, showed Resident 103 did not have the capacity to understand and make decisions. Review of Resident 103's Advance Healthcare Directive Acknowledgement Form dated 3/23/23, showed Resident 103 had an advance healthcare directive; however, there was no indication whether or not Resident 103's advance directive was requested or available in medical record. Review of Resident 103's Physician Orders for Life-Sustaining Treatment (POLST) undated, failed to show whether Resident 103 had an advance directive or not. On 6/26/23 at 0855 hours, an interview and concurrent medical record review was conducted with the SSD. The SSD stated the social services department was in charge of the residents' advance directives, and if the resident had an advance directive, they would ask the resident or responsible party for a copy 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, medical record review, and facility P&P review, the facility failed to ensure the privacy was provided for one of 36 final sampled residents (Resident 723) and two of 34 nonsampled residents (Residents 13 and 1074). * The facility failed to ensure Residents 723 and 1074 were provided a dignity bag for their indwelling urinary catheter (a catheter drains urine from the bladder into a bag outside the body) drainage bag. * The facility failed to ensure visual privacy was provided during the G-tube medication administration for Resident 13. These failures had the potential to violate the resident's right to privacy. Findings: Review of the facility's P&P titled Confidentiality of Information and Personal Privacy revised October 2017 showed the facility will strive to protect the resident's privacy regarding his or her: a. accommodations; b. medical treatment; c. written and telephone communications; d. personal care; e. visits; and f. family and resident group meetings. 1. Medical…

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, medical record review, facility document review, and facility P&P review, the facility failed to maintain a clean, sanitary, and homelike environment for the dining room and residents' rooms for two of 37 final sampled residents (Residents 4 and 76) and two of 34 nonsampled residents (Residents 62 and 90) when: * The air vents and surrounding tiles around the air vents in the dining room were observed with blank powdery-like substance. * Resident 4 and Resident 90's room was observed with food particles on the bottom of the window close to the bathroom on bottom wall board and crumbled paper. Resident 4's bed side table and the top of drawer with liquid spills. Resident 4's room floor was sticky. Resident 90 did not feel good when the room or the floor was dirty. * Two dusty electric stand fans were observed inside Resident 76's room. In addition, the front fan guard (used to provide a physical barrier around spinning fan blades to prevent accidental contact with fingers or other…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical records and facility P&P review, the facility failed to ensure one of 36 final sampled residents (Resident 72) had a mental disorder was referred to state PASARR representative for Level II evaluation and determination screening process. This failure pose risk for resident not to receive adequate level of services, comprehensive assessment, intervention and evaluation for conditions related to mental disorder. Findings: Review of the facility's P&P titled admission Criteria revised March 2019 showed, all new admissions and readmissions are screened for mental disorders, intellectual disabilities or related per the Medicaid PASARR process as follows: - The facility conducts a Level 1 PASARR screen for potential admissions, regardless of payer source, to determine if the individual meets the criteria for a mental disorder, intellectual disabilities or related. - If the level I screen indicates that the individual meets the criteria for a mental disorder, intellectual disabilities 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to develop the comprehensive plans of care to reflect the individual care needs for six of 36 final sampled residents (Residents 37, 72, 105, 147, 723, and 922). * The facility failed to develop a comprehensive person-centered care plan to address the use of bilateral grab rails for Resident 723; the use of bilateral floor mats for Residents 70 and 105; Resident 147's change in condition blood in urine and oxygen therapy; Resident 37's order to be up on wheelchair 3 times per week; and Resident 114's use of antibiotic for treatment of infection. These failures had the potential risk of not providing appropriate, consistent, and individualized care to these residents. Findings: Review of the facility's P&P titled Care Plans, Comprehensive Person-Centered revised March 2022 showed the comprehensive, person-centered care plan describes the services that are to be furnished to attain or maintain the resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the comprehensive care plan was revised to reflect specific care needs for three of 36 final sampled residents (Residents 70, 72, and 922). * Resident 70's care plan for activity did not reflect Resident 70's activity preference. * Resident 922's care plan did not reflect no longer use of Indwelling urinary drainage catheter (a catheter inserted through the urethra into the bladder to drain urine). * Resident 72's plan of care for care plan problem of pain was not revised to reflect the accurate location of Resident 72's pain. This failure had the potential risk for Resident 72 to receive adequate assessment, intervention, and evaluation of his pain. These failures posed the risk for not providing the residents with individualized and person-centered care. Findings: Review of the facility's P&P titled Care Plans, Comprehensive Person-Centered revised March 2022 showed assessments of the residents are…

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, medical record review, and facility P&P review, the facility failed to ensure one of 34 nonsampled residents (Resident 113) was provided with the tools necessary to maintain and improve the resident's communication abilities when a communication board was not available when required by Resident 113 for communication. This failure had the potential to impede the resident in maintaining and/or achieving independent functioning, dignity, and well-being. Findings: Review of the facility's P&P titled Activities of Daily Living, Supporting, revised March 2018 showed appropriate care and services will be provided for the resident who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with communication (speech, language, and any functional communication systems). During the initial tour of the facility on 6/21/23 at 0939 hours, Resident 113 was observed in his room on his…

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, medical record review, facility document review, and facility P&P review, the facility failed to provide an ongoing in room activity program to meet the needs and interests of two of 36 final sampled residents (Residents 70 and 87). * Resident 87 was assessed to prefer watching television and listening to music. However, Resident 87 was observed in bed with no sensory stimulation. * The facility failed to provide meaningful activities to meet the Resident 70's interests. These failures posed the risk for the residents to feel isolated. Findings: Review of the facility's P&P titled, Programming for Residents with Cognitive Impairments and Other Special Needs, revised June 2018, showed activity programs are provided for the maintenance and enhancement of each resident's quality of life while promoting physical, cognitive, and emotional health. The facility will offer meaningful programs for residents with cognitive impairments that use reality and sensory awareness techniques. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review and facility P&P review, the facility failed to ensure two of 36 final sampled residents (Residents 99 and 147) and one nonsampled residents (Resident 137) were provided with the necessary services to meet their highest practicable physical, mental, and psychosocial well-being. * The facility failed to ensure the change of condition evaluation was completed for Resident 147 a timely manner. This failure had the potential for Resident 147 to not receive the appropriate care and services in timely manner. * The facility failed to ensure the physician was notified promptly when Resident 99 refused to take medications. This failure had the potential to negatively impact the resident's well-being. * The facility failed to ensure the physician's order was followed by wearing gloves when administering Resident 137 finasteride (a medication that treats enlarge prostate in men) medication. This failure had the potential for exposure to hazardous agent contained in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the development of new pressure ulcers (areas of damaged skin caused by staying in one position for a long time which reduces blood flow to the area and causes the skin to die and develop a sore) and promote healing of existing pressure ulcer for two of 36 sampled residents (Residents 58 and 125). * The facility failed to ensure Resident 125 was repositioned at least every two hours as per the resident's care plan; and wound treatments were administered as per the physician's order. These failures put Resident 125 at higher risk for developing new pressure ulcers and worsening of the existing pressure ulcer on the sacral area. * The facility failed to ensure LAL mattress setting was consistent with Resident 58's weight. This posed the risk for Resident 58 to not benefit from the therapy provided by LAL mattress. Findings: 1a. During the initial…

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, medical record review, and facility P&P review, the facility failed to ensure appropriate care and services related to GT were provided to one of 36 final sampled residents (Resident 105) and one non-sampled resident (Resident 13). * The facility failed to check the GT placement for Resident 13 prior to the administration of the medications through the GT. * The facility failed to ensure Resident 105's enteral formula bottle, fluid bag, and syringe were labeled and dated. * The facility failed to ensure Resident 105's head of bed was elevated during GT feeding to reduce the risk for aspiration. These failures had the potential to negatively impact the resident's well-being. Findings: Review of the facility's P&P titled Administering Medications through an Enteral Tube revised 11/2018 showed under Steps in the Procedures to verify placement of the feeding tube. 1. Medical record review of Resident 13 was initiated on 6/26/23. Resident 13 was admitted to the facility on [DATE] 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, record review, and facility P&P review, the facility failed to provide the necessary respiratory care for three of 36 final sampled residents (Residents 76, 103, and 147) and five nonsampled residents (Residents 27, 44, 77, 172, and 60). * Resident 44 was administered oxygen four liters per minute via nasal cannula, instead of two liters per minute per the physician's order. In addition, the facility failed to ensure the nasal cannula tubing was dated, and the empty humidifier bottle was discarded properly. * Resident 60 was administered oxygen 2.5 liters per minute via nasal cannula, instead of two liters per minute per the physician's order. The facility failed to ensure the nasal cannula tubing was dated. In addition, a suction set-up was observed dated 12/29/22, and there was no physician's order to suction Resident 60. * On 6/21/23 at 1016 hours, Resident 103 was observed in bed asleep. The nasal cannula tubing attached to an oxygen concentrator was observed unlabeled 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, medical record review, and facility P&P review, the facility failed to offer or provide the adequate and appropriate pain management for two of 36 final sampled residents (Residents 74 and 72). * The facility failed to ensure Resident 74 was administered the pain medication per the physician's order. * The facility failed to ensure Resident 72 received timely assessment and intervention to ease pain to the resident's left upper arm to neck. This pose risk for Resident 72 experiencing pain not managed accordingly consistent with professional standards of practice. These failures had the potential for not effectively managing these residents' pain. Findings: Review of the facility's P&P titled Pain Assessment and Management revised 10/2022 showed to implement pain management strategies, the medication regimen is implemented as ordered. 1. On 6/21/23 at 1027 hours, during an initial tour of the facility, an interview was conducted with Resident 74. Resident 74 stated she took Soma…

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, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary care and services to attain the highest physical wellbeing for two of 36 final sampled residents (Residents 54 and 107) who required dialysis. * The facility failed to ensure the following for Residents 54 and 107: - Complete the dialysis communication record forms which included Residents 54 and 107's pre dialysis assessment (for blood sugars, vital signs, access site, skin integrity, medications sent with resident, or any information for the dialysis center) and post dialysis assessment (for vital signs, access site, skin integrity, and special instructions, recommendations, or information from the dialysis center). - Accurately assess for Residents 54 and 107's dialysis site. - Specify which medication for Residents 54 and 107 were to be administered at the dialysis center. These failures had the potential risk for Residents 54 and 107 not being provided 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, medical record review, and facility P&P review, the facility failed to ensure the assessment, physician's order, informed consent, and least restrictive alternative measures were implemented prior to the use of side rails for one of 36 final sampled residents (Resident 723). These failures had the potential to put Resident 723 at risk for serious injury. Findings: Review of the facility's P&P titled Bed Safety and Bed Rails revised August 2022 showed bed rails include side rails, safety rails, and grab or assist bars. The use of bed rails or side rails (including temporarily raising the side rails for episodic use during care) is prohibited unless the criteria for use of bed rails have been met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent. On 6/21/23 at 0910 hours, 6/23/23 at 0809 hours, and 6/27/23 at 0855 hours, Resident 723 was observed in bed with bilateral bed grab rails elevated. Medical record review 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 observation, interview, facility document review and facility P&P review, the facility failed to provide the pharmaceutical services to ensure the accurate reconciliation, administration, and disposal as evidenced by: * The facility failed to ensure the MARs for Residents 13, 80, and 140 were signed by LVN 11 immediately after the medication administration and refusal. These failures posed risks for double-dosing and missed doses of prescribed medications which may compromise resident safety. * The facility failed ensure non-controlled medications were discarded by two licensed nurses and identify method of disposal. This failure had the potential for the inaccurate reconciliation and medication administration error. * The facility failed to ensure the medications prescribed to treat depression (amitriptyline) were administered as per physician orders for Resident 76. This posed the risk of not treating the resident's depression. Findings: According to the facility's P&P titled Administering Medications…

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, medical record review, and facility P&P review, the facility failed to ensure the drug regimens reviewed and any irregularities found were acted upon for two of 36 final sampled residents (Residents 103 and 147). These failures posed the risk of the residents not receiving the necessary care and services or receiving unnecessary medications. Findings: Review of the facility's P&P titled Medication Regimen Reviews revised May 2019 showed the pharmacy consultant reviews the medication regimen of each resident at least monthly. The pharmacy consultant performs the medication regimen review for every resident in the facility receiving medication and will provide written report to attending physicians for each resident identified of non-life threatening medication irregularities within 24 hours of medication regimen review. The physician will document in the medical record that irregularity has been reviewed and what (if any) action was taken to address it. The copies of medication regimen review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility document review, the facility failed to ensure four of 36 final sampled residents (Residents 21, 147, 155, and 168) were free from the unnecessary psychotropic drugs (any drug that affects brain activity associated with mental processes and behavior). * The facility failed to ensure Resident 168's target behavior for the use of quetiapine fumarate (antipsychotic medication) was monitored accurately. * The facility failed to ensure Resident 21's monthly behavior summary was completed for the use of quetiapine (medication used to treat schizophrenia), and sertraline (medication used to treat depression). * The facility failed to ensure Resident 155's monthly behavior summary was completed for the use of mirtazapine (medication used to treat depression), escitalopram (medication used to treat major depressive and general anxiety disorders), and clonazepam (medication used to treat prevent and control seizures and treat panic attacks). * 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, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 48.39%. Two of two licensed nurses (LVNs 1 and 11) were found to have made errors during the medication administration. * The facility failed to ensure Resident 140's calcium tablet 500mg and lubricant eye drops were administered as ordered. * The facility failed to ensure Resident 13's ferrous sulfate oral syrup 300 (60 Fe) mg/5ml 5.4ml and folic acid 1mg as ordered. * The facility failed to ensure Resident 13 was assessed for loose stools as ordered prior to the administration of Miralax * The facility failed to ensure Resident 137's Aspirin chewable (medication to prevent a stroke) was administered as ordered. * The facility failed to ensure Resident 137's multivitamin with minerals (supplement) was administered as ordered. * The facility failed to ensure Resident 137's calcium 600 + D Tablet 5 mg 600-400 mg unit…

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, facility document review, and facility P&P review, the facility failed to provide the necessary pharmaceutical services to ensure proper storage, labeling, and disposal of medications. This failure had the potential for unauthorized residents and staff to have access to the medications; and posed the risk for the residents receiving expired medications. Findings: Review of the facility's P&P titled Discarding and Destroying Medication revised November 2022 showed the medication disposition record should contain the signature of witnesses. Review of the facility's P&P titled Medication Labeling and Storage revised February 2023 showed the following: - The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. - Medications would be stored in an orderly manner in cabinets. Each resident's medications are to be assigned to an individual holding area to prevent possibility of mixing medications of several residents. - Controlled substances and other drugs subject to abuse are…

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 facility P&P review, the facility failed to ensure the medical records for two of 36 final sampled residents (Residents 41 and 72) were complete and accurately documented as evidenced by: * Resident 41's Controlled Drug Record and Emergency Kit Pharmacy Log failed to show documentation on 6/17 and 6/19/23 at 1700 hours, for a scheduled pain medication that was administered to the resident. * The facility failed to ensure Resident 72's medical record had the completed POLST Form of the resident on file. These failures had the potential for the residents' care needs not being met as the clinical information was not complete. Findings: 1. Review of the facility P&P titled Preparation and General Guidelines: Controlled Medications dated 8/2014 showed when a controlled medication is administered, the licensed nurse administering the medication immediately enters the signature on the accountability record at the time the medication was removed from the supply. Medical record review…

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

Based on interview, facility document review, and facility P&P review, the facility failed to inform the physician of the residents who had not met the McGeer's Criteria and were prescribed antibiotics for two of 36 final sampled residents (Residents 43 and 160) and one of 34 nonsampled residents (Resident 11). This posed the risk for the continued use of unnecessary antibiotics, potentially resulting in adverse reactions associated with antibiotics, and the development of antibiotic resistant bacteria. Findings: According to the Centers for Disease Control and Prevention (CDC), antibiotics are among the most frequently prescribed medications in nursing homes, with up to 70% of residents in a nursing home receiving one or more courses of systemic antibiotics over a year. Studies have shown that 40-75% of antibiotics prescribed in nursing homes may be unnecessary or inappropriate. Harms from antibiotic overuse are significant for the frail and older adults receiving care in nursing homes. These harms include risk of serious diarrheal infections from Clostridium difficile, increased…

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, facility document review, and facility P&P review, the facility failed to maintain the essential equipment used to prepare, serve, and store food in the facility. * The facility failed to ensure Freezer #4 was functioning properly to maintain the required temperature of 0 degrees F or lower. * The facility failed to ensure the thermometers were calibrated weekly per the facility's P&P. These failures had the potential for equipment not functioning in the way they were intended and in turn cause contamination of food, leading to food-borne illnesses for the residents who received food from the kitchen. Findings: Review of the CMS 672 Resident Census and Conditions of Residents completed by the facility dated 6/21/23, showed 161 of 174 residents in the facility received food prepared in the kitchen. Review of the USDA Food Code 2022, Section 4-501.11, Good Repair and Proper Adjustment showed equipment shall be maintained in a state of repair and condition. 1. Review of facility's P&P titled Refrigerators and Freezers revised date 11/2022 showed 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, medical record review, and facility P&P review, the facility failed to provide the appropriate services for one nonsampled resident (Resident 77). * The facility failed to ensure Resident 77 had a functioning call light in order to summon staff for assistance. This failure had the potential for Resident 77 not having his needs known to the staff and may result in not receiving assistance in a timely manner. Findings: Review of the facility's P&P titled Maintenance Service revised December 2009 showed the maintenance services shall be provided to all areas of the building, grounds, and equipment in a safe and operable manner at all times. Review of the facility's P&P titled Answering the Call Light (undated) showed the purpose of this procedure is to ensure timely responses to the resident's requests and needs. In addition, general guidelines showed, be sure that the call light is plugged in and functioning at all times. On 6/22/23 at 0851 hours, Resident 77's call light was…

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

Based on observation, interview, facility document review, and facility P&P review, the facility failed to maintain an effective pest control program to prevent the presence of small flies in the kitchen. This failure had the potential to lead to food borne illnesses (illness caused by food contaminated with bacteria, viruses, parasites or toxins) in the facility residents who eat food prepared in the kitchen. Findings: According to the USDA Food Code 2022, 6-501.111, Controlling Pests, insects and other pests are capable of transmitting disease to humans by contaminating food and food-contact surfaces. Effective measures must be taken to eliminate their presence in food establishments. Review of the facility's P&P titled Pest Control revised date 5/2008 showed the facility maintains an ongoing pest control program to ensure that the building is kept free of insects and rodents. On 6/21/23 at 0843 hours, flies were observed flying and on the walls of the kitchen adjacent to the tray line area. On 6/22/23 at 1118 hours, fruit flies were observed flying in the kitchen area where 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 3. On 05/06/21 at 0900 hours, an interview was conducted with Residents 121 and 134. Residents 121 and 134 stated since last month, Resident 111 was sitting with his hand in his pants by their room every time they came out of the shower. Residents 121 and 134 stated they asked Resident 111 what he was looking at. Residents 121 and 134 stated Resident 111 liked watching women who just came from the shower. Residents 121 and 134 stated the nurses were made aware and they would wheel Resident 111 away. Residents 121 and 134 stated they argued with Resident 111 every time they called out his behaviors. Residents 121 and 134 stated this happened on several occasions. Residents 121 and 134 stated this concern had been brought up in the Resident Council meetings, but nothing had been done. Residents 121 and 134 stated they felt very upset and humiliated every time this happened. On 5/6/21 at 1300 hours, an interview was conducted with CNA 9. CNA 9 stated Resident 111 had the behavior of placing his hands in his pants.…

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, medical record review, facility document review, and facility P&P review, the facility failed to ensure six of 32 sampled residents (Residents 68, 86, 89, 123, 128, and 450) and five nonsampled residents (Residents 6, 26, 62, 63, and 147) remained free from accident hazards. * The facility failed to monitor the use of the Wander Guard for functionality and placement for Residents 6, 26, 63, and 86. * The facility failed to ensure one of seven exit doors (Exit Door 4) equipped with the Wander Guard alarm system was functioning properly. * The facility failed to implement the IDT recommendation for the use of Wander Guard for Resident 89. * The facility failed to ensure Resident 147 had an identification band and the Wander Guard was in place to address Resident 147's eloping behavior and suicidal gestures. In addition, the facility failed to report the elopement incident to the CDPH, L&C Program. * The facility failed to ensure safe smoking practices were followed for Residents…

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, medical record review, and facility P&P review, the facility failed to ensure the appropriate infection control practices designed to provide a safe and sanitary environment and help prevent the development and transmission of infections were implemented. * The facility failed to use the appropriate disinfectant to clean the porous foam on Resident 45's bilateral grab bars. This posed the risk for not adequately cleaning and disinfecting the resident equipment. * The facility failed to offer and provide the COVID 19 vaccine to one of 32 sampled residents (Resident 48). This failure had potential to cause residents to not be protected from the COVID 19 (a disease caused by SARS-CoV-2 that can trigger a respiratory infection) infection. * Multiple medication bottles in Medication Carts A, B, and C had dry stains and sticky residues. These failures posed the risk for transmission of disease-causing microorganisms. Findings: 1. Review of the facility's P&P titled Cleaning 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 medical record review, the facility failed to promote the dignity and respect for four of 32 final sampled residents (Residents 68, 83, 84, and 121). * The facility failed to ensure Residents 84 and 121's call lights were answered in a timely manner. * The CNAs were observed standing over Residents 68 and 83 while assisting with their meals. These failures had the potential to negatively affect the residents' well-being. Findings: 1. On 5/4/21 at 0833 hours, during the initial tour of the facility, an interview was conducted with Resident 84. Resident 84 stated he had a concern with the call light response. Resident 84 stated he had to wait for two to three hours for the staff to answer the call light. When asked how he knew the time, Resident 84 stated he used the clock in his room to check the time. Resident 84 stated he needed pain medication and for staff to assist him getting out of bed. Resident 84 stated he could be dying in his room and the staff never paid attention.…

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, medical record review, and facility P&P review, the facility failed to determine whether three of 32 final sampled residents (Residents 46, 49, and 143) had an advance directive or wished to formulate an advance directive. This had the potential for the residents' decisions regarding their health care and treatment options not being honored. Findings: Review of the facility's P&P titled Advance Directives revised 12/2016 showed upon admission the Social Services Director or designee will inquire of the resident about the existence of any written advance directives. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. 1. Medical record review for Resident 49 was initiated on 5/3/21. Resident 49 was admitted…

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, medical record review, and facility document review, the facility failed to ensure all allegations or suspicions of abuse were reported no later than two hours to the facility's Administrator for one of 32 final sampled residents (Resident 13). * Resident 13's allegation of the male resident exposed himself and masturbated in front of her was not reported to the facility's Administrator. This failure resulted in the sexual abuse allegation to go uninvestigated and placed Resident 13 and the other residents at risk for abuse. Findings: Medical record review for Resident 13 was initiated on 5/6/21. Resident 13 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 13's annual History and Physical examination dated 10/30/20, showed Resident 13 was oriented to person, place, and time and capable of decision-making. Review of Resident 13's MDS dated [DATE], showed Resident 13 was cognitively intact. On 5/4/21 at 1225 hours, a follow-up interview was conducted with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to implement the individual plan of care for one of 32 final sampled residents (Resident 94). This posed the risk of not providing the appropriate and individualized care to Resident 94. Findings: Medical record review for Resident 94 was initiated on 5/3/21. Resident 94 was admitted to the facility on [DATE]. Review of Resident 94's Post-Fall Review dated 12/30/20, showed Resident 94 had an unwitnessed fall and was found sitting on the floor. Review of Resident 94's Post-Fall Review dated 1/5/21, showed Resident 94 was found lying on the floor and had the skin abrasions to the left knee and left hand. Review of Resident 94's Post-Fall Review dated 2/30/21, showed Resident 94 had an unwitnessed fall and was found sitting on the floor. Review of Resident 94's plan of care showed a care plan problem dated 1/6/21, addressing Resident 94's fall risk and actual fall on 12/2020. The interventions showed Resident 94 was to have the bed and…

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

Based on interview and facility document review, the facility failed to provide the necessary care and services to help attain and maintain resident's highest practicable physical well-being. * The glucometers from Medication Carts A, B, and C were not calibrated on a regular basis. In addition, the glucometer calibration logs had multiple missing and incomplete entries. These failures had the potential to negatively impact the residents' well-being. Findings: 1. On 5/10/21 at 0734 hours, review of Medication Cart A's Quality Control Record Assure Platinum Blood Glucose Monitoring System forms showed multiple missing entries for the following months: - November 2020: 11/12 to 11/15, 11/25 to 11/26/20, 11/19 to 11/23, and 11/28 to 11/30/20, had incomplete documentation. - December 2020: no entries for 12/2 to 12/8/20, 12/10, 12/12, 12/17, and 12/21/20. - January 2021: no entries for 1/1, 1/3 to 1/6, 1/8, 1/9, 1/18 to 1/21, 1/24, 1/25, 1/27; and incomplete documentation on 1/13 to 1/14/ 21. - February 2021: no entries from 2/5 to 2/7/21. On 5/10/21 at 0811 hours, an interview 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 medical record review, the facility failed to provide the necessary respiratory care for two of 32 final sampled residents (Residents 42 and 128). * Resident 42 had the physician's orders for continuous oxygen to be administered at 2 to 5 liters per minute via nasal cannula and to notify the physician if Resident 42's oxygen saturation level below 92%. Resident 42 was observed on room air without the oxygen therapy as ordered, which resulted in Resident 42 having an oxygen saturation level of 90%. * Resident 128 had a physician's order for continuous oxygen to be administered at 2 liters per minute via nasal cannula. Resident 128 was observed being on and off the oxygen therapy. In addition, Resident 128's oxygen was set at 2.5 liters per minute. These failures had the potential to result in negative health outcomes to the residents. Findings: 1. Medical record review for Resident 42 was initiated on 5/3/21. Resident 42 was admitted to the facility on [DATE]. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to ensure the effective pain management was provided for three of 32 final sampled residents (Residents 84, 121, and 123). 1. Resident 121's physician's order for hydrocodone-acetaminophen (pain medication) had no distinct pain parameters. The hydrocodone-acetaminophen medication was ordered for the severe pain but was administered to Resident 121 at the lower pain levels. Resident 121 was not consistently provided non-pharmacological interventions prior to the administration of pain medications. 2. Resident 84's physician's order for morphine sulfate (pain medication) had no distinct pain parameters. The morphine sulfate medication was ordered for moderate pain but was administered to Resident 84 at the lower pain levels. Resident 84 was not provided non-pharmacological interventions prior to the administration of pain medications. 3. Resident 123 was not provided with adequate pain assessment and management. These failures had 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 medical record review, the facility failed to ensure one of 32 final sampled residents (Resident 87) who required dialysis received care and services consistent with the professional standards of practice. The facility failed to ensure Resident 87's dialysis access site was assessed pre and post dialysis treatment as ordered by the physician. This failure had the potential to delay nursing staff identifying any issues with the resident's dialysis access site, including signs of infection and active bleeding. Findings: Review of the facility's P&P titled Hemodialysis Access Care dated 9/2010, under the section Steps in the Procedure, Care of AVFs (Arterio-Venous Fistula is created by surgically connecting an artery and a vein) and AVGs (Arterio-Venous Graft uses a synthetic or animal-derived tubing to connect the artery and vein), showed care involves the primary goals of preventing infection and maintaining patency of the catheter (preventing clots). To prevent infection and/ or clotting:…

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 medical record review, the facility failed to ensure four of 32 final sampled residents (Residents 45, 116, 143, and 137) remained free from accident hazards due to the use of elevated side rails as evidenced by: * The facility failed to conduct the assessment for the risk of entrapment from elevated side rails, obtain the informed consent prior to the use of side rails, and attempt the alternatives prior to use of side rails for Resident 116. * The facility failed to conduct the assessment for the risk of entrapment from elevated side rails and attempt the alternatives prior to use of side rails for Resident 143. * The facility failed to conduct the assessment for the risk of entrapment from the elevated side rails for Residents 45 and 137. These had the potential to place the residents at risk for entrapment and serious injury. Findings: Review of the FDA issued Safety Alert entitled Entrapment Hazards with Hospital Bed Side Rails showed the residents most at risk for…

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

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure proper accounting and safeguarding of the controlled medications in order to prevent loss, diversion, or accidental exposure. * The facility failed to ensure the incoming and outgoing licensed nurses assigned to Medication Carts A and B consistently signed the QShift Controlled Substance Release Form to ensure the complete inventory of the controlled medications during the shift change narcotic medication count. These failures posed the risk for loss or diversion of controlled medications. Findings: According to the facility's P&P titled Controlled Medication Storage dated 8/2014, under the section Policy, showed the medications included in the Drug Enforcement Administration classification as controlled substances are subject to special handling, storage, disposal and recordkeeping in the facility in accordance with federal, state, and other applicable laws and regulations. The Procedures section showed at each shift change, a physical inventory of all controlled…

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, medical record review, and facility document review, the facility failed to ensure the Pharmacy Consultant and licensed staff reported irregularities for one of 32 final sampled residents (Residents 51). The facility failed to act upon irregularities reported by the Pharmacy Consultant for Resident 51. This failure had the potential for the residents not receiving necessary care and services. Findings: Medical record review for Resident 51 was imitated on 5/3/21. Resident 51 was admitted to the facility on [DATE]. Review of Resident 51's Order Summary Report for May 2021 showed a physician's order dated 8/18/20, to administer lactulose (medication for constipation) solution (10 gm/15 ml) 30 ml by mouth four times a day for bowel management and hold for loose stool. Review of the facility document titled Note to Attending Physician/Prescriber for March 2021 showed the Pharmacy Consultant recommended a review for the use of lactulose (10 gm/15 ml) 30 ml oral four times a day for bowel 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 ensure two of five unnecessary medication sampled residents (Residents 68 and 128) were free from unnecessary medications. * Resident 128's temazepam (medication to induce sleep) was administered for inability to sleep; however, the hours of sleep was not monitored as ordered by the physician. * The facility failed to accurately monitor Resident 128's behavior for inability to relax for the use of clonazepam (medication for anxiety). * The facility failed to ensure the the physician's order for Resident 128's clonazepam reflected the accurate indication for administering the clonazepam medication. * The facility failed to ensure the physician's order for lorazepam (antianxiety medication) 1 mg to be given as needed was limited to a 14-day duration for Resident 68 . These failures posed the risk of providing the resident with unnecessary medications and the potential for development of significant side effects. Findings: According to the facility's P&P…

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

Based on observation, interview, and facility document review, the facility failed to ensure the sanitary conditions were maintained during food storage and preparation as evidenced by: * The facility failed to label the food items with the open or use by dates and dispose of the food items that were kept beyond the used by dates. This posed an increased risk of cross-contamination and created a potential for pathogens to cause food borne illnesses in the facility. Findings: Review of the CMS-672 Resident Census and Conditions of Residents completed by the facility and dated 5/4/21, showed 148 of 161 residents residing in the facility received food prepared in the kitchen. Review of the facility's P&P titled Food Receiving and Storage dated 7/14 showed all foods stored in the refrigerator or freezer will be covered, labeled, and dated (used by date). Dry foods that are stored in the bins will be removed from original packaging, labeled, and dated (used by date). On 5/3/21 at 0800 hours, during the initial tour of the kitchen with the Dietary Service Supervisor, the following food…

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, facility document review, and facility P&P review, the facility failed to inform the physician of the residents who had not met the McGeer's Criteria and were prescribed antibiotics for two of 32 final sampled residents (Residents 9 and 87) and six nonsampled residents (Residents 8, 69, 125, 550, 551, and 552). This posed the risk for the continued use of unnecessary antibiotics, potentially resulting in adverse reactions associated with antibiotics, and the development of antibiotic resistant bacteria. Findings: According to the Centers for Disease Control and Infection (CDC), an estimated 70% of nursing home residents receive one or more courses of antibiotics during a year. Studies have shown that 40% to 75% of the antibiotics prescribed in nursing homes may be unnecessary or inappropriate. Frail and older adults are at significant risk of harm from antibiotic overuse including increased adverse drug events, increased drug interactions and infection with antibiotic-resistant organisms. The World Health Organization (WHO) cites antibiotic resistance as one 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.