Shafter Nursing Care

Based on interview, and record review, the facility failed to ensure MDS (Minimum Data Set - assessment tool) quarterly (every three months) assessment was completed for one of 16 sampled residents (Resident 77). This failure had the potential for the delay in development and implementation of Resident 77's individualized care plan. Findings: During an interview on 12/19/24 at 11:45 a.m. with Minimum Data Set Nurse (MDSN), MDSN stated MDS assessments need to be completed on admission, quarterly, annually and at discharge. MDSN stated MDS assessments need to be completed within 14 days of the Assessment Reference Date (ARD-the specific end point of look-back periods in the MDS assessment process). During a concurrent interview and record review on 12/19/24 at 11:53 a.m. with MDSN, Resident 77's clinical record (CR), (undated) was reviewed. The CR indicated, Resident 77's admission MDS was completed on 7/30/24. MDSN stated Resident 77's quarterly MDS assessment had not been completed and was overdue. MDSN stated Resident 77's quarterly MDS should have been completed in October 2024.…

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

Based on interview and record review, the facility failed to follow their policy and procedure (P&P) titled, Pre-admission Screening and Resident Review (PASRR) for two of two sampled residents (Resident 66 and Resident 38) with identified serious mental illness diagnoses when an updated PASRR Level 1 was not submitted. This failure had the potential for residents not to receive the specialized mental health services to meet their needs. Findings: During a review of Resident 66's History and Physical Reports (H&P) from General Acute Care Hospital (GACH), dated 1/22/24, the H&P indicated, Resident 66 had a history of Schizoaffective Disorder (a serious mental health condition with symptoms of hallucinations [seeing or hearing things that are not there]), delusion (false belief that is held even when presented with evidence that it is not true), depression (persistent sadness), and mania (abnormally elevated mood, energy, or activity), Anxiety (excessive feelings of worry, fear, or unease), and Suicidal behavior (threatening to harm or kill oneself). During a review of Resident 66's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure two of three sampled residents (Resident 2 and Resident 3) discharge care plans were developed. This failure had the potential for Resident 2 and Resident 3 to have unmet care needs upon discharge. Findings: During a review of Resident 2's admission Record, (AR) the AR indicated, Resident 2 was admitted on [DATE] and discharged on 9/12/24. During a review of Resident 2's Multidisciplinary Care Conference, (MCC) dated 9/9/24, MCC indicated, (Resident 2) wishes to return to room and board when discharge is appropriate. During a review of Resident 3's AR, the AR indicated, Resident 3 was admitted on [DATE] and discharged on 9/19/24. During a review of Resident 3's MCC, dated 6/12/24, the MCC indicated, (Resident 3) wishes to ALF (assisted living facility) when discharge is appropriate. During a concurrent interview and record review on 10/2/24 at 12:34 p.m. with the Director of Nursing (DON), DON stated Discharges are a team effort, planning start…

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

Based on interview, and record review, the facility failed to report an allegation of financial abuse for one of three sampled residents (Resident 1) within 24 hours to the California Department of Public Health (CDPH) and complete a thorough investigation within five business days. This failure had the potential for Resident 1 experiencing continued financial abuse. Findings: During an interview on 9/17/24 at 11:18 a.m. with Social Services Director (SSD), SSD stated she called Resident 1 ' s bank and stated she pretended to be Resident 1 in order to reset (change) her pin number. SSD stated, Police Department [PD] came in last week or so, they pretty much just questioned who SSD and Administrator were. SSD stated on the weekends she [Resident 1] goes out with friends [unidentified] shopping. During an interview on 9/17/24 at 11:33 a.m. with Director of Nursing (DON), DON stated, PD came in last week, they spoke to resident [1] first then spoke to SSD, it was in regard to credit card fraud [wrongful or criminal deception intended to result in financial or personal gain]. During an…

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

During an interview and record review, the facility failed to follow their policy and procedures (P&P) titled, Abuse Prevention for two of 15 sampled employees (Licensed Vocational Nurse- LVN 2 and Certified Nursing Assistant- CNA 5) when reference checks were not completed prior to the date of hire. This failure had the potential to place residents at risk for abuse. Findings: During a concurrent interview and record review on 5/22/24 at 11:49 a.m. with Director of Staff Development (DSD), LVN 2's References for Potential Hires Candidate Employer/Reference Check [RPHCERC], dated 1/25/24 was reviewed. The RPHCERC indicated, Recruiter/Hiring Manager Role: The Recruiter or Hiring Manager will ensure that all employment references are completed prior to the new hire starting work. There was no documented evidence of reference checks. DSD stated LVN 2 employee file was incomplete. DSD stated employee files need to be complete to ensure the staff member is safe to work with the residents. During a concurrent interview and record review on 6/13/24 at 4:11 p.m. with DSD, CNA 5's employee…

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

Based on interview and record review, the facility failed to ensure ordered medication for one of three sampled residents (Resident 1) was administered within the ordered time frame. This had the potential for adverse side effects for Resident 1. Findings: During an interview on 3/6/24, at 2:53 p.m., with Resident 1, Resident 1 stated her Percocet (pain medication) was supposed to be administered at 12 pm today and she did not receive it until approximately 2:30 p.m. During an interview on 3/6/24, at 4 p.m., with Director of Nursing (DON), DON stated Resident 1's Percocet was scheduled to be administered at 12:00 p.m. DON stated the medication was considered timely if it was administered one hour before or one hour after the scheduled time frame. During a concurrent interview and record review on 4/5/24, at 2:52 p.m., with DON, Resident 1's Med [medication] Admin [administration] Audit Report (MAAR), dated 3/6/24 was reviewed. The MAAR indicated, Percocet Oral Tablet.give 1 tablet by mouth every 6 hours.3/6/24 12:00 (scheduled time to be given) .3/6/24 13:59 (indicating 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 record review, the facility failed to protect one of five sampled residents (Resident 1) from staff verbal abuse. This resulted in staff verbally abused Resident 1 and had the potential to result in psychosocial harm for Resident 1. Findings: During an interview on 2/22/24 at 11:41 a.m. with Interim Administrator (IA), IA stated Certified Nursing Assistant (CNA 1), was witnessed by another staff member verbally abusing Resident 1 on 2/12/24. During an interview on 2/22/24 at 11:47 a.m. with Director of Staff Development (DSD), DSD stated CNA 1 was heard calling Resident 1 you old hag. DSD stated, calling resident you old hag is verbal abuse. During an interview on 2/22/24 at 12:01 p.m. with Housekeeper, Housekeeper stated he was in dining room cleaning when he heard CNA 1 telling Resident 1 in Spanish to shut up in a deep tone, like angry tone. Housekeeper stated when he stepped out to get a closer look as to what was happening, Housekeeper stated Resident 1 became aggravated when CNA 1 continued to tell Resident 1 in Spanish to shut up.…

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

Based on interview and record review, the facility failed to report an allegation of abuse to the proper authorities for three of five sampled residents (Resident 1). This violated Resident 1, Resident 2, and Resident 3's patient rights. Findings: During an interview on 2/22/24 at 11:41 a.m. with Interim Administrator (IA), IA stated Certified Nursing Assistant (CNA 1) was witnessed by another staff member verbally abusing Resident 1 on 2/12/24. During an interview on 2/22/24 at 12:36 p.m. with Director of Nurses (DON), DON stated Resident 2 was noted with bruising to right wrist on 2/12/24. DON stated the facility did not know how Resident 2 sustained the bruise and only suspected it may have been due to an altercation between Resident 2 and Resident 3. During an interview on 2/22/24 at 2:05 p.m. with Ombudsman Intake Specialist (OIS), OIS stated Ombudsman (department of aging) did not received an SOC 341 (a required form used to report suspected abuse of dependent adults and elders) from the facility regarding the allegation of abuse between Resident 1 and CNA 1 on 2/12/24, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow its Policy and Procedure (P&P) for Bed Hold for one of three sampled residents (Resident 1). This resulted in the facility not allowing Resident 1 to return to the facility after being transferred to the acute hospital for three days and had the potential for psychosocial harm. Findings: During an interview on 2/7/24 at 3 p.m. with acute hospital Social Worker (SW), SW stated Resident 1 had discharge order to return to the facility on 2/6/24 (3 days after hospitalization). SW stated the facility was notified on 2/6/24 of Resident 1 ' s discharge orders and was told by the facility Business Developer and Marketer (BDM) Resident 1 ' s bed had been given to another resident and they did not have any long-term beds available. During a review of Resident 1 ' s admission Record (AR), dated 2/8/24, the AR indicated Resident 1 was a female, originally admitted to the facility on [DATE]. The Progress Notes dated 2/3/24 at 1:22 a.m. indicated Resident 1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to permit one of three sampled residents (Resident 1) to return to the facility after three days of hospitalization. This resulted in Resident 1 having an unnecessary stay in the hospital for additional seven days. Findings: During an interview on 2/7/24 at 3 p.m. with acute hospital Social Worker (SW), SW stated Resident 1 had discharge order to return to the facility on 2/6/24 (3 days after hospitalization). SW stated the facility was notified on 2/6/24 of Resident 1 ' s discharge orders and was told by the facility Business Developer and Marketer (BDM) Resident 1 ' s bed had been given to another resident and they did not have any long-term beds available. During a review of Resident 1 ' s admission Record (AR), dated 2/8/24, the AR indicated Resident 1 was a female originally admitted to the facility on [DATE]. The Progress Notes dated 2/3/24 at 1:22 a.m. indicated Resident 1 complained of severe chest pain and SOB [shortness of breath] and requested…

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

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) toe was monitored when a scab was identified by the Physician and Licensed Vocational Nurse (LVN) 2 on two different occasions. This had the potential for staff to be unaware of the toe worsening. Findings: During a review of Resident 1 ' s Progress Notes (PN-completed by Physician 1) dated 11/14/23, the PN indicated, .left fourth toe healing, mild fibrous scar and scab to the distal tip which is stable, nail regrowing.Assessment/Plan.Advised her to let the scab fall off the left fourth toe. During a review of Resident 1 ' s PN (completed by Licensed Vocational Nurse (LVN 2) dated 1/5/24 (52 days after Physician 1 identified the scab to the left fourth toe) at 2:25 a.m., the PN indicated, Res [Resident 1] has c/o [complained of] sharp pain to L [left] 4th toe. Capillary refill < [less] 3 seconds, toes adjacent to affected toe is <4-5 seconds. MD notified. Nno [no new orders]. During a review of Resident 1 ' s PN (completed by LVN 2), dated 1/5/24 at 3:14…

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

Based on interview and record review, the facility failed to follow its policy and procedure (P&P) on Theft/Loss Prevention for one of three sampled residents (Resident 1). This failure had the potential for grievances to go unresolved and result in negative consequences. Findings: During a review of Resident 1 ' s MDS (Minimum Data Set - an assessment tool) under Brief Interview for Mental Status (BIMS - an assessment tool for cognition), dated 9/26/23, the BIMS indicated, Resident 1 had a score of 15 out of 15 (cognition is intact). During an interview on 12/19/23 at 2:19 p.m. with Resident 1, Resident 1 stated he noted some personal items missing from his room approximately on 10/24/23, when he was moved into a new room. Resident 1 stated he voiced his concern to the facility Social Services Director (SSD). Resident 1 stated he requested the facility P&P on Theft/Loss but did not receive anything. Resident stated he also spoke with the facility Administrator around the same time and was told to wait a few days for a response. Resident 1 stated he was missing: A. Eight to ten…

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

Based on observation, interview, and record review, the facility failed to follow their policy and procedure (P&P) titled Abuse Investigation and Reporting for one of 3 sampled residents (Resident 1) This failure had the potential to expose other residents in facility to abuse. Findings: During an observation on 12/29/23 at 11 a.m. in hallway, Certified Nursing Assistant (CNA) 1 was working in the building. During a review of untitled document, dated December 2023, the untitled indicated, CNA 1 worked on 12/27/23, 12/29/23, 12/30/23. During an interview on 12/29/23 at 10:10 a.m. with Administrator in Training (AIT), AIT stated, It ' s on me not suspending CNA. If investigation is still going on then staff under allegation should not be working on floor. During a review of the facility ' s P&P titled, Abuse Investigation and Reporting, dated 2017, the P&P indicated, All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state, and federal agencies (as…

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

Based on interview and record review, the facility failed to ensure care plans were consistently implemented for two of three sampled residents (Resident 1 and Resident 2). These failures had the potential for Resident 1 to suffer further alleged sexual altercations committed by Resident 2. Findings: During an interview on 11/30/23 at 12:49 p.m. with Resident 1, Resident 1 stated, It [alleged sexual altercation] has happened a few times, I am usually alone out front or smoking. Resident 1 stated Resident 2 still goes on smoke break. Resident 1 stated she must tell Resident 2 to get away from her. During an interview on 11/30/23 at 1:38 p.m. with Certified Nursing Assistant (CNA 1), CNA 1 stated smoke breaks are rotated. CNA 1 stated all residents go out at the same time. CNA 1 stated she has cared for Resident 1 often, she stated she has not been made aware of residents that are to be kept at a distance from Resident 1. During an interview on 11/30/23 at 1:49 pm with CNA 2, CNA 2 stated she works with Resident 2 sometimes but not that familiar with him (Resident 2). CNA 2 stated…

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

Based on interviews, document reviews, and facility policy review, the facility failed to ensure there was registered nurse (RN) coverage seven days a week for the months of September 2023 and October 2023. This had the potential to affect all residents who resided in the facility. Findings included: Review of a facility policy titled, RN Staffing Coverage Policy, revised on 08/09/2016, revealed Policy Refer to F727 Federal Requirements. Definition: F727 requires that nursing homes have an RN onsite at least 8 consecutive hours a day, 7 days a week. A review of September 2023 staff schedule revealed there was no RN scheduled on 09/02/2023, 09/03/2023, 09/08/2023, 09/09/2023, 09/14/2023, 09/15/2023, 09/20/2023, 09/21/2023, 09/26/2023, and 09/27/2023. A review of October 2023 staff schedule revealed there was no RN scheduled for 10/02/2023, 10/03/2023, 10/08/2023, 10/09/2023, 10/14/2023, 10/15/2023, 10/20/2023, 10/21/2023, 10/26/2023, and 10/27/2023. During an interview on 10/25/2023 at 1:52 PM, the Director of Nursing (DON) stated the facility had only one RN that worked five days a…

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

Based on observation, interviews, and facility policy review, the facility failed to ensure staff did not touch ready-to-eat food with their bare hands. This deficient practice had the potential to affect all residents who received food from the kitchen. Findings included: Review of a facility policy titled, Glove Use Policy, dated 2023, revealed, Gloved hands are considered a food contact service that can get contaminated or soiled. During an observation on 10/15/2023 beginning at 11:03 AM, [NAME] #9 and [NAME] #10 used various utensils and touched the countertops with their gloved hands. Without changing their gloves or sanitizing their hands, [NAME] #9 and [NAME] #10 picked up dinner rolls and placed them on resident plates. During an interview on 10/25/2023 at 12:21 PM, [NAME] #9 and [NAME] #10 stated they should not have handled any food with their bare hands. [NAME] #9 and [NAME] #10 stated they should have used tongs for the dinner rolls. During an interview on 10/25/2023 a 12:29 PM, the Dietary Manager stated she expected staff to not touch food with their bare hands. Per…

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 observations, interviews, record reviews, and policy review, the facility failed to provide a dignified meal experience for 3 (Resident #159, Resident #160, Resident #161) of 11 sampled residents who required assistance with their meals. Findings include: Review of a facility policy titled, Assistance with Meals revised July 2017, revealed 3. Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example: a. not standing over the residents while assisting them with meals. 1. A review of the Transfer/Discharge Report, indicated the facility admitted Resident #159 on 10/27/2020, with diagnoses that included encephalopathy, muscle weakness, and unspecified dementia. A review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/03/2023, revealed Resident #159 had a Brief Interview for Mental Status (BIMS) of 02, which indicated the resident had severe cognitive impairment. The MDS indicated Resident #159 required limited assistance of one person for eating. Review of Resident #159's care plan,…

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 interviews, record review, and facility policy review, the facility failed to ensure the resident representative for 1 (Resident #152) of 27 sampled residents were invited to the resident's care plan conference meeting. Findings included: A review of a facility policy titled, Care Planning - Interdisciplinary Team, revised September 2013, revealed, 3. Every effort will be made to schedule care plan meetings at the best time of the day for the resident and family. A review of the Transfer/Discharge Report, indicated the facility admitted Resident #152 on 02/26/2021, with diagnoses that included anxiety disorder, cognitive communication deficit, hemiplegia and hemiparesis, major depressive disorder, schizoaffective disorder, mood disorder, dementia, and type 2 diabetes. A review of Resident #152's annual Minimum Data Set (MDS) with an Assessment Refence Date (ARD) of 08/10/2023, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. Per the MDS, the resident had a guardian or legally…

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 observations, record review, interviews, and facility policy review, the facility failed to provide a bed-side commode (BSC) for 1 (Resident #105) of 1 sampled resident reviewed for bowel and bladder incontinence. Findings included: A review of the facility policy titled, Accommodation of Needs, revised January 2020, revealed, Our facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity and well-being. The policy specified, 2. The resident's individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, shall be evaluated upon admission and reviewed on an ongoing basis. A review of an admission Record indicated the facility admitted Resident #105 on 10/20/2023 with diagnoses that included fractures of the sternum, sacrum, left femur, muscle weakness and contusion (bruising) to the abdominal wall. A review of a Clinical Health Status with Baseline Care Plan dated 10/20/2023, indicated Resident #105 was oriented 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 interviews, record reviews, and facility policy review, the facility failed to ensure the Minimum Data Set (MDS) was accurate for 4 (Residents #52, #152, #154, and #157) of 27 sampled residents. Findings included: A review of a facility policy titled, Resident Assessments, revised 11/2019, revealed, All persons who have completed any portion of the MDS resident assessment from must sign the document attesting to the accuracy of such information. 1. A review of Resident #52's admission Record indicated the facility admitted Resident #52 on 02/25/2023. A review of Resident #52's Physician Orders for Life-Sustaining Treatment (POLST), dated 02/25/2023, indicated staff should not attempt resuscitation of the resident. A review of Resident #52's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/03/2023, revealed staff should attempt resuscitation of the resident. During an interview on 10/26/2023 at 12:23 PM, the MDS Coordinator indicated she was responsible for the completion…

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 observations, record review, interviews, and facility policy review, the facility failed to ensure 1 (Resident #101) of 1 sampled resident received oxygen therapy as ordered by the physician. Findings included: A review of the facility's policy titled, Oxygen Administration, revised 11/01/2017, revealed, Purpose To prevent or reverse hypoxemia and provide oxygen to the tissues. A review of Resident #101's admission Record indicated the facility readmitted the resident on 10/16/2023 with diagnoses that included metabolic encephalopathy and hypertension. A review of Resident #101's care plan initiated on 10/16/2023, indicated the resident had an alteration in respiratory status. Interventions directed staff to administer oxygen as needed per physician order, monitor oxygen saturations on room air and/or oxygen, and monitor the oxygen flow rate and response. A review of resident #101's physician orders revealed an order dated 10/16/2023, for continuous oxygen at five liters per minute by way of a nasal canula to maintain the resident's oxygen saturation level above 92%.…

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 interviews, record reviews, and facility policy review, the facility failed to ensure an end date was obtained and documented on the physician's order for as-needed (PRN) psychotropic medications for 2 (Resident #53 and Resident #157) of 5 residents reviewed for psychotropic medications. Findings included: Review of a facility policy titled, Antipsychotic Medication Use, revised December 2016, revealed, 14. The need to continue PRN orders for psychotropic medications beyond 14 days requires that the practitioner document the rationale for the extended order. The duration of the PRN order will be indicated in the order. 1. A review of an admission Record revealed the facility most recently admitted Resident #53 on 10/04/2023 with diagnoses that included cerebral infarction (stroke), depression, anxiety disorder, and bipolar disorder. A review of an admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/10/2023, revealed Resident #53 had a Brief Interview for Mental Status (BIMS) score of 0, which indicated the resident had severe cognitive…

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, interviews, record review, and facility policy review, the facility failed to ensure a medication that was not administered was not repackaged. Specifically, the facility did not ensure a controlled medication, alprazolam, was not placed back in the medication card and secured with tape. This deficient practice affected 1 (Resident #2) of 8 residents observed for medication administration. Findings included: Review of the facility's undated policy titled, Controlled Medications, indicated, When a dose of a controlled medication is removed from the container for administration but refused by the resident or not given for any reason, it is not placed back in the container. It must be destroyed in the presence of two licensed nurses and the disposal documented on the accountability record on the line representing that dose. A review of Resident #2's admission Record, revealed the facility admitted the resident on 08/26/2023, with a diagnosis to include anxiety disorder. A review of Resident #2's Order Summary Report for active orders as of 10/26/2023, revealed an…

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

Based on interview and record review, the facility failed to: 1. Ensure the Ombudsman (Long Term Care Resident Advocate) was notified of facility-initiated discharges prior to the resident's being discharged from the facility for three of four sampled residents (Resident 1, Resident 2, Resident 3); 2. Ensure the Ombudsman was notified of a facility-initiated discharge for one of four sampled residents (Resident 4). These failures had the potential to result in inappropriate discharges. Findings: 1a. During a review of Resident 1's Noticed of Proposed Transfer and Discharge (NPTD), dated 7/25/23, the NPTD indicated, Discharge Effective Date: 7/28/23.Reason for discharge: The discharge is appropriate because your health has improved sufficiently so that you no longer require services provided by this facility. During a review of Resident 1's Send Result Report (SRR-confirmation of fax being sent to Ombudsman), dated 7/31/23 at 12:08 p.m., the SRR indicated, Resident 1's NPTD was sent to the Ombudsman on 7/31/23 (3 days after discharge from facility) at 12:07 p.m. b. During a review of…

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

Based on interview and record review, the facility failed to: 1. Ensure sufficient nursing staff to meet the needs of four of four sampled residents (Resident 1, Resident 2, Resident 3 and Resident 4). 2. Ensure sufficient nursing staff to meet the needs of 92 out of 92 residents, when the facility did not meet the required Direct Care Service Hours Per Patient Day (DHPPD – actual hour of work performed per patient day by direct caregiver. The total number of hours worked performed per patient day divided by the average daily census). This failure had the potential for all residents in the facility to not receive timely and necessary nursing care, assure the resident's safety and maintain the highest practicable physical, mental and psychosocial well-being. Findings: 1. During an interview on 7/6/23, at 11:31 a.m., with Resident 1, Resident 1 stated, There never seems to be enough staff, seems like no one wants to work weekends. Resident 1 stated, it takes a long time for staff to answer call lights, sometimes the wait is an hour or more, especially at night and on weekends.…

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

Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1), was free from a significant medication error, when Resident 1 did not receive a physician ordered anticoagulant (a blood thinner medication for treatment of blood clots) for five days. This had the potential for Resident 1 to develop additional blood clots, have a stroke (blockage of blood supply in the brain) and/or pulmonary embolism [blood clot in lungs] and the potential to result in death. Findings: During an interview on 7/6/23, at 11:31 a.m., with Resident 1, Resident 1 stated, she has concerns about the facility running out of her medications. Resident 1 stated, It seems like they are running out of one of them [Resident 1's medications] at least once a week. Resident 1 stated, The blood thinner seems to be out the most. I worry about not taking the blood thinner and having a stroke. During a review of Resident 1's Transfer/Discharge Report (TDR), dated July 6, 2023, the TDR indicated, Resident 1's admission to the facility occurred on 3/31/23. The TDR indicated,…

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