Sherman Oaks Hospital SNF DP

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review. the facility failed to maintain accurate and complete medical record for two of five sampled residents (Residents 18 and 19) by: 1. Failing to ensure Resident 18's medical record was accurate when the written order for docusate sodium (medication used to soften stool) was in soft gel (capsule) form and the electronic order was in liquid form. 2. Failed to ensure Resident 19's medical record was accurate when Licensed Vocational Nurse 7 (LVN 7) documented presence of bleeding and administered Eliquis (medication used to prevent blood clot). These failures had the potential to cause confusion in care and the medical records containing inaccurate documentation. Findings: 1. During a review of Resident 18's Physician's Order, dated 7/25/2024, the Physician's Order indicated the facility admitted Resident 18 on 7/25/2024, with diagnoses that included chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to implement policy for antibiotic (medication used to treat infection) stewardship (efforts in doctors' offices, hospitals, long-term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate, means prescribing the right drug at the right dose at the right time for the right duration) for two of five sampled residents (Resident 16 and 19) by: 1. Failing to monitor Resident 16 for antibiotic use, side effects or adverse reaction (unintended pharmacologic effects that occur when a medication is administered correctly while a side effect is a secondary unwanted effect). 2. Failing to ensure Infection Control Surveillance Log (record that involves the systematic collection, analysis, and interpretation of data related to infections within a healthcare setting) for Resident 19's antibiotics was completely filled up in 3/2025. These failures had the potential to increase antibiotic resistance…

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 five sampled staff (Infection Preventionist [IP]) was qualified and competent in implementing the facilities infection control program by: 1. Failing to monitor Resident 16 for antibiotic (medication used to treat infection) use, side effects or adverse reaction (unintended pharmacologic effects that occur when a medication is administered correctly while a side effect is a secondary unwanted effect). 2. Failing to ensure Infection Control Surveillance Log (a documented record used to systematically track and analyze healthcare-associated infections and other infectious diseases within a healthcare facility) for Resident 19's antibiotics was completely filled in 3/2025. These failures had the potential to increase antibiotic resistance (don't respond to a drug) from unnecessary or inappropriate antibiotic use. Findings: a. During a review of Resident 16's Physician's Order dated 1/22/2024, the Physician's Order indicated the facility admitted Resident 16 on 1/22/2024, with diagnoses that included seizure…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure they have established and implemented policies in managing the facility by failing to develop and implement a policy and procedure on enhanced barrier precaution (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs, germ that is resistant to many antibiotics] in nursing homes. EBPs involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition) to four out of four sampled residents (Residents 10, 13, 12, and 14) during Medication Administration facility task. The deficient practice had a potential to spread infection among residents and staff. Cross reference to F656 and F880. Findings: 1. A review of Resident 10's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 1/23/2024, indicated the facility admitted the resident 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 interview and record review, the facility's failed to provide care in accordance with professional standards to three out of five sampled residents (Resident 7, 9, and 13) investigated during review of unnecessary medications by failing to: 1. Ensure licensed nurses rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) administration sites of heparin (a substance that slows the formation of blood clots) to Resident 7. 2. Ensure licensed nurses rotate subcutaneous administration sites of enoxaparin sodium (Lovenox, used to prevent blood clots) to Resident 9. 3. Ensure licensed nurses rotate subcutaneous administration sites of Lantus insulin (a drug used to control the amount of sugar in the blood) to Resident 13. The deficient practices had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin and anticoagulants (a substance that is used to prevent and treat blood clots in blood…

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 interview and record review, the facility failed to the facility failed to act upon the recommendations of the consultant pharmacist to two of five sampled residents investigated during review of unnecessary medications by: 1. Failing to taper (to gradually reduce dosage over time) down dosage of methadone (a powerful drug used for pain relief and treatment of drug addiction) for Resident 2. 2. Failing to indicate the behavior episodes of respiratory distress or heart rate (HR) more than (>) 120 per minute in the electronic medication administration record (eMAR) for 1 out of 5 sampled residents (Resident 17) investigated under unnecessary medications for the administration of lorazepam (a type of medication prescribed to treat conditions such as anxiety disorders [persistent and excessive worry that interferes with daily activities]. 3. Failing to act upon the recommendation of the pharmacist on 4/4/2024, to consider discontinuing Robitussin (a cough and cold medicine) if not being used for Resident 7. These deficient practices placed the residents at risk for receiving…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure residents were free of any significant medication errors to three out of five sampled residents (Resident 7, 9, and 13) investigated during review of unnecessary medications by failing to: 1. Ensure licensed nurses rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) administration sites of heparin (a substance that slows the formation of blood clots) to Resident 7. 2. Ensure licensed nurses rotate subcutaneous administration sites of enoxaparin sodium (Lovenox, used to prevent blood clots) to Resident 9. 3. Ensure licensed nurses rotate subcutaneous administration sites of Lantus insulin (a drug used to control the amount of sugar in the blood) to Resident 13. The deficient practices had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin and anticoagulants (a substance that is used to prevent and treat blood clots 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.

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety by failing to: 1. Store the ice scooper in a covered container when not being used. 2. Ensure Food Service Worker (FSW 1) was wearing a hairnet (a covering that will hold any dislodged hair in place, so it does not fall into the food or onto other equipment) while inside the kitchen. 3. Ensure an opened bottle of 90/10 blend canola/extra virgin olive oil was labeled with an open date and discard date. These deficient practices had the potential to place residents at increased risk of experiencing foodborne illness (an illness that comes from eating contaminated food or drinks). Findings: During an observation and interview on 4/16/2024, at 7:52 a.m., with the Director of Food and Nutrition (DFN), observed an ice scooper in an uncovered holder mounted of the side of the machine. The DFN stated they sanitize the ice scooper with a sanitizing solution after use and place them on the ice scooper holder. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable (capable of being passed by physical contact from one person to another) diseases and infections by failing to: 1. Ensure the barcode scanner (handheld device used to decode data contained on a barcode [a printed series of parallel bars or lines of varying width] that is then sent to a computer) was sanitized (disinfect [kill viruses and bacteria on surfaces using chemicals]) prior to use and after being placed on the resident's tablet (type of computer) for two of four sampled residents (Resident 12 and 14) observed during the Medication Administration task. 2. Ensure Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs, germ that is resistant to many antibiotics] in nursing homes. EBPs involve gown and glove use during high-contact…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan on enhanced barrier precaution isolation (an infection control intervention designed to reduce transmission of resistant organisms) to two out of four residents (Residents 10 and 13) investigated during review of medication administration facility task. The deficient practice had a potential to spread infection among residents and staff. Cross reference F837 and F880. Findings: 1. A review of Resident 10's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 1/23/2024, indicated the facility admitted the resident on 1/11/2024, with diagnoses including chronic respiratory failure (a serious condition that makes it difficult to breathe) with hypoxia (a low level of oxygen in the blood) or hypercapnia (a buildup of carbon dioxide in the blood), enterocolitis (an inflammation that occurs throughout the intestines) due to clostridium difficile (a germ…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents received adequate supervision to prevent accidents by failing to ensure a medication cup containing clear and white ointment was not left unattended and readily accessible in the residents' shared room for two of two sampled residents (Resident 18 and 5) observed during screening. This deficient practice had the potential to result in residents obtaining topical medication without staff knowledge resulting in accidental ingestion causing harm to residents. Findings: 1. A review of Resident 18's MDS, dated [DATE], indicated the facility admitted the resident on 6/1/2023 and readmitted the resident on 1/22/2024. The MDS indicated the resident was in a persistent vegetative state (a person is awake but shows no signs of awareness) with no discernible consciousness (awareness of internal and external existence). The MDS indicated the resident was totally dependent on staff for mobility, dressing, bathing, toilet hygiene, and…

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

Based on observation, interview and record review, the facility failed to administer parenteral fluids (the intravenous administration of medication) consistent with professional standards of practice for two (2) out of 2 sampled resident (Residents 1 and 2) investigated during random observations of residents with peripheral intravenous (IV) catheter (a thin, flexible tube that is inserted into a vein to draw blood and give treatments including IV fluids, drugs, or blood transfusions) by: 1. Failing to label Resident 1's midline catheter (a long, thin, flexible tube that is inserted into a large vein in the upper arm with the tip located just below the underarm) with the date of the last dressing change. 2. Failing to provide and document midline catheter care and dressing changes to Resident 2's midline catheter per facility policy. These deficient practices placed the residents at risk for developing complications such as inflammation of the vein and infection. Findings: a. A review of Resident 1's Admission/Registration Record indicated the facility admitted the resident 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, and record review, the facility failed to ensure safe provision of pharmaceutical services during inspection of one of two medication carts (Medication Cart 2) investigated during the Medication Storage and Labeling task by failing to ensure an opened and unlabeled single-use vitamin A&D ointment (a medication to treat or prevent dry, rough, itchy skin) packet was not stored and readily available for use in Medication Cart #2. This deficient practice had the potential to result in topical medication being used for multiple residents with the potential for cross contamination and decreased efficacy of topical medications. Findings: During a medication storage inspection of Medication Cart 2 on [DATE] at 7:35 a.m. with Licensed Vocational Nurse 3 (LVN 3), observed in the top drawer of Medication Cart 2 an unlabeled vitamin A&D, 5-gram (g, a unit of measurement) packet of ointment with the top portion cut off and the packet was open with clear medication inside. LVN 3 stated the…

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

Based on observation, interview, and record review, the facility failed to maintain a mechanical, electrical, and patient care equipment in safe operational condition by failing to the ensure handheld nebulizer compressor (an electrically powered device that turns liquid medication into a fine mist for inhalation [breathing in]) was inspected by the labeled next inspection due date of 7/2023 for one of two sampled residents (Resident 18) investigated under the Respiratory care area. This deficient practice had the potential to result in delay in care and services of essential respiratory treatments for residents and had the potential for device electrical malfunction resulting in fire. Findings: A review of Resident 18's Minimum Data Set (MDS- an assessment and care screening tool), dated 1/18/2024, indicated the facility admitted the resident on 6/1/2023 and readmitted the resident on 1/22/2024. The MDS indicated the resident was in a persistent vegetative state with no discernible consciousness. The MDS indicated the resident was totally dependent on staff for mobility, dressing,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure the resident has the right to be treated with respect and dignity including the right to be free from physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) when all side rails (SRs, also referred to as bed rails or bed side rails, are adjustable metal or rigid plastic bars that attach to the bed that may be positioned in various locations on the bed; upper or lower, either or both sides) were placed in raised (up) position on bilateral (two sides) upper (area including arms, shoulders and head) and bilateral lower (area including legs) for 18 of 19 sampled residents (Resident 17, 10, 8, 18, 6, 3, 1, 4, 14, 2, 11, 13, 12, 5, 7, 9, 15, and 16). This deficient practice had the potential to result in negative psychosocial outcome, decline 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, and record review the facility failed to ensure the safe and appropriate use of side rails (also referred to as bed rails and bed side rails, are adjustable metal or rigid plastic bars that attach to the bed that may be positioned in various locations on the bed; upper or lower, either or both sides) for 18 of 19 sampled residents (Resident 17, 10, 8, 18, 6, 3, 1, 4, 14, 2, 11, 13, 12, 5, 7, 9, 15, and 16). The facility failed to: 1. Attempt to use appropriate alternatives prior to using SRs 2. Conduct an assessment including the risk for entrapment from SRs. 3. Review the risk and benefits of side or bed rails with the resident or resident representative and obtain informed consent. This deficient practice had the potential to result in decline in residents' functions, negative psychosocial outcome, physical harm from entrapment (occurs when a resident is caught between the mattress and bed rail or within the bed rail itself) or falls and injuries from climbing over the SRs.…

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 17 Certified Nursing Assistants (CNAs) had the competencies and skill sets necessary to assist residents with meals for three out three residents (Resident 1, Resident 14, and Resident 17). This deficient practice had the potential for residents not receiving the care and services necessary to meet the residents' individual needs and preferences. Findings: a. A review of Resident 1's MDS, dated [DATE], indicated the facility admitted the resident on 2/24/2015 and readmitted the resident on 2/6/2023. The MDS indicated the resident usually was able to make himself understood and usually understood others. The MDS indicated the resident was totally dependent on staff for bed mobility, dressing, eating, toilet use, and personal hygiene. A review of Resident 1's History and Physical, dated 2/9/2023 indicated the resident had diagnoses including multiple sclerosis (MS, a disease that impacts the brain, spinal cord, and optic nerves) respiratory…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement its infection control policy and procedures by: 1. Failing to change disposable suction canisters (a temporary storage container connected to a suction machine and used to collect respiratory secretions or fluids removed through a long flexible tube) daily per policy for 16 of 16 sampled residents (Residents 10, 8, 18, 6, 3, 1, 4, 2, 11, 13, 12, 5, 7, 9, 15, and 16) with tracheostomy (opening surgically created through the front of the neck and into the trachea [windpipe]). These deficient practices had the potential to transmit infectious microorganisms and placed the residents at risk for respiratory infection. 2. Failing to adhere to infection control when personal items were found in one out of one medication room. This deficient practice had the potential for cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the resident's right to a dignified existence by failing to ensure an indwelling urinary catheter (a flexible tube inserted into the bladder and left in place to continuously drain urine) and nephrostomy (an opening between the kidney and skin in which a flexible tube is placed to drain urine) collection bags (attached to the catheter tube for the purpose of collecting urine) were covered with privacy bags (dignity bag, a bag that conceals urine in the collection bag) for one of one sampled residents (Resident 1) investigated under the Dignity care area. This deficient practice had the potential to result in psychosocial harm to the resident as a result of the visibility of the resident's urine to visitors and staff. Findings: A review of Resident 1's MDS, dated [DATE], indicated the facility admitted the resident on 2/24/2015 and readmitted the resident on 2/6/2023. The MDS indicated the resident usually was able to make himself…

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

Based on observation, interview and record review facility failed to maintain privacy of confidential information for one (Resident 10) of one sampled resident when Respiratory Therapist (RT 2) left the resident's electronic health record (EHR- a digital version of a patient's paper chart) open and unattended. This deficient practice violated Resident 10's right to privacy and confidentiality of their medical records. Findings: A review of Resident 10's admission record indicated the facility admitted the resident on 1/1/2023 with diagnoses including chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body) with tracheostomy (surgery to create an opening [stoma] into the windpipe), seizure disorder (sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain), and chronic encephalopathy (a progressive and fatal brain disease associated with repeated traumatic brain injuries [TBIs], including concussions and repeated blows…

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 post daily nurse staffing information in a prominent place readily accessible to residents and visitors. As a result, nurse staffing information was not readily accessible to residents and visitors. Findings: During a concurrent observation and interview on 5/20/2023 at 9:55 a.m., with Registered Nurse (RN 1), RN 1 stated nurse staffing information is usually posted on the board next to the nursing station. RN 1 stated the nurse staffing information was not posted today. RN 1 stated it is a regulation to post nursing staffing information daily so that it is available to resident and visitors. During an interview on 5/20/2023 at 7 p.m., the Nurse Manager (NM) stated posting of staffing information is done at the beginning of the shift by the charge nurse. The NM stated the staffing information is based on the facility census and should be posted daily so that everyone knows the staffing hours needed to care for the residents. The NM stated the charge nurse should have posted the nurse staffing information this…

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 licensed nurse staff completed documentation indicating reconciliation (a system of recordkeeping that ensures an accurate inventory of medications by accounting for controlled medications that have been received, dispensed, and administered) of controlled medications (substances that have an accepted medical use, have a potential for abuse, and may also lead to physical or psychological dependence) for the a.m. shift on 4/1/2023, investigated during the Medication Storage task. This deficient practice had the potential for inaccurate reconciliation of controlled medication and placed the facility at potential for inability to readily identify loss and drug diversion (illegal distribution of abuse of prescription drugs or their use for unintended purposes) of controlled medications. Findings: During an inspection of Medication Cart 1 on 4/1/2023 at 11 a.m. with Licensed Vocational Nurse 5 (LVN 5), the Narcotic Release Endorsement Sheet (form containing the reconciliation of controlled medications by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to dispose of expired medical supplies during medication storage room observation for one out of one medication room. (Med Storage 1). This deficient practice had the potential to result in the use of ineffective medical device for the residents. Findings: On [DATE] at 10:07 a.m., during a concurrent observation (inspection) of Med Storage 1 and an interview with Registered Nurse 1 (RN 1), observed the following: 1. Sterile foam tipped applicator (swabs) with expiration date of [DATE] (total 15). 2. BD vacutainer (used to transport and process blood for testing in the clinical laboratory) with expiration date of [DATE] (total of 13). 3. Tracheostomy (a hole that surgeons make through the front of the neck and into the windpipe [trachea]) tube with expiration date of 10/2017 (total 1). 4. Tracheostomy tube with disposable inner cannula (a tube within the outer tube with expiration date of [DATE] (total 1). 5. Hydrogen peroxide (cleaning…

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.