Simi Healthcare Center

Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 2) documentation in their medical record was accurate when wrongfully documenting that the resident is not currently on an antibiotic medication. This failure has the potential to create confusion upon health care team reviewing documentation and deciding the next best course of treatment. Findings: During a review of Resident 2's Physician's Orders, dated 6/16/25, the Physician's Orders indicated, Cephalexin Oral Capsule 500 MG (oral antibiotic medication) to be given 1 capsule by mouth two times a day for Pneumonia community acquired. During a review of Resident 2's Progress Notes, from 6/16/25 thru 8/5/25, the Progress Notes indicated, ten entries dated, 6/24, 6/28, 6/30, 7/7, 7/12, 7/29, 7/30, 7/31, 8/2, and 8/4/25 where nursing staff marked under special care that Resident 2 was not currently on antibiotics. During an interview on 8/6/25 at 11:46 a.m. with Assistant Director of Nursing (ADON), ADON confirmed Resident 2 is currently on antibiotics and the charting was 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.

Based on record review and interview, the facility failed to ensure one of six sampled residents (Resident 18) was assessed for a PASARR (Pre-admission Screening and Resident Review - a Federal Program that ensures individuals with serious mental illness, intellectual disabilities, or related conditions are placed in nursing facilities and receive necessary services) after a COC (change of condition) for mental illness.This failure resulted in Resident 18 not being properly evaluated and possibly referred to receiving care and services in the most integrated setting appropriate to their needs.Findings:During a review of Resident 18's Electronic Medical Administration Record (eMAR) [a digital record of all medications to be administered or has been administered to a resident] dated August 2025, the eMAR indicated, an order for Seroquel (a medication to treat mental health conditions) Oral tablet 125 mg. (milligrams) via G-tube (GT - a feeding tube inserted through the abdominal wall directly into the stomach) every 8 hours for Psychosis (a mental disorder characterized by 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 interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) care plan was implemented when Resident 1 had a change in condition and the monitoring was not documented in the residents medical record.This failure has the potential for changes in residents status to be missed and delay in proper medical intervention.During a review of Resident 1's Progress Notes dated 7/15/25, the Progress Notes indicated, Resident 1 had a change in condition (CIC) by pulling out his Gastrostomy Tube (G-tube, a feeding tube inserted through the abdominal wall directly into the stomach) during the day shift. The G-tube was reinserted at bedside on 7/15/25 during the p.m. shift. Resident 1 was placed on 72 hour CIC monitoring. Review of Resident 1's Progress Notes dated 7/15 to 7/17/25 indicated, one missing monitoring entry on 7/16/25 and three missing monitoring entries on 7/17/25. During an interview on 8/7/25 at 11:20 a.m. with Assistant Director of Nursing (ADON), ADON confirmed resident monitoring on a change of condition is for 72 hours and should…

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 six sampled residents (Resident 28), received proper treatment to maintain their vision.This failure resulted in a decline in Resident 28's vision and had the potential to result in adverse consequences.Findings:During a concurrent observation and interview on 8/4/25 at 9:16 a.m. with Resident 28, Resident 28 was observed squinting, having a difficult time watching TV. Resident 28 stated, I have requested for an eye appointment, but the facility won't get me one.During a review of Resident 28's Minimum Data Set (MDS), a standardized, comprehensive assessments used in nursing homes to evaluate the health, functional, and psychosocial status of residents, dated 11/9/24, the MDS indicated, Section B, vision was adequate.During a review of Resident 28's MDS Quarterly Assessment, dated 7/22/25, the MDS indicated, Section B, vision was moderately impaired.During a review of Resident 28's Order Summary Report, dated 8/7/2025, the Order Summary Report indicated, an Ophthalmologist Consult was ordered 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.

Based on observation, interview, and record review, the facility failed to ensure the availability of a reserve emergency tracheostomy tube (a curved, hollow tube inserted into the trachea [windpipe] to maintain an open airway) at bedside for one of six sampled residents (Resident 18).This failure had the potential to result in life threatening complications.Findings:During an observation on 8/4/25 at 10:19 a.m. in Resident 18's room, Resident 18 had a tracheostomy tube connected to a ventilator (a device that helps resident(s) breath by forcing air into their lungs when they are unable to do so on their own). On the left side of Resident 18's bed was a cupboard containing the ventilator, suction machine, nebulizer, suction supplies, and spare tracheostomy. However, there was only one spare tracheostomy instead of two.During a concurrent observation and interview on 8/4/25 at 10:40 a.m. with the respiratory therapist (RT 1), at the bedside of Resident 18, RT 1 stated they keep two emergency tracheostomy tubes at bedside (1 smaller size and 1 same size). RT 1 explained in case 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, and manufacturer's instructions, the facility failed to have sufficient, competent dietary support staff to ensure sanitation and food safety in the kitchen when: sanitizing solution was not used consistently with the Environmental Protection Agency guidelines.This failure had the potential for the chemical sanitizers to be harmful and toxic to the residents. During a concurrent observation and interview on 8/4/25 at 2:55 p.m. with the Dietary Worker (DW) in the kitchen, DW demonstrated how to test the sanitizing solution located in a red bucket. DW placed a Hydrion QT [quaternary ammonium compound]-10 quaternary test strip into the prepared sanitizing solution located in the red bucket and immediately removed it. When asked about the manufacturer's required immersion time for the strip into the sanitizer solution, DW was unable to state the correct timeframe and stated, Probably right away or 3-4 seconds, or maybe its 5-10 seconds. During a concurrent observation and interview…

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

Based on observation, interview, and record review, the facility failed to implement a vegetarian menu planned in advance with evaluation of nutritional adequacy for kitchen staff to follow for two of two sampled residents (Residents 23 and 38) to meet the resident's choices and special dietary needs in accordance with established national guidelines.This failure resulted in a lack of implementation of vegetarian menus with variety, standardized vegetarian recipes and evaluation for nutritional adequacy which had the potential to lead to deficits in some nutrients, vitamins and minerals adversely affecting residents' nutritional and/or medical status. During a concurrent observation and interview on 8/5/25 at 10:25 a.m. with Dietary Aide (DA) in the kitchen, DA was preparing cheese sandwiches with two yellow colored cheese slices. DA stated there was no recipe to follow on how to prepare a cheese sandwich. During an observation on 8/5/25 at 12:16 p.m. in the kitchen during lunch tray, Resident 23’s lunch meal tray was observed to have a cheese sandwich with two slices of yellow…

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

Based on observation, interview, and record review, the facility failed to provide a vegetarian alternate meal of similar nutritive value for one of one sampled resident (Resident 23) who received a cheese sandwich that provided 5 grams of protein versus the planned main entree of Hawaiian chicken provided approximately 21 grams of protein.Facility failure to have standardized vegetarian recipes and planned vegetarian alternatives to ensure nutritional adequacy placed residents who chose vegetarian diets at risk of decreased nutrient intake, decreased variety of choices and diminished quality of life. During a concurrent observation and interview on 8/5/25 at 10:25 a.m. with Dietary Aide (DA) in the kitchen, DA was preparing cheese sandwiches with two yellow colored cheese slices per sandwich. DA stated there was no recipe to follow to instruct on how to prepare the cheese sandwich. During an observation on 8/5/25 at 12:16 p.m. in the kitchen during lunch tray, Resident 23’s lunch meal tray was observed to have a cheese sandwich with two slices of yellow colored cheese, and sides…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide physical and occupational therapy for one of one sampled resident (Resident 101).This failure resulted in Resident 101 not receiving therapy and had the potential for the resident to not achieve their highest practicable level of function. Findings:During an interview on 8/5/2025 at 12:32 p.m. with Resident 101's family member (FM), the FM stated a Physical Therapy (PT) referral was done months ago but the insurance company stated they do not have any request. Resident 101's FM stated Resident 101 is not currently receiving PT or Occupational Therapy (OT). FM stated this issue has been brought it up numerous times and she was told it was an insurance issue. FM states PT/OT will not work with Resident 101 because of the insurance issue. FM stated that the goal is to get Resident 101 strong enough to use a commode so the FM can take her home.During a record review of Resident 101's Progress Notes, dated [DATE], the Progress Notes…

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 resident medical records were accurate and complete by not having a physician order for code status in place for 2 of 19 sampled residents, (Residents 7 and 2). This facility failure had the potential to result in residents receiving treatment inconsistent with their expressed wishes, including unwanted resuscitation in the event of cardiopulmonary arrest (heart suddenly stops pumping blood effectively, leading to a loss of consciousness and breathing). During a review of the facility’s policy and procedure (P&P) titled, “Physician Orders for Life Sustaining Treatment (POLST), dated 9/2018, the P&P indicated, “If ‘Do Not Attempt Resuscitation’ is indicated on the POLST form, the licensed Nurse will write the order to support the Resident’s wishes.” During a review of Resident 7’s “admission Record (AR),” dated 8/5/25, the “AR” indicated, Resident 7 was admitted to the facility on [DATE] with diagnoses including, but not limited to, vascular…

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 call lights were within reach for 2 of 19 sampled residents (Residents 7 and Resident 2).This failure prevented residents from calling for assistance and had the potential for delays in receiving needed care.During a review of the facility's policy and procedure (P&P) titled, Answering the Call Light, dated 10/20, the P&P indicated, The purpose of this policy is to respond to the resident's requests and needs .When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. During an observation on 8/4/25 at 10:10 a.m. Resident 7 was observed lying in bed with the call light clipped and secured near the electrical outlet, out of reach of Resident 7. During a concurrent observation and interview on 8/4/25 at 10:18 a.m. with Director of Nursing (DON), Resident 7’s call light remained clipped and secured near the electrical outlet and out of reach of Resident 7. DON confirmed the call light was out of reach, then unclipped it and placed it on Resident 7’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.

Based on interview and record review, the facility failed to ensure 24-hour licensed nursing staff coverage in the skilled nursing unit as required to meet the nursing related care needs for a total census of 73 Residents. This failure resulted in a five-hour period without licensed nurse coverage in the skilled nursing unit, placing residents at risk for delayed assessments, interventions, and unmet care needs. Findings: During a review of the facility's policy and procedure (P&P) titled, Staffing, Sufficient and Competent Nursing dated 8/2022, the P&P indicated, Licensed nurses and certified nursing assistants are available 24 hours a day, seven (7) days a week to provide competent resident care services including: a. assuring resident safety; b. attaining or maintaining the highest practicable physical, mental and psychosocial well-being of each resident; assessing, evaluating, planning and implementing resident care plans; d. responding to resident needs. During a review of the facility's Nursing Staffing Assignment and Sign-In Sheet, for the skilled nursing unit, dated 5/4/25,…

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 prescribe insulin doses and monitor blood glucose levels as ordered for five of seven sampled residents (Residents 2, 3, 4, 5, and 6). These failures resulted in missed critical diabetic treatment and placed all five residents at risk for serious complications, including hyperglycemic, hyperglycemia, and acute changes in condition. Findings: 1. During a review of Resident 2's admission Record (AR), dated 6/18/25, the AR indicated, Resident 2 was admitted in the facility on 5/14/24 with diagnoses including, but not limited to, diabetes mellitus type 2 (DM 2, a condition where your body either doesn't produce enough insulin, or your cells don't respond properly to insulin), hemiplegia and hemiparesis following cerebral infarction (a conditions that can occur after a stroke, leading to weakness or paralysis on one side of the body). During a review of Resident 2's Physician Orders (PO), dated 6/16/24, the PO indicated, to administer Novolin (Insulin) R (regular) injection solution 100 units/ml…

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

Based on interview and record review, the facility failed to ensure a licensed nurse (LN ) was trained and competent in using the electronic Point Click Care (PCC, electronic health record system) for documentation and care coordination. This failure has the potential to result in incomplete, delayed, or missing documentation of resident care, placing the resident at risk for unmet care needs. Findings: During a review of the facility's policy and procedure (P&P) titled, Competency of Nursing Staff, dated 5/2019, the P&P indicated, Facility and resident-specific competency evaluations will be conducted upon hire, annually and as deemed necessary based on the facility assessment. Facility and resident-specific competency evaluations will include: a pre-post test for documentation issues; demonstrated ability to use tools, devices, or equipment used to care for residents. During an interview on 6/25/25 at 5:18 p.m. with Licensed Nurse Supervisor (LNS) 3. LNS stated they had not received any formal training on how to use the PCC, not even one hour of instruction. During an interview 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 interviews and record reviews, the facility failed to develop and implement a person-centered care plan for one of two sampled residents (Resident 1) who was admitted with skin discoloration. This failure had the potential for Resident 1 to have further skin issues not assessed and treated. Findings: During a review of the facility's policy and procedure (P&P) titled, Care Plans - Comprehensive, dated 9/2010, the P&P indicated, An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, and psychological needs is develop for each resident .Each resident's comprehensive care plan is designed to: incorporate identified problem areas. During a review of Resident 1's admission Record (AR), dated 4/15/25, the AR indicated, Resident 1 was admitted on [DATE] with diagnoses including but not limited to, anemia (not having enough healthy red blood cells) and unspecified dementia (a general term for a group of brain disorders that cause 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 record review and interview, the facility failed to ensure a fall risk re-evaluation was done on readmission to the facility for one of one sampled resident (Resident 1) with prior history of falls. This failure had the potential to result in further fall incidents. Findings: During a review of Resident 1's, admission Record (AR), dated 3/17/25, the AR indicated, Resident 1 was an [AGE] year-old male who was initially admitted to the facility on [DATE], with admitting diagnoses including, acute toxic encephalopathy (a condition characterized by a rapid decline in brain function caused by exposure to toxic substances), lack of coordination, and cervical disc degeneration (a condition that affects the discs in the neck losing their elasticity and cushioning properties over time). During a review of Resident 1's, Health Status Notes (daily nursing notes), dated 12/18-12/22/24, the Notes indicated in part, Resident 1 had a fall incident on 12/18/24. On 12/21/24, the resident complained of right hip pain,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to revise a care plan for one of three sampled residents (Resident 1) after Resident 1 fell while at the facility and sustained injuries. This facility failure placed Resident 1 at a higher risk for fall and injury. Findings: During a review of Resident 1's Face Sheet, the Face Sheet indicated, Resident 1 was initially admitted to the facility on [DATE] and last readmitted on [DATE] with diagnoses that included, cerebral palsy (a group of disorders that affect a person's ability to move and maintain balance and posture), epilepsy (seizure - uncontrolled body movements), encounter for attention to gastrostomy ([g-tube] a tube used to provide an alternative route for delivering nutrition, fluids, and medications directly to the stomach), dysphagia (difficulty swallowing), Chronic Obstructive Pulmonary Disease (lung disease causing restricted airflow and breathing problems), chronic respiratory failure with hypoxia (the lungs are unable to adequately…

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 follow their policies and procedures to one of three residents (Resident 1) when: 1. Medications were left unsecured and unsupervised. 2. Medications were administered by a Licensed Nurse (LN 3) that LN 2 had prepared without verifying doctor's orders. LN 2 signed the Medication Administration Record (MAR). 3. Doctor's order was not followed during administration of a medication. 4. Medication was administered through a gastrostomy tube without verification of placement. 5. Oxygen tubing was not labelled. These facility failures had the potential for Resident 1 to experience negative outcomes. Findings: During a review of Resident 1's Face Sheet, the Face Sheet indicated, Resident 1 was initially admitted to the facility on [DATE] and last readmitted on [DATE] with diagnoses that included, cerebral palsy (a group of disorders that affect a person's ability to move and maintain balance and posture), epilepsy (seizure - uncontrolled body…

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 for two of two sampled residents (Residents 1 and 2) to the local law enforcement per federal regulation. This failure resulted in suspected abuse to go unreported and the local police department unable to perform an investigation. During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated 4/2021, the P&P indicated, Investigate and report any allegations within timeframes required by federal requirements. During a review of the facility's investigation report titled, Resident Abuse Investigation Report Form (IR), dated 12/23/2024, the IR indicated, the incident was not reported to the local police department. During a review of the the Report of Suspected Dependent Adult/Elder Abuse (SOC 341), dated 12/23/24, the SOC section I. indicated, a telephone report was not made to law enforcement. During an interview on 1/23/25 at 3:35 p.m. with Administrator (ADN), ADN stated it was not reported to law enforcement…

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

Based on observation, interview, and record review, the facility failed to ensure the call light (a device used to let staff know assistance is needed) was in reach for one of two sampled residents (Resident 1). This failure had the potential for Resident 1 to not receive needed care. Findings: During a concurrent observation and interview on 9/3/24 at 10:45 a.m. with Resident 1, in the residences room, Resident 1 was observed sitting in wheelchair next to the bed, the call light was located on the far side of the bed next to the wall, where Resident 1 could not reach it. Resident 1 shook head no in response to if the call light could be reached. During an interview on 9/3/24 at 10:45 a.m. with the certified nursing assistant (CNA 1), CNA 1 verbalized, was in a hurry and forgot to move the call light. During an interview on 9/3/24 at 11:05 a.m. with the Director of Nursing (DON), DON verbalized, the call light should have been placed by the resident. During a review of the facility ' s policy and procedure (P&P) titled, Call Light Policy and Procedures, dated 5/6/24, the 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 observation, interview, and record review, the facility failed to ensure kitchen and food storage sanitation was maintained when: 1. A pair of used gloves was observed on the food preparation counter. 2. One of two ice machines was not properly maintained according to manufacturer's guidelines. 3. A kitchen staff (KS 1) was observed transferring food trays, wiping down stove top and counters with ungloved hands and not performing hand hygiene in between these activities. These failures had the potential to result in an increased risk of food-borne illness (illness caused by food contaminated with bacteria, viruses, parasites or toxins) to residents. Findings: 1. During the initial tour of the kitchen on 7/23/24 at 10:10 a.m., a pair of used gloves was observed on the food preparation counter. 2. During a concurrent observation and interview on 7/24/24 at 10:40 a.m. with the facility's on-call dietary supervisor (DS 2), an ice machine was observed. The ice machine was located in a room just outside the…

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

Based on observation, interview and record review, the facility failed to ensure one of twenty sampled residents (Resident 443) was free from physical restraints. This facility failure had the potential to violate Resident 443's rights and lead to psychosocial and physical harm. Findings: During a concurrent observation and interview on 7/23/24 at 2:12 p.m. with Resident 443, Resident 443 was observed lying in bed. Resident 443's bed was observed pushed up against a wall on one side, while the other side of the bed was blocked with a locked transfer chair. Resident 443 verbalized, family wanted the chair positioned next to the bed for safety reasons, as Resident 443 had previously fallen while in the facility. During a concurrent observation and interview on 7/25/24 at 10:20 a.m. with Licensed Nurse (LN 4), the transfer chair had a sign placed on it, outside Resident 443's room which indicated, SAFETY NOTICE Please do not remove the Geri chair. The Geri chair has to be placed next to (Resident 443's bed) for patient's safety. DO NOT REMOVE. LN 4 verbalized Resident 443's spouse had…

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, the facility failed to ensure the Minimum Data Set (MDS - a comprehensive assessment of each resident's functional capabilities) information was accurate for two of two sampled residents (Residents 8 and 13) when: 1. Resident 8's MDS indicated, the resident was not taking anticoagulant medication (medications that reduce the blood's ability to clot). 2. Resident 13's MDS indicated, the resident was comatose (a state of unconsciousness). These failures resulted in inaccurate MDS assessments for Residents 8 and 13, and for the residents to potentially receive inadequate care. Findings: 1. During a record review of Resident 8's MDS Assessments, dated 6/25/24 and 7/7/24, the MDS Assessment indicated under the section for medications, the resident was on anticoagulant medication. Review of the resident's MDS assessments dated 7/14/24 and 7/17/24, under the section for medications, the MDS did not indicate resident was taking anticoagulants. Review of Resident 8's Order…

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 comprehensive person-centered care plans were developed and implemented for two of eight sampled residents (Residents 79 and 13) when: 1. Resident 79's care plan intervention for risk for shortness of breath was not followed. 2. Resident 13 did not have a care plan to address their hearing needs. These failures had the potential for Residents 79 and 13 to not receive the appropriate care and services, based on problem areas identified during admission and current health issues. Findings: 1. During a review of Resident 79's Clinical Record, the Clinical Record indicated Resident 79 was admitted with diagnoses including, heart failure, and sleep apnea (a sleeping disorder where breathing is interrupted repeatedly during sleep). Review of Resident 79's physician orders dated 7/12/24, indicated, Oxygen inhalation at 2 liters per minute (lpm) via nasal cannula (a device that delivers extra oxygen through a tube and into your nose) to keep oxygen saturation (a measure of the oxygenation of the blood) above…

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 one resident (Resident 43) received adequate nutrition when a recommendation by the Registered Dietitian to increase gastrostomy tube feedings was not ordered and implemented. This failure resulted in the resident having significant weight loss and the potential for delayed healing of pressure ulcers. Findings: During a review of Resident 43's admission Record, the admission Record indicated, Resdient 43 was originally admitted on [DATE] with most recent re-admission date of 4/30/24 with diagnoses including, cerebral infarction (stroke - disrupted blood flow to the brain due to problems with the blood vessels that supply it), encephalopathy (brain disease that alters brain function or structure), chronic respiratory failure with hypoxia (low levels of oxygen in your body tissues), tracheostomy (an incision in the windpipe made to relieve an obstruction to breathing), gastrostomy tube (GT - a tube inserted through the belly that brings nutrition…

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 Physician Orders for Life- Sustaining Treatment (POLST - a form that communicates a person's wishes for healthcare treatment during a medical emergency) was signed by the physician for one of six sampled residents (Resident 68). This failure had the potential for Resident 68 to not receive his wishes during a medical emergency. Findings: During a concurrent interview and record review on 07/24/24 at 11:18 a.m.,with licensed nurse (LN 2), the POLST for Resident 68, dated 5/9/2024 was reviewed. The POLST indicated, no physician's signature was on the order. LN 2 stated, I can't speak to why it isn't signed. It is flagged with a sticker to sign. Review of [NAME] and [NAME], Tenth Edition, Fundamentals of Nursing, page 613, in the section titled, Medication Administration, indicated in part . Order needs to have all the following parts: . Signature of health care provider . If a . order is incomplete inform the health care provider…

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 an optimal temperature was maintained in the medication storage refrigerator in Nurse Station One. This failure had the potential to result in refrigerated medications being less effective. Findings: During a concurrent observation and interview on 7/25/24 at 10:11 a.m. with licensed nurse (LN 6), inside Nurse Station One's Medication Storage Room, the refrigerator thermostat read 50 degrees Fahrenheit (F). LN 6 confirmed the thermostat read 50 F and stated, Yes it is 50 F, that's too warm. During a review of the facility's policy and procedure (P&P) titled, Medication Storage and Labeling, (undated), the P&P indicated, Temprature Control 2. Drugs requiring refrigeration shall be stored in a refrigerator between . (36 F and .46 F ). A daily Medication Refrigerator Temperature Log will be kept to assure that the temperature is maintained.

Based on interview and record review, the facility failed to employ a qualified dietary supervisor, in the absence of a full-time registered dietitian, to oversee its kitchen and food service operations. This failure had the potential to result in residents not receiving correct diets and increased risk of food-borne illness (illness caused by food contaminated with bacteria, viruses, parasites or toxins) to the residents due to lack of proper staff education and training. Findings: During an interview on 7/23/24 at 10:10 a.m. with the facility's dietary supervisor (DS 1), DS 1 verbalized that he's been an employee of the facility for the past 11 years and had assumed the position as DS a month and a half ago. DS 1 verbalized he was not certified as a dietary supervisor. During a review of kitchen staff credentials posted on the kitchen's consumer board, DS 1 had been certified as a Food Handler (a permit that shows a person completed a food safety course approved by the State). During an interview on 7/24/24 at 9:36 a.m. with the Administrator (ADM), ADM verbalized the facility'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.

Based on observation, interview, and record review, the facility failed to ensure infection control measures on storing oxygen therapy equipment were maintained for two of five sampled residents (Residents 83 and 57). These failures had the potential to result in the transmission of infectious microorganisms and increase the risk of respiratory infection of residents, visitors, and staff. Findings: During a concurrent observation and interview on 7/23/24 at 10:32 a.m. with Infection Preventionist Nurse (IP), Resident 83's nasal cannula was observed on the floor while still connected to the oxygen concentrator. Resident 57's (roommate) nasal cannula was observed on the bedside table at the left side of the bed while the nebulizer mask was observed on top of the side of table (right side of bed). Both the oxygen nasal cannula and the nebulizer mask had plastic bags provided as storage when not in use. The IP Nurse concurred with the finding and stated, They (nasal cannula and nebulizer mask) should have been stored in the provided plastic bags. During a review of the facility's policy…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide documentation indicating it had offered or explained the risks and benefits of a Covid -19 vaccination, for one of five sampled residents (Resident 443). This facility failure had the potential to lead to negative outcomes for Resident 443. Findings: During a review of Resident 443's admission Record, (undated), the Assessment Record indicated in part, Resident 443 was admitted to the facility on [DATE]. Resident 443's admission Record further indicated, Resident 443 was later diagnosed with Covid-19, with an onset date of 6/7/24. During a concurrent record review and interview on 7/26/24 at 10:12 a.m. with the Infection Preventionist (IP), Resident 443's medical record was reviewed. The IP verbalized the facility offers immunizations and/or education regarding immunizations to residents shortly after admission. The IP verbalized there was no documentation indicating Resident 443 had been offered the Covid-19 vaccine, refused the Covid-19…

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 a call light was within reach for one unsampled resident (Resident 12). This facility failure had the potential for Resident 12's needs to go unmet and/or result in a delay in care. Findings: During an observation on 7/25/24 at 9:43 a.m. Resident 12's call light was observed on the floor and out of reach of Resident 12, who was lying in bed. During an observation and concurrent interview on 7/25/24 at 10:03 a.m. with Certified Nursing Assistant (CNA 1), Resident 12's call light was still on the floor and out of reach of Resident 12, who was lying in bed. CNA 1 confirmed the call light was on the floor and verbalized the call light should not be on the floor. CNA 1 acknowledged it was out of the reach of Resident 12. During a review of the facility's policy and procedure (P&P) titled, Answering the Call Light, dated 10/20, the P&P indicated in part, The purpose of this policy is to respond to the resident's requests and needs .When the resident is in bed or confined to a chair be sure the call light is…

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

Based on observation, interview and record review, the facility failed to maintain a homelike environment for three unsampled residents (Residents 9, 12, and 14). This failure had the potential to negatively impact residents psychosocial status. Findings: During a concurrent observation and interview on 7/25/24 at 9:20 a.m. with the maintenance supervisor (MS), a tour of resident rooms was conducted. The following was observed: -Resident 9's room, a portion of the wall had peeling paint and missing plaster. -Resident 12's room a portion of the wall had peeling paint and missing plaster. -Resident 14's room a portion of the ceiling had cracked and peeling paint. The MS confirmed Resident 9 and Resident 12's walls were in a state of disrepair, as well as a portion of Resident 14's ceiling. The MS verbalized these areas would need to be repaired. The MS verbalized none of these environmental issues had been brought to the attention of the MS by staff, nor had they been logged in the facility maintenance log, as items that needed to be addressed. During a review of the facility's policy…

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 a baseline care plan was developed for one of two sampled residents (Resident 33) who was assessed as high risk for falls. This failure had the potential to result in further fall incidents for this resident. Findings: During a review of the facility's policy and procedures (P&P) titled, Baseline Care Plan, revised 5/11/22, the P&P indicated in part, Will be developed for each resident within 48 hours of admission that includes the instructions needed to provide effective and person-centered care of the residents that meets professional standards of quality care. During a concurrent observation and interview on 7/23/24 at 3 p.m. with Resident 41, in Resident 33's room, the resident was observed in bed, alert and awake. Resident 33 verbalized sustaining a right femoral fracture (a break in the long, straight part of the thighbone) after a fall incident in the facility which required surgery. During a review of Resident 33's admission Record (AR), dated 6/11/24, the AR indicated, Resident 33 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.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 2) was treated with dignity when the facility: 1. Failed to allow Resident 2 to self-determine shower times. 2. Did not provide privacy to Resident 2 when getting undressed. These failures had the potential for psychosocial harm to Resident 2. Findings: 1. During a review of the facility's P&P titled, Resident Rights Guidelines for All Nursing Procedures, dated October 2010, the P&P indicated, For any procedure that involves direct resident care, follow these steps . Ask permission to implement the procedure. If the resident refuses, notify your supervisor. During an interview on 5/15/24 at 11:05 a.m. with Resident 1, Resident 1 was asked what he remembers regarding the evening that he and his roommate were watching the Dodger game on Saturday evening of 5/4/24. Resident 1 stated they were watching the game, it was getting good and then their Certified Nursing Assistant (CNA 2) came in to give Resident 2 a shower, but he didn't want a shower and then asked her to come back…

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 monitor any change in behavior for one of two residents (Resident 2) following an allegation of staff to resident mistreatment. This failure had the potential for Resident 2 to have a psychosocial change that would go untreated. Findings: During a review of Resident 2's Nursing Notes, dated 5/6/24 at 11:11 p.m., the Nurses Note indicated, The assigned certified nurses assistant (CNA) on 5/4/24 evening was rough with him on shower time and the resident was not happy with the behavior . family made aware, director of nursing (DON) made aware will continue with investigation. There were no further entries regarding montoring Resident 2 after this allegation. During an interview on 5/15/24 at 11:22 a.m. with Resident 2, Resident 2 stated, She (CNA) brought in this lifting machine and she was pushy, I protested but she insisted on getting me to the shower. During an interview on 5/15/24 at 2:05 p.m. with DON, DON confirmed facility did not, but should have placed Resident 2 on a Change of Condition (COC) monitoring for 72 hours…

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 maintain complete and accurate medical records for one of three sampled residents (Resident 2) when a Shower Day Skin Inspection (a dated and signed record of shower/bath given with details to grooming performed and skin inspection/changes) not accounted for on a shower provided on 5/4/24. This failure had the potential to result in resident not receiving proper treatment if there was a change in skin status. Findings: During a review of the facility's policy and procedure (P&P) titled, Shower/Tub Bath, dated October 2010, the P&P indicated, The following information should be recorded on the resident's ADL (Activities of Daily Living) record and/or in the resident's medical record: 1. The date and time the shower/tub was performed. 2. The name and title of the individual(s) who assisted the resident with the shower/tub bath. 3. All assessment data (e.g., any redenned areas, sores etc., on the resident's skin) obtained during the shower/tub bath. During an interview on 5/15/24 at 10 a.m. with Director of Nursing (DON), DON…

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 maintain accurate medical records for one resident (Resident 1) when it was documented a medication was administered twice when in fact it was not. This failure resulted with Resident 1's medication administration record (MAR) to reflect inaccurate documentation of a prescribed medication. Findings: During a review of the facility's policy and procedure (P&P) titled, General Procedures to Follow for All Medications, dated 4/21/21, the P&P indicated, After administration, return to cart and document administration in Medication Administration Record (MAR). Medications shall be charted immediately after each administration, not after the med pass is completed. During a review of Resident 1's MAR, dated February 2024, the MAR indicated, Resident 1 was to receive Clobazam 30 mg (a controlled medication prescribed for seizures) every 12 hours at 9 a.m. and 9 p.m. On 2/17/24 and 2/18/24 Licensed Nurse (LN 2) did not administer Resident 1's scheduled 9 a.m. dose of Clobazam 30 mg (A controlled medication prescribed for seizures)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan that included the Resident Representative's (RP) preferences for one of two sampled residents (Resident 1). This failure had the potential to result in negatively impacting the resident's quality of life, as well as the quality of care and services received. Findings: During a review of Resident 1's Face Sheet (FS), the FS indicated, Resident 1 was a [AGE] year-old male with diagnoses including, Quadriplegia (paralysis of all four limbs), Persistent vegetative state due to a traumatic brain injury (a chronic state of brain dysfunction in which a person shows no signs of awareness), Gastrostomy tube (G-tube - a tube inserted through the belly that brings nutrition and medications directly to the stomach), Epilepsy (seizure disorder), urine retention, suprapubic catheter (hollow flexible tube that is used to drain urine from the bladder through a cut in the abdomen),…

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 twenty sampled residents (Resident 64) call light was within resident reach. This failure had the potential for resident needs not being met. Findings: During an observation and concurrent interview, on 12/6/21, at 11:12 a.m., with Resident 62's call light was observed hanging off the bed, top right corner. Resident 64 stated, is unable to reach the call light because of being paralyzed on the right side (partly incapable of movement). Resident 64 was observed only being able to move left arm and unable to reach the call light. During an interview on 12/6/21 at 11:23 a.m. with a certified nurse assistant (CNA 1), CNA 1 stated, The call light should not be on the floor. During a review of facility's policy and procedure (P&P) titled, Answering the Call Light [undated], the P&P indicated, When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to maintain an overbed light fixture for one of twenty sampled residents (Resident 88). This failure had a potential to affect the safety of Resident 88. Findings: During the initial tour observation and concurrent interview on 12/6/21 at 10:55 a.m., with Licensed Nurse 1 (LN 1), Resident 88 was observed sleeping in room [ROOM NUMBER]B. LN 1 pulled the string to switch the over bed lights on and it did not work. LN 1 stated, was unsure how long it was not working and if it was reported out of order. LN 1 tried again to switch the light on and off and confirmed it is out of order and stated, it is not safe for the resident, I will call for a work order.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of twenty sampled residents (Resident 60) was free from any form of restraint. This failure had the potential to result in decline in range of motion and injury to the area being restrained. Findings: During a review of facility's policy and procedure (P&P) titled, Use of Restraints, dated 04/2017, the policy and procedure indicated, Restraints shall only be used upon the written order of a physician. During an observation and concurrent interview on 12/06/21 at 11 a.m., with a Licensed Nurse (LN 1) in room [ROOM NUMBER]A, Resident 60 was sleeping in bed with his left hand wrapped with a sock or mitten. LN 1 stated, when the facility received Resident 60, the resident was already wearing the sock on their left hand. LN 1 did not know why the sock was applied to Resident 60's left hand. During a review of Resident 60's records and concurrent interview on 12/08/21 at 3:06 p.m. with the assistant director of nursing (ADON), the…

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

Based on observation, interview, and record review, the facility failed to ensure a care plan for oxygent treatment was followed for one of twenty residents (Resident 62). This failure had a potential for Resident 62 to not recieve appropriate amounts of oxgen. Findings: During a review of the facility's policy and procedure (P&P) titled, Oxygen Administration, dated 10/2010, the P&P indicated, Verify .a physician's order for this procedure. Review the resident's care plan . During an initial tour on 12/6/21 at 10:50 a.m., Resident 62 was observed in bed with oxygen via nasal cannula (tubing that goes into the nostrils to administer oxygen) set at 3 liters per minute. During a review of Resident 62's Physician Orders, dated 12/5/21, an order indicated, oxygen at 2 liters per minute via nasal cannula PRN (as needed) for shortness of breath or oxygen saturation (amount of oxygen in the blood) less than 90%. During a concurrent record review and interview on 12/8/21 at 2:54 p.m., with the assistant director of nursing (ADON), Resident 62's oxygen saturation dated 12/6/21 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.

Based on interview and record review, the facility failed to ensure the respiratory care plans of two of twenty sampled residents (Resident 33 and Resident 53), were reviewed and updated, to reflect the residents' current health status and respiratory needs. This failure had the potential to place the residents at risk for unrecognized changes of condition, which may delay the implementation of care interventions and cause harm. Findings: During a review of the facility's policy and procedure (P&P), titled, Care Plans - Comprehensive, dated 9/2010, the P&P indicated in part, Policy Interpretation and Implementation .3) Each resident's comprehensive care plan is designed to: .f) Identify the professional services that are responsible for each element of care .9) The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans: a) where there has been a significant change in the resident's condition; b) when the desired outcome is not met; c) when the resident has been readmitted to the facility from a hospital stay; and d) at least quarterly. 1a.…

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 quality control tests (tests performed to ensure accuracy of the blood glucose [sugar in the blood] monitor machine) were performed on two of two sampled glucometer (measures blood glucose level) machines. This failure had the potential to not accurately measure residents' blood glucose levels, that can lead to illness, and complications with diabetes (a group of diseases that result in too much sugar in the blood). Findings: During a review of facility's policy & procedure (P&P), titled, Quality Control Glucometer, dated 3/20, the P&P indicated, .The Facility will conduct quality control glucometer functionality in accordance with manufacturer's recommendation. During a review of the manufacturer's recommendations (MR) titled, Assure Platinum Blood Glucose Monitoring System, (glucose monitor used by the facility), dated 12/14, the MR indicated, .perform a control solution test every 24 hours. During a record review of Medication Cart 1's, Assure Platinum Blood Glucose Monitoring System: Quality Control Record,…

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

Based on observation, interview and record review, the facility failed to provide nail care for one sampled resident (Resident 15). This failure had the potential to harbor microorganisms (bacteria, virus, or fungus) and for infection to occur. Findings: During a review of the facility's policy and procedure (P&P) titled, Care of Fingernails/Toenails, dated 10/10, the P&P indicated, Nail care includes daily cleaning and regular trimming. During an initial tour and concurrent interview on 12/6/21, at 10 a.m., with certified nursing assistant (CNA 2), Resident 15 was observed sitting in a wheelchair watching television in the resident's room. Resident 15's fingernails were long and with black substance underneath the nail beds. Resident 15 was unable to engage in conversation. CNA 2 confirmed Resident 15's fingernails were not clean. CNA 2 stated, Fingernails should have been cleaned and trimmed by the licensed nurses because Resident 15 is a diabetic (a group of diseases that result in too much sugar in the blood (high blood glucose). CNA 2 further stated, the CNA assigned 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.

Based on observation, interview, and record review, the facility failed to ensure oxygen tubing for two of twenty sampled residents (Resident 62 and Resident 88) were dated. These failures had the potential for cross-contamination to occur. Findings: During a review of the facility's policy and procedure (P&P) titled, Oxygen Administration, revised 10/2010, the P&P indicated, .After completing the oxygen setup or adjustment, the .information should be recorded .the date and time that the procedure was performed. The name and title of the individual who performed the procedure. During an observation and concurrent interview, on 12/6/21, at 10:50 a.m., with a licensed nurse (LN 1) in Resident 62's room, the resident was observed lying in bed, asleep, connected to an oxygen concentrator at three liters per minute via nasal cannula. LN 1 was unable to find a date on the oxygen tubing to indicate when it was attached. LN 1 confirmed the oxygen tubing was without a date and stated, It should be dated. During an observation and concurrent interview, on 12/6/21, at 10:55 a.m., with a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the proper labeling and storage of drugs on three of three sampled medication carts. This failure had the potential to not ensure accurate dose and safe medication administration to residents. Findings: During a review of the facility's policy & procedure (P&P) titled, Administering Medications, dated 4/19, the P&P indicated .When opening a multi-dose container, the date opened is recorded on the container. During a review of the facility's P&P, titled Medication Storage and Labeling, not dated, the P&P indicated, .It will be the responsibility of the Nursing Staff to enter the opening date on all manufacturers' labels or blank pharmacy labels The P&P further indicated, .Drugs shall not be kept in stock after the expiration date on the label . During an observation on [DATE], at 10:39 a.m., the medication cart labeled #2 in front of sub-acute nurses' station was inspected. Two bottles of sterile saline (mixture of water and salt…

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.