Sonoma Post Acute

Based on observation, interview, and record review, the facility failed to provide support personnel to safely and effectively carry out the functions of the food and nutrition services department for a census of 79 residents when the Director of Dietary Services (DDS) did not participate in the essential duties of day-to-day operations, staffing levels were insufficient, and dietary personnel did not demonstrate competency in specific procedures and protocols necessary to carry out the functions of food and nutrition services.This failure had the potential to affect the safety and quality of the food produced by the food and nutrition services department. During an interview with Resident #19, Resident #44 and Resident #74, on 4/13/26 at 1:02 p.m. they stated their lunches were always served last and the food was cold. Resident# 19 stated he always has to ask dietary staff to re-heat his food. He stated he hated the food because the vegetables were never fresh and always overcooked. He stated the residents that could not get out of bed were not assisted with meals. During an…

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

Based on interview and record review, the facility infection preventionist failed to review three of three residents sampled for antibiotic stewardship (Residents 8, 16, and 24). This failure had the potential to result in residents receiving unnecessary antibiotics and further contribute to antibiotic resistance.During an interview and concurrent record review on 4/16/26 at 9:06 a.m., Infection Preventionist (IP) pulled up on her laptop her line list of residents who were prescribed antibiotics for the month of April 2026. IP stated her antibiotic stewardship program included using an infection screening tool built into the electronic medical record that reviewed the symptoms of the resident's suspected infection and determined if the symptoms met criteria for treatment with antibiotics. IP stated that if an antibiotic was prescribed, she did an antibiotic timeout 48 to 72 hours after the antibiotic was started to monitor for any reaction to the antibiotic and notified the doctor to see if there should be any change based on lab work or cultures. IP stated the doctor would respond…

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 allow one resident (Resident 1) of two sampled residents to return to the facility after completing treatment for Carbapenem-Resistant Enterobacteralus (CRE- a group of bacteria that are difficult to treat because they are resistant to carbapenems, which are a class of powerful antibiotics typically used for severe infections) at the hospital.This failure caused Resident 1 to experience an unnecessary 42-day hospitalization and anxiety over the forced eviction from her home.Findings:A review of Resident 1's admission sheet indicated admission to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease (a progressive lung condition that obstructs airflow and makes breathing difficult), neutropenia (a condition with lower-than-normal neutrophils (a key white blood cell fighting infections which puts the person at risk for serious bacterial illnesses), difficulty in walking, depression (a serious mood disorder which causes persistent…

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 criminal background checks were completed prior to direct resident care employment for one of three direct care staff (Certified Nurse Assistant 1 [CNA 1]) when CNA 1's criminal background check was completed nine months after he was hired. This failure had the potential to result in resident abuse, neglect and/or mistreatment by hiring staff with possible criminal records.A review of the facility's document titled, General Orientation List, dated 1/17/23, indicated CNA 1's date of hire was 1/17/23. A review of an undated facility document titled, Background Report, indicated a background report was conducted on 10/16/23 for CNA 1 by the facility.During an interview on 7/30/25 at 3:32 p.m., the Director of Staff Development (DSD) verified CNA 1's date of hire was 1/17/23. The DSD confirmed CNA 1's background check was ordered after the employee was hired and began to work directly with residents in the facility. The DSD further stated, I don't have a good answer for you. Usually, I don't let anyone get an offer…

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 professional standards of practice were met for one of five sampled residents (Resident 1) when supervisory staff did not provide oversight and follow-up after Resident 1 did not receive any showers or baths for seventeen days.This failure had the potential to increase Resident 1's susceptibility to infections, skin problems, and negatively impact his mental health and activities of daily living (ADL, activities such as bathing, dressing and toileting a person performs daily).A review of Resident 1's admission record indicated he was admitted to the facility in May 2025 with medical diagnosis which included vertebrogenic low back pain (chronic low back pain originating from the vertebral endplates, the surfaces of the vertebrae that meet the intervertebral discs in the spine), absence of left leg above the knee, schizophrenia (a mental illness that is characterized by disturbances in thought), depression (depression (a mental health condition characterized by symptoms like sadness, loss of interest 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 ensure resident care met professional standards for one resident (Resident 1) of eight sampled residents when following Resident 1's unwitnessed fall nursing and neurological (neuro, relating to the nervous system, includes: brain, spinal cord, and nerves) assessments were not conducted, monitored, or documented in Resident 1's medical record. These failures had the potential to misrepresent Resident 1's actual condition status post (after) fall, which could lead to a delay in treatment and other negative outcomes. Findings:A review of Resident 1's admission record indicated admission to the facility in September 2024 with diagnosis of malignant neoplasm (a cancerous tumor) of unspecified part of the left lung. A review of a Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 9/20/24, indicated Resident 1: Had moderate cognitive (relating to or involving the processes of thinking and reasoning) impairment; Required substantial/maximal assistance (helper does more than half the effort)…

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 provide services that met professional standards of quality for one resident (Resident 1) of three sampled residents when prescriber order to hold a blood pressure (BP - the force of your blood pushing against blood vessels) medication when BP measurement was below a certain parameter was not followed.This failure had the potential for Resident 1 to become hypotensive (low blood pressure) and experience dizziness, lightheadedness, fatigue, visual disturbances, and/or fainting, especially when standing up quickly.Findings:A review of Resident 1's admission record indicated admission to the facility on 6/6/25 with diagnoses including lung cancer, chronic lung disease, heart failure, and hypertension (HTP- high blood pressure).A record review of Resident 1's Medication Administration Record (MAR) dated June and July 2025 indicated an order for doxazosin mesylate (a medication used to control high blood pressure) oral tablet 2 milligrams (mg - a unit of measure), give 1 tablet by mouth at bedtime for HTN, hold if Systolic…

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

Based on interviews and record reviews the facility failed to provide services that meet professional standards for one of three sampled residents (Resident 1), when Resident 1 was administered glucose gel (medical product used to treat low blood sugar levels) in his mouth while unresponsive and unable to follow directions. The failure had the potential to cause Resident 1 to choke on or aspirate (accidental entry of food, liquid or other material into the lungs) the glucose gel. Findings: During a review of Resident 1 ' s admission record indicated, Resident 1 was admitted to the facility in February 2025, with a diagnosis of diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). A review of Resident 1 ' s care plan titled, Diabetes ., initiated on 2/20/25, indicated, .Resident has a diagnosis of diabetes and is at risk for complications . with goals including, .will minimize the risk for complication of diabetes to the extent possible . During an interview on 5/15/25 at 1:22 p.m., Paramedic 1 (PMD 1) stated he responded to 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 interview and record review, the facility failed to meet the requirements for a safe discharge for one of three sampled residents (Resident 1) when Resident 1 was discharged due to being unable to get a ride back to the facility at the agreed upon return time during an approved leave. This failure resulted in emotional distress for Resident 1 as she did not have access to equipment for safe ambulation (walking) or her essential medications (medications ordered by a physician for treating/and or preventing symptoms of a significant health condition). Findings: A review of Resident 1's admission record indicated she was admitted on [DATE] with diagnoses including type 2 diabetes (a chronic condition characterized by difficulty in blood sugar control and poor wound healing), acute and chronic respiratory failure (a serious condition that makes it difficult to breathe on your own. It develops when the lungs can't get enough oxygen into the blood), acute kidney failure (a sudden and significant 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 did not ensure two residents (Resident 1 and Resident 2) of three sampled residents had access to a telephone, to make private calls with friends and family. The facility only had one working wireless telephone for resident use, and this phone could not be located during an onsite visit on 1/30/25. This failure decreased the facility's potential to ensure residents, including those who were bedbound, were to free to speak to family members or acquaintances in private. Findings: Record review of Resident 1's Face Sheet (Facility demographic) indicated he was admitted to the facility on [DATE] with medical diagnoses including Fracture of Right Femur (Broken thigh bone, right leg) and Chronic Obstructive Pulmonary Disease (A chronic lung disease that causes ongoing inflammation and narrowing of the airways, leading to difficulty breathing). During an observation on 1/29/25 at 6:15 p.m., the Surveyor attempted to reach Resident 1 by phone, at 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 [AES1] the facility failed to provide pain medicine in the form of a cream (lidocaine) for one out of two sampled residents (Resident 1). This failure potentially caused Resident 1 pain and further suffering by missed medication administrations. Findings: During a review of Resident 1 ' s admission Record, dated 1/23/2007, indicated Resident 1 had initially been admitted to the facility on [DATE] with a medical history of stroke (blockage of blood supply in parts of the brain), quadriplegia (as defined as the dysfunction or loss of motor and sensory function of the cervical area [AES3] of the spinal cord, leading to partial or total loss of function in the arms legs, trunk and pelvis) and high blood pressure. During an interview with Resident 1 on 6/13/24 at 10:38 a.m., Resident 1 stated the medication, Lidocaine (ointment type cream which when applied relieves pain) Ointment was to be administered two times a day and it had not been administered for days and 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 ensure 76 out of 76 residents were provided activities on weekends, when no Activity Staff were available. This failure had the potential for all residents to experience isolation, decreased enjoyment of life and depression. Findings: During an observation and interview on 3/21/22, at 10:34 a.m., Resident 58 was observed laying on her back in bed with her pajamas on, in a dark room with the curtains pulled. She stated she would prefer to have the curtains open and see outside but her roommate sleeps in late. She stated she does not have anything to do. She stated no one had come in to speak with her about what activities she liked to do. She stated she cannot get out of bed for long because her back pain prevented her from moving around a lot. She stated she enjoyed socializing with her daughter or anyone who would come to her bedside. A review of Resident 58's document titled, admission Record, indicated she was admitted [DATE], with…

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

Based on food production observation, dietary staff interview, and dietary document review, the facility failed to ensure a Registered Dietician (RD) was overseeing the operations of the facility's Food Service Department, resulting in issues with safe and effective food storage, meal production, infection control, and a clean kitchen. Failure to ensure adequate oversight may result in compromising the nutritional status of all residents and cross contamination of resident food and foodborne illness. Findings: During the course of the survey from 3/21/22-3/29/21 through observations, interviews and dietary record reviews related to deficient practices in food service systems were noted, affecting all residents. These included: 1. Failure to ensure that resident meals were prepared and distributed in a manner that met resident preferences and maintained palatability (Cross Reference F804), 2. Failure to ensure physician ordered diets were followed (Cross Reference F805), 3. Failure to ensure safe dietetic services as evidence dietary staff not: 1.) thawing meat according to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on dietary staff observation, interview, and dietary record review, the facility failed to ensure staff possessed required competency as evidenced by dietary staff members not: 1) thawing meat according to the facility's policy and procedure, 2) using the correct Cool Down Process for cooked meats and ambient (room temperature) foods like tuna for tuna salad, 3) Following recipes, and 4) Taking food temperatures prior to food service. Failure to ensure staff competency could: 1) put residents at risk for foodborne illness, 2) result in decreased food distribution and food production systems to ensure food palpability and nutritional content, which could result in decreased dietary intake that did not meet individual resident nutritional requirement. This could result in weight loss and further compromise resident medical status, and 3) not cooking green beans at a mechanical soft texture (easier to chew foods) could have led to the residents having trouble chewing and/or swallowing, which could have led to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a comprehensive care plan for one of 25 sampled residents (Resident 57), who's Annual MDS (Minimum Data Set, a clinical assessment process provides a comprehensive assessment of the resident's functional capabilities and helps staff identify health problems), dated 2/24/22, indicated Resident 57 was incontinent of bowel and bladder, but no care plan was developed. This failure had the potential for Resident 57 not to be checked frequently for incontinence, which could lead to skin breakdown, a urinary tract infection (an infection in any part of the urinary system), feeling of low self-esteem and further impact Resident 57's physical and psychosocial wellbeing. Findings: A review of Resident 57's admission Record indicated Resident 57 was admitted on [DATE], with diagnoses including hemiplegia (paralysis of one side of the body) and hemiparesis (weakness or the inability to move on one side of the body, making it hard to perform…

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 did not ensure nursing staff utilized professional standards when providing resident care when: 1) Licensed Staff G did not verify placement of Resident 38's PEG tube (percutaneous endoscopic gastrostomy tube; a tube inserted through the wall of the abdomen directly into the stomach) per facility policy and procedure. This failure caused potential for injury when LN G did not ensure Resident 38's feeding tube was in his stomach immediately prior to administering medication. Feeding tubes can become displaced (for example: into the abdominal cavity or lungs) and delivery of tube feeding liquid into an area of the body other than the stomach can cause serious injury and death; and 2) The Director of Staff Development (DSD A) did not perform the medication rights (guide to clinical medication administration to ensure patient safety; right resident/medication/dose/route [oral, intravenous]/time) prior to administering Resident 120's IV (intravenous)…

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 recognize, evaluate and address 1 out of 25 residents (Resident 34) continued multiple meal refusals for the last 2 months. This failure had the potential for Resident 34 to have a decline in function, weakness, and unplanned weight changes. Findings: Review of Resident 34's face sheet (demographics)was diagnosed with Diabetes Mellitus Type 2 (a chronic condition that affects the way the body processes blood sugar), Dementia ( group of conditions characterized by impairment of at least 2 brain functions such as memory and judgement) and Major Depressive Disorder ( a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). During observation and interview with Resident 34 on 3/23/22 at 8:41a.m., was in bed, appears comfortable. Resident 34 stated he ate little breakfast today, was not sure if he finished it. Resident 34 stated he was unsure whether he ate dinner last night. Resident 34 stated feeling sad with little…

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 Resident 38 received appropriate nursing care to minimize potential complications associated with enteral feeding/nutrition (tube feeding; delivering nutrition directly into the stomach or small intestine as a liquid) when: 1) Licensed nurses failed to ensure administration of enteral nutrition was consistent and followed physicians orders and; 2) Licensed Staff G did not verify placement of Resident 38's PEG tube (percutaneous endoscopic gastrostomy tube; a tube inserted through the wall of the abdomen directly into the stomach) prior to medication administration per facility policy and procedure. These failures created 1) Potential for inadequate nutrition, calories, and hydration for Resident 38 when his tube feedings were not given as ordered and multiple meals were missed and 2) Potential for injury when LN G did not ensure Resident 38's feeding tube was in his stomach immediately prior to administering medication. Feeding tubes can become misplaced (for example: into the abdominal cavity or lungs)…

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 did not ensure sufficient nursing staff when: 1. Consistent and accurate meals preferences were not honored for 5 sampled residents (Resident 59, Resident 48, Resident 31, Resident 58, Resident 55, Resident 219). 2. Call lights were not answered resulting in incontinence for 2 of 8 sampled residents (Resident 220 and Resident 58). 3. All residents did not have access to activities on weekends. 4. All residents did not have access to the RNA (Restorative Nursing Assistant) program (specially trained CNA's (Certified Nursing Assistant) who provide ongoing long-term physical and occupational care to improve patient's quality of life - physically, mentally and emotionally) because the RNA had been pulled to the floor to work as a CNA for the past five months. These failures resulted in: 1. Potential for weight loss from being served unpalatable food and choking from incorrect diets because staff were too busy to check for accuracy of resident meal trays.…

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 all staff were competent and trained for: 1. Abuse Prevention Training. 2. Infection Prevention. This had to potential for resident harm when: 1. Staff were not trained to recognize and respond to family and resident complaints of abuse to ensure resident safety. 2. Staff were unable to prevent cross contamination during resident care and result in resident infection. Findings: 1. During an interview and record review on 3/29/22 at 8:50 a.m., at Director of Staff Development A's desk, four employee files were reviewed for current documentation for Abuse Prevention Training. Abuse Prevention training documentation for Licensed Staff C indicated it was completed on 3/5/19. Review of Licensed Staff B's employee file indicated Abuse Prevention Training documentation completed on 3/18/20. Review of Director of Nursing file did not indicate any documentation for Abuse Prevention Training since date of hire on 9/13/21. Review of Director of…

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

Based on observation, interview and record review, the facility: 1) Failed to ensure the consulting Pharmacist's (Consultant L) review of medications identified and addressed irregularities with Resident 38's physician order for rapid-acting insulin (medication to treat high blood sugar in diabetics; onset of action is within 15 minutes). This failure resulted in Consultant L not addressing and potentially correcting the timing and administration of Resident 38's insulin (designed to be given with meals) and potentially impairing the control of his blood sugar; and, 2) Failed to ensure Pharmacy services provided physician ordered medications when Vitamin D was not onsite and available for one resident (Resident 14) . This failure caused Resident 14 to miss two days of Vitamin D ordered by her physician. Findings: 1) Review of Resident 38's MAR indicated Resident 38's nurses were to administer tube feedings (liquid nutrition delivered via a tube inserted through the wall of the abdomen directly into the stomach) at midnight, 4 a.m., 8 a.m., 12 noon, 4 p.m., and 8 p.m. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure Pharmacy Consultant L's recommendation to attempt a dose reduction for the antidepressant Mirtazapine for one of 25 sampled residents (Resident 59) was sent to Resident 59's physician. Pharmacy Consultant L identified Resident 59 had not had any reported instances of restlessness in the past five months, but Resident 59 continued on Mirtazapine 15 mg (milligrams). This failure had the potential for the Resident 59 to have adverse consequences such as increased sleepiness, increase hunger, weight gain, amongst other adverse side effect, which could have negatively impact Resident 59's physical, mental, and psychosocial well-being. Findings: A record review of Pharmacy Consultant L's Drug Regimen recommendations, Pharmacy Consultant L noted that Resident 59 had been on Mirtazapine 15 mg since 2/28/21. The drug regimen review titled, Note to the Attending Physician/Prescriber, dated 8/5/21, recommended Resident 59's attending physician attempt a…

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

Based on observation, interview, and record review, the facility failed to ensure safe and accurate medication administration when the nursing medication error rate was 19.23%. Licensed nurse F (LN F) did not give Resident 14 her scheduled dose of Vitamin D (as it was not available) and LN D gave Resident 33 his morning medications, scheduled for 9 a.m., approximately 1 hour and 47 minutes late. These failures: 1) Caused Resident 14 to miss two days of Vitamin D ordered by her physician, and 2) Caused Resident 33 to receive his medications for blood pressure, seizures, and diabetes (to control blood sugar) almost 2 hours late, potentially impacting the control of his blood pressure, seizures and blood sugar. Findings: 1. During a medication pass observation on 03/23/22 at 8 a.m., LN F administered Resident 14 her morning medications. LN F stated the Vitamin D 1000 IU (international units; the dose) was missing (the facility only had Vitamin D 800 IU). LN F called Residents 14's physician and stated the doctor instructed her to hold the Vitamin D until the correct dose was delivered…

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 were free from medication error for one out of 25 residents, when one resident (Resident 17) was administered a medication without a physician's order. Resident 17 had an antifungal powder in use at his bedside which did not have a physician's order. This failure had the potential for ineffective treatment, unwarranted side effects, or an allergic response from using an antifungal medication product without the physician's order. Findings: During an observation and concurrent interview on 3/23/22 at 2:20 p.m., with Licensed Nurse D and Resident 17, the presence of Miconazole 2% powder (an antifungal powder used to treat fungal skin infections), was verified to be on Resident 17's bedside table. Licensed Nurse D stated that staff applied it on Resident 1's7 abdomen and groin. Licensed Nurse D verified Resident 17 had redness on his abdominal pannus (area of excess skin and fat that hangs over the pubic region) and left…

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 food storage observation, dietary staff and resident interview, and dietary record review, the facility failed to ensure meals were prepared and served in a manner to maintain palatability and nutrient content as evidence by: 1. The facility did not ensure food temperature and palatability, 2. Penne pasta was being cooked 2 hours or longer prior to the beginning of meal service, 3. Recipes where not followed, and, 4. Broccoli mushy and grayish green, pureed spinach had a gluey texture causing pureed spinach hard to swallow, and the pureed meatloaf tasted like the added thickener (additive to pureed foods to make a pudding-like consistencies), no flavor. Failure to ensure food distribution and food production systems that ensured food palpability and nutritional content may result in decreased dietary intake, which may result in weight loss and further compromise resident medical status. Findings: 1. During an interview on 3/21/22 at 11:39 a.m. Resident 59 stated the soup was always cold. During…

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 prepare a meal tray with the individual diet consistency for two of 25 sampled residents (Resident 6 and Resident 29). when 1) Resident 6's physician order for a regular diet (example: sandwich) once a week, on Saturdays, did not reflect Resident 6 was receiving on Saturdays, and 2) Resident 29, who was on a Mechanical Soft Diet (texture-modified diet that restricts foods that are difficult to chew or swallow) was served green beans that were hard. A review of residents' lunch Meal Card, dated 3/23/22, indicated fourteen residents were on a Mechanical Soft diet and two residents were on a Dysphagia Mechanical diet. This failure for the dietary department to prepare vegetables with a soft texture had the potential to cause Resident 29 and all residents on a Mechanical Soft diet or on a Dysphagia Mechanical diet to choke, leading to airway being blocked and possible death. This failure could result in decreased dietary intake, leading 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 food preferences were honored for four of 25 sampled residents (Resident 31, 55, 57, and 58), when Resident 31's dislike for gravy was not being honored, Resident 57, who requested two packets of hot sauce with each meal, but was not receiving routinely, Resident 55 did not receive two glasses of milk on her meal tray per her diet card, and Resident 58 did not receive salad dressing for her salad. These failures could result in decreased dietary intake, leading to residents not meeting their individual resident nutritional requirement, which may result in weight loss and further compromise residents' medical status. Findings: During a concurrent trayline observation, interview, and meal card review on 3/23/22 at 12:15 p.m., Dietary Aide was observed placing Resident 57's plate on her meal tray. Resident 57's tray card indicated in capital letters: Standing Order: 2 x 2 tablespoons or 2 hot sauce packets. No hot sauce packets were placed on Resident 57's meal tray. When the dietary aide was asked what…

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

Based on kitchen observations, dietary staff interview, and dietary document review, the facility failed to ensure safe dietetic services as evidence by 1) the facility did not follow its storage guidelines to store the bread, 2) the kitchen floor was dirty/sticky, and 3) garbage can lids were not on the garbage cans located underneath the cook's food prep counter. Failure to ensure effective dietetic services operations may result in placing residents at risk for foodborne illness as well as bacterial and foreign object contamination resulting in gastrointestinal (stomach and intestines) distress, weight loss and in severe instances may result in death. Findings: 1) During the initial tour of the kitchen on 3/21/22 at 9:33, the walk-in refrigerator was at 38º F. [NAME] bread, receive dated 3/17/22, and two large bags of hamburger buns, receive date 3/10/22, were being stored in the refrigerator. The Director of Dining Services (DDS) stated the bread was stored in the refrigerator because of limited space. The facility policy/procedure titled, Storage of Food and Supplies, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to complete the Pre-admission Screening and Resident Review (PASRR- a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) accurately and completely for two out of 25 residents (Resident 10 and Resident 34). This failure resulted in Resident 10 and Resident 34 not receiving Specialized Services needed. Findings: Resident 34 During an observation and concurrent interview on 3/23/22 at 08:41 a.m., Resident 34 stated feeling sad, depressed, and having little energy. During an interview and concurrent record review on 3/24/22 at 3:09 p.m., Medical Record Director (MRD), verified multiple sections on Resident 34's PASRR, dated 4/15/21, were not filled out accurately. MRD verified Resident 34 had a diagnosis of Dementia (a condition characterized by impairment of at least 2 brain functions, such as loss of memory and judgement). MRD verified Resident 34's PASRR was inaccurately…

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 a Nosey Cup (drinking cup with cut out for nose) and Plate Guard (curved to prevent food from falling off the plate and can be used as a barrier to push food against when scooping food onto a spoon or fork) when meal tray was served for one of 25 sampled residents (Resident 6), who had a CVA (cerebrovascular accident, stroke), causing flaccid (floppy or without muscle tone) hemiparesis (weakness or the inability to move one side of the body), of his left upper extremity (dominant side). This failure had the potential to impact Resident 6's: dignity, nutritional status, independence in self-feeding skills being maintained or improved when consuming meals and snacks, and swallowing difficulties, which could cause aspiration (when liquids enter the airway), leading to negative clinical outcomes. Findings: A review of Resident 6's Meal Card indicated: Diet Order: Puree (foods with a soft, pudding-like consistency), Regular, Thick…

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.