Rowntree Gardens

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of one final sampled resident (Resident 26) reviewed for falls were provided the necessary services after a fall. * The facility failed to ensure Resident 26's fall risk evaluation was completed accurately after Resident 26 had a fall on 11/19/25, and failed to monitor Resident 26 for episodes of getting out of bed, as per the care plan. These failures had the potential risk of inaccurate fall risk score, the failure to implement the appropriate fall risk interventions, and risk of injury for Resident 26.Findings: Review of the facility's P&P titled Falls- Clinical Protocol revised 3/2018 showed based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling. The staff and physician will monitor and document the individual's response to interventions intended to reduce…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility to provide the necessary respiratory care for two of two final residents reviewed for respiratory care (Residents 2 and 22). * The facility failed to obtain a physician's order for the administration of oxygen and failed to ensure the nasal cannula was stored in a sanitary condition, for Resident 2. * The facility failed to ensure Resident 22's nasal cannula was stored in a sanitary condition. These failures posed the risk for the residents' oxygen equipment to become contaminated with pathogens and had the potential to negatively impact the residents' medical condition.Findings: Review of the facility's P&P titled Oxygen Administration revised 10/2010 showed the purpose of this procedure is to provide guideline for safe oxygen administration. Verify that there is a physician's order for this procedure. 1. Medical record review for Resident 2 was initiated on 12/8/25. Resident 2 was admitted to the facility on [DATE],…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to provide the appropriate pain management for two of two final sampled residents (Residents 5 and 10) reviewed for pain management. * The facility failed to ensure Resident 5 received the appropriate intervention for pain, when a pain level of 5 (on the pain scale of 0 to 10 with 0 = no pain and 10 = worst) was reported and stronger pain medication meant for severe pain level of 7-10 was administered to the resident. * The facility failed to ensure the NPI (nonpharmacological intervention) was provided and documented prior to Resident 10 receiving a pain medication. These failures had the potential to put Residents 5 and 10 at risk for ineffective pain management and adverse effects related to the use of unnecessary pain medications. Findings: Review of the facility's P&P titled Administering Pain Medications revised 4/2025 showed the pain management program is based on a facility-wide commitment to appropriate assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to provide the pharmacy services as per the facility P&P for one of ten residents (Resident 43) reviewed for pharmacy services. * The facility failed to ensure Resident 43's new order for levetiracetam (antiseizure medication) oral solution was obtained from the pharmacy in a timely manner. (The pharmacy was notified at approximately 0800 hours and the medication was obtained at approximately 1430 hours). * The facility failed to transcribe Resident 43's physician's order for levetiracetam accurately. The physician ordered levetiracetam 1000 mg oral solution medication to be administered twice daily, however, the LVN transcribed the order in error, indicating the levetiracetam 1000 mg oral solution medication was to be administered once daily. These failures posed the risk for inhibiting the therapeutic effects of the medication and had the potential to negatively affect the resident's health. Findings: Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to maintain an accurate medical record for three of 13 final sampled residents (Residents 10, 29, and 43). * The facility failed to ensure the episodes of crying spells documented on the MAR were accurate for Resident 10. * The facility failed to ensure the skin assessment was documented accurately to reflect the bruising identified for Resident 29. * The licensed nurse documented Resident 43 received levetiracetam (antiepileptic mediation) 1000 mg tablet orally on 12/10/25 at 0900 hours, however, Resident 43 had refused the medication. These failures had the potential for the residents' care needs not being met as their medical information was inaccurate.Findings: 1. Medical record review for Resident 43 was initiated on 12/8/25. Resident 43 was admitted to the facility on [DATE]. Review of Resident 43's Order Summary Report showed a physician's order dated 11/11/25, for levetiracetam 1000 mg tablet orally two times a day…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to send the required discharge referral documents to the HHA for one of three sampled residents (Resident 1). This failure resultedin Resident 1 not receiving the ongoing care needs. Findings: Review of the facility's P&P titled Discharge Summary and Plan revised October 2022 showed the post discharge plan is developed by the care planning team with the assistance of the resident and his or her family and includes: a. Where the individual plans to reside b. Arrangements that have been made for follow- up care and services On 1/30/25 at 1421 hours, CDPH, L&C Program received a complaint stating Resident 1 did not receive PT services until the PT order was faxed on 1/29/25. The complaint showed the discharge team had waited 12 days to do anything. On 2/6/25 at 1140 hours, a telephone call was conducted with Resident 1's family member. Resident 1's family member stated Resident 1's home health with PT…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. Medical record review for Resident 10 was initiated on 10/22/24. Resident 10 was admitted to the facility on [DATE]. Review of Resident 10's H&P examination dated 9/12/24, showed Resident 10 had no capacity to understand and make decisions. Review of Resident 10's Order Summary Report dated October 2024 showed a physician's order dated 9/11/24, for bilateral 1/4 side rails up when in bed as enabler for bed mobility. Further review of Resident 10's medical record showed no documented evidence the side rail entrapment assessment was completed prior to the use of side rails. On 10/22/24 at 0907 hours, Resident 10 was observed laying in bed with bilateral upper 1/4 side rails elevated. 4. Medical record review for Resident 23 was initiated on 10/22/24. Resident 23 was admitted to the facility on [DATE], and readmitted back to the facility on 9/25/24. Review of Resident 23's H&P examination dated 9/26/24, showed Resident 23 had capacity to understand and make decisions. Review of Resident 23's Order Summary Report…

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

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food safety and sanitary requirements were met in the kitchen as evidenced by: * The facility failed to ensure the proper hand washing was performed when preparing food. * The facility failed to ensure proper labeling and dating of the opened food in the freezer. * The facility failed to ensure the expired food was discarded. * The facility failed to ensure a dry food storage container was properly sealed. * The facility failed to ensure the food preparation equipment were in good condition. * The facility failed to ensure the food preparation equipment were properly air dried prior to storage. * The ice machine was not clean. These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food prepared from the kitchen. Findings: Review of the facility's Resident Assessment Report (CMS-802) dated 10/22/24, showed 46 of 48 residents residing in the facility received food prepared in the kitchen. 1. Review of…

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

Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the residents' entrapment assessments were completed and the measurements were recorded during the bed inspection when identifying areas of possible entrapment with the use of side rails for 13 of 13 residents observed with bed rails (Residents 6, 8, 10, 14, 15, 23, 30, 35, 37, 38, 41, 545, and 602). These failures had the potential to negatively impact the residents resulting in possible entrapment, serious injury, and death. Findings: Review of the facility's P&P titled Entrapment/Bed Assessment revised 10/2018 showed the following: - The resident is assessed for the use of bed rails, which includes a review of risks including entrapment; - The facility must ensure the bed is appropriate for the resident and that the bed rails are properly installed and maintained. - Assess the resident for risk of entrapment from bed rails prior to installation; and - Ensure that the bed's dimensions are appropriate for the resident's size and weight. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the reasonable accommodations to meet the needs for one nonsampled residents (Resident 545). * The facility failed to ensure the call light was within reach and accessible for Resident 545. This failure had the potential to negatively impact the resident's psychosocial well-being or result in a delay to receive care. Findings: Review of the facility's P&P titled Answering the Call Light revised September 2022 showed the following: - Upon admission and periodically as needed, explain and demonstrate the use of call light to the resident; - Ask the resident to return and demonstration; and - Ensure the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility, and from the floor; On 10/22/24 at 0953 hours, during the initial tour of the facility, a concurrent observation and interview was conducted with Resident 545. Resident 545 was observed awake and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record, and facility P&P review, the facility failed to develop the comprehensive plans of care to reflect the individual care needs for one of 13 final sampled resident (Resident 35) and one nonsampled resident (Resident 37). * The facility failed to develop a care plan problem to address Resident 35's use of antibiotic for UTI. * The facility failed to ensure a care plan problem was developed to address the risk of infection prevention and control related to education for Resident 37 and family member to provide the PureWick catheter supplies in a timely manner and cleaning of the collection canister, collector, and pump tubing. These failures posed the risk of not providing appropriate, consistent, and individualized care to the residents. Findings: Review of the facility's P&P titled Care Plans, Comprehensive Person-Centered revised 3/2022 showed a comprehensive, person-centered care plan that includes measurable objectives and timetable to meet the resident's physical,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the development of new pressure injury and promote healing of existing pressure ulcer for one of one final sampled resident (Resident 41) reviewed for pressure injury. * Resident 41 developed a Stage 3 pressure injury to the coccyx after admission to the facility. The facility failed to ensure Resident 41 was provided with high protein snacks at bedtime as recommended by the RD. In addition, LVN 3 failed to provide protective barrier to protect the wound during wound care per facility P&P. These failures posed Residents 41 at risk for developing new pressure ulcers and worsening of the existing pressure ulcer. Findings: Review of the facility's P&P titled Wound Care undated showed the purpose of this procedure is to provide guidelines for the care of wound to promote healing. The procedure section includes to position the resident and place…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the appropriate care and services to prevent urinary tract infections for two of three sampled residents (one final sampled resident, Resident 41; and one nonsample resident, Resident 37) reviewed for urinary catheter care. * The staff failed to ensure proper monitoring and care for Resident 37's Pure Wick collection canister. Resident 37's Pure Wick collection canister was observed to have dry, dark green residue. * The facility failed to ensure Resident 41's indwelling urinary catheter drainage bag was positioned below the resident's bladder and prevent tugging of the catheter for adequate urinary drainage and resident discomfort. Resident 41's indwelling urinary catheter tubing was observed on the floor under the resident's bed. These failure posed the risk for Residents 37 and 41 to develop catheter-associated urinary tract infections. Findings: 1. According to the BD manufacturer's recommendation…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to ensure one of seven final sampled residents (Residents 38) reviewed for respiratory care was provided the appropriate respiratory care. * The facility failed to ensure Resident 38's storage bag for the Yankauer suction tip was changed weekly. This failure had the potential to affect the respiratory health and well-being of the residents in the facility. Findings: Medical record review for Resident 38 was initiated on 10/22/24. Resident 38 was admitted to the facility on [DATE], and readmitted back to the facility on 5/4/24. Review of Resident 38's H&P examination dated 5/7/24, showed Resident 38 did not have the capacity to understand and make decisions. Review of Resident 38's Order Summary Report for October 2024, showed a physician's order dated 5/27/24, to suction oral secretions as needed for excessive secretions. On 10/22/24 at 0935 hours, a concurrent observation and interview was conducted with LVN 5 in Resident 38's room.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the specific competencies and skill sets necessary to care for the residents' needs. * The facility failed to ensure the Certification of Infection Preventionist Training Course was updated for the DSD/Acting IP. * The facility failed to ensure the nursing staff' competency on how to care for Resident 37's pure wick canister, collector and tubing. These failures had the potential to negatively impact the resident's well-being. Findings: 1. Review of the facility's P&P titled Infection Preventionist revised 2001 showed the infection preventionist is responsible for coordinating the implementation and updating of the infection prevention and control program. Qualifications: 1. The infection preventionist is qualified by education, training, experience and/or certification and has sufficient knowledge to perform the role. 2. The infection preventionist remains current with infection prevention…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the pharmaceutical services to ensure accurate reconciliation and administration as evidenced by: * The facility failed to ensure administration of the controlled medications for one nonsampled resident (Resident 42) was accurately documented to ensure accurate reconciliation and to prevent the medication administration errors. This failure had the potential for medication administration error, inaccurate reconciliation, and drug diversion (illegal distribution or abuse of prescription drugs or their use for unintended purposes). Findings: 1. Review of facility's P&P titled Controlled Substance revised November 2022 showed controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss or diversion and detection follow-up. The system of reconciling the receipt, dispensing and disposition of controlled substances…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility's P&P, the facility failed to ensure the medication error rate was below 5%. The facility's medication rate was 8%. One licensed nurses (LVN 1) observed administering the medications was found to have errors while administering the medications to two nonsampled residents (Residents 11 and 29). * The facility failed to ensure Resident 11 received the prescribed eye drops and in accordance with the facility's P&P. * The facility failed to ensure Resident 29 received the prescribed medication with food as ordered by the physician. These failures had the potential for the residents developing complications and ineffective therapeutic effects of the medications. Findings: 1. Review of the facility's P&P titled Specific Medication Administration Procedures: Eye Drop Administration Revised December 2019 showed to gently pull down lower eyelid to form a pouch, while instructing resident to look up. Place other hand against resident's forehead to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the medications were properly stored and labeled. * The facility failed to dispose of the prescription medications as nitroglycerine tablets in Medication Cart A. * The facility failed to store the external and internal medications separately. *The facility failed to accurately monitor the Glucose Quality Control of the glucometer in Medication Cart A. * The facility failed to disposed of the opened sterile dressings, expired dressings, indwelling catheters in the treatment cart. *The facility failed to appropriately label multiple ointments with open date. * The facility failed to ensure accuracy and complete records in the facility's Medication Room temperature log and Medication Refrigerator temperature log. These failures had the potential to negatively impact the residents' well-being. Findings: 1. Review of the facility's P&P titled Medication Labeling and Storage revised February 2023 showed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to follow the food preferences for one nonsampled resident (Resident 25) observed during the dining observation. * The facility failed to ensure Resident 25 received a chocolate shake as shown on the meal ticket as the preferred drink. This failure had the potential to affect the resident not receiving food as per their preference. Findings: Review of the facility's P&P titled Resident Food Preferences revised on 7/2017 showed the individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. The modifications to the diet will only be ordered with the resident's or representative's consent. Upon the resident's admission (or within 24-hours after his/her admission) the dietitian or nursing staff will identify a resident's food preferences. Medical record review for Resident 25 was initiated on 10/22/24. Resident 25 was admitted to the facility on [DATE]. Review of…

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

Based on observation, interview, and facility P&P review, the facility failed to ensure the facility's P&P for the resident's food brought by the visitors was followed. * The facility failed to show evidence of safe food handling instructions provided to the residents' family or visitors bringing food to the resident from outside. * The facility failed to ensure the resident refrigerator was clean. These failures had the potential to cause foodborne illnesses to the medically vulnerable resident population who consumed food brought from outside sources. Findings: 1. Review of CMS S&C-09-39 dated 5/29/09, showed the residents have the right to choose to accept food from visitors, family, friends, or other guests according to their rights to make choices. The CMS guideline further showed the facility has the responsibility under the food safety regulation to help visitors to understand safe food handling practices such as not holding or transporting foods containing perishable ingredients at temperatures above 41 degrees Fahrenheit. Further Review of the facility's P&P untitled and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility P&P review, the facility failed to ensure infection prevention and control program were maintained per facility's P&P as evidence by: * The facility failed to ensure the clean linen folding table in the laundry was free from personal items. * The facility failed to ensure LVN 2 completely wipe off the entire BP cuff, pulse oximeter, and thermometer prior obtaining one nonsampled resident's (Resident 595) vital signs who was on EBP observed during the medication administration. * The facility failed to ensure LVN 2 performed hand hygiene before and after removing gloves prior to changing to new pair of gloves during the medication administration for one final sampled resident (Resident 38), who was on EBP. These failures had the potential to cause safety hazards and the spread of infection to staff and residents. Findings: Review of the facility's P&P titled Procedures for Handling, Storage, Transportation, and Processing of Linens, undated showed clean linen storage…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to implement their antibiotic stewardship program when the facility failed to conduct an assessment for the McGeer's criteria to determine the true infection for four sampled residents (two final sampled residents, Residents 23 and 30; and two nonsampled residents, Residents 9 and 397). * The facility failed to assess for the McGeer's criteria for Residents 9, 23, 30 and 397 with prescribed antibiotics in the month of September. This failure had the potential for inaccurately identifying for true infections and potentially inhibited the residents' physicians from discontinuing the unnecessary antimicrobials. Findings: Review of the facility's P&P titled Antibiotic Stewardship revised 12/2016 showed the antibiotics will be prescribed and administered to the residents under the guidance of the facility's antibiotic stewardship program. The purpose of our antibiotic stewardship program is to monitor 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 facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen. * The facility failed to ensure the proper hand washing was performed when preparing food. * The facility failed to ensure the wiping cloths used to sanitize the kitchen surfaces were stored in the sanitizing solution. * The facility failed to ensure the use of a cool down procedure for Time/Temperature Control for Safety Foods for the food that required time and temperature controls to limit the growth of pathogens. * The facility failed to ensure the ice machine was clean. * The facility failed to ensure the food items in the freezer was properly labeled. * The facility failed to ensure the food preparation equipment was air dried. * The facility failed to ensure the use hair restraints was implemented to the dietary staff working in the kitchen. * The facility failed to ensure the backflow prevention of two food preparation sinks was properly maintained. * The facility…

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

Based on interview, medical record, facility P&P review, and facility document review, the facility failed to ensure the staff provided care and promoted dignity and respect for one of 14 final sampled residents (Resident 16) and one nonsampled resident (Resident 7). * CNA 1 was observed going into Rooms A, B, C, and D without knocking during a dining observation. * RNA 1 was observed assisting Residents 7 and 16 with meals at the same time. RNA 1 was also observed standing over Resident 16 while assisting the resident with meals. These failures had the potential to negatively impact the residents' well-being. Findings: Review of the facility's P&P titled Dignity revised 2/2021 showed the staff are expected to knock and request permission before entering the residents' rooms. Review of the facility's P&P titled Assistance with Meals revised 3/2022 showed the residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example not standing over resident while assisting them with meals. 1. During the initial dining observation, CNA 1 was observed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review and facility P&P review, the facility failed to determine if it was safe for one nonsampled resident (Residents 405) to self-administer the medications. * Resident 405 was observed with a cup containing several Lactaid (enzyme supplement) medication at bedside. Resident 405 did not have the assessment, physician's order, and care plan problem addressing the resident's self-administration of medications. This had the potential for Resident 405 to administer medications inaccurately. Findings: Review of the facility's P&P titled Self-Administration of Medications revised 2/2021 showed as part of the evaluation comprehensive assessment, the IDT assesses each resident's cognitive and physical abilities to determine whether self-administering medication is safe and clinically appropriate for the resident. Any medication found at the bedside that are not authorized for self-administration are turned over to the nurse in charge for return to the family or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to maintain a copy of the resident's advance directives in the medical record for one of 14 final sampled residents (Resident 40). This had the potential for Resident 40's decisions regarding her healthcare and treatment options not being honored. Findings: Medical record review for Resident 40 was initiated on 2/28/23. Resident 40 was readmitted to the facility on [DATE]. Review of the POLST dated 2/25/19, showed Resident 40 had an advance directive. Review of the Advanced Healthcare Directive (AHCD) Acknowledgment Form dated 2/8/23, showed Resident 40 had an advance directive. The boxed for copy requested by facility was checked. Review of Resident 40's medical record failed to show a copy of the advance directive was maintained in Resident 40's medical record. On 3/1/23 at 1614 hours, an interview and concurrent medical record review was conducted with the SSD. The SSD verified a copy of Resident 40's advance directive was not maintained 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 interview, medical record review, facility P&P review, and facility document review, the facility failed to ensure the Long-Term Care Ombudsman (a person who routinely visits the facility and advocated for the residents) was notified of the transfer to the acute care hospital for one of three closed record sampled residents (Resident 50). This failure had the potential of not providing Resident 50 with access to an advocate who could inform them of their options or rights related to transfer. Findings: Review of the facility's P&P titled Transfer or Discharge Notice dated 3/2021 showed a copy of the notice is sent to the Office of the State Long-Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative. Review of the facility's document titled Notice of Transfer and Discharge with effective discharge date of 1/6/23, failed to show documented evidence the State Long-Term Care Ombudsman was notified of Resident 50's transfer to the acute care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to show an accurate assessment that represented an accurate picture of the residents' status during the observation period of the MDS for one of 14 final sampled residents (Resident 28). This failure had the potential for Resident 28's care needs not being met. Findings: Medical record review for Resident 28 was initiated on 2/28/23. Resident 28 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 28's Order Summary Report showed an order dated 12/7/22, for a No Concentrated Sweets (NCS - a liberalized diet to keep blood sugar levels under control) diet, regular texture, and consistency. Review of Resident 28's plan of care dated 10/10/22, showed a care plan problem addressing Resident 28 required extensive assistance (resident involved in activity) by one staff member with eating oral diet. Review of Resident 28's MDS, under the functional status section dated 10/12/22, and 1/9/23, showed Resident 28's eating…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility document review, the facility failed to provide the necessary care and services to ensure one of 14 final sampled residents (Resident 38) on hospice services attained and maintained the highest practicable well-being. * The facility failed to communicate with the hospice agency regarding the RN/ LVN and CHHA visits. This had the potential of a delay in hospice care regarding changes in Resident 38's condition. Findings: Medical record review for Resident 38 was initiated on 2/28/23. Resident 38 was admitted to the facility on [DATE]. Review of the Order Summary Report showed a physician's order dated 3/9/22, for Resident 38 to be admitted to hospice services under a routine level of care. Review of the hospice projected calendar showed the following: - For December 2022, there were no documentation for visitation frequencies for the RN/LVN, CHHA, SC, and MSW. Further review of the hospice calendar showed the RN/LVN was scheduled to visit on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the equipment utilized to provide oxygen and nebulizer treatments for three of the 14 final sampled residents (Residents 5, 28, and 403) and four nonsampled residents (Residents 8, 17, 20, and 25) were changed and/or labeled in accordance with the facility's P&P. * The facility failed to ensure Resident 5's nasal cannula and nebulizer mask were labeled with the date when they were changed. * The facility failed to ensure Resident 17's nasal cannula was labeled with the date when it was changed and failed to ensure Resident 17's oxygen concentrator humidifier bottle and plastic bag were changed every seven days as per the facility's P&P. * The facility failed to ensure Resident 20's nebulizer mask was labeled with the date when it was changed and failed to ensure Resident 20's oxygen concentrator humidifier bottle was changed. * The facility failed to ensure Resident 8's nasal cannula and humidifier were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide appropriate pain management for one of 14 final sampled residents (Resident 40). * The facility failed to ensure Resident 40 was administered her pain medication promptly after Resident 40 complained of severe pain to her right lower back. The licensed nurses failed to dispense the pain medication which was available in the facility's emergency kit (contains a small quantity of medications that can be dispensed when pharmacy services are not available). This failure resulted in Resident 40's pain left unmanaged and feeling helpless for not receiving her pain medication to manage her severe pain. Findings: Review of the facility's P&P titled Pain Assessment and Pain Management revised 3/2020 showed acute pain (or significant worsening of chronic pain) should be assessed every 30 to 60 minutes after the onset and reassessed as indicated until relief is obtained. Under Implementing Pain Management…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P, the facility failed to provide the necessary care for one of 14 final sampled residents (Resident 32). * The facility failed to ensure Resident 32's medication and supplement were administered as ordered by the physician on the days the resident left the facility for dialysis (a process of purifying the blood of a person whose kidneys are not working normally). This had the potential for Resident 32 not getting the appropriate doses of medication and supplement as ordered, resulting in health complications. Findings: Review of the facility's P&P titled Medication Administration General Guidelines revised 1/2017 showed the medications are administered as prescribed in accordance with good nursing principles and practices. It also showed that medications are administered in accordance with written orders of the attending physician. Medical record for Resident 32 was initiated on 2/28/23. Resident 32 was admitted to the facility on [DATE], and readmitted…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for two of 14 final sampled residents (Residents 14 and 40). * Resident 40 who had bilateral 1/4 (quarter) side rails in bed was not assessed for risk for entrapment. * Resident 14 who had bilateral 1/4 (quarter) side rails in bed was not assessed for risk for entrapment. This failure posed the risk for injury for Residents 14 and 40 from side rail use. Findings: The FDA issued a Safety Alert entitled Entrapment Hazards with Hospital Bed Side Rails. Residents most at risk for entrapment are those who are frail or elderly or those who have conditions such as agitation, delirium, confusion, pain, uncontrolled body movement, hypoxia, fecal impaction, acute urinary retention, etc., that may cause them to move about the bed or try to exit from the bed. Entrapment may occur when a resident is caught between the mattress and ed rail or in the bed rail itself. Inappropriate…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary pharmacy services for one of 14 final sampled residents (Resident 43) and three nonsampled residents (Residents 9, 11, and 30). * Resident 43's Tramadol (a narcotic pain medication) Controlled Medication Count Sheet did not match Resident 43's MAR. * Resident 9's hydrocodone-acetaminophen (a narcotic pain medication) Controlled Medication Count Sheet did not match Resident 9's MAR. * Resident 11's hydrocodone-acetaminophen Controlled Medication Count Sheet did not match Resident 11's MAR. * The facility failed to ensure Resident 30's biotin (a supplement) was administered as ordered by the physician. These failures posed the risk for diversion of controlled medications and possible health complications due to not administering a medication as prescribed. Findings: Review of the facility's P&P titled Preparation and General Guidelines: Medication Administration General Guidelines revised…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of 14 final sampled residents (Resident 32) was free from the significant medication errors when the facility failed to administer Resident 32's Brilinta (a blood thinner medication to prevent stroke, heart attack, and other heart problems) during dialysis (a process of purifying the blood of a person whose kidneys are not working normally) days and failed to ensure a physician's order was obtained to hold or reschedule the blood thinner medication as ordered on dialysis days. This failure had placed Resident 32 at risk for medical complications. Findings: Review of the facility's P&P titled Medication Administration General Guidelines revised 1/2017 showed the medications are administered as prescribed in accordance with good nursing principles and practices. The P&P also showed medications are administered in accordance with written orders of the attending physician. Medical records for Resident 32 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to store and label the medications properly and failed to discard the expired supplies. * Medication Cart 1 had two opened and unlabeled Chloraseptic spray bottles (a medication to treat sore throat or mouth) without resident's name and/or room number. This had the potential for the medication to be used for other residents. * The facility failed to store Resident 17's artificial tears bottle (a medication to treat dry eyes) in a safe manner. This had the potential for the medication to be used for other residents. * Medication room [ROOM NUMBER] drawer had expired port-a-cath needles. This had the potential for use of expired supplies. Findings: Review of the facility's P&P titled Storage of Medication revised [DATE] showed the facility stores all drugs and biologicals in a safe, secure, and orderly manner. Review of the facility's P&P titled Preparation and General Guidelines for Medication Administration…

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

Based on observation, interview, facility P&P, and facility document review, the facility failed to ensure the puree recipes were followed during the puree procedure of the residents food. This failure posed the risk for the inconsistent puree product which could alter the quality and nutrient content of the puree food for seven of 49 residents who received a puree diet. Findings: Review of the facility's P&P titled Puree Procedure (undated) showed to prepare regular item according to the recipe. The P&P also showed to place one portion of regular texture item in the blender or Robot Coupe/food processor, add additional appropriate liquid for the original recipe, and start with minimal amount of fluid and increase as needed to achieve puree consistency. 1. Review of the Simple Steamed Cabbage, Simply Good from Food.com dated 11/10/22, showed the handwritten instructions for puree as follows: take a four-ounce serving of cabbage and place in food processor; puree until smooth (add vegetable stock if needed); thickened with one teaspoon or one tablespoon at a time; pudding-like…

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

Based on observation, interview, facility P&P, and facility document review, the facility failed to ensure the puree food was prepared to preserve nutritive value as evidenced by: * Excess water and thickener were added to the puree vegetables. * Puree vegetables were cooked more than three hours prior to meal service and held in a hot oven. These failures posed the risk for not meeting the nutritional needs of seven residents who received a puree diet. Findings: Review of the professional reference titled https://www.healthline.com/nutrition/cooking-nutrient-content dated 11/7/19, showed the reference indicated, . The following nutrients are often reduced during cooking: water-soluble vitamins: vitamin C and the B vitamins - thiamine (B1), riboflavin (B2), niacin (B3), pantothenic acid (B5), pyridoxine (B6), folic acid (B9), and cobalamin (B12), fat-soluble vitamins: vitamins A, D, E, and K, and minerals: primarily potassium, magnesium, sodium, and calcium . Review of the Mealtimes showed the following: breakfast at 0705, lunch at 1130, and dinner at 1705 hours. On 3/1/23 at 0818…

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

Based on observation, interview, and facility document review, the facility failed to ensure the entree substitutes offered were of equal nutritive value when grilled cheese sandwiches were not equal in protein content to the main entrée. This failure had the potential of not meeting the resident's nutritional needs. Findings: On 3/1/23 at 1108 hours, during the lunch tray line observation and concurrent interview was conducted with [NAME] 3. [NAME] 3 was observed preparing a grilled cheese sandwich which consisted of two pieces of white bread and three slices of yellow cheese. [NAME] 3 stated he was preparing a grilled cheese sandwich as a meal alternate. Review of the facility document titled Nutrition Facts Sheet -US Beer Battered Fresh Cod Nutritional Facts dated 3/1/23, showed one serving of the beer battered fresh cod used to make the crispy cod sandwich entrée served for the lunch meal on 3/1/23, provided 24 grams of protein. Review of the cheese package used to make the grilled cheese sandwich entrée alternate served for the lunch meal on 3/1/23, showed Great Lakes Cheese…

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

Based on interview and facility document review, the facility failed to implement their Quality Assessment and Assurance (QA&A) plan of action. There was no documentation to show the facility was monitoring the effects of the corrective action plans to identify if they had achieved and sustained the improvement for the repeated deficient practices cited at F698 and F812 in accordance with their POC for an abbreviated survey completed on 12/9/19. This had the potential to affect the quality of care for all the residents in the facility. Findings: On 3/3/23 at 1605 hours, an interview and concurrent facility document review was conducted with the Administrator. Review of the POC submitted by the facility to the CDPH, L&C Program for the recertification survey completed on 12/9/2019, showed the following deficient practices cited: a. For F698 related to the medications held for the residents receiving dialysis care in the facility, the POC included the following: * Medication orders for all residents being admitted with dialysis treatment order would be reviewed by the admitting nurse…

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

Based on observation, interview, facility P&P review, and facility document review, the facility failed to establish and maintain the infection control program and practices designed to help prevent the development and transmission of diseases and infections. * The facility failed to ensure the licensed nurse performed hand hygiene during wound care treatment for Resident 28. * The facility failed to ensure the infection control practices were maintained in the facility's laundry room area when three dusty fans were in use in the clean linen area and empty water bottle was in the clean linen area. * The facility failed to ensure RNA 1 performed hand hygiene when assisting meals between two residents (Residents 7 and 16). * The facility failed to ensure the pads used on the bed side rails for one of 14 residents (Resident 403) were cleanable and were not porous, torn and frayed. These failures posed the risk for transmission of disease-causing microorganisms and infections to the residents. Findings: Review of the facility's P&P titled Handwashing/ Hand Hygiene revised date 8/2019…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility P&P review, the facility failed to ensure the regular inspection of all bed frames, mattresses, and side rails as part of the regular maintenance program to identify areas of possible entrapment. This had the potential to negatively impact the residents resulting to entrapment, serious injuries, and death. Findings: Review of the facility's P&P titled Bed Safety revised date 12/2007 showed to try to prevent deaths/ injuries from the beds and related equipment (including the frame, mattress, side rails, headboard, foot board and bed accessories) the facility shall promote the following approaches: - Inspection by maintenance staff of all beds and related equipment as part of our regular bed safety program to identify risks and problems including potential entrapment risks; - Review that gaps within the bed system are within the dimensions established by the FDA (Note: the review shall consider situations that could caused by the resident's weight, movement or bed…

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.