Meadowood A Health And Rehabilitation Center

Based on observation, interview, and record review, the facility failed to ensure respiratory care provided was consistent with professional standards of practice for 1 of 8 residents who received oxygen at the facility (Resident 42) when Resident 42's oxygen order was not followed. This failure placed Resident 42 at risk for respiratory distress and inadequate treatment. Findings: During a concurrent observation and interview on 2/26/25 at 10:03 AM, with Licensed Nurse (LN) 6 in Resident 42's room, Resident 42 was observed receiving oxygen via nasal cannula (NC -a small flexible tube that contains two open prongs intended to sit inside the nostrils). LN 6 observed and confirmed the oxygen concentrator (a device that delivers oxygen) was on and running at 2.5 liters per minute (LPM, a unit of measure for oxygen delivery). During a concurrent interview and record review on 2/26/25 at 10:05 AM, LN 6 reviewed Resident 42's current physician order for oxygen. LN 6 stated the physician's order for oxygen was 4 LPM. LN 6 confirmed the oxygen order was not being followed as prescribed by…

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

Based on observation, interview, and record review, the facility failed to ensure safe medication administration practices when the medication error rate was more than 5% (% or percentage - number or ratio expressed as a fraction of 100) with a resident census of 67. Medication administration observations were conducted over multiple days, at varied times, in random locations throughout the facility. The facility had a total of 2 errors out of 36 opportunities which resulted in a facility wide medication error rate of 5.55% in 1 of 4 residents (Resident 234 ) observed for medication administration. These failures had the potential to result in unsafe medication use and medication errors affecting the resident's health and well-being. Findings: During a medication administration observation, in the facility's Sequoia station, with Licensed Nurse (LN) 3, on 2/27/25 from 8:28 AM to 9:40 AM, the following observations were noted with medication administration to Resident 234 and Resident 79 as follows: a. Resident 234's order for dorzolamide-timolol (an eye drop medication used to treat…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure safe medication storage for a census of 67 when: 1. Employee's personal items were stored in two of two medication storage rooms (a locked room for storage of medication and supplies); and, 2. Expired medication was available for use in medication cart (a mobile cart containing medications used daily to give medications to the residents) #2, located on the Sequoia unit. These failures may pose unsafe medication use in the facility. Findings: 1a. During an inspection on [DATE] at 9:44 AM, of the facility's Sequoia unit medication room with Licensed Nurse (LN) 4, the cabinet under the sink was observed to contain employee's personal items. The following items were observed and confirmed with LN 4: An opened partial bottle of water in a plastic container, two coffee cups, and two tote style bags with personal belongings and a printed copy of the staffing schedule laying on top of one of the bags. All items were located under the sink.…

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 obtain the necessary medications for one of three sampled residents (Resident 1) when Resident 1 ' s Intravenous (IV, in the vein) antibiotic (medication to treat infections) and a pain-relieving medication for migraine headache were not available for use. These failures had the potential to cause prolonged illness for Resident 1 as well as unrelieved pain. Findings: a. A review of Resident 1 ' s SNF [Skilled Nursing Facility] admission HISTORY AND PHYSICAL, indicated she was admitted to the facility on [DATE], at 5:30 PM, with diagnoses which included bronchiectasis (condition in which the airways become damaged, making it hard to clear mucous) with pseudomonas/klebsiella (a group of germs that can cause severe infections and are only treated by certain antibiotics) and migraine (a headache that can cause moderate to severe throbbing pain and pulsating sensation). A review of Resident 1 ' s SNF Summary for Placement, printed 5/26/24, at 2PM,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure Resident 1 ' s right to be fully informed of her discharge and the possibility for appeal was protected, when Resident 1, who was deemed unable to make health care decisions, signed the notice for her discharge on [DATE] and was discharged on 7/15/24. Resident 1 ' s responsible party (RP) was not provided notice of the discharge appeal process. This failure resulted in Resident 1 ' s responsible party being uninformed of the right to appeal the discharge decision, with the potential that Resident 1 would not receive additional services needed if an appeal was sought and upheld. Findings: A review of Resident 1 ' s Resident Face Sheet, indicated she was readmitted to the facility in the summer of 2024 with diagnoses which included unspecified dementia (a progressive state of decline in mental abilities), severe. A review of Resident 1 ' s CALIFORNIA ADVANCE HEALTH CARE DIRECTIVE, dated 11/6/2023, indicated, DESIGNATION OF AGENT. I hereby…

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 measures were planned and implemented to prevent injury from a fall for one of two sampled residents (Resident 2), when: 1. Resident 2 was at high risk for falling and his care planned interventions did not include measures adequate to prevent an injury if a fall occurred; and, 2. Staff left Resident 2's bed in a high position after Resident 2 fell on 7/2/24, and his revised care plan directed the bed was to be kept low. These failures resulted in Resident 2 sustaining an injury from a fall on 7/2/24 and increased the risk of further falls resulting in serious injury. Findings: 1. Review of Resident 2's Physician Order Report indicated Resident 2 was admitted to the facility with a diagnosis of aftercare following hip hemiarthroplasty (a partial hip joint replacement) and severe dementia (disorder of the brain that results in declined cognition causing individuals to lose the ability to think and appropriately respond to information). Review of Resident 2's Minimum Data Set (comprehensive assessment 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 failed to ensure dental care was provided for one of two sampled residents (Resident 1) when Resident 1 had an unwitnessed fall on 7/4/24, which resulted in missing front teeth, and no oral assessment and/or follow-up dental care was provided. This failure led to Resident 1 experiencing pain, difficulty eating, potentially contributed to his weight loss, and had the potential to negatively affect his psychosocial well-being and quality of life. Findings: Review of Resident 1's Observation Report indicated Resident 1 was admitted to the facility with Parkinson disease (progressive disorder which affects the nervous system and the parts of the body controlled by the nerves) and need for assistance with personal care. Review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 6/13/24, indicated, .Section L- Oral/Dental Status .D. Obvious or likely cavity or broken natural teeth [unmarked] .E. Inflamed or bleeding gums or loose natural teeth [unmarked] F. Mouth or facial pain, discomfort with chewing…

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 medications ordered by the physician were administered to one resident (Resident 1) when dronabinol (a medication used to increase appetite) and vitamin B6 (supplement) were not acquired from the pharmacy in a timely manner. These failures resulted in Resident 1 missing 6 doses of dronabinol and 3 doses of vitamin B6 and had the potential to negatively affect Resident 1 ' s health. Findings: Resident 1 was admitted to the facility in mid-2023 with diagnoses which included severe protein calorie malnutrition (inadequate intake of food as a source of protein, calories, and other essential nutrients) and gastric bypass (surgery that helps you lose weight by changing how your body handles the food you eat but limits the nutrients that your body can absorb). A review of Resident 1 ' s Minimum Data Set (MDS, an assessment tool) revealed a brief interview of mental status (BIMS) score of 8 (score can range from 00 for severe impairment to 15 for no impairment) which indicated moderate cognitive impairment (difficulty 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 interview and record review, the facility failed to ensure one resident (Resident 1) received treatment and care in accordance with professional standards of practice on 5/16/23 when, 1a. Licensed Nurse (LN) 3 gave orange juice to Resident 1 for a low blood sugar reading of 59 milligrams per deciliter (mg/dL, units of measure. Normal blood sugar is 70 to 99 mg/dL) instead of physician ' s ordered glucagon gel (a sugary gel used to increase a low blood sugar reading) to increase Resident 1 ' s low blood sugar reading, b. LN 3 did not notify Resident 1 ' s physician of the low blood sugar reading per the physician ' s order, and, c. LN 3 did not recheck Resident 1 ' s blood sugar level every 15 minutes until a blood sugar level of at least 110 mg/dL was reached. These failures resulted in Resident 1 ' s physician ' s orders not being followed and had the potential for Resident 1 ' s health to be negatively affected. Findings: Resident 1 was admitted to the facility in mid-2023 with diagnoses which included diabetes (inability for the body to maintain normal blood sugar…

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

Based on interview and record review, the facility failed to ensure the Physician's Orders for Life Sustaining Treatment (POLST- a written physician's order that documents the types of medical treatment the resident wants to receive during serious illness, for example, chest compressions if the heart stops beating and/or a tube placed down the throat if breathing stops) was fully completed and/or uploaded to the resident's Electronic Health Record ([EHR]- information stored in the facility's computer system) per facility policy for five of eight sampled residents: 1. Resident 6 2. Resident 25 3. Resident 54 4. Resident 275 5. Resident 276 These failures could have resulted in a delay in treatment during a medical emergency and/or the incorrect life sustaining treatment administered to the Resident. Findings: 1. During a review of Resident 6's clinical record titled, Resident Face Sheet (a record that contains the resident's demographic information), indicated Resident 6's diagnoses included heart failure (when the heart doesn't pump adequately), high blood pressure (the high force…

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

Based on observation, interview, and record review, the facility failed to ensure one of twenty sampled residents (Resident 6) was treated with dignity, when the facility failed to replace Resident 6's missing upper dentures, leaving Resident 6 without her upper dentures for over one month. This failure resulted in Resident 6 requiring a change in the texture of her diet (in order to eat without upper teeth) and resulted in Resident 6 self-isolating from other residents due to embarrassment of missing teeth. Findings: Review of Resident 6's clinical record titled, Resident Face Sheet (a document that contains the resident's demographic information), indicated Resident 6's diagnosis included a need for assistance with personal care. During a concurrent observation and interview on 2/06/24 at 11:30 a.m., with Resident 6, Resident 6 was observed without upper dentures in her mouth. Resident 6 stated, Do you know how hard it is to eat with no upper teeth? Resident 6 further stated the dentures were lost soon after admission to the facility, about a month ago. A review of Resident 6's…

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

Based on observation, interview, and record review, the facility failed to maintain a clean environment for two of 20 sampled Residents (Residents 26 and 30) when the fall mats beside their beds were soiled and torn. This failure had the potential to cause infection for Residents 26 and 30. Findings: During an observation on 2/6/24, at 10:00 a.m., the two fall mats in Resident 26's room were observed with sticky substance and tears. During an observation on 2/6/24, at 10:45 a.m., the two fall mats in Resident 30's room were observed with tears. During a concurrent observation and interview on 2/9/24, at 9:00 a.m., with the Infection Preventionist Nurse (IPN), in Resident 30's room, the IPN confirmed the mats in Resident 30's room were torn. The IPN stated the torn mats could lead to infection from cross contamination because it was difficult to clean a torn surface. Review of facility policy and procedure titled, Maintenance Department undated, indicated, The Maintenance Department will implement effective systems to ensure the facility and equipment are clean, safe, and in good…

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

Based on observation, interview, and record review, the facility failed to provide oxygen therapy per its policy for one of two sampled residents (Resident 28) on oxygen therapy, when Resident 28's oxygen tubing had not been changed for 17 days. This failure had the potential to lead to respiratory infection for Resident 28. Findings: During a concurrent observation and interview with Resident 28, on 2/6/24, at 10:05 a.m., Resident 28's oxygen tubing was dated 1/20/24. Resident 28 stated, It has been a while since they changed it. During an interview on 2/6/24, at 2:17 p.m., Licensed Nurse (LN) 3 stated, Oxygen tubing should be changed every Saturday. We missed the 27th of January and the 2nd of February. Review of the facility's policy and procedure titled, Oxygen Equipment dated 5/2017, indicated, .tubing .are to be changed every 7 days and as needed.

Based on observation, interview, and record review, the facility failed to ensure the medication error rate was less than 5% (% or percentage is a fraction of a number out of 100) during medication administration. The facility had a total of five errors out of 32 opportunities, which resulted in a facility wide medication error rate of 15.6%. Medication observations were conducted over multiple days, at varied times, in random locations throughout the facility. The five medication errors were identified in two residents (Resident 35 and Resident 175) out of eight residents observed for medication administration observation as follows: 1. Resident 35's medications were crushed and mixed in one cup for Tube Feeding (TF, a way to provide nutrition and medications when one cannot eat or drink safely by mouth. The tube is surgically inserted into the stomach) administration; and, 2. Resident 175's medications were crushed when the product labeling did not indicate crushing the medication was a safe practice. These unsafe medication administration practices could result in medication…

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

Based on observation, interview, and record review, the facility failed to ensure medications were labeled and used according to the manufacture specifications for a census of 74 when: 1. The medication cart (a wheeled cart that stores medications given to residents on daily basis) in Sequoia station contained medications not dated upon opening; and, 2. The medication cart in Harmony station contained medications not dated upon opening. These failures could result in unsafe medication use in the facility and ineffective medication treatment. Findings: 1. During a concurrent interview and medication cart inspection, accompanied by Licensed Nurse (LN) 6, in the Sequoia nursing station, on 2/6/24, at 2: 22 PM, medication cart 2 contained the following medications without a date marked when opened as follows: a. albuterol and ipratropium [also called Duoneb, a liquid medication used in a breathing machine to help with asthma or shortness of breath] inhalation solution, inside a box with opened foil pouch, was not marked with an opened date. Review of the manufacturer label on the box…

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

Based on observation, interview, and record review, the facility failed to ensure one of twenty sampled residents (Resident 6) had a referral to a dentist following the loss of Resident 6's upper dentures shortly after admission to the facility. This failure resulted in Resident 6 being without upper dentures for over a month and affected Resident 6's quality of life. Findings: Review of Resident 6's clinical record titled, Resident Face Sheet (a document that contains the resident's demographic information), indicated Resident 6's diagnoses included a need for assistance with personal care. During a concurrent observation and interview on 2/6/24 at 11:30 a.m., Resident 6 was observed without upper dentures in her mouth. Resident 6 stated, Do you know how hard it is to eat with no upper teeth? Resident 6 further stated the dentures were lost soon after admission to the facility, about a month ago. A review of Resident 6's clinical record titled, Observation Report, dated 12/19/23 at 4:56 p.m., by Licensed Nurse (LN) 5, indicated Resident 6 was admitted to the facility with a full…

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

Based on observations during the initial tour of the kitchen, interview, and record review, the facility failed to follow its policy and procedure for safe storage of food when: 1. Staff was not wearing a hair covering; and, 2. Expired food was available for consumption These failures had the potential to lead to contamination of food for all 74 residents. Findings: 1. During an observation on 2/6/24, at 8:35 a.m., the Director of Dining Services was in the kitchen without a hair covering. The Director stated he should have a hair covering and forgot to put one on when he entered the kitchen. 2. During an observation on 2/6/24, at 8:42 a.m., there was a box of Popsicles observed in the freezer labeled to use by 9/16/23. During an observation on 2/6/24 at 8:43 a.m., there was a container of curry powder dated good thru 5/28/23. During an interview with the Kitchen Services Manager on 2/6/24, at 8:50 a.m., she stated all staff should be wearing head coverings while in the kitchen and there should be no expired food in the kitchen as this may cause contamination. 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.

Based on observation, interview, and record review, the facility failed to document in the electronic health record (EHR) for one of twenty sampled residents (Resident 6) when, there was no documentation on the measures taken by the facility to replace Resident 6's missing upper dentures. This failure had the potential to result in staff being unaware of Resident 6's missing upper dentures with the delay in documentation. Findings: During a concurrent observation and interview on 2/6/24 at 11:30 AM, Resident 6 was observed with lower dentures but no upper dentures. Resident 6 stated, Do you know how hard it is to eat with no upper teeth? Resident 6 stated her dentures had been missing since she arrived at the facility, about a month ago. During a concurrent interview and record review on 2/7/24 at 4 PM, Resident 6's progress notes were reviewed with the Social Services Director (SSD). The SSD stated the family reported to her that the dentures of Resident 6 were missing. The SSD stated Resident 6's family was informed the facility would reimburse them for the cost of replacement 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 failed to store foods according to professional standards for food safety for a total of 63 residents when: 1. The resident refrigerator contained unlabeled drinks and resident food past the best by date; 2. A non-food grade can liner was used to store flour; 3. There was an opened pack of tortillas that was not labeled with the open and use by date; 4. A bag of frozen biscuit dough was left open to air; and 5. A bottle of food coloring was not removed from kitchen by use by date. These failures had the potential to increase the risk of foodborne illnesses among residents who received food from the kitchen. Findings: 1. During a concurrent observation and interview, on 7/14/22, at 10:08 a.m., in the medication room of Redwood and Harmony station, the resident refrigerator where outside food was kept was checked with Licensed Nurse (LN) 1. LN 1 stated food brought in from the outside in the resident's refrigerator should be labeled with resident's name, date received, and resident's room number. LN 1 confirmed the grape…

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 respiratory care was provided in accordance with professional standards of practice for a census of 63 when: 1. Resident 59 and Resident 43's oxygen concentrator (a machine used to deliver extra oxygen to a person) filter was covered in dust/debris; and 2. Oxygen tubing and/or a nebulizer mask (a device used to administer a medicated breathing treatment) and tubing was not changed at the frequency indicated for Resident 8, Resident 59 and Resident 43. These failures had the potential to result in ineffective oxygen therapy and the spread of infection. Findings: 1. During a concurrent observation and interview, on 7/12/22, at 11:30 a.m., Licensed Nurse (LN) 2 confirmed, Resident 43's and Resident 59's filter on the oxygen concentrator was covered in lint and dust and was a gray color in appearance. LN 2 stated that the filter should be checked and cleaned at least weekly. LN 2 removed the filter from Resident 59's oxygen concentrator, washed it in the bathroom sink with water, and showed that the filter…

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 properly prepare pureed foods to ensure flavor and palatability for five of five residents (Resident 51, Resident 50, Resident 15, Resident 6, and Resident 8) who were on a pureed food diet when, pureed food recipes were not followed for the preparation of the lunch meal on 7/12/22. This failure had the potential for resident's nutritional needs not to be met. Findings: During a concurrent observation and interview on 7/12/22, at 10:14 a.m., [NAME] 2 placed a measured amount of butter into the pan of drained cooked carrots on the stove. [NAME] 2 then measured out water and poured it over the carrots. [NAME] 2 then emptied the contents of the pan into the blender and turned the blender on. When asked how much water was added to the drained pan of carrots, [NAME] 2 stated that she used the amount that the recipe called for. [NAME] 2 confirmed she then added 2/3 cups of a thickening agent to the blender and turned on the blender again.…

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 infection prevention procedures were followed when: 1. One Licensed Nurse (LN) 9 did not perform hand hygiene during wound care, 2. One LN, LN 5 did not wear the correct personal protective equipment (PPE) when caring for residents in the Yellow Zone (an area in the facility where persons under investigation (PUI) for COVID-19 rooms are). 3. A used insulin syringe with an attached needle was left on Resident 13's nightstand. 4. Shared glucometer (device used to measure the blood sugar level), was not cleaned and sanitized in between resident care. These failures had the potential to put residents at increased risk for infections, including COVID-19 (a potentially fatal respiratory illness). Findings: 1. Resident 419 was admitted to the facility in the summer of 2022 with diagnoses which included pressure ulcers (injuries to the skin and underlying tissue). During a wound care observation for Resident 419 on 7/13/22, at 9:50 a.m.,…

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 an allegation of suspected resident to resident physical abuse (Resident 4 and Resident 14) was reported to the Department in a timely manner, for a census of 63. This failure resulted in a delay in the abuse investigation process and decreased the facility's potential to protect residents from physical and psychosocial harm. Findings: A review of Resident 4's admission Record indicated Resident 4 was admitted to the facility in the Summer of 2022 with diagnoses which included difficulty in walking, muscle weakness, and dementia (a general term for loss of memory, language, problem- solving and other thinking abilities that are severe enough to interfere with daily life). A review of Resident 14's admission Record indicated Resident 14 was admitted to the facility in the Spring of 2022 with diagnoses which included dementia. On 7/7/22 the Department received a report alleging Resident 4 was pushed out of his wheelchair by Resident 14. The alleged date of the allegation was documented as 7/1/22. A review of Resident…

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 develop a comprehensive care plan for one of 22 sampled residents (Resident 22) when Resident 22's fall care plan did not include his most recent fall or the current use of fall interventions. This failure placed Resident 22 at risk for falling again and had the potential for risk of injury and harm to the resident. Findings: A review of Resident 22's admission Record indicated Resident 22 was admitted to the facility in the Spring of 2022 with diagnoses which included dementia (a general term for loss of memory, language, problem- solving and other thinking abilities that are severe enough to interfere with daily life), muscle weakness, unsteadiness on feet, and a history of falls. A review of Resident 22's clinical record titled, Event Report, dated 7/13/22, indicated, .[Resident 22] was noted by staff on floor in a sitting position at bedside on mat .No injuries noted at this time. [Resident 22] was then helped back to bed by staff . A review of Resident 22's clinical record titled, Event Report, dated 7/14/22,…

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

Based on observation, interview, and record review, the facility failed to provide professional standards of practice for two of twenty-two sampled residents (Resident 33 and Resident 14) when, Resident 33 and Resident 14's insulin (a medication used to help control the amount of blood sugar in your body) order was not followed. This deficient practice had the potential to result in hypoglycemia (low blood sugar level) for Resident 33 and Resident 14. Findings: 1. Review of Resident 33's admission record indicated that Resident 33 was admitted to the facility late 2015 with a diagnosis of diabetes mellitus (a chronic condition that affects the way the body processes blood sugar). During an observation on 7/12/22, at 12:56 p.m., Resident 33 was laying in bed, with her lunch tray in front of her. Resident 33 had eaten her potatoes, yogurt, and fruit. Licensed Nurse (LN) 3 entered Resident 33's room and checked her blood glucose level (BG; a sugar that is the body's primary source of energy). During an observation on 7/12/22, at 1:04 p.m., LN 3 administered a dose of insulin 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 observations, interviews, and record reviews, the facility failed to ensure one of two resident who smoked (Resident 16) received adequate supervision to prevent an avoidable accident when, Resident 16's smoking care plan interventions were not implemented. This failure had the potential to cause an avoidable injury to Resident 16. Findings: Review of Resident 16's admission record indicated that Resident 16 was admitted to the facility early 2021 with a diagnosis of nicotine dependence. During an interview on 7/13/22, at 2:20 p.m., Resident 16 stated that he kept his cigarettes and lighter in his pocket. Resident 16 explained, he would go outside and smoke whenever he wanted to. Resident 16 stated, he did not wear a smoking apron and staff were not present with him when he smoked. During an interview on 7/15/22, at 6:48 a.m., Licensed Nurse (LN) 8 stated he was familiar with Resident 16 and his cares. LN 8 stated that Resident 16 smoked in the past, about two months ago, but he had not seen Resident 16 smoke in a while. LN 8 stated, another resident here also smoked, but…

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, observation, and record review the facility failed to ensure safe and accountable medication handling for a census of 63 when: 1. The Ekit (Emergency Kit- a sealed container for emergency medications uses) medication box was stored unsealed with no documentations for two missing medications. 2. The unused or discontinued medications were disposed of without double signature of the two licensed staff and the hazardous medications (medications that may pose health and safety hazard to humans or the environment) were not disposed in the facility's designated hazardous waste container. 3. Narcotic medication (medications with high potential for abuse or unlawful use) called Hydrocodone/ Acetaminophen (or Norco; a combination pain medication) removal from the Controlled Drug Record (or CDR, a paper record that tracked narcotic medication use) were not documented in the Medication Administration Record (or MAR- a legal document that recorded the medications given to a residents) when administered to Resident 2. 4. The monitoring parameter for measuring blood sugar (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, observation, and record review the facility failed to ensure safe medication storage practices in the two out of two medication rooms (a locked room used to store medications and supplies) and two out of four storage carts (a mobile cart stored medications and supplies needed for administration) when: 1. Expired (outdated) medication and supplies were stored in the active storage areas of the medication room. 2. Unlabeled prescription medications were stored in the active storage areas of the medication room and the treatment cart. 3. Undated multidose containers were stored in active storage areas in the medication cart. 4. Discontinued medications were stored in the active storage areas in the medication room and treatment cart. 5. Opened and uncapped eye drop medication was stored in the medication cart. 6. Refrigerator temperature was not monitored where the TB testing medication called Mantoux was stored (TB stand for Tuberculosis which could cause serious spreadable lung infection;…

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.