Sunnyvale Gardens Post Acute

Based on observation, interview and record review, the facility failed to ensure services provided were in accordance to standards of practice when staff did not use the correct denture cleanser for one out of eight sampled residents(Resident 26). This failure had the potential to affect the integrity of Resident 26's dentures and may not be effective to remove stains and kill bacteria. Findings: During a concurrent observation and interview on 11/12/24 at 10:01 a.m. in Resident 26's room with Certified Nurse Aide (CNA) S, CNA S, with gloved hands, took the dentures from Resident 26's mouth. CNA S proceeded to go to the rest room with a basin and toothbrush. CNA S used liquid hand soap and water to clean Resident 26's dentures. CNA S confirmed she used the liquid hand soap in the rest room to clean the dentures. During an interview on 11/14/24 at 12:59 p.m. with the Infection Preventionist (IP), the IP stated toothpaste must be used to clean residents' dentures and not the liquid hand soap in the rest room. Review of facility's policy and procedure, Dentures, Cleaning and Storing…

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 follow their policy and procedures for enteral feeding (a method of delivering nutrients and fluids directly to the gastrointestinal [GI] tract) care for two of two sampled residents (Residents 110 and 64) when: 1. Licensed vocational nurse G (LVN G) did not check the placement (by injecting air and listening to the stomach with a stethoscope) of a gastrostomy tube (G-tube, a tube that goes directly into the stomach to deliver feeding formula and medications), and did not check for any residual (the amount of fluid remaining in the stomach after enteral feeding, which is measured by withdrawing the fluid with a syringe and checking the amount) prior to flushing the G-tube with water; and, 2. Registered nurse L (RN L) did not check G-tube placement before G-tube medication administration. These failures had the potential for enteral feeding complications (such as aspiration of medications, enteral formula, water) that could cause harm to Residents 110 and 64. Findings: 1. Review of Resident 110's clinical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow their policy regarding use of side rails (also called bedrails, metal or plastic bars attached to the bed ranging in size from full to one-half, one quarter, or one-eighth lengths) for one out of 26 sampled residents (Resident 22), when Resident 22 did not have a documented physician's order for the use of side rails, there was no documentation that indicated the facility attempted alternatives prior to installing the side rail, and there was no documentation that indicated the facility assessed for risk of entrapment (getting caught, trapped, or entangled in the space in or around the side rail). These failures had the potential to compromise the resident's safety. Findings: During an observation on 11/12/24 at 11:38 a.m., the bed of Resident 22 was inspected. Resident 22's bed had one upper ¼ side rail in the upright position on the left side of the bed. No side rail was observed on the right side of the bed. During an…

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

Based on observation, interview, and record review, the facility failed to ensure staff had the necessary competency to respond to resident's needs when two (Resident 90 and Resident 122) out of four residents were assisted by the laundry aide. This failure had the potential for the facility to not meet residents' safety needs. Findings: During an interview on 11/15/24 at 3:16 p.m. with the Director of Nursing (DON), the DON stated there was a monitoring log for the sitters to use for the residents. During an interview on 11/18/24 at 10:38 a.m. with Laundry Aide (LA) E, LA E stated she was assigned to be the sitter for four residents, but was not able to state the names of the residents she was assigned to watch. LA E also stated, I'm just watching them not to fall down. I call the CNA [Certified Nurse Aide] or the nurse if I need help right away. LA E confirmed she did not have a monitoring log while watching residents. During a concurrent observation and interview on 11/18/24 at 11:06 a.m., Laundry Aide E (LA E) entered Resident 122's room, took Resident 122's call light button…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide appropriate social services (SS) support for one of three residents (Resident 59) when there was a lack of SS support for Resident 59, who had a history of domestic violence (also called intimate partner violence, a pattern of behavior in any relationship that is used to gain or maintain power and control over an intimate partner). This failure resulted in a lack of timely psychosocial support for Resident 59. Findings: Review of Resident 59's clinical record titled, admission Record, indicated, Resident 59 was admitted to the facility initially on 3/22/2024 with diagnoses including chronic obstructive pulmonary disease (COPD- a long lasting lung disease), respiratory disorders (a type of disease that affects the lungs and other parts of the respiratory system), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety disorder (a mental illness that causes constant…

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 two of 26 sampled residents (Residents 6 and 111) were free from unnecessary medications when Resident 6 received Lasix (used to treat edema [fluid retention; excess fluid held in body tissues]) and Resident 111 had two orders for oxycodone (a potent controlled medication for pain) 5 milligram (mg, unit of measure). This deficient practice resulted in unmonitored medical condition; and, duplicate orders that had the potential for excessive dose/adverse effects for the resident. Findings: 1. Review of Resident 6's clinical record indicated Resident 6 was admitted to the facility with diagnosis including heart failure (a condition in which the heart muscle can't pump enough blood to meet the body's needs for blood and oxygen). A review of Resident 6's physician's orders indicated an order for Lasix 20 mg, 1 tablet by mouth one time a day for edema HOLD if (systolic blood pressure) SBP < (is less than) 100, dated 11/10/24. A review of Resident 6's medication administration record (MAR) indicated 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, interviews, and record review, the facility failed to ensure three out of 26 sampled residents (Residents 59, 6, and 63) were free from unnecessary psychotropic (drugs that affects brain activities associated with mental processes and behavior) medications when: 1. Resident 59 received an anti-anxiety (a type of medication used to prevent or relieve anxiety) and two different antidepressants (type of medication used to treat depression) without documentation wherein non-pharmacological interventions were attempted prior to psychotropic medication used; 2. Resident 63 received Abilify (is an antipsychotic [drugs treat psychosis] medication that helps treat several kinds of mental health conditions) without target behavior monitoring, and there was no documentation of non-pharmacological interventions implemented; and, 3. Resident 6 received Trazodone (anti-depressant medication) without monitoring for hours of sleep. These failures had the potential for increased risks associated with the…

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

Based on observation, interview, and record review, the facility failed to ensure implementation of their Antibiotic (medication infection) Surveillance (timely collection, analysis, and communication of data) protocol when antibiotic use for two (Resident 111 and Resident 331) out of three sampled residents whey they were not monitored and tracked. This failure had the potential to place residents at risk for a development of antibiotic resistance (when bacteria change to resist antibiotics that once effectively treated them). Findings: During an observation of Resident 331 on 11/12/24 at 9:26 a.m. in Resident 331's room, a PICC (peripherally inserted central catheter, a thin flexible tube that is inserted into a vein in the upper arm used to deliver medications and other treatments) line was noted in Resident 331's right upper arm. Resident 331's left foot was observed to be covered with elastic bandage with a drainage tubing connected to a wound vacuum (a suction device that is applied after a wound is dressed). A review of Resident 331's clinical record indicated an admission…

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 call lights were properly functioning and accessible for four sampled residents (Resident 97, 104, 122, and 232) when: 1. Resident 232 's call light was not in reach while in bed; 2. Resident 97 and Resident 104's call lights were not functioning; and, 3. Resident 122's call light was not within reach while in bed. These failures could prevent residents from communicating with staff for basic needs and in emergency situations, which could potentially compromise the resident's care and safety. Findings: 1. Review of Resident 232's minimum data set (MDS, an assessment tool) dated 11/1/24, indicated he required supervised assistance by staff for bed mobility, dressing, toileting, bathing, and personal hygiene. Resident 232 required moderate assistance for toilet transfers and chair to bed transfers. During an observation in Resident 232's room on 11/12/24 at 12:49 p.m., Resident 232 was lying in the bed and his call light was on 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, and record review, the facility failed to follow their policy and procedure (P&P) to safely secure and return personal belongings to one of one sampled resident (Resident 1) after Resident 1 was transferred to acute hospital (AH: where residents receive short term treatment for an urgent medical condition or severe illness). This failure had the potential for losing Resident 1's personal belongings, and negatively affect Resident 1's psychosocial wellbeing. Findings: A record review of Resident 1's face sheet (FS: a document that gives a resident's information at a quick glance) indicated Resident 1 was admitted to the facility on [DATE] and discharged to AH on 2/3/2024 following an episode of fall and did not return to facility from AH. Resident 1 had an assigned significant family member as resident representative (RP: a person authorized to act as a resident's agent). Review of Resident 1's inventory of personal effects (IPE) document indicated there were several personal items documented…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement their abuse policy and procedure for one of one resident (Resident 2) when the facility did not report Resident 2's injury of unknown source. This failure resulted in Resident 2's fractures of left third and fourth metacarpals (broken middle and ring fingers) of unknown source not reported to required agencies (California Department of Public Health [CDPH], law enforcement agency, and Long-Term Care Ombudsman). This failure had the potential to compromise the safety of the residents in the facility. Findings: Review of Resident 2's face sheet (a document that gives a resident's information) indicated, Resident 2 was admitted to the facility with diagnoses including unspecified sequelae (after effect of a disease, condition or injury) of cerebral infarction (also called stroke), wedge compression fracture of unspecified thoracic vertebra (broken backbone that occurs when the front part of the backbone collapses giving it a wedge…

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 maintain accurate and systematically organized documentation in accordance with accepted professional standards and practices for three of three sampled residents (Resident 1, 2, and 3) when: a. Nursing documentation for Resident 1's allegation of abuse was not documented; b. Nursing documentation for Resident 2's allegation of abuse was not documented; c. There were no care plans for Residents 1, 2, and 3 for abuse allegations. These failures resulted to an inaccurate documentation of the care provided for Residents 1, 2, and 3 Findings: a. Review of Resident 1's face sheet (a document that gives a resident's information at a quick glance) indicated Resident 1 was admitted to facility on 2/1/2023 with diagnoses including compression fracture (broken bones due to weakened bones) of T 11-12 (lower section of middle back bones), and dorsalgia (back pain) Review of Resident 1's minimum data set (MDS, an assessment tool) assessment dated [DATE] indicated…

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

Based on observation, interview, and record review, the facility failed to ensure proper medication storage and labeling of medication for two out of three medication storage rooms and three out of five medication carts, when: 1.Seven insulin (medication to treat high blood sugar) pens (devise to use to give preloaded insulin) had the pharmacy label on the caps instead of the body of the pens. 2.Two opened bottles of lorazepam ( medication used to treat anxiety disorder) were found in the medication refrigerator with no open date . 3.One inhaler (handheld portable device that delivered medication into the lungs) was found in the medication cart without open date. 4. An expired Humulin N (an intermediate acting insulin) insulin vial (a small glass or plastic bottles used to store liquids, or powder medication) was found in a medication cart These deficient practices had a potential for residents to receive medications with reduced potency from expired medications, and /or medication error due to medications not being labeled. Findings: 1. During a concurrent observation and interview…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to treat residents with respect and dignity, and care for each resident in a manner and in an environment that promoted their rights that enhanced their quality of life for four of of 23 sampled residents (Resident 36, 39,102, and 162) when 1. For Resident 102, the primary care physician (PCP, her attending physician) called her as, too heavy to reach your goal, the interdisciplinary team (IDT, facility staff members from different departments who coordinate care provided to residents) did not invite her to participate during the care planning conference, and she was categorized as incontinent (having no or insufficient voluntary control over urination or defecation) which resulted to her feeling insulted and angry; 2. For Resident 162, staff did not update him or his responsible party (RP, decision maker) of his rehabilitation therapy schedule; 3. Certified Nursing Assistant M (CNA M) did not provide the privacy to Resident 36 before cleaning…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure care and services were provided in accordance with professional standards of practice for six of 23 sampled residents (Residents 94, 28, 107, 11, 36, 43, ) when: 1. For Resident 94, a physician order for oxygen (O2, a colorless and odorless gas that people need to breathe ) was not followed and signage was not provided; 2. For Resident 28, license nurse did not follow the physician's order to administer O2 continuously at 2LPM (two liters per minute) via NC (nasal cannula); 3. For Resident 107, license nurse did not ensure the physician's order to increase the O2 to 4LPM via NC during therapy, and did not carry out the physician's order regarding the laboratory orders; 4. For Resident 11, the physician's order for oxygen was not followed; 5. For Resident 36, the physician's orders for oxygen and Norco (medication used to treat pain) were not followed; and 6. For Resident 43, there was no treatment order for his opened skin areas…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were free of accidents for four of 23 sampled residents (Residents 15, 45, 74, and 410) when: 1. Resident 15 was transferred using a Hoyer lift (equipment used to transfer residents using a sling) with only one staff; 2. Staff did not keep Resident 45 's smoking materials, and oxgen signage was not posted; 3. Staff did not provide adequate supervision to prevent Resident 74 going out of facility unattended; 4. Licensed nurses did not monitor Resident 410 post fall, inform the physician about the fall , and update the fall care plan . These failures had the potential to result in serious injury to the residents in the facility. Findings: 1. Review of Resident 15's clinical record indicated he was admitted on [DATE] and had the diagnoses of transient ischemic attack (TIA, temporary stroke), muscle atrophy (decrease in size of muscle), fall, and fracture of left femoral neck (broken hip bone). Review of Resident 15's Minimum…

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 12 of 23 sampled residents (Resident 102, 162, 10, 82, 2, 3, 7, 11, 36, 52, 22 and Resident 45) were free from unnecessary psychotropic (any drug that affects brain activities associated with mental processes and behavior) medications when the psychotropic medications ordered did not include monitoring of the targeted behaviors every shift, and the monitoring of side effects were not specific to each type/classification of psychotropic medications. These failures had the potential to result in staff not monitoring the intended target behaviors, the side effects of the medication and not properly evaluating the effectiveness of the psychotropic medications. Findings: 1. Review of Resident 102's clinical record indicated she was admitted on [DATE] with diagnosis that included depression (behavior that affects the person's ability to work, sleep, study, eat, and enjoy once-pleasurable activities). Her physician's order dated 10/4/22…

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 and interview, the facility failed to ensure food was stored in accordance with professional standards for food safety when 1. Undated food, food past their best-by or use-by date, and expired food were found in the refrigerator and on the shelves in the kitchen; and 2. The ice machines did not have air gap. These failures had the potential to cause the growth of micro-organisms which could cause foodborne illness and cross-contaminated food for the 109 residents eating at the facility. Findings: 1. On 11/14/22 at 8:55 a.m., during an observation of the refrigerator and the storage shelves in the kitchen, with the Food Service Director (FSD), the following were observed: a. Two boxes of apple juice base were undated b. Six bags of frozen spinach were undated c. Two coconut cream pies were undated d. Two boxes of croissants were undated e. Four boxes of vanilla wafers best by 12/6/21 f. Four bags of angel food cake mix used by 9/30/22 g. 100 bags of one ounce of crackers used by 6/25/22 h. One bottle of banana extract expired on 9/2022 i. One bag of 25 pounds…

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 2. Review of Resident 2's physician order indicated he had an order for oxygen 4 liters (L, a metric unit of volume) per minute every shift for short of breath, started on 1/10/22. Resident 2 also had an order for ipratropium-albuterol solution (used to relax and open the air passages to the lungs to make breathing easier) 0.5-2.5 (3) milligrams (mg, a metric unit of mass) per 3 milliliters (ml, a metric unit of volume) inhale orally four times a day for short of breath, started on 1/12/22. During an observation with licensed vocational nurse N (LVN N) on 11/14/22 at 1:09 p.m., Resident 2 was on oxygen. The oxygen tubing was undated, and the filter of the oxygen concentrator was dusty. Resident 2's nebulizer (a device that turns the liquid medicine into a mist so it can be inhaled into the lungs) mask and tubing were also undated. During a concurrent interview with LVN N, she confirmed the filter of Resident 2's oxygen concentrator was dusty. LVN N stated the filter of the oxygen concentrator should have been…

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 residents' needs were accommodated for three sampled residents (Residents 31, 9, and 40 ) and one non-sampled resident (Resident 60) when: 1. Bedside call light or equipment was not placed within reach for Resident 31, 9 and 40, which could potentially result to resident's inability to access assistance to meet his needs. 2. Call light was not answered in a timely manner for Resident 60, which had the potential to result in the delay of responding to residents' needs. Findings: 1. During a concurrent observation and interview on 11/14/22 at 9:30 a.m., Resident 31 was lying in bed and her call light was hanging on the left side wall and touching the floor. Resident 31 stated I'm right handed and I can't reach it now. Registered Nurse A( RN A) came and placed Resident 31's call light within reach. During a concurrent observation and interview on 11/16/22 at 12:25 p.m., certified nursing assistant G (CNA G) assisted Resident 31 with her lunch tray. Resident 31 was sitting on the wheelchair and her call…

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 an advance directive (AD, a written instruction, such as a living will or durable power of attorney for health care when the individual was incapacitated) accurately reflect on the Physician Order for Life-Sustaining Treatment (POLST, a document signed by the resident and by the physician which indicated the types of medical treatment the resident wished to receive towards the end of life) and the physician order for one sampled resident ( Resident 27). This failure had the potential for the facility to provide treatment and services that was against the resident's wishes. Findings: Review of Resident 27's admission record report indicated she was admitted to the facility on [DATE] with a diagnosis including dementia (impaired ability to remember, think, or make decisions). Review of Resident 27's POLST dated [DATE], indicated attempt Resuscitation/CPR (cardiopulmonary resuscitation, person would allow all interventions needed to get their heart…

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

Based on interview and record review, the facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN, a notice that transfers potential financial liability) to two of three residents (Resident 89 and 92) in timely manner. This failure had the potential to compromise the residents' right to appeal (apply for reversal of) the facility's decision to discontinue Medicare Part A services (skilled treatments paid for by Medicare). This failure also had the potential to result in the residents or residents' representatives not being informed of their payment responsibilities to the facility after Medicare Part A services ended. Findings: Review of Resident 89's medical record indicated she was admitted to the facility under Medicare Part A on 5/26/22. The medical record further indicated Resident 89 came off Medicare Part A on 6/16/22 and continued living in the facility. Review of Resident 89's SNF Beneficiary Protection Notification Review, filled out by the facility on 11/17/22, indicated the facility initiated Resident 89's discharge from…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop, implement and/or update the care plans for five of 23 sampled residents (Residents 28, 107, 164, 31, and 84) when: 1. For Resident 28, there was no care plan developed for urinary retention, and licensed nurse did not follow the doctor's order to notify the doctor when the bladder scan result was greater than 300 ml. (milliliter, unit of measurement). 2. For Resident 107, there was no care plan developed for limitation in the range of motion (ROM), and urinary incontinence to help prevent pressure ulcer (PU, an injury that breaks down the skin and underlying tissue caused when an area of skin is placed under pressure); and did not implement care plan for left ram swelling and left foot edema. 3. For Resident 31, the care plan did not reflect the correct diagnosis on admission. 4. For Resident 84, the care plan of the nutritional risk was not a person-centered care plan. A personalized care plan identifies resident's individualized…

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 update and revise the individualized and comprehensive care plans to meet individual needs for three residents (Residents 27, 45, and 96 ) when : 1. For Resident 27, an oxygen (O2, a colorless and odorless gas that people need to breathe) care plan was not discontinued when no longer in use. 2. For Resident 45, the port (a device used to draw blood and give treatments, including intravenous fluids, blood transfusions, or drugs.The port is placed under the skin, usually in the right side of the chest) site care plan was not updated to include a new diagnosis after a hospitalization, and; 3. For Resident 96, the discharge care plan was not updated when her discharge plan was changed. These failures had the potential to result in not meeting the residents' needs. Findings : 1. During an observation and concurrent interview with licensed vocational nurse D (LVN D) on 11/14/22 at 9:47 a.m., Resident 27's oxygen tubing was on top of the oxygen…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to meet professional standards when nurse practitioner (NP) added a diagnosis of Schizophrenia or bipolar disorder for the antipyschotic medication use not previously included as one of the resident's diagnoses for one of two residents (Resident 82). This failure could potentially compromise Resident 82's health and safety. Findings: A review of Resident 82's clinical record indicated he was [AGE] year old male, admitted to the facility with diagnoses of encephalopathy (a disease in which the functioning of the brain is affected by some agents or condition such as viral infection or toxins in the blood), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). His MDS (miminum data set, assessment tool) dated 11/4/22 indicated a brief interview for mental status (BIMS, an assessment for cognition) score of 5 that indicated that Resident 82 had a cognitive impairment. During an interview with the NP…

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

Based on observation, interview, and record review, the facility failed to provide nail care for one sampled resident (Resident 31). This failure placed the resident at risk for infection and self-inflicted skin injury. Findings: During an observation on 11/16/22 at 8:08 a.m., Resident 31's fingernails were long, yellowish and has black residue under her fingernails. Resident 31 was observed using her hands to feed herself. During an observation on 11/16/22 at 12:22 p.m., certified nursing assistant G (CNA G) served Resident 31's lunch tray and Resident 31 started to eat using her hand. CNA G did not clean Resident 31 hands. During a concurrent observation and interview on 11/16/22 12:51 p.m., CNA G asked Resident 31 if she wanted to have her fingernails trim and Resident 31 responded yes. CNA G stated she forgot to clean Resident 31 hands prior to eating. CNA G confirmed Resident 31 nails were long and need to be trimmed. During an interview with the director of staff development (DSD) on 11/18/22 at 8:30 a.m., she stated on 11/10/22, CNA G attended Hand Hygiene in service which…

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 appropriate treatment was rendered for one sampled resident (Resident 84) to prevent complications of enteral (refers to the delivery of a nutritionally complete feed, containing protein, carbohydrate, fat, water, minerals, and vitamins, directly into the stomach, duodenum or jejunum) feeding. This failure could result in health complications. Findings: Review of Resident 84's clinical record indicated she was admitted on [DATE] and had the diagnoses of hemoperitoneum (a type of internal bleeding in abdomen), dysphagia (difficulty swallowing), and hypertension (high blood pressure). Review of Resident 84's care plan of Need for feeding tube included Elevate head 30-45 degrees. During an observation on 11/15/22 at 10:32 a.m., Resident 84 was seen lying in bed and head of the bed was elevated less than 30 degrees during enteral feeding. During a concurrent interview and observation with the director of staff development (DSD) on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide care and services in accordance with professional standards of practice for one sampled resident (Resident 45) with a central venous line (a catheter placed into large vein commonly placed in veins of neck, chest, groin, or through veins in the arms to administer medications or prolonged intravenous therapies such as parenteral nutrition ) and receiving parenteral nutrition (TPN, to infuse specialized form of food through an IV) when the central venous dressing was not done properly, there was no flushing order, the physician order did not indicate the correct site , care plan was not revise to reflect the correct site and implement intervention, and intake and output was not initiated .These failures had the potential to affect the residents' health conditions. Findings : During a concurrent observation and interview with the director of nursing (DON) on 11/16/22 at 11:00 a.m., Resident 45's left chest central venous line has a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure resident receiving dialysis (removal of waste and excess fluid from the body) treatment received care consistent with professional standards for one sampled resident (Resident 85) when his Hemodialysis Communication Forms (HCF) were incomplete and missing. This deficient practice had the potential for Resident 85's dialysis care not being properly communicated and could put Resident 85 at risk for complications. Findings: Review of Resident 85's clinical record indicated he was admitted on [DATE] and had the diagnosis of end stage renal disease (kidneys are no longer able to work as they should to meet the body's needs). The clinical record further indicated Resident 85 received dialysis on Tuesday, Thursday, and Saturday. Review of Resident 85's HCFs indicated the HCF was not completed consistently. Resident 85's HCF dated 8/09/22, indicated the Section 1: completed by Manorcare staff was incomplete. HCFs on 7/21/22, 8/13/22, 8/25/22, 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 record review, the facility failed to ensure safe disposal of a used fentanyl patch (a potent narcotic medication applied to the skin for pain) for one of one resident (Resident 18); and controlled substance (drugs with high potential for abuse or addiction) medications were fully accounted for three out of seven residents (Residents 83, 96, and 107), when medications were signed out of the Control Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications) but not documented as given to the resident on the medication administration record (MAR). The failure had the potential for accidental exposure and/or diversion of controlled medications. Findings: 1. During a medication administration observation on [DATE], at 9:14 a.m., in Resident 18's room, Registered Nurse B (RN B) removed the used fentanyl patch and placed a new patch on the resident's right shoulder. During an interview with RN B, on [DATE], at 9:29 a.m., she stated she threw 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 had a medication error rate of 11.11 %, when three medication error out of 27 opportunities during a medication administration for three of 13 sampled residents (Residents 82, 107, and 97) as follows: 1.Resident 82 was given crushed divalproex sodium (brand name: Depakote; medication to treat seizure) ER (extended release, a long-acting form of medication) 2.Resident 107 was given Creon (medication used to treat for people who cannot digest food normally because their pancreas does not make enough enzyme) medication without a meal. 3.Resident 97 been given insulin (medication to lower blood sugar) without priming the needle. These failures had the potential to compromise the residents' medical health and the residents not receiving the full therapeutic effect of the medications. Findings: 1.During an observation of medication administration on 11/14/22 at 9:50 a.m., licensed vocational nurse N (LVN N) was observed preparing four medications for Resident 82. Using a crushing device, she crushed each medication including…

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 sanitary conditions when: 1. Dietary staff did not cover their hair completely with a hairnet; 2. There was no air gap (space in-between drain spout and the in-floor drain inlet) for the coffee machine drain system; 3. A scoop was stored on top of thickener powder container lid; 4. Mixer had multi-color substances; 5. Can opener gear (part of can opener that is behind the blade) had orange substance; 6. A sick dietary staff did not cover her nose with a face mask while she handled the food; and 7. Three of three ice machines had multi-color substances both interiorly and exteriorly. These failures had the potential to cause foodborne illness for 119 out of 125 residents who consumed the food and ice from the facility. Findings: 1. During an initial kitchen tour with food service director (FSD) on 2/24/2020 at 8:11 a.m., [NAME] H, dietary aide I (DA I), DA J, and DA K did not cover their hair on the side and back completely with a hair net. During a kitchen inspection on 2/24/2020 at 2:23 p.m., DA L…

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 accurate controlled substance (CS, medications that can be easily abused and are under strict government control) accountability for four of four CS records reviewed (for Residents 86, 95, 227, and 366), when certain counts of CS medications were signed out of the Controlled Drug Record (CDR, an inventory sheet) but were not documented on the Medication Administration Record (MAR) as given to the residents. The failure resulted in the facility not having accurate accountability of CS medications and potential for abuse or misuse of these medications. Findings: a. During a concurrent interview and record review on 2/25/2020 at 10:45 a.m. with licensed nurse D (LN D) and Unit Manager E (UM E), LN D said the nursing staff were expected to document on the resident's CDR after taking a CS medication out of the resident's supply for administration, and document on the MAR to indicate the medication was given to the resident. A review of Resident 227's physician order, dated 2/10/2020, indicated oxycodone (a CS 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 employ staff with the appropriate competencies and skills to carry out the functions of the food and nutrition service when: 1. Dietary staff did not know how to calibrate (to adjust a device such as thermometer for its accuracy use) the thermometer for the accurate temperature check; 2. Dietary staff did not know how to correctly check the quaternary sanitizer (sanitizer used to clean kitchen counters, tables and surfaces, and used to manually sanitize dishes). The lack of knowledge regarding food and nutrition services had the potential for dietary staff not being able to carry out their job functions properly and ensure sanitary conditions in the kitchen. Findings: 1a. During an observation and interview with [NAME] M on 2/24/2020 at 11:25 a.m., he demonstrated the thermometer calibration by inserting the thermometer into the ice water (ice water contained half water and half ice). The thermometer indicated the ice water temperature was 28 Fahrenheit (F, temperature measure unit). [NAME] M said there 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.

Based on observation, interview and record review, the facility failed to ensure one non-sampled resident (Resident 37) was not wearing clothing that belonged to another resident. This failure had the potential to negatively affect the resident's dignity. Findings: During an observation and concurrent interview with certified nursing assistant Y (CNA Y) on 2/26/2020 at 8:45 a.m., Resident 37 was seen wearing a pair of socks that belonged to Resident 14. Resident 14's name was written on the socks. CNA Y stated she did not notice Resident 37 was not wearing his own socks. She further stated Resident 37's belongings were washed and delivered by the facility. During an interview with Resident 14 on 2/26/2020 at 8:47 a.m., he stated he was not aware his socks were missing. During an interview with laundry supervisor Z (LS Z) on 2/26/2020 at 3:07 p.m., he stated sometimes staff would get belongings from the laundry room instead of waiting for laundry staff to deliver them to the correct rooms. Review of the facility's undated, Theft and Loss Policy, indicated It is the policy 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 observation, interview and record review, the facility failed to ensure call buttons were within reach and/or call lights were answered in a timely manner for three of 25 sampled residents (Residents 30, 72 and 166) and five non-sampled residents (Residents 10, 13, 43, 102 and 365). This failure had the potential to result in the residents' needs not being met. Findings: During an observation on 2/24/2020 at 8:12 a.m., Resident 72 was lying in bed. Her call button was on the floor. During an interview with Resident 365 on 2/24/2020 at 8:39 a.m., he stated it sometimes took an hour for staff to come when he called for assistance. He stated sometimes when he asked for the urinal (a bottle for the resident to urinate into), it took staff an hour to give it to him. Resident 365 added that staff said they were busy. During an observation on 2/24/2020 at 9:10 a.m., Resident 43 was lying in bed. His call light button was in his drawer. During an observation and concurrent interview with Resident 30 on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to verify the preferences for one of five sampled residents (Resident 166) in regards to what types of medical treatments he wanted to receive in the event of an emergency. This failure had the potential to compromise the facility's ability to act in accordance with the resident's wishes during an emergency. Findings: Review of Resident 166's History of Present Illness (description of the resident's current condition) from the acute care hospital, dated 2/3/2020, indicated he was found to have a right upper lung mass suspicious for malignancy (cancer). The document further indicated a recommendation for palliative care (an approach for improving quality of life through relief of pain and other distressing symptoms, not indented to postpone death) consult for POLST (Physician Order for Life-Sustaining Treatment, orders for treatment wishes during an emergency) and/or advanced directive (legal document that specifies what actions should be taken for a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of one sampled residents (Resident 166) received proper assistive device to maintain adequate hearing abilities, and failed to develop and implement a plan of care related to hearing impairment. This deficient practice resulted in Resident 166's limited ability to hear clearly during care and had the potential to negatively affect his psychosocial well-being. Findings: Review of Resident 166's clinical record indicated he was admitted on [DATE]. Review of Resident 166's discharge summary from the acute care hospital, dated 2/3/2020, indicated he had hearing loss. During an observation and concurrent interview with Resident 166 on 2/24/2020 at 2:04 p.m. in his room, the surveyor had to speak loudly and repeat some words during the interview. Resident 166 stated he was hard of hearing and did not have a hearing aid, but he had a new hearing aid prescription. He further stated staff did not help him get a new hearing aid. During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide the necessary assistance to prevent accidents for one of 12 sampled residents (Resident 54). This failure resulted in Resident 54 sustaining a fall with injury. Findings: Review of Resident 54's clinical record indicated he was admitted on [DATE] and had the diagnoses of muscle weakness, need for assistance with personal care and hemiplegia (one side of the body is paralyzed). Review of Resident 54's undated activities of daily living (ADL, daily self-care activities such as bed mobility, transfers, toileting, hygiene, grooming, dressing and eating) care plan indicated Resident 54 had an increased need for assistance related to his disease process. The care plan indicated facility staff was to assist Resident 54 with ADLs as needed. Review of Resident 54's undated fall risk care plan indicated Resident 54 was at risk for falls due to poor coordination, impaired mobility, potential medication side effects, and hemiplegia affecting…

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 necessary care and services for one of two sampled residents (Resident 219) receiving hemodialysis treatment (medical procedure of removing waste products and excess fluid from the blood through an artificial kidney) when the licensed nurse did not follow-up on the communications from the dialysis center. This failure had the potential to cause the resident health complications and risk for fluid overload. Findings: Review of Resident 219's clinical record indicated she had diagnoses including dependence on hemodialysis (a process of removing waste and excess water from the blood in those whose kidneys have lost normal function) and end-stage renal disease (ESRD, kidney failure that requires dialysis or a kidney transplant to survive). Resident 219 was scheduled for dialysis every Tuesday, Thursday, and Saturday. During an observation on 2/26/2020 at 7:24 a.m., Resident 219 was eating breakfast. There was one coffee mug, one glass of milk, and one glass of water on her tray. The diet card read: CHO…

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

Based on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 107) was free from unnecessary psychotropic (drugs that affects brain activities associated with mental processes and behavior) medication. Resident 107 received olanzapine (an antipsychotic medication) without an adequate indication, when his behavioral symptoms did not present a danger to himself or to others. Also, Resident 107 did not receive periodic monitoring of the blood lipids while being on olanzapine and simvastatin (medications that would affect the blood lipids). The failure resulted in unnecessary medication for the resident, and inadequate monitoring for potential side effects and effectiveness of the medication. Findings: a. On 2/25/2020, a review of Resident 107's medical record indicated he was admitted to the facility with diagnoses including vascular dementia with behavior disturbance, muscle wasting and atrophy (wasting or loss of muscle tissue), and unspecified psychosis (mental disorder characterized by a disconnection from reality). A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure an expired medication was removed from active stock in one of three medication carts inspected; and four opened medications were labeled with an open date in two of three medication carts inspected. The failure had the potential for the residents to receive expired medication; or given medications beyond their effective dates. Findings: On [DATE] at 11:14 a.m., an inspection of the Medbridge 2 Medication Cart with licensed nurse C (LN C) identified a house supply (use for multiple residents) bottle of aspirin 325 milligrams (mg, unit of measure), which had an expiration date of 1/2020. Also, there were two opened eye medications for Resident 215, Timolol 0.5% and dorzolamide 2% ophthalmic solution (medications to treat high pressure inside the eye due to glaucoma), which did not have the open date. Additionally, an inhaler Breo Ellipta (an inhaled medication to treat breathing problems) for Resident 17 was opened but did not have…

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.