Sunnyvale Post-Acute Center

Based on interview and document review, the facility failed to provide sufficient number of nursing staff on a 24-hour basis based on Staffing Data Report submitted to Centers for Medicare & Medicaid Services (CMS). This failure had the potential to affect resident's care, health, and psychosocial wellbeing. Findings: During a document review titled, Census and Direct Care Services Hours Per Patient Day (DHPPD), from April through July 2024, indicated the following dates with actual DHPPD were below 3.5 hours: 4/6 - 3.11; 4/13 -3.07; 4/14 - 3.32; 5/5 - 3.43; 5/6 - 3.46; 5/25 - 3.30; 6/16 - 3.48; 6/17: 3.48; 6/29 - 3.29; 6/30 - 3.24; 7/1 - 3.44; and 7/7 - 3.42. Further review indicated the following dates with actual certified nursing assistant (CNA) DHPPD were below 2.4 hours: 4/1 - 2.15; 4/2 - 2.31; 4/3 - 2.38; 4/4 - 2.36; 4/5 - 2.29; 4/6 - 2.05; 4/7 - 2.24; 4/8 - 2.20; 4/9 - 2.40; 4/10 - 2.35; 4/12 - 2.34; 4/13 - 2.03; 4/14 - 2.16; 4/15 - 2.11; 4/16 - 2.25; 4/17 - 2.26; 4/18 - 2.37; 4/19 - 2.30; 4/20 - 2.39; 4/23 - 2.32; 4/24 - 2.22; 4/26 -2.32; 4/27 - 2.37; 4/29 - 2.35; 4/30 -…

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 proper medication storage and labeling of medications when: 1. Multiple expired medications were stored in medication refrigerators (REF) 2 and 1; 2. Two insulin (injectable medication to lower blood sugar) pens identified in REF1 were not labeled with resident-specific information; 3. An oral inhaler was expired and identified in the active stock in the medication room (MR) 2; 4. Discontinued and expired and controlled medication in Medication carts 1 and 2; and 5. Licensed nurses left the medication on the medication cart unattended and the medication cart key on the top of the medication cart unattended. These deficient practices had the potential for residents to receive medications with unsafe and reduced potency from being used past their discard date, medication errors due to medications not being labeled, which could lead to unsafe and ineffective medications for the residents. Findings: 1. During a visit to Med room [ROOM…

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

Based on observation, interview, and record review, the facility failed to ensure the kitchen staff competently carried out the functions of the food and nutrition services department according to facility policy and standards of practice when: 1. A dietary staff member did not demonstrate the correct technique for testing the sanitation level on the dish machine or maintaining the correct wash temperature. 2. Two Dietary Aides did not know how to properly test the sanitizer in the red bucket. These failures in staff competency had the potential to result in improperly sanitized resident dishes and food contact surfaces that could expose residents to food-borne illness in a highly susceptible population of 97 residents. Findings: 1. On 10/14/24 at 8:22 a.m., an observation and interview were conducted with the Dietary Director (DD), and Dietary Aides (DA S and DA Z) about dish washing procedures. DA S stated the dish machine was a low-temp dish machine. DA S was asked to describe how he checked whether the dishwasher was working properly. DA S stated he runs the wash cycle 4-5 times…

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, interviews, and record reviews the facility failed to ensure the Food and Nutrition Services Department, the kitchen, was free from pest and an effective pest control program maintained. This failure had the potential to contaminate food stored in the kitchen which could lead to widespread foodborne illness. Findings: During the initial kitchen tour on 10/14//24 at 8:26 a.m., an observation and interview was conducted with [NAME] (CK) W. A brown bug resembling a cockroach was observed moving across the floor in front of the tray line food preparation area. CK W tried to stomp the bug with her foot but was unsuccessful. CK W stated, I see one or two of them sometimes. On 10/14/24 at 12:01 p.m. an interview was conducted with the Administrator (ADM) about pest control maintenance. The ADM stated the kitchen was due for a quarterly fogging the end of October or the first of November to kill pests like roaches. During an interview on 10/14/24 at 12:05 p.m. with the Pest Company Technician (PCT), the PCT stated the facility's kitchen received a spray out treatment…

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 needs were accommodated for five of 20 sampled residents (Residents 250, 249, 39, 25 and 48) when call light devices were not within reach of the residents. This failure had the potential for a delayed response and not meeting the resident's needs. Findings: 1. Review of Resident 250's face sheet (front page of the chart that contains a summary of basic information about the resident) indicated Resident 250 was admitted at the facility with diagnoses including sepsis (a life-threatening blood infection), pneumonia (an infection/inflammation in the lungs), and diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing). During a concurrent observation and interview with Resident 250 on 10/14/24 at 8:48 a.m., inside Resident 250's room, Resident 250 was lying in bed and his call button (also called call light, a red or white button used to request assistance) was hanging at the head 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 provide the Ombudsman's (a government employee who investigates, reports on, and helps settle complaints) contact information to all residents when the State Long-Term Care Ombudsman's contact information was not available in the resident's care and activity areas. This failure limited resident's rights to have a confidential avenue to talk about a concern and resolved issues at the lowest possible level. Findings: During a group interview on 10/15/24, at 11:30 a.m., with one of 20 sampled residents (6) and six non-sampled residents (20, 21, 27, 34, 43 and 68), Residents (6, 20, 21, 27, 34, 43 and 68) all stated, they did not have the Ombudsman's contact information in the facility. During a concurrent tour of the facility and an interview with the director of nursing (DON) on 10/15/24, at 1 p.m. to 1:09 p.m., the DON confirmed there was no Ombudsman contact information in any part of the facility. The DON stated the facility recently just had new paint put on the walls and that they forgot to place 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 the results of the most recent survey of the facility (the survey results in a binder) was readily accessible to residents, and family members and legal representatives of residents when one of 20 sampled residents (6) and six non-sampled residents (20, 21, 27, 34, 43 and 68) stated they could not access the facility's most recent survey results. This failure potentially limited resident's rights to examine and receive the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility. Findings: During a group interview on 10/15/24, at 11:30 a.m., with one of 20 sampled residents (6) and six non-sampled residents (20, 21, 27, 34, 43 and 68), Residents (6, 20, 21, 27, 34, 43 and 68) all stated, they did not know where to find the survey binder of the facility's survey results for them to review it. During an observation on 10/15/24, at 12:53 p.m., in the facility's lobby area, the facility survey binder was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their policy and procedure (P&P) for an advance directive (AD, a written instruction, such as a living will or durable power of attorney that authorizes another person to act on behalf of the resident) and completion of the Physician Order for Life-Sustaining Treatment (POLST, a document that specifies the medical treatments the residents wants to receive during serious illness) form for three out of five sampled residents (Residents 42, 16 and 26). These failures had the potential to lead to the delivery of unnecessary or inappropriate medical services against residents' goals and wishes. Findings: Review of Resident 42's admission record indicated Resident 42 was admitted to the facility on [DATE]. Review of Resident 42's POLST form dated 7/24/24 indicated section D for AD was not completed. Further review of Resident 42's clinical record indicated there was no documented copy of an AD signed by the resident or responsible party, or evidence…

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 an orderly, comfortable, and homelike environment for one of five sampled residents (Resident 69) when Resident 69's closet door did not latch to remain close. This failure had the potential to result for Resident 69's decreased sense of well-being and an uncomfortable environment. Findings: During an observation and interview on 10/14/24 at 11:18 a.m., inside Resident 69's room, Resident 69 was observed walking inside the room and was about to change clothing. Resident 69 complained about her closet door, located behind the bedroom door. Resident 69 stated her closet door was broken and did not remain close. Resident 69 further stated she complained about it to the facility's housekeeper but instead of fixing or having someone to fix it, the housekeeper placed a surgical tape at the edge of the closet door to temporarily closed it. Resident 69's closet door was observed to have a surgical paper tape to leave the door closed.…

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 the Minimum Data Set (MDS, a resident assessment and care screening tool) assessment was coded accurately for weight gain for one of 10 sampled residents (Resident 78). This failure compromised the facility's ability to develop and implement a resident-centered care plan and interventions for the resident's severe unplanned weight gain. Findings: Review of Resident 78's face sheet dated 10/15/24 indicated the resident was admitted on [DATE] and readmitted on [DATE] with multiple diagnoses including atrial fibrillation (an irregular heart rhythm which can lead to blood clots and stroke), Type 2 diabetes (elevated blood sugar), duodenal ulcer (a sore in the lining of part of the digestive tract), chronic venous hypertension with ulcer of bilateral lower extremities (end parts of the body- legs), and morbid obesity (having too much body fat). Review of Resident 78's three-month (August, September, and October 2024) Weight Summary indicated 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 implement care plan interventions for one of 20 sampled residents (Resident 13) regarding supervision with ambulation, continue encouraging to wear shirts or gowns while not in rooms, and ensure resident have non-skid socks/shoes while walking in the hallways . This failure had the potential to result in residents not receiving the appropriate care necessary to maintain their highest practicable level of health and well-being and result in Resident 13's continued behavioral issues. Findings: A review of Resident 13's face sheet (summary of resident's demographic and admitting information) indicated that Resident 13 was admitted on [DATE] with multiple diagnoses, including unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning), schizoaffective disorder ( a mental health condition that is marked by a mix of schizophrenia symptoms, such as hallucinations and delusions, and mood disorder…

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 service in accordance with professional standards of practice for two of six sampled residents (Resident 15 and 92) when: 1. The licensed nurses did not apply a Lidocaine patch (eases pain by numbing the nerves and making them less sensitive to pain) as ordered by the physician; and 2. The licensed nurses stored Resident 92's custom jewelry in a narcotic box (NB, a locked medication compartment inside a medication cart) in the medication cart (MC) 2. These failures had the potential to compromise residents' health and well-being. Findings: 1. A review of Resident 15's medical record indicated he was admitted on [DATE] and had diagnoses including fracture of unspecified lumbar vertebra (a break in a bone or bones of the spine). A review of Resident 15's Minimum Data Set (MDS, a tool used to measure health status in nursing home residents) completed on 9/23/24 indicated a Brief Interview for Mental Status (BIMS, a cognitive…

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 for effective communication when the facility did not provide language assistance or other communication aid and did not develop a baseline care plan to one of three sampled residents (Resident 254) with language barrier (speaking in foreign language). These failures had the potential to affect the psychosocial well-being of Resident 254 and a decline in the activities of daily living. Findings: 1a. Review of Resident 254's face sheet (front page of the chart that contains a summary of basic information about the resident) indicated Resident 254 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (also called stroke), hemiplegia (paralysis of one side of the body) and hemiparesis (a condition that causes partial paralysis or weakness on one side of the body) following cerebral infarction affecting left non-dominant side and dysphagia (difficulty in swallowing). 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to update the fall care plan, provide new intervention, and provide a resident centered care plan interventions to prevent the falls for one of two sampled residents (Resident 6) who was high risk of falling. These failures resulted in Resident 6's four falls since admission and had a potential to result in major injuries (broken bones, joint dislocation, head trauma or even death). Findings: Review of Resident 6's face sheet (front page of the chart that contains a summary of basic information about the resident) indicated Resident 6 was admitted to the facility with diagnoses including polyneuropathy (a condition that affects many nerves in different parts of the body, causing them to malfunction altogether), chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing), pulmonary fibrosis (a serious lung disease that causes scarring in the lungs, making it difficult to breathe), and unspecified…

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 implementation of a comprehensive systematic approach for effective monitoring for one sampled resident (78) who experienced a severe unplanned weight gain of a 9.78% in three months and did not maintain acceptable parameters of nutrition. This failure had the potential to result in additional unintentional weight gain for Resident 78, which could lead to further weight gain and decline in health and nutrition status. Cross reference F641 Findings: According to an article in the Cardiovascular Diabetology journal titled Extremes of Both Weight gain and Weight loss are associated with Increased Incidence of heart failure and cardiovascular death: Evidence from the CANVAS Program and CREDENCE.Obesity is an independent risk factor for cardiovascular disease (CVD) in patients with type 2 diabetes (T2D). Extremes of weight gain or loss were independently associated with a higher risk of the composite of congestive heart failure (CHF)…

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 that proper care and treatment services for oxygen (O2, a colorless, odorless gas) use was provided for two of two sampled residents (Resident 6 and 10) when: 1. Registered nurse F (RN F) failed to ensure the oxygen was on and at 3 liters per minute (L,metric unit of capacity, P, M) as ordered, when Resident 6's oxygen tubing was transferred from the oxygen concentrator (a medical device that provides a safe source of oxygen-enriched air) to an E-tank (a portable 3-foot-tall aluminum tank that contains oxygen), and staff did not develop a care plan related to Resident 6's oxygen use; and 2. Staff did not post an Oxygen in use/No Smoking sign at Resident 10's room entrance door and staff did not develop a care plan related to Resident 10's oxygen use. Findings: 1a. Review of Resident 6's face sheet (front page of the chart that contains a summary of basic information about the resident) indicated Resident 6 was admitted to the…

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

Based on observation, interview, and record review, the facility failed to ensure the nurse staffing information was posted clearly visible in a prominent place that was readily accessible to residents and visitors. This failure had the potential to result in nurse staffing misinformation about resident's care. Findings: During an observation on 10/14/24 at 9:33 a.m., in nurse station AA and BB (NS AA/BB), there was no nurse staffing information posted. During an observation on 10/15/24 at 1:05 p.m., in nurse station CC (NS CC), the nurse staffing information was not seen posted. During an observation on 10/15/24 at 1:06 p.m., at the lobby area, the nurse staffing information was located behind the receptionist desk, in a frame stand. The location of the nurse staffing information was not easily visible to family members, visitors, or residents. During an additional observation on 10/15/24 at 1:08 p.m., in NS AA/BB, the nurse staffing information was not seen posted. During a concurrent observation and interview with the front desk receptionist (FDR) on 10/15/24 at 1:10 p.m., at the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of 20 sampled residents (Resident 18) was free from unnecessary psychotropic drugs (medication capable of affecting the mind, emotions, and behavior) when Resident 18's physician order of Lorazepam (used to treat anxiety) as needed (PRN) was not limited to use up to 14 days. Findings: A review of Resident 18's clinical record indicated she was admitted on [DATE] with diagnoses including depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) and Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). A review of Resident 18's physician order dated 10/14/24 indicated administering Lorazepam 0.5 milligram (mg, a metric unit of mass) by mouth every four hours as needed for anxiety. During a concurrent interview and record review with the director of nursing (DON) on 10/17/24 at 4:12 p.m., 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 document review, the facility failed to comply with Federal and State laws, and regulations when the approval letter for staffing waiver was not posted where visitors and residents could easily read. This failure had the potential to result in nurse staffing misinformation about resident's care. Findings: During an observation on 10/14/24 at 8:30 a.m., in front of the facility's glass covered cork board, the approval letter for the staffing waiver was not posted. During an interview on 10/15/24 at 1:34 p.m. with the staffing coordinator (SC), the SC stated the facility had a staffing waiver. During a concurrent interview with the director of nursing (DON) and record review on 10/15/24 at 1:54 p.m., the DON reviewed the approval letter for staffing waiver. The DON confirmed the staffing waiver was not posted. During a concurrent observation and interview with the clinical consultant (CC) 10/15/24 at 1:56 p.m., in front of the facility's glass covered cork board, the CC confirmed the approval letter for staffing waiver should have been posted in 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 protect one of three sampled residents (Resident 1) from misappropriation of property (unauthorized purchases from another person's account or using someone else's property) when the housekeeper (HK) cashed out Resident 1's check without Resident 1's permission. This failure compromised the resident's financial security and violated resident's rights. Findings: Review of Resident 1's face sheet (front page of the chart that contains a summary of basic information about the resident) indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including major depressive disorder (mental health disorder characterized by depressed mood or loss of interest in activities). Review of the facility's 5-day Investigation Summary, dated 6/16/24, indicated that on 6/12/24, the facility was notified via email by Resident 1's daughter that checks had been cashed out from Resident 1's account. On 6/10/24, Resident 1 received a call 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.

Based on interview and record review, the facility failed to conduct a thorough investigation and report for nine of 11 residents (Residents 7, 8, 9, 10, 11, 12, 1, 3, and 4). This failure had the potential to compromise the facility's ability to determine the circumstances surrounding the incidents and could have compromised the residents' safety. Findings: During a review of the 5-day investigation summary of an alleged altercation between Residents 7 and 8, the summary did not indicate the outcome for the facility's investigation of whether the facility was able to determine if they thought the altercation did occur, or not. During a review of the 5-day investigation summary of an alleged altercation between Residents 9 and 10, the summary did not indicate the outcome for the facility's investigation of whether the facility was able to determine if they thought the altercation did occur, or not. During a review of the 5-day investigation summary of an alleged altercation between Residents 11 and 12, the summary did not indicate the outcome for the facility's investigation of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report an allegation of abuse involving two of two sampled residents (1 and 2) to the appropriate agencies, including the State Survey Agency. This failure to report potentially compromised residents' safety in the facility and violated mandated reporting requirements. Findings: Review of the intake information dated 6/17/24, indicated Resident 1's roommate (Resident 2) allegedly threw a fan onto Resident 1's chest. During a telephone interview with Resident 1's family member (FM) on 6/17/24 at 4:30 p.m., the FM stated Resident 2 had thrown a fan at Resident 1 on the night of 6/16/24. The FM further stated the incident was reported to the charge nurse on duty. On 6/18/24, an unannounced visit was conducted at the facility to investigate a complaint regarding a resident-to-resident alleged abuse. Review of Resident 1's admission record dated 6/19/24, indicated Resident 1 was admitted on [DATE] with a primary diagnosis of infection and inflammatory…

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 accommodate individual needs to ensure resident with the same gender shared bathroom, for 34 out of 92 residents (Residents 1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33, and 34). This failure had the potential to negatively affect the resident's psychosocial well-being. Findings: During the facility tour observation on 7/28/23 at 1:30 p.m., with the director of staff development (DSD) the following rooms were observed: Room AA (female room [FR]) and room BB (male room [MR]) shared the same bathroom. Room CC (FR) and room DD (MR) shared the same bathroom. Room EE (FR) and room FF (MR) shared the same bathroom. Room GG (FR) and room HH (MR) shared the same bathroom. Room II (MR) and room JJ (FR) shared the same bathroom. Room KK (MR) and room LL (FR) shared the same bathroom. Room MM (MR) and room NN (FR) shared the same bathroom. Room OO (FR) and room PP (MR) shared the same bathroom. Room QQ (FR) and room RR (MR) shared the same bathroom. During an interview 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 observation, interview, and record review, the facility failed to follow infection control practices for the Corona Virus 19 precaution (guidelines recommended by the Centers for Disease Control and Prevention for reducing the risk of the Corona Virus 19 [COVID-19, a respiratory illness that can spread from person to person] infection) for residents and staff when staff did not wear appropriate personal protective equipment (PPE, equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) for COVID-19 positive confirmed resident and COVID-19 exposed (having contact or close contact to an individual with confirmed or suspected COVID-19) resident (Residents 1 and 2). This failure had the potential to spread COVID-19 throughout the facility. Findings: During an interview on 2/22/2024 at 9:10 a.m. with the Assistant Director of Nursing (ADON), he stated that Resident 1 was confirmed COVID-19 positive this morning, and Resident 2 was exposed to COVID-19 as her roommate. The ADON stated that the facility started COVID-19 precautions for…

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 complete and submit an investigation summary regarding an alleged abuse incident that occurred between two of three sampled residents (Residents 2 and 3). This failure had the potential to compromise the facility's ability to determine the circumstances surrounding the incident and could have compromised the residents' safety. Findings: Review of Resident 2's medical record indicated she was admitted on [DATE] and had the diagnoses of Depression (A mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), Type 2 diabetes (A chronic condition that affects the way the body processes blood sugar) and muscle weakness. Review of Resident 3's medical record indicated she was admitted on [DATE] and had the diagnoses of major depressive disorder, seizures (uncontrolled jerking movements of the arms and legs caused by abnormal brain activity), chronic obstructive…

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 implement their antibiotic stewardship program (program intended to prevent overuse of antibiotics) for one of three sample residents (Resident 1). Resident 1 received a course of antibiotics (medication used to treat bacterial infections) for a urinary tract infection (UTI) but did not meet all the criteria that needed to be present for antibiotic use. The facility also failed to inform the physician that Resident 1 did not meet the criteria. These failures had the potential to increase the prevalence of multi-drug resistant organisms in the facility. Findings: Review of Resident 1's medical record indicated she was admitted to the facility on [DATE]. Resident 1's Minimum Data Set (MDS, an assessment tool), dated 8/13/22, indicated she did not have an indwelling catheter (flexible tube inserted into the bladder to drain urine). Review of Resident 1's Order Summary Report indicated she had a physician's order, dated 8/14/22, for Ertapenem Sodium…

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 three of 21 sampled residents (Resident 15, 46, and 76) and one non-sampled resident (Resident 6) were free from unnecessary psychotropic medications (medication capable of affecting the mind, emotions and behavior) when: 1. For Resident 15, there was no trial reduction ( tapering the dosage) for psychotropic medication use. 2. For Resident 46, the facility failed to ensure a physician's order for a PRN (as needed) psychotropic medication was limited to 14 days 3. For Resident 6, the facility failed to monitor specific targeted behaviors for psychotropic medication use. 4. For Resident 76, the facility failed to monitor specific targeted behaviors for psychotropic medication use. These failures could result in lack of adequate monitoring and had the potential for the residents to receive unnecessary medications and potentially lead to the development of significant side effects. Findings: 1. Review of Resident 15's clinical record…

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

Based on observation, interview, and facility document review, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for 91 out 96 residents who received food from the kitchen when: 1. Freezer door handle was broken; 2. Expired items were stored in dry food storage room; and 3. Undesignated staff entered in the kitchen. These failures had the potential to cause the growth of microorganisms or attract pests which could cause foodborne illness or cross-contaminate food (cross-contamination occurs when unclean surfaces or utensils spread germs to food and can potentially cause foodborne illness) for the residents eating at the facility. Findings: 1. During the initial kitchen tour with dietary cook L (DC L) on 4/03/23 at 8:02 a.m., the plastic door handle of freezer 1 was broken and covered with a white colored tape. DC L stated the door handle has been broken since 9/2022 and the dietary director (DD) reported to the maintenance supervisor (MS). DC L further stated it could cause injuries…

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

Based on observation, interview, and facility document review, the facility failed to ensure residents' food was stored in a safe and sanitary manner for 91 out 96 residents, when refrigerator designated for residents had foods that were not properly stored and labeled. This failure had the potential for food borne illness. Findings: During an inspection of the refrigerator designated for residents with the dietary director (DD) on 4/10/23 at 8:30 a.m., there were three frozen foods without resident's name stored in the top freezer. One food with Three layer spinach lasagna with meat sauce label had Best by 3/09/2023; one food with Beef patty strips & gravy label had Best by:4/05/2023; one food with Chicken patty with brown rice & teriyaki sauce label had Best by:1/07/2023 on the plastic cover. The DD stated he was responsible for checking the food inside the refrigerator. The DD acknowledged the foods were past their best by date and should have been discarded. The DD further stated resident's food should be dated and labeled with the resident's name. Review of the facility's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. Review of Resident 4's admission Record indicated she was admitted to the facility on [DATE] with pneumonitis (inflammation of lung tissue) diagnosis. Review of Resident 4's physician order, dated 1/30/23, indicated she had an order for ipratropium-albuterol (drugs work by relaxing the muscles around the airways so that they open up and the person can breathe more easily) 20-100 micrograms (mcg, a metric unit of mass) solution 3 milliliters (ml, a metric unit of volume) inhale orally every 6 hours as needed for short of breath or wheezing (a high-pitched whistling sound made while breathing). During an observation and interview with licensed vocational nurse B (LVN B) on 4/3/23 at 2:11 p.m., Resident 4's nebulizer ( a device that turns the liquid medicine into a mist which is then inhaled through a mouthpiece or a mask) mask and tubing were undated. LVN B stated Resident 4's nebulizer mask and tubing should be dated. Review of the facility's undated policy, Respiratory Therapy - Prevention of 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.

Based on interview and record review, the facility failed to notify residents' representatives and families of a confirmed COVID-19 (a respiratory disease caused by a virus which can result in severe illness and death) when four out of 96 residents (Residents 37, 241, 296, and 298) who had positive COVID-19 test result on 4/8/23 and notifications were not sent out until 4/10/23. This failure resulted in residents' representatives and families not receiving timely notification regarding the status and impact of COVID-19 in the facility. Findings: During a concurrent interview and record review on 4/10/23 at 12:44 p.m., with the director of staff development and infection preventionist, she confirmed that Residents 37, 241, 296 and 298 had positive COVID-19 test results on 4/8/2023. She further stated that the administrator was the person responsible for notifying Residents, representatives and families. During an interview on 4/10/23 at 12:48 p.m. with the Administrator (ADM), he stated the facility uses a COVR system, an automated text message system that would synch in with the PCC…

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 respect and dignity was maintained for one of three residents (Resident 46) when staff provided feeding assistance while standing. This failure had the potential to affect the emotional and psychosocial well-being of the resident. Findings: Review of Resident 46's minimum data set (MDS, an assessment tool) dated 2/4/23 indicated his cognition was severely impaired and he needed one-person physical assistance for eating. During a breakfast meal observation on 4/3/23 at 8:00 a.m., Resident 46 was sitting in his bed in his room. CNA A stood beside him while providing spoon-feeding assistance to Resident 46. During a concurrent interview with CNA A she confirmed she was standing while feeding Resident 46. She stated he should have been sitting down when she was feeding the residents. During an interview with the director of staff development (DSD) on 4/3/23 at 8:17 a.m., she stated staff are trained to sit down and be at eye level when they are feeding residents. The DSD stated when residents are in 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 resident call-light equipment was accessible for two of 96 residents (Residents 74 and 81), when the call-light button for both residents was not within reach. This failure had the potential of harm or a decrease in these residents' well-being in the case of an emergency, and they not being able to call for help. Findings: 1. Resident 74 had been admitted with diagnoses which included metabolic encephalopathy (a chemical imbalance in the brain), type 2 diabetes (increase blood sugar), schizophrenia (a serious mental disorder in which people interpret reality abnormally), non-traumatic subdural hemorrhage (bleeding between the brain and skull, which is a rare entity that presents gradually progressive neurological symptoms, not caused by trauma or hit), cognitive communication deficit (difficulty with thinking and speaking), and respiratory arrest (not able to breathe). During an observation on 4/3/23 at 8:15 a.m., Resident 74 call light button was observed on the draped over the light fixture and above…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure two of 21 residents (Residents 18 and 89) had been inquired about having an Advance Directive (AD, a written form which indicated your instructions about your own health care), when no form was found, nor any indication of an AD was documented. This failure had the potential of these residents becoming incapacitated and them not receiving the care they would want or not want. Findings: 1. Resident 18 had been admitted to the facility with diagnoses which included: fracture (broken bone) of thoracic vertebra (bone in mid spine), Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), type 2 diabetes, difficulty walking, need for assistance with personal care, and disorders of bone density and structure. During a review of Resident 18'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide evidence of documentation regarding the action, progress, and resolution of a complaint/grievance regarding missing glasses reported by Resident 89's family member (FM). This failure resulted in Resident 89's complaint not resolved. Findings: Review of the Resident 89's clinical record indicated she was admitted on [DATE]. Resident 89's Inventory of personal items, dated 12/16/22 included one pair of glasses. During a telephone interview with Resident 89's FM on 4/05/23 at 8:05 a.m., she stated she reported to social service assistant G (SSA G) on 2/07/23 that Resident 89's glasses were missing at the facility. Resident 89's FM further stated she had not heard any update or information regarding the missing glasses. Review of the facility's 2023 theft/loss and grievance binder indicated there was no written report regarding Resident 89's missing glasses. During an interview and record review with SSA G on 4/06/23 at 10:34 a.m., she confirmed…

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 implement their abuse prevention policy by failing to report one of three abuse allegations immediately and failing to screen certified nursing assistant K (CNA K) for criminal background. These failures had the potential to put the residents at risk for elder abuse and further abuse. Findings: Review of Resident 189's admission Record indicated she was admitted to the facility on [DATE] with diagnoses including muscle weakness and difficulty in walking. Review of Resident 189's Minimum Data Set (MDS, a clinical assessment tool), dated 3/30/23, indicated her cognition was intact. During an interview with Resident 189 on 4/3/23 at 10:30 a.m., she stated CNA K assisted her to transfer from her bed to the commode. While she was on the commode, CNA K asked her 'Can I sit on you and pee?' Resident 189 stated she told physical therapy assistant I (PTA I) and registered nurse J (RN J) about the incident. During an interview with PTA I on 4/4/23 at 10:14 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, facility failed to develop baseline care plans for two of 21 sampled residents (Resident 37 and 49) within 48 hours of admission to the facility. This deficient practices of not identifying individualized goals had the potential to negatively affect Resident 37 and 49 abilities to achieve their highest practicable physical, mental, and psychosocial well-being and their continuity of care. Findings: 1. Review of Resident 37's clinical records indicated he was admitted to the facility on [DATE] with diagnoses including muscle weakness, cognitive communication deficit, gastrostomy tube (GT tube, a surgical opening into the stomach for administration of nutrition and medication), dysphagia (difficulty swallowing) and foley catheter (catheter drains urine from your bladder into a bag outside your body) due to urinary retention. During a concurrent interview and record review on 4/6/23 at 2:12 p.m., with the with minimum data set nurse (MDSN), she reviewed a minimum data set (MDS,…

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 received the necessary care and services for three of 21 residents (48, 76, and 300) when: 1. Licensed nurses did not follow the physician's orders for pain medication based on the residents' pain level for Residents 48 and 76; 2. Licensed nurses did not follow ordered parameters for blood pressure medication for Resident 76; and 3. One medication was administered not in accordance with the physician's order for Resident 300. These failures had the potential to affect the residents' care and could jeopardize their health and well-being. Findings: 1a. Review of Resident 48's admission Record indicated she was admitted to the facility on [DATE]. Review of Resident 48's physician order indicated she had an order on 2/22/23 to monitor for presence of pain every shift using scale 0-10; 0 = no pain; 1-2 = least pain; 3-4 = mild pain; 5-6 = moderate pain; 7-8 = severe pain; 9-10 = very severe/horrible/worst pain. Resident 48…

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 a communication device provided to two of 21 sampled Residents (Residents 9 and 37) who spoke in their non-English language. This failure had the potential for Residents 9 and 37 not to understand and carry out activities of daily living (ADL). Findings: 1.During an observation on 4/4/23 at 9:59 a.m., Resident 9 was communicating with certified nursing assistant O (CNA O) in her non-English language and CNA O could not understand Resident 9. During concurrent observation and interview on 4/4/23 at 10:00 a.m., with CNA O stated Resident 9 spoke only in her native language and she stated that she could only communicate with the resident through gestures and pointing. CNA O further stated there was no communication device at bedside and should have been provided in the language of Resident 9 during ADL care. During concurrent interview and record review on 4/7/23 at 10:30 a.m., with the social service specialist (SSS), she acknowledged…

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

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained free from accident hazards for three residents (Resident 10, 46, and 240) when Oxygen In Use signs were not posted in their rooms while receiving oxygen therapy; and an electrical cord was left in Resident 46's occupied bed. These failures had the potential to result in serious injury to the residents in the facility. Findings: 1. During an initial tour of the facility on 4/3/23 at 9:23 a.m., Residents 10, 46, and 240 were observed receiving oxygen inhalation (medical treatment to provide extra oxygen to breathe) via nasal cannula (a tube with two prongs that connects into the nose) inside their rooms. There was no signage on Resident 10's, 46's, or 240's room doors or anywhere within the rooms to indicate that oxygen was in use. During an interview with the infection preventionist (IP) on 3/4/23 at 9:30 a.m., she confirmed the above observation that Residents 10, 46, and 240 were receiving oxygen inhalation inside their rooms. The IP confirmed there was no signage…

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 out 21 residents (Resident 295) received pain medication upon request when Resident 295 received her pain medication more than 1 hour after her request. This has the potential for physical harm with the resident due to pain and discomfort. During a review of Resident 295's clinical records she was admitted to the facility on [DATE] with diagnosis including surgical aftercare following surgery (Treats injuries, diseases, and deformities by the physical removal, repair, or readjustment of organs and tissues, often involving cutting into the body) on the digestive system, anxiety disorder (medical condition includes symptoms of intense anxiety or panic that are directly caused by a physical health problem) and major depressive disorder (A mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). The Minimum Data Set (MDS, an assessment tool)…

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 dialysis services consistent with professional standards and to ensure staff had coordinated a resident's care with the dialysis facility for one of two residents (Resident 297) who received hemodialysis (medical procedure to remove fluid and waste products from the blood and to correct electrolyte, i.e. salts and mineral imbalances by using a machine and an artificial kidney) when: 1. Resident 297 dialysis communication records (DCR) were blank and not completed, and 2. Resident 297 physician order, treatment administration record (TAR) did not reflect the dialysis access site for necessary precautions. These deficient practices had the potential for the resident to be inadequately assessed and be at risk for complications. Findings: 1. Review of Resident 297's clinical record indicated she was admitted to the facility on [DATE] with diagnoses including acute kidney failure (kidney's no longer functioning in permanent basis) 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 and timely dispensing of medications to meet the needs of residents; accurate or effective accountability and storage of controlled substance (CS, drugs with high potential for abuse or addiction) medications; and accurate administration of medications when: 1. One medication in the automated dispensing unit (ADU, a computerized unit for the storage and dispensing of medication) was not refilled timely; 2. One CS medication was stored in the medication cart without daily accounting by the nursing staff; and 3. Resident 190 was administered medications with drug-drug interaction. These deficient practices had the potential for medications being unavailable for use; loss/abuse and unaccountability of CS medications; and inaccurate administration of medications. Findings: 1. During an interview with Resident 295 on 4/04/23 at 9:17 a.m., she stated she was in pain, but her pain medication was not available in the 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure proper medication administration and storage, and labeling of medications for five out 21 residents when: 1. Expired or discontinued medications were not put away; 2. Three nasal sprays did not have resident-specific labeling on each container; 3. An eye drop medication was stored and being used past its expiration date; 4. Resident 30's medications were left on her overbed table unattended; 5. Resident 42 had one opened small packet of A&D next to her drinking glass; 6. Resident 3's room window had used calmoseptine ointment tube that was left unattended. These deficient practices had the potential for residents to receive medications with unsafe and reduced potency from being used past their expiration date; medication errors due to medications not being labeled; and inadequately monitored medications, which could lead to unsafe medication for the residents. Findings: 1. During a visit to medication room in nurse station 3 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide the required rehabilitative services for one of 21 residents (Resident 89) when physical and occupational therapy treatments were not provided as ordered for Resident 89. This failure had the potential for Resident 89 not to attain, maintain or restore her highest practicable level of physical function and well-being. Findings: Review of the Resident 89's clinical record indicated she was admitted on [DATE] and had diagnoses including hemiplegia (paralysis on one-side of body) and hemiparesis (weakness on one-side of body) following cerebral infarction (stroke), hypertension (high blood pressure), difficulty in walking, repeated falls and depression (a mood disorder that causes a feeling of sadness and loss of interest). During a telephone interview with Resident 89's family member (FM) on 4/05/23 at 8:05 a.m., she stated therapy was not provided on multiple days for Resident 89. Review of Resident 89's Physician orders (dated 12/19/22)…

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 document review, the facility failed to ensure food was prepared and served under sanitary conditions when: 1. [NAME] A used incorrect technique when testing the kitchen sanitizer solution (solution used to disinfect food contact surfaces in the kitchen); and 2. Staff did not completely cover their hair with hair nets in the food preparation area of the kitchen. These failures had the potential to cause food contamination and spread foodborne illness (illness resulting from contaminated food) to residents who received their food from the kitchen (80 of 83 residents). Findings: 1. During an observation on 3/9/2020 at 8:20 a.m., [NAME] A tested the kitchen sanitizer solution, which was contained in a red bucket at the food preparation sink. [NAME] A took a piece of test paper, dipped it in the solution for approximately one second, then checked to see if the test paper changed to the appropriate color. [NAME] A used a thermometer to check the temperature of the kitchen sanitizer solution. The reading on the thermometer indicated the solution had 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 infection control practices were followed when the following were identified: 1. Droplet precautions were not followed for two (Residents 50 and 284) out of two sampled residents that were coughing. 2. A urinary catheter drainage bag was placed above the bladder for one (Resident 284), out of two sampled residents reviewed for urinary catheters. 3. A blood pressure cuff was not cleaned after use. 4. Hand hygiene was not performed after administration of a medication. These failures had the potential to cause infection in a vulnerable population. Findings: 1. During a review of Resident 50's clinical record, indicated, Resident 50 was admitted to the facility on [DATE] and had diagnoses of hypertension (high blood pressure), heart failure (heart does not pump enough blood to meet the body's needs), and dysphagia (difficulty swallowing). Further review of the record indicated Resident 50 had a gastrostomy tube (G-tube, a tube placed…

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 dignity for one out of 18 sampled residents (Resident 14), when the facility failed to provide privacy during cares. This failure resulted in the resident, who was partially uncovered, being visible to anybody walking by his room. Findings: During a review of the Resident 14's clinical record, indicated Resident 14 had diagnoses that included Huntington's disease (a progressive brain disorder that causes uncontrolled movements, emotional problems, and loss of thinking ability (cognition), muscle weakness and needed assistance with personal care. During an observation on 3/10/2020 at 9:40 a.m., while walking in the hallway pass Resident 14's door, Resident 14 was observed lying on his bed in his room, with the curtain pulled back. Additionally, in full view of the hallway, the Resident was observed with his legs uncovered and his incontinence brief (a type of brief worn that helps to protect against incontinence or accidental urination and urine leakage) was visible. During an interview on 3/10/2020 at…

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 out of 18 sampled residents (Resident 14), preferences for getting up out of bed were met. This failure resulted in the Resident spending most of his time in bed and in his room, alone. Findings: During an observation on 3/9/2020 at 10:30 a.m., Resident 14 was in his wheelchair in the dining room where activities assistant (AA) N was sitting down. The television was on and there were a total of 19 residents in the room, and one activities assistant. During a review on of Resident 14's clinical record, indicated Resident 14 had diagnoses that included Huntington's disease (a progressive brain disorder that causes uncontrolled movements, emotional problems, and loss of thinking ability (cognition), muscle weakness and needed assistance with personal care. During a review of the most recent MDS (Minimum Data Set) assessment, a quarterly assessment dated [DATE], indicated Resident 14 was coded as needing extensive assistance of 2+…

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 care was provided according to professional nursing standards for one of 18 residents (Resident 31) when licensed vocational nurse E (LVN E) did not use the proper procedure for testing the blood sugar (a procedure performed by puncturing a person's finger with a lancet [a type of needle] to collect blood for testing sugar levels). This failure had the potential to affect the accuracy of blood testing and could cause harm to the resident. Findings: During a concurrent observation and interview on 3/10/2020 at 11:48 a.m., LVN E was observed checking the blood sugar for Resident 31. LVN E used the lancet to puncture the skin on Resident 31's finger, collected the first drop of blood, and placed an alcohol wipe at the puncture site. LVN E confirmed the first drop of blood was collected and an alcohol wipe was placed over the puncture site. During a review of the facility-provided Assure Platinum Blood Glucose Monitoring System: Quality Assurance/Quality Control (QA/QC) Reference Manual (undated), 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 perform initial pressure ulcer (damage to the skin or underlying tissue as a result of prolonged pressure) measurements and failed to provide pressure ulcer treatments for one of six sampled residents (Resident 183). These failures had the potential to cause worsening in Resident 183's pressure ulcers. Findings: Review of Resident 183's clinical record indicated he was admitted on [DATE] and had the diagnoses of cellulitis (a skin infection), muscle weakness and peripheral vascular disease (PVD, a circulatory problem that reduces blood flow to the limbs). Review of Resident 183's Compromised Skin Integrity document, dated 2/25/2020, indicated he had the following skin issues: 1. Open area on the left outer ankle that measured one by one centimeter (cm, unit of measurement) and had yellow slough (layer of dead tissue on a wound); 2. Open area on the left second toe with no specified measurements; and 3. Purplish discolorations on the left fourth toe…

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 adequate monitoring for safety for one of one sampled resident (Resident 12) when the alarm bracelet that was attached to the resident. This failure had the potential for the alarm system to not work and increased the risk for elopement. Findings: During a review of Resident 12's clinical record,it indicated Resident 12 had diagnoses that included dementia, difficulty walking and altered mental status. Further review, indicated Resident 12 had a Wander Guard alarm bracelet (a system that tracks the person using a wrist or ankle band and automatically alarms doors if the person moves outside a defined area), on her left ankle. During an observation on 3/9/2020 at 10:40 a.m., Resident 12 was observed in her wheelchair with an alarm band on her left ankle. Resident 12 was also observed wandering in her wheelchair, going into the nurse's station, and up and down the hall. During a review of the nursing progress note dated 2/13/2020 at 10:21 p.m., indicated Resident noted with restlessness, pacing along 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 proper placement of the gastrostomy tube (G-tube, a tube placed directly into the stomach through the abdomen that delivers food, fluids, and medications) for one of one resident (Resident 50). This failure had the potential to cause harm to the resident. Findings: During a concurrent observation and interview on 3/10/2020 at 9:24 a.m., with Licensed Vocational Nurse (LVN) F during medication administration, LVN F did not check Resident 50's G-tube placement (a procedure used to ensure the G-tube is positioned in the stomach) before flushing the G-tube with water (the process of pouring water into the G-tube to ensure the tube is clear of debris). LVN F stated she should have checked for placement. During a review of the facility's policy and procedure, Administering Medications through an Enteral Tube, dated 2017, the procedure indicated to confirm placement of feeding tube and check gastric residual volume (GRV) to assess for placement and tolerance of enteral feeding before flushing the G-tube 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 observation, interview, and record review, the facility failed to provide social services related to podiatry (the care and treatment of the foot) for one of 18 residents (Resident 21). This failure had the potential to result in discomfort for the resident. Findings: During an observation on 3/9/2020, at 8:15 a.m., Resident 21 was observed to have long, thick toenails, with yellow and black discoloration on her right big toe toenail. During a concurrent interview and record review on 3/11/2020 at 10:15 a.m., with the wound treatment nurse (WTN), the current Physician's Orders were reviewed. The orders indicated podiatry consult PRN (as needed). The WTN stated podiatry was coordinated with social services. During a concurrent interview and record review on 3/11/2020, at 12:34 p.m., with the Director of Social Services (DSS), the Lumina Healthcare Podiatric Evaluation & Treatment Form, dated 9/26/2018, was reviewed. The form indicated Resident 21 was treated for painful nails on 9/26/2018. The DSS confirmed the last podiatry consult was done in 2018 and stated the consult…

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

Based on observation, interview, and record review, the facility failed to ensure the accurate provision of pharmaceutical services for one of two intravenous emergency kits (IV E-kit, a storage of emergency medications that are administered directly into the vein and supplies used to deliver the medications through the vein). This failure had the potential to result in the delay of treatment for the residents. Findings: During an observation on 3/10/2020 at 8:53 a.m., in medication room (Med Room) G, the contents of the IV E-kit was missing three 24-gauge needles, three IV starter kits, and three extension max sets. The IV E-kit was last opened on 3/5/2020. During a concurrent interview and record review on 3/10/2020 at 8:53 a.m., in Med Room G with the DON, the IV E-kit Emergency Kit Dispensing Form, dated 3/5/20 was reviewed. The DON confirmed the form indicated the following items were taken out of the kit: one 24-gauge needle, one IV starter kit, and two extension max sets. During an interview on 3/10/2020, at 10:13 a.m. with the DON, she stated the IV E-kit should be replaced…

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 monitor for psychotropic medication (medication capable of affecting the mind, emotions, and behavior) side effects and target behaviors (behavior intended to be changed by the medication) for one of five sampled residents (Resident 183). These failures had the potential to compromise the facility's ability to identify harmful effects from the medications and to monitor the effectiveness of the medications. Findings: Review of Resident 183's clinical record indicated he was admitted on [DATE] and had the diagnosis of insomnia (difficulty sleeping). Review of Resident 183's Physician Order Report indicated he had an order, dated 2/26/2020, for Ambien (psychotropic medication used to treat insomnia) 5 milligrams (mg, unit of dose measurement) by mouth as needed for insomnia. Resident 183 also had an order, dated 2/27/2020, for Trazodone (antidepressant which is often used to treat insomnia) 50 mg by mouth at bedtime for insomnia. Review of Resident 183'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the safe and secure storage of medications in one of two medication rooms (Med Room H) and for one of four medication carts (Med Cart I) when: 1. For Med Room H, an expired vial of Aplisol (a medication classified as a tuberculin test used to test a person for tuberculosis [an infection in the lung]) was stored in the medication refrigerator. 2. For Med Cart I, the cart was unlocked, with a drawer open, and medications were on top of the cart. These failures had the potential to result in harm to the residents. Findings: 1. During a concurrent observation and interview on [DATE] at 11:15 a.m., with licensed vocational nurse (LVN) D, the contents of medication room (Med Room) H were observed. The refrigerator in Med Room H contained a vial of Aplisol opened on [DATE] and another vial of Aplisol opened on [DATE]. LVN D stated the Aplisol is usually kept for 30 days after the date it was opened and the vials should be thrown out.…

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 the laboratory services as ordered by the physician for one of 18 sampled residents (Resident 8). This failure had the potential for the resident not to be adequately monitored for changes in condition in order to provide necessary treatment. Findings: Review of Resident 8's admission Record indicated she had diagnoses including diabetes (elevated blood sugar) and chronic kidney disease (kidneys are unable to clean toxins and waste products from the blood properly) Review of Resident 8's physician order dated 9/16/19, indicated an order to check hemoglobin A1C (Hg AIC, blood test that indicates the average level of blood sugar over a period of two- three months) in two months. During an interview with the nurse case manager (NCM) on 3/11/2020 at 10:20 a.m., she reviewed the physician order dated 9/16/19, indicating to check HgA1C in 2 months. She stated her initials and the word noted, dated 9/16/19, written below the physician's order, indicated she had carried out the order. The NCM further stated carrying out…

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.