Temecula Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure, 11 of 14 residents reviewed for Advance Directive (AD - written statement of a person's wishes regarding medical treatment) (Residents 13, 17, 19, 70, 78, 84, 90, 97, 319, 320, and 322) a copy of the AD was available and the resident or their resident representative (RP) had been provided follow up information regarding the formulation of an AD. These failures had the potential to result in the ADs for Residents 13, 17, 19, 70, 78, 84, 90, 97, 319, 320, and 322 not being readily accessible to staff and physicians, which could lead to the residents' wishes regarding medical treatment being unknown and ultimately not honored. Findings: 1. On April 14, 2025, at 3:58 p.m., an interview was conducted with Resident 70. Resident 70 stated that he was unsure of having an AD and unsure if asked if he would like to formulate one. Resident 70's record was reviewed. Resident 70 was admitted to the facility on [DATE]. A review of the Advance Directive…

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 the policy and procedures for oxygen use for two of two sampled residents (Resident 17 and 70) when: 1. Resident 70 was observed receiving continuous oxygen at an incorrect flow rate, without proper documentation or assessment; and 2. Resident 17 had an unlabeled nasal cannula (oxygen tubing - a device that delivers oxygen). These failures had the potential to result in unnecessary or unsafe oxygen administration and increased risk of infection for Residents 17 and 70. Findings: 1. On April 14, 2025, at 2:21 p.m., a concurrent observation and interview was conducted for Resident 70. Resident 70 was alert, oriented and able to verbalize his needs. Resident 70 was observed with oxygen on at six liters per minute (a unit of measure) via nasal cannula. Resident 70 stated he had been on oxygen since the early morning. On April 14, 2025, Resident 70's record was reviewed. Resident 70 was admitted to the facility on [DATE], with diagnosis…

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 dietary staff were adequately trained to carry out duties in a sanitary and safe manner when one dietary staff did not follow the manufacturer's instructions for the testing of Quaternary (Quaternary ammonium compounds [quats]are a group of chemicals used for disinfectants) sanitizer. This failure had the potential to result in inaccurate readings of the sanitizing solution, which could lead to cross-contamination. Findings: On April 15, 2025, at 10:23 a.m., during an observation of a Dietary Aide (DA) testing the sanitizing solution in the three-compartment sink, the DA was observed dipping the Quat strip into the sanitizing solution for four seconds before comparing the strip to the color comparator chart. A review of the Directions for use Quat-10 Testing Paper indicated .Dip paper for 10 seconds then compare to colors on test strip package . During a concurrent interview with the DA, he stated he should have waited for 10 seconds before comparing the test strip to the color chart. The DA…

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 accommodate the needs for one of three sampled residents (Resident 275), when the call light button was observed on the floor and not within reach. This failure had the potential for Resident 275 not to be able to call staff for assistance which could result in needs of the resident not being met as well as a delay in the provision of care. Findings: Resident 275's record was reviewed. Resident 275 was admitted to the facility on [DATE], with diagnoses which included right below knee amputation (removal of leg). A review of Resident 275's Minimum Data Set (an assessment tool), dated April 9, 2025, indicated, Resident 275 had a Brief Interview of Mental Status (BIMS - a tool to assess cognitive function of an individual) score of 12 (moderate cognitive impairment). A review of Resident 275's Care Plan, initiated on April 2, 2025, indicated, .ADL (Activities of Daily Living) Self-Care Performance Deficit .Encourage the use of call light 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 ensure one of three residents reviewed for accidents (Resident 40) was free from exposure to chemical hazards when a housekeeper (HK) left a toilet bowl cleaning solution within the resident's reach. This failure had the potential for Resident 40 to be exposed to chemical poisoning or chemical burn if the substance was ingested or mistakenly taken. Findings: On April 16, 2025, at 12:57 p.m., during an interview with Resident 40's Family Member (FM), she stated, on April 15, 2025, at 11 a.m., she found a white cup containing a pink solution with a brush inside, placed on the bedside table near Resident 40's drinking cup. The FM stated, the nurse told her that the brush was a toilet brush and the pink solution was a toilet cleaner. A review of Resident 40's admission record, indicated, Resident 40 was admitted to the facility on [DATE], with diagnoses which included dementia (forgetfulness). A review of Resident 40's History and Physical Examination dated…

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

Based on interview and record review, the facility failed to effectively utilize its Quality Assessment and Performance Improvement (QAPI) program to address an ongoing issue involving missing covers on all three dumpsters. This failure resulted in the facility to not implement timely preventative measures and increased potential risk of cross-contamination. Findings: A review of facility document titled Food & Nutrition Services: Daily Supervisor Rounds Checklist, dated March 2, 2025, to April 17, 2025, indicated that the task Trash Lids closed and clean . was not checked off on any day. On April 17, 2025, at 8:37 a.m., during a concurrent interview and record review with the Administrator (ADM), the ADM stated, one of the current QAPI projects was replacing the covers for the three dumpster bins. The ADM stated, they have not been able to check off the task because the dumpster bins remained uncovered. The ADM stated, the facility made multiple attempts to contact the waste management company to replace or repair the bins, but appointments were repeatedly canceled. The ADM stated,…

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 infection control practices were implemented when a licensed nurse did not clean and disinfect a shared blood pressure (BP-pressure of blood in blood vessels) cuff according to the manufacturer's recommended contact time (the required duration the equipment must remain wet with the disinfectant to effectively kill microorganisms [germs]). This failure had the potential to expose vulnerable residents to cross-contamination and increase the risk of infections. Findings: On April 15, 2025 at 9:30 a.m., during a medication pass observation, LVN 3 was observed wiping a shared manual blood pressure cuff with a (brand name) disposable wipe after removing it from Resident 223's right upper arm. LVN 3 was not observed leaving the blood pressure cuff surface visibly wet for at least one minute. LVN 3 stated, she should have allowed the cuff to air dry for three minutes. LVN 3 reviewed the manufacturer's instructions and stated the required contact time was one minute. On April 15, 2025 at 10:31 a.m., 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide access to personal and medical records within two working days upon request by the resident's legal representative, for one of three sampled residents (Resident 1). This failure has the potential to delay care and treatment, affecting the resident's physical well-being. Findings: On March 3, 2025, at 9:05 a.m., an unannounced visit to the facility was conducted to investigate a resident's rights issue. A review of Resident 1's admission Record, indicated, Resident 1 was admitted to the facility on [DATE], and was discharged from the facility on January 29, 2025. A review of Resident 1's Release of Medical Information, request, dated February 11, 2025, indicated, .(name) requester .Please consider this as (Resident 1 name) request, by and through this office as legal representative, that all writings related to her within your care, custody and control .that be made available within two working days from the receipt of this correspondence . 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 ensure for one of three sampled residents (Resident 2) had a physician order prior to hospital transfer. This failure had the potential to affect Resident 2's overall health and wellbeing. Findings: On March 3, 2025, at 9:05 a.m., an unannounced visit to the facility was conducted to investigate a complaint incident. A review of Resident 2's admission Record, indicated, Resident 2 was admitted to the facility on [DATE], with diagnoses which included atrial flutter (an abnormal heart rhythm that can cause an individual to faint). A review of Resident 2's Health Status Note, dated February 19, 2025, indicated, .Was helping patient to use the bathroom, while sitting on toilet patient was straining and eyes rolled back and proceeded to pass out .AMR (American Medical Response) was called and arrived on scene where he (Resident 2) was then transported to (name of hospital) for further assessments . A review of Resident 2's SNF/NF to Hospital Transfer Form,…

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 medical records were accurate for one of three sampled residents (Resident 2) when the time of the alleged abused was not consistent with the time of reporting. This failure resulted in inconsistencies in the reporting timeline for Resident 2. Findings: On March 3, 2025, at 9:05 a.m., an unannounced visit to the facility was conducted to investigate an allegation of financial abuse. A review of Resident 2's admission Record, indicated, Resident 2 was admitted to the facility on [DATE]. A review of Resident 2's Minimum Data set (MDS - an assessment tool), dated August 12, 2024, indicated Resident 2 had a Brief Interview for Mental Status (tool used to assess a resident's cognitive function) score of 11 (moderate cognitive impairment). A review of Resident 2's eINTERACT SBAR Summary for Providers, dated February 18, 2025, at 7:49 a.m., indicated, .Alleged financial abuse against pt's (patient's) wife . A review of Resident 2's IDT…

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 environment free of accident hazards was provided, when the bed alarm was not implemented for one of five residents reviewed for falls (Resident 1). In addition, Resident 1's fall risk assessment was not updated to reflect newly identified fall risks discussed during the interdisciplinary team (IDT - a group of healthcare professionals who work together for the common goal of the resident) meeting. These failures had the potential to result in further falls and injuries for Resident 1. Findings: On January 28, 2025, at 12:58 p.m. Resident 1 was observed to be sitting in a chair at the bedside. No bed alarm was observed on the bed or chair. A review of Resident 1's record indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses which included repeated falls, unspecified dementia (memory loss). A review of Resident 1's Minimum Data Set, dated December 30, 2024, indicated Resident 1's Brief Interview for Mental…

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 physical abuse within two hours to the California Department of Public Health (CDPH) after the facility was made aware of the allegation, for one of four sampled residents (Resident 1). This failure had the potential to result in further abuse of Resident 1, affecting the resident's emotional and psychosocial well-being. Findings: On December 22, 2024 at 2:07 p.m., CDPH received a fax (facsimile - telephonic transmission of scanned-in printed material) report involving a complaint allegation of physical abuse for Resident 1. On December 2, 2024, at 9:31 a.m., an unannounced visit to the facility was conducted to investigate an allegation of abuse. A review of Resident 1's admission Record, indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses which included Bipolar Disorder (a mental illness affecting mood and concentration). A review of Resident 1's Minimum data Set (an assessment tool) dated October 10,…

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 three residents, (Residents 4 and 5), had a discharge notice sent to the Ombudsman, (advocate for residents of nursing homes), prior to their discharges. This failure had the potential for Residents 4 and 5 to not have an advocate prior to their discharges. Findings: On October 10, 2024, at 11:10 a.m., an unannounced visit to the facility on two complaints and one Facility Reported Incident was initiated. 1. A review of Resident 4's medical record indicated he was admitted to the facility on [DATE], with diagnoses of hemiplegia, (paralysis of one side of the body), and hemiparesis, (weakness of one side of the body), following cerebral infarction, (stroke), affecting left non-dominant side. Resident 4 was discharged on October 9, 2024. A review of Resident 4's History and Physical, dated September 23, 2024, indicated he was forgetful. A review of Resident 4's Order Summary Report, for the month of October 2024, indicated, .LCD (last…

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 three residents, (Resident 1), had bilateral floor mats in place as ordered. This failure had the potential for Resident 1 to have an injury due to a fall. Findings: On October 10, 2024, at 11:10 a.m., an unannounced visit to the facility on two complaints and one Facility Reported Incident was initiated. A review of Resident 1 ' s medical records indicated she was admitted on [DATE], with diagnoses of hypothyroidism, (a condition resulting from decreased production of thyroid hormones), rheumatoid arthritis, (a chronic progressive disease-causing inflammation in the joints and resulting in painful deformity and immobility), dementia, (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), hemiplegia, (paralysis of one side of the body), and hemiparesis, (weakness of one side of the body), following cerebral…

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 copies of medical records upon request and within two business days after receiving the request from an attorney on behalf of the resident, for one of four residents reviewed, Resident 3. This failure is a violation of Resident 3 and the resident's representatives ' rights. Findings: On August 29, 2024, at 9:50 a.m., an unannounced visit was conducted at the facility to investigate a complaint allegation. On August 29, 2024, at 10:39 a.m., during an interview with Licensed Vocational Nurse (LVN) 1, LVN 1 stated residents, their responsible parties and durable power of attorney (DPOA - a legal document that allows someone to appoint another person to make medical decisions on their behalf if they are unable to do so) can request for medical records. LVN 1 stated if a resident or the family member requested for medical records, they are directed to the Medical Records (MR). LVN 1 stated the timeframe to fulfill a medical record request was 24 to…

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

Based on observation, interview, and record review, the facility failed to provide adequate supervision for two residents reviewed for elopement (Resident 1 and Resident 2) when Resident 1 and Resident 2 had separate elopement (incident when a resident leaves the facility without authorization or supervision necessary for safety) episodes. This failure resulted in Resident 1 and Resident 2 being able to leave the facility undetected, which could have subsequently result in accidents, injuries, or even death to the residents. Findings: On March 28, 2024, at 9 a.m., an unannounced visit was conducted at the facility to investigate two incidents of elopement. On March 28, 2024, at 10:10 a.m., an observation and interview with Resident 1 was conducted. Resident 1 was alert and confused. Resident 1 was observed ambulating independently and stated she wanted to go home. Resident 1 did not remember the elopement incident. On March 28, 2024, at 12:26 p.m., an interview with Registered Nurse (RN) 1 was conducted. RN 1 stated Resident 1 eloped on March 26, 2024, around 8 pm. Resident 1 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, interviews, and facility policy review, the facility failed to chicken was thawed in a safe manner for 106 of 113 sampled residents who received food from the kitchen. Findings included: Review of a facility policy titled General HACCP [Hazard Analysis and Critical Control Point] Guidelines for Food Safety, with a copyright date of 2017 revealed, 6. Safe Thawing Practices a. Thaw meat, fish and or poultry in a refrigerator in a drip proof container and in a way that prevents cross contamination. b. Completely submerge the item in clean running water that is running fast enough to agitate and float off loose ice particles. c. Thaw the item in a microwave oven using the defrost mode if it is to be cooked immediately after thawing. d. Thaw as part of the cooking process. During a concurrent observation and interview on 02/20/2024 at 8:44 AM, four bags of chicken were observed in water in a sink in the facility's kitchen. There was not a continuous flow of cold water on the four bags of chicken. Dietary Aide/Assistant Supervisor (DA/AS) #35 stated the bags 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 interviews, record review, and facility policy review, the facility failed to follow-up with the local authority for the completion of a Level II Preadmission Screening and Resident Review (PASARR) for 1 (Resident #93) of 2 sampled residents reviewed for PASARRs. Findings included: Review of a facility policy titled, California Preadmission Screening and Resident Review, effective 07/01/2020, revealed It is the policy of this facility that a Preadmission Screening and Resident Review Level I is completed to identify individuals who have a mental illness (MI) or intellectual disabilities (ID) and ensure that these residents receive the services and setting determined by the California Department of Health Care Services (DHCS). Level II Full Evaluation should be conducted by a DHCS Contractor for determination when the Level I Screen identifies the resident have Mental Illness (MI) or Intellectual Disability (ID). The policy specified, 6. A positive Level I screen necessitates an in-depth evaluation of the individual by the state-designated authority, known as PASARR Level…

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 record review, interviews, and facility policy review, the facility failed to submit a Level I Preadmission Screening and Resident Review (PASARR) for 1 (Resident #63) of 2 sampled residents reviewed for PASARRs. Findings included: Review of a facility policy titled, California Preadmission Screening and Resident Review, effective 07/01/2020, revealed It is the policy of this facility that a Preadmission Screening and Resident Review Level I is completed to identify individuals who have a mental illness (MI) or intellectual disabilities (ID) and ensure that these residents receive the services and setting determined by the California Department of Health Care Services (DHCS). The policy revealed 3. The 'Resident Review (RR) (Status Change)' is selected if the resident has already been admitted to the facility and the facility is updating the existing PASRR [PASARR] on file for either of the following reasons: a. The resident stay has exceeded the 30-day exempted hospital discharge. The Resident Level I 6170 should be submitted by the 40th calendar day after admission 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.

Based on record reviews, interviews, and facility policy review, the facility failed to schedule physician ordered follow-up appointments for 2 (Resident #111 and Resident #188) of 25 sampled residents. Findings included: Review of a facility policy titled, Resident Appointments, dated March 2023, revealed Our facility has set the process on how appointments are made from the initial consult [consultation]/order to actual transport. Procedure: 1. Entering the initial order for consult in [the electronic medical record] to see a specialist falls on the RN [registered nurse] responsibility. 2. RN prints the order and place in the Case Manager's slot located in the station labeled Case Manager. 3. Case Manager collects the consult order and refer to the designated business office clerk to call the health plan/medical group for authorization as needed. 4. Business Office Clerk should note the order with the authorization number or simply write no auth [authorization] required with the case manager's name. 5. Once the schedule for the appointment is set, business office clerk enters 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 record review, interviews, and facility policy review, the facility failed to have evidence to indicate a pharmacy recommendation was reviewed by the physician for 1 (Resident #10) of 5 sampled residents reviewed for medication regimen review (MRR). Findings included: Review of a facility policy titled, Medication Regimen Reviews, revised in May 2019, revealed, The Consultant Pharmacist reviews the medication regimen of each resident at least monthly. The policy indicated, 8. Within 24 hours of the MRR, the Consultant Pharmacist provides a written report to the attending physicians for each resident identified as having a non-life threatening medication irregularity. The report contains: 1. The resident's name; b. The name of the medication; c. The identified irregularity; and d. The pharmacist's recommendation. Per the policy, 12. The attending physician documents in the medical record that the irregularity has been reviewed and what (if any) action was taken to address it. The policy specified, 15. Copies of medication regimen reports, including physician responses, are…

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 call lights (device used by residents to communicate/indicate the need for assistance) were answered in a timely manner for five of seven residents (Residents 2, 3, 4, 5, 6, and 7). This failure had the potential for delayed medical management and unmet care needs. Findings: On February 5 and 6, 2024, an unannounced visit was conducted at the facility for a complaint investigation. During an observation on February 5, 2024, the following were observed: - at 2:58 p.m., Resident 2 ' s call light was on; - at 3:01 p.m., Resident 3 ' s call light was on; and - at 3:02 p.m., Resident 4 ' s call light was on. During a concurrent observation and interview on February 5, 2024, at 3:10 p.m., with Resident 2, Resident 2 was lying in bed in an upright position. Resident 2 stated most of the time, it took longer for the call light to get answered. Resident 2 stated at times, she had to wait for an hour for her call light to be answered by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure 13 residents consented to COVID, Influenza (flu), and/or RSV (respiratory syncytial virus - a viral infection) vaccination prior to administering the vaccine (Residents 1 through Resident 13). This failure in not ensuring residents ' rights could potentially result in negative side effects and psychosocial outcomes. Findings: On January 3, 2024, at 10:45 a.m., an interview with the Licensed Vocational Nurse (LVN) was conducted. The LVN stated Resident 4 received the COVID and flu vaccine without prior consent. The LVN stated all residents should sign informed consent prior to getting any vaccine. The LVN stated Resident 4 did not have capacity to consent, and in that case the resident's representative should be given the option to consent for the vaccines. On January 3, 2024, at 10:53 a.m., an observation was conducted with Resident 4. Resident 4 was observed confused and was unable to be interviewed. Resident 4's record was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of three residents, (Resident 3)'s call light was within reach. This failure had the potential for Resident 3 to have unmet needs, and unable to call for assistance. Findings: On November 27, 2023, at 1:10 p.m., an unannounced visit to the facility on a complaint investigation was initiated. On November 27, 2023, at 3:19 p.m., a concurrent observation and interview was conducted with Resident 3. Resident 3 was lying on his back in bed. His call light was on the left side of the bed on the floor, outside of Resident 3's reach. Resident 3 stated he did not know where his call light was or how he would call for help. On November 27, 2023, at 3:31 p.m., an interview was conducted with the Certified Nursing Assistant, (CNA). The CNA stated Resident 3's call light was not within reach and should have been within reach. A record review of Resident 3's medical records indicated he was admitted to the facility on [DATE], with diagnoses…

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 reasonable care for the protection of personal property for one of three sampled residents (Resident 1). This failure resulted in the temporary loss of Resident 1's personal property. Findings: A review of Resident 1's medical record was conducted on October 5, 2023. The record indicated Resident 1 was admitted to the facility on [DATE], with a diagnosis of compression fracture (a type of break in the bones in your back that stack up to form the spine) of the first and second lumbar vertebra, type 2 diabetes (occurs when the blood glucose, also called blood sugar, is too high) and history of falls with syncope (a loss of consciousness for a short period of time) and collapse. During a telephone interview with Resident 1 on October 5, 2023, at 11:32 a.m., Resident 1 stated he was admitted to the facility with a walker as well as other personal items. Resident 1 stated the walker was missing upon his discharge on [DATE]. Resident 1…

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.