Sherwood Oaks Post Acute

Based on interview, record review, and facility policy review, the facility failed to refer 1 (Resident #49) of 2 residents reviewed for Pre-admission Screening and Resident Review (PASRR) for a Level II screening when Resident #49 was admitted with a diagnosis of psychosis and depression. Findings included: A facility policy titled, PASARR [Pre-admission Screening and Resident Review, PASRR], dated 03/2024, indicated, a. The facility verifies with [sic] acute hospital if a Level I PASARR screen for potential admissions and readmissions, regardless of payer source, to determine if the individual meets the criteria for a MD [mental disorder], ID [intellectual disability] or RD [related disorders]. b. Before a patient can be transferred from a hospital, they must undergo a PASARR Level I screening. This initial screening is designed to identify individuals who may have mental illness (MI), intellectual disability (ID) or related conditions. The goal is to determine whether they require further evaluation (Level II) to assess the need for specialized services. c. If the level I screen…

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 promote dignity and respect when Resident 1's custom-built hearing aids was lost and was not replaced timely. This failure increased the potential for Resident 1 to not effectively communicate his needs and overall well-being. Findings: During the review of medical records, Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease (a progressive disease affecting memory and other mental functions). A record titled Inventory of Personal Effects dated 6/24/24 indicated, Resident 1 had hearing aids. During an interview on 1/28/24 at 11:36 a.m., with Resident 1's responsible party (RP), RP stated when Resident 1's custom-built hearing aids got lost sometime in July last year, the facility did not replace them and provided generic type hearing aids that kept on falling off from his ears and getting lost again. During a concurrent observation and interview on 1/28/25 at 2:15 p.m.,…

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

Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1), was free from misappropriation of resident property. This failure had the potential for Resident 1 to be subject to financial abuse. Findings: During an interview on 12/30/24, at 5:09 p.m., with Resident 1, the Resident 1 verbalized a Certified Nursing Assistant (CNA 1) told Resident 1 that the CNA 1 was having car troubles and bill troubles and needed $1,000. Resident 1 verbalized upon hearing about CNA 1's financial hardship, provided the CNA 1 with a total of $740 dollars to help CNA 1 with the cost of the car repairs and bills. Resident 1 verbalized the two made an agreement that Resident 1 would be paid back by CNA 1 sometime during 1/25. During a review of Resident 1's Progress Notes dated 12/23/24, indicated in part Resident 1 stopped by the activities office and informed the activities staff that [Resident 1] had let a staff member (CNA 1) borrow some money. During a review of Resident 1's Progress Notes dated 12/27/24, indicated in part C.N.A. (CNA 1) came 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 interview and record review, the facility failed to implement a comprehensive care plan and follow physician orders, for one of two sampled residents (Resident 1). These failures had the potential to negatively impact Resident 1. Findings: During a review of Resident 1's Care Plan, dated 11/4/24, indicated in part, Resident 1 Requires Antidepressant medication related to diagnosis of depression. Resident 1's care plan further indicated in part, an intervention to Administer antidepressant medication as ordered by the physician. During a concurrent record review and interview, on 12/17/24, starting at 10:34 a.m., with the Director of Nursing (DON 1) and Medical Records Director (MRD 1), Resident 1's medication administration record (MAR) was reviewed. Resident 1's MAR indicated in part, two physician orders pertaining to the monitoring of Resident 1, due to Resident 1 taking the medication Trazadone (an antidepressant). One physician order was to monitor Resident 1 for episodes of depression manifested by difficulty in falling asleep every shift and a separate physician…

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 requested medical records in a timely manner, to a resident representative, for one of two sampled residents (Resident 1). This failure had violated Resident 1's rights. Findings: During an interview on 11/4/24, at 3:17 p.m., with the Social Services Director (SSD 1), the SSD 1 was asked to confirm when Resident 1's representative first made the request to obtain Resident 1's medical records. The SSD 1 stated Resident 1's representative verbally and in writing, requested Resident 1's medical records on 10/3/24. During an interview and concurrent record review, on 11/4/24, stating at 2:48 p.m., with the Director Of Nursing (DON 1) and Medical Records Director (MRD 1), the MRD 1 and DON 1 stated the facility required residents and/or their representatives to sign a facility authorization form titled Authorization Form For The Release of Health Information in order to obtain medical records. Both the DON 1 and the MRD 1 stated if a resident or resident representative made a verbal or written request for medical…

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 and interview, the facility failed to follow a care planned intervention to monitor the intake and output of one of two sampled residents (Resident 1). This failure had the potential for Resident 1 to experince negative outcomes. Findings: During a review of Resident 1's Care Plan undated, indicated in part, Resident 1 had a urinary tract infection on 6/22/24, with an intervention for staff to Monitor intake and output. During a concurrent record review and interview, on 10/9/24, at 4:21 p.m., with the Director of Nursing (DON 1) and Medical Records Director (MRD 1), Resident 1's Care Plan was reviewed. The DON 1 and the MRD 1 verbalized they were unable to provide documentation indicating Resident 1's care planned intervention to monitor intake and output was carried out by staff. During a review of the facility's policy and procedure titled Care Plans, Comprehensive Person-Centered dated 2001, indicated in part A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet resident's physical, psychosocial 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.

Based on record review and interview, the facility failed to follow physician orders for catheter care, for one of two sampled residents (Resident 1). This failure had the potential for Resident 1 to experience negative outcomes including an increased risk for developing urinary tract infection(s). Findings: During a concurrent interview and record review, on 10/9/24, starting at 4:30 p.m., with the Director of Nursing (DON 1) and the Medical Records Director (MRD 1), Resident 1's Treatment Administration Record (TAR), was reviewed. Resident 1's TAR indicated in part Resident 1 had a physician order of Indwelling catheter: Monitor for change in urine character .every shift for f/c (foley catheter) management. The physician order was active from 5/30/24 to 8/23/24. Resident 1's TAR indicated missing/blank entries on 6/8/24, 6/17/24, 7/2/24, 7/5/24, 7/7/24, 7/19/24, 7/21/24, 7/28/24, 7/29/24, 7/30/24, 7/31/24, 8/8/24, 8/12/24, 8/13/24. The DON 1 and MRD 1 confirmed the missing entries. During a concurrent interview and record review, on 10/9/24, starting at 4:30 p.m., with the DON 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.

Based on record review and interview, the facility failed to administer Metoprolol (a medication used to treat high blood pressure) per physician orders, for one of two sampled residents (Resident 1). This failure had the potential to result in a medication being withheld, when it should have been administered. Findings: During a concurrent record review and interview, on 8/8/24, starting at 11:28 a.m., with the Director of Nursing (DON 1) and Medical Records Director (MRD 1), Resident 1's medical record was reviewed. Resident 1's Medication Administration Record (MAR) indicated in part, Resident 1 had a physician order of Metoprolol .Give 12.5mg (milligrams) by mouth two times a day for HTN (hypertension [high blood pressure]) hold for SBP (systolic Blood Pressure) < (less than) 110 or HR (heart rate) < 60 (60 beats per minute). Resident 1's MAR indicated on 8/1/24, at 9:00 p.m., Resident 1 did not receive the scheduled dose of the medication due to Resident 1's vital signs being outside the parameters of the order. Review of Resident 1's Weights and Vitals Summary indicated in…

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

Based on record review and interview, the facility failed to provide documentation indicating a care planned intervention for falls was carried out for one of two sampled residents (Resident 1). This failure had the potential to lead to negative outcomes for Resident 1. Findings: During a review of Resident 1's Progress Notes dated 7/8/24, indicated in part on 7/6/24, at 3:20 a.m., CNA (certified nursing assistant) (CNA1) was walking by resident's room and observed the resident (Resident 1) sitting on the landing mat .Resident (Resident 1) was alert and stated that (Resident 1) got up to use the commode and lost (Resident 1) balance and fell, hitting the back of (Resident 1) head on the armrest of the commode .small laceration on the back of the head with bleeding .Resident (Resident 1) c/o (complaints of) pain on the back of the head 4/10 and right rib area 7/10. The progress note entry further indicated in part Resident (Resident 1) is at risk for further falls and injury due to non-compliance with safety precautions, transferring and ambulating without assistance. 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 ensure there was timely monitoring and skin evaluation on a resident's skin in one of three sampled residents (Resident 1). This failure had the potential for miscommunication in skin care that may result in further decline in Resident 1's skin condition after cast removal on the right lower limb . Findings: During a review of the undated admission record, Resident 1 was admitted to the facility on [DATE] following a right knee surgery and had conditions listed as encounter for orthopedic (the treatment of bones that have been damaged) aftercare. A review of the history and physical dated 3/23/24, Resident 1 has the capacity to understand and make decisions. During a review of Resident 1 s Physician's orders dated 3/22/24, it indicated right knee immobilizer on at all times, check for circulation, skin integrity, and signs and symptoms of infection and skin breakdown. During a concurrent observation and interview on 5/1/24 at 3:15 p.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, the facility failed to revise the care plan (a document which provides direction for and communicates to staff the individualized care of the resident) for one of three sampled residents (Resident 1) after a fall incident. This failure had the potential to result in Resident 1's repeat occurrence of falling. Findings: Resident 1 was admitted to the facility on [DATE], with diagnoses that include Dementia, Anxiety, Unsteadiness on Feet. History and Physical (H&P) indicated that Resident 1 has fluctuating capacity to understand and make decisions and was assessed of having a high risk of falling. Facility reported that Resident 1 had an unwitnessed fall on 3/8/24 and was not complaining of any pain or discomfort until when Resident 1 complained of hip pain on 3/16/24. An X-ray (a procedure using a machine to capture an image in any solid internal part of the body like bones) indicated right hip fracture (break in the continuity of a bone). During an observation on 4/3/24 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.

Based on observation, and interview, the facility failed to label and discard perishable food items, from the resident refrigerator, per policy and procedure. This facility failure had the potential for residents to experience negative outcomes, including foodborne illness. Findings: During a review of the facility ' s policy and procedure titled Foods Brought by Family/Visitors dated 3/22, indicated in part Containers are labeled with the resident ' s name, the item and the use by date .The nursing staff will discard perishable foods on or before the use by date. During a concurrent observation, and interview, on 3/4/24, starting at 2:15 p.m., with licensed nurse (LN 1), the facility ' s resident refrigerator was inspected. One container of Kimchi, one container of cream cheese, one container of chicken, one container of fruit salad, and one container of prunes, were not labeled with a use by date. The LN 1 acknowledged these food items, in the resident refrigerator, lacked use by dates. Also found in the resident refrigerator was one box of key lime pie, dated 2/28/24, one…

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 and interview, the facility failed to ensure a medication ordered by the physician and care planned as an intervention was implemented for one of two sampled residents (Resident 1). This facility failure had the potential for medications to be missed /administration with no follow up, placing Resident 1 at risk for non medication effectiveness or benefit in addressing the health issue the medication was prescribed for. Findings: During a review of Resident 1's admission Record undated, indicated in part, Resident 1 had diagnoses including Dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), and Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks). During a concurrent record review and interview, on 1/10/24, starting at 1:36 p.m., with the Medical Records Director (MRD 1), Resident 1's physician orders and Medication Administration Record (MAR) from 12/23 to 1/24 were…

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

Based on observation and interview, the facility failed to identify and fix a broken window frame and blind curtain handle, in one of three sampled residents (Resident 3) rooms. This facility failure had the potential for residents not to be provided with a homelike and comfortable environment. Findings: During a concurrent observation and interview, on 8/24/23, at 11:11 a.m., with the Housekeeping Supervisor (HS 1), Resident 3 ' s room was inspected. A window frame was found in a state of disrepair, off its track, and the window ' s blind tilt wand was not connected to the blinds. The HS 1 agreed both the window frame and blind tilt wand were in a state of disrepair and needed to be fixed. During a concurrent observation and interview, on 8/24/23, at 11:50 a.m., with the Maintenance Director (MTD 1), Resident 3 ' s window was inspected. The MTD 1 acknowledged staff had not previously reported the broken window frame or detached window blind tilt to the maintenance department and that the maintenance department had been unaware of the issue. During an interview on 8/31/23, at 3:54…

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 meals were served at a palatable temperature to ensure residents' satisfaction as stated by 9 of 9 residents during the confidential resident council meeting. There were eight-seven residents receiving food from the facility's kitchen. Failure to serve food at an appetizing temperature to ensure resident's satisfaction could result in poor food intake and unplanned weight loss. Findings: During a confidential resident council meeting on 11/15/22, at 2:32 p.m., nine of nine residents present stated they were not satisfied with the temperature of the food when served, specifying the food was not hot enough. During an observation on 11/17/22, at 12:35 p.m., in the kitchen, the Dietary Manager (DM) was observed calibrating a digital thermometer in ice, and DM stated, It's 32 degrees F [Fahrenheit]. During a concurrent observation and interview on 11/17/22, at 01:13 p.m., with Certified Nursing Assistant (CNA) 4, in the hallway of Wing 5, CNA 4 was observed to be the only staff delivering meal trays 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 ensure safe food handling and sanitation when: 1. Staff were not following the facility's dating system for food products to ensure used within the shelf- life guidance for safety and quality. 2. Dishes and foodservice equipment stored as clean had dried debris and a build up of grease and grime. 3. Meatballs were not cooled down safely in accordance with directions located on the Cool Down Log. 4. The food processor was not washed and sanitized between food items during puree food preparation which increased the risk of cross-contact of a potential food allergen. As a result, residents were placed at risk for developing a food borne illness. There were eighty-seven residents receiving food from the facility's kitchen. There were nine residents on a puree diet of which one of those residents had a food allergy and was at an increased risk for cross contact food allergen due to lack of washing and sanitizing the food processing equipment after each food item. According to foodallergy.org, Cross-contact happens…

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 individualized care plan, for communication, was developed when the resident was not able to avail fully and effectively the use of a communication board for one of 23 sampled residents (Resident 47). This failure had the potential for Resident 47's communication needs not being met with effects on the overall physical and mental well-being. Findings: During a review of Resident 47's, admission Record (AR), the AR indicated, Resident 47 was admitted on [DATE], with the diagnoses including: hemiplegia and hemiparesis (paralysis of one side of the body), dysphagia (difficulty swallowing), schizophrenia (a mental disorder characterized by significant impairments in which reality is perceived), and depression (a mood disorder that causes feelings of sadness). During a concurrent observation and interview on 11/14/22, at 10:30 a.m., with Resident 47, inside the resident's room, the resident was in bed, awake, alert, with difficulty…

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 fall care plan for one of 23 sampled residents (Resident 35), was re-evaluated and revised. This failure had the potential of placing Resident 35 at risk for future falls. Findings: During a review of Incidents by Incident Type,date range from 10/1/22 to 10/21/22, the Incidents by Incident Types indicated, in part .Un-witnessed Fall Incidents .Resident 35 on 10/01/22 1:45 AM. During an interview on 11/15/22, at 4:15 p.m., with Medical Records Director (MRD), MRD stated, The long term care plan wasn't updated or revised. During a review of Resident 35's Care Plan for FALLS, dated 09/21/22, the care plan indicated, no revised interventions for Residnet 35's fall which occurred on 10/01/22. During a review of the facility's policy and procedure titled, Goals and Objectives, Care Plans, [untitled], indicated, in part, .Care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence. Goals and objectives are reviewed and/or revised: a. when there…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure care rendered were according to professional standards when physician orders (PO) were not implemented : 1. Resident 74's gastro enteral feeding tube (GT - tube in stomach for liquid formula to go thru -for nourishment) water flush as ordered was documented done prior to administration. This failure has the potential for the resident not to received the water flush as ordered . 2. Oxygen administration order was not followed for Resident 74. This failure has the potential for the resident to have episodes of respiratory distress. 3. Topical medications for skin problem was not administered to Resident 60. This failure [NAME] the potential for the resident's skin to be more irritated leading to skin openings or infection. ` 4. Anticoagulant (blood thinner) medication side effects were not monitored for two residents (Resident 47 and 10). This failure has the risk and potential for signs and symptoms of the resident bleeding…

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

Based on interview and record review, the facility failed to ensure policy and procedure (P&P) in documenting all the services was followed when the turning task or schedule as part of the intervention and measures to heal off existing pressure areas (skin opening) was not documented, as completed in one resident (Resident 1). This failure placed the resident at further risk for a non healing skin wound /pressure areas detrimental to the resident's overall well being . Findings: During a review of Resident 1's clinical record, indicated, Resident 1 was admitted from the hospital with multiple pressure injuries on the sacrum area, left and right heel with the admission date of 6/25/22 and hospitalized (transferred back to the hospital) on 8/10/22 to 8/26/22, 8/28/22 to 9/15/22 and 10/28/22 (did not return back to the facility). Further review of the clinical record , the wound physician's (WP) treatment plan, dated 8/8/22, indicated, to turn patient every two hours, keep skin and dry, avoid massaging bony prominences, provide adequate intake of protein and calories, maintain current…

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

Based on observation, interview, and record review, the facility failed to ensure one of 23 sampled residents, (Resident 67), received a dental consult, within the first 90 days of admission. This failure had the potential for possible dental issues to not be assessed and addressed. Findings: During an interview on 10/21/22, at 3:10 p.m., with Resident 67, Resident 67 stated, I need to see the dentist. I never have. During a concurrent interview and record review, on 10/21/2022, at 3:45 p.m., with Social Services Assistant (SSA), SSA checked Resident 67's medical records for a dental consultation. There was nodental consulatation in the chart. SSA stated, Residents usually let someone know, and then we schedule it. SSA further stated, Resident 67 has never mentioned it. During an interview on 10/21/2022, at 4:10 p.m., with SSA, SSA explained, Resident 67 has a HMO and the consulting dentist doesn't take that insurance. When asked about the process when this occurs, SSA stated, Nothing, unless the resident complains. I don't have an answer why I didn't call the sons. During a review…

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

Based on observation, interview, and record review, the facility failed to ensure one cook (Cook 2) was competent on internal cooking temperatures for fish and poultry to ensure food safety. This failure placed the residents at risk for a foodborne illness. Findings: During a concurrent observation and interview on 11/15/22, at 10:41 a.m., with cook (Cook 2), in the presence of Dietary Manager (DM), in the kitchen, [NAME] 2 was asked how she determined fish was cooked thoroughly. [NAME] 2 stated, she would check the temperature with a thermometer and look for 40 degrees [F-Fahrenheit]. DM clarified the question with [NAME] 2 in Spanish, and [NAME] 2 repeated she would expect to see 40 degrees F to know that fish was cooked thoroughly. During a concurrent observation and interview on 11/15/22, at 10:45 a.m., with [NAME] 2, in the presence of DM, in the kitchen, [NAME] 2 was asked to check the internal temperature of the fish that was sitting on the stove range, after she took it out of the oven. [NAME] 2 inserted the bayonet thermometer, and [NAME] 2 stated, It's 31 degrees [F]. DM…

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 the menu as planned when: 1. The incorrect food item (rice) and portion size was served to one of 23 sampled residents (Resident 24) when finger foods when possible was listed on her meal tray card. 2. Too large of chicken piece sizes were served to one of 23 sampled residents (Resident 68) who was on a Soft & Bite-Sized diet order. 3. The menu for puree diet was not followed for one of 23 sampled residents (Resident 80) when the cook did not prepare puree tartar sauce as directed on the planned menu. This facility failure had the potential to cause frustration in a resident by not providing finger foods to promote independence, placed a resident at an increased risk for choking, and had the potential to cause decreased food intake, and impede dignity, when puree tartar sauce was not served for the resident to enjoy with puree fish, as residents on a regular diet received. Findings: 1. During a concurrent observation and interview on 11/15/22, at 12:05 p.m., with [NAME] 2, in the kitchen, [NAME] 2 was…

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

Based on observation, interview, and record review, the facility failed to follow the therapeutic diet, as ordered by the physician, for one of 23 sampled residents (Resident 23), when Resident 23 was fed a whole banana while on a pureed diet. This failure had the potential for Resident 23 to choke on the solid food. Findings: During a review of Resident 23's admission Record, dated 3/8/22, the admission Record indicated, in part, Diagnosis Information, and Dysphagia, Oral Phase (difficulty swallowing foods). During a review of Resident 23's Medication Review Report (MRR), dated 11/14/22, the MMR indicated, in part, Diet, Pureed Texture, and Order status, Active. During a review of Resident 23's Rehab - Dysphagia Screening Form, dated 11/7/22, the from indicated, in part, Resident is unable to swallow on demand, and Diagnosis and clinical symptoms indicate presence of dysphagia. During a review of Resident 23's Care Plan, initiated 2/11/22, the Care Plan indicated, in part, Focus, Dysphagia/Swallowing impairment, and Interventions/Tasks, Diet as ordered, Diet texture modification…

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 and implement safe infection control practices when: 1. No visible signage of transmission-based precautions (alert of precautions to prevent spread of infection) was posted at the door for one resident (Resident 76) on contact isolation. 2. Staff failed to donn (put on) personal protective equipments (PPE- disposable gloves and gown to prevent spread of infection) prior to entering contact isolation room for one resident (Resident 13). 3. Two certified nurse assistants failed to sanitize hands before entering patient rooms. 4. Staff failed to appropriately handle and dispose of soiled bandage. These failures had the potential to cause the spread of infection to a vulnerable elderly and immune compromised population. Findings: 1. During an concurrent observation and interview on 11/14/22, with the infection preventionist (IP) during initial pool, Resident 76's room was observed. There was an isolation cart by the door. There was no…

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.