Thousand Oaks Post Acute, LLC

Based on observation, interview, and record review, the facility failed to ensure medical records were kept in accordance with professional standards of practice for one of ten residents (Resident 23) observed during the medication administration observation, when Resident 23's pain scores were incorrectly documented in the medical record.This failure resulted in inaccurate documentation of Resident 23's pain which could cause inaccurate clinical assessment of pain management medications. Findings:During a medication pass observation on 7/6/26, at 4:12 PM, at Resident 23's bedside, Licensed Vocational Nurse 2 (LVN 2) was observed administering five medications to Resident 23. The medications included two tablets of acetaminophen (generic for Tylenol, pain medication) 325 milligrams (mg), total dose 650 mg, and two tablets of ibuprofen (generic for Advil, pain medication) 200 mg, total dose 400 mg. A review of Resident 23's Medication Review Report, dated 7/7/26, indicated Resident 23 had a physician's order, dated 11/15/25, for acetaminophen 325 mg, Give 2 tablet by mouth every 4…

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 two sampled residents (Resident 1), was cared for by staff (IP and CNA2) using enhanced barrier precautions (gloves and gown). This failure had the potential to result in the spread of harmful germs from contaminated uniforms to residents during the delivery of care.During a review of Resident 1's physician orders dated 3/5/26, the orders indicated Resident 1 to have Enhance Barrier Precautions due to: foot and right buttocks wounds every shit for infection control and prevention. During a review of the facilities P&P titled, Enhanced Barrier Precautions, dated January 2025, the P&P indicated, EBP are indicated for residents with any of the following: Wounds, even if the resident is not known to be infected or colonized with a Multi-Drug-Resistant Organism (MDRO). The staff will implement EBP for residents who are indicated when performing the following high contact resident care activities: providing hygiene.changing briefs . Review of the California Department of Public Health (CDPH) All…

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 two sampled residents (Resident 1): 1. Had a baseline care plan (BCP- initial instructions for care right after admission) developed for diabetes management. 2. Had BCP developed for abdominal binder (a wide, elastic compression belt worn around the abdomen) use. 3. Had BCP interventions (specific actions to be taken) that were applicable to Resident 1 regarding NPO (nothing by mouth) status. These failures resulted in Resident 1 being transferred to the hospital for elevated blood sugar and had the potential for choking or aspiration (food or liquids entering the lungs).During a review of Resident 1's admission Record (AR), the AR indicated, Resident 1 was a [AGE] year-old admitted to the facility on [DATE] with a primary diagnosis of cerebral infarction (stroke, loss of blood flow to a part of the brain) and secondary diagnoses of diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control), dysphagia (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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of two residents (Resident 1) was provided care according to accepted professional nursing standards (actions that ensure safe nursing practice) when the facility failed to: Develop a baseline care plan (BCP- initial instructions for care right after admission developed by using the nursing process) for diabetes management. 2. Develop care plans (CP- a detailed outline of health needs, goals, and preferences that guides care to ensure consistent and appropriate care) with resident specific interventions. 3. Clarify conflicting orders for the way to (route) administer medication. 4. Follow physician order for monitoring blood pressure (BP). 5. To communicate with the physician to clarify PRN (as needed) Seroquel order when ordered for an excessive duration without an end date and with conflicting physician indications for its use. 6. To include an intervention for a psychiatric assessment and a review of the results of the psychiatric…

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 two sampled residents (Resident 1):1. Had appropriate alternatives to bed rails identified and tried.2. Was adequately assessed for bed rail use. 3. Had their bed and mattress assessed for bed rails (metal bars attached to the bed) prior to the bed rail installation. 4. Had the appropriately trained staff install the bedrails.These failures had the potential to result in an increased risk of entrapment (caught, trapped, entangled, or strangled in the space in or about the bed rail).Resident 1 was admitted to the facility on [DATE] with a primary diagnosis of cerebral infarction (type of stroke- brain cells die) and secondary diagnoses including flaccid (floppy and weak) hemiplegia (paralysis of one side of the body), muscle weakness, drug-induced polyneuropathy (nerve damage that occurs as a side effect of certain medications), dysphagia (swallowing difficulties) with gastrostomy (surgical opening in the abdomen to insert a feeding tube…

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 have competent nurses who possessed the knowledge, skills, and judgment required to provide safe care for one of two sampled residents (Resident 1), when the facility failed to ensure: Licensed nurses knew to contact the physician when they did not administer Glargine (insulin- medicine used to regulate blood glucose levels) as ordered. 2. Licensed nurses knew to communicate to the charge nurse the missed doses of Glargine. 3. Licensed nurses knew to contact the physician when the medication administration record did not include blood glucose monitoring. 4. Licensed nurses knew to clarify conflicting orders for how to (route) administer medication. For Resident 1, these facility failures resulted in unsafe nursing care and admission to the hospital for an avoidable decline.1. According to Fundamentals of Nursing ([NAME] et al; Elsevier: 2023, p. 640), Administering medications requires unique nursing knowledge, clinical judgement, and skills.…

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 two sampled residents (Resident 1) had complete and accurate documentation in their health record.This failure resulted in the planning and delivery of care based on inaccurate resident assessments.According to Fundamentals of Nursing ([NAME] et al; Elsevier: 2023, p. 389), Information in a patient's record provides a detailed account of the level of quality of care delivered. The quality of care, the standards of regulatory agencies and nursing practice, the reimbursement structure in the health care system, and legal guidelines make documentation and reporting an extremely important nursing responsibility. During an interview on 9/25/25 at 3:45 p.m. with a licensed nurse (LN1), LN1 stated LN1 texted the physician to clarify Resident 1's route of medication administration. LN1 stated there is no record of this text in Resident 1's medical record. During a concurrent interview and record review on 9/25/25 at 3:45 p.m. with LN1, Resident…

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

Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1), had an accurate diagnosis recorded on their Minimum Data Set Assessment ([MDS] a tool for implementing standardized assessment and for planning care). This facility failure resulted in the facility reporting inaccurate data to Centers for Medicare & Medicaid Services (CMS). Findings: During a concurrent interview and record review on 5/28/25 at 3:34 p.m. with the Minimum Data Set Coordinator (MDSC), Resident 1's MDS 3.0 Section I - Active Diagnoses was reviewed. The section indicated, an active diagnosis of benign prostatic hyperplasia ([BPH], condition in older men where the prostate gland enlarges but is not cancerous). MDSC stated that MDS Section I - Active Diagnoses for BPH should not have been marked yes and acknowledged that MDS Section I was incorrectly coded, as Resident 1 did not have this diagnosis. During a review of the facility 's MDS manual titled, CMS's RAI Version 3.0 Manual, dated 10/2024, the MDS manual indicated, Active Diagnoses Intent: The items 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 observation, interview, and record review, the facility failed to promptly notify the physician of the x-ray results for one of two sampled residents (Resident 1). This failure resulted in a delay in treatment for Resident 1's dislocated hip and increased the potential for Resident 1 to experience unnecessary pain or worsening of her condition. Findings: During a review of Resident 1's admission Record (AR), dated 5/28/25, the AR indicated, Resident 1 was admitted in the facility on 2/24/25 with diagnoses including but not limited to, midcervical fracture of right femur (a break in the upper bone near the hip) and aftercare following joint replacement surgery. During a review of Resident 1's Radiology Results Report (RRR), dated 5/19/2025 at 7:13 p.m., the RRR indicated, postsurgical changes from a right hip hemiarthroplasty with superior dislocations (the femoral component of the hip implant had moved upward out of place). During a review of Resident 1's Change of Condition (COC), dated 5/20/25 at 7:41 p.m., the COC indicated, Resident 1 was sent out to [hospital name] via…

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.

2. An admission Record revealed the facility admitted Resident #103 on 01/25/2025. According to the admission Record, the resident had diagnoses that included other speech and language deficits following cerebral infarction, dysphagia, aphasia, apraxia, dementia in other diseases classified elsewhere, seizures, and systolic heart failure. Resident #103's discharge MDS, with an Assessment Reference Date (ARD) of 02/04/2025, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. The MDS also indicated the resident discharged to a short-term general hospital setting. Resident #103's Order Summary Report, revealed an order dated 02/04/2025, for the resident to discharge to home with home health on 02/04/2025. Resident #103's nursing Progress Notes, dated 02/04/2025 at 3:50 PM, revealed Resident #103 discharged to home with arrangements for home health. During an interview on 04/25/2025 at 9:28 AM, MDS Coordinator #3 stated that MDS accuracy was important because it drove the plan of care for residents. She…

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, record review, and facility policy review, the facility failed to resubmit a Level I Preadmission Screening and Resident Review (PASRR) as required for 1 (Resident #64) of 3 residents reviewed for PASRR. Findings included: A facility policy titled, Preadmission Screening and Resident Review (PASRR), revised 01/2025, revealed the section titled GUIDELINES, included, 4. A negative Level I screen permits admission to proceed and ends the pre-screening process unless possible serious mental disorder or intellectual disability arises later. Further review revealed, 16. If the State program permits the use of the exceptions and the resident remains in the facility longer that 30 days, the facility must screen the individual using the State's Level I screening process and refer any resident who has or may have MD [mental disease], ID [intellectual disability] or a related condition to the appropriate state-designated authority for Level II PASARR [PASRR] evaluation and determination. An admission Record indicated the facility admitted Resident #62 on 11/28/2023.…

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 resident's (Resident 1) right to be treated with dignity when a Certified Nursing Assistant (CNA 1) removed bra while in Resident 1's room. This facility failure had the potential to result in a loss of dignity for Resident 1. Findings: During a review of Resident 1's admission Record, dated 4/2/2025, the admission Record indicated in part, Resident 1 was admitted to the facility on [DATE] with the following diagnoses: muscle weakness, aphasia (language disorder that results from brain damage), type 2 diabetes mellitus (the body cannot use insulin [a hormone which regulates the amount of glucose in the blood] correctly and sugar builds up in the blood), cerebral infarction (disrupted blood flow to the brain). During a review of Resident 1's Minimum Data Set (MDS), (a standardized assessment tool to evaluate the health and functional abilities of residents) dated 2/28/2025, the MDS indicated, a Brief Interview for Mental Status…

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 two sampled residents (Resident 1) was treated with respect and dignity when the Certified Nursing Assistant (CNA) 1 repeatedly told Resident 1 to wait for a brief change. This failure had the potential to negatively impact Resident 1's sense of self-worth, self-esteem, and overall quality of life. Findings: During a review of Resident 1's admission Record (AR), dated 11/27/24, the AR indicated, Resident 1 was admitted with diagnoses including encephalopathy (disturbance of brain function), Arthritis (swelling and tenderness of one or more joints), and muscle weakness. During a review of Resident 1's, MDS (Minimum Data Sheet - a federally mandated process of clinical assessment for nursing home patients) Assessment, dated 11/22/24, the MDS indicated, Section C - Brief Interview of Mental Status (BIMS) assessment indicated, Resident 1 had a BIMS Score of 10 (The BIMS assessment uses a points system that ranges from 0 to 15 points: 0 to 7 points suggests severe cognitive impairment, 8 to 12 points…

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 three residents (Resident 1) who had a colostomy (an opening that connects the digestive tract to the surface of the belly to allow for waste material and gas to leave the body) received care consistent with professional standards of practice when Resident 1's colostomy bag was removed, emptied, and placed back on by unlicensed staff. This failure had the potential to place Resident 1 at risk for complications such as infections or dislodgment of the colostomy bag. Findings: During a review of Resident 1's admission Record (AR), dated 7/12/24, the AR indicated, Resident 1 was admitted with diagnoses including, colostomy, artificial opening of urinary tract, hypertension (high blood pressure) and hyperlipidemia (build-up of fats in the blood). During a review of Resident 1's, MDS (Minimum Data Sheet - a federally mandated process of clinical assessment for nursing home patients) Assessment, dated 7/16/24 , the MDS indicated, Section C - Brief Interview of Mental Status (BIMS) assessment indicated, 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.

Based on observation, interview, and record review, the facility failed to perform hand washing while providing colostomy (an opening that connects the digestive tract to the surface of the belly to allow for waste material and gas to leave the body) care with one of three sampled resident (Resident 3). This failure had the potential to cause infection to Resident 3's colostomy site. Findings: During an observation of Resident 3's colostomy care treatment on 8/9/24 at 12:45 p.m. with Licensed Nurse (LN 1), LN 1 with a new pair of gloves, removed the soiled colostomy bag, placed them in a garbage receptable. LN 1 removed the pair of dirty gloves, placed them in a garbage receptacle, and then put on clean gloves without washing her hands. LN 1 then proceeded to clean the stoma (any opening in the body) removed dirty gloves, grabbed a new pair of gloves, and again placing a new pair on without performing handwashing. During an interview on 8/9/24 at 12:50 p.m. with LN 1, LN 1 acknowledged not washing her hands during the treatment. LN 1 further stated that washing hands in between…

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 two sampled residents (Resident 1) had timely access to their medical records. This failure resulted in Resident 1's legal representative delayed access to their health history and violated the resident's right to medical record access. Findings: During a review of the facility's policy and procedure (P&P) titled, Resident Access to PHI or Financial Records, dated 9/1/23, the P&P indicated, If the resident and/or their personal representative requests a copy of the resident's medical or financial record, the HIPAA Privacy Officer will provide the resident and/or their personal representative with a copy of the medical record within two (2) working days after receiving the written request. During an interview on 10/12/23 at 1:20 p.m., with admission (AD), the AD stated on 10/2/23 the facility received an eFax (online fax) request for medical records from Resident 1's legal representative. AD verbalized on the same day, 10/02/23, 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 implement its policies and procedures (P&P) on dry food storage and kitchen sanitation, and ensure food quality and safety standards were met when: 1) stored food products found in the dry food storage room [ROOM NUMBER] were beyond the indicated use by date labels, and 2) the temperature of the sanitizing solution used to cleanse/sanitize non-food contact work surfaces and kitchen equipment was not measured. These failures had the potential to contaminate foods served to the residents, that can lead to serious food-borne illness. Findings: 1) During a review of the facility's P&P, titled, Food and Nutrition Services - General, dated 9/1/21, the P&P indicated, in part, The primary objectives of the dietary department include .c) Maintenance of standards for sanitation and safety, d) Maintenance of standards for quality of food During a concurrent inspection, and interview, with the Dietary Manager (DM), on 11/15/21 at 9:45 A.M., of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a homelike environment when residents shared closets/cabinets in rooms (18, 19, 20, and 36) for one of 20 sampled residents (Resident 54), and eight unsampled residents (Resident 58, 12, 28, 80, 302, 41, 7, and 83). This failure resulted in the residents not having a personalized, homelike atmosphere and could affect their psychological well-being Findings: During an observation on 11/15/21, at 3:15 p.m., in room [ROOM NUMBER], Resident 54's personal cabinet/closet space was observed next to the bed. Further observation revealed Residents 12, 54, and 58 all shared the same closet space for their personal belongings. During an interview on 11/15/21, at 3:35 p.m., with Licensed Nurse (LN 1), LN 1 confirmed all residents should have their own private closet space. LN 1 further stated, If one resident can have their own cabinet, I don't see why the other residents cannot . During another observation on 11/16/21, at 10:20 a.m., rooms…

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 professional standards in clinical practice and documentation were met, when: 1) staff administered pain medication to two of 20 sampled residents (Resident 20 and Resident 97), that did not meet the medication order parameter for its indication, and 2) staff follow-up assessment and education were not done, after resident refusal of apical pulse measurement, for two of 20 sampled residents (Resident 2 and Resident 8). These failures had the potential to inappropriately identify and manage resident health issues that may lead to serious harm. Findings: 1a) During a review of Resident 20's, admission Record (AR), dated 8/15/20, the record indicated Resident 20 was admitted with diagnoses including, Cervical Disc Disorder at C5-C6 Level with Radiculopathy (injury to the spinal cord that causes weakness); Other Chronic Pain, Adult Osteochondrosis of Spine, Lumbar Region (discs in the spine pressed together causing pain), and Other muscle spasm. During a review of Resident 20's, Order Summary Report (OSR), 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 observation, interview, and record review, the facility failed to provide an appropriate call light for one of 20 sampled residents (Resident 54). This failure has the potential for the resident to not receive necessary care and could result in complications and poor psychosocial outcome. Findings: During an observation on 11/15/21, at 3:00 p.m., in the resident's room, Resident 54 was observed in bed. Both hands of the resident were contracted, with a regular call light clipped on the bedsheet. Further observation revealed Resident 54 does not have the capacity to hold or use the call light. During an interview on 11/15/21, at 3:30 p.m., with Licensed Nurse (LN 1), LN 1 confirmed the call light was inappropriate for Resident 54. LN 1 further stated, The resident cannot even hold the light. It should be a different one. During a review of Resident 54's admission Record (AR), dated 6/22/21, the AR indicated, Resident 54 had contracture of the muscle of both the right and left hands. During a review of the facility's policy and procedure (P&P) titled, Resident Rights -…

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 20 sampled residents (Resident 82) was free of physical restraints. This failure had the potential to negatively affect the resident's physical mobility and psychosocial well-being. Findings: During an observation of Resident 82's room on 11/15/21, at 2:27 p.m., Resident 82 was observed in bed, the left side of the bed was placed against the wall and on the right side of the bed two side rails were raised. During an interview on 11/15/21, at 2:35 p.m., with a Licensed Nurse (LN 1), LN 1 stated, the physician's order was its ok to place to put the bed against the wall with one side rail up. LN 1 confirmed 2 side rails were up instead of one. During a review of Resident 82's Physician Orders, dated 11/15/21, at 4:22 p.m., the physician's order indicated, May have bed against the wall and ¼ side rails up x1 for mobility. During a review of the facility's policy and procedure (P&P) titled, Devices & Physical Restraints undated, the P&P indicated, The residents shall be provided an environment that is…

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 update a care plan for one of twenty sampled residents (Resident 85) after returning from the hospital. This failure resulted in improper monitoring of Resident 85 for bleeding episodes related to chronic anticoagulant (commonly known as blood thinners, are chemical substances that prevent or reduce chance of getting a deep vein thrombosis [DVT] - a blood clot) use. Findings: During an interview and concurrent record review, on 11/18/21, at 10:03 a.m., with a licensed nurse (LN 4), Resident 85's admission record dated 11/9/21, was reviewed and the record indicated, Resident 85 was on long term (current) use of anticoagulants. Review of Resident 85's order summary report, dated 11/9/21, indicated, Apixaban (blood thinner) tablet 2.5 MG (milligram) give 1 tablet by mouth two times a day for DVT prophylaxis. Apixaban use: Monitor for signs and symptoms of bleeding (abnormal or unexplained bruising, petechiae (unraised, round red spots under the skin…

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 activity assistant was trained to provide activities according to resident's preference and interests for one of twenty sampled residents (Resident 35). This failure resulted in Resident 35 not receiving activities that were person centered. Findings: During a review of Resident 35's admission Record, the admission record indicated, Resident 35 was admitted with diagnoses including, muscle weakness, difficulty walking, right side hemiplegia (paralysis of one side of the body), urinary catheter (a tube placed in the body to drain and collect urine from the bladder), and Gastrostomy (a surgical opening into the stomach for nutritional support). During a review of Resident 35's minimum data set (MDS-a standardized, primary screening and assessment tool of health status which forms the foundation of the comprehensive assessment for all residents of long-term care facilities) dated Sep 8, 2021, the MDS indicated: Section C - Cognitive Patterns indicated, Resident 35 had a BIMS score of 0 (brief interview…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of 20 residents (Resident 35) was monitored for signs and symptoms of a urinary tract infection ([UTI] bladder infection). This failure had the potential for the resident to have a catheter (a tube that is inserted into the bladder, allowing urine to drain) associated urinary tract infection (CAUTI) Findings: During an observation on 11/17/21, at 2:30 p.m., Resident 35 was observed to have a urinary catheter, the catheter collection bag was hanging under the bed with a blue bag covering the collection bag. During a review of Resident 35's Physician Orders, dated 9/4/21, a physician order indicated, to monitor every shift for signs and symptoms of possible urinary infection and call the physician. During a review of Resident 35's Treatment Administration Record, the treatment records dated October and November 2021 indicated, missing documentation for monitoring of signs and symptoms of infection for 10/21, 10/25, 10/27/21 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 pain medication was administered as prescribed for one of six sampled residents (Resident 453). This failure had the potential for the resident to have ineffective pain management and resulted in a medication error. Findings: During a review of Resident 453's History & Physical (H&P), dated November 9, 2021, the H&P indicated, Resident 453 was admitted with diagnoses including, right hip total arthroplasty (total hip replacement, removing damaged bone and cartilage and replacing with prosthetic components), right hip pain issues postsurgical (hip pain after surgery). During an observation on 11/16/21, at 8:40 a.m., Licensed Nurse (LN 2) was observed administering Tramadol (used to relieve moderate to moderately severe pain, including pain after surgery) per resident's request for a reported pain level of 7 out of 10 hip pain (pain level measurement, 0 indicating no pain and 10 indicating severe pain). No other pain medication was…

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

Based on observation, interview, and record review, the facility failed to ensure a medication cart and narcotic storage boxes were locked, secured, and inaccessible to unauthorized staff, residents, and visitors when one of five medication carts was left unlocked and unattended in a resident hallway. This failure had the potential for visitors, residents, and unauthorized staff to access medications and narcotics stored in the medication cart. Findings: During an observation and concurrent interview on 11/15/21, at 11:08 a.m., with the Director of Nurses (DON) and Licensed Nurse (LN 3), the DON was observed walking to an unlocked and unattended medication cart located at Station 2 hallway. The DON pulled the keys out of the narcotics drawer and locked the cart. The DON and LN 3 both confirmed the medication cart and narcotic storage box should always be locked and keys are not to be left in the medication cart unattended. During a review of the facility's policy and procedure (P&P) titled, MEDICATION STORAGE IN THE FACILITY, dated January 2007, the P&P indicated, .Medication rooms,…

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.