Thousand Oaks Post Acute, LLC

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.

Based on interview and record review, the facility failed to ensure staff administered pain medication per facility policy and procedure (P&P) for one of three residents (Resident 1). Resident 1 received pain medication for a pain level of 5/10 (pain scale 0-10 - 0 being no pain, 10 being the worst pain) when the order indicated the medication was to be given for a pain level of 7-10/10. This facility failure had the potential for Resident 1 to sustain adverse reactions. Findings: During a Review of Resident 1's, Order Summary Report, an order dated 6/1/23 indicated, Hydromorphone HCL (a Narcotic used to treat moderate to severe pain) Oral Tablet 4 MG (milligrams) give 1 tablet by mouth every 4 hours as needed for severe pain 7-10/10. During a review of Resident 1's Medication Administration Record (MAR), dated June 2023, the MAR indicated, Hydromorphone HCI oral Tablet 4 MG, was administered to Resident 1, on 6/3/23 at 0:901 a.m. and 6/3/23 at 1:07 p.m. for a pain level of 5/10, not a pain level of 7-10/10 as per physician order. During a review of the facility ' s P&P titled,…

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.

Based on interview and record review, the facility failed to address residents' grievances as indicated by 6 of 12 members (Residents 243, 494, 29, 17, 16, and 25) who attended the resident council meeting during the facility's recertification survey. This failure had the potential to compromise resident's care and safety. Findings: Review of the past three months Resident Council meeting minutes indicated the following issues: call lights not answered timely, staff turned the call lights off without giving the care needed; wandering resident entered multiple rooms uninvited; missing items; food was cold, no flavor, rice and beans were undercooked, open faced sandwich were served closed and meat was tough. The Resident council minutes' log lacked documentation of follow up for the resident council meeting on 9/18/19, 10/16/19, and 11/20/19. There were between 8 to 12 residents in attendance at each meeting. The Resident Council minutes indicated, Old business: Minutes from the previous meeting were read and followed up on. It did not indicate what specific issues were followed up…

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 storage practices when they failed to: 1. Remove a dented can from available food supply. 2. Record temperatures and document corrective action for temperatures outside acceptable ranges of refrigerator and freezers. These facility failures had the potential to result in residents developing foodborne illness. Findings: 1. During an observation, and concurrent interview with a dietary cook (DC) on 12/2/19 at 10:10 a.m., a six pound can of green enchilada sauce was observed in the dry storage room with a dent on the lower rim of the can and was available for use. The DC confirmed that the can was dented, and removed the can from resident use. During a review of the facility policy titled Receiving Food and Supplies dated 7/1/16, the policy indicated Do not accept and return to the supplier, any items that are dented, rusted, damaged. 2. During a review of the facility policy and procedure titled Refrigerator/Freezer Temperature Records, revised 7/1/16, indicated Record daily all refrigerator…

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: 1. Infection control surveillance was performed according to facility policy and procedure. 2. Oxygen tubing was labeled for one of three sampled residents (Resident 495). These facility failures had the potential to result in unidentified infections and trends, and the growth of microorganisms. Findings: 1. During a concurrent interview and record review on 12/4/19 at 10:43 a.m., with a licensed nurse (LN 1) the infection prevention data collection dated May and August 2019 was reviewed. The data collection only included the form IC-01-R. LN 1 confirmed this was not adequate infection surveillance, and policy and procedure for data collection was incomplete. During a review of the facility's policy and procedure titled Infection Prevention and Control Program, dated 1/1/17, indicated, the facility must establish an Infection Prevention and Control Program under which it identifies, investigates, controls, and prevents infections in the Facility. The infection preventionist will review the infection…

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

Based on interview and record review, the facility failed to ensure the antibiotic surveillance logs were completed to monitor trends of antibiotic usage, clinical signs and symptoms, and ensure that the residents who were receiving antibiotics meet the criteria for antibiotic use from January 2019 through April 2019 and June and July of 2019. This deficient practice had the potential for the residents to build resistance to antibiotics and receive medication unnecessarily. Findings: During a concurrent interview and record review on 12/5/19 at 11:29 a.m., with the administrator (Admin) the data collection for the antibiotic stewardship program according to policy and procedure was not present in the infection preventionist binder, and the infection preventionist was unable to locate this data for the months of January thru April and June through July 2019. This was confirmed by the Admin. The only antibiotic stewardship data present was from the laboratory. During a review of the facility's policy and procedure titled Antibiotic Stewardship Program, dated 1/1/17, indicated The…

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

Based on interview and record review, the facility failed to ensure the Physician Orders for Life-Sustaining Treatment (POLST) status for one of one sampled residents (Resident 32), was consistent when the electronic medical record (EMR) indicated no choice made for artificially administered nutrition orders, and the paper chart indicated No artificial means of nutrition, including feeding tubes. This facility failure had the potential for Resident 32's wishes related to artificial nutrition not to be followed. Findings: During a concurrent interview and record review, on 12/3/19, at 9:45 a.m., with a licensed nurse (LN 2), the POLST paper copy in Resident 32's medical chart was reviewed and compared to the physician orders, and the EMR copy of the POLST. LN 2 confirmed the documents did not match in category C artificially administered nutrition. The paper copy of the POLST dated 1/3/19 requested No artificial means of nutrition, including feeding tubes. The EMR copy of the POLST dated 1/3/19 had no choice made for artificially administered nutrition orders. Both were signed by 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 develop and implement a baseline care plan for one of 21 sampled residents (Resident 47) when Resident 47's care plan for oxygen therapy was not developed upon admission. This facility failure resulted in a care plan that did not include the care and services needed to meet Resident 47's needs. Findings: During a concurrent interview and record review, on 12/4/19, at 10:52 a.m., with a licensed nurse (LN 2), the admitting physician orders dated 10/8/19 for Resident 47 included an order for oxygen (O2) at two liters per minute continuous to maintain an 02 saturation greater than 92% every shift. The baseline care plan for Resident 47 dated 10/8/19 and 10/9/19 did not include continuous oxygen therapy and monitoring of oxygen saturation. LN 2 confirmed there was no evidence in the baseline care plan of Resident 47's oxygen requirements, and acknowledged it should have been included. During a review of the facility's policy and procedure titled Care Planning, dated 11/1/17, indicated The Facility will develop a person…

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 develop and implement a comprehensive care plan for four out of 24 sampled residents (Residents 82, 75, 47, and 10) when the: 1. Facility failed to develop a care plan for Resident 82 with diagnoses of type 2 diabetes (adult onset of a chronic condition that affects the way the body processes blood sugar) and dependence on renal dialysis (a medical procedure for people with kidney failure or damage that eliminates waste and unwanted water from the blood). 2. Facility failed to develop a care plan for Resident 75 receiving oxygen therapy. 3. Facility failed to develop a care plan for Resident 47 receiving an anticoagulant. 4. Failed to ensure care plan implementation when the physician was not notified of Resident 10's weight change. These facility failures had the potential for resident care needs to go unmet. Findings: 1. During a review of the admission record for Resident 82 dated 10/29/19, Resident 82's diagnosis include diabetes and kidney failure…

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 services according to professional standards when: 1. Orders were not followed for Resident 75 when receiving oxygen. 2. a. Orders were not followed for Resident 82 for monitoring input and output (I&O). b. Orders were not followed and Resident 27 for monitoring I&O. 3. Orders were not followed for Resident 68 for monitoring I&O. These facility failures resulted in residents not receiving treatment as ordered by the physician. Findings: 1. During an observation on 12/2/19 at 2:56 p.m., Resident 75 was observed to be receiving oxygen at three liters per minute (LPM) by nasal cannula (a device used to deliver oxygen through the nose). During a review of the clinical record for Resident 75 the Physician Order Summary Report dated 12/1/19 indicated Administer oxygen at 2 LPM via nasal cannula to keep oxygen saturation greater than 92% every shift. During an observation and concurrent interview with a licensed nurse (LN 3) on 12/3/19 at 8:45 a.m., Resident 75 was observed to be receiving oxygen at three…

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 medications and biologicals were labeled and stored appropriately when: 1. Four expired bottles of sterile saline wound solution (a cleanser for minor cuts and burns) were found in the central supply room. 2. An emergency cart containing medication and supplies was found unlocked and accessible to residents. These facility failures had the potential for expired products with compromised sterility to be used on residents and for residents to have unmonitored access to medications and supplies. Findings: 1. During a concurrent observation and interview with a central supply clerk (CSC) on [DATE], at 10:13 a.m., four bottles of sterile saline wound solution with an expiration date of [DATE] were found in the central supply room. The CSC confirmed the four bottles of sterile saline wound solution were expired, and removed the bottles. 2. During a concurrent observation and interview with the assistant director of nursing (ADON) 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.

Based on record review, and interview, the facility failed to ensure the medical record was complete and accurate for one out of 21 sampled residents (Resident 71) when assessing the atrial venous fistula ( AVF - an access site used for hemodialysis [removing waste and excess fluid from the blood of people with kidney failure]) as ordered by the physician. This facility failure had the potential for Resident 71 to not receive appropriate treatment for AVF complications. Findings: During a review of Resident 71's Order Summary Report, a physician order dated 11/8/19 indicated, Hemodialysis: Monitor Presence of Bruit (sound of blood flow in AVF), use a + or - sign every shift (day, evening and night). During a review Resident 71'sMedication Administration Record (MAR) indicated on 11/23/19 and 12/3/19 there was no entry for one shift. On 11/28/19 and 11/29/19 the bruit presence was documented incorrectly. During an interview with the assistant director of nursing (ADON) on 12/4/19 at 11:43 a.m., the ADON acknowledged the MAR had missing and inaccurate documentation.