Beachside Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the clinical records were complete and accurately documented by: a. failing to ensure the documentation for one out of six sampled residents (Resident 84) related to Resident 84's intravenous (IV, administered into a vein) access and IV fluids (liquids that are injected into a vein to prevent or treat dehydration [occurs when the body loses more fluids than it takes in]) was accurate. This deficient practice had the potential to reflect inaccurate hydration for Resident 84 b.failing to ensure one of eight sampled residents (Resident 49) with limited range of motion ([ROM] full movement potential of a joint [where two bones meet]) and mobility (ability to move) concerns had complete clinical records for the provision of Restorative Nursing Aide ([RNA] certified nursing aide program that helps residents to maintain their function and joint mobility) services. This failure resulted in Resident 49's records being incomplete regarding…

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 infection control measures by failing to: A. Ensure Resident 260's visitor was wearing Personal Protective Equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) and Licensed Vocational Nurse (LVN) 2 and LVN 3 were doffing (removing PPE in a way that avoids self-contamination) PPE properly without self-contamination after caring for Resident 260 who was on Enhanced Barrier Precautions (EBP- an infection control intervention designed to reduce transmission of multidrug-resistant organisms). B. Ensure LVN 1, LVN 4, and Certified Nurse Assistant (CNA) 1 were wearing proper PPE during the care of Resident 8 who was on EBP. C. Ensure the duct tape (a water resistant tape that is not waterproof and will eventually break down and allow water to pass) placed on 4 out of 22 sampled resident's (Resident 16, Resident 54, Resident 59, and Resident 84) beds' padded…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the call light device was within reach for one of five sampled residents (Resident 8). This failure had the potential to prevent Resident 8 from receiving the necessary care and services timely. Findings: During a review of Resident 8's admission Record, the admission Record indicated, Resident 8 was initially admitted to the facility on [DATE] and the last readmission was on 9/20/2024 with diagnoses including left leg above knee amputation (surgical removal of the portion of the left leg above the knee joint), muscle weakness, dependence on supplemental oxygen (a colorless, odorless gas element that sustains life), and pressure ulcer/injury (damage to skin and tissue underneath the skin caused by unrelieved pressure) stage 3 (Full-thickness loss of skin. Dead and black tissue may be visible) of sacral region (the portion of the spine between lower back and tailbone). During a review of Resident 8's History and Physical (H&P),…

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 monitor range of motion ([ROM] full movement potential of a joint [where two bones meet]) in both legs for one of eight sampled residents (Resident 49) with limited range of motion and mobility (ability to move) by failing to perform an annual Joint Mobility Screen ([JMS] brief assessment of a resident's range of motion in both arms and both legs) on 4/18/2024 in accordance with the facility's policy titled, Resident Mobility and Range of Motion. This failure had the potential for Resident 49 to develop further ROM limitations in both legs due to the lack of monitoring for potentially 21 months from Resident 49's Physical Therapy ([PT] profession aimed in the restoration, maintenance, and promotion of optimal physical function) discharge on [DATE] to 4/2025 (next annual JMS). Findings: During a review of Resident 49's admission Record, the admission Record indicated the facility initially admitted Resident 49 on 12/11/2019 and re-admitted…

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 prompt dental services after dentures were lost on 9/10/24 and provide documentation of what they did to ensure resident could still eat and drink adequately while awaiting dental services for one of two sample residents (Resident 30). This deficient practice resulted in Resident 30 not being able to eat the mechanical soft diet without the dentures until replacement was delivered on 10/31/24. During a review of Resident 30's admission Record, the admission Record indicated Resident 30 was admitted to the facility under Hospice (that provides medical, emotional, and spiritual support for people who are terminally ill and nearing the end of their life) on 8/2/2024 with diagnoses included dementia (a progressive state of decline in mental abilities), anemia (a condition where the body does not have enough healthy red blood cells), heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), anxiety disorder (a group of mental health…

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 three sampled residents (Resident 30) received food according to her preferences. This deficient practice resulted in Resident 30 not eating her preferred diet potentially resulting in decrease meal intake, weight loss, and malnutrition (lack of proper nutrition, caused by not eating enough). Findings: During a review of Resident 30's admission Record, the admission Record indicated Resident 30 was admitted to the facility under a Hospice (an agency that provides medical, emotional, and spiritual support for people who are terminally ill and nearing the end of their life) agency on 8/2/2024 with diagnoses included dementia (a progressive state of decline in mental abilities), anemia (a condition where the body does not have enough healthy red blood cells), heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), anxiety disorder (a group of mental health conditions that cause fear, dread and other symptoms that are out of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record, the facility failed to ensure an injury of unknown origin was reported to the California Department of Public Health (CDPH) for one of five sampled residents (Resident 1) when Resident 1 sustained a moderately displaced (a break in the bone where the bones does not always crack all the way through) fracture (a break in the bone) of the distal (farther end) diaphysis (shaft; or a long tubular structure of the bone) of the femur (thigh bone). This deficient practice resulted in the inability of CDPH to investigate Resident 1 ' s injury of femur fracture in a timely manner and had the potential for facts related to the injury to be forgotten by staff. Findings: During a review of Resident 1 ' s admission Record (Face sheet), the Face sheet indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis including encephalopathy (damage or disease that affects the brain leading to the person to be confused), dementia (a condition of loss of cognitive functioning such as…

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, the facility failed to ensure an injury of unknown origin was investigated for one of five sampled residents (Resident 1) when Resident 1 sustained a moderately displaced (a break in the bone where the bones does not always crack all the way through) fracture (a break in the bone) of the distal (farther end) diaphysis (shaft; or a long tubular structure of the bone) of the femur (thigh bone) and the cause of the fracture was unknown to the resident and staff. This deficient practice resulted in the inability of the facility to determine what might have been the cause of Resident 1 ' s injury and had the potential to recur. Findings: During a review of Resident 1 ' s admission Record (Face sheet), the Face sheet indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis including encephalopathy (damage or disease that affects the brain leading to the person to be confused), dementia (a condition of loss of cognitive functioning such as thinking, remembering, 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 interview and record review, the facility failed to update and document belongings brought by the family on the inventory list for three of four sampled residents (Resident 1, 4, 5). This failure resulted in residents losing items due to not having them written down on the inventory list. Findings: a. During a record review of Resident 1 Face Sheet (admission record), the Face Sheet indicated Resident 1 was initially admitted on [DATE] and was readmitted on [DATE] with diagnosis including hypertensive heart (chronic blood pressure elevation) and chronic kidney disease (CKD: gradual loss of the kidney function), history of falling, and dementia (impaired ability to think, make decisions) with other behavioral disturbance (verbal and physical aggression, wandering). During a record review of Resident 1 ' s Minimum Data Set [(MDS) a standardized assessment and care screening tool], dated 1/10/2024, the MDS indicated Resident 1 ' s cognitive skills (the mental action or process of acquiring knowledge 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 observation, interview, and record review, the facility failed to handle and store food in a sanitary manner to prevent growth of microorganisms (an organism that can be seen only through a microscope) that could cause food borne illness (food poisoning: any illness resulting from the food spoilage of contaminated food) for 99 out of 99 total residents in the facility by failure to: 1. Ensure enriched Farina hot wheat cereal have a received date label. 2 Ensure Dietary Aide (DA) 1, DA 2, DA 3, DA 4 and [NAME] 2 did hand hygiene (hand washing ) and don gloves when handling food during the tray line (a process of preparing and setting food for the residents in the facility). 3 Ensure ice machine maker door lining was kept clean. 4 Ensure freezer thermometer was calibrated and in working condition. These failures had the potential for growth of microorganisms (an organism that can be seen only through a microscope) that could cause food borne illness (food poisoning: any illness resulting from the food spoilage of contaminated food, pathogenic bacteria, viruses, or parasites…

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 dignity or privacy bag (a urinary drainage bag holder that restores the dignity of catheterized [insertion of a tube into the bladder to allow urine to drain for collection] residents by covering urinary drainage bags from the public view) for one of 20 sampled residents (Resident 307) indwelling catheter (a tube that drains urine from the body into a bag outside the body). This failure had the potential to result in Resident 307's low self-esteem and privacy being violated. Findings: During a review of Resident 307's admission Record (Face Sheet ), indicated Resident 307 was admitted to the facility on [DATE] with the diagnoses including acute kidney failure (a medical condition in which the kidneys can no longer adequately filter waste products from the blood), urine retention (the inability to completely empty the bladder), and benign prostatic hyperplasia (a noncancerous increase in size of the prostate gland (a gland 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 ensure one of seven sampled resident (Resident 256) responsible party (RP) was notified when the hemoglobin (a red protein responsible for transporting oxygen in the blood) dropped significantly to 7.3 grams/deciliter (g/dcl-normal levels 11.6-15) This failure violated the Resident 256's rights of notification of responsible parties of the care services provided and had the potential to result in a lack of proper care and treatment. Findings: During a review of Resident 256's admission Record (Face Sheet) indicated Resident 256 was admitted to the facility on [DATE], with diagnoses including iron deficiency anemia (a condition in which blood lacks adequate healthy red blood cells), falls, and dysphagia (difficulty in swallowing). During a review of Resident 256's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 11/19/2023, the MDS indicated Resident 256 was severely cognitively impaired (a person who has…

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 a comprehensive care plan (a resident-specific plan with defined clinical goals and interventions used to manage identified medical issues or other areas of concern) regarding the use of Depakote (a medication used to treat mood problems) to treat a behavioral problem of sudden outbursts of anger in one of five residents sampled for unnecessary medications (Resident 74.) This failure to develop and implement a care plan with measurable objectives for the use of Depakote may result in not meeting Resident 74's medical, nursing, and mental and psychosocial needs to maintain or attain Resident 74's highest practicable, physical, mental, and psychosocial well-being. Findings: During a review of Resident 74's admission Record (Face Sheet), indicated Resident 74 was admitted to the facility originally on 7/1/23 with diagnosis including unspecified dementia (loss of memory, language, problem-solving and other thinking abilities) with other behavioral disturbance. During a review of Resident 74's Order Summary Report,…

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 staff failed to ensure resident received radiation treatments (cancer treatment that uses radiation (usually high-powered X-rays) to kill cancer cells.) for basal cell carcinoma (type of skin cancer) of the left eye for one of seven sampled residents (Resident 48) by: 1.Failing to send Resident 48 to the correct outpatient department for a scheduled radiation treatment on 11/22/2023. 2.Failing to provide transportation for an outpatient scheduled radiation treatment on 11/27/2023. These failures resulted in a delay of services/treatments and the potential for Resident 48 to be exposed to radiotoxicity for back-to-back radiation treatments. Findings: During a review of Resident 48's admission Record (Face Sheet), indicated Resident 48 was admitted to the facility on [DATE]with diagnoses of major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), basal cell carcinoma of the skin, and impaired vision of the left…

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 act on one recommendation from the consultant pharmacist (a professional responsible for reviewing each resident's medication profile monthly to identify and report changes) from 10/5/23 regarding lowering of the dose of esomeprazole (a medication used to treat stomach acid problems) from twice daily to once daily in one of five residents sampled for unnecessary medications (Resident 74.) This failure of failing to respond to recommendations from the consultant pharmacist could have resulted in Resident 74 receiving a higher than necessary dose of esomeprazole possibly resulting in medication side effects (a secondary, typically undesirable effect of a drug or medical treatment). Findings: During a review of Medication Regimen Review (MRR - a monthly evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences associated with medication), dated 10/5/23, the review 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that one expired fluticasone/salmeterol (a medication used to treat breathing problems) inhaler for Resident 22, was removed from the medication cart in one of two inspected medication carts (Medication Cart 2.) This failure could have resulted in Resident 22 experiencing preventable episodes of shortness of breath and troubled breathing possibly leading to hospitalization. Findings: During a review of Resident 22's admission Record (Face Sheet), indicated Resident 22 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD - a lung disease that causes restricted airflow from the lungs and breathing problems). During a concurrent observation and interview on 11/28/23 at 1:42 p.m. of Medication Cart 2 with Licensed Vocational Nurse (LVN) 2, the following medication was found expired: 1.One opened fluticasone/salmeterol inhaler device for Resident 22, with opened date of 10/25/23.…

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 honor food preference of one of two sampled residents (Resident 356) by ensuring vegetables are not overcooked. This failure had the potential for Resident 356 to not receive their nutritional needs and food preferences. Findings: During a review of Resident 356's admission Record (Face Sheet), indicated Resident 356 was admitted to the facility on [DATE] with diagnoses including atrial fibrillation (irregular and often rapid heartbeat that can cause poor blood flow), difficulty in walking, hemiplegia (paralysis on one side of the body), and hemiparesis (weakness on one side of the body) following a cerebral infarction (damage to the brain from interruption of its blood supply) and diabetes (a condition in which the body fails to metabolize (process) glucose (sugar) correctly). During a review of Resident 356's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 11/20/2023, the MDS indicated Resident 356 had an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to observe infection control measures on two of six sampled residents (Resident 27 and Resident 43) when Certified Nursing Assistant 3 placed a plastic bag with soiled linens on the fall mat (cushioning pad placed on the floor along the side of the bed that can reduce injury due to fall) of Resident 43 while providing care to the residents. This failure had the potential to result in cross contamination (physical movement or transfer of harmful bacteria from one person, object, or place to another) and place residents at risk for infection. Findings: During a review of Resident 27's admission Record (Face Sheet), indicated the Resident 27 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including dementia (loss of cognitive functioning such as thinking, remembering, and reasoning which can affect and interfere with daily life and activities), and unspecified osteoarthritis (wearing down 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 interview and record review the facility failed to implement their antibiotic stewardship program (measures used by the facility to ensure antibiotics [drug to treat infection] are used only when necessary and appropriate) on one of two sampled residents (Resident 26) by prescribing an antibiotic without meeting the criteria of their protocol (checklist or guide to initiate antibiotic) for urinary tract infection([UTI] infection in the urine). This failure had the potential to put Resident 26 at risk for antibiotic resistance (not effective to treat infection) and inappropriate use of antibiotic. Findings: During a review of Resident 26's admission Record (Face Sheet), indicated Resident 26 was admitted on [DATE] with diagnoses including schizophrenia ( mental illness that affects how a person thinks, feels and behaves), transient ischemic attack(occurs when the blood supply to a part of the brain is briefly interrupted), benign prostatic hyperplasia ([BPH] enlarged prostate) and acute kidney…

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 sampled residents (Resident 1) call light (an alerting device for nurses or other nursing personnel to assist a patient when in need) was answered in a timely manner and helped in toileting by Certified Nursing Assistant (CNA) 4. This failure had the potential to negatively affect Resident 1's physical comfort and psychosocial well-being. Findings: During a review of Resident 1's admission Record, indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including osteoarthritis ( a joint disease, in which the tissues in the joint break down over time), heart failure (is a condition that develops when your heart doesn't pump enough blood for your body's needs), and edema (swelling caused by fluid trapped in your body's tissues). During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and screening tool), dated 11/3/23, indicated Resident 1 had ability to makes self-understood 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 interview and record review, the facility failed to ensure a Polymerase Chain Reaction ([PCR] a test used to detect the smallest amount of COVID-19 (a potentially severe respiratory illness caused by a coronavirus and characterized by fever, coughing, and shortness of breath [SOB]) test was conducted to confirm negative COVID-19 test results obtained via a Point of Care Antigen test ([Antigen] a rapid test that quickly detects the presence or absence of an antigen [a foreign substance] but is less accurate than a PCR test) test, when one out of two sampled residents (Residents 1) continued to exhibit signs and symptoms (s/s) of COVID-19, after his Antigen COVID-19 test results were negative. As a result of this deficient practice Resident 1 tested positive 10 days after his initial (9/1/2023) Antigen test result was negative and continued to exhibit s/s of COVID-19 the entire 10 days prior to being positive for COVID-19, potentially spreading the COVID-19 virus throughout the facility and placing other…

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.