Del Amo Gardens Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to accurately account for the use of controlled substances (medications with a high potential for abuse) for three out of four sampled residents (Resident 31, Resident 46, and Resident 12) reviewed. 1. Resident 31, the facility failed to accurately account for the administration of a lorazepam 0.5 milligrams ([mg-unit of measurement] a controlled substances used to relieve anxiety, a mental disorder characterized by persistent feelings of worry, nervousness, or unease strong enough to interfere with daily activities) on 10/5/2024 and 10/6/2024. 2. Resident 46, the facility failed to accurately account for the administration of tramadol (a controlled substances used to treat moderate to severe pain) 50 mg on 10/5/2024. 3. Resident 12, the facility failed to accurately account for the administration of tramadol 50 mg on 10/2/2024. These failures increased the risk that controlled medications to treat pain and anxiety may not be administered as ordered for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure it was free of medication error rate of five percent (%) or greater as evidenced by four medication errors out of 27 opportunities for error to yield a medication error rate of 14.81 %, for three of five residents (Residents 29, Resident 48, and Resident 42) observed during medication administration (med pass). The facility failed to ensure: 1. Resident 29's blood pressure ([BP] the force of blood against artery [blood vessel that carries blood away from the heart] walls as the heart pumps) and/or heart rate/pulse ([HR] the number of times the heart beats per minute [bpm]) was accurately assessed as a parameter ordered by the physician to determine whether to hold or administer resident's BP medication, amlodipine 2.5 milligrams (mg, unit of mass) 2a. Resident 48's BP and/or HR was accurately assessed as a parameter ordered by the physician to determine whether to hold or administer resident's BP medication, amlodipine 10 mg. 2b.…

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 standardized recipes for lunch menu was followed on 11/19/202024 when: 1.Facility failed to ensure five residents on mechanical soft chopped diet (for residents who have limited chewing ability and intact swallowing ability) received Chicken alfredo texture in the form that meet their needs when the broccoli was not chopped and there were large pieces of chicken and pasta in the Chicken alfredo. (chicken measured at 1.5 inches using a ruler). 17 residents who were on mechanical soft ground diet received chopped chicken alfredo instead of the ground chicken alfredo per the food production guides (food portion and serving guide). These failures had the potential to result in meal dissatisfaction, decreased nutritional intake, weight loss and increased risk of choking for the residents who were on mechanical soft chopped and or ground diet. Findings: 1.During an observation in the kitchen on 11/19/202024 at 11:50 a.m., [NAME] 1 was mixing the sauce for the Chicken alfredo and preparing the chopped…

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 and sanitary food storage and food preparation practices in the kitchen when: 1.Nutritional supplement labeled store frozen with manufactures instruction to use within 14 days of thawing, were not monitored for the date they were thawed to ensure expired shakes were discarded after this time frame. One box 30 single serve cartons of vanilla flavored high protein nutrition supplement and another box with 30 single serve cartons of sugar free chocolate high calorie nutrition supplements were stored in the walk-in refrigerator with no thaw date. This failure had the potential to result in food borne illnesses (any illness resulting from eating contaminated/spoiled foods) in 16 residents who were receiving nutrition supplements at the facility. 2.One large tray of boneless chicken thighs thawing on the bottom rack with no thaw date. 3.One bottle of thickened water stored in the reach in refrigerator with open date of 4/4/2024 exceeding storage period for the thickened water. These failures had 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 maintain right to privacy for one of six sampled residents (Resident 25) by failing to ensure privacy curtains was long enough to cover the resident's room during wound care dressing change. This failure violated Resident 25's right to privacy and had the potential for Resident 25 feeling of embarrassment. Findings: During a review of Resident 25's admission Record, the admission Record indicated Resident 25 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), paroxysmal atrial fibrillation (fast, irregular heartbeat that occurs suddenly and typically last for a short time), chronic kidney disease stage 3 (kidneys are moderately damaged and are not filtering waste and fluid from the blood as it should be), pulmonary hypertension( condition that affects the blood vessels in the lungs that makes the heart work harder than…

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 two of 27 sampled residents (Resident 1 and Resident 49), was provided a safe, clean and homelike environment by failing to provide a room that did not have peeling paint and exposed wall on the bedroom walls. This deficient practice had the potential for Resident 1 and Resident 49 to affect the residents' dignity, mood, and violation of residents' rights to have a homelike environment. Findings: During a review of Resident 1's admission record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), and hemiparesis (a condition that causes weakness or an inability to move on one side of the body). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 11/4/2024, 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 ensure one of 18 sampled residents (Resident 39) unwitnessed fall that caused a right hip fracture (a break or crack in a bone), required surgical repair and hospitalization at a General Acute Care Hospital (GACH) for four days (9/10/2024 to 9/14/2024) was reported to the state agency (California Department of Public Health [CDPH]). This failure resulted in a delay of an onsite investigation by CDPH to ensure Resident 39's fall was investigated and prevent further falls. Findings: During a review of Resident 39's admission Record, the admission Record indicated Resident 39 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including to fracture (broken bone) of the right femur (thigh bone), legal blindness ( a term used to describe a person's visual field of vision that is so limited that they are unable to see as well as most people), Alzheimer's disease, (a disease characterized by a progressive decline 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure Minimum Data Set Coordinator (MDSC) completed a significant change in status assessment (SCSA- a comprehensive assessment that must be completed when the Interdisciplinary Team [IDT- team of healthcare professionals who discuss and manage resident's care] has determined that a resident meets the significant change guidelines to either major improvement or decline) to one of six sampled residents (Resident 25). This failure had the potential for not providing appropriate care and services to Resident 25. Findings: During a review of Resident 25's admission Record, the admission Record indicated Resident 25 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), paroxysmal atrial fibrillation (fast, irregular heartbeat that occurs suddenly and typically last for a short time), chronic kidney disease stage 3 (kidneys are moderately…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure two of 18 sampled Residents (Resident 39 and 68 ) entry on the Minimum Data Set (MDS -resident assessment tool) assessment entries were accurate. The facility failed to: a. Ensure Section M in the MDS titled Skin Conditions was accurately documented to reflect Resident 39's current skin condition. b. Ensure Resident 68 discharge status was accurately documented to reflect Resident 68 was discharged home. This failure had the potential to result in a negative effect of Resident 39 and 68's plan of care and delivery of necessary care and services. Findings: a.During a review of Resident 39's admission Record, the admission Record indicated Resident 39 was admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with diagnoses including fracture (broken bone) of the right femur (thigh bone), legal blindness, Alzheimer's disease, (a disease characterized by a progressive decline in mental abilities) and dementia (a progressive…

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 b. During a review of Resident 46's admission record, the admission Record indicated Resident 46 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and osteomyelitis (inflammation of bone, usually due to infection). During a review of Resident 46's History and Physical (H&P), dated 9/13/2024, the H&P indicated Resident 46 had the capacity to understand and make decisions. During a review of Resident 46's Minimum Data Set (MDS - a resident assessment tool), dated 9/19/2024, the MDS indicated Resident 46 was able to understand and be understood by others. The MDS indicated Resident 46 required setup or clean up assistance for eating and oral hygiene and partial assistance (helper performs less than half of the effort) for toileting and dressing. During a review of Resident 46's Medication Administration Record (MAR) for July 2024, the MAR 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 interview and record review, one of one sampled resident (Resident 46) received treatment and care when Resident 46 experienced two hypoglycemic (low blood sugar) events (7/18/2024 and 8/18/2024). The facility failed to: a.Conduct and Interdisciplinary Team (IDT- team of health care professionals that work together toward and prioritize the resident's needs) meeting after Resident 46 experienced two hypoglycemic (low blood sugar) events (7/18/2024 and 8/18/2024). b.Activate the emergency response system on 8/18/2024 when Resident 46's continues to be unresponsive after interventions. This failure had the potential to result in Resident 46 experiencing repeated hypoglycemic events, diabetic coma (a life-threatening condition that occurs when someone with diabetes [ DM a disorder characterized by difficulty in blood sugar control and poor wound healing]), including death. Findings: During a review of Resident 46's admission record, the admission Record indicated Resident 46 was initially admitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a resident, who was assessed at a moderate risk (a scoring tool used to predict residents' risk of developing a pressure injury, total scores range from six to 23. A lower score indicating a higher risk of developing a pressure injury) for developing a pressure injury and had an intact skin upon admission, did not develop a Stage I ( intact skin with a localized area of redness and/ or changes in sensation, temperature , or firmness) pressure injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) on coccyx area and progressed into Stage II ( partial-thickness loss of skin, presenting as a shallow open sore or wound) pressure injury measuring two and half centimeter (cm-unit of measurement) in length by two cm in width and shearing (type of injury where different layers of skin or tissue slide against each other in opposite directions, causing damage to the deeper tissue…

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 five sampled residents (Resident 2) were provided a resting hand splint (splint [rigid material or apparatus used to support and immobilize a broken bone or impaired joint] secured from the hand to the forearm to position the hand in a functional position) to Resident 2's left arm and a hand roll splint (splint placed in the palm of the hand used to position the hand in a functional position) to Resident 2's right hand in accordance with Occupational Therapy (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) recommendations on 6/28/2024. This failure had the potential to cause Resident 2 to have further range of motion (ROM, full movement potential of a joint) decline in both arms, contracture (loss of motion of a joint associated with stiffness and joint deformity) development, decreased mobility (ability to move) and a decline in activities…

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 prevent the resident's unplanned weight loss of 9.2 percent (%) in three months and greater than 10 % in six months for one of two sampled residents (Resident 25). The facility failed to: a1 Ensure staff identified Resident 25's decrease oral intake (amount of food and water consumed), reassess, and monitor interventions to prevent a weight loss when Resident 25 had a weight loss of 15 pounds (lbs. unit of weight) from 5/7/2024 to 9/7/2024. 2. Ensure the nursing staff reported a decrease in Resident 25's oral intake to Resident 25's physician (MD1), in accordance with the Care Plan titled, Altered Nutrition/Hydration Status and Unplanned/ Unexpected weight loss of 4.8 percent (%) in one month on 9/7/2024, 9.2 % loss in three months and 10.5 % in six months on 11/11/2024. 3. Ensure licensed staff followed the facility's policy and procedure (P&P) titled, Nutrition (Impaired)/ Unplanned Weight Loss- Clinical Protocol and immediately notified…

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 residents, who were on pureed (food that had been mashed, ground, crushed until it is smooth and has the consistency of a creamy paste) diet received food consistent with diet order and according to the pureed menu recipe for one of 12 sampled residents (Resident 25. This failure had the potential to put Resident 25 at high risk for aspiration (condition when food, liquid, or other material enters a person's airway [passageway for air] and eventually the lungs), choking (life threatening condition where an object such as food lodges in the throat blocking the flow of air), and possible death. Findings: During a review of Resident 25's admission Record, the admission Record indicated Resident 25 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), paroxysmal atrial fibrillation (fast, irregular heartbeat that…

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 clinical records were accurately documented for one of five samples residents (Resident 2). The facility failed to: a Ensure Resident 2's Occupational Therapy (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) discharge recommendations for a resting hand splint (splint [rigid material or apparatus used to support and immobilize a broken bone or impaired joint] secured from the hand to the forearm to position the hand in a functional position) to Resident 2's left arm and a hand roll splint (splint placed in the palm of the hand used to position the hand in a functional position) to Resident 2's right hand to be worn for four (4) hours on and 4 hours off (removed) on 6/28/2024 were accurately documented. b.Ensure the range of motion (ROM, movement ability of a joint) status of Resident 2's both hands were accurately documented in the OT Evaluation,…

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 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, disease causing bacteria, viruses, or parasites that contaminate food, as well as toxins) for 70 out 73 total residents in the facility by not: 1. ensuring Foods were dated, labeled, properly sealed, and discarded before the used by date (expiration dates). 2. monitoring and documenting the temperature for the facility's freezers. 3. maintaining a clean environment around the dumpsters outside. 4. monitoring and documenting sanitization bucket log. 5. ensuring Kitchen staff did not touch face, scratch nose and head, and touch doorknob of walk-in refrigerator while wearing their gloves used to prepare food and did not wash hands between changing their gloves during food handling and preparation. These failures had the potential to affect residents and result in pathogen…

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: A. Follow their own policy and procedures (P/Ps) titled, Glove Use - Personal Protective Equipment, and Hand Washing - Hand Hygiene to ensure licensed nurses wash or sanitized their hands after removing gloves and before putting on a new pair of gloves. This deficient practice had the potential to expose one out of four residents (Resident 270) to contaminants and infection. B. Clean two of two cloth gait belts (assistive device used for lifting, transferring, and walking patients who have limited mobility issues) in accordance with the manufacturer's recommendations for sanitizing wipes (pre-moistened towelettes that contain a sanitizing or disinfecting formula that kill or reduce germs on surfaces) in-between residents' use with three of 19 sampled residents (Resident 1, 6, and 7). This failure had the potential to result in the spread of disease throughout the facility. C. Follow their policy and procedure on preventing the growth of Legionella (bacteria that causes a type of serious lung infection and are…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure: A. Dietary Aid (DA) 1 who worked as a cook to fill in the absences of the morning (AM) shift cook had an appropriate competencies and skills set to carry out the duties of a cook for four out of 70 total sampled residents in the facility by not: 1. providing a fortified (added vitamins and minerals that are not naturally present in those foods) diet for Resident 59. 2. providing mechanical soft diet (a diet that was designed for people who have trouble chewing and swallowing) for Resident 48 and Resident 9. This failure resulted in DA 1 not preparing and serving meals as ordered by the physician, to prevent unintended weight loss and accidents such as chocking and aspiration (when food or liquid enters the person's airway and eventually the lungs causing severe illness). Findings: 1. During a review of Resident 59's admission Record, the admission Record indicated, Resident 59 was admitted to the facility on [DATE] with diagnoses…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation interview and record review the facility failed to ensure the written diet menu instructions were followed for two of 45 sampled residents (Resident 59 and Resident 171) when making soup for Resident 59 and failed to honor Resident 171's food preferences. This failure had the potential to result in weight loss for Resident 59 and Resident 171 by not receiving the nutrition they needed for a therapeutic diet (a diet ordered by a physician or delegated registered or licensed dietician as part of treatment for a disease or clinical condition, or to eliminate or decrease specific nutrients in the diet, (e.g., sodium) or to increase specific nutrients in the diet (e.g., potassium), or to provide food the resident is able to eat (e.g., a mechanically altered diet (a diet in which the texture of a diet is altered). During a review of Resident 59's admission Record, the admission Record indicated, Resident 59 was admitted to the facility on [DATE] with diagnoses of but not limited to dysphagia…

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 lunch at the facility's established mealtime on 10/31/2023, which included five of five meal carts leaving the kitchen at least 42 minutes late. This deficient practice caused one of 10 sampled residents (Resident 169) for dining observation to feel hungry. Findings: During a review of the facility's undated mealtimes and locations schedule, the facility mealtimes indicated lunch begins at 12:15 pm. During an interview on 10/31/2023 at 11:27 am with the Dietary Supervisor (DS), the DS stated lunch was served at 12:15 pm. During an observation on 10/31/2023 at 12:42 pm, the lunch trays had not come out of the kitchen. During a review of Resident 169's admission Record, indicated Resident 169 was admitted on [DATE] with diagnoses including fracture (break in the bone) of the neck of the right femur (near the hip bone), presence of a right artificial hip bone, and muscle weakness. During a review of Resident 169's Clinical admission…

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 secure a handrail to the wall on 11/2/2023 and 11/3/2023. This failure had the potential to cause injury for residents who require the use of the handrail for balance and safety. Findings: During a concurrent observation and interview on 11/2/2023 at 2:13 pm, Restorative Nursing Aide (RNA, certified nursing aide program that helps residents to maintain their function and joint mobility) 1 leaned against a hallway handrail which caused the handrail to move. RNA 1 stated the handrail moved after leaning against it. During an observation on 11/3/2023 at 7:38 am, the hallway handrail, which measured approximately 10 feet (unit of measure) long, was loose. There were seven support brackets (structural part securing the handrail to the wall) underneath the handrail. The handrail was not secured to four of the seven support brackets causing the handrail to be loose. During an interview on 11/3/2023 at 8:28 am with RNA 1, RNA 1 observed the handrail and stated it was not safe for residents because it was loose. RNA 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain respect and dignity on one of three sampled residents (Resident 9) by standing over the resident while assisting her during a meal. This failure had the potential to result in decreased self-esteem and self-worth on Resident 9. Findings: During a review of Resident 9's admission Record indicated the Resident 9 was admitted 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), hypertension(high blood pressure) and osteoporosis( condition where bones become brittle and weak). During a review of Resident 9's Minimum Data Set( [MDS] a standardized assessment and care screening tool ) dated 7/20/2023, the MDS indicated the Resident 9 had severe cognitive impairment (person had trouble remembering things, making decisions, concentrating, or learning) and required one person assist with eating, toilet use 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 identify, appropriately assess, and monitor two of two sampled residents (Resident 18 and Resident 270) during the use of wedges (foam devices used to position residents, that have one thick end and taper to a thin edge) to prevent residents from sliding and falling from the bed. This failure had the potential to result in entrapment (being caught in) and injury. Findings: During a review of Resident 18's admission Record, indicated Resident 18 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), gastrostomy (a surgical operation for making an opening in the stomach), functional quadriplegia (a partial to complete loss of strength and sensation in both the upper and lower limbs and torso), and pressure ulcer (an injury that breaks down 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan for one of six sampled residents (Resident 4) with limited range of motion [ROM, full movement potential of a joint (where two bones meet)]. This failure had the potential to prevent Resident 4 from receiving intervention and equipment to prevent a decline in ROM in both arms and both legs. Findings: During a review of Resident 4's admission Record, indicated Resident 4 was admitted on [DATE] with diagnoses including heart failure (heart unable to pump enough blood), right and left foot drop (difficulty lifting the front part of the foot), dysphagia (difficulty swallowing), and hemiplegia (paralysis) and hemiparesis (weakness of one side of the body) following a nontraumatic intracerebral hemorrhage (bleeding in brain tissue) affecting right dominant side. During a review of Resident 4's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 8/10/2023, indicated Resident 4 had…

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 meet professional standards of quality of care for one of four residents (Resident 270) by failure to follow the facility's policy and procedures (P&Ps) titled, Feeding Tube - Administration of Medication, and Medication Administered through an Enteral Tube, to ensure medications was administered appropriately and safely to residents receiving medication through a gastrotomy/feeding tube (G-Tube, a tube inserted through the belly that brings nutrition and medication directly to the stomach). This failure had the potential to result in clogging and of medications in the G-tube and increased the risk for medication related complications for Resident 270. Findings: During a review of Resident 270's admission Record, dated 10/24/2023, the admission Record indicated, Resident 270 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included open-angle glaucoma and progressive supranuclear…

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 six sampled residents (Resident 3) with limited range of motion [ROM, full movement potential of a joint (where two bones meet)] received passive range of motion (PROM, movement of joint through the ROM with no effort from the person) exercises to the right leg from 8/29/2023 to 10/31/2023. This failure had the potential for Resident 3 to experience a decline in ROM and development of contractures (chronic joint stiffness associated with joint deformities and pain). Findings: During a review of Resident 3's admission Record, indicated Resident 3 was initially admitted on [DATE] and re-admitted on [DATE] with diagnoses including unspecified dementia (decline in mental ability severe enough to interfere with daily life), hemiplegia (paralysis) and hemiparesis (weakness to one side of the body) following cerebral infarction (brain damage due to a loss of oxygen to the area) affecting the right dominant side, and spinal stenosis…

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 six sampled residents (Resident 174) was free from unnecessary medications by failing to clarify with Resident 174's physician the need of continuance of antibiotic (medication to treat infection) medication after a negative chest x-ray result. This failure had the potential for Resident 174 to develop antibiotic resistance (not effective to treat infection) from unnecessary or inappropriate antibiotic use. Findings: During a review of Resident 174's admission Record indicated Resident 1 was admitted on [DATE] with diagnoses including fracture of upper end of left humerus (broken left upper arm), chronic kidney disease (kidneys are damaged and unable to filter waste products and excess fluids from the blood) and chronic obstructive pulmonary disease ([COPD] group of diseases that cause airflow blockage in the lungs which can cause breathing related problems). During a review of Resident 174's Minimum Data Set ([MDS]- a standardized…

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 it was free of medication error rate of five percent or greater as evidence by two out of 32 opportunities for error to yield medication error of 6.25 percent (%) for one out of four residents (Resident 270) observed during medication pass (MedPass). This failure resulted in Licensed Vocational Nurse (LVN 1) administering prescribed eye drops for Resident 270 into the wrong eye creating the potential for the resident's glaucoma (a condition in which the pressure in the eye is too high) to worsen (symptoms include, eye pain and pressure, headaches, and vision loss). Findings: During a review of Resident 270's admission Record, dated 10/24/23, the admission Record indicated, Resident 270 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included open-angle glaucoma and progressive supranuclear ophthalmoplegia (unable to move eyes at will in all directions, especially looking upward).…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow up necessary dental service for one of three sampled residents (Resident 7). This failure had resulted in delay of dental services and the potential to cause Resident 7 at risk for difficulty chewing and weight loss. Findings: During a review of Resident 7's admission Record, indicated the Resident 7 was admitted on [DATE] to the facility with diagnoses that included diabetes(high blood sugar level),heart failure( lifelong condition in which the heart muscle cannot pump enough blood to meet body's needs for blood and oxygen) and hemiplegia affecting the right dominant side( partial weakness or paralysis of the right side of the body) following cerebral infarction(stroke). During a review of Resident 7's Minimum Data Set ([MDS] standardized screening and care tool) dated 10/27/2023, the MDS indicated Resident 7 had moderately impaired cognition(when a person had trouble remembering, learning new things, concentrating, or making…

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: 1. Ensure therapeutic diets of mechanical soft (a diet that was designed for people who have trouble chewing and swallowing, chopped, ground and pureed foods [cooked and blended into a smooth, creamy consistency] as well as foods that break apart without a knife) were served as prescribed by the physician for two of 22 sampled residents (Resident 48 and Resident 9) This failure had the potential for Resident 48 and Resident 9 to choke and aspirate (food, liquid, or other material enters a person's airway and eventually the lungs by accident). Findings: During a review of Resident 48's admission Record, indicated Resident 48 was admitted to the facility on [DATE] with diagnoses including major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with daily life) , physical debility (loss of strength or increased frailty and weakness), pathological fracture (broken bones 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Cross referenced F757 Based on interview and record review, the facility failed to implement their protocol for antibiotic stewardship for one of six sampled residents (Resident 174) by prescribing antibiotic (drug that treats infection) without meeting the criteria (checklist used for Infection surveillance) for respiratory tract infection (infection affecting the lungs) used in the facility. This failure had the potential for Resident 174 to develop antibiotic resistance (not effective to treat infection) from unnecessary or inappropriate antibiotic use. Findings: During a review of Resident 174's admission Record indicated Resident 1 was admitted on [DATE] with diagnoses including fracture of upper end of left humerus (broken left upper arm), chronic kidney disease (kidneys are damaged and unable to filter waste products and excess fluids from the blood) and chronic obstructive pulmonary disease ([COPD] group of diseases that cause airflow blockage in the lungs which can cause breathing related problems).…

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.

1.Ensure one of three sampled residents (Resident 37) wheelchair's brakes was in operating condition. This failure had the potential to cause injury and fall to Resident 37 who used the wheelchair for mobility. 2. Ensure therapy equipment in the rehabilitation room were properly functioning, including one of one mechanical treatment mat (cushioned mat used in therapy that allows the therapist to customize the surface to different heights), one of one combination ultrasound (use of sound waves to penetrate soft tissues which increases blood flow) and electrical stimulation (use of mild electrical pulses through the skin to help stimulate injured muscles or manipulate nerves to reduce pain) combination machine. These failures had the potential to place residents receiving therapy services from safe and optimal use of the therapy equipment. Findings: 1.During a review of Resident 37's admission Record, indicated the Resident 37 was admitted on 7/1/2017 with diagnoses including dementia (group of symptoms affecting memory, thinking and social abilities that can interfere with daily…

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 19 sampled residents (Resident 6) was provided a safe environment by not repairing the transition strip (strips that cover the gap between two different floor types) on Resident 6's bedroom floor. This failure had the potential to result in serious injury related to slips, trips and falls for Resident 6, staff, and visitors. Findings: During a review of Resident 6's admission Record, the admission Record indicated, Resident 6 was admitted to the facility on [DATE] with diagnoses of but not limited to spinal stenosis (narrowing of the spinal canal in the part of the back), scoliosis (an abnormal curvature of the spine (backbone), osteoarthritis ( a type of degenerative joint disease that results from breakdown of joint tissue and the underlying bone), and low back pain. During a review of Resident 6's Minimum Data Set (MDS-a comprehensive assessment and care-planning tool), dated 10/5/2023, the MDS indicated, Resident 6 had 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.